[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]
IMPLEMENTATION OF ELECTRONIC HEALTH
RECORD SYSTEMS AT THE DEPARTMENT OF
VETERANS AFFAIRS (VA) AND THE DEPART-
MENT OF DEFENSE (DOD)
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HEARING
BEFORE THE
SUBCOMMITTEE ON TECHNOLOGY MODERNIZATION
OF THE
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED SIXTEENTH CONGRESS
FIRST SESSION
__________
WEDNESDAY, JUNE 12, 2019
__________
Serial No. 116-17
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Printed for the use of the Committee on Veterans' Affairs
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.govinfo.gov
__________
U.S. GOVERNMENT PUBLISHING OFFICE
40-766 WASHINGTON : 2021
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COMMITTEE ON VETERANS' AFFAIRS
MARK TAKANO, California, Chairman
JULIA BROWNLEY, California DAVID P. ROE, Tenessee, Ranking
KATHLEEN M. RICE, New York Member
CONOR LAMB, Pennsylvania, Vice- GUS M. BILIRAKIS, Florida
Chairman AUMUA AMATA COLEMAN RADEWAGEN,
MIKE LEVIN, California American Samoa
MAX ROSE, New York MIKE BOST, Illinois
CHRIS PAPPAS, New Hampshire NEAL P. DUNN, Florida
ELAINE G. LURIA, Virginia JACK BERGMAN, Michigan
SUSIE LEE, Nevada JIM BANKS, Indiana
JOE CUNNINGHAM, South Carolina ANDY BARR, Kentucky
GILBERT RAY CISNEROS, JR., DANIEL MEUSER, Pennsylvania
California STEVE WATKINS, Kansas
COLLIN C. PETERSON, Minnesota CHIP ROY, Texas
GREGORIO KILILI CAMACHO SABLAN, W. GREGORY STEUBE, Florida
Northern Mariana Islands
COLIN Z. ALLRED, Texas
LAUREN UNDERWOOD, Illinois
ANTHONY BRINDISI, New York
Ray Kelley, Democratic Staff Director
Jon Towers, Republican Staff Director
SUBCOMMITTEE ON TECHNOLOGY MODERNIZATION
SUSIE LEE, Nevada, Chairwoman
JULIA BROWNLEY, California JIM BANKS, Indiana, Ranking Member
CONOR LAMB, Pennsylvania STEVE WATKINS, Kansas
JOE CUNNINGHAM, South Carolina CHIP ROY, Texas
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
official version. Because electronic submissions are used to prepare
both printed and electronic versions of the hearing record, the process
of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
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Wednesday, June 12, 2019
Page
Implementation Of Electronic Health Record Systems At The
Department Of Veterans Affairs (VA) And The Department Of
Defense (DoD).................................................. 1
OPENING STATEMENTS
Honorable Susie Lee, Chairwoman.................................. 1
Honorable Jim Banks, Ranking Member.............................. 3
WITNESSES
Mr. John Windom, Executive Director, Office of Electronic Health
Record Modernization, Department of Veterans Affairs........... 4
Prepared Statement........................................... 31
Accompanied by:
Dr. Laura Kroupa, Chief Medical Officer, Office of Electronic
Health Record Modernization, Department of Veterans
Affairs
Mr. John Short, Chief Technical Officer, Office of Electronic
Health Record Modernization, Department of Veterans
Affairs
Mr. William J. Tinston, Program Executive Officer, Defense
Healthcare Management Systems, Department of Defense........... 6
Prepared Statement........................................... 34
Accompanied by:
Maj. Gen. Lee E. Payne, M.D., Assistant Director for Combat
Support, Defense Health Agency, Department of Defense
Dr. Lauren Thompson, Director, Interagency Program Office,
Department of Defense, Department of Veterans Affairs.......... 8
Prepared Statement........................................... 37
IMPLEMENTATION OF ELECTRONIC HEALTH RECORD SYSTEMS AT THE DEPARTMENT OF
VETERANS AFFAIRS (VA) AND THE DEPARTMENT OF DEFENSE (DOD)
----------
Wednesday, June 12, 2019
Committee on Veterans' Affairs,
U. S. House of Representatives,
Washington, D.C.
The Subcommittee met, pursuant to notice, at 10:19 a.m., in
Room 210, House Visitors Center, Hon. Susie Lee presiding.
Present: Representatives Lee, Lamb, Cunningham, Banks,
Watkins, and Roy.
Also Present: Representative Roe
OPENING STATEMENT OF SUSIE LEE, CHAIRWOMAN
Ms. Lee. Good morning. This hearing will come to order. I
would like to welcome everyone.
And last week, the Subcommittee on Technology Modernization
heard from the prime contractors on the programs to implement
electronic health record systems at the Department of Defense
and the Department of Veterans Affairs. Today, we continue
oversight of these programs with testimony from the Departments
accountable for their implementation.
In providing oversight, it is important that we have the
proper time to review documents and receiving the DoD testimony
at 10:30 p.m. last night certainly does not optimize our
ability to do our job. Accountability, obviously, is a big part
of this effort, perhaps the most important.
In the history of failed efforts to implement information
technology throughout the Federal Government, more often than
not, technology was not the problem; rather, it was a failure
of leadership and management. The questions most often asked
are after failed technology implementations were: Who is in
charge? Who is accountable to the taxpayers and Congress? And
the answers often are a confusion of finger pointing and a
leadership vacuum. And after every failed project, there are
lessons learned and promises to do before.
Before us today, we have the leadership of the respective
offices for VA's electronic health record modernization and the
DoD's health care management system modernization. We also have
the current director of the Interagency Program Office.
We are at a moment in time when critical decisions must be
made in order to advance the implementation of this program,
but we are doing so without a fully functioning joint
governance structure. For months, this Subcommittee has asked
for a joint proposal to address the longstanding programs with
the existing IPO, and as of March 1st, we now have the Federal
electronic health record modernization program office, or
FEHRM, and we will hear testimony about the initial
organizational plans.
We have a one-page slide right here about a three-phased
plan, but it is hard to find where the governance and
accountability is in this plan. We are also missing a plan
about staffing and resources. Based on the timeline for
implementation, it appears that it will come too late to
address the critical decisions that must be made now.
Further, I wonder whether the DoD and VA are invested in
the idea of true joint governance and transparency since both
declined to provide feedback on a potential legislative
solution to finally create a single accountable joint-
governance office with a role to promote and facilitate
interoperability between the Departments for health records and
beyond.
I hope I am wrong and that the VA and DoD do want a real
solution in a functional governance structure. I would like to
believe that after we made this investment, are prepared to
spend at least $16 billion in taxpayer money on modernizing
health records for our servicemembers, veterans, and their
families, that we are prepared to do this right.
Joint governance is not the only challenge DoD and the VA
are facing now. The time for VA's first go-live is March 2020,
and that is fast approaching. There are many key decisions and
tasks that have yet to be completed. We are concerned that the
VA has left itself with very little margin for error. There are
many lessons to be learned from the Department of Defense,
which now has its ongoing struggles, and I hope we will get
some transparency about that today.
But my questions really come down to these: Why not spend
the time to get the governance right? Why not take the time to
get the infrastructure in place? And why not leave yourselves
room to do the necessary testing and training to ensure a
successful rollout?
This Subcommittee has been clear that we want to work with
the VA, even if that means delay, as long as the VA is
transparent and accountable. Why insist on leaving yourselves
very little margin for error when history is not on your side
for successful IT implementations. What is the VA doing to
mitigate risk and ensure that the final product delivered to
clinicians and veterans is the best it can possibly be,
understanding that opportunities for improvement and innovation
should be part of the management of the EHRM?
I would like to get these answers to these and other
questions, and we are asking for transparency and
accountability now to pave the way for implementation ahead and
what we owe to our servicemembers and veterans.
I thank all the witnesses for being here and I look forward
to their testimony. And I would like to now recognize my
colleague, Ranking Member Jim Banks, for 5 minutes to deliver
his opening remarks that he may have.
Mr. Banks?
OPENING STATEMENT OF JIM BANKS, RANKING MEMBER
Mr. Banks. Thank you, Madam Chair.
I would like to begin by thanking our witnesses, are
especially our DoD witnesses for appearing today. You do so
voluntarily, and I sincerely appreciate it.
Anyone who watched our contractor hearing last week or any
of our Subcommittee hearings know that we think that
cooperation between DoD and VA on electronic health records is
very important.
Lack of cooperation has been the graveyard of all of the
previous efforts. I have no doubt that it is a high priority
for each of you. Case in point, you have spent much of the last
9 months hammering out a joint-management structure. I want
EHRM and MHS Genesis to succeed. I want to support your
decisions.
But it is not reasonable to expect this Subcommittee to
endorse decisions that we have scant details about; decisions
that are the product of a secretive process. By all accounts,
DoD and VA are getting close to standing up the Federal
Electronic Health Record Modernization Program Management
Office, the FEHRM, to jointly manage EHRM and MHS Genesis.
I understand the desire to make the agreement in private
before disclosing anything. The problem is, though, there has
been no agreement. Compromise has been elusive because the
stakes were so high and both sides were apparently dug in so
deeply.
My hope was, and still is, for this Committee and the Armed
Service Committee, which I am also proud to serve on, to help
mediate the situation. No one wanted the FEHRM to be stood up
this late, but this is the reality. We are now 4 months out
from the go-live dates for MHS Genesis wave 1 and 10 months out
from the go-live date for VA's initial operating capability
sites. The opportunity for the FEHRM to have impact is right
now. It is time for a candid discussion of the Department's
vision to integrate EHRM and MHS Genesis.
However, I am more interested in what the FEHRM will
accomplish than how it will be structured, or which individuals
will lead it. I expect it to solve real problems, or better
yet, prevent them from happening in the first place.
Since taking on this assignment 1 year ago, I have seen and
heard enough to have some serious concerns. VA and DoD are
different animals. VHA and the military health system have
cultures, priorities, organizational structures, and even
missions that are quite different. I happen to believe that
they should be more closely integrated in the future.
But if we force them into a one-size-fits-all solution now
and ignore these realities, it may very well break them.
Healthcare is a roughly ninety-billion-dollar enterprise in VA,
and it is one of the 3 core missions of the Department.
Military health care is a critical component of force
readiness; both are personally important to me.
But electronic health records are simply not central to the
DoD mission in the same way that they are to the VA mission.
DoD is in a unique position with the creation of the Defense
Health Agency and the consolidation of the military services
treatment facilities into one organization.
I understand MHS Genesis is a critical element in
accomplishing that, so preserving the schedule is paramount. I
have also seen for myself that AHLTA and CHCS are incredibly
difficult on popular EHR systems; on the other hand, while the
structure of VA is not changing at all, the Department is
implementing the MISSION Act and Community Care is growing in
importance.
VA is not replacing VistA because it works poorly--in fact,
some clinicians like it very much--VA is replacing Vista
because it has fallen too far behind to meet the needs of the
future. A single longitudinal DoD-VA health record would be a
major accomplishment.
But as Dr. Roe can attest, any EHR implementation is
disruptive, at best, and traumatic, at worst. In order for the
cost and time and disruption to be worthwhile, VA also needs
true interoperability with the community providers. Attaining
that 9 years from now is simply not good enough.
I believe Congress has a duty to spell out its expectations
and a time to make impact is right now. That is why I will be
offering two amendments in the National Defense Authorization
Markup Act that is going to occur today. The first puts in
place requirements to ensure the FEHRM has qualified
leadership. The second calls for DoD and VA to develop a
comprehensive interoperability strategy to accomplish strategic
goals and defines interoperability for the first time.
Unfortunately, the Armed Service Markup happens to be going
on simultaneous with this hearing, and Madam Chair, with your
forbearance, I have to be present there to advocate for these
amendments. So, I will be heading back there, but I appreciate,
once again, all of you being here today for this important
discussion.
And with that, Madam Chair, I yield back.
Ms. Lee. Thank you, Mr. Banks.
I would now like to introduce our witnesses we have before
the Subcommittee. First, we have John Windom, who is the
Executive Director of the Office of Electronic Health Record
Modernization at the Department of Veterans Affairs. Mr. Windom
is accompanied by Dr. Laura Kroupa, Chief Medical Officer for
OEHRM, and John Short, Chief Technical Officer for OEHRM.
William Tinston is the Program Executive Officer for the
Defense Healthcare Management Systems at the Department of
Defense. Mr. Tinston is accompanied by Major General Lee Payne,
the Assistant Director For Combat Support at the Defense Health
Agency.
And we have Dr. Lauren Thompson, who is the Director for
the DoD-VA Interagency Program Office.
Welcome. We will now hear from the prepared statements from
our panel Members. Your written statements, in full, will be
included in the hearing record.
Without objection, Mr. Windom, you are recognized for 5
minutes.
STATEMENT OF JOHN WINDOM
Mr. Windom. Good morning, Madam Chair Lee, Ranking Member
Banks, who just departed, Dr. Roe, Congressman Lamb, your
respective support staffs, good morning. Thank you for the
opportunity.
I am accompanied by Dr. Kroupa, ma'am, as you mentioned,
who is my chief medical officer; Mr. John Short, who is my
chief technology and integration officer.
First, I want to take this opportunity to personally thank
you and the Members of the Subcommittee for your unwavering
support of the EHR modernization effort. Without your steadfast
support, VA would not be able to deliver this critical
capability in support of our veterans.
