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25–363 PDF 2018

S. HRG. 114–737 

EXAMINING THE PROGRESS AND CHALLENGES IN 

MODERNIZING INFORMATION TECHNOLOGY AT 

THE U.S. DEPARTMENT OF VETERANS AFFAIRS 

HEARING 

BEFORE THE

COMMITTEE ON VETERANS’ AFFAIRS 

UNITED STATES SENATE 

ONE HUNDRED FOURTEENTH CONGRESS 

SECOND SESSION 

JUNE 22, 2016 

Printed for the use of the Committee on Veterans’ Affairs 

( 

Available via the World Wide Web: http://www.fdsys.gov 

(II) 

COMMITTEE ON VETERANS’ AFFAIRS 

JOHNNY ISAKSON, Georgia, Chairman 

JERRY MORAN, Kansas 

JOHN BOOZMAN, Arkansas 

DEAN HELLER, Nevada 

BILL CASSIDY, Louisiana 

MIKE ROUNDS, South Dakota 

THOM TILLIS, North Carolina 

DAN SULLIVAN, Alaska 

RICHARD BLUMENTHAL, Connecticut, Ranking 

Member 

PATTY MURRAY, Washington 

BERNARD SANDERS, (I) Vermont 

SHERROD BROWN, Ohio 

JON TESTER, Montana 

MAZIE K. HIRONO, Hawaii 

JOE MANCHIN III, West Virginia 

TOM BOWMAN, Staff Director 

JOHN KRUSE, Democratic Staff Director 

(III) 

C O N T E N T S 

JUNE 22, 2016 

SENATORS 

Page 

Isakson, Hon. Johnny, Chairman, U.S. Senator from Georgia ............................ 1 

Blumenthal, Hon. Richard, Ranking Member, U.S. Senator from Connecticut ... 4 

Rounds, Hon. Mike, U.S. Senator from South Dakota ......................................... 37 

Hirono, Hon. Mazie K., U.S. Senator from Hawaii ............................................... 39 

Boozman, Hon. John, U.S. Senator from Arkansas .............................................. 41 

Tester, Hon. Jon, U.S. Senator from Montana ...................................................... 43 

Tillis, Hon. Thom, U.S. Senator from North Carolina .......................................... 46 

Murray, Hon. Patty, U.S. Senator from Washington ........................................... 48 

Sullivan, Hon. Dan, U.S. Senator from Alaska ..................................................... 50 

WITNESSES 

Shulkin, Hon. David J., M.D., Under Secretary of Health, U.S. Department 

of Veterans Affairs; accompanied by LaVerne Council, Assistant Secretary 

for Information Technology; Laura Eskenazi, Executive in Charge and Vice 

Chairman, Board of Veterans’ Appeals; and Ron Burke, Assistant Deputy 

Under Secretary for Field Operations, Veterans Benefits Administration ..... 5 

Prepared statement .......................................................................................... 6 

Response to prehearing request submitted by Hon. Johnny Isakson .......... 2 

Response to posthearing questions submitted by: 

Hon. Richard Blumenthal ............................................................................ 53 

Hon. Jerry Moran ......................................................................................... 55 

Hon. John Boozman ...................................................................................... 56 

Melvin, Valerie, Director of Information Management and Technology Resources Issues, U.S. Government Accountability Office ................................... 13 

Prepared statement .......................................................................................... 15 

(1) 

EXAMINING THE PROGRESS AND CHALLENGES IN MODERNIZING INFORMATION 

TECHNOLOGY AT THE U.S. DEPARTMENT OF 

VETERANS AFFAIRS 

WEDNESDAY, JUNE 22, 2016 

U.S. SENATE, 

COMMITTEE ON VETERANS’ AFFAIRS, 

Washington, DC. 

The Committee met, pursuant to notice, at 2:38 p.m., in room 

418, Russell Senate Office Building, Hon. Johnny Isakson, Chairman of the Committee, presiding. 

Present: Senators Isakson, Boozman, Cassidy, Rounds, Tillis, 

Sullivan, Blumenthal, Murray, Brown, Tester, and Hirono. 

OPENING STATEMENT OF HON. JOHNNY ISAKSON, CHAIRMAN, 

U.S. SENATOR FROM GEORGIA 

Chairman ISAKSON. I call this meeting of the Senate Veterans’ 

Affairs Committee to order. 

Welcome, Dr. Shulkin and Ms. Melvin, for being here today. We 

look forward to your testimony. 

I will make a short opening statement and then refer to Ranking 

Member Blumenthal to make his. Then, we will go straight to your 

testimony and hopefully robust questions afterward. 

I would at the outset, with the permission of Dr. Shulkin, ask 

unanimous consent that the letter from Dr. Shulkin to me dated 

today be entered in the record, which is a good response that I appreciate very much, to this hearing. 

[The letter from Dr. Shulkin follows:] 

2 


622SHUltr1.eps
3 

Chairman ISAKSON. We welcome both of you and thank you for 

being here. As you well know, because you are both relative newcomers to the Veterans Administration in Washington—in fact, I 

remember when Senator Blumenthal and I were a part of your confirmation and your rapid ascent to positions of authority, which are 

to large credit to Bob McDonald. I want to make a side comment 

if I can right here, that the Veterans Administration (VA) has gotten a lot of criticism and they have earned a lot of it. Yet there 

have been a lot of things that have happened in the VA, which 

have been difficult to do that other people could not do that Bob 

McDonald has done. One of them was, in terms of physicians and 

medical information technology (IT), bringing two of the best leaders we have in the U.S. Government in Ms. Council and Dr. 

Shulkin for the work that they are doing. 

I think we will hear from the testimony the results of some of 

that work and how it is paying off, getting them moving in the 

right direction toward getting off of the High-Risk List. It is not 

easy to get on it, but once you get on it, it is hard to get off of it, 

and getting off of it takes a lot of concentration. This is one of the 


622SHUltr2.eps
4 

reasons we are having a benchmark hearing today, because I do 

not like to let reports sit on my desk, have a hearing, talk about 

them, and then never talk about them again. I like to come back 

a few months later and say, what kind of progress are we making, 

and I think that you both have done a great job in providing leadership to the VA and I know your testimony today will reveal a lot 

of the changes you have made to address the shortcomings that put 

the VA on the High-Risk List to start with. 

With that said, I would be happy to call on the Ranking Member, 

Senator Blumenthal from Kentucky—Connecticut. I do not know 

why I want to say Kentucky. 

Senator BLUMENTHAL. I will take Kentucky. [Laughter.] 

OPENING STATEMENT OF HON. RICHARD BLUMENTHAL, 

RANKING MEMBER, U.S. SENATOR FROM CONNECTICUT 

Senator BLUMENTHAL. Thank you very much to the panel for 

being here, most especially thank you to the Chairman for calling 

this hearing and for enabling us to hear directly from the VA leadership about an issue that has bedeviled the VA and, to some extent, the Department of Defense (DOD), for as long as I have been 

in the U.S. Senate, which is now close to 6 years. Every time we 

have raised the issue, we have been assured that it has been 

solved, and then we come back and ask the same question. 

The decades of unsuccessful attempts to establish an electronic 

health record system compatible across the VA and the DOD have 

caused hundreds of millions of taxpayer dollars to be wasted in efforts that have been abandoned. As I have said to Secretaries of 

both the VA and the DOD in a letter I sent earlier in Congress, 

these kinds of integrated, up-to-date electronic health care records 

are absolutely critical to ensure that health care providers have access to the health information they need to care for veterans and 

transitioning servicemembers, and the cost to VA has been very 

high, both in terms of budget and its credibility and reputation. 

As the VA undertakes efforts to transform its IT infrastructure, 

security has to be a top priority. Security breaches have to be prevented and remedied, because this information is sensitive and personal. I am hopeful that the new leadership that has taken over 

at the VA—and I join the Chairman in commending the Secretary 

for bringing into the VA that new leadership—will address these 

problems with the seriousness they deserve. 

So, I thank you very much for being here today. 

Chairman ISAKSON. We have two witnesses today: first is Dr. 

David Shulkin, and we are glad to have Dr. Shulkin join us today 

from the Veterans Administration; and second is Ms. Valerie Melvin from the Government Accountability Office. We are glad to 

have you here today. We look forward to hearing from both of you. 

I will recognize Dr. Shulkin first for up to 5 minutes. 

5 

STATEMENT OF HON. DAVID SHULKIN, M.D., UNDER SECRETARY OF HEALTH, U.S. DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY HON. LaVERNE COUNCIL, ASSISTANT SECRETARY FOR INFORMATION TECHNOLOGY; LAURA 

ESKENAZI, EXECUTIVE IN CHARGE AND VICE CHAIRMAN, 

BOARD OF VETERANS’ APPEALS; AND RON BURKE, ASSISTANT DEPUTY UNDER SECRETARY FOR FIELD OPERATIONS, 

VETERANS BENEFITS ADMINISTRATION 

Dr. SHULKIN. Great. Thank you, Chairman Isakson, Ranking 

Member Blumenthal, Senator Brown, Senator Rounds. Thank you 

for having us here today. 

I am pleased to be with here today, to my left, Assistant Secretary for Information Technology, Hon. LaVerne Council, and to 

my right, the Executive in Charge and Vice Chairman of the Board 

of Veterans’ Appeals, Ms. Laura Eskenazi, and to her right, the Assistant Deputy Under Secretary for Field Operations for the Veterans Benefits Administration, Mr. Ron Burke. 

I do know that the specific focus of today’s hearing is on the modernization of information technology and that is really what we 

want to talk to you about. Yet, I do want to start by acknowledging 

the recent letter that I did get, Chairman Isakson, from you and 

many Members of the Senate Committee on Veterans’ Affairs dated 

June 14, where you shared your concerns over access and quality 

and the pace at which we are making advances in Veterans Health 

Administration, VHA. I just wanted to let you know, I share your 

impatience, but I also want to let you all know that we really are 

making progress and we are making real progress. So, I want to 

address this just for a second and then get back to IT. 

As you know, our top priority has been access and fixing the access crisis. Through extended hours, through productivity, through 

hiring, new leases, our stand-downs, we have added 7.4 million 

hours of additional clinical time this past year. Our focus is on 

those veterans that need clinically prioritized care, and we have 

seen an 88 percent reduction in urgent consults since November of 

last year. Forty-six percent of our urgent appointments are done in 

the same day. We have seen a 20 percent reduction just since February in our most timely needed appointments for veterans. So, we 

are making real progress. 

Our veteran satisfaction data, where we ask veterans, show 90 

percent of our veterans using VA are satisfied or completely satisfied with their ability to get an appointment when they want it. 

And, as you know, we are making real progress with same day 

services for primary care and mental health. By the end of this 

year, we will have that in every medical center. So, we are working 

hard on that. 

In community care, the Choice program, in March 2014, we had 

370,000 authorizations. That is more than double what we had a 

year ago. That is going to lead to two million appointments just in 

March alone. So, we really are making progress there also. 

I do really want to thank all of you for your support and leadership in Veterans First Act. That is so important, and I know we 

have your support. That is going to make the community care systems work much better for veterans, because we know it is still 

confusing and we want to make it work better than it is right now. 

6 

In terms of quality, 74 percent of our medical centers improved 

quality last year in our Strategic Analytics for Improvement and 

Learning (SAIL) metrics, our very comprehensive analytic system. 

We saw a 35 percent reduction in mortality in our hospitals last 

year. We had a 52 percent reduction in urinary tract infections, an 

18 percent reduction in central line infections, and a 17 percent reduction in length of stay. It is not only our data. Recent peer reviewed studies have shown VA health care’s quality is better than 

the private sector in cardiac and in mental health in just two of 

the peer reviewed publications. 

Since launching our Diffusion of Excellence program, our best 

practices, we now have 160 best practices—we had talked to you 

about this, Senator Brown—being replicated in over 70 medical 

centers. An effort like that had never been going on before at VA. 

I had mentioned to you I had 35 medical centers without a medical center director just a few months ago, the last time I was before you. We have recently selected 28 medical center directors. So, 

that is going to leave seven for us to continue. So, we are not done, 

but we are really making progress in filling the leadership positions. I recognize all of you know how important that is. 

So, this is not to say that we should be patted on the back, but 

this is to say the progress is real. We have a lot to do. I am impatient. We are going to continue at it. But, there really is real 

progress being made. 

Now, on IT, under Ms. Council’s leadership, we are building on 

the legacy on VHA innovation in information technology, and there 

has never been a better working relationship between technologists 

and clinicians than there is right now. We are on track to close 100 

percent of the Inspector General’s IT recommendations by the end 

of 2017. 

In July 2015, we had 267,000 accounts with elevated privileges. 

That means people who have very open access to VA health care 

information technology. That number has been reduced by 95 percent. Since March 2015, we have identified 21 million critical 

vulnerabilities. That is going to make us safer. 

Ms. Council has developed new policies to ensure that IT dollars 

are being spent appropriately. VA continues to outpace our projections on interoperability, so the Joint Legacy Viewer (JLV) has 

more than 138,000 VA users, and that is more than 4.6 million veteran records are available through the JLV now. Finally, we are 

progressing with a new plan in the digital health platform that is 

going to prepare VA for the future in a way that is pretty exciting. 

So, Mr. Chairman, Senator Rounds, Senator Brown, thank you 

again for this opportunity to discuss these programs with you. Our 

team is here to answer your questions and we look forward to this 

hearing. 

