[House Hearing, 118 Congress]
[From the U.S. Government Publishing Office]
ELECTRONIC HEALTH RECORD
MODERNIZATION DEEP DIVE:
SYSTEM UPTIME
=======================================================================
HEARING
before the
SUBCOMMITTEE ON TECHNOLOGY
MODERNIZATION
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED EIGHTEENTH CONGRESS
FIRST SESSION
__________
WEDNESDAY, NOVEMBER 15, 2023
__________
Serial No. 118-40
__________
Printed for the use of the Committee on Veterans' Affairs
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Available via http://govinfo.gov
______
U.S. GOVERNMENT PUBLISHING OFFICE
54-363 WASHINGTON : 2024
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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WEDNESDAY, NOVEMBER 15, 2023
Page
OPENING STATEMENTS
The Honorable Matthew M. Rosendale, Sr., Chairman................ 1
The Honorable Sheila Cherfilus-McCormick, Ranking Member......... 2
WITNESSES
The Honorable Kurt DelBene, Assistant Secretary for Information
and Technology, Office of Information & Technology, U.S.
Department of Veterans Affairs................................. 4
Accompanied by:
Ms. Laura Prietula, Deputy Chief Information Officer,
Electronic Health Record Modernization Integration
Office, U.S. Department of Veterans Affairs
Mr. Bill Tinston, Director, Federal Electronic Health Record
Modernization Officer, U.S. Department of Defense.............. 5
Accompanied by:
Mr. Lance Scott, Solutions Integration Director and Acting
Technical Director, Federal Electronic Health Record
Modernization Office, U.S. Department of Defense
APPENDIX
Prepared Statements Of Witnesses
The Honorable Kurt DelBene Prepared Statement.................... 27
Mr. Bill Tinston Prepared Statement.............................. 29
Statement For The Record
Oracle Corporation............................................... 33
ELECTRONIC HEALTH RECORD
MODERNIZATION DEEP DIVE:
SYSTEM UPTIME
----------
WEDNESDAY, NOVEMBER 15, 2023
U.S. House of Representatives,
Subcommittee on Technology Modernization,
Committee on Veterans' Affairs,
Washington, D.C.
The subcommittee met, pursuant to notice, at 12:28 p.m., in
room 360, Cannon House Office Building, Hon. Matt Rosendale
(chairman of the subcommittee) presiding.
Present: Representatives Rosendale, Self, and Cherfilus-
McCormick, and Landsman.
OPENING STATEMENT OF MATTHEW M. ROSENDALE,
CHAIRMAN
Mr. Rosendale. Good afternoon. The subcommittee will come
to order.
Today, we are going to do a deep dive into another
dysfunctional area of the Oracle Cerner Electronic Health
Record (EHR) instability of the system.
VA and Oracle have come up with many different words to
describe this problem. Outages, downtime, incidents,
performance degradations, user interruptions, and incomplete
functionality. They all mean that the EHR is not working and
that staff cannot use it. That is the bottom line.
Far too often, the EHR amounts to a multibillion dollar
frozen screen or a brick on the employee's desk. When the
system goes down, the veteran's exam gets interrupted or
delayed. Or the provider has to document orders on papers and
enter them into the system later on. Sometimes a procedure has
to be postponed all together, and we all know what kind of
problems that presents by postponing these procedures. In at
least a dozen incidents, some sort of EHR outage directly
contributed to a close call or patient harm. It is an
unacceptable situation. Finger pointing and blame shifting
between VA, Department of Defense (DOD), and Oracle have gone
on for far too long.
We are going to delve into the numbers, as well as into the
root causes here today. According to VA and DOD, incident free
time under their control was between 95 percent and 99 percent
this year. According to Oracle, incident free time under the
company's control was between 87 percent and 97 percent during
the year.
It is true that complete nationwide outages have become
less and less common over the past year, but crashes, hangs,
and errors that affect one facility, one module, or one person
are still widespread. Ultimately, what the users experience is
what counts and they are not happy.
The Kent Gale, Leonard Black, Adam Gale, and Scott Holbrook
(KLAS) research surveyed VA employees about whether ``over the
past 2 weeks the EHR was available when I needed it and
downtime was not a problem.'' Only 26 percent of VA employees
agreed with that, and 58 percent of the employees surveyed said
that EHR was not available and downtime was a problem.
There is a big disconnect here. Either by design or by
accident, the criteria VA and Oracle are using are clearly not
capturing all of the system's problems. We know that the EHR
help desk ticketing process makes VA staff jump through hoops
to report issues. The Office of the Inspector General audited
the help desk last year and found widespread frustration. Many
of the employees have simply given up reporting the glitches
that they encounter, so truly the numbers are worse. Much worse
than what VA or Oracle is reporting.
Finally, the VA leaders told us 6 months ago that they had
renegotiated the Oracle contract to focus on improving the
EHR's uptime. They told us that they had added tough service
level agreements and real financial penalties. The results do
not seem to bear that out. I am not seeing much motivation. All
in all, the statistics we are being given are vastly different
from the independent data that we have and from what we are
hearing from the medical centers themselves.
I appreciate our witnesses joining us today to explain
this. With that I would yield to Ranking Member Cherfilus-
McCormick for her opening statement.
OPENING STATEMENT OF SHEILA CHERFILUS-MCCORMICK,
RANKING MEMBER
Ms. Cherfilus-McCormick. Thank you, Mr. Chairman. Thank you
to the witnesses for being here today.
While I agree that stability of VA's new EHR is a critical
part of the success of this program, I am concerned about the
fact that we have to spend so much time talking about it. It
seems to me that an operational EHR is the minimum requirement.
It is the very least that we should expect of Oracle Cerner and
VA.
I have received the data about Cerner and VA-owned
downtime. I am concerned that the data does not seem to match
what we are hearing from frontline staff. The end users that we
have heard from indicate that the system is frequently either
slow or nonfunctional and that other systems that interface
with the EHR such as Joint Legacy Viewer (JLV) are even worse.
Transitioning to a new EHR is always hard. It does not need
to be made harder by a system that is not reliably there when
you need it.
I find it especially problematic that we are still talking
about system stability more than 3 years after the initial go
live at Mann-Grandstaff VA Medical Center. These technical gaps
should have been identified and mitigated prior to the system
go live at Mann-Grandstaff in October 2022. The fact that there
were and is still a huge disservice to the staff and veterans
at the facility.
In addition to the inherent stability issues, we have heard
repeated stories of Oracle Health pushing updates that break
other functions of the EHR, and that in many cases they are
pushing these updates in the middle of the workday. This does
not seem like best practices to me. These updates would be
safer if they were pushed in the middle of the night when their
impact would be less felt.
I hope to hear today now how VA and Oracle Health are
working to improve this process. For over a year now we have
heard from Oracle that they are making major improvements to
system stability but there seems to be a lot of finger pointing
between the VA, DOD, and Cerner. I am pretty sure frontline
staff do not care who is responsible. They would just like for
their issues to be fixed.
I hope to hear today how VA and the Federal Electronic
Health Record Modernization (FEHRM) plan to do just that.
Finally, I am bothered by the fact that we are forced to
spend so much time talking about this when VA and Cerner have
much greater, much bigger, and more complicated issues that
need to be addressed. It seems that since Oracle bought Cerner
last summer it has attempted to focus on the EHRM conversation
on improving system stability. I guess they would rather talk
about this low-hanging fruit than talk about fixing the
clinical workflows. Or the fact that training and change
management are still woefully inadequate and user satisfaction
is still critically low.
I am disappointed that Oracle Health is not here to
participate in this conversation. I understand that Ms. Scalia
had another obligation but there must be someone else in the
organization that could speak to this topic. It is very
disappointing I would like to stress that they are not present
with us today. The fact that they did not send a representative
raises major concerns for me, and I expect better. I am
constantly losing faith in the process.
With that, Mr. Chairman, I yield back.
Mr. Rosendale. Thank you very much, Ranking Member
Cherfilus-McCormick.
I will now introduce the witnesses on our first and only
panel.
First, from the Department of Veterans Affairs we have
Assistant Secretary for Information and Technology, Kurt
DelBene. We also have Deputy Chief Information Officer Laura
Prietula. Finally, from the Federal EHR Modernization Office we
have Director Bill Tinston and Chief Technology Officer Lance
Scott.
I ask the witnesses all to please stand and raise your
right hands.
Do you solemnly swear under penalty of perjury that the
testimony you are about to provide is the truth, the whole
truth, and nothing but the truth?
[Witnesses sworn.]
Mr. Rosendale. Thank you very much. Let the record reflect
that all witnesses have answered in the affirmative.
Mr. DelBene, you are now recognized for 5 minutes to
deliver your opening statement.
STATEMENT OF KURT DELBENE
Mr. DelBene. Good afternoon, Chairman Rosendale, Ranking
Member Cherfilus-McCormick, and distinguished members of the
committee. Thank you for the opportunity to testify today in
support of VA's initiative to modernize its electronic health
record system.
I am accompanied by Dr. Laura Prietula, Deputy Chief
Information Officer of the Electronic Health Record
Modernization Integration Office (EHRM-IO).
I want to begin by thanking Congress and the committee for
your continued support and shared commitment to veterans. More
specifically, to your support for the VA's EHR modernization
efforts.
For VA, the successful deployment of the Federal EHR system
will facilitate seamless healthcare transitions for service
members and veterans across federal care settings.
As this committee already knows, the Federal EHR will
provide an accurate lifetime health record for veterans among
partners using the Federal EHR. Most excitingly for the newest
members of the military, the EHR will serve them from the day
they begin their military service through the rest of their
lives.
The VA is on a journey to implement this large system
transformation here. The Federal EHR system is a highly complex
software environment composed of the core medical records
system and several other connected systems that together
deliver the overall EHR experience to clinical providers and
patients.
In February 2022, VA established the Performance Excellence
Program to improve the overall system performance, resiliency,
capacity, and reliability of the Oracle Healthcare System. With
this systematic approach, we have seen the core system
stabilize over the time period resulting in an improvement in
the overall user experience. As of November 8, there have been
185 consecutive days without an outage and 100 percent system
availability in 10 of the last 12 months.
To be sure we are still experiencing partial system
failures that impact the users, we capture these in our instant
free time (IFT) which measures the time that the system
performs without significant end-user problems. While the IFT
metric is improving, it is not yet meeting the service level
agreement of 95 percent IFT on a regular basis.