On June 5th, 2017, VA announced the decision to replace
VistA, its existing legacy system, which is costly to sustain,
and cannot deliver commercially available critical capabilities
to meet the evolving needs of the health care market. Though
the decision, VA is working to adopt the same EHR solution as
the Department of Defense, allowing patient data to reside in a
single hosting site, using a single common system.
This initiative will ultimately enable the seamless sharing
of health information, deliver enhanced analytics, improve care
delivery and coordination, and provide clinicians with the
requisite data and tools to support patients safely.
On May 17th, 2018, VA awarded a contract to Cerner
Corporation, leveraging an existing commercial off-the-shelf
solution in pursuit of interoperability objectives within the
VA, between VA and DoD, and with community providers. This
contract contains the necessary conditions to foster innovation
and keep pace with the evolving commercial technology.
To the end, OEHRM hosted an industry day on May 29th, 2019,
with over 750 registered industry executives and leaders and
over 450 companies in attendance. VA and OEHRM leadership
presented a status update on EHRM modernization efforts,
consistent--what are--and your demand for transparency.
In coordination with OEHRM, Cerner Corporation and Booz
Allen Hamilton, our support contractor, informed attendees on
the way to provide value-added programmatic support to the EHR
modernization initiative.
Now, I want to highlight three important aspects of the EHR
modernization effort which will contribute to the overall
success of the program. First, given the size, scope, and
complexity of the EHR modernization effort, VA plans to deploy
its new EHR solution in slightly under 10 years. The plan will
evolve as technology advances and efficiencies are further
identified. VA's approach involves deploying a solution at
initial operating capability sites in the Pacific Northwest to
mitigate risk and to solidify processes, procedures, and
allowing enterprise initiatives before deploying to additional
sites. Additionally, the IOC sites will further hone
governance, configuration management, and a myriad of other
implementation and change management strategies we intend to
employ.
VA targeted the Pacific Northwest Region based on DoD's
deployment of the EHR solution. By deploying in the same
region, VA will be able to immediately demonstrate
interoperability and reduce potential risk at the VA sites.
Second, VA has involved and is instituting a changed
management strategy that involves engaging users in the field
early in the process to determine their specific needs and
quickly alleviate their concerns; furthermore, OEHRM
established clinical councils that include nurses, doctors, and
other end-users from the field to support assessments and
configurations of workflows. These clinical councils meet
during the 8 scheduled national workshops which educate this
diverse frontline, clinical end-user community, enabling them
to validate workflows, ensuring the new EHRM solution meets the
VA's needs. To date, VA has completed 5 national workshops,
with the remaining scheduled to occur throughout the remainder
of the fiscal year.
Finally, VA and DoD currently work with the Interagency
Program Office to facilitate governance, collaboration, and
decision-making. To further promote a comprehensive, rapid, and
agile decision-making authority in support of interoperability
objectives, DoD and VA are co-developing a joint
organizational/management structure.
To execute this strategy, DoD and VA proposed establishing
a FEHRM, Federal Electronic Health Record Modernization Office,
responsible for effectively adjudicating functional, technical,
and programmatic decisions in support of DoD's and VA's
integrated EHR solutions. This strategy will optimize the use
of DoD and VA resources, while minimizing risks, promoting
interoperability without compromising patients' safety.
As demonstrated by our efforts, it is clear that VA is
committed to providing the best care to our Nation's veterans,
including access to a single longitudinal electronic health
record. The effort to support one of VA's top priorities to
modernize the VA health care system and ensure VA remains a
source of pride for our veterans, beneficiaries, employees, and
the taxpayers.
Madam Chair, this concludes my opening remarks. I am happy
to answer any questions that you or the Subcommittee may have.
Thank you, again.
[The prepared statement of John Windom appears in the
Appendix]
Ms. Lee. Thank you, Mr. Windom.
Mr. Tinston, you are now recognized for 5 minutes.
STATEMENT OF WILLIAM J. TINSTON
Mr. Tinston. Madam Chair and distinguished Members of the
Subcommittee, it is an honor to testify before you today. I
represent the Department of Defense, as the program executive
officer, Defense Healthcare Management Systems. Our mission is
to transform the delivery of health care, advance data sharing
through modernized electronic health records for
servicemembers, veterans, and their families.
In July 2015, the DoD awarded a contract to the Leidos
Partnership for Defense Health, to deliver a modern,
interoperable EHR, designed to share data with our Federal and
private sector partners. This modern, secure, connected EHR,
known as MHS Genesis, provides a state-of-the-market,
commercial, off-the-shelf solution, consisting of Cerner
Millennium, and industry-leading EHR, and Henry Schein's
Dentrix Enterprise, a best-of-breed dental module.
Deploying a capability of this magnitude requires extensive
coordination and communication with our stakeholders and
industry partners. It is a complex business. This is not simply
an IT solution; it is a complex business transformation and
leadership is key to its success. The right people must be in
the right place to make decisions and deliver solutions.
MHS Genesis concluded its pilot deployment in January 2018.
Our deployment to 4 sites, ranging in both size and capability,
allowed us to observe the system, assess performance, and
capture user feedback. We used this information to enhance
system capabilities as we developed our strategy to deploy our
next sites, starting in September of this year.
The VA's decision to implement the same EHR as the DoD and
the United States Coast Guard will result in a single, common
record, eliminating the need for interoperability with VA. The
DoD understands this decision demands extensive collaboration
and joint decision-making between the Departments, and is
working daily to ensure efficient workflows and standardized
processes.
Cybersecurity is one area of extensive collaboration and
joint decision-making. The DoD sets the standard for
cybersecurity and PEO DHMS invests time and resources to ensure
the common system meets that second degree. Our cyber team is
co-located with the commercial data center, which strengthens
our Federal and commercial relationships and allows for
continuous cyber monitoring. As a result of our efforts, the VA
will leverage this cyber posture and actively participate in
critical decisions required to protect the environment.
We also work closely with our VA partners to ensure we
maintain system integrity. Recommendations for system
enhancements are carefully evaluated by our joint workgroups to
minimize program risks and impacts. For example, we recently
agreed to accept a Cerner software upgrade, only a few weeks
following our next site implementation. The timing of the
upgrade address complexity and a risk to DoD's implementation,
but it will ensure that VA meets its scheduled initial
operational capability in March of 2020. Understanding this, we
knew it was the right decision for the successful
implementation for both Departments.
Another example of our collaborative efforts is continuity
of operations. The Departments have agreed to a joint approach,
which provides both, technical and programmatic efficiencies,
and will focus on clinical continuity of operations and IT
disaster recovery.
As a prior beneficiary and the son of a veteran, I am
passionate about the mission and firmly believe we are on the
right track to improve health care delivery for our
servicemembers, veterans, and their families. Working with the
VA, the Coast Guard, and our industry partners, I am confident
this team is committed to the successful deployment of a modern
EHR. We are making daily strides in the implementation of an
enterprise solution that will not only advance care for our
beneficiary and veteran communities, but will ultimately lead
to a longitudinal record focused on the patient, not where care
is delivered.
Thank you, again, for the opportunity to share our progress
as we deliver a single, common record for servicemembers,
veterans, and their families. I look forward to your questions.
[The prepared statement of William J. Tinston appears in
the Appendix]
Ms. Lee. Thank you, Mr. Tinston.
Dr. Thompson, you are now recognized for 5 minutes.
STATEMENT OF DR. LAUREN THOMPSON
Dr. Thompson. Chairwoman Lee, Ranking Member Banks, and
distinguished Members of the Subcommittee, thank you for the
opportunity to testify before you today. As the director of the
Department of Defense-Department of Veterans Affairs
Interagency Program Office, I am honored to be here.
The mission of the DoD-VA IPO is to advance data
interoperability across DoD, VA, and with private-partner
systems. Providing high-quality health care to servicemembers,
veterans, and their families is the IPO's highest priority and
health data interoperability is essential to improving the care
delivered.
A key component of meeting the unique needs of our
beneficiaries and ensuring they receive the best care possible
is making certain that no matter their status, location, or
provider, their health data is readily available and accurate,
or in other words, ensuring health data interoperability.
DoD and VA represent two of the Nation's largest health
care systems; together, the Departments serve over--million
eligible beneficiaries, including servicemembers, veterans, and
their families. Over 60 percent of the DoD and 30 percent of VA
beneficiaries receive care from the private sector.
Currently, the Departments share more than 1.5 million data
elements daily and more than 430,000 DoD and VA clinicians are
able to view the real time records of more than 16 million
patients who receive care from both Departments.
The fiscal year 2008 National Defense Authorization Act
directed DoD and VA to develop and implement electronic health
records systems or capabilities that allow for full
interoperability of health care data between the DoD and VA,
instructing the establishment of the IPO to guide both
Departments in their efforts.
In January 2009, the IPO completed its first charter,
aiding the Departments in attaining interoperable electronic
health data.
In March 2011, the Secretary of Defense and Secretary of VA
instructed the Departments to develop a single, integrated EHR.
In 2013, the Departments decided to pursue modernization of
their respective EHR systems. In December 2013, the IPO was
rechartered to lead the efforts of DoD and VA to implement
national health data standards for interoperability and to
establish, monitor, and approve clinical and technical
standards for the integration of health data between the
Departments and the private sector, in accordance with the 2014
NDAA and in compliance with the THHS, Office of the National
Coordinator for Health IT's guidance on standards,
interoperability for clinical records.
The IPO acts as the point of accountability for
identifying, monitoring, and approving the clinical and
technical data standards and profiles to ensure seamless
integration of clinically relevant health data between the
Departments and private-sector providers who treat DoD and VA
beneficiaries.
In April 2016, the Departments, with the IPO's assistance,
met a requirement of the fiscal year 2014 NDAA, certifying to
Congress that their systems are interoperable with an
integrated display of data through the Joint Legacy Viewer or
JLV.
JLV integrates data from the clinical data repositories of
both Departments, as well as data on beneficiary encounters
with private providers who participate in national health
information exchange. The IPO monitors the usage of JLV and
other interoperability metrics across the Departments to track
progress on data exchange and interoperability.
The IPO collaborates extensively with ONC, other government
agencies, and industry-standards development organizations to
advance the state of interoperability across the health
industry.
In 2018, Secretaries Wilkie and Mattis issued a joint-
commitment statement pledging to align strategies to implement
an integrated EHR system. DoD and VA leaders chartered the
Joint Electronic Health Record Modernization working group,
referred to as the JEHRM, to develop recommendations for an
optimal organization construct that would enable an agile,
single-decision-making authority to efficiently adjudicate
functional, technical, and programmatic interoperability issues
while advancing unity, synergy, and efficiencies.
On March 1st, 2019, the joint VA-DoD executive leadership
group approved a course of action, plan of action, and
milestones, and implementation plan to establish the Federal
Electronic Health Record Modernization program office, or the
FEHRM, in a phased manner in order to minimize risk.
The FEHRM will provide a comprehensive, agile, and
coordinated management authority to execute requirements
necessary for a single, seamless, integrated EHR, and will
serve as a single point of authority for the Departments' EHR
modernization program decisions.
FEHRM leaders will have the authority to direct each
Department to execute joint decisions for technical,
programmatic, and functional functions under its purview and
will provide oversight regarding required funding and policy,
as necessary. This management model creates a centralized
structure for interagency decisions related to EHR
modernization, accountable to both, the VA and DoD deputy
secretaries.
And interim FEHRM director and deputy director will be
appointed to work with the implementation team in transitioning
joint functions into the FEHRM once the FEHRM has an approved
charter. The interim leaders will manage and execute joint,
technical, programmatic, and functional requirements and
synchronize strategies between the two Department EHR program
offices to ensure single, seamlessly integrated EHR is
implemented with minimal risk to cost, performance, and
schedule. The interim leaders will remain in these roles until
permanent FEHRM director and FEHRM deputy director are
appointed.
The permanent director and deputy director will report
equally to the Deputy Secretary of Defense and Deputy Secretary
of Veterans Affairs.
The IPO will continue to support the Departments as it
transitions to the FEHRM in implementing a single EHR system to
ensure a seamless, patient-centric experience that will
ultimately lead to improved care for our servicemembers and
their families.
Thank you for the opportunity to speak with you today. I
look forward to your questions.
[The prepared statement of Dr. Lauren Thompson appears in
the Appendix]
Ms. Lee. Thank you. I will now recognize myself for 5
minutes for questions.
Perhaps my first question is, why the name change? Why do
we just not--I guess this is for Mr. Tinston and Mr. Windom--
why do we just not continue with the IPO?
Mr. Tinston. Well, I wasn't--ma'am, I wasn't here when the
decision was made and the JEHRM working group was put in place.
I understand why they changed it from JEHRM to FEHRM. It just
seemed an odd name.
Ms. Lee. It is really confusing.
Mr. Tinston. So, internally we talk about it sometimes as
IPO 2.0 or joint program office, but I can't really explain why
we went with FEHRM.
Ms. Lee. Okay.
Mr. Windom. Ma'am, I can tell you, as we migrated from the
JEHRM to the FEHRM, only that the JEHRM has a connotation that
did not reflect the clinical desires, and so in the Federal
element reflected, I think, an overarching responsibility
within the Federal space that encompassed DoD and VA. I think
we are not hard and fast on any name, ma'am; we are just trying
to be distinguished that we are doing something different than
is perceived to be occurring now, hence, the name.
