Debra M. Filippi, Former Director, DoD/VA Interagency Program Office
Since it’s inception, the IPO has had a positive impact on enhancing the interagency approach to electronic health record (EHR) development for DoD and VA. The IPO created interagency plans and schedules that provided a roadmap of joint activities, established a multi-tiered governance approach that guided the interagency decision process, and provided a neutral meeting environment that minimized biases and fostered accountability between the two Departments in the execution of the their separate electronic health record initiatives. However, these steps were marginal in comparison to what could have been accomplished had the appropriate functions and necessary authorities been assigned to the IPO to fulfill Section 1635 of the 2008 NDAA law. The role and mission of the IPO, defined in a Charter signed September 2009 by the two Deputy Secretaries, was to be the “single point of accountability for coordination and oversight,” not the “single point of accountability for…development and implementation” of EHR capability as stated in the law. Furthermore, the authorities necessary to execute Section 1635 were specifically retained by the DoD and VA program offices and NOT conveyed to the IPO. Accordingly, the control of the budget, contracts and technical development remained with the two program offices. As a result, the IPO was not empowered by the departments with the necessary functions or authorities to execute the intent of section 1635. Initiatives, such as the James A. Lovell Federal Health Care Center (JALFHCC) project in N. Chicago, would have benefitted greatly from converged solutions fostered by this empowered interagency organization.
Congress established the IPO to improve the fielding of an interoperable electronic health record capability for those who have served our country so nobly. To date, DoD and VA have made strides in sharing pertinent components of electronic health information; however, the quantum leap for both organizations is to unite their development efforts as one organization and create a single, superlative electronic health record that by definition is interoperable and yields a transparent, effective and efficient capability for our service members and veterans. The IPO is the medium for these two largest Federal Departments to merge their resources, their intellectual property and their spirit as force multipliers for operational as well as economic success. The promise of a fully empowered IPO is synergy, solidarity and unity between DoD and VA. The chosen path for the IPO was only a step in the right direction—a “bunt” in baseball parlance—that has resulted in modest progress. Now we need a home run: a single program office, embraced by both DoD and VA, empowered with the necessary authorities to develop, implement and sustain the best electronic health record capability for our military, veterans and their families. This draft legislation is the designated hitter for this home run. It declares to the Departments what is expected in establishing a true interagency program organization, to include the authorities necessary to execute the functions. The language serves as a template for the necessary modifications to the IPO Charter and obviates any conflict or resistance that may still exist in the current document or in the departments. The most important issue to be reconciled is who is the responsible party for the execution of the funding, for that organization is truly the one accountable for the interoperability of the EHR systems/capabilities for DoD and VA. This is not only about interoperability; it’s also about pursuing economic-minded approaches to Federal Government best business practices. Creating the IPO was an innovative idea, one that will no doubt cast the mold for future Federal partnerships. I strongly endorse the passing of this language for the benefit of our military, veterans and their families.
Chairman Johnson, Ranking Member Donnelly, thank you for this opportunity to provide testimony on the proposed changes to Section 1635 of the 2008 National Defense Authorization Act to improve the electronic health information systems and capabilities of the Department of Defense (DoD) and the Department of Veterans Affairs (VA). I offer this testimony as the former Director of the Interagency Program Office (IPO) serving from October 2009 until June 2011. I retired from that post on June 3, 2011, after a fulfilling 34-year career with the Federal Government. It is my privilege to have this opportunity to provide remarks regarding the proposed legislation that would strengthen the authorities of the IPO to better serve our military, veterans and their families.
Since it’s inception, I believe the IPO has had a positive impact on enhancing the interagency approach to electronic health record (EHR) development for DoD and VA. The IPO created interagency plans and schedules that provided a roadmap of joint activities, established a multi-tiered governance approach that guided the interagency decision process, and provided a neutral meeting environment that minimized biases and fostered accountability between the two Departments in the execution of the their separate electronic health record initiatives. By all accounts these are very important steps in fostering a more cohesive relationship between the two Departments that should improve the interoperability of electronic health records. However, these steps, while important, were marginal in light of what could have been accomplished had the appropriate functions and necessary authorities been assigned to the IPO to fulfill the NDAA requirement. The resources of the two departments could have been merged into one program office leveraging intellect, manpower and dollars for a single solution to EHR capabilities. Projects like the James A. Lovell Federal Health Care Center (JALFHCC) in N. Chicago would have had a greater commitment to converged solutions rather than duplicative products. Not only would a greater interoperability have been achieved but also more economic-minded solutions would have prevailed. The language proposed by the committee reflects the original intent of the 2008 Law; let’s move forward to empower the IPO with the appropriate roles, responsibilities and authorities. For the benefit of our service members and our veterans, I strongly endorse the passing of this language.
