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25–126 2017

EVALUATING VA IT: SCHEDULING 

MODERNIZATION AND CHOICE CONSOLIDATION 

JOINT HEARING 

BEFORE THE

SUBCOMMITTEE ON OVERSIGHT & INVESTIGATIONS 

JOINT WITH

SUBCOMMITTEE ON HEALTH 

OF THE

COMMITTEE ON VETERANS’ AFFAIRS 

U.S. HOUSE OF REPRESENTATIVES 

ONE HUNDRED FOURTEENTH CONGRESS 

SECOND SESSION 

THURSDAY, APRIL 14, 2016 

Serial No. 114–63 

Printed for the use of the Committee on Veterans’ Affairs 

( 

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

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(II) 

COMMITTEE ON VETERANS’ AFFAIRS 

JEFF MILLER, Florida, Chairman 

DOUG LAMBORN, Colorado 

GUS M. BILIRAKIS, Florida, Vice-Chairman 

DAVID P. ROE, Tennessee 

DAN BENISHEK, Michigan 

TIM HUELSKAMP, Kansas 

MIKE COFFMAN, Colorado 

BRAD R. WENSTRUP, Ohio 

JACKIE WALORSKI, Indiana 

RALPH ABRAHAM, Louisiana 

LEE ZELDIN, New York 

RYAN COSTELLO, Pennsylvania 

AMATA COLEMAN RADEWAGEN, American 

Samoa 

MIKE BOST, Illinois 

CORRINE BROWN, Florida, Ranking 

Minority Member 

MARK TAKANO, California 

JULIA BROWNLEY, California 

DINA TITUS, Nevada 

RAUL RUIZ, California 

ANN M. KUSTER, New Hampshire 

BETO O’ROURKE, Texas 

KATHLEEN RICE, New York 

TIMOTHY J. WALZ, Minnesota 

JERRY MCNERNEY, California 

JON TOWERS, Staff Director 

DON PHILLIPS, Democratic Staff Director 

SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATION 

MIKE COFFMAN, Colorado, Chairman 

DOUG LAMBORN, Colorado 

DAVID P. ROE, Tennessee 

DAN BENISHEK, Michigan 

TIM HUELSKAMP, Kansas 

JACKIE WALORSKI, Indiana 

ANN M. KUSTER, New Hampshire, Ranking 

Member 

BETO O’ROURKE, Texas 

KATHLEEN RICE, New York 

TIMOTHY J. WALZ, Minnesota 

SUBCOMMITTEE ON HEALTH 

DAN BENISHEK, Michigan, Chairman 

GUS M. BILIRAKIS, Florida 

DAVID P. ROE, Tennessee 

TIM HUELSKAMP, Kansas 

MIKE COFFMAN, Colorado 

BRAD R. WENSTRUP, Ohio 

RALPH ABRAHAM, Louisiana 

JULIA BROWNLEY, California, Ranking 

Member 

MARK TAKANO, California 

RAUL RUIZ, California 

ANN M. KUSTER, New Hampshire 

BETO O’ROURKE, Texas 

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public hearing records 

of the Committee on Veterans’ Affairs are also published in electronic form. The printed 

hearing record remains the official version. Because electronic submissions are used to 

prepare both printed and electronic versions of the hearing record, the process of converting 

between various electronic formats may introduce unintentional errors or omissions. Such occurrences are inherent in the current publication process and should diminish as the process 

is further refined. 

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C O N T E N T S 

Thursday, April 14, 2016 

Page 

Evaluating VA IT: Scheduling Modernization And Choice Consolidation .......... 1 

OPENING STATEMENTS 

Honorable Mike Coffman, Chairman, Subcommittee on Oversight & Investigations ................................................................................................................

Honorable Dan Benishek, Chairman, Subcommittee on Health ......................... 2 

Honorable Ann Kuster, Ranking Member, Subcommittee on Oversight & Investigations ........................................................................................................... 3 

Honorable Julia Brownley, Ranking Member, Subcommittee on Health ........... 5 

WITNESSES 

Honorable David Shulkin, M.D., Under Secretary for Health, Veterans Health 

Administration, U.S. Department of Veterans Affairs ...................................... 5 

Prepared Statement ......................................................................................... 30 

Accompanied by: 

Honorable LaVerne Council, Assistant Secretary for Information and 

Technology and Chief Information Officer, Office of Information Technology, U.S. Department of Veterans Affairs 

Alan Constantian, Deputy Chief Information Officer, Office of Information Technology, U.S. Department of Veterans Affairs 

STATEMENT FOR THE RECORD 

The American Legion .............................................................................................. 37 

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EVALUATING VA IT: SCHEDULING MODERNIZATION AND CHOICE CONSOLIDATION 

Thursday, April 14, 2016 

U.S. HOUSE OF REPRESENTATIVES, COMMITTEE ON VETERANS’ AFFAIRS, SUBCOMMITTEE ON OVERSIGHT

AND INVESTIGATIONS, Washington, D.C. 

The Subcommittees met, pursuant to notice, at 10:03 a.m., in 

Room 334, Cannon House Office Building, Hon. Mike Coffman 

[Chairman of the Subcommittee] presiding. 

Present: Representatives Coffman, Benishek, Lamborn, Bilirakis, 

Wenstrup, Kuster, Brownley, O’Rourke, Takano, Ruiz, and Walz. 

OPENING STATEMENT OF CHAIRMAN MIKE COFFMAN 

Mr. COFFMAN. Good morning. This hearing will come to order. I 

want to welcome everyone, especially our good friends from the 

Subcommittee on Health, to today’s joint hearing regarding VA’s 

health information technology. 

Today we will examine the current state of key IT systems, and 

facilitate scheduling and community provider claims processing, or 

that—I am sorry, facilitate scheduling and community provider 

claims processing. And we will delve into VA’s plan for modernizing 

them. The VHA and OI&T share responsibility for these systems. 

We will also examine VHA’s strategy for the IT systems that will 

be necessary to consolidate community care. My friend, Subcommittee on Health Chairman Dr. Benishek, has done extensive 

work on the consolidation issue. VHA released a draft request for 

proposal yesterday afternoon for the consolidated community care 

network, and we need to know the IT requirements. 

Currently, VHA relies on the scheduling functions of VistA, the 

department’s health information system, which was originally developed in the 1980s. Since late 2012, VA has been planning to procure commercial, state-of-the-art scheduling software. VA awarded 

a contract for this system, called the Medical Appointment Scheduling System, or MASS, in August 2015. 

VA planned to conduct an initial pilot of MASS in Boise, Idaho, 

through 2016, but it was never started and activity on MASS has 

apparently been suspended. VA has simultaneously been developing an intermediate solution to improve VistA scheduling while 

MASS rolls out. 

It consists of two parts: the VistA scheduling enhancement, or 

VSE; and a self-scheduling application called Veteran Appointment 

Request, or VAR. VSE gives VistA a modern look similar to a 

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Microsoft Outlook calendar. It replaces VistA’s black and white 

command prompt interface. VA has described VAR as ‘‘limited.’’ 

Recently, VA determined that VSE and VAR appear to meet its 

scheduling needs and MASS is unnecessary. This decision is a dramatic about face. It means sticking with a government developed 

technology indefinitely. MASS has been stopped before, even its 

first pilot could be compared with VSE and VAR. The plan was to 

see what solution works best. It seems we will never know. 

VA’s claim processing system, called the Fee Basis Claims System, or FBCS, is also badly in need of modernization. VHA claims 

processors use it to receive, examine, and approve claims for reimbursement from community health care providers. The volume of 

claims is up dramatically since the Choice Act and the processors 

are overwhelmed. 

On this Committee, we hear complaints from frustrated providers every day about not being paid, and VA lags far behind 

Medicare and TRICARE in processing claims. FBCS, as it exists 

now, has some fundamental limitations. Today, VHA has 34 groups 

of staff around the country processing claims manually on 34 disconnected FBCS databases. 

Claims come in electronically and on paper. The paper claims 

don’t enter the system at all until they are scanned, and GAO estimates scanning takes about two weeks. The electronic claims are 

immediately viewable and trackable, but there is no national view 

across the 34 locations of paper claims until they are actually approved for payment, and there is never a national view of paper 

claims that get denied. Claims information is too hard to find and 

they can get lost in the cracks. 

VHA’s manual processing takes too long. VHA’s policy is to pay 

or reject 90 percent of claims within 30 days, and GAO found that 

VHA only meets this standard 66 percent of the time. Instead of 

manual processing, Medicare and TRICARE used auto-adjudication. Their systems automatically analyze claims for completeness 

and accuracy. FBCS can be upgraded to fix these problems. 

An upgrade to make the paper claims more transparent has been 

available since May 2015. VA still hasn’t tested it. An initial autoadjudication upgrade could have been available this month, but it 

can’t move until the earlier upgrade is implemented. 

VA has a major decision to make about whether to upgrade 

FBCS now or to wait to put in a wholly different claims system as 

part of the consolidation plan. What is certain is we have a big 

claims paying problem right now, and payment delays chase away 

providers. 

I now yield to Chairman Benishek for his opening statement. 

OPENING STATEMENT OF CHAIRMAN DAN BENISHEK 

Mr. BENISHEK. Thank you. Well, it is a pleasure to be here this 

morning with the Members of the Subcommittee on Health and our 

colleague from the Subcommittee on Oversight and Investigations. 

Ensuring that the Department of Veteran Affairs is fully 

equipped with a modern, functional information technology system 

is a priority that we all share. Many of the deficiencies in the IT 

programs that underlie the VA health care system have already 

been laid out by Chairman Coffman, and I agree with his comLeonard.horne on VACREP0180 with DISTILLER

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ments regarding the urgent nature of the ongoing efforts to modernize the VA scheduling and claims processing. 

We can’t allow the failures that have characterized previous efforts in these two important areas to continue. We also can’t continue to push decisions further down the road. Too often, IT 

projects have progressed to a critical decision point and then been 

abandoned in favor of another initiative or another plan. VA must 

realize that maintaining manual systems and deferring to archaic 

operating systems as a default cannot continue, we need a sense 

of urgency. 

As Chairman Coffman noted, improving VA IT is also important 

to community care consolidation. Many of the key features of the 

VA’s plan to consolidate community care under Choice will require 

a contemporary IT infrastructure to support them. 

The VA has shared little information to date about what IT systems the VA intends to put in place to support community care 

consolidation, what those systems are going to cost, and when 

those systems will be up and running and ready to support the 

needs of veteran patients and the VA’s community partners. 

I hope the VA’s prepared to provide that information today at the 

hearing. I am also interested in hearing today about how the Veterans Health Administration, managed by Dr. Shulkin, and the VA 

Office of Information Technology, managed by Ms. Council, are 

working together to build a modern IT program in the VA health 

care system that we need to serve our veterans. 

The independent assessment of the VA health care system that 

was required by the Access, Choice, and Accountability Act found 

that the VHA and the OI&T did not collaborate effectively with respect to planning and executing IT strategies for managing and 

furnishing health care, and often disagreed on priorities for executing strategic plans. 

I would venture to say that the disconnect is why so many previous health IT efforts have failed to achieve success. Ensuring appropriate coordination and communication between the VHA and 

OI&T is vital to moving the VA health care system toward the 21st 

century. I look forward to hearing some specifics from Dr. Shulkin 

and Ms. Council about how they are personally working together, 

side by side, to make these things happen. 

So thank you all for being here this morning, and I will yield 

back to Chairman Coffman. 

Mr. COFFMAN. Thank you, Dr. Benishek, for your remarks. 

I now yield to Ranking Member Kuster for any opening remarks 

that she may have. 

OPENING STATEMENT OF ANN KUSTER, RANKING MEMBER 

Ms. KUSTER. Thank you very much, Chairman Coffman and 

Chairman Benishek, and I appreciate you taking the time for this 

hearing, it’s an important one, and to my Ranking Member 

Brownley. We appreciate the opportunity to be with you all today. 

The wait time crisis in Phoenix highlighted the VA’s antiquated 

scheduling system and how difficult it was to use. And I have to 

say for many of us visiting VA facilities in our districts, we are 

having these same conversations. 

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VA has made a number of efforts over the last 15 years to modernize and improve its scheduling system. But as a result of the 

crisis, the Choice Act enacted by Congress last year mandated assessment of VA’s health IT systems. And we know that modern IT 

systems and processes are critical to ensuring that patients receive 

quality coordinated care and that physicians and health care providers are not wasting their time for people who don’t show up. 

As we found after multiple hearings and assessments, VA’s outdated and cumbersome patient scheduling system was a major contributor to patient access crisis, and remains a challenge. 

VA’s announcement in 2015 of a contract for commercial off-theshelf solution to replace VA’s scheduling system seemed like a 

promising response to the clear inadequacies of the current system, 

and we were all encouraged by that. There was concern that this 

would not be ready until 2017, but it was a promising step forward. 

This five-year $624 million contract was awarded in 2015. But 

now, after VA has spent $27.5 million on a pilot project for the 

Medical Appointment Scheduling System, or MASS, as the Chair 

has pointed out, we are told that the project has been put on hold. 

At the same time, VA has continued with its own in-house initiative to update their scheduling system. 

This seems like deja vu all over again to me. VA has already 

wasted 9 years, $127 million without an update to its scheduling 

system after finding a commercial product and abandoning that for 

an in-house solution that could not deliver an adequate update. 

We cannot, and will not, let this happen again. And I can say 

that on a bipartisan basis, this is very frustrating for those of us 

who have been sitting here, and some of my colleagues much longer 

than I have. 

