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0:28:19

good morning the subcommittee will'll come to order before we proceed I would like to ask unanimous consent that representative MCM Morris Rogers and representative Schneider be permitted to participate in this hearing without objection so ordered I

0:28:35

want to welcome our Witnesses back to discuss va's continued struggles with the Oracle yeah with the Oracle CER U pharmacy software uh I want to thank ranking member surus mccormic for proposing that we return to this subject the situation

0:28:52

we found in our previous Hearing in May of last year was dangerous and unsustainable and it seems much the same today simply put the medical centers using the Oracle cner EHR have been turned upside down they've had to increase their

0:29:10

Pharmacy Staffing by at least 20% to navigate all the bugs and workarounds just to process roughly the same volume of prescriptions the cost millions of dollars but these are just five small mediumsized hospitals VA projects that large complex medical

0:29:30

centers will have to increase their Pharmacy Staffing by as much as 60% to navigate the software's problems if the EHR was implemented throughout the veterans Health Administration those Personnel costs would click quickly run into the

0:29:47

hundreds of millions of dollars that's money that could otherwise fund veterans Health Care fight homelessness or renovate aging hospitals and it's all to prop up a system that is clearly inferior to what the VA has today which is

0:30:07

Vista on top of the added cost it creates a dangerous situation nearly 20% of the patient safety reports from the five medical centers are related to the pharmacy oig has come forward with alarming new findings Mr case's office

0:30:26

discovered why spread errors in va's internal drug codes and the Health Data repository when veterans are treated at a facility using the Oracle EHR and then treated at a facility using Vista their medication information may be

0:30:44

incorrect that means drug to- drug interaction checks and Allergy checks may be based on inaccurate information according to the oig this problem may affect at least 250 ,000 veterans and it's been going on for years in one incident that AIG

0:31:06

documented a veteran in a VA Residential Treatment Facility was repeatedly denied his medication because it was showing inactive in the system it took five days for the veteran to convince the staff that he needed the

0:31:25

medication but by then he was in danger and had to be transferred to the emergency room and that's just one we've got 250,000 veterans that have been having these problems with the pharmacy an or Oracle software update last April corrected

0:31:46

some of the system errors but there is still no solution to many of the others however VA still hasn't notified hasn't notified any of the veterans who were impacted or are still being impacted apparently the VA has been hiding this

0:32:07

problem according to the oig the department took no action to go back and correct the veterans medication information in the Health Data repository after the April software update resolved the underlying error but instead the VA has been

0:32:26

quietly waiting for the prescriptions to expire and the inaccurate medication information to fall out of the back end of this database and VA seems to have been concealing the errors that are still ongoing this is a breach of trust and it's absolutely

0:32:51

unacceptable I question what other dangerous Pharmacy problems have not even been uncovered yet what we do know is that the results of the VA and Oracle strategy to improve the EHR have been one step forward and one step backwards we're not gaining on

0:33:09

this two and a half years ago the pharmacists in the field created a list of 79 problems with the pharmacy software va va prioritized seven seven of the 79 and Oracle rolled out fixes over a series of software updates the

0:33:30

most recent called block 10 happened a few days ago the most important fix aimed to eliminate the confusing error prone Double Entry process in the core EHR pharmacy software and medication manager retail which is used for the

0:33:47

male outpatient pharmacies and Community Care this originally went live in April of 2023 software update but the VA had to immediately roll it back because it caused yet another problem with dosage instructions getting lost the fix was supposed to happen

0:34:09

again a few days ago but it was postponed due to testing problems this particular item demonstrates the larger issue these are peace meal painfully slow improvements to software that seem to be fundamentally inferior to

0:34:28

Vista is anybody starting to hear this reoccurring theme and they involve VA paying Oracle most of the cost to overhaul the system that the VA already bought and this is the complaint that I have had from the very beginning this is a firm this is a

0:34:50

corporation that continues to get enriched by trying to develop a program at the taxpayers and the veterans expense they're being used as guinea pigs and everyone else on this committee recognizes it even worse many of the changes

0:35:08

introduce new complications unexpected errors and safety risks that the pharmacists have to manage with yet more workarounds the VA pharmacists are telling us very clearly that they're fed up and they cannot do this forever we are way past peace meal

0:35:28

Solutions and we are not going to tolerate the VA sweeping any more dangerous errors under the rug the definition of insanity is doing the same thing over and over again while expecting a different outcome a different result I have come to believe

0:35:45

that this continuing effort to transform the Oracle cner pharmacy software into something completely different is insanity okay with that I conclude my remarks representative Sheriff McCormack are you prepared to sure sure sure okay we're going to

0:36:14

jump in with the witnesses first we have where's my swearing okay we're going to introduce okay I will now introduce to the Witnesses on our first and only panel today first from the Department of Veterans Affairs we we have Dr Neil

0:36:27

Evans the acting executive director of the electronic health record modernization integration office we also have Dr Thomas emendorfer the executive director of Pharmacy benefits management services and Dr Robert Silverman the

0:36:43

chairman of the ehrm pharmacy Council next from the VA office of Inspector General we have Deputy Inspector General David case finally from Oracle we have Mr Mike Cecil I Executive Vice President for Global Industries gentlemen if you would please

0:37:02

stand I ask the witnesses to stand and raise your right hands do you Solly swear under penalty of perjury that the testimony you are about to provide is the truth the whole truth and nothing but the truth thank you and let the record

0:37:17

reflect that all Witnesses have answered in the affirmative Dr Evans you're now recognized for five minutes to deliver your opening statement on behalf of the VA chairman Rosendale ranking member Sher L McCormick and distinguished

0:37:30

members of the subcommittee thank you for this opportunity to testify in support of va's initiative to modernize its electronic health record system as has been mentioned I'm accompanied by Dr Thomas em andorfer our executive director for pharmacy benefits

0:37:44

management and Dr Rob Silverman our pharmacy Council co-chair for the electronic health record modernization effort before I speak to Pharmacy directly uh the focus area for this hearing I'd like to take a moment to reflect on on the EHR modernization

0:37:58

program more broadly specifically the program reset that we announced in April of 2023 as you know having listened to Veterans VA staff and Congress including this subcommittee VA stopped work on future deployments of the federal EHR

0:38:13

except for the upcoming deployment at the James a level Federal healthc Care Center VA did this to prioritize improvements in support of more than 10,000 users at five medical centers 22 clinics and 52 remote sites using the new system

0:38:27

and to optimize va's Enterprise Readiness to successfully resume deployments at a pace conducive to a complete and successful rollout as we've said before we're committed to getting this right even beyond the benefits of a

0:38:43

shared record with our federal Partners within VA itself transitioning to a single instance enterprise-wide electronic health record will provide significant value allowing easier visibility of a veteran's complete health record regardless of where they

0:38:57

receive care allowing standardization of clinical and business processes across the VA Enterprise reducing variation and increasing the consistency of care delivery and allowing for better sharing of clinical resources and expertise

0:39:11

across va's Regional and National networks the level Federal healthc Care Center in North Chicago Illinois a jointly run VA and DOD facility has been another priority for us during the current program reset this is the final

0:39:25

deployment of the federal EHR at a DOD site and will also be the first VA deployment at a larger and more complex VA Health Care Facility we're still on track to go live at fhcc in early March let's transition now to the focus

0:39:39

of this hearing the pharmacy software capabilities being implemented as part of the federal EHR improving Pharmacy functionality includes addressing the needs of three key stakeholders in both the inpatient and the outpatient settings VA

0:39:55

clinicians who are prescribing Pharmaceuticals and counseling veterans about how those medications fit in their overall care VA pharmacist and the pharmacy staff who fulfill those prescriptions manage Pharmacy inventory

0:40:07

backend Pharmacy processes while also providing valuable counsel to Veterans and of course the veterans themselves as they access their prescriptions refills and more the scale of VA Pharmacy operations is also worth noting on the outpatient

0:40:23

side alone VA pharmacist and staff manage upwards of 146 million prescriptions each year and va's male fulfillment Services reach more than 350,000 veterans every day unlike many other Health Care Systems VA Pharmacists

0:40:38

and Pharmacy staff are fully integrated into patient care teams both inpatient and outpatient the division that exists between the health system and Retail pharmacies in the private sector simply doesn't exist in VA in part because of the uniqueness of

0:40:54

va's Pharmacy care delivery model and in part based on lessons learned since our initial implementation of the Oracle health record at the man gr F VA Medical Center in Spokane we've been working to continuously improve the Oracle Health

0:41:06

software Solutions and VA Pharmacy operations as they leverage the new software over a year ago the etm pharmacy Council along with Oracle Health helped identify critical early items to be sequentially addressed through code upgrades which are

0:41:22

delivered through joint VA dood block releases improving have been delivered in each of the last three block upgrades blocks 8 n and 10 in February and August 2023 and finally as has been mentioned this past weekend so where are we we've

0:41:38

made incremental but steady progress the most significant improvements have been realized in system performance and in the clinician ordering experience there have also been several enhancements delivered to improve the pharmacy

