DEPARTMENT OF VETERANS AFFAIRS Washington DC 20420 May 20, 2019 18-cv-02463 Daniel A. McGrath American Oversight 1030 15th Street NW, B255 Washington, D.C. 20005 Dear Mr. McGrath: The Office of Electronic Health Record Modernization (OEHRM) responded to your request for Genevieve Morris' records in an Initial Agency Decision (IAD) dated April 25, 2019. This letter is OEHRM's second IAD in response to your two requests dated May 4, 2018 and submitted to the Department of Veterans Affairs (VA) under the Freedom of Information Act (FOIA), 5 U.S.C. ? 552. This IAD is also in response to your request for the records of Dr. Laura Kroupa, OEHRM Chief Medical Officer (CMO), a supplemental custodian added to the search per your request in March 2019. You requested the following search terms: Search One Records containing the terms a. Isaac b. or Ike c. or Jared Kushner Search Two Records containing the terms d. Moskowitz e. Perlmutter f. Ike g. Trump's friend h. Trump's doctor i. POTUS friend j. POTUS's friend k. POTUS' friend l. POTUS doctor m. POTUS's doctor n. POTUS' doctor o. President's friend p. Friend of POTUS q. Friend of President r. Friend of the President Please note that the Office of the Secretary (OSVA), the Veterans Health Administration (VHA), and the Office of Information and Technology (OIT) will respond separately. IAD for Dr. Laura Kroupa The assigned performed a search of Dr. Kroupa's email server using the provided terms. The search produced 1,135 documents. From the 1,135 documents, 16 records are responsive. The first 15 documents are released with redactions in accordance with 5 U.S.C. ? 552(b)(6). One additional document totaling 1,474 pages, remains in process at this time. 5 U.S.C. ? 552(b)(6) exempts from required disclosure "personnel and medical files and similar files the disclosure of which would constitute a clearly unwarranted invasion of personal privacy." "Withholding a telephone number or e-mail address, alone, is not sufficient to protect that [privacy] interest; alternate means of contacting and harassing these employees would be readily discoverable on the Internet if this court ordered their names disclosed." Long v. Immigration & Customs Enf't, 2017 U.S. Dist. LEXIS 160719 (D.C. Cir. 2017). Information withheld consists of the names of GS-15 and below VA employees, contractors, and private citizens. The redacted information also includes email addresses, contact information, and VA usernames. This information reveals nothing about how the agency performs its statutory duties. The coverage of FOIA Exemption 6 is absolute unless the FOIA requester can demonstrate a countervailing public interest in the requested information by demonstrating that the individual is able to provide the requested information to members of the public and that the information requested contributes significantly to the public's understanding of the activities of the Federal government. Also, the requester must demonstrate how the public's need to understand the information significantly outweighs the privacy interest of the person to whom the information pertains. Upon consideration of the records, there is not an identifiable countervailing public interest of sufficient magnitude to outweigh the privacy interest of the individuals whose names are redacted. The protected information has been redacted and (b)(6) inserted. FOIA Mediation As part of the 2007 FOIA amendments, the Office of Government Information Services (OGIS) was created to offer mediation services to resolve disputes between FOIA requesters and Federal agencies as a non-exclusive alternative to litigation. Using OGIS services does not affect your right to pursue litigation. Under the provisions of the FOIA Improvement Act of 2016, the following contact information is provided to assist FOIA requesters in resolving disputes: VA Central Office FOIA Public Liaison: Name: John Buck Email Address: vacofoiaservice@va.gov Office of Government Information Services (OGIS) Email Address: ogis@nara.gov Fax: 202-741-5769 Mailing address: National Archives and Records Administration 8601 Adelphi Road College Park, MD 20740-6001 FOIA Appeal Please be advised that should you desire to do so, you may appeal the determination made in this response to: Office of General Counsel (024) Department of Veterans Affairs 810 Vermont Avenue, NW Washington, DC 20420 If you should choose to file an appeal, please include a copy of this letter with your written appeal and clearly indicate the basis for your disagreement with the determination set forth in this response. Please be advised that in accordance with VA's implementing FOIA regulations at 38 C.F.R. ? 1.559, your appeal must be postmarked no later than ninety (90) days of the date of this letter. Thank you for your interest in VA. Sincerely, Mingo, Fred J. Digitally signed by Mingo, Fred J. Date: 2019.05.20 14:14:50 -04'00' Mr. Fred Mingo, Jr. OEHRM FOIA Officer Attachments: LK_Records_American Oversight_Part 1_Redacted: 78 pages LK_Records_American Oversight_Part 2_Redacted: 38 pages From : To : Cc: Bee: Subject: Date : Attachments : ( Booz Allen Hamilton) < o=exc ange a s/ou=exchange admin istrat ive ~cn=recipients /cn EHRM in the News and SecVA Stand-Up--Tuesday Tue Dec 11 2018 10:18:54 EST 181211_VA Secretary 's Stand-Up Brief.pptx image001.png , December 11, 2018 News Summary : Today 's news clips include an article about how VA is rolling out AP ls to enab le health IT deve lopers ; the New York Times discusses how democrats and repub licans are uniting on one issue: ove rsight of the VA ; Rep . Mark Takano is poised to lead the House Comm ittee on Vete rans Affa irs; and fina lly Polit ico discusses Veterans Affairs rank ing member Tim Wa lz's campa ign to expose the influence of three Mar-a-Lago assoc iates on VA bus iness . EHR Intelligence : VA Rolls Out APls to Improve Interoperability , EHR Data Access (Dec. 10, 2018, Kate Mon ica) *VA is rolling out standa rds-based application programming interfaces (APls ) des igned to enab le health IT deve lopers to build too ls that improve interoperability, EHR data access, and health data exchange for vete rans and thei r providers . *The fede ral agency detailed its plans to engage with developers through AP ls on its webpage and offered informat ion about several different API offerings. *VA's health API offer ing allows health IT deve lopers to build tools that help veterans manage their health, view their EHRs , schedule appointments , find specia lty facil ities, and exchange health information with caregivers and prov iders. The New York Times : Repub licans and Democrats Unite on at Least One Issue : Overs ight of the V.A. (Dec . 10, Jenn ifer Steinhauer) *Even before the next Congress convenes, Repub licans are joining Democ rats in a vigorous examinat ion of failings by the Department of Vete rans Affa irs, a rare area of bipartisan overs ight in a blistering political environment. *The unity was emphasized in recent weeks when lawmake rs in the House and Senate from both parties sharp ly criticized the response of department officia ls after it was revea led that the agency failed to make hous ing and tuition payments unde r the G.I. Bill after its computer systems were unable to keep up with recent changes to that law. The Press Enterprise: Rep. Mark Takano poised to lead House Comm ittee on Vete rans Affa irs (Dec . 10, Jeff Horseman ) VA-18-0298-F, VA-18-0299-F-000001 00000 1 *Increased VA oversight is among the Horseman's priorities *Veterans Affairs is one of the biggest departments of the federal government, with a proposed 2019 budget of more than $196 billion. And the House committee overseeing the department is one of several in Congress with subpoena power. *Another Takano priority is making sure the VA is prepared to care for the new demographics of 21st century veterans. While the veteran population is projected to decline by more than 6 million by 2037, that population will be more diverse, according to a VA report. Politico: WALZ PUSHES WILKIE ON MAR-A-LAGO (Dec. 11, 2018, Mohana Ravindranath) *Veterans Affairs ranking member Tim Walz is continuing his campaign to expose the influence of three Mar-a-Lago associates on VA business, writes Morning eHealth's Arthur Allen. *In a Monday letter to VA Secretary Robert Wilkie, Walz raises questions about the department's response to a lawsuit brought by VoteVets. The PAC accuses the VA of violating federal advisory committee statutes by enabling the influence of Marvel Entertainment Chairman Ike Perlmutter, internist Bruce Moskowitz and attorney Marc Sherman. *Department emails released in a FOIA request indicate the VA ceded decision-making power to the three and allowed them to direct technology developments at the VA that could have enriched Moskowitz and his family, Walz wrote. *Walz, governor-elect of Minnesota, demanded unredacted documents on the relationship and said his colleagues would pursue his investigation next year. The GAO is also investigating the Mar-a-Lago group's influence. (b) (6) | U.S. Department of Veterans Affairs (contractor) | Digital Communications | Office of Electronic Health Record Modernization (OEHRM)| 811 Vermont Avenue NW (4th Floor) Washington, DC 20420| (b) (6) @va.gov Visit VA Online: www.VA.gov | www.facebook.com/VeteransAffairs |https://twitter.com/VeteransAffairs| www.flickr.com/photos/VeteransAffairs | http://www.youtube.com/user/deptvetaffairs VA-18-0298-F, VA-18-0299-F-000002 000002 (b) (6) Owner: Booz Allen Hamilton) Filename: 181211_VA Secretary's Stand-Up Brief.pptx Last Modified: Tue Dec 11 09:18:54 CST 2018 ? VA-18-0298-F, VA-18-0299-F-000003 000003 VA Secretary's Stand-Up Brief 11 December 2018 Executive Summary Multiple national storylines emerged yesterda y. Reuters and Stars and Stripes began coverage of a Dartmouth study showing the high quality of care at VA hospitals compared to other area hospitals. -- Emerged Service NBC News NBC News published a new story early th is morning pos iting the quest ion of w ho w ill be held accountable for the GI Bill delays. The article established a time line of the confusion around how the payments w ill be processed. VA messaging was absent from the piece , which w as largely based on statements from IAVA's Paul Rieckhoff , as w ell as Sens . Tammy Duckworth and Cory Gardner. Emerged Interests Senate unlikely to pass Blue Water bill this year Stars and Stripes . Military Times Stars and Stripes reported that the Blue Water Veterans bill was blocked from quick passage by Sen. Mike Enzo (R-Wyo .), w ho said , "VA's analysis shows the costs could be nearly five times what Congress assumed it was w hen the House of Representatives passed it." The article also noted Sec. Wilkie's opposition to the bill is based on "cost concerns and insufficient scientific evidence ." Military Times wrote that the Veterans affected "can 't afford more legislative delays, " and recounted critical reactions from some VSOs and Senators . Emerged Service / Interests Bipartisan cooperation in VA oversight New York Times The New York Times wrote that VA oversight is a "rare area of bipartisan oversight, " saying cooperation w as emphasized in the last weeks in reactions to GI Bill delays. Emerged Interests / Other Supreme Court to review case involving VA benefits The Hill. Law.com . Courthouse News Service . Bloomberg Law These articles covered the Supreme Court's agreement to hear the case of Kisor v. Wilkie, in w hich Veteran James Kisor is challenging the Department's refusa l to award him retroactive benefits based on its regulatory interpretation. According VA-18-0298-F, VA-18-0299-F-000004 Emerged to reporting, the case could have broad implications because it will address how 000004 much courts should defer to a federal agency 's interpretation of an ambiguous regulation. Storyline VAMCs provide higher quality care than other hospitals Accountability on GI Bill delays Outlets Analysis Reuters . Stars and Stripes Reuters and Stars and Stripes covered a Dartmouth study that found VA faci lities often outperf orm other hospitals w hen it comes to mortality rates and patient safety . Stars and Stripes quoted lead researcher Dr. William Weeks as saying VAMCs are in many cases the best regional hospita ls and are rarely the worst. Interests VA Secretary's Stand-Up Brief 11 December 2018 Twitter and Facebook Volume: 26 November - 1O December Social Media Takeaway In stark contrast to traditional media, Twitter was at a standstill yesterday. Only one post received over 10+ retweets. Key Points o The slight increase in activity yesterday compared to Monday is from the normal variation in the baseline of posts, observed daily, which receive no or nearly no user engagement. o The only post with notable engagement yesterday was by Actress @Alyssa_Milano, who wrote that Veterans deserve better than the GI Bill delays. Her post also linked to the related 28 Nov. NBC News article (700+ retweets ). o American Patriot uploaded to YouTube a computer-generated reading of a story on the Providence VA nurse who admitted to removing liquid opioids from the hospital (2.9k+ views). This is the fourth most-viewed video of the last 30 days. ,... .. I ..1 lo<< H 11 lt 1' JO 1?111111 oo 1 l J o ' I f I t lO OM:IOll ? ru-n1t.16i Notable Social Media Items Platform Item Relevance Twitter Topic: GI Bill delays 11% of Volume Twitter Topic: The Confederacy I Jefferson Davis 1% of Volume Facebook VA Medical Center donates to~s to area foster children 31O+ Reactions, 20+ Shares VA-18-0298-F, VA-18-0299-F-000005 000005 VA Secretary's Stand-Up Brief 11 December 2018 Reuters: U.S. veterans' hospitals often better than nearby alternatives (10 December , Lisa Rapaport, 16.SM uvm; New York, NY) U.S. Veterans Administration (VA) hospitals may provide better quality care than other hospitals in many American communities, a U.S. study suggests . Researchers looked at 121 regional health care markets with at least one VA hospital and one non-VA facility . Altogether they assessed 135 VA hospita ls and 2,988 non-VA hospitals using Hospital Compare, a public database that ranks hospitals on quality measures like mortality rates for common diseases and preventable complications. Hyperlink to Above Stars and Stripes: Dartmouth study finds VA hospitals outperform others in same regions (10 December , Nikki Wentling, 532k uvm; Washington, DC) A new study by Dartmouth College that compares Department of Veterans Affairs hospitals with other hospitals in the same regions found VA facilities often outperform others whe n it comes to mortality rates and patient safety . Hyperlink to Above WCPO (ABC-9, Video): Yoga, equine therapy help Cincinnati veterans find peace (10 December , Craig McKee, 289k uvm; Cincinnati , OH) Appointments with Veterans Affairs counselors and therapy groups made Jason Short feel "like a test subject ," he told WCPO in 2016. Talking through the experiences that led to his diagnosis with post-traumatic stress disorder didn't help him move past them. Training w ild horses did. Hyperlink to Above WPLN (NPR-1430, Audio): Nashville VA Attacking Patient Backlog With Dedicated Call Center (10 December , Blake Farmer , 33k uvm; Nashville , TN ) VA hospitals and clinics in Middle Tennessee are trying to attack their patient backlog by more efficiently handling phone calls. The Tennessee Valley Health Care system has established a central call center , w hich handles as many as 35,000 calls a month . The VA admits that veterans have been spending w ay too long on hold and navigating phone systems . This show s up in patient satisfaction feedback . Hyperlink to Above EHR Intelligence: VA Rolls Out APls to Improve Interoperability, EHR Data Access (10 December , Kate Monica, 18k uvm; Danvers , MA) VA is rolling out standards-based application programming interfaces (APls ) designed to enable health IT developers to build tools that improve interoperability , EHR data access, and health data exchange for veterans and their providers. The federal agency detailed its plans to engage w ith developers through APls on its webpage and offered information about several different API offerings. VA-18-0298-F, VA-18-0299-F-000006 Hyperlink to Above 000006 (b) (6) Owner: Booz Allen Hamilton) Filename: image001.png Last Modified: Tue Dec 11 09:18:54 CST 2018 ? VA-18-0298-F, VA-18-0299-F-000007 000007 666 Item: 1 (Attachmew VA [?29k pa rt It runs .\ll'zlirs From: To : Cc: Bee: Subject: Date: Attachments: ( Booz Allen Hamilton) < o=exc ange a s/ou=exchange admin istrat ive ~cn=recipients/cn EHRM in the News and SecVA Stand-Up -- Monday , December 10, 2018 Mon Dec 10 2018 10:14 :46 EST 181210_VA Secretary 's Stand-Up Brief.pptx News Summary: Today 's news includes cont inued coverage of Trump's 'Mar-a-Lago crowd ' and its impact on the EHRM ; a Politico morn ing ehealth report on VA's rollout of standards-based APls for partne rs to connect apps and programs to the Veterans Health Adm inistration, and lastly, a press release from Camilo Sandoval discusses VA's Enterp rise Cloud and the EHRM . EHRMNANews Kansas City Business Journa l: Report: Trump's 'Ma r-a-Lago crowd ' got a first crack at Gerner-VA EHR deal (Dec. 7, 20 18, Andrew Grumke) *Th ree men who belong to President Donald Trump 's private Mar-a- Lago club got a first crack at reviewing Gerner Corp.'s proposed cont ract to revamp the U.S. Department of Veteran Affairs' electronic health record system , includ ing tout ing an app one of them was deve loping. *The three men have little to no health IT or federa l contract ing expe rience , and none served in the military or elsewhere in government, but they were among a group of about 40 who received confident ial access to review the contract , including high-profile hosp ital execut ives , acco rding to ema ils and documents reviewed by ProPublica. *The three men were Ike Perlmutter , cha irman of Marve l Enterta inment ; Bruce Moskowitz , a West Palm Beach phys ician; and lawye r Marc Sherman. All were part of Trump 's circle at Mar-a- Lago, the report says. Politico: Texas needs government money to make te lemed icine happen (Dec. 10, 20 18, Arthur Allen) *VA (MORE) OPEN FOR BUSINESS : On Friday , the agency released deta ils on its rollout of standa rds -based AP ls for partners to connect apps and programs to the Veterans Health Adm inistrat ion . The APls , based on the FHIR standa rd, were discussed at a Wh ite House meet ing last week on health care data interoperability. *CNN finds speeches by VA Secretary Robert Wilkie revea ling his profound sympath ies for the confede rate cause CIO App lications : VA Looks to the Cloud (Dec. 10, 20 18, Camilo Sandova l) *The VA Enterpr ise Cloud is des igned to streamline the workf lows of project teams by represent ing a VA-18-0298-F, VA-18-0299-F-000009 000009 common, logical architecture based on open standards. *As VA moves to a single instance of its EHR, this IT modernization also extends VA an opportunity to rapidly scale health IT innovations across the entire organization in a way not possible before. VA-18-0298-F, VA-18-0299-F-000010 000010 (b) (6) Owner: ( Booz Allen Hamilton) Filename: 181210_VA Secretary's Stand-Up Brief.pptx Last Modified: Mon Dec 10 09:14:46 CST 2018 ? VA-18-0298-F, VA-18-0299-F-000011 000011 VA Secretary's Stand-Up Brief 10 December 2018 Executive Summary CNN's article on Sec. Wilkie's 1995 speech on Jeffe rson Davis led national coverage on Friday and quickly dissipated on Saturday. Storyline Outlets Analysis CNN began reporting on a speech reportedly given by Sec. Wilkie in 1995 at an event sponsored by the United Daughters of the Confederacy at the occasion of an annual celebration of Jefferson Davis' birthday . The Washington Post (1) published a similar story. Task & Purpose published additional statements from the 1995 speech. Other stories were mostly based on the original CNN article. Many articles quoted Press Sec. Cashour's statement that the events attended by the Secretary were, "historical in nature," and that, "he stopped participating in them once the issue became divisive." On Saturday, The Washington Post (2) used the previous day's reporting as a segue into an article holding that Jefferson Davis was "loathed in the Confederacy." Sec. Wilk ie's 1995 speec h on Jeffe rson Davis CNN. Washing.tonPost LJ , Task & Purpose, Huffing_tonPost, The Hill. lntel/ig_encer T elehealth program expand ing Milita[Y_Times. mHealth Intelligence, Politico This storyline increased in visibility , and coverage was supportive. Military Times incorporated Sec. Wilkie's statement from the telehealth conference that, "Virtual care is the future of medicine[ ...] It is our most powerful emerging tool. Ultimately it will improve and ease access for millions of Americans." Women Vetera ns and Suicide VOA VOA drew attention to Women Veterans and Suicide, and VA's role in lowering the prevalence. Deputy Dir. of Suicide Prevention Megan McCarthy provided some messaging for the piece. VA could be getting too much money Milita[Y_Times Military Times provided space to CVA's Dan Caldwell to make a case that VA is receiving too many funding increases. -Emerged Other Sustained Serv ice Longterm Suicide Emerged Serv ice VA-18-0298-F, VA-18-0299-F-000012 000012 VA Secretary's Stand-Up Brief 10 December 2018 Twitter and Facebook Volume: Social Media Takeaway 25 November - 9 Dece mber Social media activity on Friday and Saturday largely shifted to CNN's coverage of Sec. Wilkie and comments about the Confederacy. Volume was unusually low on Sunday. Key Points o All top posts on Sec. Wilkie's 1995 speech on Jefferson Davis linked to the original CNN article written by, among others, Andrew Kaczynski. @KFILE (Andrew Kaczynski) wrote the weekend's most-retweeted post, highlighting Sec. Wilkie's reported statement that Jefferson Davis was a "martyr to the Lost Cause" (3.5k+ retweets). Two others posts by @KFILE quoted more 1995 statements from the Secretary (330+ retweets, 300+ retweets). o In the sixth top post, @jaketapper mirrored the leading @KFILE tweet (490+ retweets). In the eighth post, @splcenter (Southern Poverty Law Center) hashtagged #LoseTheLostCause (300+ retweets). In the tenth post, @AdamSerwer , a writer at The Atlantic, labelled the Secretary as a "nee-confederate" (260+ retweets). o In the second most-retweeted post, @SenKamalaHarris promoted the offer by the "Northern California Veterans Administration" for jobplacement assistance for disaster survivors of the Camp, Hill and Woolsey fires (2.2k+ retweets ). o @SenDuckworth's 6 Dec. tweet on GI Bill delays was in third position (1.2k+ additional retweets, 2.7k+ total). o @elizabethforma (Sen. Elizabeth Warren) linked to the 3 Dec. ProPublica article on Mar-a-Lago (870+ retweets). @SenWarren 's similar 6 Dec. tweet garnered an additional 570+ retweets (2.4k+ total). IU 7t :Ir:> 1?111111. t J DKl6le I ,1 , 6 1 I I ? s...-m.1m Notable Soci al Media Items Platform Item Relevance Tw itter Topic: The Confederacy/ Jefferson Davis 37% of Volume Tw itter Topic: GI Bill delays 8% of Volume Tw itter @SenKamalaHarris 8% of Volume CNCMachines.net 5+ Reactions , Encourages Vets to Facebook 5+ Shares , 0 Consider VA-18-0299-F-000013 Manufacturing VA-18-0298-F, Comments Careers( ... ) 000013 cretary's Stand-Up Brief.pptx for Printed Item: 4 ( Attachment 1 of 1) VA Secretary's Stand-Up Brief 10 December 2018 Military Times: Online VA medical appointments expanding to Walmart sites, VFW posts (7 December , Leo Shane 11 1, 471k uvm ; Spr ingfie ld, VA) In coming months, w hen vetera ns are trying to dec ide w hether to go to a Vetera ns Affa irs hosp ita l or a private doctor for their check-up, they may opt for a trip to Walmart instead . Departme nt officials on Thursday announced a series of new telehealth partnersh ips des igned to drama tically expand the ir current remote care offerings , to include online exam rooms in Wa lmarts, Amer ican Legion posts and Vete rans of Foreign War hangouts centered in rural areas across the country. Hyperlink to Above WCJB (ABC-20 , Video): Lake City VA Medical Center receives gifts and visitors from south Georgia (8 December , 59k uvm; Gainesv ille, FL) The Lake City VA Medical Center rece ived a spec ial vis it from visitors out of south Georgia Friday. Residents from Hehira, Valdosta, and King's Bay Naval Base arrived in a caravan of over 30 vehicles. They brough t donat ions and visited w ith patients . The annua l visit provides personal care items and other gifts . It also g ives the veterans and patients someone to ta lk to . Hyperlink to Above The News-Review: Outgoing director says Roseburg VA's future is bright (8 December , Carisa Cegavske , 33k uvm; Roseburg , OR) Dave Wh itmer arrived at the Roseburg Veterans Affa irs Medical Center in February to take on the role of interim director. He was brought in as a "fixer ," tasked with turn ing around a VA that was struggling with problem manage rs, low staff mora le and allegations of bullying and whistle-blower reta liation. Hyperlink to Above Times Record: Residents pay respects at Christmas Honors (9 Decembe r, Thomas Saccente, 22k uvm; Fort Smith, AR) Cold air, light ra in and overcas t skies did nothing to stop hundreds of loca l res idents from honoring those who foug ht for the ir country on Saturday. The U.S. Nationa l Cemetery at Fort Sm ith held the 10th annua l Christmas Honors wreath event Saturday , w here fami lies laid wreaths from 8 a.m. to 11 a.m. at the cemetery , w ith a ceremony follow ing. Hyperlink to Above mHealth Intelligence: VA Announces Telehealth Partnerships With Walmart, Philips, T-Mobile (7 December , Eric Wicklund, 18k uvm; Danvers , MA) The Departme nt of Vete rans Affa irs is expanding its "Anywhe re to Anyw here VA Health Care" program with new telehea lth and telemed icine partners hips. At th is week's "Anyw here to Anyw here Together" summ it in Wash ington DC, the VA announced connected care programs w ith Wa lmart, TMobile and Philips des igned to give veterans more opportun ities to connect with healthcare providers through telehealth. VA-18-0298-F, VA-18-0299-F-000014 Hyperlink to Above 000014 From: To : Cc: Bee: Subject: Date: Attachments: ( Booz Allen Hamilton) < o=exc ange a s/ou=exchange admin istrat ive ~cn=recipients/cn EHRM in the News and SecVA Stand-Up - Tuesday , December 4, 2018 Tue Dec 04 20 1810:31:36 EST 181204_VA Secretary 's Stand-Up Brief.pptx Attached is the SECVA stand-up for today and below is the EHRM in the news. As a note , both shou ld be cons idered interna l communicat ion products for awareness only and shou ld not be shared unless otherw ise directed. EHRM in the News Tuesday , December 4, 2018 News Summary: Today 's news clips include cont inued coverage about ProPublica 's article regarding the release of ema ils from Trump assoc iates which states they influenced the EHRM effort , and a Forbes article about solut ions to health care's $6 billion patient record match ing problem. EHRMNANews The Hill: Mar-a-Lago tr io reviewed confident ial $10 billion VA contract befo re its release: report (Dec. 3, 20 18, Owen Daugherty) *Th ree Mar-a- Lago club members friend ly with President Trump were reportedly given access to review a $ 10 billion government contract to overhaul electronic health records for vete rans even though they had no prior exper ience in the fie ld. *The three men , Marve l Entertainment Chairman Ike Perlmutter, West Palm Beach physician Bruce Moskowitz and lawyer Marc She rman , were given unprecedented access to confident ial documents and shaped policy at the Department of Vete rans Affa irs (VA), according to ema ils obta ined by ProPub lica through a Freedom of Informat ion Act request. Politico: Interoperabil ity day at the Wh ite House (Dec. 4 , 20 18, Mohana Ravindranath) *WHITE HOUSE INTEROPERABILITY FORUM: The Trump adm inistration is delving deeper into health data issues , this time with an interoperab ility discussion. CMS Adm inistrator Seema Ve rma - who has partne red with Wh ite House sen ior adv iser Jared Kushner on the MyHea ltheData effort - is scheduled to attend , as is ONG head Don Rucker. We 'll have updates after the event th is afternoon. VA-18-0298-F, VA-18-0299-F-000015 000015 *MORE DIRT ON THE MAR-A-LAGO THREE: A ProPublica article based on FOIA'd emails and other documents shows how deeply the three Trump associates at the president's Florida club were involved in efforts to overhaul the VA's EHR -- a role that VA Secretary Robert Wilkie has apparently rejected, as the GAO and House Democrats have promise an investigation of the trio. *According to emails, Marvel Entertainment chairman Ike Perlmutter, West Palm Beach physician Bruce Moskowitz and lawyer Marc Sherman reviewed a confidential draft of the $10 billion Cerner EHR contract and reworded a non-disclosure agreement to allow themselves to talk about it amongst themselves. In one June 2017 email, Moskowitz named himself, Perlmutter and Sherman to an "executive committee" that included VA officials and top health care executives who'd been brought in to counsel the VA on its EHR project. General EHR Articles Forbes: The Best Solutions To Health Care's $6 billion Patient-Matching Problem (Dec. 4, 2018, Rahul Sharma) *The health care industry is plagued with a problem that harms patient safety and exacts an annual toll of $6 billion: patient record matching. *Patient record matching refers to the issue of correctly identifying a patient within the same facility or across different health care organizations. *Besides the monetary issue, patient matching challenges can also cause severe harm to patients. The issue is so acute that it impacts 1 in 5 patient records within the same health care system, and up to 50% of patient records are not matched in transfers. *So, how do we fix it? Here are the best solutions to the patient-matching problem *National Patient Identifier *A 'Smart' Enterprise Master Patient Index (EMPI) *Faster, more accurate record matching through machine learning *Standardization enforced by CMS *Other Possible Solutions VA-18-0298-F, VA-18-0299-F-000016 000016 (b) (6) Owner: ( Booz Allen Hamilton) Filename: 181204_VA Secretary's Stand-Up Brief.pptx Last Modified: Tue Dec 04 09:31:36 CST 2018 ? VA-18-0298-F, VA-18-0299-F-000017 000017 Secretary's Stand-Up Brief.pptx for Printed Item: 6 ( Attachment 1 of 1) VA Secretary's Stand-Up Brief 4 December 2018 Executive Summary Outlets began reprinting ProPub/ica's new report on Mar-a-Lago, however GI Bill delays remained the most visible storyline nationwide. Storyline New ly released documents on Mara- Lago VA "reverses course " on GI Bill Tomah VAMC hous ing program delayed Outlets Analysis ProPub/ica . The Hill ProPub/ica reported on "hundreds of newly released documents" on Mar-a-Lago, which purported ly show the trio had influence over EHR dec isions. The article stated that for a $108 EHR (Gerner) contract, VA consulted with over 40 outside experts , including the trio , who, accord ing to Isaac Arnsdorf, did not have relevant experience to contribute to the project. Among other claims, the piece argued that Bruce Moskowitz had undue influence concern ing the deve lopment of a VA app with Apple. The Hill summarized the story. -Emerged Interope rability / Othe r Politico . Stars and Stripes Politico briefed the main Congressional actions from the end of last w eek taken on the GI Bill. Stars and Stripes gave a relatively clear explana tion of where last week's confus ion came from and how VA intends to make a full retroact ive reimbursement to all concerned Veterans. The piece also stated there are questions about VA fully implementing Section 107 of the Forever GI Bill. Declined Interests La Crosse Tribune 1. g La Crosse Tribune published two articles on neighbors' concerns leading to delays for the trans itional housing project at the Tomah VAMC. Dir. Victor ia Brahm provided much of the messaging. Coverage mentioned that VA has revised parts of the program, with a proposal for increased staffing, and a reduced number of residents. Emerged Interests VA-18-0298-F, VA-18-0299-F-000018 000018 VA Secretary's Stand-Up Brief 4 December 2018 Social Media Takeaway Twitter and Facebook Volume: Mar-a-Lago trended heavily on social media while activity related to GI Bill delays all but disappeared. 19 November - 3 Dece mber Key Points o Nine of the top 10 tweets pertained to Mar-a-Lago . o @ProPublica posted the top three tweets , as well as the seventh tweet , embedding its 3 Dec. article in each. The top tweet (920+ retweets) and the second top tweet (900+ retweets) said the "3 Trump associated secretly steered the VA ," and listed decisions in which they purportedly participated. In the third and seventh most-retweeted posts , @ProPublica claimed emails show the three members were involved in some of the Department's most "consequential matters," including EHR modernization (810+ retweets and 490+ retweets, respectively). A similar tweet by @iarnsdorf garnered 380+ retweets. o @votevets (800+ retweets). @ellievan65 (470+ retweets), @elizabethforma (Sen. Elizabeth Warren, 460+ retweets), and @CREWcrew (Citizens for Ethics, 280+ retweets) also wrote on Mar-aLago with some emphasis on the trio's involvement in EHR decisions. Sen. Warren again included #EndCorruptionNow , which was the top hashtag of the period. o @JasonKander , who withdrew from the Kansas City mayoral race to seek PTSD treatment , wrote the only top ten tweet that was not on Mara-Lago. It said his appointments at the VA PTSD clinic in Kansas City are "going well" and he's "making good progress" (600+ retweets, 15.6k+ likes). o On YouTube, the 1 Dec. Daily Show video on the GI Bill garnered an additional 83k+ views (654k+ total views). 20< ,,. -~ ,ooooooo I l ?I ~ ~ n n n ~ n u u n n ~ I 2 l 0..:1018 Notable Soci al Media Items Platform Item Relevance Twitter Topic: Mar-a-Lago 52% of Volume Twitter Topic: GI Bill delays 4% of Volume Twitter #EndCorruptionNow 460+ Mentions VA-18-0298-F, VA-18-0299-F-000019 400+ Veteran of the Da)l: Reactions, Facebook Joseph L. Annello (USA)000019 80+ Shares Secretary's Stand-Up Brief.pptx for Printed Item: 6 ( Attachment 1 of 1) VA Secretary's Stand-Up Brief 4 December 2018 Berkeley News (Video): Hang in there. As couples age, humor repla ces bickering (3 December , Yasm in Anwar, 758 k uvm ; Berkeley , CA) Honeymoon long over? Hang in the re. A new UC Berke ley study shows those prickly disagreements that can mark the early and middle years of marr iage mellow with age as confl icts give w ay to humor and acceptance . Researchers analyzed videotaped conve rsations between 87 middle-aged and olde r husbands and w ives who had been married for 15 to 35 years , and tracked their emotiona l interact ions ove r the cou rse of 13 years . Hyperlink to Above Foster's Daily Democ rat: New VA c lini c to ex pand servi ces in So mers wo rth (3 Decembe r, John Doyle, 47k uvm ; Dover, NH) More commun ity-based clinical-care opt ions , as well as mental-hea lth and women's health serv ices for veterans are needed in New Hampsh ire, accord ing to U.S. Sen. Magg ie Hassan, D-NH . Hassan made her remarks Monday morning at a groundbreak ing ceremony fo r the U.S. Department of Veterans Affa irs' Somersworth Community Based Outpatient Clinic. Hyperlink to Above KCO (NBC-11 ): VA benefits coordinat or helps vets with health care (3 December , Jason Burger , 29k uvm; Grand Junction, CO) The Grand Junction VA Medical Center is trying to get more veterans enrolled for health care and benefits . They have a full-time VA Benefits Coord inator to help make that happen. Scott Johnston says he was a by the book soldier, and says he was neve r to ld how to get VA benefits afte r his time in the Army. Hyperlink to Above KREX (CBS-5 , Vide o): VA Assists Veter ans To Get Healthcare And Benefits (3 Decembe r, Sta r Harvey , 12k uvm ; Grand Junction, CO) Thousands of Western Slope veterans are not gett ing the healthcare and benefits they are ent itled to, but someth ing is now being done to cor rect that problem, and help veterans navigate the process to obtain benefits. U.S. Army Veteran Scott Johnston filled many roles to protect and honor his country. Hyperlink to Above Hawaii Public Radio (Audio): Vete rans Leading the Charge on Gene tic Medicine (3 December , Ryan Finnerty , 5k uvm; Honolulu, HI) Since 201 1 more than 700 ,000 vete rans nationwide have donated their genet ic information to help the Department of Vete rans Affa irs research the or igins of disease and find new treatments . It's called the Million Veteran Program . In 2015 MVP became the largest human genomic database in the world. Hyperlink to Above VA-18-0298-F, VA-18-0299-F-000020 000020 From : -~ Windom, John H. ; Short, John (VACO) ; Kroupa, Laura (V15) ; (b) (6) - Cc: Bcc: Subject: Date: Attachments: FYSA: EHRM in the News and SecVA Stand-Up - Wednesday, Nov. 7, 2018 Wed Nov 07 2018 15:15:54 EST 181107_VA Secretary's Stand-Up Brief.pptx EHRM in the News Wednesday, November 7, 2018 EHRM/VA News Politico: Wave breaks on GOP House control (Nov. 7, 2018, Arthur Allen)= *Democrats have -- by all indications -- taken the House Tuesday night, while the GOP tightened their grip on the Senate. The result likely rules out another GOP-led attempt to repeal and replace Obamacare, and sets House Democrats up to police the Trump administration's management of health care policy. *We might also see bipartisan national privacy legislation, which, depending on how it's handled, might jostle regulation of the health sector. *The changeover, of course, means a new cast of characters chairing the important committees. In the House, we're likely to see Rep. Frank Pallone chairing the Energy and Commerce Committee and Rep. Mark Takano (likely) leading the Veterans' Affairs Committee. Both chairs will play a role in monitoring the Trump administration's activities -- in particular the VA's implementation of the Cerner EHR. Meri Talk: VA CISO Details Modernization, EHR Implementation Efforts (Nov. 6, 2018, no author listed) *While the Department of Veterans Affairs is approaching IT modernization with a strong desire to improve systems, especially when it comes to electronic health records (EHR), the agency is taking care not to shut down existing systems too early, said deputy CIO and chief information security officer Dominic Cussatt during an episode of Government Matters that aired on Sunday. *Digitization of business processes, another one of VA's goals, also has seen success, winning the VA VA-18-0298-F, VA-18-0299-F-000023 000023 U.S. Digital Service team a Sammie award. Cussatt pointed to the creation of a strategic sourcing arm and an account management office as beneficial to digitization efforts. General EHR News The New Yorker: Why Doctors Hate Their Computers (Nov. 12, 2018 edition, Atul Gawande) *In a piece in The New Yorker this morning, Gawande, the surgeon, writer and CEO of the muchpublicized and still somewhat mysterious Berkshire-Hathaway, Amazon, JP Morgan health care venture, lays out a devastating case for how EHRs have failed doctors. *"Something's gone terribly wrong. Doctors are among the most technology-avid people in society ... yet somehow we've reached a point where people in the medical profession actively, viscerally, volubly hate their computers." *The problem isn't really limited to medicine, in many other fields, the mounting complexity of software, the requirement that it adapt and serve new people and purposes, have created what he calls "the Tar Pit." Technology will continually increase medicine's ability to make diagnoses, offer treatments, and document them--"but not necessarily to make sense of it all." VA-18-0298-F, VA-18-0299-F-000024 000024 Owner: EHRM Public Affairs Filename: 181107_VA Secretary's Stand-Up Brief.pptx Last Modified: Wed Nov 07 14:15:54 CST 2018 VA-18-0298-F, VA-18-0299-F-000025 000025 Secretary's Stand-Up Brief.pptx for Printed Item: 9 ( Attachment 1 of 1) VA Secretary's Stand-Up Brief 7 November 2018 Executive Summary The midterm elect ion results dominated national news, with many references to Veterans as a group or as cand idates, but very few of these articles mentioned VA. Veterans Day and Wreaths Across America events sparked positive local coverage. Storyline Outlets Analysis Stars and Stripes Followi ng the resu lts of the midterm election , Stars and Stripes reported that Democrats have taken over leadersh ip of the key House comm ittees of Armed Services, Veterans Affa irs and Appropr iations . Democrats' success in the House was attributed "in large part to a new wave of mi litary veterans being elected to new congressional seats ." VA CISO discusses EHR modern ization NYC helps Veterans affected by GI Bill delays Democ rats gain control of key House Veteran , Military comm ittees VHA has a "severe" job vacancy problem -Emerged Other MeriTalk Relying on extens ive messag ing from Deputy CIO and Chief Informat ion Secur ity Officer Dominic Cussatt, MeriTalk published th is support ive piece outlining VA's EHR modernizat ion goa ls of retiring legacy systems , digitizing business processes, increas ing cybersecur ity and improv ing data management. The article noted the Department 's success in bus iness process digitization, noting the Digita l Serv ice team won a Samm ie award for its efforts . Sustained Interoperabil ity Connecting Vets. com ConnectingVets.com covered NYC's efforts to help 12k Veterans affected by GI Bill paymen t delays, report ing that the city 's Department of Soc ial Services is prov iding emergency rent benefits to Veterans w ho are at risk of eviction due to the delays . Sustained Interests Pew Research Center This article deta iled an analysis by Pew's Stateline of recent federal figures showi ng VHA has a "severe " job vacancy prob lem in high-cos t urban areas and in largely rural states , report ing that 40,000 of 335 ,000 pos itions rema in unfilled . Sec. Wilkie was quoted as say ing the number of vacancies is "staggering ," and the Department has increased hiring in the past two years to address the issue. Longterm Serv ice VA-18-0298-F, VA-18-0299-F-000026 000026 VA Secretary's Stand-Up Brief 7 November 2018 Twitter and Facebook Volume: 23 October - 6 November Social Media Takeaway 7K Volume was average yesterday. All posts receiving over 100 retweets centerd on the election, with the exception of a tweet by HUD Sec . Carson. .. SK o< Key Points o lmpactful Twitter activity was highly partisan yesterday , claiming that one of the two parties will help VA on wait times, job openings, privatization, or other aspects of health care access. In support of Democrats, @lindeeloo_who wrote the most-retweeted post (650+ retweets). @amvetssupport had the second most-retweeted post (640+ retweets) . The 3 Nov. oost by @KayKosmos sustained, garnering an additional 370+ retweets (2.3k total). In support of the GOP , @KamVTV's 5 Nov. post incorporating the "false news" meme sustained, with an additional 110+ retweets (380+ total). o In the sixth-most retweeted post , @SecretaryCarson linked to the 5 Nov. article in Affordable Housing Finance on the decrease in Homelessness (140+ retweets). ,. ,. IK ll 24 2S 26 Ill 21 21 29 30 )1 l 2 3 4 S ' NOY ,018 ? ToutVol,.,. (19.036) Notable Social Media Items Platform Item Relevance Twitter Topic: Republicans or Democrats support VA 16% of Volume Tw itter #Veterans 160+ Mentions Facebook VAntage Point: On Veterans Dal? a Vet sal?s Thank You to all Vets 570+ Reactions, 70+ Shares VA-18-0298-F, VA-18-0299-F-000027 000027 Secretary's Stand-Up Brief.pptx for Printed Item: 9 ( Attachment 1 of 1) VA Secretary's Stand-Up Brief 7 November 2018 PM Network: 2018 PMI Project of the Year Winner. Full Recovery: A team rebuilt a hospital for military veterans - restoring healthcare and order for a battered city. (November, Sarah Fister Gale; Newtown Square , PA) Hurricane Katrina decimated thousands of buildings in New Orleans , Lou isiana , USA , in 2005 , including a U.S. Department of Veterans Affairs (VA) medical facil ity that served app roximate ly 40,000 military fam ilies. The hospital, also w here world-class resea rch was conducted and more than 500 medical students were train ing to become physicians , suffe red so much damage that it had to be rep laced . Hyperl ink to Above TMC News: On the front line s of health care (6 November, Britni R. McAshan , 2M uvm; Houston , TX ) Today, Burns serves as Assoc iate Director of the Stroke Program and a fam ily nurse pract itione r on the neurology care line at the Michael E. DeBakey VA Medical Cente r Houston . "One of th ings I learned and carry w ith me today is that the military is like a fam ily," Burns said. "It is similar here at the VA because we are like a fami ly ..." Hyperl ink to Above Temple Daily Telegram : Quilts of Valor: Veter ans presented w ith quilts in honor of service (5 November , 25k uvm ; Temp le, TX) Veterans w ho cont inue to serve other veterans by working and volunteering at the Olin E. Teague Veterans' Medical Cente r were given quilts today in hono r of the ir serv ice. Quilts were presented to 11 from the VA staff and a voluntee r. The Texas Patriot ic Piecema kers, a regional group of Qu ilts of Valor Foundation, brought the qui lts to Temp le on Monday to hand out. Hyperl ink to Above MeriTalk: VA CISO Details Moderniz ation, EHR Implementation Efforts (6 November , 11k uvm; A lexandr ia, VA) Wh ile the Department of Veterans Affai rs is approaching IT modern ization with a strong desi re to improve systems , espec ially when it comes to electron ic health records (EHR), the agency is tak ing care not to shut down existing systems too early, said deputy CIO and chief informat ion security officer Dominic Cussatt during an episode of Government Matters that aired on Sunday. Hyperlink to Above Beacon Senior News: Veterans on the MOVE! (6 November , Melanie Wiseman , 170 uvd; Grand Junct ion, CO ) September 16, 2017 , is a date veteran Clifford Wheeler w ill never forget. It was the day he joined the Grand Junct ion Veterans Affairs (VA) Medical Center's MOV E! program- a dec ision that radically changed his life for the better. We ighing 353 pounds when he started , Wheeler felt constantly exhausted. He suffered from severe knee pain and couldn 't tie his shoes. In just ove r a year afte r jo ining MOVE!, he dropped 127 pounds and 36 percent of his body weight, clos ing in on his goal of 190. VA-18-0298-F, VA-18-0299-F-000028 Hyperl ink to Above 000028 From: To: Cc: Bcc: Subject: Date: Attachments: (b) (6) @att.net> Kroupa, Laura (V15) [EXTERNAL] Re: article Wed Aug 08 2018 11:31:48 EDT Thanks. Though I don't think enjoy is probably the emotion I will feel. On Wednesday, August 8, 2018 9:43 AM, "Kroupa, Laura (V15)" (b) (6) @va.gov> wrote: You might enjoy this article-click on the ProPublica link. *The second, published by ProPublica, is focused on the trio of executives and doctors who have been steering VA policy in informal roles. Our colleague, Arthur Allen, first reported on this group's role in connection with the Cerner EHR deal, and the new article expands on their role. The group -- the most high-powered of which is Marvel Entertainment boss Ike Perlmutter -- is unusually tech-oriented. By the article's account, they're constantly pitching new apps and registries for VA adoption. Laura VA-18-0298-F, VA-18-0299-F-000029 000029 From: To: Cc: Bcc: Subject: Date: Attachments: (b) (6) (VISN 8) Kroupa, Laura (V15) FW: [EXTERNAL] 8 August Veterans Affairs Media Summary and News Clips Wed Aug 08 2018 05:55:04 EDT 180808_Veterans Affairs Media Summary and News Clips.docx 180808_Veterans Affairs Media Summary and News Clips.pdf Hi Laura - read 1.3 "shadow rulers of the VA". This resonates with things I have experienced with the office. Good read in my opinion! _____ From: VA Media Analysis <(b) (6) @barbaricum.com> Sent: Wednesday, August 8, 2018 4:16:22 AM To: Barbaricum VA Media Analysis Subject: [EXTERNAL] 8 August Veterans Affairs Media Summary and News Clips Good morning, Please find the attached Veterans Affairs Media Summary and News Clips. VA-18-0298-F, VA-18-0299-F-000030 000030 (b) (6) Owner: (VISN 8) Filename: 180808_Veterans Affairs Media Summary and News Clips.docx Last Modified: Wed Aug 08 04:55:04 CDT 2018 VA-18-0298-F, VA-18-0299-F-000031 000031 1. Top Stories 1.1 - WHAM (ABC-13, Sinclair, Video): 1-on-1 with new VA Secretary Robert Wilkie Jr. (7 August , Scott Thuman , 817k uvm; Rochester , NY) It's one of the most difficult jobs in all of Washington: running the Department of Veterans Affairs and looking after the well-be ing of 9 million veterans annually. After years of mismanagement, a new leader is trying to turn that around. In the video above , VA Secretary Robert Wilkie sits down with chief political correspondent Scott Thuman to explain why he thinks he'll succeed whe re others have failed. Hyperlink to Above 1.2 - Military.com: New VA Secretary Pledges Cleanup Of Scandal-Plagued DC Hospital (7 August , Richard Sisk, 9M uvm; San Francisco , CA) In his second wee k on the job, new VA Secretary Robert Wilk ie pledged a cleanup of the scandal-plagued Washington , D.C., Department of Vete rans Affairs Medical Center whe re inspectors found doctors using rusty surgical tools and identified a sense of "complacency" in the facility 's leadersh ip. Hyperlink to Above 1.3 - ProPublica: The Shadow Rulers of the VA (7 August , Isaac Arnsdorf , 1.1M uvm; New York , NY) Last February , short ly after Peter O'Rourke became chief of staff for the Departme nt of Vetera ns Affairs , he rece ived an email from Bruce Moskow itz w ith his input on a new mental health initiative for the VA. "Received," O'Rourke replied. "I will begin a project plan and develop a timeline for action." Hyperlink to Above 1.4 - U.S. News & World Report (AP): Report: Madison VA Hospital Care Deficient Before Suicide (7 August , 23.9M uvm; Washington , DC) A new federal report finds that Madison's Veterans Hospital provided deficient care for a patient who killed himself a day after being discharged last year. The report by the VA Office of the Inspector General found that hospital staff did not hold the man for an additional 72 hours, as they could have. The report also cited problems with discha rge planning , follow-up and outpatient pharmacy care. Hyperlink to Above 1.5 -The Chippewa Herald: Madison VA hospital's care deficient before veteran's death by suicide, report says (7 August , David Wahlberg, 197k uvm; Chippewa Falls , WI) Madison's Veterans Hospital provided deficient care for a mentally ill patient who killed himself a day after being discharged last year , according to a new federal report. Staff didn't hold the man for an additional 72 hours , as they could have, and there were problems with discharge planning, follow-up and outpatient pharmacy care , says a report by the VA Office of the Inspector General. Hyperlink to Above VA-18-0298-F, VA-18-0299-F-000032 000032 180808_Veterans Affairs Media Summary and News Clips.docx for Printed Item: 12 ( Attachment 1 of 2) 2. Greater Choice for Veterans 2.1 - CNBC: Three civilians from Mar-a-Lago are reportedly making decisions for the VA (7 August, Yen Nee Lee, 26.1M uvm; Englewood Cliffs, NJ) An "informal council" of three people who have neither served in the U.S. military nor hold government positions was found to exert "sweeping influence" on policies concerning America's military veterans, ProPublica reported on Tuesday. Hyperlink to Above 2.2 - The Hill: Mar-a-Lago insiders provided input on VA policy, personnel decisions: report (7 August, Brett Samuels, 11.8M uvm; Washington, DC) A trio of high-profile individuals with ties to President Trump's Mar-a-Lago golf club provided input and directives to staff at the Department of Veterans' Affairs (VA), despite never serving in government or the military. Hyperlink to Above 3. Modernize Our System 3.1 - Stars and Stripes: We can give GIs seamless, lifetime medical records (7 August, Rep. Jim Banks (R-Ind.), 1.5M uvm; Washington, DC) This Congress has been the most productive in decades in delivering results for our veterans. We've sent bipartisan legislation to President Donald Trump's desk that brings accountability to the Department of Veterans Affairs, increases transparency in the timeliness and quality of care, and streamlines the broken appeals process for disability claims -- and passed the largest expansion of GI Bill benefits since the original GI Bill was signed into law. The House has passed more than 70 veterans bills and 26 of those have been signed by the president. Hyperlink to Above 3.2 - WBTV (CBS-3): Salisbury VA to open new clinical laboratory and ICU (7 August, David Whisenant, 319k uvm; Charlotte, NC) A special ribbon cutting will be held on Wednesday for the new clinical lab and ICU at the W.G. "Bill" Hefner Veterans Administration Medical center in Salisbury. The new Salisbury VAMC clinical laboratory is a full-service lab that supports the inpatient hospital, the operating room, outpatient clinics, oncology clinic, dialysis and two free standing Health Care Centers. Hyperlink to Above 3.3 - WJCT (NPR-89.9): Outpatient Health Clinic For Veterans Will Open In Orange Park (7 August, Cyd Hoskinson, 54k uvm; Jacksonville, FL) Military veterans in Clay County are getting a new Veterans Administration outpatient health clinic. 76-year-old Gary Newman started the Clay County chapter of the Vietnam Veterans of America. He said right now, the thousands of veterans who live in the area have to go to the VA clinic in Jacksonville for routine health care. Hyperlink to Above VA-18-0298-F, VA-18-0299-F-000033 000033 180808_Veterans Affairs Media Summary and News Clips.docx for Printed Item: 12 ( Attachment 1 of 2) 3.4 - VC Daily: Military Telemedicine Extends Its Reach to Teletherapy for PTSD (7 August, Charlotte T., 2k uvd) Post Traumatic Stress Disorder is like a terrible echo of life-threatening events from the past. Its sufferers-and there are thousands of them across military and civilian life alike-can become haunted by memories of moments when they or their loved ones were faced with grave danger. Hyperlink to Above 4. Focus Resources More Efficiently 4.1 - Stars and Stripes: VA secretary to announce new leader for DC hospital (7 August, Nikki Wentling, 1.5M uvm; Washington, DC) The Department of Veterans Affairs secretary plans to announce a new, permanent leader for the Washington veterans hospital in the coming weeks after conditions at the facility were reported last month to have deteriorated to a critical level. Hyperlink to Above 4.2 - WFED (AM-1500, Audio): VA's former acting CIO reflects on his tenure (7 August, Freshta Mohammad and Sean Kelley, 854k uvm; Washington, DC) This Trump Administration has seen a great deal of turnover in career senior executives. The Veteran Affairs Department has definitely seen its share. For this month's show, Cyber Chat's host Sean Kelley sat down with a reflective Scott Blackburn. Blackburn served in many capacities while at the VA, including executive in charge of Secretary Robert McDonald's MyVA Initiative, acting deputy secretary of VA and acting CIO. Hyperlink to Above 4.3 - Johnson City Press: Mountain Home National Cemetery director resigns amid health crisis (7 August, Becky Campbell, 194k uvm; Johnson City, TN) When Mountain Home National Cemetery Director Jeny Walker and her staff accepted a national award for excellence last week, it was a professional high for her and the team. It was the second of three awards given by the National Cemetery Administration in her three years directing the cemetery. Walker oversaw a massive expansion project and established an outreach program more inclusive of the community. Hyperlink to Above 4.4 - Williamson Daily News: Hershel 'Woody' Williams VA, local professionals discuss vets' mental health (7 August, Bishop Nash, 24k uvm; Williamson, WV) The Hershel "Woody" Williams VA Medical Center in Huntington hosted its sixth annual mental health summit Friday afternoon, meeting jointly with outside mental health agencies toward serving their common goal in creating better lives and conditions for the area's military veterans. Hyperlink to Above 5. Improve Timeliness of Service 5.1 - MLive: Wurtsmith base water may have caused veteran cancers (7 August, Garret Ellison, 10.9M uvm; Ann Arbor, MI) VA-18-0298-F, VA-18-0299-F-000034 000034 180808_Veterans Affairs Media Summary and News Clips.docx for Printed Item: 12 ( Attachment 1 of 2) Drinking water laced with high levels of poisonous chemicals may be to blame for cancer and other chronic disease among veterans and families who lived at Wurtsmith Air Force Base in northern Michigan, according to a new federal health report draft. Hyperlink to Above 5.2 - Billings Gazette: Veteran finds pain relief without pills through rehab and therapy with Billings naturopaths (7 August, Susan Olp, 854k uvm; Billings, MT) Casey Jourdan, a veteran of the Iraq War, is no stranger to pain. She spent six years in the Montana National Guard, and was deployed in Iraq for a year, starting in 2003. She primarily worked as a turret gunner doing convoy security. On April 13, 2004, she was wounded in a roadside bombing. It left her with permanent joint and nerve damage in her left shoulder, elbow and wrist. Hyperlink to Above 5.3 - WZTV (FOX-17): Viral photo of Tennessee veteran on VA hospital floor sparks outrage (7 August, Kaylin Jorge, 484k uvm; Nashville, TN) A photo showing a veteran passed out on the floor at a middle Tennessee Department of Veterans Affairs hospital has sparked outrage and continues to go viral. However, the VA is saying the story being shared on social media isn't what transpired. FOX 17 News spoke with Gail Hobbs, who took a photo of her brother, Tony Sims, passed out on the floor at Murfreesboro VA. Hyperlink to Above 5.4 - The Telegraph: Veterans serving veterans: County program fosters readjustment after service (7 August, Jill Moon, 160k uvm; Alton, IL) A pair of U.S. Army combat veterans are working together on two fronts to help discharged and retired veterans of any military branch, discharge type and era. Veterans' Assistance Commission (VAC) of Madison County Supervisor Bradley Lavite and Vet Center readjustment counselor Nathan Ferguson started a two-pronged VAC/Vet Center Group Outreach program that works toward a single goal of assisting veterans navigate the complex veterans health care and benefit system... Hyperlink to Above 5.5 - WMFE (NPR-90.7, Audio): Intersection: The Road To Better Care For Veterans (7 August, Brenda Argueta, 70k uvm; Orlando, FL) One of the challenges facing Veterans after their service is getting access to healthcare. Veterans Affairs secretary Robert Wilkie, who was sworn in last week, will address American Veterans tomorrow at the group's annual convention in Orlando. Improving access to healthcare is one of the issues the service organization is looking to Wilkie to address. Hyperlink to Above 5.6 - WMBB (ABC-13): Senator Nelson Speaks with Local Veterans (7 August, Chelsie Taddonio, 50k uvm; Panama City, FL) Veterans from around Bay County expressed concerns to U.S. Sen. Bill Nelson at a round table meeting in Panama City. Sen. Nelson spoke with veterans about a piece of legislation he is proposing, that would protect the military from being taken advantage of by payday loans. The VA-18-0298-F, VA-18-0299-F-000035 000035 180808_Veterans Affairs Media Summary and News Clips.docx for Printed Item: 12 ( Attachment 1 of 2) legislation would cap the interest rate at 24 %. He says this is so... "the poor member of the service doesn't keep building up these loans that they can't pay. And then have to declare bankruptcy." Hyperlink to Above 5.7 - White Mountain Independent: Snowflake resident spearheads VA policy change (7 August, Laura Singleton, 37k uvm; Show Low, AZ) Julius Aubin, a Navy veteran and a resident of Snowflake since 2002, is a mover and a shaker. He can also breathe a little easier now - literally. Aubin has been on a mission to improve healthcare for veterans like himself who use portable oxygen tanks to help them breathe. Specifically, he wants veterans to "get out and be mobile." Hyperlink to Above 6. Suicide Prevention 6.1 - Dispatch - Argus: VA says reaching vets key to stopping suicide (7 August, Jim Meenan, 311k uvm; Moline, IL) The numbers speak harshly for themselves. Every day, about 20 U.S. veterans and current service men and women commit suicide. On average, only about six of those veterans are receiving care from the Veterans Administration. Hyperlink to Above 6.2 - The Daily News: VA center in IM to host Mental Health Summit at Bay West (7 August, 54k uvm; Iron Mountain, MI) The Oscar G. Johnson VA Medical Center will host its sixth annual Mental Health Summit on Tuesday, Aug. 21, in Fornetti Hall at Bay College West, 2801 N. U.S.2 in north Iron Mountain. The event will be 9 a.m. to noon, and is open to local government human services, community mental health agencies, hospitals, veterans and their families, and any other interested organizations or individuals. Hyperlink to Above 7. Women Veterans / Homelessness / Benefits / Cemeteries 7.1 - WCTV (CBS-6, Video): Local World War II vet has VA Clinic named in his honor (7 August, Alicia Turner, 1.4M uvm; Tallahassee, FL) You probably recognize the famous World War II photo of the flag being raised on Iwo Jima. But, the photo most think of wasn't the original flag to be raised. And, one of the soldiers who helped raise the first flag grew up in Monticello. Hyperlink to Above 7.2 - Tallahassee Democrat: VA secretary helps rename vets clinic for Monticello Marine Ernest "Boots" Thomas (7 August, James Call, 439k uvm; Tallahassee, FL) Monticello's Dr. Jim Sledge remembers the ship-borne broadcast with Sgt. Ernest "Boots" Thomas a couple days after the iconic flag raising during the World War II battle for Iwo Jima. A VA-18-0298-F, VA-18-0299-F-000036 000036 180808_Veterans Affairs Media Summary and News Clips.docx for Printed Item: 12 ( Attachment 1 of 2) photo taken of it by the Associated Press appeared around the country in 1945 while the U.S. prepared a final assault on imperial Japan. Hyperlink to Above 7.3 - SportTechie: U.S. Veteran Steve Kirk Uses Breath-Triggered Gun at Wheelchair Games (7 August, Logan Bradley, 157k uvm; Washington, DC) A 1980 skiing accident left U.S. Army veteran Steve Kirk with a dislocated neck and little use of his arms or legs. Almost forty years later, Kirk was competing at last week's National Veterans Wheelchair Games. Kirk took part in the air rifle competition thanks to a gun that is triggered by his breath. Hyperlink to Above 7.4 - St. George News: Salt Lake City Veterans Affairs office to hold first 'Benefits Fair' in St. George (7 August, Ryan Rees, 156k uvm; Saint George, UT) Area veterans will be able to get assistance for a variety of needs when the Department of Veterans Affairs Salt Lake City regional office's outreach team hosts its first "Benefits Fair" Aug. 14 in St. George. [...] "This is new for us," said Thomas Lamb, outreach specialist in the St. George Veterans Affairs office. "They (Veterans Benefits Administration) are sending down two people who are the actual people who handle the benefits paperwork in the Salt Lake office." Hyperlink to Above 8. Other 8.1 - South Bend Tribune: Viewpoint: Donnelly, a tireless advocate for vets, should be reelected (7 August, Joe Kernan, 274k uvm; South Bend, IN) As a Vietnam War veteran and prisoner of war, a former governor of Indiana and a longtime South Bend resident, I believe that we need to re-elect Joe Donnelly to the U.S. Senate. Joe has been a tireless advocate for veterans and service members in the Senate. He works in a bipartisan and common-sense way to deliver real results for all Hoosiers. Hyperlink to Above VA-18-0298-F, VA-18-0299-F-000037 000037 180808_Veterans Affairs Media Summary and News Clips.docx for Printed Item: 12 ( Attachment 1 of 2) Back to Top 1. Top Stories 1.1 - WHAM (ABC-13, Sinclair, Video): 1-on-1 with new VA Secretary Robert Wilkie Jr. (7 August, Scott Thuman, 817k uvm; Rochester, NY) WASHINGTON - It's one of the most difficult jobs in all of Washington: running the Department of Veterans Affairs and looking after the well-being of 9 million veterans annually. After years of mismanagement, a new leader is trying to turn that around. In the video above, VA Secretary Robert Wilkie sits down with chief political correspondent Scott Thuman to explain why he thinks he'll succeed where others have failed. Back to Top 1.2 - Military.com: New VA Secretary Pledges Cleanup Of Scandal-Plagued DC Hospital (7 August, Richard Sisk, 9M uvm; San Francisco, CA) In his second week on the job, new VA Secretary Robert Wilkie pledged a cleanup of the scandal-plagued Washington, D.C., Department of Veterans Affairs Medical Center where inspectors found doctors using rusty surgical tools and identified a sense of "complacency" in the facility's leadership. Wilkie went to VAMC Monday, where he was told that plans were in place for "assuring reliable availability and sterilization of instruments for surgical procedures," the VA said in a release. Wilkie also was told that an electronic inventory was being set up to make sure that the hospital, serving about 90,000 veterans in the D.C. area, overcomes chronic equipment shortages. Previous reports from the VA's Office of Inspector General charged that VAMC staffers at times had to make emergency runs to neighboring hospitals to ask for supplies. The hospital had to borrow bone material for knee replacement surgeries and also ran out of tubes needed for kidney dialysis, forcing staff to go to a private-sector hospital to procure them, the IG's report last year said. VAMC officials also told Wilkie that they were doing better at making timely appointments, particularly for prosthetics. "We had a good visit today, and I appreciated hearing from facility and regional leadership on the important work that has been done to address the Inspector General's concerns, as well as plans for resolving all its remaining recommendations," Wilkie said in a statement. "There have been substantial improvements over the past few months in practice management, logistics and prosthetics in particular, and leaders have a strong plan ahead for even more progress in the coming weeks." VA-18-0298-F, VA-18-0299-F-000038 000038 180808_Veterans Affairs Media Summary and News Clips.docx for Printed Item: 12 ( Attachment 1 of 2) Wilkie approved yet another shuffle of VAMC's leadership to implement the changes. The current acting director, Adam M. Robinson Jr., will return to his previous position as director of the VA Maryland Health Care System. A new permanent director for VAMC has been identified, and the name will be announced "in the near future," the VA said. In the interim, VAMC Chief of Staff Charles Faselis will serve as acting director of the facility. Damning reports from VA Inspector General Michael Missal on conditions at VAMC were a factor in the downfall of Wilkie's predecessor as VA Secretary, Dr. David Shulkin, who was fired in a Tweet by President Donald Trump in March. In April 2017, Missal took the unusual step of issuing an emergency report on conditions at VAMC before his inspection was complete to avoid putting patients at risk. In his scathing report, IG Missal said that storage areas for medical supplies at the VAMC were filthy, management was clueless on what was in the storage areas, medical supply rejects may have been used on patients and more than $150 million in supplies and equipment had never been inventoried. Shulkin relieved VAMC Director Brian Hawkins and replaced him with Lawrence Connell, one of his top policy advisors and a retired Army colonel. In early March, just before Shulkin was fired, Missal issued another report warning that for years VAMC had "suffered a series of systemic and programmatic failures to consistently deliver timely and quality patient care." The report charged that there were staff shortages in several departments and that about $92 million in supplies and equipment were purchased over a two-year period without "proper controls to ensure the purchases were necessary and cost-effective." In April, Connell was out as temporary director following a dispute over "technical aspects" of his appointment, the VA said. In his latest report on VAMC, Missal made 25 recommendations for improving care. The VA said Monday that VAMC had implemented six of the 25 recommendations and was working to resolve the remaining 19. Back to Top 1.3 - ProPublica: The Shadow Rulers of the VA (7 August, Isaac Arnsdorf, 1.1M uvm; New York, NY) Last February, shortly after Peter O'Rourke became chief of staff for the Department of Veterans Affairs, he received an email from Bruce Moskowitz with his input on a new mental health initiative for the VA. "Received," O'Rourke replied. "I will begin a project plan and develop a timeline for action." VA-18-0298-F, VA-18-0299-F-000039 000039 180808_Veterans Affairs Media Summary and News Clips.docx for Printed Item: 12 ( Attachment 1 of 2) O'Rourke treated the email as an order, but Moskowitz is not his boss. In fact, he is not even a government official. Moskowitz is a Palm Beach doctor who helps wealthy people obtain highservice "concierge" medical care. More to the point, he is one-third of an informal council that is exerting sweeping influence on the VA from Mar-a-Lago, President Donald Trump's private club in Palm Beach, Florida. The troika is led by Ike Perlmutter, the reclusive chairman of Marvel Entertainment, who is a longtime acquaintance of President Trump's. The third member is a lawyer named Marc Sherman. None of them has ever served in the U.S. military or government. Yet from a thousand miles away, they have leaned on VA officials and steered policies affecting millions of Americans. They have remained hidden except to a few VA insiders, who have come to call them "the Mar-a-Lago Crowd." Perlmutter, Moskowitz and Sherman declined to be interviewed and fielded questions through a crisis-communications consultant. In a statement, they downplayed their influence, insisting that nobody is obligated to act on their counsel. "At all times, we offered our help and advice on a voluntary basis, seeking nothing at all in return," they said. "While we were always willing to share our thoughts, we did not make or implement any type of policy, possess any authority over agency decisions, or direct government officials to take any actions... To the extent anyone thought our role was anything other than that, we don't believe it was the result of anything we said or did." VA spokesman Curt Cashour did not answer specific questions but said a "broad range of input from individuals both inside and outside VA has helped us immensely over the last year and a half." White House spokeswoman Lindsay Walters also did not answer specific questions and said Perlmutter, Sherman and Moskowitz "have no direct influence over the Department of Veterans Affairs." But hundreds of documents obtained through the Freedom of Information Act and interviews with former administration officials tell a different story -- of a previously unknown triumvirate that hovered over public servants without any transparency, accountability or oversight. The Mara-Lago Crowd spoke with VA officials daily, the documents show, reviewing all manner of policy and personnel decisions. They prodded the VA to start new programs, and officials travelled to Mar-a-Lago at taxpayer expense to hear their views. "Everyone has to go down and kiss the ring," a former administration official said. If the bureaucracy resists the trio's wishes, Perlmutter has a powerful ally: The President of the United States. Trump and Perlmutter regularly talk on the phone and dine together when the president visits Mar-a-Lago. "On any veterans issue, the first person the president calls is Ike," another former official said. Former administration officials say that VA leaders who were at odds with the Mar-A-Lago crowd were pushed out or passed over. Included, those officials say, were the secretary (whose ethical lapses also played a role), deputy secretary, chief of staff, acting under secretary for health, deputy under secretary for health, chief information officer, and the director of electronic health records modernization. At times, Perlmutter, Moskowitz and Sherman have created headaches for VA officials because of their failure to follow government rules and processes. In other cases, they used their influence in ways that could benefit their private interests. They say they never sought or received any financial gain for their advice to the VA. VA-18-0298-F, VA-18-0299-F-000040 000040 180808_Veterans Affairs Media Summary and News Clips.docx for Printed Item: 12 ( Attachment 1 of 2) The arrangement is without parallel in modern presidential history. The Federal Advisory Committee Act of 1972 provides a mechanism for agencies to consult panels of outside advisers, but such committees are subject to cost controls, public disclosure and government oversight. Other presidents have relied on unofficial "kitchen cabinets," but never before have outside advisers been so specifically assigned to one agency. During the transition, Trump handed out advisory roles to several rich associates, but they've all since faded away. The Mara-Lago Crowd, however, has deepened its involvement in the VA. Perlmutter, 75, is painstakingly private -- he reportedly wore a glasses-and-mustache disguise to the 2008 premiere of "Iron Man." One of the few public photographs of him was snapped on Dec. 28, 2016, through a window at Mar-a-Lago. Trump glares warily at the camera. Behind him, Perlmutter smiles knowingly, wearing sunglasses at night. When Trump asked him for help putting a government together, Perlmutter offered to be an outside adviser, according to people familiar with the matter. Having fought for his native Israel in the 1967 war before he moved to the U.S. and became a citizen, Perlmutter chose veterans as his focus. Perlmutter enlisted the assistance of his friends Sherman and Moskowitz. Moskowitz, 70, specializes in knowing the world's top medical expert for any ailment and arranging appointments for clients. He has connections at the country's top medical centers. Sherman, 63, has houses in West Palm Beach and suburban Baltimore and an office in Washington with the consulting firm Alvarez & Marsal. His legal work focuses on financial fraud, white collar investigations and damages disputes. His professional biography lists experience in eight industries, none of them related to health care or veterans. Moskowitz and Sherman helped Perlmutter convene a council of health care executives on the day of the Trump-Perlmutter photograph, Dec. 28, 2016. Offering more private healthcare to vets was a signature promise of Trump's campaign, but at that point he hadn't decided who should lead an effort that would reverse the VA's longstanding practices. A new name surfaced in that meeting: David Shulkin, who'd led the VA's health care division since 2015. Perlmutter then recommended Shulkin to Trump, according to a person familiar with his thinking. (Shulkin did not respond to requests for comment.) Once nominated, Shulkin flew to Mar-a-Lago in early February 2017 to meet with Perlmutter, Sherman and Moskowitz. In a follow-up email a few days later, Moskowitz elaborated on the terms of their relationship. "We do not need to meet in person monthly, but meet face to face only when necessary," he wrote. "We will set up phone conference calls at a convenient time." Shulkin responded diplomatically. "I know how busy all of you are and having you be there in person, and so present, was truly a gift," he wrote. "I found the time we spent, the focus that came out of our discussions, and the time we had with the President very meaningful." It wasn't long before the Mar-a-Lago Crowd wore out their welcome with Shulkin. They advised him on how to do his job even though they sometimes seemed to lack a basic understanding of it. Just after their first meeting, Moskowitz emailed Shulkin again to say, "Congratulations i[t] was unanimous." Shulkin corrected him: "Bruce- this was not the confirmation vote- it was a committee vote- we still need a floor vote." VA-18-0298-F, VA-18-0299-F-000041 000041 180808_Veterans Affairs Media Summary and News Clips.docx for Printed Item: 12 ( Attachment 1 of 2) Perlmutter, Moskowitz and Sherman acted like board members pounding a CEO to turn around a struggling company, a former administration official said. In email after email, officials sought approval from the trio: for an agenda Shulkin was about to present to Trump for a research effort on suicide prevention and for a plan to recruit experts from academic medical centers. "Everything needs to be run by them," the first former official said, recalling the process. "They view themselves as making the decisions." The Mar-a-Lago Crowd bombarded VA officials with demands, many of them inapt or unhelpful. On phone calls with VA officials, Perlmutter would bark at them to move faster, having no patience for bureaucratic explanations about why something has to be done a certain way or take a certain amount of time, former officials said. He issued orders in a thick, Israeli-accented English that can be hard to understand. In one instance, Perlmutter alerted Shulkin to what he called "another real-life example of the issues our great veterans are suffering with when trying to work with the VA." The example came from Karen Donnelly, a real estate agent in Palm Beach who manages the tennis courts in the luxury community where Perlmutter lives. Donnelly's son was having trouble accessing his military medical records. After a month of dead ends, Donnelly said she saw Perlmutter on the tennis court and, knowing his connection to Trump, asked him for help. Perlmutter told her to email him the story because he's "trying to straighten things out" at the VA, she recalled. (Donnelly separately touched off a nasty legal dispute between Perlmutter and a neighbor, Canadian businessman Harold Peerenboom, who objected to her management of the tennis courts. In a lawsuit, Peerenboom accused Perlmutter of mounting a vicious hate mail campaign against him, which Perlmutter's lawyer denied.) Perlmutter forwarded Donnelly's email to Shulkin, Moskowitz and Sherman. "I know we are making very good progress, but this is an excellent reminder that we are also still very far away from achieving our goals," Perlmutter wrote. Shulkin had to explain that they were looking in the wrong place: Since the problem was with military service records, it lay with the Defense Department, not the VA. Perlmutter, Moskowitz and Sherman defended their intervention, saying, "These were the types of stories of agency dysfunction and individual suffering that drove us to offer our volunteer experience in the first place -- veterans who had been left behind by their government. These individual cases helped raise broader issues for government officials in a position to make changes, sometimes leading to assistance for one veteran, sometimes to broader reforms within the system." Right after meeting Shulkin, Moskowitz connected him with his friend Michael Zinner, director of the Miami Cancer Institute and a member of the American College of Surgeons' board of regents. (Zinner declined to comment.) The conversation led to a plan for the American College of Surgeons to evaluate the surgery programs at several VA hospitals. The plan came very close to a formal announcement and contract, internal emails show, but stalled after Shulkin was fired, according to the organization's director, David Hoyt. Besides advocating for friends' interests, some of the Mar-a-Lago Crowd's interventions served their own purposes. Starting in February 2017, Perlmutter convened a series of conference calls with executives at Johnson & Johnson, leading to the development of a public awareness campaign about veteran suicide. They planned to promote the campaign by ringing the closing bell at the New York Stock Exchange around the time of Veterans Day. VA-18-0298-F, VA-18-0299-F-000042 000042 180808_Veterans Affairs Media Summary and News Clips.docx for Printed Item: 12 ( Attachment 1 of 2) The event also turned into a promotional opportunity for Perlmutter's company. Executives from Marvel and its parent company, Disney, joined Johnson & Johnson as sponsors of the Veterans Day event at the stock exchange. Shulkin rang the closing bell standing near a preening and flexing Captain America, with Spider-Man waving from the trading pit, and Marvel swag distributed to some of the attendees. "Generally the VA secretary or defense secretary don't shill for companies," the leader of a veterans advocacy group said. The VA was aware of the ethical questions this event raised because of Shulkin's relationship with Perlmutter. An aide to Shulkin sought ethics advice from the agency's lawyers about the appearance. In an email, the aide noted, "the Secretary is friends with the President of Marvel Comics, Mr. Ike Perlmutter, but he will not be in attendance." The VA redacted the lawyer's answer, and the agency's spokesman would not say whether the ethics official approved Shulkin's participation in the event. Perlmutter did not answer specific questions about this episode. His joint statement with Moskowitz and Sherman said, "None of us has gained any financial benefit from this volunteer effort, nor was that ever a consideration for us." Perlmutter also facilitated a series of conference calls with senior executives from Apple. VA officials were excited about working with the company, but it wasn't immediately obvious what they had to collaborate on. As it turned out, Moskowitz wanted Apple and the VA to develop an app for veterans to find nearby medical services. Who did he bring in to advise them on the project? His son, Aaron, who had built a similar app. The proposal made Apple and VA officials uncomfortable, according to two people familiar with the matter, but Moskowitz's clout kept it alive for months. The VA finally killed the project because Moskowitz was the only one who supported it. Moskowitz, in the joint statement, defended his son's involvement, calling him a "technical expert" who participated in a single phone call alongside others. "Any development efforts, had they occurred, would not have involved Aaron or any of us. There was no product of Dr. Moskowitz's or Aaron's that was promoted or recommended in any way during the call," the trio said. "Again, none of us, including Aaron, stood to receive any financial benefit from the matters discussed during the conversation -- and any claims to the contrary are factually incorrect." Moskowitz had more success pushing a different pet cause. He has spent years trying to start a national registry for medical devices, allowing patients to be notified of product recalls. Moskowitz set up the Biomedical Research and Education Foundation to encourage medical institutions to keep track of devices for their patients to address what he views as a dangerous hole in oversight across the medical profession. At one point, the foundation built a registry to collect data from doctors and patients. Moskowitz chaired the board, and Perlmutter's wife was also a member. Moskowitz's son earned $60,000 a year as the executive director, according to tax disclosures. Moskowitz pushed the VA to pick up where he left off. He joined officials on weekly 7:30 a.m. conference calls in which officals discussed organizing a summit of experts on device registries and making a public commitment to creating one at the VA. In an email to Shulkin, the VA official in charge of the project referred to it as the "Bruce Moskowitz efforts." VA-18-0298-F, VA-18-0299-F-000043 000043 180808_Veterans Affairs Media Summary and News Clips.docx for Printed Item: 12 ( Attachment 1 of 2) When the summit arrived, on June 4, Moskowitz and his son did not attend. It's not clear what role they will have in setting up the VA's registry going forward -- their foundation has shut down, according to its website, and Moskowitz's son said he's no longer involved. But in his opening remarks at the summit, Peter O'Rourke, then the acting secretary, offered a special thanks to "Dr. Bruce Moskowitz and Aaron Moskowitz of the Biomedical Research and Education Foundation" as "driving forces" behind it. Over the course of 2017, there was growing tension within the Trump administration about how much the VA should rely on private medical care. During the campaign, Trump championed letting veterans see any doctor they choose, inside or outside the VA system. But Shulkin warned that such an approach was likely to result in poorer care at a higher cost. His preferred solution was integrating government-run VA care with a network of private providers. In September 2017, the Mar-a-Lago Crowd weighed in on the side of expanding the use of the private sector. "We think that some of the VA hospitals are delivering some specialty healthcare when they shouldn't and when referrals to private facilities or other VA centers would be a better option," Perlmutter wrote in an email to Shulkin and other officials. "Our solution is to make use of academic medical centers and medical trade groups, both of whom have offered to send review teams to the VA hospitals to help this effort." In other words, they proposed inviting private health care executives to tell the VA which services they should outsource to private providers like themselves. It was precisely the kind of fox-in-the-henhouse scenario that the VA's defenders had warned against for years. Shulkin delicately tried to hold off Perlmutter's proposal, saying the VA was already developing an inhouse method of comparing its services to the private sector. Shulkin also clashed with the Mar-a-Lago Crowd over how to improve the VA's electronic recordkeeping software (the one episode involving the trio that has previously surfaced, in a report by Politico). The contract, with a company called Cerner, would cost more than $10 billion and take a decade to implement. But Moskowitz had used a different Cerner product and didn't like it. He complained that the software didn't offer voice recognition, even though newer versions of Cerner's product do. For months, the Mar-a-Lago Crowd pressured Shulkin to put the contract through additional vetting. On Feb. 27, 2018, Shulkin flew to Mar-a-Lago -- not to see Trump, who was back in Washington, but to meet with Perlmutter, Moskowitz and Sherman. The trip was supposed to close the deal on the Cerner contract, according to two people familiar with the meeting. By then, Shulkin's stature had been badly diminished by an ethics scandal, and he expected he didn't have much longer in the job, but he wanted to finish the Cerner deal first. Shulkin brought O'Rourke, an ex-Trump campaign aide who stepped in as chief of staff after the ethics scandal led to the departure of Shulkin's top aide. O'Rourke took the opportunity to ally himself with the Mar-a-Lago Crowd. "It was an honor to meet you all yesterday," he wrote in a follow-up email. "I want to ensure that you have my VA and personal contact information." He then provided his personal cell phone number and email address. (Using personal email to conduct government business can flout federal records laws, as President Trump and his allies relentlessly noted in their attacks on Hillary Clinton during the 2016 campaign.) "Thank you for your support of the President, the VA, and me," O'Rourke wrote. (O'Rourke didn't answer requests for comment.) VA-18-0298-F, VA-18-0299-F-000044 000044 180808_Veterans Affairs Media Summary and News Clips.docx for Printed Item: 12 ( Attachment 1 of 2) Perlmutter welcomed the overture. "I feel confident that you will be a terrific asset moving forward to get things accomplished," he replied. The Mar-a-Lago Crowd grew frustrated with Shulkin, feeling like he wasn't listening to them, and Perlmutter came to regret recommending Shulkin to Trump in the first place, according to people familiar with his thinking. That aligned them with political appointees in the VA and the White House who started to view Shulkin as out of step with the president's agenda. One of these officials, senior adviser Camilo Sandoval, presented himself as Perlmutter's eyes and ears within the agency, two former officials said. For instance, in an email obtained by ProPublica, Sandoval kept tabs on the Apple project and reported back to Moskowitz and Sherman. "I will update the tracker, and please do let me know if this helps answers [sic] questions around Apple's efforts or if additional clarification is required," he wrote. Sandoval, who didn't answer requests for comment, knew Perlmutter because he worked on the campaign with Trump's son-in-law, Jared Kushner, who is also close with Perlmutter. In December, White House adviser Jake Leinenkugel sent Sandoval a memo outlining a plan to upend the department's leadership. Leinenkugel would not say who asked him to write the memo. But it was clearly not intended for Sandoval alone, since it refers to him in the third person. Three people familiar with the situation said the memo was sent to Sandoval as a channel to Perlmutter. The spokeswoman for Perlmutter, Sherman and Moskowitz said they didn't know about the memo. The memo recommended easing Shulkin out and relying on Perlmutter for help replacing him. "Put [Shulkin] on notice to exit after major legislation and key POTUS VA initiatives in place," the memo said. "Utilize outside team (Ike)." Although several factors contributed to Shulkin's downfall, including the ethics scandal and differences with the White House over legislation on buying private health care, three former officials said it was his friction with the Mar-a-Lago Crowd over the Cerner contract that ultimately did him in. Perlmutter, Moskowitz and Sherman dispute that contention. "Any decisions of the agency or the president," they noted in their statement, "as well as the timing of any agency decisions, were independent of our contacts with the VA." But it wasn't just Shulkin -- all the officials that the Leinenkugel memo singled out for removal are now gone, replaced with allies of Perlmutter, Sherman and Moskowitz. The memo suggested that Sandoval take charge of the Office of Information and Technology, overseeing the implementation of the Cerner contract; he got the job in April. The memo proposed removing Deputy Secretary Tom Bowman; he left in June, and the post hasn't been filled. The memo floated Richard Stone for under secretary for health; he got the job on an acting basis in July. Leinenkugel himself took charge of a commission on mental health (the same topic Moskowitz had emailed O'Rourke about). O'Rourke, having hit it off with the Mar-a-Lago Crowd, became acting secretary in May. Trump initially nominated White House doctor Ronny Jackson to replace Shulkin, with Pentagon official Robert Wilkie filling in on a temporary basis. On Wilkie's first day at the VA, Sherman was waiting for him in his office, according to a calendar record. Within a few weeks, Wilkie made a pilgrimage to Mar-a-Lago. He tacked it onto a trip to his native North Carolina, and O'Rourke caught up with him in Palm Beach. They visited a VA VA-18-0298-F, VA-18-0299-F-000045 000045 180808_Veterans Affairs Media Summary and News Clips.docx for Printed Item: 12 ( Attachment 1 of 2) hospital and rehab facility, then headed to Mar-a-Lago to meet with Perlmutter, Moskowitz and Sherman, according to agency records. The Mar-a-Lago Crowd gave Wilkie and O'Rourke rave reviews. "I am sure that I speak for the group, that both you and Peter astounded all of us on how quickly and accurately you assessed the key problems and more importantly the solutions that will be needed to finally move the VA in the right direction," Moskowitz told Wilkie in a follow-up email. Perlmutter was similarly thrilled with the new regime. "For the first time in 1 1/2 years we feel everyone is on the same page. Everybody 'gets it,'" he said in an email. "Again, please know we are available and want to help any possible way 24/7." Wilkie replied that the honor was his. "Thank you again for taking time to see me," he wrote. Soon after, Jackson's nomination imploded over allegations of misconduct as White House physician. (Jackson denied the allegations, and they're still being investigated.) At that point, Perlmutter's endorsement cleared the way for Trump to nominate Wilkie. Wilkie, who was sworn in on July 30, now faces a choice between asserting his own authority over the VA or taking cues from the Mar-a-Lago Crowd. Wilkie reportedly wants to sideline O'Rourke and Sandoval and restock the agency leadership with his own people. But people familiar with the situation said the Mar-a-Lago Crowd's allies are pushing back on Wilkie's efforts to rein them in. As his predecessor learned the hard way, anyone who crosses the Mar-aLago Crowd does so at his own risk. Back to Top 1.4 - U.S. News & World Report (AP): Report: Madison VA Hospital Care Deficient Before Suicide (7 August, 23.9M uvm; Washington, DC) MADISON, Wis. (AP) -- A new federal report finds that Madison's Veterans Hospital provided deficient care for a patient who killed himself a day after being discharged last year. The report by the VA Office of the Inspector General found that hospital staff did not hold the man for an additional 72 hours, as they could have. The report also cited problems with discharge planning, follow-up and outpatient pharmacy care. Wisconsin U.S. Sens. Tammy Baldwin and Ron Johnson requested the review. The Wisconsin State Journal says the report doesn't name the veteran, but his mother identifies him as 24-year-old Robert Franks-Mess, a 24-year-old Marine veteran from Lake Mills. In a statement, Madison VA Director John Rohrer says the hospital has started coordinating more with family members and county crisis services before veterans are discharged. Back to Top 1.5 - The Chippewa Herald: Madison VA hospital's care deficient before veteran's death by suicide, report says (7 August, David Wahlberg, 197k uvm; Chippewa Falls, WI) VA-18-0298-F, VA-18-0299-F-000046 000046 180808_Veterans Affairs Media Summary and News Clips.docx for Printed Item: 12 ( Attachment 1 of 2) Madison's Veterans Hospital provided deficient care for a mentally ill patient who killed himself a day after being discharged last year, according to a new federal report. Staff didn't hold the man for an additional 72 hours, as they could have, and there were problems with discharge planning, follow-up and outpatient pharmacy care, says a report by the VA Office of the Inspector General. "These deficiencies in care may have set the stage for progressive worsening of this veteran's (mental health) disorder that ultimately was a factor in his death by suicide," says the report, released last week after a review requested by U.S. Sens. Tammy Baldwin, a Democrat, and Ron Johnson, a Republican. Robert Franks-Mess, a 24-year-old Marine veteran from Lake Mills, died by suicide on Feb. 18, 2017, after being treated at the Madison VA for depression, post-traumatic stress disorder and traumatic brain injury, said his sister, Dawn Franks-Mess, of Madison. The federal report doesn't name Robert Franks-Mess, but he is the subject of the report, said his mother, Kathleen Franks, of Madison. She and Dawn Franks-Mess said they were interviewed by OIG investigators as part of the review, and the details of his treatment and death match those in the report. Robert Franks-Mess, who served in the Marines from 2010 to 2013, was diagnosed with mental illness in 2014, his sister and mother said. As his symptoms worsened, he was hospitalized twice at the Madison VA in 2017. On Feb. 17 of that year, after being in the hospital two days, he was discharged after a psychiatrist told Kathleen Franks to remove guns from their home, which she had already done, Franks told the State Journal. The next day, he used a gun obtained elsewhere to take his life. "They definitely need to improve their care," Franks said. "Hopefully we can get the awareness out there, that there needs to be improvements within all of the VA facilities around the country." John Rohrer, director of the Madison VA, said in a statement that the hospital has started coordinating more with family members and county crisis services before veterans are discharged. "Unfortunately, in mental health and in all medicine, no set of policies or process will succeed in preventing every negative outcome," Rohrer said. "While we do not agree with every aspect of the OIG report, we continue aggressively to seek ways to improve our care." The report says a psychiatrist considered holding the veteran involuntarily for 72 hours to protect him from self-harm, but thought he might react negatively and said he agreed to return for clinic visits. The doctor also believed the patient's main reason for coming to the hospital was "manipulative," saying he was trying to get a wrist surgery scheduled more quickly. Franks said her son was withdrawn and feeling helpless, and clearly having a mental health crisis. When a nurse told her he was being discharged, she said she couldn't believe it. "I said, 'Are you kidding me?' Do you not see what kind of state he's in?'" Franks said. "I don't feel like I had a choice to talk with them and convince them that he needed to stay." VA-18-0298-F, VA-18-0299-F-000047 000047 180808_Veterans Affairs Media Summary and News Clips.docx for Printed Item: 12 ( Attachment 1 of 2) Dawn Franks-Mess said that other than keeping guns out of the home, there was little discussion about what the family could do to keep her brother safe. "I don't feel like we were given tools to help him," she said. During the hospital stay before the suicide, the report said, the patient reported continued suicidal thoughts and didn't appear to be responding to treatment. "Although in hindsight, it would have been better not to discharge" him, the psychiatrist "had a clear and medically acceptable rationale for doing so," the report said. Discharge planning and follow-up care were inadequate, the report said. Psychiatric clinical pharmacists didn't properly assess the patient's symptoms, evaluate his response to medication or monitor him for mood disorder and suicidal thoughts in the months before the hospital stay, the report said. Similar deficiencies among psychiatric clinical pharmacists were found for another patient who died by suicide 13 months earlier, the report said. The report also said the pharmacists acted outside of the scope of practice in changing diagnoses and providing psychotherapy. In addition, inspectors cited "ethically questionable enrollment in a research study," saying the patient participated in a study but may not have been able to consent voluntarily, thinking participation was required as part of treatment. Dawn Franks-Mess said the study involved taking lithium or a placebo, and the family later learned her brother was on the fake drug. Robert Franks-Mess, who liked hunting, fishing and working on cars, had been outgoing and funloving before becoming withdrawn, his sister and mother said. Shortly before his death, he started to help Lake Mills renovate its skateboard park, which he used growing up. That is where he was found dead, Kathleen Franks said. "How many more families need to go through this before changes are truly made?" she said. Back to Top 2. Greater Choice for Veterans 2.1 - CNBC: Three civilians from Mar-a-Lago are reportedly making decisions for the VA (7 August, Yen Nee Lee, 26.1M uvm; Englewood Cliffs, NJ) An "informal council" of three people who have neither served in the U.S. military nor hold government positions was found to exert "sweeping influence" on policies concerning America's military veterans, ProPublica reported on Tuesday. The three are Marvel Entertainment Chairman Isaac "Ike" Perlmutter, a Palm Beach doctor named Bruce Moskowitz and lawyer Marc Sherman, according to ProPublica. The report said it VA-18-0298-F, VA-18-0299-F-000048 000048 180808_Veterans Affairs Media Summary and News Clips.docx for Printed Item: 12 ( Attachment 1 of 2) was based on "hundreds of documents obtained through the Freedom of Information Act and interviews with former administration officials." All three men are members of Mar-a-Lago, U.S. President Donald Trump's private club in Palm Beach, Florida, according to the report. The trio spoke with officials from the U.S. Department of Veterans Affairs daily and reviewed "all manner of policy and personnel decisions," ProPublica said. Perlmutter also talks to Trump regularly on the phone and is the first person the president calls on issues concerning veterans, the news outlet reported. The White House, the VA, Marvel Entertainment and Sherman didn't immediately reply to CNBC's emails seeking comment. CNBC couldn't reach Moskowitz for comment through a publicly listed phone number. Perlmutter, Moskowitz and Sherman told ProPublica -- through a crisis-communication consultant -- that they offered help and advice on a voluntary basis. They insisted they have no authority over the department's decisions, the report said. White House spokeswoman Lindsay Walters told ProPublica the three "have no direct influence over the Department of Veterans Affairs," while VA spokesman Curt Cashour said "a broad range of input from individuals both inside and outside VA has helped us immensely over the last year and a half." Back to Top 2.2 - The Hill: Mar-a-Lago insiders provided input on VA policy, personnel decisions: report (7 August, Brett Samuels, 11.8M uvm; Washington, DC) A trio of high-profile individuals with ties to President Trump's Mar-a-Lago golf club provided input and directives to staff at the Department of Veterans' Affairs (VA), despite never serving in government or the military. ProPublica reported Tuesday that Marvel Entertainment chairman Ike Perlmutter, Palm Beach doctor Bruce Moskowitz and attorney Marc Sherman communicated daily with VA officials about personnel and policy decisions. The news outlet obtained hundreds of documents that showed the three men suggested new programs and met with senior VA officials in Florida to advise them on the department's agenda. ProPublica cited an instance where former VA Secretary David Shulkin clashed with Moskowitz over an overhaul of the agency's records system. Politico previously reported that Moskowitz objected to the project because he disliked the software involved. He later joined conference calls on the subject with White House approval. In another example, Moskowitz urged the VA to start a national registry for medical devices, a cause he had championed for years, ProPublica reported. He joined officials on weekly conference calls to discuss the matter. VA-18-0298-F, VA-18-0299-F-000049 000049 180808_Veterans Affairs Media Summary and News Clips.docx for Printed Item: 12 ( Attachment 1 of 2) ProPublica cited an instance where Perlmutter wrote to Shulkin urging him to consider using private medical centers and trade groups to advise the VA on which resources to outsource. Perlmutter, Moskowitz and Sherman issued a statement to ProPublica saying they offered their help "on a voluntary basis," adding that they "did not make or implement any type of policy... or direct government officials to take any actions." White House spokeswoman Lindsay Walters told the news outlet that the three men "have no direct influence over the Department of Veterans Affairs." The VA has been a focus of President Trump's, as he has repeatedly promised to deliver improved care for veterans. However, the agency has already undergone multiple leadership changes during the Trump administration and been a source of reported dysfunction. Shulkin was ousted earlier this year amid an investigation into ethical misconduct. He and Trump reportedly clashed over the privatization of the VA. During his tenure, he spoke out dealing with staffers who defied his leadership. Robert Wilkie was confirmed late last month to serve as the new secretary of the agency after Trump's initial replacement pick, Ronny Jackson, withdrew amid scrutiny over alleged workplace misconduct. Back to Top 3. Modernize Our System 3.1 - Stars and Stripes: We can give GIs seamless, lifetime medical records (7 August, Rep. Jim Banks (R-Ind.), 1.5M uvm; Washington, DC) When our servicemembers wear the uniform, they make a commitment to serve our country. In return, our country makes a commitment to them: to take care of our heroes when they come home. This Congress has been the most productive in decades in delivering results for our veterans. We've sent bipartisan legislation to President Donald Trump's desk that brings accountability to the Department of Veterans Affairs, increases transparency in the timeliness and quality of care, and streamlines the broken appeals process for disability claims -- and passed the largest expansion of GI Bill benefits since the original GI Bill was signed into law. The House has passed more than 70 veterans bills and 26 of those have been signed by the president. Although we're delivering on our promises to our nation's veterans, Congress has an important oversight role to ensure the VA stays on track. VA health care relies on an electronic health record, or EHR, system that, like so many other government IT systems, is falling behind the state of the art. While the current EHR was groundbreaking in the 1980s and its ability to share medical records among different VA hospitals was impressive, today it is increasingly starved of new capabilities. Its operations and VA-18-0298-F, VA-18-0299-F-000050 000050 180808_Veterans Affairs Media Summary and News Clips.docx for Printed Item: 12 ( Attachment 1 of 2) maintenance costs are $1 billion per year and climbing, and its ability to communicate with the Department of Defense's system is far from seamless. When servicemembers become veterans their medical records still do not automatically follow them into the VA. Similarly, when the department refers veterans to private providers in their communities, far too often the only way to transfer records is by fax. Outside experts have been recommending for years that the VA and the DOD implement the same commercial EHR system. In May, the VA began the largest EHR modernization program in the country and signed one of the largest IT contracts in the federal government -- following the DOD, which did so in 2013. This multibillion-dollar, 10-year effort, if properly implemented, will modernize not just the VA's EHR system, but the way health care is delivered, making its quality more consistent around the country. It will finally achieve the decades-old goal of a seamless, lifetime health record from enlistment to old age. The key caveat is this transition must be managed properly. The VA has a long and troubling history of IT mismanagement, and even under the best of conditions in the private sector EHR transitions are usually bumpy. The EHR modernization has huge potential to be disruptive, and its failure would be catastrophic to both veterans and taxpayers, which is why Congress must exercise extraordinary oversight. That's why last month, the House Committee on Veterans' Affairs created a new subcommittee on technology modernization dedicated to the task. I'm pleased to announce that the subcommittee will hold our first hearing on Sept. 13. The focus of this hearing will be on the role of the Interagency Program Office. The IPO was created by Congress to act as the single point of accountability for the DOD and the VA to implement a fully interoperable electronic health record system. Ten years later, we're still discussing ways to achieve interoperability, so this development has been anything but rapid. While the IPO can and should be a powerful force for good management, it's clear it is not being utilized to its full potential. We must ensure the IPO has the authority to carry out the mission Congress gave it. Close collaboration between the DOD and the VA is absolutely essential in order to achieve a seamless, lifetime medical record, and the IPO is the best forum to ensure that collaboration. I was honored to be chosen as chairman of this important subcommittee, and I commit to veterans and taxpayers to ask the hard questions. Far too often Congress only finds out a government program is failing when it has already become a crisis. I am determined to do all I can to make sure that is not the case; I pledge to monitor this program every step of the way. Furthermore, Congress and the VA must remain focused on the actual needs of veterans and the dedicated VA employees who care for them. EHR modernization for the sake of EHR modernization is not good enough. Finally, partisanship has no place in this issue, and it would be a shame to allow it to creep it into the discussion. The VA's EHR modernization will span multiple administrations and Congresses, as the DOD's already has. The House Committee on Veterans' Affairs has distinguished itself for constructive bipartisanship, and I am proud to continue this tradition. Rep. Jim Banks, an Indiana Republican, is chairman of the House Committee on Veterans' Affairs subcommittee on technology modernization. Back to Top VA-18-0298-F, VA-18-0299-F-000051 000051 180808_Veterans Affairs Media Summary and News Clips.docx for Printed Item: 12 ( Attachment 1 of 2) 3.2 - WBTV (CBS-3): Salisbury VA to open new clinical laboratory and ICU (7 August, David Whisenant, 319k uvm; Charlotte, NC) SALISBURY, NC - A special ribbon cutting will be held on Wednesday for the new clinical lab and ICU at the W.G. "Bill" Hefner Veterans Administration Medical center in Salisbury. The new Salisbury VAMC clinical laboratory is a full-service lab that supports the inpatient hospital, the operating room, outpatient clinics, oncology clinic, dialysis and two free standing Health Care Centers. The new facility will support a population of nearly 89,000 veterans, according to the VA. The ICU unit is increased from 5 beds to 10 beds with private rooms. Back to Top 3.3 - WJCT (NPR-89.9): Outpatient Health Clinic For Veterans Will Open In Orange Park (7 August, Cyd Hoskinson, 54k uvm; Jacksonville, FL) Military veterans in Clay County are getting a new Veterans Administration outpatient health clinic. 