I want to know what VA is doing to ensure that its scheduling 

system, EHR, and health care IT infrastructure are able to meet 

the current and future needs of our veterans. This means that VA 

must work toward developing a health care IT infrastructure that 

is interoperable with DoD. And I think some of us in the class of 

2012 will remember, that was one of our very first hearings on this 

Committee was the frustration about the interoperability with the 

DoD, and the precious taxpayers that have been spent—taxpayer 

dollars that have been spent searching for a solution. 

We need to ask, regarding VA health care and IT, how does this 

better enable the VA to do what it should be doing: serving our veterans, providing and coordinating health care for veterans all 

across our country. We need VA’s businesses’ processes to work so 

that community providers are able to treat veterans and receive 

prompt payment for providing care. 

I continue to receive complaints from constituents in my district 

in New Hampshire that feel abandoned and forced to navigate 

their own care outside of the VA. I have community providers who 

have stopped participating in the Choice program because they are 

not paid on time, or the eligibility rules are simply too complex. 

Our veterans deserve timely, high quality care. Health information technology has the potential to transform the VA into a leader 

in the delivery and coordination of health care, and a health care 

organization that leverages health technology to deliver the best 

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health care to our veterans. But VA needs to do its part to properly 

plan, implement, and oversee IT projects. 

And I know that the two of you are relatively new to the organization, so we don’t blame you for past faults. We certainly want to 

work with you going forward. But you need to understand that 

Congress cannot continue to give VA a blank check to spend on IT 

projects without results. 

So I look forward to hearing from our witnesses on their suggestions and solutions. And I yield back. Thank you, Mr. Chairman. 

Mr. COFFMAN. Thank you, Ranking Member Kuster. 

I now yield to Subcommittee on Health, Ranking Member 

Brownley for any opening remarks she may have. 

OPENING STATEMENT OF JULIA BROWNLEY, RANKING 

MEMBER 

Ms. BROWNLEY. Thank you, Mr. Chairman, and thank you, and 

Chairman Benishek, for bringing this hearing together, and I 

thank my Ranking Member Kuster for holding this hearing as well. 

I will be brief because I think my colleagues have already laid 

out the issues that this Committee is concerned about. But I will 

say that our health Subcommittee has held a series of hearings on 

different aspects of the Choice program. We heard from VA on billing issues, eligibility, staffing, and provider networks, and most of 

them involved some component of technology that needed to be updated or fixed. It’s fitting that we now hold a hearing on information technology and where the VA is going on this issue. 

We know that, as the second largest Federal agency after the Department of Defense, VA runs the largest integrated health system 

in the country and is tasked with providing high quality, safe 

health care to eligible veterans. So we need, and our veterans need, 

a very strong and healthy IT program to deliver that kind of care. 

And I will look forward to the testimony this morning. 

Mr. COFFMAN. Thank you, Congresswoman Brownley. 

I ask that all Members waive their opening remarks as per this 

Committee’s custom. With that, I invite the first and only panel to 

the witness table. 

On the panel, we have the Honorable LaVerne Council, Assistant 

Secretary for Information and Technology and VA’s Chief Information Officer. We have also the Honorable David Shulkin, Under 

Secretary for Health. They are accompanied by Dr. Alan 

Constantian, the VA’s Deputy Chief Information Officer. I ask the 

witnesses to please stand and raise your right hand. 

[Witnesses sworn.] 

Mr. COFFMAN. Please be seated. And let the record reflect that 

all witnesses have answered in the affirmative. 

Ms. Council, you are now recognized for five minutes. 

STATEMENT OF DAVID SHULKIN M.D. 

Dr. SHULKIN. Great. Good morning, Chairman Coffman, Chairman Benishek, Ranking Member Kuster, Ranking Member 

Brownley, and all Members of the Subcommittee. Thank you for 

the opportunity to discuss the progress being made by VHA and 

the Office of Information Technology, what we call OI&T, to provide veterans timely access to care. I do appreciate all the opening 

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statements. I think your candor and the issues that you want to 

discuss are exactly the issues that we think need to be discussed 

as well. 

I’m pleased to be joined today, as the Chairman said, by the Honorable LaVerne Council, the VA’s Chief Information Officer and Assistant Secretary for OI&T, and Alan Constantian, the Deputy 

Chief Information Officer for OI&T. 

Ms. Council and I joined the VA at the same time, in July of last 

year. We went through the confirmation process together as partners. And during that process, we committed to continuing this 

partnership throughout the terms of our office. We began our work 

with one goal: to make VA work better for veterans. I’m proud to 

say that we are holding that commitment. 

VA has a history of innovation that is deep and indelible, and we 

are proud to be part of it. The creation of the Veterans Health Information Systems and Technology Architecture, what we call 

VistA, is one of the flagship examples of that spirit. 

Forty years ago, leaders of VHA recognized that technology in 

health care had reached a monument of mutual opportunity, a time 

when patients and clinical needs were growing more complex and 

IT capability was quickly improving; VistA was that result. 

That initial visionary leadership, the recognition of a key moment in time, the collaborative partnership of the technologist, clinician, and the legislature led to the Nations first electronic health 

record and was the driver for today’s health care environment. 

But that was 40 years ago, and much has changed. The veteran, 

in 1975, had an average age of 46. Today, veterans average 60 

years old. In 1975, we served 500,000 female veterans, today we 

serve over 2 million female veterans. In 1975, VA focused primarily 

on the physical needs of the average veteran, now we have an ever 

growing suite of comprehensive health care services such as prosthetics and mental health. 

In 1975, VistA supported a handful of clinical processes, now it 

has over 200 applications, each having multiple processes, and 

there are over 130 different versions of VistA throughout VHA. 

In 1975, the veteran was carrying a paper folded by hand between points of care. Today, the veteran is tech savvy, she has 

email, uses a cell phone, and wears a personal health tracker. As 

our veterans have changed, so has technology. We must keep pace 

and we must make the right decisions to do so. 

We sit before you today with over 55 years of experience in 

transformational leadership. Today, we’re bringing our years of industry experience and a sense of urgency, that Dr. Benishek called 

for, to our work at VA. As partners, we view every decision through 

that lens. 

When Ms. Council and I arrived, the VistA evolution program 

was beginning its work on VistA 4. VistA 4 enables interoperability 

and focuses on care coordination, providing tools to better manage 

population health. Its development concludes in fiscal year 2018. 

We sit before you 40 years after the creation of VistA and two 

years prior to its final development milestone, and want you to 

know we take our responsibility to do the right thing for veterans 

very seriously. 

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We want to be certain that continuous modernization of a 40- 

year-old electronic medical record is an appropriate decision, as 

well as our approach to modernizing scheduling. We are asking our 

teams very difficult questions every day. 

Ms. Council demonstrated this commitment to asking difficult 

questions and taking difficult steps shortly after entering office. 

With the support of her team, she developed an actionable, farreaching cyber security strategy and implementation plan for VA 

to Congress that was delivered in September of 2015 as promised. 

VA, its core constituents, and external partners are all subject to 

a wide variety of cyber security threats. VA’s enterprise cyber security strategy identifies key challenges and goals and is focused on 

building a comprehensive cyber security strategy that is aggressive, 

proactive, and addresses the unique needs of each of VA’s business 

lines. This strategy is a major step forward in safeguarding veteran 

information and VA data with a complex environment, and we are 

proud of it. 

Our approach to the Choice program, or care in the community, 

is an example of the success we can experience through a close 

partnership and critical evaluation. On October 30th of 2015, VA 

provided Congress with a plan to consolidate all VA’s purchased 

care programs. 

This transformation will require a stronger health IT platform 

that allows for bidirectional flow of information between providers 

and ensures continuity of patient care. The joint VHA and OI&T 

team are working to take on this issue, and meeting daily to ensure continuous progress and address obstacles. They are evaluating each health care and technology decision through a critical 

lens, ensuring we are making the right choices for the veterans and 

the taxpayers. 

In all areas of our partnership, we must choose our path carefully and strategically as our work will lay the foundation for the 

next phase of VA’s health care and technology environments. We 

are engaging industry leaders in technology and health care as well 

as domain knowledge for our teams to ensure that the path we 

choose is the right one. 

As Ms. Council and I have the opportunity to evaluate more information from our health care technology initiatives, we gain more 

insight into which turn of the path will be the right one. We will 

share this vision with you this summer. We remain committed to 

making VA a better place for veterans, our employees, and taxpayers. 

We appreciate the opportunity to appear before you today, and 

we’ll be pleased to answer your questions at this time. 

[THE PREPARED STATEMENT OF DR. DAVID SHULKIN APPEARS IN

THE APPENDIX]

Mr. COFFMAN. Thank you, Dr. Shulkin. 

Ms. Council, do you have an opening statement? 

[Inaudible.] 

Mr. COFFMAN. Okay. Thank you, Dr. Shulkin. And the written 

statements of those who have just provided oral testimony will be 

entered into the hearing record. We will now proceed with questioning. 

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Ms. Council, what is VA’s definition of sufficient capability in a 

scheduling system, and how did you determine VSE and VA—and 

how did you determine whether VSE and VAR met it? 

Ms. COUNCIL. The requirements driven by the business in VSE 

and VOSVAR as well as the MASS decision were ones that were 

in place when we arrived. At the end of the day, we have a joint 

team led by business leaders as well as IT. The business leaders 

have really driven the requirements, and then the IT organization 

is responsible for creating the technology. 

So we see it as one that would allow the veteran to get the demand met, and that we would have a clear understanding of the 

capacity to meet that demand. 

Mr. COFFMAN. The plan was to pilot VSE and VAR alongside 

MASS and see which is the best solution. How did you rule out 

MASS—how did you rule MASS out before ever piloting it? 

Dr. SHULKIN. Chairman, I would be glad to take that. We have 

not ruled out MASS, I want to be absolutely clear about that. 

Here’s the situation that we faced, and I appreciate that the frustration of Congress in this, and I appreciate the input that you will 

give us on this. But this is what made sense to us. 

VSE is available today, right now, it’s actually in the field being 

used. I agree with Ranking Member Kuster that the wait time crisis in 2014 was in part caused by an archaic scheduling system 

that is almost impossible to figure out. If you haven’t seen it, this 

is our current scheduling system. It is DOS, it’s what we used 

when computers first came out. 

This is VSE. Okay? This is available right now, and this is in 

VAs today, in two VAs, soon to be eleven VAs with a national rollout in the next couple months. This makes scheduling errors a lot 

less likely to occur with this type of Microsoft Outlook type feel. 

So let me just give you the numbers very quickly, why we put 

a pause on MASS, we did not cancel it at all. It is a contract that 

we can execute at any time. The entire VSE project, the national 

rollout, will cost taxpayers $6.4 million. It’s available today; it will 

help veterans and schedulers today. 

If we roll out MASS, which is an absolute option for us, the pilot alone will be $152 million. It will take us ten months to roll it out 

in three sites. The pilot, as you said Chairman, was to start in 

Boise, two other sites selected, three sites $152 million, ten 

months. And that’s if VA stays on schedule with its pilots. 

So we felt the very, very best decision for veterans and taxpayers—who we’re trying to make these decisions for—was to roll 

out VSE because it’s available today and we’re going to get it all 

rolled out this summer, make a decision very, very quickly whether 

VSE meets all the needs for veterans and our employees and taxpayers, and if not, we’ll proceed with MASS. We think that’s a reasonable decision. If you have different thoughts on that, we’re glad 

to hear it. 

Mr. COFFMAN. Ms. Council, why hasn’t VA implemented the 

FBCS upgrade to improve tracking of the paper claims? 

Ms. COUNCIL. The requirements around paper claims are currently being developed with the care and the community team. We 

have the dollars, and the team is currently developing that capability. 

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Alan, do you have anything you want to add? 

Mr. CONSTANTIAN. Only that we are—some of the VOCA funds 

that we have received, we are looking at the Fee Based Claim System and making the improvements that we see are most necessary 

in the short term. 

Mr. COFFMAN. Okay. Ms. Council, what self-scheduling capability 

will VAR give veterans? How is it more limited compared to 

MASS? 

Ms. COUNCIL. The best way I can explain MASS, MASS is a— 

is based on really capacity scheduling and work planning system 

within EPIC, so it’s a much broader tool. It looks at everything, all 

your resources, your work flow, and everything, not just the schedule. And that’s why it is a larger, more impactful set of solutions. 

And VAR, is—which is the mobile device, which would allow the 

veterans to schedule, to cancel, for mental health as well as basic 

care, is currently also going through process. So DVAR is related 

to the mobile, VSE is the enhancements to VistA, and, of course, 

MASS includes not only scheduling, but the much broader 

workflow, capacity planning, and everything you need around BIZ, 

and DOCS, and Offices. 

Dr. SHULKIN. I would just add, VA needs the ability to have veterans schedule appointments themselves. No question about it. 

That’s what veterans want, and we want that for them. VAR, 

again, is available today. I spoke to a doctor last night who works 

at the Washington D.C. VA, and 25 of his patients at the Washington VA are using VAR. 

So you can actually schedule mental health, primary care and 

cancel appointments on your mobile phone. It is planned to be 

rolled out to seven additional sites in the next month or two. So 

that is, again, an immediate solution. Whether MASS provides a 

better opportunity or not, I think we are going to decide that in the 

very near future, but our goal is to give veterans tools today because we still have an access crisis, and we have to act with the 

urgency that I think all of you have asked us to act with. 

Mr. COFFMAN. Ranking Member Kuster, you are now recognized 

for five minutes. 

Ms. KUSTER. Thank you very much, and thank you for helping 

us dive right into this. And as you can tell, we are not IT experts, 

so the acronyms can take us a minute. 

I want to start, and I think I have asked some of you this before, 

but I just am curious. Couple years ago, I met with a company, the 

name of the company I believe is Zocdoc, do you know this story? 