0:41:51

fulfillment process but this is an area where further work remains to to enable increased efficiency for pharmacy staff as of today all but one of the initially identified priority enhancements have been delivered the final feature which

0:42:05

will automate the synchronization of prescription information between the Oracle provider and Pharmacy applications has been installed but is not yet enabled both Oracle and VA recognize that we're not yet done as I already mentioned an area of

0:42:19

considerable Focus will be increasing how efficiently Pharmacists and pharmacy techs can complete necessary tasks within the software suite among other improvements in conclusion VA pharmacists providers and Veterans alike

0:42:32

deserve a system including ongoing enhancements that performs as promised and continues to keep Pace with their unique demands my expectation is that this will come continue to be a shared Pro priority for both VA and Oracle and

0:42:45

that Oracle remain will remain committed to their promises including those made in front of the subcommittee to prioritize and accelerate the work on Pharmacy matters thank you again for the opportunity to testify today thank Dr

0:42:56

Evans and the written statement of Dr Evans will be entered into the hearing record Mr K you now recognize for 5 minutes to deliver your opening statement chairman Rosendale ranking member of sheris McCormack and subcommittee members thank you for the

0:43:10

opportunity to discuss the oig's oversight of the new ehrs Pharmacy functions since April 2020 we have published 16 reports on ehrm nine of them related to significant patient safety concerns such as issues with medication management far y

0:43:26

software and patient care coordination I will discuss three upcoming draft reports that are currently under review at VA consistent with our report process while we do not usually discuss reports before publication due to this hearing's timing

0:43:42

I will generally describe our findings first an oig team reviewed Pharmacy related patient safety issues facing every VHA provider VA has corrected one of a series of issues related to the transmission of inact accurate

0:43:56

medication information into a database called the HDR which stores clinical information about every patient's medications and allergies however we are concerned about unresolved and insufficiently communicated Pharmacy related patient safety

0:44:12

issues Legacy EHR sites may have inaccurate medication information for patients treated at both Legacy and new EHR sites We Believe hero and Oracle did not test for medication and Allergy d accuracy after that information was

0:44:28

transmitted to the HDR from new EHR sites thus patients seen at both new and Legacy EHR sites may be prescribed contraindicated medications and Legacy EHR providers may be making clinical decisions based on inaccurate data my

0:44:45

written statement discusses a veteran who had a delay in receiving critical medication due to this issue as of September 2023 there have been approximately 250,000 veterans friends who either received medication orders and or had medication allergies

0:45:00

documented in the new EHR they may be unaware of the potential risk for a medication or allergy related event if they visit a legacy EHR site while VA is taking efforts to reduce this potential we remain concerned that patients have

0:45:15

not been informed of their individual risk essentially being excluded as full participants in their care nor have we seen evidence that VA has sufficiently notified Legacy EHR providers about this issue and the mitigations to safely care

0:45:31

for these new EHR site patients while Legacy site leaders were told to have providers perform manual medication safety checks to replace the automated checks for new EHR patients these manual safety checks are complex and rely on

0:45:46

the vigilance of pharmacist and Frontline staff at Columbus we found a prescription backlog required a permanent 62% increase in clinical Pharmacy Pharmacy leaders had to create their own workarounds and education materials and

0:46:01

Pharmacy staff were burned out and had low morale these findings are troubling given the mitigations for pharmacy failures rely on staff vigilance although unrelated to Pharmacy I wanted to alert you to two other upcoming oig

0:46:16

reports on scheduling which also address issues requiring high levels of Staff vigilance and inadequate mitigations the first addresses problems with the display bed appointment queue that can cause staff to not handle

0:46:28

appointments needing to be rescheduled when a provider schedule changes schedulers report appointments do not always route to the queue and may disappear from it hero told us that February and April updates would address these

0:46:43

defects further the new EHR still cannot switch an appointment time between inperson VA video connect or teleah health without the scheduler cancelling the appointment and the provider ordering a new appointment creating a

0:46:56

burden on both the last report VHA is allowing mental health staff at new EHR sites to make two fewer attempts to contact no-show patients compared to Legacy sites this procedure creates a different standard of care a disparity

0:47:13

among veterans at new and Legacy sites VHA should address administrative barriers created by software deficiencies without compromising patient care and engagement standards in conclusion ehrm success is dependent on va's transparency careful

0:47:30

planning and the recognition and Remediation of plant safety issues additionally trust and VA is contingent on patients and providers being fully and quickly advised when issues are identified chairman Rosendale this concludes my statement I would be happy

0:47:45

to answer any questions you or other members may have thank you very much Mr Case the written statement of Mr Case will be entered into the hearing record Mr Celia you're now recognized for 5 minutes deliver your opening statement

0:47:57

chairman rosenell ranking member Sheriff lless McCormack and members of the subcommittee thank you for inviting me here today at the five live VA medical centers and their Associated facilities veterans are receiving their outpatient

0:48:08

prescriptions at the pharmacy window in an average of 25 minutes for January 2024 which is below va's 30-minute key performance metric on average more than 215,000 outpatient prescriptions are being filled each month the current live

0:48:23

sites do not have a backlog in filling prescription prescriptions since the first deployment in October 2020 4.3 million prescriptions have been filled through va's male Pharmacy this number of prescriptions is in line with

0:48:35

historic prescription fill volumes veterans are receiving their medication in a timely manner we know that VA has increased Pharmacy Staffing and we continue to partner with VA to find efficiency opportunities while maintaining the benefits of the new

0:48:49

capabilities some tasks like reviewing the warning information on an allergy or drug interaction and marking it as reviewed may take a little longer but also provide enhanced safety protocols we are also aware the VA is

0:49:02

considering additional enhancements that may further adapt the system to va's Unique Pharmacy needs we have already delivered seven enhancements six of which are live today that adapt the pharmacy system to a more bidirectional

0:49:14

system between providers and pharmacists as you're aware the VA Pharmacy processes are different from most of the commercial sector we remained confident that our work to update the entire EHR System including far phy to a modern

0:49:27

stateless web application along with moving the EHR system to the cloud will provide a basis for a much more user friendly interface and experience new stateless web technology is already in the hands of our commercial customers in

0:49:40

beta format with General availability planned for later this year finally we know that the work being done now with VA to standardize and simplify workflows and procedures will pay dividends in improving the overall Pharmacy and ehrm

0:49:54

experience we we acknowledge that for these early sites Pharmacy has been challenging shortly after the acquisition in June 22 when I came to the hill and met with Congressional stakeholders on ehrm improving Pharmacy

0:50:06

was one of the top complaints I heard we listened received the required changes on contract from VA and delivered them in an expedited fashion when the level Federal healthc Care Clinic in North Chicago goes live next month the

0:50:18

providers and pharmacists there will start using the system with the current enhancements they will also start with much improved training during a visit last week by VA and the Oracle team to level feedback from pharmacist was

0:50:31

positive about the training and Readiness for using the new Pharmacy system we are anxious to evaluate the deployment and get feedback from the pharmacist level it will provide valuable Insight along with the continued review of the feedback from

0:50:43

other live sites for other enhancements that may be required as we seek to continually improve the system Oracle looks forward to continuing to provide VA with a pharmacy module in the new EHR that enables veterans to receive their

0:50:56

medication when they need it and safely thank you thank you Mr cilia for your uh comments uh the written statement of Mr Celia will be entered into the hearing record I will now recognize representative Sheriff McCormack for

0:51:12

opening statements thank you Mr chairman and thank you to the witnesses for being here today to discuss what progress has been made to fix the issues with Oracle cera's Pharmacy application it has now been over 3 years since Cerna millennium

0:51:25

was deployed at man grand staff Virginia medical center in that time we have continually heard from VA providers the Inspector General and the government accountability office about issues with the system that have put veterans at

0:51:39

risk and made VA employees jobs unbearable the new EHR has required a herlean effort to in to ensure that veterans receive safe health care which has had a dramatically negative effect on employees satisfaction late April VA

0:51:56

finally listened to those concerns and to the concerns raised by the committee and undertook a reset of that program I applaud that reset during our Pharmacy hearing last May and I still applaud it however I'm extremely concerned about

0:52:10

the fact that VA and DOD plan to deploy the system at the Captain James a leville federal health care center next month before the objectives of the reset have been met in December committee staff traveled to Lille to meet with

0:52:24

leaders ship and Frontline staff it was clear then that the VA providers were not convinced that the software was ready in fact level's Pharmacy leadership indicated that they didn't feel like anything had changed while I

0:52:38

understand that the dod is motivated to finish its deployment that cannot come at the expense of our veterans or VA providers I hope the va's decision makers are being incredibly deliberative in deciding whether or not to go live

0:52:52

should be allowed to happen as scheduled in an effort to address some of these issues plaguing the system Oracle Cerner NVA deployed the much awaited block 10 upgrade this past weekend I understand that there were some major

0:53:05

pharmaceutical enhancements expected to be delivered with it but not all of them were working correctly and some of them deployed without even being turned on I hope to hear about VA and oracle's plan to fix the issues and their timely

