[House Hearing, 118 Congress]
[From the U.S. Government Publishing Office]
VETERANS HEALTH INFORMATION
SYSTEMS AND TECHNOLOGY.
ARCHITECTURE (VISTA)
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON TECHNOLOGY MODERNIZATION
OF THE
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED EIGHTEENTH CONGRESS
FIRST SESSION
__________
TUESDAY, MARCH 7, 2023
__________
Serial No. 118-2
__________
Printed for the use of the Committee on Veterans' Affairs
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Available via http://govinfo.gov
__________
U.S. GOVERNMENT PUBLISHING OFFICE
51-536 WASHINGTON : 2023
COMMITTEE ON VETERANS' AFFAIRS
MIKE BOST, Illinois, Chairman
AUMUA AMATA COLEMAN RADEWAGEN, MARK TAKANO, California, Ranking
American Samoa, Vice-Chairwoman Member
JACK BERGMAN, Michigan JULIA BROWNLEY, California
NANCY MACE, South Carolina MIKE LEVIN, California
MATTHEW M. ROSENDALE, SR., Montana CHRIS PAPPAS, New Hampshire
MARIANNETTE MILLER-MEEKS, Iowa FRANK J. MRVAN, Indiana
GREGORY F. MURPHY, North Carolina SHEILA CHERFILUS-MCCORMICK,
C. SCOTT FRANKLIN, Florida Florida
DERRICK VAN ORDEN, Wisconsin CHRISTOPHER R. DELUZIO,
MORGAN LUTTRELL, Texas Pennsylvania
JUAN CISCOMANI, Arizona MORGAN MCGARVEY, Kentucky
ELIJAH CRANE, Arizona DELIA C. RAMIREZ, Illinois
KEITH SELF, Texas GREG LANDSMAN, Ohio
JENNIFER A. KIGGANS, Virginia NIKKI BUDZINSKI, Illinois
Jon Clark, Staff Director
Matt Reel, Democratic Staff Director
SUBCOMMITTEE ON TECHNOLOGY MODERNIZATION
MATTHEW M. ROSENDALE, SR., Montana, Chairman
NANCY MACE, South Carolina SHEILA CHERFILUS-MCCORMICK,
KEITH SELF, Texas Florida, Ranking Member
GREG LANDSMAN, Ohio
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
official version. Because electronic submissions are used to prepare
both printed and electronic versions of the hearing record, the process
of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
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TUESDAY, MARCH 7, 2023
Page
OPENING STATEMENTS
The Honorable Matthew M. Rosendale, Sr., Chairman................ 1
The Honorable Sheila Cherfilus-McCormick, Ranking Member......... 2
WITNESSES
Mr. Daniel McCune, Executive Director of Software Product
Management, Office of Information & Technology, U.S. Department
of Veterans Affairs............................................ 3
Accompanied by:
Mr. Charles Hume, Chief Informatics Officer, Veterans Health
Administration, U.S. Department of Veterans Affairs
Mr. Thomas O'Toole, M.D., Deputy Assistant Undersecretary for
Health for Clinical Services, Veterans Health
Administration, U.S. Department of Veterans Affairs
Ms. Zhuchun "Emily" Qiu, Director of Health Informatics,
Office of Information & Technology, U.S. Department of
Veterans Affairs
Mr. Michael Giurbino, Director of Health Infrastructure and
Systems Management, Office of Information & Technology,
U.S. Department of Veterans Affairs
The Honorable Roger Baker, Former Assistant Secretary for
Information & Technology, U.S. Department of Veterans Affairs.. 19
The Honorable James Gfrerer, Former Assistant Secretary for
Information & Technology, U.S. Department of Veterans Affairs.. 21
Mr. Peter Levin, Co-founder and CEO, Amida Technology Solutions.. 22
APPENDIX
Prepared Statements Of Witnesses
Mr. Daniel McCune Prepared Statement............................. 41
The Honorable Roger Baker Prepared Statement..................... 43
The Honorable James Gfrerer Prepared Statement................... 45
Mr. Peter Levin Prepared Statement............................... 46
Submission For The Record
Office of Inspector General Letter to The Subcommittee on
Technology Modernization....................................... 49
VETERANS HEALTH INFORMATION
SYSTEMS AND TECHNOLOGY
ARCHITECTURE (VISTA)
----------
TUESDAY, MARCH 7, 2023
U.S. House of Representatives,
Subcommittee on Technology Modernization,
Committee on Veterans' Affairs,
Washington, D.C.
The subcommittee met, pursuant to notice, at 2:58 p.m., in
room 390, Cannon House Office Building, Hon. Matthew M.
Rosendale, Sr. (chairman of the subcommittee), presiding.
Present: Representatives Rosendale, Self, Cherfilus-
McCormick, and Landsman.
OPENING STATEMENT OF MATTHEW M. ROSENDALE, CHAIRMAN
Mr. Rosendale. This meeting will come to order.
I am glad to be here with Ranking Member Cherfilus-
McCormick to continue our work.
I first want to thank Representative Frank Mrvan for his
leadership during the last Congress. I really did enjoy working
with him. As I have stated and he is stated, this is one of the
most bipartisan committees that we found, that there was a lot
of joint work together, and we are hoping to be able to do the
same thing as we move forward.
We did, however, expose serious mismanagement in several of
the largest VA information technology systems. Now my goal is
to motivate the VA to get these efforts back on track or put
better strategies in place when that is not possible.
These IT systems exist to make the delivery of care and
benefits to our veterans easier to schedule, easier to access,
and easier to track, thereby keeping our veterans healthier and
happier. Their purpose is not to churn out cushy contracts for
technology companies. Unfortunately, the Beltway and Silicon
Valley need to be reminded of that constantly.
We are here today to discuss Veterans Health Information
Systems and Technology Architecture (VistA), the platform that
97 percent of the Veterans Health Administration relies on to
care for our veterans.
It is no secret that VistA was originally developed 40
years ago and Computerized Patient Record System (CPRS) was
introduced 25 years ago. It is also no secret that VistA is a
vast collection of hundreds of systems that do everything from
prescriptions to staffing, to accounting, to tracking car
accidents.
It is less well understood where the replacement and
modernization efforts of 10 and 20 years ago left VistA. When
the Cerner project began, some in the VA thought they could
stop paying attention to VistA. Some in Congress thought so
too. There was a discussion of a pivot plan, which initially
seemed to be a plan to mothball VistA. As the Cerner completion
schedule slipped farther and farther into the future, the pivot
plan faded.
The reality is, regardless of whether the Oracle Cerner
implementation can be accomplished and regardless of how we
feel about that, the VA will probably continue to rely on VistA
for at least another decade, and some of the elements of VistA
will probably never go away because no replacement even exists.
Medical centers all over the country and the veterans they
serve cannot be left in limbo. Let me say this as plainly as I
can: Running VistA into the ground would be a disastrous
mistake. It must be maintained.
Within the technical constraints that exist, VA should be
identifying the key areas of VistA that need to be modernized
and are feasible to undertake. That is already happening in a
few cases, and I want to explore them this afternoon.
Let me be clear: There will be no more blank checks and low
expectations for Electronic Health Record (EHR) projects. VistA
and Oracle Cerner and any other EHR will be judged by the same
standards, and those standards are: patient safety,
reliability, user satisfaction, and cost. It is not
complicated.
We have two esteemed panels of experts here with us today
to do just that, and I want to welcome our witnesses. I
appreciate you being here.
With that, I would yield to Ranking Member Cherfilus-
McCormick for her opening statement. Thank you.
OPENING STATEMENT OF SHEILA CHERFILUS-MCCORMICK, RANKING MEMBER
Mrs. Cherfilus-McCormick. Thank you, Mr. Chairman.
I am honored to serve as the ranking member on the
Technology Modernization Subcommittee. Before coming to
Congress, I was a healthcare executive for many years. I know
firsthand the critical role that technology plays in the
provision of healthcare and fully understand that just about
everything the VA does relies on computers and other
technologies.
I would like to welcome our witnesses today and thank you
for coming to discuss VA's long-serving electronic records,
VistA.
While we all know that the VA is in the midst of a major
modernization effort to replace VistA, it is also important to
note that the system will be around long as long as it needs to
be--excuse me--least as long as it needs to be, as long as the
modernization program takes.
It is imperative that the VA not only maintains VistA until
the replacement system is fully deployed but also keeps up the
healthcare innovation as best as the system allows. Veterans
who rely on the VA for their healthcare deserve no less.
There are functions of VistA that are not related to the
EHR and will likely exist long after the EHR is replaced. To be
clear, we realize that VistA is more than EHR, but my goal
today is to focus on the EHR capabilities.
VA has spent almost 20 years and, according to the
Controller General, over $1.7 billion in failed attempts to
modernize VistA.
Numerous experts told this committee that VistA is not a
viable long-term solution and must be replaced. There are
concerns about the cybersecurity risk, data management, and a
code base considered to be obsolete by many. Also, the 130-plus
different instances of VistA do not reliably communicate with
each other, let alone the Department of Defense (DOD) or
community care providers.
We must do better.
Before I conclude, I would like also to congratulate my
colleagues Mr. Rosendale on being selected as the chairman for
the subcommittee.
I look forward to working with you this Congress to ensure
the VA has the resources and technology it needs to provide the
world-class healthcare and benefits that our Nation's veterans
have earned and so richly deserve.
I yield back the balance of my time.
Mr. Rosendale. Thank you very much.
I would like to now introduce the witnesses on both panels.
First, from the Department of Veterans Affairs, we have Mr.
Daniel McCune, Mr. Michael Giurbino, and Ms. Emily Qiu from the
Office of Information and Technology. We also have Mr. Charles
Hume and Dr. Thomas O'Toole from the Veterans Health
Administration.
Thank you all for being with us today.
On our second panel, we have a distinguished group who led
VA information technology during the Obama and Trump
administrations: Mr. Roger Baker served as the Assistant
Secretary for Information Technology from 2009 to 2013; Mr.
James Gfrerer served in the same position from 2018 to 2021;
and Mr. Peter Levin, who was the VA Chief Technology Officer
from 2009 to 2013.
I ask the VA's first witnesses on our first panel to please
stand and raise your right hands.
[Witnesses sworn.]
Mr. Rosendale. Thank you.
Let the record reflect that all the witnesses answered in
the affirmative.
Thank you.
Mr. McCune, you are now recognized for 5 minutes to deliver
your opening statement.
STATEMENT OF DANIEL MCCUNE
Mr. McCune. Good afternoon, Chairman Rosendale, Ranking
Member Cherfilus-McCormick, and distinguished members of the
panel. Thank you for the opportunity to testify today about the
Department of Veterans Affairs' Veterans Health Information
Systems and Technology Architecture, or VistA.
I am accompanied by Chuck Hume, Chief Informatics Officer
in Veterans Health Administration (VHA); Dr. Thomas O'Toole,
Deputy Assistant Under Secretary for Health; Mike Giurbino,
Director of Health Infrastructure and Systems Management in IT;
and Emily Qiu, Director of Health Informatics in IT.
Veterans are at the center of everything we do, and VA is
committed to providing exceptional care, services, and a
seamless, unified experience to the veteran. To fulfill this
mission, VA clinicians must have modern tools to ensure best
outcomes for our veterans.
Office of Information and Technology (OIT) collaborates
with VHA and other VA offices to achieve this mission through
delivery of state-of-the-art technology, including a modernized
electronic health record, or EHR.
VistA provides an EHR for veteran care and services,
supporting over 150 applications in more than 1,500 VA
facilities. There are 133 instances of VistA nationwide that
share common functionality but have data and workflow tailored
to the needs of each medical center and patient population.
VistA has served VA and veterans for over 40 years, and we
are aware of its limitations. It does not have modern
capabilities like artificial intelligence, machine learning,
mobile and web access, and the capabilities providers and
veterans expect and deserve from a modern, cloud-native EHR.
In 1997, VA implemented a new graphical user interface on
top of VistA called Computerized Patient Record System, or
CPRS. CPRS is a Windows desktop application that provides an
improved, yet dated, user interface for accessing VistA data.
VistA itself is written in an old programming language
called Massachusetts General Hospital Utility Multi Programming
System (MUMPS). There are few MUMPS programmers today. MUMPS is
not taught in computer science classes, and the pool of MUMPS
programmers shrinks every year as they retire.
VA is fortunate to have dedicated MUMPS programmers
supporting VistA. They understand millions of lines of code
developed over 40 years, and they also understand VA clinical
business processes. They are committed to enabling clinicians
and supporting veteran outcomes, and we have been able to
retain them and their knowledge much longer than a typical
workforce. However, approximately 70 percent of our MUMPS
developers today are retirement-eligible, and we have few
options to hire or contract additional ones.
VistA is a member of VA's expansive and complex ecosystem
of software and infrastructure. The size and complexity of that
technology ecosystem has nearly doubled in the last 5 years,
and most of that growth has been in modern, cloud-native
applications.
MUMPS programmers are increasingly challenged keeping VistA
integrated in a growing ecosystem that is architected very
differently from the system designed 40 years ago. While
technology is a challenge, so also are the dated skills of our
VistA programmers. That challenge compounds every year.
In May 2018, after nearly a year of analysis, VA decided to
replace VistA with a Commercial Off The Shelf (COTS) solution,
Cerner Millennium. However, VA will continue to use VistA until
Cerner Millennium is fully implemented. During this time, it is
essential to maintain and enhance VistA to preserve the
uninterrupted care and continually improve the veteran service.
Some of the key recent VistA enhancements include:
standardizing VistA code, we call this our national gold
version; move to cloud: 20 instances of VistA have been moved
to the cloud, with an additional 54 planned this year;
improving access to federated health data by implementing an
Application Programming Interface (API) gateway.
Currently, there is no cost reduction tied to the new EHR
solution. The cost to support VistA will increase as we develop
new capabilities and interfaces, support congressional
mandates, and migrate to cloud. In essence, we are supporting
two EHR systems simultaneously until the Cerner implementation
is complete.
In the interim, VistA remains our authoritative source of
veteran data.
In summary, VistA is an old technology, ill-suited for the
modern digital age. Modernization would require VistA to be
rewritten almost from scratch at a great cost and great risk.
Chairman Rosendale, Ranking Member Cherfilus-McCormick, and
members of the subcommittee, thank you for the opportunity to
appear before you today to discuss OIT's improvement of VistA.
This concludes my testimony, and I look forward to answering
your questions.
[The Prepared Statement Of Daniel Mccune Appears In The
Appendix]
Mr. Rosendale. Thank you, Mr. McCune. I appreciate that.
We are going to go straight to questioning.
I mentioned in my remarks that I judge any EHR or any
system that supports healthcare according to patient safety,
reliability, user satisfaction, and cost. Does the VA
typically--or, currently use any other criteria for
establishing what they would like to have?
Mr. McCune. That is a good start, sir. I think we do look
at reliability and availability of the system too. Access to
our critical health information systems is very important to
our veterans and to our clinicians.
Mr. Rosendale. Do you have any other criteria that you are
using, because reliability and customer satisfaction, the cost,
these are all things that we are already looking at.
Mr. McCune. Yes, sir.
Mr. Rosendale. What would they be? Exactly why would you be
using these other criteria?
Mr. McCune. Sir, if--thank you for the question. If we are
looking at how do we gauge success of a large-scale
implementation--is that the question?
Mr. Rosendale. Sure.
Mr. McCune. Okay. There is a number of factors that we use.
