[House Hearing, 114 Congress]
[From the U.S. Government Publishing Office]


   TECHNOLOGY AND TREATMENT: TELEMEDICINE IN THE VA HEALTHCARE SYSTEM

=======================================================================

                             FIELD HEARING

                               BEFORE THE

                         SUBCOMMITTEE ON HEALTH

                                OF THE

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                    ONE HUNDRED FOURTEENTH CONGRESS

                             SECOND SESSION

                               __________

                        TUESDAY, AUGUST 9, 2016

              FIELD HEARING HELD IN CAMARILLO, CALIFORNIA

                               __________

                           Serial No. 114-77

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
       
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                    COMMITTEE ON VETERANS' AFFAIRS

                     JEFF MILLER, Florida, Chairman

DOUG LAMBORN, Colorado               CORRINE BROWN, Florida, Ranking 
GUS M. BILIRAKIS, Florida, Vice-         Minority Member
    Chairman                         MARK TAKANO, California
DAVID P. ROE, Tennessee              JULIA BROWNLEY, California
DAN BENISHEK, Michigan               DINA TITUS, Nevada
TIM HUELSKAMP, Kansas                RAUL RUIZ, California
MIKE COFFMAN, Colorado               ANN M. KUSTER, New Hampshire
BRAD R. WENSTRUP, Ohio               BETO O'ROURKE, Texas
JACKIE WALORSKI, Indiana             KATHLEEN RICE, New York
RALPH ABRAHAM, Louisiana             TIMOTHY J. WALZ, Minnesota
LEE ZELDIN, New York                 JERRY McNERNEY, California
RYAN COSTELLO, Pennsylvania
AMATA COLEMAN RADEWAGEN, American 
    Samoa
MIKE BOST, Illinois
                       Jon Towers, Staff Director
                Don Phillips, Democratic Staff Director

                         SUBCOMMITTEE ON HEALTH

                    DAN BENISHEK, Michigan, Chairman

GUS M. BILIRAKIS, Florida            JULIA BROWNLEY, California, 
DAVID P. ROE, Tennessee                  Ranking Member
TIM HUELSKAMP, Kansas                MARK TAKANO, California
MIKE COFFMAN, Colorado               RAUL RUIZ, California
BRAD R. WENSTRUP, Ohio               ANN M. KUSTER, New Hampshire
RALPH ABRAHAM, Louisiana             BETO O'ROURKE, Texas

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.
                            
                            C O N T E N T S

                              ----------                              

                        Tuesday, August 9, 2016

                                                                   Page

Technology And Treatment: Telemedicine In The VA Healthcare 
  System.........................................................     1

                           OPENING STATEMENTS

Honorable Brad Wenstrup, Acting Chairman.........................     1
Honorable Julia Brownley, Ranking Member, Subcommittee on Health.     2

                               WITNESSES

Zachary D. Walker, Veteran.......................................     5
    Prepared Statement...........................................    26
Herb Rogove, DO, FCCM, FACP, President and Chief Executive 
  Officer, C30 Telemedicine......................................     6
    Prepared Statement...........................................    26
Kevin Galpin, M.D., Acting Executive Director for Telehealth, 
  Veterans Health Administration, U.S. Department of Veterans 
  Affairs........................................................     8
    Prepared Statement...........................................    27
Scotte Hartronft, M.D., MBA, FACP, FACHE, Chief of Staff, VA 
  Greater Los Angeles Healthcare System, VA Desert Pacific 
  Healthcare Network (VISN 22),Veterans Health Administration, 
  U.S. Department of Veterans Affairs............................    10

                        STATEMENT FOR THE RECORD

Dr. Randall Scott Hickle, M.D., Grace Health System..............    30

 
   TECHNOLOGY AND TREATMENT: TELEMEDICINE IN THE VA HEALTHCARE SYSTEM

                              ----------                              


                        Tuesday, August 9, 2016

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
                                    Subcommittee on Health,
                                                   Washington, D.C.
    The Subcommittee met, pursuant to notice, at 9:00 a.m., at 
the Camarillo Public Library, 4101 East Las Posas Road, 
Camarillo, California, Hon. Brad Wenstrup presiding.
    Present: Representatives Wenstrup and Brownley.

      OPENING STATEMENT OF BRAD WENSTRUP, ACTING CHAIRMAN

    Mr. Wenstrup. Good morning. And I want to thank you all for 
joining us today.
    The Subcommittee will come to order. My name is Brad 
Wenstrup. I am a veteran, a doctor, and a Congressman from the 
2nd District of Ohio, and Member of the U.S. House Committee on 
Veterans Affairs.
    I am here today as Acting Chair of the Committee on Health. 
And I am so grateful to be with you here today in Southern 
California.
    Actually, my notes said ``sunny California,'' but that is 
not what we have here today. But that is okay.
    I am accompanied by your Congresswoman and the Ranking 
Member on the Subcommittee on Health, Julia Brownley, and my 
friend and colleague.
    As many of you know, Ms. Brownley is a reliable advocate 
for veterans and their families, and her focus on the Committee 
has always been finding ways to improve the lives of veterans 
at home, here in California, and across the country.
    I am grateful to her for her hard work, and for inviting me 
to be here with her this morning.
    Before continuing, I would ask all of the veterans in our 
audience today to please stand, if you are able, or raise your 
hand and be recognized.
    Thank you all so very much for serving, and it is an honor 
to have you here today.
    We are here today to continue our mission of improving the 
Department of Veterans Affairs' health care system, and to 
ensure that you and all those that have fought, served, and 
sacrificed for our country receive the care that you have 
earned and deserve.
    As a veteran and doctor, I understand firsthand the 
importance of providing timely and high quality care to our 
Nation's heros. And as a Congressman and a Member of this 
Committee, I have seen time and time again where the VA has 
sometimes come short to provide such care to veteran patients.
    There is a lot of positives. We have a lot of great 
providers, people out there wanting to take care of our 
veterans. Sometimes it is the system that fails us.
    So getting VA health care on the right track requires us to 
use every available tool at our disposal to increase access to 
care.
    Now, one of those tools is telemedicine. Telemedicine is 
the process of using telecommunications technology to remotely 
diagnose and treat patients. And it has obvious advantages for 
veterans, particularly for those in rural or medically 
underserved areas, or for those who have difficulty traveling 
to a VA medical facility.
    For example, using telemedicine could allow a veteran at 
the Oxnard Community Based Outpatient Clinic, CBOC, to see a 
specialist at the West L.A. VA Medical Center without having to 
fight traffic there and back.
    VA purports to be a leader in the use of telemedicine. And, 
according to testimony VA will provide this morning, there were 
more than 2 million telemedicine visits across the VA health 
care system last fiscal year alone.
    The Commission on Care recognized that the VA is excelling 
at telemedicine and recommends that they expand the use of it.
    As the use of telemedicine continues to expand, we need to 
be sure that VA is keeping pace with modern technology, and is 
effectively safeguarding private medical information through 
secure data channels.
    We also need to explore whether the VA is effectively 
tracking telemedicine appointments to ensure consistent, 
quality care and monitoring patient outcomes.
    If VA truly is a leader in deploying telemedicine, it is 
important to track best practices, lessons learned, and the 
impact telemedicine is having both on individual patients, and 
on the VA health care system as a whole, as well as to ensure 
that this technology is being leveraged to address the critical 
issues VA is facing today.
    For example, VA touts telemedicine as an important way to 
increase access to care.
    That may be true, but one can't help but notice that while 
the use of telemedicine has been increasing over the last 
several years, patient wait times have been increasing in some 
areas as well.
    Why is that? More importantly, how can we better utilize 
telemedicine technology to improve the care and the experiences 
that our veterans receive?
    I look forward to discussing these questions this morning.
    I now recognize Ranking Member Brownley for her opening 
statement.

      OPENING STATEMENT OF JULIA BROWNLEY, RANKING MEMBER

    Ms. Brownley. Thank you, Mr. Chairman. And really thank you 
for joining us today and traveling here to Ventura County for, 
I believe, an important hearing that is going to take place.
    I appreciate you coming all the way from your hometown, 
Cincinnati, Ohio. And I do welcome you to sunny Camarillo 
because the sun will indeed come out. And we are really, really 
happy to have you here.
    I want everyone in the audience to know that Dr. Wenstrup 
is an extraordinary Member of Congress. We were elected 
together. He is an M.D., as he mentioned, but also has served 
in service as a medical doctor. He is an Iraq veteran.
    And I think, like your district, my district is a district 
that is very rich because of its military families and 
veterans.
    So I think we both represent very very unique districts 
because I think the fabric of our community is, as I said, very 
very rich due to all the military families and veterans who 
live here.
    I want to thank our witnesses for joining us today to 
discuss this important issue.
    As technology continues to improve, the possibilities for 
providing health care are also rapidly changing.
    Companies and providers, many of them from California, I 
might add, are pushing the envelope on how we approach health 
care.
    One example of this is the growth of telemedicine, 
telehealth. So what does that really mean? Dr. Wenstrup just 
defined what telehealth is. The Health Resources and Services 
Administration defines it as the use of electronic information 
and telecommunications technologies to support long-distance 
clinical health, patient and professional health-related 
education, public health, and health administration.
    These are innovative technologies and systems that can make 
health care more accessible across geographic locations. It can 
break down barriers between health care experts, and patients 
who may be in different cities, different States, or even the 
other side of the globe. Today's hearing will focus on the use 
of telehealth within the VA health care system.
    As we know, there is not a one-size-fits-all approach to 
providing health care to veterans. The VA health care system 
serves nearly 9 million people, men and women, with different 
needs and preferences about their health care.
    Telehealth services are available for the VA to make 
diagnoses, manage care, perform checkups for veterans who may 
have trouble accessing their local regional medical center, or 
for those who need an appointment with a specialty provider not 
available locally.
    In 2015, the VA provided, by far, the most Federal 
telehealth appointments, with 2.1 million consultations to over 
677,000 veterans. And the VA expects the number of telehealth 
appointments to increase by over 12 percent in the coming year.
    I am looking forward to learning more about what the VA is 
doing to give the program greater visibility, and what benefits 
they anticipate from the use of these technologies.
    I am also interested in knowing how the VA is getting the 
word out about the availability of telehealth at the remote 
clinics, how veterans are being notified that telehealth is an 
option, and what strategies and technologies from the private 
sector the VA can look at to promote telehealth.
    Expanding telehealth appointments is especially important 
when we consider the ongoing provider shortage at the VA and 
across the health care sector in general.
    Secretary McDonald has testified about the VA provider 
shortage and the need to recruit doctors and other medical 
professionals to address this shortage.
    We also know that there is a provider shortage not just at 
the VA, but really throughout the Nation.
    We should look at ways that telehealth can help mitigate 
this challenge, and connect doctors and specialists with the 
patients who need them, regardless of geographic location.
    Again, I am looking forward to learning more about the VA's 
approach to telehealth, and how this approach fits together 
with the ultimate mission of providing quality and timely care 
for our veterans.
    Here in Ventura County, we struggle with a community clinic 
that is still too small to serve the needs of all of our 
veterans. Although we are working diligently to address this 
problem, the VA Choice program does not adequately take into 
account driving time for veterans to access care.
    And as we all know, traveling the 101 to Sepulveda or West 
Los Angeles for an appointment can take the better part, or all 
of one's day.
    So it is particularly important to me that Ventura County 
veterans have access to advanced technology, like telehealth, 
that will increase the quality and timeliness of their care 
that they have earned and deserved.
    Thank you, Mr. Chairman. And I yield back the balance of my 
time.
    Mr. Wenstrup. Thank you very much.
    We are going to begin today's hearing with our panel of 
witnesses, who are already seated at the table.
    And I am going to yield momentarily to Congresswoman 
Brownley to introduce our witnesses.
    But first, I would like to thank them all for their 
presence and participation here this morning. And for their 
service and for the work that they do for our veterans.
    I would also like to gently remind all of today's witnesses 
to please be mindful of the 5-minute time limit for your oral 
testimony and the question-and-answer period that will follow.
    The light has been placed in front of me and in front of 
you, and will change from green to yellow when there is one 
minute left, from yellow to red when the time has expired.
    So we are going to try to stay as close as we can to the 5-
minute time limit as possible so we can be sure that everyone 
has a chance to be heard. And I want to thank you in advance 
for that consideration.
    Now, Ranking Member Brownley, would you please introduce 
our panelists.
    Ms. Brownley. I will indeed. Thank you, Mr. Chairman.
    And, again, thank you for coming to this great county for 
our hearing today. And I appreciate your travels coming here, 
and looking forward to a great hearing.
    And I would like to welcome all of you here today. And I am 
looking forward to this important topic. We have a great panel 
of witnesses here with us who have graciously taken the time to 
share their perspectives on this topic.
    I would like to take a moment to briefly introduce our 
witnesses.
    Joining us today from the VA are Dr. Kevin Galpin, the 
Chief Consultant of VHA Telehealth Services. He is responsible 
for overseeing the implementation and coordination of 
telehealth technologies throughout the VA.
    With him is Dr. Hartronft, Chief of Staff of the VA Greater 
Los Angeles Healthcare System.
    And also joining us today is Dr. Herb Rogove, the President 
and Chief Executive Officer of C30 Telemedicine, based here in 
Ventura County.
    And last, but not least, also here is Dr. Zachary Walker.
    Mr. Walker. No ``doctor.''
    Ms. Brownley. Mr. Zachary Walker. A U.S. Navy veteran, most 
important title, and Ventura County Probation Agency employee, 
who will share his personal experience using telemedicine at 
our local VA. So thank you all for being here.
    And for audience members who are interested in sharing 
their comments or perspectives on telemedicine at the VA, my 
staff will be available after the hearing. They will be happy 
to take down your contact information and let you know where 
you can submit written comments that we will then share with 
the Veteran Affairs Committee back in Washington.
    So thank you very much. And I yield back.
    Mr. Wenstrup. Thank you.
    We will begin with Mr. Walker. Sir, you are recognized for 
5 minutes.