So about efficiency because one of the things that we deal with— 

we want to serve the veterans and we are tasked with protecting 

the taxpayers, and the story that I hear over and over is veterans 

miss appointments because maybe they can’t get a ride, maybe it 

is scheduled two months in advance and they don’t get reminded, 

and this system is an IT system that improves efficiency by having 

reliable patients scheduled in the morning, less reliable patients in 

the afternoon, but you can double book in the afternoon so we don’t 

have physicians waiting around for patients who don’t show. Do 

you know about this? Have you talked to them? How could we 

speed this up? They could help you. 

Leonard.horne on VACREP0180 with DISTILLER

10 

Dr. SHULKIN. First of all, I’ve known Zocdoc since they were little 

tiny start up in Manhattan in 2007. I can— 

Ms. KUSTER. It just seems like one of those great ideas. 

Dr. SHULKIN. No question about it. There are many, many commercial companies out there, Zocdoc clearly is a leader in that area, 

but I know this field extremely well. We need this capability, you 

are exactly right. This is what VAR was developed to do. Whether 

VAR meets all the requirements and whether we should abandon 

it and go with a commercial system, I think that we’re open to 

that. What we don’t want to do is start over when we have VAR 

that actually is ready to be put out into seven of our VAs— 

Ms. KUSTER. So, and my time is limited I don’t mean to be rude. 

Dr. SHULKIN. Yes. 

Ms. KUSTER. So VAR, you are in pilot right now for veterans to 

be able to self-schedule, and will that be tiered that way so it is 

done efficiently from the workflow end of things—from the VA end 

of things? 

Dr. SHULKIN. It does not have all the features that you’ve talked 

about, about adding the ability to over book and capacity management. There may be some more features that may have what 

MASS has, and that’s part of what we are going to evaluate. But 

what it begins to do is to let veterans schedule appointments themselves or cancel appointments themselves. 

Ms. KUSTER. Which is also very important. My father-in-law used 

the VA, it is important to know when you can get a ride there, 

when it works for you. So, and then, I want to follow-up. So I am 

beginning to understand the big picture. MASS is a much bigger 

platform, it is going to be able to deal with the work processes, et 

cetera. 

Can you give me a few specifics—two minutes and then lots of 

people are going to ask you the same question or more—what is 

the timing? What can we expect? And what is the cost? And we 

want to work with you, we want to solve this problem, we will go 

to our colleagues, Rs and Ds, and ask them for the funds, but we 

need some accountability. 

Dr. SHULKIN. I will try to do it briefly and then ask Ms. Council 

if she wants to add anything. I think you mentioned this in your 

opening statement, the project cost for MASS is up to $624 million. 

The pilot alone for three sites would be $152 million. We have 

spent to date on MASS, in the planning, $11.8 million. 

Ms. KUSTER. Okay. 

Dr. SHULKIN. The entire cost for VSE, the alternative scheduling 

system, is $6.4 million. 

Ms. KUSTER. Okay. 

Dr. SHULKIN. The rollout for VSE would be over the summer to 

do a national rollout. The rollout for MASS would be a ten-month 

pilot at three sites— 

Ms. KUSTER. Okay. 

Dr. SHULKIN [continued]. —which we could start at any point if 

we want to. And then the rollout nationally beyond the three sites 

would be a much longer period of time. I don’t have the exact, but 

I would guess it would be a year or greater. 

Ms. KUSTER. Could we, my time is almost up, but it occurs to me, 

could we come and have a demonstration so that we could actually 

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11 

understand? I mean, for the taxpayers, 6.4 million sounds better, 

but obviously it doesn’t do the same thing, and we want long-term 

savings, long-term accessibility for physicians’ capability for the 

whole system. 

But the frustration we have is that we keep hearing about great 

systems and then we get halfway into it then it didn’t work, so we 

gave that project up. And, you know, where I come from, 600 million that is a lot of money. That is a lot. So I am going to yield 

back, but I would love to—if we could work with the Committee 

to— 

Dr. SHULKIN. We’d be glad to do that— 

Ms. KUSTER [continued]. —schedule a demonstration so we have 

a better understanding. 

Dr. SHULKIN. And what we’re trying to say very transparently is, 

we think it’s a lot of money too. We’re trying to make the best decision for, exactly as you’re saying, the veterans and the taxpayers, 

and everything’s on the table. We’d be glad to show you this and 

get your thoughts on it. Anybody would be welcome. 

Ms. KUSTER. That would be very helpful. Thank you. I yield 

back. 

Mr. COFFMAN. Thank you, Ranking Member Kuster. 

Dr. Benishek, you are now recognized for five minutes. 

Mr. BENISHEK. Thank you, Mr. Chairman. Good morning. Ms. 

Council, in the past, you have testified that, thanks to a joint VA 

and DoD effort, we expect that interoperability will be certified 

with the DoD as defined by the 2014 National Defense Authorization Act eight months ahead of the December 2016 deadline. Well, 

that is where we are today. What is the story with that? 

Ms. COUNCIL. We have an interoperability agreed to, we are 

interoperable with DoD on the JLV, that took place on April 8th. 

So DoD and VA have that handshake, and we are fully interoperable eight months ahead of schedule. In August— 

Mr. BENISHEK. So if I go to the VA, then I can get the patient’s 

DoD record for, not every veteran, but what is the story, how many 

veterans actually have access to the DoD if I walk into the VA? 

Dr. SHULKIN. Yeah. So April 8th we’ve signed off on it, it is attested, we are interoperable. Today, 55,062 active users in VA and 

60,000 users in the Department of Defense are able to do exactly 

what you’re saying: able to get access to the records on any serviceman or member of the VA. And that number will grow to 120,000 

during the course of this year of users. 

Mr. BENISHEK. So VA personnel have access? 

Dr. SHULKIN. 55,000 are using it today. 

Mr. BENISHEK. How many veterans are in that? 

Dr. SHULKIN. I actually do have that number. It is—let me get 

back to you, Dr. Benishek, with the exact number, but I was reviewing it last night, I think it’s several hundred thousand veterans’ records have already been accessed through the Joint Legacy 

Viewer. 

Ms. COUNCIL. Exactly. 

Mr. BENISHEK. Yeah. Well, that is the key issue, right? 

Dr. SHULKIN. Yep. Oh, here—I’m sorry—what? 457,265 veterans 

are—oh, that’s through the Health Information Exchange. Let me 

get you the exact number through the Joint Legacy Viewer. 

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12 

Mr. BENISHEK. All right. Well, you understand the point I am 

trying to make is that so 60,000 VA employees have access, but are 

there, are we actually taking—is there a significant amount of veterans that we have access to those records? So that is a key issue. 

I would appreciate that. 

The other issue that I am interested in, and it has already come 

up a little bit in testimony, is the self-scheduling piece. As you 

know, in the private sector, people schedule their own appointments. So you talked about it a little bit with an app, but that 

doesn’t help most of the veterans that I deal with, because they 

can’t figure out how to use an app on their phone, you know what 

I mean? That is just a limited amount of people I think. So what 

is the timeline for that, and how is that going to actually work for 

most people? 

Dr. SHULKIN. Well, you’re right, there are two ways to give veterans more control of the experience of scheduling appointments, 

which is what our goal is: to put health care back in the hands of 

the veterans. So there is the app, and increasingly more and more 

people are comfortable with smart phones, but even—the veteran 

population does lag behind the general population. So we have to 

wait until more people catch up on that. 

The other way, of course, is the telephone. And this past week 

we announced something called the declaration of access that will 

put the decision about scheduling and canceling appointments into 

the hands of the veteran. We have a system right now that’s very, 

what I call, paternalistic, which is called a recall system; we actually tell you when you’re going to come for your appointment. 

Mr. BENISHEK. No, no, I— 

Dr. SHULKIN. We’re going to stop that. 

Mr. BENISHEK [continued]. I understand that problem. So is the 

eligibility going to be all figured out in advance then? Will the patient have an opportunity to schedule an appointment in their locale in the private sector or at the VA? Tell me how that’s going 

to work. 

Ms. COUNCIL. Actually, the largest users coming on JLV are actually the VBA in the benefit side so they can be ahead of the eligibility question. We only expected to have about 35,000 users of 

JLV, and we are actually— 

Mr. BENISHEK. JLV, what’s JLV again? 

Ms. COUNCIL. The JLV is interoperability capabilities. So you can 

see—the Joint Legacy Viewer—so you can actually see the eligibility of the active duty soldier, and then, why they would be eligible as a veteran. It’s really important that the—it’s interesting that 

the VBA is really one of the bigger users now, and that’s really 

helping to make this eligibility happen faster and much more accurately. 

Mr. BENISHEK. I guess I don’t quite understand that. But I want 

to follow-up with you later since I am out of time. 

Mr. COFFMAN. Thank you, Dr. Benishek. 

Ranking Member Brownley, you are now recognized for five minutes. 

Ms. BROWNLEY. Thank you, Mr. Chairman. I just wanted to go 

back to the Joint Legacy Viewer, and you said you were going to 

give us the number of veterans that are on there at this particular 

Leonard.horne on VACREP0180 with DISTILLER

13 

point. But I am just curious to know, is it generally within the population of new veterans or is it, you know, veterans after 1975, or 

is it just a random number of veterans across the spectrum? 

Ms. COUNCIL. No, it’s not random at all. It is the holistic look at 

the DoD’s— 

Ms. BROWNLEY. No, no, no, I know, just in terms of the capability 

we have right now in terms of numbers of veterans, you know, 

within the system that users can actually see. So I am just wondering, is it sort of—did you start with the most current ones and 

go down a list or is it random across the board? 

Ms. COUNCIL. No, it’s not random. It’s just taking the information that the DoD holds and actually finding that veteran and mapping it with the information that the VA has if they are coming 

into the VA. So it doesn’t take it based on newest first or easiest 

first, it is the active duty records tied with the current state health 

records. 

Ms. BROWNLEY. Right. But right now it is limited because it only 

has a current amount of veterans— 

Dr. SHULKIN. Uh-uh. 

Ms. BROWNLEY. No? 

Dr. SHULKIN. No. 

Ms. COUNCIL. No, no. 

Ms. BROWNLEY. Okay. Then I am misunderstanding. 

Ms. COUNCIL. No, I think what we’re talking about are users. 

When we say users, those aren’t actually patients, those are users, 

docs, the people that leverage information. 

Ms. BROWNLEY. Okay. Okay. 

Dr. SHULKIN. I did find the number I was looking for that Dr. 

Benishek asked for, which is that we just, last week, reached more 

than 1 million record lookups in the Joint Legacy Viewer. 

Ms. BROWLEY. Okay. 

Dr. SHULKIN. So those are veterans. 

Ms. BROWNLEY. Okay. Very good. So on the scheduling piece, it— 

so for the Choice program then, veterans—will veterans be able to 

call the VA, find out if they’re eligible, and then make an appointment with a community doctor? How will that work? 

Dr. SHULKIN. Well, today— 

Ms. BROWNLEY. I mean, because some of that problem— 

Dr. SHULKIN. Yes. 

Ms. BROWNLEY [continued]. —with the Choice program— 

Dr. SHULKIN. Yes. 

Ms. BROWNLEY [continued]. —is waiting for the VA to say whether you are eligible or not. 

Dr. SHULKIN. Today, we follow the current rules of Choice— 

Ms. BROWNLEY. Right. 

Dr. SHULKIN [continued]. —which is to use the TPA— 

Ms. BROWNLEY. Yep. 

Dr. SHULKIN [continued]. —where you have to call and get— 

Ms. BROWNLEY. But ultimately— 

Dr. SHULKIN [continued]. —eligible through them. 

Ms. BROWNLEY. But ultimately will we get to a place where the 

veteran knows he or she is eligible and can make the appointment 

with a community doctor? 

Dr. SHULKIN. That’s exactly our hope. 

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14 

Ms. BROWNLEY. Very good. And so another question that I have. 

It seems as you lay it out, VSE versus MASS, it seems like you are 

making the right decision going down a path that is going to be 

veteran-centric, help the taxpayers, and a quicker timeframe. So 

that all, you know, that all sounds really good. My concern is, are 

we building that system on a sort of a weaker foundation, i.e. 

VistA, you know VistA was at one point in time way back when, 

you know, a state of the art system, it is no longer and so, as Ms. 

Kuster was asking, you know, the longer-term ramifications here 

are we building a network of strength that is going to sustain over 

a period of time and really make the VA veteran-centric, veteran 

friendly system? 

Ms. COUNCIL. Chairman Brownley, actually Dr. Shulkin and myself had this conversation the end of last year and we decided that 

we needed to lay out a new strategy as it relates to EHR and what 

a great veteran experience health care system would look like because it is time. 

The EHR today is really just the heartbeat of the organism, but 

it does not have everything that is needed to mandate and manage 

care in the community to deal with the needs of the female veteran, and also to support just the overall veteran experience and 

the clinical management. 

I have given to Dr. Shulkin the recommendation around a state 

of the art, world-class system. He is evaluating it from a clinician’s 

point of view, which is the appropriate thing to do, and that’s what 

he’s laying out is, the summer would be when we can unveil that 

as this is what we suggest that the VA does. 

What I will tell you is, it is incredibly responsive, it is aligned 

with the world-class technology that everyone’s seeing today, using 

today, and things like Facebook and Google and other capabilities. 

But it also is agile and it leverages what is called a FHIR capability, which is FAST HEALTH INTEROPERABILITY RESOURCES, which means we can bring things in, we can use them, 

we can change them, we can respond. 

And so when he and I spoke about it, we sort of did the right 

leap and we said what we are going to do. We believe that VA is 

an innovator, we believe that VHA and health care should continue 

to be one, and we have provided innovative solution based on industry experts coming back and assessing it as that. 

Ms. BROWNLEY. Thank you. I apologize, Mr. Chairman, and I 

yield back. 

