Senators still seeking answers on joint DoD, VA leadership structure to manage EHR overhaul

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The Department of Veterans Affairs said it’s prepared to give lawmakers a clear answer to the question that’s been nagging the agency since VA first announced  plans to implement a commercial electronic health record (EHR) and achieve interoperability with the Pentagon.

When push comes to shove, who between the two departments is in charge?

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Jim Byrne, VA’s acting deputy secretary and general counsel, said a joint DoD-VA “tiger team” has evaluating existing governance models and will offer a report later this month that may describe an alternative structure.

“All of us have agreed, despite any rumors that are out there, that we would like to consider the option … to have one arbitrator, a ‘purple person,’ who we all agree would make decisions [if] there’s a dispute between DoD and the VA,” Byrne said to the Senate Appropriations Military Construction and Veterans Affairs Subcommittee Tuesday morning.

Both VA Secretary Robert Wilkie and then-Defense Secretary Jim Mattis signed a joint agreement back in September, which promised the two departments would create a joint governance structure.

But the promise of cooperation hasn’t satisfied House and Senate lawmakers, who have been asking VA for a clear governance structure in earnest since at least September. Both departments have a interagency program office, but it’s not working in the way its designers originally intended.

Still, the mere suggestion that VA may choose an independent arbitrator of sorts to make key decisions for the two largest departments in the federal government frustrated senators, who wanted to see more concrete, quick action.

“VA is no small partner here,” Sen. Jon Tester (D-Mont.) said. “But DoD can steamroll VA if they want.”

“I do not agree with that, sir,” Byrne said.

“Well, I hope you’re right,” Tester said.

Tester was one of eight in a bipartisan group of congressional leaders from House and Senate VA and appropriations committees, who recently wrote to Secretary Robert Wilkie and urged more transparency and detail from the department.

This has become practically an ongoing theme in recent congressional hearings with VA, as lawmakers have continually expressed frustration with the department’s communication style with both Capitol Hill and veterans service organizations.

“I hope there are not folks within the VA who see us as an enemy, because we are not,” Tester said Tuesday. “Our job is oversight, and if in fact there are folks within VA who think we are an enemy, they need to change their opinion.”

Sen. Brian Schatz (D-Hawaii), ranking member of the Senate Appropriations Military Construction and Veterans Affairs Subcommittee, said he was concerned VA wasn’t briefing lawmakers with enough regularity and detail about ongoing changes to the EHR budget.

Schatz acknowledged that Congress will likely need to appropriate money to maintain VA’s current Veterans Information Systems and Technology Architecture (VistA) system, for example, but the committee needs a better timeline and more detail from VA.

“We’re satisfied that you’re trying to make the right choices,” he said. “What I’m not satisfied about is that you’re going to tell us as we go along so that we can make appropriations that are dialed in, so that we give you enough runway to make smart choices. We don’t penalize you for not spending one fiscal year’s money, and we don’t put so much political pressure on you that you do a dumb thing. But we still need better fidelity from the standpoint of our staff’s ability to do a markup that doesn’t appropriate money into a pile.”

Democrats aren’t the only ones skeptical of VA’s 10-year timeline and $16 billion cost estimate for health record modernization.

“Where in industry do we see software solutions being introduced over a 10-year horizon?” Sen. Steve Daines (R-Mont.) said.

John Windom, program manager for VA’s Electronic Health Record Modernization Office, insisted VA’s indefinite-delivery-indefinite-quantity (IDIQ) contract vehicle with Cerner Corporation would allow the department to better shape and evolve the final product throughout the next 10 years.

“What the product looks like today in year one may look like something different in year nine, but it will be interoperable,” he said.

Interoperability was another concern for the senators.

VA will move all patient data — 20 domains worth — into the Cerner system before the department goes live at its first site next year, said Laura Kroupa, acting chief medical officer for VA’s Electronic Health Record Modernization Office.

“That data will be available to DoD sites and also will be available at our IOC sites, so clinicians will not have to work without the data that has accumulated in VistA over time,” she said.

This decision, Kroupa said, will allow VA to achieve interoperability among its medical centers and with DoD. Achieving interoperability with community care providers, however, is a different beast. Kroupa said VA would work to change business rules and develop community care provider partnerships but didn’t offer a more specific interoperability plan.

VA chooses Cerner for scheduling

VA said last week it would cancel the Medical Appointment Scheduling Solution (MASS) project, which the department and Epic initially started as a pilot at VA’s ambulatory care center in Columbus, Ohio.

Instead, the department plans to use Cerner’s scheduling system, which it will roll out after it achieves initial operating capability with the first group of EHR sites in the Pacific Northwest.

Sen. Tammy Baldwin (D-Wis.) said she couldn’t understand why VA would cancel the MASS pilot.

The decision to cancel the pilot was especially confounding given its results, she said. According to Baldwin, VA improved wait times for primary care by 30 percent and 18 percent for behavioral health wait times. It took schedulers 30-to-50 percent less time to schedule an appointment, she added.

VA told Baldwin and other appropriators that it would implement Cerner’s scheduling system because it would enhance productivity, shorten wait times for veterans and improve employee workflow.

“Since no VA medical center is currently operating on a Cerner scheduling module, I’m not sure how the VA can make such a statement,” Baldwin said.

Windom said it was too early to offer a tentative timeline or cost estimate to deploy the Cerner scheduling system nationwide.

VA will hold an industry day in the spring, where Cerner will host small vendors who are interested in supporting the EHR project, Windom said.

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