    [Senate Hearing 116-471]
    [From the U.S. Government Publishing Office]

                                                            S. Hrg. 116-471

                         VA TELEHEALTH DURING AND BEYOND
                     COVID	19: CHALLENGES AND OPPORTUNITIES
                                IN RURAL AMERICA

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

                                    HEARING

                                   BEFORE THE

                         COMMITTEE ON VETERANS' AFFAIRS
                              UNITED STATES SENATE

                         ONE HUNDRED SIXTEENTH CONGRESS

                                 SECOND SESSION

                                   __________

                                 JULY 29, 2020

                                   __________

           Printed for the use of the Committee on Veterans' Affairs

    [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

            Available via the World Wide Web: http://www.govinfo.gov

                                    __________

                        U.S. GOVERNMENT PUBLISHING OFFICE
    45-201 PDF                 WASHINGTON : 2021

    -----------------------------------------------------------------------------------

                         COMMITTEE ON VETERANS' AFFAIRS

                         Jerry Moran, Kansas, Chairman

    John Boozman, Arkansas               Jon Tester, Montana, Ranking
    Bill Cassidy, Louisiana                  Member
    Mike Rounds, South Dakota            Patty Murray, Washington
    Thom Tillis, North Carolina          Bernard Sanders, (I) Vermont
    Dan Sullivan, Alaska                 Sherrod Brown, Ohio
    Marsha Blackburn, Tennessee          Richard Blumenthal, Connecticut
    Kevin Cramer, North Dakota           Mazie K. Hirono, Hawaii
    Kelly Loeffler, Georgia              Joe Manchin III, West Virginia
                                         Kyrsten Sinema, Arizona

                      Caroline R. Canfield, Staff Director
                    Tony McClain, Democratic Staff Director

                                C O N T E N T S

                                  ----------

                            Wednesday, July 29, 2020

                                    SENATORS

                                                                       Page
    Moran, Hon. Jerry, Chairman, U.S. Senator from Kansas............     1
    Tester, Hon. Jon, Ranking Member, U.S. Senator from Montana......     3
    Manchin III, Hon. Joe, U.S. Senator from West Virginia...........     9
    Boozman, Hon. John, U.S. Senator from Arkansas...................    11
    Hirono, Hon. Mazie K. U.S. Senator from Hawaii...................    13
    Cassidy, Hon. Bill, U.S. Senator from Louisiana..................    16
    Blumenthal, Hon. Richard, U.S. Senator from Connecticut..........    18
    Loeffler, Hon. Kelly, U.S. Senator from Georgia..................    19
    Sinema, Hon. Kyrsten, U.S. Senator from Arizona..................    21

                                   WITNESSES

    Dr. Kameron Matthews, Assistant Under Secretary for Health for
      Community Care, Veterans Health Administration; Accompanied by
      Dr. Kevin Galpin, Executive Director of Telehealth Services,
      Veterans Health Administration; Dr. Thomas Klobucar, Executive
      Director, Office of Rural Health, Veterans Health
      Administration; and Mr. Eddie Pool, Executive Director,
      Solution Delivery, IT Operations and Services, Office of
      Information and Technology, U.S. Department of Veterans Affairs     4

                                    APPENDIX

    Hon. Jerry Moran, Chairman, prepared statement...................    26
    Dr. Kameron Matthews, prepared statement.........................    28
    American Federation of Government Employees, AFL-CIO, prepared
      statement......................................................    35

    Response to hearing questions submitted by:
      Hon. Jon Tester................................................    42
      Hon. John Boozman..............................................    56
      Hon. Marsha Blackburn..........................................    59
      Hon. Mazie K. Hirono...........................................    62
      Hon. Kyrsten Sinema............................................    66
      Telehealth Hearing Deliverables................................    80

                        VA TELEHEALTH DURING AND BEYOND
                     COVID-19: CHALLENGES AND OPPORTUNITIES
                                IN RURAL AMERICA

                                  ----------

                            WEDNESDAY, JULY 29, 2020

                                           U.S. Senate,
                                Committee on Veterans' Affairs,
                                                        Washington, DC.
        The committee met, pursuant to notice, at 2:03 p.m., in
    room SD-G50, Dirksen Senate Office Building, Hon. Jerry Moran,
    Chairman of the Committee, presiding.
        Present: Senators Moran, Boozman, Cassidy, Rounds, Tillis,
    Sullivan, Blackburn, Loeffler, Tester, Brown, Blumenthal,
    Hirono, Manchin and Sinema.