But I can tell you--Bill, I think I can speak for both of
us--I don't think we have any--
Ms. Lee. No, I was just curious.
Mr. Windom [continued]. --issues.
Ms. Lee. Yes.
Mr. Windom. Yes, ma'am.
Ms. Lee. All right. Thank you.
Dr. Thompson, in your testimony you stated that FEHRM
leaders will have the authority to direct the Department to
execute decisions for technical, programmatic, and functional
functions under its purview. And it sounds--based on that, it
sounds like the FEHRM has the authority to direct the
Departments to execute the decisions that have already been
agreed to.
And I would like to know what is the FEHRM's role, related
to the issues that the Departments fail to reach consensus on?
Dr. Thompson. The intention of the FEHRM is to be the
deciding authority on issues.
Ms. Lee. Okay. Thank you.
What does that mean? Like, who all--can you explain that
further.
Dr. Thompson. So, the director and deputy director of the
FEHRM, who will be hired to report equally to the deputy
secretaries of the DoD and the VA, will have the authority to
make decisions, that will then be executed by the respective
Departments.
Ms. Lee. Okay. Mr. Windom and Mr. Tinston based on the DoD
and IPO testimony; it seems like this FEHRM is just getting
operational. Have your respective agencies signed off on a
charter, and is that charter operational, functional, and are
there any establishing documents that you are able to share
with us?
Mr. Windom. Ma'am, I would start by saying that the
documents are in staffing, including the charter, as are the
persons that will serve as the director and the deputy
director.
The concept that Bill and I primarily worked out, this
three-phase concept, is a concept that was imperative to
establish because it balances where we feel the greatest risks
are. And so, the three-phase concept is not to delay, but it is
to support the proper, efficient, and timely movement of
resources into the FEHRM to support the decision-making process
without compromising the risks in our present portfolios. So,
hence, the three-phase--the second phase would be in support of
Dr. Kroupa's team solidifying workflows in alignment with DoD
in that arena. And then the third phase would revolve around a
critical milestone called IOC, Initial Operating Capabilities.
As you know, until we demonstrate that it works in an
operational environment, it really does not make sense to move
a resource until we solidify our strategies. So, we are being
consistent with what I heard you say and others regarding
accountability and regarding understanding that it is the end-
users that will solidify our success. And so, taking into
consideration those same end-users is what has driven our
three-phase strategy.
Bill?
Mr. Tinston. Well, I think Mr. Windom addressed very
clearly that the charters and staffing and the Departments are
considering their options for who the interim directors and
intend to pursue permanent hires for the deputy and the
director of the organization.
Ms. Lee. Is there a plan that can be shared with us on
timing on all of this? On timing for the hiring and the
resources that are being put behind this?
Mr. Windom. Ma'am, my understanding is that events are
being coordinated, literally, as we speak, to come over and
brief your respective staffs on the details, where Bill and I
will be co-leading an organization that comes over and
literally gives you those details. We will be prepared to do so
and offer those details and also discussion points on whatever
detail you would like, and your staff would like.
Ms. Lee. Can I expect that in the next week or two weeks?
Mr. Windom. Ma'am, I would like to kind of get with the DoD
counterparts to really solidify that date, and we will gladly
reach out to your staff, through our legislative affairs, to
solidify that. I really wouldn't want to give you a date in the
hearing and then--I haven't agreed to mutually with Bill.
Ms. Lee. Okay. I am over my time, so I yield and will
recognize Dr. Roe.
Mr. Roe. Thank you, Madam Chair.
And just to start with grumbling a little bit, I don't like
this room. We ought to have the next hearing in the Verizon
Center. I feel like that is where I am.
And, two, I actually read this stuff, so I would appreciate
you all getting this to me a little sooner so I can sit down
and read it. And I was able to read a few pages before the
hearing, so I have got the grumbling over.
There are huge challenges with this. Obviously, your
organizational structure is one; you are dealing with two
separate Departments. One of the reasons we are concerned here,
I know Mr. Lamb and the Chairwoman was not here when DoD and VA
spent a billion dollars to try to make AHLTA and VistA
interoperative, and could not.
So, I think this is a step in the right direction. And I
guess about 18 months ago, whenever it was, I went to Spokane
and was able to be there at Fairchild and began to see the
rollout, and it was a bumpy rollout. And it was not because
effort was not there.
Look, I have saluted many generals. I didn't have near as
much on my sleeve as, General Payne, as you do. So, I know what
they did, was they saluted and said, Yes, sir, we will try to
get this job done.
The problem is that was a--when I saw that, I had
implemented an electronic health record in own office with
70,000 charts in our practice. This was 10,000, basically,
healthy people in a system that really didn't seem like it
worked all that well. And I know that you had to use the legacy
reader to get back and get any information.
And I guess my first question is, I know you, Dr. Payne,
you are the champion for the providers. I do know that. Isn't
that correct, you are the person that is looking after them,
that is sitting down every day at the computer terminal?
General Payne. Yes, sir. That is correct.
Mr. Roe. And do you think that the MHS Genesis, as it
exists at Madigan, Riverton, Oak Harbor, and Fairchild, are
meeting the needs of the clinicians there now?
General Payne. Yes, sir. I do. I think we have made
significant progress since you saw the record in 2017. We have
made some significant advancements. We learned that network
stability was really, really important and we requiring that
well in advance of go-live now.
We also learned that connecting all of our medical devices
was critical, and making sure those were all working and well-
established. All the cybersecurity standards were met before we
went live.
Mr. Roe. Well, I know that slowed--I know that the security
issue was one of the things that held it up, and I think that
is, hopefully, one of the lessons learned that DoD can pass to
VA so they don't have to have the same problem that you had.
Are you rolling out--is what is in Spokane now the same as
what you are going to roll out, I think it is in California and
Idaho is the next rollout that DoD is doing; is that correct?
General Payne. Yes, sir. We start at Travis Air Force Base,
Mountain Home, Monterey, and Lamar Naval Air Station.
Mr. Roe. When does that--when do you start standing that
up?
General Payne. September.
Mr. Roe. Of this year?
General Payne. Yes, sir. It is right around the corner.
Mr. Roe. And will it be different than what you rolled out,
or the same thing, that they have now in Riverton and Spokane?
General Payne. I would like to say that the record has been
advanced markedly over the past 2 years. Number one, and one of
the great things about having a commercial off-the-shelf
product, is that we get regular updates, and we have taken
those updates, we have integrated those across the system.
We have also configured the system in a significant amount
over the past two years. During the stabilization and adoption
period, we added, to correct a lot of the problems that we were
seeing initially in the sites.
We have also, in the past year, conducted 14 sprint
sessions that were led and directed by the clinicians at the
IOC sites telling us where they thought they needed the most
help. So, that has been really well received by the community.
Mr. Roe. Well, my concern when I looked at it was, as a
clinician seeing patients. And I was reading, just, again, the
guide in here, which I find hard to believe, but it says, for
instance, we can monitor the time a provider spends documenting
care outside of duty hours, and it was less than 3 percent.
General Payne. That is correct.
Mr. Roe. Unless they are not seeing many patients, it
certainly has been our experience in the private world, I mean,
you are spending--I just saw a doctor when I got on the
airplane to fly up here at home, and he was lamenting how many
hours that he had to spend in entering data, because he had a
very busy primary care practice.
The other thing before my time expires is, I was reading
that, are we going to run the VistA and AHLTA systems with the
legacy reader throughout the full 10 years of this until it is
fully implemented or do you turn the switch off in Spokane now,
so that you can rely on--I have got the information that I need
in front of me right now?
General Payne. We do turn off.
Bill, I don't know if you want to answer that, about the
legacy system turn-offs? You are probably better than me to
answer.
Mr. Tinston. So, we run the JLV, the legacy viewer, while
we are implementing the 23 sprints and getting to all the
sites--and that is not 10 years; that is to 2023, when we get
to all the military treatment facilities. JLV is actually
embedded as a capability in the electronic health record that
we are delivering so that we can get to have continued
interoperability with the VA records, as the VA is bringing
their records over to the Cerner solution. So, it will continue
to be used and available, but it is what we are using for
interoperability while we are in both environments.
Mr. Roe. Madam Chair, I hope we have a second round. I know
I am over my time.
But, I mean, the idea is that we have the Cerner system off
the shelf and you are running a parallel system with it. Are we
going to continue doing that, because that is really a
bureaucratic mess to keep up two systems?
I yield back.
Ms. Lee. Thank you, Dr. Roe.
I now recognize Mr. Lamb for 5 minutes.
Mr. Lamb. Thank you. And I want to thank Mr. Banks' thanks
to the witnesses for appearing; we really do appreciate it.
Mr. Windom, if I could just start with you and make sure I
understand kind of where we are today in the timeline of
everything. You noted in your testimony the contract that we
are dealing with between Cerner and VA is what is known as an
indefinite delivery, indefinite quantity contract--do I have
that right--and that was not competitively bid out in the
market because Cerner was already involved with DoD and the
Government wanted to continue with Cerner, right?
Mr. Windom. Sir, VA leadership endorsed what is called a
determination and findings that allowed us to sole-source
directly to Cerner Corporation, in support of interoperability
objectives, which involved being on the same Cerner Millennium
platform. So, that is what drove--so, a DNF drove the award of
a sole-source contract.
Mr. Lamb. Right. Got it. Okay. So, that was never--it
wasn't put out for bid; it was sort of falling in line with
what DoD had already done?
Mr. Windom. Yes, sir. Correct.
Mr. Lamb. That makes sense.
Okay. So, under this type of contract, if the go-live at
the initial sites does not happen in March 2020, is there any
penalty in the contract for that? Like, will money that has
been paid to them be recouped if it doesn't happen in March of
2020?
Mr. Windom. Sir, the question that you pose spawns a number
of ``it depends.'' We are committed to the milestone identified
in March of 2020.
The IDIQ contract approach allows for flexibility,
flexibility that may be needed due to variability that is
introduced that we flat-out didn't know. As you know, we are
doing current state reviews. Discoveries may be made, such that
you need to build the rectification of those discoveries or
problems into your schedule.
We maintain an integrated master schedule, and in
understanding of our critical path, we would know clearly when
something was introduced to our critical path. Right now, our
critical path revolves around clinical workflows, as controlled
by Dr. Kroupa, in making sure that end-users embrace the
solution and are educated on the solution. But the bottom line
is--
Mr. Lamb. Yeah, but that is not really my question,
though--if I could just interrupt you--my question is more
from--I understand that you are doing everything to stay on
schedule.
Mr. Windom. Right.
Mr. Lamb. My question is, if something happens on Cerner's
end and they just don't perform and March 1st of 2020 comes and
they just don't go live--they are not ready--does the
flexibility that you are referring to include the flexibility
to impose any sort of penalty or sanction on them for not
fulfilling that goal in the contract?
Mr. Windom. So, the simple answer, sir, is yes. This is a
performance-based contract. If Cerner fails to deliver in
accordance with the performance and terms and conditions of the
contract, we can withhold money. That would be the simple
answer.
Mr. Lamb. You can withhold future money?
Mr. Windom. We could withhold money. We wouldn't obligate
additional money if we had yet to rectify the issue that may be
at hand. So, that would not be good oversight on my part. So,
sir, we could withhold money. We could withhold work, in
support of rectifying whatever concerns that have been
identified that may have caused our milestone to slip.
But, again, it depends. I don't want to say, because there
are going to be discoveries that may spawn, potentially, a
movement. But right now, we are tracking to our March 2020 go-
live, so I don't really spend a lot of time, sir, speculating
what may happen. I simply say if performance is breached--
Mr. Lamb. Again, I hate to cut you off, but you know that
my time is limited.
Mr. Windom. Yes, sir.
Mr. Lamb. I am not asking you to speculate about what may
happen. I am just asking basic questions about the terms of the
contract.
And tell me if I am correct here, it sounds like what you
are saying is that in your understanding of the contract, if
Cerner does not perform on schedule, VA has the ability to
withhold funding from them going forward, yes or no?
Mr. Windom. That is correct. Yes, sir.
Mr. Lamb. Okay. Now, Mr. Tinston or General Payne, whoever
wants to answer this, when DoD went live at the initial sites
and there were all the problems that people had, you know,
people were getting the wrong prescription drugs filled and,
you know, everything that was widely reported at that time, was
there any taken by DoD against the makers of MHS Genesis for
those failings?
Mr. Tinston. Congressman, I wasn't a part of the program at
that point. I know that the DoD took those issues very
seriously. We paused the implementation. We went through, as
General Payne described, the stabilization and adoption period,
and then set to correcting those, improving the capability of
the system, and then building a different strategy and a
different approach to--
Mr. Lamb. Of course. I mean, you have to fix the actual
product, and I can tell that is what you all are doing.
My question, though, is, we have contracted with someone to
do this work, and was there any sanction or penalty imposed for
that initial--
Mr. Tinston. Congressman, I will have to get back to you on
that. I am not positive.
Mr. Lamb. That's fine. Now, I take it from everyone--and I
am basically out of time here--but Mr. Windom, you kind of
referred to this, do you believe that as of today, Cerner is on
schedule to do the initial rollout in March of 2020?
Mr. Windom. Yes, sir.
Mr. Lamb. Okay. And I just want you all to know that you
use the terms--Mr. Windom said that we are looking to build an
interagency program decision-making that was comprehensive,
rapid, and agile. Mr. Tinston talked about being technically
and programmatically efficient.
