VA IT MODERNIZATION

Preparations for 

Transitioning to a New 

Electronic Health Record 

System Are Ongoing

Statement of David A. Powner, Director 

Information Technology Management Issues

Testimony 

Before the Committee on Veterans’ 

Affairs, House of Representatives

For Release on Delivery 

Expected at 10 a.m. ET

Tuesday, June 26, 2018

GAO-18-636T

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO-18-636T, a testimony 

before the Committee on Veterans’ Affairs, 

House of Representatives

June 26, 2018

VA IT MODERNIZATION

Preparations for Transitioning to a New Electronic 

Health Record System Are Ongoing

What GAO Found

According to the Department of Veterans Affairs (VA), the Veterans Health 

Information Systems and Technology Architecture (VistA) and related costs, as 

approximated by funding obligations, were approximately $1.1 billion, $899 

million, and $946 million in fiscal years 2015, 2016 and 2017, respectively. 

These obligations total about $3.0 billion over 3 years to support the system. As 

identified by the department, the obligations were to cover the costs for three 

programs (VistA Evolution, Interoperability, and Virtual Lifetime Electronic 

Record Health) and other supporting investments for activities such as networks 

and infrastructure sustainment. The following table provides a summary of the 

total VistA and VistA-related obligations.

Obligations for the Veterans Health Information Systems and Technology Architecture (VistA)

for Fiscal Years 2015 through 2017, as identified by the Department of Veterans Affairs

2015 2016 2017 Total

VistA Evolution $376,503,022 $195,475,101 $219,192,925 $791,171,048 

Interoperability $55,811,302 $32,755,060 $51,617,011 $140,183,373 

Virtual Lifetime 

Electronic Record 

Health $45,854,411 $28,953,893 $6,356,457 $81,164,761 

Additional VistARelated $668,717,821 $642,100,886 $668,607,654 $1,979,426,362 

Total $1,146,886,556 $899,284,941 $945,774,047 $2,991,945,544

Source: GAO analysis of data provided by the Department of Veterans Affairs. | GAO-18-636T

GAO’s preliminary results indicate that VA is working to define VistA and identify 

system components to be replaced by the new system. However, according to 

VA officials, there is no single information source that fully defines the scope of 

VistA. This situation is partly due to differences in VistA at various facilities. In 

the absence of a complete definition of VistA, program officials have taken a 

number of steps to define the system’s scope and identify the components that 

the new system will replace. These steps have included conducting analyses, 

performing preliminary site (medical facility) assessments, and planning for a 

detailed assessment of each site where the new system will be deployed.

Since VA announced in June 2017 that the department would acquire the same 

electronic health record system as the Department of Defense (DOD), GAO’s 

preliminary results indicate that VA has begun taking actions to prepare for the 

transition from VistA. These actions have included standardizing VistA, clarifying 

the department’s approach to interoperability, establishing governance for the 

new program and the framework for joint governance with DOD, and preparing 

initial program plans. VA is early in its effort to transition from VistA to the Cerner 

system and the department’s actions are ongoing.

In 2011, GAO reported on nine common factors critical to the success of major 

IT acquisitions. Such factors include ensuring active engagement of senior 

officials with stakeholders and having qualified, experienced program staff. 

These critical success factors can serve as a model of best practices that VA 

could apply to enhance the likelihood that the acquisition of a new electronic 

health record system will be successfully achieved.

View GAO-18-636T. For more information, 

contact David A. Powner at (202) 512-9286 or 

pownerd@gao.gov.

Why GAO Did This Study

VA provides health care services to 

almost 9 million veterans and their 

families and relies on its health 

information system—VistA—to do so. 

However, the system is more than 30 

years old, is costly to maintain, and 

does not support interoperability with 

DOD and private health care providers. 

Since 2001, VA has pursued multiple 

efforts to modernize the system. In 

June 2017, VA announced plans to 

acquire the same system—the Cerner

system—that DOD is implementing. 

GAO was asked to summarize

preliminary observations from its 

ongoing review of VistA and the 

department’s efforts to acquire a new 

system to replace VistA. Specifically, 

the statement summarizes preliminary 

observations regarding (1) costs 

incurred for the system and related 

activities during the last 3 fiscal years; 

(2) key components that comprise 

VistA and are to be replaced; and (3) 

actions VA has taken to prepare for its 

transition to the Cerner system. The 

statement also discusses common 

factors critical to the success of IT 

acquisitions that GAO has previously 

identified.