[The prepared statement of Dr. Shulkin follows:] 

PREPARED STATEMENT OF DAVID J. SHULKIN, M.D., UNDERSECRETARY OF HEALTH, 

VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS

Good afternoon, Chairman Isakson, Ranking Member Blumenthal, distinguished 

Members of the Committee, thank you for the opportunity to discuss the progress 

that the Department of Veterans Affairs (VA) is making toward modernizing our information technology (IT) infrastructure to provide the best possible service to our 

7 

VA business partners and our Nation’s Veterans. I will also discuss scheduling, 

medical record sharing, and cyber security initiatives at the Department. 

I am pleased to be accompanied today by Assistant Secretary for Information 

Technology and Chief Information Officer, Ms. LaVerne Council, Ms. Laura 

Eskenazi, Executive in Charge and Vice Chairman, Board of Veterans Appeals, and 

Mr. Ron Burke, Assistant Deputy Under Secretary for Field Operations, Veterans 

Benefits Administration. 

In order to successfully carry out major IT initiatives and the department’s consolidation of community care programs, VA will need a digital health platform and 

IT solutions that will meet the evolving needs of our Veterans, as well as support 

our streamlined business processes. 

The Veterans Health Administration (VHA) and the Office of Information & Technology (OI&T) are essential partners in delivering quality service to our Veterans. 

Meeting the demands of 21st century Veterans requires an interconnected system 

of systems, based on a single platform, which supports an electronic health record 

(EHR) as one of several components. 

IT plays a critical role in enabling care for our Nation’s Veterans. VA’s current 

EHR modernization efforts focus on delivering the tools for clinicians to provide 

more comprehensive, patient-centered care and will support VA’s progress to a digital health platform. 

We have made substantial progress in delivering new capabilities leveraging 

VistA, the VA Health System’s EHR, while also strategizing for our future needs. 

While our efforts to modernize the VA’s EHR and our plans for the digital health 

platform are not mutually exclusive; the success of the digital health platform is not 

dependent on any particular EHR. 

VISTA EVOLUTION/INTEROPERABILITY

Current State of VistA Evolution 

VistA Evolution is the joint VHA and OI&T program for improving the efficiency 

and quality of Veterans’ health care by modernizing VA’s health information systems, increasing data interoperability with the Department of Defense (DOD) and 

network care partners, and reducing the time it takes to deploy new health information management capabilities. We will complete the next iteration of the VistA Evolution Program—VistA 4—in fiscal year (FY) 2018, in accordance with the VistA 

Roadmap and VistA Lifecycle Cost Estimate. VistA 4 will bring improvements in efficiency and interoperability, and will continue VistA’s award-winning legacy of providing a safe, efficient health care platform for providers and Veterans. 

VA takes seriously its responsibility as a steward of taxpayer money. Our investments in VistA Evolution continue to make our Veterans’ EHR system more capable 

and agile. VA has obligated approximately $510 million in IT Development funds 

to build critical capabilities into VistA since FY 2014, when Congress first provided 

specific funding for the VistA Evolution program. In addition, VA has obligated $151 

million in IT Sustainment funds and $110 million in VHA funds for VistA Evolution. The VHA funding supports the operational resources needed for requirements development, functional design, content generation, development, training, 

business process change, and evaluation of health IT systems. 

It is important to note that VistA Evolution funding stretches beyond EHR modernization. VistA Evolution funds have enabled critical investments in systems and 

infrastructure, supporting interoperability, networking and infrastructure 

sustainment, continuation of legacy systems, and efforts—such as clinical terminology standardization—that are critical to the maintenance and deployment of the 

existing and future modernized VistA. This work was critical to maintaining our 

operational capability for VistA. These investments will also deliver value for Veterans and VA providers regardless of whether our path forward is to continue with 

VistA, a shift to a commercial EHR platform as DOD is doing, or some combination 

of both. 

Interoperability 

We know that a Veteran’s complete health history is critical to providing seamless, high-quality integrated care and benefits. Interoperability is the foundation of 

this capability as it enables clinicians to provide Veterans with the most effective 

care and makes relevant clinical data available at the point of care. Access to accurate Veteran information is one of our core responsibilities. The Department is 

happy to report that, thanks to a joint VA and DOD effort, on April 8, 2016, we 

jointly certified, to the House and Senate Committees on Appropriations, Armed 

Services, and Veterans’ Affairs that we have met the interoperability requirement 

of the National Defense Authorization Act for Fiscal Year 2014 (NDAA) Section 

8 

713(b)(1). We have not stopped our modernization efforts, as we envision further enhancements that we know are necessary for greater efficiency. 

For front-line health care teams, the two most exciting products from VistA Evolution are the Joint Legacy Viewer (JLV) and the Enterprise Health Management 

Platform (eHMP). JLV is a clinical application that provides an integrated, chronological display of health data from VA and DOD providers in a common data viewer. 

VA and DOD clinicians can use JLV to access, on demand, the health records of 

Veterans and Active Duty and Reserve Servicemembers. JLV provides a patient-centric, rather than facility-centric view of health records in near real time. Veterans 

Benefits Administration (VBA) offices have access to JLV and can use it to expedite 

claims in certain situations. 

As of June 5, 2016, JLV had more than 170,000 authorized users in VA and DOD 

together, including 109,000 authorized VA users. The team is authorizing several 

thousand new users in VA each week. Of those VA users, more than 10,000 VBA 

personnel are authorized to use JLV to help process claims. 

The process for granting access to JLV is both simple and secure. JLV allows us 

to monitor access and usage by capturing logins, records viewed, activities by users, 

and transactions per hour. In the interest of privacy, security, and safety, JLV is 

restricted to health care providers and benefits administrators. Beneficiaries cannot 

access JLV, but this in no way affects their rights to copies of their health records 

upon request. We simultaneously maintain tight controls over the system and ensure efficient access to clinicians and benefits administrators who need it to do their 

jobs. 

JLV has been a critical step in connecting VA and DOD health systems, but it 

is a read-only application. Building on the interoperability infrastructure supporting 

JLV, the Enterprise Health Management Platform (eHMP) will ultimately replace 

our current read-write point of care application. The current application, called the 

Computerized Patient Record System, or CPRS, has been in use since 1996. CPRS 

served VA for many years as an industry leading point of care tool for providers, 

but it has many limitations for modern care delivery. 

eHMP will overcome these limitations, and provide a modern web application and 

clinical data services platform to support Veteran-centric, team-based, quality driven care. eHMP will also natively support interoperability between VA, DOD and 

community health partners. We are deploying an initial read only version of eHMP 

now, and will begin deploying eHMP version 2.0 with write-back capabilities in the 

second quarter of FY 2017. Clinicians will be able to write notes and order laboratory and radiology tests in version 2.0. eHMP 2.0 will also support tasking for teambased management and communication with improved tracking to ensure follow 

through on tasks. 

Veterans will benefit from eHMP in several ways. For example, eHMP will provide a complete view of a Veteran’s health history from all available VA, DOD and 

community provider sources of information. This will help providers develop a more 

complete picture of a Veteran’s history, enabling better treatment decisions. 

The Veteran’s voice will also be front and center in eHMP. Veterans’ goals and 

preferences for care will become part of the information all providers see. eHMP will 

also provide a feature dedicated to recording and maintaining a Veteran’s service 

history, including duty locations and what type of work they performed during their 

service. This information could then be used to proactively identify Veterans who 

may be at risk for certain health issues, or eligible for medical care based on locations or times in which they served. 

Veterans will also benefit from VA care teams who can work together more efficiently and effectively using the care coordination and task management tools 

eHMP will provide. For example, if a Veteran is referred for a particular test or consultation with a specialist, workflow management tools in eHMP will ensure the 

right activities have taken place in advance of the referral. This will help reduce 

wasted or unneeded appointments, save time for both Veterans and providers. In 

turn, if providers are more efficient, they are able to serve more Veterans, which 

will have an overall positive impact on Veteran access to care. All of these efforts 

align with the goals outlined by the Federal Health Information Technology Strategic Plan 2015–2020 and Connecting Health and Care for a Nation: A Shared Nationwide Interoperability Roadmap, produced by the Office of the National Coordinator for Health Information Technology (ONC) in collaboration with VA, DOD and 

other partners. 

Upon completion, eHMP will support the following capabilities: 

• Veteran-centric health care—eHMP will allow clinicians to tailor care plans to 

specific clinical goals and help Veterans achieve their health care goals. 

• Team-based health care—eHMP will provide an interoperable care plan in 

which clinical care team members, including the patient, will understand the goals 

9 

of care and perform explicit tasks to execute the plan. eHMP will also monitor tasks 

that are not completed as specified and escalate them to the appropriate team. 

• Quality-driven health care—eHMP will support the diffusion of best practices, 

including evidence-based clinical process standardization. eHMP will collect data on 

how clinicians address conditions and power analytics to generate new evidence for 

better care and best practices. 

• Improved access to health information—eHMP will integrate health data from 

VA, DOD, and community care partners into a customizable interface that provides 

a holistic view of each Veteran’s health records. 

Fundamentally, our efforts to improve information systems are about data, not 

software. Regardless of the software platform, we need to be able to access the right 

data at the right time. Health data interoperability with DOD and network providers is important—but it is equally important to understand that this is just one 

aspect of having a comprehensive profile to streamline and unify the Veteran experience. 

Using eHMP as a tool, health care teams will better understand Veterans’ needs, 

coordinate care plans, and optimize care intensity in VA and throughout the highperforming network of care. 

LOOKING TO THE FUTURE

Modernization is a process, not an end, and the release of VistA 4 in FY 2018 

will not be the ‘‘end’’ of VA’s EHR modernization. VA has always intended to continue modernizing VA’s EHR, beyond VistA 4, with more modern and flexible components. 

Technology and clinical capabilities must consistently evolve to meet the growing 

needs of our Veterans. The VistA Evolution program is just that—an evolving capability that is an invaluable part, but not the end of VA’s EHR modernization. 

Digital Health Platform 

Due to the expansion of care in the community, a rapidly growing number of 

women Veterans, and increased specialty care needs, the need for more agility in 

our EHR has never been greater. We are looking beyond what VistA 4 will deliver 

in FY 2018, and we are evaluating options for the creation of a Digital Health Platform to ensure that we have the best strategic approach to modernizing our EHR 

for the next 25 years. 

The VA healthcare system must keep the Veteran experience at its core and incorporate effective clinical management, hospital operations capability, and predictive 

analytics. We do not have all of this today with VistA. 

To prepare for this new era in connected care, VA is looking beyond the EHR to 

a digital health platform that can better support Veterans throughout the health 

continuum. These factors drive the need for continuous innovation and press us to 

plan further into the future. 

The EHR is the central component of the digital health platform. However, an 

EHR by itself does not have all of the capabilities required to manage care in the 

community, respond to the changing needs of the Veteran population, support clinical management, and provide the best overall Veteran experience with the VA 

healthcare system. 

We have conducted a business case outlining our vision for the digital health platform. Our goal is to have a modern and integrated health care system that would 

incorporate best-in-class technologies and standards to give it the look, feel, and capabilities users have come to expect in the private sector. 

The digital health platform will be agile, and will leverage international opensource standards such as the Fast Healthcare Interoperability Resources (FHIR) 

framework. FHIR converts granular health data points into standardized data formats already well known to healthcare IT application developers. The main goal of 

FHIR is to simplify implementation without sacrificing information integrity. VA is 

working with standards organizations and industry partners to further refine FHIR 

to allow the level of interoperability necessary for the functionality described above. 

Health Level 7 International (HL7), a not-for-profit American National Standards 

Institute (ANSI)-certified standards developing organization, developed FHIR. HL7 

has produced healthcare data exchange and information modeling standards since 

its founding in 1987. Emerging industry practices and lessons learned from previous 

standards frameworks informed HL7’s development of FHIR. 

The digital health platform will be a system of systems. It is not dependent on 

any particular EHR, and VA can integrate new or existing resources into the system 

without sacrificing data interoperability. One of the digital health platform’s definVerDate Mar 15 2010 23:43 Jan 25, 2018 Jkt 000000 PO 00000 Frm 00013 Fmt 6633 Sfmt 6621 Z:\ACTIVE\062216.TXT PAULIN
10 

ing features will be system-wide cloud integration, a marked improvement over the 

more than 130 instances of VistA that we have today. 

SCHEDULING

We recognize the urgent need for improvement in VA’s appointment scheduling 

system. We are evaluating the Veteran Appointment Request (VAR) application and 

the VistA Scheduling Enhancement (VSE) through simultaneous pilot programs. We 

are testing VAR at two facilities. We have been testing VSE at 10 locations, and 

are in the training phase for national deployment of VSE. 

VAR is a new Veteran facing capability allowing Veterans to directly request primary care and mental health appointments as face-to-face, telephone, or video visits 

by specifying three desired appointment dates. The software allows established primary care patients to schedule and cancel primary care appointments directly with 

their already-assigned Patient Aligned Care Team provider. 

We are testing VAR at two facilities in the VA New England Health System (Veterans Integrated Service Network (VISN) 1)—the VA Connecticut Healthcare System (West Haven) and the VA Boston Healthcare System (Jamaica Plain). 

VSE updates the legacy command line scheduling application with a modern 

graphical user interface. This capability reduces the time it takes schedulers to 

enter new appointments, and makes it easier to see provider availability. VSE provides critical, near-term enhancements, including a graphical user interface, aggregated facility views, profile scheduling grids, single queues for appointment requests, and resource management reporting. 