Mr. COFFMAN. Thank you, Ranking Member Brownley. 

Mr. Lamborn, you are now recognized for five minutes. 

Mr. LAMBORN. Yeah. Thank you, Mr. Chairman, and thanks for 

having this hearing along with Dr. Benishek. 

Ms. Council or Dr. Shulkin, I understand you are working on another contract to provide program integration support to the Choice 

consolidation, and it has IT and non-IT elements. Are you going to 

combine the IT work with the non-IT work or separate them? 

Dr. SHULKIN. As you know, we have asked for the access to the 

802 funds to be able to improve the Choice program. Of the $421 

million that we have asked for to build the infrastructure for the 

new veterans Choice program, about $300 million is for IT and the 

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15 

rest are non-IT costs. So they are essentially combined at this point 

into the combined $421. 

Mr. LAMBORN. Okay. Okay, good. That was good for background. Ms. Council, your written testimony says ‘‘VA has obligated $510 

million in development funds to build VistA capabilities since fiscal 

year 2014. VA has also obligated $151 million in IT sustained 

funds, and $110 million in VHA funds.’’ 

So with all that spending, what new capabilities does VistA have 

as a result of this money spent? 

Ms. COUNCIL. From 2013 until now, enabling interoperability, 

doing the JLV, putting in what is called eHMP, which is our web 

capability, which is actually a long-term interoperability, fully 

interoperable with DoD solution, which we’re moving to. So the 

JLV, the Joint Legacy Viewer, is part of the solution, eHMP is the 

web abled which moves you to a fully interoperable data set working with DHMSM (Defense Health Management Systems Modernization). 

In addition, there have been clinical needs, lab needs, and different things like that implemented into VistA. Also stabilization. 

When you look at the sustainment costs, what you’re really seeing 

there is the maintenance costs for the 130 different instances of it, 

keeping the data centers up, and all the equipment related to that. 

And that’s what’s in sustainment. 

Mr. LAMBORN. All right. Dr. Shulkin, if a VA hospital is manipulating wait times, as we have seen with some of our OIG reports, 

how is a self-scheduling system like VAR going to put a stop to it? 

In other words, couldn’t someone—and I hope this would never 

happen, but, like I say we have seen otherwise—couldn’t someone 

just change the information in VAR on the back end? 

Dr. SHULKIN. Your concern is one that we are very, very concerned about. We have 25,000 employees doing scheduling today. 

So that’s a large system to have everybody doing it exactly right 

all the time. 

There are two things that will help. Number one is VSE, this is 

the new scheduling system, and makes the likelihood of committing 

scheduling errors that we have been seeing less likely, because it’s 

a—instead of that DOS system, it’s a much more intuitive system 

that actually hard codes some of these decisions so you can’t 

change them as easily. 

The other is VAR, which is where the patient will schedule directly, would be very hard to change the data. Once the veteran— 

it’s like a transaction in your bank account, you know, once the veteran pushes the button, it schedules it and it records it with an 

electronic, you know, digital print. So it would be much less likely 

that there’d be individual manipulations. 

Mr. LAMBORN. Okay. Thank you. Mr. Chairman, thanks for having this hearing. I yield back. 

Mr. COFFMAN. Thank you, Mr. Lamborn. 

Mr. O’Rourke, you are now recognized for five minutes. 

Mr. O’ROURKE. Thank you, Mr. Chairman. Secretary Shulkin, I 

really appreciated your opening comments and the harkening back 

to the spirit of innovation and leadership that allowed the VA to 

develop VistA and the Nation’s first electronic health record in the 

first place. And in answer to some of my colleagues’ questions, takLeonard.horne on VACREP0180 with DISTILLER

16 

ing the long view on how we establish a base and a platform from 

which we can do great things again. I think that is the spirit that 

we need to approach this with. 

And I know it is a real challenge because there are some basic 

questions of competency right now in the VA that are totally legitimate, and I think many of us and our constituents want to make 

sure that we at least reach competency but that cannot, be the 

goal, I mean, it has got to be excellence. 

And I think in whatever the VA evolves into over the next 10, 

20 years, the ability to schedule and expertly manage the patient’s 

medical information, share it between the VA and DoD, and then 

VA and community providers, is critical. 

And so I just want to make sure that we are approaching these 

challenges the same they did 40 years ago, let’s find out whatever 

they were drinking back then and make sure we order a case of 

that for you and your team, approach this with that same vision 

towards innovating in medicine globally. 

I mean, that is the VA’s rightful role, and that is what we should 

expect for our veterans. And I really think your vision that you outlined with us in October, which focuses the VA on where it can 

truly excel, and then leverages capacity and competencies in the 

community that complement what the VA does is the way to get 

there. I think that allows you to focus on what you can do really 

well. 

So, I wanted to make that statement to just compliment you on 

your approach. And really, my only concern is that you just started 

in July, and if conventional wisdom holds, you will leave at the end 

of this administration. It is my sincere wish, and I will do everything I can to make it happen, that our next President keeps this 

team in place so that we have the continuity and consistency to 

carry this out. I think that is really important. 

What are the near-term milestones—and I know you have answered this question in different ways from different colleagues— 

what are the near-term milestones that will lay to rest any concerns we have about competency, and then also about executing a 

long-term vision that is going to allow the VA to develop excellence 

in this field? What should we be looking for in the next seven to 

eight months? 

Dr. SHULKIN. Thank you, Congressman, for your comments. 

Let me just make one historical correction to this. The truth is, 

the history of innovation with the EMR in VA was actually that 

the administration did everything they could to stop EMR. It was 

actually done by the people in the field who had to hide their efforts until an Under Secretary, Ken Kizer, actually said you’re allowed to bring this out of the basement into the field. 

So we’re trying not to make that mistake. We’re trying to actually innovate and to help the field actually give us the feedback so 

that we can do what you’re asking us to do. 

Mr. O’ROURKE. That is great. 

Dr. SHULKIN. I think the short-term objectives that we have are 

really to focus on the veterans’ needs. This is why when we’re rolling out the VistA scheduling evolution, when we’re rolling out the 

VAR, the self-scheduling application, our evaluation criteria are 

asking veterans did we meet their needs. 

Leonard.horne on VACREP0180 with DISTILLER

17 

And so those are the short-term goals, and we should have this 

information very, very soon, this summer. As we’re rolling out both 

VSE and VAR, we are doing constant evaluations asking our veterans are their needs being met in terms of access. 

Mr. O’ROURKE. So the milestone measurement is determined by 

the veterans themselves? 

Dr. SHULKIN. Yes. 

Mr. O’ROURKE. And it is not the VA directly asking, or is it, that, 

or is there a third party whom we can trust that has got an objective distance from the VA to make sure that we are really getting 

the unvarnished truth about the success of this? That would be my 

preference. 

Dr. SHULKIN. Yeah. Yeah. Yeah. And it’s a little bit of both. The 

way that we’re asking our veterans is actually several ways. One 

is, we use a standardized Federal government survey that is, in the 

government, called a CAHPS survey, which is done by every health 

care institution, that is done by a third party. So we hire a third 

party to administer that. 

We also ask our veterans when they come to appointments, 

there’s a kiosk, so we actually, in the kiosk ask them, how satisfied 

are you with the ability to get this appointment when you needed 

it? So they’re entering that data. 

Mr. O’ROURKE. And I will just say this real quickly as I wrap up. 

I think it is critical that we ask those veterans not physically in 

the VA because there are many who could not get an appointment, 

and we want to know about their experience just as much or maybe 

more so than we do about those who could get in. 

And as you have heard me say countless times, especially when 

it comes to mental health because of the connection to veteran suicide, got to make sure that we know about their experience in 

being able to get an appointment, and then the VA honoring that 

appointment. 

Dr. SHULKIN. And we generally get that feedback from you. 

Mr. O’ROURKE. Thank you. 

Dr. SHULKIN. Yeah. 

Mr. O’ROURKE. I will yield back to the Chair. Thank you for your 

answers. 

Mr. COFFMAN. Thank you, Mr. O’Rourke. 

Ms. Walorski, you are now recognized for five minutes. 

Ms. WALORSKI. Thank you, Mr. Chairman. Dr. Shulkin, you had 

already addressed, I think twice, on VSE and VAR the cost—the 

initial rollout cost and that kind of thing. Do you know what the 

lifestyle costs are to run those two programs? 

Dr. SHULKIN. The sustainment costs? 

Ms. WALORSKI. Yeah. 

Dr. SHULKIN. I don’t know that. 

Mr. CONSTANTIAN. Well, there are no marginal additional 

sustainment costs in VSE. VSE is an augmentation of the VistA 

scheduling package, so the same funds that would go toward the 

support of the VistA scheduling package will be sufficient to support the enhanced VistA scheduling package with the VSE enhancements. 

Ms. WALORSKI. Okay. And, you know, I am kind of asking that 

question because I am sitting here listening to this, I am cautiously 

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18 

optimistic, and I appreciate what your team has done, I really do, 

because I think you have taken great steps forward. 

And to kind of just echo some of the questions my colleagues had. 

You know, I haven’t been here long, but in the four years that I 

have been here this issue with IT seems to be the one that continues to bounce back with some of the best efforts that have gone 

forward, and best trials, and then seems to bounce back, and all 

of a sudden—I will never forget the hearing where, you know, the 

VA was a billion dollars short and you needed that to go in the future. 

So I am cautiously optimistic, but I—Ms. Council, in your written 

testimony, you say that ‘‘The JLV provides limited VA to DoD medical records sharing compared to the eHMP,’’ you are working on 

now. Is it true in order to make eHMP work, you have to get rid 

of VistA’s old user interface and implement a new one that integrates with the ’Net—with the Internet? 

Ms. COUNCIL. You actually have to integrate it into the Web. And 

so you have to go through one at a time and lay that in— 

Ms. WALORSKI. So you don’t need to get rid of the old VistA program? 

Ms. COUNCIL. No, it actually can still live. 

Ms. WALORSKI. Okay. And then my final question, I think you 

may have answered this is, Ms. Council, OIT is strongly advocating 

Agile Software Development and Project Management, what specifically is OIT doing different now? VA’s been talking about its 

leadership in Agile among agencies since 2014. 

Ms. COUNCIL. Yeah. I’m excited about this. One of things that 

you should have received was the VIP Process, which is now standing up, that is our Enterprise Portfolio Management Office. That 

is our intake process. So if you look at PMAS and you compare it 

to what we’re doing now with full Agile and VIP, we reduced the 

time that we were spending in document preparation by 88 percent. 

We went from 55 documents to 6 plus available to operate. We 

are in a full Agile capability which means that you’re following the 

80/20 rule, which we will be able to produce in 70 percent faster 

time with better quality. We have the intake process which allows 

us to assess the business case. And if something does not have a 

viable business case, it will not get done. 

Ms. WALORSKI. I don’t want to interrupt, but let me just ask you 

this. So I really do think your presence to this conversation has 

been incredible. I really think you have brought this so much farther, so much quicker, than some of the folks have in the past. And 

so I really appreciate what you have done and how open you have 

been with our Committee. 

And I guess, you know, from my perspective, and you know, we— 

-I really want this to work— 

Ms. COUNCIL. Uh-huh. 

Ms. WALORSKI [continued]. You know, I want the calls that we 

get in our office to decrease. I want our veterans to actually find 

a seamless, smooth transition, and I want this to work, you know, 

just as much as they do. And I am concerned, you know, as we talk 

about, you know, another rollout, another this, another that, and 

to echo what Congressman O’Rourke just said, is there a plan in 

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19 

place, given the political realities of how this continuity often gets 

interrupted, is there a plan now, for example, that says no matter 

who is behind this seat, this is what is going to happen? That actually is a plan in place that really is not going to be changed in another, you know, another development program with another, you 

know, 20 million dollars or whatever? Is this going forward regardless? 

Ms. COUNCIL. Yes, that was the main purpose of how the strategy was defined, because that was my biggest concern. I didn’t 

want to spend the effort, either, and not see the team continue. So, 

you know, we’ve added an additional 11 new leaders within OI&T. 

We’ve added seven new senior leaders who will be out into the 

field. 

Ms. WALORSKI. And let me just ask you about those leaders. 

Ms. COUNCIL. Yeah. 

Ms. WALORSKI. Are those leaders competent in the private sector, 

competent folks like when you came in, and you come in with all 

those competency and expert—are these the same kind of 11, or are 

these people that are just elevated inside the VA? 

Ms. COUNCIL. No, these people are coming from outside in private industry as well as from other agencies. They’re highly rated 

and we are very competitive. I am excited to say that when we look 

at, even our—actually, Dr. Constantian here is an account manager 

for VHA and that’s why he’s here. There are now standing account 

managers within OIT that didn’t exist before, so that we actually 

have a head to head relationship with our business partners and 

having aggressive conversation about the work that we’re doing, 

and how we’re spending our dollars. 

Ms. WALORSKI. I appreciate it. I am out of time. And I appreciate 

it, Mr. Chairman. I yield back. 

Mr. COFFMAN. Dr. Ruiz, you are now recognized for five minutes. 

Mr. RUIZ. Thank you, thank you. Last year in testimony to this 

Committee, Secretary McDonald said the following regarding the 

VA’s accomplishment, quote, ‘‘We were the ones that discovered 

that aspirin was important for heart disease, first liver transplant, 

first implantable pacemaker. Last year, two VA doctors invented 

the shingles vaccine. That research is important for the American 

people, and I didn’t even mention PTS or TBI or prosthetics, things 

we are known for.’’ 

So, Ms. Council and Dr. Shulkin, please explain why the VA is 

unable to develop or acquire the technology possessed by most modern health care systems and required to efficiently share health 

records and schedule appointments, yet can continue to make such 

progress in other areas of the Department. What are your logistical 

and political barriers? 

