redacted Justification and Approval TXCC User Subscriptions Renewal FY24_Redacted.pdf

TriageXpert Contact Center SaaS Subscriptions VA-24-00067768

JUSTIFICATION FOR AN EXCEPTION TO FAIR OPPORTUNITY

1. Contracting Activity: Department of Veterans Affairs (VA)

Office of Procurement, Acquisition and Logistics Technology Acquisition Center 23 Christopher Way Eatontown, New Jersey 07724

2. Description of Action: The proposed action is for a firm-fixed-price delivery order issued under the National Aeronautics and Space Administration (NASA) Solutions for Enterprise Wide Procurement V (SEWP) Governmentwide Acquisition Contract (GWAC), for the renewal of brand name DSHI Systems, Inc. (DSHI) TriageXpert Contact Center (TXCC) software-as-a-service (SaaS) license subscriptions and related technical support for Veterans Health Administration (VHA) nurses and nurse triage leads in all 18 Veterans Integrated Service Networks (VISNs) across the VHA enterprise.

3. Description of the Supplies or Services: The mission of the Department of Veterans Affairs (VA), Office of Information and Technology (OI&T) Veterans Experience Services (VES), Veterans Relationship Management (VRM) is to provide benefits and services to Veterans of the United States by providing supportive Information Management/Information Technology systems. To meet organization goals, VHA has a requirement for the renewal of brand name TXCC SaaS solution, which is used across all VHA VISN sites by Telecare staff to provide telephone triage and informational services to Veterans. TXCC is a highly specialized application that supports nurse clinical decision-making by systematically assessing a Veteran’s symptoms, and by providing reference health information for Veterans and providing bio and syndromic surveillance data used in predictive modeling for the VA. The solution is designed to identify emergencies, while reducing unnecessary emergency department and clinic visits by systematically assessing a Veteran's symptoms using electronic algorithms with branching clinical logic. TXCC thereby allows VA to comply with VHA Directive 2007-033 for 24/7 access to medical advice.

TXCC uses proprietary artificial intelligence and natural language processing to guide the user through a targeted medical history. The goal of TXCC is to standardize triage recommendations, improve outcomes, and improve workflow efficiency for the Clinical Contact Center nurses. TXCC supports nurse clinical decision-making by systematically assessing a Veteran’s symptoms, while providing reference health information (a 28,000 topic medical library used to provide patients with web-based patient instructions on diseases, tests, and medications) during the process. TXCC guides the nurse through the medical history and creates a triage note, which is passed to the VA Health Connect CRM.

The CRM solution records the encounter in the VA medical record where it becomes immediately viewable by the provider.

TXCC SaaS subscriptions were initially purchased in June 2021 to accommodate a pilot rollout implemented for nurse and nurse triage leads, taking place at VISN 8 and VISN 20, as both proof of concept and for priority COVID-19 response. TXCC was subsequently rolled out nationally across all VHA VISNs between 2021 and 2023. The purpose of this action is to renew TXCC subscriptions and related technical support to accommodate the continued use of VAHC CRM across all 18 VISNs. VHA requires renewal of TXCC subscriptions for all 18 VISNs, a development environment, a production environment, technical support, application update and nurse training sessions.

The required software subscriptions and technical support are sold exclusively through DSHI Systems, Inc., or one of its authorized resellers. The period of performance shall be 6 months from the date of award, with one 6-month option period. The total estimated value of this proposed action, inclusive of the option period, is .

4. Statutory Authority: Pursuant to Federal Acquisition Regulation (FAR) 16.505(a)(4), the following brand name requirement is being justified and approved as an exception to fair opportunity under the statutory authority of Section 41 U.S.C. 4106(c)(2) as implemented by FAR 16.505(b)(2)(i)(B), entitled “Only one awardee is capable of providing the supplies or services required at the level of quality required because the supplies or services ordered are unique or highly specialized.”

5. Rationale Supporting Use of Authority Cited Above: Based upon on market research, as described in Section 8 of this justification, and based on VA’s current use/experience with TXCC, it was determined that limited competition is available among authorized resellers of DSHI Systems, specifically for TXCC software subscriptions and related technical support.

The TXCC software meets the VA interoperability and compatibility requirements of connecting to both CPRS and VistA where updates are made directly into the patient’s electronic medical record. Nurses and Medical Service Assistants across the VA have been trained to use TXCC, implementation and integration of another decision support tool would require re-training of staff. The TXCC SaaS software has been in use across VHA VISNs since 2021. TXCC is integrated with VAHC CRM and is a component of the VAHC CRM solution. Specifically, TXCC software is baseline commercial-off-the-shelf software that VA information technology staff and VHA clinical staff use to provide VHA nursing telephone liaison care management system commonly referred to in VHA as VAHC CRM System. This VAHC CRM System has been installed in all VISNs with the national rollout between 2021 and 2023. The combined VA Health Connect CRM solution with the embedded TXCC triage component is the only clinical software application which currently has the ability to interface with both VistA and CPRS to meet VA’s interoperability and compatibility requirements. In addition, TXCC is a proprietary software product owned by DSHI Systems, Inc.; therefore, support for this product can only be provided by DSHI, or one of its authorized resellers.

Only these sources have access to DSHI’s proprietary source code needed to support the TXCC software subscriptions and ensure all services provided are properly configured.