                  OPENING STATEMENT OF CHAIRMAN MORAN

        Chairman Moran. Good afternoon, everyone. The committee
    will come to order.
        We are here today in this hearing to discuss the Department
    of Veterans Affairs' use of telehealth as a modality to deliver
    care to veterans, especially those in parts of America that are
    rural, highly rural, or Tribal lands.
        For my entire time that I have been a Member of Congress, I
    have been a proponent of telehealth as a way to deliver care to
    veterans and, in fact, to all patients, particularly those in
    Kansas, and especially those who live in rural areas. It has
    great potential.
        Currently, we see these capabilities being utilized for an
    even greater share of veterans due to the pandemic of COVID-19.
        COVID-19 has unexpectedly accelerated the process of
    expanding the VA's use of telehealth. In recent years, the VA
    had advanced its capabilities, but in the spring of this year,
    as the country and the VA prepared for the anticipated spread
    of the novel coronavirus, telehealth was often the only safe
    option to provide care.
        The consolidation of resources at VA medical centers,
    postponing non-urgent in-person care, and restrictions placed
    on referrals to Community Care fueled a more widespread use of
    telemedicine.
        As we continue to move toward a new normal, it is essential
    that the VA optimize the use of telehealth delivery where it
    works best, build on the lessons learned where it can be
    enhanced, and recognize the limits of its utilization.
        Telehealth has great promise, and the unexpected expansion
    of telehealth has yielded great knowledge in the last few
    months. There are many times where it is practical for a
    veteran to see their provider through VA Video Connect or even
    through just a conversation by phone. While this flexible and
    time-saving modality can be great in many ways, we know
    telehealth cannot entirely replace the need for face-to-face
    medical appointments. This is true as it relates to access to
    care in the community, and the VA must ensure the full
    implementation of the MISSION Act to increase access to
    Community Care is pursued.
        The limitations of telehealth are also amplified for those
    living in rural America or Indian Country. VA Video Connect
    only works when you have a broadband connection at a certain
    speed. In many parts of our country, that reliable broadband
    service simply is not an option.
        I am disappointed the VA chose not to participate in a
    recent listening session led by this committee with key
    stakeholders from across the medical community,
    telecommunications industry, VSOs, and other Federal agencies.
        As of 2019, rural veterans make up approximately one-third
    of VHA enrollees and are, on the average, older than their
    urban veteran peers, tend to experience higher degrees of
    financial instability, and often live with a greater number of
    complex medical health needs and co-morbidities.
        Many veterans in rural America and Indian Country live
    prohibitively far from VA facilities, which underscores both
    the need for innovative solutions on how to reach them and the
    importance of access to Community Care.
        For rural and tribal veterans, the geographic barriers to
    VA care often go hand-in-hand with poor or nonexistent
    connectivity to broadband necessary for high-quality care via
    telehealth. I applaud the VA's outside-the-box thinking with
    regard to creative partnerships with the private sector and VSO
    community and the distribution of wireless devices to isolated
    veterans.
        Additionally, I am interested in learning from our
    witnesses today, the progress the Department has made on
    forming agreements with telecommunications companies to provide
    subsidized short-term internet access to rural veterans. This
    was a provision I was proud to champion in the CARES Act in an
    effort to better serve the mental health care needs of rural
    veterans, especially during a time of social isolation during
    COVID-19, and look forward to hearing the progress the VA has
    made on this front.
        It is also important to note, in addition to skyrocketing
    numbers of telehealth appointments, the VA has also been called
    on to fulfill its Fourth Mission across 46 States, including my
    home State of Kansas, as well as the District of Columbia,
    Puerto Rico, and the Navajo Nation.
        As we look forward to both the near-term needs and long-
    term goals, the VA should make certain that the innovation of
    telehealth is utilized in the most efficient and appropriate
    way.
        I look forward to hearing from all of our witnesses today
    on these challenges and opportunities and how we can work
    together to best leverage this modality to address long-
    standing access to care issues.
        I understand that it has not been easy to adjust how the VA
    delivers care, especially at the rapid pace the COVID-19
    pandemic has required. I thank the VA for its work, and I thank
    them for being here today.
        I want to yield now to my colleague, Senator Tester, who
    may be in the Indian Affairs Committee, where I am also
    supposed to be.
        Senator Tester?