Our ten VSE Initial Operational Capability sites are: 

1. Charles George VA Medical Center in Asheville, NC 

2. West Palm Beach VA Medical Center in West Palm Beach, F 

3. Chillicothe VA Medical Center in Chillicothe, OH 

4. VA Hudson Valley Health Care System in New York 

5. Louis Stokes Cleveland VA Medical Center in Cleveland, OH 

6. VA New York Harbor Health Care System in New York, NY 

7. VA Salt Lake City Health Care System in Utah 

8. VA Southern Arizona Health Care System in Tucson, AZ 

9. James H. Quillen VA Medical Center in Mountain Home, TN 

10. Washington, DC VA Medical Center in Washington, DC. 

VA schedulers tell us that they need a system focused purely on scheduling. VSE 

and VAR pilots are available now and show positive results in meeting the business 

requirements of our partners. In contrast, the Medical Appointment Scheduling System (MASS) project includes additional features that add complexity, leading us to 

put MASS on a strategic hold while our team ensures that we meet all requirements 

without undue processing difficulties. VA will carefully measure the results of the 

VSE pilot to determine the best use of resources that will meet Veteran needs. VA 

is working hard to ensure that every technological tool and improvement makes judicious use of taxpayer dollars while providing solutions that support today’s Veterans’ needs. 

ENTERPRISE CYBERSECURITY STRATEGY

OI&T is facing the ever-growing cyber threat head on—we are committed to protecting all Veteran information and VA data and limiting access to only those with 

the proper authority. This commitment requires us to think enterprise-wide about 

security holistically. We have dual responsibility to store and protect Veterans 

records, and our strategy addresses both privacy and security. 

In order to achieve and maintain the highest level of security, we need the active 

participation of everyone who accesses VA systems. We are providing comprehensive 

education to ensure that all VA employees remain vigilant. We have updated our 

National Rules of Behavior and our annual security training, and we are emphasizing continuous engagement with our employees. Information security poses constant challenges, and it is only through continuous reinforcement that our employees can support us in this battle. 

The first step in our transformation was addressing enterprise cyber security. We 

delivered an actionable, far-reaching, cybersecurity strategy and implementation 

plan for VA to Congress on September 28, 2015, as promised. We designed our strategy to counter the spectrum of threat profiles through a multi-layered, in-depth defense model enabled through five strategic goals. 

• Protecting Veteran Information and VA Data: We are strongly committed to protecting data. Our data security approach emphasizes in-depth defense, with multiple 

layers of protection around all Veteran and VA data. 

11 

• Defending VA’s Cyberspace Ecosystem: Providing secure and resilient VA information systems technology, business applications, publically accessible platforms, 

and shared data networks is central to VA’s ability to defend VA’s cyberspace ecosystem. Addressing technology needs and operations that require protection, rapid 

response protocols, and efficient restoration techniques is core to effective defense. 

• Protecting VA Infrastructure and Assets: Protecting VA infrastructure requires 

going beyond the VA-owned and VA-operated technology and systems within VA facilities to include the boundary environments that provide potential access and 

entry into VA by cyber adversaries. 

• Enabling Effective Operations: Operating effectively within the cyber sphere requires improving governance and organizational alignment at enterprise, operational, and tactical levels (points of service interactions). This requires VA to integrate its cyberspace and security capabilities and outcomes within larger governance, business operation, and technology architecture frameworks. 

• Recruiting and Retaining a Talented Cybersecurity Workforce: Strong cybersecurity requires building a workforce with talent in cybersecurity disciplines to implement and maintain the right processes, procedures, and tools. 

VA’s Enterprise Cybersecurity Strategy is a major step forward in VA’s commitment to safeguarding Veteran information and VA data within a complex environment. The strategy establishes an ambitious yet carefully crafted approach to 

cybersecurity and privacy protections that enable VA to execute its mission of providing quality health care, benefits, and services to Veterans, while delivering on 

our promise to keep Veteran information and VA data safe and secure. 

In addition, we have a large legacy issue that we need to address. In the FY 2017 

budget request, VA has increased requested spending on security to $370 million, 

fully funding and fully resourcing our security capability for the first time. We are 

committed to eliminating our material weakness in FY 2017, and these funds are 

enabling those efforts. In addition, VA is investing over $50 million to create a datamanagement backbone. 

IT TRANSFORMATION AND ENTERPRISE PROGRAM MANAGEMENT OFFICE (EPMO)

OI&T is transforming. Persistent internal challenges exist in delivering IT services, and external pressures have compelled us to change and adapt. Through the 

MyVA initiative, VA is modernizing its culture, processes, and capabilities to put 

Veterans first, and is giving our team the opportunity to make a real difference in 

Veterans’ lives. This momentum is driving us to transform OI&T on behalf of our 

partners, our employees, and Veterans. 

EPMO is building our momentum in OI&T’s transformation. EPMO hosts our biggest IT programs, including the Veterans Health Information Systems and Technology Architecture (VistA) Evolution, Interoperability, the Veterans Benefits Management System, and Medical Appointment Scheduling System (MASS). EPMO also 

supports the Federal Information Technology Acquisition Reform Act (FITARA) requirements. 

12 

Fig. 1—EPMO Organizational Chart 

EPMO ensures alignment of program portfolios to strategic objectives and provides visibility and governance into the programs. 

For enterprise initiatives, EPMO helps program and project teams to better develop execution plans, monitor progress, and report the status of these programs 

and projects. EPMO enables partnerships with IT architects for enterprise collaboration and serves as a program/project resource for the delivery of enterprise and 

cross-functional programs. This helps identify Shared Services Enterprise Programs 

and will help plan resource requirements with portfolios and architecture. 

EPMO has already produced results. The Veteran-focused Integration Process 

(VIP) is a project-level based process that replaces the Program Management Accountability System (PMAS). VIP streamlines IT product release activities and increases the speed of delivering high-quality, secure capabilities to Veterans. VIP is 

revolutionary because it utilizes a single release process—designed to eliminate redundancy in review, approval, and communications—that will be fully implemented 

by the end of 2016. These releases are scheduled on a three-month cadence—an improvement over the previous six-month standard—and allow greatly needed IT services to be delivered to Veterans more frequently. 

VIP reduces overhead and is more efficient and cost effective than PMAS. VIP’s 

efficiencies include reducing the review process from 10 independent groups with 90 

people to a single group of 30 people focused on ensuring that products meet specified, consistent criteria for release. 

VIP focuses on doing rather than documenting, with a reduction of artifacts from 

more than 50 to just seven, plus the Authority to Operate, and the shift from a sixmonth to a three-month delivery cycle. Further, as a guarantee to our work, EPMO 

will ensure that product teams stay assigned to their projects for at least 90 days 

after the final deployment. 

CONCLUSION

VA is at a historic crossroad and will need to make bold reforms that will shape 

how we deliver IT services and health care in the future, as well as improve the 

experiences of Veterans, community providers, and VA staff. Throughout this transformation, our number one priority has and will always be the Veteran—ensuring 

a safe and secure environment for their information and improving their experience 

is our goal. 

As with all issues, VA strongly values the input and support of all its stakeholders. We realize the vital role they play in assisting us in providing timely, highquality care to Veterans, and we look forward to continued open dialog. 

This concludes my testimony, and I am happy to answer your questions. 


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Chairman ISAKSON. Thank you, Dr. Shulkin. 

Ms. Melvin. 

STATEMENT OF VALERIE MELVIN, DIRECTOR OF INFORMATION MANAGEMENT AND TECHNOLOGY RESOURCES ISSUES, 

U.S. GOVERNMENT ACCOUNTABILITY OFFICE 

Ms. MELVIN. Good afternoon, Chairman Isakson, Ranking Member Blumenthal, and Members of the Committee. Thank you for inviting me to testify at today’s hearing. 

As we all know, the use of information technology is critically important to VA’s ability to serve veterans, and each year, the Department spends billions of dollars on information systems and related assets. However, challenges in the Department’s management 

of IT over many years have led to a number of failed initiatives and 

contributed to our designating VA health care as high-risk. 

At your request, my testimony today summarizes our reporting 

on IT concerns that helped lead to the high-risk designation. It also 

addresses some of our more recent findings about the Department’s 

management of IT as reflected in various initiatives. These include, 

as you have mentioned, its exchange of health records with DOD, 

also the development and use of the Veterans Benefits Management System, VBMS, and the modernization of the Department’s 

health care claims processing system. 

Between 2010 and 2014, our work highlighted several critical deficiencies in VA’s delivery of its IT projects. These related to the 

unsuccessful modernization of its approximately 30-year-old outpatient scheduling system after spending an estimated $127 million over 9 years, the suspended development of a system that was 

to electronically store and retrieve information about surgical implants, and almost two decades of effort toward achieving fully 

interoperable electronic health records with DOD that remains ongoing. 

Across these efforts, we noted persistent weaknesses in the Department’s IT management practices. Among others, we noted 

shortcomings in investment oversight, requirements and risk management, and system testing. We also noted weaknesses in the establishment of goals and measures that are critical to assessing the 

progress and results of IT projects. 

The Department agreed with many of the related recommendations that we made in these areas and noted various steps that it 

would take to address them. Nevertheless, we have continued to 

identify management weaknesses which present risk to delivering 

IT capabilities that effectively support VA’s mission. 

For example, while it made progress with implementing an initial version of VBMS, we recently noted the need for increased 

management attention to establishing goals for the system’s response times and user satisfaction. In addition, last month, we reported that while the Department had implemented interim measures to address some of the challenges with modernizing its health 

claims processing system, it lacked a sound plan for the modernization effort. 

Further, our recent reporting on VA’s efforts to advance electronic health record interoperability with DOD noted that VA had 

not identified outcome-oriented goals and metrics to clearly define 

14 

what it aims to achieve in its efforts with DOD and the value and 

benefits of these efforts for veterans and health care providers. 

Overall, these findings continue to highlight the need for more 

effective IT management to better position VA to deliver the modernized systems and capabilities necessary to fulfill its mission. 

And while we recognize that the Chief Information Officer, CIO, 

has undertaken a transformation effort to mitigate weaknesses, 

sustained management attention and organizational commitment 

cannot be stressed enough to ensure that this transformation is 

successful and that the weaknesses are fully addressed. Your continued Congressional attention also will be essential to help ensure 

that VA meets its challenge to establish a more rigorous and institutionalized approach to managing and delivering its IT. 

This concludes my oral statement and I would be pleased to respond to your questions. 

[The prepared statement of Ms. Melvin follows:] 

15 

PREPARED STATEMENT OF VALERIE C. MELVIN, DIRECTOR, INFORMATION

TECHNOLOGY, U.S. GOVERNMENT ACCOUNTABILITY OFFICE


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Chairman ISAKSON. Thank you, Ms. Melvin. 

Let me start with you if I can. Yesterday when I left this meeting, or another hearing we had in anticipation of this meeting 

today, a reporter from a technology publication whose name I cannot remember now stopped me in the hall and asked me if I would 

answer a couple of questions. One of the questions asked was, was 

I aware of any bad purchases of equipment or software that the VA 

had made in terms of technology. 

My answer to them was, you know, I made a lot of dumb mistakes when I ran my company and we went through the IT revoluVerDate Mar 15 2010 23:43 Jan 25, 2018 Jkt 000000 PO 00000 Frm 00035 Fmt 6633 Sfmt 6601 Z:\ACTIVE\062216.TXT PAULIN

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tion, and I was sold some stuff that ended up not doing what it 

needed to do. To the extent that you have looked at the VA, do they 

have a good process of evaluating their needs and purchasing their 

equipment in terms of technology equipment? 

Ms. MELVIN. I think over the years that we have looked at VA’s 

IT, they have had processes in place to assess and evaluate their 

information technology needs. What we found, though, were gaps 

in terms of their ability to really collaborate with the business side 

and know fully what those needs are and then to carry them 

through to fruition in terms of development. 

We have identified concerns through the course of our work relative to the current practices, if you will, or the lack of practices 

within the IT shop for making sure that they have the right—a 

sound investment process and the ability to carry through and deliver on the investments that they undertake. 

Chairman ISAKSON. I think you just hit on something I experienced in my business. A lot of times, I have bought technology 

equipment and IT equipment that my people really did not want, 

or if they got it, they did not know how to use it, and I suffered 

from a lot of not getting the people who were going to use the 

equipment to be a part of the decision in which equipment to buy. 

Do you know whether or not VA has a process to involve the rank 

and file employees with the decisions it has made in terms of 

equipment or a technology or software they buy? 

Ms. MELVIN. From what we understand, through the transformation initiative that the CIO is undertaking, there are steps 

now being put in place to have a more rigorous process of collaborating with the business side. I would say that over the course of 

the work that we have done in the past, that has been an area of 

concern, especially when it came to requirements, defining requirements and really knowing what needed to be in place and to carry 

through to get those systems developed. 

Chairman ISAKSON. Thank you very much, Ms. Melvin. 

Ms. Council, I told you when we had our little meeting before 

this meeting that the Georgia Institute of Technology, which is an 

institution in my State that I could not get into, but a lot of smart 

people that are engineers go to, wrote me a letter about how impressed they were with your work with them on the interoperability program called Fast Healthcare Interoperability Resource 

(FHIR) that they are developing at Georgia Tech. I understand you 

all are close to an agreement on that. Is that correct? 

Ms. COUNCIL. Yes, sir, in support of our new digital health platform. One of the things that we wanted to provide was a proof of 

concept that our business partners could actually take, use, and 

understand what this platform really is about and what is the 

problems it can solve. 

Chairman ISAKSON. And the main thing that software does is interpret between softwares that do not talk to each other otherwise, 

is that not correct? 

Ms. COUNCIL. Yes, and it actually allows for greater innovation 

in area health care. So, what it is is FHIR is the Fast Health Interoperable Resource. You can bring that resource in an open source 

environment, use it, try it out, and if it does not work, you spin 

it back out. So it is all leveraging software as a service. 

