Background VA is responsible for providing a variety of services to veterans and their  families (i.e., spouses and children), including health care, disability  compensation, and vocational rehabilitation. Within the department, VHA  oversees the delivery of health care services, including primary care,  specialized care, and related medical and social support at its more than  1500 medical facilities located throughout the country. As of fiscal year  2016, about 9 million veterans were enrolled in the VA health care  system, with almost 7 million patients receiving services at its medical  facilities each year. Overview of VistA VHA relies on VistA—its health information system—to assist in the daily  operations of providing health care to patients. VistA began operation in  1983 as the Decentralized Hospital Computer Program. In 1996, the  department changed the name of the system to the Veterans Health  Information Systems and Technology Architecture—VistA. The system is comprised of more than 200 different software applications,  including 17 pharmacy applications; 11 laboratory applications; 10  eligibility, enrollment, and registration applications; and 12 financial  management applications. Most VistA applications are based on an  architecture that links servers and personal computer workstations at VA  facilities. VistA also has interfaces with applications within other VA  systems, as well as selected systems of other federal agencies (e.g.,  DOD health information systems used to treat injured service members)  and private care providers and pharmacies. VistA was developed based on the collaboration of staff in the VA medical  facilities and VHA IT personnel, with the intention of providing a system  that would meet the clinicians’ needs. Specifically, clinicians and IT  personnel in the various medical facilities collaborated to define the  system’s requirements and, in certain cases, carried out its development  and implementation. In this regard, staff at a medical center could  develop and implement applications at the local level to facilitate the  potentially different functions at each location. This approach has resulted  in about 130 different instances, or variations, of the system being used  throughout the department’s medical facilities. VA has made numerous enhancements to the functionality of VistA since  1983. A significant example is the release in 1996 of the Computerized  Patient Record System (CPRS), a graphical user interface that enabled  the department to provide an individual electronic health record for each  VA patient. Specifically, CPRS enables clinicians to enter, review, and  continuously update information connected with a patient. Among other  things, clinicians can order lab tests, medications, diets, radiology tests,  and procedures; record a patient’s allergies or adverse reactions to  medications; request and track consults; enter progress notes, diagnoses,  and treatments for each encounter; and enter discharge summaries. Another example of the enhancements made to VistA was the  department’s implementation of an imaging capability (VistA Imaging) at  all of the medical facilities. This capability enabled multimedia data, such  as radiology images, to be linked to a patient’s electronic medical record. VistA contains a comprehensive, integrated, electronic health record for  each patient that is viewable by all of the department’s clinicians at all of  its medical facilities, thus eliminating the need for paper medical records.  This capability has been key to the department’s efforts over the last 20  years to share electronic medical records with DOD, and with its work to  achieve interoperability, which enables different information systems or  components to exchange information and to use the information that has  been exchanged. Nevertheless, even with the enhancements and modifications made to  VistA over time, the system is more than 30 years old and has become  increasingly difficult and costly to maintain. One reason VistA is difficult  and costly to maintain is that the system is programmed in the MUMPS  programming language, a language for which there is a continually  dwindling supply of qualified software developers, according to the  department. In 2015, an independent assessment of health IT at VA, conducted by the  MITRE Corporation, raised questions regarding the lack of any clear  advances made during the past decade with VistA and the increasing  amount of time needed for VA to release new capabilities. The study  also noted that the standards and terminology used by VistA do not  enable interoperability across the multiple systems within VA, or between  the department and non-VA facilities, including private sector providers  and DOD. Given the concerns identified, the study recommended that VA  assess the cost versus benefits of various alternatives for delivering  modernized capabilities, such as COTS electronic health record systems,  open source systems, and the continued development of VistA. VA Has Pursued Four  VistA Modernization  Initiatives Since 2001,  with Over a Billion  Dollars Obligated for  Contractors’ Activities  During Fiscal Years  2011 through 2016 Since 2001, VA has pursued four efforts to modernize VistA. These  efforts—HealtheVet, the integrated Electronic Health Record (iEHR),  VistA Evolution, and the Electronic Health Record Modernization  (EHRM)—reflect varying approaches that the department has considered  to achieve a modernized health care system over the course of nearly two  decades. The modernization efforts are described as follows. In 2001, VA undertook its first VistA modernization project, the  HealtheVet initiative, with the goals of standardizing the department’s  health care system and eliminating the approximately 130 different  systems used by its field locations at that time. HealtheVet was scheduled  to be fully implemented by 2018 at a