GAO reviewed its prior reports on the 

VistA modernization and on critical 

success factors of major IT 

acquisitions. GAO also reviewed

records of obligations for VistA for 

fiscal years 2015, 2016, and 2017; 

analyzed VA documentation that 

describes the scope of VistA, and 

reviewed program documentation.
Letter

Page 1 GAO-18-636T VA IT Modernization

Chairman Roe, Ranking Member Walz, and Members of the Committee:

Thank you for the opportunity to participate in today’s hearing on the 

planned implementation of the Department of Veterans Affairs’ (VA) 

Electronic Health Record Modernization (EHRM) program.

As you know, the use of information technology (IT) is crucial to helping 

VA effectively serve the nation’s veterans and, each year, the department 

spends billions of dollars on its information systems and assets. Over 

many years, however, VA has experienced challenges in managing its IT 

projects and programs. These challenges have spanned a number of 

critical initiatives related to modernizing major systems within the 

department, including its electronic health information system—the 

Veterans Health Information Systems and Technology Architecture 

(VistA).

We have issued numerous reports on the challenges that the department 

has faced in managing VistA and working to increase the interoperability1

of health information.2 We also have ongoing work for the Committee on 

Veterans’ Affairs to review VistA and the department’s transitional efforts 

to replace the system with a new, commercial-off-the-shelf (COTS) 

system that it is acquiring from Cerner Government Services, Inc. 

(Cerner) under the EHRM program.

 1

Interoperability is the ability to exchange and use electronic health information.

2

GAO, Veterans Affairs Information Technology: Historical Perspective on Health System 

Modernization Contracts and Update on Efforts to Address Key FITARA-Related Areas, 

GAO-18-267T (Washington, D.C.: Dec. 7, 2017); VA Health IT Modernization: Historical 

Perspective on Prior Contracts and Update on Plans for New Initiative, GAO-18-208 

(Washington, D.C.: Jan. 18, 2018); Veterans Affairs: Improved Management Processes 

Are Necessary for IT Systems That Better Support Health Care, GAO-17-384 

(Washington, D.C.: June 21, 2017); VA Information Technology: Pharmacy System Needs 

Additional Capabilities for Viewing, Exchanging, and Using Data to Better Serve Veterans, 

GAO-17-179 (Washington, D.C.: June 14, 2017); Electronic Health Records: OutcomeOriented Metrics and Goals Needed to Gauge DOD’s and VA’s Progress in Achieving 

Interoperability, GAO-15-530 (Washington, D.C.: Aug. 13, 2015); Electronic Health 

Records: VA and DOD Need to Support Cost and Schedule Claims, Develop 

Interoperability Plans, and Improve Collaboration, GAO-14-302 (Washington, D.C.: Feb. 

27, 2014); Electronic Health Records: DOD and VA Should Remove Barriers and Improve 

Efforts to Meet Their Common System Needs, GAO-11-265 (Washington, D.C.: Feb. 2, 

2011); and Electronic Health Records: DOD and VA Have Increased Their Sharing of 

Health Information, but More Work Remains, GAO-08-954 (Washington, D.C.: July 28, 

2008).

Letter
Page 2 GAO-18-636T VA IT Modernization

At your request, my testimony today summarizes preliminary 

observations from our ongoing review. Specifically, the statement 

discusses our preliminary observations regarding (1) costs incurred for 

the system and related activities during the last 3 fiscal years; (2) key 

components that comprise VistA and are to be replaced; and (3) actions 

VA has taken to prepare for its transition to the Cerner system. In 

addition, the statement discusses critical success factors related to major 

information technology acquisitions. We have previously reported that 

these success factors could enhance the likelihood that the new 

electronic health record system acquisition will be successful.

In developing this testimony, we considered our previously published 

reports that discussed the history of the department’s VistA modernization 

efforts. In addition, we relied on our prior report that discussed critical 

success factors of major IT acquisitions.3 The reports cited throughout 

this statement include detailed information on the scope and methodology 

for our prior reviews.

Further, we considered preliminary observations from our ongoing review 

of VistA’s costs, components, and the actions VA has taken to prepare for 

transitioning from VistA to the Cerner system. With regard to the total 

costs of VistA, we obtained records of obligations for VistA-related 

programs for fiscal years 2015, 2016, and 2017, as tracked by the 

Veterans Health Administration (VHA)4 and VA’s Office of Information and 

Technology (OI&T)5

. We then combined the amount of those obligations 

with the amount of other obligations, such as those for supporting 

interoperability and infrastructure, identified by VA as being closely 

related to the development and operation of VistA. We interviewed VA 

officials to understand the source and relevance of the obligations 

 3

GAO, Information Technology: Critical Factors Underlying Successful Major Acquisitions, 

GAO-12-7 (Washington, D.C.: Oct. 21, 2011).