33 

Chairman ISAKSON. Well, in my humble opinion, interoperability 

of medical IT is the single biggest problem in health care today—— 

Ms. COUNCIL. Mm-hmm. 

Chairman ISAKSON [continuing]. As a 71-year-old male that goes 

to the doctor quite frequently. [Laughter.] 

Whether on Epic or Greenway or whatever it might be, all these 

red flags go up if you get in one that it is on the other. So, I think 

what you are doing is on the leading edge of what the entire medical IT industry is going to do, am I correct? 

Ms. COUNCIL. Yes. Actually, the digital health platform has been 

said to be on the bleeding edge but the cutting edge in leveraging 

software as a service, the cloud, and also engaging in a non-infrastructure-based concept so that we can be much more agile, much 

more future ready, and only one instance at all times available to 

our friends in VHA. 

Chairman ISAKSON. Dr. Shulkin, in your testimony, and I did not 

write it down so I am going on quick memory here, but you rattled 

off a number of areas where you had reduced the infection rate and 

a number of problems that had plagued the VA and referred to 

your best practices evaluation of urinary tracts, colonostomies, 

things of that nature. Do you have a discipline system you go 

through now to make sure you are avoiding errors to the maximum 

extent possible and reinfection rates in your hospitals? 

Dr. SHULKIN. Yeah. Mr. Chairman, I think VA has for some time 

been a leader in the country in patient safety and in systems to 

measure and evaluate outcomes. And, so, we have a very, very robust system, but the credit for this really needs to go to our clinicians, who have understood the importance of infection reduction, 

the importance of patient safety and quality. These types of improvements, the numbers that I rattled off, are really extraordinary 

advances in quality. 

Chairman ISAKSON. The reason I brought it up, and my time is 

going to be up, so I am not going to ask another question, but in 

Georgia, at Augusta VA about 5 years ago, we had two deaths and 

a number of infections from improper sterilization of colonostomy 

equipment that they finally corrected by putting in some new best 

practices in that hospital. I hope you are doing that throughout the 

system to make sure we minimize compounding problems by getting people that are already sick coming in our facilities and leaving sicker. 

Dr. SHULKIN. Well, one of the reasons why we are on the GAO 

High-Risk List and one of the reasons why this is one of my top 

priorities is that in many VAs, we are doing world class care, but 

not all VAs. So, we are trying to ensure those best practices are 

consistent across the enterprise, which is one of our major areas of 

focus right now, implementing these as an integrated system, not 

as individual VAs. 

Chairman ISAKSON. Thank you for your testimony. 

Senator Blumenthal. 

Senator BLUMENTHAL. Thanks, Mr. Chairman. 

I would like to ask about the impact of lack of cooperation between the Department of Defense and the VA. As I mentioned in 

my opening statement, we have been assured repeatedly that both 

agencies are cooperating with each other, which somehow defies 

34 

credibility, because if that is so, there would have been interoperability or the issues would have been solved long ago. So, let me 

ask you, Ms. Melvin, who bears the responsibility here and what 

is happening? 

Ms. MELVIN. I place the responsibility on both Departments and 

primarily on the leadership of those Departments in terms of being 

able to establish up front what it is that the Departments want to 

achieve in the way of interoperability. 

A longstanding concern that we have had with interoperability is 

in terms of defining what interoperability is supposed to be. We 

have not been able, over the years, to really get from either agency 

what they mean in terms of full interoperability, what that end 

state is supposed to be in the way of the technology that exists, and 

how that technology is used. 

So, as we have looked at this over the years, we have had a lot 

of discussions with both VA and with DOD. We have had a lot of 

assurances along the way that that was being taken care of. But 

what we consistently see is a lack of—really, a lack of clear planning and the clear definition of what it is and then how they plan 

to implement measures and goals to get there. 

Senator BLUMENTHAL. What can—what would you recommend 

that we do on this Committee, and the U.S. Senate generally, to 

make sure that there is interoperability? 

Ms. MELVIN. I think in the immediate—right now, I would say 

that there are a lot of—we have made a lot of recommendations to 

both VA and DOD. We are still following up to see where they are 

in the process of addressing those. But we also know that they are 

in the midst of a number of changes to the approach that they are 

taking. 

We have had a lot of concerns and questions relative to the fact 

that both Departments are essentially going down separate tracks 

with their modernization efforts, for the Department of Veterans 

Affairs and the AHLTA (Armed Forces Health Longitudinal Technology Application) system within DOD. We know that they intend 

to have interoperability. 

I think from the standpoint of your role at this point is continued 

oversight, continued pressing for answers and explicit discussion 

and details relative to what the plans are, how interoperability is 

to be defined at its fullest, and how the agencies intend to progress 

and measure their progress toward getting there. 

Senator BLUMENTHAL. Ms. Council, my information is—well, actually, it is the VA’s monthly information security report for April 

2016—about 2,556 veterans were affected by incidents of data 

breach. That number is about six times the number reported by the 

VA 1 year before that, in March 2015. What accounts for the increase? 

Ms. COUNCIL. I would have to look at the data that you have. 

What I do know is that about 24 percent of any of the 

mishandlings that we have are mismailings, which is data—the letters that have gone out in the wrong envelope to a veteran who 

should not have received. So, 41 percent of those are mishandling 

or mismailing. The other parts of the situation around, umm, 

things that we look at like privacy violations, policy violations, 

unencrypted devices, those are where we really take a very, very 

35 

diligent look and ensure that we are tightening up that kind of access to any of the veterans’ information. 

So, to date, for fiscal year 2016, that is what we are basically 

seeing, which is actually about 20 percent lower than it was the 

year before. 

Senator BLUMENTHAL. What is 20 percent lower? 

Ms. COUNCIL. The number of mismailings and misappropriation 

and mishandling of veteran—— 

Senator BLUMENTHAL. Well, we are not really talking about 

mismailings. We are talking about data breaches. 

Ms. COUNCIL. The actual number—— 

Senator BLUMENTHAL. I understand that a mismailing can cause 

a data breach—— 

Ms. COUNCIL. It is considered a data breach, yes, sir. 

Senator BLUMENTHAL. If something is sent to the wrong address, 

how can that happen? Do you not—how can you send a letter to 

the wrong address? 

Ms. COUNCIL. That is actually a process within the business. It 

is not an IT process. But, because I am the CIO, I am responsible 

for all data, and any data that is misused and mismanaged or 

moved to the wrong place, and also having responsibility for privacy, it falls with us. But, it is not—— 

Senator BLUMENTHAL. No, I understand that, but here is my 

question. You have got records. 

Ms. COUNCIL. Mm-hmm. 

Senator BLUMENTHAL. You do mailings and communications to 

veterans over a period of years. It is not like somebody sits down 

for that letter and scribbles out something. It comes from a system 

that has been mailing consistently. How does it all of a sudden get 

the address wrong? 

Ms. COUNCIL. Generally, the system is not doing the mailing. 

There is a manual interface with a human error. There is a human 

interface—there is a human—— 

Senator BLUMENTHAL. So, you are saying that somebody is sitting there and actually typing out an address on an envelope? 

Ms. COUNCIL. I am saying that envelopes come together and the 

paper is put into an envelope by a human being and sent away, 

yes. It is not mechanized. 

Senator BLUMENTHAL. This sounds like very low-tech—— 

Ms. COUNCIL. Very low-tech. 

Senator BLUMENTHAL. Eminently addressable and correctable. 

Ms. COUNCIL. Yes, sir. 

Senator BLUMENTHAL. What is being done? 

Ms. COUNCIL. One of the things that we are looking at with the 

VBMS and working with them, and I will refer to Mr. Burke on 

this, is changing that process, because right now, when it occurs, 

it is not something that IT itself created, but we feel real responsible to correct it. 

Senator BLUMENTHAL. Well, these kinds of data breaches, and if 

they are rising sixfold over just a year, really have to be addressed 

right away. And, we are not talking here about some sophisticated 

hacking operation. 

Ms. COUNCIL. Mm-hmm. No. 

36 

Senator BLUMENTHAL. But it is equally dangerous and damaging 

to privacy. 

My time has expired, so thank you, Mr. Chairman. 

Chairman ISAKSON. Thank you, Senator Blumenthal. 

Senator Rounds. 

HON. MIKE ROUNDS, U.S. SENATOR FROM SOUTH DAKOTA 

Senator ROUNDS. Thank you. It sounds like they need a window 

envelope. [Laughter.] 

Dr. Shulkin, in my homestate of South Dakota, we have a large 

number of veterans who rely on the VA’s care in the community 

programs. As you are aware, health records interoperability is very 

important in making these programs succeed. A lot of the problems 

with providers not being paid on time in my State stem from difficulties transferring records back and forth between the VA and 

the providers. 

I am glad that in March VA changed the rules to allow providers 

to be paid before receiving the records back, and that has most certainly helped. It seems to me, though, that moving forward, some 

type of commercial health record would be a good solution. I understand that in its draft report, the Commission on Care recommends 

that the VA purchase and deploy an off-the-shelf electronic health 

record. I also understand you have various proposals on the future 

of VA health records currently before you and that you are making 

those considerations now. 

Can you tell me a little bit about where you are at or where you 

stand on the issue and where you see the VHA going in the future 

to better interact with private sector providers? 

Dr. SHULKIN. Yes. Yes. I would just say three quick points. Number 1 is that the health information exchanges that you talked 

about, the electronic exchange of information with the community 

and VA, is the way we need to go. We currently have an HIE, a 

Health Information Exchange, working with 721 hospitals, 10,000 

clinics, and thousands of providers, but that is, as you know, a minority of the providers. 

Senator ROUNDS. Is that a proprietary system or is that an offthe-shelf? 

Dr. SHULKIN. That is an off-the-shelf system, yes. So, we are encouraging more providers that do a lot of business with the VA to 

join this effort through our HIE. 

Second, as you said, we are not paying our providers fast enough, 

but we did suspend the fact that they have to give us their information before they get paid. So, we are working hard to pay our 

providers within 30 days, and that is a commitment that we have, 

to get better at that. 

Third on the commercial systems and where we are going with 

the future recommendations, this is something that LaVerne’s shop 

has been taking the lead on, and Ms. Council, as the CIO, has the 

lead on this, but she has been very collaborative with us as the 

customer and we have come to a point that we have reached consensus that very much agrees with where the Commission on Care 

is on this, which is that looking at a commercial product is probably the way to go, but we need to do this in a way that incorporates our ability to integrate with community providers in all of 

37 

the unique needs of veterans. So, that is what Ms. Council is referring to when she talks about the digital health platform that actually takes those recommendations but does something that I think 

will really be the way that VA needs to go in the future. 

Senator ROUNDS. Ms. Council, I know that one of Secretary 

McDonald’s breakthrough priorities for 2016 is to transform the VA 

Office of Information Technology, and the stated goal is to ensure 

50 percent of IT projects are on time and on budget. Halfway 

through the year, do you feel that you are on pace to meet that target? And I also note that one of Secretary McDonald’s stated goals 

for 2016 is to close 100 percent of current cybersecurity weaknesses. Where do you currently stand in that effort? 

Ms. COUNCIL. So, we are on point to do exactly what the Secretary has laid out. Our plan is that we will have addressed all 

Federal Information Security Modernization Act (FISMA) findings. 

By the end of 2016, we would have closed about 30 percent of what 

the IG expects us to close. And then by the end of 2017, 100 percent eliminating the things that were identified in 2015 as material 

weaknesses. 

As far as the on-time 50 percent, we have deployed our new Enterprise Portfolio Management Office, or EPMO. The EPMO actually is giving us a reduction in overhead of 80 percent on the work 

that we do, which means we should be able to do our work 50 percent faster. We will be fully using agile processes, so you will have 

access to your solution much quicker than what was happening before, and so the 50 percent should be totally doable and we are on 

track. 

Senator ROUNDS. Current cybersecurity weaknesses, you expect 

that you will meet that goal? 

Ms. COUNCIL. We are. The material weakness that we have been 

identified as in the 2015 audit process, we are scheduled and have 

planning and on schedule to meet and close those out at the end 

of 2017 in totality. 

Senator ROUNDS. I recently read that the VA has spent more 

than $1 billion developing and maintaining the Veterans Benefits 

Management System, the VBMS, since 2009. I note that the VA requested an additional $290 million for VBMS in fiscal year 2017, 

all for a system that was initially projected to cost $579 million. 

Can you tell me where you are, currently stand with the VBMS, 

and where you see the costs heading with this system. 

Ms. COUNCIL. Mr. Burke and I spoke about this. I am going to 

refer the question over to him, because the team, working with the 

leadership, is making a pivot and really looking at tying in to VBA 

and modernizing the VBMS effort. 

Mr. BURKE. Thank you, sir. The development cost of the initial 

e-folder for VBMS was approximately $560 million, but six different scope changes approved by Congress to create a processing 

solution that better served VA employees led to an increased expenditure. By the end of fiscal year 2016, VA will have spent $1.3 billion 

to create, implement, and maintain VBMS. It is important to note 

that this investment has been central in reducing the claims backlog by more than 88 percent, from a high point of 611,000 to a little 

less than 75,000. During that time, VBA also achieved an accuracy 

38 

rate of 96 percent at the medical level issue, lowered the claims inventory by 59 percent, and the days pending for each claim from 

a peak of 282 days to 91 days. VBMS is also in the process, in accordance with one of the GAO recommendations, of providing a 

plan that would take us into a next generation phase. 