0:53:21

their timeline for turning them on as for the rest of the upgrade it probably too early for too early to know for sure but I hope to hear how it went and how VA is going to measure the impact of those changes VA providers have been

0:53:35

struggling far too long under the weight of the under the weight of the mitigation efforts I'm still optimistic that there is a path to success for this project but not without major changes to the way the VA has been managing it that

0:53:49

is why I along with chairman boss co-sponsored co-sponsored ranking member to Conor's eh R program reset act last Congress and and and am still working with my colleagues across the aisle to ensure that we put adequate rail guards

0:54:04

around va's work I look forward to hearing from our Witnesses today and I yield back Mr chairman thank you very much representative Sheriff lless mccormic uh we're now going to proceed to questioning and I recognize myself

0:54:15

for five minutes Mr casee your office uncovered a multitude of Pharmacy problems will you please explain how the errors involving the Health Data reposit and the medication identifiers work and how they can cause veterans drug-to-drug

0:54:30

interaction and Drug allergy checks to be inaccurate stores clinical information for all VHA patients including a unique identifier referred to as a viid for any medication a veteran getting a prescription at a new EHR site after the

0:54:55

prescription is filled the system sends the prescription data including the V ID to the HDR if that veteran goes to a legacy or Vista site and receives a new prescription another program in Vista accesses the HDR to perform a safety

0:55:12

check and make sure the medications prescribed at the Legacy site are compatible with the prescriptions from the new EHR site it was discovered that when the Legacy system goes to access information from the HD R there are

0:55:26

times that the medication information in the HDR from the new EHR would not be accurate or could be duplicative or simply missing and so the result is when this check occurs when a veteran has gone to the new EHR and is now at the

0:55:43

old EHR getting prescription it could be based on inaccurate information so Mr casee what happens when a drug drug interaction check or drug allergy check is based on the wrong medication so when a medication check is based on wrong

0:55:59

information you could prescribe or provider could prescribe a medication that is contraindicated meaning there may be side effects there may be less efficacy to one or more medications so when we hear Mr Cecilia talking about all of the medications

0:56:16

that are going out and being delivered um if they're not the proper medications or there could be interaction problems between the medications that are being delivered to the veteran have we really accomplished anything right as I

0:56:33

understand the data referred to earlier he's talking about uh prescriptions at the new EHR sites and that information will be accurate when you compare new information or information from a new HR for prescription one to prescription two

0:56:49

the risk occurs when there's a prescription at a new HR and Veterans snow Birds people travel they get uh their Health Care at Old sites as well as new uh EHR sites so when they travel and go to an old site and a new prescription is done that's when the

0:57:06

risk occurs exactly so again is it more important to have a number of prescriptions being delivered or make sure that the number of prescriptions is accurate the most important thing in our mind is patient safety thank you Mr

0:57:21

casee how did you determine the two patient populations that may be impacted and how did you come up with that total of 250,000 unique veterans yes that number was uh provided to us by VHA uh and those populations of unique patients

0:57:36

that at new HR sites who had prescribed medication and or documented allergies so that 250 is the ones that are risk if they go to a legacy EHR and Mr casee those numbers are based on information the VA gave you in September 2023

0:57:52

correct that is correct okay do you have any idea how many veterans may be impacted today uh we do not know how that number has been modified we're not uh aware of what actions have been taken by VA since our report so VA is in the

0:58:09

best position to update that number okay so we still could have many more than the 250,000 Mr Cecilia according to the oig or built the interface to the Health Data repository that contained the coding err and Oracle corrected one of

0:58:25

the group of errors in April of 2023 but the other group of Errors has not been fixed and continues as we speak is any part of that inaccurate uh I I my understanding is that we have delivered 10 fixes 10 data files to HDR

0:58:40

to correct the database between May of 2023 and November of 2023 uh which is corrects the drug interaction and particular potential duplication checks within the VA so why do I hear about the the the system that was just introduced three days ago that

0:58:59

was actually pulled right back off again to help address this problem if a problem has already been addressed there was a final testing check that did not pass and uh as so in other words we're still working on the same problem that

0:59:12

you're trying to tell me that was that was resolved last year there was there was another issue that surfaced in the testing of one of the seven enhancements that that fix that was fixed again last night the testing begins today

0:59:25

in the interest of patient safety we decided of course not to roll out anything that did not pass all final safety checks sure Mr casee um please help me to understand this because Mr Cecilia seems to think that the the uh

0:59:38

fixes that they rote out last year resolve this problem and yet the one that he's trying to uh roll out here within the last three days is to address the same problem I'm I'm I'm confused could you clarify right the block 10

0:59:53

addresses a set of issues that they've identified among others in Pharmacy what we've identified in our report has been ongoing and to our understanding there is no fix that's the risk when a patient gets uh prescriptions at a new ahr and

1:00:10

goes to a legacy EHR site and the fact that there may be inaccurate information in the HDR from the new eh is still extent unless it's been fixed since September when we got our data thank you very much much I will now recognize

1:00:25

representative Sheriff list McCormack for five minutes questioning thank you Mr chairman Mr Cecilia during our last hearing on the pharmacy issues we discussed the corrupted data going into the Health Data repository and how it

1:00:38

was impacting va's ability to prevent dangerous drug interactions and allergies why wasn't this issue caught in the test in testing before the interface was turned on uh thank you very much for the question it is a good question uh the

1:00:52

testing around this process uh is very manual it's it's uh very rigorous and um you know when we become aware of these issues and things like this happened we did fix these these issues immediately and stop any deployment of anything until this was

1:01:09

fixed so why it actually um was not caught um I'm not exactly sure I'm happy to reply back in in writing as to what corrective actions have been taken but that combination of testing involves Oracle involves the VA it involves the

1:01:23

pharmacy councils and I'm not exactly sure on that particular issue um where the breakdown was but once it was discovered and once it was discovered we did fix it and we did offer fixes to the VA immediately so do you believe that

1:01:36

there's an issue with the fixing um the Tex testing process I don't believe that there's a core issue with the testing process I think the issue the issue is that there are a lot of manual checks meaning that human beings have to be

1:01:49

involved in testing typically uh you want to try to automate much of that testing particular for interace as you possibly can and I think we continue to work together with VA to make that process more efficient and I I think the

1:02:01

fact that U what we saw happen in these last couple days where we did not deploy something because it did not pass a test is a testament to a much better testing process you obviously do not want to deploy something and then find an issue

1:02:15

after it's deployed much rather in the interest of patient safety not deploy something that does not pass a particular safety check that's exactly what happened we got the feedback we redeployed that and again as I said that

1:02:26

has now been addressed last night testing will continue for the next two weeks so are you making any um accommodations or alterations to ensure that future issues are caught before they're deployed we we are and I think

1:02:39

that again um not to be repetitive but this issue is exactly a result of the enhanced testing processes that we put in place uh it's it's it's possible that prior to the enhanced uh testing processes that we put in place together with VA VH

1:02:55

that there could have been a Miss and somebody may have missed something that should not have been rolled out Mr casee what should be a end Oracle do to improve his testing before deploying the new ehrm functions yes I mean clearly it

1:03:07

has to be an endtoend testing from start to finish of whatever the uh process is uh it has to be as comprehensive as Oracle cner working with VA can make it and it's that comprehensive nature of the test that where attention has to be

1:03:25

made so that the test attests all features that are important to it during our last during our last hearing m in May Dr elzy in indicated that Oracle had already fixed the issue going forward but that Oracle was still working with

1:03:41

VA to do the retroactive work that needs to be done for things that were already transmitted but we heard last week that the pharmacy Council finally gave up on expecting Oracle to fix the corrupted data in November 7even months after

1:03:54

after the issue was identified because most of those prescriptions will be expiring by April of this year are you concerned about the message that this sends to VA providers that serious high-risk issues are not going to be resolved in a timely

1:04:09

manner we are always concerned about uh the fact that uh providers must be uh clearly informed of what's happening and the risks and what they should be doing to mitigate against those risks so uh yes we are concerned uh the fact that uh it was allowed to

1:04:26

stay in place and up until April 7th uh that uh data is still in there and Mr Cecilia we're we were told that part we were told that part why this data was not fixed is because it would be it would have been it would have been

1:04:41

costly do you think that the VA should be expected to pay to fix things that Oracle broke I I I'm not sure that we broke anything here this is a very complex process and it's a it's a by product of having multiple systems involved

1:04:56

multiple versions of Vista multiple ehrs and lots of interfaces in between uh we are of course responsible and do and have taken responsibility for fixing all defects in the system as designed as scoped and on contract at our at our

1:05:10

cost and have done so I don't believe that um extraordinary circumstances for system interfaces that we do not have uh direct control over are are necessarily um things that we're bilding the government for that we shouldn't be that

1:05:26

are that that are not part of the scope of the ex existing system so I'm very confident that we have maintained all of our warranties and and fix things that are respon that we are responsible for fix at no cost to the government so are