4

VHA is the major component within VA that provides health care services, including 

primary care and specialized care, and it performs research and development to improve 

veterans’ health care services.

5

VA’s OI&T oversees the department’s IT acquisitions and operations. OI&T has 

responsibility for managing the majority of VA’s IT-related functions. The office provides 

strategy and technical direction, guidance, and policy related to how IT resources are to 

be acquired and managed for the department. According to VA, OI&T’s mission is to 

collaborate with its business partners (such as VHA) and provide a seamless, unified 

veteran experience through the delivery of state-of-the-art technology.
Page 3 GAO-18-636T VA IT Modernization

identified by the department and determined that the data were reliable 

for our purposes.

To identify the key components of VistA and the extent to which they 

support health record capabilities for the department, we analyzed VA 

documentation that describes the scope of the system. This 

documentation included the department’s Health Information System 

Diagram, the VA Monograph,

6 the VA Systems Inventory, and the VistA 

Product Roadmap. We also reviewed program documentation identifying 

components of VistA to be replaced by the Cerner system. We analyzed 

these documents for consistency to provide a reasonable basis for our 

observations.

To summarize the actions VA has taken to prepare for its transition from 

VistA to the Cerner system under the EHRM program, we reviewed 

available program briefings, governance documents, and draft plans for 

the EHRM program related to, for example, interoperability, data 

migration, change management, and requirements. We supplemented 

our analysis with information obtained through interviews with relevant VA 

officials.

The work upon which this statement is based is being or was conducted 

in accordance with generally accepted government auditing standards. 

Those standards require that we plan and perform the audits to obtain 

sufficient, appropriate evidence to provide a reasonable basis for our 

findings and conclusions based on our audit objectives. We believe that 

the evidence obtained provides a reasonable basis for our findings and 

conclusions based on our audit objectives.

VA’s mission is to promote the health, welfare, and dignity of all veterans 

in recognition of their service to the nation by ensuring that they receive 

medical care, benefits, social support, and lasting memorials. In carrying 

out this mission, the department operates one of the largest health care 

delivery systems in the United States, providing health care services to 

approximately 9 million veterans throughout the United States, 

Philippines, Virgin Islands, Puerto Rico, American Samoa, and Guam.

 6

VA, VA Monograph, (Washington, D.C.: Jan.13, 2017). The VA Monograph documents 

an overview of the VistA and non-VistA applications used by VHA.

Background
Page 4 GAO-18-636T VA IT Modernization

In 2015, we designated VA health care as a high-risk area for the federal 

government, and we continue to be concerned about the department’s 

ability to ensure that its resources are being used cost-effectively and 

efficiently to improve veterans’ timely access to health care.7 In part, we 

identified limitations in the capacity of VA’s existing IT systems, including 

the outdated, inefficient nature of certain systems and a lack of system 

interoperability as contributors to the department’s challenges related to 

health care.

Providing health care to veterans requires a complex set of clinical and 

administrative capabilities supported by IT. VA’s health information 

system—VistA—has been essential to the department’s ability to deliver 

health care to veterans. VistA contains an electronic health record for 

each patient that supports clinical settings throughout the department. For 

example, clinicians can use the system to enter and review patient 

information; order lab tests, medications, diets, radiology tests, and 

procedures; record a patient’s allergies or adverse reactions to 

medications; request and track consults; enter progress notes, diagnoses, 

and treatments for encounters; and enter discharge summaries.

VistA was developed in house by clinicians and IT personnel in various 

VA medical facilities and has been in operation since the early 1980s.8

Over the last several decades, VistA has evolved into a technically 

complex system comprised of about 170 modules that support health 

care delivery at 152 VA Medical Centers and over 1,200 outpatient sites. 

In addition, customization of VistA, such as changes to the modules by 

the various medical facilities, has resulted in about 130 versions of the 

system—referred to as instances.