We have benefited from the agile environment in VBMS, which 

really gets to one of the points that was raised earlier. Our end 

users, we have a process in place where the end users get their 

product faster. They have input into the development of the product. So, while the expenditure does bring us to $1.3 billion by the 

end of this year, I think we have been able to show some of the 

benefits from the amazing support we have received. 

Senator ROUNDS. Thank you. 

My time has expired. Thank you, Mr. Chairman. 

Chairman ISAKSON. Thank you, Senator Rounds. 

Senator Hirono. 

HON. MAZIE K. HIRONO, U.S. SENATOR FROM HAWAII 

Senator HIRONO. Thank you, Mr. Chairman. 

The modernization and the interoperability of medical records, et 

cetera, it has been such an ongoing challenge. I realize that VA’s 

health care system is huge, so there are a lot of moving parts and 

all that, but we continue to ask what happens to the money and 

where are the results and all that and you generally come in and 

tell us that things are going well or much better. But, it is pretty 

much an ongoing conversation that we have on the same issues. 

I note that in Ms. Melvin’s testimony, on page seven of her testimony, she says that the GAO recommended that the Department 

take six actions to improve key systems development and acquisition processes essential to another effort to deal with the outpatient scheduling system. The Department generally concurred 

with our recommendations, but as of May 2016, which was not very 

long ago, had not addressed four of the six recommendations. 

So, this is a question for you, Dr. Shulkin. Why not, and do you 

have plans to address the remaining—well, the majority of the 

GAO recommendations? Do you know what I am referring to? It 

does not—— 

Dr. SHULKIN. No. 

Senator HIRONO [continuing]. Cite what the recommended actions are—— 

Dr. SHULKIN. Are you referring to the GAO High-Risk List—— 

Senator HIRONO. Yes. 

Dr. SHULKIN [continuing]. Or are you referring to IT recommendations from the GAO? 

Senator HIRONO. Apparently, it is in the—it is a section of your 

testimony, Ms. Melvin, that has to do with the High-Risk List. 

Maybe you can enlighten us a little bit more as to what those recommendations were and the fact that the administration has not 

met four of them. 

Ms. MELVIN. I would just like to clarify. Were you talking about 

the scheduling system we—— 

Senator HIRONO. Yes. 

Ms. MELVIN. OK. 

Senator HIRONO. Outpatient scheduling. 

39 

Ms. MELVIN. The outpatient scheduling—— 

Senator HIRONO. That is just one, but let us focus on that. 

Ms. MELVIN. Yes. That is one in which we had six recommendations that related to the acquisition management, systems testing, 

progress reporting for that initiative, and so we at this point are 

noting, I believe, that we have closed one recommendation as implemented, one as not implemented, and four remain open that relate to implementing requirements management plan for the development and management of the system, analyzing requirements, 

that type of thing. And we have also got recommendations that relate to policies and procedures for establishing meaningful oversight in terms of having a robust collection method for information 

on project costs, benefits, and schedules. So, those remain open at 

this point. 

Ms. COUNCIL. So, we have actually—— 

Senator HIRONO. I asked the wrong person, then. 

Ms. COUNCIL. No, no problem. The enterprise portfolio management process is actually creating a control tower. We stood this 

process up in February. We went and got approval from the unions 

in April. And, in fact, my Deputy Assistant Secretary for that effort 

is behind me here. We have stood up that effort, which actually 

provides us with a new intake process, replacing our Project Management Accountability Software (PMAS) process with a better and 

focused integration process which will allow us to understand benefits, ensure that the security is built in at the beginning of the 

process. It is an agile process. And it also gives us a warranty period on the back end of the process. So, it addresses all of those 

issues in those recommendations, as well as improves our ability 

to deliver and improves the quality of what we deliver. 

Senator HIRONO. So, Ms. Melvin, now that you have heard the 

response, you would maybe change your testimony to reflect that 

they are meeting your recommendations? 

Ms. MELVIN. What I would say is that we are cautiously optimistic. We would like to see more of the evidence. We will be talking more with the CIO’s shop to understand more fully what they 

are doing. It is encouraging in terms of overall, what is being said, 

but I would reserve judgment until we have had a chance to really 

evaluate more. We do like hearing them say they are on the track 

that they are on, though, toward addressing these matters. 

Senator HIRONO. Did you want to add something? 

Ms. COUNCIL. Yeah. And just to clarify, what Ms. Melvin said on 

her timing was 2010 to 2014. We came in with these changes in 

mid-2015 and we have not had a review of the 2015 to now, and 

so that is one of the reasons that, you know, it is sort of not linking, because she was well before any of these new changes have 

been made. 

Senator HIRONO. Because the VA is such a huge system, I personally look to the GAO to point out areas where improvement 

needs to occur, and I think it is really important for the administration, VA, to respond in an appropriate way to address the 

concerns. 

Since the Secretary is very focused on a veteran-focused agency, 

how are you making sure that the veterans in our various communities, many of who live in rural areas and they may not have acVerDate Mar 15 2010 23:43 Jan 25, 2018 Jkt 000000 PO 00000 Frm 00043 Fmt 6633 Sfmt 6601 Z:\ACTIVE\062216.TXT PAULIN
40 

cess to the computer, how do you—your efforts to communicate 

changes, requirements, the Choice program and all that, what kind 

of feedback are you getting from the veterans as to, well, it provided—assuming they even know that they should ask? I am very 

concerned about the information that our veterans are getting regarding what you all are doing and whether you are responding to 

those concerns. And, I am running out of time, but maybe you can 

respond really briefly with a commitment to improve. 

Dr. SHULKIN. Well, I think it is more than a commitment. I 

think, as you said, the Secretary has made it clear that our customer is the veteran and we need to change our systems to be veteran-centric. And in order to do that, you have to ask your customers in the way that you are describing, Senator. We have multiple, multiple surveys. We have created groups. We rely upon our 

Veterans Service Organizations. We rely upon you. You give us a 

lot of feedback from your constituents. And, we are answering our 

e-mails directly. We are out there talking to veteran groups. Several of you have asked me to join you at meetings where we have 

met with veterans. 

So, I think that we are getting—we always need to do a better 

job at getting feedback, but there is that commitment that currently exists. 

Senator HIRONO. Well, I may want to just talk with you on the 

side regarding a particular need that is happening in one of the islands that has veterans, so we will talk with you. Thank you. 

Thank you, Mr. Chairman. 

Chairman ISAKSON. Thank you, Senator Hirono. 

Senator Boozman. 

HON. JOHN BOOZMAN, U.S. SENATOR FROM ARKANSAS 

Senator BOOZMAN. Thank you, Mr. Chairman, and again, thank 

you for the hearing. 

Dr. Shulkin, we have talked a little bit about some of the problems in the VA pharmacy, and I know you are working hard to try 

and correct some of those. An example would be that VA pharmacies are not networked and when a veteran visits multiple providers or moves their home to a new location, or even goes on a 

trip away from their primary care manager, the veteran has to 

start over with a new doctor’s appointment and obtain an entirely 

new prescription to fill an existing prescription. There also is not 

deconfliction or adequate monitoring of drug-to-drug interactions or 

prescription duplications. 

Can you talk a little bit about what you are trying to do in the 

VA pharmacy to alleviate, really, some pretty basic problems? 

Dr. SHULKIN. Right. I think, Senator, you have identified the 

problems that we know exist in the VA very, very well. We have 

created a technology solution called OneVA Pharmacy that we are 

implementing across the system that really addresses almost everything that you have talked about. This should be just like other 

network pharmacies, that when you walk in, all that information 

is available and we can service people. That is our commitment. 

The IT solution is being implemented. 

41 

And I do not know, do you have a specific date for the implementation of OneVA Pharmacy? Here is the date. In December of this 

year, it will be completely up to be able to support that. 

Senator BOOZMAN. Good. No, that is great. We hear a lot about, 

rightfully so, about opioids and stuff, so an integrated system theoretically probably would help with that, also, so that is good. 

Ms. Melvin, you highlighted in your testimony that the VA currently has two systems that are over 50 years old. The Personnel 

Accounting Integrated Data System, which automates time and attendance for employees, is 53 years old. The Benefits Delivery Network that tracks claims by veterans for benefits eligibility, dates of 

death, is 51 years old. Both use programming language developed 

in the 1950s. I think you also said that of 12 agencies or whatever, 

these are in the top ten oldest government—— 

Ms. MELVIN. Yes, they are. Yes. 

Senator BOOZMAN. Can you talk a little bit about the importance 

of these? I guess, talk a little bit how we get ourselves in this situation where we have got two things that are fairly critical, and yet, 

again, go back to the 1950s. 

Ms. MELVIN. I think it is important to emphasize that there always has to be continual monitoring and updating of systems. 

There always has to be a focus on whether those—when those systems reach a point at which it is time to retire them, if you will, 

or get new ones to replace them in whatever form or fashion. And 

what we have found over time is that there has been a lot of focus 

on maintaining and operating older systems. It really comes down 

to the prioritization in many instances of whether those systems 

are being given the priority, being looked at in the way that they 

should be for determining when they should be retired. 

So, across the work that we have done, where we have had an 

opportunity to look at those systems, our concerns that we raised 

there were with the need to really start focusing on bringing them 

current, reshifting the emphasis, if you will, to putting focus on the 

development of newer technology, and understand—or taking a position or having a plan for how to transition them from the operational state that they are in. 

Senator BOOZMAN. So, that is not really newer technology, 

though. I mean, it is kind of going from the old to the modern era. 

I mean, it is beyond that, almost. 

Ms. MELVIN. Yes. It could be new technology, but it is also looking at what you have got in place, thinking ahead at all times, and 

really being cognizant of what you need to do relative to supporting 

your mission on a broader encompassing basis. And what we found 

is that oftentimes, the focus gets on just maintaining what is there 

without really having the vision or the forward thinking view of 

what needs to be done to really bring this into a more modernized 

capability as the environments change and needs change. 

Senator BOOZMAN. Ms. Council, can you give us kind of a—or 

whoever—give us a path forward—— 

Ms. COUNCIL. Sure. 

Senator BOOZMAN [continuing]. On how we are going to fix that, 

and then also maybe a detailed timeline as to when we are going 

to get it accomplished. 

42 

Ms. COUNCIL. Sure. Senator Boozman, what you are really referring to is what is referred to as the software development life cycle. 

Every bit of software, every system has a life. Forty, 50 years is 

ancient in the world of IT, and fundamentally, I cringe when I 

think about that, because at the end of the day, you are working 

with something that very few people can even tell you what it actually does and does well. 

Generally, what should happen is—and what we plan to do—is 

our Chief Technical Officer would own that as a life cycle and look 

at every bit of applications we have, every bit of software we have, 

and really define the legacy and what we should be taking out of 

the environment. Everything that runs does not necessarily means 

it needs to still be there, and you need to eliminate those systems, 

take them down, which means you end the life. You also need to 

plan well in advance those systems that you are going to replace 

and think about technology in a very different way, moving away 

from a hardware mentality to one where you are really focused on 

the right software linked with the right processes. 

So, as we try to be more efficient, ensure that we do not have 

some of the issues we mentioned, like earlier with the mismailings, 

those kinds of things, we change our processes. Therefore, we 

change our systems. So, our plan is that we would have an SDLC, 

a software development life cycle, that will clearly let everyone 

know what is going to startup, what is going to be put end of life, 

and where we are going with our architecture. That is a mainstay 

of a good organization in IT and it is something that we are deploying in our environment, as well. 

Senator BOOZMAN. Thank you, Mr. Chair. 

Chairman ISAKSON. Thank you, Senator Boozman. 

Senator Tester. 

HON. JON TESTER, U.S. SENATOR FROM MONTANA 

Senator TESTER. Thank you, Mr. Chairman. 

I want to thank you all for being here today. Dr. Shulkin, you 

came from Johnson and Johnson (J&J), right? 

Dr. SHULKIN. No. 

Senator TESTER. You came from Johnson and Johnson? You came 

from—— 

Dr. SHULKIN. I was running private hospitals in—— 

Senator TESTER. OK. I just got you mixed up. 

Ms. COUNCIL. That happens. 

Senator TESTER. All right. So, how long—you have been at the 

VA for how long, Dr. Shulkin? 

Dr. SHULKIN. July 6, a year. 

Senator TESTER. It will be 1 year come July 6? 

Dr. SHULKIN. It will be 1 year. 

Senator TESTER. And how about you, Ms. Council? 

Ms. COUNCIL. July 6, 1 year. 

Dr. SHULKIN. We are a package team. [Laughter.] 

Senator TESTER. Well, that is good. So, you guys kind of came 

from the private sector. 

Dr. SHULKIN. We both did. 

Senator TESTER. Yeah. And, so, does the private sector have 

these kind of problems with IT? I mean, I came out of the State 

43 

legislature. We had a program we spent hundreds of millions of 

dollars on. I get here. It does not matter if it is the VA or any other 

agency within government. It is like these guys have got a bag and 

it is Halloween and they are filling it up full of money and taking 

it out the door and we are not getting much for it. Is this the same 

thing that happens in the private sector? 

Dr. SHULKIN. It is, only bigger, yes. 

Senator TESTER. It is worse? 

Dr. SHULKIN. No. We have a bigger problem because our numbers are bigger. But, these same—you know, when you implement 

IT, it is not a magical solution. You actually have to know what 

you want the IT to do. 

Senator TESTER. Yeah. 

Dr. SHULKIN. And you have to use your workflow processes to 

improve it. 

Senator TESTER. Yeah. 

Dr. SHULKIN. So, we are experiencing the same problem that 

happens all throughout health care, and—— 

Senator TESTER. Yeah, but you guys are all smart people. I 

mean, you have set up—do you not set up your goals and your 

plans and then you contract with somebody who is a smart person 

and knows IT, right—— 

Dr. SHULKIN. Yeah. 