76-year-old Gary Newman started the Clay County chapter of the Vietnam Veterans of America. He said right now, the thousands of veterans who live in the area have to go to the VA clinic in Jacksonville for routine health care. "Most of us World War II and Vietnam veterans, Korean veterans, we're at an age where travel is pretty hard for us sometimes," said Newman. Newman said many Vietnam vets have chronic heart and respiratory conditions brought on by their exposure to Agent Orange, a chemical that was dropped from airplanes. "There were other issues, too. There were burn pits where they burned human waste in these big barrels. And the smoke--many of the veterans were exposed to that," Newman said. Newman's organization worked with Northeast Florida Congressman Ted Yoho to convince VA officials that the new clinic in Orange Park is needed. The VA is renovating a two story building on College Drive. It's expected to open in 2020. Back to Top 3.4 - VC Daily: Military Telemedicine Extends Its Reach to Teletherapy for PTSD (7 August, Charlotte T., 2k uvd) Post Traumatic Stress Disorder is like a terrible echo of life-threatening events from the past. Its sufferers-and there are thousands of them across military and civilian life alike-can become haunted by memories of moments when they or their loved ones were faced with grave danger. VA-18-0298-F, VA-18-0299-F-000052 000052 180808_Veterans Affairs Media Summary and News Clips.docx for Printed Item: 12 ( Attachment 1 of 2) It can leave them unable to sleep, feeling detached or isolated from the world around them, easily startled or irritated, and, in some cases, subject to intense flashbacks that make the sufferer feel like the event is happening again. Despite those horrors, PTSD, as it is commonly known, is treatable. One of the most successful treatments is based around talk therapy, or psychotherapy, which relies on regular, guided conversation. In an effort to make those conversations more accessible to veterans, one former-soldier-turnedpsychologist is incorporating video conferencing into PTSD treatment. His use of teletherapy for PTSD could pave the way for sufferers to receive treatment without leaving their homes and improve early detection of the disorder. Teletherapy for PTSD The veteran in question is Blake Schroedter, whose 17 years in the military included tours in Afghanistan and Iraq. Now, he is the head clinical psychologist of a new program at Rush University Chicago called Road Home aimed at helping veterans cope with the symptoms of PTSD and other mental health issues. Dr. Schroedter started the program in part because of his own difficulties transitioning back to civilian life after years of service. He recently told the Shelbyville Daily Union that veterans need to be given time to decompress and process their combat experiences once they return home. To aid that process, the Road Home program offers an intensive trauma program every month. Dr. Schroedter's group invites 12 veterans from all over the country to attend and treats and houses them at no cost. Importantly, the initial contact between the Rush team and potential patients is over video conference. In Dr. Schroeder's own words, video helps break down barriers that would otherwise prevent veterans from seeking help and saves both time and money. Unfortunately, due to legal telemedicine restrictions, the program itself cannot be conducted over video conference from outside its home state, but there is hope that could change. Veterans' Affairs Video Conferencing Over the course of an hour-long, face-to-face video conference, the Rush University team can assess a potential patient's mental health and determine their suitability for the Road Home program. That efficient way of bringing together a remotely located expert and a person in need is possible due to video conferencing's ability to recreate the in-person experience over a distance. Scientific studies in other areas of medicine have proven that remote treatment over video can be as effective as an in-person visit-VC Daily has previously highlighted studies into remote treatment for addiction, anxiety, and phobias. The success of those studies makes it a greater shame that the Road Home program can't currently be made available outside of Illinois. VA-18-0298-F, VA-18-0299-F-000053 000053 180808_Veterans Affairs Media Summary and News Clips.docx for Printed Item: 12 ( Attachment 1 of 2) If it were run under the banner of the Department of Veterans' Affairs, however, it would be open to all. The Department's public status grants it an exemption, and it has been a strong supporter of telemedicine-in 2016 the VA spent $1.2 billion on telemedicine research and delivery. Perhaps Dr. Schroedter's combined work in teletherapy assessment and the Road Home project itself could encourage the VA to follow suit with its own version. And, seeing as PTSD also affects the civilian population, his work could be incorporated into existing commercially available teletherapy sites. Online Video Therapy Anonymity The chief asset that video conferencing provides the medical field is accessibility. That's true in both a physical sense-people in remote areas need only a webcam and a laptop to potentially reach expert medical opinions the world over-and in an emotional sense. The ability to seek help from the privacy of your own home, and to do so at a time that fits yourStatistics on civilian ptsd lifestyle, offers a degree of anonymity that a trip the local clinic can't provide. Given that most cases of PTSD in the civilian world stem from childhood trauma and deeply personal events such as sexual assault, sufferers may be more open to seeking help if they can do so on their own terms. Dr. Schroedter is already assessing people online, and web-based counseling services such as TalkSpace offer wholly virtual therapy that builds from text to face-to-face meetings. We are still learning how the digital communication technologies of today can best be deployed in the healthcare field, but their core function of bringing people together over time and distance offers a unique access point to deeply sensitive issues. Back to Top 4. Focus Resources More Efficiently 4.1 - Stars and Stripes: VA secretary to announce new leader for DC hospital (7 August, Nikki Wentling, 1.5M uvm; Washington, DC) WASHINGTON -- The Department of Veterans Affairs secretary plans to announce a new, permanent leader for the Washington veterans hospital in the coming weeks after conditions at the facility were reported last month to have deteriorated to a critical level. VA Secretary Robert Wilkie, who's been on the job for one week, visited the Washington DC VA Medical Center on Monday to meet with hospital leaders. In a statement after his visit, the VA announced it found a new leader for the facility who will begin work "in the near future." In July, a senior VA health official warned the hospital's administration that they were under review because of deteriorating conditions there during the first half of 2018. The hospital was found not to be improving fast enough, despite VA executives intervening more than a year ago. VA-18-0298-F, VA-18-0299-F-000054 000054 180808_Veterans Affairs Media Summary and News Clips.docx for Printed Item: 12 ( Attachment 1 of 2) The Washington hospital, located in northwest Washington just a few miles from VA headquarters, has been under scrutiny since April 2017, when Inspector General Michael Missal warned VA officials that veterans were being put at unnecessary risk because of supply shortages. The warning prompted then-VA Secretary David Shulkin to fire the hospital director, Brian Hawkins. Since then, the hospital has been led by two temporary directors, retired Army Col. Larry Connell and Adam Robinson, director of the VA Maryland Health Care System. Connell, who previously worked on President Donald Trump's transition team and as an adviser to Shulkin, led the Washington facility for one year. He was reassigned in April amid an investigation into whether his appointment to the position broke federal protocols. Robinson was assigned to lead the Washington hospital for 120 days, which ends this month. He will return to his position in Maryland, the VA said. Hospital Chief of Staff Charles Faselis will take over for two weeks until the permanent director steps into the job. The VA did not give any further details Tuesday about when the new hospital chief would be named. Last week, an anonymous group of employees at the Washington hospital sent a letter to Wilkie and other top VA officials, urging them to take action to improve conditions there. "We ask you, our respected leaders, to stop this cover up and incompetence, to really care and live up to America's promise to its heroes," they wrote. "Enough is enough." During its investigation, the Office of Inspector General discovered a culture of complacency at the Washington hospital had allowed widespread failures to persist for years. Since the results of the investigation were released in the spring, inspection reports from the Food and Drug Administration and the VA's National Program Office for Sterile Processing have revealed ongoing problems. The reports, obtained by Stars and Stripes, detailed instances of dirty syringe bottles, unsanitary conditions, rooms in disarray and staff and supply shortages that led to canceled procedures. On Monday, the VA said the hospital had addressed six of 25 recommendations that the inspector general issued for improving the facility. Wilkie said there had been "substantial improvements" and that hospital leaders "have a strong plan ahead for even more progress in coming weeks." "We had a good visit today, and I appreciated hearing from facility and regional leadership on the important work that has been done to address the inspector general's concerns, as well as plans for resolving all its remaining recommendations," Wilkie said in a statement. Back to Top 4.2 - WFED (AM-1500, Audio): VA's former acting CIO reflects on his tenure (7 August, Freshta Mohammad and Sean Kelley, 854k uvm; Washington, DC) VA-18-0298-F, VA-18-0299-F-000055 000055 180808_Veterans Affairs Media Summary and News Clips.docx for Printed Item: 12 ( Attachment 1 of 2) This Trump Administration has seen a great deal of turnover in career senior executives. The Veteran Affairs Department has definitely seen its share. For this month's show, Cyber Chat's host Sean Kelley sat down with a reflective Scott Blackburn. Blackburn served in many capacities while at the VA, including executive in charge of Secretary Robert McDonald's MyVA Initiative, acting deputy secretary of VA and acting CIO. Blackburn graduated from both MIT and Harvard and is an Army Veteran and a partner at McKinsey. He comes from a family of veterans and he is a disabled veteran, himself. He says he chose to work at VA because he "was called to serve." Blackburn's leadership ushered in a great deal of progress in Information Security. He credits the leadership of the Dom Cussatt, VA's chief information security officer (CISO) and the Enterprise Cyber Security Plan as some key pieces of the success. Blackburn said VA's cyber program is robust. "The past year, they handled 220 million intrusion attempts, 50 million blocked or contained cases of malware, and 366 million suspicious emails that have come into the system to name a few." He said sustainment is the key to having the Agencies Material Weakness removed. Blackburn said it's difficult to attract the highest quality CIOs and CISOs because the federal government won't offer the highest salaries. But it will never happen without an overall federal strategy to attract but also maintain IT leaders. "[Leadership drain] happens in the private sector, but I have never seen it like this ... it is a reality of government," Blackburn said. "Any leader coming in can't sit back for six months. You have to get up to speed very quickly. You have to trust the career employees. Where do you want to make change that really matters?" Blackburn said he is "most proud of always putting the veterans first. VA is now more veterancentric than it was four years ago. It is more principle based rather than rule based." Blackburn's message for the folks who still work at the VA: "Keep pushing." Back to Top 4.3 - Johnson City Press: Mountain Home National Cemetery director resigns amid health crisis (7 August, Becky Campbell, 194k uvm; Johnson City, TN) When Mountain Home National Cemetery Director Jeny Walker and her staff accepted a national award for excellence last week, it was a professional high for her and the team. It was the second of three awards given by the National Cemetery Administration in her three years directing the cemetery. Walker oversaw a massive expansion project and established an outreach program more inclusive of the community. Mountain Home National Cemetery has been in the news over and over under Walker's tenure. Last week's award was given during a ceremony to announce a new project at the cemetery -- a corresponding metal arch on the corner of the cemetery across from the Washington VA-18-0298-F, VA-18-0299-F-000056 000056 180808_Veterans Affairs Media Summary and News Clips.docx for Printed Item: 12 ( Attachment 1 of 2) County/Johnson City Veterans Memorial that will say "Where Heroes Rest." The arch at the memorial says "Freedom Is Not Free." But less than 24 hours after that announcement and award, life came at Walker like a brick wall. She thought she was having a heart attack and called 911 around 4 a.m. on July 31. It wasn't a heart attack. Instead, what came out of a doctor's mouth after hours of tests was that she had a very aggressive form of cancer that had already metastasized in three places. Walker, 61, had survived lymphoma 15 years ago through the traditional methods of treating cancer, and she said she has no desire to go through that fight again because of the side effects of chemo. When the doctor said it was terminal, Walker made a big decision. Instead of spending her last days -- the doctor gave her three months because of how aggressive the cancer is -- suffering through chemo or radiation, Walker decided to plan a trip and mark a few things off her bucket list. Yes, she is still coming to terms with her diagnosis, and she's traveling the rollercoaster of emotions that comes with a fatal diagnosis. But her intent is clear -- she'll do anything within her power to not leave this world with things unsaid or undone. Pretty quickly after the diagnosis, Walker resigned her position and left the helm to a recently hired assistant director. She set about calling close friends with the news, then called a staff meeting last Friday to tell her employees what was going on. Needless to say, everyone was shocked. Walker, too, feels the shock, but has come to terms with the diagnosis. "I'm pretty resolved," to the diagnosis, Walker said on Tuesday. "It is what it is. I could sit in bed and be bitter and wait to die. I'm not sitting and waiting on it. I want to go as long as I can, as far as I can." And if she's no longer able to go, Walker said, she'll return to her hometown of Raleigh, North Carolina, for whatever time she has left. Walker said she's been amazed at the outpouring of support from the Johnson City community as well as areas where she's previously lived. "So many people have expressed love," she said. "I want to say 'thank you' to the community. This community has opened their arms and hearts to me. The veterans have embraced me, the organizations have embraced me as well as the cemetery. I've made some of the closest friends I've had in my life. It's been fabulous, probably the best three years of my life." Walker said the past 15 years were a "gift" she'd had and she's made the most of it. During her first round with cancer, Walker said she did a lot of personal growth and gained a different perspective on life. "Some people would call it borrowed time," she said. "I've had a very blessed life ... I learned to guide my life with an open heart, to always be kind and to always be honest." VA-18-0298-F, VA-18-0299-F-000057 000057 180808_Veterans Affairs Media Summary and News Clips.docx for Printed Item: 12 ( Attachment 1 of 2) Sure, she's angry, but not about what most might think. She's angry "I had to leave a job I love." Walker said she appreciates the National Cemetery Administration for "letting me do it my way, for giving me a great opportunity. I've helped a lot of people and a lot of veterans. That's the reward." One thing Walker said she tells her grandchildren is "learn something new every day. You have to look for that message every day." Walker takes that message to heart and said she's still learning and growing as a person -- and she'll continue following that path until her journey ends. Back to Top 4.4 - Williamson Daily News: Hershel 'Woody' Williams VA, local professionals discuss vets' mental health (7 August, Bishop Nash, 24k uvm; Williamson, WV) HUNTINGTON - The Hershel "Woody" Williams VA Medical Center in Huntington hosted its sixth annual mental health summit Friday afternoon, meeting jointly with outside mental health agencies toward serving their common goal in creating better lives and conditions for the area's military veterans. The summit brought under one roof voices from across the region's mental health sector, such as the Prestera Center and Marshall University, to coordinate their often overlapping and interwoven efforts, discuss what may or may not be working, identify any gaps in service, and to hear first-hand feedback from veterans themselves. "I think we're doing great mental health care here in Huntington, but you can always do better," said Chuck Weinberg, VA local recovery coordinator. "So we've giving the message to veterans that we're on an improvement program too." "The mental health summit affords partners the opportunity to learn more about the experiences and behavioral health needs of area veterans and their families," added Kim Miller, Prestera Center director of development. "It's a great opportunity to network and share information about our programs and services." Veterans are not beholden to seeking care from the VA system, making it important for outside mental health providers to understand and stay up-to-date on the needs of the veterans they mutually serve, said Kim White, assistant professor of social work at Marshall University and U.S. Navy veteran. "It's one thing to offer services, but it's very important for a service provider to understand veteran culture as sort of a subculture to our larger culture," White said. Post-traumatic stress disorder has long been the most talked about and troubling mental health issue affecting veterans since the Vietnam War, but White pointed out current issues surround problems in fully acclimating a veteran back into civilian life. Regionally, these issues primary to veterans often intersect with existing widespread mental health problems in Appalachia, such as addiction and a poor economy. VA-18-0298-F, VA-18-0299-F-000058 000058 180808_Veterans Affairs Media Summary and News Clips.docx for Printed Item: 12 ( Attachment 1 of 2) "We're in an economic situation that isn't always conducive to immediate employment when you (as a veteran) may be used to being in charge, being a leader and being paid what you're worth," White said. "To have to come back into civilian society, it can be very difficult for people and the heads of households to not be able to find a job quickly when they return. And that can be devastating for a person's identity." The Hershel "Woody" Williams VA Medical Center serves nearly 30,000 veterans in 10 counties in West Virginia, 12 counties in eastern Kentucky, and two counties in southern Ohio from its 80bed facility off Spring Valley Drive. Back to Top 5. Improve Timeliness of Service 5.1 - MLive: Wurtsmith base water may have caused veteran cancers (7 August, Garret Ellison, 10.9M uvm; Ann Arbor, MI) OSCODA, MI -- Drinking water laced with high levels of poisonous chemicals may be to blame for cancer and other chronic disease among veterans and families who lived at Wurtsmith Air Force Base in northern Michigan, according to a new federal health report draft. That conclusion, reached in July by the Agency for Toxic Substances and Disease Registry (ATSDR), sets the table for Congress to consider legislation that would force the Department of Veterans Affairs to extend health benefits to base veterans without making them somehow prove their illnesses are linked to chemical exposure. No bill has yet been introduced, although U.S. Rep. Dan Kildee, D-Flint, says he's working on legislation similar to that which forced the VA to cover similar health claims at Camp Lejeune in North Carolina, where drinking water was contaminated with chlorinated solvents. Those same chemicals, notably benzene and trichloroethylene (TCE), were documented at extremely high levels in Wurstmith water when the former B-52 bomber base was active. "We must do more to help veterans exposed to harmful chemicals during their military service," said Kildee in a statement. "It is troubling that veterans may have a higher risk of cancer and other health effects if they were exposed to TCE and other harmful chemicals." "This report's findings demonstrate that all levels of government must do more to help veterans get the health care they need," he said. The ATSDR report concludes that people who consumed or had skin contact with Wurtsmith water "may be at an increased risk for cancer." The finding is based on new lower risk levels for exposure to TCE and benzene than were used in a 17-year-old assessment, which called it "unknown" whether past contamination posed a hazard. The updated report conclusions are based largely on long-term exposure over a period of years, but note that, for pregnant mothers, even short term exposure to TCE during the first trimester could have resulted in heart birth defects in their baby children. VA-18-0298-F, VA-18-0299-F-000059 000059 180808_Veterans Affairs Media Summary and News Clips.docx for Printed Item: 12 ( Attachment 1 of 2) The base opened in 1923 and closed in 1993. TCE was found in Wurtsmith water in 1977, but the report notes the drinking water wells on base "could have (been) contaminated for many years before the initial discovery." All wells were shut down by 1997, when the base switched to a municipal system which draws from Lake Huron. The Air Force installed a groundwater treatment system to cleanup TCE in the early 1980s after being sued by the state of Michigan. The ATSDR looked at past levels of TCE and benzene, but did not consider exposure to perand polyfluoroalkyl substances, or PFAS, contamination caused by base firefighters using chemical-based firefighting foam. The chemicals were found in Wurtsmith groundwater in 1998 but did not get significant attention until the state issued a local advisory for well owners in 2016. According to the ATSDR, TCE levels in a well at the corner of Arrow Street and N. Skeel Avenue were as high as 5,173 parts-per-billion (ppb) during a 1977 test -- more than 1,000 times the EPA's current limit of 5-ppb for TCE in drinking water. TCE in another well on Jet Street near the present day Wurtsmith museum was 1,739-ppb. "When it's all said and done, I think the exposures to TCE and vinyl chloride up there are going to be higher than Camp Lejeune," said Jerry Ensminger, a veteran who spearheaded the effort to get health benefits at Lejuene after the death of his daughter, Janey. Ensminger began pushing for exposure-related benefits in 1997. In 2012, Congress passed a law named after his daughter that forced the VA to automatically presume diseases like adult leukemia, bladder, kidney and liver cancer, Non-Hodgkin's lymphoma and Parkinson's disease were caused by base water exposure. As with Wurtsmith, the initial ATSDR public health assessment of Lejeune contamination lowballed the exposure concern. It was eventually updated in 2009. The Veterans & Civilians Clean Water Alliance group of Wurtsmith veterans and families pushed the ATSDR to update the base report last year. Ensminger likened the hurdle to awaiting formal diagnosis of an obvious problem. "You know your house is on fire. You see the fire and the smoke, but your house is not 'officially' on fire until the fire department gets there and says so," he said. "That's the same thing with these contamination sites and toxic exposures. You need an official to come in and say, 'yea, they were exposed at harmful levels.'" "Now, somebody has to go to Capitol Hill." Kildee said he's working both sides of the aisle for bipartisan support on a Wurtsmith bill, but did not offer a timeline or specifics. Congress has been appropriating money to address contamination at military bases recently, but those funds are specifically tied to PFAS exposure. The cost of extending presumptive benefits to Wurtsmith veterans could be high. The VA estimated last year it will pay $2.2 billion by 2022 to Lejeune veterans under the new program, and that doesn't include coverage for certain civilians and family members. Wurtsmith veteran Scott Flannery of Manassas, Va., lived on base in the late 1970s. He's considered completely and permanently disabled after a 32-year military career. VA-18-0298-F, VA-18-0299-F-000060 000060 180808_Veterans Affairs Media Summary and News Clips.docx for Printed Item: 12 ( Attachment 1 of 2) Flannery, who helped push for the health assessment update, said he's glad that everything has "come to fruition" but also hopes the federal government will "do the right thing with the issues affecting them now with the firefighting foam." "I'm hoping all the best for all those who could have been potentially affected," Flannery said. Back to Top 5.2 - Billings Gazette: Veteran finds pain relief without pills through rehab and therapy with Billings naturopaths (7 August, Susan Olp, 854k uvm; Billings, MT) Casey Jourdan, a veteran of the Iraq War, is no stranger to pain. She spent six years in the Montana National Guard, and was deployed in Iraq for a year, starting in 2003. She primarily worked as a turret gunner doing convoy security. On April 13, 2004, she was wounded in a roadside bombing. It left her with permanent joint and nerve damage in her left shoulder, elbow and wrist. An X-ray didn't reveal the separation in her shoulder, which was discovered later. And since Jourdan didn't sustain any injuries from shrapnel and no bleeding, she decided to stay with her company. The X-ray also couldn't reveal that Jourdan had developed PTSD and a traumatic brain injury. When she came home to Montana and enrolled at Montana State University, the combination of the two led her to drop out. She sought therapy for her PTSD, and the depression and anxiety that came with it. But the TBI caused visual spatial damage, which impaired her ability to read, a connection Jourdan didn't figure out until five years after she was discharged. It forced her to re-learn that most basic skill, and she still deals with other TBI-related issues. "I have short-term memory issues, and I had to learn to read again," Jourdan said. "From a nearphotographic memory, now I can't tell you what I ate for breakfast today." She spent much of her time seeing doctors to deal with her medical issues. Through the VA medical system she got shoulder surgery to try and regain some feeling back in her hands. She praises the level of care she got, but her treatment was spread among different physicians. "I saw one doc for shoulder stuff and his answer was either pain pills or ibuprofen and therapy," Jourdan said. "I had another doc for occupational therapy for TBI and meds for anxiety. And a third doc prescribed antidepressants and mental health therapy for PTSD." Eventually she moved to Billings, where she earned a bachelor's degree in political science and a master's degree in mental health counseling. Jourdan is self-employed and does CrossFit coaching. VA-18-0298-F, VA-18-0299-F-000061 000061 180808_Veterans Affairs Media Summary and News Clips.docx for Printed Item: 12 ( Attachment 1 of 2) She went to Yellowstone Naturopathic Clinic as an alternative to pills, which she avoided, to find relief for her chronic shoulder pain. Chiropractic care and massage therapy decreased the pain and rehab helped her get back in the gym, to get more active. "I went through weeks of chiropractic care and massage therapy as part of dealing with my chronic shoulder pain, and it made a big difference for me," Jourdan said. "It really got my pain into a much more manageable area." Now, she'd like to see more veterans try the naturopathic route. And if the care isn't covered by the Veteran's Administration, then a foundation created in honor Paul Gardner, a vet who accidentally overdosed on pain medication, will pay for the treatment. Jourdan knew Gardner, who was a good friend and helped her come out of her shell when she moved to Billings. Like Jourdan, Gardner had a TBI and some nerve damage. "His injuries were a bit worse than mine, but he was working hard, getting physically and emotionally better and trying to really put his life back together," she said. Through his death, the foundation was born. Jourdan, a member of the board, and the others involved with the nonprofit, hope other veterans, with the foundation's help, will find answers to their pain so they don't suffer the same fate. "We want to show that if we take a more holistic approach to all these problems, we will get a better-long term outcome," she said. Developing the program The treatments are part of a pain clinic developed by Dr. Margaret Beeson, naturopath and founder/owner of the Yellowstone Naturopathic Clinic, and Patricia Holl, a chiropractor at the clinic. The concept for the Yellowstone Pain Relief Center began before the focus turned to helping wounded veterans, Beeson said. Many of the treatments already were available, including chiropractic care, regenerative injection therapies to spur ligament healing, acupuncture and therapeutic massage, among others. The idea was to bundle them to help patients who relied on drugs, including opioids, for pain relief. "We decided we were going to take people on paid meds struggling to get off them," she said. "We'd review their cases and come up with a four- to six-week treatment program to show them they could reduce their meds." In the middle of planning for the new center in March 2011, Beeson met with George Blackard, who worked with the clinic on IT issues. Blackard, who also is commander of American Legion Andrew Pearson Post 117, told Beeson that a young vet -- Paul Gardner -- had died the night before of an accidental overdose. Beeson and Holl thought the pain clinic might be a good fit for veterans like Gardner. They worked with Blackard and Gardner's family to create a foundation to help fund treatment for vets. VA-18-0298-F, VA-18-0299-F-000062 000062 180808_Veterans Affairs Media Summary and News Clips.docx for Printed Item: 12 ( Attachment 1 of 2) The VA referred to the clinic quite a bit, and at that time it was paying for chiropractic and massage and some acupuncture, Beeson said. But it wouldn't cover the injection therapy, and now doesn't cover some of the other treatments. To help vets seeking non-narcotic options for rehabilitation and pain relief, the Paul Gardner Veterans Pain Relief Foundation was formed. "Then we decided 'let's do a study to see if we can show these things can help vets get off their drugs,'" Beeson said. The goal of the study was to evaluate if a multi-treatment approach to healing low back pain could indeed reduce pain, decrease pain medication use and increase quality of life for vets enrolled in the study. It was open to participants ages 20-40 who had been deployed in the Iraq or Afghanistan wars. They had to meet certain qualifications and agree to take part in all the screenings and treatments. To date, seven vets have taken part in the study, and Beeson and Holl hope that number will continue to grow. Regardless of whether vets qualify for the study, the foundation will cover the costs of their treatment at the clinic. "We told vets 'we will serve you no matter what,'" Beeson said. "If they don't fit in the study, we will make sure they get the treatment they need." Holl, who oversees the vets' therapy, sees the many challenges they face, calling them a fragile population. "They come here and have other crises because they have injuries and a dependency on opioids," she said. "They can't keep jobs, their family breaks down and it cascades in a downward spiral. That's what we're trying to help." For vets who are willing to commit themselves to completing the treatment, Holl has seen a positive result. "I've gotten letters from some of the attendees thanking us for helping them get their lives back," she said. "The patient who walks in the door on day one and the one who walks out the door at the end is different. It's striking." Back to Top 5.3 - WZTV (FOX-17): Viral photo of Tennessee veteran on VA hospital floor sparks outrage (7 August, Kaylin Jorge, 484k uvm; Nashville, TN) MURFREESBORO, Tenn. - A photo showing a veteran passed out on the floor at a middle Tennessee Department of Veterans Affairs hospital has sparked outrage and continues to go viral. However, the VA is saying the story being shared on social media isn't what transpired. VA-18-0298-F, VA-18-0299-F-000063 000063 180808_Veterans Affairs Media Summary and News Clips.docx for Printed Item: 12 ( Attachment 1 of 2) FOX 17 News spoke with Gail Hobbs, who took a photo of her brother, Tony Sims, passed out on the floor at Murfreesboro VA. It's been liked and shared more than 300,000 times in just three days. Gail, who has been taking care of Tony since April, said she took Tony to the Murfreesboro VA on Thursday, where he had blood work and a urine sample taken. According to Gail, despite Tony feeling very ill, the doctor told them both that he was "OK," but the doctor wanted to do an MRI. After the MRI, Gail and Tony said they waited in a room that did not have a bed. Gail told FOX 17 News she repeatedly asked the doctor for a bed so that Tony may lie down because he was very tired, but the doctor allegedly said he couldn't be admitted, therefore not getting a bed, because he was not sick. Tony was also cold and asked for a blanket, which nurses brought to him, according to Hobbs. Tony put the blanket on the floor and went to lay down, but Gail said he passed out before he reached the floor. That's when she took the viral photo, captioned, "This is my brother Tony Mims laying in the floor at VA Hospital in Murfreesboro the Dr wasn't sure if he was sick enough to be admitted to hospital we waited eight hours for them to put him in a bed he can't even walk he deserves better treatment he served his country." As of Monday afternoon, the post had been shared more than 232,000 times with more than 103,000 likes. Gail said the nurses immediately came to Tony's aid after he was on the floor. "The nurses were wonderful," Gail said over the phone. The next day, Gail said Tony visited another doctor at the hospital who diagnosed him with pneumonia. When Gail asked how the doctor found that out, they replied, "by a simple swab of the nose." Gail says Tony's previous doctor didn't look into anything other than his blood work, urine sample and MRI. "I don't blame the VA, the VA has a long way to go to be perfect, like everyone," Gail said. "But you can't lump everything together." Gail says she only blames the doctor who she believes didn't give Tony proper care. Gail didn't want to go on camera, and said she was overwhelmed with the amount of attention the photo has gotten. She says she didn't do it for the publicity, but to get her brother proper care. Officials from the local VA, including the Murfreesboro VA director, met with Tony over the weekend. Gail is hoping to have Tony is a nursing home by the end of the week. Meanwhile, FOX 17 News reached out to the local VA and received the following response: VA-18-0298-F, VA-18-0299-F-000064 000064 180808_Veterans Affairs Media Summary and News Clips.docx for Printed Item: 12 ( Attachment 1 of 2) As soon as we learned of this photo on Friday night, we immediately reviewed the Veteran's medical record and have since spoken to the Veteran personally. Our review determined that the facts are much different than what's presented in the Facebook post. Tony Mims was admitted to VA Tennessee Valley Healthcare System August 2, the day the photo was taken. During a ten-minute wait for his provider to return to his exam room, Mims said that his sister, who had accompanied him to his appointment, helped him move to the floor of the exam room because he was tired. Mr. Mims estimated he was on the floor about ten minutes before a provider returned. Mims is now an inpatient in our facility and he is being well taken care of. Our medical center director has visited the patient and has his assurance that he received good care and has no complaints. Back to Top 5.4 - The Telegraph: Veterans serving veterans: County program fosters readjustment after service (7 August, Jill Moon, 160k uvm; Alton, IL) WOOD RIVER -- A pair of U.S. Army combat veterans are working together on two fronts to help discharged and retired veterans of any military branch, discharge type and era. Veterans' Assistance Commission (VAC) of Madison County Supervisor Bradley Lavite and Vet Center readjustment counselor Nathan Ferguson started a two-pronged VAC/Vet Center Group Outreach program that works toward a single goal of assisting veterans navigate the complex veterans health care and benefit system through the federal Veterans Health Administration and Benefits Administration, both under the U.S. Department of Veterans Affairs. Lavite and Ferguson aim to provide consistency in their approach to help veterans readjust and maintain a healthy stable life. Lavite works on the benefits administration side, assisting veterans with complicated Veterans Administration (VA) benefits paperwork and disability filings. Ferguson works on the health administration side and provides one-on-one mental health counseling, as well as readjustment counseling for groups of veterans. "When working on the benefits administrative side, we weave the question into every conversation, 'Have you met with the Vet Center?'" Lavite explained. "They can get in to be seen one-on-one, free of charge, for readjustment or other counseling services. The federal government foots the bill. These are free services sitting here -- paid for -- for veterans to access and use immediately within the community. Veterans don't have to register, they don't have to have a medical card or insurance. It's all free, because they served." Lavite and Ferguson began working together in 2015 to combine their expertise from their respective fields to maximize and capitalize on the various benefits and counseling services veterans receive throughout Madison County. Lavite provides a complex roadmap created specifically for each individual veteran and Ferguson helps those individuals navigate that roadmap specifically on the counseling side of things. VA-18-0298-F, VA-18-0299-F-000065 000065 180808_Veterans Affairs Media Summary and News Clips.docx for Printed Item: 12 ( Attachment 1 of 2) Counseling provided by the Vet Center is strictly confidential and in accordance with HIPAA laws, addressing mental health issues, such as post-traumatic stress disorder, anxiety and readjustment. "Readjustment is a primary focus because veterans in general -- not just combat -- have issues readjusting to numerous things in life," Ferguson said. Ferguson works for the federal Vet Center in East St. Louis and does outpatient clinical therapy at various Vet Center satellite locations, now including Von Dell Gallery, located at 102 E. Ferguson Ave. in Wood River. Ferguson is on site starting at 9:30 a.m. on the fourth Wednesday of each month in Wood River. "A veteran can walk into any of those location, there's no screening or pre-registration required," Lavite explained about each satellite VA center. Consistent at each meeting and location is a counseling component, led by Ferguson, which goes along with Lavite's component of navigating benefits administrative requirements, such as understanding the VA disability and compensation process and filling out the plethora of forms. Both Lavite and Ferguson, as well as their individual offices, spend numerous hours connecting veterans to resources and following-up with them to ensure that they are successfully navigating the numerous systems. Individual one-on-one appointments are available from 1 to 3:30 p.m. at each outreach location, as a convenience to the veteran and to those who may not have stable transportation. A delegation of local Madison County, Illinois, veterans established the VAC in 1933 for the sigular purpose of assisting veterans in need. Veterans who are active and participate in any of the VAC/Vet Center Group Outreach also has the opportunity to engage in a Von Dell Gallery art class provided by the VAC. Art classes give members of veteran groups a chance to maintain camaraderie in a laid-back, non-clinical environment; express themselves through art; and, complete a project to take home. At this time, the VAC is planning to have quarterly art classes for those veterans who are active and participate as part of any of the established groups. The program's first quarterly art class at Von Dell occurred approximately three weeks ago, with the group taking instruction from awardwinning artist Terry Diveley in his leathering art class. Diveley teaches the art of leather tooling and painting tooled images once pounded into a piece of leather. The VAC/Vet Center Group Outreach meetings at the Von Dell Gallery are held on a reoccurring monthly basis, while the art classes are held on a quarterly basis and actively participating veterans are pre-registered by the VAC. Lavite and Ferguson will hold the first monthly Wood River group outreach meeting, which is open to all veterans, at 9:30 a.m. Wednesday, Aug. 22, at Von Dell Gallery. After the veterans group outreach portion, veterans have the option of hanging around for Diveley's leather pictorial class, which he offers free to the general public from 11 a.m. to 3 p.m. every Wednesday. Diveley asked that interested people please register by calling Von Dell Gallery at 618-251-8550 to make sure there are enough tools for each student. Von Dell Gallery, owned by Gary Conrad, of Grafton, currently offers 14 different painting classes to the general public for a reasonable fee. VA-18-0298-F, VA-18-0299-F-000066 000066 180808_Veterans Affairs Media Summary and News Clips.docx for Printed Item: 12 ( Attachment 1 of 2) Diveley, of Bethalto, leases a studio at Von Dell Gallery and teaches regular open-to-the-public classes at the gallery. He is just one of many talented regional artists who teach and/or lease a studio at Von Dell. The art classes offered at Von Dell Gallery are all instructed by different artists who highlight each of their specific medium. Visit www.vondellgalleryandstudios.com for a complete list of classes and more information. Follow Von Dell Gallery on Facebook @vondellgalleryandstudios. To get plugged into a VAC/Vet Center Group Outreach, set up a one-on-one appointment or for additional information about the art program, call the Veterans Assistance Commission at 618296-4554. Follow the Veterans Assistance Commission on Facebook @mcVeterans for more information. Back to Top 5.5 - WMFE (NPR-90.7, Audio): Intersection: The Road To Better Care For Veterans (7 August, Brenda Argueta, 70k uvm; Orlando, FL) One of the challenges facing Veterans after their service is getting access to healthcare. Veterans Affairs secretary Robert Wilkie, who was sworn in last week, will address American Veterans tomorrow at the group's annual convention in Orlando. Improving access to healthcare is one of the issues the service organization is looking to Wilkie to address. Sherman Gillums Jr., AMVETS chief strategy officer says the VA secretary is "responsible for delivering on a country's promise." "This is the first time we're going to see him as secretary talking to these people about his agenda, his ideas on how to address some of the issues we've all heard about for years and we're going to also have some time to talk to him one-on-one," Gillums Jr. says. "I've come to expect more that we will be proactive and we will push what we think needs to happen and seek to, through a partnership with him, make those things happen," Gillums Jr. says. Lana McKenzie, AMVETS chief medical executive, says improving staffing levels can be a starting point to improve access to healthcare. "When you have demand and supply issues, you're going to face poor outcomes and I think that that's the logistic of access to care issues [still] creeping up," McKenzie says. "Because there's so little consistency between the 157 facilities, you go to one you're not going to have that same experience at another necessarily so it just kind of depends on where you happen to settle after you get out of the military," Gillums Jr. says. Gillums Jr. was injured in a car accident while in the Marine Corps. He says the secret to successful rehabilitation through the VA is peer mentorship. "The best dose of medicine you can be administered is seeing another individual who has lived with that injury or that condition being successful," Gillums Jr. says. VA-18-0298-F, VA-18-0299-F-000067 000067 180808_Veterans Affairs Media Summary and News Clips.docx for Printed Item: 12 ( Attachment 1 of 2) "The culture at the VA needs a little reshape on the attitude toward veterans. They're not beggars. I think that they have choices so if you want them to become a choice of the VA, you need to show them that they want it and you're willing to serve," McKenzie says. AMVETS is organizing a town hall meeting for veterans Tuesday night. Gillums Jr. says AMVETS will take the concerns of veterans to Wilkie, and it will be his "opportunity to demonstrate to us that he's going to listen to us." "As long as there's a veteran on the street or as long as there's somebody waiting to get in, his honeymoon will be very short if at all. We've said that publicly and I think he embraces that challenge," Gillums Jr. says. Back to Top 5.6 - WMBB (ABC-13): Senator Nelson Speaks with Local Veterans (7 August, Chelsie Taddonio, 50k uvm; Panama City, FL) Veterans from around Bay County expressed concerns to U.S. Sen. Bill Nelson at a round table meeting in Panama City. Sen. Nelson spoke with veterans about a piece of legislation he is proposing, that would protect the military from being taken advantage of by payday loans. The legislation would cap the interest rate at 24 %. He says this is so... "the poor member of the service doesn't keep building up these loans that they can't pay. And then have to declare bankruptcy." The veterans didn't comment much on the legislation because they were eager to discuss certain matters; and the conversation quickly turned to Veterans Affairs. After talking for about an hour Sen. Nelson had a clear picture of their concerns. "They have excellent care, they're very happy with the va doctors and nurses. But it's the administrative problem," said Nelson. VFW Commander of District 17, Tony Salvo continued to explain the dilemma with the VA. "If you go to get an appointment sometimes it takes 4 to 6 to 8 weeks... It's just too long." The veterans also brought up homelessness among veterans within Bay County. "Veterans particularly coming out of Vietnam have always had a real homeless problem, " said Nelson. "We do know that the VA is in the process of fixing the homeless problem. They're in the process of building homes and areas for these veterans to live. It's gonna be a long slow walk before we get there," said Salvo. Sen. Nelson took these concerns to Tallahassee, where he met with the Secretary of Veterans Affairs on Aug. 07, 2018. Back to Top 5.7 - White Mountain Independent: Snowflake resident spearheads VA policy change (7 August, Laura Singleton, 37k uvm; Show Low, AZ) VA-18-0298-F, VA-18-0299-F-000068 000068 180808_Veterans Affairs Media Summary and News Clips.docx for Printed Item: 12 ( Attachment 1 of 2) SNOWFLAKE -- Julius Aubin, a Navy veteran and a resident of Snowflake since 2002, is a mover and a shaker. He can also breathe a little easier now - literally. Aubin has been on a mission to improve healthcare for veterans like himself who use portable oxygen tanks to help them breathe. Specifically, he wants veterans to "get out and be mobile." "It's hard to go out to a kids' baseball game on a tank of oxygen that only lasts four hours," testifies Aubin. "And, you can't even go fishing because you've got this big bottle that bumps around and makes all kinds of noise." "If you go on vacation, you've got to give the VA an in-depth itinerary to get travel bottles way ahead of time," says Aubin. "I don't know about you, but when I'm on vacation, my only itinerary is 'I'm leaving and I'm coming back at some point; everything else is the in-between." So, for more than a year, he has been contacting the Veteran's Administration in Phoenix. He has also spoken with Congressman Tom O'Halleran at the local VFW Post in Show Low where he was able to demonstrate the bulky oxygen tank and cart that he has carried with him for two years. "He has really advocated strongly for veteran's issues like the portable oxygen concentrators," says Shawn Bransky, Deputy Director of the Phoenix Veteran's Administration (VA) Healthcare System. "Julius is not one that let's go; he is a champion of his cause." There are several challenges that come with the oxygen tanks and carts, in addition to the weight and overall bulkiness. According to Aubin, the tanks that people take with them only last for two to four hours, depending on the size. "This makes it difficult to go fishing, traveling or doing things outside the home that take time," says Aubin. In addition, the empty oxygen bottles stack up in the house and, in rural areas like the White Mountains, it can be difficult for the company to come pick them up regularly. This is especially the case when there is inclement weather. Aubin, originally from Baton Rouge, Louisiana, says that getting portable oxygen concentrators to veterans that are prescribed oxygen by their doctors has been a brainchild of his. It all started when he decided to travel across the country for his high school class reunion. "I had already made plans to go on vacation to Louisiana for the reunion," says Aubin. "I knew I was going to have to drag the oxygen tank and cart with me, so I started digging and trying to find a way to get a portable oxygen concentrator from the VA," he explained. "I found out that the VA needs six to eight weeks advance notice for this." "Your quality of life and your mobility is not as great with the tanks as it can be by having a mobile oxygen concentrator," says Aubin. "For example, you can bring the tanks on a plane but you have to wheel them around and I know first and foremost how it is to do that," he added. After hitting several roadblocks with his attempts to obtain a portable concentrator to travel with, he got in contact with a company that was able to help him. In addition, Dr. Simranjit S. Galhotra, a pulmonary specialst with Summit Healthcare Regional Medical Center, was willing to assist Aubin in his efforts. The end result - Aubin obtained a portable oxygen concentrator from the VA in time to take it with him on his trip. VA-18-0298-F, VA-18-0299-F-000069 000069 180808_Veterans Affairs Media Summary and News Clips.docx for Printed Item: 12 ( Attachment 1 of 2) "The whole time I was on vacation, this was on my mind," says Aubin. "All of my experience and phone calls trying to get a portable oxygen concentrator for myself led up to what the VA is doing now." "Once I was able to use the portable concentrator while traveling, I saw very clearly what was needed for other veterans," says Aubin. Upon returning from vacation, Aubin resumed his communication with the VA administration, showing them how portable oxygen concentrators could improve quality of life as well as save money. "Mr. Aubin actually came to me with a business case already done and he walked me me through it step-by-step," says Bransky. "I'm not a physician, but I understand that not everyone is a candidate for portable oxygen concentrators," he added. "As a result of Mr. Aubin's tenacity, we have now built a Phoenix VA Healthcare System policy that we are fine-tuning and will get out to the veterans at large." According to Aubin, the VA will arrange to rent a portable machine for the veteran for 30 days. If they keep it beyond the 30 days, then they pay rental fees. With this program, the idea is for the VA to buy the portable oxygen concentrator. When the veteran no longer needs it, it can be returned to the VA, serviced and authorized for another patient. Aubin claims that this process, when compared to the one-time purchase of portable oxygen concentrator will save money over time. "When the program officially gets off the ground, the VA may even rent the portable machines from the company that provides the Activator brand of concentrator," says Aubin. "They are working on the company owning the machines and the VA rents the machines from them. From $100 to $200 per month which is very inexpensive," says Aubin. Currently, this policy will only pertain to the Phoenix VA facility and the nine outpatient clinics that fall under the Phoenix VA healthcare umbrella said Bransky. "We will have specific parameters to ensure that we roll this out in a manner that is organized, well-understood and effectively communicated," he added. Bransky also said that the process must be efficient so that veterans don't get frustrated. Physicians will have the very important role of making sure that the patient is a candidate for portable oxygen before they go through the process. "We have drafted a policy this is now being reviewed by the Director Rima Nelson and we expect approval in the near future," assures Bransky. "It's not something that we have considered before I think it's a great initiative and something that enhances quality of life," he added. Although the policy is close to being signed and implemented by the VA, Aubin is not one to relax. He is continuing his information campaign and plans to organize another town hall meeting this month at the VFW in Show Low. VA-18-0298-F, VA-18-0299-F-000070 000070 180808_Veterans Affairs Media Summary and News Clips.docx for Printed Item: 12 ( Attachment 1 of 2) Aubin encourages veterans and their families to contact him at 928-536-2485 if they would like to more information about the pending healthcare policy. Back to Top 6. Suicide Prevention 6.1 - Dispatch - Argus: VA says reaching vets key to stopping suicide (7 August, Jim Meenan, 311k uvm; Moline, IL) The numbers speak harshly for themselves. Every day, about 20 U.S. veterans and current service men and women commit suicide. On average, only about six of those veterans are receiving care from the Veterans Administration. Bryan Clark is bothered by the number of veterans taking their lives, as well as how many do not reach out for the help they've earned. Clark is the public affairs officer for the Veterans Affairs Health Care System in Iowa City that serves 51 western Illinois and eastern Iowa counties. "These are earned benefits," Clark says. "Don't leave them untapped." Currently, the Quad-Cities has three VA facilities offering everything from primary care to laundry and shower facilities. A 34,000-square-foot facility near the Mississippi Valley Fairgrounds in Davenport is scheduled to replace a current one in Bettendorf early next year. Bettendorf's Victoria Street facility offers psychology and psychiatry services. Davenport's VA Community Resource and Referral Center's services on North Perry Street includes suicide prevention and psychology. The QuadCities Vet Center on 42nd Avenue in East Moline includes mental health counseling services. Additionally, any veteran can call the Veteran's Crisis Line at 1-800-273-8255 and press 1 to talk to someone. There's also immediate help, if needed, in local emergency rooms. "The vast majority of the time, (callers) are just looking for somebody to talk to," said Darin Person, Suicide Prevention Coordinator for the VA Health Care System in the Iowa City. He said that only about twice a week does someone in the vast area his office serves need a rescue. In non-emergency situations, Person's office contacts them. If the veteran has an existing mental health team working with them, that team contacts the VA office. Either way, follow-up occurs within 24 hours. The bigger problem Clark alluded to is reaching troubled veterans before they commit suicide. he said the VA does outreach on a regular basis through public meetings, American Legion posts and Veterans of Foreign Wars organizations. VA-18-0298-F, VA-18-0299-F-000071 000071 180808_Veterans Affairs Media Summary and News Clips.docx for Printed Item: 12 ( Attachment 1 of 2) "We know we can't reach all the veterans ourselves," said Dr. Jason Drwal, staff psychologist at the VA Health Center in Iowa City that tries to connect with community leaders and local mental health services. Veteran suicide rates in this region are similar to the national average, Person said. But he and the VA subscribe to the belief that any suicide is one too many. What finally pushes a veteran over the edge could be something that went untreated for years, Drwal said. "A lot of the guys that we see from the Vietnam era are struggling with things that happened when they were in the service, that happened when they got home and didn't feel welcomed here," Drwal said. "A lot of guys didn't feel they had an outlet to deal with that." It's harder to keep veterans from recent wars engaged in treatment, he said, because they sometimes find it difficult to make the time to deal with an issue. "I think the challenge with the younger guys that we see is that these are guys who just want to get back to life and don't want to bother with it," Drwal said. "They've got families and jobs and things to do." But progress is being made, Person said. In his eight years with the Iowa City VA office, things are "significantly better," he said. "Our programs have grown," he said. "We have a lot more staff. We have much more of a variety of services to fit people's needs better." Technology helps. Drwal says he now can provide therapy to a veteran anywhere in the country by using an electronic tablet. Most referrals, he said, come from the medical community. "Primary care can send a lot of referrals to (VA) psychiatry and then they prescribe meds and send them to (VA) psychology where they can get into psychotherapy," Drwal said. "Within the VA system, there is just a real strong emphasis on mental health services," he said. "They (veterans) are going to be screened by multiple services and providers." He noted, however, it might take one person six different referrals before they finally decide to come in for help. "We will eventually get them to the right services, if we are connected," Drwal said. "It's really the people who don't have any connection to us that are really left out." The ultimate goal, he said, is to get people in, treat them, educate them and arm them with the ability to cope. "Get them to start doing things so that they can start living their life differently," Drwal said. "If you are not helping them to live everyday life differently, then you are not going to make changes in terms of what they can do and how they interact with their family or their ability to either get work or maintain the work they have." VA-18-0298-F, VA-18-0299-F-000072 000072 180808_Veterans Affairs Media Summary and News Clips.docx for Printed Item: 12 ( Attachment 1 of 2) While today's therapies are more focused on teaching skills and strategies, the basic start -- listening to the veteran -- is still the same, he said. Also remaining is the stigma in seeking mental health care. "That's kind of the big hurdle we are facing on a daily basis," Drwal said. "Once they come in, there's all kinds of things that we can do for them." He said the VA is sensitive to allegations that too many vets are put on medicine instead of therapy to address mental illness. If a person had a sore throat and a pill could cure it, he said, would you not ask them to consider taking the pill? "Every case is different," Person said. "We certainly have folks who do one or the other and sustain recovery." Back to Top 6.2 - The Daily News: VA center in IM to host Mental Health Summit at Bay West (7 August, 54k uvm; Iron Mountain, MI) IRON MOUNTAIN -- The Oscar G. Johnson VA Medical Center will host its sixth annual Mental Health Summit on Tuesday, Aug. 21, in Fornetti Hall at Bay College West, 2801 N. U.S.2 in north Iron Mountain. The event will be 9 a.m. to noon, and is open to local government human services, community mental health agencies, hospitals, veterans and their families, and any other interested organizations or individuals. The purpose of the Mental Health Summit is to bring together these key stakeholders in the community with the goal of enhancing the mental health and well-being of veterans and their families "We are building bridges with community partners to serve those who served us," said Amy Fowler, this year's summit coordinator. Topics at this year's Mental Health Summit include suicide prevention, access to mental health care, eliminating mental health stigma, the Veterans Administration's new Whole Health Program and health care designed for women veterans. "We have found these Mental Health Summits to be beneficial in addressing the mental health needs of our veterans, especially in our rural patient areas," said Jim Rice, director for the Oscar G. Johnson VA Medical Center. "We cannot do it alone, especially in tackling the VA's top clinical priority, suicide prevention," Rice added. For more information or to register for the summit, contact Amy Fowler at Amy.Fowler1@va.gov or 906-774-3300, ext. 32742. Back to Top VA-18-0298-F, VA-18-0299-F-000073 000073 180808_Veterans Affairs Media Summary and News Clips.docx for Printed Item: 12 ( Attachment 1 of 2) 7. Women Veterans / Homelessness / Benefits / Cemeteries 7.1 - WCTV (CBS-6, Video): Local World War II vet has VA Clinic named in his honor (7 August, Alicia Turner, 1.4M uvm; Tallahassee, FL) You probably recognize the famous World War II photo of the flag being raised on Iwo Jima. But, the photo most think of wasn't the original flag to be raised. And, one of the soldiers who helped raise the first flag grew up in Monticello. About a week after the photo was taken, Earnest Boots Thomas was killed in the line of duty. He received multiple honors, including the Purple Heart. And, on Tuesday, he was honored again, as President Trump signed a proclamation to name the VA building on Orange Avenue after him. A table decorated with pictures of the past line the walls of the Veterans Clinic to recognize and honor the life of Sgt. Thomas. "I think they'll love it," said Reba Weams Williams, "It now has a name they can honor and respect and now more and more people are learning about Thomas." Sgt. Thomas was just 17 when he went into the Marines. He died days before his 21st birthday. Rebekah Sheats wrote a biography of his life, where she says early on he set out to make a difference. "His father died when he was young and he had to take responsibility for his family and his younger siblings and his mother. He really understood," Sheats said. "When WWII came, it was his position to stand in the gap to protect his family, his home and his country." Sheats explained his dedication to service and his country is worthy of being admired. "Boots died over 70 years ago and his name is still remembered today," Sheats continued, "And that has to be encouraging to know that their sacrifice isn't in vein that people do appreciate it and they will honor them for it." An honor that, Sgt. Thomas'family says, will never be forgotten. Senator Bill Nelson and Congressman Al Lawson were among thos who spoke at Tuesday's ceremony, and each said what a historic moment the renaming is. There's no word yet on when Thomas' name will actually be displayed. Back to Top 7.2 - Tallahassee Democrat: VA secretary helps rename vets clinic for Monticello Marine Ernest "Boots" Thomas (7 August, James Call, 439k uvm; Tallahassee, FL) VA-18-0298-F, VA-18-0299-F-000074 000074 180808_Veterans Affairs Media Summary and News Clips.docx for Printed Item: 12 ( Attachment 1 of 2) Monticello's Dr. Jim Sledge remembers the ship-borne broadcast with Sgt. Ernest "Boots" Thomas a couple days after the iconic flag raising during the World War II battle for Iwo Jima. A photo taken of it by the Associated Press appeared around the country in 1945 while the U.S. prepared a final assault on imperial Japan. At the rededication ceremony of the Veterans Affairs Clinic in Tallahassee Tuesday, Sledge recalled how his best friend from childhood deftly handled a radio interview about how he had mounted the flag in a volcanic crest atop Mount Suribachi. "Sgt. Thomas said, 'I don't want to give that impression. Every man in my platoon should be standing here with me today,'" Sledge told the nearly 400 people who attended Tuesday's ceremony. "So, there was enough honor to go around for everyone," Sledge continued. Members of the Thomas family credit Sledge with keeping Boots' story alive and the subsequent honors bestowed on him. The radio broadcast Sledge recalled aired a week after Thomas led his squadron to the top of the mount on day four of the battle. It served as a beacon to fellow Marines engaged in combat in the jungle below. Immediately after the radio broadcast, Thomas rejoined his squadron on the island. A couple days later he was among the 4,000 Marines who died before Iwo Jima was secured. He was originally laid to rest in Iwo Jima but Jefferson County brought him home to Roseland Cemetery. Three years ago, Monticello erected a memorial near his grave site and Tuesday, Veterans Affairs Secretary Robert Wilkie led a contingent from Washington that included Sen. Bill Nelson, congressmen Neal Dunn and Al Lawson and local politicians that paid a further tribute to the Monticello Marine. Nelson and Lawson acted on a request from Jefferson County residents and carried the bills through Congress that formally named the Tallahassee facility the Sergeant Ernest I. "Boots" Thomas VA Clinic "Thank you for rededicating this wonderful facility in the name of a man from a generation that continues to inspire," Secretary Wilkie told the crowd that overflowed from the facilities main lobby and down a hallway pass a coffee bar, pharmacy, a waiting area for radiology and entrances to other labs and offices. Wilkie was confirmed two weeks ago, as head of a embattled department with more than 1,500 outpatient clinics and hospitals to serve the nation's veterans. The "Boots" Thomas VA Clinic opened in 2016 and serves more than 16,000 veterans in North Florida and South Georgia. "Our family is humbled by the honor of the naming of this beautiful facility after Boots Thomas," said Lynn Blais, Thomas' great grand-niece. "We hope the veterans who come here receive the very best care a grateful nation can provide." Back to Top VA-18-0298-F, VA-18-0299-F-000075 000075 180808_Veterans Affairs Media Summary and News Clips.docx for Printed Item: 12 ( Attachment 1 of 2) 7.3 - SportTechie: U.S. Veteran Steve Kirk Uses Breath-Triggered Gun at Wheelchair Games (7 August, Logan Bradley, 157k uvm; Washington, DC) A 1980 skiing accident left U.S. Army veteran Steve Kirk with a dislocated neck and little use of his arms or legs. Almost forty years later, Kirk was competing at last week's National Veterans Wheelchair Games. Kirk took part in the air rifle competition thanks to a gun that is triggered by his breath. A sharp inhale from Kirk is enough to fire his gun. (Inhaling is used instead of exhaling as the trigger, because exhaling can happen accidentally.) The solution, customized by the Orlando VA Medical Center, follows similar adaptations for disabled athletes competing in other sports--repurposing their movements for the desired effect. "It allows them the opportunity to forget that they are disabled for a little while," said Christina Lafex, a recreational therapist and coordinator at Orlando VA, in an interview with the Orlando Sentinel. "Otherwise, they might get quiet and dig into a cocoon and just stay there." This year's games (which ran from Jul. 30 to Aug. 4) featured an exhibition space dedicated to adaptive technology products. For many like Kirk, technology has opened up a whole new competitive avenue. "If [the accident] happened today, I'd probably be able to walk again at some point," Kirk told the Sentinel. "But it's not about staying home and feeling sorry for yourself." SportTechie Takeaway Technology has allowed disabled athletes to compete in ways that they otherwise couldn't. Ahead of this year's Winter Paralympics, engineers at Toyota Motorsport helped Paralympian Andrea Eskau redesign her sled. Toyota was able to create a significant weight reduction in the sled. In PyeongChang, the German parathlete added two gold medals, two silvers and one bronze to her already impressive haul from six different Summer and Winter Games. Back to Top 7.4 - St. George News: Salt Lake City Veterans Affairs office to hold first 'Benefits Fair' in St. George (7 August, Ryan Rees, 156k uvm; Saint George, UT) ST. GEORGE -- Area veterans will be able to get assistance for a variety of needs when the Department of Veterans Affairs Salt Lake City regional office's outreach team hosts its first "Benefits Fair" Aug. 14 in St. George. The event will take place from 8 a.m. to noon at the St. George Veterans Center, 1664 S. Dixie Drive, Suite C-102. "This is new for us," said Thomas Lamb, outreach specialist in the St. George Veterans Affairs office. "They (Veterans Benefits Administration) are sending down two people who are the actual people who handle the benefits paperwork in the Salt Lake office." This will be the first time the outreach team has visited Southern Utah, but it may not be the last, said Adam Kinder, a spokesperson for the Veterans Administration in Salt Lake City. VA-18-0298-F, VA-18-0299-F-000076 000076 180808_Veterans Affairs Media Summary and News Clips.docx for Printed Item: 12 ( Attachment 1 of 2) "This is an opportunity to reach a portion of the population that doesn't have easy access to the regional office here (in Salt Lake City)," he said. "We conduct these fairs around the state and try to see if the need is there by gauging the attendance. If it's a good turnout, we'll look at doing more." Kinder said veterans will be able to get information on how to file claims, research the status of their claims, vocational rehabilitation and employment, survivor or burial benefits or find out what other benefits may be available to them at the fair. Another goal of the fair, Kinder said, is to reach veterans who are not currently involved in receiving benefits. Court Pendleton, the officer who oversees four Utah veterans service offices in the area, said the benefits fair will "help fulfill a real need in this area." Pendleton's office overseas 11 counties in Southern Utah, which he said represents about 10 percent of all veterans in Utah, adding that there are 11,800 veterans in Washington County and another 3,000 in Iron County. Lamb said the main focus in the St. George office is to offer combat veterans counseling. "We can help them with marriage problems, PTSD or if they're just having a bad day," he said. "They can walk in any time. We're very accessible." Both Lamb and Pendleton said they hope the St. George fair will encourage the Salt Lake City office to hold more events in St. George in the future. "We hold a quarterly fair of our own," Pendleton said, "but I think after this event, they will want to have a monthly fair here." Back to Top 8. Other 8.1 - South Bend Tribune: Viewpoint: Donnelly, a tireless advocate for vets, should be reelected (7 August, Joe Kernan, 274k uvm; South Bend, IN) As a Vietnam War veteran and prisoner of war, a former governor of Indiana and a longtime South Bend resident, I believe that we need to re-elect Joe Donnelly to the U.S. Senate. Joe has been a tireless advocate for veterans and service members in the Senate. He works in a bipartisan and common-sense way to deliver real results for all Hoosiers. Look no further than the new St. Joseph County VA Health Clinic for proof of Joe's tireless efforts to deliver for Hoosier veterans. Joe worked for nearly 10 years -- since he was a congressman for Indiana's 2nd Congressional District -- to make the impressive VA clinic in Mishawaka a reality for veterans living in northcentral Indiana. Gone are the days when veterans living in South Bend, Elkhart and LaPorte need to travel to Fort Wayne, Chicago or Indianapolis for care from the VA. This new clinic has been life-changing for veterans like VA-18-0298-F, VA-18-0299-F-000077 000077 180808_Veterans Affairs Media Summary and News Clips.docx for Printed Item: 12 ( Attachment 1 of 2) myself, and I can tell you that it would not have been built without Joe's passion for making life better for veterans in Indiana. He hasn't stopped at the VA health clinic in Mishawaka; he's working hard to help bring more VA clinics to Indiana and meet the needs of every Hoosier veteran. As a Vietnam veteran, I was proud that Joe authored bipartisan legislation so that March 29 of every year would be recognized as National Vietnam War Veterans Day and worked until it was signed into law by President Donald Trump. On March 29, Joe welcomed home more than 900 Hoosier Vietnam War veterans with their family members at Plainfield High School for the first Vietnam War Veterans Day and thanked them for their service to this great nation. Joe is also shining a light in Congress on the importance of mental health for service members and veterans. His Jacob Sexton Military Suicide Prevention Act and his Servicemember and Veteran Mental Health Care Package are bipartisan efforts to reduce service member and veteran suicide and help us access mental health services that are right for us. As a veteran and prisoner of war, I understand all too well that the wounds of war are both physical and mental. It's difficult for the men and women in service who are coming home to find a prepared medical professional properly trained to understand the unique traumas that they brought home from war. Joe's efforts have brought about meaningful change for how the military and veterans talk about and treat mental health. There is so much more work to be done in Washington on behalf of the men and women veterans and service members. Let's work together to send Joe back to the Senate next year because he's the guy for the job. Back to Top VA-18-0298-F, VA-18-0299-F-000078 000078 From: To: Kroupa, Laura (V15) @va.gov> WIRELESS CALLER ; NEW YORK CALL ; . ; 16/cn=recipien on ; a ministrative group dibohf23s ;(b) (6) CMIO Weekly Huddle Tue May 15 2018 11:55:39 EDT - <(b) (6) @va.gov> 10:01 AM: Howdy! (b) (6) 10:02 AM: morning - not sure how to stay the course in the wake of LK's stepping away from CMIO role here. your thoughts? (b) (6) - 10:02 AM: i agree (b) (6) ... (b) (6) 10:03 AM: :(:( (b) (6) 10:03 AM: Me too :'( (b) (6) 10:12 AM: on and muted (b) (6) 10:12 AM: good morning! (b) (6) n 10:14 AM: i'm attaching the file of the exec summary of the DOD rollout (publically sent out) (b) (6) 10:16 AM: This was article from Friday - https://www.politico.com/story/2018/05/11/kushner-backed-health-careproject-gets-devastating-review-535847 (b) (6) 10:18 AM: i would like to see the Cerner reply...link/ file? (b) (6) 10:22 AM: https://www.nextgov.com/topic/health-records/?oref=ng-article-topics (b) (6) 10:27 AM: stepping away for a minute will be back. VA-18-0298-F, VA-18-0299-F-000080 000080 (b) (6) 10:29 AM: back (b) (6) 10:30 AM: "For a successful technology, reality must take precedence over public relations, for nature cannot be fooled." This statement was Feynman's succinct way of telling NASA to clean up its act after the explosion of the space shuttle Challenger in 1986. (b) (6) 10:36 AM: I don't think I have more. Thanks for covering it (b) (6) 10:38 AM: MyHealtheVet ability to download imaging... went live about the same time the JLV problems started, but still no smoking guns identified (b) (6) 10:43 AM: In the news- VA CFO and Assistant Secretary for Management John Rychalski said we would have a decision (not signed contract, but a "decision" on Memorial day in Congressional Testamony (testimony video 1:03:12) (b) (6) (BAH) 10:51 AM: Harsh! (b) (6) 10:52 AM: - need to have an occasional laugh. I love (b) (6) but won't miss him b/c we'll be slapping him with work in a few months anyway before we lose him to one of the other teams/ councils (b) (6) (BAH) 10:52 AM: I know. I'm going to miss him, too. (b) (6) 10:52 AM: he's not getting away that easy. Neither will LK (b) (6) - V10 10:53 AM: Agree (b) (6) ! We know how to find them both! (b) (6) (BAH) 10:54 AM: Nothing from me, thanks. VA-18-0298-F, VA-18-0299-F-000081 000081 From : To: Cc: Bee: Subject: Date : Attachments : FW: EHRM in the News: Monday, May 14, 2018 Mon May 14 2018 08:07 :27 EDT EHRM in the News - Monday , May 14, 2018.docx image001.png image003.png (VISN 8) ~ @va.gov> ; com> Subject: [EXTERNAL] EHRM in the News: Monday, May 14, 2018 [USA] ._ @va.gov> ; @bah. EHRM in the News Monday , May 14, 2018 EHRM News Politico: Kushner-backed health care project gets 'devastating ' review (11 May 2018 , Arthur Allen ) *The first stage of a multibillion-do llar military-VA digital health program champ ioned by Jared Kushne r has been riddled with problems so seve re they cou ld have led to patient deaths, accord ing to a report obtained by POLITICO . *The Ap ril 30 report expands upon the find ings of a March POLITICO story in wh ich docto rs and IT specialists expressed alarm about the software system , desc ribing how clinicians at one of fou r pilot centers, Naval Station Bremerton , quit because they were terr ified they might hurt patients, or even kill them. *In a briefing with reporte rs late Friday , Pentagon officia ls said they had made many improvements to the pilot at four bases in the Pacific Northwest since the study team ended its review in November . *"MHS Genes is is extreme ly important and it is important to get MHS Genesis right," said Vice Adm. Raquel Bono, chief of the Defense Health Agency. "Feedback from the test commun ity and dedicated profess ionals at the sites has been inva luable." VA-18-0298-F, VA-18-0299-F-000082 000082 Health Data Management: DoD rollout of Cerner EHR deemed not operationally effective or suitable (14 May 2018, Greg Slabodkin) *While the Department of Defense contends that its initial deployment last year of MHS GENESIS--a new Cerner electronic health record system--at four military sites in the Pacific Northwest was a success. The EHR is "neither operationally effective nor operationally suitable," according to a scathing report from DoD's director of operational test and evaluation. *"MHS GENESIS is not operationally effective because it does not demonstrate enough workable functionality to manage and document patient care," wrote Robert Behler, director of operational test and evaluation, in a letter to senior Pentagon officials accompanying his report. "Users successfully performed only 56 percent of the 197 tasks used as measures of performance. *As a result of the findings, Behler recommended that the Under Secretary of Defense for Acquisition and Sustainment delay further fielding of the Cerner EHR until the Joint Interoperability Test Command completes the initial operational test and evaluation and the Program Management Office "corrects any outstanding deficiencies." *Stacy Cummings, program executive officer for Defense Healthcare Management Systems, told members of the press on Friday that despite the findings of the DOT&E report, DoD still plans to continue deployment of MHS GENESIS beyond the Pacific Northwest beginning in 2019, and that the system continues to be on track for full deployment by 2022. Cerner News *There were no recent news stories related to Cerner* Allscripts News *There were no recent news stories related to Allscripts* Epic News *There were no recent news stories related to Epic Systems* VA-18-0298-F, VA-18-0299-F-000083 000083 Owner: Filename: Last Modified: (b) (6) -- (VISN 8) EHRM in the News - Monday, May 14, 2018.docx for Printed Item: 16 ( Attachment 1 of 3) EHRM in the News Monday, May 14, 2018 Politico: Kushner-backed health care project gets 'devastating' review (11 May 2018, Arthur Allen) ? The first stage of a multibillion-dollar military-VA digital health program championed by Jared Kushner has been riddled with problems so severe they could have led to patient deaths, according to a report obtained by POLITICO. ? The April 30 report expands upon the findings of a March POLITICO story in which doctors and IT specialists expressed alarm about the software system, describing how clinicians at one of four pilot centers, Naval Station Bremerton, quit because they were terrified they might hurt patients, or even kill them. ? In a briefing with reporters late Friday, Pentagon officials said they had made many improvements to the pilot at four bases in the Pacific Northwest since the study team ended its review in November. o "MHS Genesis is extremely important and it is important to get MHS Genesis right," said Vice Adm. Raquel Bono, chief of the Defense Health Agency. "Feedback from the test community and dedicated professionals at the sites has been invaluable." Health Data Management: DoD rollout of Cerner EHR deemed not operationally effective or suitable (14 May 2018, Greg Slabodkin) ? While the Department of Defense contends that its initial deployment last year of MHS GENESIS--a new Cerner electronic health record system--at four military sites in the Pacific Northwest was a success. The EHR is "neither operationally effective nor operationally suitable," according to a scathing report from DoD's director of operational test and evaluation. ? "MHS GENESIS is not operationally effective because it does not demonstrate enough workable functionality to manage and document patient care," wrote Robert Behler, director of operational test and evaluation, in a letter to senior Pentagon officials accompanying his report. "Users successfully performed only 56 percent of the 197 tasks used as measures of performance. ? As a result of the findings, Behler recommended that the Under Secretary of Defense for Acquisition and Sustainment delay further fielding of the Cerner EHR until the Joint Interoperability Test Command completes the initial operational test and evaluation and the Program Management Office "corrects any outstanding deficiencies." ? Stacy Cummings, program executive officer for Defense Healthcare Management Systems, told members of the press on Friday that despite the findings of the DOT&E report, DoD still plans to continue deployment of MHS GENESIS beyond the Pacific Northwest beginning in 2019, and that the system continues to be on track for full deployment by 2022. Cerner News *There were no recent news stories related to Cerner* VA-18-0298-F, VA-18-0299-F-000085 000085 EHRM in the News - Monday, May 14, 2018.docx for Printed Item: 16 ( Attachment 1 of 3) Allscripts News *There were no recent news stories related to Allscripts* Epic News *There were no recent news stories related to Epic Systems* VA-18-0298-F, VA-18-0299-F-000086 000086 From : To : Cc: Bee: Subject: Date : Attachments : (VISN 8) cn=recip ients/cn=> < o=va ou=v 1sn ---; Gunna r, Wi lliam ? Krou V 15 FW: [EXTERNA L] EHRM in the News: Monday , Apr il 30, 2018 Mon Apr 30 20 18 07 :57:45 EDT EHRM in the News - Monday , Ap ril 30, 2018.docx image001.png image003.png From -Sent: ~ To : Cc: SubJec : [USA ] O 20186 :53 :45AM ); ) onday,Apri l 30, 20 18 EHRM in the News Monda 1/2 April30,2018 EHRM News Politico: 'Who the hell is this person? ' Trump 's Mar-a-Lago pal stym ies VA project (30 April 20 18, Arthu r Allen) *A West Palm Beach doctor 's ties to Dona ld Trump 's Mar-a- Lago socia l circle have enab led him to hold up the bigges t hea lth information techno logy proj ect in history- the transformation of the VA 's digita l records system. *Dr. Bruce Moskow itz, an intern ist and fr iend of Trump confidan t Ike Perlmutter, who adv ises the president informally on vet issues, objec ted to the $16 billion Department of Veterans Affa irs proj ect because he doesn't like the Gerne r Corp . softwa re he uses at two Florida hospita ls, accord ing to four forme r and current sen ior VA officials . Modern Healthcare: Ascens ion's Ters igni on short list for VA secretary (29 Ap ril 2018 , Au rora Aguilar) *Ascension Pres ident and CEO Anthony Ters igni is among those being cons idered to lead the Veterans VA-18-0298-F, VA-18-0299-F-000087 000087 Affairs Department, sources close to the matter say. *Tersigni's experience and knowledge of issues affecting not just the VA, but healthcare overall may give him a decided advantage. *Similar to the VA, Ascension is also upgrading and standardizing its electronic health record system, a massive task. Ascension's project stretches across 150 hospitals and 2,600 sites of care and is intended, among other things, to boost digital and telemedicine services. Cerner News *There were no recent stories related to Cerner* Allscripts News *There were no recent news stories related to Allscripts* Epic News *There were no recent news stories related to Epic* VA-18-0298-F, VA-18-0299-F-000088 000088 Owner: Filename: Last Modified: (b) (6) -- (VISN 8) EHRM in the News - Monday, April 30, 2018.docx for Printed Item: 20 ( Attachment 1 of 3) EHRM in the News Monday, April 30, 2018 Politico: 'Who the hell is this person?' Trump's Mar-a-Lago pal stymies VA project (30 April 2018, Arthur Allen) ? A West Palm Beach doctor's ties to Donald Trump's Mar-a-Lago social circle have enabled him to hold up the biggest health information technology project in history -- the transformation of the VA's digital records system. ? Dr. Bruce Moskowitz, an internist and friend of Trump confidant Ike Perlmutter, who advises the president informally on vet issues, objected to the $16 billion Department of Veterans Affairs project because he doesn't like the Cerner Corp. software he uses at two Florida hospitals, according to four former and current senior VA officials. Modern Healthcare: Ascension's Tersigni on short list for VA secretary (29 April 2018, Aurora Aguilar) ? Ascension President and CEO Anthony Tersigni is among those being considered to lead the Veterans Affairs Department, sources close to the matter say. ? Tersigni's experience and knowledge of issues affecting not just the VA, but healthcare overall may give him a decided advantage. ? Similar to the VA, Ascension is also upgrading and standardizing its electronic health record system, a massive task. Ascension's project stretches across 150 hospitals and 2,600 sites of care and is intended, among other things, to boost digital and telemedicine services. Cerner News *There were no recent stories related to Cerner* Allscripts News *There were no recent news stories related to Allscripts* Epic News *There were no recent news stories related to Epic* VA-18-0298-F, VA-18-0299-F-000090 000090 @va.gov> From : To: Cc: Bee: Subject: Date : Attachments : Conversat ion with Daniel Marsh (OIA) Thu Apr 19 201811 :10:01 EDT (OIA) 10:02 AM : Morning ... Im on the Deployment call... Not sure if - is try ing to chase me away ... Kroupa, Laura (V15) 10:02 AM : No stay-I can only stay for a few minutes .....! really need to stop coming. Kroupa, Laura (V15) 10:03 AM : Maybe I can catch up with you late today .....so much going on 10:03 AM : Okay ... 