Transcripts For CSPAN3 Hearing 20240703

I bring the subcommittee to order. A great deal has changed since our last hearing. They are finally acknowledging oracle Electronic Health record systems not fully functional and not suitable in any other facility. After nearly three years across the board despite the mounting consequences to better than safety, staff burnout and billions of dollars wasted, secretary mcdonagh have become realistic about the future of this illconceived project. Thats encouraging. What has been painful and very expensive to watch this disaster unfold its been frustrating to argue and plead with the va not to march off the cliff only to be ignored or stonewalled. Thankfully the department is now listening to what veterans and its own employees and this committee have been saying for so long. It is far past time to look under the hood and see if it can be fixed and whether progress is even being made. But be assured thats exactly what we are about to do. We are here today to take an indepth look at one particularly dysfunctional aspect of the pharmacy. Pharmacy is crucial to Veterans Health and wellbeing and unfortunately, its one of the most overridden and dangerous parts of the system. First and foremost, we need to listen to the va pharmacists who use it every day. To that end, the subcommittee sent questionnaires to each of the five Medical Centers using oracle. We received responses from walla walla, columbus and british burn. The situation they described as outrageous and dangerous. The pharmacists cannot trust the system so they have to work in a constant state of hypervigilance. The Spokane Medical Center has been liable for two and a half years and yet they continue to discover new problems every week. Across the sites patients are up over 300 since it went live and about a quarter of these incidents are directly related to pharmacies. The Medical Centers have added on an average of 20 more pharmacy employees to perform the same workload on top of relying support from remote pharmacists. Columbus even had a dedicated pharmacists to manage the help desk tickets fulltime and created a management position at the pharmacy just to deal with ve hr. Altogether the pharmacy operations at spokane and columbus have seen a more than 9 million deficit from increased staffing costs and lost copays and collections. On average, they struggle with the hr saved about 22 points off the Medical Center scores and the best places to work survey. The pharmacists are in distress and do not feel their concerns are being taken seriously. That is deeply unfortunate because they, not the va central office, have been doing the crucial work to document the systems flaws since the very beginning. It was the pharmacists who wrote the initial 57 page Patient Safety domain report in august of 2021. The pharmacists that these Medical Centers who identified the 79 business requirements change request and continued to track them. Some of the findings went into the improvement report that doctor evans Office Released in march but appears that much more was excluded. Oracle released pharmacy updates in february and late april and another one is slated for august. The pharmacists believe some of these updates have been successful, produced incremental improvements. As for the more significant updates, they seem to have created as many new complications as they even resolved. The va and oracle server are barely scratching the surface, tackling only a handful of the highpriority issues from a list that is approaching 100. With that i would yield five minutes to Ranking Member. Thank you so much mr. Chairman. Thank you to our witnesses for being here today to discuss the critical project at the department of Veterans Affairs. I want to start by saying i hope support the vas decision to to alert how they fix the issue five sites currently live on the system. Im a cosponsor along with chairman and Ranking Member on the dhr reset exact fortitude talking to my colleagues on do not arrive at any future sites until we fix the system. These sites have borne the brunt of be a struggle to properly manage this project in the very beginning we owe them our focus that being said number of concerns with the delay. Does not provide the committee of the timeline for when they expect the work to be completed at the live site. Very concerned that va has not established a baseline without a baseline every future will bring more changes to the system constant change request will continue to have impact on the cost and timeline of the project will force that at the after site to continually adjust the workflows. Ive already heard from the staff fulfill they are repeatedly bashed by rocks of the ways of change. The change fatigue associate with constant judgment was detrimental to staff morale while lasting effect on the ability to recruit and retain highquality staff and by extension access to healthcare. Must show up process to ensure any changes to the system are both necessary and the best interest of our veterans and the providers. Cannot be allowed to go the way every faculty is operating a different system. The va employees feel like theyre concerned about being addressed under bothered on the path toward communication frontline staff must improve if they expect them to adopt the change. Also there must be more emphasis on empowering employees in the decisionmaking process and having the issues fixed faster. Theres an entire workforce who are being underutilized in this project that could be empowered to manage local configuration changes would drastically improve the timeline. But also improve User Satisfaction. And they want to address recent reports of patient harm caused by new bhr. I spent much of my current healthcare and understand its not as simple as saying some role this incidence. I hope that both the va and center are looking at the system where there is a potential for patient harm instead of reactively displaces her harm has already occurred. On a more positive note im cautiously optimistic the new Leadership Team has made great progress in the short time they have been in place. The attitude and experience has brought to his role is refreshing. Im encouraged the va has chosen practicing physician from system to help turn the system around. Doctor evans you and your work are cut out for you. I look forward to that conversation im encouraged him from every and how to make a reality for all of her vas. Thank you so much leo back to you mr. Chair. Thank you very much Ranking Member. Will now introduce the witnesses first and only panel today. When the Veterans Affairs with doctor neil evans acting executive director electronic modernization integration office. Doctor Thomas Emmons are for the executive director of the Pharmacy Benefit Management services doctor Robert Silverman and chairman of the e hr Pharmacy Council. Next we have mr. Celia doctor james only Vice President for federal health. Finally we have missed carol harris the director of Information Technology cybersecurity i think Government Accountability office. I asked the witnesses to please stand and raise your right hand. You solemnly swear under penalty of perjury this testimony about to provide is a truth the whole truth and nothing but the truth . Thank you that the record reflect all the witnesses have answered in the affirmative. Doctor kevin turner recognized for five minutes simply beer your Opening Statement. Treatment rosendale, Ranking Member, distinguished members of the subcommittee be thank you for the opportunity to testify in support of the ace initiative to modernize its Electronic Health record system. Today is meant; my va colleagues Pharmacy Benefit Management doctor silverman cochair of the council the Pharmacy Council for Electronic Healthcare modernization. Before i speak about the impact of our Electronic Health record modernization efforts in the intersection with these Pharmacy Services elective or to first spend a few moments discussing a recent decision to halt deployment activities of the federal Electronic Health record va. As part of a Larger Program reset. Weve been listening to veterans in the va staff or use an Electronic Health record the Medical Centers va clinics and remote supporting locations associate with her Health Systems in spokane and washington in white oregon in columbus, ohio. Weve also been listening to congress including this subcommittee. The new Electronic Health record is not meeting our expectations. The va is electing to take the time to get things right. The program reset files an extended pause in deployments that began july of 2022 culminating in an effort to assess and address a more narrow set of issues deemed to be the most impactful selected to the lens of Patient Safety. Our network with oracle to address the issues identified on together with oracle during this reset will more comprehensively address both these issues and a broader set of changes necessary for program success. Additional points will not be scheduled to be as confident its highly functioning current sites. And is ready to deliver for clinicians and future sites. This readiness will be demonstrated by clear improvements in the clinician and veteran experience sustained