[Senate Hearing 115-608]
[From the U.S. Government Publishing Office]
MILITARY CONSTRUCTION, VETERANS AFFAIRS, AND RELATED AGENCIES
APPROPRIATIONS FOR FISCAL YEAR 2018
----------
THURSDAY, MAY 4, 2017
U.S. Senate,
Subcommittee of the Committee on Appropriations,
Washington, DC.
The subcommittee met at 10:32 a.m. in room SD-124, Dirksen
Senate Office Building, Hon. Jerry Moran (chairman) presiding.
Present: Senators Moran, Hoeven, Capito, Cochran, Schatz,
Tester, Udall, and Baldwin.
VETERANS HEALTH ADMINISTRATION
STATEMENT OF DR. KEVIN GALPIN, MD, EXECUTIVE DIRECTOR,
TELEHEALTH SERVICES
opening statement of senator jerry moran
Senator Moran. Good morning, everyone. Thank you for
joining us. Welcome to our fourth subcommittee hearing which I
now gavel to order. Thank you all for being here to discuss the
benefits of telehealth at the Department of Veterans Affairs on
behalf of veterans across the country.
I will have my formal statement submitted for the record
and reduce my remarks to just off the cuff. This is an
important hearing. In my world, it has a lot to do with access.
I represent a very rural state. But I would also admit that I
almost never hear anything from veterans or the VA about
telehealth in Kansas. I know historically and in conversations
that I have had over a long period of time that telehealth at
the VA gets high marks. It is considered one of the best
programs in the country, but I have to admit that in my
experience in dealing with veterans on almost a daily basis
every day this is not a methodology by which I have seen
veterans come to me and say, ``This works so well for me.'' So
I am very anxious to hear the story and see it demonstrated as
something of great value.
This hearing in significant part is occurring because of
the encouragement and suggestion of the senator from Hawaii.
And I appreciate very much his suggestion that we do this and I
look forward to working with him in making certain that the
outcome of this hearing is something that is beneficial to
veterans in Hawaii and Kansas and Montana and West Virginia and
across the country.
But I have a great opportunity to learn how telehealth is
making a difference in the lives of the people I represent in
Kansas and the care and concern that we all have for veterans
across the country. So this is a--I come here with fewer
preconceived ideas than I do when we talk about some other
topics within the VA, so looking forward to the conversation
and the dialog.
I wanted to correct something I said last week. I was
bragging about--in our hearing about suicide prevention, I was
bragging about the vet center and their mobile van and my
impression now is that it is not being used and it is sitting
in a parking lot. So for those of you in Kansas who are
listening to the vet center mobile van, my statements from last
week, the last hearing, were more real than what they turned
out to be.
[The statement follows:]
Prepared Statement of Senator Jerry Moran
Welcome to our fourth subcommittee hearing of 2017. The
Subcommittee will come to order. Good morning. Thank you all for being
here today to discuss the benefits of telehealth for the Department of
Veterans Affairs.
Telehealth at VA is a good news story. The Department is a leader
in the field of telehealth, and telemedicine has influenced the private
sector in positive ways over the past 20 years. We traditionally think
of telehealth as a medical provider and patient service, but I am
encouraged VA is using this platform to reduce the burden on veterans
who drive 300 miles across Kansas, or fly to Oahu, to access VA
services beyond healthcare.
Since 2011, the VA ``TeleBenefits'' program has connected veterans
virtually with a claim specialist to assist with questions and submit
claims with supporting documents. For about 6 months, TeleBenefits has
been serving veterans who visit the Community Based Outpatient Clinic
in Parsons, Kansas, which is the first site to offer TeleBenefits in
our state. The VA outreach coordinator, Ms. Tara Cisneros, told the
Parsons Sun, ``Anything we can do to reach our rural veterans, that's
what I'm aiming for. I just want them to know this service is here.''
This subcommittee is committed to being a voice for veterans and
those who serve them, and I share the same goals as Ms. Cisneros.
What our witnesses have to share today should be exciting and
interesting. Yet, like most things related to technology, new ideas and
platforms are created every day, and the Department should certainly be
striving to be even more innovative, more expansive, more connected. I
recently learned VA just awarded a $258 million VA Home Telehealth
contract in February to improve veteran access to quality, remote
healthcare. This is new information, and I look forward to learning
more about how VA intends to use this contract to improve access to
care.
Our witnesses from the private sector have stories they will share
today about how telehealth has saved significant money and time for
healthcare facilities and patients, and how lives have improved because
of direct in-home access providers have to patients through remote
devices. Their findings could be extrapolated across the country with
potentially great cost savings and cost avoidance.
Telehealth creates a bridge between our rural and urban centers--
providers at an urban site can now diagnose and provide a care plan for
veterans hundreds of miles away. VA is able to expand the resources of
one facility by connecting those providers to providers in another
area--regardless of location. Through telehealth, the Department has
the means and flexibility to provide care to veterans who do not have
easy access to a VA hospital or access to a VA hospital staffed with
the care they need. I look forward today to hearing VA's plan to
increase such care in the places that need it most, and I want to hear
from those in and outside of the Department about ways we, Congress,
can support and further expand the use of this life-changing, and in
some cases, life-saving care.
Our panel today has traveled great distances to be with us to
discuss this important topic. Thank you all for being here.
Senator Moran. With that, I would recognize the Senator
from Hawaii.
STATEMENT OF SENATOR BRIAN SCHATZ
Senator Schatz. Thank you, Mr. Chairman, and thank you so
much for holding this hearing on a topic very important to all
of us. I see the chairman of the whole committee here. We are
very honored to have you and a good compliment of members at
the dais.
Telemedicine has the potential to revolutionize the
quality, convenience, and cost effectiveness of healthcare in
this country in general and for veterans in particular and the
VA and DoD have been real leaders in this.
I want to welcome our panel of witnesses with a special
aloha to our witnesses who have traveled from my home state of
Hawaii to participate in this hearing, Ms. Thandiwe Nelson-
Brooks, Facility Telehealth Coordinator for the VA Pacific
Islands Health Care System, and Dr. Norman Okamura, PhD, from
the Pacific Basin Telehealth Resource Counsel and the
University of Hawaii in Honolulu.
Hawaii and the U.S. affiliated islands in the Pacific have
unique challenges in providing healthcare to veterans in remote
areas and there is great potential in leveraging telehealth to
reach these veterans. I look forward to hearing from our
regional experts on their recommendations for employing
telemedicine and remote patient monitoring to enhance the
delivery of healthcare to remote areas.
It is worth noting that the VA introduced telehealth
programs in the 90s and has been pioneering in the use of
telehealth in the United States. The results are very
encouraging. A VHA analysis of home telehealth services in 2013
showed a 35 percent drop in hospital admissions, an annual cost
reduction of $2,000 per patient, and a patient satisfaction
rate of approximately 90 percent. Impressive results, but in
terms of technological advancement, 2013 is a generation ago. I
have no doubt that both current and projected advances in
telehealth technology will reflect even greater savings.
Given VA's success in this space, it is important that
other Federal health programs increase implementation of these
programs, and that is why I and many others on both sides of
the aisle, including Chairman Cochran, Senators Wicker, Cardin,
Thune, and Warner introduced the Connect for Health Act of
2017.
The bill would eliminate many of the archaic restrictions
on the ability of Medicare to reimburse for telehealth and
remote patient monitoring. The goal would be to translate
achievements similar to what the VA has been able to achieve
over the last 20 years to Medicare so that our seniors can get
similarly high quality care with potential cost savings for the
Federal Government.
While I am encouraged by the advances that VA has already
made in deploying telehealth in the field, I think we have
barely scratched the surface, and that is what this hearing is
all about. So I look forward to the testimony and the
conversation.
Senator Moran. Senator Schatz, thank you. Thank you for
your leadership on this subcommittee and for your leadership
particularly on this topic.
Let me recognize the distinguished gentleman from
Mississippi, the chairman of the full committee, Senator
Cochran.
STATEMENT OF SENATOR THAD COCHRAN
Senator Cochran. Mr. Chairman, thank you. I am pleased to
join you this morning with the committee and the witnesses.
We thank you for cooperating and being here to help us
understand the practical consequences of adopting legislation
on this topic and we look forward to your testimony today.
Thank you.
[The statement follows:]
Prepared Statement of Senator Thad Cochran
Mr. Chairman, I am pleased to join you at this hearing. I look
forward to hearing from all the witnesses today, especially Michael
Adcock from the University of Mississippi Medical Center in Jackson.
Mississippi has been recognized as a national leader in telehealth. The
University of Mississippi Medical Center's telehealth program provides
access to healthcare in underserved areas of the state. We believe that
Mississippi's telehealth successes could be expanded across the country
to improve health outcomes and reduce healthcare costs.
I'd also like to thank Senator Schatz for his leadership on
telehealth issues in the Senate. I enjoyed working with him to
reintroduce the Creating Opportunities Now for Necessary and Effective
Care Technologies (CONNECT) for Health Act yesterday.
Again, Mr. Chairman, I join you in welcoming our distinguished
panelists to our hearing today. I look forward to hearing the responses
to questions of members of this subcommittee.
Senator Moran. Mr. Chairman, thank you very much.
Let me introduce the panel. Our panel has traveled a long
distance. Most of us wish we were going the other direction. We
are glad to have you come our way, but thank you very much for
being here.
Our panel consists of the following: Dr. Kevin Galpin, MD,
as the Executive Director for Telehealth Services at the
Veterans Health Administration at the Department of Veterans
Affairs, and he is accompanied by Mr. Bill James. Mr. James is
the Deputy Assistant Secretary in the Office of Enterprise
Program Management in the Office of Information and Technology
at the Department of Veterans Affairs. And Ms. Thandiwe Nelson-
Brooks, the Facility Telehealth Coordinator for VA Pacific
Islands Health Care System. She is responsible for the overall
coordination, management, and evaluation of all telehealth
services throughout the Pacific Islands Health Care System.
Mr. Michael Adcock is the Executive Director at the Center
for Telehealth at the University of Mississippi Medical Center
where he oversees the strategy and expansion of virtual medical
care in communities across the region. And I was indicating
that we would like to go west to Hawaii, but we are also happy
to go south to Mississippi. And Dr. Okamura is the Principal
Investigator at the Pacific Basin Telehealth Resources Center
which is responsible for servicing the State of Hawaii,
American Samoa, Guam, and the Northern Mariana Islands and
other Pacific Islands that have a compact of association with
the United States.
Welcome to all of you and I now recognize Dr. Galpin.
SUMMARY STATEMENT OF DR. KEVIN GALPIN
Dr. Galpin. Great. Good morning, Chairman Cochran, Chairman
Moran, Ranking Member Schatz, and distinguished members of the
subcommittee. Thank you for the opportunity to discuss the
Department of Veteran Affairs and our efforts to expand the
services VA provides to veterans through telehealth.
I am joined today by Bill James, Deputy Assistant Secretary
for the Enterprise Program Management Office in the Office of
Information Technology, and Thandiwe Nelson-Brooks, Facility
Telehealth Coordinator from the VA Pacific Islands Health Care
System.
VA telehealth is a modern veteran and family-centered
health care delivery model that leverages information and
telecommunications technologies to connect veterans with their
providers irrespective of the location of the provider or the
veteran. VA telehealth provides veterans enhanced access to
care and clinical expertise across geographic distances that
would otherwise separate some veterans, including those in
rural areas, from the providers best able to serve them.
VA's telehealth portfolio allows for enhanced clinical care
delivery in over 50 clinical specialties. Services are
delivered primarily through one of VA's three broad categories
of telehealth. The first, clinical video telehealth, is the use
of real-time interactive video conferencing, with or without
virtual examination tools like a digital stethoscope or an
otoscope, to assess, treat, and provide care to veterans
remotely.
In its most basic form, clinical video telehealth is video
conferencing between a provider and veteran. To the veteran,
this means that instead of dealing with the inconvenience of
traveling long distances to see a provider, service from the VA
provider comes to them at their preferred location, such as a
community-based outpatient clinic and into the home.
The second broad category of telehealth is home telehealth.
This is a technology-enabled remote monitoring program where
clinical data and information is collected through a VA
provided home-based device or through the patient's own mobile
device or home computer. Using one of these technologies, the
VA provider can monitor the veteran's health status, provide
clinical advice, and facilitate patient self-management as an
adjunct to the veteran's traditional in-person healthcare. This
service can help veterans continue to live independently,
reduce hospitalizations, and spend less time and money for
medical visits.
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 a picture, a
sound, or video that is then assessed by a provider at another
location at another time for clinical evaluation. VA's national
store-and-forward program delivers such services as dermatology
and retinal screening where a photo or series of photos of skin
findings or retinal findings can be captured from the veteran
at one location, transmitted electronically, and soon
thereafter interpreted for diagnosis or triage by
dermatologists, optometrists, or ophthalmologists at a
different location.
Telehealth is mission critical to the future of VA health
care. Its potential to expand access and augment services is
both vast and compelling. While telehealth is capable of
enhancing the VA health care system in many ways, I would like
to highlight how it helps in three critical areas which are
particularly critical for the successful operation of a
national integrated VA enterprise.
First, telehealth enhances the capacity for the VA to
provide clinical services for veterans in rural and underserved
areas. This is accomplished by empowering VA to hire providers
in major metropolitan areas where there is a relative abundance
of clinical services for the purpose of serving veterans in
rural communities that lack sufficient medical resources.
Second, telehealth increases the accessibility of VA care.
It brings VA clinical services to the locations that are most
convenient for veterans, including those veterans with mobility
or other health challenges that make any type of travel
difficult. Through telehealth, veterans are able to receive
care in their community-based clinics and even at home.
Third, telehealth increases the quality of care. It enables
VA to model its services so national experts that deal in rare
and complex conditions can effectively care for veterans with
those conditions regardless of the veteran's proximity to the
provider.
VA is committed to increasing access to care for veterans
and has placed special emphasis on those in rural and
underserved communities. This requires transitioning from a
health care delivery model that has been in place for decades
with a dependence on in-person care delivery to a system that
leverages modern technology to provide veterans, their
families, and their caregivers virtual access to VA teams when
clinically appropriate. But to make this transition, the VA
must operate in an environment that supports the type of
advanced healthcare and services that these technologies enable
us to provide.
This is where we need the help of Congress and a unified
Government that is fully aligned in working to fulfill our
commitment to veterans. As a first step and very simply, we
need clearly legislative authority from Congress authorizing
our VA providers to care for a veteran irrespective of the
location of the provider or the veteran, especially when that
is across State lines or in the veteran's home. This authority
will remove barriers that currently exist between a national VA
clinical expert and a veteran that needs their service.
It will allow us to leverage telehealth to enhance the
capacity of services, particularly in rural areas. It will help
us create flexible and unique employment opportunities for
providers enabling us to recruit and retain the best providers
for VA service. It will also allow us to be more efficient,
decreasing beneficiary travel expenses and our reliance on new
capital assets when needing to expand clinical services.
I will conclude by saying that delivering care via
telehealth is not aspirational for VA. VA is already recognized
as a leader in this area. Last fiscal year alone, almost 12
percent of our enrolled veterans received an element of their
care through telehealth. That number represents over 702,000
veterans served in over 2.17 million telehealth episodes of
care, but we need and want to do more. And with the support of
Congress, we have the opportunity right now to shape the future
of our VA health care system, increasing the capacity,
accessibility, and quality of our care for the benefit of
veterans so that those veterans who turn to the VA for their
health care services will know they will get the care they need
from the provider they need no matter where they are in the
nation.
Mr. Chairman, that concludes my testimony. We do appreciate
your support and look forward to responding to any questions
you may have.
[The statement follows:]
Prepared Statement of Dr. Kevin Galpin
Good morning Chairman Moran, Ranking Member Schatz, and
distinguished members of the Subcommittee. Thank you for the
opportunity to discuss the Department of Veterans Affairs' (VA) efforts
to expand the services VA provides to Veterans through telehealth. I am
joined today by Bill James, Deputy Assistant Secretary for the
Enterprise Program Management Office in the Office of Information
Technology, and Tandi Nelson-Brooks, Facility Telehealth Coordinator,
Pacific Islands Health Care System.
introduction
VA Telehealth is a modern, Veteran- and family-centered healthcare
delivery model. It leverages information and telecommunication
technologies to connect Veterans with their clinicians and allied or
ancillary healthcare professionals, irrespective of the location of the
provider or Veteran. It bridges enhanced access and expertise across
the geographic distance that would otherwise separate some Veterans,
including those in rural areas, from the providers best able to serve
them.