As of September 30, 2023, Oracle Health has reached this
metric only 4 of the past 10 months. This partially is from the
number of changes that are being introduced. It is a well-
established axiom of software development that systems
stabilize when the rate of change made in the system decreases.
The rate of change is still very high, resulting in more
incidences than we would like.
In some cases, the VA has requested functionality that has
never been deployed in Oracle Health commercially, such as the
integration of VA's consolidated mail outpatient pharmacy
making VA the first user of this functionality, which also
increases incident risk.
Regarding end-user support, we have improved the processing
of tickets and Oracle Health has met all four ticket management
Service Level Agreements (SLAs) in January, August, and
September. Every critical and high severity incident has a root
cause analysis done and a preventative action identified. These
reports are now integrated into Office of Information an
Technology's (OIT's) daily operational status review.
Ultimately, we anticipate that the system's performance
will improve when change velocity decreases and enough time has
passed to enable unanticipated defects to be found and
addressed. From a technical perspective, one of the advantages
of the reset is providing time for optimization of the system
and associated technical processes.
Improving system reliability, resilience, and availability
remains a critical focus and VA continues to monitor and
enforce contractual SLAs. As part of the contract renegotiation
of May 2023, VA increased the SLAs tied to concrete financial
consequences related to technical performance and end-user
experience.
There are now 22 SLAs and six service-level obligations in
place to hold Oracle Health accountable. As a result, VA saw
improvement in these metrics.
As my colleague on the panel Bill Tinston will attest, VA
works collaboratively with DOD and the Federal Electronic
Health Records Modernization Office to improve operations based
on lessons learned. Based on our shared learning, we applied
improvements where possible such as improving certificate
management, establishing Citrix pods that increase flexibility
in system performance, and optimizing virtual private network
setup for laptop computers.
In conclusion, veterans remain at the center of every thing
we do. They deserve high quality healthcare that is safe,
secure, timely, veteran-centric, equitable, evidence-based, and
efficient. With the activities and improvements that are now
underway, VA leaders are optimistic about the eventual success
of the current program reset, the deployment of level Federal
Health Care Center (FHCC) in March 2024, and the future full
implementation of the Federal EHR throughout VA. Having said
that, we will not do this until the system is ready to provide
a good, quality experience to users.
Again, I extend my thanks and gratitude to Congress for
your commitment to serving veterans with excellence, and we are
happy to answer any questions you may have.
[The Prepared Statement Of Kurt Delbene Appears In The
Appendix]
Mr. Rosendale. Thank you very much, Mr. DelBene.
The written statement of Mr. DelBene will be entered into
the hearing record.
Mr. Tinston, you are now recognized for 5 minutes to
deliver your opening statement.
STATEMENT OF BILL TINSTON
Mr. Tinston. Chairman Rosendale, Ranking Member Cherfilus-
McCormick, and distinguished members of the subcommittee, I
thank you for the opportunity to testify today on our
partnering efforts to get the Federal EHR's deployment
implementation and performance right.
I am accompanied today by Mr. Lance Scott, the Chief
Technology Officer for the Federal Electronic Health Record
Modernization Office, also known as the FEHRM. On behalf of the
FEHRM, I want to thank Congress and the subcommittee for your
unwavering dedication to ensure our Nation's veterans,
servicemembers, and beneficiaries receive the safe, reliable,
interoperable, and modern EHR they deserve.
The FEHRM performs a key role in the Federal EHR
modernization effort. The FEHRM oversees the shared environment
containing the Federal EHR and support systems, governs the
configuration and content changes derived through a joint
decision-making process, tracks and facilitates software
upgrades and solutions to optimize EHR performance, and
solutions to optimize EHR performance, and informs continuous
improvement through the tracking of joint risks, issues,
opportunities, and lessons learned.
I understand the concerns regarding the reports of outages,
incidents, and other technical problems associated with the
deployment of the Federal EHR. The effort to deploy our modern
EHR has been, and still is, a challenging endeavor, but in no
way do these challenges mean that the EHR modernization is not
an attainable goal. The FEHRM and its department and other
Federal partners work through these challenges every day.
The modern interoperable Federal EHR is large in scale and
complexity but this scale and complexity deliver capabilities
and enhance patient care and provider effectiveness. This
Federal EHR implementation effort also delivers on the promise
of seamless healthcare transitions for Service Members and
Veterans, and establishes a single lifetime longitudinal record
for beneficiaries.
The Federal EHR is an ecosystem of orchestrated
technologies. The overall EHR modernization effort is not about
a single product, network, interface, or application; rather,
it is about all-of these products, networks, interfaces, and
applications working together within a national enterprise. The
national enterprise that creates the right circumstances to
deliver the right experiences for clinicians and beneficiaries
alike.
This modern enterprise EHR capability enhances healthcare
delivery and delivers better outcomes. Among its many benefits,
the Federal EHR allows for standardized workflows, provides
better coordination between the VA and DOD and our other
partners, and enables efficient dissemination of innovation
technology and new capabilities.
Although the Federal EHR enterprise is not yet at the
performance threshold we demand, improvements are occurring.
Performance improves by looking at the entire Federal EHR from
an enterprise perspective. This holistic approach delivers
significant outcomes to an ever-evolving system. For example,
the mean time to restore has improved by 50 percent over the
past 18 months. Over the same 18 month period, healthy minutes
were sustained above 99.5 percent.
With an enterprise-wide approach to driving outcomes, we
have also enhanced the stability of the Defense Enrollment
Eligibility Reporting System, also known as DEERS. They
interface with the Federal EHR. These changes have had
significant impacts, and over the past 23 weeks, DEERS had a
single outage that was resolved in less than an hour.
The FEHRM, alongside its VA, DOD, and other Federal
partners, continues to collaborate and drive enhancements in
the Federal EHR. Since the initial deployment of the EHR, the
FEHRM and the departments have worked with end-users and
stakeholders to identify issues and improve the system's
reliability, functionality, usability and capabilities.
Collectively, the FEHRM, VA, DOD, and our other Federal
partners share problems, learn from each other, and develop
solutions together. There are tremendous advantages in this and
it results in a system that continuously improves.
In closing, as the son and brother of veterans and the
leader of an organization largely comprised of service members
and veterans united in modernizing the Federal EHR, this
mission is personal and critical to me. I am focused on
delivering patient-centered care and providing the greatest
capabilities available to support the most informed clinical
decision-making.
It is my observation that the more VA and DOD and our
Federal partners collaborate and team as an enterprise, the
more we raise the performance of the Federal EHR. I thank you
for your commitment to getting the EHR modernization right, and
for the opportunity to speak to you today. I look forward to
answering your questions.
[The Prepared Statement Of Bill Tinston Appears In The
Appendix]
Mr. Rosendale. Thank you very much, Mr. Tinston.
The written statement of Mr. Tinston will be entered into
the hearing record.
We will now proceed to questioning, and I recognize myself
for 5 minutes.
Unfortunately, Oracle is using the taxpayers' money and our
veterans for their own private research and development
mechanism. It is very disappointing to this committee, and we
see it time and time again.
These companies hold themselves out to be the experts in
the field. This is exactly what they were supposed to be doing.
Yet, we are being used as an experimental lab. The taxpayers
are funding it, and the veterans are the ones shouldering the
problems.
Downtime has been redefined. Service tickets are not even
being sent in anymore because there have been so many of them
and they have frustrated the employees so severely. You know
it, Mr. DelBene. You know it yourself. They are not sending in
all their tickets.
Money is still free flowing to Oracle. They are making
billions of dollars and it is, again, very disappointing.
Mr. DelBene, how do you explain the discrepancy in your
uptime statistics versus the KLAS survey?
Mr. DelBene. Thank you for the question.
I am not familiar with the exact methodology for the
survey. One distinct difference is it is a survey of people's
opinions of how the system is doing. We do hear from the people
that are using the system and there is frustration. I will
acknowledge that straight up.
At the same time, we have a set of metrics that are
actually measured based on the true system performance, and
that suggests that progress is being made. We are not happy
with the complete progress made but we actually are being very
systematic about measuring core system uptime, how systems
around the core are performing, and user uptime and how often
that they see a glitch. We are seeing improvements in each of
those metrics. Again, I will acknowledge that----
Mr. Rosendale. Okay, Mr. DelBene, when we see improvement
going from 7 percent acceptable to 10 percent, on the paper it
looks like there was a 38 percent improvement. Okay? 38 percent
improvement from 7 percent just to get you up to 10 percent,
quite frankly, Congress has a higher rating than that and it is
not really good. Okay?
How is it that the system can be up over 90 percent of the
time and yet only 26 percent of the employees say it is
available when they need it?
Mr. Delbene. The core system is up over 99----
Mr. Rosendale. Okay. The system is up. Totally, the entire
system is up 97 percent of the time, okay, but we are also
finding out now that that is based upon a 24-hour day. It is
not based upon an 8-hour workday. When you compress this down
to an 8-hour workday, okay, and you take out the 10 percent of
the time that it is not actually functioning, that is about an
hour a day that the system is not--Mr. DelBene, this is simple
math. We clarified that this is based on a 24-hour day.
Mr. Delbene. That is correct. The probability, the actual
downtime in a day under that statistic would be nowhere near an
hour.
Mr. Rosendale. Well, Mr. DelBene, I am just working off of
the numbers that we have here. If the numbers are based on this
24-hour day, and most of the medical centers are only open from
8 to 10 hours a day, are not the numbers inflated when no one
is even trying to use the EHR?
Mr. Delbene. If I may, number one, the actual core system
of time is a very high number today so there would not be----
Mr. Rosendale. Mr. DelBene, if the number is being based
upon and the survey is being based upon the number of hours
that the facilities are open, that is dramatically less than a
24-hour day; correct?
Mr. DelBene. Keep in mind that many of----
Mr. Rosendale. Mr. DelBene, is that correct?
Mr. DelBene. No, it is not correct.
Mr. Rosendale. The system is going to be functioning 24-
hours a day but we only have people who are utilizing it 8 to
10 hours a day?
Mr. Delbene. Well, with all due respect that is the part
that is wrong, because if you take someplace like Mann-
Grandstaff it is open 24 hours a day.
Mr. Rosendale. How often are the people using that system?