in highperformance high reliability of the system itself and productivity excites dhr is in use and more. Reset. Concludes a plans to release new to point schedule. The only exception to the full staff deployment activities is that captain james a lover of Healthcare Center North Chicago service at this Service Deployment activities there will continue with the plan deployment 2024 per that will of course improvements made during the concurrent program reset. I like to now turn to the focus area of this hearing big deep dive into pharmacy and the new Electronic Health record. The top priority of a Pharmacy Program is to serve and honor the men and women who are americans veterans Pharmacy Programs and the pillars of safety, quality and value. In addition Customer Service is a hallmark of the pharmacy service. One example is that mail Pharmacy Program va runs fulfillment to over veterans every day. Leads the mail order pharmacy business externally jd power and associates National Pharmacy study and of the last 14 years. Managing over 146 million total prescriptions a year at va pharmacists and pharmacy staff are fully integrated into our care teams as firstclass members of the team. The division that exist between the health the system and retail pharmacies in the private sector does not exist in va. Pharmacy programs have achieved success by cultivating a culture of continuous improvement. Want to acknowledge and thank our pharmacy to identify improvement in the oracle pharmacy system and the Electronic Health record. Aspects of Oracle Center pharmacy application med manager retail. Interaction with core Electronic Health records specifically power chart. Series of Development Efforts are underway to improve the visualization of medications for both pharmacy and ordering provider to improve synchronization between a med manager retail and power chart to prove the efficiency prefer staff is a process prescriptions and refills. Some improvements softer updates over the past few months remainder plan between now and february 2024. The feedback my Pharmacy Community regionally deployed enhancements this improvements have in small incremental. These improvements are appreciated va pharmacy staff and providers accelerated delivery of upgrades to eliminate the burden of the more laborintensive human mitigation strategies in place the current pace of new request enhancements focus areas in months to come as a work to optimize and accelerate efforts were possible chairman rosendale, Ranking Member, mccormick and members of the committee thank you again for this opportunity to testify today your continued support of your nations veterans thank you at the written statement will be entered into the hearing record. You are not recognize for five minutes to two of your Opening Statement too. Treatment rosendale members of the subcommittee. Thank you for inviting us here today. Im joined by doctor james owsley for federal team we look forward to this discussion are pharmacy capabilities for new ea. But first with vas announcement on april 21 reset for the e hr program once and stating it oracles proud to continue to Work Together to modernize the system. We support base plan to improve operation like the current sites take the necessary time to institute governance, change management, standardization changes to ensure the success of future va deployments similar to what dot did. The ids modernization is nearly complete on time and on budget. We will continue to closely coordinate with va to provide enhancements and updates to e hr as we have acquisition of certain requesting. Hr system including its pharmacy capabilities. Overall the system performance significantly improved from where it was last summer. The five currently live size on average it 2. 8 have been billed through the mail system. Veteran comes into get a prescription which is below the Key Performance metrics set by the va. The ace pharmacy system does not operate the same as commercial healthcares is a doctor evans noted. Dhr enables provider to order a prescription receiving pharmacy utilizes its own software for dispensing the medication. Va and the dispensing party to its own pharmacy fundamental difference is the reason white outpatient application provider ordering application. After the acquisition close i came to the home of many members who are interested in this program. In every single meeting i heard about pharmacy and the need these enhancements. Members were unhappy had provide a timeline of up to three years to do the work, once the va family settled on its requirements. Is clearly unacceptable. Whats the requirements for the leverage of sin va by va at august we built and deployed the top three enhancements in four months. There are seven total enhancements the order it was prioritized. The remaining four enhancements fully delivered this year for deployment in 2023 and early 2024. It is a significant faster overall time line. We hope it shows you the oracles highly capable partner for va and pharmacy enhancements or other fixes epic tremendous resources into getting the work done well and quickly. We both read survey results matter recently pharmacy enhancements we are not completely surprised first three enhancements delivers prioritized by the va focus more on improving Provider Experience the next set of enhancements or focus more improving the pharmacist experience. We believe wants to live and implemented pharmacists to be in a position to provide a bit about google feedback. What other point about the pharmacist system i like to highlight is opioid advisor tool. This allows clinicians to simultaneously and department of defense opioid advisor tool is alerted providers to avoid prescribing opioids to high risk patients in 1800 times since the member 2020. Opioid advisor the other modern enhancements completed and in process we believe the pharmacy system will provide a high degree of safety for veterans as they receive their medications. However we will continue to review it with va especially given the reset. We are now in. While make sure enhancements which are forthcoming are delivered on or ahead of schedule we continue to prioritize our work on pharmacy we are confident veterans receive the medications they need when needed. Thank you. Thank you. Ms. Harris or recognize for five minutes to deliver the Opening Statement. And members of the subcommittee im pleased to produce by the pharmacy related function of the new system. As requested up briefly summarize the findings recently completed a review this Mission Critical system. Applicable to that term as a whole including the pharmacy related concerns discussed today. As you know va provides Healthcare Services to roughly 9 million veterans and their families legacy system. In june 2017 the department initiate the e hrm program to replace and is obligated at least 9. 4 million of this program to date. This is also vas fourth attempt at replacing the legacy system and the implementation thus far has been just as challenging as the last three attempts if not even more so. We support recent decision to pause future deployments in order to focus on making improvements at the five sites for the system is currently in use. Most recent works we detail va gaps to effectively manage organizational change as well as the extreme dissatisfaction among users and system issues. This afternoon i will highlight three key points that va should address during the reset. The first is more it needs to be done to adequate address fee is organizational change management challenges. A recent review detailed eight leading practices for change management. Va had partially implemented seven did not implement one the gaps occurred for number of reasons. Most notably the department lacked eight to the efforts would supplement change management activity. As such activities focus on system deployment not unusual challenges with transitioning to new workflows. The result post the need for more attention to this error. With 68 being average. New e hr system the gap in the change management activity. Not to my second points, users of the new phr system are generally dissatisfied this needs to be fully addressed before deployment resumes. There unhappy with the system 2021 and 2022 User Satisfaction survey showed this. For example about 6 agreed enabled quality care system made them as efficient as possible. Ive been auditing for over 20 years now across the federal government. These are the low scores i have seen in government hands down. Regard to the pharmacy module users tows processing prescriptions took much longer in the new system leading to increased backlog and decreased efficiency with lead to Patient Safety concerns because the pharmacy could not fill prescriptions in a timely fashion. The Pharmacy Department at one facility increase from 15 60 staff to manage increased workloads associate with the system. Multiple instances of double prescriptions and incorrect medication i think it sucks goals in place override the department with a basis for determining when satisfaction has improved and also help ensure the system is not prematurely deployed two additional sites that could risk Patient Safety va set this goal demonstrate improvement