[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.]