The ones you mention--scope, schedule, and cost--certainly are
high on the list. Customer satisfaction, also high on the list.
Those are ones that we look at.
We look at the technical viability and how it fits in our
ecosystem. I mentioned our large ecosystem.
Those are all elements that we take into account.
Mr. Rosendale. Do you take into account the ratings or the
consideration from the employees themselves, the ability for
them to work with the system and the problems that it may not
cause or the efficiency that it delivers to them?
Mr. McCune. Yes, sir. We consider both the veteran
experience and the user experience.
Mr. Rosendale. How exactly are you measuring that?
Mr. McCune. We have a number of different ways to measure
that, sir. One of the key ways we look at that is both the
accessibility and the performance of that system. We look at
numbers--how many clicks does it take, how many screens do they
need to see, how performant is that system. Those are all
measures that we use to gauge user acceptance.
Mr. Rosendale. Are you going back and having a poll
conducted with the actual users and the patients to see what
their experience has been?
Mr. McCune. Yes, sir. I think that is an excellent question
for our VHA partners. I would ask Mr. Hume to answer that
question.
Mr. Hume. Sir, last year, we did the initial survey of
users in Veterans Integrated Services Network (VISN) 10 and 20.
That is where the Cerner product is currently deployed. We used
standard survey questions developed by KLAS. I do not recall
what that acronym is for, but it is an industry leader who
surveys the electronic health record systems across the country
and user experience with that. We got some baseline data from
that survey last year.
Mr. Rosendale. Okay.
Where is the survey? That is what I am looking for, right
there.
Okay. I happen to have a copy of that survey, and I have
got some serious concerns about this, okay? After being 4 years
in service, the VA's version of Cerner ranked dead-last in the
survey that I am looking at.
Okay. After 4 years, according to this survey, 78 percent
of the users--so these are the docs, right--78 percent of the
users do not feel that it helps them deliver high-quality care.
Seventy-eight percent. We are talking about almost 8 out of 10.
On the other hand, 64 percent said that VistA enabled them
to deliver high-quality care. It is almost a complete flip-flop
of that.
Now, we are talking about after billions of dollars have
been expended, we are talking about several years to try and
work through this system, and we are talking about at some of
the smallest facilities in the country, not the more complex
centers that the VA is even responsible for.
My question would be: Mr. McCune, does anything in the KLAS
report surprise you?
Mr. McCune. Sir, I think--thank you for the question. I
would say, no, sir. I think we are getting a lot of signal
around that.
What I would say is, with VistA, we have a relatively
stable system, one that is been in production for 40 years. Our
clinicians, our users are very, very familiar with that system.
What we also have happening is a brand-new system, the
Cerner system. I think there is some element of change
management there, there is some element of newness that has to
be considered there.
We are aware of those numbers, sir, and we are tracking
those.
Mr. Rosendale. Even though VistA is this old, why do most
of the employees like it so much, Mr. McCune?
Mr. McCune. Sir, I would defer to our VHA partners on that
one.
Mr. Hume.
Mr. Hume. I will invite Dr. O'Toole to answer as a user of
CPRS.
Dr. O'Toole. Thank you, Congressman.
I think the issue with CPRS, and having been using it
myself for the past 17 years, is that it accomplishes what we
need. It does represent high reliability.
But I would be neglectful to not say it does not have its
own problems, and it does not provide a lot of the
functionality that we see in different EHRs and more modern
EHRs.
There is a muscle memory associated with using it for quite
some time that I believe providers are comfortable with. They
know how to use it, they know how to navigate the system, and
it has worked well for us.
Mr. Rosendale. Mrs. Cherfilus-McCormick, do you have
questions?
Mrs. Cherfilus-McCormick. Yes. Thank you.
Researchers have noted current challenges with VistA and
how it negatively impacts healthcare delivery and operations,
to include quality healthcare delivery, security, care
standardization, lack of system standardization, data
standardization, access controls, and efficient business
operations.
That is no small list of problems. Would you agree that
those areas are of concern?
Mr. McCune. Yes, ma'am, I would agree with you. There is a
long list with our legacy technology and our legacy VistA
platform.
Mrs. Cherfilus-McCormick. On the major issue of lack of
standardization, I realize that this is partly the fault of the
VHA and their lack of prioritization of creating a standard
healthcare record.
How difficult would it be to standardize the health records
across the separate instances of VistA across the country, and
how long would it take?
Mr. McCune. Thank you for that question, ma'am.
That is a long, complex question, and we have not done the
analysis on that. We have tried over the last 40 years many
times to tackle that problem. If you would like, we can take--
can do the analysis and come back with a plan.
Mrs. Cherfilus-McCormick. Just for information, how many
instances of VistA are there? Is it 130 instances?
Mr. McCune. It is--technically, it is 133.
Mrs. Cherfilus-McCormick.--thirty-three.
In other situations, have we seen any organization try to
actually standardize? What would be that average time? Have we
seen it in 50? Sixty? What would that standard time be, if we
do not know what 133 variations would be?
Mr. McCune. Yes. Thank you for that question.
Ma'am, I do not think we have a good comparable. I think
that is what you are asking: Do we have a good comparable? I do
not think we have a comparable. Nothing is the size and scale
of our EHR. That is one of our largest--it is our largest
technology system.
Mrs. Cherfilus-McCormick. There has been some discussion in
Congress and elsewhere to make another attempt to modernize
VistA and abandon the current Oracle Cerner system.
I am not here to say the Oracle Cerner approach in
Electronic Health Record Modernization (EHRM) is going well,
but I am not sure returning to VistA is the correct either. We
have heard from inside VA that VA does not have the expertise
or the desire to go the pathway of modernizing VistA, which
would itself take several billion dollars, other large IT
contracts, and large management contracts such as the VA has
today.
Is that accurate?
Mr. McCune. Thank you for that question. Ma'am, I think, if
I heard you correctly, that is a fair summarization.
Mrs. Cherfilus-McCormick. What is precluding VA from taking
a more measured approach?
Mr. McCune. Ma'am, as we look to our limited resources,
right, our resource constraints and how we focus those, we have
them currently 100 percent focused on the current EHR
implementation. We do not have extra people working on a plan
B.
We are fully committed to this. Until such a time as we
need to change course, all of our resources, both our people
and our funding, are allocated toward the successful Cerner
implementation.
Mrs. Cherfilus-McCormick. My largest concern with the
current EHRM program is that staff do not feel like their
concerns are being taken into account, which is resulting in
potential patient harm.
Is there not a better way to provide a more--a better roll-
out of the Oracle Cerner system while also providing some
clarity on what will and will not be available for their use in
VistA?
Mr. McCune. Thank you for that question.
Ma'am, I think what you have today are the people
representing VistA. I do not think we are the right people to
represent the EHRM solution or the challenges that they are
facing. I would defer that question. We can take that for the
record.
Mrs. Cherfilus-McCormick. Okay. Thank you. I yield back.
Mr. Rosendale. Thank you very much, Representative.
I would now go to my friend from Texas, Representative
Self.
Mr. Self. Thank you, Mr. Chairman.
I want to explore the cloud migration.
First of all, I am not an IT person. I have looked for it
in your testimony. What is the Inquiry Routing and Information
System (IRIS) for Health 2022.1? What does that mean?
Mr. McCune. Sir, I think I--can you repeat your question?
Mr. Self. What is your reference to IRIS, I-R-I-S, for
Health 2022? It is part of your cloud migration testimony.
Mr. McCune. Yes, sir.
Mr. Giurbino, can you answer that question?
Mr. Giurbino. Yes, sir.
It is our data base platform that we are upgrading to, that
brings us new capabilities.
Mr. Self. You are upgrading VistA, the platform as well,
plus migrating it to the cloud.
How much does it cost to move it to the cloud? When will
you complete that? How important is that for the future?
Mr. McCune. Yes, sir. Thank you for that question.
Cloud migration is an important component in maintaining
and enhancing VistA.
I would say that the version of cloud migration that is
taking place today is what we call a ``lift and shift,''
meaning we are not changing VistA; we are simply taking it out
of our data center and moving it into a virtual cloud
environment. That is what we call a ``lift and shift.''
We are in midstream there. About 20 instances today have
been migrated. An additional 54 are planned this year.
That is not modernization. Modernization, making it a
cloud-native application, would involve rewriting that code.
I think you asked about cost, sir. I think it cost us
around $70,000 per instance to move it to the cloud.
Mr. Self. For 130, rough?
Mr. McCune. Yes, sir. Roughly, it would be about $70,000
per instance.
Mr. Self. Is Cerner going to be on the cloud?
Mr. McCune. Yes, sir, Cerner is in the cloud.
Mr. Self. Okay.
Let us move to the community care providers. How many
providers do you refer veterans to?
Mr. McCune. Sir, I will hand that off to Mr. Hume.
Mr. Hume. Sir, I think we are going to have to take that
one for the record.
We do health information exchanges with 130--excuse me--
with members of the eHealth Exchange, the national eHealth
Exchange, as well as CommonWell and Carequality. We are moving
toward Carequality.
We do information exchanges with partners who have joined
the health information exchange, but that is not the universe
of providers that we refer patients to.
Mr. Self. Then tell me how VistA integrates with the
70,000. What is the integration there? Is there any?
Mr. McCune. Sir, 70--I am sorry. I do not understand your
question, sir. Can you repeat that?
Mr. Self. For your community care providers that you
coordinate with, how does VistA integrate with them? Then I
would like to compare Cerner to that as well.
Mr. McCune. Thank you, sir. I am going to ask my partner
Ms. Qiu to answer that question.
What I can tell you in broad statements is: The integration
that VA does--or VistA does with our community care providers
is not nearly as comprehensive or as native as what we have
with Cerner. We are doing some things to do that integration.
Ms. Qiu, can you answer that question?
Ms. Qiu. Sure. Thank you, Mr. McCune.
To communicate with our community care providers, we are
implementing a solution called VDIF. It stands for Veterans
Data Integration and Federation Platform.
This platform is connecting to Cerner's Joint Health
Information Exchange (JHIE). At request, VDIF would respond
with the longitudinal patient record to Cerner JHIE, and then
Cerner JHIE would relay that message back to the community care
providers.
Mr. Self. You just addressed Cerner, correct?
Ms. Qiu. That is correct. We use Cerner JHIE to connect to
two networks. One is CommonWell and the other is eHealth
Exchange Network, which Cerner JHIE connects to.
Mr. Self. You already have a complex system of both VistA
and Cerner in your coordination with your community care
providers. Is that correct? Am I hearing that right?
Ms. Qiu. To make the community care communication work, we
are using both the VDIF solution and Cerner JHIE solution to
make it work.
Mr. Self. Thank you, Mr. Chairman. Sounds complex to me.
Mr. Rosendale. Thank you very much.
I would now yield to the gentleman from Ohio, Mr. Landsman.
Mr. Landsman. Thank you, Mr. Chair. I appreciate the time.
Thank you all for your service and for being here today.
A few questions, three. Some of this I suspect you can
speak to today, and some of it you will have to, you know,
circle back.
One has to do with what we have learned from the five sites
where this has been implemented: you know, Columbus is close to
where I serve, southwest Ohio, Cincinnati; but Walla Walla,
Roseburg, Spokane, White City.
What are the high-level takeaways from these pilots? I
mean, what would be most helpful for us to know in terms of
what you have seen, both the good and the bad, in these five
sites?
Mr. McCune. Thank you, Congressman.
I do want to circle back, if I can, for----
Mr. Landsman. Sure.
Mr. McCune [continuing]. just a second on the cloud
question. I think the question was, is Cerner in the cloud?
While the target is to move Cerner--or to have Cerner in
the cloud, it is not currently in the cloud today. That is a
work in progress. I just wanted to correct that.
To your question, sir, I think I am going to defer that to
Dr. O'Toole.
Mr. Self. Okay.
Dr. O'Toole. Thank you, sir.
We have learned a lot from the five deployments. I think it
has exposed a lot of challenges in both product and product
development, refinement; our staff training; and stresses to
the system. It is a learning curve.
Some provider groups have fared better than others in terms
of their adoption. I think that the decisions to date by the
agency to put a hold on the Boise deployment, to put a hold on
the Ann Arbor deployment, reflect the fact that we are actively
working to make improvements both to what we do internally, to
what is expected of the product, to what is expected of the
deployments, before we go live with additional sites.
Mr. Landsman. Yes. I mean, I think what we--that is
helpful. Perhaps for the record--so this is a request--to just
better understand what the high-level, you know, learnings,
takeaways have been, both positive and negative. I mean, I know
we are struggling on a whole host of levels, but what is
promising? What do you feel good about, or what do you see as
big opportunities?
I am assuming that is part of what we will see more of
after the pause, right? I mean, once--and we do not have to get
into--if there is high-level stuff you want to share, please
do, but I do think it would be helpful for us to better
understand those big takeaways.
Dr. O'Toole. Thank you. I definitely appreciate the
importance of the question.
There will be a report that is still in preparation related
to the sprint efforts----
Mr. Landsman. Okay.
Dr. O'Toole.--that should be released shortly as it goes
through. I think that will help define many of the criteria
that are expected to be in place for future go-lives that I
think would answer some of those questions.
I would request that we take for the record, you know,
pending that.
Mr. Landsman. Then the second question has to do with
leadership changes at the Integration Office. As these changes
have taken place, what are the gains that--I mean, what are we
not losing I think would be helpful to know.
How have you all managed or thought about that, the change
in leadership, as it relates to ensuring that what needs to be
learned is learned and what needs to be changed is changed and
so on and so forth?
I mean, that is a huge question I have, which is, when you
make a big leadership change, when you are dealing with this
kind of complexity, how are you handling that?
Mr. Hume. Well, I would just acknowledge that Dr. Neil
Evans is taking over the office as the Acting Director,
Executive Director, and we have great confidence in him. He has
been a VA clinician for many years, and he is talented in this
space, and we are looking forward to his leadership.
Mr. Landsman. I think similar to the previous question, the
gains that were--and improvements, the opportunities that his
predecessor, you know, experienced, you know, making sure those
are not lost. I mean, how do we--and things that, obviously,
were not going well. I think having a better understanding--and
maybe that will be in the report or----
Mr. Hume. In that position, there are three primary
deputies, and they are all staying in place. There is good
continuity at the next level down from the Director.
Mr. Landsman. Then, finally, this has to do with the
contracting. I mean, so much of this gets outsourced to, you
know, private companies. I think it would be helpful to this
subcommittee to better understand what you are concerned about
in terms of that contracting process.
What is being communicated effectively when you are
securing support from outside vendors? You know--and this gets
to some of the questions around the requirements, you know,
that may or may not have been articulated when you went out,
you know, to get help.
You know, it would help me to better understand how you all
are approaching that moving forward, because, clearly, you
know, you are going to--it requires a tremendous amount of
support, and the Department's ability to get the right kind of
help, having articulated the right set of requirements, is
going to be very, very important.
I am wondering if someone can speak to that and/or circle
back.
Mr. McCune. Thank you for that question, sir. I think part
of that answer is to--and we will take back. I will address
part of that question, which is us working with contractors. I
think your question is probably around accountability.
Mr. Landsman. Yes.
Mr. McCune. Working with vendors is a normal part of what
we do in VA, and particularly in my area, which is systems
development. Almost 85 percent of our workforce today is
contracted, and so that is really a partnership between the
govvies and the contractors.
Mr. Landsman. Thank you.
Mr. Rosendale. Thank you, Mr. Representative.