Do I need to go in and pull the actual hours and the charts for
how many employees are utilizing that system, because we will
pull that information as well. I do not believe that you are
going to show as many people working on that system, okay, from
a 9 to 5 as you are going to be from an 8 p.m. until 4 a.m.
Mr. Delbene. If I may step back. The measurement is
independent of the people using the system. It measures it when
it is being used by a lot of people and it measures it when it
is being used by a few people. The statistics cover over across
all of those scenarios. The distinction actually I do not think
is a material one in this case.
Mr. Rosendale. Mr. DelBene, if no one was there using the
system, okay----
Mr. Delbene. It still measures it.
Mr. Rosendale [continuing]. then you cannot gather
information from it.
Mr. DelBene. Then you cannot gather information from it.
Mr. Rosendale. How can you measure uptime when no one is
even trying to use the system?
Mr. Delbene. Because it is----
Mr. Rosendale. I will yield now to Ranking Member
Cherfilus-McCormick. She can take on her questions.
Ms. Cherfilus-McCormick. Thank you so much, Mr. Chairman.
I worked in healthcare for a long time before coming to
Congress and I wanted to make sure we put the conversation in
perspective. I think it is very easy for us to forget that this
is not just an Information Technology (IT) system but it is
really an electronic health record.
My question is for Assistant Secretary DelBene. What are
the consequences of an unstable EHR system in a healthcare
setting?
Mr. DelBene. Well, thanks for the question.
We obviously want the system and are driving toward the
system being at a very high level of reliability. The core
system is what is most important to have correct and to have
always up, and that is why we have driven a very high level of
SLA service level agreement for that core system.
The other systems that surround it, there are downtime
procedures for----
Ms. Cherfilus-McCormick. I wanted to focus specifically on
the consequences of an unstable EHR system in a healthcare
setting. Let us just identify, what are those consequences?
Mr. DelBene. I am not sure I am actually the perfect person
to answer that question since I am not a clinician myself. We
are striving toward having a high level of reliability both for
the core and the surrounding systems as well.
Ms. Cherfilus-McCormick. As you are implementing the IT
standard in the contract, are you aware of what the
consequences are or what angles of it are the most important?
Do you have awareness of that or does anybody else have
awareness of that?
Mr. DelBene. When we do triage of incidents that come in,
in every case we ask the question of are there downtown
procedures that people can use to accommodate or adjust to the
fact that there is an outage.
Ms. Cherfilus-McCormick. Okay. You have no understanding of
the consequences when it is unstable?
Mr. Delbene. I basically ask the people that are experts in
that particular topic.
Ms. Cherfilus-McCormick. Okay. How do EHR system failures
impact patient care and safety?
Mr. DelBene. Would you repeat the question, please?
Ms. Cherfilus-McCormick. How do EHR system failures impact
patient care and safety? What is the impact?
Mr. DelBene. Again, I do not think I am the subject matter
expert in that to be able to answer that question. I will say
that we focus on having downtown procedures for every place
where the EHR would be used.
Ms. Cherfilus-McCormick. If you do not understand the
implementation of it or the implications of it, how do you feel
confident with the implementation of it if you do not
understand the consequences or the safety measures that are
potentially harmful?
Mr. DelBene. Well, I do understand the system itself very
deeply. I rely on people that are subject matter experts in the
particular clinical workflows to make sure that the
requirements that come into the system that we implement or
that the team implements will implement the right workflows.
Ms. Cherfilus-McCormick. I am sure you had these
conversations with the experts before and you had the
conversation of the consequences and the seriousness of this.
In your perspective, just recalling what they have talked to
you about, could you please tell me those consequences?
Mr. DelBene. I am sorry. Again, I think I am probably not
the right person to answer this question.
Ms. Cherfilus-McCormick. The reason why I keep bringing it
up is because I have worked in a healthcare setting. When we
have contracted out and the people who we had who were actually
responsible for implementation did have an understanding of the
basic needs and consequences so they can look out for it.
Independently, without those understandings, how can you be
confident that the implementation going forward is actually
protecting those involved and also meeting the needs? I
understand that you are staying on uptime, downtime, also you
are looking on that but is there any focus on the consequences,
specifically in a healthcare setting that you, yourself, have
been exposed to? It is important we get that answer because
that would help us become more confident with the process you
are implementing.
Mr. DelBene. Thank you for the question. I think I
understand the question. What I am trying to say is that we act
as a cross-functional team where physicians and experts in
medical care work hand-in-hand with us so that the team makes
sure the right things happen.
Ms. Cherfilus-McCormick. You are not taking time to
understand it yourself? Okay.
My next question for you is what is the industry standard
for EHR uptime?
Mr. DelBene. Our goal is to have a 99.95 percent uptime. We
actually believe that is at or above the core industry
standard.
Ms. Cherfilus-McCormick. The original contract set a
standard of 99.9 when it was renegotiated earlier this year. It
was raised to 99.95. Why do you think that this contract is
still below industry standard?
Mr. DelBene. Actually, for the core uptime it is, as we
said in our testimony, it is actually achieving that standard.
Ms. Cherfilus-McCormick. Are you feeling confident with the
performance of and the implementation of Oracle?
Mr. DelBene. Overall, no. We still think there is a ways to
go. I do not want to present the system as all set and ready to
go. There are places we have significant concerns that we are
working with Oracle on so I want to make sure that is clear.
The incident free time not hitting standards is important. The
end-user responsiveness we think still has a way to go. We
think there are functional workflow issues that still have to
be resolved.
Ms. Cherfilus-McCormick. It is my understanding that the
industry standard is 99.99, and the standard set forth by the
renegotiation is 99.95, which is below industry standard.
Mr. DelBene. I do not think that is the case but we should
take that for the record and do some research there. Ninety-
nine point ninety-nine is typically a standard used for an
infrastructure component, like identity management. An end-user
focused system will tend to be more toward 99.9 or three 9s
reliability. We wanted to push it higher than that and get to
99.95. One of the things to keep in mind is, a gain, the
downtime procedures and being able to work with EHR down will
also influence when you push that vendor to get toward a higher
standard or not.
Ms. Cherfilus-McCormick. Thank you. I yield back.
Mr. Rosendale. Thank you very much, Representative
Cherfilus-McCormick.
I now recognize my good friend from Texas, Representative
Self, for 5 minutes of questions.
Mr. Self. Thank you, Mr. Chairman.
I heard you dismiss the opinion of employees in a survey
because there are people behind technology, and frankly, the VA
system is a people business. They are real people administering
care. They are real people receiving care.
In this survey--and I want to use the survey even though
you may dismiss it. When 9 percent say that the Cerner system
makes them as efficient as possible and 10 percent say it helps
them deliver high-quality care, the question is, is that a
failure of the system? I suspect you will say no, and if that
is the case, if your answer is no, what percentage would be
failure?
Mr. DelBene. Thank you for the question.
Actually, I do not dismiss the survey. I think what I said
was I do not know the methodology of the survey.
Having said that, I actually hold in very high regard the
opinions that come from end users. They are the ones that
matter. If they feel like the system is not meeting their needs
we have to rectify that situation at a full stop.
Mr. Self. What percentage?
Mr. DelBene. Percentage? I am sorry.
Mr. Self. Would constitute failure of the system?
Mr. DelBene. What percentage would constitute failure----
Mr. Self. If 9 and 10 do not, do you think the system is a
failure at this point of time, at this point in time?
Mr. Delbene. I would say that having 9 out of 10 people not
be happy with the performance of the system is a problem.
Mr. Self. Okay.
Dr. Prietula, continuing with this survey, 8 percent said
their initial training prepared them to use the system, 14
percent said the training was helpful. Is this a training
problem or a system problem?
Dr. Prietula. Thank you for your question.
In terms of training, end-user training, that is not part
of my responsibilities though we are focusing on that training
with some of the EHRM-IO components.
In terms of is it a failure of the system in terms of how
you use it, we are making every effort to ensure that training
is changed to ensure that we understand what the users need.
What kind of potential additional training or different kinds
of training we can have with them. Additionally, we are also
working with our IT local and OI&T to ensure that they are
absolutely understanding what the systems are, how they
operate, and who to call should there be any issue.
Mr. Self. Can you tell me why the employees in the private
sector do so much better with the Cerner system than the VA
system?
Dr. Prietula. I can give you an example of or an idea of.
We have a multitude number of changes that we have introduced
into the code base or the main Oracle stack. VA has
significantly customized that platform. What we are doing right
now is bringing back many of those customizations to make sure
that we are coming back to the base of what the system is
supposed to do. Most of the commercial entities as I am told
use out of the box functionality from Oracle Health. We have
significantly modified that code base. As I said, we are
working to bring that back into standards.
Mr. Self. I would question that ``use it out of the box''
because I think most people have some customization.
Mr. Tinston, I did not catch, I did not understand your
reference to DEERS. DEERS is decades old. What is that tie that
you tried to make?
Mr. Tinston. DEERS in particular has posed a problem for
operations on the VA side because calls were made to that
system. As you described, it is an aged system and so its
performance impacted the performance of the VA experience with
the EHR. The VA has changed their interaction such that they
have created resilience from an EHR perspective so that if
there is a DEERS problem or a connecting system problem that
the user is able to continue with the work and the workflow
that they were engaged in. Mr. DelBene has engaged with the DOD
Chief Information Officer (CIO) to drive improvement in the
associated connected DOD systems such as DEERS.
Mr. Self. Okay. Mr. Chairman, I yield back.
Mr. Rosendale. Thank you very much, Representative Self.
Mr. DelBene, I am going to go back and try to pin down a
little bit more information about the discrepancy between what
is actually reported through Oracle and what it is the
employees are stating because we have got this big gap, okay,
between how bad they say it is and how bad that you guys say it
is.
The incidents that are experienced by the employees--
crashes, slowdowns, hangs--all of these things are severe
enough to the point that the employees find the system
unusable. Okay? If an employee finds this system unusable, what
I am trying to figure out is how are you reporting that? They
report it to you and they say I have had this system. It is
unusable at this one facility, at this one site. Okay? How does
that get calculated in for this 97 percent, 98 percent showing
that it is up and running where we have these downtimes again
based upon an 8-hour day and one facility instead of all the
facilities and a 24-hour day? How do we do the reporting for a
person sitting at a desk and saying this system will not work
for me for an hour?
Mr. DelBene. Again, the measures that exist are 24-hour
wide measures. There is no concentration of those in a
particular 8-hour period. I think that is part of our
discrepancy.