10:03 AM : Sure ... are you in DC? Kroupa, Laura (V15) 10:03 AM : lots of org chart issues Kroupa, Laura (V15) 10:03 AM : Just got back from DC last night at 10:00 pm Kroupa, Laura (V15) 10:03 AM : Interesting meetings Kroupa, Laura (V15) 10:04 AM : Can't believe Cam Sandova l is the new CIO .....this organ ization is going to have to run itself as the top leadership is going to be clueless Kroupa, Laura (V15) 10:05 AM : But I guess if you are a friend of Jared you don't need to be qua lified 10:06 AM : VA-18-0298-F, VA-18-0299-F-000091 00009 1 LOL... Its getting more bizarre day by day... Kroupa, Laura (V15) 10:07 AM: is there any product from the deployment work over the last few months? Kroupa, Laura (V15) 10:07 AM: rhetorical question only (b) (6) 10:08 AM: - Thats a good question... (b) (6) slides? VA-18-0298-F, VA-18-0299-F-000092 000092 From : Kroupa, Laura (V15 To: cn=rec 1p1ents/cn=Cc: Bee: Subject: Date : Attachments : > RE: HISTalk Fri Mar 30 2018 08:53 :23 EDT image001 .png image002.png image003.png image004.png If you scroll down the page , you'll see this ! http:// hista1k2 .com/feed/ Laura From : Sent: n ay, arc To : Kroupa , Laura (V15) Subject: RE: HISTal k @va.gov> Nope , thanks for sharing!!! VA-18-0298-F, VA-18-0299-F-000093 000093 Subject: HISTalk You may have seen this already: From HISTalk: News 3/30/18 Yesterday, March 29, 2018, 5:27:37 PM | Jennifer Top News President Trump fires VA Secretary David Shulkin, MD after a wave of negative press around questionable funding for Shulkin's trip to Europe last summer. Shulkin believes the ouster came from political opponents who want to privatize the VA, a move he was quick to slam Wednesday in a New York Times editorial. President Trump will nominate the White House physician, Rear Admiral Ronny Jackson, MD, as Shulkin's replacement. Shulkin had reportedly recommended Jackson for a VA undersecretary position last fall, but the President wanted him to remain in the White House. Though Jackson served as an emergency medicine physician during Operation Iraqi Freedom, veterans groups question his nomination, citing concerns over a lack of administrative experience. I tweeted on the news, "Choosing an unbeholden outsider in hoping for disruption or believing that character (good or bad) outweighs experience sounds good. But I'm not sure I'd want as my first management job to be running a $200 billion, politically microscoped organization. Whatever the VA pays isn't enough." The status of the VA's proposed no-bid contract with Cerner remains cloudy as Shulkin departed without signing it. Experts are expressing confidence that Acting Secretary Robert Wilkie - who has no VA or healthcare experience -- won't want to take on the responsibility of executing the Cerner contract, but I wouldn't be so sure: Jared Kushner pushed Cerner in the first place and the White House may tell Wilkie to just get it done as a purely administrative chore that lets the White House take immediate credit. That's the bet I'd make. : VA-18-0298-F, VA-18-0299-F-000094 000094 Owner: Filename: Last Modified: - Kroupa, Laura (V15) VA-18-0298-F, VA-18-0299-F-000095 000095 image001.png for Printed Item: 25 ( Attachment 1 of 4) : :e ~ .. ~ ..o Cl u.. ~ .a e ::, z 10 :t,l Chango n Mun Notifications Por Dav Per P,o v1dtr Post .fnte rvon don lncrta t VA-18-0298-F, VA-18-0299-F-000096 A st udy of VA facilit ies finds tha t reducing low -va1ue ?HR inbox not ificat ions saved 1.5 hours per week of PCP t ime, although th e info rmat ion overload remains unmanageable and i.oJill requ ire more work to fix. 000096 Owner: Filename: Last Modified: - Kroupa, Laura (V15) VA-18-0298-F, VA-18-0299-F-000097 000097 Owner: Filename: Last Modified: - Kroupa, Laura (V15) VA-18-0298-F, VA-18-0299-F-000099 000099 Owner: Filename: Last Modified: - Kroupa, Laura (V15) VA-18-0298-F, VA-18-0299-F-000101 000101 From : To : Cc: Bee: Subject: Date: Attachmen ts: < o=va ou=v Isn cn=rec 1p1ents/cn=> Zenooz, Ashw ini ; Gunna r William ; -- ; (SBG ) ?, V15 FW: [EXTERNA L] (UPDATED ) EHRM in the News : Thursday , March 8, 2018 Thu Mar 08 2018 11 :54:00 EST EHRM in the News - Thursday , March 8, 2018 .docx image001.png image002.png From :-Sent: ~ To Cc: SubJec : [USA] ch 08 2018 10:43: 19 AM PDATED ) EHRM in the News : Thu rsday, March 8, 20 18 EHRM in the News Thursday , March 8, 2018 EHRM News Politico: 'We took a broken system and just broke it comp letely ' (8 March 2018 , Arthur Allen) *President Donald Trump last year hailed a multibillion-dollar initiative to crea te a seam less digita l health system for active duty military and the VA that he said wou ld deliver "faster, better, and far better quality care ." But the military 's $4.3 billion Gerner medical reco rd system has utterly failed to ach ieve those goals at the first hospita ls that wen t online. *Technical glitches and poor training have caused dangerous errors and reduced the numbe r of patients who can be treated, accord ing to interv iews with more than 25 military and Veterans Affai rs health IT spec ialists and doctors, including six who work at the four Pacific Northwes t military medical VA-18-0298-F, VA-18-0299-F-000103 000103 facilities that rolled out the software over the past year. *Bob Marshall, a health IT specialist at Madigan Army Medical Center, another early rollout site, blamed the poor start partly on the Pentagon acquisition office's inexperience with civilian record systems and the lack of a "sandbox" where clinicians could perfect the system before it was turned on. *"The bottom line is ... the Cerner user build is immature and needs to be brought up to a functional level," said Bob Marshall, a health IT specialist at Madigan Army Medical Center. "There were some expectations at higher levels that this ... was an out-of-the-box solution that would work perfectly, but it didn't." *Officials from Cerner and Leidos, the lead contractor on the project, acknowledge startup difficulties but said they're temporary. They said they are making fixes and physicians will get used to other changes. *Despite the startup issues, which have been glossed over in public discussion of the project, the White House continues to make the overhaul of the military and VA medical records a centerpiece of its government reform efforts. *"This was a huge win for our service," Jared Kushner told a health IT conference in Las Vegas on Tuesday, referring to Shulkin's decision last spring to use Cerner following consultations with Kushner's office. "The president wants to make interoperable health records available for all Americans." Cerner News Becker's Hospital Review: Centrus Health to use Cerner technology to create population health program (7 March 2018, Anuja Vaidya) *Centrus Health, a clinically integrated network based in Kansas, will integrate Cerner solutions and technological tools to create a population health management program. *Centrus Health includes numerous hospitals and providers in the region, including Shawnee (Kan.) Mission Health and The University of Kansas Health System in Kansas City. *Centrus Health will deploy the Cerner HealtheIntent population health management platform to coordinate care across the network. Centrus Health's 16,000-plus participants will be able to share data and work together. Cerner associates will also work to optimize the network's value-based contracts through technology. *"Centrus Health and Cerner together have the unique opportunity to make a real impact on the quality and delivery of health care in the Kansas City metro area," said Zane Burke, president of Cerner. Allscripts News *There were no recent news stories related to Allscripts* Epic News *There were no recent news stories related to Epic Systems* VA-18-0298-F, VA-18-0299-F-000104 000104 Owner: Filename: Last Modified: (b) (6) 018.docx for Printed Item: 30 ( Attachment 1 of 3) EHRM in the News Thursday, March 8, 2018 EHRMNe ws Politico: 'We took a broke n system and just broke it completely' (8 March 2018 , Aithur Allen) President Donald Tnunp last year hailed a mul tibillion-d ollar initiative to create a seamle ss digital health syste m for active duty mili tru.y and the VA that he said wo uld deliver "faster , better, and far better quality care. " Bu t the militru.y's $4.3 billion Cerner medical record syste m has utterly failed to achieve those goals at the first hospitals that went onlin e. * Techn ical glitches and poor training have caused dangero us en ors and reduced the number of patients who can be treated, according to interv iews with m ore than 25 mili tru.y and Vetera ns Affa irs health IT specialists and doctors, including six who work at the four Pa cific Northwest militru.y medical facilities that rolled out the softwa re over the past year. * Bob Mru.?shall,a health IT specialist at Madigan Almy Medical Center, another early rollout site, blamed the poor stru.t partl y on the Penta gon acqui sition office 's inexper ience with civilian record systems and the lack of a "sandbox" whe re clini cians could perfect the syste m before it was turned on . o "The bottom line is ... the Cerner user build is immature and needs to be brought up to a functional level, " said Bob Mru.?shall, a health IT specialist at Madigan Almy Medical Center. "There were some expectat ions at high er levels that this ... was an out-of-the-box solutio n that would work perfectly, but it didn 't." o Officials from Cerner and Leid os, the lead contracto r on the project , acknowledge stru.tup difficultie s but said they 're temporru.y. They said they ru.?emakin g fixes and physicians will get used to other chan ges. * Despite the sta1tup issues, which have been glossed over in public discussion of the project , the White House continues to mak e the overhaul of the milita1y and VA medical records a centerpiece of its governm ent refo1m effo1ts. o "This was a huge win for our serv ice," Jru.?ed Kushner told a health IT conference in Las Vegas on Tuesday , refen ing to Shulkin 's decision last spring to use Cerner following consultati ons with Ku shner 's office. "The president wants to make interoperable health records avai lable for all Americans ." * CernerNews Becker 's Hospital Review: Centrns Health to use Cerner techn ology to create popu lation health program (7 March 2018 , Anuja Vaidya) * Centrns Health, a clini cally integrated network based in Kansas , will integrate Cerner solutio ns and technological too ls to create a population health mana gement program . * Centrns Health includ es numerou s hospitals and provider s in the region, including Shawnee (Kan .) Mission Health and The University of Kansa s Health System in Kansas City. 1 VA-18-0298-F, VA-18-0299-F-000106 000106 018.docx for Printed Item: 30 ( Attachment 1 of 3) EHRM in the News Thursday, March 8, 2018 * Centrns Health will deploy the Cemer Healthelnt ent population health manage ment platfo1m to coordinate care across the network. Centm s Health's 16,000-plus paiiicip ants will be able to share data and work together. Cem er associates will also work to optimize the network's value-based contra cts through technology . o "Centm s Health and Cem er together have the unique oppo1iunity to make a real impact on the quality and delive1y of health cai?e in the Kansas City metro ai?ea," said Zane Bmk e, presiden t of Cem er. Allscripts Ne1vs *There were no recent news stories related to Allsc1?;pts* Epic Ne1vs *There were no recent news stories related to Epic Systems* 2 VA-18-0298-F, VA-18-0299-F-000107 000107 From : To : Cc: Bee: Subject: Date : Attachments : < o=va ou=v Isn cn=rec 1p1ents/cn=> Zenooz, Ashw ini ; Gunna r William ;-- ; Kroupa, Laura (V15 ; EHRM in the News Wednesday, March 7, 2018 EHRMNew s EHR Intelligence: My HealthE Data Initiative to Improve EHR Patient Data Access (6 March 2018 , Kate Monica) * CMS Administrator Seema Ve1ma recently announced a new initiative from the Trnmp Adm inistratio n - MyHealthEData - designed to impro ve EHR patient data access. * Acco rdin g to an ann oun cement from Ve1ma during HIMSS 18, the initiative is part of a larger effo1i to create a more patient-centric healthcare system. * The initiative is intended to give patients more control of their own EHR data and wi ll do this by breaking down existing batTiers to health data access and use. Patients will have access to their own EHRs throu gh the device or application of their choice , stated CMS . o Additio nally, MyHealthEData will enable patients to choose the provider that best meets their needs and grant that provider secure access to the patient's EHRs. Nextgov: Kushn er Anno un ces 'Who le of Gove rnment' Plan To Improve Health Tech (6 March 2018 , Aai?on Boyd) * The Trnmp administration is set to begin a "w hole of governmen t" push toward digitizing medical health records and impro ving the interoperability of patient data , Jared Kushner, senior advise r to the president, said Tuesday. * The White House -an d the Office of American Inn ovation, led by Kushner-is making "citizen access to health records and interoperability a top priority ," Kushner said during a keynote address at the annual Healthcare Infonn ation and Management Systems Society conference in Las Vegas. o "The time is now to align eve1y facet of the federal governm ent and the private secto r to ensure info1mation is commun icated and shai?ed seam lessly. Simpl y put , interoperabi lity is about our share d bottom line : saving lives ," he said . * He also said he was strnck by the interoperability problems between the Defense and Veterans Affairs depa 1ime nts. The VA last summer announced its intentio n to resta1i its electro nic health record s effo1is with a new vend or, Cerner , wh ich manages the Defense Depaiiment 's digital health records . o "This was a huge win for our serv ice members ," Kushner said. "Bu t the president is dete1mined to make interoperability a reality for all Americans. This is an issue that impacts eve1y hospital , care provider and patient in our countty. Now that electro nic health records have become digitized over the past decade , complete interoperabi lity is the logical next step. " Cerner News Cerner: Nat ional Coord inat ion Center to Supp ort VA EMR with Resources from Top US Hea lth Care Organ izations (6 March 2018) 1 VA-18-0298-F, VA-18-0299-F-000112 000112 EHRM in the News Wednesday , March 7, 2018 * * * * The founding members of the National Coord ination Center's Depaitment of Veterans Affairs 01A) Steering Comm ittee today announced their commitme nt to help support the VA 's 10-yeai? implementation of a Cemer Millennium (R)-based EMR system. To help VA create a learning health system to supp o1t their role in integrated systems of care , thought leaders have joined the NCC's VA Steering Comm ittee . he NCC VA Steering Comm ittee will consist of expe1ts from fields that will help mitigate risk to the planned EMR implementation and work to position the VA to deliver high-quality care . "Cemer is excited to work with the NCC and its esteemed group of academic leaders to create a lasting solutio n in support of the VA and our veterans," said Travis Dalton , senior vice president of Cemer Government Services . "Seamless data exchange across the vast network of VA medical facilities and with the commerc ial health care sector is our top priority ." EHR Intelligence: Cem er_NextGen Healthcare Expand Breadth of Health IT Solutions (6 Mai?ch 2018, Kate Monica) * Cem er will expand its health IT solutio n offerings through a collaboration with custome r relationship management provider Salesforce in an effo1t to improve patient and provider engagement. * The Salesforce Health Cloud and Marketing Cloud solutions will be integrated into Cem er's population health management platfo1m, Healthelntent . * Salesforce Health Cloud will enabl e healthcare organizations to collaborate more efficiently and better understand the needs of their patient s for improved communication between prov iders, care teams , and their patient s. A llscr ipts News MSN Money: Allscripts (MDRX) Launches Avenel to Revamp EHR Platform (7 March 20 18) * Allscripts Healthcare Solutions MDRX recently launched electro nic health record (EHR) solutio n - Avene l - at the annual HIMSS conference. The following sessions at the conference will comprise individual demonstrations on A venel. * In a bid to revamp EHR , A llscripts has invested significantly in the Avenel user interface and created the app-like functionality , featuring tablet-friendly swipe-and-tap navigation with easy-to -configure dashboards. It also involved a great deal of speculatio n into client and industly needs. Epic News *There were no recent news stories related to Epic Systems* 2 VA-18-0298-F, VA-18-0299-F-000113 000113 From : To : Cc: Bee: Subject: Date : Attachments : MedCity News article Wed Dec 13 2017 09:18:50 EST Hi Team GMO - here is an article that was published yesterday , that I am shar ing as FYI. Also , for your awareness, has asked one of the PEO Comms cont ract si news clips together daily moving forwa rd; we will likely use the mailgroup that establish , to share these with our team members, in the future . In the inter im as being established, I am sending these to you for awa reness . ort to pull EHRM is work ing to ose processes are 3.2 - MedCity News : Three takeaways on the VA, VistA and government health IT (12 Decembe r, Erin Dietsche , 478k online visitors/ mo; New York, NY) A new study from the U.S. Government Accountab ility Office dug deeper into what's happen ing with the Department of Veterans Affai rs and its quest to improve its health IT infrastructure . Meanwhile , an EHR interoperability summ it involving top government officia ls has been the talk of the town. Here are three takeaways regard ing the report and the meet ing. Modernization costs Accord ing to the GAO , the VA has attempted to update its EHR system -the Veterans Health Information Systems and Technology Arch itecture (or VistA) - nume rous times ove r the past 20 years . These attempts include the iEHR program and the VistA Evolution program . VA-18-0298-F, VA-18-0299-F-000114 000114 While the iEHR program set out to replace the separate systems used by the VA and the Department of Defense with a single system, the VistA Evolution program wanted to improve VistA with new capabilities and a different user interface. From fiscal year 2011 to fiscal year 2016, the VA contracted with 138 vendors and dedicated more than $1.1 billion to these two programs. The 15 main contractors that worked on the efforts cost the VA $741 million. Only recently did the department announce that it will switch to a Cerner EHR system instead of modernizing its legacy system. FITARA-related efforts The GAO report also touches on the Federal Information Technology Acquisition Reform Act, otherwise known as FITARA. Enacted by Congress in late 2014, it focuses on how the government purchases and managed technology. The VA has worked toward consolidating its data centers and reported $23.61 million in data centerrelated cost savings. But the progress isn't quite enough, as it "has fallen short of targets set by the Office of Management and Budget." On top of that, the VA doesn't anticipate more savings regarding data centers. More on federal health IT In other health IT news, a December 12 summit between a number of top officials has garnered the attention of the healthcare world. Jared Kushner, President Donald Trump's son-in-law and the leader of the Office of American Innovation, will lead the event along with CMS Administrator Seema Verma. The meeting will focus on EHR interoperability, according to Politico. A few other prominent folks will be there, including National Coordinator for Health IT Don Rucker, Intermountain Healthcare CEO Marc Harrison and CMO Officer Stan Huff, a representative from Cerner and The Sequoia Project CEO Mariann Yeager. VA-18-0298-F, VA-18-0299-F-000115 000115 As Politico also pointed out, the summit does have ties to the goings-on of the VA. Earlier this year, Kushner boasted about how quickly the VA secured the Cerner deal. According to leaked audio, Kushner claimed that with his assistance, the department was able to sort out a solution in a two-week time frame. (b) (6) VA-18-0298-F, VA-18-0299-F-000116 000116 VA U.S.Department of Veterans Affairs eoe1ve~ JUNO6 2019 ~BY:______ _ Daniel McGrath American Oversight 1030 5th Street, NW Suite B255 Washington, DC 20005 810 Vermont Ave NW Washington DC 20420 .,, www.va.gov NAY 28 2819 Re: Freedom of Information Act Tracking Number 18-07440-F Dear Mr. McGrath, This is an amended interim response to your Freedom of Information Act (FOIA) request to the Department of Veterans Affairs (VA) dated May 8, 2017, in which you requested all records reflecting communications (including emails , email attachments, text messages , messages on messaging platforms (such as Slack , GChat or Google Hangouts, Lyne, Skype , or WhatsApp) , telephone call logs , calendar entries/invitations, meeting notices , meeting agendas, informational material , draft legislation , talking points, any handwritten or electronic notes taken during any oral communications, summaries of any oral communications, or other materials) between 1) the Office of the Secretary, the Office of the Assistant Secretary for Informat ion and Technology and the Chief Information Officer , or the Electronic Health Records Modernization (EHRM) Program Executive Office and 2) Isaac "Ike" Perlmutter, Bruce Moskowitz, or Jared Kushner". On May 8, 2018 you amended your request to read as follows: All records reflecting communications (including emails, email attachments, text messages , messages on messaging platforms (such as Slack, GChat or Google Hangouts, Lyne, Skype , or WhatsApp) , telephone call logs, calendar entries/invitations, meeting notices , meeting agendas , informational material, draft legislation , talking points, any handwritten or electronic notes taken during any oral communications, summaries of any oral communications , or other materials) between 1) political appointees and Senior Executive Service (SES) employees within the Office of the Secretary , the Office of the Assistant Secretary for Information and Technolog y and the Chief Information Officer and, the Electronic Health Records Modernization (EHRM) Program Executive Office and 2) Isaac "Ike" Perlmutter , Bruce Moskowitz , or Jared Kushner. On May 17, 2018 , you agreed to aggregate two of your requests as follows: All emails , text messages and messages on messaging platforms (such as Slack , GChat or Google Hangouts , Lyne, Skype, or WhatsApp) of political appointees3 and Senior Executive Service (SES) employees within 1) the Office of the Secretary , 2) the Office of the Assistant Secretary for Information and Technology and the Chief Information Officer and, 3) the Electronic Health Records Modernization (EHRM) Program Executive Office that contain any of the following terms: a. b. c. d. e. f. AMc: ICAN Moskowitz; Perlmutter; Ike; "Trump 's friend "; "Trump's Doctor"; "POTUS friend "; pVERSIGHT FOIA Request 18-07440-F McGrath Page2 g. "POTUS's friend"; h. "POTUS' friend"; i. "POTUS doctor''; j. "POTUS's doctor"; k. "POTUS' doctor"; I. "President's friend "; m. "friend of POTUS"; n. "friend of President"; or o. "friend of the President" . o All records reflecting communications (including emails, email attachments, text messages, messages on messaging platforms (such as Slack, GChat or Google Hangouts, Lyne, Skype, or WhatsApp), telephone call logs, calendar entries/invitations, meeting notices, meeting agendas , informational material, draft legislation, talking points, any handwritten or electronic notes taken during any oral communications, summaries of any oral communications, or other materials) between 1) political appointees and Senior Executive Service (SES) employees within the Office of the Secretary, the Office of the Assistant Secretary for Information and Technology and the Chief Information Officer and, the Electronic Health Records Modernization (EHRM) Program Executive Office and 2) Isaac "Ike" Perlmutter, Bruce Moskowitz, or Jared Kushner. Please provide all responsive records from May 15, 2017, to the date of the search. The FOIA Service received your request on May 7, 2018 , and assigned it FOIA tracking number 18-07440-F. Please refer to this number when communicating with the VA about this request. OIT produced two-hundred and twenty (220) pages of responsive documents that were sent to you on March 25, 2019 . After a second review of these documents OIT unredacted 5 of the 220 pages. These pages are: 25, 29, 83, 85, and 94. We are still reviewing documents and will continue to make releases on a rolling basis until all responsive documents have been reviewed and released. We appreciate your interest in the Department of Veterans Affairs. If you have any questions concerning this letter, you may contact Ms. Jacqueline Short of my staff at (202) 632-7426. Sincerely, ~~~.~ Director , VACO FOIA Service Quality, Performance, and Risk (QPR) Office of Information and Technology (OIT) Enclosed AMERICAN pVERSIGHT From: To: Subject: Blackburn, Scott R, Zenooz.Ashwjni:Short John (VACO} FW: [EXTERNAL]Re: VA EHR Date: Friday. March 23, 201812 :16:16 PM I already sent to Windom and DepSec . I told Windom to get with the Secretary today to gauge his reactions. Sent with Good (www.good .com) From: Marc Sherman Sent: Friday, March 23, 2018 9:47:39 AM To: Blackburn, Scott R. Cc: Bruce Moskowitz ; DJS Subject: (EXTERNAL]Re: VA EHR Scott, Thanks for inviting me to listen in on your calls this week with the subject matter experts. I was happy to make time to participate as requested and always happy to provide my thoughts for your consideration when requested. I read carefully your email about the efforts to work out the holes raised by the experts. You are on the way to kicking off an exciting project with a highly respected Contractor/vendor and a VA team that has worked very hard; and I know everyone has the goal to build the best next generation system for the veterans' healthcare. However, there were several major issues raised in the calls this week with the technical and clinical experts that you try to explain away in your email as solved, but indeed are not according to the experts. These issues, they believe, will prevent a successful implementation and I fear come back to haunt this project and its overseers . I hate to be a naysayer, but I respectfully don't agree with some of your conclusions expressed in your email when I listen to the experts with whom you consulted; and the experts are in fact not swayed by the follow-up conversations with them. The experts are recommending a system for the VA that has various enhancements to today's standard system functionality . At a minimum, I heard those experts express their opinions that the contract dangerously lacks definitions, standards and a clear express ion of this required, defined enhanced (non-standard) functionality (they articulate it much better than I). Failing to express this type of definitional clarity in the contract is an invitation to ambiguity, disputes and ultimate failure of purpose. The best "oversight and management of the contract" will not turn a contract lacking specificity into a vision of clarity. Including contractual clarity allows the Contractor to understand TODAY what is expected so that today it can confirm its agreement to provide the full functionality desired and have a better understanding of what is expected of them. Clarity in the contract is a healthy ingredient for the VA and the Contractor . I would be delighted to be wrong and welcome a demonstration of where Section 5.1 of the contract provides this specificity that Ors. Cooper and Huff, for example, urged. In light of the system requirements that these experts say must be included, which are enhancements of today's standard deliverables, the contract language is ambiguous. You say that "risk cannot be 100% driven out of any transformation of this magnitude," a concept to which I subscribe. However, when you substitute this concept for clear, written and defined functionality, especially for a design that is expected to be unique in many respects, you are doomed to disappointment and conflict. AMERICAN pVERSIGHT VA-18-0298 and VA-18-0299-G-000001 on some of the discussion and thought I would offer some reaction/feedback that still seems unsettled. I will outline my nighttime thoughts below in case you find them useful. 1. I thought that Dr. Cooper made a good case for inserting specific definitions and standards on the meaning and use of "interoperability," especially since that term has as many meanings in the industry as those who speak it. It is so easy for the contractor to proceed down a design path using one definition or standard while the users will require a totally different standard . That runs the risk of not being discovered until later, perhaps even up to implementation, a very costly result . Perhaps a similar problem (a seemingly big problem) that the DODimplementation faces now where the users are rebelling. Unfortunately, if this "gap" in definition is not discovered until IOC, it will be very difficult and very expensive to fix (ala the DODproblem) . I agree with Dr. Cooper, why not set the critical definitions and standards in the contract (PWS)now and eliminate the chance for any confusion or ambiguity. It will pay dividends later in terms of less arguments, better initial design, happier user community, less overall cost, better healthcare delivery, etc. Then, with the standard fully defined and set in the original PWS,the mock-up test will be much sooner in time and much more complete the first time, allowing the users to provide input sooner and better, eliminating costly design mistakes from the beginning. The user community can tell you today what is needed to accomplish this "next generation" system that will be a model for the country and the future of healthcare (as Ms. Reel envisioned on the call last night) . Why would you not want to tel I the contractor the specifics of that now, in fai mess to them , the VA, the patients and healthcare, so they can proceed with that standard from day one or express any concerns they may have now instead of in the future after costly design has occurred? Why would you not want to be specific in the contract to prevent ambiguity? Dr. Shulkin pushed back on Dr. Cooper's view as already accomplished in the PWSand cited Section 5 (I believe he said section 5.1.1) of the PWS. Dr. Cooper, as a physician user and not a technician, deferred on the effectiveness of the existing contract language to others, but commented that the CIO of MAYOread the contract and also did not think it adequately contained the right defining language to set out unambiguous definitions and standard. I have read the contract again last night and happen to agree, or am missing it. If 1 am wrong, it would be useful for someone to point me in the right direction. 2. I was also thinking about the current reported problems of the DOD implementation seemingly caused by a user (clinician) revolt over inadequacy (or unsuitability) for their needs. The VA runs that same risk. Perhaps that problem could be a benefit to your effort. Why not accumulate all of the user complaints/issues in the DODimplementation identified by the users and chart them out. Then identify which of those issueswould be issues if they existed in the VA implementation and include them in the contract as definitional requirements. You have the benefit of knowing the failures in the very system upon which you are modeling your system... and you have an added advantage and opportunity to contractually prevent similar mistakes. 3. I have other thoughts as well that we should discuss, but these are the ones AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-G-000002 Again, we believe the construct of the contract, and more im portantly the proper oversight and management of the contract will greatly mitigate cost, schedule and performance concerns, as well as support the timely injection of technological advancements (e.g. cloud, APls, etc.) at the appropriate pace and balance necessary to support our Veterans without jeopardizing our overall care pledge. Interoperability remains at the forefront or our concerns, and your comments, the MITRE study and various other external inputs contributing significantly to our RFPlanguage and corresponding requirements. Interoperability will be a moving target for years to come, but our contract allows us to leverage the best of ideas of industry throughout the contract's life without incurring the exorbitant costs you have alluded to, as well as not be bound by potentially antiquated definitions . As recommended, an interoperability sandbox/test bed will be established during our Initial Operating Capabilit ies (IOC) implementation/deployment process to solidify the requisite interoperability requirements prior to full enterprise deployment . This is consistent with the desires of many of our external experts . Change management, governance, training and communication remain critical and foundational elements of business transformation success. The program management office (PMO) will be the primary orchestrator of these strategies but will be calling for support from the entire VA enterprise to implement these pract ices in support of EHRmodernization objectives . Marc , thank you for everything . We are ready to take the next step . We hope you will take us up on our offer to be an advisor. Scott I thought that Dr. Cooper made a good case for inserting specific definitions and standards on the meaning and use of "interoperability," especially since that term has as many meanings in the industry as those who speak it. It is so easy for the contractor to proceed down a design path using one definition or standard while the users will require a totally different standard. That runs the risk of not being discovered until later, perhaps even up to implementation, a very costly result. Perhaps a similar problem (a seemingly big problem) that the DODimplementation faces now where the users are rebelling. Unfortunately, if this "gap" in definition is not discovered until IOC, it will be very difficult and very expensive to fix (ala the DODproblem). I agree with Dr. Cooper, why not set the critical definitions and standards in the contract (PWS)now and eliminate the chance for any confusion or ambiguity. It will pay dividends later in terms of less arguments, better initial design, happier user community, less overall cost, better healthcare delivery, etc. Then, with the standard fully defined and set in the original PWS,the mock-up test will be much sooner in time and much more complete the first time, allowing the users to provide input sooner and better, eliminating costly design mistakes from the beginning. The user community can tell you today what is needed to accomplish this "next generation" system that will be a model for the country and the future of healthcare (as Ms. Reel envisioned on the call last night). Why would you not want to tell the contractor the specifics of that now, in fairness to them, the VA, the patients and healthcare, so they can proceed with that standard from day one or express any concerns they may have now instead of in the future after costly design has occurred? Why would you not want to be specific in the contract to prevent ambiguity? Dr. Shulkin pushed back on Dr. Cooper'sview as already accomplished in the PWSand cited Section 5 (I believe he said section 5.1.1) of the PWS. Dr. Cooper, as a physician user and not a technician, deferred on the AMERICAN pVERSIGHT VA-18-0298 and VA-18-0299-G-000003 Cc: DJS Subject: Re: [EXTERNAL]Re: Stan Huff I agree that the call was very helpful. I spent the night after the call reflecting on some of the discussion and thought I would offer some reaction/feedback that still seems unsettled. I will outline my nighttime thoughts below in case you find them useful. 1. I thought that Dr. Cooper made a good case for inserting specific definitions and standards on the meaning and use of "interoperability," especially since that term has as many meanings in the industry as those who speak it. It is so easy for the contractor to proceed down a design path using one definition or standard while the users will require a totally different standard. That runs the risk of not being discovered until later, perhaps even up to implementation, a very costly result. Perhaps a similar problem (a seemingly big problem) that the DODimplementation faces now where the users are rebelling. Unfortunately, if this "gap" in definition is not discovered until IOC, it will be very difficult and very expensive to fix (ala the DODproblem). I agree with Dr. Cooper, why not set the critical definitions and standards in the contract (PWS)now and eliminate the chance for any confusion or ambiguity. It will pay dividends later in terms of less arguments, better initial design, happier user community, less overall cost, better healthcare delivery, etc. Then, with the standard fully defined and set in the original PWS,the mock-up test will be much sooner in time and much more complete the first time, allowing the users to provide input sooner and better, eliminating costly design mistakes from the beginning. The user community can tell you~ what is needed to accomplish this "next generation" system that will be a model for the country and the future of healthcare (as Ms. Reel envisioned on the call last night). Why would you not want to tell the contractor the specifics of that now, in fairness to them, the VA, the patients and healthcare, so they can proceed with that standard from day one or express any concerns they may have now instead of in the future after costly design has occurred? Why would you not want to be specific in the contract to prevent ambiguity? Dr. Shulkin pushed back on Dr. Cooper's view as already accomplished in the PWSand cited Section 5 (I believe he said section 5. i.1) of the PWS. Dr. Cooper, as a physician user and not a technician, deferred on the effectiveness of the existing contract language to others, but commented that the CIO of MAYOread the contract and also did not think it adequately contained the right defining language to set out unambiguous definitions and standard. I have read the contract again last night and happen to agree, or am missing it. If I am wrong, it would be useful for someone to point me in the right direction. 2. I was also thinking about the current reported problems of the DOD implementation seemingly caused by a user (clinician) revolt over inadequacy (or unsuitability) for their needs. The VA runs that same risk. Perhaps that problem could be a benefit to your effort. Why not accumulate all of the user complaints/issues in the DOD implementation identified by the users and chart them out. Then identify which of those issueswould be issues if they existed in the VA implementation and include them in the contract as definitional requirements. You have the benefit of knowing the failures in the very system upon which you are modeling your system... and you have an AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-G-000004 From: Blackburn, Scott R. Sent: Friday, March 23, 2018 9:16:15 AM To: Zenooz, Ashwini; Short, John (VACO) Subject: FW: [EXTERNAL} Re: VA EHR I already sent to Windom and DepSec. I told Windom to get with the Secretary today to gauge his reactions. Sent with Good (www.good.com) From: Marc Sherman Sent: Friday, March 23, 2018 9:47:39 AM To: Blackburn , Scott R. Cc: Bruce Moskowitz; DJS Subject: [EXTERNAL] Re: VA EHR Scott, Thanks for inviting me to listen in on your calls this week with the subject matter experts. I was happy to make time to participate as requested and always happy to provide my thoughts for your consideration when requested. I read carefully your email about the efforts to work out the holes raised by the experts. You are on the way to kicking off an exciting project with a highly respected Contractor/vendor and a VA team that has worked very hard; and I know everyone has the goal to build the best next generation system for the veterans' healthcare. However , there were several major issues raised in the calls this week with the technical and clinical experts that you try to explain away in your email as solved, but indeed are not according to the experts. These issues, they believe, will prevent a successful implementation and I fear come back to haunt this project and its overseers . I hate to be a naysayer, but I respectfully don't agree with some of your conclusions expressed in your email when I listen to the experts with whom you consulted; and the experts are in fact not swayed by the follow-up conversations with them . The experts are recommending a system for the VA that has various enhancements to today's standard system functionality. At a minimum, I heard those experts express their opinions that the contract dangerously lacks definitions, standards and a clear expression of this required, defined enhanced (non-standard) functionality (they articulate it much better than I). Failing to express this type of definitional clarity in the contract is an invitation to ambiguity, disputes and ultimate failure of purpose. The best "oversight and management of the contract" will not turn a contract lacking specificity into a vision of clarity. Including contractual clarity allows the Contractor to understand TODAY what is expected so that today it can confirm its agreement to provide the full functionality desired and have a better understanding of what is expected of them. Clarity in the contract is a healthy ingredient for the VA and the Contractor. I would be delighted to be wrong and welcome a demonstration of where Section 5.1 of the contract provides this specificity that Ors. Cooper and Huff, for example, urged. In light of the system requirements that these experts say must be included, which are enhancements of today's standard deliverables, the contract language is ambiguous. You say that "risk cannot be 100% driven out of any transformation of this magnitude," a concept to which I subscribe. However, when you substitute this concept for clear, written and defined functionality, especially for a design that is expected to be unique in many respects, you are doomed to disappointment and conflict. AMFn1 ..,A1 pVERSIGHT VA-18-0298 and VA-18-0299-G-000005 VA U.S. Department ofVeterans Affairs 0 ecE,vEn n JUN 1 D 2019 u BY:_,,,,,,,..,,_-===--="' Daniel McGrath American Oversight 1030 5th Street, NW Suite B255 Washington, DC 20005 810Vermont Ave NW Washington DC 20420 www.va.gov JUNO 4 20I Re: Freedom of Information Act Tracking Number 18-07440-F Dear Mr. McGrath, This is an interim response to your Freedom of Information Act (FOIA) request to the Department of Veterans Affairs (VA) dated May 8, 2018, in which you requested all records reflecting communications (including emails, email attachments, text messages, messages on messaging platforms (such as Slack, GChat or Google Hangouts, Lyne, Skype, or WhatsApp), telephone call logs, calendar entries/invitations, meeting notices, meeting agendas, informational material, draft legislation, talking points, any handwritten or electronic notes taken during any oral communications, summaries of any oral communications, or other materials) between 1) the Office of the Secretary, the Office of the Assistant Secretary for Information and Technology and the Chief Information Officer, or the Electronic Health Records Modernization (EHRM) Program Executive Office and 2) Isaac "Ike" Perlmutter, Bruce Moskowitz, or Jared Kushner". On May 8, 2018 you amended your request to read as follows: All records reflecting communications (including emails, email attachments, text messages, messages on messaging platforms (such as Slack, GChat or Google Hangouts, Lyne, Skype, or WhatsApp), telephone call logs, calendar entries/invitations, meeting notices, meeting agendas, informational material, draft legislation, talking points, any handwritten or electronic notes taken during any oral communications, summaries of any oral communications, or other materials) between 1) political appointees and Senior Executive Service (SES) employees within the Office of the Secretary, the Office of the Assistant Secretary for Information and Technology and the Chief Information Officer and, the Electronic Health Records Modernization (EHRM) Program Executive Office and 2) Isaac "Ike" Perlmutter, Bruce Moskowitz, or Jared Kushner. On May 17, 2018, you agreed to aggregate two of your request as follows: All emails, text messages and messages on messaging platforms (such as Slack, GChat or Google Hangouts, Lyne, Skype, or WhatsApp) of political appointees3 and Senior Executive Service (SES) employees within 1) the Office of the Secretary, 2) the Office of the Assistant Secretary for Information and Technology and the Chief Information Officer and, 3) the Electronic Health Records Modernization (EHRM) Program Executive Office that contain any of the following terms: AMc: ilCAN pVERSIGHT FOIA Request 18-07440-F McGrath Page 2 a. b. c. d. e. f. g. h. i. j. k. I. m. n. o. • Moskowitz; Perlmutter; Ike; "Trump's friend"; "Trump's Doctor"; "POTUS friend"; "POTUS's friend"; "POTUS' friend"; "POTUS doctor"; "POTUS's doctor"; "POTUS' doctor"; "President's friend"; "friend of POTUS"; "friend of President"; or "friend of the President" . All records reflecting communications (including emails, email attachments, text messages, messages on messaging platforms (such as Slack, GChat or Google Hangouts, Lyne, Skype, or WhatsApp), telephone call logs, calendar entries/invitations, meeting notices, meeting agendas, informational material, draft legislation, talking points, any handwritten or electronic notes taken during any oral communications, summaries of any oral communications, or other materials) between 1) political appointees and Senior Executive Service (SES) employees within the Office of the Secretary, the Office of the Assistant Secretary for Information and Technology and the Chief Information Officer and, the Electronic Health Records Modernization (EHRM) Program Executive Office and 2) Isaac "Ike" Perlmutter, Bruce Moskowitz, or Jared Kushner. Please provide all responsive records from May 15, 2017, to the date of the search. The FOIA Service received your request on May 7, 2018 , and assigned it FOIA tracking number 18-07440-F. Please refer to this number when communicating with the VA about this request. On March 25, 2019 , we released two hundred and twenty (220) pages that specifically addressed your request for information . On May 28, 2019, we released 5 pages of an amended interim response. We are releasing six hundred and seventy-nine (679) pages of responsive documents on CD at no cost to you. AMFnlCAN pVERSIGHT FOIA Request 18-07440-F (McGrath) Page 3 We are withholding information pursuant to FOIA exemption 5, [5 U.S.C. § 552 (b)(5)], which protects from disclosure all inter-agency or intra-agency memorandums or letters which would not be available by law to a party other than an agency in litigation with the agency. We are withholding one hundred and sixty-six pages (166) pages under the above exemption. FOIA exemption 6 permits an Agency to withhold from disclosure personnel and medical files and similar files the disclosure of which would constitute a clearly unwarranted invasion of personal privacy. The information withheld, such as names, are of a type that the privacy interest of the individual(s) to whom this information belongs outweighs any public interest in disclosure of this information. We are withholding fortyeight (48) pages under the above exemption. We are still reviewing documents and will continue to make releases on a rolling basis until all responsive documents have been reviewed and released. We appreciate your interest in the Department of Veterans Affairs. If you have any questions concerning this letter, you may contact Ms. Jacqueline Short of my staff at (202) 632-7426. Sincerely, ~~~=-n Director, VACO FOIA Service Quality, Performance, and Risk (QPR) Office of Information and Technology (OIT) Enclosed AMFnlCAN pVERSIGHT Document ID: 0.7.1705.65544 From: Cashour, Curtis To: Sandoval, Camilo J. ; Selnick, Darin Ullyot, John Cc: Bee: Subject: Date: Attachments: II approval needed ASAP today II Perlmutter, Moskowitz and Sherman Mon Nov 26 2018 13:27:51 EST Folks - please see below from ProPublica. Are you OK with the following response? Although his predecessors may have done things differently, Sec. Wilkie has been clear about how he does business. No one from outside the administration dictates VA policies or decisions - that's up to Sec. Wilkie and President Trump. Period. Q: Why was Darin Selnick the point person on the Apple collaboration? A: We refer you to former VA employee David Shulkin for comment since this happened on his watch. We know you are in contact with him. Q: What ethics official approved of OIT beginning work on Dr. Moskowitz's app, and what was the justification? What ethics official approved of OIT beginning work on Dr. Moskowitz's app, and what was the justification? A: The premise of your question is false. VA did not begin work on the app. Q: Why did Selnick introduce Dr. Moskowitz's son to his contacts at Apple? A: We refer you to former VA employee David Shulkin for comment since this happened on his watch. We know you are in contact with him. AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000001 1 of 6274 Page 2 of 1093 Q: What became of Peter O'Rourke's effort to "salvage" the Apple collaboration, as conveyed in a March 8, 2018, email? A: We refer you to former VA employee David Shulkin for comment since this happened on his watch. We know you are in contact with him. Q: What is the current status of the collaboration with Apple on the data exchange? A: VA is in frequent contact with the private sector on how companies can work together on improving services to our nation's Veterans, but we have no announcements at this time with respect to any particular company or group of companies. Q: Why did the VA organize a medical device registry summit, even though the VA already had a 99 percent effective system for product recalls, and the FDA already has NEST? A: VA organized the Medical Device Registry Summit to bring together industry and academic leaders, as well as sister-agency experts to map out a strategy for launching the largest medical device-implant tracking program in the nation. The department is now looking to expand that collaboration to include the Food & Drug Administration and the Centers for Medicare and Medicaid Services, as well as VA 's community care partners. Medical devices are a $170 billion business, accounting for 6 percent of U.S. health spending in 2013, and implantable device sales are projected to reach $7 4 billion this year. Given the large and expanding role of medical devices in modern health care, it's important to know what works best for patients. The next steps for implementing a registry are working to ensure it would incorporate key features that enable quality measurement and outcome comparisons, patient safety monitoring, faulty-device recalls and patient notifications, and overall tracking and clinical follow-up. Q: In Peter O'Rourke's Feb. 28, 2018, email saying, "I will protect our conversations from yesterday and as instructed by the Secretary last night, not discuss the content with any of the individuals what were mentioned," who and what is he referring to? A: We refer you to former VA employee David Shulkin for comment since this happened on his watch. We know you are in contact with him. Q: On Feb. 28, 2018, Dr. Moskowitz wrote, "The emergency 'committee' is mental health and that should be the first one to get right and move ASAP. I need to know all existing committees and initiatives on a chart. I have to pull in a significant number of assets to get boots on the ground to actually give timely care. I will need you to contact besides our academic partners, the following, U of AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000002 2 of 6274 Page 3 of 1093 PENN, U. OfChicago,UCLA, U of San Francisco, Stanford, Columbia, the Mack Center of technological innovation, the Bloomberg school of public health and Ondrea Gleason MD head of American Association of Chairs of Psychiatry. This committee will need a direct working relationship with Telemedicine, the Choice Program to get the job done. They will need the authority to seep away any beuqacratic process that slows the initiative." Peter O'Rourke replied, "I will begin a project plan and develop a timeline for action." What initiative were they discussing and what became of it? A: We refer you to former VA employee David Shulkin for comment since this happened on his watch. We know you are in contact with him. Q: What was the purpose of the "Requested Names" that Dr. Moskowitz sent to Peter O'Rourke on March 9, 2018? A: We refer you to former VA employee David Shulkin for comment since this happened on his watch. We know you are in contact with him. Q: On the tracker circulated by Camilo Sandoval on March 6, 2018, why is CIO listed as one of the topics? Why was Bruce Moskowitz involved in screening applicants for CIO? A: We refer you to former VA employee David Shulkin for comment since this happened on his watch. We know you are in contact with him. Curt Cashour Press Secretary Department of Veterans Affairs 202-461-7388 Curt. Cashou r@va.gov @curtcashour From: Isaac Arnsdorf [mailto:lsaac.Arnsdorf@propublica.org] Sent: Monday, November 26, 2018 10:13 AM To: Cashour, Curtis Cc: Snyder, Jill Subject: [EXTERNAL] Perlmutter, Moskowitz and Sherman Hi Curt, AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000003 3 of 6274 Page 4 of 1093 Hope you had a nice holiday. I'm writing a follow-up article about the influence of Ike Perlmutter, Bruce Moskowitz and Marc Sherman based on the additional documents that the agency released last week. My questions are: 1.After meeting Perlmutter, Moskowitz and Sherman for the first time in April, why did Secretary Wilkie email them to say, "No matter how long I am here, there is a template in place based on your efforts to move this institution out of the Industrial Age"? What did he mean by that? 2.How is saying they provided a "template" consistent with the Secretary's repeated assertions of independence from Perlmutter, Moskowitz and Sherman? 3.Why was this sentence redacted under FOIA exemption b5 when the email was originally released to me? 4.Why was Marty Steele at the April meeting at Mar-a-Lago? 5.Why did Perlmutter, Moskowitz and Sherman review the Gerner contract before it was signed? What relevant expertise did they have to offer? 6.What ethics official approved their reviewing the contract, and what was the justification? 7.Why was Darin Selnick the point person on the Apple collaboration? 8.On May 18, 2017, why did Selnick say, "The VA staff has limited knowledge and experience, which is why you and the centers are so important to help the VA move forward"? 9.What ethics official approved of OIT beginning work on Dr. Moskowitz's app, and what was the justification? 10.Why did Selnick introduce Dr. Moskowitz's son to his contacts at Apple? 11.Why did the VA start working on Moskowitz's app even though OIT identified significant problems with its usability, functionality and scalability? 12.What became of Peter O'Rourke's effort to "salvage" the Apple collaboration, as conveyed in a March 8, 2018, email? 13.What is the current status of the collaboration with Apple on the data exchange? 14.Why did the VA organize a medical device registry summit, even though the VA already had a 99 percent effective system for product recalls, and the FDA already has NEST? 15.What was the total cost of the summit? 16.Why did Dr. Moskowitz and Aaron participate in weekly planning calls? What were their roles and tasks? 17 .On April 10, 2018, why did SreyRam Kuy say she "owed" Dr. Moskowitz a budget for the medical device registry summit? Why was it appropriate for him to "edit" a government budget? 18.What ethics official approved Dr. Moskowitz's role in the summit and what was the justification? 19.What did it mean that Dr. Moskowitz 's foundation was identified as a "private interest" in May 10, 2018, briefing materials for the secretary? 20.ln Peter O'Rourke's Feb. 28, 2018, email saying, "I will protect our conversations from yesterday and as instructed by the Secretary last night, not discuss the content with any of the individuals what were mentioned," who and what is he referring to? 21.On Feb. 28, 2018, Dr. Moskowitz wrote, "The emergency 'committee' is mental health and that should be the first one to get right and move ASAP. I need to know all existing committees and initiatives on a chart. I have to pull in a significant number of assets to get boots on the ground to actually give timely care. I will need you to contact besides our academic partners, the following, U of PENN, U. OfChicago,UCLA, U of SanFrancisco, Stanford, Columbia, the Mack Center of technological innovation, the Bloomberg school of public health and Ondrea Gleason MD head of American Association of Chairs of Psychiatry. This committee will need a direct working relationship with Telemedicine, the Choice Program to get the job done. They will need the authority to seep away any beuqacratic process that slows the initiative." Peter O'Rourke replied, "I will begin a project plan and develop a timeline for action." What initiative were they discussing and what became of it? 22.What was the purpose of the "Requested Names" that Dr. Moskowitz sent to Peter O'Rourke on March 9, 2018? AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000004 4 of 6274 Page 5 of 1093 23.Who is the Under Secretary candidate from Mayo who Dr. Moskowitz recommended to O'Rourke on July 16, 2018? 24.Why is O'Rourke back at VA? 25.On the tracker circulated by Camilo Sandoval on March 6, 2018 , why is CIO listed as one of the topics? Why was Bruce Moskowitz involved in screening applicants for CIO? We're planning to publish as soon as tomorrow. Thanks, Isaac Isaac Arnsdorf ProPublica 917.512.0256 203.464.1409 isaac@propublica.org AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000005 5 of 6274 Page 6 of 1093 Document ID: 0.7.1705.733962 From: None To: Rippen, Helga E. Tibbits, Paul A. Cc: ; Cussatt, Dominic (SES) ; James, Bill ; Hume, Charles ; Evans, Neil C Bee: Subject: FW: [EXTERNAL] Re: Meeting between Dr. Tibbits and Aneesh Chopra to discuss open API pledge Date: Sun Nov 04 2018 15:47:00 EST Attachments: VA EHRM Interoperability-Mitre- Report Jan 2018 _Redacted_FINAL.pdf Helga, Can you lead an internal meeting for us to discuss recommendations below with internal VA stakeholders. 1.FHIR First Policy 2.Apple Health API Rules 3. From: Aneesh Choprafb )(S) ~carejourney.com] Sent: Sunday, Novem er 04, 20 18 3: 18 PIVI To: Wine, Marc Cc: Tibbits, Paul A ; Soundararajan, Jude >· ra M. (CMS/CCSQ) ~b)(S) ~ _ (b)(S) ssa.gov>; Worthington, ares< harles.Worthin~toornbta arn 1>· Sandoval , am1o . < am1o. andoval@va.gov>; James, Bill ; (b)(S) @ssa.gov Subject: [EXTERNAL] Re: Meeting between Dr. Tibbits and Aneesh Chopra to discuss open API pledge Sa::ban~n Marc, thanks for the summary! Paul - it was terrific seeing you again, and thanks for hosting all of us! Here's my summary, if useful: 1) "FHIR-first" policy: I'll defer to Shannon/Alex but there is likely more information to come from CMS on how it intends to leverage open APls to communicate with the care delivery system, and to regulate where appropriate. My suggestion was to establish a policy similar to our "cloud-first" approach back in 2010 whereby all the various sub-departments within the VA know that when starting a new interop project, or investing more in an existing one, that it pursue an "APl-first" evaluation to gauge feasibility AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000006 6 of 6274 Page 7 of 1093 before relying on whatever legacy method is under way. This is the direction of 21st Century Cures, and will likely be the focus of the forthcoming ONC information blocking rules. We know that existing API rules are working with respect to Apple Health's experience. They have published a list of every site where they have established a FHIR-based connection (https://support.apple.com/en-us/HT208647), which means any consumer app can follow without additional burden. As you likely know, Apple pays NOTHING to connect to these sites; the health systems pay NOTHING to connect with Apple (presuming they have "turned on" the 2015 CEHRT edition as required to meet CMS/ONC rules); and the consumer, of course, pays NOTHING to authorize the transmission. The FHIR Argonaut Project technical specifications allow physician access, but are NOT required in regulation (as of now). The "bulk access" specifications are ready for testing (ONC has funded a project with Boston Children's - https://www.hhs.gov/about/news/2018/09/26/hhs-announces-leap-health-itwinner.html). 2) Execute the Cerner Contract's Open Data Model Provisions: Now that the MITRE report is public, you can see all of the recommendations re: accelerating API standards development (attached). But key provisions that are in the contract have NOT been executed, including: -publishing Cerner's data model in the NIH/national library of medicine (as Kaiser did with CMT - https: //www.nlm.nih.gov/research/umls/cmUcmt_faq.html) -engaging the Open API Pledge partners in prioritizing use cases for standards deve lopmenUacceleration. -articulating how Cerner intends to make the work it is doing for the VA available to non-VA Gerner clients to lower the costs of future standards adoption/use. 3) Start building SMART Apps: presuming you can adopUscale up your "Digital Veteran API Gateway" de-coupled from the timeline of the Cerner implementation, then you can do any of the following we discussed: -Train VA employees for FHIR certification (here's the online course that started last week - http://www. hl7.org/events/fhir_fun.cfm) -leverage the "micro-purchasing" framework to FHIR-enable popular VISTA apps like the JLV (https: //doi.org/10.1007/s11606-018-4708-z), or CART-CL (https://www.hsrd.research.va. gov/for _managers/stories/ca rt-cl. cfm) -Direct Leidos/Epic to open up the Scheduling API consistent with the Argonaut Specs so third party apps can build tools to help veterans access community care (https://open.epic.com/Scheduling/FHIR); and in return, API pledgees like Trinity might reciprocate in the Columbus, OH market. I look forward to our discussion in a couple of weeks! Regards, Aneesh Chopra President (703) 672-1315 I CareJourney.com This email is intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. Dissemination, distribution, or copying of this email or the information herein by anyone other than the intended recipient, or an employee or agent responsible for delivering the message to the intended recipient, is prohibited. If you have received this email in error, please immediately notify us. On Fri, Nov 2, 2018 at 12:12 PM Wine, Marc wrote: Aneesh, Jude, Drew, Alexandra, Shannon, Paul and Bill; AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000007 7 of 6274 Page 8 of 1093 - A note to say thank you for yesterday's talks on Open API approach with our office. "The API pledge encourages health-care providers to commit to work collaboratively with VA to increase the mapping pace of health data to industry standards, including the current and future versions of Fast Healthcare Interoperability Resources (FHIR)." Sharing some highlight points or ideas from discussion, more ahead; plus, feel free to add, comment, further guidance or input. *VA is Argonaut Project participant. VA Argonaut Project participant. http://www. h 17.org/documentcenter/pu bl ic_temp_ 51339323-1 C23-BA 170C8BC8A 7320A4529/wg/argonaut/ Argonaut%20Project%20Charter-12%20Dec%202014-v3.pdf *VA can encourage standards development. The purpose of the Argonaut Project is to rapidly develop a first-generation FHIR-based API and Core Data Services specification to enable expanded information sharing for electronic health records and other health information technology based on Internet standards and architectural patterns and styles. *API standards, priority use case with SMART FHIR Vet Suicide Use Case. *Open API for suicide information can be shared across healthcare in community. *VA needs to finish the data model, start with a baseline data model. *Place data model within Library of Medicine repository as open availability. *VA can encourage standards development. *API standards, priority use case with SMART FHIR Vet Suicide Use Case. *Open API for suicide information can be shared across healthcare in community. *VA needs to finish the data model, start with a baseline data model. *Place data model within Library of Medicine repository as open availability. *SSA wants to ensure ongoing sharing clinical data for SSA claims disability determination. *FHIR Online Scheduling is online on Columbus, Ohio. FHIR questionnaire, online scheduling, Vets shared patient care, VA should adopt FHIR provider directory. *VA DOD JVL interface cold be provided through app environment. *Cloud available semantic interoperability tools well available healthcare arena. *VistA functions easily convertible to FHIR Open Apps platforms. Several Apps could be built from VistA, was mentioned physicians in the private sector Like VistA; suggested train VA programmers who have MUMPS skills, to transform programming, changing EHRM environment. Again, many thanks. -----Original Appointment----From: Tibbits, Paul A. Sent: Monday, October 22, 2018 9:41 AM To: Tibbits, Paul A.; Aneesh Chopra; Wine, Marc; Sartin, Shannon (CMS/OA); Mugge, Alexandra M. :rn,~ararajan, Jude (C~S/C~~~ Cc:( b)(G) navhealth.com; Myklegard, Drew; Worthington, Charles; Sandoval, Camilo J.; James, 1 ; ut er, Suzanne Subject: Meeting between Dr. Tibbits and Aneesh Chopra to discuss open API pledge When: Thursday, November 01, 2018 12:00 PM-1:00 PM (UTC-05:00) Eastern Time (US & Canada). Where: VACO Room 350, 810 Vermont Avenue, NW, Washington, DC 20420 When you get to the building and check in with security, tell them that you are here to see me, Jonathan McBride. They will call me to come and pick you up. 202-461-4419. thanks! JMcB AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000008 8 of 6274 Page 9 of 1093 --> Join Skype Meeting Trouble Joining? Try Skype Web App Join by phone l(b)(6) English (United States) English (United States) English (United States) Find a local number Conference ID: ~ Forgot your dia~lp (same as access code above) PLEASE NOTE WE HAVE NEW PHONE NUMBERS You might want to make your attendees aware of the change. [!OC([1033])!] Jonathan McBride EHRM for Integration VA Office of Information and Technology (Ol&T) Department of Veterans Affairs 810 Vermont Ave NW cubicle #352-E Washington DC 20420 Offir. · 2D2-461-441 ~ 1 Cell: l(b)(S) ,__ ____,I ___ AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000009 9 of 6274 Page 10 of 1093 Document ID: 0.7.1705.733962-000001 Owner: None VA EHRM Interoperability-Mitre- Report Jan 2018 _Redacted _FINAL.pdf Filename: Last Modified: Sun Nov 04 14:47:00 CST 2018 AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000010 10 of 6274 Page 11 of 1093 VA EHRM Interoperab ility-Mitre- Report Jan 2018 _Redacted_FINA L.pdf for Printed Item: 2 ( Attachment 1 of 1) Document is no longer acquisition sensitive due to contract award on May 17. 2018 ACQUISITION SENSITIVE Departlllent of Veterans Affairs Electronic Health Modernization Request for Proposal Interoperability Review Report Authors: MITRE ACQUISITION SENSITIVE AMERICAN PVERSI 17 2018 VA-18-0298 and VA-18-0299-H-000011 Page 12 of 1093 VA EHRM Interoperab ility-Mitre- Report Jan 2018 _Redacted_ FINAL.pdf for Printed Item : 2 ( Attachment 1 of 1) Document is no longer acquisition sensitive due to contract award on May 17. 2018 ACQUISITION SENSITIVE This page intentionally left blank. ACQUISITION SENSITIVE AMERICAN PVERSI 17 2018 VA-18-0298 and VA-18-0299-H-000012 Page 13 of 1093 VA EHRM Interopera bility-Mitre- Report Jan 201 8 _Re dacted_FINA L.pdf for Printed Item: 2 ( Attachment 1 of 1) Document is no longer acquisition sensitive due to contract award on May 17. 2018 ACQUISITION SENSITIVE DocumentNumber:MTR180033 Authors: Jay J. Schn itzer , M.D ., Ph.D. I l(b}(6} Mclean, VA January2018 Sponsor: Department of Veterans Affairs Theviews,opinionsand/orfindings containedinthisreportarethoseof The MITRECorporation andshouldnotbe construed as anofficialgovernment position,policy,or decision,unless designated byotherdocumentation. ForInternalMITREUse.Thisdocument wasprepared for authorized distribution only.It hasnotbeenapproved for public release . © 2018TheMITRECorporation. All rightsreserved . ForDepartment of Veterans AffairsUseOnly VA EHRMRFPInteroperability ReviewReport January 31,2018 MITRE ACQUISITION SENSITIVE AMERICAN PVERSI 17 2018 VA-18-0298 and VA-18-0299-H-000013 Page 14 of 1093 VA EHRM Interoperability-Mitre- Report Jan 2018 _Redacted_FINAL.pdf for Printed Item : 2 ( Attachmen t 1 of 1) Document is no longer acquisition sensitive due to contract award on May 17. 2018 ACQUISITION SENSITIVE This page intentionally left blank. ACQUISITION SENSITIVE Confidential and Proprietary AMERICAN PVERSI For Department of Veterans Affairs Use Only er ac uisition sensitive due to contract award on MaVA-18-0299-H-000014 17 2018 VA-18-0298 and 14 of 6274 Page 15 of 1093 VA EHRM Interoperabi lity-Mitre- Report Jan 2018 _Redacted_FINAL.pdf for Printed Item : 2 ( Attachment 1 of 1) Document is no longer acquisition sensitive due to contract award on May 17. 2018 Executive Summary This Review Report presents responses to three requests from the Department of Veterans Affairs (VA) to MITRE related to the topic of interoperability within the VA Electronic Health Record Modernization Request for Proposal: I. Conduct an external Interoperability Review Panel to review the interoperability language in the existing Request for Proposal (RFP) , IL Engage an independent and unbiased legal expert to identify the specific changes to the RFP language necessary to implement the recommendations from the Interoperability Review Panel , and III. Visit the University of Pittsburgh Medical Center to understand the existing operational multi-vendor solution and interoperability solutions for applicability and scalability to the VA. I. Interoperability Review Panel In support of the Secretary of Veterans Affairs , David J. Shulkin , M.D. , The MITRE Corporation convened and hosted a VA Electronic Health Record Moderni zation (EHRM) Request for Proposal (RFP) Interoperability Review Panel on January 5, 2018, at MITRE ' s McLean headquarters. The invited external senior electronic health record (EHR) interoperability subject matter experts (the Panel) reviewed the interoperability language in the existing RFP and developed joint suggestions and recommendations for VA to consider for incorporation to support the successful execution of a new commercial EHR contract with industry. The Panel affirmed that the primary goal should be seamless Veteran-centric healthcare achieved through true EHR interoperability. Achieving this goal rests on three overarching principles that should be supported by interoperability language in the RFP: 1) free and open access to data, 2) an ecosystem that provides fair access to third parties by creating a level playing field, and 3) a seamless Veteran and health provider (clinician) experience. Four categories of recommendations from the Panel (the first three to the interoperability language in the RFP, and the fourth for future VA contracts) will enable VA to reali ze this goal on the basis of the underlying principles: 1) commit to full VA-Department of Defense (DoD) interoperability, 2) leverage current and future standards, 3) commit to open, standards-based application programming interfaces (APis) , and 4) use Care in the Community contracts to foster interoperability. For the first category (commit to full VA-DoD interoperability) , the Panel agreed that the Determination and Findings signed by Secretary Shulkin on June 1, 2017, represented the correct approach to interoperability within VA and between VA and DoD. The Panel strongly endorsed the proposed VA "API Gateway " language. The most important specific recommendations included: • Define the degree of interoperability the solution will provide, ranging from basic file sharing to fully interchangeable , integrated and functionally identical patient records. ACQUISITION SENSITIVE Confidential and Proprietary For Department of Veterans Affairs Use Only AMERICAN PVERSI V er ac uisition sensitive due to contract award on MaVA-18-0299-H-000015 17 2018 VA-18-0298 and 15 of 6274 Page 16 of 1093 VA EHRM Interoperabi lity-Mitre- Report Jan 2018 _Redacted_FINAL.pdf for Printed Item : 2 ( Attachment 1 of 1) Document is no longer acquisition sensitive due to contract award on May 17. 2018 Suggest that the Contractor conduct an annual Interoperability Self-Assessment against current and future standards that shall be specified by the VA; and • The contract language should include the following elements: o performance measures to hold Cerner accountable for reducing the administrative burden in clinician workflow with the objective of increasing efficiency , o ability for bulk data export based on standards , with no proprietary formats (e.g. , Flat FHIR [Fast Healthcare Interoperability Resources]), and o "push" capability to insert patient data back into the VA EHR / Cerner database. For the second category (leverage current and future standards) , the following specific recommendations were among the most important: • Require that Cerner implement all standards as defined by VA, current and future, • Engage Cerner as an advocate of the VA and DoD position in all relevant standardsmaking bodies , and • Ensure that VA and Veterans have complete access to data. For the third category (commit to open, standards-based APis) , the Panel voiced the following recommendations: • Establish clear publishing and access service requirements, • Provide a VA application platform that supports APis from third party providers with no barrier to entry, and • Require implementation of clinical decision support (CDS) Hooks to invoke decision support from within a clinician's EHR workflow. The body of this report contains multiple additional specific recommendations. II. Recommendations for RFP Changes MITRE engaged Morrison & Foerster, LLP as the independent and unbiased legal expert to identify the specific changes to the RFP language necessary to implement the recommendations from the Interoperability Review Panel. Appendix C presents all recommended changes to the RFP. Ill. Observations from University of Pittsburgh Medical Center Site Visit A delegation from VA and MITRE traveled to Pittsburgh, Pennsylvania, on January 19, 2018, for a meeting with representatives from University of Pittsburgh Medical Center (UPMC) Enterprises to discuss aspects of EHR interoperability that UPMC has successfully implemented over the past several years. The report includes an overview of those practices. ACQUISITION SENSITIVE Confidential and Proprietary For Department of Veterans Affairs Use Only AMERICAN PVERSI VI er ac uisition sensitive due to contract award on MaVA-18-0299-H-000016 17 2018 VA-18-0298 and 16 of 6274 Page 17 of 1093 VA EHRM Interoperab ility-M itre- Report Jan 2018 _Redacted_ FINAL.pdf for Printed Item : 2 ( Attachment 1 of 1) Document is no longer acquisition sensitive due to contract award on May 17. 2018 IV. Closing Though t s and Suggest ed Next Steps The Panelists noted that VA cannot achieve true future EHR interoperability through the Cerner RFP alone, or through techno logy alone . The state of practice today shares only a small portion of available patient data. For VA to succeed in the future , multiple other components must be present and aligned: innovation, policy , standards, customer buy-in , and legislation, to name a few. The following next steps are recommended for VA consideration: 1. Complete the RFP revisions, conduct appropriate negotiations with the Contractor expeditiously , and complete the contract process as planned. Stand firm during negot iations to maximize ease of access to data and data models for building third party APis , applications , and services for future community innovations. 2. Cont inue to work with other federa l government agencies and departments with similar interoperability interests and concerns, including, but not limited to, the White House, DoD , Food and Drug Administration (FDA) , Centers for Medicare and Medicaid Services (CMS), Office of the National Coordinator for Health Information Technology (ONC) , and other parts of the Department of Hea lth and Human Services, to align approaches to EHR interoperability and the deve lopment and support of standards government-wide . 3. Support future innovation approaches, includ ing concepts such as an Interoperability Laboratory and outreach to the broader innovation ecosystem (major medical centers, academia , traditional and non-traditional healthcare providers, startups, individual entrepreneurs, others) . It is critical to align the innovations planned in VA's Digital Veterans Platform to the VA EHR innovation efforts to ensure consistent continuous improvements to clinician and Veteran health experiences. 4. Create an External Review Pane l to prov ide expert continuous guidance, review , and feedback over the course of the implementation, to help capture best practices from the expert community going forward. Conduct ongoing demonstrations of end-to-end Veteran use cases requir ing data sharing across organizational boundaries to validate improvements in Veteran healthcare and reduct ion of burden for healthcare providers. VA and Contractor will ensure that Federal Advisory Committee Act (FACA) guidelines are followed in leverag ing any external review panels. ACQUISITION SENSITIVE Confidential and Propr ietary For Department of Veterans Affairs Use Only AMERICAN PVERSI Vll er ac uisition sensitive due to contract award on MaVA-18-0299-H-000017 17 2018 VA-18-0298 and 17 of 6274 Page 18 of 1093 VA EHRM Interoperab ility-M itre- Report Jan 2018 _Redacted_ FINAL.pdf for Printed Item: 2 ( Attachment 1 of 1) Document is no longer acquisition sensitive due to contract award on May 17. 2018 Table of Contents Background ............................................................ .... ........ .... .... .... .... .... .... .... .... .... .... .... .... .... .... . 1 I. Interoperability Rev iew Pane l ..... ........ .......... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .2 Introduct ion ................................................... .... ........ .... .... .... .... .... .... .... .... .... .... .... .... ........ .2 Goal ................................................................................................................................... 2 Methodology /Approach ...................................................................................................... 2 Topic Area: VA Definition of Interoperability .................................................................... 3 Topic Area: Comm it to Fu ll V A-DoD Interoperabi lity ...... .... .... .... .... .... .... .... .... .... .... .... .... .4 Topic Area: Leverage Current and Future Standards ...... ........ .... ........ .... .... .... .... .... .... ........ . 6 Topic Area: Comm it to Open, Standards-Based APis ........ ........ .... .... .... .... .... .... .... .... .... .... . 7 Topic Area: Use Community Care Contracts to Foster Interoperability ............................... 9 Topic Area: Additional Contract Changes ........................................................................ 11 II. Recommendations for RFP Changes ................................................................................. 12 III. Observations from University of Pennsylvania Medical Center Site Visit.. ....................... 13 IV. Closing Thoughts and Suggested Next Steps ..... ........ ........ ........ .... .... .... .... .... .... .... .... .... ... 16 Appendix A : Interoperab ility Review Forum Partic ipants .......... .... .... .... .... .... .... ........ .... .... .... ... 17 Appendix B: RFP Language for Purchasing Extensib le Health IT ...... .... .... .... .... .... .... .... .... .... ... 19 Appendix C: Recommended RFP Interoperability Language Changes ...................................... 22 Appendix D: Acrony1ns ............................................................................................................ 42 ACQUISITION SENSITIVE Confidential and Propr ietary For Department of Veterans Affairs Use Only AMERICAN PVERSI Vlll er ac uisition sensitive due to contract award on MaVA-18-0299-H-000018 17 2018 VA-18-0298 and 18 of 6274 Page 19 of 1093 VA EHRM Interoperability-Mitre- Report Jan 2018 _Redacted_FINA L.pdf for Printed Item : 2 ( Attach ment 1 of 1) Document is no longer acquisition sensitive due to contract award on May 17. 2018 This page intentionally left blank. ACQUISITION SENSITIVE Confidential and Proprietary For Department of Veterans Affairs Use Only AMERICAN PVERSI lX er ac uisition sensitive due to contract award on MaVA-18-0299-H-000019 17 2018 VA-18-0298 and 19 of 6274 Page 20 of 1093 VA EHRM Interoperabi lity-Mitre- Report Jan 2018 _Redacted_FINAL.pdf for Printed Item : 2 ( Attachment 1 of 1) Document is no longer acquisition sensitive due to contract award on May 17. 2018 Background The Department of Veterans Affairs (VA) plans to establish seamless care for Veterans throughout the health care provider market. Seamless care requires interoperability between the Department of Defense (DoD), VA, VA affiliates , community partners, electronic health record (EHR) providers , healthcare providers, and vendors. VA directed The MITRE Corporation to independently review the capability of Cemer' s proposed EHR solution to seamlessly transmit health records between EHR systems supporting healthcare providers who both use and contribute patient data to a Veteran ' s health record, to include Veterans Choice Program (VCP) community-care service providers and VA affiliates. This Review Report presents responses to three requests: I. Conduct an external Interoperability Review Panel to review the interoperability language in the existing Request for Proposal (RFP), II. Engage an independent and unbiased legal expert to identify the specific changes to the RFP language necessary to implement the recommendations from the Interoperability Review Panel, and III. Visit the University of Pittsburgh Medical Center to understand the existing operational multi-vendor solution and interoperability solutions for applicability and scalability to VA. ACQUISITION SENSITIVE Confidential and Proprietary For Department of Veterans Affairs Use Only AMERICAN 1 VA-18-0298 and VA-18-0299-H-000020 PVERSI 20 of 6274 Page 21 of 1093 VA EHRM Interoperab ility-M itre- Report Jan 2018 _Redacted_ FINAL.pdf for Printed Item : 2 ( Attachment 1 of 1) Document is no longer acquisition sensitive due to contract award on May 17. 2018 I. Interoperability Review Panel Introduction In support of the Secretary of Veterans Affairs, David J. Shulkin, M.D., MITRE convened and hosted a VA Electronic Health Record Moderni zation (EHRM) Request for Proposal (RFP) Interoperability Review Panel on January 5, 2018, at MITRE ' s McLean, VA headquarters. MITRE invited external senior EHR interoperability subject matter experts (hereafter referred to as Panelists) to review the interoperab ility language in the existing RFP and to develop joint suggestions and recommendations for VA to consider incorporating into the RFP to support the successful execution of a new commercial EHR contract with industry. Eleven Panelists took part in person , and several senior government execut ives observed the process (see Appendix A for the full list of participants). Goal The Interoperability Review Panel sought to provide Secretary Shulkin and his senior leadership team with insights into key best practices and guidance from national experts regarding EHR interoperability. The Panel evaluated the conesponding language in the draft RFP based on successful bus iness transformations and implementations of a new commercial EHR system across a distributed hospita l and provider network. Th is section of the report summarizes the outcome of the Panel: expert recommendations that will inform VA's interoperability contract language. The document also provides actionable and specific best practice recommendations and rationales to enable successful acquisition and implementation of EHR interoperability. Methodology/ Approach The first part of the session, which lasted for five hours, was conducted as a fish-bowl exercise and was guided by Chatham House Rule. The Panelists sat at a center table, with VA and other government observers sitting at sUIToundingtables. The second part, which lasted two hours, consisted of a summary debrief to the Secretary and senior VA leadership. The Secretary could ask questions and engage with the Panel throughout the second session. MITRE moderated the session to elic it inputs from all Panelists and to drive alignment toward consensus in the recommendations. The agenda for the first port ion of the session was structured to elicit inputs from all Panelists, with notes captured on-screen as redlines to the RFP interoperability language to ensure recommendations accurately reflected the Panelists' contributions. Subsequently , in a facilitated discuss ion, the Panelists grouped their recommendations into specific categories in real time. The second portion, as noted, provided opportun ities for the Secretary to discuss the recommendations in additional detail. This section of the report summarizes the discussion that took place. It high lights actionab le changes to the interoperability language contained in the RFP and additional recommendations and lessons learned that can enable interoperability of the VA EHRM solution. Text boxes ACQUISITION SENSITIVE Confidential and Propr ietary For Department of Veterans Affairs Use Only AMERICAN 2 VA-18-0298 and VA-18-0299-H-000021 PVERSI 21 of 6274 Page 22 of 1093 VA EHRM Interoperab ility-Mitre- Report Jan 2018 _Redacted_FINA L.pdf for Printed Item: 2 ( Attachment 1 of 1) Document is no longer acquisition sensitive due to contract award on May 17. 2018 throughout the report present direct quotations from Panelists. To ensure participant confidentiality, MITRE has destroyed the transcript and event recording used to develop this report. Topic Area: VA Definition of Interoperability The key to modernization is creating greater interoperability with Governmental partners, including DoD, in a way that focuses efforts in support of the Veteran's journey, beginning with their militmy service. We will partner with others to ensure Veterans can get their benefits, care, and services consistently , easily, and with excellent customer service, no matter where they are throughout their lives. VA will work with local communities, and with other Federal, State, Tribal, and Local Government entities to ensure Veterans get what they need. VA will also continue to leverage the private sector where appropriate and needed to deliver the very best outcomes for Veterans. - draft VA 2018- 2024 Strategic Plan Enable data sharing, interoperability, and agility through data standardization VA needs to allow data sharing among various business applications , such as appointment scheduling and business intelligence , as well as ensure transportability of informat ion between sites. Panelists "It really optimizes transportability of advised VA to leverage and support the best-in-class best practices, because if you are innovation currently in use within the VA culture. VA trying to transfer best practices from must also enable interoperability as the Department one site to another and you have the integrates the EHR into other supporting systems, both same system where the best practice is within the VA network and with external health service going to land, then it is much easier." providers. Agility is necessary for adoption of future innovative technologies and/or if VA wants to upgrade or change the EHR approach . The Panelists cautioned that the current EHR technology is already 20 years old and, as with all industries and information technology (IT) solutions, many possib ly disruptive technologies exist on the horizon. The session began with a discussion on interoperability as currently defined by VA (Figure 1). Prior to establishing a roadmap to inform a nationwide plan to advance health data interoperability, VA must first ensure system-w ide interoperabi lity across the Department. Throug hout the Rev iew Panel session, the Panelists described and referred to this concept as "Level 1 Interoperability" throughout the Review Panel session; it includes migration of Veteran data from ~ 130 instances of the Veterans Health Information Systems and Technology Architecture (VistA) to one VA platfonn. AC QUISITION SENSITIVE Confidential and Proprietary For Department of Veterans Affairs Use Only AMERICAN 3 VA-18-0298 and VA-18-0299-H-000022 PVERSI 22 of 6274 Page 23 of 1093 VA EHRM Interoperabi lity-Mitre- Report Jan 2018 _Redacted_FINAL.pdf for Printed Item : 2 ( Attachment 1 of 1) Document is no longer acquisition sensitive due to contract award on May 17. 2018 Figure 1. VA Definition of EHR Interoperability "Level 2 Interoperability," as described in the Panel discussion, addresses the ability for VA to leverage the same Cerner platform used by DoD to ensure seamless care from active service to Veteran status. Once this capability is implemented, the clinical data transformation will allow a true longitudinal view of a Veteran's record as he or she transitions from DoD to VA for care and other critical services such as benefit adjudication. "Level 3 Interoperability" will allow both VA and DoD to take an important step toward transforming electronic patient data exchange on a national scale. With the utilization of communjty healthcare providers via the VA Community of Care initiative and DoD's Tricare network providers , VA has the opportunity to drive interoperability between DoD and VA as well as with the extensive network of healthcare providers that serve our Nation's Veterans , active duty service members, and their beneficiaries. True nationwide EHR interoperability for the entire United States is the ultimate goal, and the Panelists agreed that VA and DoD could reach this goal if the three aforementioned levels of interoperability are achieved. Here, VA has the opportunity to drive clinical transformation and instantiation of a complete EHR for all patients at the national level. Topic Area: Commit to Full VA-DoD Interoperability The Panel focused primarily on reviewing the interoperability language within the RFP for the Ce.mer contract. However as described in Interoperability Levels 1 and 2, the commitment to the seamless integration of VA and DoD health data represents the foundation required to realize interoperability with private sector "You really have to get the basics done first. Let's just make absolutely sure that the interoperability between DoD and VA [is achieved]." ACQ UISITION SENSITIVE Confidential and Proprietary For Department of Veterans Affairs Use Only AMERICAN 4 VA-18-0298 and VA-18-0299-H-000023 PVERSI 23 of 6274 Page 24 of 1093 VA EHRM Interoperab ility-Mitre- Report Jan 2018 _Redacted_FINA L.pdf for Printed Item : 2 ( Attachment 1 of 1) Document is no longer acquisition sensitive due to contract award on May 17. 2018 healthcare providers. 1 It is important to note that the interoperability levels can be addressed simultaneously and should not be separated, as they must be integrated to efficiently achieve the larger future data sharing ecosystem . Specify the expectations for interoperability between DoD and VA During discussions about the expectation that Cerner will provide a single EHR solution to be shared by both DoD and VA, the Panel raised concerns about the lack of specificity in the contract language. Current interoperab ility data standards address a subset of the Veteran's clinical record and VA has the opportunity to ensure Cerner provides interoperability of all discrete data, at a minimum , between VA and DoD. Adopting the same platform would increase seamless sharing, but the Panel stated that VA should take additional action to ensure that such sharing is realized. The DoD and VA systems should use proprietary database-to-database interoperability if necessary , to maximi ze interoperability between those two systems. These systems should be configured to meet the distinct needs of each while being connected to each other in a native database-to-database method as necessary , leveraging open interoperability standards whereve r possible. As a result , clinic ians should experience no differences when they move from a VA system to a DoD system. These data should also be computable, or be made computable according to a specific schedule. VA should consider adding language to the RFP that specifica lly defines the degree of interoperabi lity the solution will prov ide, ranging from basic file sharing to fully interchangeable, integrated and functionally identical patient records. The Panelists also stated that, for VA and DoD collectively, the contractual language should include the following requirements: • Performance measures to hold Cerner accountable for reducing the administrative burden in clinician workflow with the objective of increasing efficiency • Capability for bulk data export based on standards, with no proprietary formats (e.g., Flat FHIR [Fast Healthcare Interoperability Resources]) • "Push" capability to insert new patient data back into the VA EHR / Cerner database. Pivot the RFP to be Veteran-centric and not system-centric The Panelists discussed the impact of EHR implementations on clinician workflow, describing the issue as one of approach ing the implementat ion as an IT system implementation rather than the preferred Veteran- or clinician-centric implementation. The current RFP appears to be written in a system-centric way rather than leveraging use-cases to describe the Veteran or clinician experience or work.flow to characteri ze the requirement. The Panelists recommended that VA incorporate use-cases to characterize requirements and amend the RFP language to emphasize the Veteran-centr ic objectives . In addition, Panelists noted that VA should recogn ize that EHRs do not currently maximi ze efficient clinical work.flow, and that VA specify that the 1 Healthcare providers is used to refer to community based physi cians/speci alist and hospitals. ACQ UISITION SENSITIVE Confidential and Proprietary For Department of Veterans Affairs Use Only AMERICAN 5 VA-18-0298 and VA-18-0299-H-000024 PVERSI 24 of 6274 Page 25 of 1093 VA EHRM Interoperabi lity-Mitre- Report Jan 2018 _Redacted_FINAL.pdf for Printed Item : 2 ( Attachment 1 of 1) Document is no longer acquisition sensitive due to contract award on May 17. 2018 solution present clinicians with relevant information where needed with a minimum number of "clicks to find." Topic Area: Leverage Current and Future Standards The integrated EHR platform that DoD and VA are implementing provides the opportunity to significantly influence interoperability standards across the healthcare community , addressing gaps and competition among current standards. The Panel recognized that commercial health systems and technologies would realize only limited business value from making data portable between them , but this would lower the barrier to patient movement among healthcare providers. Engage Cerner as an advocate of the VA and DoD position in all relevant standards-making bodies The Panel recommended increased VA presence and leadership in national health IT standardsmaking activities , in coordination with the DoD. Additionally , VA should encourage Cerner to serve as an active advocate of the VA-DoD position and to participate actively in the development and/or evaluation of new standards, policy directives, operating procedures, processes , etc. As an integrated voting bloc, VA, DoD , and Cerner will have the potential to act as a strong driver of national standards. Panelists understood that VA is not currently active in the FHIR community or in the Health Level Seven International (HL 7) Argonaut Project. In addition, Panelists identified a need for standards to exchange patient-reported outcome data for integration into the clinician's workflow. The current RFP language seemingly puts the burden on Cemer for the development of standards , and the Panel recommended that VA take a more active position. This will ensure that VA will participate and drive implementation when standards mature. Where standards are immature, VA must participate in efforts to accelerate standardization. Require Cerner to implement all standards as defined by VA, current and future Because it is unclear where health IT is heading in five years , the Panel strongly suggested VA include contract language to address possible future advancements in the form of standards as defined by VA. At a minimum, VA should seek maximum interoperability with community care organi zations , using open interoperability standards wherever possible. This flexibility would ensure that VA does not rely on external stakeholders to determine the standards that VA would be required to accept. The Panel recommended that VA pay particular attention to specific categories of standards: real-time data read/write by care providers and Veterans; interoperability tools; seamless DoD and VA vision records ; and principles for data normali zation and structure. The Panel also recogni zed Cemer ' s influence in ensuring that the Common Well network interoperates at the highest possible levels with other networks including CareQuality - an influence that VA should continue to promote. ACQUISITION SENSITIVE Confidential and Proprietary For Department of Veterans Affairs Use Only AMERICAN 6 VA-18-0298 and VA-18-0299-H-000025 PVERSI 25 of 6274 Page 26 of 1093 VA EHRM Interoperab ility-Mitre- Report Jan 2018 _Redacted_FINA L.pdf for Printed Item : 2 ( Attachment 1 of 1) Document is no longer acquisition sensitive due to contract award on May 17. 2018 VA must own its data; clear ownership and access are critical to success now and in the future The Panel highlighted an important recommendation regarding data rights that was discussed in the prior VA EHRM Listening Forum on September 7, 2017. The Panel recommended that VA define who has what rights from the perspectives of data ownership , access, and sharing (e.g ., VA owns the data and all data products vs. community care providers own the pat ient data vs. each Veteran owns all of his or her data). Determining the authoritative data source for the various elements of a Veteran's health record is an important Veteran-centric component of interoperability, the longitud inal record, and seamless access to data. "So, what you need is clear access and clear ownership of your information ...you need to have absolutely, undisputed, clear ownership and ability to move the data to any place you want to use it and use it in any way you want to use it when you get there. And not have them [Cerner] be able to say no, that's our data or hinder you in any way or have an unreasonable charge to get it." VA should define an enterprise-w ide pol icy for all VA data. A suitable policy would include, but not be limited to, EHRM-specific data, and should be issued by the VA Central Office (V ACO) or Veterans Health Administration (VHA). VA must have clear ownership of and access to all the informat ion in the EHR and be able to move that information (into new systems or among systems) as needed, now and in the future . Owning the data ensw-es that it is availab le regard less of vendor or system. VA must include this in the Cerner contract. Technology innovations occur rapid ly in the 21 st century, and VA must have full ability to move its data to future systems. Panelists also recommended that VA publish its data model , for instance to the National Library of Medicine, to further promote commercial interoperability investments. Lastly, Panelists encouraged VA to leverage its investment in the Open Sow-ce Electron ic Health Record Alliance (OSEHRA) by prov iding seed money to develop open sow-ce connectors between Cerner and Epic, which would encourage other vendors to join in the effort. Topic Area: Commit to Open, Standards-Based APls A significant technology enabler of seamless interoperability among the community of Veteran healthcare providers is the use of Applicat ion Programming Interfaces (APis). These software intermediar ies allow disparate EHR applications to communicate with each other and exchange data using standard , defined forms. The Panel emphasized the need for VA to create an environment that would minimi ze additional costs to community providers in order to interoperate with VA. VA can accomplish this by requiring the new EHR system to expose APis that support bi-directional data transactions. The Panel further recommended that VA make a commitment to open, standards-based APis , including the SMART on FHIR/Argonaut APis, to facilitate the ready and efficient exchange of data with partners providing care in the community and to support open clinical work:flow. ACQ UISITION SENSITIVE Confidential and Proprietary For Department of Veterans Affairs Use Only AMERICAN 7 VA-18-0298 and VA-18-0299-H-000026 PVERSI 26 of 6274 Page 27 of 1093 VA EHRM Interoperab ility-M itre- Report Jan 2018 _Redacted_ FINAL.pdf for Printed Item : 2 ( Attachment 1 of 1) Document is no longer acquisition sensitive due to contract award on May 17. 2018 Establish clear publ ishing and access service requir ements The Panel recogni zed that data access requirements differ depending on who provides or accesses that data. Therefore, the Panel recommended that VA be more specific in defin ing each level of data publishing and access service that is specific to (1) Veteran access (e.g., use of vets.gov); (2) VA clinician access ; (3) partner access; and (4) Health Informat ion Exchange (HIE) access. The RFP should include a clear description of identity and access management requirements, including user population types and the association of specific application permissions with particular roles /positions. "The Contractor should provide all of the data that is currently being provided in the Contractor's patient portal to the consumer via an open standards-based API gateway. The Contractor should also provide all of the reporting data required by federal law to the Veteran via an open standards based API framework, accessible via any application or thirdparty data store of the Veteran's choice, that's number one." Machine-to-machine access is also critical for efficient sharing of informat ion. The Panel recommended that VA ensw-e that all significant data stored in the software be accessible th.rough APis with no requirement for creation of custom applications to specifically access VA data. From a forward-looking perspective, VA should require that the EHR system support the ability to access data elements using open standards-based interfaces , and include the ability to interface with legacy data, pat ient-generated data , and third-party data that resides outside the EHR system. In addition, Cerner should provide the requ ired utility services to support intermediary or peer-to-peer services (e.g., support Veteran-directed or Veteran-mediated requests, data exchange , and ingestion of data from non-VA providers). Provide a VA app lication platfo rm that supports APls from third-party providers w ith no barrier to entry Cw-rently vets.gov serves as a portal to Veteran services. The Panel recommended that VA consider "The API Gateway document is awesome ... using such a portal to connect any third-party world class and future looking." application to the EHR solution without requir ing fees or vendor permissions. VA should have full authority to connect any third-party application through one of the standard open AP Is conformant with the vendor ' s API without pre-registering the application with the vendor. This is a very important authority to have in terms of the ability to innovate rapid ly, without constraints. The Panelists also reviewed the proposed VA "API Gateway" language provided during the API discuss ion to anchor the dialogue and concwTed that this requirement is fundamenta l to supporting interoperability. The Panel strongly endorsed the "API Gateway" language. Specifically, the Panelists recommended that VA include a requirement that VA have full authority to connect any third-party application to the Cemer system without requiring prior approva l by Cerne r. Furthermore , VA should ensw-e that develope rs of third-party applications connecting to the VA system via the open standard and VA-defined APis continue to own their ACQ UISITION SENSITIVE Confidential and Propr ietary For Department of Veterans Affairs Use Only AMERICAN 8 VA-18-0298 and VA-18-0299-H-000027 PVERSI 27 of 6274 Page 28 of 1093 VA EHRM Interoperab ility-Mitre- Report Jan 2018 _Redacted_FINA L.pdf for Printed Item: 2 ( Attachment 1 of 1) Document is no longer acquisition sensitive due to contract award on May 17. 2018 intellectual property (IP). From a usability perspective, the Pane l also reconunended that VA be able to establish the connectivity business rules, such as the ability for applications to remain connected for a reasonable time frame (e.g., 1 year) and to receive automatic notification about patient information updates. Require implementation of Clinical Decision Service (CDS) Hooks to invoke decision support from within a clinician's EHR workflow EHRs are essential to efficient delivery of high-quality care, as they provide the clinician with essential decision data at the time required. However , current EHR systems approach workflow from an IT system perspective rather than a clinician's perspective. The latter workflow should , of course , be paramount in the VA EHR implementation, and should also leverage a recent innovation called CDS Hooks. This technology provides the clinician with context-driven decision support and capability by enabling the EHR to trigger third-party services at key events that include ordering medication and opening a patient face sheet. For example, when the VA clinician begins to prescribe medication , a CDS Hook can call an externa l service that presents the clinician with the list of medications already prescribed to the patient by clinicians outside VA. The Panelists strongly reconunended that VA require Cemer to implement and use CDS Hooks within the clinician workflow. Topic Area: Use Community Care Contracts to Foster Interoperability The new EHR system must be able to communicate with other EHR systems (e.g. , Epic , AllScripts , etc.) within the care community. It is critical that VA ensure the Cerner EHR system remain robust for future interoperability with new products . Cerner must conunit itself to supporting other forms of interoperability, such as a presentation layer that is conunon to other systems (e.g., the App store model). The Panel reconunended that prior to execution of the Community Care Act contract VA require third-party providers (and Cerner compet itors) to conunit to supporting the contract as early adopters. "Innovations going forward are going to come from multiple directions. And having those interfaces, and going with a general interoperability approach that doesn't fork off from what's happening in the rest of the healthcare system, will allow the Veterans to benefit from technology whether that's coming from Google, from a new company, from an innovative shop within VA -- you end up creating a market with good prices, high value." Veterans must be able to access and download a computable form of their health data Panelists noted that access to data represents the biggest problem today. VA must clearly direct Cerner to expose data so it can be used by third parties . In the contract and in conversations with Cerner and third parties , VA must require specifics regarding how Veterans and providers will ACQ UISITION SENSITIVE Confidential and Proprietary For Department of Veterans Affairs Use Only AMERICAN 9 VA-18-0298 and VA-18-0299-H-000028 PVERSI 28 of 6274 Page 29 of 1093 VA EHRM Interoperab ility-Mitre- Report Jan 2018 _Redacted_FINA L.pdf for Printed Item : 2 ( Attachment 1 of 1) Document is no longer acquisition sensitive due to contract award on May 17. 2018 access and share their data. In addition, VA must require that any agreements leave the door open for future standards and technologies. Panelists believed that VA cou ld achieve this by invoking the princ iple that the data belongs to the Veteran , rather than by citing specific technologies and standards (given how rapidly they are evolving). Veterans must be able to invoke their right of access to data to support data exchange across all providers (e.g ., pull data through an API on their smartphone and push it to their commun ity care provider), now and in the future. Keeping pace with this requirement will drive continual innovation by Cerner and all providers . VA must own the API layer Cerner ownership of the API layer (across every customer) poses a real threat to achieving interoperability , speed of innovation , and cost efficiency throughout the network of community care providers. Panelists stated that it is of utmost importance that VA include specific language stipu lating that VA and Veterans be able to use third-party applications without having to register them with Cerner. VA must control the API key, not Cerner. Additionally , VA should require that Cerner provide access to MPages , a developer toolkit, and a programming interface that will enable innovators and third parties to develop APis . Require that community care contracts include VA EHR standards to support bidirectional data sharing Panelists agreed that requiring the support and collaboration of community care providers and participating active ly in health IT standards bodies would give VA the opportunity to advance the "national" standard for data sharing-closing any gaps and inconsistencies among federal , industry , and inter-industry standards. VA must require every provider in the chain of a Veteran ' s care to suppo11 the same standards for data interoperability in order to ensure seamless, best possible care for Veterans . This includes the requirement that all providers and third-party applications , in exchange for using the VA-provided API gateway , provide bi-directional health information back to VA that can be used for context-driven clinica l decisions and informatics. Change the data exchange consent model from "opt in" to "opt out" To encow-age seamless interoperability across all entities providing care to Veterans, the consent model for exchanging data between healthcare providers must be modified to follow an opt-out rather than an opt-in policy , which limits participant numbers. This would allow Veterans to invoke their individual right of access under the Health Information Portability and Accountability Act (HIP AA) to move their data as needed. Many states have already adopted an opt-out consent policy as part of their HIE.2 VA can achieve this by aligning its policy to an opt- 2 See https://www.healthit.gov/sites/default/files/State%20HIE%200p t-ln%20vs%200pt-Out %20Policy%20Research_09-30l6_FinaLpdf ACQ UISITION SENSITIVE Confidential and Proprietary For Department of Veterans Affairs Use Only AMERICAN 10 VA-18-0298 and VA-18-0299-H-000029 PVERSI 29 of 6274 Page 30 of 1093 VA EHRM Interoperabi lity-Mitre- Report Jan 2018 _Redacted_FINAL.pdf for Printed Item : 2 ( Attachment 1 of 1) Document is no longer acquisition sensitive due to contract award on May 17. 2018 out model, supported by the new VA proposed rule 3 to allow IIlEs to collect a Veteran's consent and electronically attest to the consent to VA in order to obtain the required EHR. Topic Area: Additional Contract Changes In addition to the recommendations in the prior sections, the Panelists encouraged VA to add fmiher definitions and clarity in the following areas: • Require Cerner to provide VA with full read and partial write access to all data elements within the EHR, at VA ' s sole discretion. • Require Cerner to make the VA data model , standards , and other similar interoperability changes available in all other non-VA Cerner instances of its EHR platform. • Clearly define "enabling security framework " so that users know if this means a specific security framework such as those provided by the National Institute of Standards and Technology (NIST), IIlTRUST , etc. • Amend "national Common Trust Framework" to specifically refer to the intended source. The Panelists suggested that VA replace this wording with "Trusted Exchange Framework and Common Agreement (TEFCA)" as specified in the 21 st Century Cures Act. • Amend RFP Performance Work Statement (PWS) Section 5.10.4(i) to clarify if the "provider collaboration via secme e-mail using Direct standards" is limited to the Direct protocols and just the Cerner platform. • Incorporate the model RFP language necessary for Cerner to support the API and SMART on FHIR platform and SMART-enabled applications, as described in Appendix B. 3 Sec https ://s3 .amazo naw s.com/publi c-inspcctio11.fodcralregist cr.gov/20 18-007 58.pdf ACQ UISITION SENSITIVE Confidential and Proprietary For Department of Veterans Affairs Use Only AMERICAN 11 VA-18-0298 and VA-18-0299-H-000030 PVERSI 30 of 6274 Page 31 of 1093 VA EHRM Interoperab ility-Mitre- Report Jan 2018 _Redacted_FINA L.pdf for Printed Item : 2 ( Attachment 1 of 1) Document is no longer acquisition sensitive due to contract award on May 17. 2018 II. Recommendations for RFP Changes MITRE engaged Morrison & Foerster, LLP, as the independent and unbiased legal expert to identify the specific changes to the RFP language necessary to implement the recommendations made by the Interoperability Rev iew Panel. MITRE prov ided Morrison & Foerster, LLP, with the summary recommendations and a copy of the RFP. 4 In addition , MITRE collected specific ideas for contract language from the Panel. Appendix C presents all recommended RFP changes . 4 Pe,jor mance Work Statement fo r the VA Electronic Health Record Modernization Sys tem, Final Version 1.7, Amendment 03, December 4, 2017, Department of Veterans Affairs. File name: 001 - VA EHRM IDlQ PWS (Amended 12.04.2017) - Copy.doc x ACQUISITION SENSITIVE Confidential and Proprietary For Department of Veterans Affairs Use Only AMERICAN PVERSI 12 uisition sensitive due to contract award on MaVA-18-0299-H-000031 17 2018 VA-18-0298 and 31 of 6274 Page 32 of 1093 VA EHRM Interoperab ility-Mitre- Report Jan 2018 _Redacted_FINA L.pdf for Printed Item : 2 ( Attachment 1 of 1) Document is no longer acquisition sensitive due to contract award on May 17. 