total estimated development and  deployment cost of about $11 billion. As part of the effort, the department  had planned to develop or enhance specific areas of system functionality  through six projects, which were to be completed between 2006 and  2012. Specifically, these projects were to provide capabilities to support  VA’s Health Data Repository and Patient Financial Services System, as  well as the Laboratory, Pharmacy, Imaging, and Scheduling functions. In June 2008, we reported that the department had made progress on the  HealtheVet initiative, but noted issues with project planning and  governance. In June 2009, the Secretary of Veterans Affairs announced  that VA would stop financing failed projects and improve the management  of its IT development projects. Subsequently in August 2010, the  department reported that it had terminated the HealtheVet initiative. In February 2011, VA began its second VistA modernization initiative, the  iEHR program, in conjunction with DOD. The program was intended to  replace the two separate electronic health record systems used by the  two departments with a single, shared system. In addition, because both  departments would be using the same system, this approach was  expected to largely sidestep the challenges that had been encountered in  trying to achieve interoperability between their two separate systems. Initial plans called for the development of a single, joint iEHR system  consisting of 54 clinical capabilities to be delivered in six increments  between 2014 and 2017. Among the agreed-upon capabilities to be  delivered were those supporting laboratory, anatomic pathology,  pharmacy, and immunizations. According to VA and DOD, the single  system had an estimated life cycle cost of $29 billion through the end of  fiscal year 2029. However, in February 2013, the Secretaries of VA and DOD announced  that they would not continue with their joint development of a single  electronic health record system. This decision resulted from an  assessment of the iEHR program that the secretaries had requested in  December 2012 because of their concerns about the program facing  challenges in meeting deadlines, costing too much, and taking too long to  deliver capabilities. In 2013, the departments abandoned their plan to  develop the integrated system and stated that they would again pursue  separate modernization efforts. In December 2013, VA initiated its VistA Evolution program as a joint  effort of VHA and OI&T that was to be completed by the end of fiscal year  2018. The program was to be comprised of a collection of projects and  efforts focused on improving the efficiency and quality of veterans’ health  care by modernizing the department’s health information systems,  increasing the department’s data exchange and interoperability with DOD  and private sector health care partners, and reducing the time it takes to  deploy new health information management capabilities. Further, the  program was intended to result in lower costs for system upgrades,  maintenance, and sustainment. According to the department’s March  2017 cost estimate, VistA Evolution was to have a life cycle cost of about  $4 billion through fiscal year 2028. Since initiating VistA Evolution in December 2013, VA has completed a  number of key activities that were called for in its plans. For example, the  department delivered capabilities, such as the ability for health providers  to have an integrated, real-time view of electronic health record data  through the Joint Legacy Viewer, as well as the ability for health care  providers to view sensitive DOD notes and highlight abnormal test results  for patients. VA also initiated work to standardize VistA across the 130  VA facilities and released enhancements to its legacy scheduling,  pharmacy, and immunization systems. In addition, the department  released the enterprise Health Management Platform, which is a web- based user interface that assembles patient clinical data from all VistA  instances and DOD. Although VistA Evolution is ongoing, VA is currently in the process of  revising its plan for the program as a result of the department recently  announcing its pursuit of a fourth VistA modernization program  (discussed below). For example, the department determined that it would  no longer pursue additional development or deployment of the enterprise  Health Management Platform—a major VistA Evolution component— because the new modernization program is envisioned to provide similar  capabilities. In June 2017, the VA Secretary announced a significant shift in the  department’s approach to modernizing VistA. Specifically, rather than  continue to use VistA, the Secretary stated that the department plans to  acquire the same electronic health record system that DOD is  implementing. In this regard, DOD has contracted with the Cerner  Corporation to provide a new integrated electronic health record system.  According to the Secretary, VA has chosen to acquire this same product  because it would allow all of VA’s and DOD’s patient data to reside in one  system, thus enabling seamless care between the department and DOD  without the manual and electronic exchange and reconciliation of data  between two separate systems. According to the VA Secretary, this fourth VistA modernization initiative is  intended to minimize customization and system differences that currently  exist within the department’s medical facilities, and ensure the  consistency of processes and practices within VA and DOD. When fully  operational, the system is intended to be the single source for patients to  access their medical history and for clinicians to use that history in real  time at any VA or DOD medical facility, which may result in improved  health care outcomes. According to VA’s Chief Technology Officer,  Cerner is expected to provide integration, configuration, testing,  deployment, hosting, organizational