Senator TESTER [continuing]. And they come in and they develop 

it. Are these contracts open-ended that every time you make a 

change, it is another hundred-million bucks? 

Dr. SHULKIN. Senator Tester, I will tell you, I truly believe this 

is a new VA. I think, as Senator Boozman said, some of these problems date back—— 

Senator TESTER. No, no—— 

Dr. SHULKIN [continuing]. Years and years—— 

Senator TESTER. No doubt about it, but—— 

Dr. SHULKIN [continuing]. And I am watching—I am watching 

business being done differently. The processes that LaVerne is putting in place, I think, are much smarter and will allow us to get 

much greater benefit out of our IT expenditures. 

Senator TESTER. I farm in the biggest county in Montana. 

Dr. SHULKIN. OK. 

Senator TESTER. I would own that county and six or eight more 

if I had all the money just that VA spent on IT. It is an amazing 

thing, and I do not know what the solution is, because, quite frankly, I think it is necessary, but every dollar you spend on IT is one 

less dollar that goes to the veteran. 

Ms. COUNCIL. That is correct, and coming out of private industry, 

that is the reality, is a bottom line cost. And, so, the—— 

Senator TESTER. But is there not any way that you can put controls and demand accountability and make sure that if you want 

a product, they give you the product you want, and that every time 

you adapt that product a little bit to make it meet the needs of the 

agency, they do not soak you? 

Ms. COUNCIL. You are a hundred percent correct, and you will 

see at each of your places is an update of what we have done over 

the last year, and it is all about getting those controls in place. The 

reality is, if you are going to buy a product, you do not customize 

44 

a product. You move your processes to do what the product needs 

to do—— 

Senator TESTER. Right. So—— 

Ms. COUNCIL [continuing]. And that is a big part of it. 

Senator TESTER. So, let me ask, and I hesitate to ask this question because I should probably know the answer, but I do not. Is 

the DOD and the VA, are their medical records streamlined? Can 

they go back and forth without any problems? 

Dr. SHULKIN. I would not go that far, but we do have—we do 

have a working joint viewer that has 170,000 active users between 

DOD and VA. We certified interoperability in April of this year. 

People today are using it to get information between DOD and VA, 

so it works. 

Senator TESTER. Is it helping with the claims process, I mean, 

because it would seem to me that if you guys know what went on 

in theater and it transfers—— 

Dr. SHULKIN. It is. 

Senator TESTER [continuing]. Seamlessly, it should reduce that 

number—— 

Dr. SHULKIN. Ten thousand of those users work for Veterans 

Benefits Administration. They are using it every day to access 

DOD records. 

Senator TESTER. So, let me ask you about, since the Choice program has come in, we have got hospitals—not as many as we are 

going to have, by the way, when we pass the Veterans First Act 

and we get all this mess cleaned up—but we have got a lot of different hospitals. I think the last hospital I was at, they said there 

were 13 different medical record programs in the State of Montana 

alone. 

So, what are you doing there? And, I know it is not just your 

problem, but it is just your problem, because we are talking about 

the veterans and we are talking about shipping them out to the 

private sector. Those folks have to have those medical records. You 

get the drift. You know the rules. 

Ms. COUNCIL. So, with DOD, we have actually mapped 25 different domains so that we can be very interoperable on the data 

side, and using the HIE, which is health interchange that Dr. 

Shulkin mentioned. That is how the information goes in and out 

seamlessly. Everyone is working, and National Coordinator for 

Health Information Technology (ONC) is part of this, to make sure 

we are all talking the same language, it is not two languages, so 

that the doctors do not have a burden put on them, but they can 

clearly respond into our system. 

Senator TESTER. OK. 

Ms. COUNCIL. That is a big part in this digital area. 

Senator TESTER. OK. I wanted to get into telemedicine, but I am 

out of time. 

I just want to say that I think back to when we rolled out the 

Affordable Care Act Web site and what a disaster that was in 2010, 

2012—2012, I guess it was, maybe 2010. And they had a bunch of 

kids at Stanford—I think it was Stanford, but it might have been 

MIT or it might have been the University of Great Falls—that 

were playing cards and had it figured out in about 3 or 4 days. Are 

we utilizing some of these bright young people that are in the uniVerDate Mar 15 2010 23:43 Jan 25, 2018 Jkt 000000 PO 00000 Frm 00048 Fmt 6633 Sfmt 6601 Z:\ACTIVE\062216.TXT PAULIN
45 

versity system to help save us money, because, honest to God, 

there is so much money going out the door—— 

Dr. SHULKIN. Yeah. 

Senator TESTER [continuing]. In this IT stuff, it blows my mind. 

Dr. SHULKIN. Well, first of all, we are. We do have a lot of members of the Digital Health Service, which are really people who 

sound exactly like what you are talking about, who have come into 

government from some of these startup companies and other great 

IT companies to help. We are using them. We are doing hack-athons. We are trying to be creative. 

I think right before you came in, the Chairman mentioned that 

Ms. Council is doing a relationship with Georgia Tech; again, another great IT school that is going to help us solve some of these 

problems. So, we are not beyond asking for help. 

Senator TESTER. OK. That is good. And, by the way, I do not 

mean this to be critical of you guys, but I guess it is, but if I was 

in your boat, you would be critical of me if you were in mine, and 

that is that we have got to figure out some way to get these information technologies tricked out without it breaking the bank. And, 

I honestly think we are being taken advantage of in a big, big way. 

That is just my opinion sitting from the outside looking in. Thanks. 

Chairman ISAKSON. Thank you, Senator Tester. 

Senator Tillis. 

HON. THOM TILLIS, U.S. SENATOR FROM NORTH CAROLINA 

Senator TILLIS. Thank you, Mr. Chair. 

I think I will pick up where Senator Tester left off. I think one 

thing that we have to recognize, is having been involved in large 

system transformations in my job and companies like J&J and 

Procter and Gamble, the difference there that we have to recognize 

is we have to stabilize the operating environment. When you go in 

and you do a large-scale IT and process transformation, the first 

thing you do is you—and you cannot do it unless the chief executive officer (CEO) says, everything stops. Stabilize the situation. Inventory the complexity. Prioritize the systems and processes that 

have to be changed, then start weaving in out-stage priorities. 

What you have here, though, is a group of people who continue 

to lop on, and I am talking about me and other Members of Congress, saying, by gosh, you better get that done. It better be on 

time and on budget. And here is a wholly new program we want 

you to implement within the resources that you have. There is no 

additional appropriation. 

Any executive that made that proposition in any Fortune 100 

company would be fired the next day if they had a CEO who was 

enlightened in trying to turn the business around. So, part of what 

we have to do is recognize we are part of the problem. 

Now, the flip side of that, if you take a look at the maverick IT 

spend, I think you made some comments about, oh, IT is hard to 

deal with so people do their own things. You have to reach a point 

in time inside the VA, if anybody else is spending money on net 

new IT that is outside of your purview, they should be fired because they are creating complexity that should not be there. If anybody is arguing to keep these five or six duplicative systems within 

a certain VISN that do fundamentally the same thing, you wanted 

46 

it one, they should be fired because you have to start simplifying 

things. 

Even if we stabilize the environment, and we know that is not 

going to happen as long as Congress keeps on coming back every 

couple of months, then we also have to recognize the people, process, technology, and time implications of other things that we ask 

you to do, which is why I have asked the VA to put together a construct that we can start getting our members to think about so that 

we may get to a point to where rather than saying this will be implemented on this date, this will be implemented within the construct of the overall transition strategy. If we do not, we are never 

going to get out of this mess. We will be saying the same things 

like have been said by Senator Tester and people that sat in these 

chairs long before any of us were ever here. 

But, you all have to be more assertive about when someone 

comes up with a well-intentioned idea that is disruptive to the core 

mission that you are trying to solve. If you do not, I will guarantee 

you, you will not be successful. 

So, if we have this framework—it goes beyond just Congressional 

Budget Office (CBO) scoring. It goes beyond Senator Tillis saying 

that is a great idea. 

Let me tell you how many people will be required, how many 

processes will be affected, how much time, and how much technology will have to be directed at implementing this within the 

timeframe you have asked me to implement it. Then, hopefully, 

build a dialog to where we are not disruptive. If we do not do that, 

you will make some progress, but you will not make a whole lot. 

And, if you had a CEO that could wave a wand and shut all of 

us up and not create any additional uncertainty in terms of your 

budget—you commit to a budget, you execute to it, manage the 

prices, like Senator Tester said, you can do that through supply 

chain and sourcing—then it is still going to take you 3–5 years to 

get to measurable, significant progress. If you all made a few good 

steps in 12 months, 18 months—your short-term or quick hits— 

that would be great. We need to have a session talking about those 

very specific things, particularly around scheduling, chart movement, and, really, the integration with the DOD is child’s play compared to what you need to do with the non-VA providers and 

Choice providers. You all know that. That is a key piece. 

I think you all have got to do a better job of talking about when 

we are putting proposals in place that are good ideas, but fit 

squarely in the critical path, it is on you. It is our problem if you 

communicate it in a direct way. Say, it is not about policy, it is 

about disruption to this core mission that we have been assigned. 

Then, we are going to continue to spin these wheels and you will 

not be near as successful as you were at J&J and at Beth Israel 

and places you were before. It is just not going to happen. 

One question I had around IT compliance is to what extent— 

when we went into these projects and we had to stabilize things, 

we were pretty draconian with the business managers and the 

maverick IT shops out in the operation, and you did not get one 

pass. If we saw you acquiring or bringing in a consultant under a 

different account and basically coming up with shadow IT, you lost 

your job because you were a threat to the underlying mission that 

47 

we have all agreed is right for the enterprise. Is there that sort of 

mentality in the VA right now and that sort of authority and accountability in the VA right now? 

Ms. COUNCIL. Yes. We are finalizing an IT/non-IT policy to make 

it very clear what is IT and what should be paid for and under support and supervision of IT. Also, our device policies, how many and 

what we are going to allow. We have created portfolios for each of 

the business groups in which they now have to be responsible for 

the work on the portfolio and actually putting projects on hold or 

stopping them because we need to focus to get that work done. The 

objective will be, if you want something done, you have got to take 

something else off. You have got to learn how to make tradeoffs so 

we can complete the job. 

So, the whole concept of being agile is that we are going to be 

getting things done, not having these projects that last forever, and 

owning that process is Office of Information and Technology 

(OI&T). 

Senator TILLIS. Well, Ms. Council, you know, I supported your 

nomination and I think you have a great background. I think you 

can do the job if we do not add to the impediments that will allow 

you to do it and that you continue to ask for the authority you need 

to implement some discipline that has not been evident in the VA 

for quite some time. That is why you had this hairball. I would like 

to meet maybe with you to talk about your governance model and 

specific examples of where you have had to apply it and assert that 

governance to areas in the organization. 

Thank you, Mr. Chair. 

Chairman ISAKSON. Thank you, Senator Tillis. 

Senator Murray. 

HON. PATTY MURRAY, U.S. SENATOR FROM WASHINGTON 

Senator MURRAY. Thank you, Mr. Chairman. 

Dr. Shulkin, let me just say, I was really disappointed by the VA 

and DOD’s decision to abandon the Joint Integrated Electronic 

Health Care Records System back in 2013. A fully integrated system would have provided VA and DOD with an opportunity to really lead the health industry. 

I was equally frustrated to hear earlier this year that VA is announcing a new review now of how to proceed with implementing 

an improved electronic health record. The decision of whether to 

use an upgraded version of VistA for the long term or to purchase 

a commercial product should have been settled years ago. And fundamental questions like whether to use an open source approach 

should also have been resolved. And, I am really concerned by the 

lack of long-term planning and whether the time and money invested so far will really be for nothing. What has changed in the 

Department’s thinking that would lead you to walk away from 

VistA? 

Dr. SHULKIN. First of all, I appreciate you being so direct about 

your disappointment, because I certainly think that given the 

amount of time that you have spent on this Committee and efforts 

on this, I can understand that. 

LaVerne came in, really, with a charge to take a look at these 

systems and to give her assessment, given her experience, about 

48 

where VA needs to go. The first thing that she did was to reach 

out and to partner with the customers, all of us. And, so, we have 

really taken that very seriously, which is to say, look, we came in 

without as much history, but we came in with the goal of making 

the right decision for VA in the future, because we do not want to 

find ourselves, like Senator Boozman said, 50 years down the road 

with outdated technology. We have been working on that concept. 

I do not think that anything that we are working on, which, as 

you know, right now, taking VistA and Enterprise Health Management Platform (E-HMP), which is really—instead of having 130 

separate versions of an electronic medical record, which we have 

today, creating a single version in E-HMP. We do not believe any 

of that work is going to go to waste or that money has been wasted. 

We are looking at a transition plan that brings VA into a future 

state of where all health care is going to need to be, and that is 

this issue of interoperability with community providers, with VA, 

with DOD. 

I am going to let LaVerne talk more about that, but we appreciate your perspective on this and we are really trying to do the 

right thing here. 

Ms. COUNCIL. I think, at the end of the day, there was a lot of 

care to focus on that, because I have a lot of respect for the VistA 

product. But, the VistA product is a 40-year-old product, and when 

we start to think about the care to the veteran and the clinical 

management, the clinical operations management, the fact that key 

analytics are needed to understand if we are really showing meaningful use, and then ultimately getting us to the point that we can 

really engage the veteran where they are, not where we need them 

to be. It required us to look at how we are moving data, how we 

are doing analysis, how we are using the clinical information, how 

we are using our supply chain, how we are getting the pharmacy 

aligned, all those things. 