2018 Ill. Observations from University of Pennsylvania Medical Center Site Visit A delegation from VA and MITRE traveled to Pittsbmgh , Pennsy lvan ia, on January 19, 2018, for a meeting with representatives ofUPMC Enterprises to discuss aspects of EHR interoperability that UPMC has successfully implemented over the ast several years. The VA team led b John Windom , included Dr. Ashwini Zenoo z, (b)(S) , John Short, and 6 (b)( ) . The MITRE group included Richard Byrne, Jay Schnitzer, (b)(6) . The hosts at UPMC included Dr. Rasu Shrestha, C~.-=T=-a ..,..,lb,_ o_t__ ___. (b)(6) , and (b)(6) eppenstall , r. , c ister , Dr. Robert Bart , Adam Berger, Diane Michalec, Phyllis Szymanski , and Dr. Amy Urban, as well as additional staff. The meeting was broken into four parts. Following introductions , Session 1 described the structure ofUPMC. Session 2 covered UPMC's last decade of interoperability , and Session 3 centered on the road ahead for UPMC and industry. Dr. Rasu Shrestha began the meeting by making the introductions and setting the agenda. He stated that UPMC's approach had followed a best-of-breed strategy , as opposed to a best-of -suite strategy, with the intention of failing fast and succeeding often. The overall UPMC structure has four parts: provider services, insurance serv ices, international act ivities , and enterpr ises. During the discussion of interoperabi lity, the UPMC team described its approach to interoperability , called Connected Healthcare , which is based on the commercial product dbMotion of AllScripts. UPMC has created an entity titled ClinicalConnect HIE (CCHIE) that uses HL7. Clinica lConnect exists as a separate 501c(3) company, of which UPMC is a member. CCHI E conta ins 90 live interfaces . Th is HIE went live in June 2012; its members cons ist of 10 hospitals. It competes with three other HIEs in Pennsylvania. The repository contains data on 8.3 million patients , and , in terms of patient consent, CCHI E uses an opt-out model. It currently has connect ions to four EHRs: Cerner (two vers ions) , Epic , and Varian. Data available within CCHI E spans allergies, clinical documents , diagnosis , encounters , immuni zations, labs , medications, problems , and procedures. Much of this data is in the form of documents (Continuity of Care Document (HITSP C32 CCD format, including problems, allergies , and medications); unstructured clin ica l documents (HITSP C62 format); Consolidated Clinica l Document Architecture (C-CDA CCD , including problems, allergies , medications , immuni zations , procedures , and insurance); and HL7 Interface (ADT: encounters, documents , imaging documents , and labs only). At the point of care dbMotion allows multiple views for the CCHIE: 1) a clinical view, 2) a newer view titled EHR agent , and 3) a Cerner MPage integration view . The next phase of the UPMC work in this regard w ill consist of integration with Common Well. F igure 2 shows the architecture of the system. F igure 3 depicts the data feeds. ACQ UISITION SENSITIVE Confidential and Proprietary For Department of Veterans Affairs Use Only AMERICAN 13 VA-18-0298 and VA-18-0299-H-000032 PVERSI 32 of 6274 Page 33 of 1093 VA EHRM Interoperability-Mitre- Report Jan 2018 _Redacted_FINA L.pdf for Printed Item: 2 ( Attachmen t 1 of 1) Document is no longer acquisition sensitive due to contract award on May 17. 2018 The Children'> institute Armstro~ County Me,,;~, Hosprtail The Childre n's Home Butler Hospital Herit age Va lley All scripts db Mo t 1on Node f::l Allscripts PRO • All scripts Sunrise All scripts Touch Works - St. Cla 1r Hosp,t.a I P@d1.atric Presbyt enan seri1orcare Hean h System Alliance eChnic a l Works Cerner EHR Epic EHR e Meditech EHR eMD GE Centricity Answers on Demand McKesso n H om e He a lth Evide nt NextGen Siemens EHR Source: From UPMC Enterprises, used with permission , for VA use only Figure 2. ClinicalConnect (Western Pennsylvania} Health Information Exchange - - "°"'"' '""' r ,!! fAl 119'LAN ..._AC ACH•V< EHIEAI.TH ~. ~ ~ ~ ~UN[fllHl - - CE:~ !?:,,._ ~ 0 -~ I >' ...... H31 C ci' ,.. _.n _~ -- ~- CE OBIJlTR-"SOUNI) c.,.,;Ak~ffllii/ ....._.frtalm!.LOGluliflr:t • INPATIENT •-CA Wine, Marc Tibbits, Paul A. ; Mugge, Alexandra M. (CMS/CCSQ) 1-----------"' ""'cms.hhs.gov> ; Soundararajan, Jude (b)(6) ssa.gov>; Worthington, Charles < o=exc ange a s ou=exchange administrative group (fydibohf23spdlt)/cn=recipients/cn=6fb5eda5c4a44f54940b391 f352a b1f4-worthington>; Sandoval, Camilo J. ; James, Bill 1 [EXTERNAL] Re: Meeting between Dr. Tibbits and Aneesh Chopra to discuss open API Sun Nov 04 2018 15: 17:46 EST VA EHRM Interoperability-Mitre- Report Jan 2018 _Redacted _FINAL.pdf Marc, thanks for the summary! Paul - it was terrific seeing you again, and thanks for hosting all of us! Here's my summary, if useful: 1) "FHIR-first" policy: I'll defer to Shannon/Alex but there is likely more information to come from CMS on how it intends to leverage open AP ls to communicate with the care delivery system, and to regulate where appropriate. My suggestion was to establish a policy similar to our "cloud-first" approach back in 2010 whereby all the various sub-departments within the VA know that when starting a new interop project, or investing more in an existing one, that it pursue an "APl-first" evaluation to gauge feasibility before relying on whatever legacy method is under way. This is the direction of 21st Century Cures, and will likely be the focus of the forthcoming ONC information blocking rules. We know that existing API rules are working with respect to Apple Health's experience. They have published a list of every site where they have established a FHIR-based connection (https://support.apple.com/en-us/HT208647), which means any consumer app can follow without additional burden. As you likely know, Apple pays NOTHING to connect to these sites; the health systems pay NOTHING to connect with Apple (presuming they have "turned on" the 2015 CEHRT edition as required to meet CMS/ONC rules); and the consumer, of course, pays NOTHING to authorize the transmission. The FHIR Argonaut Project technical specifications allow physician access, but are NOT required in regulation (as of now). The "bulk access" specifications are ready for testing (ONC has funded a project with Boston Chi Idren 's - https://www. h hs. gov /about/news/2018/09/26/h hs-an nou nces-lea p-health-it- AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000062 62 of 6274 Page 63 of 1093 winner.html). 2) Execute the Gerner Contract's Open Data Model Provisions: Now that the MITRE report is public, you can see all of the recommendations re: accelerating API standards development (attached). But key provisions that are in the contract have NOT been executed, including: -publishing Cerner's data model in the NIH/national library of medicine (as Kaiser did with CMT - https: //www.nlm.nih.gov/research/umls/cmUcmt _faq.html) -engaging the Open API Pledge partners in prioritizing use cases for standards deve lopmenUacceleration. -articulating how Gerner intends to make the work it is doing for the VA available to non-VA Gerner clients to lower the costs of future standards adoption/use. 3) Start building SMART Apps: presuming you can adopUscale up your "Digital Veteran API Gateway" de-coupled from the timeline of the Gerner implementation, then you can do any of the following we discussed: -Train VA employees for FHIR certification (here's the online course that started last week - http://www. hi? .org/events/fhir _fun.cfm) -leverage the "micro-purchasing" framework to FHIR-enable popular VISTA apps like the JLV (https: //doi .org/10.1007 /s 11606-018-4 708-z) , or CART-CL (https://www.hsrd.research.va . gov/for _managers/stories/cart-cl .cfm) -Direct Leidos/Epic to open up the Scheduling API consistent with the Argonaut Specs so third party apps can build tools to help veterans access community care (https://open.epic.com/Scheduling/FHIR); and in return , API pledgees like Trinity might reciprocate in the Columbus , OH market. I look forward to our discussion in a couple of weeks! Regards , Aneesh Chopra President (703) 672-1315 I CareJourney.com This email is intended only for the person or entity to which it is addressed and may contain information that is privileged , confidential or otherwise protected from disclosure. Dissemination, distribution , or copying of this email or the information herein by anyone other than the intended recipient , or an employee or agent responsible for delivering the message to the intended recipient, is prohibited. If you have received this email in error , please immediately notify us. On Fri, Nov 2, 2018 at 12:12 PM Wine, Marc wrote: Aneesh , Jude, Drew, Alexandra, Shannon , Paul and Bill; - A note to say thank you for yesterday's talks on Open API approach with our office . "The API pledge encourages health-care providers to commit to work collaboratively with VA to increase the mapping pace of health data to industry standards, including the current and future versions of Fast Healthcare Interoperability Resources (FHIR)." AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000063 63 of 6274 Page 64 of 1093 Sharing some highlight points or ideas from discussion, more ahead; plus, feel free to add, comment, further guidance or input. *VA is Argonaut Project participant. VA Argonaut Project participant. http://www. h 17.org/documentcenter/pu bl ic_temp_ 51339323-1 C23-BA 170C8BC8A 7320A4529/wg/argonaut/ Argonaut%20Project%20Charter-12%20Dec%202014-v3.pdf *VA can encourage standards development. The purpose of the Argonaut Project is to rapidly develop a first-generation FHIR-based API and Core Data Services specification to enable expanded information sharing for electronic health records and other health information technology based on Internet standards and architectural patterns and styles. *API standards, priority use case with SMART FHIR Vet Suicide Use Case. *Open API for suicide information can be shared across healthcare in community. *VA needs to finish the data model, start with a baseline data model. *Place data model within Library of Medicine repository as open availability. *VA can encourage standards development. *API standards, priority use case with SMART FHIR Vet Suicide Use Case. *Open API for suicide information can be shared across healthcare in community. *VA needs to finish the data model, start with a baseline data model. *Place data model within Library of Medicine repository as open availability. *SSA wants to ensure ongoing sharing clinical data for SSA claims disability determination. *FHIR Online Scheduling is online on Columbus, Ohio. FHIR questionnaire, online scheduling, Vets shared patient care, VA should adopt FHIR provider directory. *VA DOD JVL interface cold be provided through app environment. *Cloud available semantic interoperability tools well available healthcare arena. *VistA functions easily convertible to FHIR Open Apps platforms. Several Apps could be built from VistA, was mentioned physicians in the private sector Like VistA; suggested train VA programmers who have MUMPS skills, to transform programming, changing EHRM environment. Again, many thanks. -----Original Appointment----From: Tibbits, Paul A. Sent: Monday, October 22, 2018 9:41 AM AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000064 64 of 6274 Page 65 of 1093 To: Tibbits, Paul A.; Aneesh Chopra; Wine, Marc ; Sartin, Shannon (CMS/OA) ; Mugge, Alexandra M. (C 0S/C:~~ :n11~ararajan , Jude navhealth.com ; Myklegard, Drew; Worthington, Charles; Sandoval, Camilo J.; Cc: (b)(G) James , 1 ; ut er, Suzanne Subject: Meeting between Dr. Tibbits and Aneesh Chopra to discuss open API pledge When: Thursday, November 01, 2018 12:00 PM-1:00 PM (UTC-05:00) Eastern Time (US & Canada). Where : VACO Room 350, 810 Vermont Avenue, NW , Washington, DC 20420 When you get to the building and check in with security , tell them that you are here to see me, Jonathan McBride . They will call me to come and pick you up. 202-461-4419. thanks! JMcB --> Join Skype Meeting Trouble Joining? Try Skype Web App Join by phone (b)(6) English (United States) English (United States) English (United States) Find a local number Conference ID:l(b ...._)(_6 )__ _.l(same as access code above) Forgot your dial-in PIN? IHelp PLEASE NOTE WE HAVE NEW PHONE NUMBERS You might want to make your attendees aware of the change. [!OC([1033])!] Jonathan McBride AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000065 65 of 6274 Page 66 of 1093 EHRM for Integration VA Office of Information and Technology (Ol&T} Department of Veterans Affairs 810 Vermont Ave NW cubicle #352-E Washington DC 20420 Office: 202-461-4419 Cell: ~l (b_J(s_i __ ~ AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000066 66 of 6274 Page 67 of 1093 Document ID: 0.7. 1705.733884-00 j(001 Owner: Aneesh Chopra {b )(G) @carejourney .com> Filename: VA EHRM Interopera bility-Mitre- Report Jan 2018 _Redacted_FINAL.pdf Last Modified: Sun Nov 04 14:17:46 CST 2018 AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000067 67 of 6274 Page 68 of 1093 VA EHRM Interoperab ility-Mitre- Report Jan 2018 _Redacted_FINA L.pdf for Printed Item: 4 ( Attachment 1 of 1) Document is no longer acquisition sensitive due to contract award on May 17. 2018 ACQUISITION SENSITIVE Departlllent of Veterans Affairs Electronic Health Modernization Request for Proposal Interoperability Review Report MITRE ACQUISITION SENSITIVE AMERICAN PVERSI 17 2018 VA-18-0298 and VA-18-0299-H-000068 Page 69 of 1093 VA EHRM Interoperab ility-Mitre- Report Jan 2018 _Redacted_ FINAL.pdf for Printed Item : 4 ( Attachment 1 of 1) Document is no longer acquisition sensitive due to contract award on May 17. 2018 ACQUISITION SENSITIVE This page intentionally left blank. ACQUISITION SENSITIVE AMERICAN PVERSI 17 2018 VA-18-0298 and VA-18-0299-H-000069 Page 70 of 1093 VA EHRM Interopera bility-Mitre- Report Jan 201 8 _Re dacted_FINA L.pdf for Printed Item: 4 ( Attachment 1 of 1) Document is no longer acquisition sensitive due to contract award on May 17. 2018 ACQUISITION SENSITIVE DocumentNumber:MTR180033 Authors: Jay J. Schn itzer , M.D ., Ph.D. I l(b}(6} Mclean, VA January2018 Sponsor: Department of Veterans Affairs Theviews,opinionsand/orfindings containedinthisreportarethoseof The MITRECorporation andshouldnotbe construed as anofficialgovernment position,policy,or decision,unless designated byotherdocumentation. ForInternalMITREUse.Thisdocument wasprepared for authorized distribution only.It hasnotbeenapproved for public release . © 2018TheMITRECorporation. All rightsreserved . ForDepartment of Veterans AffairsUseOnly VA EHRMRFPInteroperability ReviewReport January 31,2018 MITRE ACQUISITION SENSITIVE AMERICAN PVERSI 17 2018 VA-18-0298 and VA-18-0299-H-000070 Page 71 of 1093 VA EHRM Interoperability-Mitre- Report Jan 2018 _Redacted_FINAL.pdf for Printed Item : 4 ( Attachmen t 1 of 1) Document is no longer acquisition sensitive due to contract award on May 17. 2018 ACQUISITION SENSITIVE This page intentionally left blank. ACQUISITION SENSITIVE Confidential and Proprietary AMERICAN PVERSI For Department of Veterans Affairs Use Only er ac uisition sensitive due to contract award on MaVA-18-0299-H-000071 17 2018 VA-18-0298 and 71 of 6274 Page 72 of 1093 VA EHRM Interoperabi lity-Mitre- Report Jan 2018 _Redacted_FINAL.pdf for Printed Item : 4 ( Attachment 1 of 1) Document is no longer acquisition sensitive due to contract award on May 17. 2018 Executive Summary This Review Report presents responses to three requests from the Department of Veterans Affairs (VA) to MITRE related to the topic of interoperability within the VA Electronic Health Record Modernization Request for Proposal: I. Conduct an external Interoperability Review Panel to review the interoperability language in the existing Request for Proposal (RFP) , IL Engage an independent and unbiased legal expert to identify the specific changes to the RFP language necessary to implement the recommendations from the Interoperability Review Panel , and III. Visit the University of Pittsburgh Medical Center to understand the existing operational multi-vendor solution and interoperability solutions for applicability and scalability to the VA. I. Interoperability Review Panel In support of the Secretary of Veterans Affairs , David J. Shulkin , M.D. , The MITRE Corporation convened and hosted a VA Electronic Health Record Moderni zation (EHRM) Request for Proposal (RFP) Interoperability Review Panel on January 5, 2018, at MITRE ' s McLean headquarters. The invited external senior electronic health record (EHR) interoperability subject matter experts (the Panel) reviewed the interoperability language in the existing RFP and developed joint suggestions and recommendations for VA to consider for incorporation to support the successful execution of a new commercial EHR contract with industry. The Panel affirmed that the primary goal should be seamless Veteran-centric healthcare achieved through true EHR interoperability. Achieving this goal rests on three overarching principles that should be supported by interoperability language in the RFP: 1) free and open access to data, 2) an ecosystem that provides fair access to third parties by creating a level playing field, and 3) a seamless Veteran and health provider (clinician) experience. Four categories of recommendations from the Panel (the first three to the interoperability language in the RFP, and the fourth for future VA contracts) will enable VA to reali ze this goal on the basis of the underlying principles: 1) commit to full VA-Department of Defense (DoD) interoperability, 2) leverage current and future standards, 3) commit to open, standards-based application programming interfaces (APis) , and 4) use Care in the Community contracts to foster interoperability. For the first category (commit to full VA-DoD interoperability) , the Panel agreed that the Determination and Findings signed by Secretary Shulkin on June 1, 2017, represented the correct approach to interoperability within VA and between VA and DoD. The Panel strongly endorsed the proposed VA "API Gateway " language. The most important specific recommendations included: • Define the degree of interoperability the solution will provide, ranging from basic file sharing to fully interchangeable , integrated and functionally identical patient records. ACQUISITION SENSITIVE Confidential and Proprietary For Department of Veterans Affairs Use Only AMERICAN PVERSI V er ac uisition sensitive due to contract award on MaVA-18-0299-H-000072 17 2018 VA-18-0298 and 72 of 6274 Page 73 of 1093 VA EHRM Interoperabi lity-Mitre- Report Jan 2018 _Redacted_FINAL.pdf for Printed Item : 4 ( Attachment 1 of 1) Document is no longer acquisition sensitive due to contract award on May 17. 2018 Suggest that the Contractor conduct an annual Interoperability Self-Assessment against current and future standards that shall be specified by the VA; and • The contract language should include the following elements: o performance measures to hold Cerner accountable for reducing the administrative burden in clinician workflow with the objective of increasing efficiency , o ability for bulk data export based on standards , with no proprietary formats (e.g. , Flat FHIR [Fast Healthcare Interoperability Resources]), and o "push" capability to insert patient data back into the VA EHR / Cerner database. For the second category (leverage current and future standards) , the following specific recommendations were among the most important: • Require that Cerner implement all standards as defined by VA, current and future, • Engage Cerner as an advocate of the VA and DoD position in all relevant standardsmaking bodies , and • Ensure that VA and Veterans have complete access to data. For the third category (commit to open, standards-based APis) , the Panel voiced the following recommendations: • Establish clear publishing and access service requirements, • Provide a VA application platform that supports APis from third party providers with no barrier to entry, and • Require implementation of clinical decision support (CDS) Hooks to invoke decision support from within a clinician's EHR workflow. The body of this report contains multiple additional specific recommendations. II. Recommendations for RFP Changes MITRE engaged Morrison & Foerster, LLP as the independent and unbiased legal expert to identify the specific changes to the RFP language necessary to implement the recommendations from the Interoperability Review Panel. Appendix C presents all recommended changes to the RFP. Ill. Observations from University of Pittsburgh Medical Center Site Visit A delegation from VA and MITRE traveled to Pittsburgh, Pennsylvania, on January 19, 2018, for a meeting with representatives from University of Pittsburgh Medical Center (UPMC) Enterprises to discuss aspects of EHR interoperability that UPMC has successfully implemented over the past several years. The report includes an overview of those practices. ACQUISITION SENSITIVE Confidential and Proprietary For Department of Veterans Affairs Use Only AMERICAN PVERSI VI er ac uisition sensitive due to contract award on MaVA-18-0299-H-000073 17 2018 VA-18-0298 and 73 of 6274 Page 74 of 1093 VA EHRM Interoperabi lity-Mitre- Report Jan 2018 _Redacted_FINAL.pdf for Printed Item : 4 ( Attachment 1 of 1) Document is no longer acquisition sensitive due to contract award on May 17. 2018 IV. Closing Thoughts and Suggested Next Steps The Panelists noted that VA cannot achieve true future EHR interoperability through the Cerner RFP alone, or through technology alone. The state of practice today shares only a small portion of available patient data. For VA to succeed in the future , multiple other components must be present and aligned: innovation, policy , standards, customer buy-in , and legislation, to name a few. The following next steps are recommended for VA consideration: 1. Complete the RFP revisions, conduct appropriate negotiations with the Contractor expeditiously , and complete the contract process as planned. Stand firm during negotiations to maximize ease of access to data and data models for building third party APis , applications , and services for future community innovations. 2. Continue to work with other federal government agencies and departments with similar interoperability interests and concerns, including, but not limited to, the White House, DoD , Food and Drug Administration (FDA) , Centers for Medicare and Medicaid Services (CMS), Office of the National Coordinator for Health Information Technology (ONC) , and other parts of the Department of Health and Human Services, to align approaches to EHR interoperability and the development and support of standards government-wide. 3. Support future innovation approaches, including concepts such as an Interoperability Laboratory and outreach to the broader innovation ecosystem (major medical centers, academia , traditional and non-traditional healthcare providers, startups, individual entrepreneurs, others). It is critical to align the innovations planned in VA's Digital Veterans Platform to the VA EHR innovation efforts to ensure consistent continuous improvements to clinician and Veteran health experiences. 4. Create an External Review Panel to provide expert continuous guidance, review , and feedback over the course of the implementation, to help capture best practices from the expert community going forward. Conduct ongoing demonstrations of end-to-end Veteran use cases requiring data sharing across organizational boundaries to validate improvements in Veteran healthcare and reduction of burden for healthcare providers. VA and Contractor will ensure that Federal Advisory Committee Act (FACA) guidelines are followed in leveraging any external review panels. ACQUISITION SENSITIVE Confidential and Proprietary For Department of Veterans Affairs Use Only AMERICAN PVERSI Vll er ac uisition sensitive due to contract award on MaVA-18-0299-H-000074 17 2018 VA-18-0298 and 74 of 6274 Page 75 of 1093 VA EHRM Interoperab ility-M itre- Report Jan 2018 _Redacted_ FINAL.pdf for Printed Item : 4 ( Attachment 1 of 1) Document is no longer acquisition sensitive due to contract award on May 17. 2018 Table of Contents Background ............................................................ .... ........ .... .... .... .... .... .... .... .... .... .... .... .... .... .... . 1 I. Interoperability Rev iew Pane l ..... ........ .......... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .2 Introduct ion ................................................... .... ........ .... .... .... .... .... .... .... .... .... .... .... .... ........ .2 Goal ................................................................................................................................... 2 Methodology /Approach ...................................................................................................... 2 Topic Area: VA Definition of Interoperability .................................................................... 3 Topic Area: Comm it to Fu ll V A-DoD Interoperabi lity ...... .... .... .... .... .... .... .... .... .... .... .... .... .4 Topic Area: Leverage Current and Future Standards ...... ........ .... ........ .... .... .... .... .... .... ........ . 6 Topic Area: Comm it to Open, Standards-Based APis ........ ........ .... .... .... .... .... .... .... .... .... .... . 7 Topic Area: Use Community Care Contracts to Foster Interoperability ............................... 9 Topic Area: Additional Contract Changes ........................................................................ 11 II. Recommendations for RFP Changes ................................................................................. 12 III. Observations from University of Pennsylvania Medical Center Site Visit.. ....................... 13 IV. Closing Thoughts and Suggested Next Steps ..... ........ ........ ........ .... .... .... .... .... .... .... .... .... ... 16 Appendix A : Interoperab ility Review Forum Partic ipants .......... .... .... .... .... .... .... ........ .... .... .... ... 17 Appendix B: RFP Language for Purchasing Extensib le Health IT ...... .... .... .... .... .... .... .... .... .... ... 19 Appendix C: Recommended RFP Interoperability Language Changes ...................................... 22 Appendix D: Acrony1ns ............................................................................................................ 42 ACQUISITION SENSITIVE Confidential and Propr ietary For Department of Veterans Affairs Use Only AMERICAN PVERSI Vlll er ac uisition sensitive due to contract award on MaVA-18-0299-H-000075 17 2018 VA-18-0298 and 75 of 6274 Page 76 of 1093 VA EHRM Interoperability-Mitre- Report Jan 2018 _Redacted_FINA L.pdf for Printed Item : 4 ( Attachmen t 1 of 1) Document is no longer acquisition sensitive due to contract award on May 17. 2018 This page intentionally left blank. ACQUISITION SENSITIVE Confidential and Proprietary For Department of Veterans Affairs Use Only AMERICAN PVERSI lX er ac uisition sensitive due to contract award on MaVA-18-0299-H-000076 17 2018 VA-18-0298 and 76 of 6274 Page 77 of 1093 VA EHRM Interoperabi lity-Mitre- Report Jan 2018 _Redacted_FINAL.pdf for Printed Item : 4 ( Attachment 1 of 1) Document is no longer acquisition sensitive due to contract award on May 17. 2018 Background The Department of Veterans Affairs (VA) plans to establish seamless care for Veterans throughout the health care provider market. Seamless care requires interoperability between the Department of Defense (DoD), VA, VA affiliates , community partners, electronic health record (EHR) providers , healthcare providers, and vendors. VA directed The MITRE Corporation to independently review the capability of Cemer' s proposed EHR solution to seamlessly transmit health records between EHR systems supporting healthcare providers who both use and contribute patient data to a Veteran ' s health record, to include Veterans Choice Program (VCP) community-care service providers and VA affiliates. This Review Report presents responses to three requests: I. Conduct an external Interoperability Review Panel to review the interoperability language in the existing Request for Proposal (RFP), II. Engage an independent and unbiased legal expert to identify the specific changes to the RFP language necessary to implement the recommendations from the Interoperability Review Panel, and III. Visit the University of Pittsburgh Medical Center to understand the existing operational multi-vendor solution and interoperability solutions for applicability and scalability to VA. ACQUISITION SENSITIVE Confidential and Proprietary For Department of Veterans Affairs Use Only AMERICAN 1 VA-18-0298 and VA-18-0299-H-000077 PVERSI 77 of 6274 Page 78 of 1093 VA EHRM Interoperab ility-M itre- Report Jan 2018 _Redacted_ FINAL.pdf for Printed Item : 4 ( Attachment 1 of 1) Document is no longer acquisition sensitive due to contract award on May 17. 2018 I. Interoperability Review Panel Introduction In support of the Secretary of Veterans Affairs, David J. Shulkin, M.D., MITRE convened and hosted a VA Electronic Health Record Moderni zation (EHRM) Request for Proposal (RFP) Interoperability Review Panel on January 5, 2018, at MITRE ' s McLean, VA headquarters. MITRE invited external senior EHR interoperability subject matter experts (hereafter referred to as Panelists) to review the interoperab ility language in the existing RFP and to develop joint suggestions and recommendations for VA to consider incorporating into the RFP to support the successful execution of a new commercial EHR contract with industry. Eleven Panelists took part in person , and several senior government execut ives observed the process (see Appendix A for the full list of participants). Goal The Interoperability Review Panel sought to provide Secretary Shulkin and his senior leadership team with insights into key best practices and guidance from national experts regarding EHR interoperability. The Panel evaluated the conesponding language in the draft RFP based on successful bus iness transformations and implementations of a new commercial EHR system across a distributed hospita l and provider network. Th is section of the report summarizes the outcome of the Panel: expert recommendations that will inform VA's interoperability contract language. The document also provides actionable and specific best practice recommendations and rationales to enable successful acquisition and implementation of EHR interoperability. Methodology/ Approach The first part of the session, which lasted for five hours, was conducted as a fish-bowl exercise and was guided by Chatham House Rule. The Panelists sat at a center table, with VA and other government observers sitting at sUIToundingtables. The second part, which lasted two hours, consisted of a summary debrief to the Secretary and senior VA leadership. The Secretary could ask questions and engage with the Panel throughout the second session. MITRE moderated the session to elic it inputs from all Panelists and to drive alignment toward consensus in the recommendations. The agenda for the first port ion of the session was structured to elicit inputs from all Panelists, with notes captured on-screen as redlines to the RFP interoperability language to ensure recommendations accurately reflected the Panelists' contributions. Subsequently , in a facilitated discuss ion, the Panelists grouped their recommendations into specific categories in real time. The second portion, as noted, provided opportun ities for the Secretary to discuss the recommendations in additional detail. This section of the report summarizes the discussion that took place. It high lights actionab le changes to the interoperability language contained in the RFP and additional recommendations and lessons learned that can enable interoperability of the VA EHRM solution. Text boxes ACQUISITION SENSITIVE Confidential and Propr ietary For Department of Veterans Affairs Use Only AMERICAN 2 VA-18-0298 and VA-18-0299-H-000078 PVERSI 78 of 6274 Page 79 of 1093 VA EHRM Interoperab ility-Mitre- Report Jan 2018 _Redacted_FINA L.pdf for Printed Item: 4 ( Attachment 1 of 1) Document is no longer acquisition sensitive due to contract award on May 17. 2018 throughout the report present direct quotations from Panelists. To ensure participant confidentiality, MITRE has destroyed the transcript and event recording used to develop this report. Topic Area: VA Definition of Interoperability The key to modernization is creating greater interoperability with Governmental partners, including DoD, in a way that focuses efforts in support of the Veteran's journey, beginning with their militmy service. We will partner with others to ensure Veterans can get their benefits, care, and services consistently , easily, and with excellent customer service, no matter where they are throughout their lives. VA will work with local communities, and with other Federal, State, Tribal, and Local Government entities to ensure Veterans get what they need. VA will also continue to leverage the private sector where appropriate and needed to deliver the very best outcomes for Veterans. - draft VA 2018- 2024 Strategic Plan Enable data sharing, interoperability, and agility through data standardization VA needs to allow data sharing among various business applications , such as appointment scheduling and business intelligence , as well as ensure transportability of informat ion between sites. Panelists "It really optimizes transportability of advised VA to leverage and support the best-in-class best practices, because if you are innovation currently in use within the VA culture. VA trying to transfer best practices from must also enable interoperability as the Department one site to another and you have the integrates the EHR into other supporting systems, both same system where the best practice is within the VA network and with external health service going to land, then it is much easier." providers. Agility is necessary for adoption of future innovative technologies and/or if VA wants to upgrade or change the EHR approach . The Panelists cautioned that the current EHR technology is already 20 years old and, as with all industries and information technology (IT) solutions, many possib ly disruptive technologies exist on the horizon. The session began with a discussion on interoperability as currently defined by VA (Figure 1). Prior to establishing a roadmap to inform a nationwide plan to advance health data interoperability, VA must first ensure system-w ide interoperabi lity across the Department. Throughout the Rev iew Panel session, the Panelists described and referred to this concept as "Level 1 Interoperability" throughout the Review Panel session; it includes migration of Veteran data from ~ 130 instances of the Veterans Health Information Systems and Technology Architecture (VistA) to one VA platfonn. ACQUISITION SENSITIVE Confidential and Proprietary For Department of Veterans Affairs Use Only AMERICAN 3 VA-18-0298 and VA-18-0299-H-000079 PVERSI 79 of 6274 Page 80 of 1093 VA EHRM Interoperabi lity-Mitre- Report Jan 2018 _Redacted_FINAL.pdf for Printed Item : 4 ( Attachment 1 of 1) Document is no longer acquisition sensitive due to contract award on May 17. 2018 Figure 1. VA Definition of EHR Interoperability "Level 2 Interoperability," as described in the Panel discussion, addresses the ability for VA to leverage the same Cerner platform used by DoD to ensure seamless care from active service to Veteran status. Once this capability is implemented, the clinical data transformation will allow a true longitudinal view of a Veteran's record as he or she transitions from DoD to VA for care and other critical services such as benefit adjudication. "Level 3 Interoperability" will allow both VA and DoD to take an important step toward transforming electronic patient data exchange on a national scale. With the utilization of communjty healthcare providers via the VA Community of Care initiative and DoD's Tricare network providers , VA has the opportunity to drive interoperability between DoD and VA as well as with the extensive network of healthcare providers that serve our Nation's Veterans , active duty service members, and their beneficiaries. True nationwide EHR interoperability for the entire United States is the ultimate goal, and the Panelists agreed that VA and DoD could reach this goal if the three aforementioned levels of interoperability are achieved. Here, VA has the opportunity to drive clinical transformation and instantiation of a complete EHR for all patients at the national level. Topic Area: Commit to Full VA-DoD Interoperability The Panel focused primarily on reviewing the interoperability language within the RFP for the Ce.mer contract. However as described in Interoperability Levels 1 and 2, the commitment to the seamless integration of VA and DoD health data represents the foundation required to realize interoperability with private sector "You really have to get the basics done first. Let's just make absolutely sure that the interoperability between DoD and VA [is achieved]." ACQ UISITION SENSITIVE Confidential and Proprietary For Department of Veterans Affairs Use Only AMERICAN 4 VA-18-0298 and VA-18-0299-H-000080 PVERSI 80 of 6274 Page 81 of 1093 VA EHRM Interoperab ility-Mitre- Report Jan 2018 _Redacted_FINA L.pdf for Printed Item : 4 ( Attachment 1 of 1) Document is no longer acquisition sensitive due to contract award on May 17. 2018 healthcare providers. 1 It is important to note that the interoperability levels can be addressed simultaneously and should not be separated, as they must be integrated to efficiently achieve the larger future data sharing ecosystem . Specify the expectations for interoperability between DoD and VA During discussions about the expectation that Cerner will provide a single EHR solution to be shared by both DoD and VA, the Panel raised concerns about the lack of specificity in the contract language. Current interoperab ility data standards address a subset of the Veteran's clinical record and VA has the opportunity to ensure Cerner provides interoperability of all discrete data, at a minimum , between VA and DoD. Adopting the same platform would increase seamless sharing, but the Panel stated that VA should take additional action to ensure that such sharing is realized. The DoD and VA systems should use proprietary database-to-database interoperability if necessary , to maximi ze interoperability between those two systems. These systems should be configured to meet the distinct needs of each while being connected to each other in a native database-to-database method as necessary , leveraging open interoperability standards whereve r possible. As a result , clinic ians should experience no differences when they move from a VA system to a DoD system. These data should also be computable, or be made computable according to a specific schedule. VA should consider adding language to the RFP that specifica lly defines the degree of interoperabi lity the solution will prov ide, ranging from basic file sharing to fully interchangeable, integrated and functionally identical patient records. The Panelists also stated that, for VA and DoD collectively, the contractual language should include the following requirements: • Performance measures to hold Cerner accountable for reducing the administrative burden in clinician workflow with the objective of increasing efficiency • Capability for bulk data export based on standards, with no proprietary formats (e.g., Flat FHIR [Fast Healthcare Interoperability Resources]) • "Push" capability to insert new patient data back into the VA EHR / Cerner database. Pivot the RFP to be Veteran-centric and not system-centric The Panelists discussed the impact of EHR implementations on clinician workflow, describing the issue as one of approach ing the implementat ion as an IT system implementation rather than the preferred Veteran- or clinician-centric implementation. The current RFP appears to be written in a system-centric way rather than leveraging use-cases to describe the Veteran or clinician experience or work.flow to characteri ze the requirement. The Panelists recommended that VA incorporate use-cases to characterize requirements and amend the RFP language to emphasize the Veteran-centr ic objectives . In addition, Panelists noted that VA should recogn ize that EHRs do not currently maximi ze efficient clinical work.flow, and that VA specify that the 1 Healthcare providers is used to refer to community based physi cians/speci alist and hospitals. ACQ UISITION SENSITIVE Confidential and Proprietary For Department of Veterans Affairs Use Only AMERICAN 5 VA-18-0298 and VA-18-0299-H-000081 PVERSI 81 of 6274 Page 82 of 1093 VA EHRM Interoperabi lity-Mitre- Report Jan 2018 _Redacted_FINAL.pdf for Printed Item : 4 ( Attachment 1 of 1) Document is no longer acquisition sensitive due to contract award on May 17. 2018 solution present clinicians with relevant information where needed with a minimum number of "clicks to find." Topic Area: Leverage Current and Future Standards The integrated EHR platform that DoD and VA are implementing provides the opportunity to significantly influence interoperability standards across the healthcare community , addressing gaps and competition among current standards. The Panel recognized that commercial health systems and technologies would realize only limited business value from making data portable between them, but this would lower the barrier to patient movement among healthcare providers. Engage Cerner as an advocate of the VA and DoD position in all relevant standards-making bodies The Panel recommended increased VA presence and leadership in national health IT standardsmaking activities, in coordination with the DoD. Additionally, VA should encourage Cerner to serve as an active advocate of the VA-DoD position and to participate actively in the development and/or evaluation of new standards, policy directives, operating procedures, processes, etc. As an integrated voting bloc, VA, DoD, and Cerner will have the potential to act as a strong driver of national standards. Panelists understood that VA is not currently active in the FHIR community or in the Health Level Seven International (HL 7) Argonaut Project. In addition, Panelists identified a need for standards to exchange patient-reported outcome data for integration into the clinician's workflow. The current RFP language seemingly puts the burden on Cemer for the development of standards , and the Panel recommended that VA take a more active position. This will ensure that VA will participate and drive implementation when standards mature. Where standards are immature, VA must participate in efforts to accelerate standardization. Require Cerner to implement all standards as defined by VA, current and future Because it is unclear where health IT is heading in five years , the Panel strongly suggested VA include contract language to address possible future advancements in the form of standards as defined by VA. At a minimum, VA should seek maximum interoperability with community care organizations, using open interoperability standards wherever possible. This flexibility would ensure that VA does not rely on external stakeholders to determine the standards that VA would be required to accept. The Panel recommended that VA pay particular attention to specific categories of standards: real-time data read/write by care providers and Veterans; interoperability tools; seamless DoD and VA vision records; and principles for data normalization and structure. The Panel also recognized Cemer' s influence in ensuring that the Common Well network interoperates at the highest possible levels with other networks including CareQuality - an influence that VA should continue to promote. ACQUISITION SENSITIVE Confidential and Proprietary For Department of Veterans Affairs Use Only AMERICAN 6 VA-18-0298 and VA-18-0299-H-000082 PVERSI 82 of 6274 Page 83 of 1093 VA EHRM Interoperab ility-M itre- Report Jan 2018 _Redacted_ FINAL.pdf for Printed Item : 4 ( Attachment 1 of 1) Document is no longer acquisition sensitive due to contract award on May 17. 2018 VA must own its dat a; clea r ownership and access are critical to success now and in the future The Panel highlighted an important recommendation regarding data rights that was discussed in the prior VA EHRM Listening Forum on September 7, 2017. The Panel recommended that VA define who has what rights from the perspectives of data ownership , access, and sharing (e.g ., VA owns the data and all data products vs. community care providers own the pat ient data vs. each Veteran owns all of his or her data). Determining the authoritative data source for the various elements of a Veteran's health record is an important Veteran-centric component of interoperab ility, the longitud inal record, and seamless access to data. "So, what you need is clear access and clear ownership of your information ...you need to have absolutely, undisputed, clear ownership and ability to move the data to any place you want to use it and use it in any way you want to use it when you get there. And not have them [Cerner] be able to say no, that's our data or hinder you in any way or have an unreasonable charge to get it." VA should define an enterprise-w ide po licy for all VA data. A suitable policy would include, but not be limited to, EHRM-specific data, and should be issued by the VA Central Office (V ACO) or Veterans Health Administration (VHA). VA must have clear ownership of and access to all the informat ion in the EHR and be able to move that information (into new systems or among systems) as needed, now and in the future . Owning the data ensw-es that it is availab le regard less of vendor or system. VA must include this in the Cerner contract. Technology innovations occur rapid ly in the 21 st century, and VA must have full ability to move its data to future systems. Panelists also recommended that VA publish its data model , for instance to the National Library of Medicine, to further promote commercial interoperability investments. Lastly, Panelists encouraged VA to leverage its investment in the Open Sow-ce Electron ic Health Record Alliance (OSEHRA) by prov iding seed money to develop open sow-ce connectors between Cerner and Epic, which would encourage other vendors to join in the effort. Topic Area : Commit to Open, Standards-Based APls A significant technology enabler of seamless interoperability among the community of Veteran healthca re providers is the use of Applicat ion Programming Interfaces (APis). These software intermediar ies allow disparate EHR applications to communicate with each other and exchange data using standard , defined forms. The Panel emphasized the need for VA to create an environment that would minimi ze additional costs to community providers in order to interoperate with VA. VA can accomplish this by requir ing the new EHR system to expose APis that support bi-directional data transact ions. The Panel further recommended that VA make a commitment to open, standards-based APis , including the SMART on FHIR/Argonaut APis, to facilitate the ready and efficient exchange of data with partners providing care in the community and to support open clinical work:flow. ACQ UISITION SENSITIVE Confidential and Propr ietary For Department of Veterans Affairs Use Only AMERICAN 7 VA-18-0298 and VA-18-0299-H-000083 PVERSI 83 of 6274 Page 84 of 1093 VA EHRM Interoperabi lity-Mitre- Report Jan 2018 _Redacted_FINAL.pdf for Printed Item : 4 ( Attachment 1 of 1) Document is no longer acquisition sensitive due to contract award on May 17. 2018 Establish clear publishing and access service requirements The Panel recogni zed that data access requirements differ depending on who provides or accesses that data. Therefore, the Panel recommended that VA be more specific in defining each level of data publishing and access service that is specific to (1) Veteran access (e.g., use of vets.gov) ; (2) VA clinician access ; (3) partner access; and (4) Health Information Exchange (HIE) access. The RFP should include a clear description of identity and access management requirements, including user population types and the association of specific application permissions with particular roles /positions. "The Contractor should provide all of the data that is currently being provided in the Contractor's patient portal to the consumer via an open standards-based API gateway. The Contractor should also provide all of the reporting data required by federal law to the Veteran via an open standards based API framework, accessible via any application or thirdparty data store of the Veteran's choice, that's number one." Machine-to-machine access is also critical for efficient sharing of information. The Panel recommended that VA ensw-e that all significant data stored in the software be accessible th.rough APis with no requirement for creation of custom applications to specifically access VA data. From a forward-looking perspective, VA should require that the EHR system support the ability to access data elements using open standards-based interfaces , and include the ability to interface with legacy data, patient-generated data , and third -party data that resides outside the EHR system. In addition, Cerner should provide the required utility services to support intermediary or peer-to-peer services (e.g. , support Veteran-directed or Veteran-mediated requests , data exchange , and ingestion of data from non-VA providers). Provide a VA application platform that supports APls from third-party providers with no barrier to entry Cw-rently vets.gov serves as a portal to Veteran services. The Panel recommended that VA consider "The API Gateway document is awesome ... using such a portal to connect any third-party world class and future looking." application to the EHR solution without requiring fees or vendor permissions. VA should have full authority to connect any third-party application through one of the standard open AP Is conformant with the vendor ' s API without pre-registering the application with the vendor. This is a very important authority to have in terms of the ability to innovate rapidly , without constraints. The Panelists also reviewed the proposed VA "API Gateway" language provided during the API discussion to anchor the dialogue and concwTed that this requirement is fundamental to supporting interoperability. The Panel strongly endorsed the "API Gateway" language. Specifically, the Panelists recommended that VA include a requirement that VA have full authority to connect any third-party application to the Cemer system without requiring prior approval by Cerner. Furthermore , VA should ensw-e that developers of third-party applications connecting to the VA system via the open standard and VA-defined APis continue to own their ACQ UISITION SENSITIVE Confidential and Proprietary For Department of Veterans Affairs Use Only AMERICAN 8 VA-18-0298 and VA-18-0299-H-000084 PVERSI 84 of 6274 Page 85 of 1093 VA EHRM Interoperab ility-M itre- Report Jan 2018 _Redacted_ FINAL.pdf for Printed Item : 4 ( Attachment 1 of 1) Document is no longer acquisition sensitive due to contract award on May 17. 2018 intellectual property (IP). From a usability perspective, the Pane l also reconunended that VA be able to establish the connectivity business rules, such as the ability for applications to remain connected for a reasonable time frame (e.g., 1 year) and to receive automatic notification about patient information updates. Require imp lementation of Clinical Decision Service (CDS) Hooks to invoke decision support from with in a clinician's EHR workflow EHRs are essential to efficient delivery of high-quality care, as they provide the clinician with essential decision data at the time required. However , current EHR systems approach workflow from an IT system perspective rather than a clinician's perspective. The latter workflow should , of course , be paramount in the VA EHR implementation, and should also leverage a recent innovation called CDS Hooks. This technology provides the clinician with context-driven decision support and capability by enabling the EHR to trigger third-party services at key events that include ordering medication and opening a patient face sheet. For example, when the VA clinician begins to prescribe medication , a CDS Hook can call an externa l service that presents the clinician with the list of medications already prescribed to the patient by clinicians outside VA. The Panelists strongly reconunended that VA require Cemer to implement and use CDS Hooks within the clinician workflow. Topic Area: Use Community Care Contracts to Foster Interoperability The new EHR system must be able to communicate with other EHR systems (e.g. , Epic , AllScripts , etc.) within the care community. It is critical that VA ensure the Cerner EHR system remain robust for future interoperability with new products . Cerner must conunit itself to supporting other forms of interoperability, such as a presentation layer that is conunon to other systems (e.g., the App store model) . The Panel reconunended that prior to execution of the Community Care Act contract VA require third-party providers (and Cerner compet itors) to conunit to supporting the contract as early adopters. "Innovations going forward are going to come from multiple directions. And having those interfaces, and going with a general interoperability approach that doesn't fork off from what's happening in the rest of the healthcare system, will allow the Veterans to benefit from technology whether that's coming from Google, from a new company, from an innovative shop within VA -- you end up creating a market with good prices, high value." Veterans must be able to access and download a computable fo rm of thei r health data Panelists noted that access to data represents the biggest problem today. VA must clearly direct Cerner to expose data so it can be used by third parties . In the contract and in conversations with Cerner and third parties , VA must require specifics regarding how Veterans and providers will ACQ UISITION SENSITIVE Confidential and Propr ietary For Department of Veterans Affairs Use Only AMERICAN 9 VA-18-0298 and VA-18-0299-H-000085 PVERSI 85 of 6274 Page 86 of 1093 VA EHRM Interoperabi lity-Mitre- Report Jan 2018 _Redacted_FINAL.pdf for Printed Item : 4 ( Attachment 1 of 1) Document is no longer acquisition sensitive due to contract award on May 17. 2018 access and share their data. In addition, VA must require that any agreements leave the door open for future standards and technologies. Panelists believed that VA could achieve this by invoking the principle that the data belongs to the Veteran , rather than by citing specific technologies and standards (given how rapidly they are evolving). Veterans must be able to invoke their right of access to data to support data exchange across all providers (e.g., pull data through an API on their smartphone and push it to their community care provider), now and in the future. Keeping pace with this requirement will drive continual innovation by Cerner and all providers. VA must own the API layer Cerner ownership of the API layer (across every customer) poses a real threat to achieving interoperability , speed of innovation , and cost efficiency throughout the network of community care providers. Panelists stated that it is of utmost importance that VA include specific language stipulating that VA and Veterans be able to use third-party applications without having to register them with Cerner. VA must control the API key, not Cerner. Additionally , VA should require that Cerner provide access to MPages , a developer toolkit, and a programming interface that will enable innovators and third parties to develop APis. Require that community care contracts include VA EHR standards to support bidirectional data sharing Panelists agreed that requiring the support and collaboration of community care providers and participating actively in health IT standards bodies would give VA the opportunity to advance the "national" standard for data sharing-closing any gaps and inconsistencies among federal , industry , and inter-industry standards. VA must require every provider in the chain of a Veteran ' s care to suppo11the same standards for data interoperability in order to ensure seamless, best possible care for Veterans. This includes the requirement that all providers and third-party applications , in exchange for using the VA-provided API gateway , provide bi-directional health information back to VA that can be used for context-driven clinical decisions and informatics. Change the data exchange consent model from "opt in" to "opt out" To encow-age seamless interoperability across all entities providing care to Veterans, the consent model for exchanging data between healthcare providers must be modified to follow an opt-out rather than an opt-in policy , which limits participant numbers. This would allow Veterans to invoke their individual right of access under the Health Information Portability and Accountability Act (HIP AA) to move their data as needed. Many states have already adopted an opt-out consent policy as part of their HIE.2 VA can achieve this by aligning its policy to an opt- 2 See https://www.healthit.gov/sites/default/files/State%20HIE%200p t-ln%20vs%200pt-Out %20Policy%20Research_09-30l6_FinaLpdf ACQ UISITION SENSITIVE Confidential and Proprietary For Department of Veterans Affairs Use Only AMERICAN 10 VA-18-0298 and VA-18-0299-H-000086 PVERSI 86 of 6274 Page 87 of 1093 VA EHRM Interoperabi lity-Mitre- Report Jan 2018 _Redacted_FINAL.pdf for Printed Item : 4 ( Attachment 1 of 1) Document is no longer acquisition sensitive due to contract award on May 17. 2018 out model, supported by the new VA proposed rule 3 to allow IIlEs to collect a Veteran's consent and electronically attest to the consent to VA in order to obtain the required EHR. Topic Area: Additional Contract Changes In addition to the recommendations in the prior sections, the Panelists encouraged VA to add fmiher definitions and clarity in the following areas: • Require Cerner to provide VA with full read and partial write access to all data elements within the EHR, at VA ' s sole discretion. • Require Cerner to make the VA data model , standards , and other similar interoperability changes available in all other non-VA Cerner instances of its EHR platform. • Clearly define "enabling security framework " so that users know if this means a specific security framework such as those provided by the National Institute of Standards and Technology (NIST), IIlTRUST , etc. • Amend "national Common Trust Framework" to specifically refer to the intended source. The Panelists suggested that VA replace this wording with "Trusted Exchange Framework and Common Agreement (TEFCA)" as specified in the 21 st Century Cures Act. • Amend RFP Performance Work Statement (PWS) Section 5.10.4(i) to clarify if the "provider collaboration via secme e-mail using Direct standards" is limited to the Direct protocols and just the Cerner platform. • Incorporate the model RFP language necessary for Cerner to support the API and SMART on FHIR platform and SMART-enabled applications, as described in Appendix B. 3 Sec https ://s3 .amazo naw s.com/publi c-inspcctio11.fodcralregist cr.gov/20 18-007 58.pdf ACQ UISITION SENSITIVE Confidential and Proprietary For Department of Veterans Affairs Use Only AMERICAN 11 VA-18-0298 and VA-18-0299-H-000087 PVERSI 87 of 6274 Page 88 of 1093 VA EHRM Interoperab ility-Mitre- Report Jan 2018 _Redacted_FINA L.pdf for Printed Item : 4 ( Attachment 1 of 1) Document is no longer acquisition sensitive due to contract award on May 17. 2018 II. Recommendations for RFP Changes MITRE engaged Morrison & Foerster, LLP, as the independent and unbiased legal expert to identify the specific changes to the RFP language necessary to implement the recommendations made by the Interoperability Rev iew Panel. MITRE prov ided Morrison & Foerster, LLP, with the summary recommendations and a copy of the RFP. 4 In addition , MITRE collected specific ideas for contract language from the Panel. Appendix C presents all recommended RFP changes . 4 Pe,jor mance Work Statement fo r the VA Electronic Health Record Modernization Sys tem, Final Version 1.7, Amendment 03, December 4, 2017, Department of Veterans Affairs. File name: 001 - VA EHRM IDlQ PWS (Amended 12.04.2017) - Copy.doc x ACQUISITION SENSITIVE Confidential and Proprietary For Department of Veterans Affairs Use Only AMERICAN PVERSI 12 uisition sensitive due to contract award on MaVA-18-0299-H-000088 17 2018 VA-18-0298 and 88 of 6274 Page 89 of 1093 VA EHRM Interoperab ility-Mitre- Report Jan 2018 _Redacted_FINA L.pdf for Printed Item : 4 ( Attachment 1 of 1) Document is no longer acquisition sensitive due to contract award on May 17. 2018 Ill. Observations from University of Pennsylvania Medical Center Site Visit A delegation from VA and MITRE traveled to Pittsbmgh , Pennsy lvan ia, on January 19, 2018, for a meeting with representatives ofUPMC Enterprises to discuss aspects of EHR interoperability that UPMC has successfully implemented over the ast several years. The VA team, led by John Windom , included Dr. Ashwini Zenoo z, (b)(S) John Short, and (b)(6) . The MITRE group included Richard Byrne, ay c 1tzer, (b)(6) ~----~ (b)(6) , an (b)(6) . The hosts at UPMC included Dr. Rasu Shrestha, C. Talbot eppenstall , r. , c lister , Dr. Robert Bart , Adam Berger, Diane Michalec, Phyllis Szymanski , and Dr. Amy Urban, as well as additional staff. The meeting was broken into four parts. Following introductions , Session 1 described the structure ofUPMC. Session 2 covered UPMC's last decade of interoperability , and Session 3 centered on the road ahead for UPMC and industry. Dr. Rasu Shrestha began the meeting by making the introductions and setting the agenda. He stated that UPMC's approach had followed a best-of-breed strategy , as opposed to a best-of -suite strategy, with the intention of failing fast and succeeding often. The overall UPMC structure has four parts: provider services, insurance serv ices, international act ivities , and enterpr ises. During the discussion of interoperabi lity, the UPMC team described its approach to interoperability , called Connected Healthcare , which is based on the commercial product dbMotion of AllScripts. UPMC has created an entity titled ClinicalConnect HIE (CCHIE) that uses HL7. Clinica lConnect exists as a separate 501c(3) company, of which UPMC is a member. CCHIE conta ins 90 live interfaces . Th is HIE went live in June 2012; its members cons ist of 10 hospitals. It competes with three other HIEs in Pennsylvania. The repository contains data on 8.3 million patients , and , in terms of patient consent, CCHI E uses an opt-out model. It currently has connect ions to four EHRs: Cerner (two vers ions) , Epic , and Varian. Data available within CCHI E spans allergies, clinical documents , diagnosis , encounters , immuni zations, labs , medications, problems , and procedures. Much of this data is in the form of documents (Continuity of Care Document (HITSP C32 CCD format, including problems, allergies , and medications); unstructured clin ica l documents (HITSP C62 format); Consolidated Clinica l Document Architecture (C-CDA CCD , including problems, allergies , medications , immuni zations , procedures , and insurance); and HL7 Interface (ADT: encounters, documents , imaging documents , and labs only). At the point of care dbMotion allows multiple views for the CCHIE: 1) a clinical view, 2) a newer view titled EHR agent , and 3) a Cerner MPage integration view . The next phase of the UPMC work in this regard w ill consist of integration with Common Well. F igure 2 shows the architecture of the system. F igure 3 depicts the data feeds. ACQUISITION SENSITIVE Confidential and Proprietary For Department of Veterans Affairs Use Only AMERICAN 13 VA-18-0298 and VA-18-0299-H-000089 PVERSI 89 of 6274 Page 90 of 1093 VA EHRM Interoperability-Mitre- Report Jan 2018 _Redacted_FINA L.pdf for Printed Item : 4 ( Attachmen t 1 of 1) Document is no longer acquisition sensitive due to contract award on May 17. 2018 The Children'> institute Armstro~ County Me,,;~, Hosprtail The Childre n's Home Butler Hospital Herit age Va lley All scripts db Mo t 1on Node f::l Allscripts PRO • All scripts Sunrise All scripts Touch Works - St. Cla 1r Hosp,t.a I P@d1.atric Presbyt enan seri1orcare Hean h System Alliance eChnic a l Works Cerner EHR Epic EHR e Meditech EHR eMD GE Centricity Answers on Demand McKesso n H om e He a lth Evide nt NextGen Siemens EHR Source: From UPMC Enterprises, used with permission , for VA use only Figure 2. ClinicalConnect (Western Pennsylvania} Health Information Exchange - - "°"'"' '""' r ,!! f Al119'LAN ..._AC ACH•V< EHIEAI.TH ~. ~ ~ ~ ~UN[fllHl - - CE:~ !?:,,._ ~ 0 -~ I >' ...... H31 C ci' ,.. _.n _~ -- ~- CE OBIJlTR-"SOUNI) c.,.,;Ak~ffllii/ ....._.frtalm!.LOGluliflr:t • INPATIENT •-CA80% of VA's needs • Est imate 18-24 months to IOC Pilot Site post acquisitio n Interoperability with other health systems Flexibilit y Modernity • All top tier COTS vendors meet multiple interop erability stan dards (e.g., FHIR)to create longitudinal record • Out-of-the-box functio nalities fulfilling >80% of V A's needs • Add itional time to redesign and scale eHMP to COTS so lution • Esti mate 18-24 months to IOC - Pilot Site po st acqu isition • Same as Opt ion I: COTS. Also, JL V provides a static view of external records , but do es not create the longitudinal record • Same as Opt ion I for COTS • In dustry leading sof tware that regularly upgrades based on best practices and industry innovation • Same as Opt ion I for CO TS • COTS out -of -the box capabilities allow sof tware config uration to meet end -user practice preference (e.g., physician note templates) AMERICAN PVERSIGHT Option 3: Commcrcrn · 11zc • d \ ' "1stA • Requires mod ern izing a single instance of VistA software prior to impleme nting, which will add at minimum an additiona l 12 month s I · Opium 4: COTS SaaS • Out-of-the-box functionalities fulfilling >80% ofVA's need s • Est imate 18-24 months to IO C - Pilot Site post acquisition • Estimate 24-36 months to IOC - Pilot Site post acquisition • In terope rability capability would have to be built into the commercia lized VistA solution • All top tier COTS vendors meet multiple interop erability standar ds (e.g., FHIR ) to create longitudina l record • Vendor admi nistered cloud decreases VA flexibility to access 3r d party vendors (e.g., best in class population health) because vend ors may have pre-existing agreements. • Vendor adminis tered cloud decreases VA flexibility to access 3rd party vendor s (e.g., best in class populat ion health ) because vendors may have pre-existing agreements. • Vendor 's com mitment to conti nuous upgrade conti ngent on ability to sell the solution at other clients and make a profit • Same as Optio n I: COTS • eHMP to provide longitud inal reco rd • VA administered cloud increases VA flexibility to access 3rd party vendo rs (e.g., best in class pop ulation health) • Fully integrated so lution with modern team based co mmun ications Tailorability Option 2: COTS + c H 'IP ,, • eHMP for new capabilities over time, dependent on developmen t time, which may exceed market timeliness • eHMP functiona lity would need to be deconflicted of overlapping capability and then integrated with the COTS product. • VA may have to invest or enter into risk sharing arrangement s if the vendor is not able to sell the solution to a critical mass to break even • Same as Opt ion I: COTS • Highest level of tailorability • eHMP adds capab ility to tailor because it is a VA develope d and managed product • May requ ire additional cost to purchase leading business and clin ical workflows from 3rd party entities © 2017All rightsreserved. 2 123 of 6274 • Same as Option I: COTS, except code level change (customization) may not be pos sible because software may be shared by othe r clients of the COTS vendor (e.g., DoD ) GrantThornton VA-18-0298 and VA-18-0299-H-000123 Page 135 of 1093 I EHR assessment FINAL 060117 .pdf for Printed Item: 6 ( Attachment 1 of 5) Reportonthe StrategicOptionsfor the Modernization of the Department of VeteransAffairsElectronicHealthRecord . . F" D ec1smn ac t or I Option H'IP 2: COTS + l>ptum . I : C80% of VA's needs • Est imate 18-24 months to IOC - AMERICAN PVERSIGHT Option II'IP 2: COTS + e ,, • Out-of-the-box functionalities fulfilling >80% of V A's needs • Additional time to redesign and scale eHMP to COTS solution Option Commercia . 11ze • 3:d , ,.1sIA • Requires modernizing a single instance of VistA software prior to implementing, which will add at minimum an addit ional 12 months © 2017All rightsreserved . 20 141 of 6274 I . 4 : C() "l'S, Saa,S O phon • Out-of-the-box functionalities fulfilling >80% of VA's needs • Estimate I 8-24 months to IOC - Pilot Site post acquisition GrantThornton VA-18-0298 and VA-18-0299-H-000141 Page 153 of 1093 I EHR assessment FINAL 060117 .pdf for Printed Item: 6 ( Attachment 1 of 5) Reportonthe StrategicOptionsfor the Modernization of the Department of VeteransAffairsElectronicHealthRecord . . F" D ec1smn actor I l>ptum . I : C > 1 0 ) ) 2 1 ) ) 3 7 ) ) 4 10 ) ) 5 25 ) ) 6 25 ) ) 7 25 ) ) 8 25 ) ) 9 25 ) ) 10 25 > > In order to show the annual maintenance cost for the modem EHR system, we then added five years to our estimate, so the total estimate provided is for 15 years, the first 10 of which is implementation. 4.6 VA Costs VA will also incur internal costs to suppo rt the migration to a new, modern EHR. These include data migration costs, change management, and funding a PMO to act on VA's behalf (the PMO can either be staffed with internal VA resources, or through a contract). To determine the cost of data migration, we analyzed a previous effort where VA was able to complete comprehensive data migration for 66 sites. 14 We assumed a similar level of effort per AMERICAN PVERSIGHT © 2017All rightsreserved. 25 146 of 6274 GrantThornton VA-18-0298 and VA-18-0299-H-000146 Page 158 of 1093 I EHR assessment FINAL 060117.pdf for Printed Item: 6 ( Attachment 1 of 5) Reportonthe StrategicOptionsfor the Modernization of the Department of VeteransAffairsElectronicHealthRecord facility would be required to migrate the full 130 instances of VistA. We aligned the timeline for data migration with the implementation timeline from above to dete1mine the total number of sites VA must migrate each year and the total cost of migration. To cost the change management portion , we leveraged our technical knowledge against a body of industry experience, as well as change management costs illustrated in the eHMP 2.0 rollout program. Change management costs are approximately 25 percent of a total projects aggregate cost, therefore a factor of 25 percent was applied to the overall project cost to calculate the change management cost. PMO costs were determined by leveraging Grant Thornton's industry experience as well as analysis of pertinent Office of Management and Budget (0MB) Form 300s and select research into other large scale ERP, EHR and information technology implementation project s to determine an appropriate benchmark. Our analysis indicates PMO costs are generally between 15-20 percent of the overall project costs. We assumed the high-end due to the inherent complexity of the scale of VA and a factor of 20 percent was applied to calculate to the PMO cost. 4. 7 Complexity Factor Finally, due to the early stage of decision-making at VA, many factors that impact overall cost are not well under stood. These factors include: • • • Specific business and clinical requirements, which may identify additional sof tware or integration need s, which may increa se overall cost. A readiness assessment, which we recommend below, may identify additional internal costs suc h as infrastructure improvement s or increased chang e management costs. Additional development needs in eHMP or VistA mod ernization. We therefore added a 20 percent complexity factor for Option2: COTS+ eHMP and Option 3: Commer cializedVistA and a 15% complexity factor for Option 1: COTS and Option 4: COTS SaaS to account for unknown costs that are likely to arise over the planning period. Figure 11 provides the detailed breakdown of costs, per our analysis.15 Appendix D provide s full detail of the steps associated with developing each cost center, and the calculations performed. Figure 11. IS-year Costs Associated with Four Options Software Vendor Team & Support IT Infrastructure HW & SW Systems Integration Application Support E nd user devices User training at Go-Live AMERICAN PVERSIGHT Vendor Costs $ l,l 79,240,741 $1,179,240,741 $1,726,745,370 $1,726,745,370 252,694,444 $252,694,444 126,347,222 $ l26,347,222 463,273,148 $463,273,148 $84,231,481 $84,231,481 $336,925,926 $336,925,926 © 2017All rightsreserved . 26 147 of 6274 $194,372,093 $284,616,279 41,651,163 20,825,581 76,360,465 13,883,721 $55,534,884 - $931,600,185 $ I ,364,128,843 $199,628,61l $99,814,306 $365,985,787 $66,542,870 $266,171,481 GrantThornton VA-18-0298 and VA-18-0299-H-000147 Page 159 of 1093 I EHR assessment FINAL 060117 .pdf for Printed Item: 6 ( Attachment 1 of 5) Reportonthe StrategicOptionsfor the Modernization of the Department of VeteransAffairsElectronicHealthRecord Oth er Project Cost eHMP (Option 2: COTS + eHMP only) VistA Modernization (Option 3: Commercializ ed VistA only) Software Implementation Cost Post-Go -Live Software Cost Vendor Total t I $42,115,741 $0 $42,115,741 $525,000,000 $6,941,860 $0 $33,271,435 $0 $0 0 $813,340,000 $0 $4,211,574,074 $4,736,574,074 $1,507,526,047 $3,327,143,519 $l,332,060,606 $1,332,060,606 $1,170,000,000 $2,664,121,212 $5,543,634,680 $6,068,634,680 $2,677,526,047 $5,991,264,731 $1,109,047,840 $505,382,301 $1,707,933,673 $2,328,407,136 $0 Services Cost Change Management Cost Data Migration Cost Prime Integrator VAPMO Cost Cloud Hosting Services Subtotal Contingency Sub-Total Complexity Factor Grand Total 5.0 $1,052,893,519 505,382,30 I $2,I 61,941,358 $2,315,962,964 $ I 84,673,700 $1,527,858,025 $505,382,30I $2,161,941,358 $2,565,954,091 $184,673,700 $1,109,047,840 $505,382,30 I $1,707,933,673 $2,328,407,136 $0 $6,220,853,842 $6,945,809,474 $5,650,770,949 $2,352,897,704 $2,602,888,83I $1,665,659,399 $14,117,386,226 $15,617,332,985 $2,117,607,934 $16,234,994,160 $3,123,466,597 $18,740,799,583 $9,993,956,395 $1,998,791,279 $11,992,747,674 5,650,770,949 $2,328,407,136 $13,970,442,816 $2,095,566,422 $16,066,009,238 Summary of Findings Grant Thornton utilized our technology adoption approach to assess various options for VA's modernized EHR. The assessment identified the clinical and IT priorities , benefits , risks and costs of each of four options for EHR modernization presented by VA. Our assessment found significant overlap in capability with respect to clinical p1iorities, and for the most part, alignment with VA's IT priorities. Options differentiate to a greater extent when assessed against the real and potential benefits and risks. These provide a framework against which VA leaders may weigh the options against one another, and infonned the decision-crite1ia discussed in the Executive Summary. While Grant Thornton was not asked to provide a specific recommended option, our analysis provide s objective information upon which a decision may be based. Figure 12 provides a summary of each option 's alignment with VA's clinical and technology prioritie s, as well as the relative benefit s and risks associated. Figure 12. Alignment with Clinical Priorities & IT Strategic Direction Clinical p1iorities + IT strategic direction AMERICAN PVERSIGHT © 2017All rightsreserved . 27 148 of 6274 GrantThornton VA-18-0298 and VA-18-0299-H-000148 Page 160 of 1093 I EHR assessment FINAL 060117 .pdf for Printed Item: 6 ( Attachment 1 of 5) Reportonthe StrategicOptionsfor the Modernization of the Department of VeteransAffairsElectronicHealthRecord Benefits Risk HIGH HIGH HIGH* HIGH * MEDIUM HIGH HIGH MEDIUM • C'-JUJlfil "k *Rating assumes VA inserts appropriate language into the contract to guarantee access to and control of data as well as ability to connect third-party software at will. In addition, Figure 13 provides the high-level cost break.down of each option. Figure 13. Costs of Four Options Vendor CosL~ Software Imp lementation Cost $4,211,574,074 $4,736,574,074 $ 1,507,526,047 $3,327,143,519 Maintenance & Support Cost $1,332,060,606 $1,332,060,606 $ 1, 170,000,000 $2,664,121,212 Vendor Total $5,543,634,680 $6,068,634,680 $2,677,526,047 $5,991,264 ,731 Change Management Cost $1,052,893,5 I 9 $1,527,858,025 $ 1,109,047,840 $1,109,047,840 $505,382,30I $505,382,301 $505,382,30I $505,382,301 $2, I6 I,941,358 $2,16 1,941,358 Services Cost Data Migration Cost Prime Integrator + $ 1,707,933,673 ~ $1,707.933,673 + $2,315,962,964 $2,565,954,091 $ I84,673,700 $ I 84,673,700 Services Subtotal $6,220, 853,842 $6,945,809,474 $5,650,770,949 $5,650,770 ,949 Conti ngency $2,352,897,704 $2,602,888,831 $ 1,665,659,399 $2,328,407,136 Subtotal $14,117386,226 $15,617,332,985 $9,993,956,395 $13,970,442,816 Complexity Factor $2,117,607,934 $3,123,466,597 $ 1,998,79 I ,279 $2,095,566,422 $11,992,747,674 $16,066,009,238 VA PMO Cost Cloud Ho sting Grand Total 6.0 $16,234,994,160 I $18,740,799,583 $2,328.407,136 $2,328,407,136 Recommendations EHR modernization is a journey. While Grant Thornton makes no recommendation on which specific option VA should pursue, no matter the choice, the following is recommended in order to inform downstream decisions such as vendor selection (should a COTS solution be involved in the modern EHR) , continued development of eHMP and other factors: • Technicalreadinessassessment: Durin g interviews , a number of VA per sonnel expressed confidence that VA had the necessary network infrastructure , bandwidth and other technical capabilities to move to the cloud or adopt enterprise-wide Saas solutions. However , there were others including VA leadership , both nationally and in the field, who expressed reservations regarding the organization having the network capacity and bandwidth to support the EHR in the cloud. We recommend that VA conduct a study to validate these statements. Readiness assessment must also include facilities, data centers and security components. AMERICAN PVERSIGHT © 2017All rightsreserved . 28 149 of 6274 GrantThornton VA-18-0298 and VA-18-0299-H-000149 Page 161 of 1093 I EHR assessment FINAL 060117 .pdf for Printed Item: 6 ( Attachment 1 of 5) Reportonthe StrategicOptionsfor the Modernization of the Department of VeteransAffairsElectronicHealthRecord • Technicalevaluationof eHMP: Dw-ing the interviews , some of the VA personnel shared their optimism that eHMP could help bridge the gap that currently exists around transparency and interoperabibty both across the different instances of VistA and also between VHA , DoD and the community providers. However , independent assessments of the technology and Grant Thornton 's analysis of eHMP program documentation raise concerns as to the long-term viability of the product. A complete, independent assessment of eHMP from a technological standpoint is recommended to determine if it is scalable in its current form, and if not , the necessary additional cost to restructure the product so that it is scalable. In addition , it is also recommended that the assessment include eHMP 's ability to integrate with COTS EHR solutions the way it promises to integrate with VistA. • A cquisitionapproa ch:VA has specific and critical needs that impact any solution VA chooses . It is critical that V A's needs are properly documented in the clinical and technical requirements of any procurement. This needs to be supported by robust business and technical architectures (capability maps , process models) , systems quality factors , service level agreements and enterprise design. In addition, contractual requirements must also address any needs VA has, such as ownership of and access to data. These contractual requirements should be assessed and included as requirements in the solicitation. Cost models are validated and Independent Government Cost Estimates (IGCE ) are established. This must include garnering best practices and lessons learned from the DoD Genesis acquisition. It may also include proof of concepts , controlled pilots and phased rollouts. • Systems engineerin g andprogram.managementplan:This should include strategy for requirements management , interface analysis, usability and human factors , architecture analysis and documentation , end-to-end testing, continuous risk management , development of performance metrics and an integrated master plan/schedule (IMP/lMS). • System (application)and hardwareinventor y: OI&T should conduct a detailed assessment and inventory or each clinical location to ensure all software is catalogued to understand interface requirements . Additionally a detailed desktop , printer and ancillary hardware inventory needs to be conducted as all of these devices will need to be evaluated against any of the strategic options for future usability. The studies and actions we recommend above will have an impact on the total cost to implement a solution. The readiness assessment may uncover additional necessary investment to improve the performance and bandwidth of the network infrastructure. The systems engineering and program management plan may also increase cost as additional requirements are identified the PMO or vendor must address. The results of these studies may also impact our findings from a benefits and risks standpoint, as significant change in network or organizational improvements to support the transition may introduce risks not assessed. However, these actions are critical to support the successful implementation of any solution. AMERICAN PVERSIGHT © 2017 All rightsreserved . 29 150 of 6274 GrantThornton VA-18-0298 and VA-18-0299-H-000150 Page 162 of 1093 I EHR assessment FINAL 060117 .pdf for Printed Item : 6 ( Attachment 1 of 5) Reportonthe StrategicOptionsfor the Modernization of the Department of VeteransAffairsElectronicHealthRecord 7 .0 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. Bibliography National Center for Veterans Analysis and Statistics. Department of Veterans Affairs Statistics at a Glance, May 2016. About VHA. https:/ /www.va.gov/health/aboutVHA.asp. VA Secretary Shulkin sets timeline on VistA decision. 2017. http:/ /www.politico.com/video/2017 /03/ shulkin-sets-timeline-on-vista-decision-0625 38. Byrne CM, Mercincavage LM, Bouhaddou 0, et al. The Department of Veterans Affairs' (VA) implementation of the Virtual Lifetime Electronic Record (VLER): Findings and lessons learned from Health Information Exchange at 12 sites. 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Fiore LD, Brophy MT, Turek S, et al. The VA Point-of-Care Precision Oncology Program: Balancing Access with Rapid Learning in Molecular Cancer Medicine. Biomark Cancer. 2016;8(Visn 1):9-16. doi:10.4137/BIC.S37548. Sitapa ti A, Kim H, Berkovich B, et al. Integrated precision medicine:the role of electronic health records in delivering personalized treatment. WileyInterdiscipRev Syst Biol Med. 2017;(Appendix l):e1378. doi: 10.1002/w sbm.1378. Welch BM, Eilbeck K, Fiol G Del , Meyer LJ, Kawamoto K. Technical desiderata for the integration of genomic data with clinical decision support. J BiomedInform. 2014;51:3-7. doi: 10.1016/j.jbi.2014.05.014. Wei W-Q, Denny JC. Extrncting research-quality phenotype s from electronic health records to support precision medicine. GenomeMed. 2015;7(1):41. doi:10.1186/s13073-015-0166-y. Center for Connected Health Policy. What is Telehealth? ht : www.cch ca.or /what-i stelehealth. Accessed January 1, 2017. Medical University of South Carolina Selects Vidyo Integrated with Epic to Enable High Quality Telehealth Visits in Electronic Health Record Portals. htt s: www.vid o.com ress-release medical-universit -of-south-ca.rolina-vid o-e ic. Accessed May 4, 2017. Srinivasan V. How Stanford achieved 60% telehealth adoption at a primary care clinic. https://www.advisory.com/research/market-innovation-center/the-growthchannel/2016/03/stanford-medicine-virtual-visits. Published 2016. Accessed May 4, 2017. Practical Integration of Telemedicine into the EPIC Electronic Health Record System. htt : www.u hs.u enn.edu roundtable slides ma 2015 ractical lnte ·ation. df. Accessed May 4, 2017. Centers for Medicare & Medicaid Services. Telehealth Services. https://www.ems.gov/Outreach-and-Education/Medicare-Leaming-NetworkMLN /MLNProducts/ download s/TelehealthSrvcsfct sht.pdf. Published 2016. Holder KA. Veteransin Rural Am erica : 2011 - 2015 AmericanCommunitySurveyReports.;2017. https ://www.ce nsus.gov/co ntent/dam /Ce nsus/ library/p ublications/2017 /acs/acs-36.pdf. National Center for Veterans Analysis and Statistics. Characteristics of Rural Veterans : 2010 Data from the American Community Survey. 2012;(July). Rand Corporation. AssessmentB (H ealthCareCapabilities).; 2015. Q--Securing Medical Device s and the Internet of Things at VA TAC-16-35272. https:/ /www .fbo .gov/i ndex ?s=oppor tunit y&mode =for m&id=4d8f5 la0ddf6667aaf36e4cbb3 da7ed7&tab =co re&_cview=0 . Published 2016. Accessed June 4, 2017. Cussatt D. Securing the Internet of Things (IoT) at the U.S. Department of Veterans Affairs. htt : www.himssconference.or sites imssconference files df 188 1. df. Published 2017. Accessed May 4, 2017. Definition of artificial intelligence. ht s: www.merriam-webster.com dictionar artificial intelligence. Accessed June 4, 2017. Szlosek DA , Ferretti JM. Using Machine Leaming and Natural Language Proce ssing Algorithms to Automate the Evaluation of Clinical Deci sion Support in Electronic Medical Record Systems. 2016;4:8-10. Meystre M, Kim Y, Gobbel GT, et al. Congestive heart failure information extraction AMERICAN PVERSIGHT © 2017All rightsreserved. 31 152 of 6274 GrantThornton VA-18-0298 and VA-18-0299-H-000152 Page 164 of 1093 I EHR assessment FINAL 060117.pdf for Printed Item: 6 ( Attachment 1 of 5) Reportonthe StrategicOptionsfor the Modernization of the Department of VeteransAffairsElectronicHealthRecord 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. framework for automated treatment performance measures assessment. 2017;24(July 2016):40-46. doi:10.1093/jamia/ocw097. Piette JD, Krein SL, Striplin D, et al. Patient-Centered Pain Care Using Artificial Intelligence and Mobile Health Tools: Protocol for a Randomized Study Funded by the US Department of Veterans Affairs Health Services Research and Development Program. JM/R Res Protoc. 2016;5(2):e53. doi: 10.2196/resprot.4995. Dilsizian SE, Siegel EL. Artificial Intelligence in Medicine and Cardiac Imaging : Harnessing Big Data and Advanced Computing to Provide Personalized Medical Diagnosis and Treatment. Curr CardiolRep. 2014;16. doi:10.1007/sl 1886-013-0441-8. Sweet LE , Moulaison HL. BIG DA TA AND HEALTHCARE ELECTRONIC HEAL TH RECORDS DATA AND META.DATA : 2013;1(4):245-251. doi:10.1089/big.2013.0023. Du Vall S. What is VINCI? https ://www. hsrd.research.va.g:ov/for researchers/cyber seminars/archives/1143note s.pdf. Accessed January 1, 2017. VA Informatics and Computing Infrastructure. https :/ /www.hsrd.re search.va.g:ov/for researchers/vinci/. Accessed January 1, 2017. Garvin JH, Kalsy M, Brandt C, et al. An Evolving Ecosystem for Natural Language Processing in Department of Veterans Affairs. J Med Syst. 2017. doi:10.1007/ sl09 16-0160681-4. Monegain B. IBM's Watson to work with VA on Vice President Biden's Cancer Moonshot. Healthcare IT News. ht : www.healthcareitnews.com news ibm's-watson-work-va-vicepresident-bidens-cancer-moonshot. Accessed January 1, 2017. Shulkin D. VA Enlists Watson to Help Doctor s Scale Precision Cancer Treatment. https :/ /www .ibm.com/blog:s/think/2016/06/va-enlists-watson/. Accessed April 4, 2017. Shaffer, Vi; Craft L. Hype Cyclefor H ealthcareProviders,2016.; 2016. Veterans Health Administration. Departmentof VeteransAffairs Blueprintfor Excellence,September 2014.; 2014. http ://www.va.gov/ HEALTH/doc s/VHA Blueprint for Excellence.pdf. Shulkin DJ. Beyond the VA Crisis - Becoming a High-Performance Network. N Engl J Med. 2016;374(11):1003-1005. doi:10.1056/NEJMp1502629. Green, Jeff, Feltham, Tom; EHR SoftwarePricingGuide;2015; EHR in Practice; htt s: www.healthit. ov roviders- rofessionals fa s how-much- oin -cost-me . Accessed April 4, 2017. AMERICAN PVERSIGHT © 2017All rightsreserved. 32 153 of 6274 GrantThornton VA-18-0298 and VA-18-0299-H-000153 Page 165 of 1093 I EHR assessment FINAL 060117.pdf for Printed Item: 6 ( Attachment 1 of 5) ReportontheStrategic Optionsfor theModernization of the Department of VeteransAffairsElectronicHealthRecord 8.0 Append ix A : Macro Assumptions In assessing the options, Grant Thornton made the following assumptions: • • • • • • • • Grant Thornton used the Health Information Management Systems Society (HIMSS) definition of an EHR, which states: "The E lectronic Health Record (EHR) is a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting. Included in this information are patient demographics, progress notes , problems , medications, vital signs, past medical history, immunizations, laboratory data and radiology reports. The EHR automates and streamlines the clinician's workflow. The EHR has the ability to generate a complete record of a clinical patient encounter - as well as supporting other care-re lated activities directly or indirectly via interface - including evidence -based decision support , quality management, and outcomes reporting." VA will implement the EHR as a component of the overall VA Digita l Platform (VDP), as described in the strategy document published in 2016 "VA Digital Platform Strategy for Next Generation of Care at the VHA." The VDP establishes a platform on which the EHR operates with other management information systems, such as human resources, financial management and customer relationship management, as well as externa l E H Rs used in the healthcare community, to include DoD. In addition , through the VDP, VA will be able to adopt other tools available in the market to augment core EHR capabilities. This assessment focused on the EHR components of VistA only (core clinical, clinical ancillary and revenue cycle). This paper does not address the modernization of other components of VistA such as police and security, financial management, supply chain or others. Appendix E contains a list of current VistA modu les that constitute the EHR. ln assessing implementation costs, the continued carrying costs for maintaining the VistA EHR were deemed to be equal no matter the option selected, therefore they were not considered during this analysis. VA currently houses backup copies of electronic health records locally at VA Medical Centers (VAMCs) in the event of network disruptions , in addition to hardware for the provision of the new EHR product. There will be minimal, if any, net new hardware costs incurred as part of the transition to a modern EHR. This assessment is based upon strategic needs of the organization, from both a clinical and technological perspective. Detailed business and clinical requirements are not yet defined. The cost assessment therefore uses an analogous methodology and provides a Rough Order of Magnitude (ROM) cost estimate . Additionally, based upon our analysis, the DoD and Kaiser Permanente EHR adoptions are analogous projects. Industry benchmarks related to the adop tion of new EHRs are relevant to this assessment. Benchmarks include the relative percentage of costs attributed to software, hardware, change management and other factors , as well as the proportional cost of Saas models versus traditional deployment. Three of the four options include the adoption of a COTS EHR solution. Although all clinical and IT priorities can be satisfied by COTS software, a single COTS vendor may not address all equally. Therefore, VA may choose to adopt a vendor for a majority of the E HR components and then add, through the VDP, best-in-class capabilities available through other vendors in order to fully meet its clinical and IT priorities. AME~lr'J\N © 2017All rightsreserved . pVE - SIGHT GrantThornton VA-18-0298 and VA-18-0299-H-000154 154 of 6274 Page 166 of 1093 I EHR assessment FINAL 060117 .pdf for Printed Item : 6 ( Attachment 1 of 5) Reportonthe StrategicOptionsfor the Modernization of the Department of VeteransAffairsElectronicHealthRecord 9.0 Appendix B: Stakeholder Interview Findings 9.1 Clinical Stakeholder Findings In order to understand the expe1ience of clinicians using CPRS and VistA for both clinical and research work, several qualitative interviews were conducted with VHA clinicians (both physicians and nurses), including some who had expertise and leadership roles in health informatics and health information technology implementation. The VHA interviews were led by the MITRE collaboration with Grant Thornton. While the majority of clinicians expressed that they are able to collaborate well with other clinicians in order to provide excellent care to Veterans , numerous themes were compiled after these discussions regarding ways in which an EHR solution improve Veteran and clinician experience. Based on multiple EHR vendor interviews conducted by Grant Thornton, it was felt that all four strategic options could support the needs and requirements of VHA clinicians and leadership. This section highlights essential themes that clinicians expressed with regard to selection and implementation of a modern EHR. 9.1.1 Leadership Key Messages: Clinicians articulated a feeling that there is a lack of central governance and that the problems are greater than just EHR choice. Many felt that: The changemanagement aspect of an EHR transition is significant and the VA needs to be committed to understanding workflows in order to improve the experience for Veterans and clinicians Some providers feel significant trustbetween clinicians andIT hasbeen lost over time with respect to partnership in VistA and CPRS development. Part of this is related to the fact that EHR improvement s are hampered by budget and approva l processes, and additionally, disconnect exists between VA facilities and IT with respect to business planning. ershipwith IT to Regardless of past issues, a number of the clinicians expressed a need for sharedpa11n deliver quality Veteran -centric care Clinicians also feel that the contracting process is too long and bureaucratic and needs attention because by the time tools are eventually developed , they are obsolete. • • • • 9.1.2 Clinical Workflow Key Messages: Providers desire modern EHR capabilities that are intuitive, efficient and allow the clinician to spend more time delivering direct care to the patient. The following are key themes shared during the interviews: • • • • There is lack of single-sign on, which makes it frustrating to go back and forth between different applications There is no ability for physicians to easily see their schedules and those of trainees they are supervising. This makes it difficult toplan their day because for example , they cannot see if a patient has canceled and then adjust. on to be presented on Multiple clinicians mentioned that they need an integrated way for patientinformati ces withclinical decisionsupport tools and makes docum entationstreamlin ed and an EHR screen that interfa accurate Despite the recognition that alerts and reminders are important parts of patient safety, there are often too many screens andclicks thatcliniciansmustencount er. One nurse noted that the computer admission AME 01 r'I\N © 2017 All rightsreserved . pVE · SIGHT GrantThornton VA-18-0298 and VA-18-0299-H-000155 155 of 6274 Page 167 of 1093 I EHR assessment FINAL 060117 .pdf for Printed Item: 6 ( Attachment 1 of 5) Reportonthe StrategicOptionsfor the Modernization of the Department of VeteransAffairsElectronicHealthRecord protocol takes up to two hours for an intensive care unit patient , and 45 minutes for a floor patient , significant time sinks for a nurse who has multiple patients and time-sensitive responsibilities In addition to the above, there were more focused comments shared such as: • Because of the decentralized nature of IT, facilities have taken to implement local solutions (both designed internally by local VA IT personnel and COTS products ). One provider provided an example that while the COTS solution for their emergency department (ED) worked very well and allowed them to easily see recent Veteran ED visits and reasons, this system did not interface with CPRS. As such, if a patient was admitted to the hospital , an admitting physician could not easily see the ED record (information is saved in cumbersome PDFs ). There Mixed feedback was shared regarding CPRS usability, with some providers expressing that they felt CPRS was very easy to use and intuitive (multiple providers noted that it worked very well for pharmacy) while others felt that COTS solution s were much more user-friendly and capable. • 9.1.3 Team-Based Care/PACT KeyMessages:As discussed previously , VA has a strong commitment to providing effective teambased care for Veterans through the PACT initiative. Each PACT "teamlet" is comprised of a Veteran, a primary care provider (physician, physician assistant, or nurse practitioner), a registered nurse who functions as a care manager for the team, a licensed practical nurse or medical assistant, and a clerical assistant. 19- 21VA research has already shown that improved relationships with Veterans and speed of care received were noted positives of PACT. 19·20Despite all of this, CPRS does not support PACT well. VA clinicians have created work-arounds to address these deficiencies , but one group of VA providers detailed several EHR features that would be beneficial in order to support team-based care (Figure B-1). • • Providers are not able to directly communicate through the EHR outside of patient records. A workaround that many use today is adding additional signers to patient notes, which creates an alert to another provider to sign that note , but does not allow for a direct specific message to that provider which is in the EHR but not in a patient note. There is no good way to manage panels of patients or cohorts based on clinical condition because of limitations in VistA's architecture. Figure 8-1. Clinical Team eeds for Team-Based Panel Management 22 Allow user to group patients by a specific clinical condition. The system should have multidimensional report capability, allowing the user to specify time pe1iod, patient group , and selected clinical data at a patient level. Provide summary Data on key clinical va,iables (e.g. lab tests , prescriptions) that are used as markers of quality of care for a group of patients. Reports need to be able to summa1ize numerator and denominator information for the patient group of interest. Need resources to facilitate patient outreach (e.g., personalized patient letters or handouts) The database system should be able to link pertinent information at a patient level, and provide an "ondemand " synopsis per individual patient. The database system should be able to access clinical data in a longitudinal fashion at the patient level. Ability to easily track care across time. AMEOlr'/\N © 2017 All rightsreserved . pVE - SIGHT GrantThornton VA-18-0298 and VA-18-0299-H-000156 156 of 6274 Page 168 of 1093 I EHR assessment FINAL 060117 .pdf for Printed Item : 6 ( Attachment 1 of 5) Reportonthe StrategicOptionsfor the Modernization of the Department of VeteransAffairsElectronicHealthRecord Clinical Needs ReleHrnl ifechnical Capability Facilitate collaboration among interdisciplinary providers. The system must have a user interface that supports the needs of interdisciplinary clinical team members. Provide timely data. Data extraction from the electronic health record should be timely (preferably on a daily basis). interface must have dual-way information flow between panel management tool and electronic medical record. eed to be able to enter clinic-specific orders and requests. 9.1.4 Analytics and Research KeyMessages:The desire for improved analytics and easier methods of accessing data for both clinical improvements and research were recuning themes expressed by clinicians and informaticists. • Though many providers emphasized that the volume of data available for Veterans is impressive, • extracting thisdatausefull y can be difficult andslow. Clinicians described difficulty withobtainin g accessto databa sesand data warehouses and even once they do, they are not userfriendly. Databases that users create often do not work outside a specific facility. • Physicians no te that they are expected to monitor their productivity but cannot view real-time metiics. Relatedly, users explained that it takes significant amounts of time to run reports that are needed quickly, which greatly hinders prospective research . 9.1.5 Mental Health KeyM essages: Mental health is an area of distinct importance to VA; there is a long history of programs and interventions to support Veterans, who at higher risk for mental health conditions in general, and others specifically such as post -traumatic stress disorder (PTSD) and suicide. Talking with providers allowed better understanding of some of the technology related challenges experienced by practitioners in this division. Veterans receive care from many providers and coordinationof careis difficultto manage across multiple sites. This is especially critical at times of transition such as when Veterans are leaving active duty and are particularly vulnerable. Clinicians felt that there need to be better methods for stratifying risk levels of patients and tracking their care within an EHR. Providers would also like the abilityto easily code more detailed information(e.g. the particular type of therapy provided or assessment completed. Documentation is highly nan-ative, and providers suggested that more standardiz ed ways of documenting health infomwtionwou ld be helpful. From the Veteran perspective, providers recommended incorporatin g Veteran inputandgoals, interventions and a care plan and allowing these to be integrated with the E HR. Cun-ently, there are numerous self-assessment tools for Veterans but they do not connect with the EHR. • • • • 9.1.6 Interoperability KeyM essages: Many providers expressed numerous difficulties with sharing patient informa tion outside the VA. • Providers note that the majority of the time, if a patient is seen in the community, when their records are obtained they are largely in paper format and scanned into the EHR. They are linked as images/PDFs and not integrated with the V eteran's clinicalinformati on in CPRS , so they cannot be linked with clinical decision support too ls or reminders. AMEOlr'/\N © 2017 All rightsreserved . pVE · SIGHT GrantThornton VA-18-0298 and VA-18-0299-H-000157 157 of 6274 Page 169 of 1093 I EHR assessment FINAL 060117.pdf for Printed Item: 6 ( Attachment 1 of 5) Reportonthe StrategicOptionsfor the Modernization of the Department of VeteransAffairsElectronicHealthRecord • • Providers note that if Walgreens and CVS can add immunization data into CPRS, it would be beneficial if other community providers could as well. Clinicians want toolsthat connectwitheachotherbetter, such as kiosks or tablets into which Veterans can enter information and communicate with the EHR. 9.2 Validation of Findings with VHA Executive Leaders Grant Thornton attended a VHA leadership dinner that included discussions surro unding the EHR Strategic Assessment. Along with seeking insights and feedback, a survey was administered to VHA leadership to compile stakeholder feedback and clinical priorities that were both discovered and considered throughout the stakeholder interviews and assessment period. In the first part of the survey, participant s were asked to identify which stakeholder feedback criteria resonated with them. Stakeholder feedback was narrowed down to the following categories; culture, communications, mental health , analytics and measurement , usability/tailorability , community care interviews, and package level discussion. The captured results are in Figure B-2 below . Figure B-2. VHA Leadership Comments Ther e is a cultural legacy of partnership between clinicians and developers. Clinicians appreciate the ability to customize locally, working with developers to implement modifications to their instances of VistA. Several clinicians expressed satisfact ion with this capab ility, and fear losing it with an enterprise COTS system. 