change management, training,  sustainment, and licenses necessary to deploy the system in a manner  that meets the department’s needs. To expedite the acquisition, in June 2017, the Secretary signed a  “Determination and Findings,” for a public interest exception to the  requirement for full and open competition, and authorized VA to issue a  solicitation directly to the Cerner Corporation. According to the  Secretary, VA expects to award a contract to Cerner in early 2018, and  deployment of the new system is anticipated to begin 18 months after the  contract has been signed. VA’s Executive Director for the Electronic Health Records Modernization  System stated that the department intends to deploy the new system  incrementally to its medical facilities. Each facility is expected to continue  using VistA until the new system has been deployed at that location. VA  expects that the new system will be implemented at all VA medical  facilities within 7 to 8 years after the first deployment. Figure 1 shows a timeline of the four efforts that VA has pursued to  modernize VistA since 2001. VA Obligated About $1.1  Billion for VistA  Modernization Contracts  from 2011 through 2016 For iEHR and VistA Evolution, the two modernization initiatives for which  VA could provide contract data, VA obligated approximately $1.1 billion  for contracts with 138 different contractors during fiscal years 2011  through 2016. Specifically, the department obligated approximately  $224 million and $880 million, respectively, for contracts associated with  these efforts. Of the 138 contractors, 34 performed work supporting both,  iEHR and VistA Evolution. The remaining 104 contractors worked  exclusively on either iEHR or VistA Evolution. Funding for the 34 contractors that worked on both iEHR and VistA  Evolution totaled about $793 million of the $1.1 billion obligated for  contracts on the two initiatives. Obligations for contracts awarded to the  top 15 of these 34 contractors (which we designated as key contractors)  accounted for about $741 million (about 67 percent) of the total obligated  for contracts on the two initiatives. The remaining 123 contractors were  obligated about $364 million for their contracts. The 15 key contractors were obligated about $564 million and $177  million for VistA Evolution and iEHR contracts, respectively. Table 1  identifies the key contractors and their obligated dollar totals for the two  efforts. Additionally, we determined that, of the $741 million obligated to the key  contractors, $411 million (about 55 percent) was obligated for contracts  supporting the development of new system capabilities, $256 million  (about 35 percent) was obligated for contracts supporting project  management activities, and $74 million (about 10 percent) was obligated  for contracts supporting operations and maintenance for iEHR and VistA  Evolution. VA obligated funds to all 15 of the key contractors for system  development, 13 of the key contractors for project management, and 12  of the key contractors for operations and maintenance. Figure 2 shows  the amounts obligated for each of these areas. Further, based on the key contractors’ documentation for the iEHR  program, VA obligated $102 million for development, $65 million for  project management, and $10 million for operations and maintenance.  For the VistA Evolution Program, VA obligated $309 million for  development, $191 million for project management, and $64 million for  operations and maintenance. Figure 3 shows the amounts obligated for  contracts on the VistA Evolution and iEHR programs for development,  project management, and operations and maintenance. In addition, table 2 shows the amounts that each of the 15 key contractors  were obligated for the three types of contract activities performed on  iEHR and VistA Evolution. VA Recently  Announced a New  VistA Modernization  Initiative;  Development of Plans  Is in Progress Industry best practices and IT project management principles stress the  importance of sound planning for system modernization projects. These  plans should identify key aspects of a project, such as the scope,  responsible organizations, costs, schedules, and risks. Additionally,  planning should begin early in the project’s life cycle and be updated as  the project progresses. Since the VA Secretary announced that the department would acquire the  same electronic health record system as DOD, VA has begun planning  for the transition from VistA Evolution to EHRM. However, the department  is still early in its efforts, pending the contract award. In this regard, the  department has begun developing plans that are intended to guide the  new EHRM program. For example, the department has developed a  preliminary description of the organizations that are to be responsible for  governing the EHRM program. Further, the VA Secretary announced in  congressional testimony in November 2017 that the Executive Director for  the Electronic Health Records Modernization System will report directly to  the department’s Deputy Secretary. In addition, the department has  developed a preliminary timeline for deploying its new electronic health  record system to VA’s medical facilities, and a 90-day schedule that  depicts key program activities. The department also has begun  documenting the EHRM program risks. Beyond the aforementioned planning activities undertaken thus far, the  Executive Director stated that the department intends to complete a full  suite of planning and acquisition management documents to guide the  program, including a life cycle cost estimate and an integrated master  schedule to establish key milestones over the life of the project. To this  end, the Executive Director told us that VA has awarded program  management contracts to support the development of these plans to  MITRE Corporation and Booz Allen Hamilton. According to the Executive Director, VA also