Telehealth is mission-critical to the future of VA care. Its
potential to expand access and augment services is both vast and
compelling. While telehealth is capable of enhancing the healthcare
system in multiple ways, three are specifically essential for the
successful operation of our national, integrated VA enterprise.
First, telehealth enhances the capacity of VA clinical services for
Veterans in rural and underserved areas. This is accomplished by
empowering VA to hire providers in major metropolitan areas, where
there is a relative abundance of clinical services, for the purposes of
serving Veterans in rural and even frontier communities where medical
services may be insufficiently available.
Second, telehealth increases the accessibility of VA care. It
brings VA provider services to locations most convenient for Veterans,
including for those Veterans with mobility or other health challenges
that make travel difficult. Through telehealth, Veterans are able to
receive care in their community-based clinic and at home.
Third, telehealth increases quality of care. It enables VA to model
its services so that national experts in rare or complex conditions can
effectively care for Veterans with those conditions, regardless of the
Veterans' location in the country.
VA is committed to increasing access to care for Veterans and has
placed special emphasis on those in rural and remote locations. This
means transitioning from older systems and a healthcare delivery model
that has been in place for decades to a system that works for Veterans
and is focused on contemporary practices in access.
VA is empowering Veterans and their caregivers to be in control of
their care and make interactions with the healthcare system a simple
and exceptional experience.
VA is recognized as a world leader in the development and use of
telehealth technology to ensure excellence in care delivery, and VA
aspires to elevate and expand this impact in the coming years. In
fiscal year 2016, of the more than 5.8 million Veterans who used VA
care, approximately 12 percent received an element of their care
through telehealth. This represented more than 702,000 Veterans, with
45 percent of those Veterans served living in rural areas. In total,
this amounted to over 2.17 million telehealth episodes of care.
brief description of telehealth services
VA leverages three broad categories of telehealth to deliver
services to Veterans in over 50 clinical specialties. The first,
Clinical Video Telehealth, is defined as the use of real-time
interactive video conferencing, with or without virtual examination
tools (e.g., digital stethoscopes), to assess, treat, and provide care
to Veterans remotely. Clinical Video Telehealth allows clinicians to
engage Veterans via video at another medical center, a remote clinic,
or in the comfort and convenience of the Veteran's home. It facilitates
delivery of a variety of clinical services including primary care,
mental healthcare, specialty care, and pre- and post-surgical care. To
the Veteran, it means that instead of having the inconvenience of
traveling by road, rail, or air to see a provider, service from their
VA provider comes to them. Last fiscal year, more than 307,000 Veterans
accessed VA care through over 837,000 Clinical Video Telehealth
encounters.
At present, 93 percent of VA's Clinical Video Telehealth occurs
between VA facilities. 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 and can be used to connect VA providers to a Veteran's personal
mobile device, smartphone, tablet, or computer. It allows for video
healthcare visits, such as telemental health visits, where a hands-on
physical examination is not required. It also makes it easier to
provide services into a Veteran's home, literally putting access to VA
healthcare in the Veteran's pocket. As a recent example, a 70 year-old
Veteran was seen by VA Video Connect at home following hospitalization
for a stroke that resulted in difficulty walking and compounded his
challenges with transportation. VA Video Connect enabled a VA provider
to promptly and remotely assess his functional status, his in-home
mobility, and to help modify his fall risk from rug or chair placement.
The second broad category of telehealth is Home Telehealth. This is
a technology-enabled monitoring program that allows a VA staff member
to follow a Veteran's care and health status on a daily basis through a
VA-provided home-based device or service. Clinical data and information
is collected securely via landline, cellular telephone network, or
through the patient's own mobile device or home computer.
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 the Veteran's traditional in-
person healthcare. 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, such as
diabetes. This service can help Veterans continue to live independently
and spend less time at medical visits. For example, a Veteran with
hypertension might transmit his blood pressure values daily from home,
and if they are elevated, a VA Home Telehealth nurse would be able to
notify the VA Primary Care team, arrange for a change in medication
dosage, and then continue home blood pressure monitoring until the goal
blood pressure was reached--leading to more prompt care and better
long-term outcomes for the enrolled Veteran.
Over 87,000 Veterans are using Home Telehealth services. VA has
found that Veterans easily learn how to use their Home Telehealth
devices and are highly satisfied with the service, reporting an 88
percent satisfaction rating in fiscal year 2016. Home Telehealth
services also make it possible for Veterans to become more actively
involved in their medical care and more knowledgeable about their
conditions, providing them the knowledge and skills needed to more
effectively self-manage their own healthcare 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, image, sound, and video) that is
then assessed by a provider at another location, at another time, for
clinical evaluation. VA's national Store-and-Forward Telehealth
programs deliver such services as dermatology and retinal screening,
where a photo or series of photos can be effectively used for diagnosis
or triage. Last fiscal year, over 304,000 Veterans accessed VA care
through more than 314,000 Store-and-Forward Telehealth encounters.
examples of telehealth use
Mental Health
VA 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 healthcare to be
equally, if not more, effective than in-person appointments. From 2002
through 2016, more than 2.2 million telemental health visits have been
provided to over 405,000 unique Veterans.
Telemental health increases the accessibility of VA mental
healthcare by bringing critical healthcare services closer to the
Veteran. It also increases the capacity of VA to provide needed mental
healthcare services in rural and remote areas by moving service supply
from urban areas to rural and other underserved communities where there
is system demand. In 2016 and 2017, in order to increase the capacity
of VA mental healthcare in rural communities, VA initiated work on 10
telemental health clinic resource hubs.
VA Telemental Health also serves to bring highly specialized mental
healthcare 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
national experts (in affective, psychotic, anxiety, and substance use
disorders) are currently located at the VA Boston Healthcare System, VA
Connecticut Healthcare System, Philadelphia VA Medical Center (VAMC),
and the Providence VAMC. The NTMHC has provided access and national
expert consultation to over 5,000 Veterans for more than 18,500
encounters at over 120 sites throughout the Nation since its inception
in 2010.
Primary Care
As part of its core access enhancement strategy, VA also initiated
work on eight TelePrimary Care resource hubs in 2016 and 2017. Similar
to the telemental health resource hubs, these centers leverage the
provider recruitment capabilities in metropolitan areas to provide
Veterans with core clinical services in areas where these providers and
services are scarce.
VA TelePrimary Care leverages telehealth digital examination
equipment along with staff at the Veteran's location to facilitate a
remote physical examination. This service is part of a hybrid model in
that providers still travel to designated facilities at regular
intervals to offer in-person visits to the Veterans when needed.
Further, the TelePrimary Care model is multidisciplinary, involving
social workers, pharmacists, and mental health providers in addition to
the primary care provider.
Rehabilitation
Rehabilitation providers leverage video teleconferencing to
increase access to specialty rehabilitation care. From the beginning of
the fiscal year through mid-April 2017, close to 33,000 clinical
episodes of care occurred using this modality, providing care to over
21,000 unique Veterans. Numerous specialty rehabilitation clinics are
offered through telehealth, including clinics focused on amputation
care, blind rehabilitation, physical therapy, speech therapy, and
traumatic brain injury. Veterans with disabilities, especially in rural
areas, benefit greatly from telerehabilitation. Many of these Veterans
experience challenges 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 reintegration.
Intensive Care Unit (ICU)
Tele-ICU is a telemedicine program that links ICUs in VAMCs 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, as well as links into the medical record
and vitals sign monitors, staff in the Tele-ICU hub not only see all of
the pertinent medical data on a Veteran, but they are capable of
performing audiovisual exams of the patient; discussing treatment plans
with patients, nurses, and families; intervening during emergencies;
and generally providing specialist-level care and consultation. The
Tele-ICU staff supplement the existing staff physically present in the
ICU with the Veteran, adding a layer of quality to existing services.
Store-and-Forward Retinal Imaging
Diabetes can cause problems with the blood vessels in the retina,
especially if the condition is poorly controlled. A special camera
takes pictures of the retina that are sent to an eye care specialist to
review, and a report is returned to the patient's primary care
physician who can provide the required treatment. This encounter 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
The diagnosis, coordination of care, and triage of surgical
patients can be enhanced by the availability of telesurgical
consultation. The use of telehealth can provide intra-operative
consultation, patient and staff education, and pre- and post- operative
assessment.
barriers to expansion
Telehealth removes key barriers that have traditionally separated
providers and patients. However, there are several barriers that are
still inhibiting the expansion of telehealth for the benefit of
Veterans in VA care. VA providers delivering telehealth across state
lines have no clear protection from the enforcement of state or local
laws, rules, or regulations that otherwise limit the practice of
telehealth. VA requests Congressional action to authorize VA providers
to furnish care for Veterans using telehealth irrespective of these
limitations. Such legislation would specifically invoke Federal
supremacy and allow VA to expand the provision of care into Veterans'
homes or on their mobile devices, regardless of the provider or
patient's location, and leverage technology to create an ever more
Veteran-centered experience. Additionally, such authority would reduce
the need to lease or build Federal workspace for telehealth providers
and would promote more rapid and cost-efficient expansion of services.
It would also strengthen VA's ability to recruit the very best
healthcare providers to furnish services to Veterans in locations where
resources are limited.
conclusion
While VA is currently a leader in telehealth, with the support of
Congress, VA has the opportunity to shape the future of this critical
strategy and ensure Veterans can access convenient, accessible, high-
quality care, anywhere in the nation.
Mr. Chairman, this concludes my testimony. We appreciate your
support and look forward to responding to any questions you may have.
Senator Moran. Thank you for your testimony.
I recognize Mr. Adcock.
STATEMENT OF MICHAEL P. ADCOCK, EXECUTIVE DIRECTOR,
CENTER FOR TELEHEALTH, UNIVERSITY OF
MISSISSIPPI MEDICAL CENTER
Mr. Adcock. Good morning, Chairman Cochran, Chairman Moran,
Ranking Member Schatz, and members of the subcommittee. I am
Michael Adcock. I am the Executive Director at the Center for
Telehealth at the University of Mississippi Medical Center in
Jackson. I am honored to talk to you this morning about
telehealth and the ways that it can help to address the health
care needs of America's veterans.
UMMC is very proud of the close relationship we have with
the G.V. (Sonny) Montgomery VA Medical Center in Jackson. As
you may know, VA hospitals were intentionally co-located with
academic medical centers so that they could work together to
educate medical professionals, conduct research, and provide
cutting edge clinical care. We interface with our VA in all of
these ways and are always seeking to broaden this relationship.
Mississippi has significant health care challenges, leading
the nation in obesity, cardiovascular disease, and diabetes. In
order to address chronic disease, improve access to care, and
give Mississippians a better quality of life, it is clear that
we need something more than traditional clinic and hospital
based services. Telehealth has been a part of the health care
landscape in Mississippi for over 13 years, beginning with an
aggressive program to address mortality in rural emergency
departments. Today the UMMC Center for Telehealth delivers more
than 30 medical specialties in over 200 sites in 68 of 82
counties, providing access for patients who might otherwise go
untreated. Maximizing our utilization of healthcare resources
through the use of technology is the only way that we can reach
all of the Mississippians who need care.
One program that has been very impactful for our patients
is remote patient monitoring (RPM), which manages chronic
disease in a patient's home. RPM is designed to educate,
engage, and empower patients so that they can learn to take
care of themselves. A pilot we undertook in Mississippi aimed
at testing the effectiveness of remote patient monitoring in a
rural underserved area of the Mississippi Delta, the
preliminary results through 6 months of the study showed a
marked decrease in blood glucose, reduced travel to see
specialists, and most importantly, no hospitalizations or ER
visits for diabetes related illness. The Mississippi division
of Medicaid extrapolated our data to show a potential savings
of over $180 million per year if 20 percent of the diabetics on
Mississippi Medicaid participated in the program.
Given the success of the pilot, UMMC Center for Telehealth
has expanded our remote patient monitoring program statewide. I
am confident that telehealth and remote patient monitoring
programs like ours can bolster the current offerings of the VA.
As already stated, the VA has one of the longest running
telehealth programs in our country, but even with this robust
system, gaps in care still exist. In Mississippi, we have only
two VA hospitals and eight CBOCs attempting to serve over
200,000 veterans. That is 10 access points in a state that
spans 48,000 square miles.
According to the U.S. Census Bureau, approximately 67
percent of Mississippi veterans do not take advantage of the VA
health care system. For those who do, wait times can be
significant. Based on appointments scheduled at the VA in
Biloxi during the first two week period of April, 3,200
patients will have to wait over 30 days for an appointment,
1,175 will have to wait more than 60 days, and some will wait
beyond 120 days for an appointment.
By layering veterans services across UMMC's 200 active
telehealth access points, the VA could quickly reach more
patients without significant investment. Because of the deep
nexus that already exists between academic medical centers and
the nation's VA hospitals, it seems a natural progression for
us to partner to provide health care and chronic disease
management for our veterans.
We have attempted this type of partnership in the past, but
were unsuccessful due to administrative red tape locally and
the VA's challenges in engaging with external health care
partners globally. After multiple attempts to bring requested
dermatology and mental health services to the VA, progress
stalled and the services were not implemented. The benefits of
partnering with established telehealth programs at academic
medical centers could go well beyond dermatology and mental
health.
With over 30 medical specialties online at UMMC today,
access to high quality specialty care is well within reach.
Partnership has the potential to open access to a statewide
network of high quality health care close to home reducing the
burden of travel and delay in receiving care. Congress should
encourage the VA to streamline contracting with programs like
ours to bring these lifechanging and lifesaving programs to all
of our veterans.
That is the end of my testimony. Thank you for your time
and attention to this very important matter.
[The statement follows:]
Prepared Statement of Michael P. Adcock
Chairman Cochran, Chairman Moran, Ranking Member Schatz, and
Members of the Appropriations Committee, thank you for the opportunity
to appear before the subcommittee today. I am Michael Adcock, Executive
Director for the Center for Telehealth at the University of Mississippi
Medical Center (UMMC) in Jackson, Mississippi. I am honored to talk to
you this morning about telehealth and the ways that its power can be
harnessed to address the healthcare needs of America's veterans.
UMMC is very proud of the close relationship we have with the G.V.
(Sonny) Montgomery VA Medical Center in Jackson. As you may know, VA
hospitals were intentionally co-located with academic medical centers
so that they could work together to educate medical professionals,
conduct research and provide cutting edge clinical care. We interface
with our VA in all of these ways and are always seeking to broaden this
relationship and interdependence.
Mississippi has significant healthcare challenges, leading the
nation in heart disease, obesity, cardiovascular disease and diabetes.
These and other chronic conditions require consistent, quality care--a
task that is made harder by the rural nature of our state. In order to
improve access to care and give Mississippians a better quality of
life, it is clear that we need something more than traditional, clinic
and hospital-based services.
Telehealth has been a part of the healthcare landscape in
Mississippi for over 13 years, beginning with an aggressive program to
address mortality in rural emergency departments. In 2003, three rural
sites were chosen to participate in a program that would allow UMMC
board certified emergency medicine physicians to interact with and care
for patients in small, rural emergency rooms via a live, audio-video
connection. The TelEmergency program has grown to serve more than 20
hospitals and continues to produce outcomes on par with that of our
Level 1 trauma center.
Today, the UMMC Center for Telehealth delivers more than 30 medical
specialties in over 200 sites across the state including rural clinics,
schools, prisons and corporations. The depth and breadth of this
network allows us to deliver world-class care in 68 of our state's 82
counties and provides access for patients who might otherwise go
untreated. Over the last decade, we have conducted over 500,000 patient
encounters through telehealth. Maximizing our utilization of healthcare
resources through the use of technology is the only way we can reach
all of the Mississippians who need lifesaving healthcare.
One program that has been very impactful for our patients is remote
patient monitoring (RPM), which manages chronic disease in a patient's
home. RPM is designed to educate, engage and empower patients so that
they can learn to take care of themselves. Our initial pilot with
diabetics in the Mississippi Delta was a public/private partnership
between critical access hospital North Sunflower Medical Center,
telecommunications provider C Spire, technology partner Care
Innovations, the Mississippi Division of Medicaid, Office of the
Governor of Mississippi and UMMC. The purpose of the pilot was to test
the effectiveness of remote patient monitoring using technology in a
rural, underserved area. The preliminary results through 6 months of
the study showed: a marked decrease in blood glucose, early recognition
of diabetes-related eye disease, reduced travel to see specialists and
no diabetes-related hospitalizations or emergency room visits among our
patients. This pilot demonstrated a savings of over $300,000 in the
first 100 patients over 6 months. The Mississippi Division of Medicaid
extrapolated this data to show potential savings of over $180 million
per year if 20 percent of the diabetics on Mississippi Medicaid
participated in this program.