So, as we started to go through it, said, what can technology do 

today that it could not do yesterday, and it can do a lot. And, so, 

we have laid out as a digital platform that we will take advantage 

of what technology can do on behalf of the veteran, but also on behalf of the community, because the care in the community, the 

number of women veterans now added into the process, as well as 

the aging of the veteran population and the mobility of the veteran, 

requires that our tools, our insight, and our engagement with them 

change. 

So, what we have laid out is really a platform that we actually 

have gotten insight from the Office of the National Coordinator for 

Health Information Technology (ONC), other industry heads, as 

well as the DOD. We meet with the DOD. I engage with the DOD 

leadership. There is no animosity or issue there and they have 

been very helpful as we start thinking about that process. 

Senator MURRAY. Except that we have been hearing that for a 

very long time, so—— 

Ms. COUNCIL. I—— 

Senator MURRAY. Excuse my skepticism, because I have sat here 

and heard that over and over again. I want you to be successful, 

but we have heard the same words over and over again. Now it is 

49 

going to be integrated. Now we are talking to DOD. So, I wish you 

the best, but we really do need results. 

I am out of time and I want to ask you very quickly about 

cybersecurity. In 2016 alone, we have seen several alarming 

attacks on hospitals, where patients’ records have been held 

ransom—— 

Ms. COUNCIL. Mm-hmm. 

Senator MURRAY [continuing]. By cyber criminals. With this push 

toward telehealth and electronic health records and all of that, talk 

to me about some steps that you are taking to collaborate with U.S. 

Department of Health and Human Services (HHS) and other agencies to secure patient data and health IT against cyber attacks. 

Ms. COUNCIL. The ransomware, we actually had the interface 

with it. You were not aware of it because we were able to address 

it from an IT perspective and correct it quickly. We did alert, as 

we normally would when one of those things happens, but it did 

come into the—try to come into the environment. We were well 

prepared for it. 

And, upon my arrival, the first thing we did was create an enterprise cyber strategy process and new strategy because it was critical. We have ten new domains, including medical cyber, which was 

not part of the things that we looked at. And we also focused on 

cybersecurity around the internet of things, which is also something we were not looking at. 

So, at this point, when we talk about the material weakness, 

U.S. Department of Homeland Security (DHS) is our partner along 

with the National Institute of Standards and Technology (NIST) 

and the various other agencies that we work with. We have been 

very collaborative with them. DHS has been doing penetration 

tests for us and giving us feedback on where our opportunities are, 

and we want to leverage whatever they are doing real time. And, 

so, I am real pleased that they have been there for us. 

Senator MURRAY. OK. And, finally, really quickly, are we on 

track to get the IT done for caregivers, the caregivers program? 

Ms. COUNCIL. Yes, as far as I am aware. Yes. 

Senator MURRAY. All right. And, if you can give me—I have got 

a few other questions I want to get to you all. Thank you. 

Chairman ISAKSON. Thank you, Senator Murray. 

Senator Sullivan. 

HON. DAN SULLIVAN, U.S. SENATOR FROM ALASKA 

Senator SULLIVAN. Thank you, Mr. Chairman, and I appreciate 

the panel’s focus on these important issues today. I just am trying 

to get a bit of the sense of the job that you have, Secretary Council. 

I know it is a big job, a big undertaking. When you talk about 

interoperability, it is a great word, but, of course, it means a lot. 

How many different technology systems exist within the VA? 

Ms. COUNCIL. Over a thousand. 

Senator SULLIVAN. A thousand? 

Ms. COUNCIL. Uh-huh. 

Senator SULLIVAN. And how many of those are currently talking 

to each other? 

Ms. COUNCIL. Oh, very few, if any. I would have to come back 

and look at that. But, integration really does not happen at a sysVerDate Mar 15 2010 23:43 Jan 25, 2018 Jkt 000000 PO 00000 Frm 00053 Fmt 6633 Sfmt 6601 Z:\ACTIVE\062216.TXT PAULIN
50 

tem level. Integration happens at the data level and that is one of 

the reasons that we are putting in enterprise data management 

function, because we did not have one. 

Senator SULLIVAN. So, are you trying to integrate the over a 

thousand systems, as well, IT systems? 

Ms. COUNCIL. You do not try to integrate the systems. You work 

with the data, and the data is key. 

Senator SULLIVAN. In terms of the interoperability with the DOD 

and the providers, what are the biggest challenges there? 

Ms. COUNCIL. The biggest challenge is that within health care, 

there is no common language of interchange. Right now, if you are 

on a particular EHR, you can talk maybe to the data out of the 

EHR, and I say maybe. It requires the mapping that was done between the DOD as well as ourselves, and that is what we have 

done to be able to say we are interoperable with the DOD. 

Senator SULLIVAN. Do you try to sequence that first at the VA, 

then at the DOD, and then within the provider community, or are 

you trying to do that simultaneously, all the three different areas? 

Ms. COUNCIL. Actually, we work with the ONC as the oversight 

body to decide on what those standards are and then work with all 

the partners to create that standard and then get that agreement. 

Senator SULLIVAN. Let me ask, on the budget, I think that the 

number I saw was $4.3 billion with regard to the IT budget. My 

understanding is the IG is currently investigating the potential 

misuse of funds of up to $60 million. Who makes the final decisions 

on expenditures like this and how are you combating waste? 

Ms. COUNCIL. Well, there is a combination. As far as combating 

waste, one of the things that we are doing is putting in a full implementation of Federal Information Technology Acquisition Reform Act (FITARA), which creates a source selection process being 

with the CIO. So, we are putting a sourcing function within OI&T 

so that we can clearly have an understanding of all the contracts 

that are going on, all the spend, and also the performance. 

Senator SULLIVAN. Do you believe you have a good understanding of that right now? 

Ms. COUNCIL. Not what I would like to have, no. 

Senator SULLIVAN. So, who does make that decision, those kind 

of decisions, and is it made in, like, levels, so $5 million goes to this 

decision level, is made by an assistant secretary, $60 million, 

maybe the under secretary? Who is responsible, because as you 

know, on accountability issues, sometimes with big organizations 

everybody is responsible and nobody is responsible. Sometimes, it 

is—actually, I think it is actually very important that it be able to 

have an individual responsible. 

Ms. COUNCIL. I totally agree with you and that is actually what 

FITARA says. It says that the CIO should be accountable as the 

source selection authority. What—— 

Senator SULLIVAN. So, is that you? 

Ms. COUNCIL. What we have done in OI&T is we delegate our 

source selection authority to a group called the TAC, which is the 

acquisition center, to do that purchasing and all those things and 

they have first right of refusal on those items. What we are doing 

right now is working with the leader of that organization to refine 

51 

that and bring that back into our processes so we can be fully accountable for every dollar spent out of the appropriation. 

Senator SULLIVAN. So, on the $60 million the IG is looking at 

right now, who is responsible for a number in that kind of magnitude? 

Dr. SHULKIN. Senator, that particular IG report was talking 

about VHA, so that would be within VHA, or me. That, as you may 

or may not know, because there was recent press coverage on this, 

was actually not a finalized IG report. It has not been released, but 

it got, essentially, leaked out into the press and so that is how we 

learned about this. 

VHA deliberately took steps to spend the money that it did, with 

legal counsel’s opinion on this. So, we will not—after we see the report first, we will review it carefully, but likely not concur that that 

was a correct conclusion, that the money was misappropriated. 

Senator SULLIVAN. Dr. Shulkin, so it is you when it is VHA? 

Dr. SHULKIN. Mm-hmm. Yes. 

Senator SULLIVAN. And Secretary Council, when is it you? Again, 

I am trying to look for names, not to—I just think it creates more 

accountability. 

Dr. SHULKIN. Sure. 

Ms. COUNCIL. The IG report is a VHA report, I think, to Dr. 

Shulkin’s point. But for IT appropriation and IT spend, and when 

it is development dollars and infrastructure dollars, it should be 

the CIO. 

Senator SULLIVAN. You? 

Ms. COUNCIL. It is me. 

Senator SULLIVAN. Good. OK. 

Thank you, Mr. Chairman. 

Chairman ISAKSON. Thank you, Senator Sullivan. 

Ms. Eskenazi, I hate to have you come and spent the whole afternoon—— 

[Laughter.] 

Chairman ISAKSON [continuing]. And not be asked a question, 

and with being on the Veterans’ Appeals Board, you are probably 

the person to ask this question. I understand the White House has 

sent to the agency a reform of the appeals process, is that correct? 

Ms. ESKENAZI. Umm—— 

Chairman ISAKSON. Or that you are working on a reform of the 

Veterans’ Appeals—— 

Ms. ESKENAZI. Yes. We are working on legislative reform for the 

appeals process, correct. 

Chairman ISAKSON. How close are you to completing that, and 

has it been scored yet? 

Ms. ESKENAZI. My understanding is that there is an informal 

scoring that has been offered, but we do not govern the CBO Office. 

But, our position is that the legislation itself is cost neutral and 

will actually save money in the long run. 

Chairman ISAKSON. We are still going to need that score. 

Ms. ESKENAZI. Indeed. Uh—— 

Chairman ISAKSON. Pass that along to Secretary McDonald and 

Sloan Gibson and the others, if you would. 

Ms. ESKENAZI. Certainly, and we hope that the Congressional— 

we know that we have provided the Congressional Budget Office 

52 

with all the information they have requested, and informally, I understand that they agree that it is cost neutral. But, the formal 

score has not been provided to Congress yet, so—— 

Chairman ISAKSON. Senator Sullivan. 

Senator SULLIVAN. Mr. Chairman, if I may, just to follow up on 

your question—— 

Chairman ISAKSON. Sure. 

Senator SULLIVAN. So, you might know that I introduced a bill 

that was a pilot program that dealt with appeals, and I know we 

have been working closely with the VA on that, and I know the VA 

is looking at a broader appeals reform. Can you talk about the differences, if you are familiar with what we have been working on 

with your staff, because one of the concerns I have is we would love 

to reform the whole program, because I think everybody recognizes 

that the appeals process needs to be reformed. 

One of the concerns is when—you know, I think we have seen 

it, certainly we have seen it with the Choice Act—that when you 

undertake a massive reform, that it can have some kind of unintended consequences that people were not—that none of us really 

thought about, and then it can kind of, in some ways, create more 

damage than the good it is meant to do. 

So, can you just talk about kind of the idea of a pilot, which we 

certainly do not want to be less ambitious, but we want to essentially test drive the idea before we go into a full-fledged, full-monty 

reform process that might solve everything, but might also create 

more problems than it solves. 

Ms. ESKENAZI. Certainly, a very fair question. The two ideas are 

substantially different. The pilot that is in the draft bill is something that was initiated a number of years ago and is something 

that offers a slight modification in the current system for volunteers who wish to enter that. 

As we looked at this more closely in recent time, with full participation by all the major VSOs and other stakeholders, together, we 

designed a much different type of a framework that would be beneficial for all appellants in the future, and it is something that 

would offer a much more timely, transparent, yet still fair process 

for all veterans, unlike the pilot, which was just kind of a sampling, making a few modifications in the existing system, but it is 

not going to have—the more we have looked at this, it is not going 

to have that measurable lift that we see that we really need in the 

appeals process. 

The appeals process is broken. What we have presented to this 

Committee is something that is a collaborative process. It really 

has some ideas that had never been part of the process in the past, 

such as the protection of that original effective date and offering 

veterans more options with the idea of trying to resolve the matter 

at the earliest point in the process while still offering opportunity 

for veterans to come back. So, what we have is something that really could change the landscape for all veterans into the future, 

whereas the pilot is really not going to make a substantial 

difference. 

So, that is kind of the major differences that we see. We are really hopeful that—I know there is a concern that it has been developed quickly, but the people that have been working on these ideas 

53 

have—are experts in the area and have really been talking about 

this for many, many years. I mean, frankly, going back 20 years, 

you can find documentation of the same discussions. 

Senator SULLIVAN. So, you are confident that that, if it were implemented across the board in a very broad fashion, that working 

the kinks out of that system is not going to be something that you 

are worried about that could overwhelm its intended benefits? 

Ms. ESKENAZI. I am very confident that this is the best design 

that I have seen in all the years that I have been working on this. 

And again, I do not think any one person can claim ownership in 

this design. It was a team effort, which is what makes it all the 

more strong. And I think that it really will offer a wonderful experience for veterans into the future. 

The current system is broken. It is never ending. And we are just 

going to—it is going to continue to get worse if we do not take 

action. 

Senator SULLIVAN. Thank you, Mr. Chairman. 

Chairman ISAKSON. Well, thank you, Senator Sullivan, and I appreciate your chiming in because your recommendation in the Veterans First bill, which we incorporated in that legislation the pilot 

program, was designed particularly to do exactly what you outlined, and that is develop a program, get the bugs out of it, and 

implement it across the system and have a better response. 

I might also add that it did not come up during the hearing, but 

we have 450,000 pending appeals that are still backlogged in the 

system, which is untenable for an organization of veterans like we 

have. So, we want to—not only do we want to put in a system that 

works, we do not ever want to be in a situation where we grow to 

a 450,000-person backlog before we do it. It is my understanding 

that the recommended changes that are going to be recommended 

to us at some point in time will not deal with the 450,000 backlog. 

It will just deal with appeals in the future. Is that correct? 

Ms. ESKENAZI. That is correct. We have two separate issues. We 

have changing the system for the future, and that is the reform 

that is in Senator Blumenthal’s draft bill. And then we have a plan 

that we have been developing with the VSOs on managing the current inventory of appeals that were filed under the current legal 

framework. 