has begun reviewing the  VistA Evolution Roadmap, which is the key plan that the department has  used to guide VistA Evolution since 2014. This review is expected to  result in an updated plan that is to prioritize any remaining VistA  enhancements needed to support the transition from VistA Evolution to  the new system. According to the Executive Director, the department  intends to complete the development of its plans for EHRM within 90 days  after award of the Cerner contract, which is anticipated to occur in early  2018. Further, beyond the development of plans, VA has begun to staff an  organizational structure for the modernization initiative, with the Under  Secretary of Health and the Assistant Secretary for Information and  Technology (VA’s Chief Information Officer) designated as executive  sponsors. It has also appointed a Chief Technology Officer from OI&T,  and a Chief Medical Officer from VHA, both of whom are to report to the  Executive Director. VA’s efforts to develop plans for EHRM and to staff an organization to  manage the program encompass key aspects of project planning that are  important to ensuring effective management of the department’s latest  modernization initiative. However, the department remains early in its  modernization planning efforts, many of which are dependent on the  system acquisition contract award, which has not yet occurred. The  department’s continued dedication to completing and effectively executing  the planning activities that it has identified will be essential to helping  minimize program risks and guide this latest electronic health record  modernization initiative to a successful outcome—one which VA, for  almost two decades, has been unable to achieve. Agency Comments  and Our Evaluation We provided a draft of this product to VA for comment. Via email, a  liaison in VA’s Office of Congressional and Legislative Affairs stated that  the department appreciated the opportunity to comment on the draft  report and provided technical comments, which we incorporated as  appropriate. We are sending copies of this report to the appropriate congressional  committees, the Secretary of Veterans Affairs, the Under Secretary for  Health, the Chief Information Officer, and other interested parties. In  addition, the report is available at no charge on the GAO website at  http://www.gao.gov  If you or your staffs have any questions on matters discussed in this  report, please contact me at (202) 512-9286 or pownerd@gao.gov.  Contact points for our Offices of Congressional Relations and Public  Affairs may be found on the last page of this report. GAO staff who made  major contributions to this report are listed in appendix II. Appendix I: Objectives, Scope, and  Methodology The objectives for this study were to (1) identify the efforts that the  Department of veterans Affairs (VA) has undertaken to modernize VistA,  including key contractors, contract costs, and expected contractor  activities and (2) to determine the department’s current plans for, and  progress to date, in modernizing VistA. To address the first objective, we reviewed VA’s prior budget  submissions, in addition to VistA Evolution planning documentation, such  as the VistA 4 Product Roadmap, VistA 4 Life Cycle Cost Estimate, VistA  Evolution Integrated Master Plan, and VistA Evolution Business Case.  We also reviewed meeting minutes for the VistA modernization projects  and prior GAO work on efforts to modernize VistA. To determine the contractors, costs, and expected contractor activities for  these efforts, we requested data from VA’s Office of Information and  Technology (OI&T) and the Veterans Health Administration (VHA) on all  contracts, related obligations, and expected activities for the HealtheVet  program for fiscal years 2001 through 2010; the integrated Electronic  Health Record (iEHR) program for fiscal years 2011 through 2013; and  the VistA Evolution program for fiscal years 2014 through 2016. Neither  OI&T nor VHA was able to provide contract data related to the HealtheVet  program. The department stated that it could not verify any HealtheVet  contractors receiving payments because the time frame for the effort falls  outside the record retention required by regulations. According to the  Federal Acquisition Regulation, government agencies are required to  retain contract records for 6 years after the final payment. VA provided contract data for the iEHR and VistA Evolution programs,  which included contractor names, obligated amounts of funding, and  descriptions of the work that the contractors were to perform. OI&T  provided such data for fiscal years 2011 through 2016 and VHA provided  data for fiscal years 2012 through 2016. VHA program officials told us  that they were unable to provide contract data prior to 2012. In addition,  we did not request contract data subsequent to fiscal year 2016 because  that is the last fiscal year for which data for a full year were available at  the time that we performed our analysis. We assessed the reliability of the contract data we received by reviewing  it for missing elements and outliers. We then met with officials responsible  for VistA-related contracting to address questions about any missing data  and outliers, as well as to obtain additional information about how the  data were developed. Further, we supplemented the data by using  additional information received from VA and the Federal Procurement  Data System. We determined that the data were sufficiently reliable for  the purposes of our reporting objective. To determine the key contractors, we first identified all of the contractors  that worked on both the iEHR and VistA Evolution modernization efforts.  