You should know that that is not how the contractors
described the current situation, as it stands right now. They
were with us last week. They said that decisions are slow.
When I asked them open-endedly, what is the number one
thing you need to succeed? It is faster decision-making by the
two Departments, which are two large Departments--I can
understand how they would be slow--but that is what is driving
our interest in a more efficient process that is implemented
quickly.
So, with that, Madam Chairwoman, I yield back.
Ms. Lee. Thank you. I now recognize Mr. Watkins for 5
minutes.
Ms. Lee. Thank you.
I now recognize Mr. Watkins for 5 minutes.
Mr. Watkins. Thank you, Madam Chair.
I represent Kansas' 2nd Congressional District, think small
towns, rural communities, and that makes expanded community
care programs so very important.
And so, Mr. Short, what systems and mechanisms do you have
in place to assure that the exchange records with community
providers runs smoothly?
Mr. Short. Sir, with our contract with the Cerner
Corporation, we have their Health Information Exchange that
they have used in many other partnerships that they have
through community providers. The process we are working through
right now is before we Go-Live in March for those processes and
connections to be in place, so it will grow the connectivity
and ability for VA to have community partner access data
exchange at a greater level than we have ever had before.
Mr. Watkins. That is good to hear. Thanks.
And, General Payne and Mr. Short, would it be fair to say
that the considerations for that interoperability are different
for the DoD as compared to the VA, and so the DoD is
implementing systems for the first time while the VA is
replacing systems. Would either of you care to comment on that
difference?
General Payne. Just a clarifying question, sir. We are
implementing systems for the first time. We have had, you know,
AHLTA, CHCS for 30-plus years for our in-patient systems. I
think what we are doing is taking multiple separate systems and
bringing them together in an integrated system, which is a huge
advantage for us.
Mr. Short. And, sir, I will add to that. Currently, today,
DoD and VA both have an HIE, Health Information Exchange, that
are much smaller than what Cerner is going to provide for us
later in this year where DoD and VA will both be able to share
the same Health Information Exchange.
As you know, VA has a lot of care on the outside with
MISSION Act, community care, that has potential to grow.
Obviously, DoD has been on record many times, they have a large
portion of their care on the outside. So when Cerner launches
that next year, both DoD and VA will have the ability to get a
lot more records from the outside than we ever have.
Mr. Watkins. And just as a clarification, General, what
major systems or mechanisms do you have in place to exchange
medical records with TRICARE providers?
General Payne. I will start and then I think Mr. Tinston
might be able to add. We use joint legacy viewer today, I want
to say the number is over 50 health care information exchanges
we have established with the civilian community, and that is
going to expand, as Mr. Short pointed out. As we move into a
Common Well into the future, there will be thousands of health
information exchange. And we are exchanging information with
both our civilian counterparts, as well as the VA, on a daily
and hourly basis.
Mr. Tinston?
Mr. Tinston. Well, the number is 59 HIEs that we are
connected to right now. When we move to Common Well and when we
are joining VA in the Cerner environment, we get the added
advantage that any HIEs or networks that we are connected to
that the VA connects to, we also get to share the advantage of
that same connection, and vice versa.
Mr. Watkins. Thank you, Madam Chair. I yield my time.
Ms. Lee. Thank you. I now recognize myself for 5 minutes.
I would like to focus a little bit about patient
identification. As I understand it, the VA and the DoD have
different patient identification standards, understandably, in
their medical record number formats; we heard that there has
been more than some conversations about standardizing them.
Mr. Short, what is the status of those conversations and
have you been able to reach a consensus?
Mr. Short. Ma'am, DoD and VA work together to create what
is called a Joint Patient Identity Management Service. We have
taken the back-end systems that we have had connected for many
years, we have enhanced and created some new business rules.
The current connections that DoD has feeding MHS GENESIS, as
they call it, the EHRM platform, we have taken that connection
and made modifications to it.
As part of that, we have also had to make sure that every
veteran had a unique identifier. DoD issues out an EDIPI
identifier to all soldiers, sailors, airmen, Marines, but many
veterans in the past didn't have those. So, as part of this, we
also had those identifiers issued to all veterans that ever
existed that we have a record of. They could have been a World
War II veteran that passed away 30 years ago. If we have a
record of them, they now have been issued this identifier.
We have completed that in the last couple of months. We are
down to about three or 400 left that had to go through manual
checks, because someone with a similar name had similar Social
Security numbers and they have to manually double check those.
So that has been put together and in the next couple of
months that will go into testing, so that service is together,
that way we feed one system of one identity service to the
common EHR. Since you have the same population or very similar
populations, you needed a common interface for identity going
to the system for patient safety. So we engineered that early
on in the system, we have put it in place, and testing will
start in a couple months.
Ms. Lee. Great, thank you.
Now that the MISSION Act has been implemented and more
veterans are going to be receiving their care in the community,
has there been any conversation around standardizing patient
identifiers with the VA and community providers?
Mr. Short?
Mr. Short. I'm sorry, ma'am, I didn't know who the question
was to. So we currently today, we work with the HIEs, as I
mentioned earlier, the health information exchanges, and Cerner
has Common Well, which General Payne mentioned. So currently
today, when we send someone out in the community, we have the
advantage, we have already identified them before we send them
out, so that part is taken care of. When it is accepted, when
the community partner accepts them, that our community partner
exchanges that we work with validate those identities also.
So we have the advantage of we kind of manage that
process--or don't kind of, we manage that process through the
community care referral process. So, from that standpoint, we
keep that. We have the Social Security number, as well as the
Veteran identifier I mentioned earlier. We actually track a
number of identifiers on everybody and we double check that
inside the VA system, the Identity and Access Management Team
under VA OI&T, they have a whole process where they use all--a
large number of identifiers to validate those from the outside.
Ms. Lee. Okay, thank you.
After--I would like to now turn to some infrastructure
questions and after the contract between VA and Cerner was
signed last year, Cerner completed a current-state review. The
reports generated indicated the obvious concerns with
infrastructure, including insufficient network capability,
outdated hardware, necessary facility modifications. Did the VA
conduct their own assessment in concert with Cerner?
Mr. Short. Ma'am, the VA staff went with Cerner when they
did their current-state review, so it was done in partnership
along with our government and contract staff. And then, once
that was completed, there was subsequent reviews done by VA OIT
for the technical pieces of it and VHA facilities as well.
Ms. Lee. So I understand now that VA has plans with MITRE
to perform an assessment as well; has that assessment been
completed?
Mr. Windom. Ma'am, I know of no plans with MITRE to conduct
a technical assessment. We are using a number of other
entities, but MITRE has not been one. We have got MITRE
personnel on our staff who participate in some of these
assessments, but we have not contracted specifically with MITRE
to go do these assessments.
Ms. Lee. Okay, so no MITRE request to do an assessment?
Mr. Windom. No, ma'am.
Ms. Lee. Have there been any updates made to these
assessments?
Mr. Windom. Ma'am, I am going to defer to John Short, my
CTIO, for that.
Mr. Short. Yes, ma'am. Cerner did their initial review, we
had some feedback, we did our review and, as we completed that,
Cerner updated those current-state reviews. And again, as I
mentioned, OIT and VHA facilities also did those reviews. Since
then, we had a meeting in the Pacific Northwest to go over all
the facility work that needed to be done and put that all under
plan and action.
Ms. Lee. Thank you.
I now recognize Dr. Roe.
Mr. Roe. Thank you, Madam Chair. A couple of quick
questions.
Any concerns about the 10-year rollout, because technology
changes so fast now, are we afraid--do you think that the
rollout now is going to look like in 2019 like it is going to
look in 2027 or '28? Are you going to be able to adapt and make
those changes as inevitably technology will change?
Mr. Windom. Dr. Roe, I think you have highlighted an
important element of the IDIQ contract, indefinite delivery,
indefinite quantity, where we get to leverage the commercial
advancements that Cerner undertakes in its commercial
environment with our own portfolio without incurring additional
expenses. So we expect to evolve with the commercial market; to
stay current, we will evolve with the market. And technology,
as you just highlighted, moves very quickly, so we intend to
use things like cloud computing and APIs and things that may
become the prevailing methodologies in the technological arena.
Mr. Roe. And, Mr. Tinston, I hope that the mentality to
listen to providers in the MHS system about why they don't like
it, I think we should, and not just reeducate them about what
is good about it, but have these providers out there that can
change it and make it a better system. Are you doing that? Have
you all done that?
And, Dr. Payne, you also may want to jump in.
Mr. Tinston. So the way the DoD has set the program up
subsequent to the IOC sites, it is designed to do exactly that.
I have a team of IT business system implementers who make sure
the IT is right and make sure that it reflects what the medical
facilities need, and the clinicians need, and then General
Payne takes care of that. So we are two elements of getting
this right and he works with the clinicians to make sure that
on the implementation side we are doing the right thing.
Mr. Roe. What I found out in implementing an electronic
health record was you had the IT people that didn't really know
what we needed, so they put everything in there. And I know I
would get a stack of paper this much and I am thinking
somewhere in this pile of you know what there is some
information I might be able to use if I can find it. And that
was the frustration I had with it, because we have these cut-
and-paste things that you end up with misinformation being in
there and you never can get it out.
And so are you listening to providers to say, look, I need
this amount of information in my little silo right here, I
don't need every question that has ever been asked anybody in
their life every time I see them, which is what these records
did. And it wasn't--I don't think it was the IT folks' fault, I
think they just didn't understand what was clinically important
to me as a doctor.
General Payne. As I mentioned to you about our Sprint
sessions, I think the front-line clinicians, we also have
clinical communities that are working with the VA councils in
configuring the record. One of the great things about MHS
GENESIS is it is configurable; we can adjust the system. As a
provider, you can adjust it to your likes and dislikes.
We are working--the other part I really like about this is
we are part--we are not an isolated--just isolated in DoD, we
are participating with the Cerner client universe. We visited
the University of Missouri, the Tiger Institute, to see how
they are operating. We are about to go to Memorial Hermann
Hospital in Texas to see how they are implementing MHS GENESIS,
that is one of the safest hospital systems in the country. And
we are also, our ophthalmologists are working with Cerner to
help devise the ophthalmology workflows.
So I think this record gives us an opportunity we have
never had before and, with our VA colleagues, I think there is
a huge amount of power in that.
Mr. Roe. And this is just a question, Mr. Windom, I read
this last night, I have no idea what it means. ``VA is
leveraging several efficiencies, including revised contract
language to improve trouble ticket resolution based on DoD
challenges.''
Could you translate that into something English?
Mr. Windom. Yes, sir. Sir, that was pre-contract award, so
there is no contract modification. Basically, our partners in
DoD shared with us very forthright and honestly some of the
challenges they were dealing with, with trouble ticket
management in the Pacific Northwest, and we were able to add
terms and conditions to our contract to facilitate a high level
of performance and review by Cerner in adjudicating ours sooner
rather than later. So, it really is just a lesson learned, sir.
Mr. Roe. Thank you.
Mr. Windom. I will be more clear next time.
Mr. Roe. Thank you. The last couple things. One is a big
challenge, Dr. Thompson, you know this, across the country is
interoperability. It is not DoD and VA; it is the private
sector: how do we share information? And, unfortunately, a lot
of people don't want to share information, because the
information they have is power and they can leverage it for
money. But it is critical for us to be able--as clinicians to
be able to share clinical information across VA to the
private--look, it does me no good to have a MISSION Act if I am
sitting out here and I can't get any information from the VA.
And, by the way, after I see the patient, if that information
doesn't end up back at the VA, it doesn't do the patient any
good.
I am going to leave one question, you can think about it,
both of you, because my time is expired, but in this rollout,
what is the major thing that keeps you up at night?
And I will end on that. I yield back.
Ms. Lee. Thank you, Dr. Roe.
I now recognize Mr. Lamb for 5 minutes.
Mr. Lamb. Thank you. And if you would like to answer Dr.
Roe's question, that is I think a major question on all of our
minds, just sort of a current assessment right now, what is our
biggest obstacle? Mr. Windom, if we could start with you.
Between now--let's say between now and March 2020, what is the
biggest thing that keeps you up at night?
Mr. Windom. Sir, I have listened to this Committee and I
have listened to the end users intently, and it is about user
adoption. The technology will work, the technology will
support, the embracing of the end user to our change management
strategies, our education strategy, training strategy, that is
our critical path element. So the critical path element keeps
me up.
I think Dr. Kroupa and her team are doing a great job. I
would like to pass the question over to her, if you don't
mind--
Mr. Lamb. I appreciate that. I was--
Mr. Windom [continued]. --and--
Mr. Lamb. --going to move to her anyway.
Mr. Windom. --but that is what keeps me up.
Mr. Lamb. And, Dr. Kroupa, are you the one who oversees the
18 councils and the input from the clinicians?
Dr. Kroupa. Yes.
Mr. Lamb. Okay. So if you could just let me know sort of
what is at the forefront of your mind, but also what are the
most recent examples that you are hearing from them of issues?
Dr. Kroupa. I think that the biggest challenge for us in VA
is, as has been mentioned, we are going from a CPR system,
which people are very accustomed to, to a commercial system. So
there has been a lot of education about what does that mean,
how does the commercial system work, how do we even speak the
same language as the commercial system.