According to VA, VistA modules are comprised of one or more software 

applications that support various health care functions, such as providing 

care coordination and mental health services. In addition to VistA, the 

 7

GAO maintains a high-risk program to focus attention on government operations that it 

identifies as high risk due to their greater vulnerabilities to fraud, waste, abuse, and 

mismanagement or the need for transformation to address economy, efficiency, or 

effectiveness challenges. VA’s issues were highlighted in our 2015 high-risk report, GAO, 

High-Risk Series: An Update, GAO-15-290 (Washington, D.C.: Feb. 11, 2015) and 2017 

update, GAO, High-Risk Series: Progress on Many High-Risk Areas, While Substantial 

Efforts Needed on Others, GAO-17-317 (Washington, D.C.: Feb. 15, 2017).

8

VistA began operation in 1983 as the Decentralized Hospital Computer Program. In 

1996, the name of the system was changed to VistA.
Page 5 GAO-18-636T VA IT Modernization

department has other health information systems that must interface with 

VistA to send, exchange, or store related health (e.g., clinical and patient) 

data.9

Since 2001, VA has identified the need for enhancements and 

modifications to VistA and has pursued multiple efforts to modernize the 

system. Two major efforts have included the VistA Evolution program 

and, most recently, the planned acquisition of the same electronic health 

record system that the Department of Defense (DOD) is acquiring.

In 2013, VA established VistA Evolution as a joint program between OI&T 

and VHA that was comprised of a collection of projects and efforts 

focused on improving the efficiency and quality of veterans’ health care.

This program was to modernize the department’s health information 

systems, increase VA’s data exchange and interoperability capabilities 

with DOD and private sector health care partners, and reduce VA’s time 

to deploy new health information management capabilities.10

In June 2017, the former VA Secretary announced a significant shift in the 

department’s approach to modernizing VistA. Specifically, rather than 

continue to use VistA, the Secretary stated that the department planned 

 9

Interfaces enable VistA to communicate with applications within other VA systems, as 

well as selected systems or other federal agencies (e.g., DOD health information systems 

used to treat injured service members), health information exchange networks, and other 

COTS products. There are various mechanisms used to facilitate these exchanges to 

allow the extraction of health information to and from these external products. These 

interfaces utilize, for example, remote procedure calls, Health Level 7, and in a few cases 

secure file transfer protocol for queries and other transactions with VistA.

10VA’s former Executive in Charge for Information and Technology testified in December 

2017 that the cost to upgrade and maintain VistA to industry standards would be 

approximately $19 billion over 10 years, and this still would not provide all the needed 

enhancements, upgrades, and interoperability with DOD.
Page 6 GAO-18-636T VA IT Modernization

to acquire the same Cerner electronic health record system that DOD has 

been acquiring.11

Accordingly, the department awarded a contract to Cerner in May 2018 

for a maximum of $10 billion over 10 years. Cerner is to replace VistA 

with a commercial electronic health record system. This new system is to 

support a broad range of health care functions that include, for example, 

acute care, clinical decision support, dental care, and emergency 

medicine. When implemented, the new system will be expected to 

provide access to authoritative clinical data sources and become the 

authoritative source of clinical data to support improved health, patient 

safety, and quality of care provided by VA.

As previously mentioned, this acquisition is being managed by VA’s 

EHRM program. According to program documentation, EHRM is also to 

deliver program management support and the infrastructure 

modernization required to install and operate the new system.

According to EHRM program documentation, the department has 

estimated that an additional $5.8 billion in funding, above the contract 

amount, would be needed to fund project management support and 

infrastructure improvements over the 10-year period. This amount does 

not fully include government employee costs.

Deployment of the new electronic health record system at the initial sites 

is planned for within 18 months of October 1, 2018,12 with a phased 

implementation of the remaining sites over the next decade. Each VA 

medical facility is expected to continue using VistA until the new system 

has been deployed at that location.

 11In July 2015, DOD awarded a $4.3 billion contract for a commercial electronic health 

record system developed by Cerner, to be known as MHS GENESIS. The transition to the 

new system began in February 2017 in the Pacific Northwest region of the United States 

and is expected to be completed in 2022. The former Secretary of Veterans Affairs signed 

a “Determination and Findings,” to justify use of the public interest exception to the 

requirement for full and open competition, and authorized VA to issue a solicitation directly 

to Cerner. A “Determination and Findings” means a special form of written approval by an 

authorized official that is required by statute or regulation as a prerequisite to taking 

certain contract actions. The “determination” is a conclusion or decision supported by the 

“findings.’’ The findings are statements of fact or rationale essential to support the 

determination and must cover each requirement of the statute or regulation. FAR, 48 

C.F.R. § 1.701.