Given the success of the pilot, UMMC Center for Telehealth has
expanded remote patient monitoring to include adult and pediatric
diabetes, congestive heart failure, hypertension, bone marrow
transplant and kidney transplant patients. Working closely with a
patient's primary care provider, we continue to grow this program both
in terms of volume and number of diseases that can be managed. This
program is giving patients the knowledge and tools they need to improve
their health and manage their chronic disease.
I am confident that telehealth and remote patient monitoring
programs like ours can bolster the current offerings at the VA. The VA
has one of the longest running telehealth programs in the country, but
even with this robust system, gaps in care still exist. VA hospitals
and CBOCs are typically located in urban areas, and patients have to
travel long distances to receive specialty care. In Mississippi, we
have only two VA hospitals and eight CBOCs attempting to serve over two
hundred thousand veterans. That's ten access points in a state that
spans 48,000 square miles.
According to the US Census Bureau, approximately 67 percent of
Mississippi veterans do not take advantage of the VA healthcare system.
For those who do, wait times are significant. The Gulf Coast Veterans
Health Care System in Biloxi, Mississippi, for example, enjoys higher
utilization than others. Based on appointments scheduled in the two
week period of March 31-April 15, 2017:
--3,200 patients will have to wait over 30 days for an appointment,
--1,175 will have to wait more than 60 days, and
--Some will wait beyond 120 days for an appointment.
Additional telehealth sites could be an excellent complement to the
existing VA healthcare system. Because of the deep nexus that already
exists between academic medical centers and the VA hospitals across the
nation, it seems a natural progression for us to partner to provide
healthcare and chronic disease management for our veterans. By layering
veterans' services across UMMC's 200 active telehealth access points,
the VA could quickly reach more patients without significant
investment.
We have attempted this type of partnership in the past but were
unsuccessful due to administrative red tape at the local level and the
VA's challenge in engaging with external healthcare partners globally.
Two services we've tried to bring to the VA population are mental
health and dermatology. Due to the limited number of dermatologists in
Mississippi, UMMC and the Jackson VA attempted to work together to
provide this service to veterans throughout the state using telehealth.
After multiple attempts, progress stalled and the service was not
implemented.
Many veterans and active service members seek professional help for
mental healthcare. In Mississippi, the wait time to meet with a
psychiatrist or psychologist is quite long. Through telehealth,
veterans could access appropriate mental health services more quickly
and more often. If UMMC were to partner with the VA on mental health,
we could easily increase the number of veterans seen by mental health
professionals, allowing them to receive the treatment they need in a
shorter timeframe.
The benefits of partnering with established telehealth programs at
academic medical centers could go well beyond dermatology and mental
health. With over 30 medical specialties online at UMMC today, access
to high quality specialty care is well within reach. This type of
working relationship has the potential to open access to a statewide
network of high quality healthcare close to home. This limits the
burden of travel and delays due to waiting for in person care. Congress
should encourage the VA to streamline contracting with programs like
ours to bring these life changing and lifesaving programs to all of our
veterans.
Thank you for your time and attention to this very important
matter.
Senator Moran. Mr. Adcock, thank you very much.
Dr. Okamura.
STATEMENT OF NORMAN OKAMURA, PHD, FACULTY SPECIALIST
AND PRINCIPAL INVESTIGATOR, PACIFIC BASIN
TELEHEALTH RESOURCE CENTER
Dr. Okamura. Thank you. Good morning.
Senator Moran. Good morning.
Dr. Okamura. Chairman Moran, Ranking Member Schatz,
Chairman Cochran, Members of the Appropriations Subcommittee on
Military Construction and Veteran Affairs.
We appreciate the opportunity to be here today. My name is
Norman Okamura. I am with the University of Hawaii Telehealth
Resource Center. And I work with basically the University of
Hawaii system and with our health care providers not only in
Hawaii, but also in the Pacific Island region.
The telehealth issue is really important and moving forward
with the Pacific Islands region, we are trying to really work
hard to promote the continued use and expansion of telehealth
resource services. Our center basically provides technical
assistance to health care providers throughout the region, but
the region is very vast. And we are supported also by two
national telehealth centers as well, one focused on policy and
one focused on technology assessments in all--the program
supports all 50 States.
So our telehealth center, as noted earlier, but basically
we include Hawaii and the Pacific Island territories and the
freely associated states. I wanted to just take a second to
kind of talk about distances and services.
Between the State of Hawaii and Guam, which is a U.S.
territory that has both a U.S. Military Air Force base and a
Naval station, the distance is 3,800 air miles. There are four
hours of time zone differences between Guam and Hawaii. Now,
Hawaii is basically 2,500 miles away from Los Angeles. There is
a nine to ten-hour time zone difference between Washington,
D.C. and Guam. That is not including the Republic of Palau,
which is one more hours after. So the care for veterans with
smaller populations in this very distant remote area is really
important and can only be delivered via telehealth to support
the CBOCs out there.
So when they ask for the senior person from there, they
sent me because I am just older. And so I have had a chance to
actually see some of the telehealth developments over the
years. And because of all the comments that have been offered
and that are really on point to some of the technologies and
the uses, I am kind of deviating from what I originally was
going to say.
And having said all of that, you know, I am really pleased
to report on some good things that have happened in the region
as well as the outstanding issues. So the good things include,
for example, the fact that, yes, telehealth and applications
between the VA and the DOD and the Pacific actually were
implemented way early in the 1990s. So there was actually a lot
of consultation being done with the technologies through
satellite communications. And I had a chance to actually visit
all of those locations very early.
So, Kwajalein, which if, of course, where the, you know,
Star Wars missile defense system is actually located and
tracking all of those activities actually used their satellite
links as a co-activity between the DOD for telehealth
applications as well as communications between the missile
range facility and the State of Hawaii and, of course, the
Department of Defense and Pearl Harbor there.
So, with respect to the successes of telehealth, that
history was translated into a lot of activities from store-and-
forward consultation, again, in the 1990s, to more advanced
applications including the sharing of electronic health record
software and technologies which is really important. It is very
difficult to do telehealth and telemedicine without having a
copy of the patient record and without populating the patient
record again.
So the video conferencing is really good and very
important, but you also need the medical records and some of
those activities were actually done through the assistance
provided by Congress to an activity called the Pacific
Telehealth and Technology Hui that actually develops some of
these technologies, some of which are being used today and
supportive of making sure that medical record information
between the VA and the DOD and the VA sites are all available
to the clinicians, the very important point.
So, with respect to the successes of the VA telehealth,
there is nothing more that I can add to what has already been
said in terms of its value to being able to promote access to
care in terms of quality in terms of the net results that would
actually occur by getting care early so that hospitalizations
do not need to occur. And that is obviously one of the big
challenges right across the United States with all health
systems. And the great news is that, you know, the VA health
system is the largest integrated care system and able to
deliver the full range and compliment of services. And through
telehealth, that allows that extension everywhere although in
our environment we still have some challenges.
And the relationship obviously between the VA and the
medical centers is really important, famous, contributes to
knowledge, contributes to the development of clinical
protocols, that can then be moved out into the broader
environments. And that is actually one of the areas where I
think it is really important to kind of emphasize, so how to
translate all of that into basically the community at large and
the telehealth resource centers may be able to help facilitate
that communication as well.
So one of the areas that I would like to kind of spend just
a second on is basically the Choice Program it is really
important because it allows access to services to veterans in
their own communities. At the same time, the Choice Program
needs to make sure that that, the data from the community
providers, is actually populated back into the VA electronic
health record for care purposes because there are a little bit
of some data gaps that are occurring that kind of have an
impact on the opportunities to provide clinical care and have
all of the data and information that is really available right
now in the VA system.
So, for us, the other issue, I think, is that the Veterans
Choice Program is really good because it allows for care to be
provided in the community through the community partnerships
except that in our environment we still do not have all of the
expertise that we need even within the communities. In the
State of Hawaii, we do not have enough dermatologists. In Guam,
same problem. I can go down the list of things that the VA is
able to deliver through their subspecialty consultations in all
of these areas and it would be really beneficial for all of
that to be extended into the region so that it also saves on
airfare.
One note on airfare costs, how do I put this really nicely?
Airfare for me to here is $1,000. When I travel out to Guam,
even though the distances are less, it is double the cost. And
the reason for that is there is not enough traffic and many
have argued that it is also the size of the monopoly.
So having said that, I would like to basically suggest that
if I could in kind of summarizing the comments, I would like to
recommend that authorizing the VA to be able to provide
telehealth services to the freely associated states, and these
are those that have Compacts of Free Association with the
United States, they are unable to get services today
technically because they are countries, but they have compacts.
And this is a region that is very important for long-term
military purposes. So just be aware and using some of these
technologies to be able to extend and provide services to the
region would be very beneficial. The VA are experts in this
area.
[The statement follows:]
Prepared Statement of Norman H. Okamura, PhD.
Good Morning Chairman Moran; Ranking Member Schatz; and Members of
the Appropriations Subcommittee on Military Construction/Veterans
Affairs:
Thank you for the opportunity to provide some comments on
telemedicine and telehealth as Leveraging Technology to Increase
Access, Improve Health Outcomes, and Lower Costs.
In a meeting with Medicaid Health Information Technology programs
in the multi- state western region, a question was asked in a small
group session on the pace of transformation in care quality and
coordination. There was significant pessimism with primary care
providers. My response was that some things were getting better. When
asked why I believed that, I said that after seeing my primary care
provider for 2 years, I was shocked to receive a letter that contained
patient education information on my diabetic condition. The letter also
contained tests that I should undertake and general literature on the
condition. Now, the letter was generated by a company that worked for
the insurer probably as a result of analyzing the medical claims data;
but, it was at least signed by my primary care provider (PCP). I told
the group that that even though I had seen the same PCP for many years,
I never received anything like this before. The same thing happened
with my drug store. For years, I managed my own prescriptions. Now, the
drug store follows up on medication refills, sends text messages about
refills and pick up, and other reminders. This is promising--that at a
very personal level, I am seeing and experiencing better healthcare
coordination.
I was invited to this hearing as the Principal Investigator of the
Pacific Basin Telehealth Resource Center (PBTRC) at the University of
Hawaii. I work with two Co- Directors at the University of Hawaii--Ms.
Christina Higa of the College of Social Sciences and Dr. Deborah Peters
of the University of Hawaii John A. Burns School of Medicine.
The Pacific Basin Telehealth Resource Center (PBTRC) is one of 14
Telehealth Resource Centers (TRCs) funded by the Health Resources and
Services Administration (HRSA). The TRCs provide assistance to
healthcare providers and stakeholders in developing policies, programs,
and operational and systems protocols for support. Two of the 14 TRCs
provide national support for policy and technology. They are the
National Telehealth Policy Resource Center and the National Telehealth
Technology Assessment Resource Center. The 12 regional TRCs support all
50 states.
The PBTRC works closely and collaboratively with other programs and
projects in the Social Science Research Institute of the University of
Hawaii, including electronic health record (EHR) implementation, health
information exchange, healthcare innovation model planning, and
healthcare analytics. The PBTRC supports the State of Hawaii, Pacific
Island Territories of American Samoa, Guam, and the Commonwealth of the
Northern Mariana Islands (CNMI), and US Compact of Freely Associated
States (FAS) in the Pacific including the Republic of Palau, Federated
States of Micronesia, and the Republic of the Marshall Islands.
veterans care in hawaii and the pacific islands region
The Department of Veterans Affairs (VA) healthcare system provides
care to veterans that is deserved and earned. This care is provided to
millions of veterans who are geographically dispersed throughout the
whole of the United States, including the U.S. territories; the FAS in
the Western Pacific that have Compacts of Free Association with the
United States; and veterans in the Philippines recruited during World
War II.
To provide perspective on this challenge, the VA coverage area
includes island land masses in a water area of the Pacific Ocean almost
equal to the continental land mass of the United States. The U.S.
territories of Guam and CNMI, and the FAS of Palau, are respectively 10
and 11 time zones from Washington, DC, plus a day since the dateline is
in the Pacific. Guam is about 3,800 air miles from Hawaii. Hawaii is
about 2,500 miles from California. California is 2,300 air miles from
Washington DC. Distance, time, and day challenges are massive and so is
the cost of travel to these locations.
There are approximately 127,000 veterans in Hawaii, the U.S.
Pacific territories, and the Freely Associated States. The VA Pacific
Islands Health Care System (VAPIHCS) provides medical care to veterans
in Hawaii and the USAPI in the VAPIHCS facilities. In Hawaii, care is
provided to 50,000 veterans through the Spark Matsunaga VA Medical
Center (VAMC) that is co-located on the Tripler Army Medical Center of
the Department of Defense and the Community Based Outpatient Clinics
(CBOCs) on the islands of Kauai, Maui, Hawaii, and Oahu.
The VAPIHCS is also responsible for providing care to the veterans
in the U.S. territories in Guam, CNMI, and American Samoa, the latter
where Vice President Pence, on his return from Australia, recently
rededicated the CBOC in memory of the late Congressman Eni
Faleomavaega, who was a fierce advocate for veteran care. The CBOC in
Guam is co-located next to the Guam Naval Hospital. The Anderson Air
Force base is also located on Guam. The VA contracted a clinician in
the CNMI to provide services to veterans there.
successes in health information technology and telehealth
The VA is the largest integrated healthcare system in the United
States that serves six million veterans annually. The VA is a leader in
the use of health information technology (HIT) as an early adopter of
an integrated electronic health record system that was implemented in
all VA medical centers and clinics from 1984. The patient medical
record is a critical infrastructure in providing care. Clinicians rely
on medical diagnosis and clinical notes from other providers and
specialists, laboratory test results, radiology images, and knowledge
of what drugs a patient may or may not be taking to diagnose patient
conditions and prescribe regimens of care. The VA views this from both
hospital, clinics and other sources (e.g., reference laboratories) as
one composite record.
The VA is also a pioneer in telehealth to improve access to care,
health outcomes, and lower costs for veterans. The VA provides care to
about 6 million veterans through more than 1,200 facilities, and
conducts more telemedicine encounters than any other private or public
health system. The VA supports many modalities of telehealth from store
and forward and home telehealth monitoring, to teleconsultation in more
than 45 specialty areas of care. In fiscal year 15, 12 percent of
enrolled veterans received care through telehealth services. 2.14
million telehealth encounters were conducted servicing 677,000 Veterans
(Slabodkin, 2016).
Further, the VA's high priority on quality performance measures and
evaluation has resulted in the VA's prolific contribution to research
in telehealth. A quick Google Scholar search on ``Veteran
Administration Telehealth'' results in 7,660 results, with 304 current
citations in 2017. Atkins, Kilbourne, Shulkin (2017) indicate the VA
conducts more than $1 billion of research annually, significantly
contributing to the translation of research to policy and care
practices throughout healthcare facilities in the U.S. This includes
improved algorithms for identifying high risk re-admission patients who
need closer monitoring and additional healthcare interventions, such as
remote home monitoring via telehealth.
Telehealth is a substantial means for access to care for the 45
percent of Veterans that live in rural areas. It also affords
significant cost saving in consideration of the reported 58 percent
reduction of hospital bed days care and 32 percent reduction of
hospital admissions (Slabodkin, 2016).
This is important because the Centers for Medicare and Medicaid
(CMS) National Health Expenditure in 2016 reported that healthcare
costs reached $3.2 trillion in 2015, approximately 18 percent of the
total Gross Domestic Product (GDP) of the U.S., and was expected to
rise to 19.9 percent of the GDP in 2025. A commentary in the Journal of
the American Medical Association in December 2016 pointed out that this
was five times the total budget of the Defense Department and made
healthcare the fifth largest economy in the world. At the same time,
studies on the Organization for Economic Co-operation and Development
(OECD) countries shows that despite spending more per-capita on
healthcare, the U.S. does not fare as well in many metrics for
healthcare quality. Further, there is a need for systematic studies of
telehealth operations, costs, and quality in the VA. Such studies will
have immense value not only to the VA, but to all healthcare system
providers and payers such as CMS.
barriers and opportunities
The Veterans Choice Program (Public Law 115-26) aims to extend
access to services for veterans in their own communities by authorizing
and partnering with non-VA healthcare facilities. This provides
opportunities for reduction of wait times for veterans and more
frequent care that can result in less complications, less readmissions
and healthcare utilization, improved health outcomes, reduced cost, and
overall improved patient satisfaction. However, the program also
introduces challenges for the VA to sustain continuity of care of
veterans especially if healthcare information is not integrated back
into their care record. This also impacts the data VA collects for
research on interventions and outcomes. At a minimum, medical
documentation should be made again a requirement for payment of
services of a non-VA healthcare provider through the Veterans Choice
Program. Further and more complex, attention and funding must be
prioritized for addressing the challenges of health information
exchange among non-VA and VA electronic health record systems and or
databases.