                 STATEMENT OF ZACHARY D. WALKER

    Mr. Walker. Good morning, and thank you for the opportunity 
to give my testimony with my experience with telemedicine.
    I am Zachary Walker, a veteran of the United States Navy, 
1975 to 1979.
    My introduction to telemedicine was presented to me by my 
VA medical clinic not as an option, but as a last resort.
    My journey began when I received a phone call from my local 
VA clinic one day before my scheduled appointment, that my 
appointment had been canceled. The clinic informed me that my 
health care provider was not available. I was told the next 
available appointment would be within 2 months.
    Having already waited 2 months for an appointment, I 
requested to see the next available health care provider.
    Again, I was informed that the wait time would be 2 months 
because they were all booked.
    I took the next available appointment, now having to wait 4 
months to see a provider.
    I terminated the call feeling frustrated and angry that my 
health care was being jeopardized due to the backlog in the 
system.
    The next week, I called my VA clinic and asked to speak to 
a supervisor, who was not available. I then provided my 
information for a return call.
    Not having received a returned call for 2 days, I again 
called the clinic and spoke with a supervisor. I reiterated my 
story, but it was apparent that she was unable and unwilling to 
help.
    She gave me some unclear information about how to proceed 
if my condition worsened, which I felt was not a solution to my 
problem.
    Out of desperation, I called my local VA representative and 
explained my situation.
    To my surprise, I received a call the next day from a 
clinic nurse who presented the option of telemedicine.
    Initially, I was reluctant because being seen by a doctor 
through a monitor was counterproductive to any medical 
experience I had in the past.
    The nurse was thorough, explaining the process, and 
assuring me that the doctor would have my lab results. And she 
would also review my medical history. I scheduled an 
appointment and was seen within a week.
    I arrived for my appointment and was escorted back to an 
examination room in a timely manner. I was seated in front of a 
monitor and a two-way camera. The doctor introduced herself. 
She was very pleasant, did not appear rushed, and she was well 
prepared. It was evident, based on her questions, that she had 
reviewed my recent tests and medical history.
    During my appointment, the doctor ordered more tests and 
made a referral for a new medical condition that she noted. She 
even apologized for not having the ability to examine me.
    Even more surprisingly, I received a call from her one week 
later with my test results.
    In conclusion, I had a great experience with telemedicine. 
My appointment wait time was reduced from 2 months to 1 week. 
My appointment started on time rather than a normal 1-hour 
lobby wait time. The doctor was not rushed during my 
appointment, and took the time to listen to my concerns.
    The only obvious drawback is not having a doctor to 
physically examine you. But I would use telemedicine in the 
future.
    Telemedicine should be presented to veterans as an option 
for medical care and not as a last resort.
    Thank you very much.
    Mr. Wenstrup. Thank you, Mr. Walker.

    [The prepared statement of Zachary D. Walker appears in the 
Appendix]

    Mr. Wenstrup. Dr. Rogove, you are now recognized for 5 
minutes.

                    STATEMENT OF HERB ROGOVE

    Mr. Rogove. Thank you, Acting Chairman Wenstrup and Ranking 
Member Brownley.
    It is a great privilege to be able to appear before the 
Committee and testify about telemedicine, and, in particular, 
about the critical role and contribution to the VA telehealth 
system.
    I am a physician and founder of C3O Telemedicine, located 
in Ojai, California, Ventura County. And when my company was 
founded, it was founded upon the principle that Americans 
should not be penalized for gaining access to health care based 
upon geography, whether it is rural or inner-city areas.
    To that end, we provide acute stroke care through 
telemedicine to over 30 hospitals across the country, including 
the great State of California.
    Additionally, I have served as the secretary-treasurer on 
the board of directors for the American Telemedicine 
Association. And I might mention the current president is 
General Peake, former VA Secretary.
    In January of 2015, Mr. Carl Blake, with the Paralyzed 
Veterans of America, testified before this very same Committee. 
And, just to paraphrase him, he stated that the viability of 
the VA health care system depends upon a fully integrated 
system so that veterans get the care that they need, when and 
where they need it, in a user-friendly manner.
    I think the VA telehealth program addresses his comments.
    For the past 10 years, I have studied many telehealth 
models and have been most impressed by the VA models, both 
exemplary and successful.
    This past May, I had the privilege of meeting with Dr. 
David Shulkin, Under Secretary of Health for the VA, at our 
national meeting. And he provided us with some key elements and 
statistics that some of you have just mentioned: Over 2 million 
telehealth encounters, it affected 12 percent of the total VA 
population; 45 percent of those encounters occurred in rural 
areas, therefore, precluding them having to waste time to go 
for a 10-minute visit, which might take 2 hours in both 
directions. And, more importantly, the outcomes--which in 
medicine we always want to know what kind of outcomes there 
were.
    In 2015, home telehealth reduced hospital bed days by 58 
percent, hospital admissions by 32 percent, and the use of 
psychiatric beds by 35 percent.
    So, looking at the future, the VA telehealth model has a 
tremendous opportunity to, number one, provide the continued 
leadership in developing a system-wide telehealth network.
    Those of us in the private world of telehealth look at that 
as an exemplary model and something we should strive for.
    We have the opportunity to develop public-private 
partnerships; particularly as was previously mentioned, the 
shortage of physicians.
    We currently provide as a private company to some major 
universities around the country to fill in the gap for a 
shortage of neurologists that universities don't have.
    I could see that happening between the VA, companies such 
as mine and others; major systems like, down the road, UCLA, 
which is developing a telehealth program, et cetera.
    We need to push for CMS to expand reimbursement for 
telehealth, particularly to metropolitan statistical areas, 
which essentially is urban areas.
    Right now, Medicare laws do not pay for telehealth in urban 
areas.
    Fourth, the establishment and criteria for adequate, 
accurate, and safe consumer technology that can serve our 
homebound veterans and patients.
    And, finally, something that is really, really important, 
from my perspective, and that is to deal with the interstate 
licensing. The VA, the military has the phenomenal ability to 
have one license to practice in 50 States, just like you have 
one license to drive from California to New York or Cincinnati.
    Right now, it costs over $600 million to pay for it, 
exorbitant amount of time, it is a hundred-year-old system that 
is antiquated. And the State medical boards sometimes may not 
be looking at the best interest to get programs out and 
functioning. And, hopefully, we could address that.
    So, once again, thank you very much for allowing me to 
appear before you today.

    [The prepared statement of Herb Rogove, appears in the 
Appendix]

    Mr. Wenstrup. Thank you, Doctor.
    Dr. Galpin, you are now recognized for 5 minutes.