Dr. O'Toole, let us review the information that we have
about VistA. The subcommittee submitted questions in advance of
this hearing, and the VA has answered them.
First, patient safety, which is a priority for everybody in
this room. The VA provides statistics on the number of patient
safety reports related to the system. How many patient safety
reports were there in each of the last 3 years across the 166
medical centers and their clinics using VistA?
Dr. O'Toole. Sir, I am looking through my notes here, in
terms of what we submitted in response to that question.
Mr. Rosendale. Okay.
Dr. O'Toole. I believe the data, which reflected two
different modes of presenting, shows a significant increase. It
is not broken down by medical center.
In terms of what are referred to as Joint Patient Safety
Reports, or JPSRs, which reflects a concern raised by the
field, not necessarily a validated concern, not necessarily
something that was reflected in a safety event or patient
harm--and I think that is an important----
Mr. Rosendale. Let me tell you the numbers that I have, and
you----
Dr. O'Toole. Yes.
Mr. Rosendale [continuing]. can tell me if this is accurate
or not.
Through the 166 medical centers and their clinics using
VistA, we have in 2020, 12,644; in 21, we did have an increase,
it was 14,637; but then in Fiscal Year 22, it went all the way
down to 9,211.
Dr. O'Toole, the information we have from Spokane for the 2
years after Cerner went live is 1,033 patient safety reports.
This is something that this committee has complained about for
quite some time, extensively, in a bipartisan manner. That is
over 500 reports per year from 1 hospital using Cerner--1
hospital--compared to an average of 55 reports annually from
the VistA hospitals.
How do you explain this huge difference? In short, why has
the Mann-Grandstaff VA Hospital become the most dangerous VA
hospital in the country?
Dr. O'Toole. Well, thank you for the question, sir.
Again, I am not going to try to minimize, by any stretch,
the concerns that staff raised at Mann-Grandstaff and continue
to raise at Mann-Grandstaff regarding safety concerns. I think
it has been well-documented and well-noted, challenges that we
have had with the deployment of the Cerner product, the Cerner
Millennial product, at Mann-Grandstaff related to a lot of
issues, not the least of which is deployment during the
pandemic, deployment with significant concerns about product
readiness, training, and so on.
We are striving to be a high-reliability organization. We
continue to encourage these reports to be generated so they can
be investigated and acted on. To the extent that we continue to
act on them, as reflected by the pauses that have occurred in
our deployment of future sites while actively deploying tiger
teams and others to address those concerns, I think has, you
know, been well-noted.
You know, not to make any excuses about the concerns at
hand.
I will say that there have been improvements to the Cerner
product over time, and we have made several improvements in the
care delivery, in the workstream----
Mr. Rosendale. Can I just cut to the chase and say, would
you attribute this increase to the Cerner system, Dr. O'Toole?
Dr. O'Toole. Yes.
Mr. Rosendale. Thank you.
Dr. O'Toole, I asked the Office of Inspector General to
identify the reports related to VistA and patient safety in
preparation of this hearing. They looked back 6 years and found
five reports.
I am going to enter this letter from the Office of
Inspector General (OIG) into the record.
Mr. Rosendale. These all involve automated view alerts,
which let providers know test results are available, and the
lack of ability to track who observes and acts on those alerts.
What component of VistA generates and tracks these alerts?
How are you addressing this issue?
Mr. Hume. Well, I believe you are talking about reminder
alerts and reminders that the system generates usually as a
result of the configuration of--or mandates to perform certain
tasks, clinical tasks--Dr. O'Toole would be better to answer
that--perform certain tasks at certain times, and the providers
are reminded through those alerts to perform those tasks.
Dr. O'Toole. For clarification, is that what you are
referring to, Congressman?
Mr. Rosendale. Yes.
Dr. O'Toole. Okay.
Yes, so the clinical reminder and clinical alert system
within VA is something that has been used for decades now as a
means of reminding providers both for specific screening
questions, view alerts for patients who may be at risk for
certain events, as well as reminders for different clinical
activities.
It is something that is currently tracked and actively
tracked and fed back to the Department through our data and
analytics group.
Mr. Rosendale. Again, the question was: What component of
VistA generates and tracks these alerts? How are you addressing
this issue that they are not being resolved?
Dr. O'Toole. Well, sir, I think that there are several
concerns with that, not the least of which is that there are
probably too many alerts and not all of them are relevant, and
there is an issue of alert fatigue, which we are actively
looking at in terms of trying to streamline some of those
alerts so that the most pertinent ones, the ones that are most
timely to the clinical event and patient care issue and where
the risk is highest are those that are prioritized and others
that may be less important can be sunsetted. That is a current
and active issue that is going on.
All of the clinical stations, though, do receive reports on
compliance with that and are being tracked, both nationally and
locally, in terms of their performance in that space.
Mr. Rosendale. Representative Cherfilus-McCormick, do you
have more questions?
Mrs. Cherfilus-McCormick. Thank you, Mr. Chair.
If the VA is itself admitting that it does not want and
does not have the capacity to manage a VistA modernization, why
would we, Congress, force them to?
Mr. McCune. Thank you for that question, ma'am.
I do not think we are asking you to force us to do that,
right? I think what we have today and what is before Congress
is a difficult choice. We have got a system implementation
underway today, and we have an aging legacy system that we have
struggled multiple times in the past to modernize. It is not an
easy choice, sir--or ma'am. It is one that we are continually
looking at.
Mrs. Cherfilus-McCormick. Previous testimony indicates the
VA spends about $800 million a year to maintain, improve, and
stabilize VistA. Is that accurate?
Mr. McCune. Yes, ma'am.
Mrs. Cherfilus-McCormick. Is it accurate that VA continues
to keep VistA healthy and plans to until the last proposed EHRM
deployment is finished? In other words, the VA is not walking
away from VistA today, correct?
Mr. McCune. That is correct, ma'am.
Mrs. Cherfilus-McCormick. Mr. Chair, I yield back.
Mr. Rosendale. Representative Self?
Mr. Self. Thank you, Mr. Chairman.
You have testified that you have delayed Boise and Ann
Arbor. Given that you restart your Cerner roll-out, when do
you--when would you anticipate the last use of VistA?
Mr. McCune. Thank you for that question, sir.
I think that timeline is a little uncertain. As we started
the Cerner roll-out, we were planning for 10 years. VistA is
our interim solution. It is an interim solution for an
indefinite amount of time. Five to 10 years is the time window
we are looking at now, but that may extend.
Mr. Self. From what I am seeing, let us take the 10 years
out, with the delays. What is VistA going to look like in 10
years?
Let us go back to your MUMPS coders. This is not unique, by
the way. Companies are pulling Common Business Oriented
Language (COBOL) coders out of retirement. It is not unique
across the industry. Old codes are--old programs are being
resurrected because of their simplicity and so forth.
But--so what is VistA going to look like in 10 years?
Mr. McCune. Thank you for that question, sir.
We do have COBOL programmers as well.
Mr. Self. Okay.
Mr. McCune. It is hard to tell what VistA is going to look
like between now and then, for a number of reasons. It is a
moving target.
Number one, we are going to need to make changes to VistA
in order to support the Cerner roll-out, particularly
integrations.
Number two, we are going to have emerging requirements from
our clinicians, and so we are going to need to adapt VistA.
We are also going to need to adapt VistA to changing
technologies. You are seeing some of that right now with our
move to cloud.
So, predicting 10 years from now, sir, that is difficult to
do for VistA. All the problems we have talked about--aging
workforce, a programming language that is not taught today--all
of those concerns are compounded particularly if you talk about
a 10-year window.
Mr. Self. That leads me to the $17 billion for Cerner. You
said it would be very expensive to rewrite VistA. Do you have
an estimate on that?
Mr. McCune. No, sir, we do not. We have not done an
analysis on a large-scale full modernization of VistA. We
have--I think the committee is equally versed on the cost
estimates for Cerner. We have not done that similar kind of
cost estimate for VistA.
Mr. Self. I would assume you did that, though, before you
gave the--before you awarded the Cerner contract, because do
not you examine all your options?
Mr. McCune. Yes, sir. We considered all of our options back
in 2017 and 2018. We had about a year's worth of analysis that
went into making that decision.
Any data we had around VistA and its viability for
modernization is old and dated, and we would have to revisit
it.
Mr. Self. I have been handed a piece of paper that looks
like far more than my $17 billion.
I would--so you did or did not do that analysis before you
awarded Cerner?
Mr. McCune. Sir, thank you for that question.
We did do the analysis back in 2017 and 18 on all of our
options, and that is when we chose the Cerner solution.
Mr. Self. Do you remember what the VistA rewrite was?
Mr. McCune. No, sir, I do not, but we can get that
information.
Mr. Self. I would like to see that.
Mr. Self. Thank you, Mr. Chairman.
Mr. Rosendale. The gentleman from Ohio, Mr. Landsman.
Not there? Okay.
Representative Cherfilus-McCormick. Go ahead.
Mrs. Cherfilus-McCormick. Thank you, Mr. Chairman.
In 2017, Government Accountability Office (GAO) issued a
report documenting the challenges with VistA's pharmacy system.
The report was entitled ``Pharmacy System Needs Additional
Capabilities for Viewing, Exchanging, and Using Data to Better
Serve Veterans.''
Many of VA's plans to address the pharmacy system were to
use the Oracle Cerner pharmacy solution as part of the EHR
suite. If VA were to abandon the Oracle Cerner product, would
VA need to go back and fix each of the pharmacy issues outlined
in that report and others?
Mr. Hume. Well, many of those findings were addressed--have
been addressed over the last 5 years, particularly with respect
to a graphical user interface for pharmacy.
We would have to take for the record a specific--the
specific things that were done and were not done out of that
report.
Mrs. Cherfilus-McCormick. Do you know how many were already
fixed versus how many are left?
Mr. Hume. We would have to take that, ma'am.
Unless you are able to answer that? No.
Mrs. Cherfilus-McCormick. Okay. VistA may have less
problems today, but is part of that because everyone knows how
to use it and knows its quirks?
It is like a stable old family car. Everyone knows you need
to jiggle the clutch when it gets stuck in third gear. Would
you agree with that statement?
Dr. O'Toole. Yes. Yes, ma'am.
Mrs. Cherfilus-McCormick. What patient safety issues comes
up with VistA? My concern is the lack of coordination for all
veterans, with a focus on veterans often overlooked and left
out.
Dr. O'Toole. There are a lot of safety concerns within
VistA that, you know, I would be neglectful to say do not
exist. A lot of them are instance-specific and not necessarily
generalized to the entire system, I think some of which we
referenced earlier with the clinical reminders as one element,
view alerts being another one. Again, it is difficult to kind
of speak to it in generalities.
You know, I think we do a better job than most systems in a
lot of our population health work and a lot of our tracking of
potentially vulnerable populations. Could it be done better,
and could there be system improvements either within VistA or
within other systems to enhance those capabilities, you know, I
think, are clearly questions that would need to be explored.
Mrs. Cherfilus-McCormick. Thank you so much for your
answers.
Mr. Chairman, I yield back.
Mr. Rosendale. Thank you very much, Representative.
Mr. McCune, let us turn to reliability on the system,
uptime. According to the information provided, VistA's uptime
in 2022 was 99.9967 percent--that is better than Ivory soap--
and in 2021, it was 99.999964 percent. This is almost perfect.
That is excellent.
How in the world is that possible even through upgrades and
changes?
Mr. McCune. Thank you for that question, sir.
We strive to get to four 9's, and with VistA we have been
able to do that.
What I would say is that you have new systems. Generally,
as we release new systems, we have more issues, particularly
with uptime and reliability, than we do with systems that have
a long life span.
With VistA, for instance, we have had decades to work out
the bugs, fine-tune performance, and that is how we are able to
get to those high reliability rates.
Mr. Rosendale. Mr. McCune, is it true that if one VistA
instance goes offline for whatever reason, some reason or
another, the other instances may not be affected?
Mr. McCune. That is correct, sir.
Mr. Rosendale. Okay.
This brings me to one of the problems that I have been made
aware of. How does that compare with the Cerner system? It is
my understanding that when a system goes down, it is across all
instances, in many cases, and during upgrade periods.
Mr. McCune. Sir, I think I can speak to VistA. I do not
feel comfortable speaking to the Cerner implementation and
their configuration.
I will tell you that they are on-prem today and they are
looking to move to cloud. I would expect different kinds of
availability once that migration is complete.
Mr. Rosendale. Okay.
Mr. McCune, the VA also provides statistics on the
workforce that maintains VistA. This committee has been hearing
for years that the employees who are able to write the code are
retiring--you said it just earlier, as a matter of fact--and
can not be replaced, but the numbers do not bear that out.
In 2022, 1,129 full-time equivalents, FTEs, worked on
VistA, and 10 years ago, it was almost the exact same number at
1,134. That is only five people different.
The VA seems to be maintaining a stable workforce even
after all of the challenges that everybody seems to be facing.
How are you able to keep those folks on?
Mr. McCune. Yes. Thank you, sir, for that question.
We have been fortunate. I think our employees are committed
to the mission, and they have stayed long beyond what a typical
workforce would stay.
That number I mentioned earlier, 70 percent retirement-
eligible, that number has been creeping up year over year.
Eventually we are going to start to lose them.
Mr. Rosendale. Eventually. I mean, right now that is the
definition of a stable workforce. I mean, a 10-year period and
you have virtually the same number of people there.
Mr. McCune, the VA provided figures for spending on VistA
over the last 5 years. In 2022, VA spent, excuse me, $890
million, including about $70 million in development.
What factors drive the steady-state cost, and how do you
determine the amount to allocate development?
The reason I ask that is because I look at fiscal 18, 19,
20, 21, 22, and the development modernization enhancement, DME,
has changed dramatically: $16 million, call it $17 million, in
18; $25 million in `19--I am sure you have these numbers in
front of you--$51 million in 20; $104 million in 21; and then
drops down again to almost $70 million in 22.
What factors drive this?
Mr. McCune. Thank you for that question.
Sir, every year, we go through the budget drill and we set
priorities for the administrations. What you will see in the
variability with development and enhancement is a reflection of
those priorities. Sometimes there is an improvement needed to
VistA and that rises to the level of funding; other times it
does not.
Mr. Rosendale. Okay. I will tell you my concern, and that
is, when we see that Cerner is now on year 5 of 10 and we were
told about this roll-out taking place and we look at 18 and we
see the development modernization enhancement being starved out
of VistA, I have grave concern when I also hear that we are
relying so heavily on VistA still, not only for separate
facilities--166 of the 171 facilities--but for the existing
facility, even some of the functions we are still relying upon
VistA, and yet we are basically creating a self-fulfilling
prophecy by starving that system of the investment that it
needs so that it can perform the very duties that you are
calling upon it for.
I mean, can you respond to that at all?
Mr. McCune. Yes, sir. I appreciate the concern around
funding levels, particularly for development of VistA.
What I will tell you, sir, is that our resources are
limited. Right now, both our people and our budget are fully
committed to that Cerner implementation.
Mr. Rosendale. Mr. McCune, I understand that your funds are
limited, okay, and that you are budgeting. When I see a system
that is providing the vast amount of healthcare delivery
information for you and I see you starving it, and then you
come in before us and tell us that it is not only being
utilized for the vast majority of the facilities but the
facilities that are utilizing Cerner are still depending upon
this system as well, why would you still starve that system of
the revenue it needs to provide the technology that is working?