Let me step back. We definitely think that there are issues
around getting good performance, end user responsiveness still
in the system. The three measures that we have defined as SLAs,
which without going into too much detail get to the average
responsiveness, the 10 percent worse responsiveness, and the 1
percent worst. We are very careful to make sure that we had all
three of those. In each case they are hitting it but in
particular for the 1 percent of people there is still a lot of
hangs that happen in the system. We define a hang as a 5-second
pause. What that metric is, the threshold is 50 of those in a
day. The current number is somewhere around 20 of those in a
day. I actually think if you were looking at the screen and
seeing 20 such hiccups, if you will, in a day, you would
perceive that as unacceptable performance. I think that is a
place where we actually are aligned and we need to do better.
The other thing I would make clear is we particularly set
up the contract so that as we go into additional option years
we can change those SLA numbers and we can ratchet them down to
be more strict. We are looking at those SLAs and saying which
ones would we change moving forward?
Mr. Rosendale. Again, this gets down to the definitions and
it gets down to the math. Okay? I think that that is where we
have the big problem, because if you are having this problem,
the same problem, the hangup, the delay, and it is taking place
in different facilities at different times throughout the
course of the day then it is not really getting calculated
accurately about the system having a deficiency because we are
basing it on a 24-hour day. You and I can debate back and forth
but you are not going to have the amount of traffic on that
system from 6 or 7 p.m. until 4 a.m. that you have from 9 to 5.
Okay. Moving on. Only 11 percent of the VA employees told
the KLAS research that the Oracle Cerner EHR has the fast
response time that they expect when logging in, refreshing the
screen, and retrieving the information. That sounds a lot like
the definition of incidents. Yet, you are reporting incident
free time in the high 90's. Again, how do you explain that?
Mr. DelBene. Well, thank you for the question.
We know for each of the systems whether they are responded
or not and we separately measure what is the actual response of
the user experience. What you see is the number. We can
actually measure a particular system is up, and we can
accurately measure as a result how much incident time there is
in aggregate. We separately measure whether the actual system
is responding adequately. That is the number I tried to give
you a sense of. They are meeting the SLAs but we still think,
particularly for that 1 percent of users which probably will be
more vocal, and rightly so, that the experience may well be
unacceptable.
Mr. Rosendale. Mr. DelBene, if your definitions are not
capturing problems with the EHR that are preventing the VA
staff from doing their jobs, okay, they are just saying this is
not working for me and you do not have a definition to capture
that, does that not mean the definitions are incomplete or not
accurate?
Mr. DelBene. I think it means that we need to really make
sure that we are well aligned with users to make sure we have
their--and we are. To make sure we understand how they are
perceiving the system. There are two separate questions. There
is the performance of the system and what do the numbers tell
us? Then there is how end users----
Mr. Rosendale. Let me make this real simple. If I file a
complaint and you are speaking a different language, okay, that
does not accept that complaint, then it is not getting
registered.
Representative Cherfilus-McCormick, I recognize you for
your next round of questioning.
Ms. Cherfilus-McCormick. Thank you so much, Mr. Chairman.
I have huge concerns as I was considering the conversation
we just had. One of my concerns is, you know, I am trained as a
lawyer. I did not have a healthcare background when I got into
healthcare, but one of the basic things that we do is to
understand the healthcare system. The reason why it is
important to understand the healthcare system is because you
have to understand if you are actually weighing the right
variables and if you are actually weighing the right matrices
to determine success.
The end users of Cerner and Oracle. I want to know what
your relationship is with them because they do understand the
healthcare system and they work together. Now, do you have any
system or a survey that you may have used to find out what
their perceptions are, because what you are reporting does not
match what they are reporting.
Mr. DelBene. Thank you for the question. It is a very good
one, and we do those end-user feedback sessions as well as
surveys. Let me pass to Dr. Prietula who can talk more about
that.
Dr. Prietula. Yes. Thank you for the question.
We do recognize that we needed to be much more close to our
end users. We established during this Reset period, we
established some integrated teams with Veterans Health
Administration (VHA) and our groups and EHRM, to really assess
where are we in terms of the user experience. We have human
factors engineering groups working with us now to make sure
that--and with Oracle Health as well as our partnership--to
make sure that we start working on remediating what the users
are understanding that needs to be improved from an end-user
perspective. We also have from some surveys that the pre-and
post-deployment of a code block, which is a major release. We
have some of those that we started to do to understand where we
are in terms as to the experience that the users are having
with it.
Ms. Cherfilus-McCormick. Could you please provide us with
those surveys and that data? How frequent is that, those
surveys?
Dr. Prietula. We just started them.
Ms. Cherfilus-McCormick. You just started them? How many
rounds of surveys have you conducted?
Dr. Prietula. One.
Ms. Cherfilus-McCormick. One round of surveys. When was the
last survey that was conducted?
Dr. Prietula. That was with our code block release 9. That
was in September.
Ms. Cherfilus-McCormick. In September of this year?
Dr. Prietula. Of this year. Yes.
Ms. Cherfilus-McCormick. Who does the critical analysis of
that, the surveys?
Dr. Prietula. We are working, like I said, with human
factors engineering, and VHA.
Ms. Cherfilus-McCormick. When are they delivering the
results of that?
Dr. Prietula. We are looking at those results now.
Ms. Cherfilus-McCormick. Once you receive it, how are you
planning on doing the critical analysis of what they deliver to
you?
Dr. Prietula. We have projects established. As we go and do
the root cause analysis as to what is going on, what did they
identify as being an issue, we go and evaluate where should we
be starting? We have projects that we can kick off to go and
address each one of those.
Ms. Cherfilus-McCormick. Will you and Mr. DelBene be a part
of the critical analysis?
Dr. Prietula. We work as a partnership.
Ms. Cherfilus-McCormick. Okay. Then could you tell me what
the consequences are of a failing EHR system?
Dr. Prietula. I cannot tell you the consequences. I am not
a clinician.
Ms. Cherfilus-McCormick. Are you substantially confident
that you can, in fact, be able to do that critical analysis if
you do not understand that?
Dr. Prietula. Like I said, we are working with VHA as well
in that evaluation. It is a technology----
Ms. Cherfilus-McCormick. You are relying totally on their
analysis of it?
Dr. Prietula. It is a joint analysis because if it is like
the front end portion of it, that is with our VHA. If it is
something that the system can enhance or can fix, that is where
we come in as engineering and architects.
Ms. Cherfilus-McCormick. Do you feel comfortable knowing
that that part of understanding the basic part of healthcare,
the necessities, the safety for our veterans, that lack of
knowledge, are you comfortable making decisions without
understanding the implication on our veterans?
Dr. Prietula. When we look at the requirements that are
given to us from our functional community, we work with them on
every step of the way.
Ms. Cherfilus-McCormick. You are comfortable with that,
knowing that a failing system can cause death and safety
hazards for our veterans, are you comfortable with that?
Dr. Prietula. No, I am not comfortable, and I did not say
that.
Ms. Cherfilus-McCormick. I guess what I am asking is
relying on--well, you can go ahead and answer, Mr. DelBene.
Mr. DelBene. Yes. I think that we have gotten a little off
track here. I think what we are trying to express is that we
act as a cross-functional team, multi-functional team. In the
end what matters is that the team concludes, are we ready to
continue to pass the reset or not.
Ms. Cherfilus-McCormick. We are actually right on track. I
did not want to step in but we are on track. As I said, as
leading a healthcare company, there is a certain amount of
reliance that you can have on your team. As a leader you have
to understand certain principles. Understand the consequences
of the people who you are protecting. Carrying out the mission
of taking care of our veterans is an important mission but
understanding the critical nature of the system is also
important. That is the baseline, the near baseline.
Understanding that is one thing and ensuring that everyone who
is working on the team understands that is another thing.
I wanted to see, I am trying to become more confident about
this structure and what is present. The more we talk about it,
the more confidence I am losing because I am not seeing that
independent process of understanding the basics. These are the
basic system that are not being understood.
I will just yield back, Mr. Chairman. Thank you.
Mr. Rosendale. Thank you very much, Representative
Cherfilus-McCormick.
I will now represent my friend again from Texas, Mr. Self.
Mr. Self. Thank you, Mr. Chairman.
I want to go back to those end users. I assume those are
your employees and not the veterans. What are they instructed
to do when they have either a shutdown or what did you call it?
A pause. A 5-second pause or more. What are they instructed to
do. They are with a patient and the system becomes unusable for
some period of time. What do they do?
Dr. Prietula. We have, again, in that collaboration with
our Veterans Health Administration working groups, we notify
employees when there is an issue, either that they have
reported or that we know that the system is not executing where
it needs to be, we have a process in place where we can notify
them.
Mr. Self. No, no. We are sitting in the room. You are
getting an exam or whatever. The system is unstable. Do they
use it during the actual clinical treatment or is this only a
planning system? I assume it is used during treatment.
Mr. DelBene. If I may, the system, again, the uptime for
the system is such that for the vast majority of the time the
system is operating these days. We should just be clear there.
If there is a system issue incident going on, they have
downtime procedures which allow them to continue to do their
work.
Mr. Self. Okay. You said your average is 20 of these. What
did you call them, pauses?
Mr. DelBene. Oh, so you are saying, yes, for the average
person I think that Laura can tell me.
Dr. Prietula. Two.
Mr. DelBene. The statistic for the average person is two
such instances of less than 5 seconds in a particular day.
Mr. Self. Okay.
Mr. DelBene. That actually will not significantly----
Mr. Self. You do not think it impacts the quality of their
care at all.
Mr. DelBene. I think the 1 percent is the place we need to
really focus. The 1 percent of users that are seeing the worst
possible experience are still seeing 20 such incidents in a day
on average. That is unacceptable.
Mr. Self. The VA, the Dallas VA is in--it is not in my
district but it is close to my district. The second largest in
the system, I believe, 200,000 veterans. The 1 percent would be
a significant number of veterans that would----
Mr. DelBene. It would be end users. I am sorry. That would
be the 1 percent of people operating the system.
Mr. Self. Operating the system.
Mr. DelBene. Yes. The other thing I would like to be clear
on is the place that we have had best progress so far is
actually in the clinician experience. Particularly in this last
block upgrade, their experience has improved the most. It is
around registration and scheduling that we probably have some
issue. We have more issues centered in that end-user group.
