The Department of Veterans Affairs said it will spend nearly $5 billion over the next 10 years to maintain its legacy electronic health record while it develops and implements a separate, multi-billion-dollar system at medical facilities across the country.

VA told the Government Accountability Office it spent $2.3 billion to maintain and develop the  Veterans Information Systems and Technology Architecture (VistA) between 2015 and 2017. The department estimated it’ll spend a total of $426 million this year on the legacy system — with a total of $4.89 billion over the next 10 years.

But VA’s cost estimates to sustain and develop VistA are under dispute and likely unreliable, the Government Accountability Office said this week, raising congressional concerns that the department’s estimates to replace the legacy system with Cerner’s Millennium health record are also inaccurate.

“More than half of VA’s $2.3 billion costs couldn’t be verified based on the source data that we looked at in our review,” Carol Harris, director of GAO’s IT acquisition management team, told the House Veterans Affairs Subcommittee on Technology Modernization. “This is of concern because without reliable information, VA will not be a position to make critical management decisions about the system.”

The challenge, Harris said, is that VA hasn’t been able to fully define the scope, environment and technical performance of VistA since the department began decentralizing the electronic health record shortly after the system’s inception. To date, VistA, which supports 150 applications and operations of 1,500 VA medical centers and other facilities, has 130 separate instances.

“The purpose of figuring out how much VistA costs is to compare it to Cerner,” Rep. Jim Banks (R-Ind.), the subcommittee’s ranking member, said. “But I don’t see VA making much effort that [electronic health record modernization] is going to save money, all things considered.”

Achieving interoperability with the Defense Department was and is the main driver behind VA’s decision to implement Cerner’s health record, said Paul Tibbits, executive director of VA’s Office of Technical Integration.

“Yes, what the costs will turn out to be is very important,” he said. “We certainly will make a great effort to make that very clear to whoever needs to know what that is for our own internal management purposes, but… it’s the well-being of the servicemember and veteran that is the principle motivation for going to Cerner, not necessarily an economic argument.”

VA last publicly estimated it would spend at least $16 billion to implement a version of the Cerner electronic health record.

“We don’t have any confidence in what VistA actually entails, so I don’t think we have any confidence in that $4.8 billion, but more importantly, that makes me less confident in the… estimate for Cerner as well,” Rep. Susie Lee (D-Nev.), chairwoman of the technology modernization subcommittee, said. “At what point do we lay out exactly what the costs are?”

The department is beginning to use the technology business management (TBM) framework to categorize and track the legacy system’s costs. Once VA implements TBM, the department believes it’ll have a better sense of VistA’s true scope and costs, Tibbits said.

Still, developing an accurate return on investment for Cerner health record will be difficult, if not impossible, until VA fully defines VistA, Harris said.

VA is planning to deploy Cerner Millennium at VA medical facilities in the Pacific Northwest starting in spring 2020. The department will begin to decommission VistA instances as it rolls out the new Cerner electronic health record, a process that will take at least 10 years.

“VA medical centers will be required to run the nationally released ‘gold’ version of VistA, creating a common set of software routines where possible,” Tibbits said.

In planning for the initial rollout at three VA sites in the Pacific Northwest, Tibbits said the department has conducted an analysis of VistA instances in those locations. That work, which should continue as VA implements the new electronic health record at additional locations, will help the department develop more accurate cost estimates for both Cerner and VistA, he added.

VistA’s migration to the cloud

VA is also continuing to develop a transition plan for VistA, which is expected some time in the fall.  Discussions for this plan have been in the works for months, the department said.

Part of the transition plan will incorporate VA’s expectations for the cloud. The department plans to eventually migrate all 130 instances of VistA to a commercial cloud. The first VistA instance has been migrated, Tibbits said.

VA’s Office of Information and Technology is also finalizing which VistA capabilities and applications will be part of the new Cerner platform.

The department has already determined at least 40% of VistA’s current capabilities won’t be part of Cerner’s system. The majority of those functionalities, will be developed and replaced as part of other VA IT modernization efforts, such as the department’s financial management business transformation.

In addition, VA is partnering with DoD to use its Defense Medical Logistics Standard Support System, which will manage much of Veterans Health Administration’s supply chain functions, with a few exceptions.

“There’s a small percentage of capabilities beyond that that are not being replaced by one of those three modernization systems, and we’re in the process of identifying the solution to that,” Charles Hume, acting assistant deputy undersecretary for health for VHA’s Office of Informatics, said. “It may be an interface to VistA for some time [or] a replacement by a commercial product; we have yet to figure that out.”

Meanwhile, both DoD and VA are also continuing to meet and finalize the details for the Federal Electronic Health Record Modernization (FEHRM) Program Office, the entity that’s supposed to serve as a joint decision-making body for the two departments.

Congress has long asked for both departments to develop a more concrete governance structure, after lawmakers had determined the original inter-agency office never truly served as a single point of accountability.

A timeline to stand up the new office is still unclear, Tibbits told the subcommittee.

“From my point of view, [the] lack of plan on joint governance continues to be a problem with the rollout of this program,” Lee said.

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