We subsequently ranked the contractors according to the total dollars  obligated for contracts that each contractor had been awarded. Further,  we designated the top 15 ranked contractors, in terms of dollars  obligated, as key contractors. These 15 key contractors received  contracts that accounted for about two-thirds of the funds obligated to  VistA modernization contracts from fiscal year 2011 through 2016. We  then analyzed the information provided from VA on the work to be  performed by these key contractors to identify obligations made for  contracts to provide different types of work supporting the two  modernization initiatives, including systems development, project  management, and operations and maintenance. We then calculated the  funds that were obligated to each of the key contractors for the types of  work performed. To determine current plans for modernizing VistA, we reviewed draft  program schedules, organization charts, Congressional testimonies of the  VA Secretary, a White House press conference transcript, departmental  press releases, and the department’s justification for awarding a non- competitive contract for a commercial off-the-shelf electronic health  record system. To determine the progress achieved on the current efforts,  we obtained documentation, such as draft schedules and organization  charts, and met with program officials in VA’s Electronic Health Record  Modernization program office to obtain updated information on the efforts. We conducted this performance audit from September 2016 to January  2018 in accordance with generally accepted government auditing  standards. Those standards require that we plan and perform the audit to  obtain sufficient, appropriate evidence to provide a reasonable basis for  our findings and conclusions based on our audit objectives. We believe  that the evidence obtained provides a reasonable basis for our findings  and conclusions based on our audit objectives. Appendix II: GAO Contact and Staff  Acknowledgements GAO Contact David A. Powner, (202) 512-9286 or pownerd@gao.gov. Staff  Acknowledgments In addition to the contact named above, Mark Bird (assistant director),  Eric Trout (analyst in charge), Chris Businsky, Vern Cumarasegaran,  Nancy Glover, Paris Hawkins, Jacqueline Mai, Jennifer Stavros-Turner,  Christy Tyson, and Charles Youman made key contributions to this  report.
VA operates the largest health care delivery system in America and VistA is essential to helping deliver the health care services and ensure the quality of health care received by the nation's veterans and their dependents. The system has been in operation for more than 30 years, is costly to maintain, and does not readily support VA's need to electronically exchange health records with the Department of Defense and private health care providers. VA has pursued initiatives to modernize VistA, using government contractors to support its efforts. In June 2017, VA announced a new effort to purchase a commercial solution to replace VistA. GAO was requested to review VA's prior and current efforts to modernize VistA. This review determined (1) VA's efforts to modernize VistA, including key contractors, contract costs, and expected contractor activities and (2) VA's current plans for modernizing VistA and the progress that has been achieved to date. To conduct its study, GAO reviewed VA documentation and its prior work and requested and obtained data on contracts, related obligations, and expected contractor activities for previous efforts. GAO also obtained documentation on plans for VA's current modernization efforts and progress made on the efforts, and interviewed VA officials. GAO has made recommendations to VA aimed at improving its prior modernization efforts. The department concurred with the recommendations and generally took responsive actions. GAO is making no recommendations at this time. VA provided technical comments on this report, which were incorporated as appropriate. The Department of Veterans Affairs (VA) has, since 2001, pursued four separate initiatives to modernize its health information system—the Veterans Health Information Systems and Technology Architecture (VistA). These efforts—HealtheVet, the integrated Electronic Health Record (iEHR), VistA Evolution, and the Electronic Health Record Modernization (EHRM)—reflect varying approaches that the department has considered to achieve a modernized health system over the course of nearly two decades (see figure). This latest effort, the EHRM program, is to include the adoption of the same commercial electronic health record system that the Department of Defense is in the process of acquiring. VA obligated about $1.1 billion to 138 different contractors that worked on iEHR and VistA Evolution (the two efforts for which VA could provide contract data) during fiscal years 2011 through 2016. Funding for the 34 contractors that worked on both efforts totaled about $793 million of the $1.1 billion obligated for contracts on the two initiatives. The top 15 of the contractors that worked on the two efforts (key contractors) accounted for approximately $741 million—$411 million for the development of new system capabilities, $256 million for project management activities, and $74 million for operations and maintenance for iEHR and VistA Evolution. VA has begun planning for the transition from VistA Evolution to EHRM. However, the department is still early in its efforts and has begun developing plans that are intended to guide the new EHRM program. According to the EHRM Executive Director, the department intends to complete development of its plans for EHRM within 90 days after awarding the contract for its new system, which is planned to occur in early 2018. VA has also begun to staff the EHRM program's leadership positions. The department's dedication to completing and effectively executing the planning activities that it has identified will be essential to helping minimize program risks and expeditiously guide this latest electronic health record modernization initiative to a successful outcome—which VA, for almost two decades, has been unable to achieve.