I think we are now getting into a phase where the councils
understand that. They are really hitting their stride in terms
of understanding how the system works and are able to really
see the places where we can accept commercial best practice and
places where there are specialized things that VA needs to do
for our patient population and for our mission.
Mr. Lamb. And what are some specific things that they have
identified recently?
Dr. Kroupa. So there are some things, some basic things
like service connection. No one else in the world cares about
service connected veterans, except for VA. That is not
something that is in the commercial system to start with. We
have a lot of programs in VA that other commercial systems
don't have. We do things with PTSD, with blind rehab, you know,
a lot of comprehensive--
Mr. Lamb. No, I am sorry to interrupt. I understand why the
VA system is different than the commercial clients. What I am
asking is there a recent example you know of where a clinician
has flagged for Cerner and for you this thing that you already
have programmed will not work for me for this reason?
Dr. Kroupa. There has certainly been a--probably in every
council, there is something that has been flagged that says we
need development in this. We need configuration in this to make
sure that it meets the VA standards.
Mr. Lamb. But do you know what those are?
Dr. Kroupa. There is a whole list of those. So those are
all the things that we are working on now with Cerner to
rectify.
Mr. Lamb. Okay. And is there a--is it planned in the
schedule where before March 2020, some of these clinicians,
either on the councils or otherwise, are actually going to go
through like a dry run testing in front of the computer?
Dr. Kroupa. Yes.
Mr. Lamb. How is--can you tell me how that is scheduled?
Dr. Kroupa. Sure, sure. So part of the council process is
that they validate their decisions from the last time around.
So they are constantly validating and reviewing the decisions
they made before they move forward with the next phase. Then we
have an extensive testing time frame. People from the council
has already been identified that will be the testers. So that
we will make sure that their intentions are met in the product
when it is--before it is ready to go out. And then we will have
extensive testing in Spokane and Seattle, including mock
GoLives and a variety of validation events to make sure that it
is ready to go.
Mr. Lamb. And do you know when that starts in relation to
March of 2020?
Dr. Kroupa. The testing will start in November.
Mr. Lamb. Okay.
Dr. Kroupa. That is our current plan.
Mr. Lamb. Thank you. Mr. Windom, if you would, yes.
Mr. Windom. Mr. Lamb, may I add just real quickly is that
we knew at the inception, there are certain capabilities that
aren't delivered as part of the Cerner integrated solution. We
knew that. Things like prosthetics, things like long term care.
These are capabilities that will be interfaced with the
existing system as Cerner and us, to be frank, walk through the
coding process to actually integrate it into a solution. So no
capabilities will be lost. We may interface in the interim and
then replace the capability in the future as part of our
overall implementation strategy.
Mr. Lamb. Right. No, I understand that in general terms. I
guess, I think I am just a little bit surprised that nobody can
name a specific instance of where an end user doctor said to
you guys, ``Hey, the program falls short in this area of
something that I do and we need to get it fixed,'' and how it
was fixed. It seems to me that is what you are describing that
you want to be taking place, but I am just a little concerned
that we don't have specific examples of that. And you can feel
free to get back to us later. I understand we are putting you
on the spot.
Madam Chairwoman, I yield back.
Ms. Lee. Thank you. I would now like to recognize Mr. Roy
for 5 minutes.
Mr. Roy. I thank the Chairwoman. I appreciate you all being
here and taking your time to address this Committee. And I
apologize for missing the first part of it, so hopefully I
won't repeat anything. We have got redundant duties in another
Committee. Fortunately, this is a Committee where we actually,
on a bipartisan basis, tend to try to do something productive.
So I am glad you all are here.
Mr. Windom, I might start with you. I understand that the
VA is pursuing a best of suite strategy with the Cerner
contract and not a best of breed strategy. Could you please
explain what that means to you and how you all decided to
pursue that path?
Mr. Windom. Sir, a best of breed is an individual set of
capabilities that are basically daisy chained together, where
often the government becomes the integrator of those products.
Where a best of suite is an integrated solution that is built,
that is developed, that is coded to perform in an integrated
fashion such that there is no integration requirement in
between the individual components of the solution. And so AHLTA
and CHCS on the DoD side, that is an example of two different
products where the DoD is the integrator between the two. So
that is how I would describe it to you, sir.
Best of breed is a set of solutions that are daisy chained
together to deliver the requisite end state, where a best of
suite is an integrated set of elements where the end state is
delivered without the interactions in between each stage.
Mr. Roy. So quick question, quick follow up on that,
though, isn't the risk sort of putting all of the eggs in one
basket, versus having other alternatives and options we might
be able to have? Especially with modern technology, with APIs
and all of the different ways that we can, you know, integrate
across platforms, is that not putting all the eggs in that one
basket or no?
Mr. Windom. Sir, we have not restricted innovation in any
way, shape, or form on even a best of suite platform. So if
there is capabilities being delivered in the market that we,
the VA, want to leverage, we have the ability to present that
to Cerner Solutions set as a requirement in fulfillment of VA
mission objectives and pursue integration of those, if you
will, enhancements or improvements.
So a best of suite does not imply you can't inject new
capability or innovation into the product line.
Mr. Roy. Well, on a follow up then, Mr. Tinston, I assume
DoD also has a best of suite strategy; is that correct? And if
so, could you please walk me through your thought process
there?
Mr. Tinston. We do, in fact, have a best of suite strategy.
And the idea is that you get an integrated set of capabilities,
as Mr. Windom said. There may be a best product in this area,
but what works best in the combination of capabilities that we
are delivering to clinicians and the patients. So--
Mr. Roy. Okay. Slightly--I would love to engage on that
probably for hours, but in our limited time, Mr. Windom, back
to you. How do you define vendor lock in as it pertains to
electronic health records, and health IT companies? And what
would it mean for the VA to become locked into a particular
company?
Mr. Windom. Sir, very sensitive in not only my DoD life but
now to restrictions on the use of intellectual property. You
know, the open sourcing, the things that allow us, if you will,
to inject capabilities and not be bound by a solution that we
have contracted for. So the--having access to code, having
access in an unrestricted way to bringing in the requisite
solutions, whether it be apps, you know, applications that are
now very prevalent, that is where I deem vendor lock is. And in
our terms and conditions of our contract, we have greatly
inhibited vendor lock by promoting Cerner opening up their
gateway to allow better solutions, enhancements to the product
line that they may not only want to incorporate on behalf of
the VA before their commercial customers as well. So, sir,
hopefully that gets to where you were looking for.
Mr. Roy. Well, on a more specific basis, does buying the
Cerner Millennium EHR pose the risk of vendor lock in?
Mr. Windom. No, sir. The terms and conditions, again, we
have got an innovation CLIN, contract line item number. We have
got--again, I don't--this is a VA requirement. We drive the
requirement. We drive the behavior of Cerner and performance of
the terms and conditions of the contract. We have no desire to
give up on the innovative talent that the VA brings to bear,
nor the solutions that are being developed in the market today.
So we believe we have that relationship in the terms and
conditions of our contract, and we will exercise it as
necessary down the road to support, again, our veterans.
Mr. Roy. And relatedly, does the VA getting rid of its
patient portal, My HealtheVet, and adopting Cerner's patient
portal pose the risk of vendor lock in?
Mr. Windom. Sir, that is--I am going to defer that question
to Dr. Kroupa, but that is not our strategy. So I am going to--
we are not getting rid of our patient portal.
Mr. Roy. Okay.
Mr. Windom. We have a methodology that we are going to move
forward with that leverages the qualities of both patient
portals in our strategy. The key is that this is not a turnkey
solution set. We can't just turn one thing off and turn
something on. We know there are benefits in the way our system
performs. It is not our intent at all to reduce the
capabilities being provided to our veterans, but to enhance the
capabilities.
So Dr. Kroupa, ma'am, did you want to touch on patient
portal specifically?
Dr. Kroupa. Certainly, so we have done a side by side
comparison of what the Cerner portal offers versus My
HealtheVet. We are working on a strategy of how we can assure
that the veteran experience is as close to the same across the
country as we can make that. There will be some transition
time, but we are basically working with Cerner to upgrade their
portal to make sure that it offers the information and the ease
of use of My HealtheVet.
So we are still working, outlining that strategy, but we
are constantly working with Cerner to make sure that their
product gets better to serve our veterans.
Mr. Roy. Madam Chair, I am a minute over my time. Thank
you.
Ms. Lee. Thank you. The Subcommittee has copies of the
current state reviews and we have received updates and we
appreciate that very much. I just want to make sure that we
have every infrastructure report. So besides the CSRs, is there
any other analysis review about infrastructure readiness?
Mr. Windom. Ma'am, we have a joint infrastructure plan that
was co-authored by the OI&T office, headed by the CIO and also
John Short and our team. We gladly share that with you, because
what we feel is that the synergy between OI&T and our office is
essential. They are the managers of the network today. So we
can provide that if you don't have that.
John, did you have any other documents that you are hiding
from me?
Mr. Short. No, sir, not hiding documents, but OIT, as I
mentioned, there was other reviews that were done and the
Office of Information and Technology did create a report on
Seattle, Spokane, American Lake--we can get that for you.
Ms. Lee. Can we get that? Thank you.
Mr. Short. Yes, ma'am.
Ms. Lee. In the past, you have indicated that you will have
the infrastructure projects completed within six months of go
live. And then you just stated that--I just want to ask for
clarification, you are going to do testing in November. Do you
need the full infrastructure done for the testing? Are you
going to sort of test modules while you are completing--like
how does that timing work out?
Mr. Windom. Yes, ma'am, there is testing in the operational
environment and testing outside. The testing outside of the
operational environment does not require the infrastructure to
be ready to go. We are sticking to our plan of the
infrastructure will be ready six months prior to Go-Live. And
so the testing environment that we build in support of testing
in a non-operational environment is separate, with possibly
some connections or interfaces.
John, did you want to touch on that anymore?
Mr. Short. Yes, ma'am. Just for clarification. The
infrastructure needed for Go-Live will be ready in that time.
But there is still some additional infrastructure work that
will be completed later, not required for Go-Live, but for a
better user experience overall, some of those things, but not
necessarily for operation. But all of the ones necessary for
testing onsite, necessary for operations onsite, will be done
in time.
Ms. Lee. Do you worry that if you implement the
infrastructure for operation, but it is not optimal and
ultimately, you said the thing that keeps you up at night is
the end user experience, and so if you don't have the proper
infrastructure in place, you actually set yourself back.
Mr. Windom. Ma'am, I think you are right on point. It goes
hand in hand. What we do is we build plans to support being
ready as intended. We would owe you that transparency to your
staff if we are not meeting what we think our objectives are in
support of that.
I have indicated quite a few times that IOC is a period of
time, initial operating capability. What is available at Go-
Live, we will continue to update the infrastructure to deliver
capabilities throughout the IOC process, which is a period of
time, vice a single point in time. So I wanted to make sure
that was understood.
And then obviously tech refreshes will be ongoing to
support the system operating at the optimal level. As you know,
we are going to be running VistA and Cerner in parallel for a
while. And so we know that the infrastructure will not run
better with two systems, but we intend to--so we intend to make
the appropriate and prioritize decisions on infrastructure
upgrades.
Ms. Lee. So what is your timeline on just beginning the
infrastructure construction at IOC sites and the ordering of
the hardware?
Mr. Short. Ma'am, a lot of that is already taking place.
Some devices will be arriving soon. Some cabling has been done.
Wireless infrastructure has been replaced at one facility. So
all the work is actually ongoing already. We can provide you a
full schedule, ma'am.
Mr. Windom. Yes, and ma'am, we would gladly provide you a
full schedule so you can see all of the spreadsheets that are
being worked. We are leveraging--this is where I compliment the
CIO and the OIT. We are leveraging their contracts to the
maximum extent possible. I mean, we are talking about commodity
type hardware that they already procure, that we are simply
being able to leverage their vehicles for efficiencies on our
side.
So that is actually a time saving mechanism that is giving
us schedule back that we appreciate the CIO support in.
Ms. Lee. Good to hear. Thank you. I now recognize Dr. Roe
for 5 minutes.
Mr. Roe. I thank the Chair very much. And we here on this
Committee are here to try to help roll this out, not get in the
way. But I would like to be invited to one of your sites, with
no Power Point presentations, and so I could just sit down with
nurses, and doctors, and other people using this system and
actually see how it works. I, personally, would like to do
that.
And to Mr. Roy's question, to follow up on what he was
doing, and I guess anybody can get this here, what other
functions will this system do? I mean, is it going to--are you
going to be able to contract with it, schedule with it,
appointments, what else is the Cerner system capable of?
Dr. Kroupa. So this is really very a full set of
capabilities that we have bought from Cerner. So it will have
the electronic health record, the clinical portions of that. It
will have the revenue cycle side of things, so scheduling
appointments, registration, billing, those types of things. It
will have--we have HealtheIntent, which is the data analytics
section--
Mr. Roe. Did you say it would be able to do billing also?
Dr. Kroupa. It will be part of the billing process, yes. We
have HealtheIntent, which is the data warehouse side of that,
where we will be able to do reporting and analytics. It has
extensive management modules, so that it will help clinical
managers understand the flow through clinics, the--as you
mentioned, the time that providers use on the system. So we
will be able to say that this particular provider is having
trouble getting through this order set and we need to go help
and train them, and help them understand the system better. So
it has an extensive suite of both management and clinical uses.