Chairman ISAKSON. Are you not glad I did not let you get away 

without asking the question? [Laughter.] 

Well, tell them back home we are still concentrating on the veterans’ appeal process and we are going to do everything we can to 

facilitate improving that. 

I want to thank all of you for coming today and being a part of 

the hearing, and unless there is any further input, we stand 

adjourned. 

[Whereupon, at 4 p.m., the Committee was adjourned.] 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. RICHARD BLUMENTHAL

TO HON. DAVID SHULKIN, M.D., U.S. DEPARTMENT OF VETERANS AFFAIRS

Question 1. On June 20, 2016, the Department of Veterans Affairs, Office of Inspector General, issued the report, Review of VHA’s Alleged Manipulation of Appointment Cancellations at VAMC Houston, Texas (Report No. 15–03073–275). In it, 

the Inspector General states ‘‘VHA’s current scheduling software is antiquated and 

54 

cumbersome to use and as we have recently reported, it is time for VA to commit 

to make its replacement or modernization a priority.’’ Dr. Shulkin, in his written 

testimony for the hearing on June 22, 2016, wrote ‘‘VA recognizes the urgent need 

for improvement in VA’s appointment scheduling system.’’ However, two years after 

the initial wait list and scheduling scandals broke, the VistA Scheduling Enhancement program is still in the pilot phase and being tested in only 10 locations. 

a. How does this slow pace of improvement translate into addressing what Dr. 

Shulkin referred to as an ‘‘urgent need? 

Response. The VA Scheduling System project is in the implementation phase. 

VistA Scheduling Enhancements (VSE) has been developed, tested, and deployed for 

initial use in VA medical centers or clinics at Tucson, Salt Lake City, Asheville, 

Chillicothe, Cleveland and Hudson Valley. Based on initial user acceptance testing 

and feedback, VHA is making adjustments to the software and scheduling best practices guidelines before VSE is deployed to additional facilities. In addition to VSE, 

the Office of Information and Technology (OIT) Mobile team has been working with 

VHA on the development of the Veteran Appointment Request (VAR). The VAR mobile application allows Veterans, who are enrolled in VA’s health care system, to request and view primary care and mental health appointments at VA facilities. The 

mobile application also allows Veterans to schedule and cancel selected primary care 

appointments at facilities where they have a Patient Aligned Care Team (PACT). 

Additionally, another web application, Schedule Manager (SM), will enable VA staff 

to process the VAR incoming requests for appointments and/or enable Clinical staff 

to schedule appointments for patients. Veterans surveyed indicated that 91 percent 

felt that once completed, the VAR would improve Veterans’ sense of access to care. 

b. When will we see a true modernization or replacement of the scheduling system 

available in all VA locations? 

Response. VHA is implementing scheduling system improvements through the use 

of VHA’s VSE, which provides a graphical, point-and-click interface for schedulers 

to make appointments. VSE version 1.0 has been developed, tested, and deployed 

for initial use at six sites. Based on initial user acceptance, adjustments to the software and scheduling processes are being made before VSE is further expanded to 

other VA facilities. It is important to clarify that VSE is an improvement, but not 

a full replacement for a VHA scheduling system. 

The comprehensive strategy moving forward is the Digital Health Platform 

(DHP). The DHP will support a better overall experience for Veterans throughout 

the continuum of care. VA is in the early planning stage for the DHP, and will develop a business case and cost model to shape the strategy. That strategy is includes 

a commercial-off—the-shelf (COTS) EHR component with comprehensive scheduling 

capabilities. VA is also in the early stages of assessing business process reengineering and other related planning for moving from VistA to a Commercial offthe-shelf (COTS) Electronic Heath Record (EHR). A decision regarding VA’s plans 

and next steps for the COTS EHR component of the DHP is expected by the end 

of calendar year 2016. 

Question 2. VA delivered a report to the Senate Committee on Veterans’ Affairs 

on December 1, 2014 describing how VA intended to use the funding allocated under 

the Veterans Access Choice and Accountability Act. In that report, VA outlined its 

needs for IT development, maintenance, and staffing and estimated it would need 

$376.6 million to support IT development and infrastructure through October of this 

year. However, according to data VA provided to my staff of June 6, 2016 VA has 

spent less than a third of that amount—just under $107 million—through 

May 2016. Congress allocated these funds so that critical IT investments would be 

made to expeditiously improve the care of veterans. Please explain why we see such 

a large discrepancy between what VA estimated it needed for IT and what it has 

spent to date. Is this an indication that the needs have changed? 

Response. VA’s needs have not changed. The approximately $270M remaining 

funds is broken into three funding accounts: Development, Modernization, and Enhancements (DME); Infrastructure Sustainment; and Pay and Administration. 

• Within DME, approximately $46M of the $151M originally allocated for fiscal 

years (FYs) 2015 and 2016 have been obligated, leaving $105M remaining. Of the 

$105M remaining funds, $71M, or 68 percent, is unobligated for the Medical Appointment Scheduling System (MASS) program, while VA assesses the implementation of VSE, currently in pilot. VA is determining whether VSE will immediately 

improve scheduling operations without the complexity of integrating a completely 

new scheduling system into our environment. As VA explores the direction that we 

will take for a 21st Century Digital Health Platform, an integrated scheduling capability will be included as one of our top priority requirements. The additional $35M 

unobligated balance is being used to implement mobile applications, expand teleVerDate Mar 15 2010 23:43 Jan 25, 2018 Jkt 000000 PO 00000 Frm 00058 Fmt 6633 Sfmt 6621 Z:\ACTIVE\062216.TXT PAULIN
55 

health initiatives, and improve Veteran’s access to VA care and services. For example, VA recently released the VAR mobile application, which allows Veterans to request and view primary care and mental health appointments at VA facilities. Expansion of this application and the creation of new mobile solutions will help VA 

meet the Veteran access demands. Additionally, VA has implemented Vets.gov to 

create a single, on-line access point for Veteran benefits and information. • Approximately $54M of the $186M for Infrastructure Sustainment has been obligated. The funding provides information technology (IT) equipment for the more 

than 10,000 new VHA staff. The balance of the funding is used to build-out the IT 

requirements of new VA facilities. Although the construction and leasing of these 

facilities has taken longer than expected, the funding needed to procure, install, and 

maintain the IT equipment necessary to open these new VHA locations is critical 

to the success of these facilities. • To date, VA has obligated approximately $10M of the $39M set aside for Pay 

and Administration. The hiring of new IT staff to support VHA’s staffing increase 

took longer than expected, but we are currently staffed at 93 percent of those positions, with only 13 current vacancies that we expect to have filled by the end of the 

fiscal year. The remaining $29M unobligated balance will be used to fully fund the 

192 positions in FY 2017. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. JERRY MORAN TO

HON. DAVID SHULKIN, M.D., U.S. DEPARTMENT OF VETERANS AFFAIRS

Question 3. What new technologies, such as the use of commercial cloud service 

providers, does VA plan to incorporate into the new EHR platform to ensure that 

it is future proofed? Who is the IT POC managing the initiative? 

Response. For the Digital Health Platform for Next Generation of Care, VA will 

adopt a cloud-first approach that looks at commercial offerings that are architected 

to operate on a cloud infrastructure. Pending final decision, the core of this platform 

would be a COTS Electronic Health Record (EHR) system. COTS EHR vendors 

would be key partners to assist VHA with their needs by optimizing available solutions that operate in a cloud infrastructure. The core principles for creating and operating the platform include: 

• Adopting a Software-as-a-Service (SaaS) platform paradigm for ‘‘future proofing’’ VHA’s technologies. The essential elements of a SaaS product model would incorporate the following concepts: 

– One Logical Data base system: The EHR system needs to have an underlying 

database that has one data model. This means: 

• VHA will always be on one version of the data 

• VHA is using the same, up-to-date nomenclature for clinical terms 

• There is no requirement of synchronization of the data. This is unlike 

the current scenario with over 130 instances of VistA at the application 

level (i.e., a transaction made in the system is available immediately VHAwide and enabled by the internal architecture). An update (i.e., Medication 

updates from RxNorm database), will instantly be available to everyone. 

– One Application Codebase: To ensure that all VHA providers have access to 

the same software capability and are able to use common and consistent processes, the application will be on only one live version of running code. Upgrades 

to the code will be simultaneously accessible to all providers. The architecture 

would allow for scale-out of the application tier to provide a high performance 

user experience. 

– One Set of Workflows: In order to have consistent business processes, VHAspecific workflows would be established to allow for best practices to be disseminated across VHA consistently. Setup of one set of workflows in one logical instance will ensure that policy compliance is simplified. 

– One Gateway for Data: Given the critical need of data exchange between multiple care settings, within and outside VHA, there will be a single, authoritative 

gateway for the exchange of data between the EHR and non-VA systems. The 

data exchange will need to support semantic interoperability. 

• Leveraging the innovation of multiple partners by replacing legacy and homegrown systems with best-fit, class-leading COTS solutions for all key components to 

create and sustain the platform. For all the foundational components, we will look 

first at the commercial products that have the best cloud-based architecture within 

their solution, (i.e., solutions that are either already on the cloud or have a robust 

architecture and roadmap that will allow VA to deploy the solution using commercial and government cloud providers). 

56 

• Retaining the flexibility to use VA’s negotiating position and encouraging competition among cloud infrastructure vendors who provide similar capabilities to 

manage Total Cost of Operations. 

• Enabling interoperability and rapid innovation through Application Programming Interfaces (APIs) to create value from shared resources and promote an entrepreneurial ecosystem. Working with multiple partners on standards for APIs. The 

ONE API framework will allow VA to use new and innovative solutions, directly 

from the cloud, without having to install or develop such solutions in-house. These 

principles will provide the capability of swapping in or out solutions with a great 

deal of flexibility that will allow VA to future-proof its platform by adapting to 

change in the commercial technology environment. VA is currently working on a 

Public-Private partnership with the Interoperability Integration Innovation Lab of 

Georgia Institute of Technology where a rapid proof of concept will be developed to 

validate several of the Digital Health Platform concepts, through working demonstration of clinical scenarios that are applicable to our Veteran population. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. JOHN BOOZMAN TO

HON. DAVID SHULKIN, M.D., U.S. DEPARTMENT OF VETERANS AFFAIRS

Question 4. In February 2016, we met in my office and discussed third-party collections and possible IT solutions for non-VA care. VA-OIG specifically has reported 

that as of 2011 over $110M annually was left uncollected from third party payments. With the rise of non-VA care those dollars left uncollected have most likely 

increased. Language in the FY 2016 Omnibus Appropriations conference report instructed the Department of Veterans Affairs to ‘‘conduct a pilot similar to the one 

described in the Senate report.’’ 

Specifically, the report language ‘‘instructs VA to initiate within 90 days after the 

enactment of the act a pilot program in one Veteran Integrated Service Network 

[VISN] that shall last 18 months. The Department shall choose through a fair and 

open competition a non-government entity with substantial private sector revenue 

cycle management experience to conduct the pilot.’’ The purpose of seeking best of 

breed with commercial experience is to provide best value to VA by leveraging the 

best the private sector has to offer. 

As we discussed in our February meeting, the language is specific that the entity 

conducting the Pilot be a ‘‘non-government entity.’’ This language was written so 

that VA could not send this pilot to a federally funded research development center 

(FFRDC). This pilot is designed to improve and reengineer the processes at the front 

end, middle, and backend at the CPACs so that these dollars collected are maximized and can be put back into VA health care system. 

Please provide me with an update on the status of this important pilot as well 

as if there has been any publication of a procurement or RFP for the pilot utilizing 

full and open competition. 

Response. In May 2016, VA submitted its report to Congress on Veterans Access, 

Choice, and Accountability Act (Act): Third Party Fee Collections, as requested in 

the Senate Appropriations Report, page 53, Public Law 114–57. The Senate Appropriations Committee’s recommendation to contract with a private-sector entity that 

supports the initiation of a pilot within 90 days after enactment of the Act is not 

feasible. VA could begin developing an acquisition package within 90 days of enactment of the Act, but it is not feasible to secure a contract and establish a pilot within the required timeframe. On average, it takes six months to develop an acquisition 

package and award the contract. 

VHA currently works with several non-governmental entities with substantial private sector revenue cycle management experience. In addition, VHA works with 

Third-party vendors experienced in VA and commercial revenue cycle management. 

These vendors provide expertise on several activities, including: 

• Developing standard operating policies 

• Performance monitoring 

• Developing annual collections forecasts for VA and Care in the Community collections. 

These vendors have supported VHA’s Non-VA Revenue Team and ongoing efforts 

to monitor performance and project collections at individual VA medical centers and 

across the Nation. VHA also utilizes industry expertise to develop and distribute the 

annual collection targets for VA and Non-VA Care collections and reviews the potential impact of the Veterans Choice Act on Medical Care Collections Fund collections. 

Additionally, VA has taken several steps to address the initiatives requested 

through the pilot program. This collaboration continues today. 

57 

VA has taken important steps to implement a business case that is focused on 

process standardization, staff education and training, and consistent system applications to increase reimbursement to VA from Non-VA fee care. VHA has implemented process improvements that have positively impacted Non-VA Medical Care/ 

Revenue results, including: 

1. Reengineered standardized business processes, policies, and procedures 

2. Developed the standardized reports for first and Third-Party revenue billing 

and Third-Party revenue precertification 

3. Developed Non-VA Care/Revenue metrics and monitoring process 

4. Developed and delivered standardized training to revenue staff 

5. Developed Internal Controls for testing, which started in FY 2014 

Æ