55% Many clinicians will accept a change and are ready for a decision to be made. They are, however, reticent about the organization 's ability to make a decision and successfully imp lement it. 20 61% Some concern of an exodus from VA for retirement eligible clinicians as they do not want to go through a difficult transition at this stage in their career. 8 24% Team-BasedCare: Communication between services is difficult no w, so they have work arounds where they enter notes into the record and ask for a cosignature so another provider sees it and can respond. Need secure communications tools so the care team can interact without using the patient 's record to do so . 16 48% With com1111111ir y provide rs: Care coordination and communication goes beyond just the care team. Communication with the patient, community providers, and others is important. Need a system that is easier to use for all parties. Jn the interview with Karen Hudgins, she noted that they are now up with encrypted email with community providers. 21 64% With the Veteran: Current capabilities with MyHealtheVet are clunky and hard to use. Th e Epic solut ion was brought up as a very good tool, used throughout the industry. VA shou ld look to that type of solution to communicate with Veterans. Focus on mobile , getting ready for the younger generatio ns. 14 42% AMEOlr'/\N © 2017All rightsreserved. pVE - SIGHT GrantThornton VA-18-0298 and VA-18-0299-H-000158 158 of 6274 Page 170 of 1093 I EHR assessment FINAL 060117.pdf for Printed Item: 6 ( Attachment 1 of 5) Reportonthe StrategicOptionsfor the Modernization of the Department of VeteransAffairsElectronicHealthRecord :E :E ... C'::I .9 ·; E--"C = C'::I .Q :3 .c C'::I t lll"J'PO'I 1::1,C :IIC!Otn~~ ar. ccd. rdm1 ., old-..- mlO , fiHll C.pabililieoRrq,ii~d Ani6cul1, ,~n"~ ..... pmu ' l'I.CCllalll I gca.om,c, ~.. -'"!I"'-"~ \"J:;(: ;«>'>dnmOIK80% of VA's needs • Est imate 18-24 months to IOC Pilot Site post acquisitio n Interoperability with other health systems Flexibility Modernity • All top tier COTS vendors meet multiple interop erability stan dards (e.g., FHIR)to create longitudinal record • Out-of-the-box functio nalities fulfilling >80% of V A's needs • Add itional time to redesign and scale eHMP to COTS so lution • Esti mate 18-24 months to IOC - Pilot Site po st acqu isition • Same as Opt ion I: COTS. Also, JL V provides a static view of external records , but do es not create the longitudinal record • Same as Opt ion I for COTS • In dustry leading sof tware that regularly upgrades based on best practices and industry innovation • Same as Opt ion I for CO TS • COTS out -of -the box capabilities allow sof tware config uration to meet end -user practice preference (e.g., physician note templates) AMERICAN PVERSIGHT Option 3: Commcrcrn · 11zc • d \ ' "1stA • Requires mod ern izing a single instance of VistA software prior to impleme nting, which will add at minimum an additiona l 12 month s I · Opium 4: COTS SaaS • Out-of-the-box functionalities fulfilling >80% ofVA's need s • Est imate 18-24 months to IO C - Pilot Site post acquisition • Estimate 24-36 months to IOC - Pilot Site post acquisition • In terope rability capability would have to be built into the commercia lized VistA solution • All top tier COTS vendors meet multiple interoperability standards (e.g., FHIR ) to create longitudina l record • Vendor admi nistered cloud decreases VA flexibility to access 3r d party vendor s (e.g., best in class population health) because vend ors may have pre-existing agreements. • Vendor adminis tered cloud decreases VA flexibility to access 3rd party vendor s (e.g., best in class populat ion health ) because vendors may have pre-existing agreements. • Vendor 's com mitment to conti nuous upgrade conti ngent on ability to sell the solution at other clients and make a profit • Same as Option I: COTS • eHMP to provide longitud inal reco rd • VA administered cloud increases VA flexibility to access 3rd party vendo rs (e.g., best in class pop ulation health) • Fully integrated so lution with modern team based co mmun ications Tailorability Option 2: COTS + c H 'IP ,, • eHMP for new capabilities over time, dependent on developmen t time, which may exceed market timeliness • eHMP functiona lity would need to be deconflicted of overlapping capability and then integrated with the COTS product. • VA may have to invest or enter into risk sharing arrangement s if the vendor is not able to sell the solution to a critical mass to break even • Same as Opt ion I: COTS • Highest level of tailorability • eHMP adds capab ility to tailor because it is a VA develope d and managed product • May requ ire additional cost to purchase leading business and clin ical workflows from 3rd party entities © 2017All rightsreserved. 2 184 of 6274 • Same as Option I: COTS, except code level change (customization) may not be pos sible because softwa re may be shared by othe r clients of the COTS vendor (e.g., DoD ) GrantThornton VA-18-0298 and VA-18-0299-H-000184 Page 215 of 1093 I EHR assessment FINAL 060117 .pdf for Printed Item: 12 ( Attachment 1 of 4) ReportontheStrategic Optionsfor theModernization of the Department of VeteransAffairsElectronicHealthRecord . . F" D ec1smn ac t or I Option H'IP 2: COTS + l>ptum . I : C80% of VA's needs • Est imate 18-24 mon ths to IOC - AMERICAN PVERSIGHT Option II'IP 2: COTS + e ,, • Out-of -the-box functionalities fulfilling >80% of V A's needs • Add itional time to redesign and scale eHMP to COTS so lution Option Commercia . 11ze . 3:d , ,.1sIA • Requir es mod ern izing a single instance of VistA software pr ior to implementin g, which will add at minimum an additiona l 12 month s © 2017All rightsreserved. 20 202 of 6274 I . 4: C() "l'S, Saa,S O phon • Out -of -the-box functionalities fulfilling >80% of VA's needs • Est imate I 8-24 months to IOC - Pilot Site post acquisition GrantThornton VA-18-0298 and VA-18-0299-H-000202 Page 233 of 1093 I EHR assess ment F INAL O6O117.pdf fo r Printed Item: 12 ( Attach ment 1 of 4) ReportontheStrategic Optionsfor theModernization of the Department of VeteransAffairsElectronicHealthRecord . . F" D ec1smn actor I l>ptum . I : C > 1 0 ) ) 2 1 ) ) 3 7 ) ) 4 10 ) ) 5 25 ) ) 6 25 ) ) 7 25 ) ) 8 25 ) ) 9 25 ) ) 10 25 > > In order to show the annual maintenance cost for the modem EHR system, we then added five years to our estimate, so the total estimate provided is for 15 years, the first 10 of which is implementation. 4.6 VA Costs VA will also incur internal costs to suppo rt the migration to a new, modern EHR. These include data migration costs, change management, and funding a PMO to act on VA's behalf (the PMO can either be staffed with internal VA resources, or through a contract). To determine the cost of data migration, we analyzed a previous effort where VA was able to complete comprehensive data migration for 66 sites. 14 We assumed a similar level of effort per AMERICAN PVERSIGHT © 2017 All rightsreserved. 25 207 of 6274 GrantThornton VA-18-0298 and VA-18-0299-H-000207 Page 238 of 1093 I EHR assessment FINAL O6O117.pdf for Printed Item : 12 ( Attachment 1 of 4) ReportontheStrategic Optionsfor theModernization of the Department of VeteransAffairsElectronicHealthRecord facility would be required to migrate the full 130 instances of VistA. We aligned the timeline for data migration with the implementation timeline from above to dete1mine the total number of sites VA must migrate each year and the total cost of migration. To cost the change management portion, we leveraged our technical knowledge against a body of industry experience , as well as change management costs illustrated in the eHMP 2.0 rollout program. Change management costs are approximately 25 percent of a total projects aggregate cost, therefore a factor of 25 percent was applied to the overall project cost to calculate the change management cost. PMO costs were determined by leveraging Grant Thornton 's industry experience as well as analysis of pertinent Office of Management and Budget (0MB) Form 300s and select research into other large scale ERP , EHR and information technology implementation projects to determine an appropriate benchmark. Our analysis indicates PMO costs are generally between 15-20 percent of the overall project costs. We assumed the high-end due to the inherent complexity of the scale of VA and a factor of 20 percent was applied to calculate to the PMO cost. 4. 7 Complexity Factor Finally, due to the early stage of decision-making at VA, many factors that impact overall cost are not well understood. These factors include: • • • Specific business and clinical requirements, which may identify additional software or integration needs, which may increase overall cost. A readiness assessment, which we recommend below, may identify additional internal costs such as infrastructure improvements or increased change management costs. Additional development needs in eHMP or VistA modernization. We therefore added a 20 percent complexity factor for Option2: COTS+ eHMPand Option3: CommercializedVistA and a 15% complexity factor for Option1: COTS and Option4: COTS SaaS to account for unknown costs that are likely to arise over the planning period. Figure 11 provides the detailed breakdown of costs, per our analysis.15 Appendix D provides full detail of the steps associated with developing each cost center , and the calculations performed. Figure 11. IS-year Costs Associated with Four Options Software Vendor Team & Support IT Infra structure HW & SW Systems Integration Application Support End user devices User training at Go-Live AMERICAN PVERSIGHT Vendor Costs $ l,l 79,240,741 $1,179,240,741 $1,726,745,370 $1,726,745,370 252,694,444 $252,694,444 126,347,222 $ l26,347,222 463,273,148 $463,273,148 $84,231,481 $84,231,481 $336,925,926 $336,925,926 © 2017 All rightsreserved. 26 208 of 6274 $194,372,093 $284,616,279 41,651,163 20,825,581 76,360,465 13,883,721 $55,534,884 - $931,600,185 $ I ,364,128,843 $199,628,61l $99,814,306 $365,985,787 $66,542,870 $266,171,481 GrantThornton VA-18-0298 and VA-18-0299-H-000208 Page 239 of 1093 I EHR assessment FINAL 060117 .pdf for Printed Item: 12 ( Attachment 1 of 4) ReportontheStrategic Optionsfor theModernization of the Department of VeteransAffairsElectronicHealthRecord Oth er Project Cost eHMP (Option 2: COTS + eHMP only) VistA Modernization (Option 3: Commercializ ed VistA only) Software Implementation Cost Post-Go -Live Software Cost Vendor Total t I $42,115,741 $0 $42,115,741 $525,000,000 $6,941,860 $0 $33,271,435 $0 $0 0 $813,340,000 $0 $4,211,574,074 $4,736,574,074 $1,507,526,047 $3,327,143,519 $1,332,060,606 $1,332,060,606 $1,170,000,000 $2,664,121,212 $5,543,634,680 $6,068,634,680 $2,677,526,047 $5,991,264,731 $1,109,047,840 $505,382,301 $1,707,933,673 $2,328,407,136 $0 Services Cost Change Management Cost Data Migration Cost Prime Integrator VAPMO Cost Cloud Hosting Services Subtotal Contingency Sub-Total Complexity Factor Grand Total 5.0 $1,052,893,519 505,382,30 I $2,I 61,941,358 $2,315,962,964 $ I 84,673,700 $1,527,858,025 $505,382,30I $2,161,941,358 $2,565,954,091 $184,673,700 $1,109,047,840 $505,382,30 I $1,707,933,673 $2,328,407,136 $0 $6,220,853,842 $6,945,809,474 $5,650,770,949 5,650,770,949 $2,352,897,704 $2,602,888,83I $1,665,659,399 $2,328,407,136 $14,117,386,226 $15,617,332,985 $9,993,956,395 $13,970,442,816 $2,117,607,934 $3,123,466,597 $1,998,791,279 $2,095,566,422 $16,234,994,160 $18,740,799,583 $11,992,747,674 $16,066,009,238 Summary of Findings Grant Thornton utilized our technology adoption approach to assess various options for VA's modernized EHR. The assessment identified the clinical and IT priorities , benefits , risks and costs of each of four options for EHR modernization presented by VA. Our assessment found significant overlap in capability with respect to clinical p1iorities, and for the most part, alignment with VA's IT priorities. Options differentiate to a greater extent when assessed against the real and potential benefit s and risks. These provide a framework against which VA leaders may weigh the options against one another, and infonned the decision-crite1ia discussed in the Executive Summary. While Grant Thornton was not asked to provide a specific recommended option, our analysis provide s objective information upon which a decision may be based. Figure 12 provides a summary of each option 's alignment with VA's clinical and technology prioritie s, as well as the relative benefit s and risks associated. Figure 12. Alignment with Clinical Priorities & IT Strategic Direction Clinical p1iorities + IT strategic direction AMERICAN PVERSIGHT © 2017All rightsreserved . 27 209 of 6274 GrantThornton VA-18-0298 and VA-18-0299-H-000209 Page 240 of 1093 I EHR assessment FINAL 060117 .pdf for Printed Item: 12 ( Attachment 1 of 4) ReportontheStrategic Optionsfor theModernization of the Department of VeteransAffairsElectronicHealthRecord Benefits Risk HIGH HIGH HIGH* HIGH * MEDIUM HIGH HIGH MEDIUM • C'-JUJlfil "k *Rating assumes VA inserts appropriate language into the contract to guarantee access to and control of data as well as ability to connect third-party software at will. In addition, Figure 13 provides the high-level cost break.down of each option. Figure 13. Costs of Four Options Vendor CosL~ Software Imp lementation Cost $4,211,574,074 $4,736,574,074 $ 1,507,526,047 $3,327,143,519 Maintenance & Support Cost $1,332,060,606 $1,332,060,606 $ 1, 170,000,000 $2,664,121,212 Vendor Total $5,543,634,680 $6,068,634,680 $2,677,526,047 $5,991,264 ,731 Change Management Cost $ 1.052,893,5 I 9 $1,527,858,025 $ 1,109,047,840 $1,109,047,840 $505,382,30I $505,382,301 $505,382,30I $505,382,301 $2, I6 I,941,358 $2,16 1,941,358 Services Cost Data Migration Cost Prime Integrator + $ 1,707,933,673 ~ $1,707.933,673 + $2,315,962,964 $2,565,954,091 $ I84,673,700 $ I 84,673,700 Services Subtotal $6,220, 853,842 $6,945,809,474 $5,650,770,949 $5,650,770 ,949 Conti ngency $2,352,897,704 $2,602,888,831 $ 1,665,659,399 $2,328,407,136 Subtotal $14,117386,226 $15,617,332,985 $9,993,956,395 $13,970,442,816 Complexity Factor $2,117,607,934 $3,123,466,597 $ 1,998,79 I ,279 $2,095,566,422 $11,992,747,674 $16,066,009,238 VA PMO Cost Cloud Ho sting Grand Total 6.0 $16,234,994,160 I $18,740,799,583 $2,328.407,136 $2,328,407,136 Recommendations EHR modernization is a journey. While Grant Thornton makes no recommendation on which specific option VA should pursue, no matter the choice, the following is recommended in order to inform downstream decisions such as vendor selection (should a COTS solution be involved in the modern EHR) , continued development of eHMP and other factors: • Technicalreadinessassessment: Durin g interviews , a number of VA per sonnel expressed confidence that VA had the necessary network infrastructure , bandwidth and other technical capabilities to move to the cloud or adopt enterprise-wide Saas solutions. However , there were others including VA leadership , both nationally and in the field, who expressed reservations regarding the organization having the network capacity and bandwidth to support the EHR in the cloud. We recommend that VA conduct a study to validate these statements. Readiness assessment must also include facilities, data centers and security components. AMERICAN PVERSIGHT © 2017All rightsreserved . 28 210 of 6274 GrantThornton VA-18-0298 and VA-18-0299-H-000210 Page 241 of 1093 I EHR assessment FINAL 060117 .pdf for Printed Item: 12 ( Attachment 1 of 4) ReportontheStrategic Optionsfor theModernization of the Department of VeteransAffairsElectronicHealthRecord • Technicalevaluationof eHMP: Dw-ing the interviews , some of the VA personnel shared their optimism that eHMP could help bridge the gap that currently exists around transparency and interoperabibty both across the different instances of VistA and also between VHA , DoD and the community providers. However , independent assessment s of the technology and Grant Thornton 's analysis of eHMP program documentation raise concerns as to the long-term viability of the product. A complete, independent assessment of eHMP from a technological standpoint is recommended to determine if it is scalable in its current form, and if not , the necessary additional cost to restructure the product so that it is scalable. In addition , it is also recommended that the assessment include eHMP 's ability to integrate with COTS EHR solutions the way it promises to integrate with VistA. • A cquisitionapproa ch:VA has specific and critical needs that impact any solution VA chooses . It is critical that V A's needs are properly documented in the clinical and technical requirements of any procurement. This needs to be supported by robust business and technical architectures (capability maps , process models) , systems quality factors , service level agreements and enterprise design. In addition, contractual requirements must also address any needs VA has, such as ownership of and access to data. These contractual requirements should be assessed and included as requirements in the solicitation. Cost models are validated and Independent Government Cost Estimates (IGCE ) are established. This must include garnering best practices and lessons learned from the DoD Genesis acquisition. It may also include proof of concepts , controlled pilots and phased rollouts. • Systems engineerin g andprogram.managementplan:This should include strategy for requirements management, interface analysis, usability and human factors , architecture analysis and documentation , end-to-end testing, continuous risk management , development of performance metrics and an integrated master plan/schedule (IMP/lMS). • System(application)and hardwareinventor y: OI&T should conduct a detailed assessment and inventory or each clinical location to ensure all software is catalogued to understand interface requirements . Additionally a detailed desktop , printer and ancillary hardware inventory needs to be conducted as all of these devices will need to be evaluated against any of the strategic options for future usability. The studies and actions we recommend above will have an impact on the total cost to implement a solution. The readiness assessment may uncover additional necessary investment to improve the performance and bandwidth of the network infrastructure. The systems engineering and program management plan may also increase cost as additional requirements are identified the PMO or vendor must address. The results of these studies may also impact our findings from a benefits and risks standpoint, as significant change in network or organizational improvements to support the transition may introduce risks not assessed. However, these actions are critical to support the successful implementation of any solution. 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JM/R Res Protoc. 2016;5(2):e53. doi: 10.2196/resprot.4995. Dilsizian SE, Siegel EL. Artificial Intelligence in Medicine and Cardiac Imaging : Harnessing Big Data and Advanced Computing to Provide Personalized Medical Diagnosis and Treatment. Curr CardiolRep. 2014;16. doi:10.1007/sl 1886-013-0441-8. Sweet LE , Moulaison HL. BIG DA TA AND HEALTHCARE ELECTRONIC HEAL TH RECORDS DATA AND META.DATA : 2013;1(4):245-251. doi:10.1089/big.2013.0023. Du Vall S. What is VINCI? https ://www. hsrd.research.va.g:ov/for researchers/cyber seminars/archives/1143note s.pdf. Accessed January 1, 2017. VA Informatics and Computing Infrastructure. https :/ /www.hsrd.re search.va.g:ov/for researchers/vinci/. Accessed January 1, 2017. Garvin JH, Kalsy M, Brandt C, et al. An Evolving Ecosystem for Natural Language Proces sing in Department of Veterans Affairs. J Med Syst. 2017. doi:10.1007/sl0916-0160681-4. Monegain B. IBM's Watson to work with VA on Vice President Biden's Cancer Moonshot. Healthcare IT News. ht : www.healthcareitnews.com news ibm's-watson-work-va-vicepresident-bidens-cancer-moonshot. Accessed January 1, 2017. Shulkin D. VA Enlists Watson to Help Doctor s Scale Precision Cancer Treatment. https :/ /www .ibm.com/blog:s/think/2016/06/va-enlists-watson/. Accessed April 4, 2017. Shaffer, Vi; Craft L. Hype Cyclefor Healthcar e Providers,2016.; 2016. Veterans Health Administration. Departmentof VeteransAffairs Blueprintfor Excellence,September 2014.; 2014. http ://www.va.gov/ HEALTH/doc s/V HA Blueprint for Excellence.pdf. Shulkin DJ. Beyond the VA Crisis - Becoming a High-Performance Network. N Engl J Med. 2016;374(11):1003-1005. doi:10.1056/NEJMp1502629. Green, Jeff, Feltham, Tom; EHR SoftwarePricingGuide; 2015; EHR in Practice; htt s: www.healthit. ov roviders- rofessionals fa s how-much- oin -cost-me . Accessed April 4, 2017. AMERICAN PVERSIGHT © 2017All rightsreserved. 32 214 of 6274 GrantThornton VA-18-0298 and VA-18-0299-H-000214 Page 245 of 1093 I EHR assessment F INAL O6O117.pdf for Printed Item: 12 ( Attachment 1 of 4) ReportontheStrategic Optionsfor theModernization of the Department of VeteransAffairsElectronicHealthRecord 8.0 Append ix A : Macro Assumptions In assessing the options , Grant Thornton made the following assumptions: • • • • • • • • Grant Thornton used the Health Information Management Systems Society (HIMSS) definition of an EHR, which states: "The E lectronic Health Record (EHR) is a longitudinal electronic record of pati ent health information generated by one or more enco unt ers in any care delivery setting. Included in this information are patient demographics , progress notes , problems , medications, vital signs, past medical history, immunizations, laboratory data and radiology reports. The EHR automates and streamlines the clinician's workflow. The EHR has the ability to generate a complete record of a clinical patient encounter - as well as supporting other care-re lated activities directly or indirectly via interface - including evidence -based decision support, quality management, and outcomes reporting." VA will implement the EHR as a component of the overall VA Digita l Platform (VDP), as described in the strategy document published in 2016 "VA Digital Platform Strategy for Next Generation of Care at the VHA." The VDP establishes a platform on which the EHR operates with other management information systems, such as human resources, financial management and customer relationship management, as well as externa l E H Rs used in the healthcare community, to include DoD. In addition, through the VDP, VA will be able to adopt other tools available in the market to augment core EHR capabilities. This assessment focused on the EHR components of VistA only (core clinical, clinical ancillary and revenue cycle). This paper does not address the modernization of other component s of VistA such as police and security, financial management , supply chain or others. Appendix E contains a list of current VistA modu les that constitute the EHR. ln assessing implementation costs, the continued carrying costs for maintaining the VistA EHR were deemed to be equal no matter the option selected, ther efore they were not considered during this analysis. VA currently houses backup copies of electronic health records locally at VA Medical Centers (VAMCs) in the event of network disruptions , in addition to hardware for the provision of the new EHR product. There will be minimal, if any, net new hardware costs incurred as part of the transition to a modern EHR. This assessment is based upon strategic needs of the organization , from both a clinical and technological perspective. Detailed business and clinical requirements are not yet defined. The cost assessment therefore uses an analogous methodology and provides a Rough Order of Magnitude (ROM) cost estimate . Additionally, based upon our analysis, the DoD and Kaiser Permanente EHR adoptions are analogous projects. Industry benchmarks related to the adop tion of new EHRs are relevant to this assessment. Benchmarks include the relative percentage of costs attributed to software, hardware , change management and other factors, as well as the proportional cost of Saas models versus traditional deployment. Thre e of the four options include the adoption of a COTS EHR solution. Although all clinical and IT priorities can be satisfied by COTS software, a single COTS vendor may not address all equally. Therefore , VA may choose to adopt a vendor for a majority of the E HR components and then add, through the VDP, best-in-class capabilities available through other vendors in order to fully meet its clinical and IT priorities. AME~lr'J\N © 2017All rightsreserved. pVE - SIGHT GrantThornton VA-18-0298 and VA-18-0299-H-000215 215 of 6274 Page 246 of 1093 I EHR assessment F INAL O6O117.pdf for Printed Item: 12 ( Attachment 1 of 4) ReportontheStrategic Optionsfor theModernization of the Department of VeteransAffairsElectronicHealthRecord 9.0 Appendix B: Stakeholder Interview Findings 9.1 Clinical Stakeholder Findings In order to understand the expe1ience of clinicians using CPRS and VistA for both clinical and research work, several qualitative interviews were conducted with VHA clinicians (both physicians and nurses), including some who had expertise and leadership roles in health informatics and health information technology implementation. The VHA interviews were led by the MITRE collaboration with Grant Thornton. While the majority of clinicians expressed that they are able to collaborate well with other clinicians in order to provide excellent care to Veterans, numerou s themes were compiled after these discussions regarding ways in which an EHR solution improve Veteran and clinician experience. Based on multiple EHR vendor interviews conducted by Grant Thornton, it was felt that all four strategic options could support the need s and requirements of VHA clinicians and leadership. This section highlights essential themes that clinicians expressed with regard to selection and implementation of a modern EHR. 9.1.1 Leadership KeyMessages: Clinicians articulated a feeling that there is a lack of central governance and that the problem s are greater than just EHR choice. Many felt that: The changemanagement aspect of an EHR transition is significant and the VA needs to be committed to understanding workflows in order to improve the experience for Veterans and clinicians clinicians andIT hasbeenlostovertimewith respect to Some provid ers feel significant trustbetween partnership in VistA and CPRS development. Part of this is related to the fact that EHR improvements are hampered by budget and approva l processes, and additionally, disconnect exists betwe en VA facilities and IT with respect to business plannin g. with IT to Regardless of past issues, a number of the clinicians expressed a need for sharedpa11nership deliver quality Veteran -centric care processis toolongand bureaucratic and needs attention because Clinicians also feel that the contracting by the time tools are eventually developed, they are obsolete. • • • • 9.1.2 Clinical Workflow KeyMessages: Providers desire modern EHR capabilities that are intuitive, efficient and allow the clinician to spend more time delivering direct care to the patient. The following are key themes shared during the interviews: • • • • There is lackof single-sign on, which makes it frustrating to go back and forth between different applications There is no ability for physicians to easily see their sched ules and those of trainees they are supervising. This makes it difficulttoplan theirday becau se for example, they cannot see if a patient has cance led and then adjust. wayfor patientinformation to be presented on Multiple clinicians mentioned that they need an integrated withclinicaldecision supporttoolsand makes documentation streamlined and an EHR screen that interfaces accurate De spite the recognition that alerts and reminders are important part s of patient safety, there are often toomanyscreens andclicksthatclinicians mustencounter. One nurse not ed that the computer adm ission AME 01 r'I\N © 2017All rightsreserved. pVE · SIGHT GrantThornton VA-18-0298 and VA-18-0299-H-000216 216 of 6274 Page 24 7 of 1093 I EHR assess ment FINAL 060117.pdf fo r Printed Item: 12 ( Attach ment 1 of 4) ReportontheStrategic Optionsfor theModernization of the Department of VeteransAffairsElectronicHealthRecord protocol takes up to two hours for an intensive care unit patient , and 45 minu tes for a floo r patient , significant time sinks for a nurse who has multiple patients and time-sensitive responsibilities In addition to the above, there were more focused comments shared such as: • Because of the decentralize d nature of IT, facilities have taken to implement local solutions (both designed interna lly by local VA IT personnel and COTS products). One provider provided an example that while the COTS solution for their emergency dep artment (ED) worked very well and allowed them to easily see recent Vetera n ED visits and reasons, this system did not interface with CPRS. As such , if a patient was adm itted to th e hospital , an admitting physician could not easily see the ED recor d (information is saved in cumbersome PDFs). There Mixed feedback was shared regard ing CPRS usability, with some providers expressing that they felt CPRS was very easy to use and intuitive (multiple providers noted that it worked very well for pharmacy) while others felt that COTS solution s were much more user-frie ndly and capable. • 9.1.3 Team-Based Care/PACT KeyMessages: As discussed previously, VA has a stron g commitment to providin g effective teambased care for Veterans through the PACT initiative. Each PACT "teamlet" is comprised of a Veteran, a primary care provid er (physician, physician assistant, or nurse practitioner), a registered nurse who functions as a care manager for the team, a licensed practical nurse or medical assistant, and a clerical assistant. 19- 21VA research has already shown that improved relationships with Veterans and speed of care received were noted po sitives of PACT. 19·20De spite all of this, CPRS does not support PACT well. VA clinicians have created work-arounds to address these deficiencies, but one group of VA provider s detailed several EHR features that would be beneficial in order to support team-ba sed care (Figure B-1). • • Providers are not able to directly communicate throu gh the EHR outside of patient records. A workaround that many use tod ay is addin g additio nal signers to patient no tes, which creates an alert to another pro vider to sign th at note, but does not allow for a direct specific message to that provider which is in the EHR but not in a patient no te. There is no good way to manage panels of patients or cohorts based on clinical con dition because of limitations in VistA's architec ture. Figure 8-1. Clinical Team eed s for Team-Based Panel Management 22 Allow user to group patients by a specific clinical cond ition. The system should have multidimensional report capability, allowing the user to specify time pe1iod, patient group, and selected clinical data at a patient level. Provide summary Data on key clinical va,iab les (e.g. lab tests, prescriptions) that are used as markers of quality of care for a group of patients. Reports need to be able to summa1ize num erator and denominator information for the patient group of interest. Need resources to facilitate patient outreach (e.g., personalized patient letters or handouts) Th e database system shou ld be able to link pertinent information at a patient level, and provide an "ondemand " synopsis per individual patient. The database system should be able to access clinical data in a longitudinal fashion at the patient level. Ability to easily track care across time. AMEOlr'/\N © 2017All rightsreserved . pVE - SIGHT GrantThornton VA-18-0298 and VA-18-0299-H-000217 217 of 6274 Page 248 of 1093 I EHR assessment F INAL O6O117.pdf for Printed Item : 12 ( Attachment 1 of 4) ReportontheStrategic Optionsfor theModernization of the Department of VeteransAffairsElectronicHealthRecord Clinical Needs ReleHrnl ifechnical Capability Facilitate collaboration among interdisciplinary providers. The system must have a user interface that supports the needs of interdisciplinary clinical team members. Provide timely data. Data extraction from the electronic health record should be timely (preferably on a daily basis). interface must have dual-way information flow between panel management tool and electronic medical record. eed to be able to enter clinic-specific orders and requests. 9.1.4 Analytics and Research KeyMessages:The desire for improved analytics and easier methods of accessing data for both clinical improvements and research were recuning themes expressed by clinicians and informaticists. • Though many providers emphasized that the volume of data available for Veterans is impressive, • extracting thisdatausefull y can be difficult andslow. Clinicians described difficulty withobtainin g accessto databa sesand data warehouses and even once they do, they are not userfriendly. Databases that users create often do not work outside a specific facility. • Physicians no te that they are expected to monitor their productivity but cannot view real-time metiics. Relatedly, users explained that it takes significant amounts of time to run reports that are needed quickly, which greatly hinders prospective research . 9.1.5 Mental Health KeyM essages: Mental health is an area of distinct importance to VA; there is a long history of programs and interventions to support Veterans, who at higher risk for mental health conditions in general, and others specifically such as post -traumatic stress disorder (PTSD) and suicide. Talking with providers allowed better understanding of some of the technology related challenges experienced by practitioners in this division. Veterans receive care from many providers and coordinationof careis difficultto manage across multiple sites. This is especially critical at times of transition such as when Veterans are leaving active duty and are particularly vulnerable. Clinicians felt that there need to be better methods for stratifying risk levels of patients and tracking their care within an EHR. Providers would also like the abilityto easily code more detailed information(e.g. the particular type of therapy provided or assessment completed. Documentation is highly nan-ative, and providers suggested that more standardiz ed ways of documenting health infomwtionwou ld be helpful. From the Veteran perspective, providers recommended incorporatin g Veteran inputandgoals, interventions and a care plan and allowing these to be integrated with the E HR. Cun-ently, there are numerous self-assessment tools for Veterans but they do not connect with the EHR. • • • • 9.1.6 Interoperability KeyM essages: Many providers expressed numerous difficulties with sharing patient informa tion outside the VA. • Providers note that the majority of the time, if a patient is seen in the community, when their records are obtained they are largely in paper format and scanned into the EHR. They are linked as images/PDFs and not integrated with the V eteran's clinicalinformati on in CPRS , so they cannot be linked with clinical decision support too ls or reminders. AMEOlr'/\N © 2017 All rightsreserved. pVE · SIGHT GrantThornton VA-18-0298 and VA-18-0299-H-000218 218 of 6274 Page 249 of 1093 I EHR assessment FINAL O6O117.pdf for Printed Item : 12 ( Attachment 1 of 4) ReportontheStrategic Optionsfor theModernization of the Department of VeteransAffairsElectronicHealthRecord • • Providers note that if Walgreen s and CVS can add immunization data into CPRS, it would be beneficial if other community providers could as well. Clinicians want toolsthat connectwitheachotherbetter, such as kiosks or tablets into which Veterans can enter information and communicate with the EHR. 9.2 Validation of Findings with VHA Executive Leaders Grant Thornton attended a VHA leadership dinner that included discussions surrounding the EHR Strategic Assessment. Along with seeking insights and feedback, a survey was administered to VHA leadership to compile stakeholder feedback and clinical priorities that were both discovered and considered throughout the stakeholder interviews and assessment period. In the first part of the survey, participant s were asked to identify which stakeholder feedback criteria resonated with them. Stakeholder feedback was narrowed down to the following categories; culture, communications, mental health , analytics and measurement , usability/tailorability , community care interviews, and package level discussion. The captured results are in Figure B-2 below . Figure B-2. VHA Leadership Comments Ther e is a cultural legacy of partnership between clinicians and developers. Clinicians appreciate the ability to customize locally, working with developers to implement modifications to their instances of VistA. Several clinicians expressed satisfact ion with this capab ility, and fear losing it with an enterprise COTS system. 55% Many clinicians will accept a change and are ready for a decision to be made. They are, however, reticent about the organization 's ability to make a decision and successfully imp lement it. 20 61% Some concern of an exodus from VA for retirement eligible clinicians as they do not want to go through a difficult transition at this stage in their career. 8 24% Team-BasedCare: Communication between services is difficult no w, so they have work arounds where they enter notes into the record and ask for a cosignature so another provider sees it and can respond. Need secure communications tools so the care team can interact without using the patient 's record to do so . 16 48% With com1111111ir y providers:Care coordination and communication goes beyond just the care team. Communication with the patient, community providers, and others is important. Need a system that is easier to use for all parties. Jn the interview with Karen Hud gins, she noted that they are now up with encrypted email with community providers. 21 64% With the Veteran: Current capabilities with MyHealtheVet are clunky and hard to use. Th e Epic solut ion was brought up as a very good tool, used throughout the industry. VA shou ld look to that type of solution to communicate with Veterans. Focus on mobile , getting ready for the younger generatio ns. 14 42% AMEOlr'/\N © 2017 All rightsreserved. pVE - SIGHT GrantThornton VA-18-0298 and VA-18-0299-H-000219 219 of 6274 Page 250 of 1093 I EHR assess ment FINAL 060117.pdf fo r Printed Item: 12 ( Attach ment 1 of 4) ReportontheStrategic Optionsfor theModernization of the Department of VeteransAffairsElectronicHealthRecord :E :E ... C'::I .9 ·; E--"C = C'::I .Q :3 .c C'::I t lll"J'PO'I 1::1,C :IIC!Otn~~ ar. ccd. rdm1 ., old-..- mlO , fiHll C.pabililieoRrq,ii~d Ani6cul1, ,~n"~ ..... pmu ' l'I.CCllalll I gca.om,c, ~.. -'"!I"'-"~ \"J:;(: ;«>'>dnmOIK Sandoval, Camilo J. To: Ullyot, John Cc: ; Wagner, John (Wolf) Bee: RE: EHR Modernization Subject: Thu Oct 25 2018 13:25:25 EDT Date: Attachments: Cam - Please respond to his email with the following: Thanks, Isaac. I refer you to Curt.Cashour@va.gov for comment. From: Sandoval, Camilo J. Sent: Thursday, October 25, 2018 12:59 PM To: Cashour, Curtis Cc: Ullyot, John ; Wagner, John (Wolf) Subject: FW: EHR Modernization No comment Camilo Sandoval 202-461-6910 From: Isaac Arnsdorf [mailto:lsaac.Arnsdorf@propublica.org] Sent: Thursday, October 25, 2018 12:43 PM To: Sandoval, Camilo J. Subject: [EXTERNAL] Re: EHR Modernization AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000241 241 of 6274 Page 279 of 1093 Hi Cam, just making sure you saw this. Looking forward to hearing from you. Thanks! From: Isaac Arnsdorf on behalf of Isaac Arnsdorf Date: Tuesday, October 23, 2018 at 1 :05 PM To: "Camilo.Sandoval@va.gov" Subject: EHR Modernization Cam, I'm interested in speaking with you for an in-depth article about the EHR modernization. My questions for you are: 1.Why did you transfer from Treasury to VA? 2.How do you know Ike Perlmutter? 3.Why do you have a standing daily call with Ike Perlmutter? 4.Why do you keep a spreadsheet tracking projects for Perlmutter? 5.Why did you tell Perlmutter that he shouldn't trust Shulkin on the Cerner contract because Shulkin was positioning himself for a post-government job? What evidence do you have to support this allegation? 6.Why did you tell people that Shulkin planned to sign the Cerner contract on March 29? 7.How did you know ahead of time that Shulkin would be fired that week? 8.Why did you become executive in charge of 01& T? 9.What experience do you have in health care IT? 10.Why did you, John Windom and Rich Stone meet about ousting Genevieve Morris? 11.Why didn't Genevieve Morris want you to come to the kickoff event? 12.Why do you walk around the office in socks or flip flops? 13.Why have you canceled speaking engagements as executive in charge? 14.Why did you move back into the CIO office from the OEHRM? What have these repeated moves cost taxpayers? Thanks, Isaac Isaac Arnsdorf ProPublica 917.512.0256 203.464.1409 AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000242 242 of 6274 Page 280 of 1093 isaac@propublica .org AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000243 243 of 6274 Page 281 of 1093 Document ID: 0.7.1705.52604 Sandoval, Camilo J. From: To: Cashour, Curtis Ullyot, John Cc: ; Wagner, John (Wolf) Bee: FW: EHR Modernization Subject: Thu Oct 25 2018 12:58:55 EDT Date: Attachments: No comment Camilo Sandoval 202-461-6910 From: Isaac Arnsdorf [mailto:lsaac.Arnsdorf@propublica.org] Sent: Thursday, October 25, 2018 12:43 PM To: Sandoval, Camilo J. Subject: [EXTERNAL] Re: EHR Modernization Hi Cam, just making sure you saw this. Looking forward to hearing from you. Thanks! From: Isaac Arnsdorf on behalf of Isaac Arnsdorf Date: Tuesday, October 23, 2018 at 1:05 PM To: "Camilo.Sandoval@va.gov" Subject: EHR Modernization Cam, AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000244 244 of 6274 Page 282 of 1093 I'm interested in speaking with you for an in-depth article about the EHR modernization. My questions for you are: 1.Why did you transfer from Treasury to VA? 2.How do you know Ike Perlmutter? 3.Why do you have a standing daily call with Ike Perlmutter? 4.Why do you keep a spreadsheet tracking projects for Perlmutter? 5.Why did you tell Perlmutter that he shouldn 't trust Shulkin on the Cerner contract because Shulkin was positioning himself for a post-government job? What evidence do you have to support this allegation? 6.Why did you tell people that Shulkin planned to sign the Cerner contract on March 29? 7.How did you know ahead of time that Shulkin would be fired that week? 8.Why did you become executive in charge of 01& T? 9.What experience do you have in health care IT? 1a.Why did you, John Windom and Rich Stone meet about ousting Genevieve Morris? 11.Why didn't Genevieve Morris want you to come to the kickoff event? 12.Why do you walk around the office in socks or flip flops? 13.Why have you canceled speaking engagements as executive in charge? 14.Why did you move back into the CIO office from the OEHRM? What have these repeated moves cost taxpayers? Thanks, Isaac Isaac Arnsdorf ProPublica 917.512.0256 203.464.1409 isaac@propublica .org AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000245 245 of 6274 Page 283 of 1093 Document ID: 0.7.1705.52602 Sandoval, Camilo J. From: To: Cashour, Curtis ; Connell, Lawrence B. ; Windom, John H. ; Stone, Richard A., MD Cc: Ullyot, John ; Hutton, James ; Eason, William J. ; Snyder, Jill ; Screen, Gina Bee: Subject: Date: Attachments: RE:// for approval// Interview with Secretary Wilkie about EHR implementation Thu Oct 25 2018 12:58:25 EDT I'm good here Camilo Sandoval 202-461-6910 From: Cashour, Curtis Sent Thursday, October 25, 2018 12:56 PM AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000246 246 of 6274 Page 284 of 1093 To: Connell, Lawrence B.; Windom, John H. ; Stone, Richard A., MD ; Sandoval , Camilo J. Cc: Ullyot, John ; Hutton, James ; Eason, William J. ; Snyder, Jill ; Screen, Gina Subject: RE:// for approval// Interview with Secretary Wilkie about EHR implementation Cam? From: Connell, Lawrence B. Sent: Wednesday , October 24, 2018 3:50 PM To : Windom, John H. ; Cashour, Curtis ; Stone, Richard A., MD ; Sandoval, Camilo J. Cc: Ullyot, John ; Hutton, James ; Eason, William J. ; Snyder, Jill ; Screen, Gina Subject: RE: // for approval// Interview with Secretary Wilkie about EHR implementation My only comment would be to change "tall tales" to read "false statements " or "inaccurate statements " My $.02. Larry Connell Chief of Staff Veterans ' Health Administration lawrence .connell@va.gov 202.461 .7016 From: Windom, John H. Sent: Wednesday, October 24, 2018 3:07 PM To : Cashour, Curtis ; Stone, Richard A. , MD ; Sandoval , Camilo J. Cc: Connell, Lawrence B. ; Ullyot, John ; Hutton, James ; Eason, William J. ; Snyder, Jill ; Screen, Gina Subject: RE: // for approval// Interview with Secretary Wilkie about EHR implementation Reads fine to me. Thank you. AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000247 247 of 6274 Page 285 of 1093 Vr John Sent with Good (www.good.com) From: Cashour, Curtis Sent: Wednesday, October 24, 2018 9:26:03 AM To: Stone, Richard A., MD; Sandoval, Camilo J.; Windom, John H. Cc: Connell, Lawrence B.; Ullyot, John; Hutton, James; Eason, William J.; Snyder, Jill; Screen, Gina Subject// for approval// Interview with Secretary Wilkie about EHR implementation Folks - Please see below from ProPublica. The reporter has asked for interviews with SecVA, Cam, and Dr. Stone. In lieu of interviews, we recommend the below. Let us know if you have any issues or edits. Thanks. We welcome the opportunity to discuss any allegations from named current or former employees. But due to Privacy Act restrictions, in order to comment on specific complaints from any current or former employees, we would need their written consent (by having them fill out and return this form) to discuss all aspects of their job performance. Can you provide that consent? If you cannot, please note in your story that those making these allegations refused to allow VA to comment on them. Allegation: The article will be an in-depth look at the dysfunction and turmoil that are undermining the VA's effort to transform its electronic health records. Response: The premise of your article is false. VA's electronic health record modernization (EHRM) efforts thus far have been successful and we are confident they will continue to be successful. While that may not comport with the tall tales you are hearing from disgruntled former employees, all of those people -whether they left by choice or not- no longer work at VA for a reason. VA has made a historic decision to modernize its electronic health record system to provide our nation's Veterans with seamless care as they transition from military service to Veteran status and when they choose to use community care. While past administrations and VA secretaries failed to achieve this longstanding goal, the Trump AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000248 248 of 6274 Page 286 of 1093 administration and Secretary Wilkie succeeded. VA established the Office of Electronic Health Record Modernization (OEHRM) to ensure VA successfully prepares for, deploys and maintains the new EHR solution and the health IT tools dependent upon it. The OEHRM Executive Director is Mr. John Windom, who has been with the effort since its inception and has the necessary expertise and institutional knowledge to lead this initiative effectively. Prior to joining VA , Windom was a program manager for the Program Executive Office of the Defense Healthcare Management Systems (OHMS). He led his team to acquire, test , integrate and deploy a new EHR to replace DoD's legacy system in support of over 9.6 million military service members and other beneficiaries . As Secretary Wilkie has said, "The new EHR system will be interoperable with DOD, while also improving VA's ability to collaborate and share information with community care providers. This will ease the burden on service members as they transition from military careers and will be supported by multiple medical providers throughout their lives. "The EHR will give health care providers a full picture of patient medical history, driving better clinical outcomes. It will also help us identify Veterans proactively who are at higher risk for issues, such as opioid addiction and suicide, so health care providers can intervene earlier and save lives." Curt Cashour Press Secretary Department of Veterans Affairs 202-461-7388 Curt. Cashou r@va.gov @curtcashou r From : Isaac Arnsdorf [mailto:lsaac .Arnsdorf@propublica .org] Sent: Tuesday , October 23, 2018 1:04 PM To : Cashour, Curtis Cc: Snyder, Jill AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000249 249 of 6274 Page 287 of 1093 Subject [EXTERNAL] Re: Interview with Secretary Wilkie about EHR implementation Hi Curt, Nice to hear from you again. I will direct questions to you for Secretary Wilkie, Dr. Stone and John Windom. The article will be an in-depth look at the dysfunction and turmoil that are undermining the VA's effort to transform its electronic health records. As a recent internal progress report said, the program is "Yellow trending towards Red." 1.Discussing his April 20 meeting with Ike Perlmutter, Bruce Moskowitz and Marc Sherman, why did Secretary Wilkie tell senators he "went against their wishes, because I approved it," when they were not opposed to the EHR modernization - in fact, they were the ones who set the process in motion? 2.Why does Secretary Wilkie's joint statement on interoperability discuss "a single, seamlessly integrated electronic health record" that "maximizes commercial health record interoperability" instead of "seamless care," which was the justification for the sole-source contract? 3.What, in the Secretary's view, is the different between a "seamlessly integrated EHR" and "seamless care"? 4.Who in the Office of Electronic Health Records Modernization has the appropriate qualifications or experience to lead this program? 5.Why is OEHRM housed in the secretary's office rather than inside VHA, even though experts advised putting clinicians in charge? 6.Why did Secretary Wilkie tell Dr. Stone to back off the EHR implementation and focus instead on the MISSION Act implementation? 7.Why does the IT steering committee have nobody representing VA doctors? 8.How is the Secretary mitigating infighting between OEHRM, VHA and Ol&T? 9.Why is the VA replicating the DoD's unsuccessful governance structure of a program office run by contracting officers and accountability spread across a health division and an IT division? 10.Why is the Secretary considering having the VA follow DoD's lead on the EHR implementation? 11.Why is the Secretary considering James Ellzy for CMO or CHIO? How can a non-VA person be the champion for VA clinicians? 12.Why should DoD lead the EHR implementation even though VA will be the bigger user and has different needs? 13.Why does Windom want to copy DoD's workflows, over the objection of VA clinicians and industry experts? 14.When the VA asked Cerner to assess the overlap between the two departments' needs, why did Cerner instead assess DoD's adherence to Cerner's commercial baselines? 15.Why did Cerner's cost and schedule estimates assume the VA would match the DoD's implementation? 16.Why would the VA import the DoD's workflows when the DoD's workflows failed at the DoD's IOC sites? 17 .How is the VA learning from the Do D's mistakes? For example, how will routing trouble tickets directly to Cerner solve the problem of overwhelming volume and lack of on-site support? 18.How is the VA addressing Cerner's lack of functionality for some of VA's core specialties such as AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000250 250 of 6274 Page 288 of 1093 Agent Orange exposure, spinal cord injury, PTSD and military sexual trauma? 19.How is the VA addressing Cerner's functionality in other areas, such as optometry and telehealth, that DoD and VA clinicians have identified as inadequate? 20.How is the VA addressing the fact that DoD's cyber security specifications will interfere with some of Cerner's usability functions? Is the VA still planning to match DoD's cyber security specifications? 21.How is the VA addressing Cerner's incomplete data migration plan, which an internal report said raises patient safety issues? 22.Does the VA plan to migrate ALL patient data to the new platform, or only the past three years, like DoD? 23.ln early 2018, why did Don McGahn call Jim Byrne to tell him not to sign off on the Cerner contract? 24.Why didn't Marc Sherman become a Special Government Employee to review the Cerner contract? 25.Why was Genevieve Morris detailed to VA for 30 days? 26.What was her assessment of the Cerner contract? 27.Why did Secretary Wilkie determine the contract was ready to sign in May? 28.Why did Morris stay at VA to take over OEHRM? Was her background working on small-scale ambulatory EHR implementations sufficient for this role? 29.Morris agreed to stay for one year, but the GAO says a change of this size requires a leader to stay for five to seven years. Also, OEHRM's own management plan says "the program must be perceived to be stable." How can the VA achieve this, when the office's leader was only supposed to stay for one year, and ended up staying less than two months? 30.Why were the VA's own health IT experts blocked from working on the EHR implementation? 31.Why did OEHRM want its own staff to lead the clinical councils, even though experts advised putting clinicians in charge? 32.Why did VHA clinicians say they didn't have time to join the councils? How can the program succeed without buy-in from VHA leadership? 33.Why did Dr. Stone, John Windom and Camilo Sandoval meet about unseating Morris? 34.Why did Windom block information from getting to Morris? 35.Why did the VA spend $874,000 on the formal kickoff event? 36.Why did the VA cut the staff in the OEHRM? 37.Why is Windom qualified to lead OEHRM despite lacking health care experience? 38.Why is Windom rejecting clinicians' input, against the advice of industry experts? 39.At the Sept. 13 House subcommittee hearing, Chairman Banks asked Windom, "Is there anyone working in the Office of EHR Modernization who has managed an EHR implementation in a large health system to its completion?" Windom answered yes. Who are these people? 40.Who are the experts that Boaz Allen is providing who have EHR implementation experience? 41.On the Booz Allen contract, what is the breakdown of the work done by junior aides versus senior experts? 42.Does Jim Byrne have the skill set to oversee the OEHRM as acting deputy secretary? 43.Why did Windom and Dr. Stone make a truce to let Dr. Stone run the medical aspects as long as Windom stayed nominally in charge? 44.Why did Camilo Sandoval move back into the CIO's office after moving into the OEHRM? What was the cost to taxpayers of these repeated office moves? 45.Why hasn't the VA accepted the offer of KLAS research on what makes EHR implementations successful? Thanks, Isaac Isaac Arnsdorf ProPublica AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000251 25 1 of 6274 Page 289 of 1093 917.512.0256 203.464.1409 isaac@propublica.org From: "Cashour, Curtis" Date: Monday, October 22, 2018 at 10:30 AM To: Isaac Arnsdorf Subject: RE: Interview with Secretary Wilkie about EHR implementation Hi, Isaac. What are your findings? What questions do you have? Thanks, Curt Cashour Press Secretary Department of Veterans Affairs 202-461-7388 Curt. Cashou r@va.gov @curtcashour From: Isaac Arnsdorf [mailto:lsaac.Arnsdorf@propublica.org] Sent: Monday, October 22, 2018 9:51 AM To: VA Public Affairs ; VA Public Affairs Cc: Cashour, Curtis Subject: [EXTERNAL] Interview with Secretary Wilkie about EHR implementation AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000252 252 of 6274 Page 290 of 1093 Hi, I'm writing to request an interview with Secretary Wilkie about the EHR implementation. I'm preparing an in-depth article based on extensive reporting , and I'm eager to discuss my findings with the Secretary. I hope you will grant this request since the EHR is one of the department's top priorities. Thanks, Isaac Isaac Arnsdorf ProPublica 917.512.0256 203.464.1409 isaac@propublica.org AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000253 253 of 6274 Page 291 of 1093 Document ID: 0.7.1705.52599 Cashour, Curtis From: Connell, Lawrence B. To: ; Windom, John H. ; Stone, Richard A., MD ; Sandoval, Camilo J. Ullyot, John Cc: ; Hutton, James ; Eason, William J. ; Snyder, Jill ; Screen, Gina Bee: Subject: RE:// for approval// Interview with Secretary Wilkie about EHR implementation Date: Thu Oct 25 2018 12:55:40 EDT Attachments: Cam? From: Connell, Lawrence B. Sent: Wednesday, October 24, 2018 3:50 PM To: Windom, John H.; Cashour, Curtis ; Stone, Richard A., MD ; Sandoval, Camilo J. Cc: Ullyot, John ; Hutton , James ; Eason , William J. ; Snyder, Jill ; Screen, Gina Subject: RE:// for approval// Interview with Secretary Wilkie about EHR implementation AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000254 254 of 6274 Page 292 of 1093 My only comment would be to change "tall tales" to read "false statements" or "inaccurate statements" My $.02. Larry Connell Chief of Staff Veterans' Health Administration lawrence.connell@va.gov 202.461.7016 From: Windom, John H. Sent: Wednesday, October 24, 2018 3:07 PM To: Cashour, Curtis ; Stone, Richard A., MD ; Sandoval, Camilo J. Cc: Connell, Lawrence B. ; Ullyot, John ; Hutton, James ; Eason, William J.; Snyder, Jill ; Screen, Gina Subject: RE:// for approval// Interview with Secretary Wilkie about EHR implementation Reads fine to me. Thank you. Vr John Sent with Good (www.good.com) From: Cashour, Curtis Sent: Wednesday, October 24, 2018 9:26:03 AM To: Stone, Richard A., MD; Sandoval, Camilo J.; Windom, John H. Cc: Connell, Lawrence B.; Ullyot, John; Hutton, James; Eason, William J.; Snyder, Jill; Screen, Gina Subject:// for approval// Interview with Secretary Wilkie about EHR implementation Folks - Please see below from ProPublica. The reporter has asked for interviews with SecVA, Cam, and Dr. Stone. In lieu of interviews, we recommend the below. Let us know if you have any issues or edits. Thanks. AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000255 255 of 6274 Page 293 of 1093 We welcome the opportunity to discuss any allegations from named current or former employees. But due to Privacy Act restrictions, in order to comment on specific complaints from any current or former employees, we would need their written consent (by having them fill out and return this form) to discuss all aspects of their job performance. Can you provide that consent? If you cannot, please note in your story that those making these allegations refused to allow VA to comment on them. Allegation: The article will be an in-depth look at the dysfunction and turmoil that are undermining the VA's effort to transform its electronic health records. Response: The premise of your article is false. VA's electronic health record modernization (EHRM) efforts thus far have been successful and we are confident they will continue to be successful. While that may not comport with the tall tales you are hearing from disgruntled former employees, all of those people - whether they left by choice or not - no longer work at VA for a reason. VA has made a historic decision to modernize its electronic health record system to provide our nation's Veterans with seamless care as they transition from military service to Veteran status and when they choose to use community care. While past administrations and VA secretaries failed to achieve this longstanding goal, the Trump administration and Secretary Wilkie succeeded. VA established the Office of Electronic Health Record Modernization (OEHRM) to ensure VA successfully prepares for, deploys and maintains the new EHR solution and the health IT tools dependent upon it. The OEHRM Executive Director is Mr. John Windom, who has been with the effort since its inception and has the necessary expertise and institutional knowledge to lead this initiative effectively. Prior to joining VA, Windom was a program manager for the Program Executive Office of the Defense Healthcare Management Systems (OHMS). He led his team to acquire, test, integrate and deploy a new EHR to replace DoD's legacy system in support of over 9.6 million military service members and other beneficiaries. AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000256 256 of 6274 Page 294 of 1093 As Secretary Wilkie has said, "The new EHR system will be interoperable with DOD, while also improving VA's ability to collaborate and share information with community care providers. This will ease the burden on service members as they transition from military careers and will be supported by multiple medical providers throughout their lives. "The EHR will give health care providers a full picture of patient medical history, driving better clinical outcomes. It will also help us identify Veterans proactively who are at higher risk for issues, such as opioid addiction and suicide, so health care providers can intervene earlier and save lives." Curt Cashour Press Secretary Department of Veterans Affairs 202-461-7388 Curt. Cashou r@va.gov @curtcashour From: Isaac Arnsdorf [mailto:lsaac.Arnsdorf@propublica.org] Sent: Tuesday, October 23, 2018 1:04 PM To: Cashour, Curtis Cc: Snyder, Jill Subject: [EXTERNAL] Re: Interview with Secretary Wilkie about EHR implementation Hi Curt, Nice to hear from you again. I will direct questions to you for Secretary Wilkie, Dr. Stone and John Windom. The article will be an in-depth look at the dysfunction and turmoil that are undermining the VA's effort to transform its electronic health records. As a recent internal progress report said, the program is "Yellow trending towards Red." AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000257 257 of 6274 Page 295 of 1093 1.Discussing his April 20 meeting with Ike Perlmutter, Bruce Moskowitz and Marc Sherman, why did Secretary Wilkie tell senators he "went against their wishes, because I approved it," when they were not opposed to the EHR modernization - in fact, they were the ones who set the process in motion? 2.Why does Secretary Wilkie's joint statement on interoperability discuss "a single, seamlessly integrated electronic health record" that "maximizes commercial health record interoperability " instead of "seamless care," which was the justification for the sole-source contract? 3.What , in the Secretary's view, is the different between a "seamlessly integrated EHR" and "seamless care"? 4.Who in the Office of Electronic Health Records Modernization has the appropriate qualifications or experience to lead this program? 5.Why is OEHRM housed in the secretary's office rather than inside VHA, even though experts advised putting clinicians in charge? 6.Why did Secretary Wilkie tell Dr. Stone to back off the EHR implementation and focus instead on the MISSION Act implementation? 7.Why does the IT steering committee have nobody representing VA doctors? 8.How is the Secretary mitigating infighting between OEHRM, VHA and Ol&T? 9.Why is the VA replicating the DoD's unsuccessful governance structure of a program office run by contracting officers and accountability spread across a health division and an IT division? 10.Why is the Secretary considering having the VA follow DoD 's lead on the EHR implementation? 11.Why is the Secretary considering James Ellzy for CMO or CHIO? How can a non-VA person be the champion for VA clinicians? 12.Why should DoD lead the EHR implementation even though VA will be the bigger user and has different needs? 13.Why does Windom want to copy DoD's workflows , over the objection of VA clinicians and industry experts? 14.When the VA asked Gerner to assess the overlap between the two departments' needs, why did Gerner instead assess DoD's adherence to Cerne r's commercial baselines? 15.Why did Cerner 's cost and schedule estimates assume the VA would match the DoD 's implementation? 16.Why would the VA import the DoD's workflows when the DoD's workflows failed at the DoD's IOC sites? 17 .How is the VA learning from the Do D's mistakes? For example , how will routing trouble tickets directly to Gerner solve the problem of overwhelming volume and lack of on-site support? 18.How is the VA addressing Cerner 's lack of functionality for some of VA 's core specialties such as Agent Orange exposure, spinal cord injury, PTSD and military sexual trauma? 19.How is the VA addressing Cerner 's functionality in other areas , such as optometry and telehealth , that DoD and VA clinicians have identified as inadequate? 20.How is the VA addressing the fact that DoD's cyber security specifications will interfere with some of Cerner 's usability functions? Is the VA still planning to match DoD's cyber security specifications? 21.How is the VA addressing Cerner 's incomplete data migration plan, which an internal report said raises patient safety issues? 22.Does the VA plan to migrate ALL patient data to the new platform, or only the past three years , like DoD? 23.ln early 2018, why did Don McGahn call Jim Byrne to tell him not to sign off on the Gerner contract? 24.Why didn't Marc Sherman become a Special Government Employee to review the Gerner contract? 25.Why was Genevieve Morris detailed to VA for 30 days? 26.What was her assessment of the Gerner contract? 27.Why did Secretary Wilkie determine the contract was ready to sign in May? 28.Why did Morris stay at VA to take over OEHRM? Was her background working on small-scale ambulatory EHR implementations sufficient for this role? 29.Morris agreed to stay for one year , but the GAO says a change of this size requires a leader to stay for five to seven years. Also, OEHRM's own management plan says "the program must be perceived to be stable." How can the VA achieve this , when the office 's leader was only supposed to stay for one year , and ended up staying less than two months? 30.Why were the VA's own health IT experts blocked from working on the EHR implementation? 31.Why did OEHRM want its own staff to lead the clinical councils , even though experts advised putting AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000258 258 of 6274 Page 296 of 1093 clinicians in charge? 32.Why did VHA clinicians say they didn't have time to join the councils? How can the program succeed without buy-in from VHA leadership? 33.Why did Dr. Stone, John Windom and Camilo Sandoval meet about unseating Morris? 34.Why did Windom block information from getting to Morris? 35.Why did the VA spend $874,000 on the formal kickoff event? 36.Why did the VA cut the staff in the OEHRM? 37.Why is Windom qualified to lead OEHRM despite lacking health care experience? 38.Why is Windom rejecting clinicians' input, against the advice of industry experts? 39.At the Sept. 13 House subcommittee hearing, Chairman Banks asked Windom, "Is there anyone working in the Office of EHR Modernization who has managed an EHR implementation in a large health system to its completion?" Windom answered yes. Who are these people? 40.Who are the experts that Booz Allen is providing who have EHR implementation experience? 41.On the Booz Allen contract, what is the breakdown of the work done by junior aides versus senior experts? 42.Does Jim Byrne have the skill set to oversee the OEHRM as acting deputy secretary? 43.Why did Windom and Dr. Stone make a truce to let Dr. Stone run the medical aspects as long as Windom stayed nominally in charge? 44.Why did Camilo Sandoval move back into the CIO's office after moving into the OEHRM? What was the cost to taxpayers of these repeated office moves? 45.Why hasn't the VA accepted the offer of KLAS research on what makes EHR implementations successful? Thanks, Isaac Isaac Arnsdorf ProPublica 917.512.0256 203.464.1409 isaac@propublica.org From: "Cashour, Curtis" Date: Monday, October 22, 2018 at 10:30 AM To: Isaac Arnsdorf Subject: RE: Interview with Secretary Wilkie about EHR implementation Hi, Isaac. AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000259 259 of 6274 Page 297 of 1093 What are your findings? What questions do you have? Thanks, Curt Cashour Press Secretary Department of Veterans Affairs 202-461-7388 Curt. Cashou r@va.gov @curtcashour From: Isaac Arnsdorf [mailto:lsaac.Arnsdorf@propublica.org] Sent: Monday, October 22, 2018 9:51 AM To: VA Public Affairs ; VA Public Affairs Cc: Cashour, Curtis Subject [EXTERNAL] Interview with Secretary Wilkie about EHR implementation Hi, I'm writing to request an interview with Secretary Wilkie about the EHR implementation. I'm preparing an in-depth article based on extensive reporting , and I'm eager to discuss my findings with the Secretary. I hope you will grant this request since the EHR is one of the department's top priorities. Thanks, Isaac Isaac Arnsdorf ProPublica AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000260 260 of 6274 Page 298 of 1093 917.512.0256 203.464.1409 isaac@propublica.org AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000261 26 1 of 6274 Page 299 of 1093 Document ID: 0.7.1705.52594 Isaac Arnsdorf From: < isaac.a rnsdorf@propu b Iica. org> Sandoval, Camilo J. To: Cc: Bee: Subject: Date: Attachments: [EXTERNAL] Re: EHR Modernization Thu Oct 25 2018 12:42:55 EDT Hi Cam, just making sure you saw this. Looking forward to hearing from you. Thanks! From: Isaac Arnsdorf on behalf of Isaac Arnsdorf Date: Tuesday, October 23, 2018 at 1 :05 PM To: "Camilo.Sandoval@va.gov" Subject: EHR Modernization Cam, I'm interested in speaking with you for an in-depth article about the EHR modernization. My questions for you are: 1.Why did you transfer from Treasury to VA? 2.How do you know Ike Perlmutter? 3.Why do you have a standing daily call with Ike Perlmutter? 4.Why do you keep a spreadsheet tracking projects for Perlmutter? 5.Why did you tell Perlmutter that he shouldn't trust Shulkin on the Gerner contract because Shulkin was positioning himself for a post-government job? What evidence do you have to support this allegation? 6.Why did you tell people that Shulkin planned to sign the Gerner contract on March 29? 7.How did you know ahead of time that Shulkin would be fired that week? 8.Why did you become executive in charge of 01& T? 9.What experience do you have in health care IT? 10.Why did you, John Windom and Rich Stone meet about ousting Genevieve Morris? 11.Why didn't Genevieve Morris want you to come to the kickoff event? 12.Why do you walk around the office in socks or flip flops? 13.Why have you canceled speaking engagements as executive in charge? 14.Why did you move back into the CIO office from the OEHRM? What have these repeated moves cost taxpayers? Thanks, AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000262 262 of 6274 Page 300 of 1093 Isaac Isaac Arnsdorf ProPublica 917.512.0256 203.464.1409 isaac@propublica.org AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000263 263 of 6274 Page 301 of 1093 Document ID: 0.7.1705.51384 Connell, Lawrence B. From: To: Windom, John H. ; Cashour, Curtis ; Stone, Richard A., MD ; Sandoval, Camilo J. Cc: Ullyot, John ; Hutton, James ; Eason, William J. ; Snyder, Jill ; Screen, Gina Bee: Subject: Date: Attachments: RE:// for approval// Interview with Secretary Wilkie about EHR implementation Wed Oct 24 2018 15:50:16 EDT My only comment would be to change "tall tales" to read "false statements" or "inaccurate statements" My $.02. Larry Connell Chief of Staff Veterans' Health Administration AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000264 264 of 6274 Page 302 of 1093 lawrence.connell@va.gov 202.461.7016 From: Windom, John H. Sent: Wednesday, October 24, 2018 3:07 PM To : Cashour, Curtis ; Stone, Richard A. , MD ; Sandoval , Camilo J. Cc: Connell, Lawrence B. ; Ullyot , John ; Hutton, James ; Eason, William J.; Snyder, Jill ; Screen, Gina Subject RE:// for approval// Interview with Secretary Wilkie about EHR implementation Reads fine to me. Thank you. Vr John Sent with Good (www.good.com) From: Cashour, Curtis Sent: Wednesday, October 24, 2018 9:26:03 AM To: Stone, Richard A., MD; Sandoval, Camilo J.; Windom, John H. Cc: Connell, Lawrence B.; Ullyot, John; Hutton, James; Eason, William J.; Snyder , Jill; Screen, Gina Subject// for approval// Interview with Secretary Wilkie about EHR implementation Folks - Please see below from ProPublica. The reporter has asked for interviews with SecVA, Cam, and Dr. Stone. In lieu of interviews, we recommend the below. Let us know if you have any issues or edits. Thanks. We welcome the opportunity to discuss any allegations from named current or former employees. But due to Privacy Act restrictions , in order to comment on specific complaints from any current or former employees, we would need their written consent (by having them fill out and return this form) to discuss all aspects of their job performance. Can you provide that consent? If you cannot, please note in your story that those making these allegations refused to allow VA to comment on them. Allegation: The article will be an in-depth look at the dysfunction and turmoil that are undermining the VA's effort to transform its electronic health records. AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000265 265 of 6274 Page 303 of 1093 Response: The premise of your article is false. VA's electronic health record modernization (EHRM) efforts thus far have been successful and we are confident they will continue to be successful. While that may not comport with the tall tales you are hearing from disgruntled former employees , all of those people - whether they left by choice or not - no longer work at VA for a reason. VA has made a historic decision to modernize its electronic health record system to provide our nation 's Veterans with seamless care as they transition from military service to Veteran status and when they choose to use community care. While past administrations and VA secretaries failed to achieve this longstanding goal, the Trump administration and Secretary Wilkie succeeded. VA established the Office of Electronic Health Record Modernization (OEHRM) to ensure VA successfully prepares for, deploys and maintains the new EHR solution and the health IT tools dependent upon it. The OEHRM Executive Director is Mr. John Windom, who has been with the effort since its inception and has the necessary expertise and institutional knowledge to lead this initiative effectively. Prior to joining VA, Windom was a program manager for the Program Executive Office of the Defense Healthcare Management Systems (OHMS). He led his team to acquire, test , integrate and deploy a new EHR to replace DoD's legacy system in support of over 9.6 million military service members and other beneficiaries. As Secretary Wilkie has said, "The new EHR system will be interoperable with DOD, while also improving VA's ability to collaborate and share information with community care providers. This will ease the burden on service members as they transition from military careers and will be supported by multiple medical providers throughout their lives. "The EHR will give health care providers a full picture of patient medical history, driving better clinical outcomes. It will also help us identify Veterans proactively who are at higher risk for issues, such as opioid addiction and suicide, so health care providers can intervene earlier and save lives." AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000266 266 of 6274 Page 304 of 1093 Curt Cashour Press Secretary Department of Veterans Affairs 202-461-7388 Curt. Cashou r@va.gov @curtcashour From: Isaac Arnsdorf [mailto:lsaac.Arnsdorf@propublica.org] Sent: Tuesday , October 23, 2018 1:04 PM To : Cashour, Curtis Cc: Snyder, Jill Subject [EXTERNAL] Re: Interview with Secretary Wilkie about EHR implementation Hi Curt, Nice to hear from you again. I will direct questions to you for Secretary Wilkie, Dr. Stone and John Windom. The article will be an in-depth look at the dysfunction and turmoil that are undermining the VA's effort to transform its electronic health records. As a recent internal progress report said, the program is "Yellow trending towards Red." 1.Discussing his April 20 meeting with Ike Perlmutter, Bruce Moskowitz and Marc Sherman, why did Secretary Wilkie tell senators he "went against their wishes, because I approved it," when they were not opposed to the EHR modernization - in fact, they were the ones who set the process in motion? 2.Why does Secretary Wilkie's joint statement on interoperability discuss "a single, seamlessly integrated electronic health record" that "maximizes commercial health record interoperability" instead of "seamless care," which was the justification for the sole-source contract? 3.What , in the Secretary's view, is the different between a "seamlessly integrated EHR" and "seamless care"? 4.Who in the Office of Electronic Health Records Modernization has the appropriate qualifications or experience to lead this program? 5.Why is OEHRM housed in the secretary's office rather than inside VHA, even though experts advised putting clinicians in charge? 6.Why did Secretary Wilkie tell Dr. Stone to back off the EHR implementation and focus instead on the MISSION Act implementation? 7.Why does the IT steering committee have nobody representing VA doctors? 8.How is the Secretary mitigating infighting between OEHRM, VHA and Ol&T? AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000267 267 of 6274 Page 305 of 1093 9.Why is the VA replicating the DoD's unsuccessful governance structure of a program office run by contracting officers and accountability spread across a health division and an IT division? 10.Why is the Secretary considering having the VA follow DoD 's lead on the EHR implementation? 11.Why is the Secretary considering James Ellzy for GMO or CHIO? How can a non-VA person be the champion for VA clinicians? 12.Why should DoD lead the EHR implementation even though VA will be the bigger user and has different needs? 13.Why does Windom want to copy DoD's workflows , over the objection of VA clinicians and industry experts? 14.When the VA asked Gerner to assess the overlap between the two departments' needs, why did Gerner instead assess DoD's adherence to Cerner's commercial baselines? 15.Why did Cerner's cost and schedule estimates assume the VA would match the DoD's implementation? 16.Why would the VA import the DoD's workflows when the DoD's workflows failed at the DoD 's IOC sites? 17.How is the VA learning from the DoD's mistakes? For example , how will routing trouble tickets directly to Gerner solve the problem of overwhelming volume and lack of on-site support? 18.How is the VA addressing Cerner 's lack of functionality for some of VA's core specialties such as Agent Orange exposure, spinal cord injury , PTSD and military sexual trauma? 19.How is the VA addressing Cerner 's functionality in other areas , such as optometry and telehealth , that DoD and VA clinicians have identified as inadequate? 20.How is the VA addressing the fact that DoD's cyber security specifications will interfere with some of Cerner's usability functions? Is the VA still planning to match DoD's cyber security specifications? 21.How is the VA addressing Cerner 's incomplete data migration plan, which an internal report said raises patient safety issues? 22.Does the VA plan to migrate ALL patient data to the new platform, or only the past three years , like DoD? 23.ln early 2018, why did Don McGahn call Jim Byrne to tell him not to sign off on the Gerner contract? 24.Why didn't Marc Sherman become a Special Government Employee to review the Gerner contract? 25.Why was Genevieve Morris detailed to VA for 30 days? 26.What was her assessment of the Gerner contract? 27.Why did Secretary Wilkie dete rmine the contract was ready to sign in May? 28.Why did Morris stay at VA to take over OEHRM? Was her background working on small-scale ambulatory EHR implementations sufficient for this role? 29.Morris agreed to stay for one year , but the GAO says a change of this size requires a leader to stay for five to seven years. Also, OEHRM 's own management plan says "the program must be perceived to be stable ." How can the VA achieve this, when the office 's leader was only supposed to stay for one year , and ended up staying less than two months? 30.Why were the VA's own health IT experts blocked from working on the EHR implementation? 31.Why did OEHRM want its own staff to lead the clinical councils , even though experts advised putting clinicians in charge? 32.Why did VHA clinicians say they didn 't have time to join the councils? How can the program succeed without buy-in from VHA leadership? 33.Why did Dr. Stone , John Windom and Camilo Sandoval meet about unseating Morris? 34.Why did Windom block information from getting to Morris? 35.Why did the VA spend $874 ,000 on the formal kickoff event? 36.Why did the VA cut the staff in the OEHRM? 37.Why is Windom qualified to lead OEHRM despite lacking health care experience? 38.Why is Windom rejecting clinicians' input, against the advice of industry experts? 39.At the Sept. 13 House subcommittee hearing , Chairman Banks asked Windom, "Is there anyone working in the Office of EHR Modernization who has managed an EHR implementation in a large health system to its completion?" Windom answered yes. Who are these people? 40.Who are the experts that Booz Allen is providing who have EHR implementation experience? 41.On the Booz Allen contract, what is the breakdown of the work done by junior aides versus senior experts? 42 .Does Jim Byrne have the skill set to oversee the OEHRM as acting deputy secretary? AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000268 268 of 6274 Page 306 of 1093 43.Why did Windom and Dr. Stone make a truce to let Dr. Stone run the medical aspects as long as Windom stayed nominally in charge? 44.Why did Camilo Sandoval move back into the CIO's office after moving into the OEHRM? What was the cost to taxpayers of these repeated office moves? 45.Why hasn't the VA accepted the offer of KLAS research on what makes EHR implementations successful? Thanks, Isaac Isaac Arnsdorf ProPublica 917.512.0256 203.464.1409 isaac@propublica.org From: "Cashour, Curtis" Date: Monday, October 22, 2018 at 10:30 AM To: Isaac Arnsdorf Subject RE: Interview with Secretary Wilkie about EHR implementation Hi, Isaac. What are your findings? What questions do you have? Thanks, Curt Cashour AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000269 269 of 6274 Page 307 of 1093 Press Secretary Department of Veterans Affairs 202-461-7388 Curt. Cashou r@va.gov @curtcashour From: Isaac Arnsdorf [mailto:lsaac.Arnsdorf@propublica.org] Sent: Monday, October 22, 2018 9:51 AM To: VA Public Affairs ; VA Public Affairs Cc: Cashour, Curtis Subject: [EXTERNAL] Interview with Secretary Wilkie about EHR implementation Hi, I'm writing to request an interview with Secretary Wilkie about the EHR implementation. I'm preparing an in-depth article based on extensive reporting, and I'm eager to discuss my findings with the Secretary. I hope you will grant this request since the EHR is one of the department's top priorities. Thanks, Isaac Isaac Arnsdorf ProPublica 917.512.0256 203.464.1409 isaac@propublica.org AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000270 270 of 6274 Page 308 of 1093 Document ID: 0.7.1705.51282 Windom, John H. From: Cashour, Curtis To: ; Stone, Richard A., MD ; Sandoval, Camilo J. Connell, Lawrence B. Cc: ; Ullyot, John ; Hutton, James ; Eason, William J. ; Snyder, Jill ; Screen, Gina Bee: Subject: RE:// for approval// Interview with Secretary Wilkie about EHR implementation Date: Wed Oct 24 2018 15:07:08 EDT Attachments: Reads fine to me. Thank you. Vr John Sent with Good (www.good.com) From: Cashour, Curtis Sent: Wednesday, October 24, 2018 9:26:03 AM To: Stone, Richard A., MD; Sandoval, Camilo J.; Windom, John H. AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000271 27 1 of 6274 Page 309 of 1093 Cc: Connell, Lawrence B.; Ullyot, John ; Hutton, James; Eason , William J.; Snyder , Jill; Screen, Gina Subject:// for approval// Interview with Secretary Wilkie about EHR implementation Folks - Please see below from ProPublica. The reporter has asked for interviews with SecVA, Cam, and Dr. Stone . In lieu of interviews, we recommend the below . Let us know if you have any issues or edits. Thanks. We welcome the opportunity to discuss any allegations from named current or former employees. But due to Privacy Act restrictions , in orde r to comment on specific complaints from any current or former employees, we would need their written consent (by having them fill out and return this form) to discuss all aspects of their job performance. Can you provide that consent? If you cannot, please note in your story that those making these allegations refused to allow VA to comment on them. Allegation : The article will be an in-depth look at the dysfunction and turmoil that are unde rmining the VA 's effort to transform its electronic health records . Response: The premise of your article is false . VA 's electronic health record modernization (EHRM) efforts thus far have been successful and we are confident they will continue to be successful. While that may not comport with the tall tales you are hearing from disgruntled former employees , all of those people - whether they left by choice or not - no longer work at VA for a reason. VA has made a historic decision to modernize its electronic health record system to provide our nation 's Veterans with seamless care as they transition from military service to Veteran status and when they choose to use community care. While past administrations and VA secretaries failed to achieve this longstanding goal , the Trump administration and Secretary Wilkie succeeded. VA established the Office of Electronic Health Record Modernization (OEHRM) to ensure VA successfully prepares for, deploys and maintains the new EHR solution and the health IT tools dependent upon it. The OEHRM Executive Director is Mr. John Windom , who has been with the effort since its inception and has the necessary expertise and institutional knowledge to lead this initiative effectively . AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000272 272 of 6274 Page 31 o of 1093 Prior to joining VA, Windom was a program manager for the Program Executive Office of the Defense Healthcare Management Systems (OHMS). He led his team to acquire, test, integrate and deploy a new EHR to replace DoD's legacy system in support of over 9.6 million military service members and other beneficiaries. As Secretary Wilkie has said, "The new EHR system will be interoperable with DOD, while also improving VA's ability to collaborate and share information with community care providers. This will ease the burden on service members as they transition from military careers and will be supported by multiple medical providers throughout their lives. "The EHR will give health care providers a full picture of patient medical history, driving better clinical outcomes. It will also help us identify Veterans proactively who are at higher risk for issues, such as opioid addiction and suicide, so health care providers can intervene earlier and save lives." Curt Cashour Press Secretary Department of Veterans Affairs 202-461-7388 Curt. Cashou r@va.gov @curtcashour From: Isaac Arnsdorf [mailto:lsaac.Arnsdorf@propublica.org] Sent Tuesday, October 23, 2018 1:04 PM To: Cashour, Curtis Cc: Snyder, Jill Subject [EXTERNAL] Re: Interview with Secretary Wilkie about EHR implementation Hi Curt, Nice to hear from you again. AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000273 273 of 6274 Page 311 of 1093 I will direct questions to you for Secretary Wilkie, Dr. Stone and John Windom. The article will be an in-depth look at the dysfunction and turmoil that are undermining the VA's effort to transform its electronic health records. As a recent internal progress report said, the program is "Yellow trending towards Red." 1.Discussing his April 20 meeting with Ike Perlmutter, Bruce Moskowitz and Marc Sherman, why did Secretary Wilkie tell senators he "went against their wishes, because I approved it," when they were not opposed to the EHR modernization - in fact, they were the ones who set the process in motion? 2.Why does Secretary Wilkie's joint statement on interoperability discuss "a single, seamlessly integrated electronic health record" that "maximizes commercial health record interoperability" instead of "seamless care," which was the justification for the sole-source contract? 3.What , in the Secretary 's view, is the different between a "seamlessly integrated EHR" and "seamless care"? 4.Who in the Office of Electronic Health Records Modernization has the appropriate qualifications or experience to lead this program? 5.Why is OEHRM housed in the secretary's office rather than inside VHA, even though experts advised putting clinicians in charge? 6.Why did Secretary Wilkie tell Dr. Stone to back off the EHR implementation and focus instead on the MISSION Act implementation? 7.Why does the IT steering committee have nobody representing VA doctors? 8.How is the Secretary mitigating infighting between OEHRM, VHA and Ol&T? 9.Why is the VA replicating the DoD's unsuccessful governance structure of a program office run by contracting officers and accountability spread across a health division and an IT division? 10.Why is the Secretary considering having the VA follow DoD's lead on the EHR implementation? 11.Why is the Secretary considering James Ellzy for CMO or CHIO? How can a non-VA person be the champion for VA clinicians? 12.Why should DoD lead the EHR implementation even though VA will be the bigger user and has different needs? 13.Why does Windom want to copy DoD's workflows, over the objection of VA clinicians and industry experts? 14.When the VA asked Gerner to assess the overlap between the two departments' needs, why did Gerner instead assess DoD's adherence to Cerner's commercial baselines? 15.Why did Cerner's cost and schedule estimates assume the VA would match the DoD's implementation? 16.Why would the VA import the DoD's workflows when the DoD's workflows failed at the DoD 's IOC sites? 17.How is the VA learning from the DoD's mistakes? For example , how will routing trouble tickets directly to Gerner solve the problem of overwhelming volume and lack of on-site support? 18.How is the VA addressing Cerner 's lack of functionality for some of VA's core specialties such as Agent Orange exposure, spinal cord injury, PTSD and military sexual trauma? 19.How is the VA addressing Cerner 's functionality in other areas , such as optometry and telehealth, that DoD and VA clinicians have identified as inadequate? 20.How is the VA addressing the fact that DoD's cyber security specifications will interfere with some of Cerner's usability functions? Is the VA still planning to match DoD's cyber security specifications? 21.How is the VA addressing Cerner's incomplete data migration plan, which an internal report said raises patient safety issues? 22.Does the VA plan to migrate ALL patient data to the new platform, or only the past three years, like DoD? 23.ln early 2018, why did Don McGahn call Jim Byrne to tell him not to sign off on the Gerner contract? 24.Why didn't Marc Sherman become a Special Government Employee to review the Gerner contract? 25.Why was Genevieve Morris detailed to VA for 30 days? AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000274 274 of 6274 Page 312 of 1093 26.What was her assessment of the Gerner contract? 27.Why did Secretary Wilkie determine the contract was ready to sign in May? 28.Why did Morris stay at VA to take over OEHRM? Was her background working on small-scale ambulatory EHR implementations sufficient for this role? 29.Morris agreed to stay for one year, but the GAO says a change of this size requires a leader to stay for five to seven years. Also, OEHRM's own management plan says "the program must be perceived to be stable." How can the VA achieve this, when the office's leader was only supposed to stay for one year, and ended up staying less than two months? 30.Why were the VA's own health IT experts blocked from working on the EHR implementation? 31.Why did OEHRM want its own staff to lead the clinical councils, even though experts advised putting clinicians in charge? 32.Why did VHA clinicians say they didn't have time to join the councils? How can the program succeed without buy-in from VHA leadership? 33.Why did Dr. Stone, John Windom and Camilo Sandoval meet about unseating Morris? 34.Why did Windom block information from getting to Morris? 35.Why did the VA spend $874,000 on the formal kickoff event? 36.Why did the VA cut the staff in the OEHRM? 37.Why is Windom qualified to lead OEHRM despite lacking health care experience? 38.Why is Windom rejecting clinicians' input, against the advice of industry experts? 39.At the Sept. 13 House subcommittee hearing, Chairman Banks asked Windom, "Is there anyone working in the Office of EHR Modernization who has managed an EHR implementation in a large health system to its completion?" Windom answered yes. Who are these people? 40.Who are the experts that Booz Allen is providing who have EHR implementation experience? 41.On the Booz Allen contract, what is the breakdown of the work done by junior aides versus senior experts? 42.Does Jim Byrne have the skill set to oversee the OEHRM as acting deputy secretary? 43.Why did Windom and Dr. Stone make a truce to let Dr. Stone run the medical aspects as long as Windom stayed nominally in charge? 44.Why did Camilo Sandoval move back into the CIO's office after moving into the OEHRM? What was the cost to taxpayers of these repeated office moves? 45.Why hasn't the VA accepted the offer of KLAS research on what makes EHR implementations successful? Thanks, Isaac Isaac Arnsdorf ProPublica 917.512.0256 203.464.1409 isaac@propublica.org From: "Cashour, Curtis" AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000275 275 of 6274 Page 313 of 1093 Date: Monday, October 22, 2018 at 10:30 AM To: Isaac Arnsdorf Subject RE: Interview with Secretary Wilkie about EHR implementation Hi, Isaac. What are your findings? What questions do you have? Thanks, Curt Cashour Press Secretary Department of Veterans Affairs 202-461-7388 Curt. Cashou r@va.gov @curtcashour From: Isaac Arnsdorf [mailto:lsaac.Arnsdorf@propublica.org] Sent Monday, October 22, 2018 9:51 AM To: VA Public Affairs ; VA Public Affairs Cc: Cashour, Curtis Subject [EXTERNAL] Interview with Secretary Wilkie about EHR implementation Hi, I'm writing to request an interview with Secretary Wilkie about the EHR implementation. I'm preparing an in-depth article based on extensive reporting, and I'm eager to discuss my findings with the Secretary. I hope you will grant this request since the EHR is one of the department's top priorities. AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000276 276 of 6274 Page 314 of 1093 Thanks, Isaac Isaac Arnsdorf ProPublica 917.512.0256 203.464.1409 isaac@propublica.org AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000277 277 of 6274 Page 315 of 1093 Document ID: 0.7.1705.51212 Cashour, Curtis From: To: Stone, Richard A., MD ; Sandoval, Camilo J. ; Windom, John H. Connell, Lawrence B. Cc: ; Ullyot, John ; Hutton, James ; Eason, William J. ; Snyder, Jill ; Screen, Gina Bee: Subject: // for approval// Interview with Secretary Wilkie about EHR implementation Date: Wed Oct 24 2018 12:26:03 EDT Attachments: Folks - Please see below from ProPublica. The reporter has asked for interviews with SecVA, Cam, and Dr. Stone. In lieu of interviews, we recommend the below. Let us know if you have any issues or edits. Thanks. We welcome the opportunity to discuss any allegations from named current or former employees. But due to Privacy Act restrictions, in order to comment on specific complaints from any current or former employees, we would need their written consent (by having them fill out and return this form) to discuss all aspects of their job performance. Can you provide that consent? If you cannot, please note in your story that those making these AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000278 278 of 6274 Page 316 of 1093 allegations refused to allow VA to comment on them. Allegation: The article will be an in-depth look at the dysfunction and turmoil that are undermining the VA's effort to transform its electronic health records. Response: The premise of your article is false . VA's electronic health record modernization (EHRM) efforts thus far have been successful and we are confident they will continue to be successful. While that may not comport with the tall tales you are hearing from disgruntled former employees , all of those people - whether they left by choice or not - no longer work at VA for a reason. VA has made a historic decision to modernize its electronic health record system to provide our nation 's Veterans with seamless care as they transition from military service to Veteran status and when they choose to use community care . While past administrations and VA secretaries failed to achieve this longstanding goal , the Trump administration and Secretary Wilkie succeeded. VA established the Office of Electronic Health Record Modernization (OEHRM) to ensure VA successfully prepares for, deploys and maintains the new EHR solution and the health IT tools dependent upon it. The OEHRM Executive Director is Mr. John Windom , who has been with the effort since its inception and has the necessary expertise and institutional knowledge to lead this initiative effectively. Prior to joining VA, Windom was a program manager for the Program Executive Office of the Defense Healthcare Management Systems (OHMS). He led his team to acquire, test , integrate and deploy a new EHR to replace DoD's legacy system in support of over 9.6 million military service members and other beneficiaries. As Secretary Wilkie has said, "The new EHR system will be interoperable with DOD, while also improving VA's ability to collaborate and share information with community care providers. This will ease the burden on service members as they transition from military careers and will be supported by multiple medical providers throughout their lives. AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000279 279 of 6274 Page 317 of 1093 "The EHR will give health care providers a full picture of patient medical history, driving better clinical outcomes. It will also help us identify Veterans proactively who are at higher risk for issues, such as opioid addiction and suicide, so health care providers can intervene earlier and save lives." Curt Cashour Press Secretary Department of Veterans Affairs 202-461-7388 Curt. Cashou r@va.gov @curtcashour From: Isaac Arnsdorf [mailto:lsaac.Arnsdorf@propublica.org] Sent: Tuesday, October 23, 2018 1:04 PM To: Cashour, Curtis Cc: Snyder, Jill Subject: [EXTERNAL] Re: Interview with Secretary Wilkie about EHR implementation Hi Curt, Nice to hear from you again. I will direct questions to you for Secretary Wilkie, Dr. Stone and John Windom. The article will be an in-depth look at the dysfunction and turmoil that are undermining the VA's effort to transform its electronic health records. As a recent internal progress report said, the program is "Yellow trending towards Red." 1.Discussing his April 20 meeting with Ike Perlmutter, Bruce Moskowitz and Marc Sherman, why did Secretary Wilkie tell senators he "went against their wishes, because I approved it," when they were not opposed to the EHR modernization - in fact, they were the ones who set the process in motion? 2.Why does Secretary Wilkie's joint statement on interoperability discuss "a single, seamlessly integrated electronic health record" that "maximizes commercial health record interoperability" instead of "seamless care," which was the justification for the sole-source contract? 3.What, in the Secretary's view, is the different between a "seamlessly integrated EHR" and "seamless care"? 4.Who in the Office of Electronic Health Records Modernization has the appropriate qualifications or AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000280 280 of 6274 Page 318 of 1093 experience to lead this program? 5.Why is OEHRM housed in the secretary's office rather than inside VHA, even though experts advised putting clinicians in charge? 6.Why did Secretary Wilkie tell Dr. Stone to back off the EHR implementation and focus instead on the MISSION Act implementation? 7.Why does the IT steering committee have nobody representing VA doctors? 8.How is the Secretary mitigating infighting between OEHRM, VHA and Ol&T? 9.Why is the VA replicating the DoD's unsuccessful governance structure of a program office run by contracting officers and accountability spread across a health division and an IT division? 10.Why is the Secretary considering having the VA follow DoD's lead on the EHR implementation? 11.Why is the Secretary considering James Ellzy for CMO or CHIO? How can a non-VA person be the champion for VA clinicians? 12.Why should DoD lead the EHR implementation even though VA will be the bigger user and has different needs? 13.Why does Windom want to copy DoD's workflows, over the objection of VA clinicians and industry experts? 14.When the VA asked Gerner to assess the overlap between the two departments' needs, why did Gerner instead assess DoD's adherence to Cerner's commercial baselines? 15.Why did Cerner's cost and schedule estimates assume the VA would match the DoD's implementation? 16.Why would the VA import the DoD's workflows when the DoD's workflows failed at the DoD's IOC sites? 17 .How is the VA learning from the Do D's mistakes? For example, how will routing trouble tickets directly to Gerner solve the problem of overwhelming volume and lack of on-site support? 18.How is the VA addressing Cerner's lack of functionality for some of VA's core specialties such as Agent Orange exposure, spinal cord injury, PTSD and military sexual trauma? 19.How is the VA addressing Cerner's functionality in other areas, such as optometry and telehealth, that DoD and VA clinicians have identified as inadequate? 20.How is the VA addressing the fact that DoD's cyber security specifications will interfere with some of Cerner's usability functions? Is the VA still planning to match DoD's cyber security specifications? 21.How is the VA addressing Cerner's incomplete data migration plan, which an internal report said raises patient safety issues? 22.Does the VA plan to migrate ALL patient data to the new platform, or only the past three years, like DoD? 23.ln early 2018, why did Don McGahn call Jim Byrne to tell him not to sign off on the Gerner contract? 24.Why didn't Marc Sherman become a Special Government Employee to review the Gerner contract? 25.Why was Genevieve Morris detailed to VA for 30 days? 26.What was her assessment of the Gerner contract? 27.Why did Secretary Wilkie determine the contract was ready to sign in May? 28.Why did Morris stay at VA to take over OEHRM? Was her background working on small-scale ambulatory EHR implementations sufficient for this role? 29.Morris agreed to stay for one year, but the GAO says a change of this size requires a leader to stay for five to seven years. Also, OEHRM's own management plan says "the program must be perceived to be stable." How can the VA achieve this, when the office's leader was only supposed to stay for one year, and ended up staying less than two months? 30.Why were the VA's own health IT experts blocked from working on the EHR implementation? 31.Why did OEHRM want its own staff to lead the clinical councils, even though experts advised putting clinicians in charge? 32.Why did VHA clinicians say they didn't have time to join the councils? How can the program succeed without buy-in from VHA leadership? 33.Why did Dr. Stone, John Windom and Camilo Sandoval meet about unseating Morris? 34.Why did Windom block information from getting to Morris? 35.Why did the VA spend $874,000 on the formal kickoff event? 36.Why did the VA cut the staff in the OEHRM? 37.Why is Windom qualified to lead OEHRM despite lacking health care experience? 