Mr. Self. Okay. Mr. Chairman, I yield back.
Mr. Rosendale. Thank you very much, Representative Self.
Mr. DelBene, you acknowledged in your testimony that the
EHR is not meeting veterans' and VA clinicians expectations.
Activities to prepare for the go live at the James A. Lovell
Federal Health Care Center in North Chicago are underway right
now. Does the system meet those expectations now? If not, how
is it going to improve by March?
Mr. DelBene. Thank you for the question.
We are not at a point that we are launching today. I think
we believe we are on track to launch in terms of the
expectations of the people managing the system in Lovell. I
actually might ask Mr. Tinston to reply on that one if you are
okay with that.
Mr. Tinston. Representative Rosendale, we work every single
day cross-functionally with the technical team at the VA,
technical team at the DOD, the two programs and the leadership
at North Chicago to make sure that we are on track to deliver
in March. Our understanding and our intent there is to get a
yes. That we can improve their ability to deliver care before
we go live with anything in North Chicago. I expect that answer
will be yes. I have no reason to believe it is anything but yes
at this point. We are diligently watching every single day.
Mr. Rosendale. Okay. Mr. DelBene and Ms. Prietula, you
should be familiar with the EHR reset legislation that was
provided to the VA in September.
Mr. Delbene. Yes.
Mr. Rosendale. Okay. It would establish criteria for each
medical center director to certify that the Oracle EHR is
appropriate to install and the facility is prepared to receive
it. The bill is not law yet but this is a common sense
standard. Are you going to apply the standard to Lovell without
the legislation? Do you believe that Lovell would need it?
Mr. Delbene. I believe that it is important for the end
users and for the management of that facility to be onboard and
supportive of the rollout.
Mr. Rosendale. Okay. I do, too. That is why we had that
language in the legislation.
What I am asking is, are you ready to apply all of those
standards to the Lovell rollout? Do you believe that they would
meet it?
Mr. DelBene. I believe at this point we are on track to
meet that when we do launch, but we will not launch until we
have met the standards that are part of our go live criteria.
Mr. Rosendale. Mr. Tinston, Mr. Scott, James Lovell is the
only fully integrated DOD VA hospital. You are implementing the
Oracle Cerner EHR there before VA can finish their reset work.
What unique challenges does Lovell pose, and how are you going
to overcome them? This is a facility that is different than any
other place we have had a rollout. Again, what are the
challenges, and what do you think needs to be done?
Mr. Tinston. Sir, the problem is different at James A.
Lovell Federal Healthcare Center. They are an organization led
by the VA that was asked about a decade ago to work in an
integrated fashion supporting both DOD beneficiaries and VA
beneficiaries out of one common facility. We did not equip them
with the right IT tools to do that. They use at least three
different EHRs trying to create integrated care delivery at
that facility. We are solving that problem and we work every
day, to your prior question, with the director of the facility
to make sure that we are addressing the problems and we are
making things better as we approach a go live at that facility.
That is the last remaining DOD facility. It is the only one
they have not deployed the common record to, and we work every
day, and to your point, specific issues to that are that they
see beneficiaries from both systems every single day, and they
do that in an integrated fashion and we have to improve their
ability to do that because the people there have already done
the work and working in an integrated fashion. We need to give
them the tools. That is what we are striving to do.
Mr. Rosendale. I have grave concerns because of watching
the other facilities and the rollouts, and we know that level
is a lot more complex. Forgive me if I am a Doubting Thomas
about this but when we see the deficiencies and the failures in
the other facilities that are not nearly as complex, as level,
again, we are going to need to apply these metrics. If the
legislation is not passed, I am hoping that we can get you to
agree to this metrics, but right now as you look at it, what
level of comfort do you truly have that we are going to be able
to meet those metrics in March?
Mr. Tinston. It actually pretty high. It is the highest it
has ever been and it has improved every day in the last year
because we work on a daily basis with the leadership team that
delivers care at FHCC in North Chicago. As we continue that
engagement, and I had our situation report with the broad team
yesterday afternoon and there were no showstoppers. This is led
by the Veterans Integrated Services Network (VISN). We have the
VISN there. We have the director of the facility there. We have
the Veterans Health Administration representatives there in the
conversation every day to make sure that we are meeting the
criteria that they need to go live and deliver effective care
and safe care better than they do today.
Mr. Rosendale. Thank you. Thank you.
Mr. Tinston. Absolutely.
Mr. Rosendale. Okay. I am going to yield to Representative
Cherfilus-McCormick. Thank you.
Ms. Cherfilus-McCormick. Thank you.
Mr. Tinston, what do you see as the FEHRM's role in
improving system stability for VA and the DOD?
Mr. Tinston. The FEHRM is about the things that we do
together between the DOD and the VA. Not things that we both do
but the things that we do together. The FEHRM by charter is set
up to manage all of those joint processes. Part of your
question--yes, ma'am?
Ms. Cherfilus-McCormick. Are there any factors that limit
your ability to succeed?
Mr. Tinston. We work within the boundaries that the two
departments have set for us. I do not know that anything limits
our ability to succeed. No, ma'am.
Ms. Cherfilus-McCormick. This is a little off the topic but
since I have you here, in May 2022, the VA and the DOD
Inspector General published a report that found that the DOD
and the VA did not take all the action necessary to achieve
interoperability because FEHRM program office officials did not
develop and implement a plan to achieve for all Fiscal Year
2020 National Defense Authorization Act (NDAA) requirements or
take an active role to manage the program's success as
authorized by its charter.
My question is, what is the status of the FEHRM's efforts
to address this recommendation?
Mr. Tinston. Ma'am, with regard to that recommendation, the
two deputy secretaries whom I work for, Deputy Secretary of the
VA and Deputy Secretary of the DOD asked me to come back with
our plan to address that. I have done that. What we are doing
is focusing at this point on the joint site at FHCC because
that is the culmination of all our efforts to create a joint
single federal record.
Ms. Cherfilus-McCormick. Okay. When do you plan to be fully
compliant with the NDAA recommendation?
Mr. Tinston. Ma'am, I believe we are.
Ms. Cherfilus-McCormick. All right. I yield back. Thank
you.
Mr. Rosendale. Thank you very much.
Mr. Tinston, why is there not any survey data for the
Military Health System (MHS) Genesis for this year? Did the DOD
decline to participate?
Mr. Tinston. Not that I am aware of.
The FEHRM works with both departments to include EHR-
related questions in surveys that the departments were already
doing. Interesting, we just completed as NDAA 2020 requires, an
annual EHR summit with users from each department. The results
of that will be coming out soon. In general, what we got from
the users was that they recognized the importance of the EHR.
They think that things are improving. Their complaints were, as
you noted in some of your questions and comments, that the
training is not right yet. We are not quite there but we are
moving in the right direction and we are compiling the results
of that at EHR summit where we had 1,000 users participating
with us for 2 days and we will have that available in the near
future.
Mr. Rosendale. I would love to see that survey information
again. When we show improvements and you are going from 7
percent satisfaction rate to a 10 percent satisfaction rate, as
a percentage that looks great but it is really not that much of
an improvement. I mean, I am sorry. When we also are taking
calculations on downtimes, slowdowns and things like that that
are for one person, one facility, and we are not even gathering
in all of the tickets any longer that we know that are out
there, that does not give us confidence about the working
system either.
Mr. Tinston, last year only 24 percent of the military
health system employees told KLAS that EHR was available when
they needed it. That is even worse than the VA. Is that what we
can expect at Lovell FHCC?
Mr. Tinston. Absolutely not. I cannot speak to what people
will say but when we look at people's satisfaction surveys on
an enterprise system we have to consider multiple factors. It
is incredibly important that they be satisfied and that we do
everything we can to create their ability to effectively use
the system and ensure that we deliver an effective system.
Mr. Rosendale. Again, the surveys are showing that the
people are not satisfied with it. Mr. DelBene can say that the
system is up and functioning but again, I continue to go back,
if it is up and functioning because nobody is utilizing it and
it is between 8 p.m. and 4 a.m., then it does not really
matter. It is when people are there trying to utilize it.
Dr. Prietula, here is the most troubling response from the
KLAS survey. Only 10 percent of the VA employees said that
Oracle Cerner EHR enables them to deliver high quality care.
Only 10 percent. I will grant you that is up from 7 percent
last year. Again, I am going to these percentages. These
numbers are abysmal. Compare that to the number for Veterans
Health Information Systems and Technology Architecture (VistA),
which is at 56 percent. We are talking a dramatic difference.
How many billions of dollars more is it going to cost to get
the Oracle Cerner number up to the VistA level How long is it
going to take for us to get there?
Dr. Prietula. Thank you for the question.
We are working very closely with Oracle Health in terms of
improving system performance in general. We have made a number
of improvements since I have got to this position. We have at
least 47 different projects that we have been executing and
around 36 of them we have----
Mr. Rosendale. Ms. Prietula, I have to interrupt but as you
know, we only have a limited amount of time. We are approaching
$4 billion spent on this system. Okay? It has been in place
since I have been here, so my tenure is coming on 3 years now
and I know that it was on before that.
How much more would you say that we should begin to have
conversations about allocating toward this system? How long is
it going to take us to bring those numbers up to where VistA is
today?
Dr. Prietula. I think that you will see improvements in the
coming deployments that we have. I cannot tell you when we are
going to be reaching the same numbers as VistA but I am very
confident that we will be able to get to numbers that are going
to be acceptable to our end users.
Mr. Rosendale. Okay. I still have a little bit of time.
At this rate of improvement it would take Oracle EHR 15
more years to come up to the level of VistA. Fifteen years
based upon the incremental changes and improvements that you
all have been making. Do you think that that is reasonable? Is
that worth investing in?
Dr. Prietula. Thank you for the question.
I believe that with the changes that we are bringing on we
are starting to get more velocity on the changes and we are
trying to ensure that all of those--in every release we have a
performance improvement. I believe that it is not going to take
us 15 to get to the VistA performance.
Mr. Rosendale. Thank you very much.
Mr. Landsman, I would defer to you, yield to you for 5
minutes of questioning.
Mr. Landsman. Thank you, Mr. Chairman. Thank you all for
being here. You all have gotten into a lot, so let me just ask
a couple high level questions. This is for Mr. DelBene.