toward meeting them prior to future system deployments. Now to my final point va did not adequately identify e hr system issues. Va has not conducted an independent operational assessment of the new system as of january did not plan to do so with greater rigor, transparency and accountability. We recommended v8 make plans to have the independent assessment done in the summary the implementation of the new system across the va will require a level of program management, adaptability to change sustained system performance the department and contractor have yet to demonstrate. The continuance is not without risk with strong oversight from this committee in addition to improved management i concludes my statement that concludes my questions. Thank you good statement will be entered into the hearing record before i asked hims consent when youre able to get here. Hearing and no objection so ordered and now recognize myself for five minutes for questions. Doctor evans. Are you committed to making the software and e hr as a whole fully functional before restarting . Yes that is the purpose of our program reset at the highest level have a singleminded focus in the process and privilege necessary for us to have the confidence we can move forward with further deployments. Are you willing to rely upon the input from the director of the facilities that the system is fully functional in order to account for that recognition . Looks absolutely. On the in columbus last week we with the soviet leadership in columbus and look forward to meeting with all of the facilities. Pharmacy is one aspect of her problems but is very important because it directly affects veterans. What is necessary to make the system fully functional . Rex as was mentioned for three main stakeholders. Ordering provider ordering the prescription. Need to process that and interact with the ordering provider. And of course there is the yvette who is receiving the prescription. We talk about technologies effective pharmacy operation, we need to take into account all of the stakeholders. One of the areas you heard discussion about some of the opening remarks here was around supporting the efficiency pharmacist themselves. To get their work whether be communicating with provider prescriptions and refills. Efficiency and quality of processing prescriptions and engaging with veterans we are measuring the success of technology to meet our needs. Thank you very much great you testify to the Veterans Senate Veterans Affairs committee in march. We believe from a performance and scalability standpoint the system is ready for the resumption of deployments. Five weeks later secretary halts at all what is your definition of ready . I was referring to the technical readiness. The clinical decisions of course plunk the va. Clearly here than secretary had different definition of ready . Would we say . I dont believe any Clinical Care and are my responsibility. I dont make those decisions because the va has budgeted 1. 8 billion based on the old schedule you both that which is 10 facilities, that has been froze at the original five are not fully functional under the terms of the agreement. Ive heard a lot of pledges over the last six or seven months about standing by the product and being Large Institution that is prepared to take this on. The product is never put forward as advertised. So many problems a secretary for their implementation cannot blame that on staff. If you think 1 for fiscal 24 is fair compensation for an phr system that is not fully functional in the five facilities its located in and the elimination of the 10 that were scrubbed . The total amount of money contemplated is lots of Different Things software go Live Services i was of the going live are not going to be compensated for the services. You would say 1. 8 billion would be excessive for oracle to receive her compensation in fiscal 24 based upon the 10 facilities not defined or not functioning now . Us and for not going to resume go live sets thats not going to be. Do you think its fair to enter into a new contract and hold taxpayers responsible for failing system and sites are never added onto . Score fundamentally flawed. Would not be led walter reed, by the way live at the same time the same we can imperil to the sites. Renzi same exact the system picnics are not tied by the department of defense. In case you did not read the sign on the door this is the Veterans Administration this is the house Veterans Affairs committee. You think the taxpayer should pay 1. 8 billion which was scheduled for 24, for a bill for 10 facilities that are not even going to be utilized . For the five could not fully functional . I dont think they should. Thank you put out turn over too representative mccormick. Thank you so much mr. Generate my question is for doctor evans. Doctor evans, how pharmacy related safety events reported . Aunt investigated at the sites using oracle sonar . Any Patient Safety related concern is reported in the same way whether or not its ready to pharmacy for any other part of care delivery these are reported when a user is calling in and a ticket or entering a ticket. They are entered into something called the joints Patient Safety reporting system. Our National Center for Patient Safety as well as within va as well as Patient Safety experts within the Health Record modernist as well as Patient Safety experts the Veterans Health administration take every one of those reports seriously, evaluate what has been reported, investigate the issue and identify solutions to address any findings that are there. One of things very important to report concerns. We would rather have it over reporting of concerns so we can do proved to have Patient Safety at risk for the second thing i would say i think there is a mention of this in the comments earlier, prospective forward leaning of approach to Patient Safety is also an important part of this program. That is as we are configuring the record and improving the record we are evaluating where there might be at risk to Patient Safety in making those decisions on the front end to mitigate or lessen the risk. Specifically how does the d8 leadership receive the results of the investigation . This is part of our routine management we are trying but Patient Safety reports or Patient Safety concerns are the changes we need to make to the system if there is a concern there mightve been patient harm will do a root cause analysis. We have very irregular discussions and meetings with that group to identify what has been found so we can take action to improve anything thats necessary within the record. How many actual patient harm events at the Columbus Center were aware of . I would have to take that for the record to give an exact number. Do you know if any of them or how many were from pharmacy or medical related . I think we talk harm, patient harm healthcare can be complicated it is complicated we are orchestrating a team of individuals taking care of the veteran. Imaging studies, or is giving place, medications for this a lot happening in healthcare. And in general only look at patient harm, patient harm is not singly attributed to Electronic Health record. Electronic Health Record can have a role in patient harm but it is often one of many facets. So when we think about patient harm, it is hard to say to answer your question to say how many events show potential patient harm that is near misses or actual patient harms can be directly and solely attributed to the Electronic Health record. What im trying to get at is were trying to identify or we can really get in the number of va leadership or how many patients are harmed . And how can we improve it that is what we are looking for a due failure getting the real numbers i put together a pathway for improving . Yes. Seeing the real numbers on it weekly if not daily basis. Im able to review the numbers that are being evaluated. We have a process by which we take the findings and what we learn and hit safety. Thank you so much doctor evans i yield back. Thanks thank you representative. I will not yield to representative from texas for five minutes per. Thank you, mr. Chairman. I brought up in hearings before the va is currently not in my district its my cap i think the second largest in the system. Even under the investec system i hear from veterans all the time there pharmacy prescriptions dont allow. They arrived infrequently, they have to request them again. Its very interesting to hear the gao. [inaudible] a human factor issue. So my question is, will that the vista just a Second Period how do prescriptions get filled differently under oracle and sooner than they do under investec . I assume that using the same pharmacy Human Factors. Thank you congressman. So oracle there are five sites the prescriptions are filled the same pathway as our va medical facility. Across the nation 84 of our prescriptions go through our mail order pharmacy system. The difference with sites is what you heard from the different folks at the panel today. The increase in staffing for our sites. So for example from visiting with our staff it takes approximately twice as long to process the prescription. Its our staffs dedication to the mission to care for a nations veterans