                  OPENING STATEMENT OF SENATOR TESTER

        Senator Tester. No. I have got a few minutes before either
    one of us have to get there, but I want to thank you, Mr.
    Chairman, for holding this hearing.
        Chairman Moran. Jon, we need greater volume.
        Senator Tester. Good God. That is always a problem, but I
    will work on it.
        I want to thank you, Mr. Chairman.
        Chairman Moran. I am glad we raised the volume and allowed
    you to say that. I have never asked you to speak louder to me
    before.
        Senator Tester. Can you hear me now? I feel like an
    internet provider.
        Chairman Moran. I can hear you now.
        Senator Tester. You can hear me?
        Chairman Moran. Yes.
        Senator Tester. Good deal.
        Well, I will say it for the third time. I want to thank
    you, Mr. Chairman, and I also want to thank our witnesses for
    being here today.
        VA's recent efforts to expand telehealth options deserve a
    lot of praise. The Department has prioritized the health and
    well-being of its patients while working to keep its work force
    safe, and for that, you need to be commended.
        However, a 75 percent increase in daily telehealth
    appointments as of May has not been without its challenges.
    Today's hearing is going to offer us an opportunity to take
    stock of where the VA is now and to discuss further steps that
    can be made to improve the care provided to veterans.
        I want to hear directly from the VA, the Nation's largest
    integrated health care system, about the challenges that it is
    facing and what it is doing to address them.
        In Montana, many vets, especially those in highly rural
    areas, are accustomed to virtual appointments, but we need to
    remember that not all veterans have access to smart telephone
    technology or reliable internet access. To address these
    technological shortcomings, I know the VA has conducted nearly
    6 million more telephone appointments with veterans compared to
    the same period last year. What more can we be doing to make
    these visits more valuable for the patients and the providers,
    and how are providers coping with a change in practice? We need
    to ensure that VA staff is supported and have the tools that
    they need to adequately care for our vets.
        We especially need management to work with employees in
    good faith to hear what the folks on the ground think about
    virtual or telephone care and what suggestions they have for
    improvement. That effort by the VA leadership will pay off
    greatly, particularly when the health care system is
    experiencing increased demand and has a staff at risk of
    burning out as the coronavirus pandemic continues to rate.
        As VA begins to reopen certain service lines in some
    facilities, it will be important to monitor the shift from
    telehealth appointments to in-person appointments. Many
    veterans may still feel uncomfortable seeing their providers
    face-to-face and will want to continue to utilize telehealth
    services. We need to make sure that that opportunity and the
    resources for that ongoing care are available.
        And as hotspots and surges move from one location to
    another, VA's ability to expand and retract its telehealth
    capabilities will be critical. Therefore, it will be important
    to monitor whether the CARES Act funding is adequate to meet
    ongoing telehealth demand or if the successor COVID packages
    will need to include additional emergency funding to provide
    these services to veterans, and we will need a good accounting
    of where the appropriated funds are being spent in order to
    make informed decisions on a path forward.
        I want to again thank the Chairman, and I want to thank the
    VA team for being here and being a part of this conversation. I
    look forward to this hearing.
        Chairman Moran. Senator Tester, thank you very much.
        We are going to take a pause. So we will stand in recess
    just for a moment while we fix one of our own technical
    glitches so we can hear our witnesses who are appearing
    virtually.
        [Recess.]
        Chairman Moran. So the committee will resume its work.
        Thank you, Senator Tester, for your comments, and let me
    now introduce the witnesses from the Department of Veterans
    Affairs.
        Dr. Kameron Matthews is the Assistant Under Secretary for
    Health for Community Care, Veterans Health Administration. Dr.
    Kevin Galpin is the executive director of Telehealth Services,
    Office of Connected Care, Veterans Health Administration; Dr.
    Thomas Klobucar, executive director, Office of Rural Health,
    Veterans Health Administration; and Mr. Eddie Pool, the
    executive director, Solutions Delivery, IT Operations and
    Services, Office of Information and Technology, Department of
    Veterans Affairs.
        I thank you all for being here in person or virtually by
    connectivity, and we are grateful for your presence.
        Dr. Matthews, I understand you are speaking for the group
    of VA witnesses today instead of individual Statements from
    each of our witnesses. As such, you are now recognized for 5
    minutes to delivery your testimony.