I am curious, because this is obviously not the first time
you have taken on something like this. I am curious about the
approach. I mean, this highly complicated system that has a
whole host of very serious issues. This is a big picture. How
do you approach something like that and, you know, as it
relates to the larger problem but then if you drill down to the
sort of end user, the staff, and those they care for, in this
case, veterans, what is your approach? What are the big North
Stars? How do you tackle something like this?
Mr. DelBene. It is a good question. Thank you for it.
I have experienced a lot of these sorts of systems in my
career.
I think first, you have to be anchored on whether you
believe the system is addressing end-user needs directly. Is it
a good fit for the system relative to what you are trying to
accomplish? At that point, you have to make sure that you are
taking the feature requirements that you get from end users,
and are you on a good path to actually implementing them in
software, in the system?
At some point it gets down to a period of winnowing down
the changes until you get to a point where the system is
stable. If you feel like you have addressed the end-user
issues, you then drive down toward what we would consider a
release of that software. That is probably one of the most
uncertain times in the system because you just do not know
what, as we say, the tail looks like. How long is that tail
going to last?
The reason we set up the reset the way we did is because of
that uncertainty of how long is it going to take us, and we are
committed not to actually start to deploy again until we get
into that chute, into a place where the end-user experience is
good. That is the challenge we have in this system in
particular.
I want to just acknowledge again, we do not think we are
there. We do not think we have got everything done that we need
to get done for the system to be acceptable to end users. We
are committed to not deploying in further locations until it
is.
Mr. Landsman. So very helpful.
There are sort of these two things, or at least I picked up
on two big things. One is you have got to get to a place where
it does this work for the end user. Then if the answer is yes,
you start working through the problems and, you know, until you
knock them all out. You are at this point where you are trying
to sort out whether or not this is--or how do you get to a
place where this is a good fit or this works for the end user?
What are the two or three big things you are looking for?
Not exactly the things that have to happen, but as you are
sort of, you go in every day. What are the things that you are
monitoring as it relates to are we heading in the right
direction in terms of this being a good fit for the end user?
Mr. DelBene. Well, there are people, other parts of the
team that are saying, you know, how are we doing in terms of
the clinical experience? As a technical person, the pieces that
I am looking for is does this system look stable? Are we making
progress on those things we are managing? I am also looking to
the team and saying, like, when I triage, or I meet every
morning, we walk through every incident that happened in the
last 24 hours.
The thing I am looking for is patterns. I am looking for
are we doing enough due diligence and change control? Are we
causing incidents because of the change that we should not? I
am looking beyond and saying is there some instability beyond
this? This is a telltale for us. I am kind of looking at an
entire system and saying so what are the hidden things behind
this that this might be an indicator of? Trying to look deeper
into the system every day.
Then there are the metrics of just success. Are we on those
SLAs that we defined, are we actually hitting them on a regular
basis? It is one thing to hit them once. You have got to hit
them on a sustained basis to feel like the system is truly
stable.
Mr. Landsman. Last question. How long do you give this? I
mean, that is not a ``got you'' question. In general, maybe not
for this specific thing but when do you start feeling like,
okay, this may not be a good fit? Or do you know what I mean?
Mr. DelBene. I do.
Mr. Landsman. Okay. Are you at that point?
Mr. DelBene. I think having done this a number of times,
the first thing you look for is are you not within some bounds
of stability? Like this thing is coming in for a landing.
Mr. Landsman. Gotcha. Yes.
Mr. DelBene. I do not think this system looks that way to
me. However, if you want to talk about how long that tail is, I
think at this point we do not honestly know.
Mr. Landsman. Got it. Thank you.
I yield back.
Mr. Rosendale. Thank you very much, Representative
Landsman.
Thank you very much to all of the witnesses for joining us
today. The panel is excused from the table.
I would yield to Representative Landsman if you have any
closing remarks that you would like to add.
Mr. Landsman. Just a few. One is thank you all for
everything you are doing. This is incredibly complicated. It is
also very, very important, as you know. I mean, this is you are
at work right now and for some of you I suspect it has been
your work for a long, long time. I just want to say thank you.
I have a VA hospital in my district. It is a huge facility. It
serves thousands and thousands of people who served us and for
them to get to a place where the system that they are using is
helping them in a way that the current does not. Right? Is it
helping them serve the folks that they care so much about?
It is just so important so I just appreciate what you all
are doing. Mr. DelBene, for bringing your expertise. I suspect
it gives a lot of people a lot of confidence that you are here
and you are sorting through it and being as deliberate and
thoughtful as you clearly are. Thank you all. Thank you, Mr.
Chairman.
Mr. Rosendale. Thank you very much.
Today's hearing should have been unnecessary. The very
least we expect from a piece of software is that it runs
reliably when we launch it. The complexity and the rate of
change within the VA should be no surprise to anyone and this
is no excuse for Oracle. Again, they hold themselves out as the
experts in this field.
The irony is that the VA already has an EHR platform with
more than 99.9 percent uptime. This is like Ivory soap pure,
folks. It is called VistA. We delved into how it achieves that
level of performance in March. It is baffling that anyone could
pay billions of dollars and set a lower standard. Set a lower
standard. I understand the determination to make Oracle Cerner
work, especially now the DOD has nearly finished implementing
it.
I hope the two departments and Oracle can put the blame
shifting behind them once and for all and address the problems
regardless of who may have created them. We are going to be
giving special scrutiny to how the system performs at James A.
Lovell and, at the joint facility. Finger pointing is not just
counterproductive. It can be fatal.
Once again, I want to thank the witnesses who appeared
today.
I ask unanimous consent that all members have 5 legislative
days to revise and extend their remarks and include extraneous
material.
Without objection, this hearing is adjourned.
[Whereupon, at 1:38 p.m., the subcommittee was adjourned.]
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A P P E N D I X
=======================================================================
Prepared Statements of Witnesses
----------
Prepared Statement of Kurt DelBene
Good afternoon, Chairman Rosendale, Ranking Member Cherfilus-
McCormick and distinguished Members of the Committee. Thank you for the
opportunity to testify today in support of VA's initiative to modernize
its electronic health record (EHR) system. I am accompanied by Ms.
Laura Prietula, Deputy Chief Information Officer, Electronic Health
Record Modernization-Integration Office.
I want to begin by thanking Congress and this Committee for your
continued support and your shared commitment to Veterans and, more
specifically, for your support of VA's EHR modernization efforts. For
VA, the successful deployment of the Federal EHR system will facilitate
seamless health care transitions for Service members and Veterans
across health care settings. The Federal EHR will provide an accurate,
lifetime health record for Veterans among partners using the Federal
EHR. For the newest members of the military, this EHR will serve them
from the day they begin their military service through the rest of
their lives.
The new Federal EHR system integrates with other health information
technologies and will ultimately simplify the experience for Veterans
and for VA staff, enhance standardization across the VA enterprise, and
improve VA and the Department of Defense's (DoD) interoperability with
the rest of the United States health care system. Moreover, the
adoption of a product used by VA and DoD will help to simplify health
care delivery by providers in both Departments, benefiting patients who
receive care in both systems or who are transitioning from DoD to VA
for care. It will also enable VA to deliver and optimize a unified and
seamless trusted information flow between VA, DoD, the U.S. Coast Guard
and community providers.
Since the initial go-lives of the Federal EHR in VA, we have been
listening to Veterans and clinicians, and it is clear that the system
is not yet fully meeting their expectations. As part of an Electronic
Health Record Modernization (EHRM) Program Reset (Reset) announced in
April 2023, VA halted work on future deployments of the Federal EHR,
with the exception of our planned joint deployment with DoD at the
Captain James A. Lovell Federal Health Care Center (FHCC), while the
Department prioritizes improvements at the five sites that currently
use the Federal EHR. The purpose of the Reset is to closely examine and
address the issues that clinicians and other end users are experiencing
with the current Federal EHR, and position VA for future deployment
success.
During this Reset, VA is addressing the issues with the Federal EHR
and redirecting resources from deployment activities other than Lovell
FHCC to work on optimizing the Federal EHR at the sites where it is
currently in use. The area of technical system performance is one of
several areas that is receiving dedicated attention and needs
resolution before deployments can resume at full pace.
VA has an obligation to Veterans and taxpayers to get this correct.
We understand the concerns of this Committee regarding the Federal EHR
system and its impact on the Veterans and VA staff who rely on it. We
are committed to full transparency, and we appreciate your oversight.
We look forward to further engagement with you and your staffs to
ensure that this modernization effort and related health information
technology modernization efforts are successful.
EHR System Changes
VA is on a journey to implement a large system transformation. The
Federal EHR system is a highly complex software environment composed of
the core medical records system and several other connected systems
that together deliver the overall EHR experience to clinical providers
and patients.
In February 2022, VA established a Performance Excellence Program
to improve the overall system performance, resiliency, capacity, and
reliability of the Oracle Health system. Due to this systematic
approach, we have seen the core system stabilize over time, resulting
in improvements to the user experience. As of November 8, 2023, there
have been 185 consecutive days without an outage, and 100 percent
system availability in 10 out of the last 12 months.
However, we are still experiencing partial system failures that
impact end users. We capture these failures in our incident free time
(IFT) metric, which measures the time that the system performs without
a significant end-user problem. While our IFT metric has slightly
improved from last year, it is not yet meeting the Service Level
Agreement (SLA) of 95 percent IFT on a regular basis. As of September
30, 2023, Oracle Health has reached this metric for only 4 of the last
10 months.
This is due in part to the number of changes still being
introduced. These changes are made to improve the performance, system
functionality, and user experience. It is a well-established axiom of
software development that systems stabilize when the rate of changes
made to the system decrease. The rate of change is still high, and as a
result, we are still seeing more incidents than we would like.
While we have been able to improve the stability of the core
product, we continue to make regular changes to the environment to
achieve the functional capabilities needed for VA. Though system change
may bring different and improved experiences to the users of the
system, it also introduces the possibility of unintended consequences
or system instability.
In some cases, VA has requested functionality from Oracle Health
that has never been deployed by Oracle Health commercially, such as an
integration with the VA Consolidated Mail Outpatient Pharmacy, making
VA the first user of the functionality, which also increases incident
risk.
We have seen suboptimal and/or inconsistent end-user responsiveness
of the system. We measure both the mean responsiveness as well as the
90th and 95th percentile response times. The core system is becoming
more stable, and the mean user responsiveness is improving. While
Oracle Health has met the SLA for these metrics, we are refining these
metrics based on user feedback and will likely seek to tighten these
for option year 2 of the contract. We are also measuring performance in
areas that are not currently on contract, but still of interest to VA.