12The three initial deployment sites are the Mann-Grandstaff, American Lake, and Seattle 

VA Medical Centers. 
Page 7 GAO-18-636T VA IT Modernization

According to VA, the department’s costs for VistA and related activities 

are approximated by funding obligations of about $1.1 billion, $899 

million, and $946 million in fiscal years 2015, 2016 and 2017, 

respectively, for a total of about $3.0 billion over 3 years to support the 

system. Specifically, VHA and OI&T reported obligations to cover the 

costs for the VistA Evolution program, including costs for development, 

operation and maintenance, and payroll for government employees over 

the 3 fiscal years.

Further, in their efforts to fully determine the costs associated with VistA, 

VA officials also reported obligations for activities that supported VistA, 

but were not included in the VistA Evolution program. These other 

obligations were for investments in interoperability initiatives, such as 

increasing data standardization and data sharing between VA, DOD, and 

other government and non-government entities, and the Virtual Lifetime 

Electronic Record Health.13 These obligations also include other VistArelated technology investments, such as networks and infrastructure 

sustainment, continuation of legacy systems, and overall patient safety, 

security, and system reliability.

Table 1 provides a summary of the total VistA and related obligations that 

VA identified for fiscal years 2015 through 2017.

Table 1: Obligations for the Veterans Health Information Systems and Technology 

Architecture (VistA) for Fiscal Years 2015 through 2017, as identified by the 

Department of Veterans Affairs

2015 2016 2017 Total

VistA Evolution $376,503,022 $195,475,101 $219,192,925 $791,171,048 

Interoperability $55,811,302 $32,755,060 $51,617,011 $140,183,373 

Virtual Lifetime 

Electronic 

Record Health

$45,854,411 $28,953,893 $6,356,457 $81,164,761 

Additional 

VistA-Related

$668,717,821 $642,100,886 $668,607,654 $1,979,426,362 

Total $1,146,886,556 $899,284,941 $945,774,047 $2,991,945,544

Source: GAO analysis of data provided by the Department of Veterans Affairs. | GAO-18-636T

 13Virtual Lifetime Electronic Record Health is a program initially started in 2009 to 

streamline the transition of electronic medical, benefits, and administrative information 

between VA and DOD. It is now referred to as the Veterans Health Information Exchange. 

VA Has Reported 

Obligating about $3.0 

Billion to VistA and 

Related Activities 

from Fiscal Years 

2015 through 2017
Page 8 GAO-18-636T VA IT Modernization

Understanding the scope of VA’s current health information system is 

essential to effectively planning for the new system. However, according 

to VA officials, there is no single information source that fully defines the 

scope of VistA. Instead, existing definitions of the system, including the 

components that comprise it, are identified by multiple sources. These 

sources include the VA Systems Inventory, VistA Document Library, and 

VA Monograph.

Each of these sources describes VistA from a different perspective. For 

example, the VA Monograph provides an overview of VistA and non-VistA 

applications used by VHA. The monograph also describes modules and 

their associated business functions, but does not document all 

customization at local facilities. The VA Systems Inventory is a database 

that identifies current IT systems at VA, including systems and interfaces 

that are related to VistA. The VA Document Library is an online resource 

for accessing documentation on VA’s nationally released software 

applications, including VistA.

In the absence of a complete definition of VistA, EHRM program officials 

have taken a number of steps to define the system’s scope and identify 

the components that the Cerner system will replace. These steps have 

included conducting two analyses, performing preliminary site 

assessments, and planning for Cerner to perform a detailed assessment 

of each site where the new system will be deployed.

Specifically, EHRM program subject-matter experts undertook an analysis 

that identified 143 VistA modules and 35 software applications as 

representing the scope of the system. They then compared the 

functionality provided by the VistA modules to the Cerner system’s 

capabilities to identify the VistA components that are expected to be 

replaced by the Cerner system. The analysis identified 131 (92 percent) 

of the 143 VistA modules and 32 (91 percent) of the 35 applications that 

are expected to be replaced by the Cerner system. For example, the 

analysis determined that the Care Management and Mental Health 

modules would be replaced by the new system.

EHRM program officials also undertook a subsequent, broader analysis to 

identify, among other things, the scope of VistA, as well as the 

department’s other health IT systems that could also be replaced by the 

Cerner system. These other systems include, for example, dentistry and 

oncology applications. As part of this analysis, the department combined 

data from the VA Systems Inventory, the VistA Document Library, the VA 

VA Is Working to 

Define VistA’s Scope 

and Identify 

Components to Be 

Replaced by the 

Cerner System
Page 9 GAO-18-636T VA IT Modernization

Monograph, and other sources to identify the health information 

technology environment at a typical VA medical center.