Dr. SHULKIN. We appreciate the question and the recognition of 

VA’s track record of innovation. VA is a leader in electronic medical 

records. There is no system that has the extensive experience with 

EHR than VA. I will tell you, I’ve spent my life practicing in the 

private sector. I’ve now practiced in the VA system. It’s my first 

time using the EHR. And our clinicians really like the VistA EHR. 

What Ms. Council is saying is, and I think what Congresswoman 

Brownley was getting at is, the world has changed a lot. And is 

this 40-year-old EHR going to be the system that VA should stick 

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20 

with for the next 20 years? And that’s where Ms. Council is saying 

we owe it to veterans and to all of you to make sure that we believe 

that’s the right answer, and that’s where I— 

Mr. RUIZ. I think you got to be careful with that notion, because 

health care information, diseases, recordkeeping changes, and it is 

flexible, so you can’t make a guarantee that what we have now is 

going to last 15 years, because we don’t want it to last 15 years. 

We want it to change with the ever needs of the patients and the 

community. And so you have got to, you know, manage some expectations that the information we get changes. So I don’t, you know— 

if you say you are going to pick one, and then you are going to keep 

that same one for the next 15 years, then you are setting yourself 

up for failure. And you are also going to keep an archaic, 20 years 

from now, system in place just because you have committed to that. 

Dr. SHULKIN. I think we’re—I may not have been articulate 

enough, I think we’re agreeing with that— 

Mr. RUIZ. Okay. 

Dr. SHULKIN [continued]. —which is saying today, VistA is actually 130 separate VistA systems, and new technology puts stuff in 

the cloud and makes it a singular system so you can be more agile 

and change it. 

Mr. RUIZ. And I think one of the most important things you can 

do other than creating a more modern, flexible system that 

matches the needs of the patients and the doctors where you practice, in order to provide the best care, is to make it interoperable 

with the private sector, and in the private sector they are having 

difficulties in doing that themselves— 

Dr. SHULKIN. Right. 

Mr. RUIZ [continued]. —so it would be helpful if you could lead 

the charge to make sure that you do that, because, if I am an emergency physician, and I see a patient that is a veteran, and I can’t 

get the last CAT scan to compare their abdominal CAT scan or I 

can’t get their latest EKG, then I am limited in the decisions that 

require resources that I can make and more than not, because I 

care about the patient, I tend—you know, I will not take the risk 

for the patient, and I will do what I need to ensure that the patient 

is going to be healthy. And that means more cost, simply because 

I can’t access a CAT scan or an EKG from another institution. 

Ms. COUNCIL. Exactly. And so, Congressman, we assessed the solution that we’ve laid out, the one system, actually does that in the 

cloud using software as a service. It builds around, I have mentioned earlier, the FHIR concept, which is Fast Health Interoperability Resources, which allows you to pull those resources together, use that information, and redeploy it back out. 

Mr. RUIZ. With the private sector, not within— 

Ms. COUNCIL. Wholly with the private sector, and we believe that 

the VA should be the leader in this, as the largest health integrator, and actually drive that forward on an HL7 platform. 

Mr. RUIZ. Thank you. I yield back my time. 

Mr. COFFMAN. Thank you, Dr. Ruiz. 

Mr. Huelskamp, you are now recognized for five minutes. 

Mr. HUELSKAMP. Thank you, Mr. Chairman. Chairman, I appreciate this joint hearing on this topic, and I apologize for my tardiness. 

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I want to follow-up on just a few things, and I apologize if they 

have been covered before. But the strategic hold on the MASS system, can you describe that for me, if you haven’t already for the 

full Committee, and I was kind of curious what a strategic hold is 

versus a non-strategic hold? 

Dr. SHULKIN. I’d be glad to do that briefly, Congressman. We do 

have a contract with MASS and we could execute that at any point. 

We’ve decided since we have a system that’s currently available, 

VSE, VistA Scheduling Enhancement, that is being rolled out as 

we speak to VAs, to roll that out because it’s in the best decisions 

right now since it’s available to veterans, and to taxpayers to do 

that. We will have that done over the summer and be able to evaluate did the VistA Scheduling Evolution meet the needs of veterans, 

and if not, then we’ll proceed with a pilot for MASS, which would 

be a ten-month pilot at three sites at a cost of $152 million. 

Mr. HUELSKAMP. So what have you spent on MASS already, and 

that is all on hold, and that— 

Dr. SHULKIN. Yes. 

Mr. HUELSKAMP [continued]. —if it doesn’t go forward, we would 

lose all that— 

Dr. SHULKIN. Yes, $11.8 million to date on MASS, already. The 

VistA Scheduling Enhancement total cost is 6.4 million. 

Mr. HUELSKAMP. Yeah, and VistA, that is—you talk about rolling 

it out, it is still just pilot, correct? We are not rolling anything out, 

we are still testing it, beta testing it? 

Dr. SHULKIN. Yes. Today, it’s actually being used in two sites, in 

Asheville, North Carolina, and Salt Lake City. I have the user evaluations which I reviewed last night, which are tremendous in 

terms of its receptivity. It’s planned to roll out to 11 more, or 11 

total VAs by the end of this month or within six weeks, and then 

the national rollout. 

Mr. HUELSKAMP. You mentioned Salt Lake City. I am looking at 

the testimony, I don’t see that on the list of the— 

Dr. SHULKIN. Yeah. 

Mr. HUELSKAMP [continued]. —the VSE IOC sites? 

Dr. SHULKIN. Yeah, I’ll be glad to share—actually last night, I 

have it on me, I’ll be glad to share the user feedback from Salt 

Lake City. 

Mr. HUELSKAMP. Okay. How seriously did you consider a commercial alternative to the contract, which apparently strategic hold 

could be abandoning that work and doing it with VistA? Strategically, what did you consider on the commercial side, and I know 

Zocdoc was mentioned, I haven’t used that. I was looking at it preparing for this hearing, but describe the process by which you decided not to use any commercial alternatives. 

Dr. SHULKIN. Well, MASS is a commercial alternative. It’s made 

by the Epic Company, which is a leader in health information systems. It was selected through a competitive process, and we do 

have an IDIQ contract with them that we could execute at any 

point. 

Mr. HUELSKAMP. It is an operating system? 

Dr. SHULKIN. Oh, yes. 

Mr. HUELSKAMP. And so you spent how many dollars just to— 

Dr. SHULKIN. Eleven point eight million. 

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Mr. HUELSKAMP. Did you ever use it as a pilot program— 

Dr. SHULKIN. No. 

Mr. HUELSKAMP [continued]. —or at least try it? 

Dr. SHULKIN. Nope, the pilot program would be $152 million to 

implement because of all the interfaces and the spreads, so that’s 

the decision which we’re facing right now. We decided, you called 

it a strategic hold, is that it’s in the best interest of taxpayers before we proceed with the $152 million, to see if VSE, which is in 

the field now being rolled out, meets the needs of veterans. If not, 

we can proceed with MASS. 

Mr. HUELSKAMP. Still, maybe you can follow-up with something 

later if—went down the MASS road for a while and then apparently have abandoned it. Strategic hold is your name, not mine, 

and I am just trying to figure out how we got there. Now we are 

back on something that has, you know, been around for decades, 

and trying to make that work. 

Another question, and more directly, or I guess more broadly on 

this, does anything in the Choice legislation or other current statutes require you to set up a system in which a contract or a third 

party or somebody other than the veteran can make their own appointment? 

Ms. COUNCIL. Not that I’m aware of. 

Dr. SHULKIN. I’m not aware of that in the legislation. 

Mr. HUELSKAMP. So you are free to do that? 

Dr. SHULKIN. Yes. 

Mr. HUELSKAMP. And that is what bothers me more broadly, I 

think we are still—what I am seeing is just kind of this attempt 

at pushing through a model which doesn’t work, in my opinion, in 

the 21st century. Maybe it works for a few folks. But it is also, for 

instance, we have got another system out there with many of the 

veterans who are in other systems. Many of them are in Medicare, 

and this is not the Medicare system at all. We don’t require you 

to go through Medicare to make an appointment, but somehow it 

looks like the track is still push veterans through this system. Can 

you describe a little bit more why we still think we have got to 

push it through a system rather than letting, you know, something 

like a commercial term where you don’t have to call the VA, you 

don’t have to work through the contractor, you call the hospital and 

do like you do for Medicare. 

Again, these veterans, many of them, go through the Medicare 

system. That was one of the concerns that the cost would be so 

great of Choice because folks would, yeah, abandon Medicare or 

other options because the VA system would work so well, and not 

quite happen that way. So but just, more description of that, I am 

concerned about still trying to put us in the same old model from 

30 or 40 years ago, which I don’t think fits our needs of veterans 

in this century. 

Dr. SHULKIN. Yeah. VA has a long history of using care in the 

community for veterans. We’ve been doing this for a long time. You 

used to have a system, I think like you were describing, where veterans would seek care in the community, and we would go and 

schedule it, very similar to the way that you schedule with Medicare. The Choice legislation did require— 

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Mr. HUELSKAMP. If I interrupt, with Medicare, they don’t schedule the appointment, do they? 

Dr. SHULKIN. No, and so I think what you’re describing now, 

where we’re seeing so many complaints is the veteran needs to go 

to the TPA to access Choice. And so that has added a level of complexity. And this is where we’ve submitted legislation for your consideration to try to simplify and streamline these care in the community programs. Because we agree with you, it’s too complex 

today. 

Mr. HUELSKAMP. Yeah, that is why I asked first and this is—do 

we need any legislative changes to allow the veteran to make their 

choice directly, and I don’t think so. But I appreciate that. With 

that, Mr. Chairman, I yield back. 

Mr. COFFMAN. Thank you, Mr. Huelskamp. 

Mr. Takano, you are now recognized for five minutes. 

Mr. TAKANO. Thank you, Mr. Chairman. 

Is it Dr. Shulkin? There are some aspects to the legacy VistA 

system that you definitely want to see preserved and continued; am 

I understanding that correctly? 

Dr. SHULKIN. I think there are many, many good things about 

the VistA system and VistA Evolution, which is the newer sort of 

what we call eHMP, it’s the web-based version; it also has many, 

many great features. I think at the same time, what Ms. Council 

is saying is, is that she wants to make sure, and we’re going to do 

this together, that this is the appropriate technology for the future 

of VA. 

Mr. TAKANO. And you are going through that evaluation process 

now? 

Dr. SHULKIN. Yes. 

Ms. COUNCIL. Yes. 

Mr. TAKANO. Okay. You know, I mean, I heard about the 130 

separate systems, you are going to use the cloud, and try to get it 

all sorted together. And you are also looking at possibly a major 

replacement, or not. You are sort of trying to figure all of that out; 

is that correct? 

Ms. COUNCIL. We actually have defined a new technical digital 

health platform for VHA. It’s currently being looked at by the 

users, and I am currently looking for an ability to build the prototype, so that we can show it to you, but also, so that the users can 

play with it. It leverages EHR as a health record and does not have 

all that complexity that VistA has in it, and so we’re agnostic as 

to which VHR, but it also is in the cloud, it’s highly agile, and it’s 

highly interoperable with care in the community, the DoD, and 

anyone else that we’d have to engage with on behalf of the veteran. 

Mr. TAKANO. So that leads me to this next question. Dr. Shulkin, 

in your testimony you mentioned much of what, is it Dr. Council, 

or is it Ms. Council? 

Ms. COUNCIL. It is sometimes, it depends on whatever you 

want— 

Mr. TAKANO. That the VA plans to expand partnership with 

health information exchanges that are outside the VA— 

Dr. SHULKIN. Uh-huh. 

Mr. TAKANO [continued]. —or HIEs to improve access to health 

information between the VA and community providers. I want to 

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24 

mention that we have a very, very successful HIE in the Inland 

Empire, the region of California that I represent and Dr. Ruiz represents, and we, actually by the end of the year, expect that health 

information exchange to include all of our hospitals in our region, 

a three million population strong, and we even—in other parts of 

southern California, other parts of California rather than start 

their own HIEs are actually leveraging off the work that our HIE 

has done. I understand it supports nine million patient files. 

Dr. SHULKIN. Uh-huh. 

Mr. TAKANO. And by the end of the year, it will include all the 

hospitals by the end of the year. How has the outreach to HIEs 

gone, and what challenges do you face as you look to form partnerships with HIEs such as the one I just described? 

Dr. SHULKIN. Right. I completely agree with you, Congressman. 

When I was running hospitals prior to taking this position, I was 

participating in functional HIEs. So VA wants to be part of these 

regional HIEs. We currently are partners with 71 today, 71 HIEs 

active throughout the country. That’s where it does impact 475,000 

veterans today, where we’re exchanging records with 713 hospitals 

as part of these 71 community partnerships. So we want to expand 

that. It’s the future, and it’s the only way that you’re going to make 

community care and VA care work as an integrated network. 

Mr. TAKANO. And what is your timeline for that? What is your 

timeline to get that done? 

Dr. SHULKIN. It goes region by region, because as I said, some 

regions are really pushing it and others are a little bit slower to 

get there. But part of what we’re doing with the revised care in the 

community program that Representative Huelskamp asked about, 

we are using the 421 million dollars to accelerate a VA portal into 

these HIEs. 

Mr. TAKANO. And how—of the 77 that you already are doing 

partnerships with— 

Dr. SHULKIN. Uh-huh. 

Mr. TAKANO [continued]. —how meaningful is the interoperability? 

Dr. SHULKIN. It’s an exchange of documentation, an exchange of 

lab information, medical record information, it’s what HIEs do. I 

mean, there’s no—you don’t enter new data into it, it’s really readonly capabilities. 

Mr. TAKANO. Okay. Thank you, Mr. Chairman. I yield back. 

Mr. COFFMAN. Thank you, Mr. Takano. 