Use of any other software would result in duplicated efforts to recode and reconfigure the interface between VA Health Connect CRM and the triage tool. Custom integrations would have to be built if using any tool other than TXCC. Specifically, the use of any alternative telephone triage and informational services software product will first require retaining a System Integrator to conduct an extensive and complex reconfiguring and recoding effort in order to achieve the same capabilities as TXCC. The aforementioned effort would include sorting through thousands of lines of code and also a substantial effort to develop a fully operable interface for the triage tool and VA Health Connect CRM, which is already readily available through DSHI TXCC. VA would need to provide the requirements, as well as management and oversight of the project. Required development would include integration with the VA Health Connect SalesForce system; to include reporting and dashboards as well as necessary changes to interfaces with existing VA systems like VistA and CPRS. Any such recoding and development effort is estimated to cost $2M and take up to two years to complete; the aforementioned two years does not include the time it would take to rollout an alternative software product. The $2M estimate does not include the required training and certification of end users. These estimated duplicative costs and time are based on previous software design and integration efforts of similar size and scope and would not be recovered through competition.

In addition, TXCC is used by the VA Office of Public Health for bio and syndromic surveillance. The data points captured by TXCC are used by the VA Office of Public Health to report seamlessly on year over year trends and use that uniform data structure for future predictions because the symptoms captured are used in predictive modeling (i.e., enables VA to predict upcoming hotspots for influenza outbreaks). TXCC’s syndromic (pre-diagnostic) data source, streaming from nurse interactions in the call center and in clinics, provide VA with a treasure trove of surveillance data.

The current workforce is trained and familiar with using TXCC. TXCC triage content has been written specific to VHA requirements. The pilot and national rollout confirmed that TXCC is already integrated with VAHC CRM, and the VAHC CRM solution is already fully integrated into the VistA and CPRS systems. Having software that integrates with VistA and CPRS is critical so clinicians can access and evaluate a patient’s medical records during the triage process. Failure to access patient records would result in incomplete information with which to advise the patient, which would severely negatively impact the quality-of-care VA can offer to its Veterans, causing degradation of service and impacts to life-or-death situations, especially in emergency triage situations. According to a study conducted by the National Institute of Health (NIH) published in 2019 (Performance of triage systems in emergency care: a systematic review and meta-analysis – PMC; nih.gov), a significant patient safety concern was created when care providers were asked to use multiple triage systems resulting in some cases in different outcomes. Changing to an alternative triage system without months of prior training and practice may introduce a significant risk to patient safety. Without the TXCC and VAHC CRM solution, a Veteran being triaged might not be told to call 911 or be transferred to TeleUrgent Care when it was necessary, due to human error or lack of a triage tool, which could result in harm or death. Additionally, training VA staff on multiple triage software products increases the opportunity for human error and degradation of Veteran care.

6. Efforts to Obtain Competition: Market research was conducted, details of which are in the market research section of this document. This effort did not yield any additional sources that can meet the Government's requirements. However, the undersigned VA technical representative determined that limited competition is available among authorized resellers for brand name DSHI Systems, Inc. subscriptions, as well as software maintenance and support. In accordance with FAR 16.505(a)(4)(iii)(A)(1), this justification will be provided with the solicitation to all appropriate NASA SEWP V GWAC holders.

Furthermore, in accordance with FAR 5.301, 16.505(b)(2)(ii)(D), and 16.505(a)(4)(iii), the award notice for this action will be synopsized on the Contracting Opportunities website and this justification will be made publicly available within 14 days of award.

7. Actions to Increase Competition: With rapid changes in the industry with the implementation of Artificial Intelligence (AI) and natural language processing as well as enhancements to the interoperability of healthcare software, VA will continue to explore alternatives and new products that will fulfill the evolving need of the Government.

8. Market Research: The Government’s technical experts conducted web-based market research from August 2023 to November 2023. Four triage decision support software as a service (SaaS) were evaluated; TXCC, Clear Triage, CareXM, and Microsoft Dynamics 365.

It was determined at the time of the research that only TXCC met the necessary interoperability requirements. Microsoft Dynamics 365 does not offer an out-of-the-box solution specific to clinical triage. Clear Triage can integrate with VAHC CRM but is not FedRamp High certified. Clear Triage is a cloud-based SaaS solution which does not run locally on the end user’s computer. To support communication, Clear Triage will use a cloud-to-cloud connection and will bypass the Trusted Internet Connection gateway, this type of connection does not meet VA information security requirements and may put patient health information at risk of accidental exposure. CareXM is a solution which includes triage nurses as part of the solution. VHA already has triage nurses and because CareXM could not be separated from the nurses, Additionally, CareXM is not interoperable with the current CRM solution and would require significant development work to integrate. CareXM did not meet VA’s requirements. For purposes of this acquisition, TXCC is the only software product which is already integrated with VA Health Connect CRM and meets all of the current requirements.

In November 2023, VA’s technical experts conducted extensive market research to ascertain the extent of limited competition among resellers of the required software subscriptions and related technical support. Through the use of the Provider Look-up tool on the NASA SEWP V GWAC website, four Service-Disabled Veteran-Owned Small Businesses (SDVOSB) were identified as resellers of the required TXCC SaaS subscriptions.

9. Other Facts: None.