Mr. McCune. Yes, sir. Most of our funding today around
VistA is with that integration with Cerner. Again, it is
limited resources, sir. A lot of funding is being spent on
migration of data, on building integrations between VistA and
our legacy systems and the Cerner system.
Yes, sir, you are seeing a tapering off of development on
the VistA platform.
Mr. Rosendale. At the same time, we have got a $1.1 billion
investment that is being sent to Cerner, again, where we see
five facilities that they are funding that are not working
properly, that are still relying on the VistA system.
Do you think that is a wise allocation of funds, Mr.
McCune?
Mr. McCune. Sir, I can speak to the VistA system and our
funding and allocations there. I would take it back for the
record and our experts on the EHRM side of the house.
Mr. Rosendale. Okay.
Mr. Rosendale. Mrs. Cherfilus-McCormick, I am sorry, I went
way over. Do you have any additional questions for this round?
Mrs. Cherfilus-McCormick. No.
Mr. Rosendale. Mr. Self, do you have any additional
questions?
Mr. Self. Thank you, Mr. Chairman. I just want to follow up
on your point there.
Will there be an end to VistA? Will the integration, will
it be required well beyond Cerner roll-out?
I think I am hearing there may not be an actual end to
VistA. Am I hearing that correctly?
Mr. McCune. Thank you for that question, sir.
I think there is a couple of facets to that question. One
is what is going to be replaced by Cerner. Of the, I think, 150
modules, all but 5 of those are targeted to be replaced by
Cerner, so very little would be left over from a VistA
perspective.
On the VistA side of the house, we are cognizant that, as
an interim solution, that end date is indeterminate at this
point. We are making investments in VistA to make sure that it
is resilient, that we maintain the level of performance that we
have today. We are not stopping work on VistA. We realize it is
going to be around for a long time.
Mr. Self. The five that will remain, are they important?
Are they minor?
Mr. McCune. Those five, sir, will be replaced either in the
short term or the long term. That list has been a little bit
fluid, and so we are waiting for it to stabilize before we take
action on that. If we do indeed stabilize on those five
modules, we will start to work on modernization plans around
those five.
Mr. Self. Thank you, Mr. Chairman. I yield back.
Mr. Rosendale. I would like to thank this panel for joining
us today. This panel is excused from the witness table.
We will bring the second round up.
Thank you very much.
Mr. Rosendale. I would now like to welcome the witnesses to
our second panel to the witness table. I ask you to please
stand and raise your right hands, Mr. Baker, Mr. Gfrerer, Mr.
Levin.
[Witnesses sworn.]
Thank you so much.
Let the record reflect that all witnesses have answered in
the affirmative.
Mr. Baker, you are now recognized for 5 minutes to offer
your opening statement.
STATEMENT OF ROGER BAKER
Mr. Baker. Thank you, Chairman Rosendale and Ranking Member
Cherfilus-McCormick, for holding this hearing today.
With over $50 billion at stake, misinformation regarding
VistA has been rampant. Numerous parties continue to repeat
this misinformation in an effort to convinces Congress that
VistA is a problem in need of their solution.
The primary success measurement for an electronic health
record system at VA should be veteran health outcomes. That is,
after all, the fundamental reason the VA and the EHR exist.
The EHR program has effectively run a controlled experiment
over the last 6 years, complete with a hypothesis, a control
group, and metrics. This experiment has provided concrete proof
that veterans achieve better medical outcomes when VA
facilities use VistA than when they use the alternative.
Because VistA excels in medical care, it sets a high
comparative bar. VistA, and the work processes encoded in it,
was designed, implemented, and honed by VA clinicians to do
exactly what a clinician needs and exactly what a clinician
wants. That is both its blessing and its curse.
Independent surveys have shown that VistA is the most liked
her by clinicians nationally, and that is among all EHRs.
Lobbyists would have you believe that the IT difficulties
of VistA are more important than the medical care advantages.
VistA is a problem because of its age, its complexity, and the
language it is written in. In fact, at least one lobbyist would
have you believe VistA cannot be made better.
That is provably false. During just my 4-year tenure, many
improvements were introduced to VistA, including bed
management, blood bank, pharmacy reengineering, registries, and
numerous others, notably Cerner Labs.
In fact, VistA can be difficult to modernization. The
difficulties in modernizing VistA stem not from the software,
but from three root causes that come directly from VA itself.
First, every time VA has attempted to replace VistA,
starting in the year 2000 under the HealteVet program and from
2017 under EHRM, VA has prohibited further modernization of
VistA. This has included eliminating promising technology such
as VistA Exchange and Enterprise Health Management Platform
(EHMP) even when they were already in beta test. The fact that
you are told that VistA cannot be made better, when the primary
barrier to modernizing VistA has been a lack of investment for
16 of the last 24 years, is rich indeed.
Second, years ago VHA made the decision that veterans
receive better medical care if each VA is allowed to tailor its
care to local needs, that veterans in Fort Harrison VA can have
different medical needs from those in West Palm Beach. This
local control of medical care is a fundamental part of the
medical culture of VHA, and VistA is reflective of that
culture. This is where the sound byte, ``This is not a single
system, it is 130 systems'' comes from. Local customizations,
including local development staff, were a celebrated part of
VistA development for many years until the advent of the Gold
Disk Program in 2011. These local customizations are what has
made designing, programming, and testing changes to VistA more
difficult because every change must be tested to work with each
VistA instance.
Third, Federal pay grades and procurement practices have
eroded the base of skilled software developers needed to
maintain a complex her product. Capping salaries at GS 14
levels for the most skilled Federal IT staff has caused them to
seek other employment. VA continuously awards contracts for
complex VistA improvements to companies that cannot employ the
necessary skills at the rates that were bid to win the work.
They would rather tell VA: We can not find MUMPS programmers
without adding at those rates to justify why they can not
deliver.
VA has repeatedly failed at efforts to replace, not to
modernization VistA. Unless a decision is made that software
standardization is more important than local control of
healthcare at VA, attempts to replace VistA with a product that
does not support that fundamental part of the VHA culture are
doomed to failure.
Mr. Chairman, misinformation regarding VistA is being
promulgated to justify the now $50 billion need for the EHRM
program. The EHRM program itself has provided the best proof
that they are untrue. After 6 years veterans continue to
achieve better healthcare outcomes in VA facilities that use
VistA. That remains the single most important fact that you
will hear today.
I commend this committee for demanding the actual facts
regarding VistA, its role in veteran healthcare, and its
ability to be modernized. I look forward to working with you
and answering your questions as you further search out these
facts.
Thank you.
[The Prepared Statement Of Roger Baker Appears In The
Appendix]
Mr. Rosendale. Thank you, Mr. Baker.
The written statement of Mr. Baker will be entered into the
hearing record.
Mr. Gfrerer, you are now recognized for 5 minutes to
deliver your statement.
STATEMENT OF JAMES GFRERER
Mr. Gfrerer. Thank you, Chairman Rosendale, Ranking Member
Cherfilus-McCormick, and the subcommittee today, for the
opportunity to appear.
As a veteran I am a patient in VHA's health system. I am a
beneficiary in the benefit system, and now preregistered in
VA's burial benefits. As more than 28-year career Marine
infantry officer, with four combat deployments, I fully
empathize with all of our veteran men and women who endure both
the visible and invisible wounds of military service.
There is much misunderstanding around VA healthcare in
general. VA healthcare is unlike commercial systems. VA is
funded by government appropriation versus commercial health
systems who operate on a business revenue model. In commercial
healthcare, each patient is eligible for all services, where in
VA, eligibility is based on complex service-connected
conditions. VA healthcare is more specialized and expansive
than commercial systems comprising unique capabilities, such as
prosthetics, long-term care, and dental among others. These are
substantial differences even as compared to Department of
Defense healthcare and the first set of challenges for any
commercial her to be successfully implemented into VHA.
The bottom line is that Federal law, regulation, and policy
have created this unique health system, and the VistA her is
representative of those complex and unique business rules. It
may come as no surprise that when a commercial her programmed
for different financial frameworks, with significantly
different eligibility rules, and not addressing unique VA
clinical services, that there are problems and problems that
can not be overcome by change management. Without substantial
customization, no commercial her could address the business
rules that law, regulation, and policy mandate for veteran
healthcare. If you did not have a business system configured
like VistA, you would have to create or heavily customize a
system to perform just like it.
In the remainder of this hearing, we will get into greater
detail about VistA, its modernization efforts and some
additional facts and misconceptions, but allow me to offer some
highlights:
First, VistA is more than an her. It is what professionals
term an Enterprise Resource Planning or ERP system, which has
grown over the years to encompass many administrative,
financial, and other modules, a number of these which will live
on.
Second, it is not--I repeat not--a, quote, IT system but
rather a business and mission system. Why does this matter?
First, because the business, in this case VHA, must take prime
ownership to include the life cycle management, the capital
investment, and change management, with OIT playing a
supporting technical role.
Third, some would have you believe that VistA has not been
modernized, but that assertion is predicated on the fallacy
that modernization can only be achieved by replacement. Tech
modernization as defined by Gartner, Forrester, and others can
be--they say can be achieved in a myriad of other ways,
rehosting, moving to the cloud; refactoring, optimizing the
existing code; and encapsulating, exposing to APIS, all of
which were done to VistA during my tenure.
Also, let me offer in many respects veteran health care
business and technology discussions remain mired in the 2017
timeframe. It was in this timeframe that the pursuit of a fully
longitudinal health record was revalidated with an assumption
that it must be on the same platform in order for this to be
achieved. I will tell you in 2023, with the maturity and
adoption of health information exchanges and health standards,
that is no longer the case.
In an era of increasing technical debt and mounting
technology modernization costs, the Congress must determine
where the greatest need is for precious taxpayer dollars.
Presently there are roughly 300,000 Active Duty members who
matriculate from military service to VA every year. Last year
on the community care side, VA saw 6 million referrals for 36
million episodes of care. To compare 300,000 one-time transfer
to those staggering numbers, there is no doubt that the latter
is the substantially larger problem set and needs to be
addressed.
Finally, in an era where technology plays an increasingly
mainstream and critical role in healthcare delivery, VA must
begin to operate more efficiently and effectively, as do its
commercial and non-profit healthcare system partners, who are
well on their way in this regard. These systems understand that
technology and information technology is the success path and,
reciprocally, health systems cannot hire their way out of the
problem much as VHA attempts to do every year.
Mr. Chairman, thank you and the subcommittee for your time
today, and I look forward to your questions.
[The Prepared Statement Of James Gfrerer Appears In The
Appendix]
Mr. Rosendale. Thank you, Mr. Gfrerer.
The written statement of Mr. Gfrerer will be entered into
the hearing record.
Mr. Levin, you are now recognized for 5 minutes to deliver
your opening statement.
STATEMENT OF PETER LEVIN
Mr. Levin. Thank you for the privilege of testifying before
you today regarding the Electronic Health Record modernization
at the Department of Veterans Affairs.
I am deeply grateful to you, Chairman Rosendale, Ranking
Member Cherfilus-McCormick, and members of this subcommittee,
for the opportunity to share with you my perspective on one of
the largest civilian information technology projects in
history.
Our commitment to our Nation's veterans transcends party
lines and political idealogy. In an era of especially deep
ideology divide and social tension, I applaud your leadership,
Mr. Chairman, in soliciting the best ideas and constructive,
objective, fact-based perspectives from across the spectrum.
During my time in public service and under the leadership
of Assistant Secretary Baker, with whom I am deleted to appear
today, this afternoon, I have the honor of working on several
medical information technology systems that are still in use
today. Especially relevant to this testimony are the Joint
Longitudinal Viewer, JLV, originally known as Janus, and the
Blue Button personal health record that was launched during a
democratic administration and was warmly embraced by the most
recent Republican one as a fundamental component of any effort
to empower patients in their healthcare decisions. JLV enables
hundreds of thousands of clinicians to see health records
across platforms every day.
In this context, health aid interoperability, I
respectfully offer my observations.
There are three issues before the government regarding
VistA and Veterans Affairs: One, that billions of dollars
already spent on the commercial implementation will not scale
to enterprise wide clinical care services on the current path,
budget, or timeline. Two, that VA can and should sustain the
data interfaces and connection frameworks already built to send
and receive data from Military Health System (MHS) GENESIS.
Three, and most important of all, that VA consolidate its
current instances of VistA onto a VA-centered clinical
workflow, and augment the VistA model to receive data from
third-party providers.
As you will hear from my colleagues and other witnesses,
the differences in VA healthcare between points of care is
simply not that large. It is not tens of billions of dollars
large. Veterans receive terrific healthcare, but their care is
delivered with different processes depending upon which
hospital or clinic they go to. That is the primary problem.
In my opinion, the department should not announce its
intention to change the contract unless and until it has a
backup plan in place. That plan cannot be to, quote, revert
back to VistA in its current form, or anything that concedes to
VA's continued digital isolation and process insularity.
Switching back to VistA and walking away does not fix the root
problem. How do we address this issue?
First and foremost, cloud technologies are now stable and
mature enough to enable consolidation onto an authentically
single platform. Additionally, there have been substantial
improvements to the code base that are now available to VA from
the commercial sector. It would be straightforward to
reinstantiate Open Source Health Record Alliance (OSEHRA) with
a powerful charter and legislative mandate.
Moreover, commercially available data management
infrastructure has made substantial progress in the last 5
years. There are no technology impediments here. I would like
to repeat that. There are no technology impediments here. This
is simply a matter of political will, imaginative leadership,
and execution accountability.
Indeed, these policy changes, consolidation onto an
enterprise clinical workflow and adoption of proven platform
and data management services would accelerate health record
modernization at a fraction of the cost now earmarked for EHRM.
The transcendent goal of our work has to be the
continuously better care of healthcare of veterans. Unless and
until VA resolves its internal tension around consolidated care
pathways and comprehensive data management, no amount of
technology will automate its operations and no amount of money
will solve its policy problems.
Thank you for my opportunity.
[The Prepared Statement Of Peter Levin Appears In The
Appendix]
Mr. Rosendale. Thank you very much, Mr. Levin.
The written statement of Mr. Levin will be entered into the
hearing record.
We are now going to proceed to questioning and, I will
start with the first 5 minutes' worth.
Mr. Baker, I have heard it said that VistA was developed as
a healthcare delivery software and that the Cerner Oracle
system was developed as a billing software. What is the basic
differences of that? What problems does it present?
Mr. Baker. I think it goes back to the environments they
grew up in. On the commercial side, billing is where her is
started, to be able to accurately bill and get paid. On the VA
side, they did not have to worry about billing out for most of
the tenure of VistA.
VistA focused on keeping a record that was completely
oriented around how good is the medical care we are providing
this veteran, whereas commercially EHRs tend to be excellent on
the financial side and have added more recently the medical
record side of things, at least to the extent that VistA has.
The difference there is clearly on the focus. You know, as
I mentioned in mine, there is a culture difference between the
VA system and the commercial systems related to the preeminence
of medical care. Congress provides an appropriation that
provides most of the money that VHA needs. They do not have to
worry as much about am I billing things out, am I going to be
able to pay people as a commercial her does. They both have
very valid reasons for why they grew up. What we are trying to
do now with EHRM is to take a financial system and lay it over
top of a medical records system.
Mr. Rosendale. I think that very clearly describes exactly
the frustrations that I have had since I was exposed to this,
and that is that the benefit, the healthcare benefit is not
being provided properly. I think that this has been expressed
by the docs and physicians at the facility at Mann-Grandstaff.