Dr. Shulkin, using VAR, can the veterans actually see a calendar 

for available appointment slots? 

Dr. SHULKIN. Yes, Mr. Chairman. In relatively limited today, primary care and mental health. But they can see what appointments 

are available to them so they select what’s best for them. 

Mr. COFFMAN. And what happens if the veteran requests say, 

three dates that are not available? What would occur in the system? 

Dr. SHULKIN. I assume that if it’s not working for them, because 

I would call that not working, I’d be frustrated. They have to pick 

up the phone and call. 

But Alan, do you have a better answer? 

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Mr. CONSTANTIAN. If the three dates they selected with the VAR 

system were not available, they’d have to either pick up the phone, 

as Dr. Shulkin said, or make a subsequent request. 

Mr. COFFMAN. So let me just say something. I think we are coming full circle on this, that we instituted a Choice Program because 

of problems in the VA scheduling system. Secretary McDonald was 

in Denver, Colorado last weekend, and his statement about the socalled quote-unquote scandal was that it was merely a lack of 

training of VA appointment personnel. I differ with that. I think 

it was fundamentally due to corruption, that they had manipulated 

the system in creating a secret list in order to get cash bonuses. 

And, you know, there is not even an acknowledgment of that. I 

think only six people out of what was a systemic problem were held 

accountable, that were responsible. 

And so, I am very concerned about turning the—going full circle 

and giving it back to the people that created this problem, that 

caused us to enact the Choice Program. And where we have programs like Medicaid, Medicare, TRICARE, that, don’t require that 

and so I just want to state my reservation about this. I think there 

are some other things that are being worked on that are very important. Obviously, I had a discussion about cyber security yesterday, and I was very disappointed in the answer that I received on 

that. But I just have—I think there is a cultural problem here that 

has not been resolved. 

And, let’s see. Ms. Brownley? You are now recognized for five 

minutes. 

Ms. BROWNLEY. Thank you, Mr. Chairman. I appreciate it. 

I just wanted to follow-up on my line of questioning earlier with 

regards to, you know, the core VistA system, and it is my understanding that the independent assessment recommended the VA 

conduct a cost-benefit analysis between a commercial, off the shelf 

product and/or continuing the use of the VistA health record currently in use. So is the VA currently undergoing that, or what are 

we doing? 

Ms. COUNCIL. We actually— 

Ms. BROWNLEY. It sounds like you are thinking a lot about it— 

Ms. COUNCIL. No, we actually have done the business case. The 

business case analysis was done last fall. Based upon that, we decided that the right thing to do is lay out the new digital health 

platform, because that’s really what’s needed for the future. 

Ms. BROWNLEY. Uh-huh. 

Ms. COUNCIL. If VHA is going to provide health care in the future and today, it needs to move into a digital platform, and that’s 

what we have laid out. We’re building the view for it, so people can 

see what we’re talking about, and Dr. Shulkin is looking at it from 

a functional point of view and the user. 

Ms. BROWNLEY. So when you say you have done a business analysis, that is not really a cost-benefit analysis, is it, or— 

Ms. COUNCIL. The business case is a cost-benefit analysis— 

Ms. BROWNLEY. Okay. 

Ms. COUNCIL [continued]. —looking at the overall long-term ability to maintain it, what it would take if we wanted to change it, 

how could we get it onto an architecture that is more agreeable and 

agile so they can move and change as health care is changing. 

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Ms. BROWNLEY. Uh-huh. 

Ms. COUNCIL. Also, how would we work with the care in the community, but fundamentally four core things need to be in a health 

care system. You need to have clinical management, you need to 

have hospital operations capability, you also need to have the veteran experience core to what we offer, and you have to have predictive analytics. We do not have that today with VistA, and so we 

decided to pull and build the new digital health platform to address 

it after reviewing that business case last fall. 

Ms. BROWNLEY. Okay. Very good. And, you know, I would like to 

know more about the digital health platform and all of the different 

possibilities in terms of how it can support veterans and their 

needs. 

I know I mentioned this to you in my office yesterday, and one 

of my frustrations, and I think probably all of us who sit here on 

the dais, their frustration is that we never—in terms of accountability, we never seem to have an agreed-upon matrix of what we 

are looking for, and let’s just talk about scheduling and wait times 

is one of those metrics. 

And so I’m just hoping that as we proceed in this system, that 

we all can agree on what we are looking for, and how we can hold 

you accountable and ourselves accountable for making sure that we 

are meeting the appropriate needs that we are looking for, because 

I think sometimes we have—you may be looking at something, and 

but we are looking for something else, and those two issues never 

seem to meet. 

Ms. COUNCIL. And that’s a core backbone of the new development, because you need analytics. That’s what you really want to 

understand: how well things are performing, how well are we responding, and frankly, how well the diagnoses and what we decide 

to do for the veteran’s actually working for that veteran. That is 

core to this system and it doesn’t require human interface to get 

that information. 

Ms. BROWNLEY. Well, and I think we need to have that discussion about what those—you know, what are we going to get from 

those analytics, and so that we all have sort of a common understanding of it. 

And just one last, very quick question, you know I don’t want to 

dwell on this, but we obviously have spent millions and billions of 

dollars on trying to make an IT system that works. And I guess 

my question is, of those millions and billions of dollars that we 

have spent, was any of that money, in essence sort of worthwhile 

in terms of what you are building on and trying to come to today? 

Dr. SHULKIN. Yeah. First of all, you know, seeing patients in the 

system and using VistA, the country should be proud that we developed this system. Doesn’t mean that it’s going to be the system 

for the future, but it’s working today, millions of veterans’ lives depend upon it, and it helps VA provide better quality than the private sector in many, many measures that’s consistently published 

in the best journals in America. 

Secondly, VSE, which is the, I’m sorry, VistA Evolution, which 

is where this 510 million went to over the last couple years, is actually now being launched. April 5th it went into five sites. So 

you’re finally seeing, with all these years in development, all that 

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money, it’s actually now, just this April, being put into the system. 

It’s going to be a major advance. So whether all of it was necessary, 

whether it could have been done more efficiently, I’m sure that it 

could have been done more efficiently, but absolutely not a waste, 

Congresswoman. It’s here now. 

Ms. BROWNLEY. Thank you very much and thank you all for your 

testimony. I yield back. 

Mr. COFFMAN. Thank you, Ms. Brownley, Ranking Member 

Brownley. 

Dr. Benishek, you are now recognized for five minutes. 

Mr. BENISHEK. Thank you, Mr. Chairman. 

I have got just a few more questions about where I was when I 

was asking the questions last time, and the DoD, VA interoperability now, so there was 55,000 VA people who are able to access 

both DoD and VA records of veterans. We are not sure the amount 

of veterans that they are actually able to access. Are these health— 

I wasn’t sure because I think maybe you answered them in different ways—are these health professionals that have access to 

this, or are these veteran benefit people that have access? 

Dr. SHULKIN. Both. Both. 

Mr. BENISHEK. Both. So then what percentage of this and how 

many people are we talking about. 55,000, is that what percentage 

of that, is that ten percent of the system or— 

Dr. SHULKIN. Well, of health professionals. You know, it may be 

as low as 20, 25 percent of the system. 

Mr. BENISHEK. All right. Okay. That is kind of where I was going 

there. 

Dr. SHULKIN. Yeah. 

Mr. BENISHEK. So there is some definite work to be done there. 

Dr. SHULKIN. Absolutely. Training, yes. 

Mr. BENISHEK. So it is basically a training issue then, you think? 

Dr. SHULKIN. It’s primarily a training issue. You have to—it’s not 

easy, at least not easy for me. You have to leave, you have to go 

out of a system— 

Mr. BENISHEK. So by December you think we will have that better then, I mean, full up to speed then— 

Dr. SHULKIN. Yeah. 

Mr. BENISHEK [continued]. —Ms. Council? 

Ms. COUNCIL. Yeah, it’s an integration issue with VistA, and 

that’s one of the reasons we need to get to a new digital health 

platform. Everything’s separate, and that is the root of the issue. 

Mr. BENISHEK. I want to ask another question, now this is still 

about this self-scheduling thing. So in the consolidation, we are not 

going to rely on the third party people to do the scheduling, or we 

don’t know that yet? See, I have a problem if a veteran calls, I need 

an appointment, they get the appointment and then the eligibility 

and everything is figured out later? How is that going to actually 

work, Dr. Shulkin? 

Dr. SHULKIN. Yeah. We know the current system isn’t working 

the way it should for veterans. No disagreement there. So what we 

have proposed is a new streamlined system. We have actually released this week a draft RFP to the industry to seek industry partners who could help us do this better. We believe we’re going—VA 

can’t do this alone. I hear the skepticism. I don’t think we’re trying 

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28 

to say that we should be doing this alone. So we are seeking—and 

the RFP will be released, a full one, later on this spring with a selection in the fall, for partners to help us do this better, because 

frankly this is what many managed care plans and other companies are doing much better than we are right now. 

Mr. BENISHEK. All right. Okay. 

Let me ask you another question now. There is this Fee Based 

Claim System, that is involved with paying providers in the community, and apparently the VA has this auto-adjudication update 

possibility to speed this along. Do you intend to make that happen, 

or, this is a problem with the payment issue? 

Ms. COUNCIL. Yes, we do. 

Mr. BENISHEK. What is the story there? 

Ms. COUNCIL. Yes, we do. As part of the integration for community and care includes eligibility, referral authorizations, provider 

payments and customer service being tied into one service, so we 

can see that seamlessly, because it can’t be done choppy like it is 

right now. Right now it’s very human labor intensive. 

Mr. BENISHEK. Is that something that is going to happen soon, 

or you have to wait until the whole integration is done, or, can it 

just be done now? 

Ms. COUNCIL. No, I think what we needed were the requirements 

coming in from the business partners which we now have. We can 

make the changes and then upload that system. 

Mr. BENISHEK. All right. Well, I have just got a few more minutes here, so I am just going to comment. And this has been an 

ongoing issue, and, you know, I appreciate your working on all 

these things. But it seems to me that in the private sector, many 

of this IT stuff is, you know, the problems are solved and then the 

system is improved on a constant basis rather than trying to develop a huge comprehensive fix. And then, you know, by the time 

the fix is actually figured out, it is obsolete, you know, so why isn’t 

that more the way that we are doing this than what seems to be 

happening here? 

Ms. COUNCIL. That is actually the way it should work. We have 

365 data centers within the VA, 130 instances of VistA, and 834 

custom systems. In addition, they’re spread out across the 1,500 

health systems, and it was built as it went. It looks nothing like 

what you would see in private industry, and fundamentally, what 

we’re laying out is a digital health platform that will get us there. 

I hundred percent agree with you, you don’t have to get a hundred 

percent of the solution in place to start. You could start with 20, 

30, 40 percent and just get better over time. But that requires a 

standard platform, it requires one instance, one solution, and a 

process that everybody uses, and that was not how the VA was 

built. 

Mr. BENISHEK. All right. I am out of time. Thank you, Mr. Chairman. 

Mr. COFFMAN. Thank you, Dr. Benishek. And thank you to our 

witnesses, you are now excused. 

I ask unanimous consent that all Members have five legislative 

days to revise and extend their remarks and include extraneous 

materials. Without objection, so ordered. I would like to once again 

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29 

thank all of our witnesses and our audience members for joining 

us in today’s discussion. With that, this hearing is adjourned. 

[Whereupon, at 11:37 a.m., the Subcommittees were adjourned.] 

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A P P E N D I X 

Prepared Statement of Dr. David Shulkin 

Good afternoon, Chairman Benishek, Chairman Coffman, Ranking Member 

Brownley, Ranking Member Kuster, and Members of the Subcommittees. Thank you 

for the opportunity to discuss the progress that the Department of Veterans Affairs 

(VA) is making towards modernizing our information technology (IT) infrastructure 

to better serve our VA business partners and our Nation’s Veterans. We will also 

discuss scheduling, claims processing and adjudication, and medical record sharing 

initiatives at the Department. In order to successfully carry out those initiatives and 

our consolidation of community care programs, in addition to the legislative authorities and resources identified in our October 30, 2015 report to Congress, 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. We are accompanied today by Dr. Alan Constantian, Deputy Chief Information Officer in the 

Office of Information Technology (OI&T). 

New VA IT Strategic Plan 

OI&T is at a critical inflection point. Persistent internal challenges exist in delivering IT services, and external pressures are compelling 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. 

With this in mind, VA developed a new IT strategic plan. Our new vision is to 

become a world-class organization that collaborates with its business partners to 

provide a seamless, unified Veteran experience through the delivery of state-of-theart technology. Our guiding principles are to be transparent, accountable, innovative, and team-oriented. To build trust, we are committed to measuring success, investing in the capabilities of our employees, and collaborating across VA. 

We have created five new key functions to support VA’s strategic objectives. 

1.The Account Management function establishes a clear, consistent process for understanding and meeting the needs of our business partners and our customers. 

2.The Enterprise Program Management Office (EPMO) function monitors key information to improve project execution and deliver better outcomes. 

3.The Data Management function will ensure interoperability with our partners 

and protect Veteran data. 

4.The Strategic Sourcing function will focus on knowledge sharing, best practices, 

and sharing insights on new technologies. 

5.Finally, the Quality and Compliance function enables us to adhere to appropriate policies and standards to eliminate material weaknesses. 

Building a strong team and ensuring that the mission continues past 2016 is vital 

to OI&T’s transformation. IT is a field characterized by constant evolution. Veterans 

have earned the best care and benefits available which must be enabled by the best 

technological solutions and be empowered by the most skilled employee base. We 

must embrace creative staffing approaches and incentivize the best and brightest 

talent, both within and beyond the Federal government, to deliver world-class solutions. 

