VA Has Begun to Acquire a New System after a Long History of Efforts to Modernize VistA

Over nearly 2 decades, VA pursued multiple efforts to modernize VistA. Rather than continue to use the system,  the Secretary stated that the department planned to acquire the same  EHR system that DOD is acquiring—Cerner Millennium. As a result of these findings, we recommended that VA clearly define  the role and responsibilities of the Interagency Program Office within  the governance plans for acquisition of the department’s new EHR  system. Definition of VistA remains important because VA plans to  continue using the system during the department’s decade-long transition  to the Cerner system. VA maintains multiple documents and a database that describe parts of  VistA, including various components and interfaces. For example,  EHRM program officials recognized the need to further understand the  customization of VistA components at the various medical facilities and  have conducted analyses to do so. EHRM program officials stated that they have not been able to fully define  VistA and understand all local customizations due to the decentralization  of the development of the system and its evolution over more than 30  years. According to EHRM program documentation, Cerner’s contract calls for  the company to conduct comprehensive assessments to capture the  current state of technical and clinical operations at specific facilities, as  well as identify site-specific requirements where the Cerner system is  planned to be deployed. The continuation of planned site assessments  should provide a thorough understanding of the 130 VistA versions, help  the department better define VistA, and position it for transitioning from  VistA to Cerner’s COTS solution. VA identified costs for VistA and its related activities adding up to  approximately $913.7 million, $664.3 million, and $711.1 million in fiscal  years 2015, 2016, and 2017, respectively—for a total of about $2.3 billion  over the 3 years. However, of the $2.3 billion, the department was only  able to demonstrate that approximately $1 billion of these costs were  reliable. VA Did Not Sufficiently Demonstrate the Reliability of Data for All VistA Costs

Of the $2.3 billion total costs for VistA, VA demonstrated that only  approximately $1 billion of these costs were reliable. The lack of sufficiently reliable and comprehensive costs indicates that  the department is not positioned to accurately report the annual costs to  develop and sustain VistA. This is due, in part, to the fact that VA has not  followed a well-documented methodology that describes how the  department determined the total costs for the system. As a  result, the department, legislators, and the public do not have the  comprehensive, reliable information needed to understand how much it  actually cost to develop and maintain the system. Further, VA does not  have the reliable information needed to make critical management  decisions for sustaining the many versions of VistA over the next 10 years  until the Cerner system is fully deployed. These activities represent important initial steps  to prepare for the transition to the new system. In addition, VA  has prepared charters for the governance boards and identified board  membership. The baseline review also included identifying and addressing program  risks related to the Cerner system implementation. Consequently, VA has engaged in efforts to provide additional  insight into the system. VA has taken a number of actions to prepare for the transition from VistA  to the Cerner system, such as establishing and beginning to staff a  program office, forming a governance structure, conducting site  assessments at initial sites, preparing program plans to guide the initial  implementation, and setting an initial program baseline to help guide  implementation of the system at three key sites. Appendix I: Objectives, Scope, and Methodology

Our objectives were to: (1) determine the extent to which the Department  of Veterans Affairs (VA) has defined the Veterans Health Information  Systems and Technology Architecture (VistA), (2) evaluate VA’s annual  costs to develop and sustain VistA, and (3) describe the actions VA has  taken to transition from VistA to the Cerner system. In addition, we reviewed program documentation related to three  analyses undertaken by VA to further define VistA. These analyses  included the department’s efforts to ascertain variances between versions  of VistA, identify components of VistA to be replaced by the Cerner  System, and document the current state of a sample instance of VistA. To address the second objective, we examined department  documentation of costs associated with the development and sustainment  (operation and maintenance) of VistA for fiscal years 2015, 2016, and  2017. Specifically, we examined VA’s  plans to establish a structure for governing technical and functional issues  and joint decisions that arise with the Department of Defense.
Why GAO Did This Study

VA provides health care services to approximately 9 million veterans and their families and relies on its health information system—VistA—to do so. However, the system is more than 30 years old, is costly to maintain, and does not fully support exchanging health data with DOD and private health care providers. Over nearly 2 decades, VA has pursued multiple efforts to modernize the system. In June 2017, the department announced plans to acquire the same system—the Cerner system—that DOD is implementing. VA plans to continue using VistA during the decade-long transition to the Cerner system.
GAO was asked to review key aspects of VistA and VA's plans for the new acquisition of the Cerner system. The objectives of the review were to (1) determine the extent to which VA has defined VistA, (2) evaluate VA's annual costs to develop and sustain VistA, and (3) describe the actions VA has taken to transition from VistA to the Cerner system.
GAO analyzed documentation that defines aspects of VistA and identifies components to be replaced; evaluated the reliability of cost data, including obligations associated with the development and sustainment of VistA for fiscal years 2015, 2016, and 2017; and reviewed program documentation related to VA's program, governance, and plans to transition to Cerner.

What GAO Found

The Department of Veterans Affairs (VA) has various documents and a database that describe parts of the Veterans Health Information Systems and Technology Architecture (VistA); however, the department does not have a comprehensive definition for the system. For example, VA has identified components that comprise VistA, identified interfaces related to the system, and collected system user guides and installation manuals. VA has also conducted analyses to better understand customization of VistA components at various medical facilities. Nevertheless, the existing information and analyses do not provide a thorough understanding of the local customizations reflected in about 130 versions of VistA that support health care delivery at more than 1,500 sites. Program officials stated that they have not been able to fully define VistA due to the decentralization of the development of the system for more than 30 years. Cerner's contract to provide a new electronic health record system to VA calls for the company to conduct comprehensive assessments to identify site-specific requirements where its system is planned to be deployed. Three site assessments have been completed and additional assessments are planned. If these assessments provide a thorough understanding of the 130 VistA versions, the department should be able to define VistA and be better positioned to transition to the new system.
VA identified costs for VistA and its related activities adding up to approximately $913.7 million, $664.3 million, and $711.1 million in fiscal years 2015, 2016, and 2017, respectively—for a total of about $2.3 billion over the 3 years. However, of the $2.3 billion, the department was only able to demonstrate that approximately $1 billion of these costs were sufficiently reliable. In addition, the department omitted VistA-related costs from the total. The lack of a sufficiently reliable and comprehensive total cost for VistA is due in part to not following a well-documented methodology that describes how the department determined the costs for the system. As a result of incomplete cost data and data that could not be determined to be sufficiently reliable, the department, legislators, and the public do not have a complete understanding of how much it has cost to develop and maintain VistA. Further, VA lacks the information needed to make decisions on sustaining the many versions of the system.
VA has initiated a number of actions to prepare for the transition from VistA to the Cerner system. These actions include taking steps to establish and begin to staff a program office, forming a governance structure, conducting assessments at the initial sites, preparing program plans to guide the initial system implementation, and setting a program baseline to help guide implementation at the initial sites. The department's actions in these important areas are ongoing. Additional actions are in progress to address GAO's September 2018 recommendation that VA clearly define the role and responsibilities of the joint Department of Defense (DOD) and VA Interagency Program Office in the department's governance plans for the new electronic health record system. VA intends to continue maturing and fully establishing a program management organization and a program governance structure to track program progress.

What GAO Recommends

GAO is recommending that VA develop and implement a methodology for reliably identifying and reporting the total costs of VistA. VA agreed with the recommendation.