Mr. Baker or Mr. Levin, there have been previous efforts to
modernize VistA as well as replace it. First of all, in the
2000's, there was replacement effort. I understand it cost
about $600 million.
What was this project's genesis, how did it perform, and
what happened to it?
Mr. Baker. Well, since I was the person who terminated the
HealtheVet program, I will speak to that one.
In roughly the 2000 timeframe, VA decided that it could
replace VistA by developing a new system called HealtheVet, and
they launched down that path. A good friend of mine was the
deputy Chief Information Officer (CIO) at that time, and his
responsibility was to terminate all spending on VistA so that
it could be focused on HealtheVet.
There were a few good pieces of software that came out of
HealtheVet. The My HealtheVet website that you see now came out
of that, as well as a few other things that we were able to add
to VistA. By and large, that $600 million, by the time I got
there, it was obvious that was a wasted program, and so we
terminated it and focused on the VistA improvements that I
mentioned in my testimony.
Mr. Rosendale. Very good.
Then, Mr. Baker, next came the Integrated Electronic Health
Record (iEHR) between 2011 and 2014. VA and DOD attempted to
build a new joint EHR. I understand that that one cost about $1
billion.
How was that different, and why was it abandoned?
Mr. Baker. I was very key and core to iEHR, and I would
describe iEHR this way. It was a battle between VA and DOD. VA
had a requirement that the only her they could use was VistA.
DOD had a requirement that they could use any her but VistA.
And we spent a lot of time in that battle.
Now, let me--since Dr. Levin sees that time much more
rationally than I do, given how deeply I was involved, let me
just ask him if he has any further comments there.
Mr. Levin. Thank you, Mr. Baker.
I do have a couple of comments. I think that there is a
gigantic difference that we ought to acknowledge that we have
tried to replace VistA a couple of times, but our modernization
efforts, looking at this holistically and trying to module by
module, object by object replace it, upgrade it, modernize it,
transfer it to the cloud, this has never actually received full
attention and support from the institution.
I think one of the conversations that we are having today--
and iEHR is a perfect example of that--is to distinguish and
differentiate what is a replacement and what is a
modernization.
The single biggest problem with VistA, at least in my
opinion, has nothing to do with MUMPS or the availability of
language competencies of any individual programmer. As
Secretary Baker has pointed out many times, if you speak 11
computer languages, you can learn the 12th one without too much
extra effort. I think that that is a little bit of a red
herring to throw out the particular language and expression of
the system.
The number one handicap of VistA today is its lack of
modularity. That is a word that Secretary Baker led when he was
in office and I participated in, and I think that VistA itself
or any her would benefit tremendously from attention on its
modularity, its extensibility, its scaleability, its
testability. These are things that are fixable inside the
incumbent program today.
Mr. Rosendale. Thank you very much.
Representative Cherfilus-McCormick.
Mrs. Cherfilus-McCormick. Thank you, Mr. Chair.
Mr. Levin, in your written testimony you stated that the
department should not announce its intention to change the
contract unless and until it has a backup plan in place.
Furthermore, you stated that that plan cannot be reverted
back to VistA in its current form or anything that concedes to
VA's continued digital isolation and process insularity. I just
want to State I cannot agree with you more.
The EHRM program is one particular case study that is part
of a larger issue surrounding the VA's inability to manage and
contract for large IT systems. Whether it is EHRM, supply
change, or HR modernization, the lack of progress and success
is not contained through a single program. Without real program
and acquisition management at VA, this program will continue to
not be successful.
Mr. Levin, would you be supportive of holistic changes with
how VA manages and is held accountable for these large IT
modernization efforts?
Mr. Levin. Thank you very much for your question,
Congresswoman.
The short answer is yes, I could not agree with you more. I
would like to introduce you to some members of my family to
find somebody to agree with.
The things that we could do structurally operationally
inside the VA I think are very accessible to us. I can not
explain why we do not do them on a regular basis, but written
down plans, accountability metrics, performance metrics--and I
do not just mean by individuals; I mean by the systems that we
are putting in place. I think that we have confused--and we can
have probably a larger societal discussion about this. We have
confused the difference between best efforts and outcomes. I
think that, at least in my world, the commercial world that I
live in today, my customers do not very much care how hard I
work. They very much care about whether I deliver to my
promises on time.
There is a huge difference, a vast difference between how
the processes and the accountability metrics, the hiring that
we have to go through at any government institution. Of course,
VA is not unique in that way at all. We can do better. There
are lots of things in the private sector, obviously, that I
think we would agree are sometimes inequitable or sometimes
ineffective. The pendulum has swung too far, in my opinion. In
my personal opinion, the pendulum has swung too far, and we
should be able to structure programs inside of government,
inside of VA that hold the leadership accountable, that have
sensible budgets associated with them, and that have
performance-measured outcomes. I do not think that we are doing
that sufficiently well right now.
Mrs. Cherfilus-McCormick. Thank you.
Given that EHRM was allowed to be awarded as a sole source
contract, do you think that the VA's requirement requires more
checks and balances internally before awarding future contracts
for IT modernization given the results that we have seen thus
far?
Mr. Levin. Again, thank you for your question.
I believe that my copanelists will have divergent views on
this.
I was relatively close to the process. As a private sector
observer, I was relatively close to the process. I do not think
that it was unfair. There was political exigencies. There were
operational exigencies at the time. I think that if we could
wind back history, it was not so much that we made a decision.
I was a very loud advocate of not going the direction that we
went, but I had the privilege of speaking to a senior most
leader at the time who was part of the decisionmaking and who
reported to me: okay. The decision is made. Now what?
I said to that individual: Well, now it is just an
engineering problem. Anybody can do that. Right? I still
believe that. I really do.
I think that--if I can recommend attention of this
committee, the focus of this committee would not be so much on
how do we get to the DNF and why did we follow the DOD. Those
are important questions. Those are policy questions. It is what
all happened afterwards, where many of us who were loudly
advocating the misdirection, the misapplication, the lack of
framework, the lack of accountability, the personalities that
were involved, and there was almost no accountability
whatsoever, I think that that is where I would direct this
committee's attention, and I think that that is what we could
be doing much better at VA.
Mrs. Cherfilus-McCormick. Thank you so much for your
testimony.
Mr. Chair, I yield back.
Mr. Rosendale. Representative Self.
Mr. Self. Thank you, Mr. Chairman.
I want to go back to the languages, though. That seems to
be a major point for the VA.
As we have said, other old languages are used. Is there any
other language that could be used to modernize VistA?
Mr. Baker. As modules are changed in VistA, frequently they
are written in other languages. In my written testimony, I talk
about VA's attempt to implement Cerner Labs, which is written
in a completely different language.
The points at which MUMPS is critical is as you understand
the complexities and the architecture of VistA and making
changes to that as you add the new modules that are going to
interface to it. That MUMPS expertise is necessary. Even in
saying MUMPS, what you are really saying is expertise about
VistA as a large-scale application. It is, by definition, by
what it tries to do, a very complex piece of software because
it is also a very accurate and very extensive piece of medical
software. We want it to be as good as it is because we get our
medical care from that.
The short answer is yes. Frequently the new pieces are
written in different languages, but you have to have some level
of MUMPS expertise to be able to interface to what remains
there from the VistA system.
Mr. Self. If I understood you correctly, surely there are
people, other than your more mature MUMPS coders, that
understand the VistA architecture?
Mr. Baker. It is a--it is not something that you want to
give a neophyte access to. It is like having them drive, you
know, your Maserati, having your 16-year-old son drive your
Maserati, not a good idea.
You would like them to get some training on other things.
Again, a lot of times the problems that VA runs into from a
procurement standpoint is that they do not--they award
contracts when even those senior level people are necessary to
guide the more junior people, they are just too expensive for
that contract. You end up with a solution that does not work.
Mr. Self. I understand that clinicians like VistA; IT does
not. What are the IT reasons to cancel VistA? Then we will get
to the clinicians.
Mr. Gfrerer. Congressman, I would probably reject that
characterization. I mean, IT is--certainly what is not to like
is that when you are working with riddled systems, you know,
that are not, you know, refactored and hosted and, you know,
the most--the best environments, right. It is a work in
progress on VistA. Ultimately, when you are back in 2017--and I
was admittedly not with the agency--it was an agency decision
to go to VistA. It was not a vote of no confidence within OIT.
I think the other thing too is, to get back to your
language point, at some point, you know, the increasing trend
you see in all verticals, in healthcare, and others, is managed
services where companies that do this work well can take on
bits and pieces, those modules that we are talking about. You
are going to see more of that, right, companies that do
pharmacy real well, companies that do scheduling real well. You
know, the VA should not be in that business. Right? They should
look to who are the vendors that are best of sweet with regard
to these capabilities and incorporate them. At that point you
have shifted the risk to the vendor, to the commercial
provider, and you do not care if it is written in MUMPS or C
Plus or COBOL, or whatever language it is in.
Mr. Baker. If I could add, sir, the interesting point the
chair was making earlier about same number of staff, the IT
people that work on VistA love the product. They love the
product. The affinity--the people that I have heard from inside
VA since they found out I was going to testify telling me, you
know, please do this, has been extensive.
There is this large group of people, several thousand, that
know this product well and want to see it succeed. They are
part of what we looked to engage with the open source community
at the time we were doing that, and they would like to continue
to participate in moving this product forward. They have a lot
of expertise.
Mr. Self. Interesting.
That brings me to a simple question. What advantages to the
veteran does Cerner bring?
Mr. Baker. I do not think I am going to be somebody who is
going to give you any of those. I am not aware of things that,
for the veteran today, are better because of the Cerner
implementation in the five facilities than they were before
VistA was there.
I will ask if my partners want to say anything.
Mr. Gfrerer. Yes. Maybe as the lone veteran, I will hazard
a guess here and say that, ultimately, it should be about the
clinician deciding that the care outcome is going to be better
for the veteran. Largely, as the veteran--and I saw this in
some of the earliest communication about how great the new
Electronic Medial Record (EMR) was. Again, as a veteran
patient, it does not matter to me. I should not know whether it
is VistA or, you know, whatever the EMR is that the care is
being provided for.
At the point that I care about what the system is that is
being provided, I am probably being negatively impacting.
Mr. Self. I am speaking to former secretaries. In your view
or in the view of the current VA, I just--I am not--I am
starting to not understand any advantages of Cerner.
Mr. Baker. I am not aware of any----
Mr. Self. I am not talking--I understand you are a veteran,
I am a veteran, and it should be transparent to us. But at your
level, at the decisionmaking, the policymaking level, what are
the advantages that Cerner will bring?
Mr. Baker. The theoretical advantages--I do not believe
they have been realized yet--is that Cerner would be easier to
maintain and easier to move forward than VistA in the out years
of the program. That would be the theoretical advantage, but
there is no hard evidence that that theoretical advantage will
actually be true. The cost, in my opinion, is going to be
substantially more than it would be, from a VistA perspective,
for the near and the midterm.
Mr. Self. Okay. You have just gone back to my first
question: What is the IT advantage of Cerner? There does not
seem to be one.
Mr. Chairman, I yield back.
Thank you.
Mr. Rosendale. We will come back around for another round
so you can have some more.
Now we are starting to get to the crux of where I wanted to
go for this next round of questioning, and that is the
investment as opposed to the theoretical promise of benefit in
the future; okay.
Mr. Baker and Mr. Levin, let us turn now to the
modernization efforts. What was the purpose of the Gold Disk
project? How much did it cost? What did it accomplish?
Mr. Levin. Secretary Baker, I do not remember how much it
cost, but I do remember it not being very expensive. Is that
true?
Mr. Baker. My best understanding is it was single digit
millions, probably in the 5--I would want to ask VA for the
specific numbers, but it was not an expensive program.
Mr. Levin. I would have hazard--I am glad that Secretary
Baker went first. I would have guessed it was much smaller than
that.
The outcome of the Gold Disk Program, which I want to
immediately confess, was not perfectly successful. It was a
great first start. There was a tremendous amount of resistance
to consolidating that because, of course, that was the
premonition of consolidating workflows and understanding the
differences and highlighting the variations in the clinical
care pathways at the various installations.
I do not want to make it sound like the Gold Disk was, in
fact, what its name implies, the nomenclature amplifies a
little bit the success. That not withstanding, probably the
most important outcome--I am looking at Secretary Baker when I
say this--was that we consolidated FileMan.
The most challenging, the most difficult, arguably the--
not--if we use an anatomical analogy, it was not the heart and
brains, but it was one of the vital organs. We went after it
first because it was difficult, because we wanted to
demonstrate that, in fact, you could start modularizing the
code, you could start creating test harnesses around the code,
that you can do what we are discussing here today. This goes
back 12 years ago, sir.
Mr. Rosendale. Then for several million dollars, you were
able to accomplish this?
Mr. Levin. Yes.
Mr. Rosendale. Okay. Mr. Baker, Mr. Levin, why were you not
able to eliminate all of the differences between the VistA
instances?
Mr. Baker. Well, the most important thing was it was a
joint program between VHA and OIT and we got to the point where
there were differences that VHA was unwilling to, if you will,
exert their internal political capital to get their
organization to agree to. When we achieved--we had gotten to
about 95 percent commonality across the platform when I left.
We felt that was a good start, and we felt it would continue
on.
I want to commend Mr. McCune. My understanding is that it
has continued on and that they are now achieving, if not a
single Gold Disk, but very close to that with VistA at this
point. His efforts on that part have been great from our
perspective.
Mr. Rosendale. Very good.
Mr. Baker, Mr. Levin, VistA Evolution began in 2014, and it
was canceled in 2017 when Cerner started. It was estimated to
cost about $5.3 billion over a decade.
What were its goals and what was accomplished with that
program?
Mr. Baker. I do not know that I can speak to the goals. I
think VA's goals were bigger. It was developed after I left,
and so I think the goals were bigger.
I actually was at one of the contractors at that point that
was developing that. What was developed was something called
VistA Exchange, the ability for a clinician--the data provided
to a clinician to come from a wide variety of data sources,
multiple EHRs, multiple data sources, and present a single
computable view to the clinician and a web-based version of the
CPRS interface, so a modernization of that into what is called
a widgets-based interface.
Both of those were in beta tests, and other things were in
beta tests at the Hampton Roads facility when that project was
canceled.
Mr. Rosendale. Okay. This question is going to be for all
three witnesses.
Regardless of the EHR system chosen, is the VA ever going
to be able to accomplish a monumental rip-and-replace project?
Should they even be trying to do that?
We can start over to my right, Mr. Levin.
Mr. Levin. Congressman, with respect, I believe that the
answer to your question is no. It is not so much even a
question of the competency and skills. It is certainly not a
question, not a question of the commitment of the people who
work at VA. It is absolutely a question of the structure, the
accountability metrics, the frameworks in which they have to
operate today.
Under its current framework and structure, the answer is
no.
Mr. Gfrerer. Over the past decade, commercial entities have
gone away from big ERP, Enterprise Resource Planning, rip-and-
replace. It is just fraught with too much peril and failure.
The incremental modernization path is generally the one that
you see followed.
I would like to layer in too at some point that, you know,
any organization, whether it be the VA or a major healthcare
system, really only undergoes these sorts of, you know,
changes, you know, once every 30 to 40 years. I mean, it is
almost like big iron in the sense of they are there--you know,
look at VistA, it was there for 40 years. It is still there.