Mr. Roe. Well, this is a--look, this is a monstrous
undertaking that you all are doing, both of you. And there are
going to be some bumps in the road. There is no question about
that. So please just share them with us. Look, I have been down
that road, know how it is. It is disruptive to the practice and
the clinicians. So if you run across things like that, don't
sweep them under the rug. Come to this Subcommittee and let us
know about it. We are here to try to help you, provide what you
need to get your job done.
And I think it is one of the most important projects that
is going on now. At the end of the day, it is not about
technology, it is about patient care. It is about going into
the room and seeing a patient with their ailment, and providing
the absolute best quality of care we can do. It is not about--
nobody cares about Wi-Fi and 5G and all of that. They just want
to get well when they come see me. They don't care how they do
it or come see the doctor. That is what you do and what I do
when we go in.
But our job is to make sure all of that other stuff works
so we can do that. So I would encourage you to be as forthright
with us as you can be. Mr. Windom or Mr. Tinston, either one,
it doesn't matter, or both of you can answer this, but who
decides, or have you all decided who is going to lead the firm?
Has that decision been made and who made it?
Mr. Tinston. To my knowledge, Congressman, that decision
has not been made. So I think the two departments are in
discussions about who is going to be the interim leadership,
the interim director and the interim deputy director for the
firm, and then they are going to pursue permanent hires in the
future.
Mr. Roe. Okay. So that hadn't been made yet. Lastly, and I
will finish up and yield back my time, you have been very--
thank you all. It has been a very good hearing. Do you see, Mr.
Windom, any delays that could happen right now? Looking out
your windshield, do you see anything that would hold you up,
because if you do, to me, that is fine, if you just--if it
takes another month or two, I would rather have you get it
right then get it quick and get it wrong.
Mr. Windom. Yes, sir. And you have been clear, sir, in a
number of hearings and we appreciate that support. I will tell
you March 2020 is where we are tracking for Go-Live. I keep
pointing to the clinical decision-making process that Dr.
Kroupa leads. It is about when they are ready. When they are
ready is when we will go deploy this thing.
And so we have got our last workshop, I think, in September
and we will be looking toward where we are in aligning the
workflows with DoD being involved in those. And I think we,
obviously, would owe you an interaction to say, ``Sir, here is
where we are in the workflows.'' But I view that as our
critical path item. And as you know about the integrative
master schedule process, my critical path--we can work a myriad
of things in collateral and parallel, and we are doing that. So
that critical path element for me is the clinicians and their
embracing of the solution coming forward.
So I will--can I come back and see you in November?
Mr. Roe. Absolutely.
Mr. Windom. Yes, sir. Okay.
Mr. Roe. I hope so. I hope I am here in November. One last
question. When will you know it is interoperable? When will a--
because we are going to have folks separating from the military
during this time and they are going to be leaving? When will we
know you can punch a button and move that medical record over
from DoD to VA?
Mr. Windom. I think, and I will defer to John after I make
just two remarks, is that, sir, I think that is one of the
benefits of us being in the Pacific Northwest simultaneously
with the Department of Defense is that you should be able to
walk from Madigan--after Go-Live, you should be able to walk
from Madigan and into American Lake and to Seattle Medical
Center, and to Mann-Grandstaff, and you ought to be able to
bring up each other's records. That is where we are striving,
what we are striving for. Let me turn this over--
Mr. Roe. Yes, I should be able to make a three foot putt,
but I can't a lot of times and so--
Mr. Windom. Well, so that is what our testing is going to
be in support of. That is what our strategy is going to be in
support of. And we will welcome you out there for the Go-Live
session to prove that to you.
Mr. Roe. When will that be?
Mr. Windom.'' Yes, sir.
Mr. Roe. When will that be?
Mr. Windom. March of 2020, sir.
Mr. Roe. March of 2020?
Mr. Windom. Yes, sir.
Mr. Roe. I yield back. Thank you.
Ms. Lee. Thank you, Dr. Roe. I now recognize Mr. Roy.
Mr. Roy. Thank you, Madam Chairwoman. Just to follow up
with a few more questions. I started with Mr. Windom. Does
using Cerner's HealtheIntent product as the repository for all
veteran health data pose the risk of vendor lock in, just
continuing the conversation about lock in?
Mr. Windom. Sir, we selected a solution to benefit the
veterans and the active duty servicemembers. So the vendor lock
thing, I don't know enough about the inter-workings of
HealtheIntent to be able to give you, and so if you don't mind,
I will take the look up--
Mr. Roy. Okay.
Mr. Windom[continued]. --and I will defer to John and Dr.
Kroupa for maybe their assessment of the product.
Mr. Short. Sir, when we were negotiating the contract, we
required Cerner, upon VA's request, to extract the data from
Millennium and HealtheIntent into the form and structure that
we require it in. So if in the future we decided to go
somewhere else, we could have the data extracted to go
somewhere else. And obviously that would be a whole effort in
itself. But we do have that ability, so it is not locked into
their system.
Mr. Roy. Okay. And relatedly, you know, in general terms, I
just want to go back to Mr. Tinston. I understand DoD plans to
buy HealtheIntent but has not done it yet and is vendor lock in
a consideration in this decision?
Mr. Tinston. So we are, in fact, we have a joint team with
the VA for the implementation of HealtheIntent. We are setting
up the environments now. I am not worried about lock in with
HealtheIntent. As John Short just mentioned, the data is not
Cerner's, but importantly with HealtheIntent, it is a set of
capabilities built on other products, some of them even open
source products that are not Cerner exclusive products. So I
don't see a risk of vendor lock in here.
Mr. Roy. So just to clarify, you know, the questions that I
am asking about vendor lock in are not meant to be critical of
Cerner or anything along those lines. You know, I think, you
know, obviously, one of the leading companies out in the
industry. It is meant to just focus in on some of the concerns
that we might have. This project is very large and difficult,
and we want to complete the basics before turning attention to
other stuff.
But I believe innovation is really important. And as I
know, I think all of you do, believe it or not, I have a
masters in Management Information Systems from my previous
life, which was in 1995, so it is about as useful as, you know,
having a putter in my hand right now.
But I do care about these issues and think about them, at
least analytically, in the way that I would when I was in that
realm of my life. So the question I would have here that I am
trying to understand is how we are getting the kind of
competition and innovation that needs to continue through this
process, right? And particularly for veterans, I know I hear in
my district all the time about their concerns, about under
choice and mission, being able to go access private sector
health care and having trouble doing so, and trying to make
sure that we have got the best health records to make that
process as smooth as possible.
So one question here, Mr. Windom, is do you know what
Cerner's market share is now?
Mr. Windom. I do not, sir.
Mr. Roy. Okay. My basic understanding is it would sort of
be in the upper 20s or something in that zip code of the market
and then do--I assume the answer will be no, but do you know
what the market share would be if the military health system
and VA both finish implementing Cerner nationwide? Do you have
an estimate of what that market share might look like?
Mr. Windom. I do not, sir.
Mr. Roy. Okay. We have some rough estimates that that might
put it in the sort of mid to upper 30s. And again, nothing
inherently wrong with that per se. We have got a lot of
industries where there is some significant market dominance. I
think it is just a question that should influence at least some
of our thinking about making sure that there is the kind of
innovation that is necessary. And you know, we are not talking
about monopoly here, obviously, but we are talking about
concerns about making sure there is continued innovation.
So this seems to have been one of VA's considerations when
it negotiated the contract with Cerner. And so I want to ask
you one question. The contract says VA will have access to
Cerner's data architecture, not just the data in the system,
which VA should already own. VA hailed this as a big victory
when the contract was signed. What is Cerner doing differently
to give VA this access and how is VA using it?
Mr. Short. Sir, on the access to the data models and the,
so what we have done already, data migration is the main area
where this hits first. And that is--and there is many elements
to data migration, many steps. So when we did this, we had to
map VistA data to the HealtheIntent data model, which CMO staff
did with--Dr. Kroupa's staff did with Cerner. And then they had
to be mapped to the Millennium data model so Cerner can move
that data.
So the first steps that have been done, and now Cerner is
taking the next steps over the next couple of months to move
that into the HealtheIntent model and to the Millennium model.
And by having access to the data models to be able to map that,
we can actually make use of all of VA's Legacy data and VistA
back to 1981 so it can be used by DoD and VA.
Mr. Roy. Anybody else have any other, anything to add to
that? Okay. Well, okay. Well, thank you, Madam Chairwoman.
Ms. Lee. Thank you. Well, this wraps it up. I just want to
thank you all for your time today and your testimony.
Certainly, we understand how incredibly complex and important
this project is and the opportunity to improve care for not
only our active servicemembers, but our veterans. And,
certainly, the example that Mr. Tinston provided with the
nursing, rapid response that helped save a life is obviously
what we look for as the future of this project and the great
opportunity we have, not just within the VA and the Department
of Defense, but for health care, not just across this country,
but throughout the world. So, not a small undertaking.
You know, last week--I just want to reiterate this--last
week, the contractors said that their single greatest risk to
their success was the timing and their ability to make
decisions. And, you know, we had the IPO and now--then it was
the JEHRM and now it is the FEHRM. But still, today, my
understanding from the questions that were answered today, that
this is really just still a concept and not an actionable plan,
at this point.
And then, layered on top of that, we have the IDIQ contract
which, you know, according to Mr. Windom, you have clear
responsibilities that are Cerner's versus yours. So, we are
happy to hear that you are confident you are on schedule for
the March 2020 rollout.
So, my concern is as we get closer and closer and if we
start to miss deadlines, there is going to be a clear decision
point when we want to understand who is responsible. And
without a clear plan on this FEHRM, and I am going to reiterate
that again, it really puts us and the taxpayers at risk.
Because, you know, there is going to be a point where Cerner is
going to say, No, it is your fault. We are going to say, No, it
is your point.
That is why it is so important that we have this governance
structure in place, so we can understand, and we have one point
of decision-making and one point that can say, this is what
happened. And we are either going to hold Cerner accountable or
we are going to hold ourselves accountable.
And, clearly, especially as Dr. Roe said, you know, we know
this is an undertaking and when we come up to bumps in the
road, we would rather than understand them than find out about
them after the fact.
And so, I just need to close this out by reiterating, as
soon as we can see the actionable plan on the FEHRM, it will
give us a lot more clarity and comfort as we move forward and
work together with you to try to meet the March 2020 rollout.
So, best of luck. Continue the great work. Thank you all
for your service to our country and our veterans and our active
military members, and we look forward to continuing the
conversation. Thank you.
Oh, Members, before we end, will have 5 legislative days to
revise and extend their remarks and include extraneous
material. This hearing is now adjourned.
[Whereupon, at 11:51 a.m., the Subcommittee was adjourned.]
A P P E N D I X
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Prepared Statement of John H. Windom
Good morning Chairwoman Lee, Ranking Member Banks, and
distinguished Members of the Subcommittee. Thank you for the
opportunity to testify today in support of the VA initiative to
modernize its electronic health record (EHR) through the acquisition
and deployment of the Cerner Millennium (Cerner) EHR solution. I am
accompanied today by Dr. Laura Kroupa, Chief Medical Officer for the
Office of Electronic Health Record Modernization (OEHRM), and Mr. John
Short, OEHRM Technology and Integration Officer.
My thanks to Congress, and specifically this Subcommittee, for your
continued support and shared commitment for the program's success.
Because of your unwavering support, VA has stayed on track for
implementation, enabling us to continue our mission of improving health
care delivery to our Nation's Veterans being a responsible steward of
taxpayer dollars.
Background
On May 17, 2018, VA awarded an Indefinite Delivery/Indefinite
Quantity (ID/IQ) EHR contract to Cerner. Given the complexity of the
environment, VA has awarded this ID/IQ to provide maximum flexibility
and the necessary structure to control cost. Through this acquisition,
VA will adopt the same EHR solution as the Department of Defense (DoD).
The solution allows patient data to reside in a single hosting site
using a single common system to enable the sharing of health
information; improve care delivery and coordination; and provide
clinicians with data and tools that support patient safety. VA believes
that implementing a single EHR solution will allow for seamless care
for our Nation's Servicemembers and Veterans. Since contract award, VA
has accomplished several key events outlined below.
Task Orders
As mentioned earlier, VA awarded the Cerner contract on May 17,
2018. VA also awarded the first three Task Orders (TO), which are
project management, Initial Operating Capabilities (IOC) site
assessments, and data hosting. In September 2018, VA awarded three TOs
for Data Migration and Enterprise Interface Development, and Functional
Baseline Design and Development and IOC Deployment. VA leverages the
ID/IQ contract structure awarding firm-fixed-price TOs as requirements
are validated. This strategy affords VA the flexibility to moderate
work and modify implementation and deployment plans efficiently. Since
contract award, VA has awarded additional TO's to begin activities
around data migration and IOC deployment. Additional details about the
TOs are as follows:
TO 1 - EHRM Project Management, Planning Strategy, and
Pre-IOC: Cerner will provide project management, planning, strategy,
and pre-IOC build support. More specifically, the scope of services
included in this task order are project management; enterprise
management; functional management; technical management; enterprise
design and build activities; and pre-IOC infrastructure build and
testing.