The charter for the IPO implementing Section 1635 of the 2008 NDAA was signed in September 2009 by the Department Deputies. The IPO was cast in a “coordination and oversight” role for the two department program offices versus that of “the” single, accountable program office. Also specified in the charter, the control of the budget, contracts and technical development remained with the two program offices. As a result, each Department continued to pursue separate strategies and implementation paths that were true to their desired approaches rather than coming together to build a unified, interoperable approach. Additionally, the governance structure for leading the interagency initiatives was driven by a committee of department senior executives. There was no interagency decision authority below this committee. As a result, the departments maintained the functions and authority—and therefore the accountability—for their individual EHR efforts; it was not instilled in the IPO.
I believe the role intended for the IPO in Section 1635 of the 2008 NDAA was to be the sole program office for EHR initiatives and, if chartered accordingly, would become that single point of accountability, leveraging the intellect and experience of the DoD and VA assets to yield one strategy, one design and one implementation of an EHR capability. Providing one solution versus two compatible solutions would establish the critical bedrock for a seamless, premier health care continuum that our service members, veterans and their families so deeply deserve. For this to be effective, the Departments must empower the interagency program office with planning, programming, budgeting and execution authorities commensurate with the mission of accountability. These authorities will be the very tools used by the IPO to accomplish the necessary program management activities for the EHR, unite the efforts of the two Departments and implement an integrated, interoperable capability.
The draft legislation clarifies Congress’ intent for the role of the IPO to be the “single program office” in the development of the EHR capabilities. The language acknowledges that the necessary authorities—programming, budgeting and execution—MUST be vested in the IPO in order for it to successfully execute the role. It also clarifies that the IPO should indeed become the “sole responsible office” on behalf of DoD and VA and not be considered as a separate, third party organization to “coordinate” two distinct efforts. The draft language is pivotal in ensuring that the Departments shift from a two-department approach to a single interdepartmental approach with the IPO at the helm. In my opinion, the most important issue to be reconciled is who is the responsible party for the execution of the funding, for that organization is truly the one accountable for the interoperability of the EHR systems/capabilities for DoD and VA.
Ideally, this interagency effort should be led by an executive from a third party Department such as Health and Human Services (HHS) or Office of Management and Budget (OMB) that would create a more neutral environment and obviate any concerns by either department of bias. However, if the Director of the IPO reported to the two Department Secretaries or their Deputies, each having equal authority over the Director as well as the Director having their support, this, too, would result in a more positive organizational alignment that would strengthen the effectiveness of a single, accountable program. The real key to success is that the two Departments turn to this organization as their “go to” asset, empowering them as their spokesperson, their program manager and their “single point of accountability” for EHR. Each Department must invest in this interagency organization and feel ownership and have the confidence in its ability to deliver on behalf of each.