The knowledge base around putting in a new system in
whatever manner, it is fairly limited, fairly exclusive. It is
not astronaut exclusive, but there is only--when you look
across the executive base in the U.S., there is only, you know,
dozens of people that have really done this. I can tell you
that at VA during my time and others' times there are none of
those people. Right.
The requirement to leverage external advisors and to visit
and--you know, I can talk more about this later--I do not think
that has been anywhere near sufficiently leveraged. I know when
I compare during my time the level of governance that was
exerted on the program compared to what I have talked to some
of my commercial counterparts, it is not even a shadow of what
they did in term of these programmatic deployments.
Mr. Rosendale. Thank you.
Mr. Baker.
Mr. Baker. No is the simple answer. The government in
general is not good at large IT programs. There was a point in
time in about 2010 when the National Defense Authorization Act
included the language that 16, 1-6, percent of large Federal IT
programs succeed.
The EHRM is the largest Federal IT program. It is not being
done by DOD. VA does not have the same program management
capabilities that DOD has. Especially looking at the evidence
of the growth in the budget of the program, it is a very good
indicator that, at this point in time, VA has no chance of
actually succeeding on this program.
Mr. Rosendale. Thank you. Thank you very much.
Ms. Cherfilus-McCormick.
Mrs. Cherfilus-McCormick. Thank you, Mr. Chair.
Mr. Gfrerer, what role did you play in Cerner's EHR
modernization at the VA?
Mr. Gfrerer. I feel like I am back in my confirmation
hearing.
Certainly the Office of Primary Responsibility for EHRM and
VA very deliberately was segmented into a specific office,
during my time the Office of Electronic Health Record
Modernization. Then it was supported by two business units that
were the existing EMR owners; VHA as the business owner and OIT
as the technical owner and operator of the system.
Both VHA and OIT supported the Office of Electronic Health
Record Modernization and their programmatic oversight and
scheduling of those waived deployments.
Mrs. Cherfilus-McCormick. Do you think in retrospect that
was a bad decision to have OIT on the outside of the program
with CIO having such a limited role?
Mr. Gfrerer. When you look at innovation and putting in new
applications and new systems, often you have to get past the
current, you know--the existing system owners, both the
business and the IT. I do not think that that was necessarily a
bad decision. You know, each organization does it a little
differently.
I had a conversation with a commercial CIO, as just kind of
a refresher for this panel, the other day. He elected in, like,
his own cylinder of excellence to have a separate organization.
There is pluses and minuses to both approaches, and that is the
one the VA selected.
Mrs. Cherfilus-McCormick. I recognize you entered VA
service a few months after the Oracle Cerner contract was
signed. From your perspective now, do you think the strategy to
do a sole source contract with Oracle Cerner was a good
decision?
Mr. Gfrerer. Well, as I said in my opening remarks, in that
timeframe, the premise when you looked at where technology was
or, more importantly, where it was not in terms of Health
Information Exchange, again, you could make a case that if you
are going to derive the benefit of having that longitudinal
record, you know, all the way from the time someone enters
military service until the time they are buried in a VA
cemetery, that it needed to be on a single platform.
That is why I said a lot has changed in the past 6 years,
certainly the development of the Health Information Exchanges,
and then when you layer in this whole notion that you have this
smoldering ember of a problem over here with 300,000 people
changing hands every year and over here you have 6 million
community care, you know, referrals,.
Thirty-six million episodes of care, that is only going to
grow larger. We need to kind of make a rational decision about,
you know, where those precious investment--those tax dollars
are paid.
By the way, where you are having that progress on the Joint
Health Information Exchange, that can also accrue benefits back
into the DOD VA system and that data exchange.
Mrs. Cherfilus-McCormick. Do you think the VA did
appropriate planning, research, and standard program management
related to this contract and program?
Mr. Gfrerer. As I mentioned just a few minutes ago, when
you compare and contrast what the VA has done and likely
continues to do and compare it to any one of the number of
large commercial systems that have been on a similar electronic
health record journey, you would be concerned about the
disparity between the governance and the efforts that these
commercial systems have exhibited compared to VA.
It is what Secretary Baker said too is, by and large, not
to give an excuse, government agencies do an exceptionally poor
job at managing. I would call them--I said it before--business
transformations. They are not IT programs. It is not an
enterprise IT. It is not a security program. We are not putting
in a new service management tool. This is a business admission
healthcare system program.
Mrs. Cherfilus-McCormick. My final question for you is do
you think it was a wise decision to deploy Cerner EHR in the
middle of the pandemic, a facility that was not yet ready, with
technology that was not ready, just a few weeks before a
Presidential election?
Mr. Gfrerer. Well, I know that the original date, having
been in those meetings, was October 2019. The decision at that
point on go, no go was really predicated around--what the
chairman and others have talked about was those 73 different
applications or interfaces that Millennium was going to have to
draw services from. Those were just not ready. That was the
initial decision to push off.
Then at the point that it went into the following year, it
really was more in VHA and to the facility, to Spokane's
decision as to when they would be ready to go live. I think
that decision was really pushed down to the lowest level
possible, certainly to the medical center director at Spokane.
Mrs. Cherfilus-McCormick. Thank you for your testimony.
Mr. Chairman, I yield back.
Mr. Rosendale. Representative Self.
Mr. Self. Thank you, Mr. Chairman.
Given you all's history with VistA, order of magnitude,
what would it take to rewrite VistA in dollars? Order of
magnitude.
Mr. Baker. I would hope I am on the high side with $10
billion.
Mr. Self. Thank you.
Mr. Chairman, I yield back.
Mr. Rosendale. Thank you, Representative Self.
I am going to go into these instances. I have got a batch
of questions about that. This question is for anyone who wants
to answer.
Why do the different VistA instances exist? How are they
different? How much of--what I am trying to figure out is how
much of each instance is identical, okay, that they all match
up, and what are the examples of the differences of the
instances?
Mr. Gfrerer. I will start off, Mr. Chairman. I am sure
Secretary Baker and Mr. Levin will jump in.
As you heard earlier, the rough average is about 95 percent
commonality between the 133 instances. I would say, again, it
is a business admission decision as to that variability; right.
The first thing you have to realize is, you know, not every
VA facility is the same. There are a range of clinical
capabilities all the way from--let me just use the Northwest
where it is currently being deployed, all the way from Puget
Sound, which is a level 1a facility with all the top levels of
care, Intensive Care Unit (ICU), Operating Rooms (ORs), things
like that. Then you compare it to Spokane which is down at
level 3. You can imagine that based on those different levels
of facility care and those clinical capabilities, there would
have to be some variability or differences in the instances.
I will pass it off from there.
Mr. Rosendale. Basically it is talking about the, so I am
understanding, types of procedures that are offered in each of
these facilities, some being much more complex and some being
just a standard primary care?
Mr. Gfrerer. I mean, literally different clinical
capabilities. Again, you know, Puget Sound has an OR and an
Emergency Room (ER) and I do not believe----
Mr. Rosendale. Outside of that, let us just say outside of
that, if we have similar--we will call it similar facilities
offering similar procedures, okay, what are the differences?
Are we still dealing with 95 percent commonality, or is it
greater?
Mr. Baker. I think today you are dealing with more. At the
time that I left off, there were a few packages where there
were alternative versions of the package that one facility
might choose to implement and another facility would choose the
alternative. Again, this comes from the day and time when the
way packages got developed is one facility would build them,
and another facility would build an alternative to that, and
various hospitals would choose which of those they liked.
By the time we started the Gold Disk Program, there was a
plethora of what is called class 3 software.
Mr. Rosendale. Were they all still communicating?
Mr. Baker. Communicating to the sense that you can see the
record from any VistA system in any other VistA system. I do
not know whether that data is computable in all circumstances
when it goes from one VistA system to another VistA system. It
depends on your definition of, quote, communicating.
There was a plethora of this class 3 software, and what we
did was basically asked VHA to settle on one version of each of
those packages and then make that the standard. They got down
to about 5 percent where they said, We need to offer both of
these or all three of these because we can not tell the
facilities to just go with one.
The variation was not, if you will, things all over the
map. It was, oh, you have chosen the 1a option instead of the
1b option for your facility, but we support both the 1a and the
1b option across the enterprise.
Mr. Rosendale. Okay. They were supporting them.
To make sure that I am clear, so when I say communicating,
so you could view it--regardless of which facility you were in,
you could view it?
Mr. Baker. Yes.
Mr. Rosendale. Could you enter data--if a veteran came from
one facility to the other, could you still enter data in if you
were at a different facility?
Mr. Baker. My understanding is that the veteran would have
a new record, a new record at the new VA.
For example, like I live in Florida. Lots of people will
come down to live in Florida for 6 months and a day for tax
reasons and, you know--but they will have a record in their
Florida hospital, as well as their Ann Arbor hospital, for
example, and you can view. They will have separate records
between the two hospitals. That is my understanding, subject to
correction by VA.
Mr. Gfrerer. No, that is correct.
I can use myself as example. While on Active Duty, I had
a--had to be seen for a minor accident in Minneapolis. I had a
record there, and I have a record in Department of Veterans
Affairs Medical Center (VAMC) D.C., right, and the two are just
related.
Mr. Rosendale. Again, can either facility make amendments
on either record?
Mr. Baker. I do not----
Mr. Rosendale. Or can you only make amendments in your
facility for that record?
Mr. Baker. I believe that you would have to specifically go
to the other record and sign in as a user on the other VistA
system to make actual changes in the other record is, I
believe, the answer.
Mr. Rosendale. Okay. Let me ask you this. At least does it
come up as, like, a file, as an additional file so that you can
see it as part of the patient chart?
Mr. Baker. Yes. My understanding is that you get an alert
as a doctor that says there are other records, other VistA
records available on this patient. Would you like to view them?
Again, I want to leave this subject to correction by VA.
They know the system in depth much better than I do.
Mr. Rosendale. Okay. Thank you. Thank you very much.
I am out of time myself. I am going to turn this over to
Representative Cherfilus-McCormick.
Mrs. Cherfilus-McCormick. Thank you, Mr. Chair.
This question is for Mr. Baker.
You participated in VA's iEHR program, which eventually
collapsed and the transition to VistA evolution, the program
which has stopped, before the current Oracle Cerner EHRM, a
very conservative estimate from the GAO using VA data show that
efforts costing at least $1.1 billion.
What makes you think going back to VistA is a good idea
right now?
Mr. Baker. I base my assessment on--of why you go back to
VistA on two things that I talked about.
One is just based on the track record at this point of the
program. For someone like me, who has seen a lot of these
programs, it is obvious this program has failed. The question
is how much money we will spend before we fully recognize that.
The second thing is one of the main metrics I use is are
veterans getting better healthcare. If today veterans were
getting better healthcare in facilities where the commercial
product was being used, my view would be entirely different.
You know, compared to the amount of money we spend on medical
care at VHA, $50 billion is a relatively small amount. If you
are not going to produce better healthcare, then why spend that
money, because it is all about better healthcare for veterans.
That is my reason why I believe we have got to go back to
VistA and then a path forward. I do not think VistA is the end
solution. I want to make that very clear. We are at this point
now because we have failed on the EHRM, and we need a solution
for the midterm while we figure out how to get to the long
term.
Mrs. Cherfilus-McCormick. Thank you.
Do you have ideas for how VA could descope the current
contract with Oracle Cerner and use it for the bear minimum
services and then use other IT service providers and companies
to fill in the gaps so as to diversify risk?
Mr. Baker. I do. It would take us much longer than we have
in testimony. I think about--sadly, I think about this a lot.
Something about VA gets into your blood. I can speak to all
three people here. We remain dedicated public servants even
though we are not getting paid by the government at this point.
Yes, we have talked about this. We have lots of thoughts on
it. We would be happy to share those with you.
Mrs. Cherfilus-McCormick. That would be wonderful.
Given what you know about the IT industry, would you have
done a sole source, no-bid contract like VA under the Trump
administration did? Would you have mandated the use of an
integrator?
Mr. Baker. I am not a fan of integrators on large programs
like this, just from all of the--from everything I have seen
from that standpoint. My track record speaks to that.
No, I did not like the sole source. I am loathed to
criticize people that were in the arena at the time, but it was
an odd way to go at things.
Mrs. Cherfilus-McCormick. I read your written testimony and
agree with you that the VA culture of allowing customization in
its medical centers has contributed greatly to failed attempts
at modernization.
Is there any management structure in place at the VA where
Under Secretary for Health and the CIO would be required to sit
down and make decisions based upon priorities for deploying a
modern EHR?
Mr. Baker. I will just start by saying it depends on what
administration you are talking about. Under Secretary Shinseki,
absolutely, absolutely. I know it varied in other
organizations.
Mr. Gfrerer. I would add to that that I know, toward the
end of my tenure, we attempted to re-implement the Office of
Military and Veterans Affairs (OMVA) 130 Required Investment
Review Board Process managing information as a strategic
resource, and I can tell you that was met with not a lot of
enthusiasm. That is--there is a reason that OMVA circular
exists, because you have--and we saw it within our unfunded
requirements process every year. You had 10X of requirements
chasing 3X of IT spent dollars. If you did not deliberately,
through an investment review board process, prioritize and be
very clear eyed about where you were going to spend it, it was
going to sort itself out and probably not in a very clean way.
Mrs. Cherfilus-McCormick. I am looking for an opportunity
to produce legislation this Congress to provide the VA with
tools to make consensus decisions that put the care of veterans
and the well-being of frontline staff at the forefront of
requirements development and not cater to fractions within the
VA. I prefer one software product over another. I do not care
what system the VA uses. I want veterans and employees to be
delivered what they are promised and what taxpayers are paying
for.
Thank you, Mr. Chair. I yield back.
Mr. Rosendale. Thank you very much, Representative.
Okay. Mr. Levin, I am going to ask a couple more questions
before we let you all get out of here.
VA leaders have said many times that they want an EHR with
one instance, to eliminate the variations from facility to
facility. Yet I hear regularly, almost every hearing that we
hold, that if you have been to one VA, you have been to one VA
because they are so different.
My question is, is that realistic? How can it be
accomplished?
Mr. Levin. Thank you, Chairman.
It is realistic. It can be accomplished.
Let us spend a couple of seconds on how we got to now.
There are endogenous reasons, internal reasons for the
differences between the different facilities, and these are
good reasons. These are things that we need to protect and
nourish.
The VA has a culture of innovation. We spend a lot of money
every year with new medicines, new therapies, new processes,
new instruments.
Secretary Gfrerer mentioned during his remarks that it was
a business decision. I strongly agree with him, and I strongly
agree that that was the right thing to do.
The VA is a greenhouse of training and new ideas, and you
actually want that. We do not want to force or force feed some
kind of rigid, unchangeable structure, because they are also
teaching hospitals. Something like a third of all practicing
physicians in the United States did at least some part of their
residency at the VA. You need the VA to be vibrant that way, to
be intellectually challenging, to show the hardest cases, to
get the best care in order to attract the talent that, as
Secretary Baker said--and I will say it slightly differently--
for many of us, those who are veterans and those who are not,
those who are in public service today and those who are not, VA
is a transcendent moral cause. It is a moral cause of our
country, and I think that we made a promise that we need to
keep. One of the ways that we keep that promise is by making
sure that we are at the vanguard, at the forefront of that kind
of care.
The differences between the institutions, we have talked a
lot about, well, how many of the clinical care pathways are the
same or how much of the code base is the same. I respectfully
submit that that may not be the right metrics. It is an easy
metric. We know how to measure lines of code. We know how to
articulate the differences.