38.Why is Windom rejecting clinicians' input, against the advice of industry experts? AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000281 281 of 6274 Page 319 of 1093 39.At the Sept. 13 House subcommittee hearing, Chairman Banks asked Windom, "Is there anyone working in the Office of EHR Modernization who has managed an EHR implementation in a large health system to its completion?" Windom answered yes. Who are these people? 40.Who are the experts that Booz Allen is providing who have EHR implementation experience? 41.On the Booz Allen contract, what is the breakdown of the work done by junior aides versus senior experts? 42.Does Jim Byrne have the skill set to oversee the OEHRM as acting deputy secretary? 43.Why did Windom and Dr. Stone make a truce to let Dr. Stone run the medical aspects as long as Windom stayed nominally in charge? 44.Why did Camilo Sandoval move back into the CIO's office after moving into the OEHRM? What was the cost to taxpayers of these repeated office moves? 45.Why hasn't the VA accepted the offer of KLAS research on what makes EHR implementations successful? Thanks, Isaac Isaac Arnsdorf ProPublica 917.512.0256 203.464.1409 isaac@propublica.org From: "Cashour, Curtis" Date: Monday, October 22, 2018 at 10:30 AM To: Isaac Arnsdorf Subject: RE: Interview with Secretary Wilkie about EHR implementation Hi, Isaac. What are your findings? What questions do you have? Thanks, AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000282 282 of 6274 Page 320 of 1093 Curt Cashour Press Secretary Department of Veterans Affairs 202-461-7388 Curt. Cashou r@va.gov @curtcashour From: Isaac Arnsdorf [mailto:lsaac.Arnsdorf@propublica.org] Sent: Monday, October 22, 2018 9:51 AM To: VA Public Affairs ; VA Public Affairs Cc: Cashour, Curtis Subject: [EXTERNAL] Interview with Secretary Wilkie about EHR implementation Hi, I'm writing to request an interview with Secretary Wilkie about the EHR implementation. I'm preparing an in-depth article based on extensive reporting , and I'm eager to discuss my findings with the Secretary. I hope you will grant this request since the EHR is one of the department's top priorities. Thanks, Isaac Isaac Arnsdorf ProPublica 917.512.0256 203.464.1409 isaac@propublica.org AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000283 283 of 6274 Page 321 of 1093 Document ID: 0.7.1705.51185 From: Windom, John H. To: Tucker, Brooks ; Byrne, Jim ; Powers, Pamela Ullyot, John Cc: ; Sandoval, Camilo J. ; Stone, Richard A., MD Bee: RE: Interview with Secretary Wilkie about EHR implementation Subject: Wed Oct 24 2018 11 :26:36 EDT Date: Attachments: Thank you fir sharing. I did not realize my selection was based on a truce. I have far more power than I ever imagined. For the record and as you know, I serve at the pleasure of the Secretary and VA leadership. No false sense of power here. Vr John Sent with Good (www.good.com) From: Tucker, Brooks Sent: Wednesday, October 24, 2018 7:12:52 AM To: Windom, John H.; Byrne, Jim; Powers, Pamela Cc: Ullyot, John; Sandoval, Camilo J.; Stone, Richard A., MD Subject: RE: Interview with Secretary Wilkie about EHR implementation For edification, Bill Mallison asked Question# 43 yesterday during the EHRM briefing to 4 Corners PSMs. AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000284 284 of 6274 Page 322 of 1093 From: Windom, John H. Sent: Wednesday, October 24, 2018 7:16 AM To: Byrne, Jim ; Powers, Pamela Cc: Ullyot, John ; Sandoval , Camilo J.; Stone, Richard A., MD ; Tucker , Brooks Subject: FW: Interview with Secretary Wilkie about EHR implementation DEPSEC/CoS: The Hill engagements went very well yesterday. Congressman Banks made a surprise visit to the second two hour session accompanying Bill Mallison and stayed for about an hour. The DoD Politico article came up as did the Joint Memorandum. I believe we addressed both very well. Overall, I do not believe our sessions could have gone much better. Thank you for your leadership and comments during the prep session Monday. I received the below questions from my Comms lead while on the Hill yesterday , and after reviewing do not believe we should respond to a single one of the questions. Clearly a compilation of rhetoric, untruths, inaccuracies and the comments from disgruntled/angry people . I literally find all of the questions to be without truth or accuracy. I served on six Navy ships and deployed on the ground to Iraq twice in my 34 year Naval career, and cannot remember an assault by the enemy as divisive as what appears to be comments fueled by present or past employees. Thank you for your confidence in my leadership and unwavering support of my efforts and the efforts of the OEHRM team. We will continue to you press forward. It is great to be on the side of RIGHT! Very respectfully, John John H. Windom, Senior Executive Service (SES) Office of Electronic Health Record Modernization (OEHRM) 811 Vermont Avenue NW (5th Floor Suite 5080) Washington, DC 20420 John.Windom@va.gov Office: (202) 461-5820 AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000285 285 of 6274 Page 323 of 1093 Mobile: (202) 794-4911 (b_)(6_) _ Executive Assistant: Ms. ,_l ,_l (b_)(6_) _ ____, ~ Appointments and Scheduling __.@va.gov Office: 202-382-3792 From: Snyder , Jill Sent: Tuesday, October 23, 2018 1:31 PM To: Windom, John H. Cc: Snyder, Jill Subject: FW: Interview with Secretary Wilkie about EHR implementation Mr. Windom, Below is a very large list of questions from Propublica, I am working to divide up between Gerner , OEHRM, OIT, and VHA. I have already spoken with Curt and we have a way forward, but I wanted to you to see the questions as soon as possible. Happy to discuss. Thanks, Jill From: Isaac Arnsdorf [mailto:lsaac .Arnsdorf@propublica .org] Sent: Tuesday , October 23, 2018 1:04 PM To : Cashour, Curtis Cc: Snyder, Jill Subject: [EXTERNAL] Re: Interview with Secretary Wilkie about EHR implementation Hi Curt, Nice to hear from you again. AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000286 286 of 6274 Page 324 of 1093 I will direct questions to you for Secretary Wilkie, Dr. Stone and John Windom. The article will be an in-depth look at the dysfunction and turmoil that are undermining the VA's effort to transform its electronic health records. As a recent internal progress report said, the program is "Yellow trending towards Red." 1.Discussing his April 20 meeting with Ike Perlmutter, Bruce Moskowitz and Marc Sherman, why did Secretary Wilkie tell senators he "went against their wishes, because I approved it," when they were not opposed to the EHR modernization - in fact, they were the ones who set the process in motion? 2.Why does Secretary Wilkie's joint statement on interoperability discuss "a single, seamlessly integrated electronic health record" that "maximizes commercial health record interoperability" instead of "seamless care," which was the justification for the sole-source contract? 3.What , in the Secretary 's view, is the different between a "seamlessly integrated EHR" and "seamless care"? 4.Who in the Office of Electronic Health Records Modernization has the appropriate qualifications or experience to lead this program? 5.Why is OEHRM housed in the secretary's office rather than inside VHA, even though experts advised putting clinicians in charge? 6.Why did Secretary Wilkie tell Dr. Stone to back off the EHR implementation and focus instead on the MISSION Act implementation? 7.Why does the IT steering committee have nobody representing VA doctors? 8.How is the Secretary mitigating infighting between OEHRM, VHA and Ol&T? 9.Why is the VA replicating the DoD's unsuccessful governance structure of a program office run by contracting officers and accountability spread across a health division and an IT division? 10.Why is the Secretary considering having the VA follow DoD's lead on the EHR implementation? 11.Why is the Secretary considering James Ellzy for CMO or CHIO? How can a non-VA person be the champion for VA clinicians? 12.Why should DoD lead the EHR implementation even though VA will be the bigger user and has different needs? 13.Why does Windom want to copy DoD's workflows, over the objection of VA clinicians and industry experts? 14.When the VA asked Gerner to assess the overlap between the two departments' needs, why did Gerner instead assess DoD's adherence to Cerner's commercial baselines? 15.Why did Cerner's cost and schedule estimates assume the VA would match the DoD's implementation? 16.Why would the VA import the DoD's workflows when the DoD's workflows failed at the DoD 's IOC sites? 17.How is the VA learning from the DoD's mistakes? For example , how will routing trouble tickets directly to Gerner solve the problem of overwhelming volume and lack of on-site support? 18.How is the VA addressing Cerner 's lack of functionality for some of VA's core specialties such as Agent Orange exposure, spinal cord injury, PTSD and military sexual trauma? 19.How is the VA addressing Cerner 's functionality in other areas , such as optometry and telehealth, that DoD and VA clinicians have identified as inadequate? 20.How is the VA addressing the fact that DoD's cyber security specifications will interfere with some of Cerner's usability functions? Is the VA still planning to match DoD's cyber security specifications? 21.How is the VA addressing Cerner's incomplete data migration plan, which an internal report said raises patient safety issues? 22.Does the VA plan to migrate ALL patient data to the new platform, or only the past three years, like DoD? 23.ln early 2018, why did Don McGahn call Jim Byrne to tell him not to sign off on the Gerner contract? 24.Why didn't Marc Sherman become a Special Government Employee to review the Gerner contract? 25.Why was Genevieve Morris detailed to VA for 30 days? AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000287 287 of 6274 Page 325 of 1093 26.What was her assessment of the Gerner contract? 27.Why did Secretary Wilkie determine the contract was ready to sign in May? 28.Why did Morris stay at VA to take over OEHRM? Was her background working on small-scale ambulatory EHR implementations sufficient for this role? 29.Morris agreed to stay for one year, but the GAO says a change of this size requires a leader to stay for five to seven years. Also, OEHRM's own management plan says "the program must be perceived to be stable." How can the VA achieve this, when the office's leader was only supposed to stay for one year, and ended up staying less than two months? 30.Why were the VA's own health IT experts blocked from working on the EHR implementation? 31.Why did OEHRM want its own staff to lead the clinical councils, even though experts advised putting clinicians in charge? 32.Why did VHA clinicians say they didn't have time to join the councils? How can the program succeed without buy-in from VHA leadership? 33.Why did Dr. Stone, John Windom and Camilo Sandoval meet about unseating Morris? 34.Why did Windom block information from getting to Morris? 35.Why did the VA spend $874,000 on the formal kickoff event? 36.Why did the VA cut the staff in the OEHRM? 37.Why is Windom qualified to lead OEHRM despite lacking health care experience? 38.Why is Windom rejecting clinicians' input, against the advice of industry experts? 39.At the Sept. 13 House subcommittee hearing, Chairman Banks asked Windom, "Is there anyone working in the Office of EHR Modernization who has managed an EHR implementation in a large health system to its completion?" Windom answered yes. Who are these people? 40.Who are the experts that Booz Allen is providing who have EHR implementation experience? 41.On the Booz Allen contract, what is the breakdown of the work done by junior aides versus senior experts? 42.Does Jim Byrne have the skill set to oversee the OEHRM as acting deputy secretary? 43.Why did Windom and Dr. Stone make a truce to let Dr. Stone run the medical aspects as long as Windom stayed nominally in charge? 44.Why did Camilo Sandoval move back into the CIO's office after moving into the OEHRM? What was the cost to taxpayers of these repeated office moves? 45.Why hasn't the VA accepted the offer of KLAS research on what makes EHR implementations successful? Thanks, Isaac Isaac Arnsdorf ProPublica 917.512.0256 203.464.1409 isaac@propublica.org From: "Cashour, Curtis" AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000288 288 of 6274 Page 326 of 1093 Date: Monday, October 22, 2018 at 10:30 AM To: Isaac Arnsdorf Subject RE: Interview with Secretary Wilkie about EHR implementation Hi, Isaac. What are your findings? What questions do you have? Thanks, Curt Cashour Press Secretary Department of Veterans Affairs 202-461-7388 Curt. Cashou r@va.gov @curtcashour From: Isaac Arnsdorf [mailto:lsaac.Arnsdorf@propublica.org] Sent Monday, October 22, 2018 9:51 AM To: VA Public Affairs ; VA Public Affairs Cc: Cashour, Curtis Subject [EXTERNAL] Interview with Secretary Wilkie about EHR implementation Hi, I'm writing to request an interview with Secretary Wilkie about the EHR implementation. I'm preparing an in-depth article based on extensive reporting, and I'm eager to discuss my findings with the Secretary. I hope you will grant this request since the EHR is one of the department's top priorities. AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000289 289 of 6274 Page 327 of 1093 Thanks, Isaac Isaac Arnsdorf ProPublica 917.512.0256 203.464.1409 isaac@propublica.org AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000290 290 of 6274 Page 328 of 1093 Document ID: 0.7.1705.51155 Tucker, Brooks From: To: Windom, John H. ; Byrne, Jim ; Powers, Pamela Cc: Ullyot, John ; Sandoval, Camilo J. ; Stone, Richard A., MD Bee: Subject: RE: Interview with Secretary Wilkie about EHR implementation Wed Oct 24 2018 10: 12:52 EDT Date: Attachments: For edification, Bill Mallison asked Question# 43 yesterday during the EHRM briefing to 4 Corners PSMs. From: Windom, John H. Sent: Wednesday, October 24, 2018 7:16 AM To: Byrne, Jim ; Powers, Pamela Cc: Ullyot, John ; Sandoval, Camilo J.; Richard A., MD ; Tucker, Brooks Subject: FW: Interview with Secretary Wilkie about EHR implementation Stone, DEPSEC/CoS: The Hill engagements went very well yesterday. Congressman Banks made a surprise visit to the second two hour session accompanying Bill Mallison and stayed for about an hour. The DoD Politico article came up as did the Joint Memorandum. I believe we addressed both very well. Overall, I do not believe our sessions could have gone much better. Thank you for your leadership and comments during the prep session Monday. AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000291 291 of 6274 Page 329 of 1093 I received the below questions from my Comms lead while on the Hill yesterday , and after reviewing do not believe we should respond to a single one of the questions. Clearly a compilation of rhetoric, untruths, inaccuracies and the comments from disgruntled/angry people. I literally find all of the questions to be without truth or accuracy. I served on six Navy ships and deployed on the ground to Iraq twice in my 34 year Naval career, and cannot remember an assault by the enemy as divisive as what appears to be comments fueled by present or past employees. Thank you for your confidence in my leadership and unwavering support of my efforts and the efforts of the OEHRM team. We will continue to you press forward. It is great to be on the side of RIGHT! Very respectfully, John John H. Windom, Senior Executive Service (SES) Office of Electronic Health Record Modernization (OEHRM) 811 Vermont Avenue NW (5th Floor Suite 5080) Washington, DC 20420 John.Windom@va.gov Office: (202) 461-5820 Mobile: ._l (b_l(6_l ___ ___, Executive Assistant: Ms. ~l (b_l(_si__ l._ (b_l(6_l_~ ~va.gov ~I - Appointments and Scheduling Office: 202-382-3792 From: Snyder, Jill Sent: Tuesday , October 23, 2018 1:31 PM To: Windom, John H. Cc: Snyder, Jill Subject: FW: Interview with Secretary Wilkie about EHR implementation AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000292 292 of 6274 Page 330 of 1093 Mr. Windom, Below is a very large list of questions from Propublica, I am working to divide up between Gerner, OEHRM, OIT, and VHA. I have already spoken with Curt and we have a way forward, but I wanted to you to see the questions as soon as possible. Happy to discuss. Thanks, Jill From: Isaac Arnsdorf [mailto:lsaac.Arnsdorf@propublica.org] Sent: Tuesday, October 23, 2018 1:04 PM To: Cashour, Curtis Cc: Snyder, Jill Subject: [EXTERNAL] Re: Interview with Secretary Wilkie about EHR implementation Hi Curt, Nice to hear from you again. I will direct questions to you for Secretary Wilkie, Dr. Stone and John Windom. The article will be an in-depth look at the dysfunction and turmoil that are undermining the VA's effort to transform its electronic health records. As a recent internal progress report said, the program is "Yellow trending towards Red." 1.Discussing his April 20 meeting with Ike Perlmutter, Bruce Moskowitz and Marc Sherman, why did Secretary Wilkie tell senators he "went against their wishes, because I approved it," when they were not opposed to the EHR modernization - in fact, they were the ones who set the process in motion? 2.Why does Secretary Wilkie's joint statement on interoperability discuss "a single, seamlessly integrated electronic health record" that "maximizes commercial health record interoperability" instead of "seamless care," which was the justification for the sole-source contract? 3.What, in the Secretary's view, is the different between a "seamlessly integrated EHR" and "seamless care"? 4.Who in the Office of Electronic Health Records Modernization has the appropriate qualifications or experience to lead this program? 5.Why is OEHRM housed in the secretary's office rather than inside VHA, even though experts advised AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000293 293 of 6274 Page 331 of 1093 putting clinicians in charge? 6.Why did Secretary Wilkie tell Dr. Stone to back off the EHR implementation and focus instead on the MISSION Act implementation? 7.Why does the IT steering committee have nobody representing VA doctors? 8.How is the Secretary mitigating infighting between OEHRM, VHA and Ol&T? 9.Why is the VA replicating the DoD's unsuccessful governance structure of a program office run by contracting officers and accountability spread across a health division and an IT division? 10.Why is the Secretary considering having the VA follow DoD 's lead on the EHR implementation? 11.Why is the Secretary considering James Ellzy for CMO or CHIO? How can a non-VA person be the champion for VA clinicians? 12.Why should DoD lead the EHR implementation even though VA will be the bigger user and has different needs? 13.Why does Windom want to copy DoD's workflows , over the objection of VA clinicians and industry experts? 14.When the VA asked Gerner to assess the overlap between the two departments' needs, why did Cerner instead assess DoD's adherence to Cerner's commercial baselines? 15.Why did Cerner's cost and schedule estimates assume the VA would match the DoD's implementation? 16.Why would the VA import the DoD's workflows when the DoD's workflows failed at the DoD 's IOC sites? 17 .How is the VA learning from the Do D's mistakes? For example , how will routing trouble tickets directly to Cerner solve the problem of overwhelming volume and lack of on-site support? 18.How is the VA addressing Cerner 's lack of functionality for some of VA 's core specialties such as Agent Orange exposure, spinal cord injury , PTSD and military sexual trauma? 19.How is the VA addressing Cerner 's functionality in other areas , such as optometry and telehealth , that DoD and VA clinicians have identified as inadequate? 20.How is the VA addressing the fact that DoD's cyber security specifications will interfe re with some of Cerner 's usability functions? Is the VA still planning to match DoD's cyber security specifications? 21.How is the VA addressing Cerner 's incomplete data migration plan, which an internal report said raises patient safety issues? 22.Does the VA plan to migrate ALL patient data to the new platform, or only the past three years , like DoD? 23.ln early 2018, why did Don McGahn call Jim Byrne to tell him not to sign off on the Cerner contract? 24.Why didn't Marc Sherman become a Special Government Employee to review the Cerner contract? 25.Why was Genevieve Morris detailed to VA for 30 days? 26.What was her assessment of the Cerner contract? 27.Why did Secretary Wilkie determine the contract was ready to sign in May? 28.Why did Morris stay at VA to take over OEHRM? Was her background working on small-scale ambulatory EHR implementations sufficient for this role? 29.Morris agreed to stay for one year , but the GAO says a change of this size requires a leader to stay for five to seven years. Also , OEHRM's own management plan says "the program must be perceived to be stable." How can the VA achieve this , when the office 's leader was only supposed to stay for one year , and ended up staying less than two months? 30.Why were the VA's own health IT experts blocked from working on the EHR implementation? 31.Why did OEHRM want its own staff to lead the clinical councils , even though experts advised putting clinicians in charge? 32.Why did VHA clinicians say they didn't have time to join the councils? How can the program succeed without buy-in from VHA leadership? 33.Why did Dr. Stone , John Windom and Camilo Sandoval meet about unseating Morris? 34.Why did Windom block information from getting to Morris? 35.Why did the VA spend $874 ,000 on the formal kickoff event? 36.Why did the VA cut the staff in the OEHRM? 37.Why is Windom qualified to lead OEHRM despite lacking health care experience? 38.Why is Windom rejecting clinicians' input, against the advice of industry experts? 39.At the Sept. 13 House subcommittee hearing , Chairman Banks asked Windom, "Is there anyone working in the Office of EHR Modernization who has managed an EHR implementation in a large health AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000294 294 of 6274 Page 332 of 1093 system to its completion?" Windom answered yes. Who are these people? 40.Who are the experts that Booz Allen is providing who have EHR implementation experience? 41.On the Booz Allen contract, what is the breakdown of the work done by junior aides versus senior experts? 42.Does Jim Byrne have the skill set to oversee the OEHRM as acting deputy secretary? 43.Why did Windom and Dr. Stone make a truce to let Dr. Stone run the medical aspects as long as Windom stayed nominally in charge? 44.Why did Camilo Sandoval move back into the CIO's office after moving into the OEHRM? What was the cost to taxpayers of these repeated office moves? 45.Why hasn't the VA accepted the offer of KLAS research on what makes EHR implementations successful? Thanks, Isaac Isaac Arnsdorf ProPublica 917.512.0256 203.464.1409 isaac@propublica.org From: "Cashour, Curtis" Date: Monday, October 22, 2018 at 10:30 AM To: Isaac Arnsdorf Subject: RE: Interview with Secretary Wilkie about EHR implementation Hi, Isaac. What are your findings? What questions do you have? Thanks, AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000295 295 of 6274 Page 333 of 1093 Curt Cashour Press Secretary Department of Veterans Affairs 202-461-7388 Curt. Cashou r@va.gov @curtcashour From: Isaac Arnsdorf [mailto:lsaac.Arnsdorf@propublica.org] Sent: Monday, October 22, 2018 9:51 AM To: VA Public Affairs ; VA Public Affairs Cc: Cashour, Curtis Subject [EXTERNAL] Interview with Secretary Wilkie about EHR implementation Hi, I'm writing to request an interview with Secretary Wilkie about the EHR implementation. I'm preparing an in-depth article based on extensive reporting, and I'm eager to discuss my findings with the Secretary. I hope you will grant this request since the EHR is one of the department's top priorities. Thanks, Isaac Isaac Arnsdorf ProPublica 917.512.0256 203.464.1409 isaac@propublica.org AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000296 296 of 6274 Page 334 of 1093 Document ID: 0.7.1705.50544 Windom, John H. From: Byrne, Jim ; Powers, Pamela Ullyot, John Cc: ; Sandoval, Camilo J. ; Stone, Richard A., MD ; Tucker, Brooks Bee: FW: Interview with Secretary Wilkie about EHR implementation Subject: Wed Oct 24 2018 07:15:59 EDT Date: Attachments: DEPSEC/CoS: The Hill engagements went very well yesterday. Congressman Banks made a surprise visit to the second two hour session accompanying Bill Mallison and stayed for about an hour. The DoD Politico article came up as did the Joint Memorandum. I believe we addressed both very well. Overall, I do not believe our sessions could have gone much better. Thank you for your leadership and comments during the prep session Monday. I received the below questions from my Comms lead while on the Hill yesterday , and after reviewing do not believe we should respond to a single one of the questions. Clearly a compilation of rhetoric, untruths, inaccuracies and the comments from disgruntled/angry people. I literally find all of the questions to be without truth or accuracy. I served on six Navy ships and deployed on the ground to Iraq twice in my 34 year Naval career, and cannot remember an assault by the enemy as divisive as what appears to be comments fueled by present or past employees. Thank you for your confidence in my leadership and unwavering support of my efforts and the efforts of the OEHRM team. We will continue to you press forward. It is great to be on the side of RIGHT! AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000297 297 of 6274 Page 335 of 1093 Very respectfully, John John H. Windom, Senior Executive Service (SES) Office of Electronic Health Record Modernization (OEHRM) 811 Vermont Avenue NW (5th Floor Suite 5080) Washington , DC 20420 John.Windom@va.gov Office: (202) 461-5820 Mobile: ._l (b_)(6_l ___ __. Executive Assistant: Ms . ._l (b_l(6_l_~I l._ (b_l(6_l_~ - Appointments and Scheduling ~va .gov Office : 202-382-3792 From: Snyder, Jill Sent: Tuesday , October 23, 2018 1:31 PM To : Windom, John H. Cc: Snyder , Jill Subject: FW: Interview with Secretary Wilkie about EHR implementation Mr. Windom, Below is a very large list of questions from Propublica, I am working to divide up between Cerner , OEHRM, OIT, and VHA. I have already spoken with Curt and we have a way forward, but I wanted to you to see the questions as soon as possible. Happy to discuss. Thanks, AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000298 298 of 6274 Page 336 of 1093 Jill From: Isaac Arnsdorf [mailto:lsaac.Arnsdorf@propublica.org] Sent: Tuesday, October 23, 2018 1:04 PM To: Cashour, Curtis Cc: Snyder, Jill Subject: [EXTERNAL] Re: Interview with Secretary Wilkie about EHR implementation Hi Curt, Nice to hear from you again. I will direct questions to you for Secretary Wilkie, Dr. Stone and John Windom. The article will be an in-depth look at the dysfunction and turmoil that are undermining the VA's effort to transform its electronic health records. As a recent internal progress report said, the program is "Yellow trending towards Red." 1.Discussing his April 20 meeting with Ike Perlmutter, Bruce Moskowitz and Marc Sherman, why did Secretary Wilkie tell senators he "went against their wishes, because I approved it," when they were not opposed to the EHR modernization - in fact, they were the ones who set the process in motion? 2.Why does Secretary Wilkie's joint statement on interoperability discuss "a single, seamlessly integrated electronic health record" that "maximizes commercial health record interoperability" instead of "seamless care," which was the justification for the sole-source contract? 3.What, in the Secretary's view, is the different between a "seamlessly integrated EHR" and "seamless care"? 4.Who in the Office of Electronic Health Records Modernization has the appropriate qualifications or experience to lead this program? 5.Why is OEHRM housed in the secretary's office rather than inside VHA, even though experts advised putting clinicians in charge? 6.Why did Secretary Wilkie tell Dr. Stone to back off the EHR implementation and focus instead on the MISSION Act implementation? 7.Why does the IT steering committee have nobody representing VA doctors? 8.How is the Secretary mitigating infighting between OEHRM, VHA and Ol&T? 9.Why is the VA replicating the DoD's unsuccessful governance structure of a program office run by contracting officers and accountability spread across a health division and an IT division? 10.Why is the Secretary considering having the VA follow DoD's lead on the EHR implementation? 11.Why is the Secretary considering James Ellzy for CMO or CHIO? How can a non-VA person be the champion for VA clinicians? 12.Why should DoD lead the EHR implementation even though VA will be the bigger user and has different needs? 13.Why does Windom want to copy DoD's workflows, over the objection of VA clinicians and industry experts? AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000299 299 of 6274 Page 337 of 1093 14.When the VA asked Gerner to assess the overlap between the two departments' needs, why did Gerner instead assess DoD's adherence to Gerner's commercial baselines? 15.Why did Cerner's cost and schedule estimates assume the VA would match the DoD's implementation? 16.Why would the VA import the DoD's workflows when the DoD's workflows failed at the DoD 's IOG sites? 17 .How is the VA learning from the Do D's mistakes? For example , how will routing trouble tickets directly to Gerner solve the problem of overwhelming volume and lack of on-site support? 18.How is the VA addressing Gerner's lack of functionality for some of VA's core specialties such as Agent Orange exposure, spinal cord injury , PTSD and military sexual trauma? 19.How is the VA addressing Cerner 's functionality in other areas , such as optometry and telehealth , that DoD and VA clinicians have identified as inadequate? 20.How is the VA addressing the fact that DoD's cyber security specifications will interfe re with some of Cerner's usability functions? Is the VA still planning to match DoD's cyber security specifications? 21.How is the VA addressing Gerner's incomplete data migration plan, which an internal report said raises patient safety issues? 22.Does the VA plan to migrate ALL patient data to the new platform, or only the past three years , like Do □ ? 23.ln early 2018 , why did Don McGahn call Jim Byrne to tell him not to sign off on the Gerner contract? 24.Why didn't Marc Sherman become a Special Government Employee to review the Cerner contract? 25.Why was Genevieve Morris detailed to VA for 30 days? 26.What was her assessment of the Cerner contract? 27.Why did Secretary Wilkie determine the contract was ready to sign in May? 28.Why did Morris stay at VA to take over OEHRM? Was her background working on small-scale ambulatory EHR implementations sufficient for this role? 29.Morris agreed to stay for one year , but the GAO says a change of this size requires a leader to stay for five to seven years. Also, OEHRM's own management plan says "the program must be perceived to be stable ." How can the VA achieve this, when the office 's leader was only supposed to stay for one year , and ended up staying less than two months? 30.Why were the VA's own health IT experts blocked from working on the EHR implementation? 31.Why did OEHRM want its own staff to lead the clinical councils , even though experts advised putting clinicians in charge? 32.Why did VHA clinicians say they didn 't have time to join the councils? How can the program succeed without buy-in from VHA leadership? 33.Why did Dr. Stone , John Windom and Camilo Sandoval meet about unseating Morris? 34.Why did Windom block information from getting to Morris? 35.Why did the VA spend $874 ,000 on the formal kickoff event? 36.Why did the VA cut the staff in the OEHRM? 37.Why is Windom qualified to lead OEHRM despite lacking health care experience? 38.Why is Windom rejecting clinicians' input, against the advice of industry experts? 39.At the Sept. 13 House subcommittee hearing, Chairman Banks asked Windom, "Is there anyone working in the Office of EHR Modernization who has managed an EHR implementation in a large health system to its completion?" Windom answered yes. Who are these people? 40.Who are the experts that Booz Allen is providing who have EHR implementation expe rience? 41 .On the Booz Allen contract, what is the breakdown of the work done by junior aides versus senior experts? 42 .Does Jim Byrne have the skill set to oversee the OEHRM as acting deputy secretary? 43.Why did Windom and Dr. Stone make a truce to let Dr. Stone run the medical aspects as long as Windom stayed nominally in charge? 44 .Why did Camilo Sandoval move back into the CIO's office after moving into the OEHRM? What was the cost to taxpayers of these repeated office moves? 45.Why hasn't the VA accepted the offer of KLAS research on what makes EHR implementations successful? AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000300 300 of 6274 Page 338 of 1093 Thanks, Isaac Isaac Arnsdorf ProPublica 917.512.0256 203.464.1409 isaac@propublica.org From: "Cashour, Curtis" Date: Monday , October 22, 2018 at 10:30 AM To : Isaac Arnsdorf Subject: RE: Interview with Secretary Wilkie about EHR implementation Hi, Isaac. What are your findings? What questions do you have? Thanks, Curt Cashour Press Secretary Department of Veterans Affairs 202-461 -7388 Curt. Cashou r@va.gov @curtcashour AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000301 301 of 6274 Page 339 of 1093 From: Isaac Arnsdorf [mailto:lsaac.Arnsdorf@propublica.org] Sent: Monday, October 22, 2018 9:51 AM To: VA Public Affairs ; VA Public Affairs Cc: Cashour, Curtis Subject: [EXTERNAL] Interview with Secretary Wilkie about EHR implementation Hi, I'm writing to request an interview with Secretary Wilkie about the EHR implementation. I'm preparing an in-depth article based on extensive reporting, and I'm eager to discuss my findings with the Secretary. I hope you will grant this request since the EHR is one of the department's top priorities. Thanks, Isaac Isaac Arnsdorf ProPublica 917.512.0256 203.464.1409 isaac@propublica.org AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000302 302 of 6274 Page 340 of 1093 Document ID: 0.7.1705.50478 From: Windom, John H. To: Sandoval, Camilo J. Cc: Bee: Subject: Date: Attachments: FW: Interview with Secretary Wilkie about EHR implementation Tue Oct 23 2018 20:53:49 EDT Fyi. John H. Windom, Senior Executive Service (SES) Office of Electronic Health Record Modernization (OEHRM) 811 Vermont Avenue NW (5th Floor Suite 5080) Washington, DC 20420 John.Windom@va.gov Office: (202) 461-5820 Mobile: l._ (b_)(S_ l ---~ l._ (b_)(S_ l_ Execut ·1veAss·1stant·. Ms. _ ___,I · t menst - A ppo1n an d S c he d u1· 1ng 6 ._l (b_l(_ l_ ___, ~ va.gov Office: 202-382-3792 From: Snyder, Jill Sent: Tuesday, October 23, 2018 1:31 PM To: Windom, John H. Cc: Snyder, Jill Subject: FW: Interview with Secretary Wilkie about EHR implementation AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000303 303 of 6274 Page 341 of 1093 Mr. Windom, Below is a very large list of questions from Propublica, I am working to divide up between Gerner, OEHRM, OIT, and VHA. I have already spoken with Curt and we have a way forward, but I wanted to you to see the questions as soon as possible. Happy to discuss. Thanks, Jill From: Isaac Arnsdorf [mailto:lsaac.Arnsdorf@propublica.org] Sent: Tuesday, October 23, 2018 1:04 PM To: Cashour, Curtis Cc: Snyder, Jill Subject: [EXTERNAL] Re: Interview with Secretary Wilkie about EHR implementation Hi Curt, Nice to hear from you again. I will direct questions to you for Secretary Wilkie, Dr. Stone and John Windom. The article will be an in-depth look at the dysfunction and turmoil that are undermining the VA's effort to transform its electronic health records. As a recent internal progress report said, the program is "Yellow trending towards Red." 1.Discussing his April 20 meeting with Ike Perlmutter, Bruce Moskowitz and Marc Sherman, why did Secretary Wilkie tell senators he "went against their wishes, because I approved it," when they were not opposed to the EHR modernization - in fact, they were the ones who set the process in motion? 2.Why does Secretary Wilkie's joint statement on interoperability discuss "a single, seamlessly integrated electronic health record" that "maximizes commercial health record interoperability" instead of "seamless care," which was the justification for the sole-source contract? 3.What, in the Secretary's view, is the different between a "seamlessly integrated EHR" and "seamless care"? 4.Who in the Office of Electronic Health Records Modernization has the appropriate qualifications or experience to lead this program? 5.Why is OEHRM housed in the secretary's office rather than inside VHA, even though experts advised putting clinicians in charge? AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000304 304 of 6274 Page 342 of 1093 6.Why did Secretary Wilkie tell Dr. Stone to back off the EHR implementation and focus instead on the MISSION Act implementation? 7.Why does the IT steering committee have nobody representing VA doctors? 8.How is the Secretary mitigating infighting between OEHRM, VHA and Ol&T? 9.Why is the VA replicating the DoD's unsuccessful governance structure of a program office run by contracting officers and accountability spread across a health division and an IT division? 10.Why is the Secretary considering having the VA follow DoD's lead on the EHR implementation? 11.Why is the Secretary considering James Ellzy for CMO or CHIO? How can a non-VA person be the champion for VA clinicians? 12.Why should DoD lead the EHR implementation even though VA will be the bigger user and has different needs? 13.Why does Windom want to copy DoD's workflows , over the objection of VA clinicians and industry experts? 14.When the VA asked Gerner to assess the overlap between the two departments' needs, why did Gerner instead assess DoD's adherence to Cerner's commercial baselines? 15.Why did Cerner's cost and schedule estimates assume the VA would match the DoD 's implementation? 16.Why would the VA import the DoD's workflows when the DoD's workflows failed at the DoD's IOC sites? 17 .How is the VA learning from the Do D's mistakes? For example , how will routing trouble tickets directly to Gerner solve the problem of overwhelming volume and lack of on-site support? 18.How is the VA addressing Cerner 's lack of functionality for some of VA 's core specialties such as Agent Orange exposure, spinal cord injury, PTSD and military sexual trauma? 19.How is the VA addressing Cerner 's functional ity in other areas , such as optometry and telehealth , that DoD and VA clinicians have identified as inadequate? 20.How is the VA addressing the fact that DoD's cyber security specifications will interfe re with some of Cerner's usability functions? Is the VA still planning to match DoD's cyber security specifications? 21.How is the VA addressing Cerner 's incomplete data migration plan, which an internal report said raises patient safety issues? 22.Does the VA plan to migrate ALL patient data to the new platform, or only the past three years , like DoD? 23.ln early 2018, why did Don McGahn call Jim Byrne to tell him not to sign off on the Gerner contract? 24.Why didn't Marc Sherman become a Special Government Employee to review the Gerner contract? 25.Why was Genevieve Morris detailed to VA for 30 days? 26.What was her assessment of the Gerner contract? 27.Why did Secretary Wilkie determine the contract was ready to sign in May? 28.Why did Morris stay at VA to take over OEHRM? Was her background working on small-scale ambulatory EHR implementations sufficient for this role? 29.Morris agreed to stay for one year , but the GAO says a change of this size requires a leader to stay for five to seven years. Also, OEHRM's own management plan says "the program must be perceived to be stable." How can the VA achieve this , when the office's leader was only supposed to stay for one year , and ended up staying less than two months? 30.Why were the VA's own health IT experts blocked from working on the EHR implementation? 31.Why did OEHRM want its own staff to lead the clinical councils , even though experts advised putting clinicians in charge? 32.Why did VHA clinicians say they didn't have time to join the councils? How can the program succeed without buy-in from VHA leadership? 33.Why did Dr. Stone , John Windom and Camilo Sandoval meet about unseating Morris? 34.Why did Windom block information from getting to Morris? 35.Why did the VA spend $874 ,000 on the formal kickoff event? 36.Why did the VA cut the staff in the OEHRM? 37.Why is Windom qualified to lead OEHRM despite lacking health care experience? 38.Why is Windom rejecting clinicians ' input, against the advice of industry experts? 39.At the Sept. 13 House subcommittee hearing , Chairman Banks asked Windom, "Is there anyone working in the Office of EHR Modernization who has managed an EHR implementation in a large health system to its completion? " Windom answered yes. Who are these people? AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000305 305 of 6274 Page 343 of 1093 40.Who are the experts that Booz Allen is providing who have EHR implementation experience? 41.On the Booz Allen contract, what is the breakdown of the work done by junior aides versus senior experts? 42.Does Jim Byrne have the skill set to oversee the OEHRM as acting deputy secretary? 43.Why did Windom and Dr. Stone make a truce to let Dr. Stone run the medical aspects as long as Windom stayed nominally in charge? 44.Why did Camilo Sandoval move back into the CIO's office after moving into the OEHRM? What was the cost to taxpayers of these repeated office moves? 45.Why hasn't the VA accepted the offer of KLAS research on what makes EHR implementations successful? Thanks, Isaac Isaac Arnsdorf ProPublica 917.512.0256 203.464.1409 isaac@propublica.org From: "Cashour, Curtis" Date: Monday, October 22, 2018 at 10:30 AM To: Isaac Arnsdorf Subject: RE: Interview with Secretary Wilkie about EHR implementation Hi, Isaac. What are your findings? What questions do you have? Thanks, AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000306 306 of 6274 Page 344 of 1093 Curt Cashour Press Secretary Department of Veterans Affairs 202-461-7388 Curt. Cashou r@va.gov @curtcashour From: Isaac Arnsdori [mailto:lsaac.Arnsdori@propublica.org] Sent: Monday, October 22, 2018 9:51 AM To: VA Public Affairs ; VA Public Affairs Cc: Cashour, Curtis Subject: [EXTERNAL] Interview with Secretary Wilkie about EHR implementation Hi, I'm writing to request an interview with Secretary Wilkie about the EHR implementation. I'm preparing an in-depth article based on extensive reporting , and I'm eager to discuss my findings with the Secretary. I hope you will grant this request since the EHR is one of the department's top priorities. Thanks, Isaac Isaac Arnsdori ProPublica 917.512.0256 203.464.1409 isaac@propublica.org AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000307 307 of 6274 Page 345 of 1093 Document ID: 0.7.1705.50476 From: Sandoval, Camilo J. To: Windom, John H. Cc: Bee: Subject: Date: Attachments: FW: EHR Modernization Tue Oct 23 2018 20:53:02 EDT #12 is the best one 9 Camilo Sandoval 917-544-1298 From: Sandoval, Camilo J. Sent: Tuesday, October 23, 2018 3:47:12 PM To: Cashour, Curtis Cc: Ullyot, John; Wagner, John (Wolf) Subject: FW: EHR Modernization CurtisPossibly coming your way ... and as always no comment. Thanks Camilo From: Isaac Arnsdorf [mailto:lsaac.Arnsdorf@propublica.org] Sent: Tuesday, October 23, 2018 1:05 PM To: Sandoval, Camilo J. Subject: [EXTERNAL] EHR Modernization Cam, AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000308 308 of 6274 Page 346 of 1093 I'm interested in speaking with you for an in-depth article about the EHR modernization. My questions for you are: 1.Why did you transfer from Treasury to VA? 2.How do you know Ike Perlmutter? 3.Why do you have a standing daily call with Ike Perlmutter? 4.Why do you keep a spreadsheet tracking projects for Perlmutter? 5.Why did you tell Perlmutter that he shouldn't trust Shulkin on the Gerner contract because Shulkin was positioning himself for a post-government job? What evidence do you have to support this allegation? 6.Why did you tell people that Shulkin planned to sign the Gerner contract on March 29? 7.How did you know ahead of time that Shulkin would be fired that week? 8.Why did you become executive in charge of 01& T? 9.What experience do you have in health care IT? 10.Why did you, John Windom and Rich Stone meet about ousting Genevieve Morris? 11.Why didn't Genevieve Morris want you to come to the kickoff event? 12.Why do you walk around the office in socks or flip flops? 13.Why have you canceled speaking engagements as executive in charge? 14.Why did you move back into the GIO office from the OEHRM? What have these repeated moves cost taxpayers? Thanks, Isaac Isaac Arnsdorf ProPublica 917.512.0256 203.464.1409 isaac@propublica.org AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000309 309 of 6274 Page 34 7 of 1093 Document ID: 0.7.1705.50460 From: Sandoval, Camilo J. To: Cashour, Curtis Ullyot, John Cc: ; Wagner, John (Wolf) Bee: FW: EHR Modernization Subject: Tue Oct 23 2018 18:47:12 EDT Date: Attachments: CurtisPossibly coming your way ... and as always no comment. Thanks Camilo From: Isaac Arnsdorf [mailto:lsaac.Arnsdorf@propublica.org] Sent: Tuesday, October 23, 2018 1:05 PM To: Sandoval, Camilo J. Subject: [EXTERNAL] EHR Modernization Cam, I'm interested in speaking with you for an in-depth article about the EHR modernization. My questions for you are: 1.Why did you transfer from Treasury to VA? 2.How do you know Ike Perlmutter? 3.Why do you have a standing daily call with Ike Perlmutter? 4.Why do you keep a spreadsheet tracking projects for Perlmutter? 5.Why did you tell Perlmutter that he shouldn't trust Shulkin on the Cerner contract because Shulkin was positioning himself for a post-government job? What evidence do you have to support this AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000310 310 of 6274 Page 348 of 1093 allegation? 6.Why did you tell people that Shulkin planned to sign the Cerner contract on March 29? 7.How did you know ahead of time that Shulkin would be fired that week? 8.Why did you become executive in charge of 01& T? 9.What experience do you have in health care IT? 1a.Why did you, John Windom and Rich Stone meet about ousting Genevieve Morris? 11.Why didn't Genevieve Morris want you to come to the kickoff event? 12.Why do you walk around the office in socks or flip flops? 13.Why have you canceled speaking engagements as executive in charge? 14.Why did you move back into the CIO office from the OEHRM? What have these repeated moves cost taxpayers? Thanks, Isaac Isaac Arnsdorf ProPublica 917.512.0256 203.464.1409 isaac@propublica.org AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000311 311 of 6274 Page 349 of 1093 Document ID: 0.7.1705.50458 None From: Cashour, Curtis To: Ullyot, John Cc: ; Wagner, John (Wolf) ; Powers, Pamela Bee: FW: EHR Modernization Subject: Tue Oct 23 2018 18:42:40 EDT Date: Attachments: CurtisPossibly coming your way ... all nonsense as always, and no comment:) Thanks Camilo From: Isaac Arnsdorf [mailto:lsaac.Arnsdorf@propublica.org] Sent: Tuesday, October 23, 2018 1:05 PM To: Sandoval, Camilo J. Subject: [EXTERNAL] EHR Modernization Cam, I'm interested in speaking with you for an in-depth article about the EHR modernization. My questions for you are: 1.Why did you transfer from Treasury to VA? 2.How do you know Ike Perlmutter? 3.Why do you have a standing daily call with Ike Perlmutter? 4.Why do you keep a spreadsheet tracking projects for Perlmutter? 5.Why did you tell Perlmutter that he shouldn't trust Shulkin on the Cerner contract because Shulkin was positioning himself for a post-government job? What evidence do you have to support this allegation? 6.Why did you tell people that Shulkin planned to sign the Cerner contract on March 29? 7.How did you know ahead of time that Shulkin would be fired that week? 8.Why did you become executive in charge of 01& T? 9.What experience do you have in health care IT? 10.Why did you, John Windom and Rich Stone meet about ousting Genevieve Morris? 11.Why didn't Genevieve Morris want you to come to the kickoff event? 12.Why do you walk around the office in socks or flip flops? 13.Why have you canceled speaking engagements as executive in charge? 14.Why did you move back into the CIO office from the OEHRM? What have these repeated moves cost taxpayers? AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000312 312 of 6274 Page 350 of 1093 Thanks, Isaac Isaac Arnsdorf ProPublica 917.512.0256 203.464.1409 isaac@propublica.org AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000313 313 of 6274 Page 351 of 1093 Document ID: 0.7.1705.49514 Isaac Arnsdorf From: < isaac.a rn sdorf@propu b Iica. org> To: Sandoval, Camilo J. Cc: Bee: Subject: Date: Attachments: [EXTERNAL] EHR Modernization Tue Oct 23 2018 13:05:04 EDT Cam, I'm interested in speaking with you for an in-depth article about the EHR modernization. My questions for you are: 1.Why did you transfer from Treasury to VA? 2.How do you know Ike Perlmutter? 3.Why do you have a standing daily call with Ike Perlmutter? 4.Why do you keep a spreadsheet tracking projects for Perlmutter? 5.Why did you tell Perlmutter that he shouldn't trust Shulkin on the Gerner contract because Shulkin was positioning himself for a post-government job? What evidence do you have to support this allegation? 6.Why did you tell people that Shulkin planned to sign the Gerner contract on March 29? 7.How did you know ahead of time that Shulkin would be fired that week? 8.Why did you become executive in charge of 01& T? 9.What experience do you have in health care IT? 10.Why did you, John Windom and Rich Stone meet about ousting Genevieve Morris? 11.Why didn 't Genevieve Morris want you to come to the kickoff event? 12.Why do you walk around the office in socks or flip flops? 13.Why have you canceled speaking engagements as executive in charge? 14.Why did you move back into the CIO office from the OEHRM? What have these repeated moves cost taxpayers? Thanks, Isaac Isaac Arnsdorf ProPublica 917.512.0256 203.464.1409 AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000314 314 of 6274 Page 352 of 1093 isaac@propublica.org AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000315 315 of 6274 Page 353 of 1093 Document ID: 0.7.1705.30470 From: Sandoval, Camilo J. To: Myklegard, Drew Cc: James, Bill ; Tibbits, Paul A. Bee: Subject: Mitre Report Date: Sun Oct 14 2018 17:15:58 EDT VA EHRM Interoperability Review Report Jan 2018 FINAL.PDF Attachments: Drew- Not sure if I shared or if you have seen this report previously. It's a little dated (pre Cerner acquisition), but the topics are still valid. Also, Bill may have mentioned that last week in Kansas City we met with folks from CareQuality and Common Well. I foresee in the very near future a meeting (led by you in November:) where we invite all the key stakeholders internally (OEHRM , VHA, VBA, NCA) and externally (HHS, CMS, DoD , IPO , WH, Cerner + their HIE's) to discuss strategy and roadmap to achieve national interoperability. Very exciting stuff ... look forward to supporting you lead this effort. Please let me know how I can help. Thanks Camilo Topic Area: VA Definition of Interoperability ............. ........... ......... ................................... 3 Topic Area : Commit to Full VA-DoD Interoperability ....................................................... 4 Topic Area: Leverage Current and Future Standards ........................................................... 6 Topic Area: Commit to Open, Standards-Based APls ......................................................... 7 Topic Area: Use Community Care Contracts to Foster Interoperability ............................... 9 Topic Area: Additional Contract Changes ........................................................................ 11 AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000316 316 of 6274 Page 354 of 1093 Document ID: 0.7.1705.30470-000001 Owner: Sandoval, Camilo J. Filename: VA EHRM Interoperability Review Report Jan 2018 FINAL.PDF Last Modified: Sun Oct 14 16:15:58 CDT 2018 AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000317 317 of 6274 Page 356 of 1093 VA EHRM Intero perability Review Report Jan 2018 FINAL.PDF for Printed Item: 33 ( Attach ment 1 of 1) ACQUISITION SENSITIVE Departlllent of Veterans Affairs Electronic Health Modernization Request for Proposal Interoperability Review Report Authors: Jay J. Schnitzer, M.D., Ph.D. l(b}(6} I MITRE AM ERiCAN PVERSIGHT ACQUISITION SENSITIVE Confidential and Proprietary VA-18-0298 and VA-18-0299-H-000318 For Department of Veterans Affairs Use Only 318 of 6274 Page 357 of 1093 VA EHRM Interoperabi lity Review Report Jan 2018 FINAL.PDF for Printed Item: 33 ( Attachment 1 of 1) ACQUISITION SENSITIVE This page intentionally left blank. ACQUISITION SENSITIVE AM ERiCAN PVERSIGHT Confidential and Proprietary VA-18-0298 and VA-18-0299-H-000319 For Department of Veterans Affairs Use Only 319 of 6274 Page 358 of 1093 VA EHRM Intero perability Review Report Jan 2018 FINAL.PDF for Printed Item: 33 ( Attach ment 1 of 1) ACQUISITION SENSITIVE DocumentNumber:MTR180033 Authors: Jay J. Schnitzer, M.D., Ph.D. rbX6) 1 Mclean, VA January2018 Sponsor: Department of Veterans Affairs Theviews,opinionsand/orfindings containedinthisreportarethoseof The MITRECorporation andshouldnotbe construed as anofficialgovernment position,policy,or decision,unless designated byotherdocumentation. ForInternalMITREUse.Thisdocument wasprepared for authorized distribution only.It hasnotbeenapproved for public release. © 2018TheMITRECorporation. All rightsreserved. ForDepartment of Veterans AffairsUseOnly VA EHRMRFPInteroperability ReviewReport January 31,2018 MITRE ACQUISITION SENSITIVE AMERICAN PVERSIGHT Confidential and Proprietary VA-18-0298 and VA-18-0299-H-000320 For Department of Veterans Affairs Use Only 320 of 6274 Page 359 of 1093 VA EHRM Interoperability Review Report Jan 20 18 FINAL.PDF for Printed Item : 33 ( Attach ment 1 of 1) ACQUISITION SENSITIVE This page intentionally left blank. ACQUISITION SENSITIVE Confidential and Proprietary AMERICAN For Department of Veterans Affairs Use Only PVERSIGHT VA-18-0298 and VA-18-0299-H-000321 321 of 6274 Page 360 of 1093 VA EHRM Interoperabi lity Review Report Jan 2018 FINAL.PDF for Printed Item: 33 ( Attachment 1 of 1) Executive Summary This Review Report presents responses to three requests from the Department of Veterans Affairs (VA) to MITRE related to the topic of interoperability within the VA Electronic Health Record Modernization Request for Proposal: I. Conduct an external Interoperability Review Panel to review the interoperability language in the existing Request for Proposal (RFP) , II. Engage an independent and unbiased legal expert to identify the specific changes to the RFP language necessary to implement the recommendations from the Interoperability Review Panel , and III. Visit the University of Pittsburgh Medical Center to understand the existing operational multi-vendor solution and interoperability solutions for applicability and scalability to the VA. I. Interoperability Review Panel In support of the Secretary of Veterans Affairs , David J. Shulkin , M.D. , The MITRE Corporation convened and hosted a VA Electronic Health Record Moderni zation (EHRM) Request for Proposal (RFP) Interoperability Review Panel on January 5, 2018, at MITRE ' s McLean headquarters. The invited external senior electronic health record (EHR) interoperability subject matter experts (the Panel) reviewed the interoperability language in the existing RFP and developed joint suggestions and recommendations for VA to consider for incorporation to support the successful execution of a new commercial EHR contract with industry. The Panel affirmed that the primary goal should be seamless Veteran-centric healthcare achieved through true EHR interoperability. Achieving this goal rests on three overarching principles that should be supported by interoperability language in the RFP: 1) free and open access to data, 2) an ecosystem that provides fair access to third parties by creating a level playing field , and 3) a seamless Veteran and health provider (clinician) experience. Four categories of recommendations from the Panel (the first three to the interoperability language in the RFP, and the fourth for future VA contracts) will enable VA to reali ze this goal on the basis of the underlying principles: 1) commit to full VA-Department of Defense (DoD) interoperability, 2) leverage current and future standards, 3) commit to open, standards-based application programming interfaces (APis) , and 4) use Care in the Community contracts to foster interoperability. For the first category (commit to full VA-DoD interoperability) , the Panel agreed that the Determination and Findings signed by Secretary Shulkin on June 1, 2017, represented the correct approach to interoperability within VA and between VA and DoD. The Panel strongly endorsed the proposed VA "API Gateway " language. The most important specific recommendations included: • Define the degree of interoperability the solution will provide, ranging from basic file sharing to fully interchangeable , integrated and functionally identical patient records. ACQUISITION SENSITIVE Confidential and Proprietary For Department of Veterans Affairs Use Only AMERICAN V PVERSIGHT VA-18-0298 and VA-18-0299-H-000322 322 of 6274 Page 361 of 1093 VA EHRM Interoperabi lity Review Report Jan 2018 FINAL.PDF for Printed Item: 33 ( Attachment 1 of 1) Suggest that the Contractor conduct an annual Interoperability Self-Assessment against current and future standards that shall be specified by the VA; and • The contract language should include the following elements: o performance measures to hold Cerner accountable for reducing the administrative burden in clinician workflow with the objective of increasing efficiency , o ability for bulk data export based on standards , with no proprietary formats (e.g. , Flat FHIR [Fast Healthcare Interoperability Resources]), and o "push" capability to insert patient data back into the VA EHR / Cerner database. For the second category (leverage current and future standards) , the following specific recommendations were among the most important: • Require that Cemer implement all standards as defined by VA, current and future, • Engage Cemer as an advocate of the VA and DoD position in all relevant standardsmaking bodies , and • Ensure that VA and Veterans have complete access to data. For the third category (commit to open, standards-based APis) , the Panel voiced the following recommendations: • Establish clear publishing and access service requirements, • Provide a VA application platform that supports APis from third party providers with no barrier to entry , and • Require implementation of clinical decision support (CDS) Hooks to invoke decision support from within a clinician's EHR workflow. The body of this report contains multiple additional specific recommendations. II. Recommendations for RFP Changes MITRE engaged Morrison & Foerster , LLP as the independent and unbiased legal expert to identify the specific changes to the RFP language necessary to implement the recommendations from the Interoperability Review Panel. Appendix C presents all recommended changes to the RFP. Ill. Observations from University of Pittsburgh Medical Center Site Visit A delegation from VA and MITRE traveled to Pittsburgh, Pennsylvania, on January 19, 2018, for a meeting with representatives from University of Pittsburgh Medical Center (UPMC) Enterprises to discuss aspects of EHR interoperability that UPMC has successfully implemented over the past several years. The report includes an overview of those practices. ACQUISITION SENSITIVE Confidential and Proprietary For Department of Veterans Affairs Use Only AMERICAN VI PVERSIGHT VA-18-0298 and VA-18-0299-H-000323 323 of 6274 Page 362 of 1093 VA EHRM Interoperabi lity Review Report Jan 2018 FINAL.PDF for Printed Item: 33 ( Attachment 1 of 1) IV. Closing Thoughts and Suggested Next Steps The Panelists noted that VA cannot achieve true future EHR interoperability through the Cerner RFP alone, or through technology alone. The state of practice today shares only a small portion of available patient data. For VA to succeed in the future , multiple other components must be present and aligned: innovation, policy, standards, customer buy-in , and legislation, to name a few. The following next steps are recommended for VA consideration: 1. Complete the RFP revisions, conduct appropriate negotiations with the Contractor expeditiously , and complete the contract process as planned. Stand firm during negotiations to maximize ease of access to data and data models for building third party APis , applications, and services for future community innovations. 2. Continue to work with other federal government agencies and departments with similar interoperability interests and concerns, including, but not limited to, the White House, DoD, Food and Drug Administration (FDA) , Centers for Medicare and Medicaid Services (CMS), Office of the National Coordinator for Health Information Technology (ONC), and other parts of the Department of Health and Human Services, to align approaches to EHR interoperability and the development and support of standards government-wide. 3. Support future innovation approaches, including concepts such as an Interoperability Laboratory and outreach to the broader innovation ecosystem (major medical centers, academia , traditional and non-traditional healthcare providers, startups, individual entrepreneurs, others). It is critical to align the innovations planned in VA's Digital Veterans Platform to the VA EHR innovation efforts to ensure consistent continuous improvements to clinician and Veteran health experiences. 4. Create an External Review Panel to provide expert continuous guidance, review, and feedback over the course of the implementation, to help capture best practices from the expert community going forward. Conduct ongoing demonstrations of end-to-end Veteran use cases requiring data sharing across organizational boundaries to validate improvements in Veteran healthcare and reduction of burden for healthcare providers. VA and Contractor will ensure that Federal Advisory Committee Act (FACA) guidelines are followed in leveraging any external review panels. ACQUISITION SENSITIVE Confidential and Proprietary For Department of Veterans Affairs Use Only AMERICAN Vll PVERSIGHT VA-18-0298 and VA-18-0299-H-000324 324 of 6274 Page 363 of 1093 VA EHRM Interoperab ility Review Report Jan 2018 FINAL.PDF for Printed Item : 33 ( Attachment 1 of 1) Table of Contents Background ..................................................... ................... .... .... .... .... .... ........ .... ........ .... .... ......... 1 I. Interoperability Review Panel ..... ........ .... ........ .... ...... ........ .... .... ............ .... ........ .... .... .........2 Introduct ion ................................................................... .... .... ........ ........ ............ .... ............ .2 Goal ................................................................................................................................... 2 Methodology /Approach ...................................................................................................... 2 Topic Area: VA Definition ofinteroperability .................................................................... 3 Topic Area: Comm it to Full VA-DoD Interoperabi lity ...................................................... .4 Topic Area: Leverage Current and Future Standards ...... ........ ................ ............ .... ............. 6 Topic Area: Comm it to Open, Standards-Based APis ................ .... ........ .... ........ .... .... ......... 7 Topic Area: Use Community Care Contracts to Foster Interoperability ............................... 9 Topic Area: Additional Contract Changes ........................................................................ 11 II. Recommendations for RFP Changes ................................................................................. 12 III. Observations from University of Pennsylvania Medical Center Site Visit.. ....................... 13 IV. Closing Thoughts and Suggested Next Steps ....................... ...... .... ........ .... ........ .... .... ....... 16 Appendix A : Interoperability Review Forum Partic ipants ......................................................... 17 Appendix B: RFP Language for Purchasing Extensib le Health IT ............................................. 19 Appendix C: Recommended RFP Interoperability Language Changes ...................................... 22 Appendix D: Acrony1ns ............................................................................................................ 42 ACQUISITION SENSITIVE Confidential and Proprietary For Department of Veterans Affairs Use Only AMERICAN Vlll PVERSIGHT VA-18-0298 and VA-18-0299-H-000325 325 of 6274 Page 364 of 1093 VA EHRM Interoperability Review Report Jan 20 18 FINAL.PDF for Printed Item : 33 ( Attach ment 1 of 1) This page intentionally left blank. ACQUISITION SENSITIVE Confidential and Proprietary For Department of Veterans Affairs Use Only AMERICAN lX PVERSIGHT VA-18-0298 and VA-18-0299-H-000326 326 of 6274 Page 365 of 1093 VA EHRM Interoperabi lity Review Report Jan 2018 FINAL.PDF for Printed Item: 33 ( Attachment 1 of 1) Background The Department of Veterans Affairs (VA) plans to establish seamless care for Veterans throughout the health care provider market. Seamless care requires interoperability between the Department of Defense (DoD), VA, VA affiliates, community partners, electronic health record (EHR) providers, healthcare providers, and vendors. VA directed The MITRE Corporation to independently review the capability of Cemer' s proposed EHR solution to seamlessly transmit health records between EHR systems supporting healthcare providers who both use and contribute patient data to a Veteran ' s health record, to include Veterans Choice Program (VCP) community-care service providers and VA affiliates. This Review Report presents responses to three requests: I. Conduct an external Interoperability Review Panel to review the interoperability language in the existing Request for Proposal (RFP), II. Engage an independent and unbiased legal expert to identify the specific changes to the RFP language necessary to implement the recommendations from the Interoperability Review Panel, and III. Visit the University of Pittsburgh Medical Center to understand the existing operational multi-vendor solution and interoperability solutions for applicability and scalability to VA. ACQUISITION SENSITIVE Confidential and Proprietary For Department of Veterans Affairs Use Only AMERICAN 1 PVERSIGHT VA-18-0298 and VA-18-0299-H-000327 327 of 6274 Page 366 of 1093 VA EHRM Interoperabi lity Review Report Jan 2018 FINAL.PDF for Printed Item: 33 ( Attachment 1 of 1) I. Interoperability Review Panel Introduction In support of the Secretary of Veterans Affairs, David J. Shulkin, M.D., MITRE convened and hosted a VA Electronic Health Record Moderni zation (EHRM) Request for Proposal (RFP) Interoperability Review Panel on January 5, 2018, at MITRE's McLean, VA headquarters. MITRE invited external senior EHR interoperability subject matter experts (hereafter referred to as Panelists) to review the interoperability language in the existing RFP and to develop joint suggestions and recommendations for VA to consider incorporating into the RFP to support the successful execution of a new commercial EHR contract with industry. Eleven Panelists took part in person , and several senior government executives observed the process (see Appendix A for the full list of participants). Goal The Interoperability Review Panel sought to provide Secretary Shulkin and his senior leadership team with insights into key best practices and guidance from national experts regarding EHR interoperability. The Panel evaluated the corresponding language in the draft RFP based on successful business transformations and implementations of a new commercial EHR system across a distributed hospital and provider network. This section of the report summarizes the outcome of the Panel: expert recommendations that will inform VA's interoperability contract language. The document also provides actionable and specific best practice recommendations and rationales to enable successful acquisition and implementation of EHR interoperability. Methodology/ Approach The first part of the session, which lasted for five hours, was conducted as a fish-bowl exercise and was guided by Chatham House Rule. The Panelists sat at a center table , with VA and other government observers sitting at surrounding tables. The second part, which lasted two hours, consisted of a summary debrief to the Secretary and senior VA leadership. The Secretary could ask questions and engage with the Panel throughout the second session. MITRE moderated the session to elicit inputs from all Panelists and to drive alignment toward consensus in the recommendations. The agenda for the first portion of the session was structured to elicit inputs from all Panelists, with notes captured on-screen as redlines to the RFP interoperability language to ensure recommendations accurately reflected the Panelists' contributions. Subsequently , in a facilitated discussion , the Panelists grouped their recommendations into specific categories in real time. The second portion, as noted, provided opportunities for the Secretary to discuss the recommendations in additional detail. This section of the report summarizes the discussion that took place. It highlights actionable changes to the interoperability language contained in the RFP and additional recommendations and lessons learned that can enable interoperability of the VA EHRM solution. Text boxes ACQUISITION SENSITIVE Confidential and Proprietary For Department of Veterans Affairs Use Only AMERICAN 2 PVERSIGHT VA-18-0298 and VA-18-0299-H-000328 328 of 6274 Page 367 of 1093 VA EHRM Interoperab ility Review Report Jan 2018 FINAL.PDF for Printed Item : 33 ( Attachment 1 of 1) throughout the report present direct quotations from Panelists. To ensure participant confidentiality , MITRE has destroyed the transcript and event recording used to develop this report . Topic Area: VA Definition of Interoperability The key to modernization is creating greater interoperability with Governmental partners, including DoD, in a way that focuses efforts in support of the Veteran's journey , beginning with their militm y service. We will partner with others to ensure Veterans can get their benefits, care, and services consistently , easily, and with excellent customer service, no matter where they are throughout their lives. VA will work with local communities , and with other Federal , State, Tribal, and Local Government entities to ensure Veterans get what they need. VA will also continue to leverage the private sector where appropriate and needed to deliver the very best outcomes for Veterans. - draft VA 2018- 2024 Strategic Plan Enable data sharing, interoperability, and agility through data standardization VA needs to allow data sharing among various business applications , such as appointment scheduling and business intelligence , as well as ensure transportability of informat ion between sites. Panelists "It really optimizes transportability of advised VA to leverage and support the best-in-class best practices, because if you are innovation currently in use within the VA culture. VA trying to transfer best practices from must also enable interoperability as the Department one site to another and you have the integrates the EHR into other support ing systems, both same system where the best practice is within the VA network and with external health service going to land, then it is much easier." providers. Agility is necessary for adoption of future innovative technologies and/or if VA wants to upgrade or change the EHR approach . The Panelists cautioned that the current EHR technology is already 20 years old and, as with all industries and information technology (IT) solut ions, many possib ly disruptive technologies exist on the horizon. The session began with a discussion on interoperability as currently defined by VA (Figure 1). Prior to establishing a roadmap to inform a nationwide plan to advance health data interoperability, VA must first ensure system-w ide interoperab ility across the Department. Throughout the Rev iew Panel session, the Panelists described and referred to this concept as "Level 1 Interoperability" throughout the Review Panel session ; it includes migration of Veteran data from ~ 130 instances of the Veterans Health Information Systems and Technology Architecture (VistA) to one VA platform. ACQUISITION SENSITIVE Confidential and Proprietary For Department of Veterans Affairs Use Only AMERICAN 3 PVERSIGHT VA-18-0298 and VA-18-0299-H-000329 329 of 6274 Page 368 of 1093 VA EHRM Interoperabi lity Review Report Jan 2018 FINAL.PDF for Printed Item: 33 ( Attachment 1 of 1) Figure 1. VA Definition of EHR Interoperability "Level 2 Interoperability," as described in the Panel discussion, addresses the ability for VA to leverage the same Cerner platform used by DoD to ensure seamless care from active service to Veteran status. Once this capability is implemented, the clinical data transformation will allow a true longitudinal view of a Veteran's record as he or she transitions from DoD to VA for care and other critical services such as benefit adjudication. "Level 3 Interoperability" will allow both VA and DoD to take an important step toward transforming electronic patient data exchange on a national scale. With the utilization of community healthcare providers via the VA Community of Care initiative and DoD's Tricare network providers , VA has the opportunity to drive interoperability between DoD and VA as well as with the extensive network of healthcare providers that serve our Nation's Veterans , active duty service members, and their beneficiaries. True nationwide EHR interoperability for the entire United States is the ultimate goal, and the Panelists agreed that VA and DoD could reach this goal if the three aforementioned levels of interoperability are achieved. Here, VA has the opportunity to drive clinical transformation and instantiation of a complete EHR for all patients at the national level. Topic Area: Commit to Full VA-DoD Interoperability The Panel focused primarily on reviewing the interoperability language within the RFP for the Cerner contract. However as described in Interoperability Levels 1 and 2, the commitment to the seamless integration of VA and DoD health data represents the foundation required to realize interoperability with private sector "You really have to get the basics done first. Let's just make absolutely sure that the interoperability between DoD and VA [is achieved]." ACQUISITION SENSITIVE Confidential and Proprietary For Department of Veterans Affairs Use Only AMERICAN 4 PVERSIGHT VA-18-0298 and VA-18-0299-H-000330 330 of 6274 Page 369 of 1093 VA EHRM Interoperabi lity Review Report Jan 2018 FINAL.PDF for Printed Item: 33 ( Attachment 1 of 1) healthcare providers. 1 It is important to note that the interoperability levels can be addressed simultaneously and should not be separated, as they must be integrated to efficiently achieve the larger future data sharing ecosystem. Specify the expectations for interoperability between DoD and VA During discussions about the expectation that Cerner will provide a single EHR solution to be shared by both DoD and VA, the Panel raised concerns about the lack of specificity in the contract language. Current interoperability data standards address a subset of the Veteran's clinical record and VA has the opportunity to ensure Cerner provides interoperability of all discrete data, at a minimum , between VA and DoD. Adopting the same platform would increase seamless sharing, but the Panel stated that VA should take additional action to ensure that such sharing is realized. The DoD and VA systems should use proprietary database -to-database interoperability if necessary , to maximi ze interoperability between those two systems. These systems should be configured to meet the distinct needs of each while being connected to each other in a native database-to-database method as necessary , leveraging open interoperability standards wherever possible. As a result , clinicians should experience no differences when they move from a VA system to a DoD system. These data should also be computable, or be made computable according to a specific schedule. VA should consider adding language to the RFP that specifically defines the degree of interoperability the solution will provide, ranging from basic file sharing to fully interchangeable , integrated and functionally identical patient records. The Panelists also stated that, for VA and DoD collectively, the contractual language should include the following requirements: • Performance measures to hold Cerner accountable for reducing the administrative burden in clinician workflow with the objective of increasing efficiency • Capability for bulk data export based on standards, with no proprietary formats (e.g., Flat FHIR [Fast Healthcare Interoperability Resources]) • "Push" capability to insert new patient data back into the VA EHR / Cerner database. Pivot the RFP to be Veteran-centric and not system-centric The Panelists discussed the impact of EHR implementations on clinician workflow, describing the issue as one of approaching the implementation as an IT system implementation rather than the preferred Veteran- or clinician-centric implementation. The current RFP appears to be written in a system-centric way rather than leveraging use-cases to describe the Veteran or clinician experience or workflow to characteri ze the requirement. The Panelists recommended that VA incorporate use-cases to characterize requirements and amend the RFP language to emphasize the Veteran-centric objectives. In addition, Panelists noted that VA should recognize that EHRs do not currently maximi ze efficient clinical workflow, and that VA specify that the 1 Healthcare providers is used to refer to community based physicians/speci alist and hospitals. ACQUISITION SENSITIVE Confidential and Proprietary For Department of Veterans Affairs Use Only AMERICAN 5 PVERSIGHT VA-18-0298 and VA-18-0299-H-000331 331 of 6274 Page 370 of 1093 VA EHRM Interoperabi lity Review Report Jan 2018 FINAL.PDF for Printed Item: 33 ( Attachment 1 of 1) solution present clinicians with relevant information where needed with a minjmum number of "clicks to find." Topic Area: Leverage Current and Future Standards The integrated EHR platform that DoD and VA are implementing provides the opportunity to significantly influence interoperability standards across the healthcare community , addressing gaps and competition among current standards. The Panel recognized that commercial health systems and technologies would realize only limited business value from making data portable between them, but this would lower the barrier to patient movement among healthcare providers. Engage Cerner as an advocate of the VA and DoD position in all relevant standards-making bodies The Panel recommended increased VA presence and leadership in national health IT standardsmaking activities, in coordination with the DoD. Additionally, VA should encourage Cerner to serve as an active advocate of the VA-DoD position and to participate actively in the development and/or evaluation of new standards, policy directives, operating procedures, processes, etc. As an integrated voting bloc, VA, DoD, and Cerner will have the potential to act as a strong driver of national standards. Panelists understood that VA is not currently active in the FHIR community or in the Health Level Seven International (HL 7) Argonaut Project. In addition, Panelists identified a need for standards to exchange patient-reported outcome data for integration into the clinician's workflow. The current RFP language seemingly puts the burden on Cerner for the development of standards , and the Panel recommended that VA take a more active position. This will ensure that VA will participate and drive implementation when standards mature. Where standards are immature, VA must participate in efforts to accelerate standardization. Require Cerner to implement all standards as defined by VA, current and future Because it is unclear where health IT is heading in five years , the Panel strongly suggested VA include contract language to address possible future advancements in the form of standards as defined by VA. At a minimum, VA should seek maxjmum interoperability with community care organi zations, using open interoperability standards wherever possible. This fleribility would ensure that VA does not rely on external stakeholders to determine the standards that VA would be required to accept. The Panel recommended that VA pay particular attention to specific categories of standards: real-time data read/write by care providers and Veterans; interoperability tools; seamless DoD and VA vision records; and principles for data normalization and structure. The Panel also recognjzed Cerner' s influence in ensuring that the Common Well network interoperates at the highest possible levels with other networks including CareQuality - an influence that VA should continue to promote. ACQUISITION SENSITIVE Confidential and Proprietary For Department of Veterans Affairs Use Only AMERICAN 6 PVERSIGHT VA-18-0298 and VA-18-0299-H-000332 332 of 6274 Page 371 of 1093 VA EHRM Interoperab ility Review Report Jan 2018 FINAL.PDF for Printed Item : 33 ( Attachment 1 of 1) VA must own its dat a; clea r own ership and access are critica l to success now and in the future The Panel highlighted an important recommendation regarding data rights that was discussed in the prior VA EHRM Listening Forum on September 7, 2017. The Panel recommended that VA define who has what rights from the perspectives of data ownership, access, and sharing (e.g ., VA owns the data and all data products vs. commun ity care providers own the pat ient data vs. each Veteran owns all of his or her data). Determining the authoritative data source for the various elements of a Veteran's health record is an important Veteran-centric component of interoperab ility, the longitudinal record, and seamless access to data. "So, what you need is clear access and clear ownership of your information ...you need to have absolutely, undisputed, clear ownership and ability to move the data to any place you want to use it and use it in any way you want to use it when you get there. And not have them [Cerner] be able to say no, that's our data or hinder you in any way or have an unreasonable charge to get it." VA should define an enterprise-w ide policy for all VA data. A suitable policy would include, but not be limited to, EHRM-specific data, and should be issued by the VA Central Office (V ACO) or Veterans Health Administration (VHA). VA must have clear ownership of and access to all the informat ion in the EHR and be able to move that information (into new systems or among systems) as needed, now and in the future . Own ing the data ensw-es that it is availab le regard less of vendor or system. VA must include this in the Cerner contract. Technology innovations occur rapidly in the 21 st century, and VA must have full ability to move its data to future systems. Panelists also recommended that VA publish its data model , for instance to the National Library of Medicine, to further promote commercial interoperability investments. Lastly, Panelists encouraged VA to leverage its investment in the Open Sow-ce Electron ic Health Record Alliance (OSEHRA) by prov iding seed money to develop open sow-ce connecto rs between Cerner and Epic, which would encourage other vendors to join in the effort. Topic Area : Commit to Open, Standards-Based APls A significant technology enabler of seamless interoperability among the community of Veteran healthcare providers is the use of App lication Programming Interfaces (APis). These software intermediar ies allow disparate EHR applications to communicate with each other and exchange data using standard , defined forms. The Panel emphasized the need for VA to create an environment that would minimi ze additional costs to community providers in order to interoperate with VA. VA can accomplish this by requir ing the new EHR system to expose APis that support bi-directional data transact ions . The Panel further recommended that VA make a commitment to open, standards-based APis , including the SMART on FHIR/Argonaut APis, to facilitate the ready and efficient exchange of data with partners providing care in the community and to support open clinical work:flow. ACQUISITION SENSITIVE Confidential and Propr ietary For Department of Veterans Affairs Use Only AMERICAN 7 PVERSIGHT VA-18-0298 and VA-18-0299-H-000333 333 of 6274 Page 372 of 1093 VA EHRM Interoperabi lity Review Report Jan 2018 FINAL.PDF for Printed Item: 33 ( Attachment 1 of 1) Establish clear publishing and access service requirements The Panel recogni zed that data access requirements differ depending on who provides or accesses that data. Therefore, the Panel recommended that VA be more specific in defining each level of data publishing and access service that is specific to (1) Veteran access (e.g., use of vets.gov) ; (2) VA clinician access ; (3) partner access; and (4) Health Information Exchange (HIE) access. The RFP should include a clear description of identity and access management requirements, including user population types and the association of specific application permissions with particular roles /positions. "The Contractor should provide all of the data that is currently being provided in the Contractor's patient portal to the consumer via an open standards -based API gateway. The Contractor should also provide all of the reporting data required by federal law to the Veteran via an open standards based API framework, accessible via any application or thirdparty data store of the Veteran's choice, that's number one." Machine-to-machine access is also critical for efficient sharing of information. The Panel recommended that VA ensure that all significant data stored in the software be accessible through APis with no requirement for creation of custom applications to specifically access VA data. From a forward-looking perspective, VA should require that the EHR system support the ability to access data elements using open standards-based interfaces , and include the ability to interface with legacy data, patient-generated data, and third -party data that resides outside the EHR system. In addition, Cerner should provide the required utility services to support intermediary or peer-to-peer services (e.g. , support Veteran-directed or Veteran-mediated requests, data exchange , and ingestion of data from non-VA providers). Provide a VA application platform that supports APls from third-party providers with no barrier to entry Cw-rently vets.gov serves as a portal to Veteran services. The Panel recommended that VA consider "The API Gateway document is awesome ... using such a portal to connect any third-party world class and future looking." application to the EHR solution without requiring fees or vendor permissions. VA should have full authority to connect any third-party application through one of the standard open APis conformant with the vendor ' s API without pre-registering the application with the vendor. This is a very important authority to have in terms of the ability to innovate rapidly , without constraints. The Panelists also reviewed the proposed VA "API Gateway" language provided dw-ing the API discussion to anchor the dialogue and concwTed that this requirement is fundamental to supporting interoperability. The Panel strongly endorsed the "API Gateway " language. Specifically, the Panelists recommended that VA include a requirement that VA have full authority to connect any third-party application to the Cerner system without requiring prior approval by Cerner. Furthermore , VA should ensw-e that developers of third-party applications connecting to the VA system via the open standard and VA-defined APis continue to own their ACQUISITION SENSITIVE Confidential and Proprietary For Department of Veterans Affairs Use Only AMERICAN 8 PVERSIGHT VA-18-0298 and VA-18-0299-H-000334 334 of 6274 Page 373 of 1093 VA EHRM Interoperab ility Review Report Jan 2018 FINAL.PDF for Printed Item : 33 ( Attachment 1 of 1) intellectual property (IP). From a usability perspective, the Panel also recommended that VA be able to establish the connectivity business rules , such as the ability for applications to remain connected for a reasonable time frame (e.g., 1 year) and to receive automatic notification about patient information updates. Require implementation of Clinical Decision Service (CDS) Hooks to invoke decision support from within a clinician's EHR workflow EHRs are essential to efficient delivery of high-quality care, as they provide the clinician with essential decision data at the time required. However , current EHR systems approach workflow from an IT system perspective rather than a clinician's perspective. The latter workflow should , of course , be paramount in the VA EHR implementation , and should also leverage a recent innovation called CDS Hooks. This technology provides the clinician with context-driven decision support and capability by enabling the EHR to trigger third-party services at key events that include order ing medication and opening a patient face sheet. For example, when the VA clinician begins to prescribe medication , a CDS Hook can call an externa l service that presents the clinician with the list of medications already prescribed to the patient by clinicians outside VA. The Panelists strongly recommended that VA require Cemer to implement and use CDS Hooks within the clinician workflow. Topic Area: Use Community Care Contracts to Foster Interoperability The new EHR system must be able to communicate with other EHR systems (e.g. , Epic , AllScripts , etc.) within the care community. It is critical that VA ensure the Cerne r EHR system remain robust for future interoperability with new products . Cerner must commit itself to supporting other forms of interoperability , such as a presentation layer that is common to other systems (e.g., the App store model). The Panel recommended that prior to execution of the Community Care Act contract VA require third-party providers (and Cerner compet itors) to commit to supporting the contract as early adopters. "Innovations going forward are going to come from multiple directions. And having those interfaces, and going with a general interoperability approach that doesn't fork off from what's happening in the rest of the healthcare system, will allow the Veterans to benefit from technology whether that's coming from Google, from a new company, from an innovative shop within VA -- you end up creating a market with good prices, high value." Veterans must be able to access and download a computable form of their health data Panelists noted that access to data represents the biggest problem today. VA must clearly direct Cerner to expose data so it can be used by third part ies. In the contract and in conversations with Cerner and third parties , VA must require specifics regarding how Veterans and providers will ACQUISITION SENSITIVE Confidential and Proprietary For Department of Veterans Affairs Use Only AMERICAN 9 PVERSIGHT VA-18-0298 and VA-18-0299-H-000335 335 of 6274 Page 37 4 of 1093 VA EHRM Interoperabi lity Review Report Jan 2018 FINAL.PDF for Printed Item: 33 ( Attachment 1 of 1) access and share their data. In addition, VA must require that any agreements leave the door open for future standards and technologies. Panelists believed that VA could achieve this by invoking the principle that the data belongs to the Veteran , rather than by citing specific technologies and standards (given how rapidly they are evolving). Veterans must be able to invoke their right of access to data to support data exchange across all providers (e.g., pull data through an API on their smartphone and push it to their community care provider), now and in the future. Keeping pace with this requirement will drive continual innovation by Cerner and all providers. VA must own the API layer Cerner ownership of the API layer (across every customer) poses a real threat to achieving interoperability , speed of innovation , and cost efficiency throughout the network of community care providers. Panelists stated that it is of utmost importance that VA include specific language stipulating that VA and Veterans be able to use third-party applications without having to register them with Cerner. VA must control the API key, not Cerner. Additionally , VA should require that Cerner provide access to MPages , a developer toolkit, and a programming interface that will enable innovators and third parties to develop APis. Require that community care contracts include VA EHR standards to support bidirectional data sharing Panelists agreed that requiring the support and collaboration of community care providers and participating actively in health IT standards bodies would give VA the opportunity to advance the "national" standard for data sharing-closing any gaps and inconsistencies among federal , industry , and inter-industry standards. VA must require every provider in the chain of a Veteran's care to support the same standards for data interoperability in order to ensure seamless, best possible care for Veterans. This includes the requirement that all providers and third-party applications, in exchange for using the VA-provided API gateway , provide bi-directional health information back to VA that can be used for context-driven clinical decisions and informatics. Change the data exchange consent model from "opt in" to "opt out" To encourage seamless interoperability across all entities providing care to Veterans, the consent model for exchanging data between healthcare providers must be modified to follow an opt-out rather than an opt-in policy , which limits participant numbers. This would allow Veterans to invoke their individual right of access under the Health Information Portability and Accountability Act (HIP AA) to move their data as needed. Many states have already adopted an opt-out consent policy as part of their HIE.2 VA can achieve this by aligning its policy to an opt- 2 See https://www.healthit.gov/sites/default/files/State%20HIE%200p t-ln%20vs%200pt-Out %20Policy%20Research_09-30l6_FinaLpdf ACQUISITION SENSITIVE Confidential and Proprietary For Department of Veterans Affairs Use Only AMERICAN 10 PVERSIGHT VA-18-0298 and VA-18-0299-H-000336 336 of 6274 Page 375 of 1093 VA EHRM Interoperabi lity Review Report Jan 2018 FINAL.PDF for Printed Item: 33 ( Attachment 1 of 1) out model, supported by the new VA proposed rule 3 to allow HIEs to collect a Veteran's consent and electronically attest to the consent to VA in order to obtain the required EHR. Topic Area: Additional Contract Changes In addition to the recommendations in the prior sections, the Panelists encouraged VA to add further definitions and clarity in the following areas: • Require Cerner to provide VA with full read and partial write access to all data elements within the EHR, at VA ' s sole discretion. • Require Cerner to make the VA data model, standards, and other similar interoperability changes available in all other non-VA Cemer instances of its EHR platform. • Clearly define "enabling security framework" so that users know if this means a specific security framework such as those provided by the National Institute of Standards and Technology (NIST), HITRUST, etc. • Amend "national Common Trust Framework" to specifically refer to the intended source. The Panelists suggested that VA replace this wording with "Trusted Exchange Framework and Common Agreement (TEFCA)" as specified in the 21 st Century Cures Act. • Amend RFP Performance Work Statement (PWS) Section 5.10.4(i) to clarify if the "provider collaboration via secure e-mail using Direct standards" is limited to the Direct protocols and just the Cerner platform. • Incorporate the model RFP language necessary for Cerner to support the API and SMART on FHIR platform and SMART-enabled applications, as described in Appendix B. 3 Sec https://s3 .amazonaws.com /public-inspcction.fodcralregi stcr.gov/2018-007 58.pdf ACQUISITION SENSITIVE Confidential and Proprietary For Department of Veterans Affairs Use Only AMERICAN 11 PVERSIGHT VA-18-0298 and VA-18-0299-H-000337 337 of 6274 Page 376 of 1093 VA EHRM Interoperab ility Review Report Jan 2018 FINAL.PDF for Printed Item: 33 ( Attachment 1 of 1) II. Recommendations for RFP Changes MITRE engaged Morrison & Foerster, LLP, as the independent and unbiased legal expert to identify the specific changes to the RFP language necessary to implement the recommendat ions made by the Interoperability Rev iew Panel. MITRE prov ided Morrison & Foerster, LLP, with the summary recommendations and a copy of the RFP. 4 In addition, MITRE collected specific ideas for contrac t language from the Panel. Appendix C presents all recommended RFP changes . 4 Pe,jormance Work Statement for the VA Electronic Health Record Modernization System, Final Version 1.7, Amendment 03, December 4, 2017, Department of Veterans Affairs. File name: 001 - VA EHRM IDlQ PWS (Amended 12.04.2017) - Copy.docx ACQUISITION SENSITIVE Confidential and Propr ietary For Department of Veterans Affairs Use Only AMERICAN 12 PVERSIGHT VA-18-0298 and VA-18-0299-H-000338 338 of 6274 Page 377 of 1093 VA EHRM Interoperab ility Review Report Jan 2018 FINAL.PDF for Printed Item : 33 ( Attachment 1 of 1) Ill. Observations from University of Pennsylvania Medical Center Site Visit A delegation from VA and MI TRE traveled to Pittsbmgh, Pennsylvan ia, on January 19, 2018, for a meeting with representatives ofUPMC Enterprises to discuss aspects of EHR interoperability that UPMC has successfully implemented over the ast several years. The VA team led b John Windom , included Dr. Ashwini Zenoo z, (b)(6) John Short and 6 (b)( ) The MITRE group included Richard Byrne , Jay Schnitzer, ..... (b_ )(_6)____ ___, 6 l(b)(6) ~ and (b)( ) The hosts at UPMC included Dr. Rasu Shrestha, C. Talbot Heppenstall , Jr., Ed McAllister , Dr. Robert Bart , Adam Berger, Diane Michalec, Phyllis Szymanski , and Dr. Amy Urban, as well as add itional staff. The meeting was broken into four parts. Following introductions , Session 1 described the structure of UPMC. Session 2 covered UPMC' s last decade of interoperability , and Session 3 centered on the road ahead for UPMC and industry. Dr. Rasu Shrestha began the meeting by making the introductions and setting the agenda. He stated that UPMC ' s approach had followed a best-of-breed strategy , as opposed to a best-of-suite strategy, with the intent ion of failing fast and succeed ing often. The overall UPMC structure has four parts: provider serv ices, insurance serv ices, international activities , and enterprises. During the discussion of interoperabi lity, the UPMC team described its approach to interoperability , called Connected Healthcare , which is based on the commercial product dbMotion of AllScripts. UPMC has created an entity titled ClinicalConnect HIE (CCHIE) that uses HL7. ClinicalConnect exists as a separate 501c(3) company , of which UPMC is a member. CCHIE conta ins 90 live interfaces . Th is HIE went live in June 2012; its members cons ist of 10 hospitals. It competes with three other HIEs in Pennsylvania. The repository contains data on 8.3 million patients , and, in terms of patient consent, CCHI E uses an opt-out model. It currently has connect ions to four EHRs: Cerne r (two vers ions) , Epic, and Varian. Data available within CCHI E spans allergies, clinical documents , diagnosis , encounters , immuni zations, labs , medications , problems , and procedures. Much of this data is in the form of documents (Continuity of Care Document (HITSP C32 CCD format, including problems, allergies , and medications); unstructured clin ical documents (HITSP C62 format); Consolidated Clinical Document Architecture (C-CDA CCD , including problems, allergies , medications , immuni zations , procedures , and insurance); and HL7 Interface (ADT: encounters, documents , imaging documents , and labs only). At the point of care dbMotion allows multiple views for the CCHIE: 1) a clinical view, 2) a newer view titled EHR agent , and 3) a Cerner MPage integrat ion view . The next phase of the UPMC work in this regard will consist of integrat ion with Common Well. Figure 2 shows the architecture of the system. Figure 3 dep icts the data feeds. ACQUISITION SENSITIVE Confidential and Proprietary For Department of Veterans Affairs Use Only AMERICAN 13 PVERSIGHT VA-18-0298 and VA-18-0299-H-000339 339 of 6274 Page 378 of 1093 VA EHRM Intero perability Review Report Jan 2018 FINAL.PDF for Printed Item: 33 ( Attach ment 1 of 1) _____. - eHeaitt, ·--- " Exchange .. --- The Children'> institut e Armstro~ County Me,,;~, Hosprtail The Children's Home Butler Hospital Heritage Va lley All scripts db Mot1on Node f::l Allscripts PRO • All scripts Sunrise All scripts Touch Works - St. Cla 1r Hosp,t.a I P@d1.at ric Presbytenan seri1orcare Hean h System Alliance eChnical Works Cerner EHR eMD GE Cent ricity Epic EHR e Meditech EHR McKesson Answers on Demand Home Evident Health NextGen Siemens EHR Source: From UPMC Enterprises, used with permission , for VA use only Figure 2. ClinicalConnect (Western Pennsylvania} Health Information Exchange - - "°"'"' '""' r ,!!fAl119'LAN ..._AC EHIEAI.TH~ CORNER ,U ~ ~ ~ -- ~ UN[fllHl CE:~ !?:,,._ C ci' ~ 0 ,.. _.n _~-- C:tli;rnJ111nl - ~ -~ I >' ...... H31 ACH•V< . ~- ,...""'"""-to a:fllN(R. C{RNl(A:H;I ~ lflDfll 2!:.