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When the COVID-19 pandemic hit, digital project priorities for the U.S. Department of Veterans Affairs CIO quickly shifted, much like for CIOs at healthcare systems across the U.S.
James Gfrerer, assistant secretary for information and technology and VA CIO, said COVID-19 forced him to rely on his team to focus on long-term digital projects, such as the VA's ongoing migration to a new Cerner EHR, while he turned his attention to more immediate IT needs, such as enabling physicians and support staff remote access to systems.
Gfrerer also focused on building out the department's telehealth services, which grew more than 10 times beyond its pre-pandemic use. He credited the department's earlier shift to the VA Enterprise Cloud with the department's ability to manage the uptick in telehealth volume. Gfrerer said the VA plans to shift 350 VA systems and applications to the enterprise cloud platform, which already contains critical systems such as the Veterans Benefits Management System.
In this Q&A, Gfrerer, a Marine Corps veteran, discusses how digital project priorities shifted at the beginning of the pandemic, and how the pandemic has altered the course for those digital projects moving forward.
How did the pandemic affect your department's handling of digital projects?
James Gfrerer: One of the biggest concerns was that the VA is a largely on-premises workforce, unlike some federal agencies. People show up to work each day. Pre-COVID we had about 40,000 people that were remoting in through our VPN. About 16,000 were using the Citrix Access Gateway. We saw that number essentially triple. The only thing I was really concerned about, was with over 400,000 people in the organization, what if everyone went to telework. You're supporting contractor teammates on top of that, and those numbers go up pretty fast. We needed to think really creatively.
We debated for the better part of a day, how are we going to stress test our ... internet connection gateways so we can prepare for an onslaught of additional remote workers? We finally said, 'You know what, there's no getting around this, we have to stress test in the production environment, in the live environment.' No sane person pre-COVID would do that. We ended up, across our ... tech gateways, and across both the VPN and Citrix environment, stress testing and essentially stuffing all of our daily traffic through one gateway. It allowed us and our vendor partners, our carriers, our infrastructure providers at the data centers, to get great real-time metrics on what the current architecture was able to support. We worked with our infrastructure partners and their engineers to figure out, 'OK, how are we going to improve capacity? What can be done in terms of configuration?' We pulled what's called high-availability mirroring, which essentially doubled capacity. ... Remote access was a big [focus]. As every entity in the world, and certainly the U.S. and the federal government, found out, without the right technology and without the right access, you would have no business continuity.
Did the COVID-19 pandemic usher in any trends or technologies?
Gfrerer: The one that was the largest need, the greatest need, was telehealth. Pre-COVID-19, we had about 2,400 telehealth visits a day. Earlier this week, we were at 38,000 sessions in one day. You look at the growth on that. We had 10 workstreams within IT to focus everybody and get organized, and one of the major workstreams was working with Veterans Health Administration and the telehealth team. Largely, the providers around the scheduling and the actual VA Video Connect telehealth platform was on premises, so we expanded as fast and as far as we could in the on-prem environment, that took us to about 17,000 daily sessions. Our team recognized early on we weren't going to be able to scale beyond that without moving it to the cloud. And so, thank goodness for our digital transformation, our enterprise cloud service. We have about 100 of our 350 goal applications that are already in flight, migrated, so what's another one or two with telehealth.
How has the pandemic impacted your overall digital transformation strategy?
Gfrerer: I think any national emergency, which this was, is kind of an equal opportunity player. It creates opportunities, but it certainly presents threats. When we were stress testing in our environment for our operational networks and trying to provision for greater remote access, we found weakness. We worked with our vendor partners to upgrade, to take the right steps, to provision the right employee access. Same thing with cloud migration, it's definitely accelerated that. We've seen and proven all the benefits of cloud in terms of scalability and the ability to rapidly provision. We're looking at those sorts of services in a multitude of areas.
How has the pandemic impacted long-term digital projects like the EHR modernization effort?
Gfrerer: From the department's perspective, it's full speed ahead. We have our [rolling] wave implementation plan. The thing about the [Office of Information and Technology], for example, is we do current state assessments of the facilities 12 to 18 months out. We always have to be staying ahead of demand, staying ahead of the curve. All the infrastructure and modernization efforts that have to occur, we certainly have to be ahead of that wave implementation. But from a department perspective I don't see that slowing. That said, I'm sure that if there were another significant wave of COVID that could obviously ... have some impact.
How has the pandemic affected the way you will lead digital transformation efforts?
Gfrerer: It's an acceleration and more of what we had even pre-COVID. One of our big efforts is we want to run IT as a business. What I mean by that is the VA itself is a Fortune 10-size entity if you put it in a corporate framework in terms of its scale, its budget, the client base that it serves. We're a substantial entity and that requires that IT and IT investments be very deliberate.
*Editor's note: Responses have been edited for brevity and clarity.