                   STATEMENT OF KEVIN GALPIN

    Mr. Galpin. Good morning. Mr. Chairman, Ranking Member 
Brownley, thank you for the opportunity to discuss the efforts 
the VA has taken for developing telehealth, the services VA 
provides to veterans through it, and its expansion.
    I am accompanied today by Dr. Scotte R. Hartronft, Chief of 
Staff at the Greater Los Angeles Healthcare System.
    VA is recognized as a pioneer in the practice of telehealth 
and has used telehealth to substantially increase health care 
access for veterans.
    Since 2002, over 2 million veterans have obtained some of 
their health care through telehealth services, and the number 
of veterans utilizing these services continues to grow. In 
fiscal year 2015, VA conducted over 2 million telehealth 
visits, serving almost 700,000 veterans.
    The mission of VA telehealth services is to provide the 
right care in the right place at the right time through the 
effective, economical, and responsible use of health 
information and telecommunications technologies.
    Telehealth changes the location where health care services 
can be provided, making care accessible to veterans in their 
local communities, in their homes, and even in their pockets on 
mobile devices.
    Equally critical, it allows services to be delivered from 
any location, allowing the VA to hire providers in large 
metropolitan locations in order to serve veterans in areas of 
provider scarcity. Leveraging telehealth affords the VA an 
opportunity to increase access, especially for those veterans 
in rural or underserved areas.
    The VA currently offers over 50 types of clinical services 
through telehealth. Of the services offered through video 
conferencing, telemental health is the most heavily utilized, 
and is also an area of strategic growth. For context, more than 
2 million mental health visits have been provided to almost 
400,000 veterans since 2002.
    The VA has found telemental health to be equally effective, 
if not more so, than in-person appointments. This exemplifies a 
patient-centered model that efficiently brings mental health 
care to veterans who might otherwise need to travel significant 
distances to obtain such care.
    In 2016, building on the success of the existing telemental 
health program, the VA is establishing four regional telemental 
health clinical resource centers. The goal of these centers is 
to expand mental health provider services at rural facilities, 
where recruitment of providers can be challenging. When fully 
staffed, these resource hubs are projected to provide an 
additional 65- to 82,000 mental health visits per year at 
locations of need.
    The VA also manages a national telemental health specialty 
consult center. This center has a virtual clinical team 
comprised of leading national experts on specific mental health 
conditions who can be located anywhere in the country.
    These providers are able to deliver their specialized 
mental health consultation services to locations in the 
country--to any locations in the country to assist veterans 
with the most complex conditions. This center has delivered 
services to over 4,600 veterans at over 120 locations.
    The VA continuously adds new telehealth specialties and 
services as technology improves. For example, teleintensive 
care is a telemedicine program that links intensive care units 
in VA medical centers to a central monitoring hub staffed with 
intensivist physicians and experienced critical care nurses.
    Through the use of cameras mounted above each patient's 
bed, along with links to the medical record and vital sign 
monitors, staff in the tele-ICU hub not only see all the 
pertinent medical data on a patient, but they are capable of 
performing audio-visual exams; discussing treatment plans with 
patients, nurses, and families; intervening during emergencies; 
and generally providing specialist-level care and consultation 
to the local staff.
    Tele-ICU does not replace the local ICU care team, but adds 
specialist resources and another set of expert eyes to watch 
over our most critically ill veterans.
    Looking forward, the VA is excited to expand the 
teleprimary care model, similar to telemental health, that will 
bring virtual primary care providers, social workers, 
psychologists, and pharmacists into rural sites where needed.
    The VA is also developing the VA Video Connect application, 
which can provide a fast, easy, encrypted realtime video 
connection between a veteran's personal mobile device and 
computer and a provider.
    The VA recognizes we are still at the beginning of our 
journey to best leverage our integrated national health care 
system and remote care technologies.
    The VA would be able to accelerate this expansion and 
leverage new opportunities if our clinical and technical 
capabilities to deliver outstanding health care through virtual 
technologies were unambiguously supported by legal authority to 
deliver clinical services, irrespective of the veteran or the 
provider's location.
    The VA is a leader in providing telehealth services, which 
remains a critical strategy in ensuring veterans can access 
health care when and where they need it. With the support of 
Congress, we have an opportunity to shape the future and ensure 
that VA is leveraging cutting-edge technology to provide 
convenient, accessible, high quality care to all veterans.
    Mr. Chairman, this concludes my testimony. Thank you for 
the opportunity to testify before the Committee today. We 
appreciate your support, and look forward to responding to any 
questions you and Members of the Committee may have.

    [The prepared statement of Kevin Galpin appears in the 
Appendix]

    Mr. Wenstrup. Thank you, Doctor.
    Mr. Wenstrup. Dr. Hartronft, you are now recognized for 5 
minutes.

                 STATEMENT OF SCOTTE HARTRONFT

    Mr. Hartronft. Good morning, Mr. Chairman and Ranking 
Member Brownley.
    Thank you for the opportunity to discuss the efforts that 
GLA has taken to develop, deploy, and expand telehealth. In 
fiscal year 2015, GLA provided 20,000 health visits to over 
6,000 veterans.
    GLA uses all telehealth-related modalities to include 
clinical video telehealth, Store-and-Forward technology, and 
home telehealth.
    Clinical video telehealth involves a clinical provider and 
a patient interacting via video telecommunications, such as 
telemental health, while Store-and-Forward technology takes 
digital images that can be reviewed remotely by specialists, 
such as things like diabetic retinas being examined by an eye 
specialist, or a suspicious looking mole by a dermatologist.
    And then, lastly, the home telehealth, which allows 
prompting and monitoring for chronic diseases, such as 
diabetes.
    GLA currently has 34 different clinics available that range 
from audiology to mental health. At the Oxnard CBOC, we 
currently have seven different telehealth clinics, which 
include different types of mental health clinics, such as 
general mental health, PTSD, compensation and pension, and 
others.
    A major focus at GLA is to improve access for our veterans, 
and the use of the telehealth services is one way to help do 
that.
    One example is, in May, GLA began a pilot primary care 
program at the Oxnard CBOC. Since GLA did not have a 
teleprimary care program at the time, this pilot was set up 
specifically to help address the primary care access demand at 
the Oxnard CBOC.
    This pilot was not to replace traditional face-to-face 
primary care provided at the CBOC, but as a supplement, while 
additional needed primary care staff were being recruited and 
hired.
    Due to the pilot success in improving access to primary 
care at Oxnard, GLA has made arrangements to continue providing 
teleprimary care services until the traditional primary care 
clinical access reaches a stable and improved state, and 
provide another option for veterans based on their preferences.
    Another example of how telehealth programs can improve, as 
previously testified, is the chronic disease states that we use 
with the home telehealth.
    And veterans enrolled in home telehealth in fiscal year 
2016 have had a decrease in hospital admissions 6 months after 
being enrolled, when compared to how often they were requiring 
hospital admission before enrollment.
    GLA is currently reviewing the demand for telehealth as 
well as face-to-face services and implementing action plans to 
continue improving access.
    Specifically, for the Oxnard CBOC, GLA has recently added 
teleaudiology and a face-to-face audiology technician to help 
with hearing aids.
    Additional face-to-face specialty care services are 
scheduled to begin soon at the Oxnard CBOC to include 
cardiology, cardiac echocardiography, this month, in August; 
gastroenterology in September; and physical therapy in October.
    In conclusion, telehealth will not completely replace the 
traditional face-to-face clinical care. But GLA is adding 
additional telehealth resources to improve access to care for 
veterans by supplementing traditional face-to-face clinical 
care, when, to whom, and where appropriate.
    Mr. Chairman and Ranking Member Brownley, this concludes my 
testimony. Thank you for the opportunity to testify before the 
Committee today, and we appreciate your support. I look forward 
to responding to any questions you or others may have. Thank 
you.

    [The prepared statement of Scotte Hartronft appears in the 
Appendix]