-- "'IC ll!PIC· AOMINISTERIED FRAM OBIJlTR-"SOUNI) c.,.,;Ak~ffllii/ ....._.frtalm!.LOGluliflr:t • INPATIENT ,....,.CA To: Cussatt, Dominic (SES) ; Sandoval, Camilo J. Cc: Bee: Subject: Date: Attachments: FOIA request & planned release of the Mitre Report Thu Sep 06 2018 07:50:38 EDT VA EHRM Interoperability Review Report Jan 2018 FINAL.PDF Camilo, Dom, Good morning. I am also the acting FOIA officer for OEHRM. We have received three separate FOIA requests for the attached Mitre report and now that our contract is awarded and upon review by John Windom we are preparing to release the entire document without any redactions. We am sharing this document with you in advance for your awareness, no action is required. VHA leadership has also received a similar email. Please let me know if you have any questions. Warm regards, Fred Mingo VA Office of Electronic Health Record Modernization (OEHRM) Director, Program Control Acting FOIA Officer 811 Vermont Ave; Rm 2158 M ~(b)(6) AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000369 369 of 6274 Page 408 of 1093 Document ID: 0.7.1705.689785-000001 Owner: Mingo, Fred J., Jr. Filename: VA EHRM Interoperability Review Report Jan 2018 FINAL.PDF Last Modified: Thu Sep 06 06:50:38 CDT 2018 AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000370 370 of 6274 Page 409 of 1093 VA EHRM Intero perability Review Report Jan 2018 FINAL.PDF for Printed Item: 35 ( Attach ment 1 of 1) ACQUISITION SENSITIVE Departlllent of Veterans Affairs Electronic Health Modernization Request for Proposal Interoperability Review Report Authors: Jay J. Schnitzer, M.D., Ph.D. l(b}(6} I MITRE AM ERiCAN PVERSIGHT ACQUISITION SENSITIVE Confidential and Proprietary VA-18-0298 and VA-18-0299-H-000371 For Department of Veterans Affairs Use Only 371 of 6274 Page 410 of 1093 VA EHRM Interoperabi lity Review Report Jan 2018 FINAL.PDF for Printed Item: 35 ( Attachment 1 of 1) ACQUISITION SENSITIVE This page intentionally left blank. ACQUISITION SENSITIVE AM ERiCAN PVERSIGHT Confidential and Proprietary VA-18-0298 and VA-18-0299-H-000372 For Department of Veterans Affairs Use Only 372 of 6274 Page 411 of 1093 VA EHRM Intero perability Review Report Jan 2018 FINAL.PDF for Printed Item: 35 ( Attach ment 1 of 1) ACQUISITION SENSITIVE DocumentNumber:MTR180033 Authors: Jay J. Schnitzer, M.D., Ph.D. I l(b}(6} Mclean, VA January2018 Sponsor: Department of Veterans Affairs Theviews,opinionsand/orfindings containedinthisreportarethoseof The MITRECorporation andshouldnotbe construed as anofficialgovernment position,policy,or decision,unless designated byotherdocumentation. ForInternalMITREUse.Thisdocument wasprepared for authorized distribution only.It hasnotbeenapproved for public release . © 2018TheMITRECorporat ion. All rightsreserved . ForDepartment of Veterans AffairsUseOnly VA EHRMRFPInteroperability ReviewReport January 31,2018 MITRE ACQUISITION SENSITIVE AMERICAN PVERSIGHT Confidential and Proprietary VA-18-0298 and VA-18-0299-H-000373 For Department of Veterans Affairs Use Only 373 of 6274 Page 412 of 1093 VA EHRM Interoperability Review Report Jan 20 18 FINAL.PDF for Printed Item : 35 ( Attach ment 1 of 1) ACQUISITION SENSITIVE This page intentionally left blank. ACQUISITION SENSITIVE Confidential and Proprietary AMERICAN For Department of Veterans Affairs Use Only PVERSIGHT VA-18-0298 and VA-18-0299-H-000374 374 of 6274 Page 413 of 1093 VA EHRM Interoperabi lity Review Report Jan 2018 FINAL.PDF for Printed Item: 35 ( Attachment 1 of 1) Executive Summary This Review Report presents responses to three requests from the Department of Veterans Affairs (VA) to MITRE related to the topic of interoperability within the VA Electronic Health Record Modernization Request for Proposal: I. Conduct an external Interoperability Review Panel to review the interoperability language in the existing Request for Proposal (RFP) , II. Engage an independent and unbiased legal expert to identify the specific changes to the RFP language necessary to implement the recommendations from the Interoperability Review Panel , and III. Visit the University of Pittsburgh Medical Center to understand the existing operational multi-vendor solution and interoperability solutions for applicability and scalability to the VA. I. Interoperability Review Panel In support of the Secretary of Veterans Affairs , David J. Shulkin , M.D. , The MITRE Corporation convened and hosted a VA Electronic Health Record Moderni zation (EHRM) Request for Proposal (RFP) Interoperability Review Panel on January 5, 2018, at MITRE ' s McLean headquarters. The invited external senior electronic health record (EHR) interoperability subject matter experts (the Panel) reviewed the interoperability language in the existing RFP and developed joint suggestions and recommendations for VA to consider for incorporation to support the successful execution of a new commercial EHR contract with industry. The Panel affirmed that the primary goal should be seamless Veteran-centric healthcare achieved through true EHR interoperability. Achieving this goal rests on three overarching principles that should be supported by interoperability language in the RFP: 1) free and open access to data, 2) an ecosystem that provides fair access to third parties by creating a level playing field , and 3) a seamless Veteran and health provider (clinician) experience. Four categories of recommendations from the Panel (the first three to the interoperability language in the RFP, and the fourth for future VA contracts) will enable VA to reali ze this goal on the basis of the underlying principles: 1) commit to full VA-Department of Defense (DoD) interoperability, 2) leverage current and future standards, 3) commit to open, standards-based application programming interfaces (APis) , and 4) use Care in the Community contracts to foster interoperability. For the first category (commit to full VA-DoD interoperability) , the Panel agreed that the Determination and Findings signed by Secretary Shulkin on June 1, 2017, represented the correct approach to interoperability within VA and between VA and DoD. The Panel strongly endorsed the proposed VA "API Gateway " language. The most important specific recommendations included: • Define the degree of interoperability the solution will provide, ranging from basic file sharing to fully interchangeable , integrated and functionally identical patient records. ACQUISITION SENSITIVE Confidential and Proprietary For Department of Veterans Affairs Use Only AMERICAN V PVERSIGHT VA-18-0298 and VA-18-0299-H-000375 375 of 6274 Page 414 of 1093 VA EHRM Interoperabi lity Review Report Jan 2018 FINAL.PDF for Printed Item: 35 ( Attachment 1 of 1) Suggest that the Contractor conduct an annual Interoperability Self-Assessment against current and future standards that shall be specified by the VA; and • The contract language should include the following elements: o performance measures to hold Cerner accountable for reducing the administrative burden in clinician workflow with the objective of increasing efficiency , o ability for bulk data export based on standards , with no proprietary formats (e.g. , Flat FHIR [Fast Healthcare Interoperability Resources]), and o "push" capability to insert patient data back into the VA EHR / Cerner database. For the second category (leverage current and future standards) , the following specific recommendations were among the most important: • Require that Cemer implement all standards as defined by VA, current and future, • Engage Cemer as an advocate of the VA and DoD position in all relevant standardsmaking bodies , and • Ensure that VA and Veterans have complete access to data. For the third category (commit to open, standards-based APis) , the Panel voiced the following recommendations: • Establish clear publishing and access service requirements, • Provide a VA application platform that supports APis from third party providers with no barrier to entry , and • Require implementation of clinical decision support (CDS) Hooks to invoke decision support from within a clinician's EHR workflow. The body of this report contains multiple additional specific recommendations. II. Recommendations for RFP Changes MITRE engaged Morrison & Foerster , LLP as the independent and unbiased legal expert to identify the specific changes to the RFP language necessary to implement the recommendations from the Interoperability Review Panel. Appendix C presents all recommended changes to the RFP. Ill. Observations from University of Pittsburgh Medical Center Site Visit A delegation from VA and MITRE traveled to Pittsburgh, Pennsylvania, on January 19, 2018, for a meeting with representatives from University of Pittsburgh Medical Center (UPMC) Enterprises to discuss aspects of EHR interoperability that UPMC has successfully implemented over the past several years. The report includes an overview of those practices. ACQUISITION SENSITIVE Confidential and Proprietary For Department of Veterans Affairs Use Only AMERICAN VI PVERSIGHT VA-18-0298 and VA-18-0299-H-000376 376 of 6274 Page 415 of 1093 VA EHRM Interoperabi lity Review Report Jan 2018 FINAL.PDF for Printed Item: 35 ( Attachment 1 of 1) IV. Closing Thoughts and Suggested Next Steps The Panelists noted that VA cannot achieve true future EHR interoperability through the Cerner RFP alone, or through technology alone. The state of practice today shares only a small portion of available patient data. For VA to succeed in the future , multiple other components must be present and aligned: innovation, policy, standards, customer buy-in , and legislation, to name a few. The following next steps are recommended for VA consideration: 1. Complete the RFP revisions, conduct appropriate negotiations with the Contractor expeditiously , and complete the contract process as planned. Stand firm during negotiations to maximize ease of access to data and data models for building third party APis , applications, and services for future community innovations. 2. Continue to work with other federal government agencies and departments with similar interoperability interests and concerns, including, but not limited to, the White House, DoD, Food and Drug Administration (FDA) , Centers for Medicare and Medicaid Services (CMS), Office of the National Coordinator for Health Information Technology (ONC), and other parts of the Department of Health and Human Services, to align approaches to EHR interoperability and the development and support of standards government-wide. 3. Support future innovation approaches, including concepts such as an Interoperability Laboratory and outreach to the broader innovation ecosystem (major medical centers, academia , traditional and non-traditional healthcare providers, startups, individual entrepreneurs, others). It is critical to align the innovations planned in VA's Digital Veterans Platform to the VA EHR innovation efforts to ensure consistent continuous improvements to clinician and Veteran health experiences. 4. Create an External Review Panel to provide expert continuous guidance, review, and feedback over the course of the implementation, to help capture best practices from the expert community going forward. Conduct ongoing demonstrations of end-to-end Veteran use cases requiring data sharing across organizational boundaries to validate improvements in Veteran healthcare and reduction of burden for healthcare providers. VA and Contractor will ensure that Federal Advisory Committee Act (FACA) guidelines are followed in leveraging any external review panels. ACQUISITION SENSITIVE Confidential and Proprietary For Department of Veterans Affairs Use Only AMERICAN Vll PVERSIGHT VA-18-0298 and VA-18-0299-H-000377 377 of 6274 Page 416 of 1093 VA EHRM Interoperab ility Review Report Jan 2018 FINAL.PDF for Printed Item : 35 ( Attachment 1 of 1) Table of Contents Background ..................................................... ................... .... .... .... .... .... ........ .... ........ .... .... ......... 1 I. Interoperability Review Panel ..... ........ .... ........ .... ...... ........ .... .... ............ .... ........ .... .... .........2 Introduct ion ................................................................... .... .... ........ ........ ............ .... ............ .2 Goal ................................................................................................................................... 2 Methodology /Approach ...................................................................................................... 2 Topic Area: VA Definition ofinteroperability .................................................................... 3 Topic Area: Comm it to Full VA-DoD Interoperabil ity ...................................................... .4 Topic Area: Leverage Current and Future Standards ...... ........ ................ ............ .... ............. 6 Topic Area: Comm it to Open, Standards-Based APis ................ .... ........ .... ........ .... .... ......... 7 Topic Area: Use Community Care Contracts to Foster Interoperability ............................... 9 Topic Area: Additional Contract Changes ........................................................................ 11 II. Recommendations for RFP Changes ................................................................................. 12 III. Observations from University of Pennsylvania Medical Center Site Visit.. ....................... 13 IV. Closing Thoughts and Suggested Next Steps ....................... ...... .... ........ .... ........ .... .... ....... 16 Appendix A : Interoperability Review Forum Partic ipants ......................................................... 17 Appendix B: RFP Language for Purchasing Extensib le Health IT ............................................. 19 Appendix C: Recommended RFP Interoperability Language Changes ...................................... 22 Appendix D: Acrony1ns ............................................................................................................ 42 ACQUISITION SENSITIVE Confidential and Proprietary For Department of Veterans Affairs Use Only AMERICAN Vlll PVERSIGHT VA-18-0298 and VA-18-0299-H-000378 378 of 6274 Page 417 of 1093 VA EHRM Interoperability Review Report Jan 20 18 FINAL.PDF for Printed Item : 35 ( Attach ment 1 of 1) This page intentionally left blank. ACQUISITION SENSITIVE Confidential and Proprietary For Department of Veterans Affairs Use Only AMERICAN lX PVERSIGHT VA-18-0298 and VA-18-0299-H-000379 379 of 6274 Page 418 of 1093 VA EHRM Interoperabi lity Review Report Jan 2018 FINAL.PDF for Printed Item: 35 ( Attachment 1 of 1) Background The Department of Veterans Affairs (VA) plans to establish seamless care for Veterans throughout the health care provider market. Seamless care requires interoperability between the Department of Defense (DoD), VA, VA affiliates, community partners, electronic health record (EHR) providers, healthcare providers, and vendors. VA directed The MITRE Corporation to independently review the capability of Cemer' s proposed EHR solution to seamlessly transmit health records between EHR systems supporting healthcare providers who both use and contribute patient data to a Veteran ' s health record, to include Veterans Choice Program (VCP) community-care service providers and VA affiliates. This Review Report presents responses to three requests: I. Conduct an external Interoperability Review Panel to review the interoperability language in the existing Request for Proposal (RFP), II. Engage an independent and unbiased legal expert to identify the specific changes to the RFP language necessary to implement the recommendations from the Interoperability Review Panel, and III. Visit the University of Pittsburgh Medical Center to understand the existing operational multi-vendor solution and interoperability solutions for applicability and scalability to VA. ACQUISITION SENSITIVE Confidential and Proprietary For Department of Veterans Affairs Use Only AMERICAN 1 PVERSIGHT VA-18-0298 and VA-18-0299-H-000380 380 of 6274 Page 419 of 1093 VA EHRM Interoperabi lity Review Report Jan 2018 FINAL.PDF for Printed Item: 35 ( Attachment 1 of 1) I. Interoperability Review Panel Introduction In support of the Secretary of Veterans Affairs, David J. Shulkin, M.D., MITRE convened and hosted a VA Electronic Health Record Moderni zation (EHRM) Request for Proposal (RFP) Interoperability Review Panel on January 5, 2018, at MITRE's McLean, VA headquarters. MITRE invited external senior EHR interoperability subject matter experts (hereafter referred to as Panelists) to review the interoperability language in the existing RFP and to develop joint suggestions and recommendations for VA to consider incorporating into the RFP to support the successful execution of a new commercial EHR contract with industry. Eleven Panelists took part in person , and several senior government executives observed the process (see Appendix A for the full list of participants). Goal The Interoperability Review Panel sought to provide Secretary Shulkin and his senior leadership team with insights into key best practices and guidance from national experts regarding EHR interoperability. The Panel evaluated the corresponding language in the draft RFP based on successful business transformations and implementations of a new commercial EHR system across a distributed hospital and provider network. This section of the report summarizes the outcome of the Panel: expert recommendations that will inform VA's interoperability contract language. The document also provides actionable and specific best practice recommendations and rationales to enable successful acquisition and implementation of EHR interoperability. Methodology/ Approach The first part of the session, which lasted for five hours, was conducted as a fish-bowl exercise and was guided by Chatham House Rule. The Panelists sat at a center table , with VA and other government observers sitting at surrounding tables. The second part, which lasted two hours, consisted of a summary debrief to the Secretary and senior VA leadership. The Secretary could ask questions and engage with the Panel throughout the second session. MITRE moderated the session to elicit inputs from all Panelists and to drive alignment toward consensus in the recommendations. The agenda for the first portion of the session was structured to elicit inputs from all Panelists, with notes captured on-screen as redlines to the RFP interoperability language to ensure recommendations accurately reflected the Panelists' contributions. Subsequently , in a facilitated discussion , the Panelists grouped their recommendations into specific categories in real time. The second portion, as noted, provided opportunities for the Secretary to discuss the recommendations in additional detail. This section of the report summarizes the discussion that took place. It highlights actionable changes to the interoperability language contained in the RFP and additional recommendations and lessons learned that can enable interoperability of the VA EHRM solution. Text boxes ACQUISITION SENSITIVE Confidential and Proprietary For Department of Veterans Affairs Use Only AMERICAN 2 PVERSIGHT VA-18-0298 and VA-18-0299-H-000381 381 of 6274 Page 420 of 1093 VA EHRM Interoperab ility Review Report Jan 2018 FINAL.PDF for Printed Item : 35 ( Attachment 1 of 1) throughout the report present direct quotations from Panelists. To ensure participant confidentiality , MITRE has destroyed the transcript and event recording used to develop this report . Topic Area: VA Definition of Interoperability The key to modernization is creating greater interoperability with Governmental partners, including DoD, in a way that focuses efforts in support of the Veteran's journey , beginning with their militm y service. We will partner with others to ensure Veterans can get their benefits, care, and services consistently , easily, and with excellent customer service, no matter where they are throughout their lives. VA will work with local communities , and with other Federal , State, Tribal, and Local Government entities to ensure Veterans get what they need. VA will also continue to leverage the private sector where appropriate and needed to deliver the very best outcomes for Veterans. - draft VA 2018- 2024 Strategic Plan Enable data sharing, interoperability, and agility through data standardization VA needs to allow data sharing among various business applications , such as appointment scheduling and business intelligence , as well as ensure transportability of informat ion between sites. Panelists "It really optimizes transportability of advised VA to leverage and support the best-in-class best practices, because if you are innovation currently in use within the VA culture. VA trying to transfer best practices from must also enable interoperability as the Department one site to another and you have the integrates the EHR into other support ing systems, both same system where the best practice is within the VA network and with external health service going to land, then it is much easier." providers. Agility is necessary for adoption of future innovative technologies and/or if VA wants to upgrade or change the EHR approach . The Panelists cautioned that the current EHR technology is already 20 years old and, as with all industries and information technology (IT) solut ions, many possib ly disruptive technologies exist on the horizon. The session began with a discussion on interoperability as currently defined by VA (Figure 1). Prior to establishing a roadmap to inform a nationwide plan to advance health data interoperability, VA must first ensure system-w ide interoperab ility across the Department. Throughout the Rev iew Panel session, the Panelists described and referred to this concept as "Level 1 Interoperability" throughout the Review Panel session ; it includes migration of Veteran data from ~ 130 instances of the Veterans Health Information Systems and Technology Architecture (VistA) to one VA platform. ACQUISITION SENSITIVE Confidential and Proprietary For Department of Veterans Affairs Use Only AMERICAN 3 PVERSIGHT VA-18-0298 and VA-18-0299-H-000382 382 of 6274 Page 421 of 1093 VA EHRM Interoperabi lity Review Report Jan 2018 FINAL.PDF for Printed Item: 35 ( Attachment 1 of 1) Figure 1. VA Definition of EHR Interoperability "Level 2 Interoperability," as described in the Panel discussion, addresses the ability for VA to leverage the same Cerner platform used by DoD to ensure seamless care from active service to Veteran status. Once this capability is implemented, the clinical data transformation will allow a true longitudinal view of a Veteran's record as he or she transitions from DoD to VA for care and other critical services such as benefit adjudication. "Level 3 Interoperability" will allow both VA and DoD to take an important step toward transforming electronic patient data exchange on a national scale. With the utilization of community healthcare providers via the VA Community of Care initiative and DoD's Tricare network providers , VA has the opportunity to drive interoperability between DoD and VA as well as with the extensive network of healthcare providers that serve our Nation's Veterans , active duty service members, and their beneficiaries. True nationwide EHR interoperability for the entire United States is the ultimate goal, and the Panelists agreed that VA and DoD could reach this goal if the three aforementioned levels of interoperability are achieved. Here, VA has the opportunity to drive clinical transformation and instantiation of a complete EHR for all patients at the national level. Topic Area: Commit to Full VA-DoD Interoperability The Panel focused primarily on reviewing the interoperability language within the RFP for the Cerner contract. However as described in Interoperability Levels 1 and 2, the commitment to the seamless integration of VA and DoD health data represents the foundation required to realize interoperability with private sector "You really have to get the basics done first. Let's just make absolutely sure that the interoperability between DoD and VA [is achieved]." ACQUISITION SENSITIVE Confidential and Proprietary For Department of Veterans Affairs Use Only AMERICAN 4 PVERSIGHT VA-18-0298 and VA-18-0299-H-000383 383 of 6274 Page 422 of 1093 VA EHRM Interoperabi lity Review Report Jan 2018 FINAL.PDF for Printed Item: 35 ( Attachment 1 of 1) healthcare providers. 1 It is important to note that the interoperability levels can be addressed simultaneously and should not be separated, as they must be integrated to efficiently achieve the larger future data sharing ecosystem. Specify the expectations for interoperability between DoD and VA During discussions about the expectation that Cerner will provide a single EHR solution to be shared by both DoD and VA, the Panel raised concerns about the lack of specificity in the contract language. Current interoperability data standards address a subset of the Veteran's clinical record and VA has the opportunity to ensure Cerner provides interoperability of all discrete data, at a minimum , between VA and DoD. Adopting the same platform would increase seamless sharing, but the Panel stated that VA should take additional action to ensure that such sharing is realized. The DoD and VA systems should use proprietary database -to-database interoperability if necessary , to maximi ze interoperability between those two systems. These systems should be configured to meet the distinct needs of each while being connected to each other in a native database-to-database method as necessary , leveraging open interoperability standards wherever possible. As a result , clinicians should experience no differences when they move from a VA system to a DoD system. These data should also be computable, or be made computable according to a specific schedule. VA should consider adding language to the RFP that specifically defines the degree of interoperability the solution will provide, ranging from basic file sharing to fully interchangeable , integrated and functionally identical patient records. The Panelists also stated that, for VA and DoD collectively, the contractual language should include the following requirements: • Performance measures to hold Cerner accountable for reducing the administrative burden in clinician workflow with the objective of increasing efficiency • Capability for bulk data export based on standards, with no proprietary formats (e.g., Flat FHIR [Fast Healthcare Interoperability Resources]) • "Push" capability to insert new patient data back into the VA EHR / Cerner database. Pivot the RFP to be Veteran-centric and not system-centric The Panelists discussed the impact of EHR implementations on clinician workflow, describing the issue as one of approaching the implementation as an IT system implementation rather than the preferred Veteran- or clinician-centric implementation. The current RFP appears to be written in a system-centric way rather than leveraging use-cases to describe the Veteran or clinician experience or workflow to characteri ze the requirement. The Panelists recommended that VA incorporate use-cases to characterize requirements and amend the RFP language to emphasize the Veteran-centric objectives. In addition, Panelists noted that VA should recognize that EHRs do not currently maximi ze efficient clinical workflow, and that VA specify that the 1 Healthcare providers is used to refer to community based physicians/speci alist and hospitals. ACQUISITION SENSITIVE Confidential and Proprietary For Department of Veterans Affairs Use Only AMERICAN 5 PVERSIGHT VA-18-0298 and VA-18-0299-H-000384 384 of 6274 Page 423 of 1093 VA EHRM Interoperabi lity Review Report Jan 2018 FINAL.PDF for Printed Item: 35 ( Attachment 1 of 1) solution present clinicians with relevant information where needed with a minjmum number of "clicks to find." Topic Area: Leverage Current and Future Standards The integrated EHR platform that DoD and VA are implementing provides the opportunity to significantly influence interoperability standards across the healthcare community , addressing gaps and competition among current standards. The Panel recognized that commercial health systems and technologies would realize only limited business value from making data portable between them, but this would lower the barrier to patient movement among healthcare providers. Engage Cerner as an advocate of the VA and DoD position in all relevant standards-making bodies The Panel recommended increased VA presence and leadership in national health IT standardsmaking activities, in coordination with the DoD. Additionally, VA should encourage Cerner to serve as an active advocate of the VA-DoD position and to participate actively in the development and/or evaluation of new standards, policy directives, operating procedures, processes, etc. As an integrated voting bloc, VA, DoD, and Cerner will have the potential to act as a strong driver of national standards. Panelists understood that VA is not currently active in the FHIR community or in the Health Level Seven International (HL 7) Argonaut Project. In addition, Panelists identified a need for standards to exchange patient-reported outcome data for integration into the clinician's workflow. The current RFP language seemingly puts the burden on Cerner for the development of standards , and the Panel recommended that VA take a more active position. This will ensure that VA will participate and drive implementation when standards mature. Where standards are immature, VA must participate in efforts to accelerate standardization. Require Cerner to implement all standards as defined by VA, current and future Because it is unclear where health IT is heading in five years , the Panel strongly suggested VA include contract language to address possible future advancements in the form of standards as defined by VA. At a minimum, VA should seek maxjmum interoperability with community care organi zations, using open interoperability standards wherever possible. This fleribility would ensure that VA does not rely on external stakeholders to determine the standards that VA would be required to accept. The Panel recommended that VA pay particular attention to specific categories of standards: real-time data read/write by care providers and Veterans; interoperability tools; seamless DoD and VA vision records; and principles for data normalization and structure. The Panel also recognjzed Cerner' s influence in ensuring that the Common Well network interoperates at the highest possible levels with other networks including CareQuality - an influence that VA should continue to promote. ACQUISITION SENSITIVE Confidential and Proprietary For Department of Veterans Affairs Use Only AMERICAN 6 PVERSIGHT VA-18-0298 and VA-18-0299-H-000385 385 of 6274 Page 424 of 1093 VA EHRM Interoperab ility Review Report Jan 2018 FINAL.PDF for Printed Item : 35 ( Attachment 1 of 1) VA must own its dat a; clea r own ership and access are critica l to success now and in the future The Panel highlighted an important recommendation regarding data rights that was discussed in the prior VA EHRM Listening Forum on September 7, 2017. The Panel recommended that VA define who has what rights from the perspectives of data ownership, access, and sharing (e.g ., VA owns the data and all data products vs. commun ity care providers own the pat ient data vs. each Veteran owns all of his or her data). Determining the authoritative data source for the various elements of a Veteran's health record is an important Veteran-centric component of interoperab ility, the longitudinal record, and seamless access to data. "So, what you need is clear access and clear ownership of your information ...you need to have absolutely, undisputed, clear ownership and ability to move the data to any place you want to use it and use it in any way you want to use it when you get there. And not have them [Cerner] be able to say no, that's our data or hinder you in any way or have an unreasonable charge to get it." VA should define an enterprise-w ide policy for all VA data. A suitable policy would include, but not be limited to, EHRM-specific data, and should be issued by the VA Central Office (V ACO) or Veterans Health Administration (VHA). VA must have clear ownership of and access to all the informat ion in the EHR and be able to move that information (into new systems or among systems) as needed, now and in the future . Own ing the data ensw-es that it is availab le regard less of vendor or system. VA must include this in the Cerner contract. Technology innovations occur rapidly in the 21 st century, and VA must have full ability to move its data to future systems. Panelists also recommended that VA publish its data model , for instance to the National Library of Medicine, to further promote commercial interoperability investments. Lastly, Panelists encouraged VA to leverage its investment in the Open Sow-ce Electron ic Health Record Alliance (OSEHRA) by prov iding seed money to develop open sow-ce connecto rs between Cerner and Epic, which would encourage other vendors to join in the effort. Topic Area : Commit to Open, Standards-Based APls A significant technology enabler of seamless interoperability among the community of Veteran healthcare providers is the use of App lication Programming Interfaces (APis). These software intermediar ies allow disparate EHR applications to communicate with each other and exchange data using standard , defined forms. The Panel emphasized the need for VA to create an environment that would minimi ze additional costs to community providers in order to interoperate with VA. VA can accomplish this by requir ing the new EHR system to expose APis that support bi-directional data transact ions . The Panel further recommended that VA make a commitment to open, standards-based APis , including the SMART on FHIR/Argonaut APis, to facilitate the ready and efficient exchange of data with partners providing care in the community and to support open clinical work:flow. ACQUISITION SENSITIVE Confidential and Propr ietary For Department of Veterans Affairs Use Only AMERICAN 7 PVERSIGHT VA-18-0298 and VA-18-0299-H-000386 386 of 6274 Page 425 of 1093 VA EHRM Interoperabi lity Review Report Jan 2018 FINAL.PDF for Printed Item: 35 ( Attachment 1 of 1) Establish clear publishing and access service requirements The Panel recogni zed that data access requirements differ depending on who provides or accesses that data. Therefore, the Panel recommended that VA be more specific in defining each level of data publishing and access service that is specific to (1) Veteran access (e.g., use of vets.gov) ; (2) VA clinician access ; (3) partner access; and (4) Health Information Exchange (HIE) access. The RFP should include a clear description of identity and access management requirements, including user population types and the association of specific application permissions with particular roles /positions. "The Contractor should provide all of the data that is currently being provided in the Contractor's patient portal to the consumer via an open standards -based API gateway. The Contractor should also provide all of the reporting data required by federal law to the Veteran via an open standards based API framework, accessible via any application or thirdparty data store of the Veteran's choice, that's number one." Machine-to-machine access is also critical for efficient sharing of information. The Panel recommended that VA ensure that all significant data stored in the software be accessible through APis with no requirement for creation of custom applications to specifically access VA data. From a forward-looking perspective, VA should require that the EHR system support the ability to access data elements using open standards-based interfaces , and include the ability to interface with legacy data, patient-generated data, and third -party data that resides outside the EHR system. In addition, Cerner should provide the required utility services to support intermediary or peer-to-peer services (e.g. , support Veteran-directed or Veteran-mediated requests, data exchange , and ingestion of data from non-VA providers). Provide a VA application platform that supports APls from third-party providers with no barrier to entry Cw-rently vets.gov serves as a portal to Veteran services. The Panel recommended that VA consider "The API Gateway document is awesome ... using such a portal to connect any third-party world class and future looking." application to the EHR solution without requiring fees or vendor permissions. VA should have full authority to connect any third-party application through one of the standard open APis conformant with the vendor ' s API without pre-registering the application with the vendor. This is a very important authority to have in terms of the ability to innovate rapidly , without constraints. The Panelists also reviewed the proposed VA "API Gateway" language provided dw-ing the API discussion to anchor the dialogue and concwTed that this requirement is fundamental to supporting interoperability. The Panel strongly endorsed the "API Gateway " language. Specifically, the Panelists recommended that VA include a requirement that VA have full authority to connect any third-party application to the Cerner system without requiring prior approval by Cerner. Furthermore , VA should ensw-e that developers of third-party applications connecting to the VA system via the open standard and VA-defined APis continue to own their ACQUISITION SENSITIVE Confidential and Proprietary For Department of Veterans Affairs Use Only AMERICAN 8 PVERSIGHT VA-18-0298 and VA-18-0299-H-000387 387 of 6274 Page 426 of 1093 VA EHRM Interoperab ility Review Report Jan 2018 FINAL.PDF for Printed Item : 35 ( Attachment 1 of 1) intellectual property (IP). From a usability perspective, the Panel also recommended that VA be able to establish the connectivity business rules , such as the ability for applications to remain connected for a reasonable time frame (e.g., 1 year) and to receive automatic notification about patient information updates. Require implementation of Clinical Decision Service (CDS) Hooks to invoke decision support from within a clinician's EHR workflow EHRs are essential to efficient delivery of high-quality care, as they provide the clinician with essential decision data at the time required. However , current EHR systems approach workflow from an IT system perspective rather than a clinician's perspective. The latter workflow should , of course , be paramount in the VA EHR implementation , and should also leverage a recent innovation called CDS Hooks. This technology provides the clinician with context-driven decision support and capability by enabling the EHR to trigger third-party services at key events that include order ing medication and opening a patient face sheet. For example, when the VA clinician begins to prescribe medication , a CDS Hook can call an externa l service that presents the clinician with the list of medications already prescribed to the patient by clinicians outside VA. The Panelists strongly recommended that VA require Cemer to implement and use CDS Hooks within the clinician workflow. Topic Area: Use Community Care Contracts to Foster Interoperability The new EHR system must be able to communicate with other EHR systems (e.g. , Epic , AllScripts , etc.) within the care community. It is critical that VA ensure the Cerne r EHR system remain robust for future interoperability with new products . Cerner must commit itself to supporting other forms of interoperability , such as a presentation layer that is common to other systems (e.g., the App store model). The Panel recommended that prior to execution of the Community Care Act contract VA require third-party providers (and Cerner compet itors) to commit to supporting the contract as early adopters. "Innovations going forward are going to come from multiple directions. And having those interfaces, and going with a general interoperability approach that doesn't fork off from what's happening in the rest of the healthcare system, will allow the Veterans to benefit from technology whether that's coming from Google, from a new company, from an innovative shop within VA -- you end up creating a market with good prices, high value." Veterans must be able to access and download a computable form of their health data Panelists noted that access to data represents the biggest problem today. VA must clearly direct Cerner to expose data so it can be used by third part ies. In the contract and in conversations with Cerner and third parties , VA must require specifics regarding how Veterans and providers will ACQUISITION SENSITIVE Confidential and Proprietary For Department of Veterans Affairs Use Only AMERICAN 9 PVERSIGHT VA-18-0298 and VA-18-0299-H-000388 388 of 6274 Page 427 of 1093 VA EHRM Interoperabi lity Review Report Jan 2018 FINAL.PDF for Printed Item: 35 ( Attachment 1 of 1) access and share their data. In addition, VA must require that any agreements leave the door open for future standards and technologies. Panelists believed that VA could achieve this by invoking the principle that the data belongs to the Veteran , rather than by citing specific technologies and standards (given how rapidly they are evolving). Veterans must be able to invoke their right of access to data to support data exchange across all providers (e.g., pull data through an API on their smartphone and push it to their community care provider), now and in the future. Keeping pace with this requirement will drive continual innovation by Cerner and all providers. VA must own the API layer Cerner ownership of the API layer (across every customer) poses a real threat to achieving interoperability , speed of innovation , and cost efficiency throughout the network of community care providers. Panelists stated that it is of utmost importance that VA include specific language stipulating that VA and Veterans be able to use third-party applications without having to register them with Cerner. VA must control the API key, not Cerner. Additionally, VA should require that Cerner provide access to MPages, a developer toolkit, and a programming interface that will enable innovators and third parties to develop APis. Require that community care contracts include VA EHR standards to support bidirectional data sharing Panelists agreed that requiring the support and collaboration of community care providers and participating actively in health IT standards bodies would give VA the opportunity to advance the "national" standard for data sharing-closing any gaps and inconsistencies among federal , industry , and inter-industry standards. VA must require every provider in the chain of a Veteran's care to support the same standards for data interoperability in order to ensure seamless, best possible care for Veterans. This includes the requirement that all providers and third-party applications, in exchange for using the VA-provided API gateway , provide bi-directional health information back to VA that can be used for context-driven clinical decisions and informatics. Change the data exchange consent model from "opt in" to "opt out" To encourage seamless interoperability across all entities providing care to Veterans, the consent model for exchanging data between healthcare providers must be modified to follow an opt-out rather than an opt-in policy, which limits participant numbers. This would allow Veterans to invoke their individual right of access under the Health Information Portability and Accountability Act (HIP AA) to move their data as needed. Many states have already adopted an opt-out consent policy as part of their HIE.2 VA can achieve this by aligning its policy to an opt- 2 See https://www.healthit.gov/sites/default/files/State%20HIE%200pt-ln %20vs%200pt-Out %20Policy%20Research_09-30l6_FinaLpdf ACQUISITION SENSITIVE Confidential and Proprietary For Department of Veterans Affairs Use Only AMERICAN 10 PVERSIGHT VA-18-0298 and VA-18-0299-H-000389 389 of 6274 Page 428 of 1093 VA EHRM Interoperabi lity Review Report Jan 2018 FINAL.PDF for Printed Item: 35 ( Attachment 1 of 1) out model, supported by the new VA proposed rule 3 to allow HIEs to collect a Veteran's consent and electronically attest to the consent to VA in order to obtain the required EHR. Topic Area: Additional Contract Changes In addition to the recommendations in the prior sections, the Panelists encouraged VA to add further definitions and clarity in the following areas: • Require Cerner to provide VA with full read and partial write access to all data elements within the EHR, at VA ' s sole discretion. • Require Cerner to make the VA data model, standards, and other similar interoperability changes available in all other non-VA Cemer instances of its EHR platform. • Clearly define "enabling security framework" so that users know if this means a specific security framework such as those provided by the National Institute of Standards and Technology (NIST), HITRUST, etc. • Amend "national Common Trust Framework" to specifically refer to the intended source. The Panelists suggested that VA replace this wording with "Trusted Exchange Framework and Common Agreement (TEFCA)" as specified in the 21 st Century Cures Act. • Amend RFP Performance Work Statement (PWS) Section 5.10.4(i) to clarify if the "provider collaboration via secure e-mail using Direct standards" is limited to the Direct protocols and just the Cerner platform. • Incorporate the model RFP language necessary for Cerner to support the API and SMART on FHIR platform and SMART-enabled applications, as described in Appendix B. 3 Sec https://s3 .amazonaws.com /public-inspcction.fodcralregi stcr.gov/2018-007 58.pdf ACQUISITION SENSITIVE Confidential and Proprietary For Department of Veterans Affairs Use Only AMERICAN 11 PVERSIGHT VA-18-0298 and VA-18-0299-H-000390 390 of 6274 Page 429 of 1093 VA EHRM Interoperab ility Review Report Jan 2018 FINAL.PDF for Printed Item: 35 ( Attachment 1 of 1) II. Recommendations for RFP Changes MITRE engaged Morrison & Foerster, LLP, as the independent and unbiased legal expert to identify the specific changes to the RFP language necessary to implement the recommendations made by the Interoperability Rev iew Panel. MITRE prov ided Morrison & Foerster, LLP, with the summary recommendations and a copy of the RFP. 4 In addition, MITRE collected specific ideas for contrac t language from the Panel. Appendix C presents all recommended RFP changes . 4 Pe,jormance Work Statement for the VA Electronic Health Record Modernization System, Final Version 1.7, Amendment 03, December 4, 2017, Department of Veterans Affairs. File name: 001 - VA EHRM IDlQ PWS (Amended 12.04.2017) - Copy.docx ACQUISITION SENSITIVE Confidential and Propr ietary For Department of Veterans Affairs Use Only AMERICAN 12 PVERSIGHT VA-18-0298 and VA-18-0299-H-000391 391 of 6274 Page 430 of 1093 VA EHRM Interoperab ility Review Report Jan 2018 FINAL.PDF for Printed Item : 35 ( Attachment 1 of 1) Ill. Observations from University of Pennsylvania Medical Center Site Visit A delegation from VA and MI TRE traveled to Pittsbmgh, Pennsylvan ia, on January 19, 2018, for a meeting with representatives ofUPMC Enterprises to discuss aspects of EHR interoperability that UPMC has successfully implemented over the ast several years. The VA John Short, and ....,., ................ ""--"''--'--':..>..Ll-4 Windom , included Dr. Ashwini Zenoo z, (b)(6) l,...---~-----1-::-:-:~ T_h_e_M __,ITRE group included Richard Byrne , Jay Schnitzer,~(b_)(_6)____ ~ '-'--'--'--'----'and (b)(S) The hosts at UPMC included Dr. Rasu Shrestha, C. Talbot Heppenstall , Jr. , Ed McAllister , Dr. Robert Bart , Adam Berger, Diane Michalec, Phyllis Szymanski , and Dr. Amy Urban, as well as add itional staff. The meeting was broken into four parts. Following introductions , Session 1 described the structure of UPMC. Session 2 covered UPMC' s last decade of interoperability , and Session 3 centered on the road ahead for UPMC and industry. Dr. Rasu Shrestha began the meeting by making the introductions and setting the agenda. He stated that UPMC ' s approach had followed a best-of-breed strategy , as opposed to a best-of-suite strategy, with the intention of failing fast and succeeding often. The overall UPMC structure has four parts: provider services, insurance services, international activities , and enterprises. During the discussion of interoperability, the UPMC team described its approach to interoperability , called Connected Healthcare , which is based on the commercial product dbMotion of AllScripts. UPMC has created an entity titled ClinicalConnect HIE (CCHIE) that uses HL7. ClinicalConnect exists as a separate 501c(3) company , of which UPMC is a member. CCHIE conta ins 90 live interfaces . Th is HIE went live in June 2012; its members cons ist of 10 hospitals. It competes with three other HIEs in Pennsylvania. The repository contains data on 8.3 million patients , and , in terms of patient consent, CCHI E uses an opt-out model. It currently has connections to four EHRs: Cerne r (two vers ions) , Epic , and Varian. Data available within CCHI E spans allergies, clinical documents , diagnosis , encounters , immuni zations, labs , medications , problems , and procedures. Much of this data is in the form of documents (Continuity of Care Document (HITSP C32 CCD format, including problems, allergies , and medications); unstructured clin ical documents (HITSP C62 format); Consolidated Clinical Document Architecture (C-CDA CCD , including problems, allergies , medications , immuni zations , procedures , and insurance); and HL7 Interface (ADT: encounters, documents , imaging documents , and labs only). At the point of care dbMotion allows multiple views for the CCHIE: 1) a clinical view, 2) a newer view titled EHR agent , and 3) a Cerner MPage integrat ion view . The next phase of the UPMC work in this regard will consist of integrat ion with Common Well. F igure 2 shows the architecture of the system. F igure 3 depicts the data feeds. ACQUISITION SENSITIVE Confidential and Proprietary For Department of Veterans Affairs Use Only AMERICAN 13 PVERSIGHT VA-18-0298 and VA-18-0299-H-000392 392 of 6274 Page 431 of 1093 VA EHRM Intero perability Review Report Jan 2018 FINAL.PDF for Printed Item: 35 ( Attach ment 1 of 1) _____. - eHeaitt, ·--- " Exchange .. --- The Children'> institut e Armstro~ County Me,,;~, Hosprtail The Children's Home Butler Hospital Heritage Va lley All scripts db Mot1on Node f::l Allscripts PRO • All scripts Sunrise All scripts Touch Works - St. Cla 1r Hosp,t.a I P@d1.at ric Presbytenan seri1orcare Hean h System Alliance eChnical Works Cerner EHR eMD GE Cent ricity Epic EHR e Meditech EHR McKesson Answers on Demand Home Evident Health NextGen Siemens EHR Source: From UPMC Enterprises, used with permission , for VA use only Figure 2. ClinicalConnect (Western Pennsylvania} Health Information Exchange - - "°"'"' '""' r ,!!fAl119'LAN ..._AC EHIEAI.TH~ CORNER ,U ~ ~ ~ -- ~ UN[fllHl CE:~ !?:,,._ C ci' ~ 0 ,.. _.n _~-- C:tli;rnJ111nl - ~ -~ I >' ...... H31 ACH•V< . ~- ,...""'"""-to a:fllN(R. C{RNl(A:H;I ~ lflDfll 2!:.-- "'IC ll!PIC· AOMINISTERIED FRAM OBIJlTR-"SOUNI) c.,.,;Ak~ffllii/ ....._.frtalm!.LOGluliflr:t • INPATIENT ,....,.CA To: Sandoval, Camilo J. Cc: Bee: i(b)/61 @gmail.com j(b)(6) @gmail.com> FW: Please Review Tonight Subject: Mon Aug 13 2018 11:46:17 EDT Date: [EXTERNAL] NDA.pdf (1 ).msg Attachments: NDA.pdf [EXTERNAL] RE: VA EHR NOA (2).msg Perlmutter.EHR NOA v2 mbs.pdf [EXTERNAL] Re: VA EHR NOA (3).msg EHR NOA v2 mbs.pdf EHR NOA v2 RL.pdf EHR NOA v2.pdf Camilo Sandoval 202-461-6910 From: Sandoval, Camilo J. Sent: Friday, May 04, 2018 2: 16 AM To: Spero, Casin D.; Hayes-Byrd, Jacquelyn ; O'Rourke, Peter M. Subject RE: Please Review Tonight And in case anyone ask, here are the signed NDA's of Ike, Bruce, and Marc. From: Sandoval, Camilo J. Sent: Friday, May 04, 2018 2:12 AM To: Spero, Casin D.; Hayes-Byrd, Jacquelyn; O'Rourke, Peter M. Subject: RE: Please Review Tonight Pete- AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000422 422 of 6274 Page 461 of 1093 This request from members of congress is based on inaccurate reporting by Arthur Allen from Politico, which was fueled by David Shulkin and Scott Blackburn. In fact, the real outside interference and conflict of interest came from Peter Levin, who was attempting to shape the direction of ongoing contract negotiations between the VA and Gerner. According to John Windom and Ash Zenooz, on several occasions Secretary Shulkin suggested to the EHRM team that Peter Levin be hired as a direct contractor. When those efforts failed, Peter Levin then acquired VA contracts through MITRE with Secretary Shulkin's influence. Please note that Peter Levin, Scott Gould, Stephen Ondra and Michele Flournoy (married to Scott Gould) all work for or are associated with AMIDA and MITRE. Ironically, they were all senior VA or DOD employees under the Obama administration with access to insider information. A key question Arthur Allen and interested members of congress should investigate and write about is, why did Shulkin and Blackburn continue to communicate with Peter Levin, and put undue pressure on John Windom to hire Peter Levin's firm-AMIDA-as a contractor. Also, why was Shulkin in such a rush to sign the Gerner contract last year(Oct/Nov) when there was over 51 major findings and recommendations added to the contract over the past several months? And for the record, it was a team of top medical CIOs and practitioners-put together by Ike Perlmutter and Bruce Moskowitz-who identified the flaws in the contract and made the recommendations, not MITRE. MITRE had advised against a strategic pause, and then took credit for the work done after. Please read attachments. From: Spero, Casin D. Sent: Thursday, May 03, 2018 7:31 PM To: Sandoval, Camilo J.; Hayes-Byrd, Jacquelyn; O'Rourke, Peter M. Subject RE: Please Review Tonight Good info Cam, we may want to remind the interested parties of that. From: Sandoval, Camilo J. Sent: Thursday, May 03, 2018 4:13:22 PM To: Hayes-Byrd, Jacquelyn; O'Rourke, Peter M.; Spero, Casin D. Subject RE: Please Review Tonight Thank you Jacquie. If we go back to Shulkin's EHRM hearing testimony, he mentions under oath that he and Scott Blackburn requested outside, non-governmental help from the top 5 Medical CIO's. These experts are who alerted him to the many interoperability issues previously unknown to Gerner or VA staff. From: Hayes-Byrd, Jacquelyn AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000423 423 of 6274 Page 462 of 1093 Sent Thursday, May 03, 2018 5:42 PM To: O'Rourke, Peter M.; Sandoval, Camilo J.; Spero, Casin D. Subject: Please Review Tonight Please see these two documents tonight as the Dep Sec provided this to Colonel Gainey late this afternoon And Andy will be giving it to the Secretary first in the a.m. don't want you to be blindsided and I would like for you to be prepared to discuss. Jacquie From: Washington, Conrad Sent Thursday, May 03, 2018 5:32 PM To: Hayes-Byrd, Jacquelyn Subject: REQUESTED SCAN Conrad Washington Special Assistant Office of the Secretary 810 Vermont Ave, NW Washington, DC 20420 202-461-7865 (0) Con rad.wash ington@va.gov VA Core Values: Integrity, Commitment, Advocacy, Respect, and Excellence-I CARE AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000424 424 of 6274 Page 463 of 1093 Document ID: 0.7.1705.630946-000001 Owner: Sandoval, Camilo J. Filename: [EXTERNAL] NDA.pdf (1).msg Last Modified: Mon Aug 13 10:46:17 CDT 2018 AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000425 425 of 6274 Page 464 of 1093 Cc:[E XTERN6~~~&8&H~W~a~g5~J~~W~fli~~waJ1M~~8W11 (b)(6) @a mai I.coml{b)(6) To: Blackburn, Scott R. (DISABLED ACCT)[Scott.Blackb~u-rn---=-va.g-o~vJ;l,_\b_ )(_6)__________ H.[Joh n.Windom@va.gov ] From: Bruce Moskowitz Sent: Tue 3/13/2018 6:59:21 PM Subject: [EXTERNAL] NDA.pdf NDA .pdf @qmai I.com ) ___.I Windom, Sent from my iPad Brnce Moskowitz M.D. AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000426 426 of 6274 Page 465 of 1093 John Document ID: 0.7.1705.630946-000002 Owner: Sandoval, Camilo J. Filename: NDA.pdf Last Modified: Mon Aug 13 10:46:17 CDT 2018 AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000427 427 of 6274 Page 466 of 1093 NDA.pdf for Printed Item: 37 ( Attachment 2 of 8) NON-DISCLOSURE AGREEMENT (Dated March 13, 2018) 1. I acknowledge that I have been selected to participate in the planning r.for an electronic health record acquisition. In the course of participating in this acquisition, I may be or have been given access to or entrusted with Source Selection Information (as defined in Federal Acquisition Regulation (FAR) 2.101 and 3.104), and/or other sensitive Government data marked as "proprietary" (e.g., restrictive legend per FAR 52.215-1) that I cannot release to others nor can I use for the fipancial benefit of others or mysel£ Source Selection Information is defined in FAR 2.101 & 3.104 and other sensitive Government data includes data marked as "proprietary '1 ( e.g., restrictive legend per FAR 52.215-1 ). Data includes all data, information and software, regardless of the medium (e.g. electronic or paper) and/or format in which the data exists, and includes data which is derived. from, based on, I incorporates, includes or refers to such Source Selection and/or proprietary data (collectively referred to herein as "the data"). Any data which is derived from, based on, incorporates, includes or refers to data shall be treated as Source Selection, or proprietary data and shall be subject to the terms of this Non-Disclosure Agreement. \ 2. I understand that 41 U.S.C. § 423, commonly referred to as the Procurement Integrity Act, and now codified at U.S.C.A. § § 2101-2107, and provisions FAR 3.104 govern the release of proprietary and source ~election information . As it relates to the information that has been made available to me pursuant to this Non-Disclosure Agreement, I certify that I will not disclose any contractor 1bid, solicitation, proprietary, or Source Selection Information directly or indirectly to any persorl. other than the President of the United States or a member of his administration to whom the President authorizes, another person subject to an equally restrictive Non-Disclosure Agreement related to the subject matter of this Agreement, the Secretary of the Department of Veterans Affairs or a person authorized by the head of agency or the contracting officer to receive such )nformation. I understand that unauthorized disclosure of such information may subject me to substantial administrative, civil and criminal penalties, including fines, imprisonment, and loss of employment under the Procurement Integrity Act or other applicable laws and regulations. 3. I certify that I will n6t discuss evaluation of source selection matters with any unauthorized individuals (including Qovep :~rnentpersonnel other than those set out in Paragraph 2 above), even after contract award, without specific prior approva l from proper authority. 1 4. These provisions are consistent with, and do not supersede, conflict with, or otherwise alter the employee obligations, rights, or liabilities created by existing statute or Executive order relating to (1) classified information, (2) communications to Congress, (3) the reporting to an Inspector General of a violation of any law, rule, or regulation, or mismanagement, a gross waste of funds, an abuse of authority, or a substantial and specific danger to public health or safety, or (4) any other whistleblower protection. The definitions, requirements, obligations, rights, sanctions, and liabilities' created by controlling Executive orders and statutory provisions are incorporated into this agreement and are controlling. These statutes and Executive orders include the following: AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000428 428 of 6274 Page 467 of 1093 NDA.pdf for Printed Item: 37 ( Attachment 2 of 8) NON~DISCLOSURE AGREEMENT Planning for an electronic health record acquisition Dated Tuesday March 13, 2018 Pagel2 CExecutive Order No. 12958; Drhe Privacy Act (5 U.S.C. § 552a); Ofhe Trade Secrets Act (18 U.S.C. § 1905); [J;ection 7211 of title 5, United States Code (governing disclosures to Congress); [:Bection 1034 of title 10, United States Code, as amended by the Military Whistleblower Protection Act (governing disclosure to Congress by members of the military); []ection 2302(b)(8) of title 5, United States Code, as amended by the \Vhist1eblower Protection Action (governing disclosures of illegality, waste, fraud, abus~ or public health or safetythreats); · . i Ofhe Intelligence Identities Protection Act of 1982 (50 U.S.C. § 421 et seq.) (governing disclosures that could expose confidential Government agents); and Ofhestatutes which protect against disclosure that may compromise the national security, including sections 641, 793, 794, 798, and 952 of title 18, United States Code, and section 4(b) of the Subversive Activities Act of 1950 (50 U.S.C. § 783(b)). Additionally, pursuanttd 38 Code of Federal Regulations 1.201, all VA employees with knowledge or information about actual or possible violations of criminal law related to VA programs, operations, facilities, contracts, or information technology systems shall immediately report such lmowledge or information to their supervisor, any management official, or directly to the Offi o .- BRUCE MOSKOW\TZ, M.D. 1411 N.FLAGER DR., #7100 BEACH, FL33401 Name Printed: {j (I.A.; e, -e. 11ostow i t 2- , VU) " Organizational Conflict(s) of Interest (OCis): AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000429 429 of 6274 Page 468 of 1093 Document ID: 0.7.1705.630946-000003 Owner: Sandoval, Camilo J. Filename: [EXTERNAL] RE: VA EHR NOA (2).msg Last Modified: Mon Aug 13 10:46:17 CDT 2018 AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000430 430 of 6274 Page 469 of 1093 i11~86~1~M~ilbof~,~1ffil~ .1 ~f~ABLEO ~':'=-:- -----'-'---'--'--'--- -'="=......_......_......,_:...:......:. _ ----F gmail.com]; Bruce Moskowitz (b)(6) 'r-=r o=m= :,------.~--------' ; Windom, John H.[John.W indom@va .gov; ACCT Scott.Blackbu~ov] mac.com]~ va.gov] Tue 3/13/2018 6:07:06 PM [EXTERNAL] RE: VA EHR NOA Perlmutter.EHR NOA v2 mbs.pdf Sent: Subject: Attached is my signed NDA. Thank you. From: Marc Sherman ~(b)(6) ~gmail.com] Sent: Tuesday, March 13, 2018 1:40 PM To: Bla~ott R. Cc: JP; (b)(G) gmail.com; Bruce Moskowitz; l(b)(6) Subject: e: EHR NDA .__ ____ IWindom, John H.; DJS __, Scott, Matt and John Thank you for the NDA draft that you sent along and the organized approach. to close the loop: 1. a marked up version of the NDA with a few necessary adjustments I have attached the following in red-line so you can see the changes that were made, 2. a blank copy of the amended NDA for Bruce and Ike to sign, and 3. a signed version by me of the amended NDA. Thanks and happy to help as requested. Marc On Tue, Mar 13, 2018 at 10:31 AM, Blackburn, Scott R. wrote: Ike, Bruce, Marc: Thank each of you for agreeing to lend an extra set of outside eyes on the EHR contract. We appreciate your support and want to make sure we get to the best place possible for Veterans, the country and taxpayers. As we are incredibly grateful to you for volunteering your time, we want to make this as easy as possible for you. Here are 3 next steps. 6 1) We will need you to sign the attached NDA. Please return to l.... (b-)(_ )____ ___, 2) Matt will then send you the latest package under separate cover. 3) Given government contracts are different than what you are used to reading, we would propose a quick phone call so can orient you to the contract and help focus you on the parts where your experti.se will be most valuable. ltb)(G) I (who is ~hegovernmentrntracting officer) and John Windom (who is our EHR leader) will lead this from our will ask (b)(G) c 'd) here to help set up a time. We can either do this all together, if calendars match up , or separately if need be. We have also connected with Stephanie Reel , Stan Huff, Dr. Karson , Dr. Ko , Dr. Shretha, and Jon Manjs who all have all received the NDA and we are working with them. I am hoping to connect with Dr. Cooper today. Thanks again! Scott VA-18-0298 and VA-18-0299-H-000431 431 of 6274 Page 470 of 1093 [EXTERNAL] RE: VA EHR NDA (2).msg for Printed Item: 37 ( Attachmen t 3 of 8) AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000432 432 of 6274 Page 471 of 1093 Document ID: 0.7.1705.630946-000004 Owner: Sandoval, Camilo J. Filename: Perlmutter.EHR NOA v2 mbs.pdf Last Modified: Mon Aug 13 10:46:17 CDT 2018 AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000433 433 of 6274 Page 4 72 of 1093 Perlmutter.EHR NOA v2 mbs.pdf for Printed Item: 37 ( Attachment 4 of 8) • NON-DISCLOSURE AGREEMENT (Dated March 13, 2018) 1. I acknowledge that I have been selected to participate in the planning for an electronic health record acquisition. In the course of participating in this acquisition, I may be or have been given access to or entrusted with Source Selection Information (as defined in Federal Acquisition Regulation (FAR) 2. I 01 and 3.104), and/or other sensitive Government data marked as "proprietary" (e.g., restrictive legend per FAR 52.215 -1) that I cannot release to others nor can I use for the financial benefit of others or myself i Source Selection Information is defined in FAR 2.101 & 3.104 and other sensitive Government data includes data marked as "proprietary" (e.g., restrictive legend per FAR 52.215-1). Data includes all data, information and software, regardless of the medium (e.g. electronic or paper) and/or format in which the data exists, and includes data which is derived from, based on, incorporates, includes or refers to such Source Selection and/or proprietary data (collectively referred to herein as "the data"). Any data which is derived from, based on, incorporates, includes or refers to data shall be treated as Source Selection, or proprietary data and shall be subject to the terms ofthis Non-Disclosure Agreement. 2. I understand that 41 U.S.C. § 423, commonly referred to as the Procurement Integrity Act, and now codified at U.S.C.A. § § 2101-2107, and provisions FAR 3.104 govern the release of proprietary and source selection information . As it relates to the information that has been made available to me pursuant to this Non-Disclosure Agreement, I certify that I will not disclose any contractor bid, solicitation, proprietary, or Source Selection Information directly or indirectly to any person other than the President of the United States or a member of his administration to whom the President authorizes, another person subject to an equally restrictive Non-Disclosure Agreement related to the subject matter of this Agreement, the Secretary of the Department of Veterans Affairs or a person authorized by the head of agency or the contracting officer to receive such information. I understand that unauthorized disclosure of such information may subject me to substantial administrative, civil and criminal penalties, including fines, imprisonment, and loss of employment under the Procurement Integrity Act or other applicable laws and regulations. 3. I certify that I will not discuss evaluation of source selection matters with any unauthorized individuals (including Government personnel other than those set out in Paragraph 2 above), even after contract award, without specific prior approval from proper authority. 4. These provisions are consistent with, and do not supersede, conflict with, or otherwise alter the employee obligations, rights, or liabilities created by existing statute or Executive order relating to (1) classified information, (2) communications to Congress, (3) the reporting to an Inspector General of a violation of any law, rule, or regulation, or mismanagement, a gross waste of fimds, an abuse of authority, or a substantial and specific danger to public health or safety, or (4) any other whistleblower protection. The definitions, requirements, obligations, rights, sanctions, and liabilities created by controlling Executive orders and statutory provisions are incorporated into this agreement and are controlling. These statutes and Executive orders include the following: AM( f~ICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000434 434 of 6274 Page 473 of 1093 Perlmutte r.EHR NOA v2 mbs.pdf for Printed Item : 37 ( Attach ment 4 of 8) NON-DISO...OSURE AGREEMENT Planning for an electronic health record acquisition , Dated Tuesday March 13, 2018 Page 12 [Executive Order No. 12958; [][be Privacy Act (5 U.S.C. § 552a); [][be Trade Secrets Act (18 U.S.C. § 1905); [J;ection 7211 of title 5, United States Code (governing disclosures to Congress); [J;ection 1034 of title 10, United States Code, as amended by the Military Whistleblower Protection Act (governing disclosure to Congress by members of the military); , [);ection 2302(b)(8) of title 5, United States Code, as amended by the Whistleblower Protection Action (governing disclosures of illegality, waste, fraud, abuse or public heaJth or safety threats); []The Intelligence Identities Protection Act of 1982 (50 U.S.C. § 421 et seq.) (governing disclosures that could expose confidential Government agents); and [Jfhe statutes which protect against disclosure that may compromise the national security, including sections 641, 793, 794, 798, and 952 of title 18, United States Code, and section 4(b) of the Subversive Activities Act of 1950 (50 U.S.C. § 783(b)) . ., Additionally, pursuant to 38 Code of Federal Regulations 1.201, all VA employees with knowledge or information about actual or possible violations of criminal law related to VA programs, operations, facilities, contracts, or information technology systems shall immediately report such knowledge or information to their supervisor, any management official, or directly to the Office of Inspector General. . (b)(6) S1gnature: Name Printed: Isaac Perlmutter Organizational Conflict(s) of Interest (OCis): AMERICAN PVERSIGHT L.---------------------- VA-18-0298 and VA-18-0299-H-000435 .. _____________ 435---offi'L? - P__, age 474 of 10_93 __ Document ID: 0.7.1705.630946-000005 Owner: Sandoval, Camilo J. Filename: [EXTERNAL] Re: VA EHR NOA (3).msg Last Modified: Mon Aug 13 10:46:17 CDT 2018 AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000436 436 of 6274 Page 4 75 of 1093 To:[EXTER~fd&b~fh~"~&Y?tP/!5f§A~r~&tc~ff~tMY:§icrJfMtll'ffi ~!aocuf ) IR(b)@frenchanael59.comlkb),6) l§>gmail.com(b)(6) gmail.com]; Bruce Moskowitzl(b)(6l j; Windom, John H.[John.Windom@va.gov] ; OJS[vacodjs1@va~_-go-v~]----~ From: Marc Sherman Sent: Tue 3/13/2018 5:39:36 PM Subject: [EXTERNAL] Re: VA EHR NOA EHR NOA v2.pdf EHR NOA v2 mbs.pdf EHR NOA v2 RL.pdf Cc: @mac.com] ; l(b)(6) Scott, Matt and John Thank you for the NOA draft that you sent along and the organized approach. I have attached the following to close the loop: 1. a marked up version of the NOA with a few necessary adjustments in red-line so you can see the changes that were made, 2. a blank copy of the amended NOA for Bruce and Ike to sign, and 3. a signed version by me of the amended NOA. Thanks and happy to help as requested. Marc On Tue, Mar 13, 2018 at 10:31 AM, Blackburn, Scott R. wrote: Ike, Bruce, Marc: Thank each of you for agreeing to lend an extra set of outside eyes on the EHR contract. We appreciate your support and want to make sure we get to the best place possible for Veterans , the country and taxpayers. As we are incredibly grateful to you for volunteering your time, we want to make this as easy as possible for you. Here are 3 next steps. 1) We will need you to sign the attached NDA. Please return to~l (b_l(_6l____ ~ 2) Matt will then send you the latest package under separate cover. 3) Given government contracts are different than what you are used to reading , we would propo se a quick phone call so ~can orient you to the contract and help focus you on the parts where your expertise will be most valuable .l(b)(6) I ~ho is the government contracting officer) and John Windom (who is our EHR leader) will lead this from our side. I will as~(b)(G) fc°d) here to help set up a time. We can either do this all together, if calendars match up, or separately if need be. We have also connected with Stephanie Reel, Stan Huff, Dr. Karson, Dr. Ko, Dr. Shretha, and Jon Manis who all have all received the NDA and we are working with them. I am hoping to connect with Dr. Cooper today. Thanks again! ,,, i\J VA-18-0298 and VA-18-0299-H-000437 'VERSIGHT 437 of 6274 Page 476 of 1093 [EXTERNAL] Re: VA EHR NDA (3).msg for Printed Item: 37 ( Attachmen t 5 of 8) Scott Blackburn Acting ClO & Executive-in-Charge, Office of Information & Technology Department of Vetera ns Affairs AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000438 438 of 6274 Page 477 of 1093 Document ID: 0.7.1705.630946-000006 Owner: Sandoval, Camilo J. Filename: EHR NOA v2 mbs.pdf Last Modified: Mon Aug 13 10:46:17 CDT 2018 AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000439 439 of 6274 Page 4 78 of 1093 EHR NDA v2 mbs.pdf for Printed Item: 37 ( Attachment 6 of 8) NON-DISCLOSURE AGREEMENT (Dated March 13, 2018) 1. I acknowledge that I have been selected to participate in the planning for an electronic health record acquisition. In the course of participating in this acquisition, I may be or have been given access to or entrusted with Source Selection Info1mation (as defined in Federal Acquisition Regulation (FAR) 2.101 and 3.104), and/or other sensitive Government data marked as "proprietary" (e.g., restrictive legend per FAR 52.215-1) that I cannot release to others nor can I use for the financial benefit of others or myself. Source Selection Information is defined in FAR 2.101 & 3.104 and other sensitive Government data includes data marked as "proprietary" (e.g., restrictive legend per FAR 52.215-1). Data includes all data, information and software, regardless of the medium (e.g. electronic or paper) and/or format in which the data exists, and includes data which is derived from, based on, incorporates, includes or refers to such Source Selection and/or proprietary data (collectively refe1Tedto herein as "the data"). Any data which is derived from, based on, incorporates, includes or refers to data shall be treated as Source Selection , or proprietary data and shall be subject to the terms of this Non-Disclosure Agreement. 2. I understand that 41 U.S.C. § 423, commonly referred to as the Procurement Integrity Act, and now codified at U.S.C.A. § § 2101-2107, and provisions FAR 3.104 govern the release of proprietary and source selection information . As it relates to the information that has been made available to me pursuant to this Non-Disclosure Agreement, I certify that I will not disclose any contractor bid, solicitation, proprietary, or Source Selection Information directly or indirectly to any person other than the President of the United States or a member of his administration to whom the President autl1orizes, another person subject to an equally restrictive Non-Disclosure Agreement related to the subject matter of this Agreement, the Secretary of the Department of Veterans Affairs or a person authorized by the head of agency or the contracting officer to receive such information. I understand that unauthorized disclosure of such information may subject me to substantial administrative, civil and crinlinal penalties, including fines, imprisonment, and loss of employment under the Procurement Integrity Act or other applicable laws and regulations. 3. I certify that I will not discuss evaluation of source selection matters with any unauthorized individuals (including Government personnel other than those set out in Paragraph 2 above), even after contract award, without specific prior approval from proper authority. 4. These provisions are consistent with, and do not supersede, conflict with, or otherwise alter the employee obligations, lights, or liabilities created by existing statute or Executive order relating to (1) classified information, (2) communications to Congress , (3) the reporting to an Inspector General of a violation of any law, rule, or regulation, or mismanagement , a gross waste of funds, an abuse of autholity, or a substantial and specific danger to public health or safety, or (4) any otl1er whistleblower protection. The definitions, requirements , obligations, rights, sanctions, and liabilities created by controlling Executive orders and statutory provisions are incorporated into this agreement and are controlling. These statutes and Executive orders include the following: AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000440 440 of 6274 Page 479 of 1093 EHR NDA v2 mbs.pdf for Printed Item: 37 ( Attachment 6 of 8) NON-DISCLOSURE AGREEMENT Planning for an electronic health record acquisition Dated Tuesday March 13, 2018 Page 12 [Executive Order No. 12958; Dfhe Privacy Act (5 U.S.C. § 552a); OI'he Trade Secrets Act (18 U.S.C. § 1905); [:section 7211 of title 5, United States Code (governing disclosures to Congress); [:section 1034 of title 10, United States Code, as amended by the Military Whistleblower Protection Act (governing disclosure to Congress by members of the military); [:section 2302(b)(8) of title 5, United States Code, as amended by the Whistleblower Protection Action (governing disclosures of illegality, waste, fraud, abuse or public health or safety threats); Dfhe Intelligence Identities Protection Act of 1982 (50 U.S.C. § 421 et seq.) (governing disclosures that could expose confidential Government agents); and OI'he statutes which protect against disclosure that may compromise the national security, including sections 641, 793, 794, 798, and 952 of title 18, United States Code, and section 4(b) of the Subversive Activities Act of 1950 (50 U.S .C. § 783(b)). Additionally, pursuant to 38 Code of Federal Regulations 1.201, all VA employees with knowledge or information about actual or possible violations of criminal law related to VA programs, operations, facilities, contracts, or information technology systems shall immediately report such knowledge or information to their supervisor, any management official, or directly to the Office of Inspector General. Signature: l(b)( 6) 0 0 Name Printed: Marc Sherman Organizational Conflict(s) of Interest (OCis): AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000441 441 of6274 Page 480 of 1093 Document ID: 0.7.1705.630946-000007 Owner: Sandoval, Camilo J. Filename: EHR NOA v2 RL.pdf Last Modified: Mon Aug 13 10:46:17 CDT 2018 AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000442 442 of 6274 Page 481 of 1093 EHR NDA v2 RL.pdf for Printed Item : 37 ( Attachment 7 of 8) b)(6) AMERICAN ()VERSIGHT VA-18-0298 and VA-18-0299-H-000443 443 of 6274 Page 482 of 1093 EHR NDA v2 RL.pdf for Printed Item : 37 ( Attachment 7 of 8) b)(6) AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000444 444 of 6274 Page 483 of 1093 Document ID: 0.7.1705.630946-000008 Owner: Sandoval, Camilo J. Filename: EHR NOA v2.pdf Last Modified: Mon Aug 13 10:46:17 CDT 2018 AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000445 445 of 6274 Page 484 of 1093 EHR NDA v2.pdf for Printed Item: 37 ( Attachment 8 of 8) NON-DISCLOSURE AGREEMENT (Dated March 13, 2018) 1. I acknowledge that I have been selected to participate in the planning for an electronic health record acquisition. In the course of participating in this acquisition, I may be or have been given access to or entrusted with Source Selection Info1mation (as defined in Federal Acquisition Regulation (FAR) 2.101 and 3.104), and/or other sensitive Government data marked as "proprietary" (e.g., restrictive legend per FAR 52.215-1) that I cannot release to others nor can I use for the financial benefit of others or myself. Source Selection Information is defined in FAR 2.101 & 3.104 and other sensitive Government data includes data marked as "proprietary" (e.g., restrictive legend per FAR 52.215-1). Data includes all data, information and software, regardless of the medium (e.g. electronic or paper) and/or format in which the data exists, and includes data which is derived from, based on, incorporates, includes or refers to such Source Selection and/or proprietary data (collectively refe1Tedto herein as "the data"). Any data which is derived from, based on, incorporates, includes or refers to data shall be treated as Source Selection, or proprietary data and shall be subject to the terms of this Non-Disclosure Agreement. 2. I understand that 41 U.S.C. § 423, commonly referred to as the Procurement Integrity Act, and now codified at U.S.C.A. § § 2101-2107, and provisions FAR 3.104 govern the release of proprietary and source selection information . As it relates to the information that has been made available to me pursuant to this Non-Disclosure Agreement, I certify that I will not disclose any contractor bid, solicitation, proprietary, or Source Selection Information directly or indirectly to any person other than the President of the United States or a member of his administration to whom the President autl1orizes, another person subject to an equally restrictive Non-Disclosure Agreement related to the subject matter of this Agreement, the Secretary of the Department of Veterans Affairs or a person authorized by the head of agency or the contracting officer to receive such information. I understand that unauthorized disclosure of such information may subject me to substantial administrative, civil and criminal penalties, including fines , imprisonment, and loss of employment under the Procurement Integrity Act or other applicable laws and regulations. 3. I certify that I will not discuss evaluation of source selection matters with any unauthorized individuals (including Government personnel other than those set out in Paragraph 2 above), even after contract award, without specific prior approval from proper authority. 4. These provisions are consistent with, and do not supersede, conflict with, or otherwise alter the employee obligations, rights, or liabilities created by existing statute or Executive order relating to (1) classified information, (2) communications to Congress , (3) the reporting to an Inspector General of a violation of any law, rule, or regulation, or mismanagement, a gross waste of funds, an abuse of authority, or a substantial and specific danger to public health or safety, or (4) any otl1er whistleblower protection. The definitions, requirements, obligations, rights, sanctions, and liabilities created by controlling Executive orders and statutory provisions are incorporated into this agreement and are controlling. These statutes and Executive orders include the following: AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000446 446 of 6274 Page 485 of 1093 EHR NDA v2.pdf for Printed Item: 37 ( Attachment 8 of 8) NON-DISCLOSURE AGREEMENT Planning for an electronic health record acquisition Dated Tuesday March 13, 2018 Page 12 [Executive Order No. 12958; Dfhe Privacy Act (5 U.S.C. § 552a); OI'he Trade Secrets Act (18 U.S.C. § 1905); [:section 7211 of title 5, United States Code (governing disclosures to Congress); [:section 1034 of title 10, United States Code, as amended by the Military Whistleblower Protection Act (governing disclosure to Congress by members of the military); [:section 2302(b)(8) of title 5, United States Code, as amended by the Whistleblower Protection Action (governing disclosures of illegality, waste, fraud, abuse or public health or safety threats); Dfhe Intelligence Identities Protection Act of 1982 (50 U.S.C. § 421 et seq.) (governing disclosures that could expose confidential Government agents); and OI'he statutes which protect against disclosure that may compromise the national security, including sections 641, 793, 794, 798, and 952 of title 18, United States Code, and section 4(b) of the Subversive Activities Act of 1950 (50 U.S.C. § 783(b)). Additionally, pursuant to 38 Code of Federal Regulations 1.201, all VA employees with knowledge or information about actual or possible violations of criminal law related to VA programs, operations, facilities, contracts, or information technology systems shall immediately report such knowledge or information to their supervisor, any management official, or directly to the Office of Inspector General. Signature: Name Printed: Organizational Conflict(s) of Interest (OCls): AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000447 447 of 6274 Page 486 of 1093 Document ID: 0.7.1705.630888 From: Sandoval, Camilo J. To: Sandoval, Camilo J. Cc: Bee: Subject: FW: Please Review Tonight Mon Aug 13 2018 11:46:17 EDT Date: [EXTERNAL] NDA.pdf (1 ).msg Attachments: NDA.pdf [EXTERNAL] RE: VA EHR NOA (2).msg Perlmutter.EHR NOA v2 mbs.pdf [EXTERNAL] Re: VA EHR NOA (3).msg EHR NOA v2 mbs.pdf EHR NOA v2 RL.pdf EHR NOA v2.pdf Camilo Sandoval 202-461-6910 From: Sandoval, Camilo J. Sent: Friday, May 04, 2018 2: 16 AM To: Spero, Casin D.; Hayes-Byrd, Jacquelyn ; O'Rourke, Peter M. Subject RE: Please Review Tonight And in case anyone ask, here are the signed NDA's of Ike, Bruce, and Marc. From: Sandoval, Camilo J. Sent: Friday, May 04, 2018 2:12 AM To: Spero, Casin D.; Hayes-Byrd, Jacquelyn; O'Rourke, Peter M. Subject: RE: Please Review Tonight Pete- AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000448 448 of 6274 Page 487 of 1093 This request from members of congress is based on inaccurate reporting by Arthur Allen from Politico, which was fueled by David Shulkin and Scott Blackburn. In fact, the real outside interference and conflict of interest came from Peter Levin, who was attempting to shape the direction of ongoing contract negotiations between the VA and Gerner. According to John Windom and Ash Zenooz, on several occasions Secretary Shulkin suggested to the EHRM team that Peter Levin be hired as a direct contractor. When those efforts failed, Peter Levin then acquired VA contracts through MITRE with Secretary Shulkin's influence. Please note that Peter Levin, Scott Gould, Stephen Ondra and Michele Flournoy (married to Scott Gould) all work for or are associated with AMIDA and MITRE. Ironically, they were all senior VA or DOD employees under the Obama administration with access to insider information. A key question Arthur Allen and interested members of congress should investigate and write about is, why did Shulkin and Blackburn continue to communicate with Peter Levin, and put undue pressure on John Windom to hire Peter Levin's firm-AMIDA-as a contractor. Also, why was Shulkin in such a rush to sign the Gerner contract last year(Oct/Nov) when there was over 51 major findings and recommendations added to the contract over the past several months? And for the record, it was a team of top medical CIOs and practitioners-put together by Ike Perlmutter and Bruce Moskowitz-who identified the flaws in the contract and made the recommendations, not MITRE. MITRE had advised against a strategic pause, and then took credit for the work done after. Please read attachments. From: Spero, Casin D. Sent: Thursday, May 03, 2018 7:31 PM To: Sandoval, Camilo J.; Hayes-Byrd, Jacquelyn; O'Rourke, Peter M. Subject RE: Please Review Tonight Good info Cam, we may want to remind the interested parties of that. From: Sandoval, Camilo J. Sent: Thursday, May 03, 2018 4:13:22 PM To: Hayes-Byrd, Jacquelyn; O'Rourke, Peter M.; Spero, Casin D. Subject RE: Please Review Tonight Thank you Jacquie. If we go back to Shulkin's EHRM hearing testimony, he mentions under oath that he and Scott Blackburn requested outside, non-governmental help from the top 5 Medical CIO's. These experts are who alerted him to the many interoperability issues previously unknown to Gerner or VA staff. From: Hayes-Byrd, Jacquelyn AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000449 449 of 6274 Page 488 of 1093 Sent Thursday, May 03, 2018 5:42 PM To: O'Rourke, Peter M.; Sandoval, Camilo J.; Spero, Casin D. Subject: Please Review Tonight Please see these two documents tonight as the Dep Sec provided this to Colonel Gainey late this afternoon And Andy will be giving it to the Secretary first in the a.m. don't want you to be blindsided and I would like for you to be prepared to discuss. Jacquie From: Washington, Conrad Sent Thursday, May 03, 2018 5:32 PM To: Hayes-Byrd, Jacquelyn Subject: REQUESTED SCAN Conrad Washington Special Assistant Office of the Secretary 810 Vermont Ave, NW Washington, DC 20420 202-461-7865 (0) Con rad.wash ington@va.gov VA Core Values: Integrity, Commitment, Advocacy, Respect, and Excellence-I CARE AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000450 450 of 6274 Page 489 of 1093 Document ID: 0.7.1705.630888-000001 Owner: Sandoval, Camilo J. Filename: [EXTERNAL] NDA.pdf (1).msg Last Modified: Mon Aug 13 10:46:17 CDT 2018 AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000451 451 of 6274 Page 490 of 1093 Cc: [EXTERf'Jd~~~&8&H\W~a~g51}J!~fil~fli~~Ag'W1M~~8W11 (b)(6) m ii. m (b)(6) To: Blackburn, Scott R. (DISABLED ACCT)[Scott.Blackburn@va .gov];(b)(6) H.[John.Windom@va.gov] ,._____________ From: Sent: Subject: NDA.pdf ; Windom, John __. Bruce Moskowitz Tue 3/13/2018 6:59:21 PM [EXTERNAL] NDA.pdf Sent from my iPad Brnce Moskowitz M.D. AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000452 452 of 6274 Page 491 of 1093 Document ID: 0.7.1705.630888-000002 Owner: Sandoval, Camilo J. Filename: NDA.pdf Last Modified: Mon Aug 13 10:46:17 CDT 2018 AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000453 453 of 6274 Page 492 of 1093 NDA.pdf for Printed Item: 46 ( Attachment 2 of 8) NON-DISCLOSURE AGREEMENT (Dated March 13, 2018) 1. I acknowledge that I have been selected to participate in the planning r.for an electronic health record acquisition. In the course of participating in this acquisition, I may be or have been given access to or entrusted with Source Selection Information (as defined in Federal Acquisition Regulation (FAR) 2.101 and 3.104), and/or other sensitive Government data marked as "proprietary" (e.g., restrictive legend per FAR 52.215-1) that I cannot release to others nor can I use for the fipancial benefit of others or mysel£ Source Selection Information is defined in FAR 2.101 & 3.104 and other sensitive Government data includes data marked as "proprietary' 1 ( e.g., restrictive legend per FAR 52.215-1 ). Data includes all data, information and software, regardless of the medium (e.g. electronic or paper) and/or format in which the data exists, and includes data which is derived. from, based on, I incorporates, includes or refers to such Source Selection and/or proprietary data (collectively referred to herein as "the data"). Any data which is derived from, based on, incorporates, includes or refers to data shall be treated as Source Selection, or proprietary data and shall be subject to the terms of this Non-Disclosure Agreement. \ 2. I understand that 41 U.S.C. § 423, commonly referred to as the Procurement Integrity Act, and now codified at U.S.C.A. § § 2101-2107, and provisions FAR 3.104 govern the release of proprietary and source ~election information . As it relates to the information that has been made available to me pursuant to this Non-Disclosure Agreement, I certify that I will not disclose any contractor 1bid, solicitation, proprietary, or Source Selection Information directly or indirectly to any persorl. other than the President of the United States or a member of his administration to whom the President authorizes, another person subject to an equally restrictive Non-Disclosure Agreement related to the subject matter of this Agreement, the Secretary of the Department of Veterans Affairs or a person authorized by the head of agency or the contracting officer to receive such )nformation. I understand that unauthorized disclosure of such information may subject me to substantial administrative, civil and criminal penalties, including fines, imprisonment, and loss of employment under the Procurement Integrity Act or other applicable laws and regulations. 3. I certify that I will n6t discuss evaluation of source selection matters with any unauthorized individuals (including Qovep :~rnentpersonnel other than those set out in Paragraph 2 above), even after contract award, without specific prior approva l from proper authority. 1 4. These provisions are consistent with, and do not supersede, conflict with, or otherwise alter the employee obligations, rights, or liabilities created by existing statute or Executive order relating to (1) classified information, (2) communications to Congress, (3) the reporting to an Inspector General of a violation of any law, rule, or regulation, or mismanagement, a gross waste of funds, an abuse of authority, or a substantial and specific danger to public health or safety, or (4) any other whistleblower protection. The definitions, requirements, obligations, rights, sanctions, and liabilities' created by controlling Executive orders and statutory provisions are incorporated into this agreement and are controlling. These statutes and Executive orders include the following: AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000454 454 of 6274 Page 493 of 1093 NDA.pdf for Printed Item: 46 ( Attachment 2 of 8) NON~DISCLOSURE AGREEMENT Planning for an electronic health record acquisition Dated Tuesday March 13, 2018 Pagel2 CExecutive Order No. 12958; Drhe Privacy Act (5 U.S.C. § 552a); Ofhe Trade Secrets Act (18 U.S.C. § 1905); [J;ection 7211 of title 5, United States Code (governing disclosures to Congress); [:Bection 1034 of title 10, United States Code, as amended by the Military Whistleblower Protection Act (governing disclosure to Congress by members of the military); []ection 2302(b)(8) of title 5, United States Code, as amended by the \Vhist1eblower Protection Action (governing disclosures of illegality, waste, fraud, abus~ or public health or safetythreats); · . i Ofhe Intelligence Identities Protection Act of 1982 (50 U.S.C. § 421 et seq.) (governing disclosures that could expose confidential Government agents); and Ofhestatutes which protect against disclosure that may compromise the national security, including sections 641, 793, 794, 798, and 952 of title 18, United States Code, and section 4(b) of the Subversive Activities Act of 1950 (50 U.S.C. § 783(b)). Additionally, pursuanttd 38 Code of Federal Regulations 1.201, all VA employees with knowledge or information about actual or possible violations of crim in al law related to VA programs, operations, facilities, contracts, or information technology systems shall immediately report such knowledge or information to their supervisor, any management official, or directly to the Offi (b)(6) Signatu Name Printed: {j (I.A.:e, -e. 11ostow i t 2- , VU) " OrganizationalConflict(s) of Interest (OCis): AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000455 455 of 6274 Page 494 of 1093 Document ID: 0.7.1705.630888-000003 Owner: Sandoval, Camilo J. Filename: [EXTERNAL] RE: VA EHR NOA (2).msg Last Modified: Mon Aug 13 10:46:17 CDT 2018 AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000456 456 of 6274 Page 495 of 1093 Mill~86~1~M~llb~?~,~1ffi7~ .1 rQ1f ~.h.BLEO ACCT ---".L.1..<.J'-'-"--'-'-"-'-'....._..LLLIJ~~=::;:;;;e;r1.::2~5~2[;~ gma il.com]; Bruce Moskowit (b)(6) Windom, John H.[John.W indom@va .gov; '=F~ ro _m_ : -- i=p------~ ~~ - Scott. Blackbur~ov] mac .com ] ;~ va .gov] Sent: Tue 3/13/2018 6:07:06 PM Subject: [EXTERNAL] RE: VA EHR NOA Perlmutter.EHR NOA v2 mbs.pdf Attached is my signed NDA. Thank you. From: Marc Sherman l(b)(S) Sent: Tuesday, March 13, 2018 1:40 PM To:Bl~ttR. Cc: JP; (b)(S) Subject: e: @gmail.com] gmail.com; Bruce Moskowitz; l(b)(S) EHR NDA .__ ____ ~ Windom, John H.; DJS _. Scott, Matt and John Thank you for the NDA draft that you sent along and the organized to close the loop: approach. 1. a marked up version of the NDA with a few necessary adjustments changes that were made, 2. a blank copy of the amended NDA for Bruce and Ike to sign, and 3. a signed version by me of the amended NDA. I have attached in red-line the following so you can see the Thanks and happy to help as requested. Marc On Tue, Mar 13, 2018 at 10:31 AM, Blackburn, Scott R. wrote: Ike, Bruce, Marc: Thank each of you for agreeing to lend an extra set of outside eyes on the EHR contract. We appreciate your support and want to make sure we get to the best place possible for Veterans, the country and taxpayers. As we are incredibly grateful to you for volunteering your time, we want to make this as easy as possible for you. Here are 3 next steps. 1) We will need you to sign the attached NDA. Please return to l~ (b_)(_5 )____ ~ 2) Matt will then send you the latest package under separate cover. 3) Given government contracts are different than what you are used to reading, we would propose a quick phone call so ~ can orient you to the contract and help focus you on the parts where your expertise will be most valuable.i(b)(6) I ~who is the overnment contracting officer) and John Windom (who is our EHR leader) will lead this from our side. I will ask(b)(6) (cc'd) here to help set up a time. We can either do this all together, if calendars match up, or separately if need be. We have also connected with Stephanie Reel , Stan Huff, Dr. Karson , Dr. Ko , Dr. Shretha, and Jon Manjs who all have all received the NDA and we are working with them. I am hoping to connect with Dr. Cooper today. Thanks again! Scott VA-18-0298 and VA-18-0299-H-000457 457 of 6274 Page 496 of 1093 [EXTERNAL] RE: VA EHR NDA (2).msg for Printed Item: 46 ( Attachmen t 3 of 8) AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000458 458 of 6274 Page 497 of 1093 Document ID: 0.7.1705.630888-000004 Owner: Sandoval, Camilo J. Filename: Perlmutter.EHR NOA v2 mbs.pdf Last Modified: Mon Aug 13 10:46:17 CDT 2018 AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000459 459 of 6274 Page 498 of 1093 Perlmutter.EHR NOA v2 mbs.pdf for Printed Item : 46 ( Attach ment 4 of 8) • NON-DISCLOSURE AGREEMENT (Dated March 13, 2018) 1. I acknowledge that I have been selected to participate in the planning for an electronic health record acquisition. In the course of participating in this acquisition, I may be or have been given access to or entrusted with Source Selection Information (as defined in Federal Acquisition Regulation (FAR) 2. I 01 and 3.104), and/or other sensitive Government data marked as "proprietary" (e.g., restrictive legend per FAR 52.215 -1) that I cannot release to others nor can I use for the financial benefit of others or myself i Source Selection Information is defined in FAR 2.101 & 3.104 and other sensitive Government data includes data marked as "proprietary" (e.g., restrictive legend per FAR 52.215-1). Data includes all data, information and software, regardless of the medium (e.g. electronic or paper) and/or format in which the data exists, and includes data which is derived from, based on, incorporates, includes or refers to such Source Selection and/or proprietary data (collectively referred to herein as "the data"). Any data which is derived from, based on, incorporates, includes or refers to data shall be treated as Source Selection, or proprietary data and shall be subject to the terms ofthis Non-Disclosure Agreement. 2. I understand that 41 U.S.C. § 423, commonly referred to as the Procurement Integrity Act, and now codified at U.S.C.A. § § 2101-2107, and provisions FAR 3.104 govern the release of proprietary and source selection information . As it relates to the information that has been made available to me pursuant to this Non-Disclosure Agreement, I certify that I will not disclose any contractor bid, solicitation, proprietary, or Source Selection Information directly or indirectly to any person other than the President of the United States or a member of his administration to whom the President authorizes, another person subject to an equally restrictive Non-Disclosure Agreement related to the subject matter of this Agreement, the Secretary of the Department of Veterans Affairs or a person authorized by the head of agency or the contracting officer to receive such information. I understand that unauthorized disclosure of such information may subject me to substantial administrative, civil and criminal penalties, including fines, imprisonment, and loss of employment under the Procurement Integrity Act or other applicable laws and regulations. 3. I certify that I will not discuss evaluation of source selection matters with any unauthorized individuals (including Government personnel other than those set out in Paragraph 2 above), even after contract award, without specific prior approval from proper authority. 4. These provisions are consistent with, and do not supersede, conflict with, or otherwise alter the employee obligations, rights, or liabilities created by existing statute or Executive order relating to (1) classified information, (2) communications to Congress, (3) the reporting to an Inspector General of a violation of any law, rule, or regulation, or mismanagement, a gross waste of fimds, an abuse of authority, or a substantial and specific danger to public health or safety, or (4) any other whistleblower protection. The definitions, requirements, obligations, rights, sanctions, and liabilities created by controlling Executive orders and statutory provisions are incorporated into this agreement and are controlling. These statutes and Executive orders include the following: AM( f~ICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000460 460 of 6274 Page 499 of 1093 Perlmutter.EHR NOA v2 mbs.pdf for Printed Item : 46 ( Attach ment 4 of 8) NON-DISO...OSURE AGREEMENT Planning for an electronic health record acquisition , Dated Tuesday March 13, 2018 Page 12 [Executive Order No. 12958; [][be Privacy Act (5 U.S.C. § 552a); [][be Trade Secrets Act (18 U.S.C. § 1905); [J;ection 7211 of title 5, United States Code (governing disclosures to Congress); [J;ection 1034 of title 10, United States Code, as amended by the Military Whistleblower Protection Act (governing disclosure to Congress by members of the military); , [);ection 2302(b)(8) of title 5, United States Code, as amended by the Whistleblower Protection Action (governing disclosures of illegality, waste, fraud, abuse or public heaJth or safety threats); []The Intelligence Identities Protection Act of 1982 (50 U.S.C. § 421 et seq.) (governing disclosures that could expose confidential Government agents); and [Jfhe statutes which protect against disclosure that may compromise the national security, including sections 641, 793, 794, 798, and 952 of title 18, United States Code, and section 4(b) of the Subversive Activities Act of 1950 (50 U.S.C. § 783(b)) . ., Additionally, pursuant to 38 Code of Federal Regulations 1.201, all VA employees with knowledge or information about actual or possible violations of criminal law related to VA programs, operations, facilities, contracts, or information technology systems shall immediately report such knowledge or information to their supervisor, any management official, or directly to the Office of Inspector General. Name Printed: Isaac Perlmutter Organizational Conflict(s) of Interest (OCis): AMERICAN PVERSIGHT L.---------------------- VA-18-0298 and VA-18-0299-H-000461 .. _____________ 461-of-62?" - P__, age 500 of 10_93 __ Document ID: 0.7.1705.630888-000005 Owner: Sandoval, Camilo J. Filename: [EXTERNAL] Re: VA EHR NOA (3).msg Last Modified: Mon Aug 13 10:46:17 CDT 2018 AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000462 462 of 6274 Page 501 of 1093 arc erman Tue 3/13/2018 5:39:36 PM Subject: [EXTERNAL] Re: VA EHR NOA EHR NOA v2.pdf EHR NOA v2 mbs.pdf EHR NOA v2 RL.pdf Scott, Matt and John Thank you for the NOA draft that you sent along and the organized approach. I have attached the following to close the loop: 1. a marked up version of the NOA with a few necessary adjustments in red-line so you can see the changes that were made, 2. a blank copy of the amended NOA for Bruce and Ike to sign, and 3. a signed version by me of the amended NOA. Thanks and happy to help as requested. Marc On Tue, Mar 13, 2018 at 10:31 AM, Blackburn, Scott R. wrote: Ike, Bruce, Marc: Thank each of you for agreeing to lend an extra set of outside eyes on the EHR contract. We appreciate your support and want to make sure we get to the best place possible for Veterans , the country and taxpayers. As we are incredibly grateful to you for volunteering your time, we want to make this as easy as possible for you. Here are 3 next steps. 6 1) We will need you to sign the attached NDA. Please return to l~ (b-)(_ )____ ~ 2) Matt will then send you the latest package under separate cover. 3) Given government contracts are different than what you are used to reading , we would propose a quick phone call so that we can orient you to the contract and help focus you on the parts where your expertise will be most valuable. l(b)(6) ~who is the government contracting officer) and John Windom (who is our EHR leader) will lead this from our side. I will ask l(b)(6) cc' d) here to help set up a time. We can either do this all together, if calendars match up, or separately if need be. I t We have also connected with Stephanie Reel, Stan Huff, Dr. Karson, Dr. Ko, Dr. Shretha, and Jon Manis who all have all received the NDA and we are working with them. I am hoping to connect with Dr. Cooper today. Thanks again! ,,, i\J VA-18-0298 and VA-18-0299-H-000463 'VERSIGHT 463 of 6274 Page 502 of 1093 [EXTERNAL] Re: VA EHR NDA (3).msg for Printed Item: 46 ( Attachmen t 5 of 8) Scott Blackburn Acting ClO & Executive-in-Charge, Office of Information & Technology Department of Vetera ns Affairs AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000464 464 of 6274 Page 503 of 1093 Document ID: 0.7.1705.630888-000006 Owner: Sandoval, Camilo J. Filename: EHR NOA v2 mbs.pdf Last Modified: Mon Aug 13 10:46:17 CDT 2018 AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000465 465 of 6274 Page 504 of 1093 EHR NDA v2 mbs.pdf for Printed Item: 46 ( Attachment 6 of 8) NON-DISCLOSURE AGREEMENT (Dated March 13, 2018) 1. I acknowledge that I have been selected to participate in the planning for an electronic health record acquisition. In the course of participating in this acquisition, I may be or have been given access to or entrusted with Source Selection Info1mation (as defined in Federal Acquisition Regulation (FAR) 2.101 and 3.104), and/or other sensitive Government data marked as "proprietary" (e.g., restrictive legend per FAR 52.215-1) that I cannot release to others nor can I use for the financial benefit of others or myself. Source Selection Information is defined in FAR 2.101 & 3.104 and other sensitive Government data includes data marked as "proprietary" (e.g., restrictive legend per FAR 52.215-1). Data includes all data, information and software, regardless of the medium (e.g. electronic or paper) and/or format in which the data exists, and includes data which is derived from, based on, incorporates, includes or refers to such Source Selection and/or proprietary data (collectively refe1Tedto herein as "the data"). Any data which is derived from, based on, incorporates, includes or refers to data shall be treated as Source Selection, or proprietary data and shall be subject to the terms of this Non-Disclosure Agreement. 