that still ensures we are delivering highquality Pharmacy Services to our veterans. So to my knowledge i do not believe there is significant delays from prescription delivery services. Or whether it is from a vista site. The big issue for our staff is the amount of time it takes to process a prescription, to get the medication to the veterans. Picture difference in method what is the advantage . What is the value added . The value added is if you look globally at our pharmacy system we do have elements of our Electronic System that did need to be modernized. So just to give one example, we had a requirement going back to the early 2000s we do need an Inventory System. Silly perpetual Inventory System would be advantageous to our enterprise. That would give us the ability to be sitting here in my office and be able to look at the inventory that is on hand across enterprise. That would be one advantage regardless of modernization of our public Health Record. A beat one example food seem pharmacy. Wow, your testimony said taking me too a higher level than my question. I want to drop down to one of my last questions. Is this a matter of will to make this happen . Because again the Human Factors to me are fascinating. Oracle said the system itself is ready to go. Get the Human Factors are not there. That is where we are failing. Is this a matter of will we have heard it is incredibly more expensive to do the system. And yet the va, if i heard the oracle representative right is where the Human Factors have not been taken into account. Is the va want to do this . I think i can help answer that. There are capabilities that have been on our list of things we need to modernize for a long time. Perpetual Inventory System for example a graphical user interface. It is a modern graphical interspace for pharmacist to use. Right now pharmacy prescriptions are still processed role in scroll interface. One of the issues you have heard laid out here is processing those prescriptions right now is not as efficient for our pharmacy staff. In part there are system improvements that you have heard mentioned that need to be put in place to allow us to deliver that more efficient operation. So that is a human factor element i would say the majority of this is we need to adapt the workflows. How the system works for our frontline pharmacist is processing prescriptions to be more efficient. To allow them to turn to the same level of workload they were able to achieve. Quick site yield back chairman. Thank you representative. Appreciate that. Ms. Harris, we heard some testimony the problem is the clinics the clinician not the software itself. What is going on is clinically related if you will probably end to look at that a little but we coming up with the renewal. For this contract. Ive got Major Concerns about how bad is going to be addressed. If mechanically who have a system that is functioning but the people who are supposed to implemented are not able to do so and it requires additional staffing they have decreased morale because of utilizing this new system. To deliver the exact same number of units it might be functioning it clearly isnt the people delivering the work if you will. It is their problem because of something new that has been addressed to them. How do we know if dhr is fully functional . And how are we going to know when it is ready in your opinion . What you just described is not a functioning system. Yes, technically the system were to work in of someone extremely dissatisfied is not sustainable to have workarounds and ad hoc processes outside of the system but its not a sustainable solution for the will be increased safety risks as a result. What we have identified through our work lacked set goal of User Satisfaction with that is what we need to see. Very clear objective measures for what constitutes adequate User Satisfaction. We need to have that defines and v8 need to demonstrate progress before the reset. Closes and before they move forward with any future deployment sets a major issue change management is also another issue. Id be driven strategy for change management for the oracle has been in quite a bit of work on training users in the system itself. Users are not prepared to change their business workflows because they have not been adequately trained. That is a major issue. V8 basic take a leadership role in changing that effort. Users fully understand expectations about how their business processes will change . The new system has rolled out offers either safety, quality or value at this current time . Thank you very much. In order to ever have confidence we need to see that is working while in spokane, columbus, roseburg. We are a long way from that today. May become even more and partly the system has to demonstrate value to justify the enormous expense it is not enough to merely swap systems. How are you reevaluating your strategic goals . How will this project ever demonstrate a Value Proposition . I wholeheartedly agree. Simply changing from one Electronic Health record to another Electronic Health record is not a strategy or value realization. The Electronic Health record is an absolute critical element of the functioning of the modern Healthcare System. It is how what uses Electronic Health record. How one configures it. How one enhances its ability to meet your business goals and frankly your Customer Service goals that delivers the real value. An example of that is beat operate as an enterprise Healthcare System. So there are elements of this transition that are quite critical for us. To meet our strategic goals if they are functioning properly. What if one of our strategic goals is for us to be able to deliver care across the enterprise. Regular tele Critical Care physicians, there there paint remotely at 20 or 30 different va Medical Centers. They have 20 30 instances open to do that. It would be great to have one instance of the Electronic Health record open to be able to deliver care. So, to your point this is learning to understand what we need to achieve strategically to make sure our investment in Electronic Health record is allowing us to achieve. Thank you. Doctor evans, representative mccormick. Thank you, mr. Chairman. We understand an issue has arisen with certain medication, allergy information from oracle sites. Not transmitting correctly to vista. Vista provides a receiving a warning to check the joint longitude view whether their patients have received the medication and oracle sites. If so the provider must check for all allergies and drug interactions before prescribing any new medication for are you aware of this issue . Im not personally where this issue but i would ask a clinician. Yes, maam. I am aware of the situation. We have rectified for anything Going Forward. We have come up with a remapping to make sure was going back to the vista site is correct i will work with the va to get retroactive work that needs to be done for things that are already transmitted. When you do discover that and whats the root cause . Ought to say that will record thank you. Thank you. My next question is for doctor evans. Are you aware of this issue or were you aware of this issue . I am aware the issue. Was eight mitigation plans you went into before they corrected their plan . This is an issue that has to do with again i will highlight follows on with the team from chairman rosendale. Its important for va we operate as an enterprise Healthcare System. It is our expectation if the medication is ordered at any site that regardless of what site it is ordered at we are doing drug drug interaction tests. We are doing to say thanks for prescription of that medication. And so with this issue there is bill between the oracle system and what we call our Health Data Repository where we keep track of prescriptions that havent written across the enterprise. When we realized there was an issue there, we again and gave instructions to our users to how to find the information they need. We have been working very closely with oracle to execute the technical fix which is already been done. Now to fix the data that needs to be adjusted and followup. Again, we find an issue like this the answer to your question is all hands on deck to fix it. Thank you pretty want to ensure we have that communication and the lag time if we can actually make sure there is not a big lag time. Mitigation with allergies mixing is a deadly combination which im sure youre aware but pictures like these have been a concern of the passing of course are going to be a concern Going Forward for the committee. Eh art reset would require to contract independent verification and validation phr program. I feel it this is a perfect example of why Something Like this is needed. My next question is for doctor evans. We understand these continued to be a problem with veterans reverting to their address and der s. The question is this issue identified shortly after the first go live. Why does it continue to be an issue . As you are aware the Electronic Health record is a federal Electronic Health record. Its been used the department of defense and Veterans Affairs ruth 96 coast guard and noaa as well. Its the identity system used by the department of defense. The system is architected