1:05:38

you saying that who should bear this cost I I don't have all the details on this particular issue since it goes back a very long time and we've been making lots of fixes to the system I'm happy to respond in writing uh with the details

1:05:50

on this one thank you Mr chairman i y back thank you representative sherff lless McCormack I now recognize representative self for five minutes questioning uh thank you Mr chairman Dr Evans a question for you um I think we try to take human error

1:06:06

out of everything I'm not sure it's been taken out in this case how many veterans have actually been harmed do you have any idea from these drug interactions and the reason I ask is because I've seen returning veterans come into the

1:06:23

civilian community taking 20 pills a day 25 pills a day that seems to me I don't even know you'd probably need a supercomputer to figure out the interactions for that but do you have any idea how many veterans have been harmed by this issue we're

1:06:40

discussing uh we have not found an instance of harm though we are Vigilant and looking and interested if we will look to find one if we can but we've not found an instance of harm specifically related relateded to the drug drug

1:06:55

interaction issue from this um HDR challenge okay um next question is you are going to roll out level when the federal health center when the scheduled uh go live is March 9th March the 9th that's a couple of weeks from now why in Heaven's name

1:07:16

are you going to roll out a more complex system which is not only Vista which is not only e EHR but it's also includes da uh DOD so is that not more complex and we're trying to fix the complexity just in the VA so as you alluded the the Medical

1:07:38

Center at the James a level Federal Healthcare Center is a unique Medical Center it is a fully joint EOD and VA facility um there um are deep interdependencies there between the dod Health Care system and the VA healthare

1:07:53

system mhm one of the advantages that we anticipate in going live at James a level is that we have a partner in DOD who has been able to successfully deploy the record across the rest of their Enterprise Health Care system and so um

1:08:10

I'd say a couple reasons that I feel confident about moving forward uh number one part of the goal of the reset one of the three primary goals of the reset was to put our focus on fhcc we haven't had just we've been working to improve the

1:08:25

system and do the Enterprise work that we need um to be able to successfully move forward with this program but we've also been able to put a significant amount of attention on fhcc and we will benefit from the dod's experience in

1:08:41

support of all of our users there is the is their system exactly the same one that Oracle is doing for you the dod system it is the same system yes there are some differences in workflows for example at the J level Federal

1:08:55

Healthcare Center 40 thou nearly 40,000 Naval recruits come through every year and some of the healthcare they' receive on what's referred to as the East Campus is a little bit different in preparing our Naval recruits but the software

1:09:10

system that will support uh clinicians whether those be VA or DOD clinicians is the same well then all of these patches that Oracle has been doing have been done in the dod system I mean because if they're doing this for you why is it not

1:09:27

if they've already done it for DOD why is it not the same because you've said the systems are basically the same why are we having this problem in VA the the fixes and improvements that are delivered so we heard referenced

1:09:41

earlier the block 10 upgrade right our block upgrades occur every six months they are major software uplifts so these are already into DOD they are a joint work in DOD why do they not work in VA well which specific ones I mean for

1:10:02

example in the block 10 all of the upgrades that we put through in Block 10 are to the benefit of both VA and DOD there are some that are specific to maybe a connected uh set of technologies that we own in VA that connects to the

1:10:16

electronic health record that DOD has a different set of Technologies so there's some difference but the core system is the same okay and for Mr Case uh I I want to get into the displaced appointment Q um why are they falling through the cracks the

1:10:35

the appointment system why right we do not have a root cause for the displaced appointment queue not capturing every displaced appointment which is simply a shorthand for a provider has to cancel a set of appointments and they have to be

1:10:52

uh re scheduled so we know that uh uh there's been workarounds put in place Pro uh schedulers are supposed to take actions now and the displaced appointment queue has been described to the providers and us as now a safety net

1:11:09

well it's not a very effective safety net if not all uh canceled appointments are going there or they disappear once there and so we understand that VA has uh fixes that they're going to put into place to address the displaced

1:11:25

appointment Cube but as it exists right now it's still there and is not an effective safety net so the software can't handle it and the human error is introduced right because of the software not uh being comprehensively accurate

1:11:42

workarounds always introduce the possibility of human error that's correct sir thank you chairman I yield back thank you very much representative self um Dr emor orer we just uh listened to Dr Evans say that nothing to see here

1:11:59

everything's going to be fine we've got all the fixes in seems to think that the folks at James level are going to be a okay we roll this thing out in March uh it's a much larger much more complex facility what is your what is your

1:12:12

feedback from from James a level and and and the folks there that are that are going to have to implement this system what what kind of feedback are you getting yeah so thank you Congressman uh for question so in VA Pharmacy as Dr

1:12:26

Evans testified to we really have a culture of safety and quality and continuous process Improvement and not only from our level sites but from our other Oracle health sites uh they've done an amazing job of providing the feedback identifying the manual

1:12:43

workarounds that are needed and what is needed uh to improve the efficiency of the system and so one of the major uh enhancements that we need is the bidirectional data synchronization the one that we've heard that has been

1:13:00

deployed but not enabled so the VA Pharmacy Community this has been their highest ranked uh feature that they want to see um be put in place in the Oracle health system and how long has that request been out there to try and get

1:13:13

this resolved um I'm going to ask Dr Silverman or Dr Evans for the exact date the good morning Congressman good morning the request for the synchronization uh which has been referred to now as enhancements 3B and 3C was initially targeted for Block 8

1:13:31

would have been February 23 was not ready at that time and as you've heard February of 2023 yes sir okay thank you that's all thank you very much Dr San according to Mr case's testimony uh this is on page four the VHA pharmacy Council

1:13:46

that you chair withdrew a request for Oracle to correct the medication data in the Health Data Repository that predated the April 2023 software update the errors go all the way back to October 2020 when Spokan went live with

1:14:04

cner this decision was based on the expectation that all of the prescriptions would expire by April of 2024 and the inaccurate data would eventually fall out of the veterans records which is what I referred to in my opening statement Dr Silverman were

1:14:19

you a party to this decision and did you make this decision I was part of the council's recommendation for that decision yes and the um options for correcting the existing data included when we began evaluating it in April of

1:14:37

2023 a process to resend data from the Millennium health record to the HDR or for HDR to correct the data neither of those processes existed or exist and so if you take estimates that it would have been about a six-month software delivery

1:14:55

by the time we reached November if that software project had been started it would have been cost expense and attention taken away from other efforts such as the ones we're talking about with again Mr Mr Dr Silman what we're

1:15:09

talking about is is time and money okay and we the the taxpayers are continuously providing both of those and the veterans are are the ones that are at risk for all of them and this very time and money that the taxpayers are absorbing the burden of

1:15:30

Oracle continues to get the benefit of for producing a product that that is simply not delivering as promised we're close to it because of this decision your Council made there are still holes today in the medication records of

1:15:49

veterans all over the country that feed into automated safety check checks and unless every single one of those veterans Health Care Providers have received and understood the warning and exercise vigilance every day those

1:16:04

veterans are being put at risk Dr San do you regret this decision and how will you direct Oracle to immediately correct the remaining errors thank you for the followup on that the decision to withdraw a request for a software change was accompanied by

1:16:21

actions that have been taken and those actions include a weekly task being operated by va's HDR team to inactivate the older records that are in the HDR removing all of them from the order checks um leaving the portion described up through

1:16:40

April of 2024 to be addressed and these are the exact holes that I was just referencing um thank you very much I will now recognize representative Sheriff l mccor thank you Mr chairman in our this is questions for Dr endorf in

1:16:57

our last hearing on the pharmacy issue you indicated that it took three times as long to process a prescription fill in Cerna as it does in Vista have you seen any improvements in the in that time and does it still take three times

1:17:10

as long thank you congresswoman uh yes it still is taking approximately three times as long for our VA Oracle health sites to process prescriptions do you expect the upgrades in Block 10 are going to make a Major Impact for

1:17:23

improvement we're going to have to wait for more time to go by so we can evaluate uh the data synchronization piece is one that we'll be paying uh close attention to because that is a scenario where our pharmacists now need

1:17:39

to um do dual entry basically in the MMR and the provider application to keep the data in sync given most of your mitigations for known Pharmacy issues calls on more labor intensive manual workarounds which require great

1:17:55

vigilance by staff what are you doing to attract and retain Pharmacy staff yeah so you know our Pharmacy Workforce I just want to take this opportunity because we have a very highly trained professionally trained Workforce really

1:18:11

we're leading the industry and the profession we have just under 12,000 pharmacists in our system right around five uh 6,000 pharmacy technicians in our residency program we have around 660 Pharmacy residents every year that

1:18:29

go through our training and we're able to retain about 90% of them they go on to become VA Pharmacists and so we're really operating at the top of our license uh inside of va so I believe that helps us attract top quality pharmacists into our health care

1:18:47

System how are you coordinating with VHA to make sure you can add so many Farm phy staff at the next deployment sites yeah so um before this hearing just was it last week or the week before I was out at level and uh spent time um