    Mr. Wenstrup. Thank you all very much.
    At this time, I am going to yield myself 5 minutes for 
questions.
    I want to start with you, Mr. Walker. You mentioned that it 
was--telemedicine was offered as a last resort.
    Mr. Walker. Correct.
    Mr. Wenstrup. Could you expound on that a little bit?
    And what would you say to veterans who are becoming aware 
of telemedicine as a possible choice for a method of care?
    Mr. Walker. I say, when I spoke on it being a last resort, 
I have used health care since I got discharged from the 
military in 1979 up to my--this last episode. And I had never 
been introduced to the thought of telemedicine.
    I think it was through my frustration and my pushing to get 
some adequate care that it was presented to me as a last 
resort, not as an option.
    Maybe if it was presented to me early on in the process 
when I was given the 2-month timeframe to see a doctor, it 
might have been a more positive result. But me pushing, then it 
was, like, a last resort.
    I say for any veteran that may be going in there for normal 
testing--the doctor spoke of diabetes--any related tests that 
you normally go through and you want the results, and you want 
the results in a timely manner, that is a good option.
    Any kind of medical condition that doesn't necessarily 
preclude a doctor actually putting hands onto you, I think, is 
an outstanding idea. I am glad it was introduced to the VA.
    Mr. Wenstrup. Thank you.
    So in that context about him feeling as a last resort, as 
this is developing and growing, my question for Dr. Galpin, if 
you would talk about expanding telemedicine throughout the VA 
system, what kind of an algorithm do you anticipate? Is there 
one in place? Should we put one in place for that being an 
option? Rather than, Hey, you know what? We got somebody on the 
phone who is kind of upset their appointment got cancelled. 
Let's throw that at them.
    Is this going to be part of an algorithm that is an option 
up front for people? And what does that look like? And will 
that be sort of about VISN to VISN or national program?
    Mr. Galpin. I appreciate that question. So right now, it is 
actually very much part of our strategic plan to help develop 
the capacity of telehealth. And so, we have discussed a little 
bit our telemental health hubs and the teleprimary care hubs we 
want to develop.
    Those hubs will serve as essentially an interim staffing 
program for facilities. So if a provider leaves and a veteran 
is left without a primary care provider, or without the 
resources of a mental health provider, we will have resource 
centers that can help out and fill in on those staffing levels.
    So that is kind of regional level and the type of help we 
can provide to each other across an integrated health care 
systems like the VA.
    In addition, I mean, we want to see telehealth being used 
on a day-to-day basis in the regular practice of medicine. So 
when a veteran comes into a clinic and they need a retinal 
screening, we want to make sure we have that option available. 
We want to make sure we have the dermatology option available 
in every clinic. Doesn't necessarily have to all be through 
telehealth.
    But we have the capability now of offering services in a 
standard way across the board at convenient locations that we 
didn't have before. So we want to integrate those practices, 
and really take advantage of that.
    Mr. Wenstrup. Well, the question I have, though, is, if 
someone calls for an appointment and they are being told, you 
know what, you can be seen in 3 weeks, you know, here at the 
VA.
    When they make that initial call for an appointment, might 
they not be given that option right off the bat? Is what I am 
asking.
    Mr. Galpin. I think if the services are available, I think 
that is the key question.
    So at this point, we are still expanding our telemedicine 
programs. And we have a lot to do. We are still at the 
beginning of a journey. This is one of those areas that we are 
seeking help from Congress so we can more rapidly increase our 
program.
    If the services are available, then we have the opportunity 
to leverage those services for the individual patient when they 
call in. We first have to get to the point where they are 
available, and we have that resource-sharing capability.
    Mr. Wenstrup. So, and let me go to you for a second, Dr. 
Rogove, when you are talking about the licensure across States 
and things like that.
    Because, currently, to be a provider at a VA or Federal 
facility, you just need a State license. And then you apply and 
credential, as you normally would.
    So if someone is in a different State, but they are 
credentialed to the VA, is there a barrier for someone in Ohio 
to take care of someone in California via telemedicine if they 
are credentialed with the VA in some way?
    Mr. Rogove. Specifically the VA?
    Mr. Wenstrup. Yes. Particular to a Federal agency.
    Mr. Rogove. My understanding is, yes, they have that 
capability of being a physician licensed in one, and taking 
care of a patient in another State.
    Mr. Wenstrup. If you have gone and credentialed through the 
VA itself.
    Mr. Rogove. Correct.
    Mr. Wenstrup. So there is an option to be able to do that.
    Mr. Rogove. Yes. That is my understanding.
    Mr. Wenstrup. You want to say something, Dr. Galpin, on 
that?
    Mr. Galpin. Yes. This is actually what we are seeking from 
Congress on this. Is that actually the laws are somewhat 
ambiguous in this area. And it is one of our major barriers to 
being able to expand services quickly.
    So, you are correct. If I have a license to practice in a 
State, and I am licensed in Georgia, I can go to a VA facility 
and I can provide care at that facility for veterans.
    It gets ambiguous when you take that provider outside of VA 
property, where you take care of the patient outside of VA 
property.
    So if you look at the way we want to leverage to this type 
of technology, we can overcome space barriers and use alternate 
work sites, and set up providers quickly in their homes without 
having to build new spaces, or take care of veterans in their 
homes, or as they are on their mobile devices, going across 
country, it is not clear.
    So that is really what we are seeking, is an unambiguous 
law that says VA providers, irrespective of our location or the 
veteran's location, can take care of our patients.
    That is our major ask.
    Mr. Wenstrup. Sounds like you are seeking some--seeking for 
us to codify this to some degree. And say, look--because I have 
always felt, and especially as we put Choice in place, you can 
be a VA doctor; you don't have to be within those walls of the 
VA.
    So if you are a VA doctor in Ohio that participates in the 
telemedicine program, whether you ever go within the walls of 
the VA, but you are credentialed by the VA, that you can do 
that anywhere in the country for one of our veterans.
    Am I on track with what you are seeking to clarify that or 
make that available?
    Mr. Galpin. That is what we are looking for. Again, I want 
to be able to provide care, regardless of my location, 
regardless of the veteran's location.
    And it is--you know, we are looking for, I think, a pretty 
straightforward legislation that gives us that authority that 
we essentially have within our own buildings. We need that 
within legislation.
    Mr. Wenstrup. Got you.
    I now yield to Ms. Brownley.
    I am sorry.
    Did you want to add something to that?
    Mr. Rogove. Yes. Just briefly.
    It is interesting, CMS just released the fee schedule for 
2017. And in it they are redefining who are the telehealth--
    The way you look at telehealth, there is the originating 
site, which is the hospital that is requesting where the 
patient is, and then there is the distance site, which is where 
the telehealth doctor is.
    The way it works right now is, it is the patient centered, 
which means you are crossing State boundaries and need a 
license.
    However, what CMS is now proposing is that it is based on 
the distance site where the physician is. In other words, that 
physician in California could take care of a VA patient whether 
it is at their home or in the VA hospital in the State of Ohio.
    So this is something that is--the proposal was just 
released a couple weeks ago. And this will change the game a 
bit and maybe give us some leverage.
    Ms. Brownley. That is very new information that I wasn't 
aware of.
    I just wanted to follow-up with Mr. Galpin on the line of 
questioning, though, in terms of solutions for expansion of 
these resources.
    Is it that simple really just to pass a piece of 
legislation that says you can do it? Or is it more complex and 
interwoven with all of the various States and their licensing 
and so forth and so on?
    So, you know, it sounds to me like what you are expressing 
is something that is, you know, pretty simple.
    I served in the State Legislature in California. And, boy, 
scope of practices issues where, oh, my goodness, you would 
pass a Committee room and that is where you had 50 people 
standing in line to testify in the Committee.
    So I just want to make sure that it is something as 
straightforward and relatively simple to resolve this issue.
    Mr. Galpin. Yes. I would say, I think with pretty simple 
clarity, I do think it is a simple solution from a legislative 
standpoint.
    As a lot of people already assume, there is kind of an 
understanding or belief that the VA already has this express 
authority.
    And, again, it is ambiguous. We, in some people's eyes, 
have the authority, but it is not codified. We can't point to 
legislature and say, Listen, we can do this.
    And so when we want to set up telemedicine hubs and move 
providers from where we have relative abundance, to where we 
have relative scarcity becomes this large legal question. And 
really slows us down. And in some cases, it hampers us from 
moving forward quickly.
    So, yes, I think there is a fairly simple solution that can 
be provided that will significantly help us expand.
    Ms. Brownley. When we are seeking providers in a network--
here it is TriWest. So they are sought out and approved based 
on the standard within VA. That is the one central standard 
that is across the board nationally. That is correct; right?
    Mr. Galpin. Can you clarify the question on that.
    Ms. Brownley. So as we recruit providers to--for the Choice 
program, for example, for veterans to be able to use doctors in 
their communities rather than the VA, if--you know, based on 
the criteria now as--you know, if you can't get an appointment 
within 30 days and the 40-mile rule, although all of our 
veterans here know that the 40-mile rule doesn't apply to us 
here in the county. We keep trying to fix that. But we haven't 
achieved that yet.
    So all I am saying, is that when they are recruited to be 
community providers for the VA, are they approved by the VA by 
the same standard by which you approve doctors within the VA?
    Mr. Galpin. Okay. So one piece I just need to clarify. So 
when we are talking about our telemedicine program, we are 
actually talking about providers that are hired or work 
directly with VA.
    Ms. Brownley. Correct.
    Mr. Galpin. So we bring them into our system. We go through 
the same process to credential and privilege them. They have to 
be credentialed and privileged at a VA facility. So they go 
through the same standard.
    Plus, then they get additional training to become 
telemedicine providers so they can serve in that capacity.
    So, yes, the standards--I mean, that is the foundation of 
our program, to make sure we can provide quality services--
    Ms. Brownley. So you are not talking about expanding 
telehealth to our community partners?
    Mr. Galpin. No. I am talking about the authority for VA 
providers to provide services to veterans.
    Ms. Brownley. Okay. All right. Very good.
    So I wanted to go back, you know, to our CBOC here in 
Oxnard and serving our Ventura County veterans.
    So if you could describe to me, Dr. Hartronft, exactly--my 
understanding is--there is sort of three pillars of telehealth 
services. And if you could describe to me, are all three of 
those pillars embedded into the Oxnard CBOC or are we not there 
yet?
    Mr. Hartronft. Yes. All three are currently available at 
the CBOC. The CVT, which is the clinical video 
teleconferencing; the Store-and-Forward, which is teleretinal; 
and then also with the home telehealth, which are the monitors 
that people have at home that remind them, with the chronic 
disease.
    Ms. Brownley. So the Store-and-Forward telehealth is there?
    Mr. Hartronft. Yes.
    Ms. Brownley. And Store-and-Forward telehealth, how does 
that synchronize with electronic medical records? Once you have 
that data, is it merged into, permanently into the record of 
the veteran?
    Mr. Hartronft. That is the nice part, is-- it does merge 
into a part of CPRS where it can be viewed, and then notes 
taken by the reviewer at the remote site directly into the 
records.
    And that is, you know, not having to send slides off to a 
far, distant university that sometimes people have to do. This 
could be realtime, literally the next day, where it arrives, 
the person reads it, and it goes right into the record and 
available for the provider to see the next day.
    So it is really, a very timely modality when one thinks of 
the traditional means of sending out, that most facilities do 
if they don't offer in-house services.
    Ms. Brownley. Very good.
    My time is up. I will yield back.
    Mr. Wenstrup. Then we will go another round.
    Ms. Brownley. Sure.
    Mr. Wenstrup. Dr. Rogove, if I can get from you your 
opinion on how we can better partner telemedicine practices 
like yours and increase the availability of telemedicine to the 
VA.
    Mr. Rogove. Yes. I think one of the examples I mentioned, 
briefly alluded to, was the fact that the capacity is really 
important right now for health systems. And I think you have 
physicians, let's say, in an academic medical center or VA 
system where they have responsibilities, on-site 
responsibilities, clinic responsibilities, education 
responsibilities, and now you are adding on telehealth 
responsibilities. There is so much you could get out of the 
physicians to do that.
    And it is predicted that we are going to be, by the year 
2025, we will probably be 90-, 95,000 physicians short. A 
little bit less than we thought.
    So in an effort to do that, I think this is where the 
public-private partnership comes in. Universities used to be in 
one silo, the VA is in another silo, and there is private 
enterprise in another silo.
    If certain facilities have the capacity to help another 
facility or system, I think now is the time that we start to do 
that.
    Our case in point is that we just got a big contract in 
northern New Jersey. It is two academic medical centers 
together with a bunch of rural and community hospitals. And 
they just don't have the capacity for their physicians, their 
neurologists, in particular, for stroke. And they have 
solicited us to come in there and help solve the problem.
    And while we are not physically present, we helped to 
augment their practice. And, euphemistically, I say it is like 
having a partner without having to provide a 401K for. They are 
here to help you and do what's necessary: Night call, weekend 
call, vacation call. To help alleviate the burden and prevent 
more burnout.
    So I think there is a tremendous opportunity and drop the 
barriers between academic, government, and private, and bring 
us all together and find out where the resources are, and re-
deploy them.
    Mr. Wenstrup. Ultimately, our goal is to get care to our 
patients.
    Mr. Rogove. Correct.
    Mr. Wenstrup. And in some ways, as references, get help 
from Congress or get Congress to get out of the way and let 
those things happen.
    Dr. Galpin, credentialing process. This is always an issue, 
even at the CBOCs. You lose a doctor, and you try to replace 
them. You may even have a VA doc from somewhere else who wants 
to come to your CBOC. And he has got, you know, several months' 
credentialing process to go through. Rather than being able to 
just say, Look, I already work at this CBOC over here. Why 
can't I just come in and start working there?
    But the credentialing process for telemedicine, for 
example, how is that operating? And are there any--any flies in 
the ointment there that you want to address?
    Mr. Galpin. So credentialing/privileging, of course, is a 
foundation, one of the key ways that we maintain quality 
services.
    We have the authority within our integrated health care 
system, which is really key for us to being able to do this 
efficiently, to share privileging--share privileging decisions 
from one facility to another under joint commission.
    So if I am privileged at the Atlanta VA, and I want to work 
through telemedicine at another VA facility anywhere in the 
country, the other facility does not need to go through all the 
primary resource verification that takes a tremendous amount of 
time. But they can develop an agreement that essentially says, 
yes, we can trust another facility, that they are utilizing the 
processes they are expected to be utilizing under the joint 
commission, and VA policy to do the right thing. And so we 
accept this provider as a provider that can provide services to 
our patients.
    As a piece of that, then, that provider needs to be 
monitored, there needs to be a bidirectional exchange of 
information between those facilities to make sure that the 
provider is competently performing their privileges after the 
fact.
    But that is a process that makes it easier to move 
resources from one place to another.
    Mr. Wenstrup. I appreciate that.
    Mr. Walker, I have a question for you: When is the next 
appointment with the VA?
    Mr. Walker. Presently, I don't have one scheduled.
    Mr. Wenstrup. Okay.
    Mr. Walker. I am going through process of the referral that 
the doctor made for me. So not with my primary care clinic. But 
I do have one in the Valley, off Plummer.
    Mr. Wenstrup. Do you plan on your next primary care visit 
to be through telemedicine unless you feel a need to be 
physically examined?
    Mr. Walker. I am not sure. I was told later that my primary 
care physician retired. And that I have--I do not at the 
present time have one assigned to me.
    Mr. Wenstrup. Okay.
    Mr. Walker. So we will move forward, and hopefully it will 
go a lot smoother transition than the last.
    Mr. Wenstrup. Thank you.
    I yield to you, Ms. Brownley.
    Ms. Brownley. Thank you. And I want to again sort of harken 
back a little bit to the Oxnard CBOC.
    Because I know there are many veterans here in the room who 
utilize that facility. So I want to be as transparent, so 
everyone in this room knows that we have gone through some 
growing pains at the Oxnard CBOC. We have expanded the physical 
footprint of the CBOC. And once we did that, then we were 
understaffed for a while.
    And now I think we are at a point where we are now fully 
staffed and beginning to expand some specialty services at the 
CBOC.
    So we are just sort of getting there in terms of a larger 
space and fully staffed.
    And I think that, you know, telehealth is going to be a 
critical component in the services that our CBOC can offer.
    But I want to be clear that, you know, if our veterans are 
calling up for appointments, are coming into the CBOC for an 
appointment, I think at this particular point most of our 
veterans are expecting that they are going to see a doctor, and 
there is not going to be another course or avenue for them to 
go down.
    So, you know, it is the educational component here. I want 
veterans to understand that if they want to see a primary care 
doctor in the CBOC, they can see a primary care doctor in the 
CBOC. I don't want them to think we are talking about all of 
this to substitute the traditional doctor-patient relationship 
and those visits.
    But I do think, and certainly based on Mr. Walker's 
testimony, that there is a large learning curve that is going 
to take place.
    I think probably some of our older veterans are going to be 
a little leery about using technology around their health, 
because that is a new concept for them. I think our younger 
veterans might be more susceptible to it and open to it.
    I think once we understand how telehealth can augment their 
health care services, and particularly to understand that this 
could eliminate those follow-up travels to Sepulveda or West 
L.A., that that can be done in the CBOC, seeing a doctor face-
to-face, and perhaps even your doctor sitting with you in the 
examination room.
    I think people then, you know, their sort of fears and 
misunderstandings about what this all is, can be alleviated and 
helped.
    So I just want to understand. And for everyone who is here 
today listening, and I think almost everyone in the audience 
here today is here because of their positive or not-so-positive 
experiences within the CBOC.
    So if you could, you know, just kind of walk us through a 
new patient who has never been in the CBOC before, and what 
their experience might look like. And the experience of a 
veteran who comes into the CBOC, has been seen by a primary 
physician, who may have diabetes or who may have heart issues. 
And explain, you know, what the procedures might be in those 
two pathways.
    Mr. Hartronft. Okay. First of all, I would like to 
apologize to Mr. Walker for his experience with his first 
introduction to telehealth.
    Just to give a history of the health introduction at the 
CBOC, I arrived as the new chief of staff on April 4th, and 
noticed the demand was exceeding our supply currently. And by 
May 8th, we were starting to see our first patient with 
teleprimary care.
    The problem with forward deployment in a rapid fashion of 4 