There is significant potential for the VA and community health
providers to synergize with the HRSA-funded TRCs that serve all 50
states. As an example, the PBTRC works in collaboration with VAPIHCS
specifically to identify and outreach to non-VA clinics in areas of
high veteran populations for possible collaboration, provider support
and training in adoption of telehealth, and other technical assistance.
There are many opportunities to partner with the TRCs. TRCs may also
assist in raising awareness of VA telehealth options for veterans. For
example, the VA could collaborate with the Southeastern Telehealth
Resource Center and large established telehealth networks such as the
Georgia Partnership for Telehealth using the network's existing
originating sites across the region as a place where healthcare can be
delivered to the rural veteran in his/her rural community. This could
be VA providers or non-VA providers of primary or specialty care.
veterans in compact of free association (cofa) freely associated states
(fas)
I would also like to highlight a moral obligation we have to the
veterans in the US Freely Associated States (FAS) in the Pacific--the
Republic of Palau, Federated States of Micronesia and the Republic of
the Marshall Islands. The U.S. entered into Compacts of Free
Association with these countries and as part of these agreements, the
U.S. is responsible for the defense of these countries, has the right
to operate armed forces in these jurisdictions and exclude other
militaries, which is key to our strategic interests in the Pacific, and
the U.S. military is allowed to recruit on-site in these countries--the
only foreign countries in which it may do so. Our military recruits
heavily in these nations and the enlistment rate of FAS citizens is
significantly higher than that of U.S. citizens in the States and
Territories.
However, under current law, the Veterans Health Administration is
not able to provide on-site care to veterans in their home
jurisdiction, as it is able to do in Guam, American Samoa and CNMI. Nor
it is able to provide care via telehealth from a Veterans Health
Administration (VHA) facility to a health facility in a FAS. To receive
VA health services, a veteran must travel, at his/her own cost, to a VA
health facility, which means traveling to Guam or Hawaii. Although FAS
veterans are eligible for the VA Foreign Medical Program, which is a
VHA ``health insurance'' program for veterans residing in foreign
countries, this program only covers service-connected conditions and
again the veteran would be responsible for covering the cost of travel
to a country with the needed specialty care. Given the high cost of
travel in the Pacific and the inherently poor island economies, many
FAS veterans are never able to access the VA health services due them.
This not only affects veterans and their families, but it further
burdens the already limited, fragile health systems in these countries.
The veterans in Hawaii and the Pacific Region have not only made
important contributions, but, per capita, they are among the higher
veteran populations the states. The limited number of FAS veterans will
not add significant burden to the already well- established telehealth
services that are provided to veterans including those in the U.S.
Pacific Island Territories. Regardless, the FAS veterans are as
deserving to have access to care as any other veteran in the U.S.
There are two concurrent resolutions in the current Hawaii State
Legislative 2017- 2018 session (SCR54 and HCR176) urging Hawaii's
Congressional Delegation to work with the VA to develop a health
services program or pass legislation to assist FAS veterans.
Other possible solutions for your consideration include at a
minimum: authorize the VHA to provide telehealth services to veterans
in the FAS (for example, tele-behavioral health for post-traumatic
stress disorder); and support the outreach of VHA's robust Project ECHO
education program to healthcare providers in the FAS, enabling them to
participate in these tele-education/tele-mentoring sessions via video
teleconference and present their most difficult cases for review by an
expert panel strictly for training purposes. This would enable
healthcare providers in the FAS to increase their capacity to care for
the veterans in their local communities. Another possible solution is
to authorize the U.S. Embassies in the FAS to be a place for veterans
to receive telehealth consultation. I encourage the VA to work
collaboratively with the DoD and the U.S. Department of Health and
Human Services (HHS) to address U.S.-affiliated Pacific Islands (USAPI)
veteran issues. Recently the HHS Insular Policy Group, comprised of HHS
senior leadership, created a veteran subgroup to address USAPI veteran
issues. Again, the PBTRC is working with healthcare providers in the
FAS and could assist in providing technical assistance to the VHA
should authorization be given to provide telehealth services to these
underserved veterans.
There are many healthcare leaders in the Pacific Islands who are
strong advocates for the FAS veterans, including the Director of Public
Health and Social Services in Guam and the Minister of Health in the
Republic of the Marshall Islands, who are both veterans. A U.S. career
service officer in the FSM strongly stated that, ``It's more than cost
. . . it's also a deep sense that they [FAS veterans] have been largely
discarded once used. They can be recruited here, serve as Micronesian,
but can't receive benefits when they return home. This is NOT what they
should be feeling--it's not the way they should be treated.''
recognition of telehealth and supporting efforts in the region
There are challenges with using telehealth in the Pacific region.
The efforts to use technology to improve access to care and to improve
outcomes, while reducing costs, have been many. We should keep in mind
the progress and some of the individuals who worked to make a
difference.
Over the many years, I have had the opportunity to observe and
interact with some very committed individuals from the Tripler Army
Medical Center and the Department of Veterans Affairs. I would like to
acknowledge that some individuals that had big hearts and truly cared
about veteran healthcare in Hawaii and the Pacific region. General Dr.
James Hastings, Colonel Tom Driskill, Dr. Steven McBryde, the late Dr.
Stan Saiki and Dr. Donald Person are individuals that that were really
special, and tried to work collaboratively with community providers and
academia to improve veteran and community care years ago. Additionally,
the efforts of several foreign service officers to improve veteran care
in the Freely Associated States that should also be recognized.
Individual efforts are often not recognized, but are the grist of
positive change. Two ambassadors to the FAS that visited us at the
University of Hawaii (Suzanne Hale from the FSM and Joan Plaisted from
Republic of the Marshall Islands) on their own initiative to discuss
how telehealth could be extended. They too were genuinely concerned
with veteran care.
highlights of historical telemedicine developments in the region
There have been historical efforts to use information technology to
provide the right care, at the right place, and at the right time
within the Hawaii and the Pacific region.
These efforts should be acknowledged. The DoD, way back in 1992,
used their dedicated satellite connection between the Kwajalein Clinic
in the Marshall Island to link to healthcare providers in the Tripler
Army Medical Center.
Despite what seems to be an overwhelming challenge to provide
deserved care to veterans, there have been some bright spots in the use
of telemedicine, telehealth, and health information technology in the
VAPIHCS and the DoD.
--In 1992, the DoD clinic in Kwajalein used its dedicated satellite
capacity to enable two-way medical consultations back in 1992
using a video teleconferencing. The Tripler Army Medical Center
used the dedicated satellite capacity of the DoD to provide
consultation for its military and civilian contractor
population on the island.
--The DoD Tripler Army Medical Center developed a web-based
telehealth consultation platform to share information and
undertake case consultation among healthcare providers. Dr.
Person connected the medical doctors through a web-enabled
capability that enabled the clinicians to communicate with each
other for both teaching and clinical care purposes.
--In 1997, the State of Hawaii held a two and a half day Institute
for Telehealth at the East-West Center collocated at the
University of Hawaii.
--To fulfill its responsibilities to the veterans in the U.S.
territories, the VAPIHCS was able to establish a VA CBOC in
Guam and American Samoa, and hired a clinician to take care of
Veterans in the CNMI.
--The VAPIHCS in Hawaii, in the early 2000s, was the first VA program
in the nation to take advantage of Rural Health Care Program
funding, established under the Telecommunications Act of 1996,
to interconnect the CBOCs on the islands of Maui, Kauai, and
Hawaii to Honolulu for both consultations and the access to the
VA VISTA electronic medical record.
--The DoD, in building its fiber optics infrastructure to lessen the
latency of satellite communications for the U.S. Space and
Missile Defense Command, built a fiber optics network capacity
from Kwajalein to Guam. In so doing, the DoD enabled the Freely
Associated States of the Federated States of Micronesia and the
Republic of the Marshall Islands to establish fiber optics
connectivity.
--The USDA helped the carriers with long-term low interest loans to
finance the connectivity. Just recently, the World Bank has
stepped up to assist these Pacific Island FAS countries with
fiber optics through grants. The Asian Development Bank has
also helped with a loan to Palau. Coupled with commercial
developments in the Pacific, these have changed the face of
communications, enabling more telehealth and telemedicine to
occur.
--The Pacific Telehealth and Technology Hui, a project of the
Telemedicine & Advanced Technology Research Center (TATRC) of
the U.S. Medical Research and Material Command, developed a
website that was used to provide teaching cases to Tripler Army
Medical Center, a project enabled communication among
clinicians to consult on cases.
--The Hui was also successful in testing the usefulness of the VA
software in American Samoa's Lyndon B. Johnson Tropical Medical
Center. This enabled the center to implement a medical record.
It has since moved to the certified OpenVistA that used the
open source version of the Hui to establish a business.
--The Hui also converted the VA VistA to an OpenVistA. This
development was initiated by dedicated VA personnel that were
unhappy with cost of proprietary software following the end of
a contract. The software converted by the Hui has been taken up
and supported by private companies and non-profits.
--The VA is today has a telehealth program and many activities. The
VA coordinator is attending the hearing and will be able to
respond to VA telemedicine and telehealth questions.
summary
The VA is the national leader in the use of telemedicine to improve
access, patient outcomes, and to be cost effective. However, there
needs to be continued efforts to ensure that veterans get the care
deserved wherever they live, that quality outcomes are achieved, and
that continuous effort be applied to lessen and bend the cost curve in
healthcare through rigorous business management. The Veterans Choice
program should not sacrifice the strides that the VA has achieved with
healthcare data and interoperability, beginning with continued health
information exchange or integration with the DoD and the VA Choice
providers. Since the VA relies on community providers wherever the VA
might not have facilities, interoperability needs to be bidirectional
and administratively seamless; but, that will, in part, require
national progress in electronic health records and ubiquity in health
information exchange; and we are not there yet. Finally, VA should
continue its collaboration with academic research centers to ensure
quality metrics are established and routinely reported on. You can't
improve what you cannot measure.
From a national level, there may be a need to establish the
authority for VA and VA- certified Choice providers to be able to
provide services to veterans in any state, territory, or FAS without
state board approval. At the same time, VA should be authorized to
monitor and require community healthcare providers to meet VA high
quality standards.
There may also need to be improvements to Joint Ventures so that
there can be more seamless care between collocated VA and DoD
facilities.
Thank you for the opportunity to provide some input into your
processes.
Dr. Okamura. Thank you very much.
Senator Moran. Thank you, Doctor.
I recognize the chairman of the full committee, Senator
Cochran, for his questions.
RURAL AND REMOTE CARE
Senator Cochran. When we hear you testifying about the fact
that so much of what you provide in terms of health care for
veterans is tied to local customs, and do you find the cost and
expenses of these remote area veterans who are not in a
metropolitan area, how do you make up the slack there? What are
the alternatives?
Dr. Okamura. There are no really good alternatives. In our
particular areas, Mr. Chairman, you know, some of the ways in
which the services could be delivered would be building out
those community partnerships with the health care providers
there, co-locating facilities with the health care systems that
are already there, and certainly trying to save, of course, on
travel and other costs and the inconvenience of those services.
But for the freely associated states, they actually have to
call the Foreign Affairs Office in the VA to get their services
versus the territories that are in the Pacific. So it is a lot
more difficult. I wish that there was some flexibility provided
for the Pacific Island Health Care System, the VAPIHCS Program
in Hawaii to be able to reach out and provide those services
better.
Thank you.
UNIVERSITY OF MISSISSIPPI MEDICAL CENTER
Senator Cochran. Could you tell us more about the
telehealth services you offer and some of the successes the
University of Mississippi in particular, has experienced
through telehealth.
Mr. Adcock. Yes, sir. Thank you, Chairman Cochran.
The University of Mississippi Medical Center, as I stated
earlier, has a very broad system of telehealth. We have not
been at it as long as the VA and certainly do not have national
reach, but we do have over 200 locations across the state. As
we talk about telehealth, we have live telemedicine, which is
scheduled and unscheduled. That is that live audio/video
interaction between a patient and the provider. We also have
store-and-forward and multiple different specialties:
radiology, cardiology, audiology, dermatology. We have talked
about that here today as an issue.
There are not enough dermatologists in Mississippi to have
live appointments with all the patients as quickly as we
should, so store-and-forward provides us a great option to be
able to diagnose and treat a patient at a distance in a much
quicker fashion.
The other big program is remote patient monitoring. We
provide all these services in multiple different locations,
hospitals and clinics, not just our hospitals and clinics. We
do have community partnerships but far and away the majority of
our locations are not in University of Mississippi Medical
Center sites. They are actually in community sites and co-
located using space that is being used for primary care for
rural health, FQHCs. We are in corporations, schools,
universities, rural health care clinics, and prisons. So we are
actually delivering telemedicine in prisons as well.
One of the biggest, newest locations and we think is
optimal for patient care is in a patient's home. So remote
patient monitoring with chronic disease we have shown to be
extremely effective not just with diabetes, as I talked about
earlier, but we also offer it for pediatric diabetics. We offer
it for hypertensive patients, for congestive heart failure
patients. We also offer it for kidney transplant, bone marrow
transplant patients. And the goal is to get patients in home
quickly, keep them at home, teach them about their disease.
There is not enough time as we interact with patients in
hospitals and clinics to provide them the education that they
need to fully understand their disease. So remote patient
monitoring allows us to give them that education on a daily
basis and actually teach them how to manage their own care. And
we think that is the key to keeping them out of the hospital.
We are soon to provide asthma and bone marrow transplant as
well as high risk pregnancy through remote patient monitoring.
So we have seen many successes throughout our state. We are in
68 of the 82 counties. We are working with the health
department to be in every county in Mississippi, but one does
not have to drive very far to find a telehealth access point in
Mississippi.
Thank you.
Senator Cochran. Thank you very much, Mr. Chairman.
Senator Moran. Mr. Chairman, thank you very much. Thank you
for joining us.
Senator Schatz, the Ranking Member.
Senator Schatz. Thank you, Mr. Chairman. Thank you all for
your testimony.
COST EFFECTIVENESS OF TELEHEALTH
I want to start with Dr. Galpin. What metrics does the VA
have built into its program regarding cost effectiveness?
Dr. Galpin. So I am going to--that is a great question.
And, you know, I talked about some of the things that
telehealth can do for an organization: improve capacity,
accessibility, and increase quality. Four and five on that list
are cost avoidance and recruitment and retention.
So when we look at what telehealth can do, we can look at
it as what direct costs can we see coming back to the
organization right now. And one of the direct costs we see
which is very unique to the VA is our decrease in expenses for
beneficiary travel.
So for the VA, we reimburse veterans to get to their
appointments in some cases. And last year, for instance, in
fiscal year 2016, our Allocation Resource Center estimated that
we saved about $24 million in beneficiary travel expenses
because of the telehealth that we did. So that is one way we
could save the Government money.
The other things and I would say the two big areas beyond
that, are cost avoidance related to hospitalizations. As has
already been mentioned, when you have a remote monitoring
program like we have that veterans can enroll in, get trained,
get education on their care, get information that helps them
maintain independence at home, we see reduction in
hospitalizations.
And as you have mentioned, in studies that have been, in
data that has been produced by the VA we can see a 20 percent
reduction in hospitalization for veterans enrolled in that
program. For our telemental health program, not necessarily
remote monitoring, but the video care, we can see a 25 percent
reduction, and that was published data. We track that yearly.
Last year we saw about a 30 percent reduction in both those
programs reducing hospitalization. Last year we saw about a 60
percent reduction in bed days of care in our home telehealth
program.
So it is not a direct cost avoidance like we talk about
with beneficiary travel, but certainly that is helpful. The
healthier you keep our patients, the better their health. The
more accessible to the care, the better their health, and we
prevent longer term chronic conditions.
Senator Schatz. Thank you. And to Ms. Nelson-Brooks and Mr.
Adcock, if you have anything to add on cost savings, I would be
interested to hear from you.