1:19:04

actually sing through some of the training sessions uh to see how those worked as well and spending time with our Pharmacy staff and so really va's journey to a high reliability organization i' I saw very good communication between our Pharmacy

1:19:18

leadership and the facility leadership so this is a very big undertaking and there's a realization of everyone involved that level that additional Pharmacy staff will be needed how long do you expect to need large Pharmacy

1:19:34

Staffing so um I don't have a good answer to that question just to be honest and that I think is part of our reset process is uh through our reset process being able to listen to our end users obtain their feedback um for the

1:19:51

testing of the three b3c that's been referenced for example it's been really important that in our Pharmacy Council it's just we're also including field Representatives into that testing um so making some of those changes but time

1:20:05

will tell so my next question is for Mr Cecilia um does it make sense to you that modern solution takes three time longer to use in the predecessor even with additional or new safeguards no it certainly does not make sense and it is

1:20:18

not the aspirational goal of the program nor should it be uh as uh as the doctor said we look forward to go live at level and I think at that point we will level will be the first sight to go live with all of the new enhancements that we put

1:20:31

into the system since we acquired Cerner in the last 18 months and I think that will be a very good Baseline and the feedback that we should get and that feedback should come very quickly uh from Pharmacy in all aspects uh to get

1:20:42

to a much better process in your testimony indicated that productivity in Oracle cannot be compared to productivity in Vista because the new H EHR included addition safeguards that ensure patient safety and improve improved Health outcomes for veterans

1:20:58

given the topic of today's hearing does that ask assertation ring Hollow I'm sorry I I missed the last Point does that is that assertion ring Hollow uh no I I don't believe it does like I don't think that there are different processes

1:21:11

between the systems certainly we're not here to say that it should take three times as long that that is that is obviously not what we're what we're saying um I'm not a pharmacist I'm not a patient safety expert um what what

1:21:23

should the Baseline be what are what are the new Pro and how do those protocols impact sta Staffing that's what we continue to work together with VA and with the pharmacy councils to determine the best practice again I do believe

1:21:33

level is the best Baseline that we'll have given that uh this will not be incremental fixes to existing GoLive sites this will be a brand new GoLive where all the features will be recognized and consumed at once thank you I Y

1:21:47

back thank you uh this question is for all the VA Witnesses oig's testimony also explains how in June of 2023 the VHA got a clinical episode review team together and it recommended notifying all the potentially impacted veterans they've

1:22:06

recommended notifying all the impacted veterans this went all the way up to under secretary for health Dr elal on August the 7th the team sent a Communications plan throughout the whole VHA organization including the visions

1:22:22

that include the facilities using the Oracle cner EHR but no one at VA ever sent the notification to any of the veterans Dr Evans Dr em and dford Dr Silman how do you explain this how do you explain this and do you commit to

1:22:44

notifying the Veterans as soon as possible when you leave this hearing room today so that they are aware that they may be exposed to some kind of safety and health problem potentially because of interactions I'll start with the second part of your

1:23:08

question we agree wholeheartedly with both you and with the um IG that it is important that veterans are full participants in their healthc care they are the most important part of the healthcare team and so informing them um and making sure that

1:23:29

we are optimizing the care that is delivered in the exam room when our VA Healthcare Providers are sitting with veterans writing prescriptions the making sure that we are optimizing the awareness of those folks about how to deliver the best and

1:23:47

highest quality Safe Care is very important we agree and we are working on communication and will communicate with the affected veterans around frankly many of the of the actions that can enhance the care delivery um in the

1:24:08

context of this EHR trans transformation one of the recommendations Dr Evans this is not a really complex question yes okay it's really not all of this these words that you're filling the air with right now all I want to hear is that Mr K says that there's

1:24:30

250,000 veterans that very well may have problems with drug interactions very well I can't think of another business or industry that would be allowed to perpetuate such an issue without disclosing it to their customers

1:24:48

that there could be a problem I'm asking can I get the commitment Dr look I've worked with Dr elal very closely and he has been so so very responsive to everything that I have asked him to do when it comes to Patient Care he really

1:25:05

has and and so I need the three of you to tell me that we're going to make sure that we get this information out to these to these exposed veterans 250,000 and and Mr case we don't even know what the number is potentially right now

1:25:22

um Mr Roselle so I did use too many words I'll make it a little bit simpler yes thank you Dr emendorfer Dr Silverman can can we all work together to make sure that we get this this disclosure sent out to these exposed veterans yes yes Congress

1:25:43

Christmas according to the oig you notified the VA staff to be alert to the danger but you did not notify the veterans how can you possibly possibly justify this when you're telling me that you're focused on making sure that we have the

1:26:01

best care delivered to our veterans um so first I think with regard to I mean how can we justify can you repeat the question for me second how can you justify not notifying the veterans of this possible drug interaction

1:26:24

problems after after you notified the VA staff you have been you have been notified and and how is it that you have you can justify not notifying the veterans of this information yeah I would well so I think most important in

1:26:41

my mind the most important part is notifying the staff so when I'm in clinic at the dcva seeing patients I'm aware of and by the way there's a a clinical reminder in the electronic health record in cpr's Vista for me that

1:26:56

would warn me if a patient has received Care at one of our news sites and so the most important person to be aware is the prescribing provider because it's the prescribing provider who's going to have to take the action to make sure that

1:27:11

they're verifying the medication list and that they are then making sure that there are no drug drug interactions for that particular patient and so um I agree as I just said that notifying the patients is important and is something

1:27:26

we will do um it's also very important that the providers are aware of the need for the extra vigilance in this circumstance representative Sheriff l mccor i yield back you're welcome for your next five minutes question thank you so much Mr chairman Dr

1:27:44

Evans of the 79 business requirements originally identified how many did VA adjudicate as warranting change requests the of the SE of the 79 um so we started with as I mentioned in in my opening statement we started with

1:28:07

the highest priority early changes that were necessary there are further change requests that are in process um for delivery and we will be working through all 79 items and frankly new items that we discover uh that are needed for

1:28:23

improvement so do you have a specific number of how many have been completed and how many are still awaiting action I would have to take that for the record unless Dr Silverman would you know how many business requirements are solutions in

1:28:35

this weekend's black 10 upgrade in this weekend's block 10 upgrade there were three major um improvements um there were also some minor um fixes um as part of the platform upgrades but three major improvements how are you measuring

1:28:54

improvements driven by block 10 and what are you specific what what's the specific criteria is employee satisfaction a part of that criteria um for Block 10 yes absolutely employee satisfaction is part of that criteria um I think we've spoken at

1:29:12

prior hearings about the class survey which is a user satisfaction or user confidence survey that we were doing once yearly we've committed to to um surveying our users of the federal EHR more frequently and the next survey is

1:29:29

being timed specifically to make sure that we're delivering that survey after block 10 so we can assess um in a robust way the um the satisfaction of our end users with the blockchain improvements and what is your timeline for these

1:29:45

measures for the user satisfaction survey I I can certainly get you the official uh timeline I think we were going to wait um at least a month after block 10 to make sure that folks had had The Full Experience um with block 10 before they

1:30:01

were asked to uh comment on their satisfaction with it Mr K the oig has been watching this program closely from the beginning have your people observed any improvements in the program management what are their biggest issues

1:30:13

that the VA needs to address to improve its management of this program yes uh we have seen an improvement in the sense that uh the senior leadership uh some of which is right here uh we find to be uh receptive to issues that arise either from us or

1:30:32

other areas and committed to resolving them and uh we need and we think that going forward uh there needs to be enhanced project management to get uh VA through the reset and out of the reset including accurate measurements as to

1:30:50

whether the reset is successful and achieved its goals and then once that's done the real work of project management occurs in large scale to try to assess how to go forward once you're out of the reset repeatedly oig and others have

1:31:06

found that the scheduling and Pharmacy staff in particular have found themselves overwhelmed when using the system in part this appears to be due to insufficient or inadequate training focused on day-to-day usage of the

1:31:18

system VA has modified training plans previously but it's clear that these efforts need to be stepped up how did you train staff differently at LEL and how are you measuring training success that question is for me uh I'm

1:31:35

not implementing the training program at level uh we do need uh VA and I understand they will be measuring the success of that program that was for Dr okay I thought so um so yes we've um so first of all at level we have inod uced several new

1:31:54

um um we've we've changed training um you know as you mentioned right it's important through training to learn how the software works but what we've heard consistently from our end users is that understanding how the software works is

1:32:11

not sufficient it's really to deeply understand how the software will work in their daytoday work and so understanding um how can I configure this software for optimal use saving favorites to make things more efficient for me when I'm

1:32:30

seeing a patient in my type of clinical medicine what um are the best practices um and in support of that we've added um some new um I'll call them adoption activities at fhcc um I think sometimes when we think about training uh that's a

1:32:49

often times an online training class or sitting with an instructor in a classroom most of us as Learners we learn yes we learn in a classroom yes we learn online but we really learn by doing and trying and one of the new events that um we've gotten great

1:33:06

feedback from at the fhcc uh site is what we call our learning Labs where we allow users to really practice their full work in our sandbox environment um we also are um going to be able to bring even more what we call Pay It Forward