to 5 weeks is, again, that education curve was something we 
definitely--again, that is the area I would like to apologize 
for. Because it is definitely something that gets another 
preference, is the choice, it is not going to fit everyone. But 
it also was, again, giving them another choice to base that on.
    So that is kind of how we rolled that out, as to seeing 
that. Because, as you can imagine, how much longer it takes to 
bring on other providers through the process, where one can see 
the problem after being here just a couple weeks, and then 
within 2 or 3 weeks actually having the first patient being 
seen by teleprimary care.
    Actually, for a new veteran, if they are coming into our 
system, as we are rolling out the education curve, is giving 
them, again, the--explaining the process to veterans as they 
are coming on as a new patient. Just saying, What are your 
preferences? We have options. To include your face-to-face 
visit or a teleprimary care visit.
    And then they would actually be able to--our goal is to get 
that to where they can choose one of those on their preference. 
Especially while--as we are building our capacity at the 
current clinic.
    So we definitely never want to replace face-to-face 
interaction with primary care. That is not our goal. But our 
goal is to give another option as we are bringing on the 
capacity.
    The nice thing is that we are adding peripheral devices, as 
we call it, to where they can actually have more interaction 
with a physician with, like, a stethoscope that the tech on 
their side of the patient can actually put to the chest of 
veteran. It can be heard well by someone remotely, and other 
devices, so that they can do more of a contact physical exam.
    Largely, for the veteran, as they come in, it will be 
preference choice as to which they prefer. And then some of it 
could be, again, that option based on what may be available 
sooner until we get all the panels fully expanded.
    Ms. Brownley. And so when a patient comes into the CBOC and 
has an appointment, then in terms of follow-up, are the--are 
the medical teams that are set up at the CBOC, are they trained 
to say, rather than you having to go--I need you to have these 
tests. But rather than going--having the tests, but then not 
having to go back to go West L.A. or Sepulveda, we are going 
to--if you were willing, we will--you know, we can have that 
follow-up meeting here in the CBOC through our technology, and 
you'll be able to see the doctor that you might have seen. Or, 
you know, at least see the doctor or the specialist who can 
give you the results of these tests?
    Mr. Hartronft. Yes. And also one of the choices, a veteran 
may start off with a telehealth provider through teleprimary 
care. But then we would like to give the option even at some 
point, if they want to change over to an in-person, face-to-
face.
    So that is one of the things that we would definitely like 
to focus on is to--
    And then we train, with the techs that--we have expanded 
resources to where techs on each side are being able to better 
walk the veterans through the process, as Mr. Walker explained, 
about bringing them back, doing their assessment by the nurse, 
and bringing them in.
    So, again, we are in that--teleprimary care was a new 
event, new program, especially at the Oxnard program. So we are 
definitely trying to--
    Ms. Brownley. And continuity of care. I know that that is 
an issue that veterans, you know, are very concerned about. If 
they--if they have a health issue, they are interested in 
seeing the same physician, you know, over the course of a 
treatment.
    So how do you get that continuity of care through 
telehealth?
    Mr. Hartronft. Again, I think a lot of that is just the 
comfort and preference of the veteran. As to--if they don't 
mind seeing a secondary provider, if they can't be worked into 
their doctor's schedule same day.
    A lot of times, as we have seen in private practice, 
sometimes you can see a provider, an extended provider, the 
same day.
    But they work with your provider and have the same record.
    So our goal is to--even the veterans who start off with 
teleprimary care, the option eventually would be to go to more 
of the face-to-face model, unless their preference is to 
strictly stay with teleprimary care.
    The nice thing, though, is with our electronic records and 
our ability to have all the--you know, the information right 
there in front us, unlike many closed systems in the private 
sector, it is really a lot more streamlined as to handoffs with 
patients.
    So a lot of it is really--we would like to make it somewhat 
they choose, as to, I don't want to make a template, one size 
fits all. I would really like to have these decision trees 
based on their preferences and choices. So it is kind of hard 
to describe what it would be for every veteran.
    Ms. Brownley. Thank you.
    Mr. Wenstrup. You just touched on one of the things that I 
wanted to talk about. Which is making this type of an option, 
the decision between the doctor and the patient on how they 
choose to proceed.
    And, in my practice--you know, I started practice in 1986. 
And, you know, in later years, I would have a patient call--I 
treated a lot of diabetics. They have wounds, they have ulcers. 
They are worried: Is it infected? And this and that.
    And I could get on the phone and say, Take a picture of it. 
You know, let me just see it.
    It might save them a trip in. Because it looks fine. Or, 
yes, I might need to put you on an antibiotic. And then I will 
schedule for your follow-up in a couple days.
    So there is a lot of advantages that save time and money, 
and really provide better care. Because you have that instant 
access, rather than--especially somebody who is homebound. You 
know, what a huge advantage these things can be. And in a 
simple way.
    I would like to hear from, really, all of you. Because my 
feeling, in the ideal situation for the VA or for any--for any 
health care system whatsoever, that everyone has a primary care 
doctor.
    And this is one of the things in my district that I saw was 
of huge value at the CBOC. You know, I would go out in the 
lobby, and I would talk to the patients out there. And they 
love it. They love it because that is my doctor, I know who it 
is, I know this person.
    Rather than, I am going to the VA. I don't know who I am 
going for see today. You know, who will be there. It is a 
different one than I saw last time.
    It happens in every practice.
    But, nonetheless, they feel like they have got someone 
where there is a relationship and some ownership. And so 
whether it is through telemedicine or through the face-to-face 
visit, you have that opportunity.
    And the other thing that I would like to see, and maybe 
have you comment on, referral decisions should be between that 
primary care doctor and the patient only. We don't need another 
layer of bureaucracy.
    If you are hiring primary care doctors and you credential 
them, you must trust them to make decisions and the patients to 
make decisions with them.
    And that to me is one of the things that we are tying 
people up in bureaucracy when it is time to move someone over.
    And I think you--you somewhat commented on, Mr. Walker, 
where you said ``my doctor retired.''
    Mr. Walker. Yes.
    Mr. Wenstrup. So I would imagine that you are very 
interested in meeting your next primary care doctor.
    Mr. Walker. I would like to, yes.
    Mr. Wenstrup. Okay. But comment on those other aspects, if 
you would. Go down the line.
    Mr. Galpin. So I--my background is internal medicine, 
clinical informatics. But I work as a primary care provider in 
the VA.
    And I agree with you. I think it is very important to have 
that one provider who is recognized as the face of the VA for 
the patient, who coordinates their care.
    I mentioned the teleprimary care hubs. This model where we 
can provide interim staffing. What I really love about this 
program is that they commit a provider to work with a panel of 
patients.
    So, again, if your provider retires, and we have the option 
to bring in a provider, they commit to at least 6 months for 
that provider to take over that patient panel. So it is at 
least the same telemedicine provider until they can hire the 
new provider in the clinic. So you do get continuity.
    In addition, we have more than just the capability of 
bringing the provider in, but they have psychologists and 
social workers and pharmacists.
    So they can bring, actually, other members of the PACT team 
to some of the rural sites that may not have those resources. 
So it functions as a very effective interim staffing program.
    In addition, we try and hire those providers somewhat 
regionally located to where they are going to be delivering 
services.
    So even though their primary focus is on delivering 
teleprimary care, they do travel to those centers 1 week, at 
least, out of every quarter to provide some in-person 
appointments for veterans who may not be interested in having 
their care through virtual means.
    So we are really excited about these programs. We are 
really just getting started on setting up that model. But I 
think it is a very exciting model. And it helped me overcome 
some of the barriers that I personally had as a former primary 
care provider of how would this all work and will it fit--fit 
all of our needs.
    So very exciting. But I think it helps address some of the 
questions you have.
    Mr. Wenstrup. Thank you.
    Doctor, do you have anything else to add?
    Mr. Hartronft. No. I completely agree with that.
    In addition to--the nice thing with telehealth is, even 
when someone has their established provider, the other 
modalities, the Store-and-Forward, they can potentially have 
the dermatologist help the primary care provider decide, like 
with teledermatology, whether that--you know, a suspicious 
lesion should be removed.
    And then also the home telehealth, which is very nice with 
chronic diseases, and provides better information for the--more 
data points for the primary care provider to base longer term 
decisions over, instead of single-point blood pressures when 
they come into the clinic, per se, or blood sugar.
    So the nice thing is you can--even if you are not in the 
tele CVT program, where you are face to face, the primary care 
doc can actually use the other modalities to expand their care 
to others.
    Mr. Wenstrup. Thank you.
    Ms. Brownley.
    Ms. Brownley. Yes. Thank you.
    I have a question.
    So Dr. Galpin, I--my staff made me actually aware of a 
report from the Commonwealth Fund which noted that patients who 
used VHA telehealth services between 2003 and 2007, that 96 
percent were male and 4 percent were female.
    I was wondering if you can add something to that data 
point.
    Mr. Galpin. Yes. So we looked at that information, looking 
at our most recent fiscal year, so fiscal year 2015.
    And we have about 7.4 percent of our veteran population 
being served in the VA. Our female veterans. And about the same 
proportion use telehealth services. So if you look at all the 
encounters, it is about 7.2 to 7.4 percent for our clinic-based 
telehealth programs and Store-and Forward programs. Similar to 
home telehealth model.
    So it is a program that is utilized by female veterans. I 
think at about the consistent rate as with our male veterans. 
We have also got some programs that are uniquely geared toward 
female veterans.
    So we have a--there is actually a fairly long list, but 
women's health primary care, we have a women's health stress 
disorder clinic, OB/GYN.
    And actually as of last week, we just signed a women's 
telehealth operations manual that will help facilities set up 
these programs, provide the guidelines, and basically how to 
get started.
    So it is certainly an area of focus. There is a lot of 
great opportunities in there, and I think we are beginning to 
really take advantage of those.
    Ms. Brownley. Very good.
    In your testimony, at least in your written testimony, you 
kind of describe these sort of three pillars of telehealth.
    And is it fair to say that all three of those pillars are 
available throughout the country at every clinic across the 
country, every medical center across the country? Is that where 
we are in terms of scale?
    Mr. Galpin. So, yes. That is--I will have to spend a little 
bit of time on this question.
    So, yes, the three general pillars are generally available 
across the country. People have clinical video telehealth 
services, and they have Store-and-Forward telehealth services, 
and home telehealth services.
    From one location to another, though, the facilities may 
have chosen to invest in different types of offerings through 
those services.
    So you can't say, for instance, that every CBOC, every 
community-based clinic is going to have a dermatology program, 
or teleretinal program, or this type of program.
    So the variety of the clinic is still a local decision. 
Based on what--what are the needs at that facility or can that 
facility safely offer, you know, what is the decision of the 
medical executive committee, and what are the needs of the 
veterans in those locations.
    So, again, in general, yes, they are available pretty 
ubiquitously around the country. However, any individual 
offering, it is hard to say that is available at every 
location.
    Ms. Brownley. And are rural areas using it more than urban 
areas? Or is it, you know, pretty consistent or inconsistent 
across the country?
    Mr. Galpin. Last year, in fiscal year 2015, we had about 45 
percent of our encounters were for veterans living in rural 
areas. So it is pretty split.
    I mean, there is a lot of advantages to doing it both in 
rural and urban communities.
    Ms. Brownley. Very good.
    And I think, Dr. Hartronft, you talked about--I think it 
was you that talked about sort of consultation services? These 
are specialists?
    Mr. Hartronft. Yes.
    Ms. Brownley. And so are those services, or hubs is sort of 
the way I am thinking about them, specialty hubs, are they 
across the country? Do we have one in West Los Angeles?
    Mr. Hartronft. We have kind of taken an approach with the 
new leadership of being data-driven and being strategic. In the 
sense of what we have done is, the veterans that we currently 
are looking at that drive to West L.A. or Sepulveda from 
Oxnard, we have looked at what type of services are requiring 
them to do so. And those are the ones that we are focusing on 
primarily first, whether it be face to face, and why we chose 
some of the programs we have.
    And then what we do is, based on that demand and how many 
we calculate would be during a week, to save efficiency with 
that provider in our grids, we have used--decide whether the 
telehealth would be--provide enough.
    And so we are kind of using both the face-to-face driven on 
supply, demand, and how we are seeing our current veterans 
having to make that trip. It is kind of how we are rolling it 
out.
    We are wanting to--I think we will look a lot different 
down the road.
    But, right now, how we are choosing is just based off of 
what we are seeing, the veterans from Ventura County having to 
make that drive to Sepulveda or West Los Angeles.
    Ms. Brownley. Very good.
    It seems to me that, you know, we have Dr. Rogove here, who 
is really trying to push the envelope in terms of private 
health care delivery. And he has barriers that the VA doesn't. 
That the VA doesn't have.
    And I think it is fair to say that the VA has been a leader 
in telehealth.
    And, you know, I think the VA has a large responsibility to 
keep pushing, you know, and pushing that envelope.
    Because if we are successful within the VA providing these 
services and proving, really, to the rest of the world that 
this is indeed the future, and the way--the most efficient way 
to provide services, most likely, and certainly in terms of 
physician shortages and so forth.
    And so I think we have a big responsibility to work not 
only with private industry and work with some of their issues, 
but we have a responsibility to be the trend leader here and to 
push the envelope.
    And so I think, you know, I am certainly more interested 
in, you know, how we--you know, to the degree that--you know, 
we can continue to kind of keep pushing and pushing and pushing 
on this.
    Particularly when, you know, I think about specialty care 
and for those veterans who have a particular kind of illness or 
an unusual illness where we really need expertise from, you 
know, across the country, or a brain surgeon that there is only 
three in the country that perform this particular kind of 
surgery.
    And that we are really continuing to really push, push, 
push.
    When I first was elected, I mean, I knew very quickly that 
we were providing mental health through--mental health services 
through telehealth.
    And for some veterans, that is wonderful. They can be in 
the privacy of their own home; they could come to an office and 
wait in a waiting room, and they feel more comfortable using 
telehealth for their mental health services.
    And to the degree that we can get more veterans utilizing 
our mental health services who need it, that is a good thing.
    So, you know, I want that. But I also want to really be 
kind of pushing, you know, pushing on the edges.
    So that we can kind of break barriers, really, for--and--
and as we try to do in the Choice Act, to bring community 
partners with the VA, that we can do--be community partners 
within the telehealth arena as well.
    And so, you know, I am certainly interested in following up 
and making sure that we are overseeing, you know, the data on 
this and overseeing how we are pushing the envelope on this.
    And I will bring that down to another level entirely, and 
that is the local level here, making sure that we are--the 
education and so forth, that I think needs to take place at the 
CBOC is there so that people know more of their options.
    But, you know, in terms of where we might be scaling, it 
sounds like we have scaled up, you know, across the country. 
Different regions are using it differently. But that the 
hardware, so to speak, the equipment that one needs to be able 
to provide these services, seem to be--you are telling me that 
they really are--they exist, you know, across the country.
    And so I will just be interested in the future to see, you 
know, where we are really kind of pushing that envelope 
further, and where we can be better partners as in the private 
health care delivery as well.
    Mr. Wenstrup. Thank you.
    I have one more quick question.
    Do you measure wait times for telemedicine?
    Mr. Galpin. So not specifically for telemedicine.
    I have some internal data from one of our programs. I just 
know because I look at data one of our dermatology programs. We 
are looking at. A very exciting program, serving a lot of 
veterans with dermatology.
    And they are able to turn around an image and a 
consultation in one day, on average, when they look at their 
12-month averages and average them.
    So there is certainly some exciting areas where, you know, 
the wait times can be reduced.
    But we don't separate out the services we provide through 
telemedicine. I mean, the wait time for the veteran is still 
the wait time. And telemedicine is one of our services. So the 
key is, did we get the veteran into service, regardless of what 
modality we used.
    So we don't have--I mean, there may be individual programs 
doing it, but at a national level, that is not something I am 
tracking. There is just the wait time.
    Mr. Wenstrup. That may be something we want to look at.
    As we move forward, obviously, you know, this is exciting, 
this is new, this is growing. And, you know, through that 
process, no matter what it is, you are always looking for what 
becomes the best practice. And that is the work in progress. 
Right?
    And so I don't think either of us or many people in our 
audience anticipate that you've got it all down right from the 
get-go. Because it is growing and it is changing. And you've 
got to also educate patients on the opportunity as well. So it 
is a mixed bag.
    And I think the other thing too that you've--is in 
implementing this, let's make sure you have the flexibility to 
do the things that you want to do to provide care, and we don't 
box ourselves in to some type of protocol that may end up doing 
more harm than good sometimes. We want to have the flexibility 
to make decisions on behalf of the patients.
    So a couple take-aways have to do with the credentialing 
and the licensing questions that may exist. And I think that 
that may be something we can work on.
    Ms. Brownley. Yes.
    Mr. Wenstrup. And work with you on that to try and make it 
very clear as to how this is done.
    One thing that crossed my mind is, no matter where the doc 
is, virtually, he is in the VA or she is in the VA, right? And 
no matter where the patient is, they are in the same State as 
the doctor that they are working with.
    So maybe we take that concept and apply it to the licensing 
and be able to take away that burden and make it more flexible, 
and more opportunities for you.
    But if there is no further questions, the panel is now 
excused.
    And I want to thank you all for being here. I think you all 
had wonderful input for us. And, again, thank you.
    And I want to thank the members of the audience for being 
here today as well. It has been a pleasure for me to come to 
sunny California and be with all of you. Hopefully, I won't 
have any problems on my flight back.
    With that, I ask unanimous consent that all Members have 5 
legislative days to revise and extend their remarks, and 
include extraneous material. Without objection, so ordered. The 
hearing is now adjourned. Thank you.