Ms. Nelson-Brooks. Sure. So in terms of cost savings for
audiology specifically for VA Pacific Islands Health Care
System, we have a challenge with obtaining audiology services
in the community as well. The capacity is not there for Choice,
for the Choice Program. And so VA Pacific Islands Health Care
System receives services from the San Francisco VA for
teleaudiology. And we estimate that the average cost of an
audiology appointment in the community for the VA is $100 per
visit. And so far this fiscal year, we have done over 500
teleaudiology visits between Pacific Islands and San Francisco,
which roughly equates to a cost savings of about $50,000 so far
this year.
Senator Schatz. Mr. Adcock.
Mr. Adcock. Sure. Thank you.
As a part of our remote patient monitoring program, we are
monitoring the number of ER visits, which are certainly more
costly than receiving care in home, hospitalizations, patient
engagement. So we are measuring how our patients are engaged
and whether or not they are participating in the program and
medication adherence because if they are not taking their
medications, they are likely to end up in a higher level of
care.
We are also measuring decreased length of stay, working
with managed care companies to enroll their patients in remote
patient monitoring. They are working with us to measure the
overall cost of care. So they obviously have the most data on
their clients on their covered panel, so they know exactly what
the cost of care is and we are working with them to see what
impact we are having on decreasing that cost of care.
Senator Schatz. Thank you.
BROADBAND AVAILABILITY
Dr. Okamura, I wanted to ask you. Between remote patient
monitoring and store-and-forward and the sort of face-to-face
telehealth, you know, there is a conversation around broadband
availability or satellite connectivity. And I just wonder
whether we know already which ones of--in terms of the kinds of
care you can get with telehealth, which ones require a really
robust broadband connection and which can be done? Because I
think we are all looking at--and I am looking at Senator Capito
especially.
We are looking at rural broadband as a national objective
for a number of reasons, but including telehealth. But I would
like to roll some of these technologies out sort of in advance
of the rural broadband being laid out. And it seems too that
store-and-forward remote patient monitoring, you do not
necessarily need big home broadband. If you could briefly
comment on that, Dr. Okamura.
Dr. Okamura. Yeah. I think that that is absolutely correct
in ways, but in the Pacific Island region you actually have
infrastructure challenges as remote areas where basic
connectivity for----
Senator Schatz. Right. Where there is zero connectivity.
Dr. Okamura. Yes. Zero connectivity. I really hate to put
it that way, but absolutely true. So the rural broadband and
the telecom initiatives are really kind of important. And on
that front, you know, the Universal Service Fund (USF) has kind
of reached its limit at this point in time. They once had an
excess. Today they actually are bumping up against the limits,
so the amount of resources available to the rural community has
really kind of hit its limits.
If we could get some of these programs to kind of just work
together and have some authorization of these service
components in there, also as part of the USF type programs, it
would be really beneficial because listening to the other
applications in Mississippi, Mississippi has always been a
leader in telehealth activities. And some of these applications
would be really good to be able to move out.
So the only other thing I would add as part of all of
those, if we could figure out the mechanisms for assisting the
rural providers to be able to use these funds and get a little
more collaboration and cooperation, it would be really great.
Thank you.
Senator Schatz. And you are always smart to recognize
Mississippi as a leader on this committee.
Senator Moran. Senator Capito.
Senator Capito. Thank you, Mr. Chairman. And I want to
thank all of you.
MENTAL HEALTH
I have a couple of questions related to this. We have in
our general population in many states an opioid and drug abuse
problem and I think it is reflected in the VA as well, I am
sure. And so my question is have you at the VA looked at
telehealth and mental health--yeah--mental health and
treatments for opioid and drug abuse treatments in the
telehealth space? Is that something that you are offering? Is
it successful? How does that work?
Dr. Galpin. So we offer--probably our most utilized program
is our telemental health program. We have services in all sorts
of clinical areas within the mental health space, including
addiction type services. I do not have the specific data on the
outcomes for that specific type service, but it is certainly
something that is critical and important for us. It is why
there has been such an investment in our mental health arena
and getting those services out there.
Senator Capito. When a veteran accesses that, do they go to
a CBOC to maybe have a session with a psychiatrist at one of
the main facilities or do they do it in their home and tap in?
How does that technically work?
Dr. Galpin. Well, it is going to be dependent on the area.
So I would say that the future of where we are going is it is
going to be the preference of the veteran. So we see going out
5 years that we are going to offer more and more services in
the home if that is preferable to the veteran through a variety
of devices. At present, we have a combination. We have some
locations that offer services into the home. We have other
locations where it is a clinic-based appointment.
And one of the barriers we have actually, and this goes
back to the legislation that I mentioned in my opening
statement, is that when we create a mental health resource hub
in one state and we want to deliver care to a veteran in a home
in another state that, is when we get concerned about this.
Senator Capito. In terms of licensing, physicians, and--
Dr. Galpin. Licensure, State laws, yes.
Senator Capito. Yeah. That would be a problem.
THE CHOICE PROGRAM AND TELEHEALTH
Let me ask you this. In the Choice Program, we have heard,
I think, through this committee and others various problems
with it that we have tried to solve, some of it being
understanding by the veteran of what the Choice card really
does, understanding by the medical community what it really
means. And then the third-party administrators have been a
subject of discussion as well.
In terms of reimbursing physicians through the Choice
Program that are I guess paid by the VA to deliver care even
though they are not part of the VA, have there been any issues
with that in terms of reimbursing for telehealth or is that an
issue or not?
Dr. Galpin. So I am probably not the person who can really
speak to the Choice Program, but that is information we can get
back to you.
[The information follows:]
Reimbursement of our VA telehealth providers is not considered a
constraint in the use and expansion of VA telehealth services.
Senator Capito. Do either of the other VA?
Dr. Galpin. No.
Senator Capito. No. I am curious on that. I do not know
that there is a problem there, but I know there has been some
problems with the Choice Program in general.
Mr. Adcock, or is it Dr. Adcock.
Mr. Adcock. Mr.
BROADBAND CONNECTIVITY
Senator Capito. Mr. Adcock, Mississippi and West Virginia
have a lot of similarities and we are really looking at
telehealth in our State just in the general population and I am
excited for what it can do for our VA. I am really interested
in your chronic disease delivery of service, particularly as we
have older states and if you can get somebody into the home to
help with chronic disease monitoring, it does--we have some
pilot projects in West Virginia that are working.
Following on what Senator Schatz brought up about broadband
connectivity, is that an issue for you in Mississippi? I mean,
it certainly is for us and obviously, it is for the Pacific
Islands as well.
Mr. Adcock. Connectivity can be an issue. I would say that
it is less of an issue in Mississippi than you would expect and
I think a lot of that is due to our partnerships with
telehealth providers and with providers out in the community
and our telecom provider in Mississippi. C-Spire is a telecom
provider in Mississippi and they have worked with us to grow
the network across the state, whether it be fiber or cellular
connectivity, to help reach these patients' homes. So we have a
very strong success rate in being able to offer our chronic
disease management program in homes that would normally you
think would not be accessible.
Senator Capito. Well, good. That is good. That is good.
Mr. Adcock. There is still work to do.
VETERAN SATISFACTION RATE
Senator Capito. Right. And my last question is more of a
general question and I think it was sort of touched on in the
discussion. Many of our veterans, we have some great hospitals
in West Virginia in Huntington, Beckley, Clarksburg and
Martinsburg. When you visit a VA hospital, the camaraderie, the
socialization that occurs at a VA hospital or even at your CBOC
is something that I think particular veterans are very
welcoming of that interaction, that ability to see the same
practitioner, but to also maybe have appointments the same time
your fellow veterans that you know do or you can talk about
similarities of where and when you served.
Is there a pushback from the veteran on, okay, that is
nice, Mr. Smith, but you know what? You can actually stay in
your home and we can do your retinal screening that way. Are
you getting any pushback on that because of the socialization
aspect of being a veteran, you know, and the camaraderie of
that, and then going to the VA?
Dr. Galpin. Yeah. No. I think that is a great question.
And, I mean, the nice thing about this program is it provides
an option for the veteran. So it is not a requirement to do
telehealth, so if you want your care in person, you can have
your care in person. So the veterans who are getting care via
telehealth are choosing to do it that way, which means that
they want it. And honestly, our satisfaction rates and
utilization of our services reflect that. Our satisfaction
ranges from 88 to 94 percent depending on which of the programs
you are looking at. So people seem very satisfied with the
service, but if they do want that in-person care, that is their
choice.
Senator Capito. Okay. That is a good answer. Thank you.
Thank you very much.
Senator Moran. Thank you, Senator.
Senator Tester.
TELEHEALTH IN THE HOME
Senator Tester. Well, I will start where I was going to end
and that is because it goes off of Senator Capito's question.
And that is: are there any plans for taking telehealth to the
home?
Dr. Galpin. Yes, absolutely. That is one of the, I would
say the critical areas. I mean, if we look out 5 years I think
a lot of our services are going to be provided into the home.
Senator Tester. Okay. But it will be at the vet's option?
They can go to CBOC if they want. They can go to CBOC and have
telehealth if they want, or they can do it at their house.
Dr. Galpin. Correct.
Senator Tester. Cool. Look, my opinion on telehealth has
changed over the last 10 years. I remember when I first heard
about it I thought, no, it is not going to work. Technology has
improved. The vets who have had experience with it have
expressed some very positive impacts and the fact that we have
very few mental health professionals in Montana in the areas of
mental health, at least, it makes a big difference. So I have
got a couple of questions.
TELEHEALTH LOCATIONS
I know there are some expansions into Indian country and
into CBOCs to be able to have Salt Lake support our telehealth.
Can you talk about if you have a short and long-term telehealth
model on where you are going to be putting centers or, you
know, what CBOCs you are going to actually put in mental health
telehealth potential into?
Dr. Galpin. Yeah. And I think I understand the question.
Let me tell you----
Senator Tester. Well, the question is where are you going
to go with this because there used to be few. Now there is more
and if there is going to be even more, could I see the diagram?
That is what I am asking you.
Dr. Galpin. Okay. Yeah. So last year we started out by
saying we need to prioritize what we are doing in telehealth.
Senator Tester. Yeah.
Dr. Galpin. We have access issues that we want to respond
to. One of the five work streams we developed was related to
our core ambulatory services. That is mental health and primary
care.
Senator Tester. Okay.
Dr. Galpin. And what we said is in certain areas of the
country it is hard to recruit those providers. And I think that
is what you are speaking to. And so what we set out to do was
not replace in-person care with telecare, but it was to
supplement. So if you have a rural facility----
Senator Tester. Yeah.
Dr. Galpin. And you have a provider who leaves.
Senator Tester. Yeah.
Dr. Galpin. We want to have a bench of providers. We want
to have providers available who can move over and fill in the
space.
Senator Tester. I got you. And just to put this in
perspective, there is one. It might have changed. We might have
two now--east of Billings. So as far as mental health goes, we
meet those criteria. The question is what is the VA going to do
to help meet those veterans who live in those frontier areas
and what does this committee need to do to support you to make
that happen?
Dr. Galpin. I appreciate that. So from a national strategy
standpoint, we want to develop more of those resource centers
and increase their capacity to take care of veterans. Again, it
is hire the providers in the large academic sites where we have
the ability to hire and serve the veterans in the rural
communities. From a committee standpoint, that is across the
nation. That is our expectation. That is where we want to go
with that specific program model.
What we need, I mean, to support--and I appreciate you
asking that question--is we need the legislative authority that
says we can go across state lines into the veteran's home so
that if the place where we can hire is not in your state, we
can still serve the veterans in your state and continue that
care into the home if that is their preference.
The other things that I think are needed, we need to have
and maintain a modern IT structure and modern telehealth
equipment.
Senator Tester. Yeah.
Dr. Galpin. And so from a perspective of what this
committee could do is help ensure that when the VA does come to
request and say, ``These are our needs,'' that that is heard
within that need request.
Senator Tester. Okay. Okay. So I think that the Chairman or
Ranking Member can ask you for that language then when that
time comes and I hope they will. I would ask if you have any
plans to--I would ask that if you have a document that shows
your plans for expansion in telehealth across the country--in
my case, Montana--I would love to see that document. And not to
be critical of it, just so I know what to expect. And then we
can help encourage you to do it and you can help encourage us
to fund it, okay.
Dr. Galpin. We have got it and we will provide it.
Senator Tester. Okay. That will be great.
[The information follows:]
Describing our vision, operating plan, and our IT expansion
initiative (documents available upon request):
--``VA Telehealth-Strategic Priorities Goals Barriers and
Constraints''
--``VA Connected Care Operating Plan''
--``VA Telehealth Expansion Hub Initiative and Interfacility Access
(OIT) BCTA''
Senator Tester. The other thing is we have got a number of
folks that head south for the winter and they say they have
different providers when they are down in Arizona, say, than
they have in Montana. Is there--could this telehealth replace
one of those--and I do not mean replace by replace, but replace
it so that that person would be dealing with the same provider?
Say they have a provider in Montana or the other way around, in
Arizona. They go move to Arizona in the wintertime. They could
access that Montana provider by telehealth. Is that something
that would be possible so there would be some consistency
there?
Dr. Galpin. Yeah, certainly. I think particularly with that
legislation where you can go across state lines. I think there
are two models that we could potentially envision to resolve
that problem. So, one is for a patient who is in a very complex
position as far as their disease state.
Senator Tester. Yeah.
Dr. Galpin. They can take their mobile device. They can
still maintain a relationship with their provider wherever they
are for the winter, get some basic care.
Senator Tester. Got it. Good.
Dr. Galpin. We could also set up access points at
facilities or with community partners so that we can provide a
broader range of more complex services for the veterans that
need those types of services.
MENTAL HEALTH CARE FOR NATIONAL GUARD MEMBERS
Senator Tester. And this is not a question. This is a
comment, so hopefully the Chairman will let me say this. We
have some issues with the National Guard with suicide, quite
frankly. And I think if there was some prospect of the Guard
being able to tap into the VA's mental health options for those
members, I think it could work. If you could think about that,
Doctor, and if there are any barriers, if you could recommend
for us, number one, if you had the capacity to actually do that
because we do not want to take the service away from the
veterans themselves, but we have got a huge issue in rural
America with suicide anyway and Guardsmen are no different. In
fact, it is probably ramped up a bit. So if there is some way
we could take down some of those barriers, if you have the
capacity that would be great.
Thanks, Mr. Chairman.
Senator Moran. Thank you, Senator Tester.
TELEHEALTH SERVICES
Dr. Galpin, let me ask a series of questions in a sense
really directed toward my home State. Broadly, first, what
would be the array of telehealth services that are available?
Dr. Galpin. So we provide services in over 50 clinical
specialties. The most commonly utilized are mental health, our
store-and-forward retinal imagining program, and dermatology.
Right now it is not the same from one site to the next, so it
depends on what that center has decided is their most important
need and what services they want to provide.
So other than the home telehealth program, the remote
monitoring program, which is fairly universally available, the
others have been chosen by the facilities on what they want to
prioritize.
Senator Moran. And that prioritization would occur based
upon the particular specialists that might be available within
that VISN?
Dr. Galpin. So it would be a combination of the services
that are available as well as what the needs of the veteran
population is at that location.
Senator Moran. So there is a wide array, with fifty some
specialties that would be available to veterans across the
country. The decision is then made at what level, the hospital,
the VISN?
Dr. Galpin. Well, so we are speaking current state, but
also I think there is a vision of where we will go in the
future. So, right now services that are available to a veteran
in one area are not going to be the same as a veteran in
another area. What we like to do and what we are moving toward
is more national enterprise initiatives. So for our teleprimary
care program, that was funded by the Office of Rural Health as
an enterprise initiative. Same with our mental health expansion
plans. We just added in a sleep medicine plan.
So I think the goal more is to standardize which will help
us out in a tremendous amount of areas including communicating
the services to veterans. Right now it is hard for me to say.
We have teledermatology because if a veteran goes to a clinic
and they are disappointed they do not have it there, I do not
want to be in that situation for them, so.
Senator Moran. I had not thought of that. You said
something that caught my attention. Everything you said caught
my attention, but where is the provider? Not necessarily in
Kansas. Not necessarily within our VISN today?
Dr. Galpin. So most likely the providers who are taking
care of the patients at----
Senator Moran. And this goes back to the state line issue?
Dr. Galpin. Yeah.
Senator Moran. All right.
Dr. Galpin. So let me--if I could, let me take some time
and kind of tell you where I think we are going.
Senator Moran. If you would only do one thing first.
Dr. Galpin. Sure.
Senator Moran. Which is to tell me where we are today? Who
in Kansas makes the determination as to what telemedicine
services are currently available?