1:33:23

peer support at the time of goli to improve um our ability to sort of stand at the side of each of our end users and helping them adopt the new solution I you back thank you thank you very much representative um Pay It

1:33:39

Forward Pay It Forward is that what you just said we've been paying this forward for 5 years now to the tune of 9 billion do 9 billion and quite frankly Dr Evans I find it disingenuous to blame this on training when the users okay you're

1:34:04

saying it's they have to they have to be more comfortable with the software it is disingenuous to try and blame this on training and the users when they cannot even rely upon the data and the information that they are receiving from this software program

1:34:22

I will representative MCM Morris Rogers are you ready or do you want me to give you a dive in thank you so much for joining us I now Rec recognize representative MCM Morris Rogers for five minutes questioning thank you thank

1:34:34

you chairman Rosendale I I really appreciate you hosting this important hearing today and giving me the opportunity to address this committee the Oracle cner electronic Health Care system has been a disaster for the veterans it was designed to serve we're

1:34:52

familiar with the devastating problems that EHR has created for veterans especially in Eastern Washington where it was first launched problems were clear from the beginning prescription orders and referrals disappearing into

1:35:04

unknown queries long outages making the system useless dropped appointments and other errors directly harming nearly 150 mil uh 150 veterans things have gotten so bad that some veterans have been told to work around the system all together to call

1:35:22

their local pharmacy rather than use the EHR to do something as basic as filling a prescription it's hard to Fathom that this system was so broken that our VA pharmacies cannot serve their sole purpose but that's exactly what happened

1:35:38

and our veterans are paying the price accumulating hundreds and sometimes thousands of dollars in debt after being forced to pay out a pocket for treatment at manang grand staff Pharmacy employees continue to work under extreme pressure

1:35:53

relying on memory to recognize Dangerous Drug combinations and other problems the system is failing to catch burnout and low morale have become The New Normal adding pharmacists to the list of providers and support staff that simply

1:36:07

can't take it anymore their leaving is making bad staff shortages worse creating longer wait times and making it more difficult for veterans to get the care that they need it's unsustainable and the EHR is to blame let me be clear

1:36:24

the time for an action is over we owe it to our nation's Heroes to get this right and I believe that starts with pulling the plug on this deeply broken system and going back to one that works that's the only way to restore broken trust and

1:36:40

help our veterans who have nowhere else to turn our Witnesses here today will play a vital role in achieving that goal and I'd like to ask a few question Dr el el Elm dorer you represent the pharmacist and they've reached out

1:36:56

they've really reached a Breaking Point in Spokane and other medical centers that are using the Oracle cner EHR so I'd like to ask what are they telling you yeah so this yeah this last uh September we had a pharmacy leadership

1:37:11

meeting and during this reset period congresswoman one of the things we're trying to do is just ensure that we're hearing the voice of our end users and of our pharmacists so our chief of pharmacies from there and and sunny who's our chief in

1:37:26

Spokane um it's really I it's because of his leadership that he has that it requires more staff it takes three times as long to process prescriptions um in the Oracle health system and it's really their dedication to the mission of

1:37:46

caring for the veterans to ensure that we're still able to get the prescriptions to the veterans that they need um and it does require more staff uh there's manual work workarounds that the staff do have to use like you referenced

1:37:59

we are aware of those and so during this reset period it's important that uh we get as many of those issues addressed for our Pharmacy staff thank you for that I I guess I would from from your perspective what needs to happen with this the pharmacy

1:38:17

software in order to avoid a a Breaking Point yeah so so um earlier we we're were talking and VA Pharmacy has this culture of quality and safety and continuous process Improvement and those will continue to be our traits in VA

1:38:32

Pharmacy so by first of all that's it's our health care providers delivering the care that provides that high quality and the electronic health record regardless of what it is needs to support that delivery of care and on that Journey one

1:38:49

of the things that we do also need to to do is get back closer to a baseline productivity okay Mr Scalia the men and women who work in our VA pharmacies are at the end of the rope and I'd like to read to you what one of the pharmacists

1:39:03

in my district had to say about the Oracle cner system quote I cannot do this anymore the stress of this system added workload to make it function I cannot care for my patients and have stopped being able to care for my own

1:39:17

well-being what am I supposed to say to someone who's been destroyed by the system well I certainly acknowledge that there have been issues in the pharmacy system and in the system in general and since we took ownership of this contract

1:39:30

I do believe that we have made improvements and I'll speak in two two two phases there the first is the system as you mentioned when we took it over was unstable was unacceptable there were five slas we signed up for 23 in the new

1:39:45

contract and we've largely met them and paid Financial penalties when we did not meet them and we'll continue to do so in the future Pharmacy has been and in the federal Enclave the one thing that's different between the va8 every all the

1:39:59

other tenants is Pharmacy it is a unique process and it has been the most difficult and the most challenging to uh get it right I do believe with what we're about to roll out at the Captain James a level federal health center in

1:40:11

North Chicago we will see the benefits of all of the focus that we had to improving Pharmacy I still don't believe and I'm not here to say that that equals success and that equals a baseline or a productivity goal that we want to say uh

1:40:26

that's all we can do and we'll move on I do believe though that um the move towards standards the move towards better testing and and better um you know better reliability will y you will yield better results for pharmacists and

1:40:40

I think the evidence of that is in a function for pharmacy the 3B 3C that we didn't roll out this week not that we did even though it was scheduled to be rolled out we didn't roll out out because it did not pass all of the safety protocol test that is a

1:40:54

difference between what what may have happened in the past versus now now it has been fixed and it has been addressed and and now it is in testing but we caught it this we caught it and that is I think a big difference between the way

1:41:06

program used to work and is working now I do believe that there are better protocols and better functional testing in place to make sure that we don't make pharmacist lives more difficult okay I appreciate that however the veterans in

1:41:20

Eastern Washington and feel like they've been left behind in the midst of all of this this was this uh health record was first new record was rolled out in October of 2020 and I've yet to hear the plan for how we're going to make it work and make

1:41:34

sure that our veterans get the care that they need without a yield back thank you very much um forgive me if I don't celebrate because we uh should commend you for not rolling out yet another failed update representative schn I recognize you for

1:41:51

five minutes of questioning thank you and uh first I'm grateful for you allowing me to be a part of this hearing I represent the 10th district of Illinois uh level uh healthc Care Center is uh not just in my district it's

1:42:05

Central to my district it's critical uh to the veterans in the 10th district of Illinois as as well around the region um I'll start I'm not sure exactly who I'll start with you Dr AB I'm not sure the right one but level is we are the first

1:42:20

and so far the only joint DOD uh VA Hospital which makes the March 9th roll out uh a little bit uh um uh interesting because it's the first time we're trying to uh do it over this bridge can you talk about what steps have been taken to make sure that it's

1:42:38

going to be rolled out effectively uh without a a uh discontinuity or or breakdown um sure I'd be happy to first of all um I have had the privilege of traveling relatively frequently to um North Chicago Illinois and to the James

1:42:53

a level Federal healthc care center and I have to say that it is a it's a really special facility I agree and its mission is um is is really compelling on top of that the staff at the James a level federal health care center are committed

1:43:12

to delivering outstanding care to service members beneficiaries veterans it's the one VA Medical Center you go to with a pediatrics clinic it's a pretty interesting place special place um and because of that we have needed a

1:43:29

significant level of focus on fhc including some of the complexities that you are well aware of that are introduced by trying to run a joint DOD VA facility um there are a lot of eyes on James a level from the federal electronic health record modernization

1:43:48

office which is leading the deployment to to the two program offices in both DOD and VA who are really putting a tremendous amount of resources uh to uh Oracle health and the lios partnership for defense Health as well as the

1:44:04

defense Health Administration VHA but when it comes down to it we are all here there to support the staff on the ground at fhcc success at fhcc Is our commitment to those 3,200 staff who come to work every day to care for those who are served by that

1:44:21

facility and that's really been where we've anchored our attention thank you let me turn to Mr cilia I listening to the testimony here I'm getting I guess the technological equivalent of PTSD 40 years ago I worked in systems development uh it wasn't the

1:44:38

team I worked on but uh uh one of our office practices in New Jersey installed a new system to the DMV and when it went live uh there was a 4 second 4 second lay between every keystroke uh it worked well in testing it didn't work well in

1:44:55

implementation uh you've talked about some of the challenges in a of a system that you acquired and inherited and and trying to uh make those fixes there's fixes that are are dealing with uh efficiency and we've heard some of that

1:45:07

today the concerns about efficiency and just making the job better and there's concerns that uh relate to patient safety and one of the things that impressed me uh in Dr Evan's testimony is the idea that the pharmacists are

1:45:20

integrated part of the Care team and I think that's something that we owe all of our uh veterans is the best and and not just the the the most Professional Care but the safe care that delivers on their needs um what confidence as we go

1:45:34

to this live roll out in in level next month can you give us that we're going to uh support the the teams on the ground they're going to be able to continue to Del deliver the level of care uh they historically have if not