The resulting analysis of VA’s health IT environment identified a total of 

330 applications that support health care delivery at a medical center, of 

which 119 applications (approximately 36 percent) have been identified 

as having similar functionality as a capability of the Cerner system. 

Further, 128 of the 330 applications are identified as VistA applications. 

Of the 128 applications designated as VistA, 58 (approximately 45 

percent) have been identified as having similar functionality as a 

capability of the Cerner system, including pharmacy, laboratory, and 

scheduling capabilities.

In addition to the analyses discussed above, VA has taken steps to 

understand differences in VistA at individual facilities. Specifically, 

according to EHRM officials, representatives from VA and Cerner have 

visited 17 VA medical facilities to conduct preliminary site assessments. 

The intent of these assessments is to obtain a broad perspective of the 

current state of the systems, applications, integration points, reporting, 

and workflows being utilized at individual facilities. These site visits 

identified VistA customization that may be site specific. The identification 

of such site specific customization is intended to help Cerner plan for 

implementation of its system at each location. According to EHRM 

program officials, full site assessments that are planned at each location 

in preparation for implementation of the Cerner system are expected to 

identify the full extent of VistA customization.

Since the former VA Secretary announced in June 2017 that the 

department would acquire the same electronic health record system as 

DOD, VA has taken steps to position the department for the transition to 

the new system. These actions, which are ongoing, have included 

standardizing VistA, assessing the department’s approach to increasing 

interoperability, establishing governance for the new program and the 

framework for joint governance with DOD, and preparing initial program 

plans.

VA’s goal is for all instances of VistA being used in its medical facilities to 

be standardized where practical. Such standardization is intended to 

better position the department to switch to the Cerner system. To 

increase standardization, the VistA Evolution program has been focused 

over the last 5 years on standardizing a core set of VistA modules related 

VA’s Preparations for 

Transitioning from 

VistA to the Cerner 

System Are Ongoing

Standardizing VistA
Page 10 GAO-18-636T VA IT Modernization

to interoperability which, according to the department, accounts for about 

60 percent of VistA.

In addition, the program has focused on identifying software that is 

common to each VistA instance. VA refers to this collection of standard 

software as the gold instance. As part of its effort to standardize VistA, VA 

has implemented a process to compare the system at each site with the 

gold instance. Sites that are identified as having variations from the gold 

instance must apply for a waiver to gain approval for continuing to 

operate a non-standard VistA instance. OI&T and VHA assess the 

waivers, which may be approved if a site needs non-standard functionality 

that is deemed critical to that site. Alternatively, waivers are not approved 

if the assessment determines that a site’s needs can be met by reverting 

to the gold instance of VistA.

VA has identified increased interoperability as a key expected outcome of 

its decision to switch from VistA to the Cerner system. To ensure that the 

contract with Cerner will improve interoperability with community care 

providers (i.e., non-VA and third party providers), the former VA Secretary 

announced in December 2017 that the department had taken a “strategic 

pause” on the electronic health record acquisition process. During the 

pause, an independent study was undertaken to assess the approach to 

interoperability with the new acquisition.14 The assessment made 

recommendations to improve imported data, address data rights and 

patient safety risks, and improve data access for patients. VA agreed with 

all of the resulting recommendations and, according to EHRM program 

officials, included provisions in the contract with Cerner to address the 

recommendations.

Our prior work has identified strong agency leadership support and 

governance as factors that can increase the likelihood of a program’s 

success.15 Such leadership and governance can come from the 

establishment of an effective program management organization and a 

related governance structure.

 14The MITRE Corporation coordinated the assessment and reported related 

recommendations in the VA EHRM Request for Proposal Interoperability Review Report

on Jan. 31, 2018.

15GAO, Information Technology: Opportunities for Improving Acquisitions and Operations, 

GAO-17-251SP (Washington, D.C.: April 11, 2017).

Assessing the Approach to 

Increasing Interoperability

Establishing a Program Office 

and Governance
Page 11 GAO-18-636T VA IT Modernization

VA has taken steps to establish a program management office and 

drafted a structure for technology, functional, and joint governance of the 

electronic health record implementation. Specifically, in January 2018, the 

former VA Secretary established the EHRM Program Executive Office 

(PEO) that reports directly to the VA Deputy Secretary. According to 

EHRM program officials, this office supported the contract negotiations 

with the Cerner Corporation and is expected to continue to manage the 

program going forward.