    [Whereupon, at 10:23 a.m., the Subcommittee was adjourned.]


                           A P P E N D I X

                              ----------                              

                Prepared Statement of Zachary D. Walker
    Good Morning,

    I am Zachary Walker, a veteran of the United States Navy from 1975 
to1979. My introduction to Telemedicine was presented to me by my 
Veteran's Administration (V.A.) medical clinic, not as an option, but 
as a last resort. My journey began when I received a phone call from my 
local V.A. clinic one day before my scheduled appointment that my 
appointment was canceled. The clinic informed me that my health care 
provider was not available. I was told the next available appointment 
would be in two months. Having already waited two months for an 
appointment, I requested to see the next available health care 
provider. Again, I was informed that the wait time would be two months 
because they were booked. I took the next available appointment; now 
having to wait four months to see a provider. I terminated the call 
feeling frustrated and angry that my health care was being jeopardized 
due to a backlog in the system.
    The next week, I called the V.A. clinic and asked to speak to the 
supervisor who was not available. I then provided my information for a 
return call. Not having received a return call for two days, I again 
called and spoke with a supervisor at the clinic. I reiterated my 
story, but it was apparent that she was unable and unwilling to help. 
She gave me some unclear information about how to proceed if my 
condition worsen, which I felt was not a solution to my problem. Out of 
desperation, I called my local V.A. representative and explained my 
situation. To my surprise, I received a call the next day from a clinic 
nurse, who presented the option of telemedicine. Initially, I was 
reluctant because being seen by a doctor through a monitor was 
counterproductive to any medical experience I have had in the past.
    The nurse was through explaining the process and assured me that 
the doctor would have all my lab results. She also reviewed my medical 
history. I scheduled an appointment and was seen within a week. I 
arrived for my appointment and was escorted back to a examination room 
in a timely manner. I was seated in front of a monitor and two-way 
camera. The doctor introduced herself. She was very pleasant, did not 
appear rushed, and she was well prepared. It was evident based on her 
questions that she had reviewed my recent tests and medical history. 
During my appointment, the doctor ordered more tests and made a 
referral for a new medical condition she noted. She even apologized for 
not having the ability to examine me. Even more surprising, I received 
a call from her one week later with my test results.
    In conclusion, I had a great experience with telemedicine. My 
appointment wait time was reduced from the normal two months to one 
week. My appointment started on time rather than the normal one hour 
lobby wait time. The doctor was not rushed during my appointment and 
took the time to listen to my concerns. The only obvious drawback is 
not having a doctor to physically examine you, but I would use 
telemedicine in the future. Telemedicine should be presented to 
veterans as an option for medical care, and not as a last resort.