with the dependency before it was even involved with this project. This is an area we are continuing to work closely with the department of defense. In fact we have meetings scheduled within the next week and half a very senior level. Addressing issues around some of these points of intersection of this dependency on the system itself. How has this affected the amount of medication . Are you aware that work medications were delivered to the incorrect address . Im not personally aware of that. And i do not know whether my pharmacy colleagues can speak to that. Thank you doctor evans. I am aware of some of the incidents in which medication was mailed to incorrect address as a result of information being overwritten it is my understanding with block h which was installed february this year the ability for that to overrate va data has been addressed employees working on the eh are recognized by the system as va it will no longer take information to overrate. Leo back. Recognized for five minutes of questioning. Thank you, mr. Chairman. I want to go to the drop in average scores of best places to work. These are dramatic as the gao briefs. Did you see similar drops and locations that were vista only . And im trying to get at are there other factors include point alone . I have not done that analysis of the level of detail will i feel confident to answer that question. I have read the reports from the pharmacy those numbers with regards with the pharmacists are reporting at these sites are compelling. I would agree. Okay, the next question is once something gets ingrained in a psyche of your organization, it is going to be hard to overturn. Are you confident you could overturn numbers . Believe you me people know these numbers as well as we do. Will you be able to recover regardless of how well you do in your human factor advantages now that you are assuring us. Can you recover because of the deep ingrained dissatisfaction in your five sites . As ms. Harris testified it is not without risk as we move forward. But i think so. Why . Will he think about what motivates Va Health Care in one time a primary care provider. What matters to me is how eh are lets me take care of my patients. What drives the heart and motivation of va Healthcare Providers and pharmacists who are Healthcare Providers really all of those of us to come to work every day to take care patient in va, is taking care of the veteran but is the delivery of healthcare. That is what we do break phr is to enable that. Phr is performing technically at that level it should that is consistently up. The capabilities are working in the system and is performing quickly for rut reliability standpoint this hands, crushes, lags. Users the changes in the system that increases our confidence the system is going to be there is going to get out of the way and let them take care of the veterans they work to take care of. They start to see improved efficiency in using be a chart get to talking to the veteran, this will drive change freight that will drive confidence. Confidence in the tool occurs when that tool is something that is fit for purpose. But guess what i wanted to do. Has great theory of you now have been graded deep dissatisfaction with it. I see my time is going to close well faster. Look at new systems relook at cost, time to implement and productivity. Ive not heard a single positive out of the system in several briefings that i have been in. I think it into exam that read carefully, can you recover . A simple as that. Mr. Chairman i yield back. I yelled five minutes to representative for questioning. Thank you, mr. Chairman for allowing me too questions and thank you all for being here. My first question is for doctor evans. Its been abundantly clever buddy or the eh our system is unsafe and has undermined healthcare delivery, operation, and morale in columbus. Advertisement place in veterans of white veterans out patient clinic matured last fall. Unfortunate towns Like Washington and oregon are experiencing the same issues but i understand you have been there and heard the same concerns i have heard up with your efforts are successful, what should we expect to see . In fact i was there this past tuesday. I am incredibly grateful for the leadership on the frontline staff in columbus. They are leaning forward and have been raising their hands and pointing at the issues we need to fix. A major part of the program reset is listening to endusers and more rapidly addressing issues. As i mentioned before what is the path to improvement . System reliability increased efficiency in using the system a better configuration that will allow improvement in the configuration regular closed loops around improvement. That is what we are committed to do with all of our sites as part of the reset. Thank you. Next couple questions i have are for anybody coming to directly asked somebody i can do that. But if anyone would like to speak up its for any witness here today. We have heard from pharmacists in columbus seven over seven and 30 Health Tickets log averaging over three tickets per day for each pharmacist. Just keeping track of the help desk tickets is literate someones fulltime job. How do you justify the sheer administrative version that is been placed on the facility . First good afternoon. So as you heard i am cochair for the pharmacy counsel we are aware of the tickets and in fact it is part of our recommendation for there to be a staff member of the pharmacy was focused on addressing those tickets and be able to essentially be aware of them. Part of that is how the interaction plays but in the pouring staff of the pharmacy the help desk staff that receive those. We actually find it is advantageous to have one person or a manager of staff that are aware of this issues in order to avoid the undesirable impact of two people reporting a ticket of similar issue and then having to tickets worked concurrently with potentially not in the same result on that. We like to give appreciation to the office for the funds that will allow doctor emma darfur and myself to travel to columbus tomorrow and back for ongoing discovery visit the team is already in place though this week i have no concern at their need to be tickets recorded. We want that. We want to be accessible. You to be approachable about that. Then the tickets think should be addressed to resolution, thank you. Thank you. My next question at the pharmacy piece and maybe just want to continue on. They had to increase staffing by 20 . This is pretty much what you just set them down to 42nd separation while being here and answer the question pretty thorough so mr. Chairman i yield back my remaining time. Thank you very much. I believe, i really do believe the physicians and the folks delivering healthcare to the veterans really do have a mission, a goal and a life goal to make sure they deliver top Quality Health care to our veterans i really do believe that. But she used an analogy if you are given new tools summit gives you a chainsaw. You are a lumberjack he does not give you any gas. Youre better off using a handsaw that you used to have. You will actually be a lick up more wood and to sit there and try to make the chain drag across the lobby. This question assert doctor silverman. Going to redo a quote from one of the questionnaires. This meant life or two and half years yet we all continue to discover new problems weekly 79 change request referenced earlier with a started but this quilt goal to not many more issues have been identified since that time and a list of change request continues to grow at a rate outpacing that of resolutions meet implemented. How could there be this new problems in just one area and how could the software be this ill suited for the pharmacist need . Posting for the question. Is your word in opening testing are the pharmacy solution as part of the millennium the software is designed for the traditional workflow prescriptions are sent to the pharmacy for their process by the pharmacy and dispense to the patient. Because ba pharmacy operates a very tightknit closed circuit operation pharmacy interacting with prescribers it is important to us to have the synchronization between the assistance of the activity of the pharmacist are then reflected in the prescribers application. That is among the top earners you heard referenced over seeking to work with is the ability for our pharmacy dispensing activities to show up in the ordering profile. As if they are working back closely which is out of the ordinary from what you see in a typical setting in the public sector, why wouldnt it be easier to get this sorted out instead of more difficult . For that i get opportunity like the comment what it would take to synchronize the pharmacy and prescriber systems . Permanent chairman if either sugar question correctly what about 500 things that need to be changed in the system. My pharmacist set of the va pharmacist it was a top priority . They come up with 10 this the first 10 we need to go afterward is not listed on the fastest and these are the prioritize 10. As the ones we went after that turned into the seven projects youve seen outlined three already went live. The one in q more in the block. Then what va prioritizes the most