However, talent management is not simply attracting the right people. It is retaining those with a passion and a commitment to our mission by fostering a compelling, rewarding environment. We are emphasizing our team’s development as a 

key priority. The goals and milestones of our enterprise strategy will cascade 

throughout the team’s performance plans at all levels. We are also customizing development and education programs, and by the end of 2017, VA will develop a 

meaningful employee career plan - a first in OI&T. Most importantly, we are leading talent development from the highest tiers of the OI&T team. We are evaluating 

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our leadership approach to ensure that we have the right leaders in the right positions. We are infusing new perspectives and skills by hiring new talent. OI&T has 

added 5 senior leaders in critical roles and will add 11 more in the next 90 days. 

This team will realize our strategies and carry out our mission now and into the 

future. 

This transformation will be different because we have the key components for success. Over three phases of implementation, OI&T will stabilize and streamline core 

processes and platforms, eliminate material weaknesses, and institutionalize a new 

set of capabilities to drive improved outcomes. 

Enterprise Program Management Office 

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 requirements. 

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 establishes a single release process with a predictable cadence that all VA organizations will follow by the end of 2016. It reduces 

overhead and eliminates redundancy in review, approval, and communication processes. These 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 6- 

month to a 3-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. 

Enterprise Cybersecurity Strategy 

OI&T is facing the ever-growing cyber threat head on. The first step in our transformation was addressing enterprise cyber security. We delivered an actionable, farreaching, cybersecurity strategy and implementation plan for VA to Congress on 

September 28, 2015, as promised. 

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OI&T is 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. 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. • 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. VA is increasing our spending on security to $370 million, fully funding and fully resourcing our 

security capability for the first time. In addition, we are investing over $50 million 

to create a data-management backbone. 

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 also testing VAR at 2 facilities and VSE at 10 locations. 

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 VSE Initial Operational Capability (IOC) sites are: 

• Charles George VA Medical Center in Asheville, NC 

• West Palm Beach VA Medical Center in Florida 

• Chillicothe VA Medical Center in Chillicothe, OH 

• VA Hudson Valley Health Care System in New York 

• Louis Stokes Cleveland VA Medical Center in Cleveland, OH 

• VA New York Harbor Health Care System in New York 

• VA Salt Lake City Health Care System in Utah 

• VA Southern Arizona Health Care System in Tucson, AZ 

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

• Washington, DC VA Medical Center in Washington, DC 

VAR allows Veterans to 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. 

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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, MASS includes additional features that 

add complexity, leading us to put MASS on a strategic hold while our VA team ensures that all requirements are met without undue processing difficulties. 

VistA Evolution 

VA is committed to the continued success of VistA, our electronic health record 

(EHR). 

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 development funds to 

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

specific funding for the VistA Evolution program. VA has obligated $151 million in 

IT Sustainment funds and $110 million in VHA funds. 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 Certification 

At VA, we know that a Veteran’s complete health history is critical to providing 

seamless, high-quality 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, we expect that interoperability will 

be certified with DoD, as defined by the 2014 National Defense Authorization Act, 

8 months ahead of the end of the December 2016 deadline. 

For front-line health care teams, the most exciting products from VistA Evolution 

are the Joint Legacy Viewer (JLV) and the Enterprise Health Management Platform 

(eHMP). 

Joint Legacy Viewer 

JLV is the basis for achieving interoperability. JLV is a clinical application that 

provides an integrated, chronological display of health data from VA, DoD, and community health care partners in a common data viewer. It provides a Veteran-centric 

view of the Veteran’s health record rather than a facility-centric view. JLV’s user 

base has outpaced our projections. As of March 27, 2016, JLV had 55,607 VA users, 

and is adding thousands of new users in VA and DoD every week. JLV also provides 

a near real-time view of DoD and VA health care data to benefits administrators, 

which facilitates the processing of Veterans’ claims. All Veterans Benefits Administration offices have access to JLV and can use it to expedite claims. 

Enterprise Health Management Platform 

JLV has been instrumental in connecting the VA and DoD health systems, but 

it does have limitations. We must do more to achieve data interoperability. eHMP 

will expand JLV’s capabilities. eHMP is a modern, secure, configurable web-based 

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health information platform that will expand JLV’s capabilities. eHMP is a major 

cornerstone of building VistA into a Generation 3 EHR, building on the capability 

for clinically actionable, patient-centric data pioneered by JLV. By August 2016, we 

will have a feed set up from VA to DoD through eHMP and the DoD Healthcare 

Medical System Modernization EHR. As the system matures, we will make it available to a broader base of clinicians. We will deploy eHMP with expanded capabilities in mid-2017. Clinicians will be able to write notes and order laboratory and radiology tests. During this deployment, eHMP will support tasking for team-based 

management and communication with improved communication and tracking. Instead of a static, ‘‘one-size-fits-all’’ desktop view, eHMP will allow clinicians to customize their workspaces to treat particular conditions more efficiently or best fit 

their clinical workflows. 

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 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-when fully deployed, eHMP will 

allow clinicians to input new data directly into the system. 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, this is 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 

high-performing network of care. 

Looking to the Future 

Modernization is a process, not an end, and the release of VistA 4 will not be the 

‘‘end’’ of VA’s EHR modernization. VistA 4 has always been scheduled to conclude 

in FY 2018, but there was always an intention to continue modernizing VA’s EHR, 

beyond VistA 4, with more modern and flexible components. 

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 is delivered with 

VistA 4 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. 

To prepare for this new era in connected health, 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. 

Consolidation of Community Care 

On October 30, 2015, VA provided Congress with a plan to consolidate all VA’s 

purchased care programs. The plan included some aspects of the current Veterans 

Choice Program (VCP), established by section 101 of the Veteran’s Choice Act, and 

incorporated additional elements designed to improve the underlying IT infrastructure and therefore, the delivery of community care. In this plan, VA identified several areas for needed IT solutions and improved IT infrastructure including care coordination, claims processing, and medical records management. 

Care Coordination: Robust care coordination requires a strong health IT platform. VA’s future health IT platform will perform the following functions: maintenance of care plans; a user-friendly interface for Veterans and caregivers to see their 

information; and accurate, timely information for providers. Patient-facing and telehealth technologies will allow Veterans to view their health data, care plan, and upLeonard.horne on VACREP0180 with DISTILLER

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date their health and medical needs. Providers will use VA’s medical records exchange to support health information transactions, and care teams will use the platform to support Veterans in their health care experience. 

Claims Processing: VA will pursue simplified processes as it implements industry best practices. VA will focus on standardizing business rules and logic to support 

claims processing and improving interfaces and coordination with dependent systems (e.g., Eligibility). This solution will require a scalable, flexible claims platform 

that supports emerging, value-based care models and streamlines data maintenance, 

storage, and retrieval. This new claims solution will be integrated with Veteran Eligibility Systems, Authorization Systems, and standardized fee schedules to support 

auto adjudication. Integration with fee schedules will support new payment models 

and enable better tracking and billing integration with other health insurance 

(OHI). VA will also integrate the claims processing system with patient information, 

increasing VA’s ability to efficiently bill OHI. 

Medical Records Management: As more Veterans receive care in the community, it is increasingly important to develop tools and solutions for easy access of 

health information between VA and community providers. To address this issue, VA 

will adopt a phased plan consistent with a systems approach to achieve a solution 

that is secure, efficient, effective, and standards based, using health information exchanges (HIEs). In the near-term, VA will focus on building upon current infrastructure to improve consistency, simplicity, and timeliness of information exchange. In 

the medium-term and long-term, VA plans to deploy a robust health information 

gateway and services, and share most clinical information through HIEs. 

As described previously, we are further implementing the web-based JLV to offer 

a simple, complete, and easy-to-understand view of VA and DoD patient data. Second, VA plans to integrate existing exchange services to receive and store standards-based electronic documents, such as Continuity-of-Care Documents. This reduces the use of paper and builds on current VA investments. Third, VA plans to 

expand partnerships with HIEs and use direct secure email protocols. VA plans to 

continue to work with the critical Federal stakeholders to expand the usage of national standards for clinical terminology and data elements. As VA continues to 

evaluate the future solutions, VA will consider the needs of Veterans, community 

providers, and VA staff to ensure that any solution will support the future delivery 

of community care. 

In the medium- and long-term, VA plans to create an electronic, secure, efficient, 

effective, and standards-based environment in compliance with relevant privacy 

laws affecting Veterans and their beneficiaries. VA plans to implement a health information gateway and associated services and share most clinical information 

through HIEs, when available. Currently, HIEs reach 40 percent of U.S. hospitals 

and serve approximately one third of the U.S. population. 

Providers will be able to view, append, and share clinical and administrative information electronically through a VA health information gateway and associated 

services. Veteran clinical and administrative information will then be transferred 

back to VistA. VistA will incorporate an industry-leading information model, terminology normalization, knowledge enrichment, and search indexing for VA, Federal, 

and HIE partner sources. Available health information will drive enterprise-wide 

analytics efforts for process improvement. 

Community Care IT Implementation Strategy 

The New VCP will be implemented through a system of systems approach. A system-of-systems approach involves the design, deployment, and integration of metasystems that are themselves composed of complex systems, which are integrated to 

deliver the desired functionality and end-to-end user experience. Consistent with 

this approach, VA will begin by understanding the desired experience and required 

outcomes for Veterans, caregivers, VA staff, and community providers. VA will then 

examine all the components necessary to achieve the desired outcomes and understand how various component systems will integrate into the broader VA health 

care system and funding environment. To successfully implement this system-of-systems approach requires legislative changes, resources, and a budget. 

Implementation of the system-of-systems approach will be executed through rapid 

cycle deployment using agile methodologies. This will allow VA to fix the most 

pressing issues with community care today, while making continuous updates to 

promote a learning health system that evolves with the needs of the Veteran population. This approach enables VA to implement an integrated system design that allows people, processes, facilities, equipment, and organizations to deliver high-quality, high-value care. 

Based on preliminary analysis of Veteran needs and the desired Veteran experience, VA has determined that the component systems of the New VCP are: 1) InteLeonard.horne on VACREP0180 with DISTILLER

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grated Customer Service Systems; 2) Integrated Care Coordination Systems; 3) Integrated Administrative Systems (Eligibility, Patient Referral, Authorization, and Billing and Reimbursement); 4) High-Performing Network Systems; and 5) Integrated 

Operations Systems (Enterprise Governance, Analytics, and Reporting). 

In order to execute a program of this scope and scale, VA has outlined a transition 

plan consistent with the system-of-systems approach to sequence the design, development, and delivery of the New VCP. In developing the transition plan, VA considered recommendations from stakeholder feedback and the Independent Assessment 

Report. While the transition plan lays out a path forward for the program, the complexity of the change will require development of detailed implementation plans. In 

addition, any changes to the New VCP described in this plan, as a result of input 

from Congress or other stakeholders, will impact the activities described. 

Transitions of this magnitude take years to design and implement; therefore, this 

plan is organized into three phases. 

• Phase I can start immediately and will last 1 year, assuming available resources and required legislative and regulatory changes. This phase will focus 

on the development of minimum viable systems and processes that can meet 

critical Veteran needs without major changes to supporting technology or organizations. • In Phase II, also lasting approximately 1 year, VA will enhance the changes implemented in Phase I through interfaced systems that will appear seamless to 

Veterans and community providers, but will largely continue to employ existing 

infrastructure and technology. • Phase III will be a multi-year effort. In Phase III, VA will begin deploying an 

integrated system-of-systems approach that will support changes in Phases I 

and II and enable a seamless experience across VA and community care for all 

stakeholders. VA also will collect and analyze data on the progress and performance of the implementation to identify opportunities for continuous improvement. 

Through all phases of the transition, VA will build a foundation for a health care 

system that can respond to the evolving needs of Veterans and the changing health 

care landscape at VA and in the community. 

PHASE I: DEVELOP IMPLEMENTATION PLAN AND IMPLEMENT MINIMUM VIABLE SOLU- TIONS AND PROCESSES

During Phase I, VA has begun to develop an implementation plan that articulates 

a clear path forward for each system component across the three phases. This will 

include decisions about long-term system changes and outcomes of make/buy analyses for clinical and administrative technology solutions and network development. 

Phase I will also include the implementation of minimum viable systems and processes for the Veteran, community provider, and VA staff experience. These systems 

will focus on improvements that can be executed without major changes to organizations or technology. 

Phase II: Implement Interfaced Systems and Process Changes 

During Phase II, VA will implement interfaced systems and associated processes 

that will enable a seamless experience for Veterans and community providers. Interfaces will employ existing resources and technology infrastructure, but will appear 

integrated to end users. VA will need support from Congress to ensure that this implementation takes place. Simultaneously, VA will continue to develop fully integrated solutions that will be deployed in Phase III. 

Phase III: Deploy Integrated Systems, Operate High-Performing Network, 

and Make Data-Driven Improvements 

During Phase III, VA will begin to deploy integrated systems, including process 

and organization changes that will enable a seamless Veteran, community provider, 

and VA staff experience. These systems will build on changes in Phases I and II 

and will support collection of quality, value, and performance data for continuous 

improvements. Similar to Phase II, VA will rely on Congress to support Phase III. 

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. 

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1http://www.legion.org/legislative/testimony/231677/va-cybersecurity-and-it-oversight 

2https://oversight.house.gov/hearing/va-cybersecurity-and-it-oversight/ 

Additionally, to make these reforms, as we have discussed in a series of hearings 

on the October 30, 2015, Consolidation of Care report, VA will need short- and longterm assistance with legislative authorities and resources. Transformation of VA’s 

community care program will address gaps in Veterans’ access to health care in a 

simple, streamlined, and effective manner. This transformation will take into account the interdependent nature of external and internal factors involved in VA’s 

health care system. 