For example, the time to recover from an incident remains at around 2
hours. Faster incident resolution times are better.
Regarding user support, we have improved the processing of tickets.
Oracle Health met all four ticket management SLAs in July, August, and
September 2023. Every critical or high severity incident has a root
cause analysis performed and a preventive action identified. These
reports are also integrated now into the VA Office of Information and
Technology daily operational status reviews.
Ultimately, we anticipate that the system's performance will
improve when the change velocity decreases, and enough time has passed
to enable unanticipated defects to be addressed. From a technical
perspective, one of the advantages of the Reset is providing time for
optimization of the system and associated technical processes.
Block and Cube Releases
Blocks 8 and 9 were deployed in February and August 2023,
respectively, and provided enhanced functionality to the field. A total
of 47 system performance improvements and enhancements were pushed into
production as part of the Block 9 release, which resulted in a 24
percent decrease in user interruptions and a 24 percent reduction in
application freezes for all users.
Just last week, we deployed our November 2023 cube release, which
fixed some bugs in the system and enhanced existing interfaces and
capabilities. In February 2024, we plan to release Block 10, with more
than 20 different enhancements and improvements being deployed across
the enterprise. Each one of these releases has a planned improvement to
the system performance and resiliency.
Accountability
Improving system reliability, resiliency, and availability remains
a critical focus for our program. VA continues to monitor and enforce
contractual SLAs. As part of the contract renegotiation in May 2023, VA
increased the SLAs tied to concrete financial consequences related to
technical performance and user experience. The renegotiated performance
metrics include reliability, responsiveness, interoperability with
other health care systems, and interoperability with other
applications. There are now 22 SLAs and 6 service level obligations in
place to hold Oracle Health accountable. As a result, VA has seen
improvement to those metrics. VA expects to refine and potentially
expand the SLAs in the upcoming option year 2 negotiations.
Lessons Learned from DoD
VA works collaboratively with DoD and the Federal Electronic Health
Record Modernization Office to improve operations based on lessons
learned and to collaboratively address issues with interfaced non-
Federal EHR systems and networks that can impact system performance.
Based on our shared learning, we have applied improvements where
possible, such as improving certificate management, establishing Citrix
Pods for increased flexibility and system performance, and optimizing
virtual private network setup for laptop computers.
Conclusion
Veterans remain the center of everything we do. They deserve high-
quality health care that is safe, secure, timely, Veteran-centric,
equitable, evidence-based, and efficient. As improvements continue to
be made through the duration of this Reset, VA will continually
evaluate the readiness of sites and the Federal EHR system to ensure
success and patient safety.
With the activities and improvements that are now underway, VA
leaders are optimistic about the eventual success of the current
program Reset, the deployment at Lovell FHCC in March 2024, and the
future full implementation of the Federal EMR throughout VA. Having
said that, we will not do this until the system is ready to provide a
good quality experience to our users.
I again extend my gratitude to Congress for your commitment to
serving Veterans with excellence. With your continued oversight and
support, VA will realize the full promise of a modern integrated health
record to cultivate the health and well-being of Veterans. We are happy
to respond to any questions that you may have.
______
Prepared Statement of Bill Tinston
Good afternoon, Chairman Rosendale, Ranking Member Cherfilus-
McCormick and distinguished Members of the Subcommittee, I thank you
for the opportunity to testify today on federal electronic health
record (EHR) modernization and interoperability, and our partnering
efforts to get the deployment, implementation, and performance of this
critical health care capability right. I am accompanied by Mr. Lance
Scott, the Chief Technology Officer for the Federal Electronic Health
Record Modernization (FEHRM) program office.
On behalf of the FEHRM program office, I want to thank Congress,
and this Subcommittee, for your unwavering dedication to ensure our
nation's Veterans, Service Members, and beneficiaries receive the safe,
reliable, interoperable, and modern EHR they deserve. I also want to
thank you for the support we received to deliver this transformational,
patient-centered health care capability.
I understand the concerns regarding reports of outages, incidents,
and other technical problems associated with the deployment of the
Federal EHR (FEHR) that we will discuss today. The effort to deploy a
modern EHR has been, and still is, a challenging endeavor. But in no
way do these challenges mean that EHR modernization is an unattainable
goal. The FEHRM and its Department and other federal partners work
through these challenges every day.
The modern, interoperable FEHR is large in scale and complexity.
But this scale and complexity deliver capabilities that enhance patient
care and provider effectiveness. This FEHR implementation effort also
delivers on the promise of seamless health care transitions for Service
Members and Veterans, and establishes a single lifetime, longitudinal
record for its beneficiaries.
Today, I look forward to sharing how the FEHRM partners with
Department of Veterans Affairs (VA), Department of Defense (DOD), and
other federal agencies to address the challenges and make the single,
common FEHR a reality.
THE FEHRM and its Mission
The FEHRM serves a key role in the modernization effort we are
discussing today. Congress gave the FEHRM many responsibilities to
drive EHR modernization forward. Among other responsibilities, the
FEHRM is charged with pursuing the highest level of VA and DOD health
care interoperability, maintaining the common EHR configuration
baseline for the VA and DOD, continually evaluating the state of
configuration and any impacts on interoperability, promoting the
enhancement of the EHR system, and implementing a single lifetime,
longitudinal health record between the VA and DOD.
To meet this charge, the FEHRM performs a host of functions
advancing the FEHR. The FEHRM unites efforts and delivers common
capabilities that enable VA, DOD, and other federal agencies to
implement the FEHR. Common capabilities the FEHRM delivers include
performing oversight of the shared environment containing the FEHR and
supporting systems, governing configuration and content changes derived
through a joint-decisionmaking process, tracking and facilitating
software upgrades and solutions to optimize EHR performance, and
informing continuous improvement through the tracking of joint risks,
issues, opportunities, and lessons learned.
The Federal EHR
The FEHR is an ecosystem of orchestrated technologies. The overall
EHR modernization effort is not about a single product, network,
interface, or application, Rather, its about all of these products,
networks, interfaces, and applications working together within a
national enterprise to create the right circumstances to deliver the
right experience for clinicians and beneficiaries alike.
This modernized, enterprise EHR capability enhances health care
delivery, and delivers better outcomes. Among its many benefits, it
allows for standardized workflows, better coordination between the VA,
DOD, other federal partners, and private sector health care systems,
and the efficient dissemination of innovation, technology, and new
capabilities.
Within the VA, the FEHR is currently in use at five medical
centers, 22 community-based outpatient clinics, and 52 remote sites.
Following these initial deployments, the VA halted work on further
deployments of the FEHR, with the exception of the Captain James A.
Lovell Federal Health Care Center (FHCC), to focus on improvements at
the five sites currently using the FEHR. FEHR technical performance is
one of the areas the VA Reset is focused . Beyond the VA's current
deployment posture, the FEHR is in wide use across the federal health
care space.
The United States Coast Guard completed its FEHR deployment across
109 sites, and the National Oceanic and Atmospheric Administration
successfully deployed the FEHR across its seven sites.
DOD is the most mature in its deployment of this capability. The
DOD routinely implements lessons learned and refines its deployment
processes, building on established practices to improve each subsequent
deployment. With the exception of the FHCC, the DOD completed its
deployment of the FEHR throughout its clinical sites within the
continental United States.
The DOD is now completing its global deployment of the FEHR to
multiple overseas sites. As an example of the FEHR enterprise driving
outcomes, last month the DOD completed its Europe deployment in
multiple clinical facilities in nine countries, across four time zones,
in twelve days. The deployment to the DOD's Pacific sites is underway,
and our early results indicate similar outcomes.
Improving the Federal EHR
I share the frustrations of many of today's fellow witnesses, and
the distinguished members of this Subcommittee, over issues that
emerged in the VA's deployment of the Federal EHR. However, I see the
rigor VA is demonstrating in this Reset, and the collaboration that
occurs everyday across the breadth and depth of our modernization
effort. I am confident we will get this right.
The FEHR, and the implementation effort that drives its success,
continuously evolve. Since the initial deployment of the FEHR, the
FEHRM and the Departments have worked with end users and stakeholders
to identify issues and improve the system's reliability, functionality,
usability, and capabilities. Collectively, the FEHRM, VA, DOD, and our
other federal partners share problems, learn from each other, and
develop solutions together. There are tremendous advantages in this,
and it results in a system that continuously improves.
System performance is not a discussion about a single product.
Rather, through joint deployments and increased users, we learned much
about the criticality of maintaining a common EHR baseline. The
performance of this single enterprise system is driven by a multitude
of different factors and interactions within a complex ecosystem of
interfaces and interfacing systems. To optimize performance, we must
employ the right configurations while minimizing deviations, such as
local end user device configurations, from the enterprise configuration
baseline.
Although the FEHR enterprise is not yet at the performance
threshold we demand, improvements occur every single day. Many of these
improvements are realized through the FEHRM's understanding that
performance improves dramatically by looking at the entire FEHR
ecosystem from an enterprise perspective. This holistic approach
delivered significant outcomes to an ever evolving system. For example,
through the success of the Oracle Health Corrective Action-Preventive
Action (CAPA) process, the mean-time-to-restore (MTTR) improved by 50
percent over the past 18 months. Currently, the MTTR is now under 4
hours for more than 95 percent of events. Over this same 18-month
period healthy minutes were sustained above 99.5 percent.
With its enterprise-wide approach to driving outcomes, the FEHRM
improved the stability of the DOD Defense Enrollment Eligibility
Reporting System (DEERS) interface with the FEHR enterprise. In the
early years of the FEHR deployment, DEERS led the cause of FEHR system
degradation and downtime. The FEHRM engaged, along with the DOD and VA
and coordinated a series of engagement sessions with the Defense
Manpower Data Center (DMDC) to highlight and improve reliability. Over
a period of months, DMDC as well as the FEHR made changes to DMDC
infrastructure as well as the way DEERS and the FEHR interacted. These
changes had significant impacts, and over the past 23 weeks, DEERS had
a single outage that was quickly resolved in 53 minutes.