important to them to go after. Not this is like intels which way do fastest . Still we are having an issue. Using the Pharmacy Software is satisfactory right now . Is it satisfactory to me all the goals of how the va practices pharmacy right now . No it does not. You testified senate Veterans Affairs committee in march we can achieve quite a bit of this by reconfirming the system without touching the code it can be done relatively quickly i am told weeks not months. This oracles stand by the you made when to rewrite the Software Code and went to just reconfigure the system . Yes we did the pharmacy examples of which we are not finished that is the driver for a lot of this dissatisfaction because of the seven major things that need to be fixed for pharmacy three had not been delivered and as i said in my Opening Statement they are focused on the provider side of the prescription at the pharmacy said the next four are focused on pharmacist in terms of reconfiguring my testament in that hearing was specific to the feedback i heard in columbus but i was with doctor evans in the wrestling team. The workflows in the system not have anything to pharmacy twitter workflows to lockdown and not a time is just send them a statement should the ba choose to make those changes their configuration changes we can make in weeks not months, not years. The pharmacy piece is a recoding of function. Im out of time and im going have to move on, thank you for comments. Represented mccormick too. Thank you mr. Gemma question is for doctor evans. As i said in my opening i am concerned about the number of change requested or socially not more than two years after the first goal of private. I suspect the vas history of a lively medical operate independently of each other has made this program complicated. What is the status of establishing a baseline would expect to adopt . There are many layers to that question. I think first, one of the places where we do have opportunity is in the devices and capabilities that connect to the Electronic Health record. Again, in order to deliver a comprehensive solution that allows us to the Technology Necessary for the safe i call the health care that we expect to deliver in the va, we need more than Electronic Health record. We need bedside monitors in the icu we need laboratory equipment. Radiologic systems for reading imaging. And many of those of buying decisions have been made at the local level traditionally. Because the interface of that system only had to be plugged into the local instance of our Electronic Health records. As we move forward with an enterprise Healthcare System every one of those additional systems bears a cost for us as we have to interface it with the federal electronic record with the thought Technology Oracle brings to the table these are technologies were vying to be able to run our Technology Suite et cetera. We are working to establish a baseline close of what we believe would be the capabilities for which we have existing interfaces so plugging them into the Electronic Health record is easier and faster as we move forward. The second part is the baseline around workflows. How do you run a Primary Care Clinic . How do you do preoperative care . How do you care of someone after an operation . What should the screeds show . What are the questions were going to ask nurses or clinicians to answer . Let us work our councils assist us with. And frankly the voice of the field is incredibly important. We do need to increasingly standardize what that looks like. It needs to be a standard that is workable from an efficiency standpoint and the delivery of healthcare. Both of those areas are significant areas of focus as we engage in the reset. Presently help you evaluate workflow and practice across enterprise to ensure the baseline means everyones needs . One way is to clinical counsel. We have just recently made changes to how we organize the clinical counsels preclinical councils are now part of the Veterans Health administration. We have a cochair here. All the councils are now cochaired including field representation. They all include existing users of the new modernized hr. So impart what we need to do is make sure we have the voices representing end users across assistant and making those standardized decisions. We are still learning this is an area we are seeing positive movement in the right direction. Ms. Harris step anything to add to this when it comes the baseline . Establishing a baseline is critical as one as complicated as va. I think what i would like to note it is very important the increased rate at which sterner addresses these issues. You mention the 79 business changer requests. To date that was to have years ago. The list is growing. Only six have been completed that is a major issue. The rate at which these issues to step up as well as va and contractor oversight as well. Its incredibly important. Getting satisfaction scores to increase as well is really critical to recovering from where we are today. Mr. Chairman i yield back too. Thank you. Thank you, mr. Chairman. Before i go on i think ive heard you say twice i just not the pharmacist it is a supply system is that laymans terms . It is the initial focus the enhancement on the provider said. Another was the person or informative not yet delivered enhancements that pharmacist will consume that a seat next to bark ive delivery. Got it. Now i understand what youre saying. There is a quote from one of your pharmacist. The increased risk due to delays, inefficiencies, vulnerabilities vulnerable workarounds and the lack of responsiveness to identified patient risk. Pharmacy staff must remain in a constant state of hyper vigilance to recognize and intervene on those risks. Hyper vigilance by the pharmacist. Can you comment on that . Hilehis pharmacist used that address those concerns for me. I would appreciate doctors comments since it deals with the clinicians question. Hypervigilance and pharmacy, pharmacists may find a way to say that they are very much attention to detail oriented what comes to pharmacy billing medications out to nature every i is dotted twice every p is ts crossed twice to check hypervigilance that is somewhat the norm. Quick stop at that is out this pharmacist is saying. We are talk about staff burnout. Say do not understand a question to me though. The question is why did they think they have to be hyper vigilant under the system as opposed to the vista system . I too am a veteran. But i am hearing from the veterans as they are not getting good pharmacy support. Under cerner or misstep. That is my question to you. Why did that be hyper vigilant even more than vista if what i am hearing is a vista that work that well either . For the standpoint of where i sat, whenever you change systems are not going to be as comfortable as a system you can working for decades but its going to take times to learn the new system. Two years is not enough time to get comfortable in the pharmacy spirit within you system. Do you all have numbers as to the vista versus the stern errors system wide . Pharmacy errors . Congress and i do not have those in front of them a pair but may just follow up a little bit on the question it was just past. V8 pharmacist in general should not be operating in the statement of hypervigilance. We should be operating within our wellestablished processes and procedures to safely limit prescription fulfillment services. Better pharmacist for over 26 years and use our Electronic Health record over a portion of that career. I felt very safe and comfortable without estate of hypervigilance. Va takes a lot of pride in pharmacy and what we do. We have a very dedicated staff to the mission of the agency which is to care and serve our nations veterans. And i just want to say im very grateful for. Regards your question about the rates between the rates is something i would have to take back to the record of the someone else has those rates. I like to hear that. Ms. Harris do you have anything to add . The main thing i want to add is going back to your original question which i think is so important. How do you recover . In this particular situation with where we are today than it ph part system implementing content recommendations that open relative to increasing User Satisfaction is incredibly important establishing goals to assess User Satisfaction. That is the most important thing they need to do. Demonstrate radical improvement before they move forward with future deployment. The second thing is to have ba take ownership of change management strategy. All these things were done with today, there are system performance issues but for the most part its largely driven by the human component work users have to understand exactly what it is they need to do in this new changed environment. That is really difficult to do with the need to take that leadership role in getting their users to be comfortable mr. Environment. If the chair mode when indulging from uncut questions you have a recommendation . Can they do this . Think they can do this with very close scrutiny and oversight from this committee. As well as through just really increase performance is well with the va as well. Honestly i was very disappointed to hear while