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 dialogue. 

This concludes our testimony, and we are prepared to answer any questions you 

or other Members of the Committee may have. 

f 

Statements For The Record 

THE AMERICAN LEGION 

It is no simple task to reform the Information Technology (IT) enterprise of an 

organization the size of the Department of Veterans Affairs (VA). Compounding this 

challenge is the need to mesh reform with the larger goal of a national system in 

which health data flows seamlessly and securely, not only between Federal agencies, 

but between public and private health care systems too. 

Chairmen Coffman and Benishek, Ranking Members McLane-Kuster and 

Brownley and distinguished members of the Subcommittees on Oversight And Investigations and Health, on behalf of National Commander Dale Barnett and The 

American Legion; the country’s largest patriotic wartime service organization for 

veterans, comprising over 2 million members and serving every man and woman 

who has worn the uniform for this country; we welcome this opportunity to comment 

on ‘‘Evaluating VA Information Technology.’’ 

When a patient moves from one health system to another, there’s no guarantee 

his or her electronic medical records are compatible with the new systems. This is 

an issue the nation is struggling with, both in the private and public sectors. Much 

attention has been given to the issue of examining the Departments of Defense 

(DOD) and Veterans Affairs information technology with an emphasis on the departments’ efforts to develop and implement an interoperable electronic health record 

(EHR). 

The 2008 National Defense Authorization Act (NDAA) directed DOD and VA to 

jointly develop and implement a ‘‘fully interoperable’’ EHR, creating an Interagency 

Program Office to facilitate and coordinate the Departments’ efforts. In July 2015, 

DOD awarded a $4.3 billion contract to upgrade the Armed Forces Health Longitudinal Technology Application, while the VA continues to modernize and evolve its 

open-source platform, the Veterans Health Information Systems and Technology Architecture (VISTA). However, problems exist for the EHR platform. The EHR program has been listed on the GAO’s high risk list for 2015. Additionally, recent inspectors general audits of both departments’ Federal Information Security Management Act compliance identified weaknesses and deficiencies in cybersecurity. 

Just last month, The American Legion submitted written testimony to the House 

Subcommittee On Information Technology, Committee On Oversight And Government Reform on ‘‘VA Cybersecurity And IT Oversight.’’ 1 The hearing examined VA’s 

implementation of the Federal Information Security Management Act and Federal 

Information Technology Acquisition Reform Act (FITARA), as well as specific IT investments, including the modernization of the VISTA system. 2

VA is currently engaged in an effort to modernize VISTA. The centerpiece of VA’s 

modernization program, referred to as VISTA Evolution, is an electronic health 

record (EHR) that should be interoperable with the Department of Defense, as well 

as private sector health care providers. The VA received an overall grade of ‘C’ on 

the Committee’s 2015 FITARA Implementation Scorecard, with F’s on both Data 

Center Consolidation and IT Portfolio Review Savings. Additionally, the VA Office 

of Inspector General has found repeat ‘‘material weaknesses’’ in the VA’s 

cybersecurity posture. 

In March of 2013, over a year before the scheduling wait time scandal in Phoenix, 

Arizona would open a wider window of scrutiny onto the entire VA healthcare system, The American Legion was raising concerns about problems with VA’s schedLeonard.horne on VACREP0180 with DISTILLER

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3Testimony of Roscoe Butler, Waiting for Care: Examining Patient Wait Times at VA March 

14, 2013 

4 U.S. Medicine Magazine, VA Leadership Lacks Confidence in New $145M Patient Scheduling 

System, May 2009 5GAO–10–579, Management Improvements Are Essential to VA’s Second Effort to Replace Its 

Outpatient Scheduling System, May, 2010 6 No New VA Patient Schedule System Until 2020 - Bob Brewin, NEXTGOV September 26, 

2014 

uling software. In a hearing before this committee’s Oversight and Investigation 

(O&I) Subcommittee, The American Legion sounded the alarm that contrary to reported numbers, veterans were waiting far longer for care and ‘‘figures are being 

manipulated by employees to look better, statistics such as VA’s reported 94 percent 

of primary care appointments within the proper period, mean very little.’’ 3

A year after our testimony, VA found itself embroiled in the center of a nationwide scandal as concerns that advocates such as The American Legion had raised 

in the past became a staple of nightly news reports. At the heart of this scandal 

was the accusation that, exactly as The American Legion had predicted a year previous, figures were being manipulated to hide wait times through the use of offline, 

paper lists that avoided the public record of the computer scheduling software and 

its automatic tracking of wait times. 

VA would see massive leadership change over the summer of 2014, but would still 

struggle with an IT plan to fix the problems. 

In 2013 The American Legion noted a large portion of the problem was that previous attempts to replace the software had wasted money to no result and that 

there was not plan in place at the time to fix the problems. The American Legion 

stated: 

As we are now a decade into the 21st Century, The American Legion believes that 

VA should also begin implementing 21st Century solutions to its problems. In 1998, 

GAO released a report that highlighted the excessive wait times experienced by veterans trying to schedule appointments, and recommended that VA replace its VistA 

scheduling system. 4 To address the scheduling problem, the Veteran’s Health Administration (VHA) solicited internal proposals from within VA to study and replace the 

VistA Scheduling System, with a Commercial Off-the-Shelf (COTS) software program. VA selected a system, and about 14 months into the project they significantly 

changed the scope of the project from a COTS solution to an in-house build of a 

scheduling application. After that, VHA ended up determining that it would not be 

able to implement any of the planned system’s capabilities, and after spending an 

estimated $127 million over 9 years, The American Legion learned that VHA ended 

the entire Scheduling Replacement Project in September 2009. 5 We believe that this 

haphazard approach of fits and starts is crippling any hope of progress. It has now 

been over three years since VHA cancelled the Replacement Scheduling Application 

project, and as of today, The American Legion understands that there is still no 

workable solution to fixing VA’s outdated and inefficient scheduling system. 

In the summer of 2014 VA announced plans to replace the software, going back 

to the original idea of Commercial Off the Shelf (COTS) software to accomplish that 

end. However, by September reports out of VA estimated the COTS plan would not 

roll out until 2020, over half a decade down the road. 6 VA would ultimately backtrack from this and revise that estimate down to 2017; however the move did little 

to ensure confidence in the ability to rectify the very real problems that the Phoenix 

scandal had highlighted. 

Recent leadership changes, including the addition of Dr. David Shulkin as the Undersecretary for Health and LaVerne Council as VA’s Assistant Secretary for Information and Technology and Chief Information Officer, have been promising moves 

and The American Legion has generally been impressed with the leadership team 

as they have worked to move forward on this issue. 

While briefing VSOs on plans for future integration upgrades, VA shared ideas 

about a plan to move to an online scheduling system where veterans could schedule 

their own appointments. Because our Four Pillars include veterans issues as well 

as issues related to a strong national defense, The American Legion is well versed 

in both VA healthcare as well as TRICARE and military healthcare and was able 

to point out the many problems that arose when TRICARE implemented a similar 

scheduling system online. 

Without scheduling personnel to oversee the process, and manage appointments, 

doctors’ calendars rapidly overfill, clogging the system and making it impossible for 

patients to find time on the schedule. With a scheduling specialist available to determine what the type of appointments are and whether there can be multiple paLeonard.horne on VACREP0180 with DISTILLER

39 

7Plan to Consolidate Programs of Department of Veterans Affairs to Improve Access to Care 

- Oct 2015 8 VA Independent Assessment - Sept.2015 

tients scheduled during certain time periods, the system is reduced to inelegant, 

brute force blocks of time, with little regard to whether doctors and support staff 

could handle different volumes of patients. This is just one example of how a strong 

and transparent partnership between VA and VSO stakeholders improves services 

to veterans. 

We are hopeful that the dialogue with The American Legion and other groups will 

help guide VA moving forward with plans to reform the scheduling software. There 

were serious problems with the way VA had gone about business scheduling appointments for veterans. Under the old system, while veterans were left out on secret lists, few alarm bells were raised inside the system because employees had developed pencil and paper workarounds to the computer solutions VA had implemented. It took the combined pressure of groups like The American Legion and 

brave whistleblowers within VA who cared deeply about the safety of veterans to 

step forward and identify the problem. 

We are now at a stage where VA is engaging with the very people whose membership utilize VA facilities across the country on a daily basis and are best in a position to identify problem areas. Hopefully VA is listening to these critical stakeholders. 

New Veterans Choice Program 

VA’s current community care programs still utilize labor-intensive business processes that are too reliant upon manual data input, prone to errors and processing 

delays. The current system is a decentralized and highly manual process. 7 The New 

VCP plan proposes integrating most of VA’s community care programs into one single program that would be seamless, transparent, and beneficial to enrolled veterans. The New VCP envisions a three-phased approach to implement these changes 

to support improved health care delivery for enrolled veterans. 

The first phase will focus on the development of minimum viable systems and 

processes that can meet critical veteran needs without major changes to supporting 

technology or organizations. Phase II will consist of implementing interfaced systems and community care process changes. Finally, Phase III will include the deployment of integrated systems, maintenance and enhancement of the high-performing network, data-driven processes, and quality improvements. 

To improve the accuracy of claims and reimbursement processing, the 2015 Independent Assessment Report recommended that VA employ industry standard automated solutions to bill claims for VA medical care (revenue) and pay claims for NonVA Health Care (payment). 8 VA states its New VCP will focus on operational efficiencies, to include standardized billing and reimbursement, as well as geographically adjusted fee schedules that are tied to Medicare, as deemed appropriate. These 

foci will make it easier and more appealing for community health care providers to 

partner with VA. 

The American Legion supports VA developing a 21st Century claims and reimbursement processing system that is rules-based, and to the extent possible, eliminates as much human intervention as possible. The system must eliminate the 

guess work out of the claims and reimbursement process and establish an error-free 

claims process that is responsive to veteran’s needs. 

Therefore, we are pleased to see that VA proposes to implement a claims solution 

which is able to auto-adjudicate a high percentage of claims, enabling VA to pay 

community health care providers promptly and correctly and to move to a standardized regional fee schedule, to the extent practicable for consistency in reimbursement. 

Additionally VA proposes to simplify eligibility criteria so veterans can easily determine their options for community care, streamline the referral and authorization 

process to enable more timely access to community care, and standardize business 

processes to minimize administrative burden for community providers and VA staff. 

Improvements in how VA processes claims will enable VA to reimburse community 

providers in a timely and efficient fashion. 

The American Legion understands VA’s New VCP is a huge undertaking and understands the plan will take time to fully implement, particularly the IT component 

required to auto-adjudicate a high percentage of claims. However, we do not believe 

Congress should continue to provide VA an open check book without any assurance 

from VA that their IT plan will work. Congress must require VA to not only provide 

an IT plan, but provide some proof that the claim and reimbursement system will 

work. Too often Congress has authorized funding in support of process improvement 

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9Florida Hospitals: VA owes $134 million in unpaid claims: Miami Herald; November 17, 2015 

initiatives like CoreFLS, and VA’s scheduling system, to name a few, without any 

deliverables, resulting in wasted tax payer dollars that can never be recovered. In 

these situations, the ones who are impacted are our nation’s veterans who are calling out to Congress to fix the system. 

An immediate remedy would be for VA to authorize payment for any Non-VA 

claim immediately upon receipt of a valid bill for health care services that a veteran 

receives. So, we were pleased to hear the recent VA announcement that the TPA’s 

are now authorized to begin paying any Non-VA health care claim under the VCP 

without first obtaining the veterans medical record from the Non-VA health care 

provider. The American Legion applauds VA for initiating this action. This will prevent stories like the November 2015 Miami Herald article about Florida hospitals 

trying to get the Department of Veterans Affairs to pay about $134.4 million in outstanding claims for medical services they provided to veterans. 9 If it is determined 

VA overpaid for the care and services, cost recovery should occur after VA has 

verified the care and services provided to veterans receiving that health care. Of 

course, ensuring that records are ultimately returned to VA is very important and 

we look forward to hearing more about how VA plans to achieve this. 

Finally, VA’s IT systems need to be much more interoperable with the private sector, and veterans should be able to access their records from any setting. The overarching goal should be for the VA to use technology and health information to improve the health and well-being of veterans in ways that makes the information accessible when and where it matters most. 

VA needs to develop a coordinated IT infrastructure for appointment scheduling, 

coding, billing, claims payment and other core VHA business processes, which include the automation of claims payment. This is essential to expanding veteran care 

with community providers. Billing and payment systems must be efficient. 

The entire American healthcare economy is struggling to figure out ways to develop interoperable electronic healthcare records. If this nation is to have truly 21st 

century healthcare, this concept in both the public and private sector is essential. 

VA can take the lead in this field, as they have in so many fields of healthcare in 

providing true innovation. VA healthcare pioneered electronic healthcare records 

with VISTA. VA healthcare pioneered improvements in modern heart surgery, in 

the treatment of Posttraumatic Stress Disorder, and integrated care. There should 

be no reason they should not be trailblazers in this arena if properly supported. 

Conclusion 

The American Legion is deeply committed to working with VA to ensure that not 

only are these IT challenges worked out, but that any and all challenges are resolved to help protect the healthcare system designed specifically to service the 

unique needs and challenges of the veterans’ population. Consistently, veterans 

speak highly of the high quality of care they receive when they can see their VA 

providers, and note how well VA understands their unique sacrifices and military 

culture when they are treating them. Therefore it is doubly important that we solve 

these challenges and make it easier for veterans to access the system best suited 

to treat them. 

The American Legion thanks this committee for the opportunity to explain the position of the over 2 million veteran members of this organization. For additional information regarding this testimony, please contact Mr. Warren J. Goldstein at The 

American Legion’s Legislative Division at (202) 861–2700 or wgoldstein@legion.org 

Æ 

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