    Thank You

    Zachary D. Walker

                                 ----------
                                 
                   Prepared Statement of Herb Rogove
    Thank you, Chairman Benishek and Ranking Member Brownley and 
Members of the Subcommittee. I am most appreciative for the opportunity 
and privilege to testify about telemedicine and in particular the 
critical role and contribution of the VA telehealth programs.
    I am the physician founder and CEO of C3O Telemedicine which is 
based in Ojai, CA in Ventura County. My company was founded on the 
principle that no American citizen should be penalized for gaining 
access to best practice medical care because of geography or no access 
to certain specialty physicians. To that end, we provide stroke care 
via telemedicine to over 30 hospitals located in soon to be seven 
states including CA. Additionally, I recently served on the Board of 
the American Telemedicine Association (ATA) as it's secretary/
treasurer.
    In January of 2015, Mr. Carl Blake, Associate Executive Director 
for Government Relations, Paralyzed Veterans of America testified 
before this same Committee and commented:
    ``the viability of the VA Healthcare System depends on upon a fully 
integrated system in which the organization and management of services 
are interdependent so that veterans get the care they need, when and 
where they need it, in a user-friendly way to achieve the desired 
results and provide value for the resources spent.'' The VA Telehealth 
program addresses his comment.
    For the past ten years, I have studied many telehealth models and 
have been most impressed by the VA model as both exemplary and 
successful. In May, I had the privilege of meeting Dr. David Shulkin, 
Under Secretary of Health for the VA, at our national meeting. He 
shared that last year the VA had 2.4M encounters with 677,000 veterans 
(12% of all vets) using real-time telehealth, home telehealth care, and 
store and forward telemedicine. Forty-five percent of these encounters 
were in rural areas. The types of care provided varied from ICU, 
primary care, outpatient kiosks, sleep apnea and behavioral health. In 
2015 home telehealth reduced hospital bed days of care by 58%; hospital 
admissions by 32%; and Telemental health reduced psych bed days of care 
by 35%.
    Looking at the future, the VA Telehealth Model has a tremendous 
opportunity to:

      Serve as a national leader as VA telehealth programs 
continue to evolve.
      Partner with public-private partnerships with companies 
such as C3O Telemedicine as well as major health and academic systems 
to meet the current and expanding physician shortage.
      Establish a national medical license which is a 
significant barrier to telehealth. The VA has a national license, but 
outside of the VA, companies have to apply to many states costing time, 
money, and a significant delay up to one year to implement a program 
that a hospital needed yesterday.
      Push for CMS to expand reimbursement to Metropolitan 
Statistical Areas (MSA's).
      Evaluate and establish criteria for adequate and accurate 
technology that can serve our patients.

    Thank you again for this opportunity.

                                 -----------
                                 
                Prepared Statement of Kevin Galpin, M.D.
    Good morning, Mr. Chairman, Ranking Member Brownley, and Members of 
the Committee. Thank you for the opportunity to discuss the efforts 
that VA has taken to develop telehealth, the services VA provides to 
Veterans through telehealth, and the expansion of telehealth at VA. I 
am accompanied today by Dr. Scotte R. Hartronft, Chief of Staff of the 
VA Greater Los Angeles Healthcare System (GLA).
    Through the MyVA transformation, VA is working to rebuild trust 
with Veterans and the American people, improve service delivery, and 
set the course for long-term VA excellence, while delivering better 
access to care. MyVA will empower Veterans and their caregivers to be 
in control of their care and make interactions with VA a simple and 
exceptional experience. To empower Veterans, VA is transitioning to a 
system that is user-friendly and focused on contemporary practices in 
access to care. Accordingly, the Under Secretary for Health developed 
the ``MyVA Access Declaration,'' a set of foundational principles for 
every VA employee. It represents VA's pledge to expand access to care 
for all Veterans seeking VA health services.
    VA has substantially increased access to care for Veteran patients 
using telehealth services and is a recognized pioneer in the practice 
of telehealth. Since 2002, over two million Veterans have accessed VA 
care through telehealth services, and Veterans are utilizing more 
telehealth services from VA than ever before. In fiscal year (FY) 2015, 
VA conducted 2.14 million telehealth visits, reaching more than 677,000 
Veterans. GLA, specifically, increased its outpatient encounters from 
the prior year by 61,500, including more than 20,000 telehealth visits 
that reached over 6,200 Veterans.
    Leveraging telehealth technologies affords VA a noteworthy 
opportunity to increase access to care for Veterans, especially for 
those in rural or underserved areas. It allows Veterans access to VA 
health providers or services that may otherwise be unobtainable 
locally. VA is recognized as a world leader in the development and use 
of telehealth, which is now considered mission critical for effectively 
delivering quality health care to Veterans. VA remains committed to 
ensuring that America's Veterans have access to the health care they 
have earned through their service, and we will continue to expand 
telehealth services to meet the growing needs of our Veterans.

Brief History of Telehealth

    The mission of VA Telehealth Services is to provide the right care 
in the right place at the right time through the effective, economical, 
and responsible use of health information and telecommunications 
technologies. Telehealth leverages health informatics, disease 
management principles, and communications technologies to deliver care 
and case management to Veterans. This aspect of telehealth changes the 
location where health care services can be provided, making care 
accessible to Veterans in their local communities and even in their 
homes.
    VA leverages three broad categories of telehealth to deliver 
services to Veterans in 50 clinical specialties. The first of the three 
categories, Clinical Video Telehealth, is defined as the use of real-
time interactive video conferencing to assess, treat, and provide care 
to a patient remotely. Typically, Clinical Video Telehealth links a 
Veteran at a clinic to a provider at a VA medical center in another 
location. Clinical Video Telehealth allows clinicians to engage 
patients in the comfort and convenience of their homes and facilitates 
delivery of a variety of clinical services including primary and 
specialty care. Clinical Video Telehealth means that instead of having 
the cost and inconvenience of the Veteran traveling by road, rail, or 
air to see a provider, the VA provider delivers care through telehealth 
to the Veteran.
    VA Video Connect (VVC) represents the next step for Clinical Video 
Telehealth and is currently undergoing field testing. VVC provides 
fast, easy, encrypted, real-time access to VA care. VVC can be used to 
connect VA providers to a Veteran's personal mobile device, smartphone, 
tablet, or computer. It allows for video health care visits, such as 
telemental health visits, where a hands-on physical examination is not 
required. It also makes it easier for Veterans to choose where they'd 
like to receive services, whether that is in their home or any other 
place the Veteran desires.
    The second broad category of telehealth is Home Telehealth. Home 
Telehealth uses VA-provided devices, along with regular telephone 
lines, mobile broadband modems, cell phones, or web browsers, to 
connect a Veteran with a VA provider, most often a registered nurse. 
Using Home Telehealth technologies, the VA provider can monitor the 
Veteran's health status, provide clinical advice, and facilitate 
patient self-management as an adjunct to traditional face-to-face 
health care. The goal of VA's Home Telehealth program is to improve 
clinical outcomes and access to care while reducing complications, 
hospitalizations, and clinic or emergency room visits for Veterans who 
are at high-risk due to a chronic disease (e.g. Diabetes). Not every 
patient is suitable for this type of care; however, for those Veterans 
who are, Home Telehealth can help them live independently and spend 
less time on medical visits. Over 85,000 Veterans are regularly using 
Home Telehealth services. VA found that patients easily learn how to 
use their Home Telehealth devices and are highly satisfied with the 
service. Home Telehealth services make it possible for Veterans to 
become more involved in their medical care and more knowledgeable about 
their conditions, providing an opportunity to more effectively self-
manage their health care needs.
    The third category of telehealth is Store-and-Forward Telehealth, 
which is the use of technologies to asynchronously acquire and store 
clinical information (such as data, images, sound, and video) that is 
then assessed by a provider at another location for clinical 
evaluation. VA's national Store- and-Forward Telehealth programs 
deliver such services as Dermatology and Retinal Screening, where a 
health care provider can use a photo or a series of photos for 
diagnosis or triage.

Examples of Telehealth Use

Mental Health

    VHA uses information technology and telecommunication modalities to 
augment care provided by its mental health clinicians to Veterans 
throughout the United States. VA has found telemental health care to be 
equally effective, if not more so, than in-person appointments. From 
2002 through July 2, 2016, more than 2 million telemental health visits 
have been provided to over 389,400 unique Veterans. Telemental health 
is also a way to bring highly specialized care to patients who 
otherwise would have to travel great distances to receive such care.
    VA's National Telemental Health Center (NTMHC) provides Veterans 
throughout the country with access to the highest level of clinical 
experts using telemedicine. The NTMHC clinical national experts (in 
affective, psychotic, anxiety, and substance use disorders) are located 
at the VA Boston Healthcare System, the VA Connecticut Healthcare 
System, the Philadelphia VA Medical Center (VAMC), and the Providence 
VAMC. The NTMHC has provided access and expert consultation to over 
4,600 Veterans for more than 16,500 encounters at over 120 sites 
throughout the Nation. Building on the success of NTMHC, in 2016, VA 
announced the establishment of four regional Telemental Health Hubs, 
with mental health providers at these hubs available for facilities in 
need of mental health resources.

Rehabilitation

    Rehabilitation providers leverage video teleconferencing to 
increase access to specialty rehabilitation care. In FY 2015, over 
57,000 rehabilitation encounters occurred using this modality, 
providing care to over 33,000 unique Veterans. Numerous specialty 
rehabilitation clinics are offered through telehealth, including, but 
not limited to, Amputation, Blind Rehabilitation, Physical Therapy, 
Speech Therapy, and Traumatic Brain Injury. Clinical Video Telehealth 
allows the rehabilitation provider to be located at a tertiary medical 
center while the patient is at a Community Based Outpatient Clinic 
(CBOC), another VAMC, or a non-VA location. Veterans with disabilities, 
especially in rural areas, benefit greatly from telerehabilitation. 
Many of these Veterans have mobility issues and/or socioeconomic 
factors that affect their ability to travel to receive needed care. 
Telerehabilitation increases access to specialty rehabilitation 
therapies, which assists in increasing functional gains and social re-
integration.
    Tele-Intensive Care (Tele-ICU) is a telemedicine program that links 
Intensive Care Units (ICU) in VA medical centers to a central 
monitoring hub staffed with intensivist physicians and experienced 
critical care nurses. Through the use of a camera mounted above each 
patient's ICU bed, along with links to the medical record and vital 
sign monitors, staff in the Tele-ICU hub not only see all of the 
pertinent medical data on a patient, but they are capable of performing 
audiovisual exams; discussing treatment plans with patients, nurses, 
and families; intervening during emergencies; and generally providing 
specialist-level care and consultation.

Store-and-Forward Retinal Imaging

    Diabetes can cause problems with the blood vessels in the retina, 
especially if the diabetes is poorly controlled. A special camera takes 
pictures of the retina, which are then sent to an eye care specialist 
for review. A report is returned to the patient's primary care 
physician, who can provide any required treatment. This investigation 
does not replace a full eye exam but does mean that those at risk of 
eye problems from diabetes can be assessed easily and conveniently in a 
local clinic.