TO 2 - EHRM Site Assessments - Veterans Integrated
Service Network (VISN) 20: Cerner will conduct facility assessments, to
prepare for the commercial EHR implementation, for the following
Veterans Integrated Service Network 20 IOC sites: Mann-Grandstaff VA
Medical Center (VAMC) in Spokane Washington; the Seattle, Washington
VAMC; and the American Lake VAMC in Tacoma, Washington. Cerner will
also provide VA with a comprehensive current-state assessment to inform
site-specific implementation activities and task order-specific pricing
adjustments.
Task Order 3 - EHRM Hosting: Cerner is funded to deliver
a comprehensive EHRM hosting solution and start associated services to
include hosting for EHRM applications, application services, and
supporting EHRM data.
Task Order 4 - Data Migration and Enterprise Interface
Development: Cerner will provide data migration planning refinement,
analysis, development, testing, and execution. Cerner will support
enterprise interface planning refinement, design, development, testing,
and deployment. Cerner will provide a commercially available registry
selected by VA for IOC as well as details and updates on the progress
of IOC data migration and enterprise interface development.
Task Order 5 - Functional Baseline Design and
Development: Cerner will provide project management, workflow,
training, change management, and EHRM stakeholder communication.
Task Order 6 - IOC Deployment: Cerner will provide
project management; IOC planning and deployment; test and evaluation;
pre-deployment training; go-live readiness assessment, deployment, and
release; go-live event; post-production health check and deployment
completion; post-deployment support; and continued deployment decision
support.
Task Order 7 - Technical Baseline: Cerner will provide
project management; adherence to enterprise technical plans and
strategies; technical training plans and materials; technical and
functional analysis; system integration; Health Information Exchange/
Veteran Health Information Exchange modification; forward-deployed
hardware; VA-specific functionality integration; and additional
technical support.
Task Order 8 - Additional Interface Development for IOC:
Cerner will provide additional interface development, testing, and
execution in support of interfaces required for VA's IOC sites. These
tasks include interface development, integration, testing, deployment,
sustainment, and maintaining the EHR Master System Integration list.
Current State Review
In July 2018, VA and Cerner conducted a Current State Review at
VA's IOC sites to gain an understanding of the sites' specific as-is
state, and how it aligns with the Cerner commercial standards to
implement the proposed to-be state. The team conducted organizational
reviews around people, processes, and technology. They observed and
captured current state workflows; identified areas that will affect
value achievement and present risk to the project; identified benefits
from software being deployed; and identified any scope items that need
to be addressed.
VA reviewed final reports analyzing the Current State Review in
October 2018 and discovered there are infrastructure readiness areas
that are in better condition than initially forecasted and areas that
require slightly more investment due to aging infrastructure. However,
there were no unexpected major needs or significant deviations from the
current projected spend plan.
Model Validation Event
In September 2018, VA held its Model Validation Event, where VA's
EHR Council met with Cerner to begin the national and local workflow
development process for VA's new EHR solution. There was a series of
working sessions designed to examine Cerner's commercial recommended
workflows and evaluate the current workflows used at VAMCs. This allows
VA to configure the workflows to best meet the needs of our Veterans,
while also implementing commercial best practices.
Because of Model Validation, VA planned eight national workshops to
educate diverse clinical end-users and validate workflows to ensure
VA's new EHR solution meets the Department's needs. During the events,
VA collaborates with front-line clinicians across VA's enterprise to
validate workflows ensuring VA's new EHR solution meets the
Department's needs. To date, VA has completed five national Workshops.
The remaining workshops are scheduled to occur throughout the rest of
this fiscal year.
Cerner Baseline Review
VA is committed to aligning its workflows closely with commercial
best practices. As such, VA commissioned Cerner to complete a baseline
assessment of how closely DoD's Military Health System GENESIS aligns
with these practices. In September 2018, Cerner presented the results
of the assessment. VA learned that DoD has a high adoption of
recommendations and system configuration, which are generally in
alignment with commercial best practices.
Organizational Structure and Strategic Alignment with DoD
On June 25, 2018, VA established OEHRM to ensure that we
successfully prepare for, deploy, and maintain the new EHR solution and
the health information technology (IT) tools dependent upon it. OEHRM
reports directly to VA Deputy Secretary and works in close coordination
with the Veterans Health Administration and Office of Information
Technology.
I currently serve as the program's Executive Director and have
supported this effort at a leadership-level since its inception. Prior
to joining VA, I served as the Program Manager for the Defense Health
Management Systems Modernization, the organization which competitively
and successfully acquired the Cerner EHR solution on behalf of DoD.
To ensure appropriate VA and DoD coordination, we emphasize
transparency within and across VA through integrated governance and
open decision-making. The OEHRM governance structure has been
established and is operational, consisting of technical and functional
boards that will work to mitigate any potential risks to the EHRM
program. The structure and process of the boards are designed to
facilitate efficient and effective decision-making and the adjudication
of risks to facilitate rapid implementation of recommended changes.
At an inter-agency level, the Departments are committed to
instituting an optimal organizational design that prioritizes
accountability and effectiveness, while continuing to advance unity,
synergy, and efficiencies between VA and DoD. The Departments have
instituted an inter-agency working group, facilitated by the
Interagency Program Office, to review use-cases and collaborate on best
practices for business, functional, and IT workflows, with an emphasis
on ensuring that interoperability objectives are achieved between the
two agencies. VA's and DoD's leadership meet regularly to verify the
working group's strategy and course correct when necessary. By learning
from DoD, VA will be able to address challenges proactively and reduce
potential risks at VA's IOC sites. As challenges arise throughout the
deployment, VA will mitigate adverse effects to Veterans' health care.
Federal Electronic Health Record Modernization
DoD and VA are developing a Federal Electronic Health Record
Modernization (FEHRM) joint governance strategy to further promote
rapid and agile decision-making. This structure will maximize DoD and
VA resources, minimize EHR deployment and change management risks, and
promote interoperability through coordinated clinical and business
workflows, data management, and technology solutions while ensuring
patient safety. The FEHRM program office will be responsible for
effectively adjudicating functional, technical, and programmatic
decisions in support of DoD and VA's integrated EHR solutions. DoD and
VA will jointly present the final construct of the plan to Congress,
including our implementation, phase execution, and leadership plans.
Implementation Planning and Strategy
It will take OEHRM several years to fully implement VA's new EHR
solution and the program will continue to evolve as technological
advances are made. The new EHR solution will be designed to accommodate
various aspects of health care delivery that are unique to Veterans and
VA, while bringing industry best practices to improve VA care for
Veterans. Most medical centers should not expect immediate major
changes to their EHR systems.
VA's approach involves deploying the EHR solution at IOC sites to
identify challenges and correct them. With this IOC site approach, VA
will hone governance, identify efficient strategies, and reduce risk to
the portfolio by solidifying workflows and detecting course correction
opportunities prior to the deployment at additional sites. As
mentioned, VA and Cerner have conducted Current-State Reviews for VA's
IOC sites. These site assessments include a current-state technical and
clinical operations review and the validation of the facility
capabilities list. VA started the go-live clock for the IOC sites, as
planned, on October 1, 2018.
Further, VA is continuing to work proactively with DoD and experts
from the private sector to reduce potential risks during the deployment
of VA's new EHR by leveraging DoD's lessons learned from its IOC sites.
Most recently, on May 29, 2019, VA held an Industry Day with over 750
registered industry executives and leaders. OEHRM presented a status
update on the program. Cerner and Booz Allen Hamilton joined OEHRM to
inform eligible vendors on ways to potentially provide contracting and
subcontracting support to the EHRM effort.
VA is leveraging several efficiencies including revised contract
language to improve trouble ticket resolution based on DoD challenges;
optimal VA EHRM governance structure; fully resourced program
management office with highly qualified clinical and technical
oversight expertise; effective change management strategy; and using
Cerner Corporation as a developer and integrator consistent with
commercial best practices.
During the multi-year transition effort, VA will continue to use
Veterans Information System and Technology Architecture and related
clinical systems until all legacy VA EHR modules are replaced by the
Cerner solution. For the purposes of ensuring uninterrupted health care
delivery, existing systems will run concurrently with the deployment of
Cerner's platform while we transition each facility. During the
transition, VA will ensure a seamless transition of care. A continued
investment in legacy VA EHR systems will ensure patient safety,
security, and a working functional system for all VA health care
professionals.
Change Management and Workflow Councils
Because the program's success will rely heavily on effective user-
adoption, VA is deploying a comprehensive change management strategy to
support the transformation to VA's new EHR solution. The strategy
includes providing the necessary training to end-users: VAMC
leadership, managers, supervisors, and clinicians. In addition, there
will be on-going communications regarding deployment schedule and
anticipated changes to end-user's day-to-day activities and processes.
VA will also work with affected stakeholders to identify and resolve
any outstanding employee resistance and any additional reinforcement
that is needed.
VA has established 18 EHR Councils (EHRC) to support the
development of national standardized clinical and business workflows
for VA's new EHR solution. The Councils represent each of the
functional areas of the EHR solution, including behavioral health,
pharmacy, ambulatory, dentistry, and business operations. VA
understands that to meet the program's goals we must engage frontline
staff and clinicians. Therefore, the composition of the EHRCs will
continue to be about 60 percent clinicians from the field who provide
care for Veterans, and 40 percent from VA Central Office. As VA
implements its new EHR solution across the enterprise, certain Council
memberships will evolve to align with contemporaneous implementation
locations. While deploying in a particular VISN, the needs of Veterans
and clinicians in that particular VISN will be incorporated into
national workflows.
Funding
With the support of Congress, OEHRM has not experienced funding
shortfalls that would impact the success of the EHRM initiative.
Additionally, OEHRM appreciates Congress for providing the program with
three-year funding availability. This flexibility in funding execution
is critical, as it allows OEHRM to fund key operations on a timeline
that aligns with a successful implementation.
OEHRM's enacted fiscal year (FY) 2019 budget has allowed the
program to continue the preparation of VA's EHR solution at VA's three
IOC sites. VA's FY 2020 budget request of $1.6 billion would provide
the necessary resources for the post Go-Live activities of the IOC
sites, the in-process deployment of seven sites, 18 new site
assessments, and 12 site transitions scheduled to begin in 2020.
OEHRM reviews its lifecycle cost estimate at least once per month
to reflect actual execution and to fulfill its programmatic oversight
responsibilities. OEHRM will continue to provide Congress with regular
updates to ensure that the program is fully funded and to support our
commitment to transparency.
Conclusion
Again, the EHRM effort will enable VA to provide the high-quality
care and benefits that our Nation's Veterans deserve. VA will continue
to keep Congress informed of milestones as they occur. Madam Chair,
Ranking Member, and Members of the Subcommittee, thank you for the
opportunity to testify before the Subcommittee today to discuss one of
VA's top priorities. I am happy to respond to any questions that you
may have.
Prepared Statement of William J. Tinston
Chairwoman Lee, Ranking Member Banks, and distinguished members of
the Subcommittee, it is an honor to testify before you today. We
represent the Department of Defense (DoD) as the Program Executive
Officer and the Military Health System (MHS) Electronic Health Record
(EHR) System Functional Champion responsible for modernizing the
military's EHR and developing one EHR with the Department of Veterans
Affairs (VA), which is also interoperable with private sector
providers.
The mission of the Program Executive Office, Defense Healthcare
Management Systems (PEO DHMS) is to transform the delivery of health
care and advance data sharing through a modernized EHR for
servicemembers, retirees, and their families. As the information
technology acquisition provider and part of the Defense Health Agency,
we support the Quadruple Aim: improved readiness, better health, better
care, and lower cost; specifically committing to three equally
important objectives: deploy a single, common inpatient and outpatient
EHR, eliminating the need for interoperability with the VA; improve
data sharing with our private sector health care partners; and
successfully transform the delivery of health care in the MHS through
advanced tools that provide beneficiaries more control over their
health care.
In July 2015, the DoD competitively awarded a contract to the
Leidos Partnership for Defense Health (LPDH) to deliver a modern,
interoperable EHR capable of complying with DoD's high cyber security
standards without compromising performance and designed to share data
with our Federal and private sector partners regardless of their
operational platform. This modern, secure, connected EHR, MHS GENESIS,
provides a state of the market commercial off the shelf solution
consisting, at its core, of Cerner Millennium, an industry-leading EHR,
and Henry Schein's Dentrix Enterprise, a best of breed dental module.
Delivering a capability of this magnitude is a monumental challenge
and the DoD recognizes this. The deployment and implementation of MHS
GENESIS is a complex business transformation that requires extensive
coordination and communication with stakeholders and partners.
Understanding the importance, the DoD worked directly with the
functional and technical communities to capture requirements and
standardize workflows, minimizing variation and increasing the
capabilities available via an enterprise system.
MHS GENESIS deployed to its pilot sites in 2017, beginning with
Fairchild Air Force Base in February. Naval Hospital Bremerton and
Naval Health Clinic Oak Harbor followed in the summer and our pilot
officially concluded in January 2018 at Madigan Army Medical Center.
These four pilot sites continue to use MHS GENESIS today and are safely
delivering, managing, and documenting health care daily - completing
more than 100,000 patient encounters each month.
Lessons Learned
Deploying to the pilot sites provided an opportunity to observe the
system and capture user feedback, the intended purpose of a pilot. No
system is flawless, and deploying to a small clinic, progressing to a
larger hospital allowed us to assess system performance at various
levels of capability.
In January 2018, PEO DHMS, along with the Defense Health Agency,
implemented an eight week stabilization and adoption period to optimize
MHS GENESIS, with a specific focus on improving network stability and
medical device interfaces, governance, training, change management, and
adoption of workflows.