2. I understand that 41 U.S.C. § 423, commonly referred to as the Procurement Integrity Act, and now codified at U.S.C.A. § § 2101-2107, and provisions FAR 3.104 govern the release of proprietary and source selection information . As it relates to the information that has been made available to me pursuant to this Non-Disclosure Agreement, I certify that I will not disclose any contractor bid, solicitation, proprietary, or Source Selection Information directly or indirectly to any person other than the President of the United States or a member of his administration to whom the President autl1orizes, another person subject to an equally restrictive Non-Disclosure Agreement related to the subject matter of this Agreement, the Secretary of the Department of Veterans Affairs or a person authorized by the head of agency or the contracting officer to receive such information. I understand that unauthorized disclosure of such information may subject me to substantial administrative, civil and crinlinal penalties, including fines , imprisonment, and loss of employment under the Procurement Integrity Act or other applicable laws and regulations. 3. I certify that I will not discuss evaluation of source selection matters with any unauthorized individuals (including Government personnel other than those set out in Paragraph 2 above), even after contract award, without specific prior approval from proper authority. 4. These provisions are consistent with, and do not supersede, conflict with, or otherwise alter the employee obligations, lights, or liabilities created by existing statute or Executive order relating to (1) classified information, (2) communications to Congress, (3) the reporting to an Inspector General of a violation of any law, rule, or regulation, or mismanagement, a gross waste of funds, an abuse of autholity, or a substantial and specific danger to public health or safety, or (4) any otl1er whistleblower protection. The definitions, requirements, obligations, rights, sanctions, and liabilities created by controlling Executive orders and statutory provisions are incorporated into this agreement and are controlling. These statutes and Executive orders include the following: AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000466 466 of 6274 Page 505 of 1093 EHR NDA v2 mbs.pdf for Printed Item: 46 ( Attachment 6 of 8) NON-DISCLOSURE AGREEMENT Planning for an electronic health record acquisition Dated Tuesday March 13, 2018 Page 12 [Executive Order No. 12958; Dfhe Privacy Act (5 U.S.C. § 552a); OI'he Trade Secrets Act (18 U.S.C. § 1905); [:section 7211 of title 5, United States Code (governing disclosures to Congress); [:section 1034 of title 10, United States Code, as amended by the Military Whistleblower Protection Act (governing disclosure to Congress by members of the military); [:section 2302(b)(8) of title 5, United States Code, as amended by the Whistleblower Protection Action (governing disclosures of illegality, waste, fraud, abuse or public health or safety threats); Dfhe Intelligence Identities Protection Act of 1982 (50 U.S.C. § 421 et seq.) (governing disclosures that could expose confidential Government agents); and OI'he statutes which protect against disclosure that may compromise the national security, including sections 641, 793, 794, 798, and 952 of title 18, United States Code, and section 4(b) of the Subversive Activities Act of 1950 (50 U.S .C. § 783(b)). Additionally, pursuant to 38 Code of Federal Regulations 1.201, all VA employees with knowledge or information about actual or possible violations of criminal law related to VA programs, operations, facilities, contracts, or information technology systems shall immediately report such knowledge or information to their supervisor, any management official, or directly to the Office of Inspector General. Signature: l(b)( 6) 0 0 Name Printed: Marc Sherman Organizational Conflict(s) of Interest (OCis): AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000467 467 of 6274 Page 506 of 1093 Document ID: 0.7.1705.630888-000007 Owner: Sandoval, Camilo J. Filename: EHR NOA v2 RL.pdf Last Modified: Mon Aug 13 10:46:17 CDT 2018 AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000468 468 of 6274 Page 507 of 1093 EHR NDA v2 RL.pdf for Printed Item : 46 ( Attachment 7 of 8) I (b)(6) Af\lERICAN P'VERSIGHT VA-18-0298 and VA-18-0299-H-000469 469 of 6274 l"'age ouo OT I U::1,j EHR NDA v2 RL.pdf for Printed Item: 46 ( Attachment 7 of 8) b)(6) AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000470 470 of 6274 Page 509 of 1093 Document ID: 0.7.1705.630888-000008 Owner: Sandoval, Camilo J. Filename: EHR NOA v2.pdf Last Modified: Mon Aug 13 10:46:17 CDT 2018 AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000471 471 of 6274 Page 510 of 1093 EHR NDA v2.pdf for Printed Item: 46 ( Attachment 8 of 8) NON-DISCLOSURE AGREEMENT (Dated March 13, 2018) 1. I acknowledge that I have been selected to participate in the planning for an electronic health record acquisition. In the course of participating in this acquisition, I may be or have been given access to or entrusted with Source Selection Info1mation (as defined in Federal Acquisition Regulation (FAR) 2.101 and 3.104), and/or other sensitive Government data marked as "proprietary" (e.g., restrictive legend per FAR 52.215-1) that I cannot release to others nor can I use for the financial benefit of others or myself. Source Selection Information is defined in FAR 2.101 & 3.104 and other sensitive Government data includes data marked as "proprietary" (e.g., restrictive legend per FAR 52.215-1). Data includes all data, information and software, regardless of the medium (e.g. electronic or paper) and/or format in which the data exists, and includes data which is derived from, based on, incorporates, includes or refers to such Source Selection and/or proprietary data (collectively refe1Tedto herein as "the data"). Any data which is derived from, based on, incorporates, includes or refers to data shall be treated as Source Selection, or proprietary data and shall be subject to the terms of this Non-Disclosure Agreement. 2. I understand that 41 U.S.C. § 423, commonly referred to as the Procurement Integrity Act, and now codified at U.S.C.A. § § 2101-2107, and provisions FAR 3.104 govern the release of proprietary and source selection information . As it relates to the information that has been made available to me pursuant to this Non-Disclosure Agreement, I certify that I will not disclose any contractor bid, solicitation, proprietary, or Source Selection Information directly or indirectly to any person other than the President of the United States or a member of his administration to whom the President autl1orizes, another person subject to an equally restrictive Non-Disclosure Agreement related to the subject matter of this Agreement, the Secretary of the Department of Veterans Affairs or a person authorized by the head of agency or the contracting officer to receive such information. I understand that unauthorized disclosure of such information may subject me to substantial administrative, civil and criminal penalties, including fines , imprisonment, and loss of employment under the Procurement Integrity Act or other applicable laws and regulations. 3. I certify that I will not discuss evaluation of source selection matters with any unauthorized individuals (including Government personnel other than those set out in Paragraph 2 above), even after contract award, without specific prior approval from proper authority. 4. These provisions are consistent with, and do not supersede, conflict with, or otherwise alter the employee obligations, rights, or liabilities created by existing statute or Executive order relating to (1) classified information, (2) communications to Congress , (3) the reporting to an Inspector General of a violation of any law, rule, or regulation, or mismanagement, a gross waste of funds, an abuse of authority, or a substantial and specific danger to public health or safety, or (4) any otl1er whistleblower protection. The definitions, requirements, obligations, rights, sanctions, and liabilities created by controlling Executive orders and statutory provisions are incorporated into this agreement and are controlling. These statutes and Executive orders include the following: AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000472 472 of 6274 Page 511 of 1093 EHR NDA v2.pdf for Printed Item: 46 ( Attachment 8 of 8) NON-DISCLOSURE AGREEMENT Planning for an electronic health record acquisition Dated Tuesday March 13, 2018 Page 12 [Executive Order No. 12958; Dfhe Privacy Act (5 U.S.C. § 552a); OI'he Trade Secrets Act (18 U.S.C. § 1905); [:section 7211 of title 5, United States Code (governing disclosures to Congress); [:section 1034 of title 10, United States Code, as amended by the Military Whistleblower Protection Act (governing disclosure to Congress by members of the military); [:section 2302(b)(8) of title 5, United States Code, as amended by the Whistleblower Protection Action (governing disclosures of illegality, waste, fraud, abuse or public health or safety threats); Dfhe Intelligence Identities Protection Act of 1982 (50 U.S.C. § 421 et seq.) (governing disclosures that could expose confidential Government agents); and OI'he statutes which protect against disclosure that may compromise the national security, including sections 641, 793, 794, 798, and 952 of title 18, United States Code, and section 4(b) of the Subversive Activities Act of 1950 (50 U.S.C. § 783(b)). Additionally, pursuant to 38 Code of Federal Regulations 1.201, all VA employees with knowledge or information about actual or possible violations of criminal law related to VA programs, operations, facilities, contracts, or information technology systems shall immediately report such knowledge or information to their supervisor, any management official, or directly to the Office of Inspector General. Signature: Name Printed: Organizational Conflict(s) of Interest (OCls): AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000473 473 of 6274 Page 512 of 1093 Document ID: 0.7.1705.630777 From: Sandoval, Camilo J. To: Sandoval, Camilo J. Cc: l(b)(6 ) @gmail.co fli,_ (b~ )(~S )~~ @gmail.com> Bee: Subject: FW: Please Review Tonight Mon Aug 13 2018 11 :46:03 EDT Date: [EXTERNAL] call today? (1).msg Attachments: [EXTERNAL] dad data sharing (2).msg Levin slide on DoD data sharing -october 2017.pptx [EXTERNAL] extremely confidential - eyes only - please do not forward or share secva message this morning (3).msg (EXTERNAL] Fwd: amida weekly ehrm data migration update (4).msg Amida VA EHRM Weekly Report -sept 14 -final.docx [EXTERNAL] Re: call today? (5).msg EsaEmbeddedMsg (6).msg EsaEmbeddedMsg (7).msg FW: (External] connecting scott to charlie (8).msg FW: [EXTERNAL] dad data sharing (9).msg ATT00001.htm Levin slide on DoD data sharing -october 2017.pptx FW: [EXTERNAL] roger baker (10).msg RE: [EXTERNAL] check in (11).msg RE: [EXTERNAL] check in (12).msg RE: [External] connecting scott to charlie (13).msg RE: [EXTERNAL] extremely confidential - eyes only - please do not forward or share secva message this morning (14).msg RE: [EXTERNAL] follow-up from our last meeting (15).msg RE: [EXTERNAL] Fwd: meeting with rob on wednesday (16).msg RE: [EXTERNAL] stakeholder enterprise portal (sep) and ebenefits (17).msg RE: [EXTERNAL] susan perez (18).msg RE: RE: (EXTERNAL] thursday check in (19).msg RE: Schedule important: Jack Bates' Availability - Peter needs to re-schedule (20).msg RE: Schedule important: Jack Bates' Availability - Peter needs to re-schedule (21 ).msg Windom (22).msg Camilo Sandoval 202-461-6910 From: Sandoval, Camilo J. AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000474 474 of 6274 Page 513 of 1093 Sent: Friday, May 04, 2018 2:12 AM To: Spero, Casin D.; Hayes-Byrd, Jacquelyn ; O'Rourke, Peter M. Subject: RE: Please Review Tonight Pete- This request from members of congress is based on inaccurate reporting by Arthur Allen from Politico, which was fueled by David Shulkin and Scott Blackburn. In fact, the real outside interference and conflict of interest came from Peter Levin, who was attempting to shape the direction of ongoing contract negotiations between the VA and Gerner. According to John Windom and Ash Zenooz, on several occasions Secretary Shulkin suggested to the EHRM team that Peter Levin be hired as a direct contractor. When those efforts failed, Peter Levin then acquired VA contracts through MITRE with Secretary Shulkin's influence. Please note that Peter Levin, Scott Gould, Stephen Ondra and Michele Flournoy (married to Scott Gould) all work for or are associated with AMIDA and MITRE. Ironically, they were all senior VA or DOD employees under the Obama administration with access to insider information. A key question Arthur Allen and interested members of congress should investigate and write about is, why did Shulkin and Blackburn continue to communicate with Peter Levin, and put undue pressure on John Windom to hire Peter Levin's firm-AMIDA-as a contractor. Also, why was Shulkin in such a rush to sign the Gerner contract last year(Oct/Nov) when there was over 51 major findings and recommendations added to the contract over the past several months? And for the record, it was a team of top medical CIOs and practitioners-put together by Ike Perlmutter and Bruce Moskowitz-who identified the flaws in the contract and made the recommendations, not MITRE. MITRE had advised against a strategic pause, and then took credit for the work done after. Please read attachments. From: Spero, Casin D. Sent: Thursday, May 03, 2018 7:31 PM To: Sandoval, Camilo J.; Hayes-Byrd, Jacquelyn; O'Rourke, Peter M. Subject: RE: Please Review Tonight Good info Cam, we may want to remind the interested parties of that. From: Sandoval, Camilo J. Sent: Thursday, May 03, 2018 4:13:22 PM To: Hayes-Byrd, Jacquelyn; O'Rourke, Peter M.; Spero, Casin D. Subject: RE: Please Review Tonight AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000475 475 of 6274 Page 514 of 1093 Thank you Jacquie. If we go back to Shulkin's EHRM hearing testimony, he mentions under oath that he and Scott Blackburn requested outside, non-governmental help from the top 5 Medical CIO's. These experts are who alerted him to the many interoperability issues previously unknown to Gerner or VA staff. From: Hayes-Byrd, Jacquelyn Sent Thursday, May 03, 2018 5:42 PM To : O'Rourke, Peter M.; Sandoval , Camilo J.; Spero , Casin D. Subject: Please Review Tonight Please see these two documents tonight as the Dep Sec provided this to Colonel Gainey late this afternoon And Andy will be giving it to the Secretary first in the a.m. don 't want you to be blindsided and I would like for you to be prepared to discuss. Jacquie From: Washington, Conrad Sent Thursday, May 03, 2018 5:32 PM To : Hayes-Byrd, Jacquelyn Subject: REQUESTED SCAN Conrad Washington Special Assistant Office of the Secretary 810 Vermont Ave, NW Washington, DC 20420 202-461-7865 (0) Con rad. wash ington@va.gov AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000476 476 of 6274 Page 515 of 1093 VA Core Values : Integrity, Commitment , Advocacy , Respect, and Excellence- I CARE AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000477 477 of 6274 Page 516 of 1093 Document ID: 0.7.1705.630777-000001 Owner: Sandoval, Camilo J. Filename: [EXTERNAL] call today? (1).msg Last Modified: Mon Aug 13 10:46:03 CDT 2018 AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000478 478 of 6274 Page 517 of 1093 To: [EXTER~fdat~t?Afts8Mr~. 'WI~~~~ fp!ee,'jf~c6fti~~B\jffi@%~~Qov] From: Peter Levin Sent: Mon 9/4/2017 5:20:22 PM Subject: [EXTERNAL] call today? Hi Scott, I hope this finds you well and enjoying your last weekend, for now ;), as a federal employee. I am sorry to disturb you. I hope you'll agree it was the right thing to do. Good news and bad news: The good news is that Marcy and Rob apparently had a good discussion this week. You may or may not know this, and you may or may not understand this, but it is a direct result of your "intervention". I can explain as useful. But it was useful. The bad news is that things with EHRM are going off the rails a bit. My advice from folks you know and trust is to raise this to David. I can see this going both ways. On the one hand, he needs to know. On the other hand, it will hurt Windom (which I absolutely don't want). The root cause of the trouble is that he (David, and John W) are being told that everything is "all set" on data migration. It is simply not true. The people doing the telling are eager to see MITRE/ Amida bounced from the team. I got that call on Friday afternoon. As usual, the contractors are just telling leadership what they want to hear. And the government employees have an agenda all their own. I personally admire Windom a lot, but he does not have the technical judgment to make a decision, and he is relying on Short a lot. Sweeping stuff under the rug (for the next guy) is a pretty typical VA approach. Indeed, the reason so many programs have failed at VA is because people don't accept and deal with the truth. Eventually that blows up and kills the program. This is what happened to HealtheVet, CoreFLS, Strategic Asset Management, Scheduling , and many other big VA IT programs. The only way we made VBMS successful was by forcing VBA and OIT to deal with all the hard truths of the program. That's exactly not what's happening here. My draft to the secretary is below, and I think I should send it later this evening or very first thing (6am) tomorrow. Your advice and perspective would be invaluable. Thanks and best, Peter Mr. Secretary: This email is to alert you that I have been told my contract with VA to analyze the data migration plan for Cerner is at risk and may be cancelled as soon as tomorrow. Senior members of tl1eprogram office are not happy that I continue to tell you that I do not believe their data migration plan is adequate, and will put the program at long-term risk. For as long as you care to hear it, I will continue to tell you the facts as I see them. And yes, this also means I am willing to forgo my sub-contract to do so. You should expect nothing less from any of us. AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000479 479 of 6274 Page 518 of 1093 Document ID: 0.7.1705.630777-000002 Owner: Sandoval, Camilo J. Filename: [EXTERNAL] dad data sharing (2).msg Last Modified: Mon Aug 13 10:46:03 CDT 2018 AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000480 480 of 6274 Page 519 of 1093 To:[EXTER~hlJl~&t,51affi i~~.(~fi1~a{1J<8~ fMrk fW@{Jli~a6t.tir: 55 ( Attachment 2 of 26) Cc: Windom, John H.[John.Windom@va.gov]; Blackburn, Scott R. (DISABLED ACCT)[Scott.Blackburn@va.gov] From: Peter Levin Sent: Fri 10/20/2017 10:49:17 AM Subject: [EXTERNAL] dod data sharing Levin slide on DoD data sharing -october 2017 .pptx Dear Mr Secretary, further to our discussion on Monday about DoD data sharing, plea se find attached a two-slide power point that captures the current situation, with a propo sed solution that is achievable and affordable. The current approach to a single shared VA-DoDEHRsystem has two critical limitations: 1) The data set shared by DoD excludes key data elements needed for complete point -of-care clinical decision support (including but not limited to lab results, radiology reports, and Tricare claims data ) 2) DoD data is made available in Cemer's Millennium EHRfor only servicemembers who have been seen at an MHS Gene sis-converted site. This mean s that fewer than 10 percent of servicemember s actually have data accessible through the Cerner platform. To the topic of "return data from Cemer", we strongly recommend that Cerner-provided Medicines and Allergies be provided back to VA(HDR)and DoD (CDR)to leverage built-in critical safety checks that otherwise will not have complete data and which JLV - just a viewer - will not catch. The following sentence is propo sed language that captures our suggestion to you, and that you could use to convey secretarial intent, perhaps also to colleagues and partner s at DoD: I believe there would be tremendou s benefit if DoD expanded the available data set to include a complete longitudinal medical record (excluding fields indicating force readiness) now. This can be accomplished by conducting a bulk data load of historical data from the legacy DoD EHRto Healthelntent, similar to the VAapproach. Only then can we legitimately claim our records are consolidated and the platform s unified. Most respectfully, Peter AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000481 481 of 6274 Page 520 of 1093 Document ID: 0.7.1705.630777-000003 Owner: Sandoval, Camilo J. Filename: Levin slide on DoD data sharing -october 2017.pptx Last Modified: Mon Aug 13 10:46:03 CDT 2018 AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000482 482 of 6274 Page 521 of 1093 Levin slide on DoD data sharing -october 2017.pptx for Printed Item: 55 ( Attachment 3 of 26) Cerner VA DoD PAMPI 1,1 <10% loaded I I I I I ,-(-------------- Complete Data Set (bulk load) I--+ Undecided --►• I I Suggested connection would replicate VAplans now neanng completion Decided/ Existin g PAMPI- Problems, Allergies, Medications, Procedures, Immunizations Not currently included: Laboratory Results, Radiology Reports, Vital Signs, Notes, and Tricare Claims data JLV is displayed within Millennium - Attaches to legacy DoD, VistA, other Cerner instances, eHealth Exchange Important: Cemer provided Medicines and Allergies should be provided back to VA(HOR)and DoD (CDR) f IVlr-tilvAI PVERSIGHT VA-18-0298 and VA-18-0299-H-000483 483 of 6274 Page 522 of 1093 Levin slide on DoD data shar ing -october 2017.pptx for Printed Item : 55 ( Attachment 3 of 26) VA-DoD Data Comparison Cerner Data Domain VA Migration DoD Migration 1. Demographics X X 2. Allergies X X 3. Conditions * X X 4. Immunizations X X 5. Laboratory Results X 6. Medications X X 7. Procedures X X 8. Appointments X 9. Encounters X 10. Notes and Radiology Reports X 11. Advance Directives TBD 12. (Tricare for DoD) Claims Data TBD 13. Providers TBD 14. TBD Questionnaires * Conditions are also referred to as problems/diagnoses ** Only Anatomic Pathology laboratory results The DoD Migration isfocused on migrating the "PAMPI+" domains directly to Millennium, which constitute a subset of the domains VA is targeting for migration. AMf-HICA PVERSIGHT VA-18-0298 and VA-18-0299-H-000484 484 of 6274 Page 523 of 1093 Document ID: 0.7.1705.630777-000004 Owner: Sandoval, Camilo J. Filename: [EXTERNAL] extremely confidential - eyes only - please do not forward or share secva message this morning (3).msg Last Modified: Mon Aug 13 10:46:03 CDT 2018 AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000485 485 of 6274 Page 524 of 1093 To:[EXTER~R~;~~tHi~@CJ~¥,%Pt6r6~~faiiBcBWsfa8'1d9u~~icr~~ PrintedItem : 55 ( Attachme 4 From: Sent: Subject: Peter Levin Thur 1/4/2018 10:58:02 AM [EXTERNAL] extremely confidential - eyes only - please do not forward or share - secva message this morning Jackie suggested last night that I close the loop with the secretary. She was right/great idea. My message to him this morning, below. Scott, literally my waking thought was of you. Best ofluck with the surgery. And best personal regards to both of you , -P Hi David , Three meetings yesterday: 1) with Windom and two MITRE reps - WH issues about my previous VA affiliation came up - I believe these were fully addressed to John's satisfaction. As you know, the outcome of the presidential election was a surprise; there are some hurt feelings from an appointee aspirant who thought I could have done more to help them prior to the election. This was also addressed to his satisfaction. That said, we spent most of the hour reviewing information architecture, surprisingly good agreement (he liked the way I explained it, exactly the same way I explain it to you [PLL - and Scott and Jackie]). From a content perspective we are fully aligned, in sequence, priority, and most of the packaging. The discussion confirmed that. 2) unexpectedly , as I was walking out (coat on, rushing to elevator) Ash came out and asked me to speak to Camilo Sandoval, who I did not know or know of, and had not previously met. From a technical perspective, I had the identical conversation with him that I just had, literally minutes before, with John W. When I left I thought we were okay. We weren't. I left the building and was well on my way to my office when John called me back. 3) we then had the architectmal discussion for the third time, this time with Camilo, Ash, and Short (who came in late but was there for most of it, and did most of the talking after he affived). In a professional-but-clear way, after net five hours , I went around the table and asked each of the participants a) if there was any difference or deviation between the discussions we had independently and the ones we had together (the answer was no, as it should have been) and b) if whatever crisis or misunderstanding existed before the third meeting was fully and satisfactorily resolved (the answer was yes, as it should have been). There were some things in the Camilo discussion that may be worth a short call (or visit, as you prefer). Best, -P AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000486 486 of 6274 Page 525 of 1093 Document ID: 0.7.1705.630777-000005 Owner: Sandoval, Camilo J. Filename: [EXTERNAL] Fwd: amida weekly ehrm data migration update (4).msg Last Modified: Mon Aug 13 10:46:03 CDT 2018 AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000487 487 of 6274 Page 526 of 1093 To: [E XTER~fdt',~1:%Pfr,i'§doiriw _~§cm}i.cefflYt~~i>t~fucVrJarfr@JW .g8~dItem: 55 ( Attachment From: Peter Levin Sent: Thur 9/14/2017 9:43:47 PM Subject: [EXTERN AL] Fwd: amida weekly ehrm data migration update Amida VA EH RM Weekly Report -sept 14 -final.docx 5 of 26) Scott - confidential to you, please do not forward or share. MITRE instructed us to stop send ing these to VA (Windom, Short , Bate s, Hilton, Mingo) three or four weeks ago; I doubt they forward these or anyth ing like them to stakeho lders there, so I don't know what they now know (or think). This report is sent by my program manager to theirs; I normally cc Jackie as a courtesy. Jimmy asked this week to be included. I have not spoken with John W (or the secretary) since before Labor Day. I did speak to David immediately after his "anno uncement " of the data migration strategy in mid-August, and advised caution on technical grounds. That was the last I spoke with him on this project. I have not spoken to him at all about the threat to end our work at MITRE. We have had brief (and successful) interactions on other non EHRM top ics. Most re spec tfully and best regards, Peter ---------- Forwarded messa From: Peter Levin (b)(G) amida.com> Date: Thu, Sep 14, 2017 at 4:05 PM Subject: amida weekl ehrm data migration update mitre.or >, "Providake s, Jame s F.' Ll(b_l(_6 l__ To: "Wynn, Jackie" (b)( 6 l Cc: "Fugate , Tom" L_(b)(6) __ r---- ---1@'""""m =1=·u'-'·e-'-.o""""r__,g> Dear Jackie, dear Jimmy, please find attached the Amida weekly report , due today. Its long, I know . We've been at it now for 6 week s, and this is basically what I would have expected in term s of depth, synthe sis, and detail. Please note that the go-forwa rd plan (something we worked on hard last week) is included in Appendix A, exh ibit 7 (the data migration plan and LOE). Also, if you just look at one thing. please go to figure 9 on page 23. Honestly, this is the "money sho t" becau se it is such a good examp le. Ba sically it is really hard to do data mapping (right) . The capt ion reads : The Vx130 Immunization Domain includes 18 fields, and the Cerner Immunization Data Domain model includes 23 fields. This figure illustrates the beginning of a crosswalk to show example migration paths for six fields from the source data model to the target Cerner model. Note that this is an incomplete crosswalk intended only for purposes of illustration. Many thanks and best regards, Peter AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000488 488 of 6274 Page 527 of 1093 Document ID: 0.7.1705.630777-000006 Owner: Sandoval, Camilo J. Filename: Amida VA EHRM Weekly Report -sept 14 -final.docx Last Modified: Mon Aug 13 10:46:03 CDT 2018 AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000489 489 of 6274 Page 528 of 1093 Amida VA EHRM Weekly Report -sept 14 -final.docx for Printed Item: 55 ( Attachment 6 of 26) ~n,ida CONFIDENTIAL Weekly Status Report For the MITRECorporation On Data Migration Support for VA Electronic Health Record Modernization September 14, 2017 Jeremy Collins Joy Hwang Matthew McCall Leslie Ramirez Afsin Ustundag Peter L. Levin Prepared by Amida Technology Solutions, Inc. AME Amida Techno logy Solution s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000490 490 of 6274 Page 529 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 55 ( Attachmen t 6 of 26) CO FIDENTIAL ~b)(5) AME 1 Amida ·1echnology Solut1on s, Inc. pvErt§'i(3 ~1t 4 VA-18-0298 and VA-18-0299-H-000491 491 of 6274 Page 530 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 55 ( Attachmen t 6 of 26) ~n,ida CO FIDENTIAL b)(5) AME 2 Amida Technology Solutions, Inc. pvErt§'i(3 ~1t 4 VA-18-0298 and VA-18-0299-H-000492 492 of 6274 Page 531 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 55 ( Attachmen t 6 of 26) CO FIDENTIAL b)(5) AME 3 Amida Techno logy Solution s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000493 493 of 6274 Page 532 of 1093 Amida VA EHRM Weekly Report -sept 14 -final.docx for Printed Item : 55 ( Attachment 6 of 26) ~n,ida CO FIDENTIAL II. Weekly Summary September 2 - September 8 ~b)(5) AME 4 Amida Techno logy Solution s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000494 494 of 6274 Page 533 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 55 ( Attachmen t 6 of 26) CO FIDENTIAL b)(5) AME 5 Amida Techno logy Solution s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000495 495 of 6274 Page 534 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 55 ( Attachmen t 6 of 26) CO FIDENTIAL b)(5) A VIl::. 6 Amida Techno logy Solution s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000496 496 of 6274 Page 535 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 55 ( Attachmen t 6 of 26) CO FIDENTIAL b)(5) 7 VA-18-0298 and VA-18-0299-H-000497 497 of 6274 Page 536 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 55 ( Attachmen t 6 of 26) ~rnida CO FIDENTIAL (b)(5) AME 8 Amida Techno logy Solution s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000498 498 of 6274 Page 537 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 55 ( Attachmen t 6 of 26) CO FIDENTIAL (b)(5) 9 VA-18-0298 and VA-18-0299-H-000499 499 of 6274 Page 538 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 55 ( Attachmen t 6 of 26) CO FIDENTIAL (b)(5) - Amida Techno logy Solution s, Inc. 4 10 p'VER~ie3 ~1t VA-18-0298 and VA-18-0299-H-000500 500 of 6274 Page 539 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 55 ( Attachmen t 6 of 26) CO FIDENTIAL b)(5) 11 VA-18-0298 and VA-18-0299-H-000501 501 of 6274 Page 540 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 55 ( Attachmen t 6 of 26) ~n,ida CO FIDENTIAL (b)(5) AME 12 Amida Techno logy Solution s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000502 502 of 6274 Page 541 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 55 ( Attachmen t 6 of 26) ~n,ida CO FIDENTIAL b)(5) AME 13 Amida Techno logy Solution s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000503 503 of 6274 Page 542 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 55 ( Attachmen t 6 of 26) CO FIDENTIAL b)(5) AME 14 Amida Techno logy Solution s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000504 504 of 6274 Page 543 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 55 ( Attachmen t 6 of 26) CO FIDENTIAL b)(5) AME 15 Amida Techno logy Solution s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000505 505 of 6274 Page 544 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 55 ( Attachmen t 6 of 26) CO FIDENTIAL (b)(5) AME 16 Amida Techno logy Solution s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000506 506 of 6274 Page 545 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 55 ( Attachmen t 6 of 26) CO FIDENTIAL (b)(5) 17 VA-18-0298 and VA-18-0299-H-000507 507 of 6274 Page 546 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 55 ( Attachmen t 6 of 26) CO FIDENTIAL (b)(5) AME 18 Amida Techno logy Solution s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000508 508 of 6274 Page 54 7 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 55 ( Attachmen t 6 of 26) ~n,ida CO FIDENTIAL (b)(5) AME 19 Amida Techno logy Solution s, Inc. 4 pvER~ifi~1t VA-18-0298 and VA-18-0299-H-000509 509 of 6274 Page 548 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 55 ( Attachmen t 6 of 26) CO FIDENTIAL (b)(5) AME 20 Amida Techno logy Solution s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000510 510 of 6274 Page 549 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 55 ( Attachmen t 6 of 26) CO FIDENTIAL (b)(5) AME 21 Amida Techno logy Solution s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000511 511 of 6274 Page 550 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 55 ( Attachmen t 6 of 26) ~rnida CO FIDENTIAL (b)(5) - 22 Amida Techno logy Solution s, Inc. 4 p'VE rt'"'ie3~1t VA-18-0298 and VA-18-0299-H-000512 512 of 6274 Page 551 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 55 ( Attachmen t 6 of 26) ~rnida CO FIDENTIAL b)(5) AME 23 Amida Techno logy Solution s, Inc. 4 pvER~ifi~1t VA-18-0298 and VA-18-0299-H-000513 513of6274 Page 552 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 55 ( Attachmen t 6 of 26) ~n,ida CO FIDENTIAL ~b)(5) AME 24 Amida Techno logy Solution s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000514 514 of 6274 Page 553 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 55 ( Attachmen t 6 of 26) CO FIDENTIAL (b)(5) AME 25 Amida Techno logy Solution s, Inc. 4 pvER~ifi~1t VA-18-0298 and VA-18-0299-H-000515 515of6274 Page 554 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 55 ( Attachmen t 6 of 26) ~n,ida CO FIDENTIAL (b)(5) AME 26 Amida Techno logy Solution s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000516 516 of 6274 Page 555 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 55 ( Attachmen t 6 of 26) ~n,ida CO FIDENTIAL (b)(5) AME 27 Amida Techno logy Solution s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000517 517of6274 Page 556 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 55 ( Attachmen t 6 of 26) ~rnida CO FIDENTIAL ~b)(5) AME 28 Amida Techno logy Solution s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000518 518 of 6274 Page 557 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 55 ( Attachmen t 6 of 26) CO FIDENTIAL ~b)(5) AME 29 Amida Techno logy Solution s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000519 519 of 6274 Page 558 of 1093 Amida VA EHRM Wee kly Report -sept 14 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t 6 of 26) CO FIDENTIAL (b)(5) 34 VA-18-0298 and VA-18-0299-H-000524 524 of 6274 Page 563 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 55 ( Attachmen t 6 of 26) CO FIDENTIAL (b)(5) AME 35 Amida Techno logy Solution s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000525 525 of 6274 Page 564 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 55 ( Attachmen t 6 of 26) CO FIDENTIAL (b)(5) AME 36 Amida Techno logy Solution s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000526 526 of 6274 Page 565 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 55 ( Attachmen t 6 of 26) CO FIDENTIAL b)(5) AME 37 Amida Techno logy Solution s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000527 527 of 6274 Page 566 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 55 ( Attachmen t 6 of 26) CO FIDENTIAL (b)(5) 38 VA-18-0298 and VA-18-0299-H-000528 528 of 6274 Page 567 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 55 ( Attachmen t 6 of 26) CO FIDENTIAL (b)(5) 39 VA-18-0298 and VA-18-0299-H-000529 529 of 6274 Page 568 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 55 ( Attachmen t 6 of 26) ~rnida CO FIDENTIAL ~b)(5) AME 40 Amida Techno logy Solution s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000530 530 of 6274 Page 569 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 55 ( Attachmen t 6 of 26) CO FIDENTIAL (b)(5) VA-18-0298 and VA-18-0299-H-000531 531 of 6274 Page 570 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 55 ( Attachmen t 6 of 26) ~rnida CO FIDENTIAL ~b)(5) AME 42 Amida Techno logy Solution s, Inc. 4 pvErf§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000532 532 of 6274 Page 571 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 55 ( Attachmen t 6 of 26) CO FIDENTIAL (b)(5) AME 43 Amida Techno logy Solution s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000533 533 of 6274 Page 572 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 55 ( Attachmen t 6 of 26) ~rnida CO FIDENTIAL b)(5) 44 VA-18-0298 and VA-18-0299-H-000534 534 of 6274 Page 573 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 55 ( Attachmen t 6 of 26) ~rnida CO FIDENTIAL b)(5) 45 VA-18-0298 and VA-18-0299-H-000535 535 of 6274 Page 57 4 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 55 ( Attachmen t 6 of 26) ~rnida CO FIDENTIAL ~b)(5) AME 46 Amida Techno logy Solution s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000536 536 of 6274 Page 575 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 55 ( Attachmen t 6 of 26) ~rnida CO FIDENTIAL b)(5) AME 47 Amida Techno logy Solution s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000537 537 of 6274 Page 576 of 1093 Amida VA EHRM Wee kly Report -sept 14 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Wee kly Report -sept 14 -final.docx for Printed Item : 55 ( Attachmen t 6 of 26) CO FIDENTIAL b)(5) AME 57 Amida Techno logy Solution s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000547 547 of 6274 Page 586 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 55 ( Attachmen t 6 of 26) CO FIDENTIAL (b)(5) AME 58 Amida Techno logy Solution s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000548 548 of 6274 Page 587 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 55 ( Attachmen t 6 of 26) ~rnida CO FIDENTIAL b)(5) 59 VA-18-0298 and VA-18-0299-H-000549 549 of 6274 Page 588 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 55 ( Attachmen t 6 of 26) ~rnida CO FIDENTIAL (b)(5) 60 VA-18-0298 and VA-18-0299-H-000550 550 of 6274 Page 589 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 55 ( Attachmen t 6 of 26) CO FIDENTIAL (b)(5) VA-18-0298 and VA-18-0299-H-000551 551 of 6274 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EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 55 ( Attachmen t 6 of 26) ~rnida CO FIDENTIAL (b)(5) AME 66 Amida Techno logy Solution s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000556 556 of 6274 Page 595 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 55 ( Attachmen t 6 of 26) ~rnida CO FIDENTIAL b)(5) AME 67 Amida Techno logy Solution s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000557 557 of 6274 Page 596 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 55 ( Attachmen t 6 of 26) ~rnida CO FIDENTIAL (b)(5) AME 68 Amida Techno logy Solution s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000558 558 of 6274 Page 597 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 55 ( Attachmen t 6 of 26) ~rnida CO FIDENTIAL ~b)(5) 69 VA-18-0298 and VA-18-0299-H-000559 559 of 6274 Page 598 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 55 ( Attachmen t 6 of 26) ~n,ida CO FIDENTIAL ~b)(5) AME 70 Amida Techno logy Solution s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000560 560 of 6274 Page 599 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 55 ( Attachmen t 6 of 26) CO FIDENTIAL b)(5) AM t::_ 71 Amida Techno logy Solution s, Inc. 4 pvER~ifi~1t VA-18-0298 and VA-18-0299-H-000561 561 of 6274 Page 600 of 1093 DEPARTMENT OF VETERANS AFFAIRS Washington DC 20420 May 20, 2019 18-cv-02463 Daniel A. McGrath American Oversight 1030 15th Street NW, B255 Washington, D.C. 20005 Dear Mr. McGrath: The Office of Electronic Health Record Modernization (OEHRM) responded to your request for Genevieve Morris' records in an Initial Agency Decision (IAD) dated April 25, 2019. This letter is OEHRM's second IAD in response to your two requests dated May 4, 2018 and submitted to the Department of Veterans Affairs (VA) under the Freedom of Information Act (FOIA), 5 U.S.C. ? 552. This IAD is also in response to your request for the records of Dr. Laura Kroupa, OEHRM Chief Medical Officer (CMO), a supplemental custodian added to the search per your request in March 2019. You requested the following search terms: Search One Records containing the terms a. Isaac b. or Ike c. or Jared Kushner Search Two Records containing the terms d. Moskowitz e. Perlmutter f. Ike g. Trump's friend h. Trump's doctor i. POTUS friend j. POTUS's friend k. POTUS' friend l. POTUS doctor m. POTUS's doctor n. POTUS' doctor o. President's friend p. Friend of POTUS q. Friend of President r. Friend of the President Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 55 ( Attachmen t 6 of 26) CO FIDENTIAL ~b)(5) 72 VA-18-0298 and VA-18-0299-H-000562 562 of 6274 Page 601 of 1093 Please note that the Office of the Secretary (OSVA), the Veterans Health Administration (VHA), and the Office of Information and Technology (OIT) will respond separately. IAD for Dr. Laura Kroupa The assigned performed a search of Dr. Kroupa's email server using the provided terms. The search produced 1,135 documents. From the 1,135 documents, 16 records are responsive. The first 15 documents are released with redactions in accordance with 5 U.S.C. ? 552(b)(6). One additional document totaling 1,474 pages, remains in process at this time. 5 U.S.C. ? 552(b)(6) exempts from required disclosure "personnel and medical files and similar files the disclosure of which would constitute a clearly unwarranted invasion of personal privacy." "Withholding a telephone number or e-mail address, alone, is not sufficient to protect that [privacy] interest; alternate means of contacting and harassing these employees would be readily discoverable on the Internet if this court ordered their names disclosed." Long v. Immigration & Customs Enf't, 2017 U.S. Dist. LEXIS 160719 (D.C. Cir. 2017). Information withheld consists of the names of GS-15 and below VA employees, contractors, and private citizens. The redacted information also includes email addresses, contact information, and VA usernames. This information reveals nothing about how the agency performs its statutory duties. The coverage of FOIA Exemption 6 is absolute unless the FOIA requester can demonstrate a countervailing public interest in the requested information by demonstrating that the individual is able to provide the requested information to members of the public and that the information requested contributes significantly to the public's understanding of the activities of the Federal government. Also, the requester must demonstrate how the public's need to understand the information significantly outweighs the privacy interest of the person to whom the information pertains. Upon consideration of the records, there is not an identifiable countervailing public interest of sufficient magnitude to outweigh the privacy interest of the individuals whose names are redacted. The protected information has been redacted and (b)(6) inserted. FOIA Mediation As part of the 2007 FOIA amendments, the Office of Government Information Services (OGIS) was created to offer mediation services to resolve disputes between FOIA requesters and Federal agencies as a non-exclusive alternative to litigation. Using OGIS services does not affect your right to pursue litigation. Under the provisions of the FOIA Improvement Act of 2016, the following contact information is provided to assist FOIA requesters in resolving disputes: VA Central Office FOIA Public Liaison: Name: John Buck Email Address: vacofoiaservice@va.gov Office of Government Information Services (OGIS) Email Address: ogis@nara.gov Fax: 202-741-5769 Mailing address: National Archives and Records Administration 8601 Adelphi Road College Park, MD 20740-6001 FOIA Appeal Please be advised that should you desire to do so, you may appeal the determination made in this response to: Office of General Counsel (024) Department of Veterans Affairs 810 Vermont Avenue, NW Washington, DC 20420 If you should choose to file an appeal, please include a copy of this letter with your written appeal and clearly indicate the basis for your disagreement with the determination set forth in this response. Please be advised that in accordance with VA's implementing FOIA regulations at 38 C.F.R. ? 1.559, your appeal must be postmarked no later than ninety (90) days of the date of this letter. Thank you for your interest in VA. Sincerely, Mingo, Fred J. Digitally signed by Mingo, Fred J. Date: 2019.05.20 14:14:50 -04'00' Mr. Fred Mingo, Jr. OEHRM FOIA Officer Attachments: LK_Records_American Oversight_Part 1_Redacted: 78 pages LK_Records_American Oversight_Part 2_Redacted: 38 pages Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 55 ( Attachmen t 6 of 26) CO FIDENTIAL ~b)(5) AME 73 Amida Techno logy Solution s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000563 563 of 6274 Page 602 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 55 ( Attachmen t 6 of 26) ~rnida CO FIDENTIAL b)(5) AME 74 Amida Techno logy Solution s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000564 564 of 6274 Page 603 of 1093 From : To : Cc: Bee: Subject: Date : Attachments : ( Booz Allen Hamilton) < o=exc ange a s/ou=exchange admin istrat ive ~cn=recipients /cn EHRM in the News and SecVA Stand-Up--Tuesday Tue Dec 11 2018 10:18:54 EST 181211_VA Secretary 's Stand-Up Brief.pptx image001.png , December 11, 2018 News Summary : Today 's news clips include an article about how VA is rolling out AP ls to enab le health IT deve lopers ; the New York Times discusses how democrats and repub licans are uniting on one issue: ove rsight of the VA ; Rep . Mark Takano is poised to lead the House Comm ittee on Vete rans Affa irs; and fina lly Polit ico discusses Veterans Affairs rank ing member Tim Wa lz's campa ign to expose the influence of three Mar-a-Lago assoc iates on VA bus iness . EHR Intelligence : VA Rolls Out APls to Improve Interoperability , EHR Data Access (Dec. 10, 2018, Kate Mon ica) *VA is rolling out standa rds-based application programming interfaces (APls ) des igned to enab le health IT deve lopers to build too ls that improve interoperability, EHR data access, and health data exchange for vete rans and thei r providers . *The fede ral agency detailed its plans to engage with developers through AP ls on its webpage and offered informat ion about several different API offerings. *VA's health API offer ing allows health IT deve lopers to build tools that help veterans manage their health, view their EHRs , schedule appointments , find specia lty facil ities, and exchange health information with caregivers and prov iders. The New York Times : Repub licans and Democrats Unite on at Least One Issue : Overs ight of the V.A. (Dec . 10, Jenn ifer Steinhauer) *Even before the next Congress convenes, Repub licans are joining Democ rats in a vigorous examinat ion of failings by the Department of Vete rans Affa irs, a rare area of bipartisan overs ight in a blistering political environment. *The unity was emphasized in recent weeks when lawmake rs in the House and Senate from both parties sharp ly criticized the response of department officia ls after it was revea led that the agency failed to make hous ing and tuition payments unde r the G.I. Bill after its computer systems were unable to keep up with recent changes to that law. The Press Enterprise: Rep. Mark Takano poised to lead House Comm ittee on Vete rans Affa irs (Dec . 10, Jeff Horseman ) VA-18-0298-F, VA-18-0299-F-000001 00000 1 *Increased VA oversight is among the Horseman's priorities *Veterans Affairs is one of the biggest departments of the federal government, with a proposed 2019 budget of more than $196 billion. And the House committee overseeing the department is one of several in Congress with subpoena power. *Another Takano priority is making sure the VA is prepared to care for the new demographics of 21st century veterans. While the veteran population is projected to decline by more than 6 million by 2037, that population will be more diverse, according to a VA report. Politico: WALZ PUSHES WILKIE ON MAR-A-LAGO (Dec. 11, 2018, Mohana Ravindranath) *Veterans Affairs ranking member Tim Walz is continuing his campaign to expose the influence of three Mar-a-Lago associates on VA business, writes Morning eHealth's Arthur Allen. *In a Monday letter to VA Secretary Robert Wilkie, Walz raises questions about the department's response to a lawsuit brought by VoteVets. The PAC accuses the VA of violating federal advisory committee statutes by enabling the influence of Marvel Entertainment Chairman Ike Perlmutter, internist Bruce Moskowitz and attorney Marc Sherman. *Department emails released in a FOIA request indicate the VA ceded decision-making power to the three and allowed them to direct technology developments at the VA that could have enriched Moskowitz and his family, Walz wrote. *Walz, governor-elect of Minnesota, demanded unredacted documents on the relationship and said his colleagues would pursue his investigation next year. The GAO is also investigating the Mar-a-Lago group's influence. (b) (6) | U.S. Department of Veterans Affairs (contractor) | Digital Communications | Office of Electronic Health Record Modernization (OEHRM)| 811 Vermont Avenue NW (4th Floor) Washington, DC 20420| (b) (6) @va.gov Visit VA Online: www.VA.gov | www.facebook.com/VeteransAffairs |https://twitter.com/VeteransAffairs| www.flickr.com/photos/VeteransAffairs | http://www.youtube.com/user/deptvetaffairs VA-18-0298-F, VA-18-0299-F-000002 000002 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 55 ( Attachmen t 6 of 26) ~rnida CO FIDENTIAL (b)(5) AME 75 Amida Techno logy Solution s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000565 565 of 6274 Page 604 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 55 ( Attachmen t 6 of 26) ~rnida CO FIDENTIAL (b)(5) AME 76 Amida Techno logy Solution s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000566 566 of 6274 Page 605 of 1093 (b) (6) Owner: Booz Allen Hamilton) Filename: 181211_VA Secretary's Stand-Up Brief.pptx Last Modified: Tue Dec 11 09:18:54 CST 2018 ? VA-18-0298-F, VA-18-0299-F-000003 000003 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 55 ( Attachmen t 6 of 26) ~rnida CO FIDENTIAL (b)(5) AME 77 Amida Techno logy Solution s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000567 567 of 6274 Page 606 of 1093 VA Secretary's Stand-Up Brief 11 December 2018 Executive Summary Multiple national storylines emerged yesterda y. Reuters and Stars and Stripes began coverage of a Dartmouth study showing the high quality of care at VA hospitals compared to other area hospitals. -- Emerged Service NBC News NBC News published a new story early th is morning pos iting the quest ion of w ho w ill be held accountable for the GI Bill delays. The article established a time line of the confusion around how the payments w ill be processed. VA messaging was absent from the piece , which w as largely based on statements from IAVA's Paul Rieckhoff , as w ell as Sens . Tammy Duckworth and Cory Gardner. Emerged Interests Senate unlikely to pass Blue Water bill this year Stars and Stripes . Military Times Stars and Stripes reported that the Blue Water Veterans bill was blocked from quick passage by Sen. Mike Enzo (R-Wyo .), w ho said , "VA's analysis shows the costs could be nearly five times what Congress assumed it was w hen the House of Representatives passed it." The article also noted Sec. Wilkie's opposition to the bill is based on "cost concerns and insufficient scientific evidence ." Military Times wrote that the Veterans affected "can 't afford more legislative delays, " and recounted critical reactions from some VSOs and Senators . Emerged Service / Interests Bipartisan cooperation in VA oversight New York Times The New York Times wrote that VA oversight is a "rare area of bipartisan oversight, " saying cooperation w as emphasized in the last weeks in reactions to GI Bill delays. Emerged Interests / Other Supreme Court to review case involving VA benefits The Hill. Law.com . Courthouse News Service . Bloomberg Law These articles covered the Supreme Court's agreement to hear the case of Kisor v. Wilkie, in w hich Veteran James Kisor is challenging the Department's refusa l to award him retroactive benefits based on its regulatory interpretation. According VA-18-0298-F, VA-18-0299-F-000004 Emerged to reporting, the case could have broad implications because it will address how 000004 much courts should defer to a federal agency 's interpretation of an ambiguous regulation. Storyline VAMCs provide higher quality care than other hospitals Accountability on GI Bill delays Outlets Analysis Reuters . Stars and Stripes Reuters and Stars and Stripes covered a Dartmouth study that found VA faci lities often outperf orm other hospitals w hen it comes to mortality rates and patient safety . Stars and Stripes quoted lead researcher Dr. William Weeks as saying VAMCs are in many cases the best regional hospita ls and are rarely the worst. Interests VA Secretary's Stand-Up Brief 11 December 2018 Twitter and Facebook Volume: 26 November - 1O December Social Media Takeaway In stark contrast to traditional media, Twitter was at a standstill yesterday. Only one post received over 10+ retweets. Key Points o The slight increase in activity yesterday compared to Monday is from the normal variation in the baseline of posts, observed daily, which receive no or nearly no user engagement. o The only post with notable engagement yesterday was by Actress @Alyssa_Milano, who wrote that Veterans deserve better than the GI Bill delays. Her post also linked to the related 28 Nov. NBC News article (700+ retweets ). o American Patriot uploaded to YouTube a computer-generated reading of a story on the Providence VA nurse who admitted to removing liquid opioids from the hospital (2.9k+ views). This is the fourth most-viewed video of the last 30 days. ,... .. I ??1 lo<< H 11 lt 1' JO 1?111111 oo 1 l J o ' I f I t lO OM:IOll ? ru-n1t.16i Notable Social Media Items Platform Item Relevance Twitter Topic: GI Bill delays 11% of Volume Twitter Topic: The Confederacy I Jefferson Davis 1% of Volume Facebook VA Medical Center donates to~s to area foster children 31O+ Reactions, 20+ Shares VA-18-0298-F, VA-18-0299-F-000005 000005 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 55 ( Attachmen t 6 of 26) CO FIDENTIAL ~b)(5) AME 78 Amida Techno logy Solution s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000568 568 of 6274 Page 607 of 1093 VA Secretary's Stand-Up Brief 11 December 2018 Reuters: U.S. veterans' hospitals often better than nearby alternatives (10 December , Lisa Rapaport, 16.SM uvm; New York, NY) U.S. Veterans Administration (VA) hospitals may provide better quality care than other hospitals in many American communities, a U.S. study suggests . Researchers looked at 121 regional health care markets with at least one VA hospital and one non-VA facility . Altogether they assessed 135 VA hospita ls and 2,988 non-VA hospitals using Hospital Compare, a public database that ranks hospitals on quality measures like mortality rates for common diseases and preventable complications. Hyperlink to Above Stars and Stripes: Dartmouth study finds VA hospitals outperform others in same regions (10 December , Nikki Wentling, 532k uvm; Washington, DC) A new study by Dartmouth College that compares Department of Veterans Affairs hospitals with other hospitals in the same regions found VA facilities often outperform others whe n it comes to mortality rates and patient safety . Hyperlink to Above WCPO (ABC-9, Video): Yoga, equine therapy help Cincinnati veterans find peace (10 December , Craig McKee, 289k uvm; Cincinnati , OH) Appointments with Veterans Affairs counselors and therapy groups made Jason Short feel "like a test subject ," he told WCPO in 2016. Talking through the experiences that led to his diagnosis with post-traumatic stress disorder didn't help him move past them. Training w ild horses did. Hyperlink to Above WPLN (NPR-1430, Audio): Nashville VA Attacking Patient Backlog With Dedicated Call Center (10 December , Blake Farmer , 33k uvm; Nashville , TN ) VA hospitals and clinics in Middle Tennessee are trying to attack their patient backlog by more efficiently handling phone calls. The Tennessee Valley Health Care system has established a central call center , w hich handles as many as 35,000 calls a month . The VA admits that veterans have been spending w ay too long on hold and navigating phone systems . This show s up in patient satisfaction feedback . Hyperlink to Above EHR Intelligence: VA Rolls Out APls to Improve Interoperability, EHR Data Access (10 December , Kate Monica, 18k uvm; Danvers , MA) VA is rolling out standards-based application programming interfaces (APls ) designed to enable health IT developers to build tools that improve interoperability , EHR data access, and health data exchange for veterans and their providers. The federal agency detailed its plans to engage w ith developers through APls on its webpage and offered information about several different API offerings. VA-18-0298-F, VA-18-0299-F-000006 Hyperlink to Above 000006 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 55 ( Attachmen t 6 of 26) ~rnida CO FIDENTIAL (b)(5) AME 79 Amida Techno logy Solution s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000569 569 of 6274 Page 608 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 55 ( Attachmen t 6 of 26) ~rnida CO FIDENTIAL ~b)(5) AME 80 Amida Techno logy Solution s, Inc. 4 pvER~ifi~1t VA-18-0298 and VA-18-0299-H-000570 570 of 6274 Page 609 of 1093 (b) (6) Owner: Booz Allen Hamilton) Filename: image001.png Last Modified: Tue Dec 11 09:18:54 CST 2018 ? VA-18-0298-F, VA-18-0299-F-000007 000007 Item: 1 (Attachmew VA qu?ll'r?ll? .Kll'alirs Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 55 ( Attachmen t 6 of 26) ~rnida CO FIDENTIAL (b)(5) AME 81 Amida Techno logy Solution s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000571 571 of 6274 Page 610 of 1093 From: To : Cc: Bee: Subject: Date: Attachments: ( Booz Allen Hamilton) < o=exc ange a s/ou=exchange admin istrat ive ~cn=recipients/cn EHRM in the News and SecVA Stand-Up -- Monday , December 10, 2018 Mon Dec 10 2018 10:14 :46 EST 181210_VA Secretary 's Stand-Up Brief.pptx News Summary: Today 's news includes cont inued coverage of Trump's 'Mar-a-Lago crowd ' and its impact on the EHRM ; a Politico morn ing ehealth report on VA's rollout of standards-based APls for partne rs to connect apps and programs to the Veterans Health Adm inistration, and lastly, a press release from Camilo Sandoval discusses VA's Enterp rise Cloud and the EHRM . EHRMNANews Kansas City Business Journa l: Report: Trump's 'Ma r-a-Lago crowd ' got a first crack at Gerner-VA EHR deal (Dec. 7, 20 18, Andrew Grumke) *Th ree men who belong to President Donald Trump 's private Mar-a- Lago club got a first crack at reviewing Gerner Corp.'s proposed cont ract to revamp the U.S. Department of Veteran Affairs' electronic health record system , includ ing tout ing an app one of them was deve loping. *The three men have little to no health IT or federa l contract ing expe rience , and none served in the military or elsewhere in government, but they were among a group of about 40 who received confident ial access to review the contract , including high-profile hosp ital execut ives , acco rding to ema ils and documents reviewed by ProPublica. *The three men were Ike Perlmutter , cha irman of Marve l Enterta inment ; Bruce Moskowitz , a West Palm Beach phys ician; and lawye r Marc Sherman. All were part of Trump 's circle at Mar-a- Lago, the report says. Politico: Texas needs government money to make te lemed icine happen (Dec. 10, 20 18, Arthur Allen) *VA (MORE) OPEN FOR BUSINESS : On Friday , the agency released deta ils on its rollout of standa rds -based AP ls for partners to connect apps and programs to the Veterans Health Adm inistrat ion . The APls , based on the FHIR standa rd, were discussed at a Wh ite House meet ing last week on health care data interoperability. *CNN finds speeches by VA Secretary Robert Wilkie revea ling his profound sympath ies for the confede rate cause CIO App lications : VA Looks to the Cloud (Dec. 10, 20 18, Camilo Sandova l) *The VA Enterpr ise Cloud is des igned to streamline the workf lows of project teams by represent ing a VA-18-0298-F, VA-18-0299-F-000009 000009 Document ID: 0.7.1705.630777-000007 Owner: Sandoval, Camilo J. Filename: [EXTERNAL] Re: call today? (5).msg Last Modified: Mon Aug 13 10:46:03 CDT 2018 AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000572 572 of 6274 Page 611 of 1093 common, logical architecture based on open standards. *As VA moves to a single instance of its EHR, this IT modernization also extends VA an opportunity to rapidly scale health IT innovations across the entire organization in a way not possible before. VA-18-0298-F, VA-18-0299-F-000010 000010 [EXTER~fd&bo,~ )ogwt(14~~ 1~f.!B1E~'o' ~c;c~l~~iJff sM~P~1~~1 To: From: Sent: Subject: Peter Levin Mon 9/4/2017 6:40 :27 PM [EXTERNAL] Re: call today? Okay, that was quick. I don't know if this is you in the background, but I just got a call from a "VA insider" saying that VA has told MITRE *not * to cut us, but to cut themselves back. I can't wait to speak to you on Thursday (or later) ;) THANKS and best, -P On Mon, Sep 4, 2017 at 1:20 PM , Peter Le~~'.b_)(_G) -~ ~amid a.com> wrote: Hi Scott, I hope this finds you well and enjoying your last weekend, for now ;), as a federal employee. I am sorry to disturb you. I hope you'll agree it was the right thing to do. Good news and bad news: The good news is that Marcy and Rob apparently had a good discussion this week. You may or may not know this , and you may or may not understand this, but it is a direct result of yom "intervention". I can explain as useful. But it was useful. The bad news is that things with EHRM are going off the rails a bit. My advice from folks you know and trust is to raise this to David. I can see this going both ways. On the one hand, he needs to know. On the other hand, it will hurt Windom (which I absolutely don't want). The root cause of the trouble is that he (David, and John W) are being told that everythjng is "all set" on data migration. It is simply not true. The people doing the telling are eager to see MITRE/ Amida bounced from the team. I got that call on Friday afternoon. As usual, the contractors are just telling leadership what they want to hear. And the government employees have an agenda all their own. I personally admire Windom a lot, but he does not have the technical judgment to make a decision, and he is relying on Short a lot. Sweeping stuff under the rug (for the next guy) is a pretty typical VA approach. Indeed, the reason so many programs have failed at VA is because people don't accept and deal with the truth. Eventually that blows up and kills the program. This is what happened to HealtheVet, CoreFLS, Strategic Asset Management, Scheduling, and many other big VA IT programs. The only way we made VBMS successful was by forcing VBA and OIT to deal with all the hard truths of the program. That's exactly not what's happening here. My draft to the secretary is below, and I think I should send it later this evening or very first thing (6am) tomon-ow. Your advice and perspective would be invaluable. Thanks and best, Peter Mr . Secre tt' : AN Tln Q::{;fF, ~.§ ti9" t!thave been 10ld my contract with VA to analyze the data migration plan,cfgg,ffil'of ¥b1\3"isk 573 6274 VA-18-0298 and VA-18-0299-H-000573 of (b) (6) Owner: ( Booz Allen Hamilton) Filename: 181210_VA Secretary's Stand-Up Brief.pptx Last Modified: Mon Dec 10 09:14:46 CST 2018 ? VA-18-0298-F, VA-18-0299-F-000011 000011 [EXTERNAL] Re: call tqda~'? (5).msg for Printed Item: 55 ( Attachment 7 of 26) anct may be canceueu as soon as tomorrow. Senior members of the program office are not happy that I continue to tell you that I do not believe their data migration plan is adequate, and will put the program at long-term risk. For as long as you care to hear it, I will continue to tell you the facts as I see them. And yes, this also means I am willing to forgo my sub-contract to do so. You should expect nothing less from any of us. AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000574 574 of 6274 Page 613 of 1093 VA Secretary's Stand-Up Brief 10 December 2018 Executive Summary CNN's article on Sec. Wilkie's 1995 speech on Jeffe rson Davis led national coverage on Friday and quickly dissipated on Saturday. Storyline Outlets Analysis CNN began reporting on a speech reportedly given by Sec. Wilkie in 1995 at an event sponsored by the United Daughters of the Confederacy at the occasion of an annual celebration of Jefferson Davis' birthday . The Washington Post (1) published a similar story. Task & Purpose published additional statements from the 1995 speech. Other stories were mostly based on the original CNN article. Many articles quoted Press Sec. Cashour's statement that the events attended by the Secretary were, "historical in nature," and that, "he stopped participating in them once the issue became divisive." On Saturday, The Washington Post (2) used the previous day's reporting as a segue into an article holding that Jefferson Davis was "loathed in the Confederacy." Sec. Wilk ie's 1995 speec h on Jeffe rson Davis CNN. Washing.tonPost LJ , Task & Purpose, Huffing_tonPost, The Hill. lntel/ig_encer T elehealth program expand ing Milita[Y_Times. mHealth Intelligence, Politico This storyline increased in visibility , and coverage was supportive. Military Times incorporated Sec. Wilkie's statement from the telehealth conference that, "Virtual care is the future of medicine[ ...] It is our most powerful emerging tool. Ultimately it will improve and ease access for millions of Americans." Women Vetera ns and Suicide VOA VOA drew attention to Women Veterans and Suicide, and VA's role in lowering the prevalence. Deputy Dir. of Suicide Prevention Megan McCarthy provided some messaging for the piece. VA could be getting too much money Milita[Y_Times Military Times provided space to CVA's Dan Caldwell to make a case that VA is receiving too many funding increases. -Emerged Other Sustained Serv ice Longterm Suicide Emerged Serv ice VA-18-0298-F, VA-18-0299-F-000012 000012 Document ID: 0.7.1705.630777-000008 Owner: Sandoval, Camilo J. Filename: EsaEmbeddedMsg (6).msg Last Modified: Mon Aug 13 10:46:03 CDT 2018 AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000575 575 of 6274 Page 614 of 1093 VA Secretary's Stand-Up Brief 10 December 2018 Twitter and Facebook Volume: Social Media Takeaway 25 November - 9 Dece mber Social media activity on Friday and Saturday largely shifted to CNN's coverage of Sec. Wilkie and comments about the Confederacy. Volume was unusually low on Sunday. Key Points o All top posts on Sec. Wilkie's 1995 speech on Jefferson Davis linked to the original CNN article written by, among others, Andrew Kaczynski. @KFILE (Andrew Kaczynski) wrote the weekend's most-retweeted post, highlighting Sec. Wilkie's reported statement that Jefferson Davis was a "martyr to the Lost Cause" (3.5k+ retweets). Two others posts by @KFILE quoted more 1995 statements from the Secretary (330+ retweets, 300+ retweets). o In the sixth top post, @jaketapper mirrored the leading @KFILE tweet (490+ retweets). In the eighth post, @splcenter (Southern Poverty Law Center) hashtagged #LoseTheLostCause (300+ retweets). In the tenth post, @AdamSerwer , a writer at The Atlantic, labelled the Secretary as a "nee-confederate" (260+ retweets). o In the second most-retweeted post, @SenKamalaHarris promoted the offer by the "Northern California Veterans Administration" for jobplacement assistance for disaster survivors of the Camp, Hill and Woolsey fires (2.2k+ retweets ). o @SenDuckworth's 6 Dec. tweet on GI Bill delays was in third position (1.2k+ additional retweets, 2.7k+ total). o @elizabethforma (Sen. Elizabeth Warren) linked to the 3 Dec. ProPublica article on Mar-a-Lago (870+ retweets). @SenWarren 's similar 6 Dec. tweet garnered an additional 570+ retweets (2.4k+ total). IU 7t :Ir:> 1?111111. t J DKl6le I ,1 , 6 1 I I ? s...-m.1m Notable Soci al Media Items Platform Item Relevance Tw itter Topic: The Confederacy/ Jefferson Davis 37% of Volume Tw itter Topic: GI Bill delays 8% of Volume Tw itter @SenKamalaHarris 8% of Volume CNCMachines.net 5+ Reactions , Encourages Vets to Facebook 5+ Shares , 0 Consider VA-18-0299-F-000013 Manufacturing VA-18-0298-F, Comments Careers( ... ) 000013 To:EsaEmbe~~Wft!e\9i~~~\!tt1~1~cbr~r Cc: From: Sent: Subject: Item:55 ( Attachment 8 of 26) Short, John {VACO)[John.Short@va.gov] Blackburn, Scott R. Wed 2/21/2018 7:47 :29 PM RE: [EXTERNAL] data migration (request from jackie/mitre) I'm guessing John Short is the right guy to talk to here From: Peter LevinJb)(S) ~amida.coml ·ebruary 21 , 2018 7: 14 AM To: Blackbum, Scott R. Subject: [EXTER AL] data migration (reque st from jack ie/mitre) Sent: Wednesday, Hi Scott, Jackie asked me to follow up with you regarding a data migration task (or initiative?) that you are heading (or just know about?). Thinking about you guys a lot; eager to see you at your convenience. Best, -P 617-921-0471 AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000576 576 of 6274 Page 615 of 1093 Document ID: 0.7.1705.630777-000009 Owner: Sandoval, Camilo J. Filename: EsaEmbeddedMsg (7).msg Last Modified: Mon Aug 13 10:46:03 CDT 2018 AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000577 577 of 6274 Page 616 of 1093 cretary's Stand-Up Brief.pptx for Printed Item: 4 ( Attachment 1 of 1) VA Secretary's Stand-Up Brief 10 December 2018 Military Times: Online VA medical appointments expanding to Walmart sites, VFW posts (7 December , Leo Shane 11 1, 471k uvm ; Spr ingfie ld, VA) In coming months, w hen vetera ns are trying to dec ide w hether to go to a Vetera ns Affa irs hosp ita l or a private doctor for their check-up, they may opt for a trip to Walmart instead . Departme nt officials on Thursday announced a series of new telehealth partnersh ips des igned to drama tically expand the ir current remote care offerings , to include online exam rooms in Wa lmarts, Amer ican Legion posts and Vete rans of Foreign War hangouts centered in rural areas across the country. Hyperlink to Above WCJB (ABC-20 , Video): Lake City VA Medical Center receives gifts and visitors from south Georgia (8 December , 59k uvm; Gainesv ille, FL) The Lake City VA Medical Center rece ived a spec ial vis it from visitors out of south Georgia Friday. Residents from Hehira, Valdosta, and King's Bay Naval Base arrived in a caravan of over 30 vehicles. They brough t donat ions and visited w ith patients . The annua l visit provides personal care items and other gifts . It also g ives the veterans and patients someone to ta lk to . Hyperlink to Above The News-Review: Outgoing director says Roseburg VA's future is bright (8 December , Carisa Cegavske , 33k uvm; Roseburg , OR) Dave Wh itmer arrived at the Roseburg Veterans Affa irs Medical Center in February to take on the role of interim director. He was brought in as a "fixer ," tasked with turn ing around a VA that was struggling with problem manage rs, low staff mora le and allegations of bullying and whistle-blower reta liation. Hyperlink to Above Times Record: Residents pay respects at Christmas Honors (9 Decembe r, Thomas Saccente, 22k uvm; Fort Smith, AR) Cold air, light ra in and overcas t skies did nothing to stop hundreds of loca l res idents from honoring those who foug ht for the ir country on Saturday. The U.S. Nationa l Cemetery at Fort Sm ith held the 10th annua l Christmas Honors wreath event Saturday , w here fami lies laid wreaths from 8 a.m. to 11 a.m. at the cemetery , w ith a ceremony follow ing. Hyperlink to Above mHealth Intelligence: VA Announces Telehealth Partnerships With Walmart, Philips, T-Mobile (7 December , Eric Wicklund, 18k uvm; Danvers , MA) The Departme nt of Vete rans Affa irs is expanding its "Anywhe re to Anyw here VA Health Care" program with new telehea lth and telemed icine partners hips. At th is week's "Anyw here to Anyw here Together" summ it in Wash ington DC, the VA announced connected care programs w ith Wa lmart, TMobile and Philips des igned to give veterans more opportun ities to connect with healthcare providers through telehealth. VA-18-0298-F, VA-18-0299-F-000014 Hyperlink to Above 000014 From: To : Cc: Bee: Subject: Date: Attachments: ( Booz Allen Hamilton) < o=exc ange a s/ou=exchange admin istrat ive ~cn=recipients/cn EHRM in the News and SecVA Stand-Up - Tuesday , December 4, 2018 Tue Dec 04 20 1810:31:36 EST 181204_VA Secretary 's Stand-Up Brief.pptx Attached is the SECVA stand-up for today and below is the EHRM in the news. As a note , both shou ld be cons idered interna l communicat ion products for awareness only and shou ld not be shared unless otherw ise directed. EHRM in the News Tuesday , December 4, 2018 News Summary: Today 's news clips include cont inued coverage about ProPublica 's article regarding the release of ema ils from Trump assoc iates which states they influenced the EHRM effort , and a Forbes article about solut ions to health care's $6 billion patient record match ing problem. EHRMNANews The Hill: Mar-a-Lago tr io reviewed confident ial $10 billion VA contract befo re its release: report (Dec. 3, 20 18, Owen Daugherty) *Th ree Mar-a- Lago club members friend ly with President Trump were reportedly given access to review a $ 10 billion government contract to overhaul electronic health records for vete rans even though they had no prior exper ience in the fie ld. *The three men , Marve l Entertainment Chairman Ike Perlmutter, West Palm Beach physician Bruce Moskowitz and lawyer Marc She rman , were given unprecedented access to confident ial documents and shaped policy at the Department of Vete rans Affa irs (VA), according to ema ils obta ined by ProPub lica through a Freedom of Informat ion Act request. Politico: Interoperabil ity day at the Wh ite House (Dec. 4 , 20 18, Mohana Ravindranath) *WHITE HOUSE INTEROPERABILITY FORUM: The Trump adm inistration is delving deeper into health data issues , this time with an interoperab ility discussion. CMS Adm inistrator Seema Ve rma - who has partne red with Wh ite House sen ior adv iser Jared Kushner on the MyHea ltheData effort - is scheduled to attend , as is ONG head Don Rucker. We 'll have updates after the event th is afternoon. VA-18-0298-F, VA-18-0299-F-000015 000015 To:EsaEmb~~c18Ms8rti,).§lcBt1Efi:trfltd~t~Be.S.eetftsb~'ir.'BYRr:~b9u9h~va.gov] From: Peter Levin Sent: Wed 2/21/2018 12:13:37 PM Subject: [EXTERNAL] data migration (request from jackie /mitre) Hi Scott, Jackie asked me to follow up with you regarding a data migration task (or initiative?) that you are heading (or just know about?). Thinking about you guys a lot; eager to see you at your convenience. Best, -P 617-921-0471 AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000578 578 of 6274 Page 617 of 1093 Document ID: 0.7.1705.630777-000010 Owner: Sandoval, Camilo J. Filename: FW: [External] connecting scott to charlie (8).msg Last Modified: Mon Aug 13 10:46:03 CDT 2018 AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000579 579 of 6274 Page 618 of 1093 *MORE DIRT ON THE MAR-A-LAGO THREE: A ProPublica article based on FOIA'd emails and other documents shows how deeply the three Trump associates at the president's Florida club were involved in efforts to overhaul the VA's EHR -- a role that VA Secretary Robert Wilkie has apparently rejected, as the GAO and House Democrats have promise an investigation of the trio. *According to emails, Marvel Entertainment chairman Ike Perlmutter, West Palm Beach physician Bruce Moskowitz and lawyer Marc Sherman reviewed a confidential draft of the $10 billion Cerner EHR contract and reworded a non-disclosure agreement to allow themselves to talk about it amongst themselves. In one June 2017 email, Moskowitz named himself, Perlmutter and Sherman to an "executive committee" that included VA officials and top health care executives who'd been brought in to counsel the VA on its EHR project. General EHR Articles Forbes: The Best Solutions To Health Care's $6 billion Patient-Matching Problem (Dec. 4, 2018, Rahul Sharma) *The health care industry is plagued with a problem that harms patient safety and exacts an annual toll of $6 billion: patient record matching. *Patient record matching refers to the issue of correctly identifying a patient within the same facility or across different health care organizations. *Besides the monetary issue, patient matching challenges can also cause severe harm to patients. The issue is so acute that it impacts 1 in 5 patient records within the same health care system, and up to 50% of patient records are not matched in transfers. *So, how do we fix it? Here are the best solutions to the patient-matching problem *National Patient Identifier *A 'Smart' Enterprise Master Patient Index (EMPI) *Faster, more accurate record matching through machine learning *Standardization enforced by CMS *Other Possible Solutions VA-18-0298-F, VA-18-0299-F-000016 000016 TotW : [ExteJ1~Jfj1igg~~Al~iff~JMrWEfB~~J~~B\JP for Printed Item: 55 ( Attachment 10 of 26) From: Sent: Subject: Blackburn, Scott R. Tue 11/7/2017 12:57:39 AM FW: [External] connecting scott to char lie Do you know this guy? l 1 From: De Sanno, Charles [USAJ... (b~) (~S)~~~---~ ~bah.com] Sent: Monday, November 06, 20b 11:23 AM To: Peter Levin; Blackburn , Scott R. Subject: [EXTER AL] Re: [Externa l] connecting sco tt to charlie Peter, thank you very much for the introduction! Scott, I'd love to have the opportunity to meet you and discuss OIT and future road ahead. I can also discuss the past if interested as I created OIT in 2006 and ran engineering and operations for 8 years before leaving. I am the architect of many systems and processes still in place at VA. Additionally, I architected and won MASS while at Leido s and of course the EHRM PMO at Booz Allen. My goal is to help in any way! Perhaps we can synch up in person soon! I know you are very busy, so please let me know who I can work with to possibly find some time whether it be in person or via phone! My cell i~~(b_l(_6 l____ ~ Thank you! Charlie De Sanna Partner, Boo z Allen Hamilton From: Peter Levin (b)(S) amida.com> Sent: Saturday , ovem er 4, 2017 10:57: 10 AM To: Blackburn, Scott R.; De Sanna , Charles [USA] Subject: [External] connecting scott to charlie Dear Scott, dear Charlie, with this email I'd like to briefly connect you. Scott is the recently-former interim deputy secretary, and the acting CIO at VA. It has been a great privilege and joy to get to know and occasionally work with him. Charlie was a deputy CIO when we both worked for Roger , and someone I admire and trust as a "no nonsense, get it done" guy with a tremendous sense of humor and wonderful administrative touch. He is today at BAH and is leading the EPMO effort on their behalf. I warmly recommend you to each other. Best regards, Peter =RICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000580 580 of 6274 Page 619 of 1093 Document ID: 0.7.1705.630777-000013 Owner: Sandoval, Camilo J. Filename: Levin slide on DoD data sharing -october 2017.pptx Last Modified: Mon Aug 13 10:46:03 CDT 2018 AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000581 581 of 6274 Page 624 of 1093 Levin slide on DoD data sharing -october 2017.pptx for Printed Item: 55 ( Attachment 13 of 26) Cerner VA DoD PAMPI 1,1 <10% loaded I I I I I ,-(-------------- Complete Data Set (bulk load) I--+ Undecided --►• I I Suggested connection would replicate VAplans now neanng completion Decided/Existin g PAMPI- Problems, Allergies, Medications, Procedures , Immuni zations Not currently included: Laboratory Results, Radiology Reports, Vital Signs , Notes , and Tricare Claims data JLV is displayed within Millennium - Attaches to legacy DoD, VistA, other Cerner instances , eHealth Exchange Important: Cemer provided Medicines and Allergies should be provided back to VA(HOR)and DoD (CDR) f IVlr-tilvAI PVERSIGHT VA-18-0298 and VA-18-0299-H-000582 582 of 6274 Page 625 of 1093 Levin slide on DoD data shar ing -october 2017.pptx for Printed Item : 55 ( Attachment 13 of 26) VA-DoD Data Comparison Cerner Data Domain VA Migration DoD Migration 1. Demographics X X 2. Allergies X X 3. Conditions * X X 4. Immunizations X X 5. Laboratory Results X 6. Medications X X 7. Procedures X X 8. Appointments X 9. Encounters X 10. Notes and Radiology Reports X 11. Advance Directives TBD 12. (Tricare for DoD) Claims Data TBD 13. Providers TBD 14. TBD Questionnaires * Conditions are also referred to as problems/diagnoses ** Only Anatomic Pathology laboratory results The DoD Migration isfocused on migrating the "PAMPI+" domains directly to Millennium, which constitute a subset of the domains VA is targeting for migration. AMf-HICA PVERSIGHT VA-18-0298 and VA-18-0299-H-000583 583 of 6274 Page 626 of 1093 Document ID: 0.7.1705.630777-000016 Owner: Sandoval, Camilo J. Filename: RE: [EXTERNAL] check in (12).msg Last Modified: Mon Aug 13 10:46:03 CDT 2018 AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000584 584 of 6274 Page 631 of 1093 irffigfr.?!o'rfifor Printed Item: 55 ( Attachment 16 of 26) From: Sent: Subject: Blackburn, cott Wed 4/4/2018 12:39:41 AM RE: [EXTERNAL] check in Thanks for the note. I'm trying to keep IT momentum going . EHRMis completely up in the air until leadership questions shake out. From: Peter Levin r )(S) ~amida.com] Sent: Tuesday, Apri 03, 20[8 L2:23 PM To: Blackburn, Scott R. Subject: [EXTER AL] check in Hi - just a quick hello and sign of life. Hope you're holding up okay. I've enjoyed and appreciated your social media posts/tweets. Best, -P AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000585 585 of 6274 Page 632 of 1093 RE: [EXTERNAL ] extremely confidential - eyes only- please do not forwa rd or share - secva message this morning (14).msg for Printed Item: 55 ( Attachm 18 of 26) There were some things in the Camilo discussion that may be worth a short call (or visit, as you prefer). Best, -P AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000586 586 of 6274 Page 638 of 1093 Document ID: 0.7.1705.631071 From: Sandoval, Camilo J. To: Sandoval, Camilo J. Cc: Bee: Subject: FW: Please Review Tonight Mon Aug 13 2018 11 :46:03 EDT Date: [EXTERNAL] call today? (1).msg Attachments: [EXTERNAL] dad data sharing (2).msg Levin slide on DoD data sharing -october 2017.pptx [EXTERNAL] extremely confidential - eyes only - please do not forward or share secva message this morning (3).msg (EXTERNAL] Fwd: amida weekly ehrm data migration update (4).msg Amida VA EHRM Weekly Report -sept 14 -final.docx [EXTERNAL] Re: call today? (5).msg EsaEmbeddedMsg (6).msg EsaEmbeddedMsg (7).msg FW: (External] connecting scott to charlie (8).msg FW: [EXTERNAL] dad data sharing (9).msg ATT00001.htm Levin slide on DoD data sharing -october 2017.pptx FW: [EXTERNAL] roger baker (10).msg RE: [EXTERNAL] check in (11).msg RE: [EXTERNAL] check in (12).msg RE: [External] connecting scott to charlie (13).msg RE: [EXTERNAL] extremely confidential - eyes only - please do not forward or share secva message this morning (14).msg RE: [EXTERNAL] follow-up from our last meeting (15).msg RE: [EXTERNAL] Fwd: meeting with rob on wednesday (16).msg RE: [EXTERNAL] stakeholder enterprise portal (sep) and ebenefits (17).msg RE: [EXTERNAL] susan perez (18).msg RE: RE: (EXTERNAL] thursday check in (19).msg RE: Schedule important: Jack Bates' Availability - Peter needs to re-schedule (20).msg RE: Schedule important: Jack Bates' Availability - Peter needs to re-schedule (21 ).msg Windom (22).msg Camilo Sandoval 202-461-6910 From: Sandoval, Camilo J. AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000587 587 of 6274 Page 658 of 1093 Sent: Friday, May 04, 2018 2:12 AM To: Spero, Casin D.; Hayes-Byrd, Jacquelyn ; O'Rourke, Peter M. Subject: RE: Please Review Tonight Pete- This request from members of congress is based on inaccurate reporting by Arthur Allen from Politico, which was fueled by David Shulkin and Scott Blackburn. In fact, the real outside interference and conflict of interest came from Peter Levin, who was attempting to shape the direction of ongoing contract negotiations between the VA and Gerner. According to John Windom and Ash Zenooz, on several occasions Secretary Shulkin suggested to the EHRM team that Peter Levin be hired as a direct contractor. When those efforts failed, Peter Levin then acquired VA contracts through MITRE with Secretary Shulkin's influence. Please note that Peter Levin, Scott Gould, Stephen Ondra and Michele Flournoy (married to Scott Gould) all work for or are associated with AMIDA and MITRE. Ironically, they were all senior VA or DOD employees under the Obama administration with access to insider information. A key question Arthur Allen and interested members of congress should investigate and write about is, why did Shulkin and Blackburn continue to communicate with Peter Levin, and put undue pressure on John Windom to hire Peter Levin's firm-AMIDA-as a contractor. Also, why was Shulkin in such a rush to sign the Gerner contract last year(Oct/Nov) when there was over 51 major findings and recommendations added to the contract over the past several months? And for the record, it was a team of top medical CIOs and practitioners-put together by Ike Perlmutter and Bruce Moskowitz-who identified the flaws in the contract and made the recommendations, not MITRE. MITRE had advised against a strategic pause, and then took credit for the work done after. Please read attachments. From: Spero, Casin D. Sent: Thursday, May 03, 2018 7:31 PM To: Sandoval, Camilo J.; Hayes-Byrd, Jacquelyn; O'Rourke, Peter M. Subject: RE: Please Review Tonight Good info Cam, we may want to remind the interested parties of that. From: Sandoval, Camilo J. Sent: Thursday, May 03, 2018 4:13:22 PM To: Hayes-Byrd, Jacquelyn; O'Rourke, Peter M.; Spero, Casin D. Subject: RE: Please Review Tonight AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000588 588 of 6274 Page 659 of 1093 Thank you Jacquie. If we go back to Shulkin's EHRM hearing testimony, he mentions under oath that he and Scott Blackburn requested outside, non-governmental help from the top 5 Medical CIO's. These experts are who alerted him to the many interoperability issues previously unknown to Gerner or VA staff. From: Hayes-Byrd, Jacquelyn Sent Thursday, May 03, 2018 5:42 PM To : O'Rourke, Peter M.; Sandoval , Camilo J.; Spero , Casin D. Subject: Please Review Tonight Please see these two documents tonight as the Dep Sec provided this to Colonel Gainey late this afternoon And Andy will be giving it to the Secretary first in the a.m. don 't want you to be blindsided and I would like for you to be prepared to discuss. Jacquie From: Washington, Conrad Sent Thursday, May 03, 2018 5:32 PM To : Hayes-Byrd, Jacquelyn Subject: REQUESTED SCAN Conrad Washington Special Assistant Office of the Secretary 810 Vermont Ave, NW Washington, DC 20420 202-461-7865 (0) Con rad. wash ington@va.gov AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000589 589 of 6274 Page 660 of 1093 VA Core Values : Integrity, Commitment , Advocacy , Respect, and Excellence- I CARE AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000590 590 of 6274 Page 661 of 1093 Levin slide on DoD data sharing -october 2017.pptx for Printed Item: 82 ( Attachment 3 of 26) Cerner VA DoD PAMPI 1,1 <10% loaded I I I I I ,-(-------------- Complete Data Set (bulk load) I--+ Undecided --►• I I Suggested connection would replicate VAplans now neanng completion Decided/ Existin g PAMPI- Problems, Allergies, Medications, Procedures, Immunizations Not currently included: Laboratory Results, Radiology Reports, Vital Signs, Notes, and Tricare Claims data JLV is displayed within Millennium - Attaches to legacy DoD, VistA, other Cerner instances, eHealth Exchange Important: Cemer provided Medicines and Allergies should be provided back to VA(HOR)and DoD (CDR) f IVlr-tilvAI PVERSIGHT VA-18-0298 and VA-18-0299-H-000591 591 of 6274 Page 667 of 1093 Levin slide on DoD data shar ing -october 2017.pptx for Printed Item : 82 ( Attachment 3 of 26) VA-DoD Data Comparison Cerner Data Domain VA Migration DoD Migration 1. Demographics X X 2. Allergies X X 3. Conditions * X X 4. Immunizations X X 5. Laboratory Results X 6. Medications X X 7. Procedures X X 8. Appointments X 9. Encounters X 10. Notes and Radiology Reports X 11. Advance Directives TBD 12. (Tricare for DoD) Claims Data TBD 13. Providers TBD 14. TBD Questionnaires * Conditions are also referred to as problems/diagnoses ** Only Anatomic Pathology laboratory results The DoD Migration isfocused on migrating the "PAMPI+" domains directly to Millennium, which constitute a subset of the domains VA is targeting for migration. AMf-HICA PVERSIGHT VA-18-0298 and VA-18-0299-H-000592 592 of 6274 Page 668 of 1093 Document ID: 0.7.1705.631071-000004 Owner: Sandoval, Camilo J. Filename: [EXTERNAL] extremely confidential - eyes only - please do not forward or share secva message this morning (3).msg Last Modified: Mon Aug 13 10:46:03 CDT 2018 AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000593 593 of 6274 Page 669 of 1093 To:[EXTER~ri~;~~K~~,%Pt6r6~~faiit!fll/R~cdo~f ~-aro1~}3lrrnsA~~[§>cBWsfa8'1d9u~~icr~~ PrintedItem: 82 ( Attachme 4 From: Sent: Subject: Peter Levin Thur 1/4/2018 10:58:02 AM [EXTERNAL] extremely confidential - eyes only - please do not forward or share - secva message this morning Jackie suggested last night that I close the loop with the secretary. She was right/great idea. My message to him this morning, below. Scott, literally my waking thought was of you. Best ofluck with the surgery. And best personal regards to both of you , -P Hi David , Three meetings yesterday: 1) with Windom and two MITRE reps - WH issues about my previous VA affiliation came up - I believe these were fully addressed to John's satisfaction. As you know, the outcome of the presidential election was a surprise; there are some hurt feelings from an appointee aspirant who thought I could have done more to help them prior to the election. This was also addressed to his satisfaction. That said, we spent most of the hour reviewing information architecture, surprisingly good agreement (he liked the way I explained it, exactly the same way I explain it to you [PLL - and Scott and Jackie]). From a content perspective we are fully aligned, in sequence, priority, and most of the packaging. The discussion confirmed that. 2) unexpectedly , as I was walking out (coat on, rushing to elevator) Ash came out and asked me to speak to Camilo Sandoval, who I did not know or know of, and had not previously met. From a technical perspective, I had the identical conversation with him that I just had, literally minutes before, with John W. When I left I thought we were okay. We weren't. I left the building and was well on my way to my office when John called me back. 3) we then had the architectmal discussion for the third time, this time with Camilo, Ash, and Short (who came in late but was there for most of it, and did most of the talking after he affived). In a professional-but-clear way, after net five hours , I went around the table and asked each of the participants a) if there was any difference or deviation between the discussions we had independently and the ones we had together (the answer was no, as it should have been) and b) if whatever crisis or misunderstanding existed before the third meeting was fully and satisfactorily resolved (the answer was yes, as it should have been). There were some things in the Camilo discussion that may be worth a short call (or visit, as you prefer). Best, -P AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000594 594 of 6274 Page 670 of 1093 Document ID: 0.7.1705.631071-000005 Owner: Sandoval, Camilo J. Filename: [EXTERNAL] Fwd: amida weekly ehrm data migration update (4).msg Last Modified: Mon Aug 13 10:46:03 CDT 2018 AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000595 595 of 6274 Page 671 of 1093 To: [E XTER~fdt',~1:%Pfr,i'§doiriw _~§cm}i.cefflYt~~i>t~fucVrJarfr@JW.g8~d Item: 82 ( Attachment From: Peter Levin Sent: Thur 9/14/2017 9:43:47 PM Subject: [EXTERN AL] Fwd: amida weekly ehrm data migration update Amida VA EH RM Weekly Report -sept 14 -fina l.docx 5 of 26) Scott - confidential to you, please do not forward or share. MITRE instructed us to stop send ing these to VA (Windom , Short, Bates, Hilton, Mingo) three or four weeks ago; I doubt they forward these or anyth ing like them to stakeho lders there, so I don't know what they now know (or think). This report is sent by my program manager to theirs; I normally cc Jackie as a courtesy. Jimmy asked this week to be included. I have not spoken with John W (or the secretary) since before Labor Day. I did speak to David immediately after his "announcement" of the data migration strategy in mid-August, and advised caution on technical grounds. That was the last I spoke with him on this project. I have not spoken to him at all about the threat to end our work at MITRE. We have had brief (and successful) interactions on other non EHRM top ics. Most respectfully and best regards, Peter ---------- Forwarded messa From: Peter Levin b)( S) amida.c om> Date: Thu , Sep 14, 2017 at 4:05 PM Subject: amida weekl ehrm data migration update mi tre.or >, "Providakes, James To: "Wynn, Jackie" b)(6) Cc: "Fugate, Tom" b)(S) -------- 6 F. Ll (b_l (_ l__ ___.. ~'""' m =itr"·e'--'-. """o"""'r"-' g> Dear Jackie, dear Jimmy, please find attached the Amida weekly report, due today. Its long , I know . We've been at it now for 6 weeks, and this is basically what I would have expected in terms of depth, synthesis, and detail. Please note that the go-forward plan (something we worked on hard last week) is included in Appendix A, exh ibit 7 (the data migration plan and LOE). Also, if you just look at one thing. please go to figure 9 on page 23. Honestly, this is the "money shot" because it is such a good examp le. Basically it is really hard to do data mapping (right) . The capt ion reads : The Vx130 Immunization Domain includes 18 fields, and the Cerner Immunization Data Domain model includes 23 fields. This figure illustrates the beginning of a crosswalk to show example migration paths for six fields from the source data model to the target Cerner model. Note that this is an incomplete crosswalk intended only for purposes of illustration. Many thanks and best regards , Peter AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000596 596 of 6274 Page 672 of 1093 Document ID: 0.7.1705.631071-000006 Owner: Sandoval, Camilo J. Filename: Amida VA EHRM Weekly Report -sept 14 -final.docx Last Modified: Mon Aug 13 10:46:03 CDT 2018 AMERICAN PVERSIGHT VA-18-0298 and VA-18-0299-H-000597 597 of 6274 Page 673 of 1093 Amida VA EHRM Weekly Report -sept 14 -final.docx for Printed Item: 82 ( Attachment 6 of 26) ~n,ida CONFIDENTIAL Weekly Status Report For the MITRECorporation On Data Migration Support for VA Electronic Health Record Modernization September 14, 2017 Jeremy Collins Joy Hwang Matthew McCall Leslie Ramirez Afsin Ustundag Peter L. Levin Prepared by Amida Technology Solutions, Inc. AME Amida Techno logy Solution s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000598 598 of 6274 Page 67 4 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 82 ( Attachmen t 6 of 26) CO FIDENTIAL (b)(5) AME Amida Techno logy Solution s, Inc. 4 pvErf§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000599 599 of 6274 Page 675 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 82 ( Attachmen t 6 of 26) ~rnida CO FIDENTIAL b)(5) AME 2 Amida Techno logy Soluti ons, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000600 600 of 6274 Page 676 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 82 ( Attachmen t 6 of 26) CO FIDENTIAL ~b)(5) AME 3 Am ida Techno logy So lution s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000601 601 of 6274 Page 677 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 82 ( Attachmen t 6 of 26) ~n,ida CO FIDENTIAL b)(5) AME 4 Am ida Techno logy So lution s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000602 602 of 6274 Page 678 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 82 ( Attachmen t 6 of 26) CO FIDENTIAL ~b)(5) AME 5 Amida Techno logy Solution s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000603 603 of 6274 Page 679 of 1093 Amida VA EHRM Weekly Report -sept 14 -final.docx for Printed Item: 82 ( Attachment 6 of 26) ~n,ida CO FIDENTIAL (b)(5) AME 6 Amida Techno logy Solution s, Inc. 4 pvER~ifi~1t VA-18-0298 and VA-18-0299-H-000604 604 of 6274 Page 680 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 82 ( Attachmen t 6 of 26) CO FIDENTIAL (b)(5) AME 7 Am ida Techno logy So lution s, Inc. 4 pvER~ifi~1t VA-18-0298 and VA-18-0299-H-000605 605 of 6274 Page 681 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 82 ( Attachmen t 6 of 26) ~rnida CO FIDENTIAL ~b)(5) AME 8 Am ida Techno logy So lution s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and 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kly Report -sept 14 -final.docx for Printed Item : 82 ( Attachmen t 6 of 26) CO FIDENTIAL (b)(5) AME 22 Amida Techno logy Solution s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000620 620 of 6274 Page 696 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 82 ( Attachmen t 6 of 26) ~n,ida CO FIDENTIAL (b)(5) 23 VA-18-0298 and VA-18-0299-H-000621 621 of 6274 Page 697 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 82 ( Attachmen t 6 of 26) ~rnida CO FIDENTIAL (b)(5) _ 24 Amida Techno logy Solution s, Inc. 4 j:)VErf~ifi ~1t VA-18-0298 and VA-18-0299-H-000622 622 of 6274 Page 698 of 1093 Amida VA EHRM Weekly Report -sept 14 -final.docx for Printed Item: 82 ( Attachment 6 of 26) ~n,ida CO FIDENTIAL (b)(5) - 25 Amida Technology Solution s, Inc. p'VE rt'"'ie3~1t 4 VA-18-0298 and VA-18-0299-H-000623 623 of 6274 Page 699 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 82 ( Attachmen t 6 of 26) CO FIDENTIAL b)(5) AME 26 Amida Techno logy Soluti ons, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000624 624 of 6274 Page 700 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 82 ( Attachmen t 6 of 26) ~n,ida CO FIDENTIAL ~b)(5) AME 27 Am ida Tec hno logy So lution s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000625 625 of 6274 Page 701 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 82 ( Attachmen t 6 of 26) CO FIDENTIAL (b)(5) AME 28 Amida Techno logy Solution s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000626 626 of 6274 Page 702 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 82 ( Attachmen t 6 of 26) ~n,ida CO FIDENTIAL (b)(5) AME 29 Amida Techno logy Solution s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000627 627 of 6274 Page 703 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 82 ( Attachmen t 6 of 26) CO FIDENTIAL ~b)(5) AME 30 Am ida Techno logy Solution s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000628 628 of 6274 Page 704 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 82 ( Attachmen t 6 of 26) ~n,ida CO FIDENTIAL (b)(5) AME 31 Amida Techno logy Solution s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000629 629 of 6274 Page 705 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 82 ( Attachmen t 6 of 26) CO FIDENTIAL (b)(5) AME 32 Am ida Techno logy So lution s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000630 630 of 6274 Page 706 of 1093 Amida VA EHRM Weekly Report -sept 14 -final.docx for Printed Item: 82 ( Attachment 6 of 26) ~rnida CO FIDENTIAL ~b)(5) AME 33 Amida Techno logy Solut ion s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000631 631 of 6274 Page 707 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 82 ( Attachmen t 6 of 26) ~n,ida CO FIDENTIAL ~b)(5) AME 34 Am ida ·1echno logy So lut1on s, 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Attachmen t 6 of 26) CO FIDENTIAL (b)(5) AME 57 Amida Techno logy Solution s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000655 655 of 6274 Page 731 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 82 ( Attachmen t 6 of 26) ~rnida CO FIDENTIAL ~b)(5) AME 58 Am ida Techno logy So lution s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000656 656 of 6274 Page 732 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 82 ( Attachmen t 6 of 26) ~n,ida CO FIDENTIAL (b)(5) A VIC 59 Am ida Techno logy So lution s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000657 657 of 6274 Page 733 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 82 ( Attachmen t 6 of 26) CO FIDENTIAL ~b)(5) AME 60 Am ida Techno logy Solution s, Inc. 4 pvER~ie3 ~1t VA-18-0298 and VA-18-0299-H-000658 658 of 6274 Page 734 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 82 ( Attachmen t 6 of 26) CO 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-sept 14 -final.docx for Printed Item : 82 ( Attachmen t 6 of 26) u~rnida CO FIDENTIAL ~b)(5) AME 70 Amida Techno logy Solution s, Inc. 4 pvER~ifi~1t VA-18-0298 and VA-18-0299-H-000668 668 of 6274 Page 744 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 82 ( Attachmen t 6 of 26) ~rnida CO FIDENTIAL b)(5) AME 71 Am ida Tec hno logy Solution s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000669 669 of 6274 Page 745 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 82 ( Attachmen t 6 of 26) ~rnida CO FIDENTIAL b)(5) AME IL Am ida ·1echno logy So lut1on s, In c. pvErt§'i(3 ~1t 4 VA-18-0298 and VA-18-0299-H-000670 670 of 6274 Page 746 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 82 ( Attachmen t 6 of 26) ~rnida CO FIDENTIAL (b)(5) AME 73 Amida Techno logy Solution s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000671 671 of 6274 Page 747 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 82 ( Attachmen t 6 of 26) ~rnida CO FIDENTIAL (b)(5) AME 74 Am ida Techno logy So lution s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000672 672 of 6274 Page 748 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 82 ( Attachmen t 6 of 26) CO FIDENTIAL b)(5) AME 75 Amida Techno logy Solution s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000673 673 of 6274 Page 749 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 82 ( Attachmen t 6 of 26) CO FIDENTIAL ~b)(5) AME 76 Am ida Tec hno logy So lution s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000674 674 of 6274 Page 750 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 82 ( Attachmen t 6 of 26) CO FIDENTIAL b)(5) AME 77 Amida Techno logy Solution s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000675 675 of 6274 Page 751 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 82 ( Attachmen t 6 of 26) ~rnida CO FIDENTIAL (b)(5) AME 78 Am ida Techno logy So lution s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000676 676 of 6274 Page 752 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 82 ( Attachmen t 6 of 26) ~rnida CO FIDENTIAL (b)(5) AME 79 Amida Techno logy Solution s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000677 677 of 6274 Page 753 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 82 ( Attachmen t 6 of 26) ~rnida CO FIDENTIAL ~b)(5) 80 VA-18-0298 and VA-18-0299-H-000678 678 of 6274 Page 754 of 1093 Amida VA EHRM Wee kly Report -sept 14 -final.docx for Printed Item : 82 ( Attachmen t 6 of 26) ~rnida CO FIDENTIAL ~b)(5) AME 81 Amida Techno logy Solution s, Inc. 4 pvErt§'i(3 ~1t VA-18-0298 and VA-18-0299-H-000679 679 of 6274 Page 755 of 1093