Telesurgery

    Telesurgical consultation can enhance the diagnosis, the 
coordination of care, and the triage of surgical patients. The use of 
telehealth can provide intra-operative consultation, patient and staff 
education, and pre- and post-operative assessment.
    We continually add new telehealth specialties as technology 
improves, allowing VA to integrate telehealth technologies into more 
areas of Veteran care. These technologies make it possible for Veterans 
to come to many of VA's CBOCs and connect to a specialist physician or 
another practitioner at a distant location.

Telehealth Potential

    Though advanced compared to other health care systems, VA is still 
at the beginning of its journey of leveraging its integrated national 
health care system and remote care opportunities through telehealth 
technologies. VA would be able to accelerate expansion of clinical 
services if our clinical and technical capabilities to deliver health 
care through virtual technologies were supported by legal authority, 
unambiguously authorizing health care providers to deliver clinical 
services irrespective of the Veteran's or the provider's location.

Conclusion

    In closing, VA is a leader in providing telehealth services, which 
remains a critical strategy in ensuring Veterans can access health care 
when and where they need it. With the support of Congress, we have an 
opportunity to shape the future and ensure that VA is leveraging 
cutting-edge technology to provide convenient, accessible, high-quality 
care to all Veterans.
    Mr. Chairman, this concludes my testimony. Thank you for the 
opportunity to testify before the Committee today. We appreciate your 
support and look forward to responding to any questions you and Members 
of the Committee may have.

                                 ---------
                                 
                        Statement For The Record

          GRACE HEALTH SYSTEM - DR. RANDALL SCOTT HICKLE, M.D.
Dr. Randall Scott Hickle, MD, Founder/CEO, Grace Health System, 
    Lubbock, Texas

    MISTER CHAIRMAN AND DISTINGUISHED MEMBERS OF THE SUBCOMMITTEE, 
thank you for hosting this important oversight hearing today on the 
topic of telemedicine in the VA Healthcare System. This is a vitally 
important technology that can increase much needed access to care for 
our veterans at a significantly reduced cost. It is my pleasure to 
participate in this hearing and share some private sector solutions for 
the VA Healthcare crisis.

STATEMENT

    My name is Dr. Randy Hickle, MD and I am the Founder/CEO of the 
Grace Health System located in Lubbock, Texas. Grace Health System 
started in 2006 as Grace Clinic with just eight doctors on staff. Over 
the past decade, we have grown to more than 50 doctors and other 
specialists along with 22 centers of care offering patient-centered 
care to people from all of over the West Texas region.
    The growth of Grace doesn't end there. Since 2012, we have started 
a new hospital, upgraded the in-house pharmacy, opened a new cardiac 
imaging center, and added 15 new doctor's offices. We are also changing 
the region's medical landscape by breaking ground on a new 350,000 
square-foot hospital in the next several months. More importantly, we 
are planning for the future of medicine and have launched a 
telemedicine program reaching medically underserved and chronically ill 
patients in rural communities throughout Texas and New Mexico. It is 
Grace's telemedicine program that has inspired me to share my thoughts 
with you today.
    While West Texas comprises almost half the state in geographic 
size, it is home to mostly rural towns that make up only 12 percent of 
the state of Texas' population. Telemedicine provides a way for these 
rural patients to receive critical access to care by eliminating the 
cost and inconvenience of traveling to a population center. We are 
experiencing great success in monitoring and treating patients that 
otherwise may have gone untreated which often result in higher costs to 
the overall system from unnecessary hospitalizations and ER admissions. 
About a year-and-a-half ago after reading about some of the tragic 
consequences of some of our veterans that are committing suicide at 
alarming rates, I decided that it was time to employ some of the 
telemedicine successes we are experiencing in the private sector with 
the VA.
    Last year, I was honored to visit with House Veteran's Affairs 
Committee Chairman Jeff Miller (R-Florida) and his staff about my 
successful experiences with treating patients through Grace's 
telemedicine program and how I would like to help provide such a 
solution to our veterans who have given so much for their country. We 
owe them nothing less. Chairman Miller and his staff have been 
supportive of my efforts to provide proven private sector solutions to 
address this VA Healthcare crisis. Unfortunately, my attempts to 
collaborate with the VA directly have been frustrating.
    I was encouraged to hear VA Secretary Robert A. McDonald state 
recently, ``A brick-and-mortar facility is not the only option for 
health care. We are exploring how we can more efficiently and 
effectively deliver health care services to better serve our veterans 
and improve their lives. Telehealth is one of those areas we have 
identified for growth.''
    I could not agree more with Secretary McDonald. And I would implore 
the Secretary and the Members of this Subcommittee to not reinvent the 
wheel with telemedicine. There are many talented and successful 
telemedicine programs that are currently available to immediately 
assist with the VA's alarming backlog. In September 2015, the Texas VA 
facilities required a wait time of over 30 days for 34,665 
appointments. This is unacceptable, and we can do much better.
    My whole career has been focused on creating innovative solutions 
for areas where I see real health care needs. Your decision to hold 
this hearing today tells me that you all feel the same way. There are 
many private sector solutions across this great country, and I would 
strongly encourage you to review the Grace Veterans Telehealth 
Initiative. I believe telemedicine can improve health care for all 
veterans by improving accessibility, affordability, and accountability. 
I collaborated with a leading expert in addiction recovery, Dr. Kitty 
Harris, to create a behavioral health program for veterans that would 
serve their needs for PTSD, depression, anxiety, and substance abuse. I 
have asked that a one-page summary be submitted to the record for your 
review and consideration.
    Once again, I thank Chairman Dan Benishek, MD and the distinguished 
Members of the Subcommittee on Health for hosting today's Oversight 
hearing on Telemedicine in the VA System. This is a very important and 
vital health care solution that deserves a congressional hearing. I 
would also like to thank House Veterans' Affairs Committee Chairman 
Jeff Miller (R-Florida) and Ms. Christine Hill, Staff Director, 
Subcommittee on Health for their continued leadership to find proven 
telemedicine techniques that increase access to quality care for our 
veteran patients.
                     Veterans Telehealth Initiative
                   Expanding Behavioral Health Access
Overview

    Many veterans who need behavioral health services do not receive 
it. Those who do seek out services frequently terminate prematurely 
(1). It is hypothesized that veterans engage in treatment less often 
for the following reasons (2, 3): transportation costs, fear of 
stigmatization for receiving behavioral health services, living in 
rural areas, provider shortage areas that lack mental health 
specialists. Telemedicine has proven to be effective for treatment of 
behavioral health conditions and addresses the reasons for lack of 
services among veterans. Telemedicine has been proven effective for a 
variety of conditions including:

    Post-Traumatic Stress Disorder (4)
    Anxiety Disorders (5)
    Depression (6)
    Acute Suicidality (6)
    Eating Disorders (7)
    Smoking Cessation (8)

    It is well known that frequency of therapy is highly tied to 
efficacy (9). However, issues such as worktimes and available childcare 
still impede veterans from receiving services. Psychoeducation is also 
known to enhance the efficacy of treatment (10). Maintaining high 
engagement is critical for disseminating psychoeducation. The Veterans 
Telehealth Initiative (VTI) Program provides solutions to both of these 
issues by removing common barriers (e.g., location, childcare), 
allowing high frequency therapy, and highly engaging video-based 
psychoeducation.


Evidence-Based Programs

    Post-Traumatic Stress Disorder: Trauma-Focused Cognitive Behavioral 
Therapy
    Substance Use Disorders: 12-Step Facilitation Education, CBT, and 
Mindfulness
    Depression: Behavioral Activation and Cognitive Behavioral Therapy
    Obsessive Compulsive Disorder: Exposure and Response Prevention and 
CBT
    Panic Disorder: Relaxation, Panic Induction and Reaction, and CBT

Professional Services Provided:

      Psychotherapy weekly
      Telepsychiatry PRN
      Telemonitoring of symptoms
      Multidisciplinary treatment team meetings
      Personalized feedback, which has been shown to enhance 
electronically mediated treatment (11)

Example Program Overview: Alcohol Use Disorder Treatment

    A typical program covers approximately one month of intensive 
treatment. All 4 science-based treatments are included. The program 
includes interactive feedback, peer-facilitated components, multimedia 
rich presentation, and a holistic approach with links to other mental 
health treatment programs.

[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]


                               References
    (1) Garcia, H.A.,Kelley, L. P.,Rentz, T.O., & Lee, S. (2011). 
Pretreatment predictors of dropout from cognitive behavioral therapy 
for PTSD in Iraq and Afghanistan war Veterans. Psychological Services, 
8, 1-11.
    (2) Gros, D. F., Strachan, M., Ruggiero, K. J., Knapp, R. G., 
Frueh, B. C., Egede, L. E., Acierno, R. (2011). Innovative service 
delivery for secondary prevention of PTSD in at-risk OIF-OEF servicemen 
and women. Contemporary Clinical Trials, 32, 122-128.
    (3) Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, 
D. I., & Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, 
mental health problems, and barriers to care. New England Journal of 
Medicine, 351, 13-22.
    (4) Yuen, E. K., Gros, D. F., Price, M., Zeigler, S., Tuerk, P. W., 
Foa, E. B., & Acierno, R. (2015). Randomized controlled trial of home-
based telehealth versus in-person prolonged exposure for combat-related 
PTSD in veterans: Preliminary results. Journal of Clinical Psychology, 
71(6), 500-512.
    (5) Bouchard, S., Paquin, B., Payeur, R., Allard, M., Rivard, V., 
Fournier, T., Lapierre, J. (2004). Delivering cognitive-behavior 
therapy for panic disorder with agoraphobia in videoconference.
    (6) Gros, D. F., Morland, L. A., Greene, C. J., Acierno, R., 
Strachan, M., Egede, L. E., Frueh, B. C. (2013). Delivery of evidence-
based psychotherapy via video telehealth. Journal of Psychopathology 
and Behavioral Assessment, 35, 506-521.
    (7) Mitchell, J. E., Crosby, R. D., Wonderlich, S. A., Crow, S., 
Lancaster, K., Simonich, H., Myers, T. C. (2008). A randomized trial 
comparing the efficacy of cognitive-behavioral therapy for bulimia 
nervosa delivered via telemedicine versus face-to-face. Behaviour 
Research and Therapy, 46, 581-592.
    (8) Carlson, L. E., Lounsberry, J. J., Maciejewski,O.,Wright, K., 
Collacutt, V.,& Taenzer, P. (2012). Telehealth delivered group smoking 
cessation for rural and urban participants: Feasibility and cessation 
rates. Addictive Behaviors, 37, 108-114.
    (9) Erekson, D. M., Lambert, M. J., & Eggett, D. L. (2015). The 
relationship between session frequency and psychotherapy outcome in a 
naturalistic setting. Journal of Consulting and Clinical Psychology, 
83(6), 1097-1107.
    (10) Lucksted, A., McFarlane, W., Downing, D., Dixon, L., & Adams, 
C. (2012). Recent developments in family psychoeducation as an 
evidence-based practice. Journal of Marital and Family Therapy, 38(1), 
101-121.
    (11) Walters ST, Hester RK, Chiauzzi E, Miller E. Demon Rum: High-
Tech Solutions to an Age-Old Problem. Alcoholism: Clinical and 
Experimental Research. 2005;29(2):270-7. doi: 10.1097/
01.ALC.0000153543.03339.81. PubMed PMID: 2005-02202-011.

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