Dr. Galpin. It is going to be the facility. It is going to
be the facility with probably some input from the VISN.
Senator Moran. Okay, and then your vision?
THE FUTURE OF TELEMEDICINE AT VA
Dr. Galpin. Yeah. And this is going to take a few minutes.
And I hope that is okay, but I think it will help kind of
answer some of the questions because where we are going with
telemedicine is exciting and I think it kind of brings this all
together. And what we do is we do think about it as what are we
going to be offering at a facility level, you know, in the
remote clinics at the medical facilities then. What is going to
be organized? More at the network level and then more at the
national level. And at the facility level, I think we are going
to be doing a tremendous amount of services into the home.
There is tons we can offer and that is where it is probably
most convenient for most people to get their care.
Also at the facility, telehealth is just going to be
integrated into our daily operations. And what does that mean
is that probably every specialty is going to adopt some portion
of remote care or virtual care to make their services more
accessible.
It is also just going to be a part of routine operations in
the sense that when a veteran leaves a clinic appointment there
is going to be a question of how do we best deliver this next
visit? Is it in person? Is it by telephone? Is it by video? So
it is just going to be kind of part of the regular routine and
thought processes.
Also, at the facility level we are going to make care more
accessible to families and caregivers. As we know, you get
better care when you have someone navigate a complex medical
system, especially if you have a lot of comorbidities. Some of
our elder veterans fit into that category. So being able to
invite someone and saying, ``Yes, it is hard for you to make
this appointment and help the veteran out, but we are going to
bring you in virtually so you can attend the appointment,
listen to the doctor, help them after they leave the clinic.''
That is really important. I mean some family caregivers live
across state lines.
We also want to enhance our remote monitoring program. I
mean, obviously, that has been very successful. We want to add
more options. Right now there is a certain threshold that
people have to meet to get into that program. They have to
respond every day. They provide information. We need to have
something and we are going toward more of a continuum of
services so that no matter where you are on your healthcare
journey there is some way you are going to be able to engage
with us and we are going to be able to engage with you to get
services. So that is at the facility kind of medical center.
When you look at the VISN or region, and this is where the
across state line comes in. What we have in this country in our
VA system, but also in our communities, is there are certain
places where there are just gaps in services. And this is where
the legislation comes in. It is so critical to provide is that
we need to look and say, ``Where can't you get a certain
service in the VA? Where can't you get neurology care? And
where also is that care not available in the community?'' And
that is on the top of our work list. We need to figure out a
program so we can remote in that care or do a hybrid model
where we bring in some in-person, some remote care.
For primary care and mental health, core ambulatory
services, we need to expand our interim staffing program. This
is where again at a site that is rural you lose one of your
primary care providers. We do not want to wait 6 months to a
year to get someone else in there. We are going to start hiring
that provider, but we want to bring in a remote primary care
provider to fill in those services so we provide consistent
access.
Similarly, at the regional level, we need to do consultant
networks. If a provider--I will speak to my own experience in
this. I worked at a large academic site. I had a list of all of
the subspecialists that I could contact. When I needed help, I
got help. If you are in a rural clinic, we can provide that
same level support for every provider that is sitting even in a
one doctor clinic. They should be able to go to an icon on
their desktop and just say, ``Who is on call for cardiology,
nephrology, pulmonary?'' Be able to text them, email them,
start a video, start a phone call.
And it does not matter where that provider is sitting. That
provider may be two states over at a large academic site. The
point is the provider that is sitting out in the rural
community needs to feel they have the entire organization at
their back taking care of the veteran in front of them.
And at the national level, we need to have failover
capacity. We need to make sure that when we set up our
telestroke program, our teleICU program, that we do it in a way
that if one network goes down, we have failover. We also need
to move around our national experts. So if there is an expert
in a rare condition, that person--let's say there is ten
veterans that have that rare condition--that provider is
providing input into all of their care.
And so I think when you look at that you see, you know,
yes, right now a lot of it is the decisions are made at the
facility. It is facilities try and take care of the veterans in
their cachement areas. We are moving toward a model where we
are doing more intrastate, more across the VISN, but where we
expect to go, we are going to leverage the VA enterprise in a
way that you cannot do if you do not have a national integrated
health care system. And I think that is where it starts getting
incredibly exciting.
Senator Moran. You answered my question in a different
direction than I was intending to go, but I found it very
helpful. And as I think about this, and it pains me to say it,
we have too many locations in Kansas in which we cannot recruit
a medical provider.
Dr. Galpin. That is correct.
Senator Moran. It is a consistent problem in the VA and in
the private sector. We have tried for as long as I have been in
the United States Senate to get the VA to hire a physician at a
CBOC in Liberal, Kansas, almost in Oklahoma, almost in
Colorado. And that has been apparently an insurmountable
challenge.
What you described to me tells me that there is a way to
solve this problem with a provider who--this is the part that
is painful to say--who may be unwilling to live in a particular
location, but is willing to provide services to veterans and he
or she is providing service from Maryland. It reminds me that
we provide radiology services across the country.
Dr. Galpin. Absolutely.
Senator Moran. For communities in Kansas and the
radiologist may be in Australia, may be in Maryland or
Virginia. And the VA is not--what you are telling me is the VA
is not there yet, but that is the vision.
Dr. Galpin. That is the vision. And let me state this
because I think this is really important. It is not that we do
not want to continue recruiting that provider to live in that
community. That is the direction we want to go, but in the
meantime, let's make sure the services are provided and let's
bring in a provider in the way we can.
Senator Moran. I appreciate that answer even more.
Senator Baldwin.
Senator Baldwin. Thank you.
TELESTROKE PROGRAMS
Dr. Galpin, much of our discussion and your testimony has
been focused on the beneficial uses of telemedicine to treat
chronic conditions, issues like diabetes, like mental health. I
heard you just reference it quickly a moment ago. I want to
focus on a more acute use for telemedicine, stroke care,
utilizing telestroke programs.
Stroke is the third leading cause of death in the United
States. I think slightly more than 1 out of every 15 deaths are
due to stroke. And according to the American Stroke
Association, the American Heart Association, telestroke
services could save thousands of people every year and
certainly cut costs by perhaps even over a billion dollars in
the next decade. Yet only 3 to 5 percent of those diagnosed
with a stroke are given the clot busting drug, TPA, in time to
avoid brain damage.
So do you agree that our veterans would benefit from
telestroke programs, especially in our rural areas where
primary stroke centers can be sometimes hours away?
Dr. Galpin. So the very simple answer to this is yes. And I
do not know the awareness on this, but the VA has a plan to
develop a national telestroke network within the next 5 years.
That work is ongoing now. They have already identified their
first ten pilot sites and we expect to have the implementation
of the first services this year.
So it is, I would say--you know, we focus a lot on
ambulatory care, but the inpatient potential for this is
dramatic. And that specialty consultant network, that ability
to walk into an ICU and have a button on the wall that says,
``I need to talk to an intensivist,'' or, ``I need the
neurologist right now.'' That is critical and that is
lifesaving. So I appreciate that you brought up inpatient and
acute care.
Senator Baldwin. Yeah. And I want to dig down a little bit
deeper on this. You mentioned pilots. Maybe they are in
response to a couple of the OIG recommendations of the past few
years. And there have been some specific recommendations and I
want to hear the progress the VA has made on them.
One in June of 2015 was an inspection report dealing with
treatment of a veteran in Wisconsin. And that OIG report
recommended that the VA review current acute stroke treatment
policies and assess the use of telehealth evaluation for more
aggressive local treatment in patients presenting to rural and
low complexity VHA facilities with signs and symptoms of acute
stroke. And the VA agreed with the recommendation and stated,
``At this time VHA does not have national or local guidance for
the emergency department stroke management using telestroke.''
I am asking sort of where are you in that process. Does the
VA now have national guidance for emergency department stroke
management using telehealth and if so, can you please provide
us with copies and also tell me a little bit today?
Dr. Galpin. Sure. So the decision by the VA to develop and
commit to a five-year plan to develop the national telestroke
network I think was informed by the cases that we saw that the
OIG responded to. So this is the year, again, they have the
first 10 sites that are supposed to go live with this program,
but it has not been activated yet. That is anticipated this
year.
Senator Baldwin. That is helpful to hear. In reference to
another OIG report, there was a recommendation. Let's see. This
was all of the VA facilities, not Wisconsin specific, but the
VA--the OIG recommended that the VA improve the availability in
expertise in stroke treatment across the system. And in
concurring with the recommendation, the VA stated, ``Patient
Care Services will develop a plan for phased implementation of
telestroke program to link stroke specialists with emergency
departments and include identification of patients that may
benefit from endovascular therapies.''
The target completion date for this effort was April of
2016. Wisconsin is part of VISN 12 and currently there are no
telestroke programs or partnerships that are currently
operating within our VISN. So I am wondering of these first 10
sites if you can give us some indication will there be any in
VISN 12? I do not know if you are able to announce those at
this point, but certainly we are very anxious to hear progress
on that.
Dr. Galpin. You know I wish I could. I will have to bring
that back for the record. I believe that list can be readily
available and we can get that back to you.
[The information follows:]
Please see response to Question for the Record on the same topic.
Senator Baldwin. Great. I have a couple more specific
questions with regard to this issue that I am happy to submit
for the record. I suspect you do not have the data with you
right now, but we are very interested in seeing these
partnerships and agreements, especially recognizing that the
supporting stroke facilities have more limited capacity and we
want to see robust agreements both for telestroke as well as
treatment with the primary stroke centers in the regions.
Dr. Galpin. Okay.
Senator Moran. Thank you, Senator Baldwin.
Senator Udall.
Senator Udall. Thank you very much, Chairman Moran, and let
me just thank the panel overall. I have been listening here for
a bit and I think you have really pointed out the real
potential for telehealth. And, Dr. Galpin, I want to thank you
for your vision and where you are headed. I think that is where
we all want to go.
Telehealth and telemedicine is often seen as a silver
bullet, especially in a rural state like New Mexico where
health care practitioners and specialists are in short supply.
If you are a veteran in Farmington, New Mexico, for example,
and the nearest specialist is three and a half hours away in
Albuquerque, telemedicine is a blessing. But what we often fail
to see is that telemedicine does not fix capacity, nor does it
address the VA's provider shortage.
For example, while that specialist in Albuquerque is
treating the rural veteran, the doctor is unable to see the
other veterans in Albuquerque. Fortunately, there is a growing
evidence base that other technology enabled models could make a
real difference here.
CLINICAL RESEARCH STUDY
And, Mr. Chairman, I have a research study I want to put in
that demonstrates this point. It is titled, ``Clinical Research
Study April 2017, American Journal of Medicine. Telemedicine
Specialty Support Promotes Hepatitis C Treatment by Primary
Care Providers.'' Ask consent to put that in.
Senator Moran. Without objection.
[The information URL follows:]
https://www.amjmed.com/article/S0002-9343(16)31227-X/pdf.
Senator Udall. All right. Thank you, Mr. Chairman.
In 2010, and this study drives home the point that I am
going to ask about in terms of Project ECHO which I think you
are very familiar with. In 2010, the VA Specialty Care Services
adopted a new model to transform the delivery of care
throughout the VA. They began utilization of a technology
enabled model that was developed by Dr. Sanghi Varroa at the
University of New Mexico called Project ECHO. Since then, VA's
Scan ECHO Program has created specialist teams at 11 VA
facilities that reach over 600 VA clinics throughout the
country and assist treating veterans with 39 otherwise very
difficult illnesses.
The key difference between Project ECHO and the traditional
telemedicine is that Project ECHO helps expand capacity through
the system. Rural VA practitioners collaborate with VA
specialists around the other country and over time by treating
patients they become specialists themselves. And so you are
really--it is pretty special expanding that capacity.
So, Dr. Galpin, Scan ECHO is accessible from over 600 VA
clinics. Does the VA plan to provide the same access to all
1,233 VA health care facilities around the nation?
Dr. Galpin. So the Scan ECHO Program is not under our
telehealth operations. I am familiar with it because I think it
is a brilliant program. I actually applied to set up a center
where I was in Atlanta when we initially had the opportunity,
but I cannot speak for the office that does that or the
organization, but we can get that information back to you.
[The information follows:]
The VA ECHO program is offered and available to all 1,233 points of
care. Currently 516 VHA site receive ECHO programs, some from multiple
hub sites. Additionally there are 18 DOD sites which receive VA ECHO
programs.
Senator Udall. Yeah. But you understand the idea in terms
of expanding capacity and that is one of the problems, isn't
it, with telehealth is what happens with this new model, this
enabled model, is that you grow the specialists out in the area
and then they are able to do a lot more rather than just
relying on the specialists at the facility. And so that is
something I just hope you look at and take a hard look at
expanding that out.
Dr. Galpin. Well, I would love to--oh, sorry.
Senator Udall. Go ahead.
Dr. Galpin. Well, I would love to respond to that because I
think this is one of the things that I think is important to
understand about telemedicine is that it can do a lot of
things. And so it increases accessibility. It does move that
appointment from one spot to another. Excuse me. And that makes
the care more convenient. Like you mentioned, it does not add
appointment slots though. But we can do that when we leverage
our large academic sites. That is where we talk about increase
in capacity, going across state lines, having that authority to
really leverage that value proposition from telehealth. It is
``I am going to hire people here because I can. I am going to
serve veterans over here because it is hard to hire. I am
increasing capacity in the places that it is hard to hire.''
Scan ECHO, I think similarly gives us another avenue to do
something similar. It is a great way of educating providers. I
have been able to attend some of those sessions. At the same
time, you are helping to take care of a veteran. They are not
part of it, but it is an education session where you get
specialists who then get to participate and you get a
multidisciplinary approach to managing a veteran and then you
get learning from all of the other providers around.
So when you are at, like, a large academic tertiary site,
you participate in those type of conferences. When you get out
in the rural communities, you cannot. Scan ECHO helps us invest
in our primary care providers to build new skillsets and
therefore have the capacity and the ability to manage more
complex diseases.
I do not think it is a one or the other. I think we have to
look at all of these options that increase capacity in your
organization and that is one of the models that I think has
been very successful and proven.
Senator Udall. Right. Thank you very much. And let me
just--Chairman Moran, if I could just have one more second.
Senator Moran. You may.
BROADBAND IN RURAL AREAS
Senator Udall. Commenting on what Dr. Okamura and your
vision, Dr. Galpin, in terms of where the Veterans
Administration is going to move to plug these holes so that we
do not have in broadband, as he said, Universal Service Fund
has hit its limits. I would urge you all and I would urge your
Secretary to be at the table when the President puts together
his infrastructure package. And you all be advocating that it
is absolutely essential in project number one to fill these
holes so that we can get this telehealth out into the rural
areas of America.
And I know there is reluctance in terms of stepping outside
your agency. You had mentioned your whole vision, but the
biggest part of the vision that all of us have talked about is
you have these big holes in terms of broadband. And if we had a
national effort to put that broadband into all these rural
areas, it would really make a difference in terms of your
vision, I think.
So thank you for your courtesies and thank you.
Senator Moran. I share your view and was therefore pleased
to extend you additional time.
Senator Udall. Okay.
Senator Moran. The Senator from North Dakota. Senator
Hoeven.
Senator Hoeven. Thank you, Mr. Chairman.
EMPOWERING HEALTHCARE PROVIDERS IN THE FIELD
I guess my question is primarily for Dr. Galpin, but the
others may want to weigh in as well. So in terms of making sure
that you are providing care to our veterans out in the rural
areas, I am going to give you an example from North Dakota. We
have a VA medical center at Fargo that serves North Dakota and
also western Minnesota. They do a fantastic job. The veterans
really appreciate the high-quality care they get from the Fargo
VA Health Center. They are really good.
If you live in Williston, North Dakota though, it is an
800-mile round trip to the Fargo VA, 800-mile round trip. Now,
we have a CBOC out there. And so it creates kind of an
interesting dynamic with Veterans Choice because under Veterans
Choice if you cannot get an appointment in 30 days or you live
more than 40 miles from a VA facility, then you go in to your
local provider.
So, not too far from Williston, but more than 40 miles, is
Tioga. Now somebody in Tioga can go into Williston, go to Mercy
Hospital, and get VA care under Veterans Choice. Somebody in
Williston lives within 40 miles of a CBOC which has limited
services and if they want more services they would have to
drive all the way to Fargo, 800-mile round trip, under that
provision.