The difference that I would propose is that we see how much
does it costs. How much does it cost to sustain these various
pathways and do they actually deliver superior care? The trade
space, the decision that we have to make together as a country
is how do we sustain and maintain and nourish the vibrancy of
those environments but not charge the taxpayer tens of billions
of dollars because we are trying to let every VA hospital do it
by themselves? At the end of the day, this is an implementation
framework question. This is a question of authority. This is a
question of accountability, and it is not a technology problem.
I think that we can achieve it quite easily.
Mr. Rosendale. It seems like the VA is counting on the
Oracle Cerner EHR to force some kind of a standardization on
the Veterans Health Administration without doing any of the
hard work to change how the medical centers operate. And the
result is breaking the EHR as well as the medical centers where
they actually are functioning.
What do you think is going to happen if they continue down
that road?
Mr. Levin. Mr. Chair, I think that this is a shared
responsibility. If you look at the implementation frameworks at
other large clinics--the one that I have in mind specifically
is Mayo, but there are many of them that we could talk about--
there is a halfway point.
It does not have to be all one way, my way or the highway--
there are some vendors that do it that way--or the way that we
have done it at the VA, where it is sort of let a thousand
flowers bloom, right, until the moment that we are trying to
modernize the program and exchange data. Even between VistA
systems, as Secretary Baker described, we can not do that.
The VA, I believe, is actually primarily responsible. I do
not want to exonerate any vendor here, right, but the VA is
responsible, should have been responsible, for making sure that
they had consolidated those clinical care pathways. I think the
canonical number is 6, is what we are looking for now, but not
131.
Mr. Gfrerer. I think, Mr. Chairman, when you look at the
capability sets that the EMR vendor or her vendor is going to
provide, I think there is actually fairly good agreement
between VHA and the vendor in terms of what compromises those
capability sets.
Mr. Rosendale. Thank you so much.
Representative, do you have any more questions?
Mrs. Cherfilus-McCormick. No.
Mr. Rosendale. Then we are all clear. Okay.
I want to thank our witnesses on both panels for joining us
today. I do appreciate it. It was incredible information.
This is not a conversation about IT systems. When we get
caught up in that, we lose sight of our purpose. It has to be a
conversation about whether the VA healthcare is meeting our
veterans' needs and what policies and systems support that.
It also cannot be a conversation about hypotheticals. It
has to be grounded in hard data. I appreciate our witnesses
helping us better understand that data.
By every measure--by every measure that has been presented
here today, VistA is still performing well. The VA is still
very dependent upon it, even after being put on a starvation
diet in the early years of Cerner. By choice or by default, the
VA will probably continue to rely on VistA for years into the
future.
I realize that not everyone likes that reality, but we all
need to recognize it. It certainly would not have been my
choice to operate two different EHRs in a healthcare system,
but I think it would do a tremendous disservice to the veterans
who rely on the VA for their care to neglect or even dismantle
the only platform that supports that care effectively and
safely.
We need to be identifying the VistA improvements that are
most badly needed and make the most sense and get them done in
months or in years, not in decades. That is what I will be
advocating.
Thank you all again for your participation in today's
hearing.
I ask unanimous consent that all members have 5 legislative
days to revise and extend their remarks and exclude extraneous
material.
Without objection, so ordered.
Mr. Rosendale. This hearing is adjourned. Thank you.
[Whereupon, at 5 p.m., the subcommittee was adjourned.]
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A P P E N D I X
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Prepared Statement of Witnesses
----------
Prepared Statement of Daniel McCune
INTRODUCTION
Good Afternoon, Chairman Rosendale, Ranking Member Cherfilus-
McCormick, and distinguished Members of the Subcommittee. Thank you for
the opportunity to testify today about the Department of Veterans
Affairs' (VA) Veterans Health Information Systems and Technology
Architecture (VistA). I am accompanied today by Charles C. Hume, Chief
Informatics Officer, Veterans Health Administration, Dr. Thomas
O'Toole, Deputy Assistant Under Secretary for Health for Clinical
Service, Veterans Health Administration, Ms. Zhuchun ``Emily'' Qiu,
Director of Health Informatics, Office of Information and Technology,
and Mr. Michael Giurbino, Director, Health Infrastructure and Systems
Management, Office of Information and Technology.
OVERVIEW
VA is committed to providing exceptional care, services, and a
seamless, unified experience to Veterans. The Office of Information and
Technology (OIT) collaborates with the Veterans Health Administration
(VHA) and various VA offices to achieve this mission through the
delivery of state-of-the-art technology, including a modernized
Electronic Health Record (EHR).
Today, VistA and its integrated systems provide an integrated EHR
for Veteran care and services, supporting over 150 applications,
including the operations of more than 1,500 VA facilities. There are
133 instances of VistA nationwide that share standard functionality but
have data and workflow tailored to the needs of each VA Medical Center
and its patient population. Like any IT system, VistA requires updates
and maintenance to keep it functioning at a high level. Critical
upgrades to the system could be extremely costly over the years, and
maintenance costs are even higher. Often, it becomes more expensive to
maintain a legacy system than to replace it. VistA itself is written in
an old programming language, Mumps. There are few Mumps programmers
today, Mumps is not taught in computer science classes, and the pool of
Mumps programmers shrinks every year as they retire. VA is fortunate to
have dedicated Mumps programmers supporting VistA. They understand
millions of lines of code developed over 45 years and VA's clinical
business processes. They are committed to enabling clinicians and
supporting Veteran outcomes. We've been able to retain them, and their
knowledge, much longer than a typical workforce. However, approximately
70 percent of our Mump programmers today are retirement eligible, and
we have few options to hire or contract additional ones.
VistA has served VA and Veterans for over 45 years and we aware of
its limitations. It doesn't have modern capabilities like Artificial
Intelligence/Machine Learning, mobile and web access, and capabilities
providers and Veterans expect and deserve from a modern cloud-native
EHR. VistA is a member of VA's expansive and complex ecosystem of
software and infrastructure. The size and complexity of that technology
ecosystem has nearly doubled in the last 5 years, and most of that
growth was in modern cloud-native applications. Mumps programmers are
increasingly challenged keeping VistA integrated in a growing ecosystem
that is architected very different from the system designed 45 years
ago. While technology is a challenge, so also are the dated skills of
the VistA programmers. These challenges compound every year.
To modernize VA's legacy EHR systems and achieve interoperability
with DoD and community care providers, VA is transitioning to a new EHR
solution. In May 2018, VA awarded Cerner a contract to replace VistA
with a Commercial Off the Shelf (COTS) solution, Cerner Millennium,
which is also currently being deployed by DoD. During implementation of
the new EHR solution, VA will need to maintain VistA systems for a
period of time. This ensures that current patient records remain
accessible and that there will be no interruption in the delivery of
quality care.
FUTURE VISTA DEVELOPMENT
VA recognizes the planned Electronic Health Record Modernization
(EHRM), Financial Management Business Transformation (FMBT), and Supply
Chain Modernization (SCM) efforts will take years to scale across the
enterprise. During this time, maintaining Vista is necessary to ensure
VA preserves the standard of care in the interim and continues
innovation to serve the Veteran. VA embraces the responsibility to
consistently and constantly drive modernization and look for efficient
ways to sustain VistA. Some of the key strategies include:
Development, Security, and Operations Approach - OIT
shifted to a DevSecOps approach focused on collaboration, innovation,
agile principles, and automation--so that it can develop, enhance,
maintain, and roll out better, more secure products at a faster pace
than using the existing separate development and operations processes.
VistA Standardization - VAMCs are required to run the
nationally released ``Gold'' version of VistA. In addition to having a
common set of software routines for each VistA instance, there are some
additional normalization activities, including work on terminology
extensions, to account for local differences that will need to be
addressed to ensure standardization of the VistA data base and file
system.
Merging Resources - OIT continues merging VistA teams and
resources for maximum efficiency throughout VA.
Maintain excellent customer support - OIT will continue
to respond to patient safety issues; hiring and retention of VistA
support resources; maintaining security and compliance (scans,
remediation, Section 508 compliance, Authority to Operate, etc.);
refreshing hardware (life-cycle upgrades, hardware, cloud migration
etc.); and maintaining software versions and upgrades.
VistA enhancements require enabling teams to work in a development
paradigm using modern tools and practices such as automation of
testing, integration, and deployment of code. VistA enhancements share
VistA data and applications through Application Programming Interfaces
(APIs) that use modern messaging standards. This approach accelerates
integration and supports innovation in the short term. It also
facilitates migration to target solutions like EHRM, FMBT and SCM in
the long-term.
CLOUD MIGRATION
On June 22, 2019, one instance of VistA, at Valley Coastal Bend,
was successfully migrated to VA's Enterprise Cloud (VAEC) which is the
future direction for VistA instance maintenance until they are subsumed
by Cerner Millennium. Since then, a total of 20 VistA sites were
successfully migrated to the VAEC and an additional 54 VistA site
migrations are planned for Fiscal Year 2023. VA is taking advantage of
cloud-based infrastructure management practices and leveraging cloud
native features including security, monitoring, backups, and
scalability. As part of the current VistA Cloud Migration Project, the
VistA software platform is also being upgraded to IRIS for Health
2022.1.
COSTS OF SUSTAINMENT
For the purposes of ensuring uninterrupted health care delivery, VA
will continue to use VistA until all legacy systems are replaced by the
new solution. Below are the current costs to operate, maintain, and
upgrade VistA in each of the last five fiscal years. The below costs
reflects a steady increase year-over-year:
Total Fiscal Year 2018: VistA cost $417,730,309
Total Fiscal Year 2019: VistA cost $634,138,491
Total Fiscal Year 2020: VistA cost $720,312,589
Total Fiscal Year 2021: VistA cost $841,426,084
Total Fiscal Year 2022: VistA cost $890,098,856
Currently, there is no VistA sustainment cost reduction directly
tied to the new EHR solution rollout. VistA must run without service
degradation to support EHR migration and overall VA modernization.
VistA clinical modules that are deemed redundant when the EHR migration
is complete will be decommissioned. However, VistA modules that are not
replaced by the EHR must be performant and maintained until replacement
capabilities are developed. The cost to maintain VistA will increase as
we must include development for new capabilities and interfaces,
congressional mandates, cloud costs, hiring and retention of VistA
support resources, and maintenance. To continue fulfilling our
commitment to ensure uninterrupted care and benefit delivery to
Veterans, VA must continue to use VistA.
CONCLUSION
As VistA functionality is replaced by a COTS solution and other
systems, VA can decommission VistA products as appropriate. Until the
new EHR solution is implemented across VA's enterprise, VistA remains
VA's authoritative source of Veteran data. Sustaining VistA for the
duration of our EHRM effort ensures that Veterans continue receiving
uninterrupted care and services while VA looks to the future and
improves the Veteran experience.
Chairman Rosendale, Ranking Member Cherfilus-McCormick, and Members
of the Subcommittee, thank you for the opportunity to appear before you
today to discuss OIT's progress toward VistA transition. I look forward
to continuing working with this Subcommittee and address our greatest
priorities. This concludes my testimony, and I look forward to
answering your questions.
______
Prepared Statement of Roger Baker
Thank you Chairman Rosendale and Ranking Member Cherfilus-McCormick
for holding this hearing today. With over $50 billion at stake,
misinformation regarding VistA has been rampant. Numerous parties,
largely those with no expertise in VistA, medical care, or software
development, continue to repeat misinformation designed to convince
Congress that VistA is a problem in need of their solution.
Not that I need to remind this committee, but I served 4 years as
the Assistant Secretary and CIO for VA, from 2009 to 2013. In that
role, I was responsible for all investments in VistA, including
budgeting, daily operations, bug fixes, improvements, modernizations,
and strategic direction. I was responsible for analyzing and then
stopping the failed HealtheVet program. I was the VA lead for the iEHR
program and dealt with all of its complexities. Perhaps most useful for
our discussion today, I analyzed why VA continued to fail in its
software development efforts, and introduced a program management
approach that increased the rate of on-time software deliveries across
the development portfolio from under 30 percent to over 84 percent.
Several years ago, I published three articles regarding the EHRM
program and VistA, which I have linked below. I believe the information
in these articles is still largely relevant.
Why VA's Electronic Health Record Mega Project is Failing https://
fcw.com/it-modernization/2021/07/why-vas-electronic-health-record-mega-
project-is-failing/259229/
How VA Can Succeed with its EHR Mega-Program https://fcw.com/
acquisition/2021/08/how-va-can-succeed-with-its-ehr-mega-program/
258949/
Why VA Must Keep VistA Healthy https://fcw.com/acquisition/2021/08/
why-va-must-keep-vista-healthy/259006/
The primary success measurement for an electronic health record
(EHR) system at VA should be Veteran health outcomes. The fundamental
reason that VA, VHA, and the EHR exist is to provide Veterans with
superior health care. An EHR should be an aid to clinicians and medical
staff in doing their jobs, help speed their work, provide them with
information to make better decisions, reliably communicate work orders
such as lab tests, prescriptions, treatments, and specialty referrals,
and coordinate and track the medical activities of the entire medical
center needed to improve health outcomes.
The EHRM program has effectively run a controlled experiment over
the last six years, complete with a hypothesis, control group, and
metrics. This experiment has provided concrete proof that Veterans
achieve better medical outcomes when VA facilities use VistA than when
they use the commercial alternative. And while service impacts should
be expected in the initial days of an EHR swap, I have seen no
projections from VA as to when productivity and medical quality
measurements using the new EHR will exceed those previously seen in the
same facility using VistA.
Because Vista excels at medical care, and it sets a high
comparative bar. Vista, and the work processes encoded in it, was
designed, implemented, and honed by VA clinicians to do exactly what a
clinician needs and what a clinician expects. That is both its blessing
and its curse.
Independent surveys show that VistA is the most liked EHR by
clinicians nationally.
Medscape EHR Report 2014
Medscape EHR Report 2016: Physicians Rate Top EHRs
However, as an IT product, VistA is complex and difficult to
change. But which would we rather have for medical care, a system that
clinicians love and IT people hate, or one that IT people love and the
medical staff hates?
Some lobbyists would have you believe that the IT difficulties of
VistA are more important than the medical care advantages. That VistA
is a problem because of its age, complexity, and the language it is
written in. In fact, at least one lobbyist would have you believe that
``Vista cannot be made better.''
This is provably false. During just my 4-year tenure, many
improvements were introduced to VistA, including bed management, blood
bank, Pharmacy re-engineering, registries, and numerous others
including, fairly notably, Cerner Labs.
In fact, VistA can be difficult to modernize. But the difficulties
in modernizing VistA stem not from the software itself, but from three
root causes that come from VA itself.
First, every time VA has attempted to replace VistA, first from
2000 to 2009 under HealtheVet, and second from 2017 until now under
EHRM, VA has prohibited investment in VistA. This has included
eliminating promising technologies such as VistA Exchange by
terminating the EHMP program when it was in beta test. The fact that
you are told that ``VistA cannot be made better'' as an argument for
why $50 billion needs to be spent to replace it, when the primary issue
is that VA has cutoff investment in VistA improvements for 16 of the
last 24 years, is rich indeed.