As with any transition, leadership is key. Ensuring the right
people are in place to make decisions significantly impacts a
successful site deployment. Understanding this, DHA established a
clear, agile, and accountable management structure to provide guidance
and policy for effective enterprise decisions. Further, DHA implemented
processes to ensure network stabilization and medical device
configuration prior to MHS GENESIS Go-Live.
To address the change management and training challenges, we
implemented three fundamental adjustments to the MHS GENESIS training
strategy: functionally led workflow adoption; role based training
configuration; and implementation of a peer expert training program.
Going forward, MHS GENESIS will deploy using a Wave approach. This
deployment strategy allows optimal use of lessons learned to enhance
our efforts as we proceed through enterprise- wide deployment.
Progress and Patient Safety Enhancements
Statistics revealed significant progress in 2018, ultimately
improving patient care. For example, we avoided nearly 2,500 duplicate
lab orders. Further, through new and effective decision support tools,
MHS GENESIS equips our clinicians with the right tools and resources to
evaluate a patient's status and quickly determine the best solution.
Recently at Madigan Army Medical Center, the MHS GENESIS inpatient
nursing management module alerted the staff to an emergent patient
situation. The nurses responded to the patient's bedside, identified
the distressed patient, and activated the rapid response team. The
patient immediately transferred to the cardiac catheterization lab and
received a life-saving procedure. This example illustrates the new
record's improved capabilities over our legacy systems. There are
markedly improved tools within MHS GENESIS to monitor care and measure
improvement as well as monitor care to the individual provider. For
instance, we can monitor the time a provider spends documenting care
outside of duty hours (current less than 3% of the time). This allows
us to identify providers experiencing challenges and focus our training
efforts in this area. Further, with our VA partners, we are now
connected to a wide range of commercial partners across the globe, who
are collectively dedicated to improving care and interoperability
within the DoD, VA, and the nation.
Joint Engagement
The VA's decision to implement the same EHR as the DoD and the
United States Coast Guard (USCG) will result in a single, common record
enabling more efficient, highly reliable, safe, and quality care,
ultimately protecting our most important asset - our people. The DoD
does not take this lightly, and understands this decision comes with
the practicality of implementation. A single, common record requires
extensive collaboration and joint decision making to ensure efficient
workflows and standardized processes.
Federal Electronic Health Record Modernization Working Group
On September 28, 2018, the Secretaries of Defense and Veterans
Affairs signed a Joint Commitment Statement pledging to align VA and
DoD strategies to implement an interoperable EHR system. In response to
this commitment, the DoD and VA evaluated program dependencies such as
infrastructure, incorporation of clinical and business processes, and
other requirements from the functional, technical, and programmatic
communities. DoD and VA leadership determined the optimal and lowest
risk alternative is to re-charter the DoD/VA IPO into the Federal
Electronic Health Record Modernization (FEHRM) Program Office. The
FEHRM, which will incorporate key members of the IPO as well as DoD and
VA program office staff, will provide a more comprehensive, agile, and
coordinated management authority to execute requirements necessary for
a single, seamless integrated EHR.
Another example, of the DoD and VA currently collaborating and
sharing best practices via joint workshops which focus on system
standardization and configuration versus customization.
Specifically, the clinical nursing workshop recently completed an
extensive process optimization review, identifying and agreeing to more
than 2,300 workflow process optimizations, reducing nurse charting by
70%. This significant time savings provides more time for our priority
- the patient. A DoD clinical nurse at one of our pilot sites
highlights the improvements provided via MHS GENESIS and our commitment
to collaboration with the VA in the quote below.
``Modernization of the DoD Electronic Health Record was a
necessity. MHS GENESIS became our opportunity. It shined a light onto
the Military Health System, illuminating the best practices throughout
the MHS and identifying areas in need of improvement. It caused us to
breakdown not only the barriers between services and the barriers
between the DoD and the VA, but also the barriers between all
specialists within a hospital's or clinic's care continuum. Never
before have I seen nurses, physicians, surgeons, and transfusion
technicians sit side-by-side and collaborate as intensely as I witness
daily with MHS GENESIS. Every day, multi-disciplinary teams work across
the pilot sites and the country to bring timely, relevant, evidenced-
based practice to MHS GENESIS. This is more than an Electronic Health
Record; it is a collaborative health record serving our nation's
Service Members, Veterans, and beneficiaries. There is much work to be
done to deploy and optimize MHS GENESIS, but it has been a great leap
forward in support of the health care of this deserving population.''
Joint Solutions
Cybersecurity, the foundation of a joint solution, demands
practical implementation. The DoD sets the standard for cybersecurity,
and we invested significant time and resources to satisfy those
requirements. By co-locating personnel at one commercial DoD/VA data
center, our people assist with continuous cyber monitoring and are
engaged in maintaining cyber integrity. Further, this strengthens the
collaborative Federal and commercial relationship, encouraging the VA
to leverage these capabilities and actively participate in critical
activities to uphold the DoD cybersecurity standards. The continuous
collaborative cyber work will not only benefit DoD and VA users, but it
will contribute to the development of national standards, raising the
bar for protecting the patient health information.
Further, the DoD and VA established workgroups which consists of
cross-organizational representatives who resolve technical challenges
and establish new processes to identify enterprise solutions and
opportunities for both Departments to leverage. They work together to
minimize the impact to both Department's schedules and ensure the most
efficient use of program resources. For example, the DoD agreed to
accept a Cerner software upgrade only a few weeks following its Wave 1
Go-Live to ensure VA fields its desired baseline solution to meet its
scheduled Initial Operational Capability Go-Live in March of 2020. The
timing of the upgrade adds complexity and risks to DoD's Wave 1, but it
is the right decision for the DoD and VA's successful implementation.
Patient Centered Delivery
Patient centered delivery relies on the continued advancement of
system capabilities, while maintaining system integrity and patient
data throughout the life of the patient. To support this effort, the
DoD and VA agreed to the joint execution of HealtheIntent, a data
warehouse and analytics platform which captures all patient data and
migrates it into a single, common record that stays with the patient
throughout their lifetime. Once executed, the Departments agreed to
numerous decisions, including a joint URL which required collaborative
decision making.
Continuous delivery demands established processes to address system
enhancements and maintain the integrity of the system baseline and the
hosting environment. Recognizing the significance, the DoD and VA
established a joint decision making process to evaluate any request
that would modify the technology solution, ensuring the practical
implementation of an enterprise solution.
Conclusion
MHS GENESIS is on track for full deployment by the end of calendar
year 2023. In December 2018, the DoD EHR Defense Acquisition Board met,
and the Assistant Secretary of Defense for Acquisition affirmed MHS
GENESIS met the criteria for approved deployment to Waves 1-6 beginning
with Wave 1 in September 2019. The DoD and VA remain committed to
continued communication and collaboration to ensure the successful
implementation of a single, common record throughout the MHS, the USCG,
and the VA.
Prepared Statement of Dr. Lauren Thompson
Chairwoman Lee, Ranking Member Banks, and distinguished members of
the subcommittee, thank you for the opportunity to testify before you
today. As the Director of the Department of Defense/Department of
Veterans Affairs Interagency Program Office (IPO), I am honored to be
here today. The mission of the DoD/VA IPO is to advance data
interoperability across DoD, VA, and other partner systems. Providing
high-quality health care to service members, veterans, and their
families is one of the IPO's highest priorities, and health data
interoperability is essential to improving the care delivered. A key
component meeting the unique needs of our beneficiaries and ensuring
they receive the best care possible, is making certain that no matter
their status, location, or provider, their health data is readily
available and accurate, or in other words ensuring health data
interoperability-the ability of two or more systems or components to
exchange information and to use the information that has been exchanged
in a meaningful way.
The DoD and VA represent two of our nation's largest health care
systems. Together, the Departments represent over 30 million eligible
beneficiaries including service members, veterans, and their families.
A significant amount of their care is provided via the private sector,
providing more than 60 percent of DoD care and 30 percent for the VA.
Currently, the Departments share more than 1.5 million data elements
daily, and more than 430,000 DoD and VA clinicians are able to view the
real-time records of the more than 16 million patients who receive care
from both Departments.
The Fiscal Year 2008 National Defense Authorization Act (NDAA)
directed the DoD and VA to develop and implement electronic health
record (EHR) systems or capabilities that allow for full
interoperability of personal health care information between the DoD
and VA, instructing the establishment of the IPO to guide both
Departments in their efforts. In January 2009, the IPO completed its
first charter, sharing its mission and functions with respect to
attaining interoperable electronic health data. In March 2011, both
Secretaries of Defense and VA instructed the Departments to develop a
single, jointly integrated EHR. In 2013, the Departments decided to
pursue modernization of their respective EHR systems instead. In
December 2013, the IPO was re-chartered to lead the efforts of the DoD
and VA to implement national health data standards for interoperability
and to establish, monitor, and approve clinical and technical standards
for the integration of health data between both Departments and the
private sector.
INTEROPERABILITY AND DATA SHARING
The IPO's goal is to support interoperability of clinically
relevant health data in accordance with the FY 2014 NDAA, and in
compliance with The Office of the National Coordinator for Health IT's
(ONC) guidance on standards and interoperability for clinical records.
Specifically, the IPO is chartered to jointly oversee and monitor the
efforts of the DoD and VA in implementing national health data
standards and act as the point of accountability for identifying,
monitoring, and approving the clinical and technical data standards and
profiles to ensure seamless integration of clinically relevant health
data between the Departments and private sector providers who treat DoD
and VA beneficiaries.
In April 2016, the Departments, with the IPO's assistance, met a
requirement of the Fiscal Year 2014 NDAA, certifying to Congress that
their systems are interoperable with an integrated display of data
through the Joint Legacy Viewer, or JLV. JLV integrates data from the
clinical data repositories of both Departments, as well as data on
beneficiary encounters with private providers who participate in
national health information exchange networks. The Departments also
share documents and images with each other and private providers
through DoD and VA data exchange and access services. The IPO monitors
the usage of JLV and other interoperability metrics across the
Departments to track progress on health data exchange and
interoperability.
The IPO also serves a convening function, facilitating functional
and technical discussions across the Departments and interoperability
information exchange forums with industry. As executive secretary to
the DoD/VA Interagency IT Steering Committee, a joint CIO-led body, the
IPO works to ensure DoD and VA's technical alignment, planning, and
implementation oversight of technical infrastructure and enterprise
solutions meet the business needs of joint activities.
The IPO collaborates extensively with ONC, other government
agencies, and standards development organizations to advance the state
of interoperability across the health industry. IPO staff participate
in ONC work groups, and IPO and ONC leaders meet regularly to discuss
current interoperability initiatives and future collaboration
opportunities to support national interoperability efforts.
FEDERAL ELECTRONIC HEALTH RECORD MODERNIZATION PROGRAM OFFICE
In 2018, Secretaries Wilkie and Mattis issued a Joint Commitment
Statement pledging to align strategies to implement an integrated EHR
system. DoD and VA leaders chartered the Joint Electronic Health Record
Modernization Working Group, referred to as the JEHRM, to develop
recommendations for an optimal organizational construct that would
enable an agile, single decision-making authority to efficiently
adjudicate functional, technical, and programmatic interoperability
issues while advancing unity, synergy, and efficiencies.
On March 1, 2019, the joint VA/DoD Executive Leadership Group
approved a course of action, plan of action and milestones, and
implementation plan to establish the Federal Electronic Health Record
Modernization Program Office, or the FEHRM, in a phased manner in order
to minimize risk. Leveraging the existing 2008 and 2014 NDAA Statute,
the IPO will be re-chartered into the FEHRM and will provide a
comprehensive, agile, and coordinated management authority to execute
requirements necessary for a single, seamless integrated EHR and will
serve as a single point of authority for Department's EHR modernization
program decisions. FEHRM leaders will have the authority to direct each
Department to execute joint decisions for technical, programmatic, and
functional functions under its purview and will provide oversight
regarding required funding and policy as necessary. This management
model creates a centralized structure for interagency decisions related
to EHR modernization, accountable to both the VA and the DoD Deputy
Secretaries.
An interim FEHRM Director and Deputy Director will be appointed to
work with the implementation team in transitioning joint functions into
the FEHRM once the FEHRM has an approved charter. The interim leaders
will manage and execute joint technical, programmatic, and functional
requirements and synchronize strategies between the two Department EHR
program offices to ensure the single, seamlessly integrated EHR is
implemented with minimal risks to cost, performance, and schedule. The
interim leaders will remain in these roles until the permanent FEHRM
Director and FEHRM Deputy Director are appointed.
The permanent Director and the Deputy Director will report to the
Deputy Secretary of Defense and Deputy Secretary of Veterans Affairs.
CONCLUSION
The IPO will continue to support the Departments in implementing a
single EHR system to ensure a seamless patient-centric health care
experience that will ultimately lead to improved care for our service
members, veterans, and their families.
Enhancing interoperability with private providers who provide care
to DoD and VA beneficiaries will be of the utmost importance during
this process to ensure the availability of a complete and comprehensive
longitudinal health record.
We will continue our collaboration with ONC and industry partners
to ensure the DoD and VA are employing the most current industry
standards, and our industry partners are able to learn from our
experiences.
Thank you for the opportunity to speak with you today. I look
forward to your questions.
[all]