va has concurred with our recommendations they expect to complete the implementation of a recommendation of october 2023 by that assignment away. To me they are not serious about a recommendation of what it take to implement it. If they do effectively implement them in a much better city for success for you, i yield back. You have the mock microphone hot youth it gives too much to expect for someone who has a new system that supposed to improve their outfit, learn it, understand it and deliver it to have yours . Serve, based on the current management of the system i think two and half years is not enough time for i think the plaintiff safe a much longer runway for va to change their culture. Event 130 different versions of the staff for the users of the different medical facilities are you for doing business in a certain way that is tailored to their facilities. Standardizing across the enterprises is going to be very challenging thing. But again it takes va Senior Leadership to really ensure that the change management is done done properly. Work users are in a better position to understand what they need to do an existing. Turning to april release it is my understanding it is supposed to synchronize power toward the medication manager retail automatic description records in one system invented and another another. Eliminate timeconsuming shovel entry process for you explain how this works and what it entails . Yes, thank you congressman. The synchronization from enhancement 3d when the pharmacy at a va Medical Center since a prescription is within arm, pharmacy practice there may be several changes at the prescript to dispense an author of the appeal of a prescription for 40 milligrams of a particular drug the Stock Available is 20 milligrams tablets we update the directions accordingly come up with the quantity accordingly and dispense. That enhancement is to ensure that information goes from and are back to power chart automatically rather than asking pharmacist to both make the dispensing process and the power of curved document that i have regrets. This is it true you discovered a serious flaw in his enhancement involving prescription instructions and we were rolling back the Software Update . Prophetic direct this was supposed to be the most important pharmacy permit according to a questionnaire and the it would make with bayesian assistant more cluttered and confusing. But it sounds like it blew up right on the launchpad. Why did this happen . What does that say about prospects improve . Thank you for that. In terms of why it happened i would like to assure counsel was in close cooperation with oracle. The initial testing, the evaluation or nonproduction domains our contribution to the overall decision yes lets deploy this with the cubit release. What i believe happened congressman so we have not been doing as a va and what we need to introduce is a longer Testing Process that would include what i would call end to end testing. From prescriber, to the pharmacist reviewing the prescription to stimulate dispensing for automated equipment. Because we have not been testing to that thoroughness in an environment that can adequately stimulate our production, we did not recognize old help with this patient instructions. Posting is at issue was reported and reported through joint Patient Safety recording the council moved immediately towards request and recommendation to an disabled enhancement. Appreciate that we do not risk any more safety to our veterans. No offense but do you its fair to the va internation heroes as a testing ground for your products . Or they dont believe we are frequencies are custom products. Do you think it is fair to use the va at our nations heroes as a testing ground for your product . Were not universally creating custom products at our discretion but we are instructed and contracted to do so by the d. A. Is doctor silverman point out theres a Testing Process that happens were not ruling out something that is not been tested in office for the vha. In the event issues are discovered after the rohit i do think doctor silvermans comments are correct there has to be more into end testing something that discovered we quickly rolled back. Christ thank you. Quick thinking mr. Chairman. Gao has an extensive body of work on va struggles for largescale it products. Specifically be a struggle with program management. Can you elaborate by what gao has observed and what recommendations you have for the va to be successful . Sure. But we have observed stems back to poor it project management in general. Not having defined user cap front and not really understanding desktop having reliable cost and schedule estimates for the it initiative. So those in general have been many of the issues we have identified with it programs. Now, in this particular case we have made 15 total recommendations related to the program. Ten of them are priority that comes from our most recent work. Again it goes back to increasing user dissatisfaction and ensuring satisfaction scores go up for that is critical to the success as well as improving change management ensuring their users are adequately trained in how to use the system. But also understand the business process related to the changes in the transformation that is happening enterprisewide. In your testimony you state contractor change management activities focus on activities required to deploy the system but did not address user challenges transitioning to new work. Is there any reason why d. A. Should continue to focus on and Fund Training for oracle system until they have focus and standardize workflow processes . I think the priority a significant amount of effort needs to be paid toward training the users on the new business processes for the new workflows. Understanding what they need to do the new system as well as understanding as a whole but they are expected to do. Think at these facilities i think they are team players. They want to and they are on board with changing its just that the systems the e hr system has a significant amount of issues. And again its a step up in addition to ba in terms of trusting those performance issues. Again i will go back to the 79 business change requests. Only six have been addressed in two and half. That pace is unacceptable. Chr reset act will require change management activities be led by rather than contract exists consistent with your recommendation question work with this benefit va longterm to take greater control over the change management activities . Absolutely. Having an independent validation and verification of the system post deployment is critical. It is something we have made a recommendation on so that va can have a thirdparty go and take a look systematically catalogue put those issues are and then systematically address those issues. That is something that is called for by best practice its also something dod did when they rolled out genesis after the first deployment they pause the program, they did not deploy to future sites until they addressed everything related to this issues in that report. Your testimony addresses issues with User Satisfaction in vas lack of established target can you expand on your testimony let the committee know why not establishing youth satisfaction goals is essential to the use of the program . Absolutely. Its hard to tell how much progress has been made if you do not have a baseline established for where you are in where you need to be relative to User Satisfaction. You have to have this metrics in place so you are measuring and being very objective about the progress made. And being in a position to show you have demonstrated adequate improvements before you move forward with future deployment. Thank you so much mr. Chairman appeal back. Fixed thank you representative mccormick. Doctor evans. We have been hearing about many of the unresolved issues described in the christian nurse for over a year. Im not talking about technicalities and talk about things a Serious Health and safety consequences. Like dispensing duplicate medication refills have failed to be created, and prescriptions it never reached the pharmacy request file. How are you going to implement these fixes without creating more complications . Well, first i think is you have heard ms. Harris testified we need to balance and increase velocity of delivering these fixes as well as increased rigor on the testing and understanding and prioritization of how we deliver those fixes. That is something that is going to require tight collaboration between the council, are end users who are using the system and know what it feels like and is every day. Oracle and the program as we execute this at the larger level so impart it is about getting aligned in prioritizing with the most important issues are. And then executed those with sufficient velocity. I agree i dont think we have been executed with the velocity that we need to in order to get where we need to get to have the system functioning in a way that meets vas need the pharmacist and the providers are functioning as a team reading from the same sheet of music caring for the same veteran. Thank you. Making these enhancements to oracle Pharmacy Software and the e hr in general i apologize but seems