So what we have worked to do is create the Veterans Care
Coordination Initiative in North Dakota whereby we actually
have the business center at the Fargo VA working with veterans
to try to make sure that we empower people in places like
Williston to--or authorize, I should say--them to go in to get
local care rather than making that 800-mile trip which makes no
sense. And it follows the old Non-VA Care model.
The point being you could have telemedicine, but you have
to empower your people out there in the field and rural areas
to make good common sense decision on when they can go and get
care locally versus when they would have to come to a VA
facility that can actually provide the care they need.
So talk to me in terms of as you develop telehealth
telemedicine which you are doing in North Dakota which is
coming and we will support you in that effort. Tell me how you
are making sure that the medical professionals can do what
makes sense for the VA client, the VA patient, and so you are
getting them in to some place close where it makes sense when
it makes sense and not having them caught up in the red tape.
So it is both the technology and the capability, but it is also
the empowerment of your healthcare providers out in the field.
Dr. Galpin. I think that is a good question. I think that
is a good question and I think that I will start out by saying
that telehealth is an option for veterans, so veterans get to
choose to do telehealth and if it is not the right solution for
them. They can choose another option.
I think also for a provider you have to choose what makes
sense for the veteran. What is the best way to provide the
care? So it is there is a choice at the provider's side too. Is
this appropriate? Is this the best way to provide it?
You are speaking, I think--I think I understand your
question that in addition to having a telehealth option, we
need to have other options that are equally accessible to the
veteran. And that right now----
Senator Hoeven. I am saying with your telehealth: let's say
you use your telehealth to determine that that patient needs a
procedure that they cannot get from the CBOC in the community
and it does not make sense to make them drive 800 miles round
trip to get it.
Then does it follow on your telehealth you have got to be
able to send him into that local hospital or other local
healthcare provider to get that care when you cannot provide it
through the CBOC or you are defeating both your regional system
of CBOCs and your telehealth. You are putting him right back
into driving 800 miles, you follow me, if you are not empowered
to deliver that local care? Because you may make a diagnosis
through your telehealth, but that does not mean you can conduct
the operation.
Dr. Galpin. No. And so we have to be comprehensive in the
services we provide. We have to provide them at convenient
locations. I think the telehealth only gets you so far. And in
the situation you are describing, the telehealth got you to
this point and now you still need a convenient patient centered
system to allow you to get the next step in your care.
So I am agreeing with you. I think that it is in an area of
our agency. That is more the Choice Program or the Non-VA Care
Program, but I cannot speak to as an SME, but I hear your
point. It is not--we cannot set up our system in isolation and
not think about the next step. And so I am going to take away
is what I think you wanted to make sure I walked away with.
Senator Hoeven. I want you to be an advocate for the
follow-on. In other words, I want you to go in and say, ``Look,
through telehealth we can make diagnosis. There is a lot we can
do, but if we do not combine that with empowerment of our local
health care providers in the field to send the person where
they need to go and we do not have the flexibility to do it,
you are going to defeat the effectiveness of the telehealth.''
So I want you to be an advocate in that process.
Dr. Galpin. I hear you. Yes. Thank you. I appreciate that
now and fully understand and can do that.
Senator Hoeven. Thank you.
Senator Moran. Senator Hoeven, thank you very much.
My understanding is Senator Schatz has concluded his
questions. I hate to tell in front of Senator Hoeven that I am
going to ask a second round, but you should go ahead and leave
if you would like.
Dr. Galpin, you did a good job of using my time and so----
Senator Hoeven. The Chairman asked such profound questions.
If I did not have a time constraint, I would want to stay and
learn, but unfortunately, I have to go.
Senator Moran. Thank you, Senator Hoeven.
COST BENEFIT OF TELEHEALTH
I want to direct--well, first of all, maybe there is a
question to Dr. Galpin. Is there any financial benefit, or at
least not a disincentive, for the use of telehealth within a
VISN? In other words, to try to ask the question more
succinctly, you talked about it being cost effective, saves
money in addition to prevention and hospitalization and that
kind of thing. Does the VISN reap the benefits of using
telehealth such that they get to keep the dollars saved within
their VISN?
Dr. Galpin. Okay. So let me--I will go through just a
little bit of where the cost benefits are.
Senator Moran. Now do not take my full five minutes.
Dr. Galpin. I will try not to. So, I mean, there is the
travel reimbursement. So I am not exactly sure, you know, would
they get to keep the money or not the money, but again last
year $24 million estimated in travel cost savings. If you are
not paying for more advanced care like nursing home care,
institutional care, hospitalizations which we show that
telehealth can reduce, that money can be redirected to other
patient care services.
Senator Moran. Within the VISN?
Dr. Galpin. I would imagine so.
Senator Moran. Okay.
Dr. Galpin. And that is, again, a little--I believe that
their budget would be their budget. And we can confirm that
when we look at the testimony.
The third space which we have not really even talked about
and it does require the legislation again. And I apologize. I
keep bringing that up. But, how critical it is. It is space. I
mean, we--capital assets. I mean, the idea that when we want to
expand services right now we are traditionally needing to build
more spaces. Telehealth does not require traditional spaces and
so you can have a provider working in an academic site in their
private office, in a home private office as long as it is
approved, so when you want to say, ``I need to do more of
this,'' your barrier is how long does it take me to find the
best doctor, not how long does it take me to lease or build a
space.
Senator Moran. All right. Let me follow up. The impediment
is finding the physician, finding the provider. It is not
acquiring the equipment. That is available. If you are a VISN
director or you are a--I guess in this you told me it is going
to be decided at the hospital level. If you are a director of a
hospital in the VA in Wichita, Kansas, the Dole Hospital or the
Colmery-O'Neil in Topeka, you have the availability of the
equipment necessary if you decide to pursue more telehealth
access?
Dr. Galpin. So I would say it is a barrier, but it is a
smaller barrier. We have a national blanket purchasing
agreement for telehealth equipment to help facilitate people
ordering and obtaining the equipment they need. I mean,
depending on the clinic you are at you might not have space. I
mean, we certainly hear that. We do not have space for the
equipment. We do not have space for the personnel on the
patient side or we cannot hire that person in this community
because of the salary. I mean, so there are other constraints,
but in general the equipment is available.
Senator Moran. What does telehealth equipment cost? Is this
a significant expenditure if you just?
Dr. Galpin. Significant is certainly a relative term. I
mean, I think it is something that I think our organization
certainly has made a commitment to. It is not a nominal cost
and to keep it refreshed and modern is a fairly sizable cost.
But to outfit one clinic compared to the other maybe activation
costs of a clinic, I think it is a very reasonable----
Senator Moran. What does the VA spend on telehealth?
Dr. Galpin. So there is a big number and then there is----
Senator Moran. Okay.
Dr. Galpin. Smaller numbers and the big number, I do not
know if I wrote it down, but when we looked at I think it was
$1.2 billion. That certainly does not come to my office, but
that is what it is approximately estimated across the
organization. And we can get that final number for you.
Senator Moran. Thank you. Mr. Adcock, are there still--in
the private sector at the University of Mississippi Health
Systems are there still reimbursement issues that diminish the
use of telemedicine? When a patient shows up with a ``Blues''
card or Medicare or Medicaid who gets compensated for providing
that care?
Mr. Adcock. So in Mississippi, as far as state-based
payers, there is not as much of a barrier anymore. We have
legislation that was passed in Mississippi that requires parity
for both telemedicine visits and remote patient monitoring. So
we are able to be reimbursed there. There are some private
payers that interpret those rules a little bit differently, but
as far as Medicare, yes, there is an issue in getting paid for
telehealth.
Senator Moran. So at least in Mississippi you have solved
the issue with Medicaid.
Mr. Adcock. Medicaid has been solved.
Senator Moran. You may have solved the circumstance with
the private payers.
Mr. Adcock. For the most part, yes.
Senator Moran. In Kansas, generally the ``Blues''.
Mr. Adcock. Right.
Senator Moran. And the issue still is Medicare.
Mr. Adcock. Correct.
Senator Moran. What is the challenge there?
Mr. Adcock. There are, and many of these will be addressed
in the Connect for Health Act. Geographic restrictions--so it
has to be in certain areas. They only pay for certain things.
There is no reimbursement for remote patient monitoring at all.
There is a code with chronic care management that can be used,
but it does not cover the intensive program that we have with
remote patient monitoring. So those are the biggest issues,
geographic barriers and then no payment for remote patient
monitoring.
Senator Moran. It seems to me that in one of my visits to a
hospital in Kansas the CEO of that hospital indicated that one
of their providers, and I think it was psychiatric services,
actually found a psychiatrist who lives in Arizona willing to
provide services to a community in western Kansas, but could
not get reimbursed related to the fact that the provider was
out of State.
Mr. Adcock. We do not have those issues in Mississippi as
long as they are licensed in Mississippi.
Senator Moran. Okay.
Mr. Adcock. So it is by State. You have to be licensed in
the state that you are providing care, but we can reimburse
physicians from out of State.
TELEHEALTH ACCESS TO CARE
Senator Moran. So your experience in Mississippi, what is
the differentiation? What is the difference between what a
veteran could receive in telehealth services through the VA
versus what a patient with Medicare, Medicaid, or private pay
could receive as a citizen that is not a veteran in
Mississippi? Is the access--how would you describe?
Mr. Adcock. I think it is a differentiation in access. We
have so many access points throughout the state that can be
used by all of the others that you mentioned. As I stated,
there are only ten access points in Mississippi for VA
patients. That is something we could certainly--I would love to
see layered on top so that we could work together to provide
that service and utilize those access points.
Senator Moran. So it is a fair statement to say that it
would--if you want to use telehealth services you are less
likely to be able to access those if you are veteran than if
you are not?
Mr. Adcock. In Mississippi?
Senator Moran. In Mississippi.
Mr. Adcock. I would say that we offer many more access
points than they do at the VA. I would not want to say that----
Senator Moran. I am not trying to trick you. I am----
Mr. Adcock. No, I understand.
Senator Moran [continuing]. Trying to make sure that
veterans have the same access to care that anyone else would
have.
Mr. Adcock. Absolutely. And we certainly want that same
thing. I think that there are access points that the VA does
not currently utilize in the State of Mississippi.
Senator Moran. Well, and this lends itself to my--I think
final question or conversation with you, is I think your number
was 68 percent, 68 percent of veterans in Mississippi do not
access health care through the VA.
Mr. Adcock. According to the U.S. Census Bureau, 67
percent, yes.
Senator Moran. And you do not know the next part of that,
the next set of facts, where they do access health care?
Mr. Adcock. I do not. I do not have that information.
Senator Moran. And it could be that they do not access
health care at all.
Mr. Adcock. Could be.
Senator Moran. Or they could be in your system or something
else in Mississippi.
Mr. Adcock. Could be. Could be.
Senator Moran. But there is a number out there that says 68
percent of veterans in Mississippi do not access health care
through the VA.
Mr. Adcock. At the VA Health System, correct.
Senator Moran. Okay. That may be taking you right back to
the access point issue. I mean, in Mississippi. We have no
Kansas witness here today, but it would be very similar to the
circumstances we face at home. I am going to talk about that in
just a second. Well, let me do that now.
I mean, we have CBOCs in Kansas. I talked about Liberal,
Kansas, in which it has been more than 4 years since there has
been a physician there. We have CBOCs that have hours two days
a week and so actually getting to the telehealth side of the VA
still is a huge challenge if your access point--if you are
rural, you are a long way from Wichita, Topeka, or Leavenworth,
and your access point should be something at home.
Now, let me ask this question. So under the Choice Act, you
show up. The VA approves you to see a hometown physician. Does
that physician then have the ability to refer--I am looking at
you, Dr. Galpin? Does that hometown physician under the Choice
Program, can he or she refer that veteran back to telehealth
through the VA? Would that be an access point?
Dr. Galpin. That I would have to get back to you on. I am
just not familiar with that part of the Choice Program. I know
the Choice Program is piloting the use of telehealth within the
Choice Program, but the actual referral patterns I would have
to get back to you on.
[The information follows:]
A Choice provider cannot formally refer a Veteran back to the
telehealth program, but can work with the referring Medical Center,
should appropriate telehealth services be available within the VA.
Senator Moran. What my point is that lack of access points.
One of the things we are trying to do to solve that is Choice.
With permission, you can go see a hometown physician, be
admitted to a hometown hospital, but it may turn out that the
VA and even a more efficient way than Choice can provide
services through telehealth, but I bet there is probably no
physician who would think, ``Oh, the VA has a telehealth
program. We ought to refer you back to the VA and you can get
the services through the VA at telehealth.''
I would guess there is no connection between telehealth at
the VA and the Choice Program at the VA. That question or does
that comment make sense?
Dr. Galpin. Yes.
Senator Moran. Okay.
Dr. Galpin. Yes.
THE FUTURE OF TELEHEALTH
Senator Moran. And then, Dr. Okamura, you heard Dr. Galpin
tell me about the vision. From your experience, is the VA on
the right track? Do you agree with that vision? Are they
missing something? What they described is what we ought to have
both at the VA and in the private sector or is there a
differentiation?
Dr. Okamura. Thank you, Mr. Chairman. That is a really good
question. And I was listening and trying to ferret out how this
would actually impact Hawaii that has eight islands and the
Pacific Islands region and the remote islands.
And just hearing your conversation on the access points, my
question would have been at least in the past, the ability to
kind of work with, and that is why in my written testimony you
will see some references to some people that have really worked
hard that are in leadership positions that really tried to do
the outreach through community share facilities and things so
that the resources could be extended.
So, to directly answer that question, I am not certain at
the present point in time. I would really like to see the
VAPIHCS be able to--that is the regional side from Hawaii on
out to the Pacific, have a little more resources and authority,
be flexible, because I think that leadership has tried to build
these bridges with the community providers.
That question that you just asked Dr. Galpin would have
also been for me a different kind of question. It would have
been, okay, so how can we work collaboratively to take
advantage of these community access points when we do not have
a physical facility to actually extend resources. But to get to
that point, we then have issues of some other things like
interoperability and shared information.
So I am listening to these. I am saying that as long as
some of these other visions are articulated at a lower level
and then at least the community can provide some input, I think
that that would be very valuable. Thank you.
Senator Moran. You are welcome. Thank you.
A couple of observations from your comments. There is often
the circumstance in which I am sitting in this committee or in
the authorizing committee which I serve on as well and the VA
officials here who are testifying tell me what the circumstance
is, but I go home and nobody has heard that story. And it could
be the veteran, but often it is the people that work for the VA
in Kansas. And so that communication could be strengthened.
The other part about access point is the access point, it
could be just a phone call to Colmery-O'Neil in Topeka saying,
``I need.'' We had a hearing last--a couple of days ago on
suicide prevention within the VA. There is a hotline. That
hotline could be an access point for telehealth services for
psychiatric and mental health services. Is that true? There is
another access point that we have not talked about which is
just the telephone calling the VA or sending an email saying,
``I need help.''
Dr. Galpin. Yeah. I mean, so one part of the vision I did
not talk about was contact centers. And I think let me address
a couple of things here because I think the idea of working
with public private partnerships, I mean, that is something we
would love to do. And one of the challenges we have is, again,
about where our providers are licensed and what they are
allowed to do across state lines because within the VA you can
be licensed in any state and deliver services, but when you get
outside of Federal property, then you start getting restricted.
So, again, this legislation is really critical to realize
the vision. We really need to be authorized to deliver care to
a veteran in any location and then we can really take advantage
of, I mean, you know, libraries or post offices or academic
sites or any private site where a veteran can come for care
that would allow us to deliver that care, even if our provider
is in another location.
So I just wanted to put it out there. I hear what the other
part of the division is. That is something we would love to do.
We just really are looking forward to the authority on that.
And then talking about access points, so I did not mention.
There is so much that we are doing and trying to do at one
time. I think it is very exciting, but, you know, one is we
want a veteran to be able to contact us very simply and get not
just what we have now which is scheduling, support, pharmacy,
supported nurse triage, but licensed independent provider
urgent type care. And you see this in the private sector. We
would like to bring it into the VA.
And it would not necessarily just be by video. I mean, this
could be--you could initiate with a text message. I think that
is how a lot of us start communications. That would then going
forward, looking at some new technologies, allow you to
activate a video session right from that or an audio session.
You could do an email.
So I think the point is we want it to be really easy to
contact to us. We want veterans to have no real activation
barrier for initiating or engaging with us in that
communication. So I think part of the contact center is I think
looking at access points outside Federal property. I think that
is all critical. Again, we are looking for the authority to
allow us to do that effectively. And, yeah, I mean that is part
of the vision.