III. Interagency Office Functions
This proposed language is clear in describing what Congress intended for the IPO with respect to the EHR initiatives: “…be the single program office”; “…the function of the office shall be to develop, implement, and sustain electronic health record systems and capabilities for the Department of Defense and the Department of Veterans Affairs”; “Sole responsible office…be the only office of the Department of Defense and the Department of Veterans Affairs responsible for electronic health record capabilities….” It is clear by these words that the IPO is intended to be the one and only program office responsible for developing and representing the EHR initiatives for both DoD and VA. The Charter stipulates that the IPO is the single point of accountability for “coordination and oversight” which established a very limited, passive role for the IPO. The IPO was not seen OR staffed as a program office responsible for the design, development, test, implementation and fielding of the EHR capabilities; instead, it was used more as a “check point” for the two Departments in reviewing plans, schedules and milestones after they were developed, resulting in a more inefficient and less effective interagency plan. For example, the Departments developed separate strategies for implementing the information technology (IT) capabilities that were to support the N. Chicago demonstration project, the James A. Lovell Federal Health Care Center (JALFHCC). These strategies were linked to each Department’s health IT plans versus a joint JALFCC plan. At one progress review, The IPO questioned DoD and VA regarding their decisions to implement separate pharmacy capabilities rather than just one at N. Chicago. The Department representatives acknowledged that the chosen paths for each complimented their separate strategies and were committed accordingly. This approach ultimately resulted in a delay in the delivery of the pharmacy capability due to additional time needed to develop highly complex interfacing software to support the two systems. Additionally, in another function fielded at JALFHCC, Medical single sign on (MSSO), each Department implemented the same capability using two different commercial tools. This has resulted in a burden for the user to learn two different interfaces and missed opportunities to leverage contracts and other sustainment costs. Each of these examples illuminates the challenge to interoperability if the Departments continue separate development paths. Recently, the departments revisited these decisions and are now planning to field one pharmacy capability and converge on one MSSO tool. Ultimately, this is the right decision; however, now they are incurring additional expenses and a delay in fielding a capability that could have been avoided had the Departments been working together as a single program office with joint goals. One organization needs to be responsible for promoting common solutions for the same requirements or we will continue to be consumed by overbearing mediation that at best will result in lowest common denominator solutions—neither efficient nor effective for the taxpayer, veteran, military and their families.
IV. Authorities for the IPO
All the critical authorities—program management, supervisory and most important, financial—remained under the control of the two separate Departmental program offices as stipulated by the charter: “… DoD and VA will retain responsibility for … life cycle program management activities including financial management, IT systems development and implementation.” This eliminated any ability of the interagency office to be accountable as envisioned by the Law. Furthermore, this language implied that the IPO was not a part of either Department, which represents the mindset of each department relative to the IPO. The IPO should be considered as the single program office for electronic health care records development and be vested with the appropriate authorities to execute that role. This would enable the IPO to perform the design, development, test, acquisition, implementation and sustainment of all electronic health record initiatives—all those activities reflective of a true program office. DoD and VA must embrace the IPO as “their” program office with all the same confidence and trust they have today in their individual program offices. Most importantly, the IPO MUST be given planning, programming, budgeting and execution authorities in order to be the single point of accountability. The proposed language does this and therefore should obviate any confusion or contradiction by the 2009 Charter. The proposed language that calls for the IPO to “be the single program office” of DoD and VA, “responsible for the development, implementation and sustainment of all electronic health record systems and capabilities” greatly clarifies what Congress originally expected of the two Departments in empowering the IPO. This language should cause a shift in the “center of gravity” of the electronic health record initiatives from the DoD and VA program offices to that of the IPO. In addition to this proposed language, the most important mechanism necessary to execute this language is to assign the budget for EHR to the IPO, as proposed in the following words: “…the budget materials submitted to the President by the Secretary of Defense and the Secretary of Veterans Affairs in connection with the submission to Congress, …each Secretary shall ensure that the Office is listed as a separate, dedicated budget line.” To ensure the IPO is indeed vested with the Program Management and execution authorities for EHR, assign the EHR budgets from both Departments to the IPO. The current 2011 budget for the IPO is $14.6 million, while the EHR budgets in DoD and VA are in the hundreds of millions of dollars. This is a clear indication that the Departments are executing the program management role of design, develop, test and implement, and the IPO is executing a very small coordinating role in the EHR effort. The resources that exist in the respective Department budget lines today should be “merged” into a single “virtual line” to be executed and accounted for by the IPO for the EHR program.
V. Supervision and Organization
The hierarchy, mission and composition of the IPO organization are critical to its foundation and its success. Working across the two largest Departments in the Federal Government poses certain challenges to customary practices, but they are not insurmountable. The reporting relationship of the IPO must connote trust and assurance that the interests of the two Departments will be honored and supported and, moreover, that the IPO is seen as the Department’s asset versus an outsider. The Director should be the “go to person” for Department Secretaries and Deputy Secretaries rather than other Department executives. This will reflect that the effort is a single, joint initiative and establish a single information loop that is consistent and responsive to both Department leaders. In the past, each Department has had a separate spokesperson they turn to on the various EHR projects (e.g., Virtual Lifetime electronic Record (VLER), N. Chicago, EHR) and the message was often inconsistent or tailored to the specific Department. This caused much confusion and posed challenges for establishing a baseline platform to report from and measure progress against. The IPO should be the organization responding to all inquiries and issues associated with the electronic health record initiatives on behalf of DoD and VA. They should be the “sole responsible office” contacted by any outside entity, to include Congress, OMB, and GAO to respond on all EHR inquiries. The mission needs to be clear, unambiguous and universally supported throughout the two Departments, particularly at the execution level.