similar to constantly patching a leaking roof to me, to the general public. Is the only true solution described the pharmacy module and buyer build new software . Im sorry i missed the end . Click is the only true solution just scrap the pharmacy modules and buy or build new software . I dont believe so. As we said in the beginning the pa process is different than the rest of the world. We have been working together to build the enhancements. As he said the seven main things three of them are done the next four to go. I think it is early in the pharmacy process to judge as to whether or not the end product is not so good but not surprised to hear right now people dont like it because its not complete not finished. The problem is though, the taxpayers continue to pay for this experiment and the veterans continue to pay for this experiment. And so what point is oracle going to be there to take possession of this obligation, this responsibility that they entered into. They took and stop link the responsibility off on everyone else . Was i dont believe we are relying on everyone else 10 and half months ago we took the responsibility the estimate timeframe to complete the pharmacy enhancements was three years. We deliver the first three and four months we will deliver the rest this year. Doctor evans assists a situation or we can have it good or fast but not both . Maximum in general, right . I guess i would say i think we are working together to identify what good is boot we have had a discussion about that during this hearing. One of the reasons that the va announced a reset is to say we need to be able to turn our attention towards these improvements. That is turn all of our attention to the improvements that are necessary so we are not balancing both a significant effort of preparing for deployment of new facilities and actually executing those deployments with the improvements of the system. And so i do believe there is an opportunity for us by focusing just on the system improvements for us to get more people, more talent directed at making the improvements necessary faster while preserving quality. So i do think there is a path to both good and faster. Ask her my standpoint what i see are things getting fix of the of the list, creating more problems and then get added to the bottom of the list in the list continues to get larger. With that i will yield. Focus on some of these Significant Program improvements that are necessary to prepare us for the longerterm success of the program that is lets stop flying the plane while also building it. Lets build the plane as it needs to be and a piece of that is increased clarity around the system baseline to support the delivery of an enterprise system which is a big change. An important change and big change so thats partly what we are doing and the reset is that important work. In your testimony you mentioned that they are ongoing at the federal Health Care Center. My question is will the system deployed be more aligned with the version . The federal Health Care Center as you are aware is a unique facility. It is a fully integrated joint va and dod healthcares facility. They operate as a single staff caring for both veterans, Service Members and beneficiaries of the dod. The needs are unique. The only path forward to the deployment is a synchronous deployment where we come together with of the dod and the federal Electronic Health record Modernization Office in support of the federal Health Care System to deliver the capabilities that they need. We will be looking at what the workflows are and to reconcile on that to allow us to deliver a single experience to support care delivery at the site. I dont think i can predict exactly what percentage of dod specific workflows or what that hybrid will look like but i can say we are fully committed to being in an outlined path forward again coordinated by the record Modernization Office with dod and va driving success. Of the system isnt prepared to be rolled out in any other system, why are you planning to deploy their . By the time we get to the federal Health Care Center the system will have been deployed across the entire department of defense Healthcare System with the exception of the federal fel Healthcare System joint facility. So when we arrived there the only dod employees who will not be used in the system would be those who are employees of the federal Healthcare System so i think first it will be a system used across the entire enterprise and a second i anticipate we will benefit from this program. The scheduled go live isnt until 2024. We have numerous months ahead of us and improvements weve been talking about here will be able to be delivered and in anticipation of that go live for so we will be adding value to what has been a successful program. A quick question do you have any recommendations before the go live . I think taking seriously the recommendations that weve made is going to be critical to understanding the users needs and this integration and ensuring that they are committed but ensuring that the users understand what it is they need to do in the system and adequately training them not just in the system themselves but in the workflows is essential. Thank you mr. Chairman. I yield back. Thank you representative and im glad to recognize representative carry. Thank you for joining us. I sent a letter last november after two veterans who were patients at the columbus va died. One of the veterans never received his antibiotic end of the other wasnt contacted to reschedule after hed missed an appointment. The va responded to the letter in february providing some information. It turns out the antibiotic was never actually mailed. The tracking number in the system was misleading. The Family Member knew why they were supposed to pick up the medication. Can you explain how this happened and how is that of being corrected . I am aware of the incident you described and while i cant discuss the specifics of the case, the root of the information was that the report in the system that identified the tracking number was providing the information in this case identified that and has been corrected. One of the staff was supposed to call and reschedule. The system was supposed to remind him to do that. How do the veterans fall through the cracks in situations like that . Either one of you . If you do have information im not familiar. Im not either. Appointment reminders are of an important capability of the Electronic Health record. They are in ancillary capability. They are done differently in the technical reminders with the oracle record has been different than how we do reminders although we are working to align data back to a single approach but i would have to take for the record to look into more of the details. I missed a doctors appointment not one i really wanted to do anyway but i missed a doctors appointment and got five reminders not to mention from my wife to tell me that i missed the appointment but it was very simple i got emails and texts and it seemed very odd that there was no followup appointment. So i appreciate it. Thank you, mr. Chairman. Representative we will yield for some closing statements now. Thank you everyone for your testimony today. We had a productive discussion this afternoon and spent a lot of time talking about the issues but its clear to me that they are a symptom of something much bigger. Theres a long history when it comes to efforts and most are because they lack Strong Program management. With of the delay of the future go live im confident that we can move the needle forward. Thank you mr. Chairman. I yield back. I want to thank all the witnesses for appearing today to discuss the future of the Electronic Health record modernization effort responsible for the wellbeing of millions of veterans. As i said in the last hearing this cannot be a conversation just about it systems. It has to be a conversation about whether the healthcare is meeting our veterans needs and what policies and Systems Support that. The only honest conclusion is the Pharmacy Software is failing to do that and that failure stretches far beyond the pharmacy. The worst thing the va could do is continue down that a deadend road perpetuating the same field strategy and paying out billions of dollars. That would be incredibly irresponsible. Contract renegotiation deadlines are coming up next week and i expect to see the va disentangle itself on this monopoly. If there is a continued role for oracle its using its own resources to improve its products to make the existing server sites whole. Todays hearing gives us every indication that many of the products simply are not capable of improving in the timeframe that we need. They should cut their losses and move on. Otherwise youre doing nothing more than continuing to march down the same deadend road and betraying the veterans end of the taxpayers that you are supposed to serve. I want you to think about that very carefully. Thank you all for your participation in todays hearing and i ask unanimous consent all members have five legislative days to revise and extend their remarks and include extraneous material. Without objection, so ordered. This hearing is adjourned. [inaudible conversations]