Program officials stated that the office is beginning the process of hiring 

full-time employees. In addition, to support the program office, the 

department has awarded a contract for project management support and 

has also reassigned a number of VA staff to the PEO.

Further, VA has drafted a memorandum that describes the role of 

governance bodies within VA, as well as governance intended to facilitate 

coordination between DOD and VA. For example, according to the draft 

memorandum, within VA, the EHRM Steering Committee is expected to 

provide strategic direction for the efforts while monitoring progresses 

toward goals and advising the Secretary on the progress and 

performance of the EHRM efforts. This committee is to include the Deputy 

Secretary, the Undersecretary for Health, and the Chief Information 

Officer, among others, and is to meet quarterly or as necessary to make 

its reports to the Secretary.

Additionally, according to EHRM program documentation, VA is in the 

process of establishing a Functional Governance Board, a Technical 

Governance Board, and a Governance Integration Board comprised of 

program officials intended to provide guidance; coordinate with DOD, as 

appropriate; and inform the Steering Committee. Further, a joint 

governance structure between VA and DOD has been proposed that 

would be expected to leverage existing joint governance facilitated by the 

DOD/VA Interagency Program Office.16

Nevertheless, while the department’s plans for governance of the EHRM 

program provide a framework for high-level oversight for program 

 16The National Defense Authorization Act for Fiscal Year 2008 (Pub. L. No. 110-181, Sec. 

1635 (2008)) called for DOD and VA to set up an interagency program office. This office is 

intended to function as the single point of accountability for ensuring that electronic health 

records systems or capabilities allow for full interoperability of health care-related 

information between DOD and VA.
Page 12 GAO-18-636T VA IT Modernization

decisions moving forward, EHRM officials have noted that the 

governance bodies will not be finalized until October 2018.

Program planning is an activity for ensuring effective management of key 

aspects of an IT program. These key aspects include identification of the 

program’s scope, responsible organizations, costs, and schedules.

VA has prepared initial program plans, including a preliminary timeline for 

deploying the new electronic health record system to its medical facilities. 

The department also has a proposed 90-day schedule that depicts key 

program activities currently underway now that the contract has been 

awarded. For example, the department’s preliminary plans include an 8-

year deployment schedule beginning with planned implementation at 

initial sites within 18 months of October 1, 2018.

According to the executive director for the EHRM program, the 

department also intends to complete a full suite of planning and 

acquisition management documents to guide the program. These 

documents include, for example, a life cycle cost estimate, a data 

migration plan, a change management plan, and an integrated master 

schedule to establish key milestones over the life of the project. EHRM 

PEO officials have stated that the department intends to complete the 

development of its initial plans for the program within 30 to 90 days of 

awarding the contract (between mid-June and mid-August 2018), and 

intends to update those plans as the program matures. The plans are to 

be reviewed during the milestone reviews identified in the department’s 

formal project management framework.

Preparing Initial Program Plans
Page 13 GAO-18-636T VA IT Modernization

Our prior work has determined that successfully overcoming major IT 

acquisition challenges can best be achieved when critical success factors 

are applied.17 Specifically, we reported in 2011 on common factors critical 

to the success of IT acquisitions, based on seven agencies having each 

identified the acquisition that best achieved the agency’s respective cost, 

schedule, scope, and performance goals.18 These factors remain relevant 

today and can serve as a model of best practices that VA could apply to 

enhance the likelihood that the acquisition of a new electronic health 

record system will be successfully achieved.

Among the agencies’ seven IT investments, agency officials identified 

nine factors as having been critical to the success of three or more of the 

seven investments. These nine critical success factors are consistent with 

leading industry practices for IT acquisition. The factors are:

• Active engagement of senior officials with stakeholders.

• Qualified and experienced program staff.

• Support of senior department and agency executives.

• Involvement of end users and stakeholders in the development of 

requirements.

• Participation of end users in testing system functionality prior to formal 

end user acceptance testing.

• Consistency and stability of government and contractor staff.

• Prioritization of requirements by program staff.

• Regular communication maintained between program officials and the 

prime contractor.

• Sufficient funding.

 17GAO-12-7.