The reporting relationship for the IPO has endured ambiguity and ineffectiveness. As a DOD employee, the Director reports to and is rated by the Undersecretary for Personnel and Readiness. This has caused some concern by the VA leadership that the IPO was more favorable to DoD. As an interagency initiative legislated to execute Title 10 and Title 38 authorities on behalf of DoD and VA, the IPO needs to be organized equitably so the Departments trust that the organization serves both with a balanced perspective. The IPO did not have the visibility with the Department executives as the interagency organization responsible for EHR. If the IPO reported to a third-party Federal organization outside of DoD or VA, the Departments may be more trusting of the IPO. However, an equally suitable alternative would be to have the Director report to the Department Secretaries to instill confidence and trust that this organization is acting in their best interests. Stipulating in the draft legislation that the IPO Director report to both Secretaries or Deputy Secretaries with each having 50% input to the performance review of the Director is a significant step toward building the needed trust. This will also bolster the Director to be the trusted agent on the EHR subject matter with top Departmental Executives and dissuade the Secretaries from turning to other department executives within DoD or VA.
Organizationally, the IPO should be structured as any other organization with the Deputy Director reporting to the Director, the next-tier employees reporting to the Deputy, and so on down the hierarchy. This reinforces the unity of chain of command within the IPO, regardless of whether they occupy DoD or VA billets. The current billet structure for the IPO consists of 10 DoD employees and 10 VA employees, plus 2 Senior Executives—the Director from DoD and the Deputy Director from VA. However, most of the VA billets (7) remained vacant since the inception of the IPO as a result of no hiring authority. Additionally 5 of the 10 VA billets were downgraded to GS-14 and -13 levels, while DoD rated all of their billets at the GS-15 level. This billet structure is austere in comparison to that of the Department program offices and clearly indicates that a very modest role was intended for the IPO. Additionally, this low-graded structure made it very difficult for the IPO to engage peer-to-peer with the Departments
A more effective way to provide staffing to the IPO is to merge the personnel from the DoD and VA program offices into the IPO so that it is a true “unity of effort.” Collocate the personnel; capitalize on the intellectual property that already exists in the Department PMOs and position DoD and VA personnel to start thinking as one team. In this scenario, the discussions, the thinking and the solutions will take on a solidarity that will result in a cohesive end-to-end solution for the military and veterans. “They” will become “us,” “their ideas” will become “our ideas” and the solutions will be joint.
Congress established the IPO to improve the fielding of an interoperable electronic health record capability for those who have served our country so nobly. To date, DoD and VA have made strides in sharing pertinent components of electronic health information; however, the quantum leap for both organizations is to unite their development efforts as one organization and create a single, superlative electronic health record that by definition is interoperable and yields a transparent, effective and efficient capability for our users. The IPO is the medium for these two largest Federal Departments to merge their resources, their intellectual property and their spirit as force multipliers for operational as well as economic success. The promise of the IPO is synergy, solidarity and unity between DoD and VA. The 2008 law created an innovative yet startling approach to the interdepartmental development environment that challenged the accepted practices of both Departments. The chosen path for the IPO was only a step in the right direction—a “bunt” in baseball parlance—that has resulted in modest progress. Now we need a home run: a single program office, embraced by both DoD and VA, empowered with the necessary authorities to develop, implement and sustain the best damned electronic health record capability for our military, veterans and their families. This draft legislation is the designated hitter for this home run. It declares to the Departments what is expected in establishing a true interagency program organization, to include the authorities necessary to execute the functions. The language serves as a template for the modifications to the IPO Charter as well as the streamlining of fielding EHR capability. This is not only about interoperability; it’s also about pursuing economic minded approaches to Federal Government business practices. Creating the IPO was an innovative idea, one that will no doubt cast the mold for future Federal partnerships.
Thank you for the privilege of providing testimony on this subject. I wish you and the Departments all the best in achieving success on this very worthy cause.