TELEBENEFITS
Senator Moran. The final thing I would indicate and then I
will turn it to Senator Schatz, in preparation for this hearing
I found an article, we found an article from the Parson Sun, a
community newspaper in southeast Kansas. And the bragging by
the VA was a program that I had never heard of which is
telebenefits. We have been talking all morning about
telehealth, but the ability to access your benefits now is
apparently available through a different program in which you
connect with the VA to talk to somebody about getting your
benefits. I suppose this goes back to you, Dr. Galpin.
Dr. Galpin. Yeah. You know, that is not in my shop, per se,
but I think it goes back to my comments that for everything
that we deliver in the VA, I mean, for every clinical specialty
I see a role for doing at least part of it virtually. So when
people say, ``Well, how about surgery?'' Well, we are not going
to do the operation virtually at this point, but, you know, at
the post-op where we want to look at the wound or you are in
the middle of the night concerned that it does not look right
this is where you can get on the video call and show someone.
So I think there is tremendous potential and it really is going
to be integrated into pretty much everything we do.
Senator Moran. The article says, ``Parsons area veterans
can now ask VA staff questions about their benefits face to
face without driving to Wichita, the regional office.''
Dr. Galpin. Perfect.
Senator Moran. ``For now, Parsons is the only site in
Kansas with others to be added after the pilot site is running
smoothly.'' The director of that outreach, the coordinator,
indicates that we are trying to do everything we can to access
veterans where we are. And while we focused on telehealth, as
you are confirming, there is other opportunities to better
serve veterans who do not live next door to a VA office.
Senator Schatz.
Senator Schatz. I really want to thank the chairman for
conducting this hearing. As some of you may or may not know,
that for a subcommittee we have got a good level of
participation on a bipartisan basis. And through the
conversations, Senator Moran and I are going to look at the
possibility of legislation specific to VA and telehealth and
whether or not there are some additional resources that can be
provided, authorities that can be looked at to try to assist
all of you in your good work.
So my first question, and it is really a request, is to ask
if you could work with our staffs to develop a kind of wish
list going forward. You know, we have the Connect for Health
Act. I know a lot of you are familiar with it and helped us to
craft it. We have a good bipartisan group behind that
legislation and I think that will only grow in this Congress,
but this is a specific area of opportunity and I think the
momentum is pretty strong. So we would like to work with you on
some--in a certain way, it is a little more modest than the
Connect for Health Act which is broader and outside of just VA,
but we would like to get your recommendations and we think we
could hit a good solid double, maybe a triple on this one.
TECHNOLOGY NEEDS
The final question I have is for Ms. Nelson-Brooks. Dr.
Galpin talked about resources in response to Senator Tester's
questions about, you know, what do you need? On the ground,
what are your unmet needs when it comes specifically
technology? I am thinking obviously hardware connectivity is
one question. I am also wondering about the software and worry
a little bit about there being, in terms of the way this stuff
gets contracted out, that you end up having the software
platforms that are not interoperable and you end up with the
problem that you had with EMRs between DOD and VA.
And so I am just wondering since we are kind of at the
nascent stage whether there is any guidance that the committee
or the Congress can give to make sure that you do not end up
with everybody having to contract their own software vendor and
then by the time we are trying to do a national rollout we have
got standards that do not fit. And then by the time you get
your authorities to have the doctors serve across state lines,
then we are dealing with software and jurisdictional and
licensure questions that all do not match up. So I guess the
first question is hardware and resources. The second question
is the software aspect.
Ms. Nelson-Brooks. Okay. So that is a great question. So we
have had some challenges in some of the Pacific Islands,
specifically American Samoa, when it comes to the
infrastructure. In addition to that, we have had challenges in
Guam. So the VA is able to provide hardware for patients who do
not have access to their own Internet connection. And that
hardware has been successful on Oahu and the neighbor islands
of Hawaii, but we have experienced challenges in Guam because
they do not subscribe to the same carrier that we have. So the
carrier that we have is Verizon and Verizon 4G, so that is
readily accessible on the neighbor islands, but not so much in
Guam and American Samoa.
So it would be helpful if things like that are taken into
consideration when we are looking at places like Hawaii because
Hawaii is unique and we do not experience some of the same
challenges that other facilities across the country do.
In addition to that and going back to Dr. Galpin's issue on
the licensure, Hawaii in and of itself is in the process of
standing up two teleprimary care and telemental health hubs.
One of the reasons for us putting the hub in the Pacific is in
addition to serving the Pacific Islands we wanted to be able to
capitalize on that time zone difference between Hawaii and the
rest of the United States.
When it is five o'clock in California and we still have
hours to go in our day, and so we would be able to----
Senator Schatz. I am ten minutes from calling my wife and
kids this morning for breakfast, so.
Ms. Nelson-Brooks. Right. So we would be able to provide
some of the services going back towards the mainland in the
event that we had capacity. And so we are restricted in that
area currently by the regulations requiring licensure.
Senator Schatz. Thank you very much. Appreciate all of you.
Senator Moran. Yes. Thank you very much all of you for your
testimony.
Dr. Okamura, you highlighted for me. Senator Tester and I
were talking as you talked about distance and miles and air
travel, we always make this pitch about how rural our states
are and the long distances people have to go. And you have
increased my respect and admiration for the Senator from
Hawaii, Senator Schatz, and the challenges that Hawaiians and
Islanders face in regard to distance and time and travel.
Does any member of the panel wish to say something that
they feel needs to be said before we conclude our hearing?
Anybody feel like they have missed an opportunity to respond or
say something or wants to correct something they said? Good.
A week from today we will have a hearing in regard to
Choice. I had not realized the connection between telemedicine
and Choice, but it gives us some additional information as we
go to pursue how to make certain that the resources are
available for the Choice Act as well.
ADDITIONAL COMMITTEE QUESTIONS
Senator Moran. With that, I will conclude the hearing.
Members who wish to submit written questions for the panel
should do so by Tuesday of next week and this hearing is now
adjourned. Thank you very much. Thanks for doing that.
Questions Submitted by Senator Thad Cochran
Question. I understand that the University of Mississippi Medical
Center has used telehealth to provide mental healthcare services to
patients throughout Mississippi. These services also are beneficial to
VA patients. Mr. Adcock, could you tell us about this program at the
University of Mississippi Medical Center? How have patients responded
to this service?
Answer. Thank you, Senator Cochran, for the question and for your
leadership. The Center for Telehealth at the University of Mississippi
Medical Center (UMMC) has been providing telehealth services for over
13 years. Our program started in 2003 with our TelEmergency program,
which connects rural hospital emergency rooms to the expertise of the
level one trauma center and Board Certified Emergency Medicine
physicians at UMMC. This program, like all of our telehealth programs,
began as a solution to address the need for access to high quality
emergency healthcare throughout rural Mississippi. This combination of
expertise and technology allowed patients who would have normally been
transferred to a higher level of care to stay in their community and
receive the same high level of care close to home. This program
continues to be successful throughout Mississippi, but our Center did
not stop there.
To meet the need for access to mental healthcare in Mississippi,
UMMC next introduced TelePsychiatry services. While we have grown our
telehealth program and now offer more than 30 medical specialties, to
date, our Tele-Mental Health program is the most requested and most in-
demand service of any of our offerings.
A primary benefit of telehealth is that it reaches patients where
and when they need care. For mental healthcare, telehealth provides a
way to deliver care in convenient locations without the stigma often
associated with these services. A success story is our partnership with
one of Mississippi's largest universities, where we offer Tele-Mental
Health services in the university's student health center. Here,
students receive the care they need without going into a traditional
mental health or counseling center--instead, they are able to access
this service in the convenience and anonymity of the student health
center. The students have responded favorably, and the university has
continued to grow the partnership and increase the availability of this
service, demonstrating its value for meetings students' mental
healthcare needs on campus.
Today, the UMMC Center for Telehealth has more than 200 telehealth
sites located in 68 of Mississippi's 82 counties. We deliver this care
in multiple settings, including: community hospitals and clinics, rural
health clinics, federally qualified health centers, mental health
clinics, universities, schools, corporations and the prison system.
Delivering mental healthcare in any of these locations offers promising
ways to bring this needed care to patients where and when they need it.
While we have been very successful in establishing live
telemedicine along with store and forward telehealth programs across
our state, one of the newest and we believe, most impactful, telehealth
programs is our remote patient monitoring program.
Thank you for this thoughtful question.
Question. The University of Mississippi Medical Center now has many
years of experience in telehealth, and Mississippi is considered a
national telehealth leader. Mr. Adcock, given these years of
experience, what do you see as the greatest opportunity for the use of
telehealth in the future?
Answer. While our telehealth programs have been and continue to be
successful, we still have work to do. We work daily on improving our
current programs, expanding needed services, increasing access to high
quality care and building new, needed programs. We continue to educate
providers on the appropriate usage of telehealth and how it can help
improve their practice and patients' health. We also continue to
educate patients on how telehealth can improve access to high quality
care close to home.
One of the greatest opportunities for the use of telehealth is in
chronic disease management and prevention. Our remote patient
monitoring program has demonstrated success in helping patients learn
about their disease, engage in their own health and empowers them to
improve their overall health.
Remote patient monitoring (RPM) is chronic disease management
delivered to the patient where they live. This program started as a
public private partnership in Sunflower County Mississippi as an
attempt to address the overwhelming diabetes issue in the Mississippi
Delta. The program provides patients with the education, engagement and
empowerment they need not only to manage their disease, but also to
improve their overall health status. The preliminary results from this
pilot study exceeded our expectations with the following results:
decrease of Hemoglobin A1C of 1.7 percent, 96 percent medication
adherence, high rate of compliance with the daily health sessions and
zero ER visits or hospitalizations over the first 6 months of the
program. This resulted in a real savings of $339,000 for the first 100
patients during the first 6 months. The Mississippi Division of
Medicaid extrapolated this data and estimated that if 20 percent of the
diabetics on Mississippi Medicaid participated and had similar results,
the savings would be $189 million per year. The pilot project ended in
September of 2016, and we expect final results in the next 3 months.
We have expanded this program statewide and now manage multiple
chronic diseases. These diseases include adult and pediatric diabetes,
hypertension, heart failure, kidney transplant and bone marrow
transplant. We will soon offer adult and pediatric asthma, chronic
obstructive pulmonary disease (COPD) and other chronic diseases. This
program allows patients to not only have real time monitoring, but also
educates them daily on their disease and how to manage it.
While the management of chronic disease is extremely important, we
also are working to prevent chronic disease and are developing virtual
prevention programs to assist with this effort. These virtual
prevention programs use technology that the majority of Americans
already possess and allow them to follow proven prevention programs
from their own homes. These programs benefit the great number of
Americans who are already at risk for developing chronic diseases.
There are many important ways that telehealth can improve
healthcare delivery and the overall health status of our state and
nation. Telehealth allows us to maximize our limited healthcare
workforce and reach patients where they live. Telehealth is the only
way that we are going to spread our current resources and improve
access to care.
______
Questions Submitted by Senator Tammy Baldwin
Question. Dr. Galpin: you stated there were ten pilot projects
within the VA working on telestroke. Can you provide the committee with
the locations of these pilot projects?
Answer. VA is committed to providing the best and fastest acute
stroke care to Veterans. In an effort to increase Veteran access to
acute stroke care expertise, VA is implementing the first nationwide
telestroke program.
On March 23, 2016, VA leadership approved funding for a five-year
plan to establish a nationwide `hub and spoke' telestroke program.
The program uses mobile devices (tablets) at `both ends', to
connect patient `spoke' sites (i.e., VA emergency departments and
intensive care units that lack on-site stroke expertise) to VA provider
`hub' sites with on-call telestroke neurologists.
Veterans with acute stroke symptoms are assessed in real-time via
videoconferencing by the telestroke neurologist who advises the patient
site physician as to the recommended diagnosis and treatment.
VA has established a roster of VA telestroke hub neurologists
located throughout the country that are responsible for providing 24/7/
365 telestroke coverage and has selected the first 10 patient `spoke'
sites. Initial pilot implementation is expected before the end of
fiscal year 2017.
telestroke patient site selection criteria
VA chose the initial (Phase 1) telestroke patient spoke sites by
reviewing the following criteria:
--volume of stroke patients seen in the preceding fiscal year (fiscal
year 2015)
--response to a prior emergency department survey
--rurality of Veterans served
--lack of access to a nearby academic medical center
--availability of critical support services (CT scanner, CT tech on
call 24/7, STAT labs), and
--facility interest as expressed in an exploratory teleconference
with local leadership/key stakeholders, followed by an on-site
assessment of the most promising candidates. Initial sites were
also asked to help provide feedback and refine the program if
selected as a Phase 1 participant.
current/potential (phase 1) va telestroke patient spoke sites
1) VISN 21/Mather (Sacramento), CA
2) VISN 5/Martinsburg, WV
3) VISN 5/Clarksburg, WV
4) VISN 5/Beckley, WV
5) VISN 19/Muskogee, OK
6) VISN 23/Fort Meade, SD
7) VISN 1/Togus (Augusta), ME
8) VISN 15/Marion, IL
current (phase 1) va telestroke provider hub sites (with number
participating)
1) VISN 1/West Haven, CT (4 neurologists)
2) VISN 7/Birmingham, AL (1 neurologist)
3) VISN 8/San Juan, PR (1 neurologist)
4) VISN 9/Nashville, TN (2 neurologists)
5) VISN 16/Houston, TX (1 neurologist)
6) VISN 19/Salt Lake City, UT (1 neurologist)
7) VISN 20/Seattle, WA (1 neurologist)
8) VISN 21/Mather (Sacramento), CA (2 neurologists)
9) VISN 22/Greater Los Angeles, CA (1 neurologist)
10)VISN 22/Long Beach, CA (1 neurologist)
All telestroke hub providers are centrally credentialed and
privileged at the VA's Palo Alto Healthcare System, so that they can be
available as a virtual resource for any telestroke spoke site; in
addition to VA Palo Alto most VA telestroke providers are affiliated
with a host/home VA medical center, although a few are new to the VA
system and are solely telestroke providers though VA Palo Alto.
VA continues to recruit and credential appropriately trained,
experienced providers.
Please note that two VISN 12 sites, Iron Mountain, MI and Danville,
IL, have declined to participate in VA's national telestroke program at
the present time.
Question. A June 2015 VA Office of Inspector General healthcare
inspection report on the treatment of a veteran in Wisconsin
recommended that the VA, ``review current acute stroke treatment
policies, and assess the use of telehealth evaluation . . .'' The VA
Agreed with the recommendation and stated, ``At this time, VHA does not
have national or local guidance for Emergency Department stroke
management using telehealth.'' Please provide the committee with VA's
national guidance for Emergency Department stroke management using
telehealth.
Answer. VHA has developed a ``Telestroke Packet'' to guide facility
stroke management using telehealth. The packet includes a detailed
protocol, actions and guidelines, supplemental information, forms,
orders, templates, step-by-step instructions, checklists, and
Frequently Asked Questions. ``VA's telestroke packet is available upon
request.''
Question. Published on November 2, 2012, VHA Directive 2011-038
deals with the Treatment of Acute Ischemic Stroke (AIS). This VHA
Directive expired on November 30, 2016. Please provide the committee
with the current VHA Directive on the Treatment of AIS.
Answer. VHA Directive 2011-038 ``Treatment of Acute Ischemic
Stroke,'' future Directive 1155, has been drafted, undergone technical
review, and has been circulated internally to program offices and the
field for comments. The comments are currently being compiled and
addressed, and will undergo review by VHA medical ethics officials
regarding consent issues. After these issues are addressed, the final
reviews by VA leadership will take place before publication.
Question. The VA has three classifications of VA facilities for
stroke care: Primary Stroke Center, Limited Stroke Facility and
Supporting Stroke Facility. Right now, Supporting Stoke Facilities
(SSF) are not required to stock the clot-busting drug, TPA, yet each
year veterans present to SSF's with stroke symptoms. Can you provide
the committee with the number of veterans who presented at a SSF with
stroke symptoms in 2016, or in the previous year in which that data is
available? If this data is not available, please inform the committee
if it is because the data is not collected, or if it is because the VA
cannot aggregate the data from each SSF.
Answer. In calendar year 2016, 2,338 Veterans presented to a VA
supporting stroke facility (SSF) with stroke symptoms.
SUBCOMMITTEE RECESS
Senator Moran. We will stand adjourned.
[Whereupon, at 12:12 p.m., Thursday, May 4, the
subcommittee was recessed, to reconvene at a time subject to
the call of the Chair.]