18The seven departments and associated successful IT investments are the Department 

of Commerce, Decennial Response Integration System; Department of Defense, Global 

Combat Support System-Joint Increment 7; Department of Energy, Manufacturing 

Operations Management Project; Department of Homeland Security, Western Hemisphere 

Travel Initiative; Department of Transportation, Integrated Terminal Weather System; 

Department of the Treasury, Customer Account Data Engine 2; and Department of 

Veterans Affairs, Occupational Health Record-keeping System.

Critical Factors 

Underlying 

Successful Major 

Acquisitions
Page 14 GAO-18-636T VA IT Modernization

Officials for all seven selected investments cited active engagement with 

program stakeholders—individuals or groups (including, in some cases, 

end users) with an interest in the success of the acquisition—as a critical 

factor to the success of those investments. Agency officials stated that 

stakeholders, among other things, reviewed contractor proposals during 

the procurement process, regularly attended program management office 

sponsored meetings, were working members of integrated project 

teams,19 and were notified of problems and concerns as soon as 

possible. In addition, officials from two investments noted that actively 

engaging with stakeholders created transparency and trust, and 

increased the support from the stakeholders.

Additionally, officials for six of the seven selected investments indicated 

that the knowledge and skills of the program staff were critical to the 

success of the program. This included knowledge of acquisitions and 

procurement processes, monitoring of contracts, large-scale 

organizational transformation, Agile software development concepts,20

and areas of program management such as earned value management 

and technical monitoring.

Finally, officials for five of the seven selected investments identified 

having the end users test and validate the system components prior to 

formal end user acceptance testing for deployment as critical to the 

success of their program. Similar to this factor, leading guidance 

recommends testing selected products and product components 

throughout the program life cycle.21 Testing of functionality by end users 

prior to acceptance demonstrates, earlier rather than later in the program

life cycle, that the functionality will fulfill its intended use. If problems are 

found during this testing, programs are typically positioned to make 

 19The Office of Management and Budget defines an integrated project team as a multidisciplinary team led by a project manager responsible and accountable for planning, 

budgeting, procurement, and life-cycle management of the investment to achieve its cost, 

schedule, and performance goals. Team skills include budgetary, financial, capital 

planning, procurement, user, program, architecture, earned value management, security, 

and other staff as appropriate.

20Agile software development is not a set of tools or a single methodology, but a 

philosophy based on selected values, such as prioritizing customer satisfaction through 

early and continuous delivery of valuable software; delivering working software frequently, 

from every couple of weeks to every couple of months; and making working software the 

primary measure of progress. 

21See, for example, Carnegie Mellon Software Engineering Institute, Capability Maturity 

Model® Integration for Acquisition (CMMI-ACQ), Version 1.3 (November 2010).
Page 15 GAO-18-636T VA IT Modernization

changes that would be less costly and disruptive than ones made later in 

the life cycle.

Use of the critical success factors described above can serve as a model 

of best practices for VA. Application of these acquisition best practices 

presents opportunities for the department to increase the likelihood that 

its planned acquisition of a new electronic health record system will meet 

its cost, schedule, scope, and performance goals.

In conclusion, VA continued to obligate billions of dollars for its VistA 

system. Recently, the department has undertaken important analyses to 

better understand the scope of the system and identify capabilities that 

can be provided by the Cerner electronic health record system it is 

acquiring. VA has additional key activities underway, such as establishing 

program governance and EHRM program planning. Based on these 

preliminary observations and as the department continues its activities to 

transition from VistA to the Cerner electronic health record system, critical 

success factors can serve as a model of best practices that VA could 

apply to enhance the likelihood that the acquisition of the new system will 

be successfully achieved. While it is early in VA’s acquisition of the 

Cerner system, it will be important for the department to leverage all 

available opportunities to ensure that its transition to a new system is 

carried out in the most effective manner possible. Our experience has 

shown that challenges can successfully be overcome through using a 

disciplined approach to IT acquisition management.

Chairman Roe, Ranking Member Walz, and Members of the Committee, 

this concludes my prepared statement. I would be pleased to respond to 

any questions that you may have.

If you or your staffs have any questions about this testimony, please 

contact David A. Powner at (202) 512-9286 or pownerd@gao.gov. 

Contact points for our Offices of Congressional Relations and Public 

Affairs may be found on the last page of this testimony statement. GAO 

staff who made key contributions to this statement are Mark Bird 

(Assistant Director), Jennifer Stavros-Turner (Analyst in Charge), John 

Bailey, Rebecca Eyler, Jacqueline Mai, Scott Pettis, and Charles 

Youman.

GAO Contact and 

Staff 

Acknowledgments

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