1:45:46

improved and that the bugs that have been uh uh harming the the uh care of the system in the past won't be there in the next round sure well I I think your your characterization uh is is correct there are two buckets there's system

1:45:59

reliability and availability and then usability being able to use the system and as you mentioned when when we acquired the system uh it was not reliable it was not at a functional level that I think um we we could we

1:46:11

could warrant that it was an acceptable experience for end users and uh We've largely addressed those system reliability issues those those issues that sort of keep the plane in the air I mean if you can't do that then the rest

1:46:23

of it really isn't going to function well and now we've turned as Dr Evans said our our full attention uh during the reset period to making level the best roll out and the best experience that it can be I do believe that level

1:46:35

will benefit from all of the learnings we've had in both of those buckets both the system reliability standpoint the networking standpoint things like Printing and all those things which are very important uh inside inside a system

1:46:46

as well as the functional enhancements there are lots of functional enhancements that have also been made Beyond Pharmacy over and above Pharmacy that U level will be the first site to absorb everything at once well they will

1:46:57

they will get the best of the new system at one time the others the other uh five life sites have have had to take these uh these functional enhancements peace meal because they were already live and they were already um um you know already

1:47:11

functioning on a system that admittedly when we took it over was not stable and was not acceptable so I think their experience has been very different than the experience that level as a result well thank you we'll be watching we're

1:47:22

counting on it sticking with your airplane analogy it's uh not just getting the flight Airborne it's getting its toward destination safely um but it helps to be on time and without bumps and bruises so with that I yield back

1:47:34

you thank you very much representative Schneider uh Dr Evans the big ticket item in last weekend software update was supposed to involve automated coordination of prescription information between power chart and MMR but you

1:47:49

postponed it because because it had too many errors in testing what were the testing errors what problems would they have caused when do these errors have to be corrected in order to avoid causing problems at level so what were the problems what

1:48:09

what issues would it have caused for for our veterans and and how can we make sure that we don't have this problem introduce introduce a virus level right um so I'll let me just describe quickly what the what the capability was to do when a when a

1:48:28

physician or a licensed independent provider writes a prescription that prescription is then sent to the pharmacist who's going to process that in a different application called Med manager retail and that pharmacist as part of the normal um practice of

1:48:46

Pharmacy is going to adjust that prescription if there's a need to adjust it maybe a certain strength of the tablet is not in stock at the pharmacy and so instead of issuing um a 20 milligram pill we have to issue two 10

1:48:59

milligram pills U maybe the provider spelled something wrong and the pharmacist is a better speller and can correct that um on behalf of the pharmacist but the pharmacist will adjust the prescription and that information then should be in a in a

1:49:14

normal ret in a commercial Healthcare System the pharmacist May fix that at at a a commercial Pharmacy and it doesn't synchronize back to the electronic health record that the provider is using but in the VA our expectation is that

1:49:26

it's that those changes the pharmacist made are now visible to the provider so that the provider knows exactly what the the patient was given and so that when the provider a year later renews that prescription again they're now renewing

1:49:42

the appropriate prescription which means the pharmacist doesn't have to redo the work of fixing the prescription that would have been renewed if it was the erroneous initial one so that's what the software is supposed to do and it worked

1:49:54

for all of the normal circumstances a single pill that was two pills correcting the spelling mistake but there were some places in testing where a non-traditional insulin regimen um or an inhaler where the strength of the

1:50:11

inhaler um was a unique strength of the inhaler some you know it was not most of the cases well over 95% of the cases I don't know the exact number but it was a high percentage we're just working fine there were these subcases where we

1:50:26

recognized we needed to address those issues um our expectation is that it will be delivered as Mr this small number of cases is this is 250,000 that we're talking about entirely separate issue okay entirely separate issue um

1:50:41

and so the the our expectation is the it the fix has been put into testing it is now being tested as of today and our expectation is that we will deliver prior to the fhcc go live uh Dr Evans this is closely related to the update

1:50:57

that Oracle launched and then you quickly turned off last April why has this particular issue been so difficult to resolve um I think um in part because of you know we're dealing with this is one Consolidated set of Technologies But ultimately two

1:51:22

different information systems that were asking to to coordinate with each other and there are some technical complexities there uh also um some some work to identify what that I mean the issue before was that we we we realized that there was one field

1:51:40

that wasn't synchronizing that needed to be better synchronized but I'll let Mr uh Dr Silverman can probably comment to that um more accurately thank you Dr Evans chairman Rosendale as you've asked during this hearing the initial plan on

1:51:53

enhancement 3B was scheduled for Block 8 February 2023 Oracle Health identified an issue and made the decision not to deploy there and moved it to that April cube in 2023 which was right before our previous hearing yeah so so what's why

1:52:08

is it why is this particular issue so so being so hard to address I don't know that I know the answer to that other than when the uh Oracle okay if you don't know that's that's fine Dr amford the five medical centers using

1:52:24

the Oracle C EHR have had to increase their Staffing by at least 20% we we've been discussing that um of manage all workarounds and I understand that your office estimates that a large complex Medical Center would have to increase

1:52:37

its Pharmacy Staffing by as much as 60% uh give me a rough estimate how many staff have been added so far and how much this cost annually if you could yeah so right now at our smaller sites the complexity 2 and three on average

1:52:53

it's been about a 20% increase in Staffing I don't have the exact FTE the staff numbers but that would equate to um as far as cost you know I don't have an exact number but it would add Millions to our staff to our salaries

1:53:09

okay thank you so much um defer to you back and now thank you Mr chairman I wanted to go back to our questioning on um Education and Training so my question is going back to Dr Evans where we left off how are veterans and caregivers being

1:53:24

educated on mitigating the issues the oig identified when in with inacurate medications and Allergy checks at Legacy sites um first I think it's important uh the in jlv which is the application where um most well it's the application where VA

1:53:49

provider ERS would go to look to see a Consolidated medication list that is medications that were prescribed at the facility where they're seeing patients as well as medications at any other VA facility as well as medications

1:54:01

prescribed by the dod including in the federal EHR which is in use at the five sites that we've mentioned in jlv the medication list is an accurate medication list um and um also uh so so so the first thing is that uh it's important um we we emphasize with

1:54:25

all patients in in any of our visits the importance of what we call medication reconciliation this is an important part of Health Care in general um is making sure that we have an accurate medication list um is the veteran taking any

1:54:41

medications that we don't even know about in the VA because they were prescribed by um a commercial provider and and and and fulfilled at a commercial Pharmacy and so it's through that process of medication reconciliation that then that

1:54:57

foundational medication list can serve as the guide for now as I'm going to prescribe or add a new medication to that list or change a medication that I understand uh whether there's any interactions there and so the the primary thing that we've been

1:55:11

emphasizing with patients is the importance of bringing your medications to your visit um make sure that we're spending that together we spend the time getting an accurate assessment of what you're taking including over-the-counter

1:55:23

medications herbal medications supplements Etc so that medication reconciliation that's part of normal Health Care practices throughout the industry but now with this increased um level of inaccuracy are you taking any

1:55:36

other steps further steps to make sure that they're aware caregivers and the veterans are aware of or we just are you still doing the regular medication yeah I think what I was trying to get at is medication to your point medication reconciliation is

1:55:50

fundamental to good Healthcare um and as Mr Rosendale asked um are we going to notify veterans and and communicate with veterans and precisely we responded to that in the affirmative are there any extra steps you're taking that's what I'm really

1:56:05

asking in light of these inaccuracies right so the the the the issue for the subset of individuals which is a increasingly SM shrinking number of individuals who might have this challenge where the automated drug drug interaction checking is potentially

1:56:24

inaccurate or could be inaccurate there are other ways for a provider to be able to check for drug drug interactions as an example in clinic whenever I'm concerned we have a national contract uh with a um with a with a web-based

1:56:40

solution that can help providers get access to trusted clinical information it has a very very good drug drug interaction Checker in it um I enter the medicine that the patient is receiving in that drug drug interaction Checker

1:56:53

and actually get frankly more valuable uh information from that um on the specific interactions when I'm making those decisions so providers are having to do that manual step actually frankly many providers would do that anyway

1:57:05

that's not a required manual step correct that's correct and that's not a system that's in place correct that's what it's not a system that's in place throughout the entire there is a national contract for that drug drug

1:57:15

database okay so my next question is how are you ensuring Legacy it providers and pharmacists know that these issues exist with respect to inaccurate duplicative or missing information VA providers and pharmacists um a notification was sent

1:57:32

um to um facilities um to um about the um the issue um in addition as I mentioned uh some facilities have implemented uh what's called a clinical reminder to provide um realtime clinical DEC decision support um to Providers when they're prescribing

1:57:52

medications Dr Evans Oracle uses use of cues has come up again and again has VA done a evaluation of all the cues to identify any other issues um so so this is I think re uh referring to the displaced appointment q that was

1:58:14

mentioned in the IG um testimony um with regard to that specific issue in December um the fix uh was entered into production to make sure that we can support the number of contact attempts that VHA policy dictates after certain