Beyond the subject of this hearing, the FEHRM continues to
collaborate in the development of significant FEHR advances. In terms
of data exchange and interoperability, in April 2020, the FEHRM
deployed the Joint Health Information Exchange (JHIE). This grew to be
the largest Health Information Exchange in the world, exchanging
bidirectional health care data with over 95 percent of health care
organizations. This created the most complete patient health care
record in history, for all members of the FEHR.
Another example of a significant release is the upcoming release of
the ``Seamless Exchange'' capability to the FEHR. This exciting
capability is currently undergoing a pilot at the VAMC at Walla Walla,
Washington. Seamless Exchange will allow the auto ingestion of external
community partner health care records directly into the FEHR, provide a
data deduplication capability, and for the first time, establish data
provenance for FEHR supported clinicians.
And, most notably, in response to the COVID pandemic, the FEHRM
established a bidirectional exchange between state immunization
registries and the FEHR. This new capability provided states and FEHR
partners an enterprise means to create a more complete patient record
by exchanging State immunization data.
Conclusion
In closing, as a son and brother of Veterans, and leader of an
organization largely comprised of Service Members and Veterans united
in modernizing the FEHR, I am focused on delivering patient-centered
care, and providing the greatest capabilities available to support the
most informed clinical decision making. The success of deploying this
modern FEHR is fulfilling a solemn promise to our Service Members,
Veterans and their families.
The single, common FEHR enhances health care delivery, and delivers
better outcomes. It is my observation that the more VA, DOD, and our
federal partners collaborateand team as an enterprise, the more we
raise the performance of the FEHR. The FEHRM, with its VA, DOD, and
other federal partners, are committed to deploying and evolving this
transformational health care capability together.
The FEHRM is dedicated to providing health care providers with IT
they do not need to think about by seamlessly providing the right data
about the right patient at the right time. Focusing on continuous
capability delivery not only improves the delivery of health care by
our partnered clinicians, it improves the health care experience for
our valued beneficiaries. I look forward to our continued partnership,
transparent communications and commitment to provide our nation's
Veterans the care they deserve and informing you of our progress as we
continue this vital mission.
I thank you for your commitment to getting EHR modernization right,
and for the opportunity to speak with you today. I look forward to
answering your questions.
Statement for the Record
----------
Prepared Statement of Oracle Corporation
Introduction:
Chairman Rosendale, Ranking Member Cherfilus-McCormick and members
of the Subcommittee, thank you for the opportunity to provide a
Statement for the Record for today's hearing. I regret having an
unavoidable scheduling conflict that prevents me from being with you
in-person.
In this Statement for the Record I will provide an update on
Oracle's work on the Department of Veterans Affairs' (VA) Electronic
Health Record Modernization (EHRM) program, specifically related to
system performance as measured by Outage Free Time (OFT), Incident Free
Time (IFT) and User Interruptions.
Outage Free Time:
At the time of Oracle's acquisition of Cerner in June 2022, one of
the top issues impacting the federal EHR system was outages. We made
stabilizing the system to prevent outages our top priority, and our
efforts have paid off.
Our contractual obligation since June 2023 is for Oracle-owned OFT
to be 99.95 percent or higher per month. (This more stringent
obligation than the previous one of 99.9 percent was agreed to in the
new contract signed in May 2023.)
For 12 of the last 13 months, Oracle-owned OFT has been at 100
percent. This means that in each of those 12 months the EHR system
components operated or owned by Oracle, mainly the Cerner Millennium
EHR, have been performing with 100 percent uptime, without an outage.
The one month in which the OFT obligation was missed was April
2023, due to two systems related incidents that caused OFT to drop to
99.319 percent. Both of these incidents went through our comprehensive
Corrective Action / Preventative Action (CAPA) program for a full
technical review. As a result, Oracle took immediate action to harden
our layered technologies and have modified significant aspects of our
domain restart sequencing to resolve the core issue.
These, as well as all major incidents, are thoroughly and
transparently discussed with lessons learned along with short and long
term irreversible corrective actions to prevent reoccurrence. Every
week Oracle conducts detailed operational reviews with VA EHRM-IO and
DoD PMO leaders. There has been significant improvement in system
performance and OFT since the time of the acquisition, which reflects
the strong engineering expertise Oracle has brought to this project.
Oracle is confident the EHR system is capable of taking on new
users and continuing to perform well. The last weekend of October 2023,
the EHR was deployed to DoD's Asia Pacific region medical facilities.
This wave of deployments completed DoD's OCONUS medical facilities.
Other than the joint DoD-VA facility in Chicago, DoD is now fully
deployed across its domestic and global healthcare system. In the most
recent wave, DoD has added 8,000 new users to the federal EHR system,
with a total of 184,000 across DoD. These increases in user-load have
been accomplished while maintaining OFT as required under our contract.
Incident Free Time:
Instances of degradations in service for the EHR, but not a full
outage, are tracked in IFT. We know that these degradations are very
frustrating to users and have directed significant engineering
resources to make improvements in IFT. After reducing outages,
improving IFT has been our next highest priority, and it is trending in
the right direction.
Acknowledging that improving IFT needed to be a high priority focus
for both Oracle and VA, we agreed to add a new obligation in the
renegotiated contract to measure our performance and increase
accountability. We did this knowing that our work to increase IFT is in
progress and that there could be months, in the short run, where
meeting the obligation may be difficult, but with the belief that the
work we are doing will succeed in the long-run.
Thus, under the new contract, we were obligated to attain 93
percent or higher IFT for the months of June, July and August 2023, and
we are obligated to attain 95 percent or higher IFT each month starting
in September 2023 and moving forward.
In the months of May, June and July 2023 Oracle-responsible IFT for
VA was greater than 95 percent. In September 2023, Oracle-responsible
IFT for VA was 96.41 percent. However, in August 2023, IFT was 91.93
percent, and we accordingly issued a credit under the terms of the new
contract.
A significant contributor to the IFT result in August 2023 were
incidents related to the Block 9 upgrade. IFT would have been 95.44
percent if the incidents related to Block 9 were excluded. Looking back
over past years, approximately half of IFT incidents are a result of
change introduced into the system, as in block or cube updates. This
has been true for 2023 with approximately half of all Oracle-
responsible IFT incidents being related to the Block 8 and 9 upgrades
conducted in February and August, respectively.
Oracle has taken steps to assess the root cause of the issues
impacting IFT and to prevent recurrence in future block or cube
updates. We are driving improvement by running our CAPA program across
70 percent of all VA incidents, overhauling our procedures for release
management related to block, cube and other updates, and establishing
clear accountability to product, platform and service performance.
As a result, the impact to IFT in the August Block 9 upgrade was
2,372 minutes compared with 3,533 minutes in the February Block 8
upgrade, a reduction of 1,161 minutes (33 percent less). Of note, this
reduction for Block 9 was achieved with an upgrade package that was
nearly twice as large as Block 8.
Overall IFT of course is impacted not only by Oracle but also by
VA, DoD and other federal users and third parties. One positive step
that we have taken with VA and DoD to improve overall IFT is increased
joint testing prior to block or cube upgrades going live. Moving
forward, we also will be validating third party products that are
embedded in the EHR because that was a driver for degradations with
Block 9.
We worked closely with DoD in preparing for OCONUS deployments of
the EHR to reduce degradations and impacts to IFT. We found that
improving VPN and network hardware as well as ensuring users have up-
to-date devices made a difference in improving performance. We are
conducting similar work with VA to improve performance and reduce
impacts to IFT.
User Interruptions:
A user interruption is most frequently experienced when the EHR
freezes, crashes or hangs for a period of more than five seconds.
In the Block 9 upgrade conducted in August 2023, updates were made
to reduce user interruptions across the federal EHR, including:
Eighteen freeze and hang improvements that reduce freezes
by approximately 14,000 freezes per month (23 percent improvement);
Twelve error and response time improvements across
registration, pharmacy, labs, problem lists, orders and more for more
than 20,000 users.
The new contract that was agreed to earlier this year requires that
we meet three different obligations regarding user interruptions.
First, P50 user interruptions requires that 50 out of 100 users
must average five or fewer daily interruptions. Since January 2023, P50
interruptions have been nearly eliminated and met the contractual
obligation each month, with an average of 0.01 since May 2023, and with
Block 9 improvements it was 0.00 in September 2023. This means that 50
out of 100 users of the EHR system experienced no interruptions.
Second, P90 user interruptions requires that 90 out of 100 users
must average ten or fewer daily interruptions. Since January 2023, P90
interruptions have been reduced by 55 percent and met the contractual
obligation each month, with an average below 3.5 since May 2023, and
with Block 9 improvements it was 2.53 in September 2023.
Third, P99 user interruptions requires that 99 out of 100 users
must average fifty or fewer daily interruptions. Since January 2023,
P99 interruptions have been reduced by 31 percent and met the
contractual obligation each month, with an average at 26 or below since
May 2023, and with Block 9 improvements it was 19.89 in September 2023.
Reset/Future Work:
While significant progress toward system stability has been made
over the last year and a half, the work of continuous improvements for
the federal enclave, as with any system of its size and complexity, is
and will be ongoing.
As we look ahead and leverage the foundational work from the last
eighteen months, the focal points of the next phase of continuous
improvement effort will be across six key areas: architectural changes;
product improvements; release management; testing and testing
automation, change management, and the ongoing effort to move to Oracle
Cloud Infrastructure (OCI).
While such work is incremental in nature, the continuous progress
will be reflective in both the upcoming Block 10 upgrade and the
deployment of the system at Lovell Federal Health Care Center (FHCC) in
North Chicago in March 2024.
Block 10
Building off the success and leveraging lessons learned from the
Block 9 upgrades in August 2023, Block 10 - scheduled for February 2024
- includes over 30 tracking actions reflecting our key areas of focus.
These enhancements will continue to improve change controls, layer in
additional third party testing, expand testing environments to
troubleshoot issues before they are problems, and continue to reduce
manual steps in the process.
Lovell Federal Health Care Center
We continue to be highly focused on the success of the deployment
of the system at Lovell FHCC. This includes continued checks on the
capacity of the system across all components of the federal enclave,
weekly internal readiness reviews across teams, interface validation
and enhanced testing to account for the unique aspects of deploying at
a joint facility.
Closing:
Oracle is committed to working with VA and DoD to continue to
improve the performance of the EHR system and ensure that it is
prepared for additional scaling when VA resumes deployments. Thank you
for the opportunity to provide this update on system performance and
uptime, and please let us know if there are any follow-up questions.
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