Second, years ago VHA made the decision that veterans receive
better medical care if each VA is allowed to tailor its care to local
needs. That Veterans in Fort Harrison can have different care needs
from those in Palm Beach. This local control of medical care is a
fundamental part of the medical culture of VHA. As you would therefore
expect, VistA was specifically designed to easily support that local
customization. I am certainly not qualified to tell you whether
localization is a good medical decision. For that discussion, I would
suggest a discussion with Dr. Ken Kizer as well as numerous other
medical professionals who have given this topic much more thought than
I ever could. I can tell you that it is where the sound bite ``VistA is
not a single system, it is 130 separate systems'' comes. Local
customizations were a celebrated part of VistA development for many
years, until the advent of the ``Gold Disk'' program. But these local
customizations are what make designing, programming and testing changes
to Vista more difficult, because every change must be tested to work
with each VistA system.
VA's experience with Cerner Labs is a good example of the effects
of the VHA culture on VistA. In (approximately) 2007, VA decided to
replace the VistA Laboratory module with one from Cerner. Integration
of the cloud version of Cerner Labs into VistA proceeded, and by 2012
VA had completed a successful introduction of the package at the
Huntington, WV VA, where it is (to the best of my knowledge) still in
use today. The functionality was well received, and a plan was
presented to roll-out across the rest of VA. Unfortunately, that plan
was wildly expensive and would take many years. When asked why, the
program team explained that all of the customization parameters in the
lab package, which had been a significant portion of the development
work, would need to be re-discovered, re-verified, re-entered, and re-
tested for each VA hospital, since business process and even the names
used for each drug vary at each VA. As a result, Huntington remains the
only VA running Cerner Labs (again, to the best of my knowledge).
As noted above, VA began its ``Gold Disk'' program in 2011, as part
of the decision to move VistA to an Open Source model. The goal of the
Gold Disk was to eliminate the variations between VistA instances by
identifying software differences and working with VHA to agree on which
business process, and therefore which software modules, could be used
at all VA's. By 2015, this had reduced variations in the VistA software
to under 5 percent across all instances. It is my understanding that VA
has continued this effort and has further reduced software variations,
possibly to the point of achieving our goal, a single ``Gold Disk''
version of VistA to be distributed to all VA facilities.
Third, Federal pay grades and procurement practices have eroded the
base of skilled software developers needed to maintain a complex EHR
product. Capping salaries at GS 13/14 levels for the most skilled
Federal IT staff has caused them to seek other employment. And VA
continuously awards contracts for complex VistA improvements to
companies that lower their prices to win the work, and then cannot
employ the necessary skills at the rates that were bid. They would
rather tell VA ``we can't find MUMPS programmers'' than ``we underbid
the work'' to justify why they failed to deliver.
VA has repeatedly failed at efforts to replace VistA. HealtheVet,
iEHR, and now EHRM were each attempts to replace VistA, not to make it
better. Each failed, in part, because the difficulty in making the
software better is not in the software, but in the fundamental VHA
culture. VistA is tightly attuned to that culture, and well liked by
the medical staff for exactly that reason. Unless and until a decision
is made that software standardization is more important than local
control of healthcare, attempts to replace the VistA product with a
commercial product that does not support that fundamental part of the
VHA culture are doomed to certain failure.
Mr. Chairman, there is much misinformation regarding VistA being
promulgated in an effort to justify the $50 billion needed for the EHRM
program. I have attempted to address only a few of them. But the EHRM
program has provided the best proof that they are either wholly or
partially untrue. After six years, Veterans continue to achieve better
healthcare outcomes in VA facilities that use VistA versus the
alternative. That remains the single most important fact you will hear.
I commend this committee for demanding to deal with the actual facts
regarding VistA, its role in veteran healthcare, and its ability to be
modernized, and I look forward to working with you and answering your
questions as you further search out those facts.
______
Prepared Statement of James Gfrerer
Chairman Rosendale, Ranking Member Cherfilus-McCormick, thank you
for the opportunity today to appear before the Technology Modernization
Subcommittee with my fellow former VA Technology Panelists to address
the VA's current Electronic Health Record.
As a Veteran, I am a patient in the VA health system, and a
beneficiary in the VA benefits system, and now pre-registered for VA
burial benefits. And as a more-than 28-year career Marine Infantry
Officer with 4 combat deployments, I fully empathize with all our
Veteran men and women who endure both the visible and invisible wounds
of military service.
There is much misunderstanding around VA health care in general. VA
Health care is unlike commercial systems. VA is funded by government
appropriation versus commercial health systems who operate on a
business revenue model. In commercial health care, each patient is
eligible for all services, where in VA eligibility is based-on complex
service-connected conditions. VA health care is more specialized and
expansive than commercial systems comprising unique clinical services
such as prosthetics, long term care, and dental among others. These are
substantial differences, even as compared to Department of Defense
Health care, and are the first set of challenges for any commercial EHR
to be successfully implemented in the Veterans Health Administration
(VHA).
The bottom line is that Federal law, regulation, and policy have
created this unique health system - and the Veteran Health Information
and Technology System Architecture (VistA) Electronic Health Record is
representative of those complex and unique business rules. So it may
come as no surprise that when a commercial EHR programmed for different
financial frameworks, with significantly different eligibility rules,
and not addressing unique VA clinical services, that there are problems
- and problems that can't be overcome by ``change management.'' Without
substantial customization, no commercial EHR could address the business
rules that law, regulation, and policy mandate for Veteran Health care.
So, if you didn't have a business system configured like VistA, you'd
have to create or heavily customize a system to perform just like it.
In the remainder of this Hearing, we will get into greater detail
about VistA, its modernization efforts, and some additional facts and
misconceptions, but allow me to offer some highlights as a capstone to
the larger conversation:
First, VistA is more than an EHR. It is what
professionals term an Enterprise Resource Planning or ``ERP'' system,
which has grown over the years to encompass many administrative,
financial, and other modules. A number of these will live-on, past any
end of service date for VistA.
Second, it is not - I repeat - not an ``IT system'' but
rather a BUSINESS/MISSION system. Why does this matter? First, because
the ``Business'' - in this case, VHA - must take prime ownership, to
include the lifecycle management, capital investment, and change
management, with OIT playing a continue supporting and technical role.
Third, some would have you believe that VistA has not
been modernized, but that assertion is predicated on the fallacy that
modernization can only occur by replacement. Tech modernization as
defined by Gartner, Forrester, and others, can be achieved in a myriad
of other ways from rehosting (e.g., moving to the Cloud), refactoring
(optimizing the existing code), and encapsulating (exposing to APIs) -
all of which were done to VistA during my VA tenure.
Also, let me offer that in many respects Veteran Health Care
business and technology discussions remain mired in 2017. It was in
this timeframe that the pursuit of a fully longitudinal health record
was revalidated with the assumption that it must be on the same
platform in order for this to be achieved. In 2023, with the maturity
and adoption of Health Information Exchanges and Heath data standards
such as HL7 and FHIR, that is no longer the case, which raises another
topline business issue. Which is the greater challenge for VA presently
- is it DoD/VA interoperability - or is it VA/Community Care
interoperability?
In an era of increasing technical debt and mounting technology
modernization cost, the Congress must determine where the greatest need
is for precious technology budget. Presently there are roughly 300,000
active-duty members annually who matriculate from DoD to VA. Last year
on the Community Care side, VA saw 6 million referrals out of network
for 36 million episodes of care. To recap - a one-time transfer of 300K
servicemember records as compared to 6 million referrals with 36
million appointments - there is no doubt that the latter is the
substantially larger problem, across thousands of Community Care
providers, who are on every available EHR, not one single EHR on which
DoD and/or VA are operating. Community Care is only anticipated to grow
larger every year, so VA must address it soon.
Finally, in an era where technology plays and increasingly
mainstream and critical role in healthcare delivery, VA must begin to
operate more efficiently and effectively, as do its Commercial and Non-
Profit Health System counterparts, who are well on their way in this
regard. These systems understand that technology and information
technology is the success path, and reciprocally, Health Systems can't
hire there way out of the problem, much as VHA attempts to do every
year.
Mr. Chairman, thank you and the Subcommittee for your interest in
this vital topic, and I look forward to our discussion.
______
Prepared Statement of Peter Levin
Thank you for the privilege of testifying before you today
regarding the Electronic Health Record Modernization effort at the
Department of Veterans Affairs.
I am deeply grateful to Chairman Rosendale, Ranking Member
Cherfilus-McCormick, and members of this subcommittee for the
opportunity to share with you my perspective on one of the largest
civilian information technology projects in history.
Our commitment to our Nation's veterans transcends party lines and
political ideology. In an era of especially deep ideological divide and
social tension, I applaud your leadership, Mr. Chairman, in soliciting
the best ideas and constructive, fact-based perspectives from across
the spectrum.
During my time in public service, and under the leadership of
Assistant Secretary Baker with whom I am delighted to appear this
afternoon, I had the honor of working on several medical information
technology systems that are still in use today. Especially relevant to
this testimony are the Joint Longitudinal Viewer (JLV) (originally
known as ``Janus'') and the Blue Button personal health record.
Launched during a Democratic administration, Blue button was warmly
embraced by the most recent Republican one, too, ``as a fundamental
component of any effort to empower patients in their healthcare
decisions.'' And JLV enables hundreds-of-thousands of clinicians to see
records across platforms every day.
It is in that context - access to and interoperability of clinical
data - that I respectfully offer my observations.
In my opinion, there are three issues before the government
regarding VistA at Veterans Affairs:
1) That the billions of dollars already spent on the Cerner
implementation will not scale to enterprise-wide clinical care
services on the current path, budget, or timeline
2) That VA can-and-should sustain the data interfaces and
connection frameworks already built to send and receive data
from MHS GENESIS
3) And, most important of all, that VA consolidate its current
instances of VistA onto a VA-centered clinical workflow, and
augment the VistA model to receive data from third-party
providers
Our ability to deploy VHA's nearly 1,300 facilities is hopelessly
challenged by the incompatibility of those with each other. Leadership
- then and now - presumed that VistA instances are fundamentally
congruent, from clinical workflow as well as data interoperability
perspectives. This is incorrect. VistA instances do not inter-operate,
and the agency was unsuccessful in catalyzing alignment around a single
clinical process and record, the sine qua non of a commercial
deployment.
Thoughtful members of our community will sensibly ask how it was
possible to install Cerner at the Military Health Service was
ostensibly successful, while the VA's has been a failure. There are
three reasons. First, DoD had already made the transition to a
centrally administered system, as opposed to VA's decentralized
approach that perpetuates workflow (and data model) autonomy across 130
hosts. Second, the DoD's ``command and control'' structure not only
enforced protocol alignment, every deployment was preceded by careful
preparation, training, and integration. Third, their system was in
substantially worse condition than ours, and Cerner is perceived as an
improvement over AHLTA, although according to KLAS this is not a widely
held perception, even at MHS.
Although VA is one the Nation's largest integrated delivery
platforms, there are several others in the private sector - including,
for example, HCA (186 hospitals), Ascension (150 hospitals), and Kaiser
Permanente (39 hospitals) - each with similarly sized patient
populations. Before VA embarked on a multi-billion dollar health record
modernization, we should have been clear on the price-and-performance
benchmarks from near peer enterprises. We should well understand the
capabilities they prioritize in their information systems before we try
to install one ourselves. As you'll hear from other witnesses, the
differences in VA healthcare between cities is simply not that large.
It is not tens-of-billions-of-dollars large.
The inescapable solution to the real-world challenges of first-
class healthcare services at VA is an institutional commitment to
rebalance the ``have it our way'' approach. VA must truly, sincerely,
authentically, put the Veteran first, and streamline its own processes
before it attempts to automate them. As straightforward as this sounds
to anyone who works for (or is a customer of) a manufacturer, a school,
a hospital, a store, a publisher, or a transportation, energy, or
services company, it is exactly not what happens at VA. Veterans
receive terrific healthcare, but their care is delivered with different
processes depending on which hospital or clinic they go to.
There is surprisingly little in the operational literature about
how to drape an enterprise management framework over complex clinical
environments, never mind one as large and diverse as VA's.
From a data perspective, this has profound implications. When we
try to connect applications-to-pipelines-to-governance, the
transactional perspective and the analytical one are, literally,
geometrically orthogonal to each other. Transactions are row based
(every new interaction, like delivering a vaccine, or serving a meal,
requires a new entry) and analytics are column based (so as to avoid
the need to ingest every attribute of every transaction for every
report, like how many injections were made, and how many meals were
served).
In practical terms, while VistA communicates between members of the
care team one patient at a time, all of its data is exported to a
separate system to measure outcomes and improve service. The current
effort to replace both components of that at once is difficult to do.
We're trying to fit round transactional pegs into square analytical
holes. We should stop doing that.
In my opinion, the department should not announce its intention to
change the contract unless and until it has a backup plan in place.
That plan cannot be ``revert back to VistA'' in its current form, or
anything that concedes to VA's continued digital isolation and process
insularity. Yes, Cerner has performance deficits in response time,
uptime, and data syndication latency; these will only get worse as more
hospitals are brought online.
The problems are compounded, however, by VA's inability to prepare
for Cerner's deployment. VA in general relies too much on industry to
``tell it what it needs,'' never mind what it could have. Unless and
until the institution is committed to aligning its internal processes,
no amount of technology will automate its operations, and no amount of
money will solve its policy problems.
The trade-space is simple: VA must go on the record and publicly
State their commitment to a single enterprise--workflow and--data
model. Congress could develop objective and quantitative measures to
validate compliance, with real consequences for noncooperation or
nonparticipation.
If we change the agreement with the commercial vendor, VA must also
prepare itself for an onslaught of criticism because of previous
attempts that also failed, including HealtheVet, iEHR, and Vista
Evolution. Switching back to VistA and walking away does not fix the
root problems. How do we address the issue?
First and foremost, cloud technologies are now stable and mature
enough to enable consolidation onto an authentically single platform.
Additionally, there have been substantial improvements to the codebase
that are now available to VA from the commercial sector. I believe that
the Open Source Electronic Health Record Alliance was the right idea,
but it was poorly implemented because of VA's (and DoD's) lack of
sustained commitment and the peculiarity of a ``single customer''
market. Nonetheless, it would be straightforward to re-instantiate
OSEHRA with a powerful charter and legislative mandate. It would
certainly be objectively better, and cheaper, than what we have now.
Moreover, commercially available data management infrastructure has
made substantial progress in the last 5 years. The VA has been
dreadfully slow to adopt these standards and tools, including FHIR and
bi-directional Blue Button, because of VistA's inability to ingest
third-party clinical data into the enterprise model. There are no
technology impediments here; this is simply a matter of political will,
imaginative leadership, and execution accountability.
Indeed, both these policy changes - consolidation onto an
enterprise clinical workflow, and adoption of proven platform and data
management services - would accelerate health record modernization at a
fraction of the costs now earmarked for EHRM. They can be
systematically procured, thoroughly tested, and methodically deployed
during this Congress and sustainably thereafter.
Software is designed to help automate repetitive tasks that we do
every day. If what clinicians do every day is different at every
hospital, and we allowed those points of care to grow their own for
decades, it is no surprise that all the software is going to be
different. How we got here is no mystery.
If VA shared best practices between hospitals, identified optimal
workflows, disseminated them to their network, and updated the software
unto a unified platform, then clinicians throughout the enterprise
would provide care in a similar (and probably better) way. This would
not only improve safety and outcomes, it would be more amenable to a
wholesale replacement.
The transcendent goal is continuously better healthcare for
Veterans. Until VA resolves its internal tension around a consolidated
workflow and comprehensive data management, no new or renovated
electronic record will be successful.
Submission for the Record
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Office of Inspector General Letter to The Subcommittee on Technology
Modernization
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