1:58:35

um no-show appointments particularly for Mental Health appointments um as for management of cues I think you know inherent in the delivery of Health Care and delivery of healthcare to large populations are making sure that we are

1:58:50

managing the list of individuals who are waiting for any given service um and so yes we have spent a considerable amount of time making sure that we understand um any cu um that needs to be managed in support of Veteran Healthcare thank you

1:59:06

so much for your testimony I yield back thank you so much representative Sheriff McCormack uh Dr mandorfer I want to go back to the the additional Staffing that's going to be required by the pharmacist to accommodate this system

1:59:19

uh right now the total spend on pharmacists my understanding is that it's $2.7 billion that's annually correct $2.7 billion annually if we have a 10% increase a 10% increase in in that spend that's 270 million if we have a 20% increase in

1:59:38

that spend that's that's $540 million that's nearly half a billion dollar Dr Amor for your office is developing a pharmacy Staffing model for future medical centers to use to figure out how many positions they will need to add

1:59:59

based on all of this um this is based on an assumption and I think it's an absolutely correct assumption that the Oracle c pharmacy software will continue posing these difficulties and the medical centers will need extra Staffing

2:00:13

for the foreseeable future how does Staffing how does that Staffing model work and who's going to pay for all the extra Pharmacy staff yeah I can speak to what we're doing with the Staffing model because we do need to develop a

2:00:27

resource when uh our Oracle health sites first went live there wasn't enough data points to develop a reliable model so maybe a month and a half ago or so we convened a work group that includes representatives from every level in the

2:00:43

Enterprise including um staff that are using the Oracle Health uh system to help us try to Define some of those parameters and right now because of the number of manual workarounds uh the the the processes vary because of the manual workarounds

2:01:01

and we're still working on and we still have a goal of trying to develop the model but we do need to see some standardization to develop that Staffing model so some of the areas that are kind of new inputs uh for our staffing model

2:01:19

that we need to consider is there's multiple cues now in Oracle health serner and I don't have the I think there's like five or so and each of those cues could range anywhere from an extra five to 20 or 40 hours of different staff time per week um it's a

2:01:36

process and outpatient um controlled substance for one step of that process like an additional minute could occur um and then with our controlled substance inv inventory system that's something we need to maintain uh for Drug Enforcement

2:01:55

Administration to have those counts one of the manual workarounds that our staff has is that they have to stop the production why those manual count or why those counts are done because of the way that the system decrements the inventory

2:02:10

so that causes a Slowdown so once some of these things start stabilizing um we'll um we definitely have a goal of developing that resource and analyzing it for the fut so so what we are talking about though just to make

2:02:22

sure I I understand completely is is not that it's a lack of training on the uh pharmacist behalf it's the fact that the the system itself requires additional steps which we call workarounds I hear you reference workarounds many times

2:02:39

it's additional steps in order to get to the same place which is consuming this additional time and requiring all the all the extra work yes we have a highly trained VA pharmac y Workforce so it's it's we know how to act and and and

2:02:55

perform in the profession of Pharmacy thank you so much Mr casee I want to go back to one detail in your testimony uh we did not recognize the enormity of this until your office breath the committee staff previously VHA staff

2:03:10

were required to make four attempts to contact Veterans for Mental Health appointments and this is very very very serious because we all hear about and want to reduce the number of Veteran suicides that are taking place the the

2:03:26

22 per day because the consequences of not getting this care can be so damaging but when the Oracle cner EHR was implemented that was reduced to attempts because of the burden of documenting these calls or letters in the system who made this decision and

2:03:46

how could an IT system drive a policy decision decision that can have life or death consequences I have here in my hand the the VA policy that says that it's uh let me see here directive 1232 one in parentheses and number four uh on page two says for mental

2:04:12

health appointment the minimal scheduling effort for scheduling rescheduling totals of four attempts and then it describes how those four attempts are to be made could you tell me how and who made the decision about reducing that to two attempts and by

2:04:26

what Authority did they do so yes we believe it's a combination of things first of all the decision was done by the uh office of integrated veteran care to do the reduction and you combine that with the uh directive that where the new

2:04:42

EHR uh is in place then that's the rules for the new HR uh predominate so to speak so the staff followed the rules in the one instance in our report and made two notifications uh but they did not have the extra step because uh two more

2:05:04

notifications were not made and so uh you know our view is that this is a problem uh and first of all the Lesser number of notifications but second you really setting up a system where there's two uh different uh approaches to uh the

2:05:22

same issue uh there's uh different Health Care uh efforts in whether it's in the new so did you so did you did you find any place where the rule and the policy had actually been changed or is this just a decision that was handed

2:05:39

down because I haven't found it yeah this was what happened uh once our report is published we'll describe the exact details how it was done but this is what happened this came up an incident in Columbus Ohio thank you

2:05:52

thank you so much I will now recognize the sheriff listen mccor thank you thank you Mr chairman this question is for anyone who would like to answer it how would you measure the success of level fhcc go live and are you confident that it will be

2:06:09

successful thank you uh thank you for the question it's obviously the the key focus of of what we're all working on here together uh I think we have um lots of benchmarks and lots of inefficiencies and things that have been measured in

2:06:22

all the other go lives most of which are not favorable um most of which U experience difficulties uh with staff engagement with training with with retention of the training uh not being uh not being repetitive and not being

2:06:37

available on demand as well as general overall system performance so if we compare level to the go lives at the other site we should see a marked improvement and uh satisfaction we should see a marked improvement in system system reliability and we should

2:06:52

also I think be in a position um as as the pharmacy Council has testified to figure out how much extra staff is required for the long term because what is unusual it's not it's not unusual that when you have a major go life or a

2:07:07

very complicated system that extra staff are required this happens in commercial commercial markets this happens all the time what is unusual is that you have to sustain that staff for a long period of time so believe that the metrics and

2:07:19

feedback that we will get very quickly after the go live at level will put us all in a much better um position to determine that that issue uh for the future as well I am confident that the go live will be successful to directly answer

2:07:33

your question as well thank you um I can answer that question as well I think um yes it's important to remember that there have been challenges with regard to health it um at the James a level Federal Healthcare Center they've been

2:07:54

running two different electronic health records including maintaining custom software to try to keep those two electronic health records talking to each other while trying to run a single joint facility with a fully integrated

2:08:10

staff and those challenges um have been long documented and uh I remember traveling to fhcc I think in 2019 and they were very very eager to move to having a single integrated electronic health record and so one measure of

2:08:29

success is that some of the challenges that they've had in running two electronic health records are improved in running a single integrated electronic health record there are still going to be issues um because there are

2:08:42

different workflows unique to the dod versus the VA Pharmacy benefits are different in VA versus DOD but having a single record will be important and the other area where I would measure as success is whether the 3,200 approximate users there feel

2:09:02

better supported than prior users have in this transition is are we are we committing to supporting those users as they as they navigate The Journey um to use the new software not just in a couple weeks after go live um but in the

2:09:18

months to follow and frankly years to follow thank you I wanted to go back to Mr Scalia um I have a qu I want to pick up from where you left off when we were talking about the success um so far with the go lives what do you feel have been

2:09:32

the biggest um causes of it not being successful and what could the VA do to support Oracle well in in the in the initial set of go lives um I I think there were system reliability issues that made it very difficult for end users to to feel

2:09:48

comfortable using the system on um that it wasn't going to have an outage or something like that and that's um you know that was not good but as Dr Evans said I I do think that the human element I think the the uh standing

2:10:00

shoulder-to-shoulder and making sure that we have that support for a much longer period of time than we had at the initial goiz the lesson learned is that we need to be there longer we need to be on site longer we need to be next to the

2:10:11

providers longer and we need to be rolling out um fixes for feedback far more quickly than we than we have and um I believe that those things are in place I believe that the we have absorbed the lessons and uh we've been listening very

2:10:26

closely to all the providers to all the councils and I do believe that um prior to previous go lives which were which were largely handled um frankly before most of us were involved with them that the collaboration between Oracle and the

2:10:40

VA and the VHA as I've testified before uh is the best that it's ever been I'm very optimistic in our collaboration I'm very optimistic in our our daily in somewhat daily meetings for for specific issues like Pharmacy happening right now

2:10:53

as well as uh our our continued sync with the deps SEC and and others to make this happen I I do believe that the team all in together is better than it's ever been and I do believe that we will see results of that uh in the level go live

2:11:08

thank you a back thank you very much representative sheris mccormic and I want to thank everyone for are participating today um I just want to close by saying saying that we're $9 billion and 5 years into this system and we still don't have a

2:11:25

functioning system we don't have a fully functioning system here's a nice list here's a list of contributions that Oracle Cerner has made to people that are serving in this body and I wish that you invested as much time effort and money into getting

2:11:53

that system straight as you have in trying to buy votes on Capitol Hill with that I ask unanimous consent that all members have five legislative days to revise and extend the remarks and include extraneous material with without objection this meeting is

2:12:17

adjourned for SC

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