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James Gfrerer, assistant secretary for information and technology and CIO for the Department of Veterans Affairs, is involved in one of the largest electronic health record upgrades in IT history.
The VA is migrating from Veterans Information Systems and Technology Architecture to Cerner Millennium. The goal is to bring Veterans Affairs and the Department of Defense onto the same EHR to make sharing medical records between the two departments seamless. And the process is neither cheap nor easy. In November 2018, the price tag for the migration increased to $16 billion from $10 billion in May 2018. Late last week, the department confirmed it will delay a chunk of the implementation for more training and development.
But the EHR upgrade is just one element of a massive digital transformation taking place at the VA, the second largest federal agency and includes the Veterans Health Administration, Veterans Benefits Administration and the National Cemetery Administration. Gfrerer, who was confirmed by the Senate in January, is helping modernize every other major VA platform, as well as build out new veterans services that make experience a priority.
In this Q&A, Gfrerer explains the importance of customer experience to the VA today and the success of the Mission Act, a push to make healthcare more accessible to veterans. He believes that a DevOps methodology has been crucial to the Office of Information and Technology's digital transformation success.
Editor's note: SearchHealthIT spoke with Gfrerer before the delay of the Cerner rollout was confirmed.
Was digital transformation an inherited goal or something you brought to the VA?
James Gfrerer: It's something that had just been embarked upon as I was arriving, so I can't take much credit for its implementation. But certainly, the timing is right. Secretary [of Veterans Affairs Robert] Wilkie has said his number one priority is customer service. And that's something that's inherently in our DNA within the Office of Information and Technology. At the end of the day, it's how we enable the businesses to do their job that ultimately reflects on our success or failure.
How did you assess what the agency had accomplished and where it still needed to go?
Gfrerer: I promised the Senate in my confirmation hearing that I was going to come up with a balanced scorecard to track our progress on those initiatives. So that's our last step: to come out with a balanced scorecard to rate and score ourselves and see our progress.
As Secretary Wilkie says, the VA is in the midst of the greatest period of transformation probably in its history. And I absolutely agree with that. When you look at everything we're doing around electronic health records, modernizing our financial management business system, modernizing our HR system, our medical logistics system -- we're going to be adopting [the Defense Medical Logistics Standard Support], the Defense supply chain system. These are very big things.
The Mission Act, which is focused on making healthcare more accessible to veterans, is viewed as a digital transformation success by the VA. What did it take to get there?
Gfrerer: Let me make a couple of points because one of the things I try to convey to leadership is what's different. The VA has had a bit of a checkered past in terms of not delivering on time -- or not delivering at all -- on some of these large transformational issues.
The Mission Act is all about delivering new entitlements to veterans, the largest of which is, if you meet certain requirements, you can receive care in your community instead of driving a long distance or waiting a month. ... What's different in terms of a story line? I would say the first thing was we're in a very time-competitive environment. I came on Jan. 7, and we had to deliver on the initial obligations around the Mission Act June 6, which was a super high bar to meet.
We have fully embraced the DevOps methodology. A tenant of DevOps is to be agile and to deliver a minimum viable product [MVP]. One of the causes of undelivered projects in the past for the VA, and probably other agencies, is that waterfall-I-want-it-all development cycle. In partnership with the business -- and we had great business project managers and champions -- we convinced them that we had to develop on a minimum viable project. My hats off to VHA; it hit the 'I believe' button.
If you look at some of the systems now, we got to the point where we had one delivery run -- an MVP -- on June 6, and in the past three to four months, we've been delivering weekly releases around some of the systems. That's the cadence and the pace -- small, incremental, quick delivery as opposed to big bang waterfalls that fail by virtue of scope.
Did that DevOps methodology exist in the VA before you arrived?
Gfrerer: The only credit I'd give myself, it's a bit of a culture shift within the department, as it is within a lot of federal agencies. People don't necessarily like the idea of MVP. They want it all. But when they realize it's a serious risk to product delivery, they understand it.
How much did bringing in a new leader help with the culture shift?
Gfrerer: Whenever a new leader comes in, there is an opportunity -- that isn't unique to me. I looked at it, and I feel like our office and department looked at it, as kind of a reset.
The other thing I found was kind of this attitude of business success or IT failure. Folks would want to blame it on IT. I said, 'We're not going to have that in VA. We are here as a critical requirement to business success; we're going to do everything we can, leave it all in the fields, to use that cliché, to make sure we're delivering around these programs and these projects.'
It starts with the business requirement, it starts with partnering with the business, and it starts with delivering business outcomes. There is no business success or IT failure. There's only business success or business failure. We are focused on that.
You've said you want to migrate 350 apps by 2024. Why is cloud so important to the VA's digital transformation efforts?
Gfrerer: When you look at it, that's probably about half of our portfolio, and we're on pace to meet or maybe even exceed that it in terms of time execution. This is part of a larger shift. The VA, like a lot of federal agencies, had been in a CapEx mentality. It was buying a lot of equipment, having a lot of on-prem facilities. We want to rebalance that portfolio and migrate some of that to an OpEx, an operating expense, mentality.
This is not about cost savings, ultimately. There will be some cost efficiency, but some of the value of going to the cloud is that we will know to the penny what our applications cost because our enterprise cloud providers have that level of fidelity around billing. It will also allow us to only buy the resources we actually need. Think of it almost like an Uber mentality. Cloud providers will provision additional services as needed to meet requirements for an application.
It will also increase our reliability. The one example I use is our single sign-on, our means of authentication within our own network. We moved that application into our enterprise cloud. Before moving it, it had a 70% availability rate, which ... does not meet the business requirements. We moved that to the cloud this year, and now we're at 99% availability. That's a critical application.
VA's Office of Information and Technology by the numbers
- Team is comprised of 8,000 employees and 8,000 contractors
- Operates an IT budget of $4.2 billion
- Oversees Veterans Benefits, Veterans Health and National Cemetery Administration
- Represents the federal government's largest centralized IT department
- Supports the second largest U.S. federal agency
From the headlines I've seen, the Cerner EHR rollout has been delayed. Where do things stand today?
Gfrerer: We have an office of electronic health record modernization led by our executive director John Windom. The Office of Information and Technology, the Veterans Health Administration, we work with that office as we go down the path of deploying the new electronic health record, Cerner Millennium.
This is, without a doubt, the largest electronic health record migration that's ever occurred. It's a monstrous process. It's going to roll out over 10 years to 170 facilities. Folks think this is a long time, but one commercial health system with 50 facilities took 10 years. So it's actually a pretty aggressive timeline from a deployment standpoint.
The value will be tremendous. We will have interoperability with the Department of Defense and with their military treatment facilities. It's going to increase interoperability around with our community care providers that we're already partnering with. I always use as an example, if you have a child born to a military family, let's say born in a military treatment facility, a hospital, his or her record will start there; it will carry during the period of military dependency, when they're a family member.
Say that young woman or young man enlists or is commissioned and does a 20-year career, that same record will follow them into their active duty career. When they retire from active duty ranks after 20 years and become a veteran, we're going to be using the same record. That's the longitudinal record that would go across their entire life. Eventually, that's where we're going to get to. The value of that from a clinician's standpoint is just endless.
Editor's note: This interview has been edited for brevity and clarity.