      STATEMENT OF KAMERON MATTHEWS; ACCOMPANIED BY KEVIN GALPIN,
                     THOMAS KLOBUCAR AND EDDIE POOL

        Dr. Matthews. Thank you so much, sir.
        Good afternoon, Chairman Moran, Ranking Member Tester, and
    distinguished members of the committee. I appreciate the
    opportunity to discuss VA's telehealth activities during the
    COVID-19 pandemic.
        I am accompanied today by Dr. Kevin Galpin, Executive
    Director of Telehealth Services in the Offices of Connected
    Care; Dr. Thomas Klobucar, Executive Director of the Office of
    Rural Health; and Mr. Eddie Pool, Executive Director, Office of
    Information and Technology.
        This is a transformational time in U.S. health care,
    accelerated by the unprecedented challenge of the COVID-19
    pandemic. VA is proud to be leading the response to COVID-19
    beside our Federal partners. As a result of early proactive
    planning and the unmatched dedication and resilience of the VA
    work force, we are continuing to deliver excellence for the
    more than 9 million veterans who entrust us with their care.
        In addition, we consider it a privilege to be the backstop
    to the Nation's health care system, serving veteran and
    civilian Americans in 46 States and the District of Columbia
    through our Fourth Mission, providing testing and supplies, and
    deploying more than 1,000 personnel in support of community
    facilities in areas of the Nation most severely affected by
    COVID-19.
        VA has been open throughout the pandemic for all in-person
    care where clinical urgency rises above the risk of COVID-19,
    and we are now expanding in-person services at more than 100
    sites.
        We are grateful for the opportunity today to discuss a key
    area where VA's early and proactive commitment to innovation
    and health care delivery is paying significant dividends for
    those we serve; that is, telehealth. VA has long been
    recognized as a national leader in telehealth, and together
    with our strategic partners, we are rapidly advancing our
    vision to leverage telehealth to enhance the accessibility,
    capacity, quality, and experience of VA health care for
    veterans, their family members, and their caregivers anywhere
    in the country.
        Continued expansion and deep integration of telehealth into
    clinical and technical operations is an essential element of
    our strategy. Telehealth can make it easy and enjoyable for
    veterans to partner with VA in optimizing health, and it can
    enhance the delivery of health care, enabling expert
    consultation, facilitating remote management of acute and
    chronic conditions, and enhancing coordination of care.
        VA's early investment in virtual technologies, including
    our patient portal, My HealtheVet, provided a solid foundation
    for VA's agile and effective response to COVID-19. More than 60
    percent of primary care and mental health providers had already
    used video telehealth prior to the pandemic, and VA delivered
    more than 2 million episodes of care through telehealth in
    Fiscal Year 2019, with approximately a third of the veterans
    served living in rural areas.
        In a matter of weeks, at the beginning of this pandemic,
    that solid foundation enabled us to increase video telehealth
    delivery to veterans' homes by more than 1,000 percent. We have
    delivered more than 9 million additional virtual care
    interactions this year over last year, and the numbers continue
    to grow.
        Achieving this progress required strong cross-functional
    partnerships. The Veterans Health Administration and the Office
    of Information and Technology have worked closely at all levels
    of the organization to address and stay ahead of the
    anticipated increase in demand for virtual care. Our IT
    colleagues strengthen and enhance the existing environment and
    are continuously monitoring and optimizing its performance. New
    and enhanced capabilities improve telehealth visit performance
    and quality, and new scalable options expanded access, tripling
    the concurrent use of capacity of VA's video telehealth
    platform and enabling care delivery in a location of a
    veteran's choosing, such as at home.
        Importantly, amidst the collective stress of this time,
    this capacity has allowed VA to provide over 1.5 million
    telemental health visits to more than 400,000 veterans so far
    this year. We want each veteran to know that VA is here for
    them, that we will meet them where they are, and that we
    believe in their resilience.
        Expanded capacity has also advanced our other critical
    operations, including the tele-Intensive Care Unit program,
    which brings remote monitoring and consultation to augment care
    teams at the bedside of critically ill patients, and
    meaningfully, the benefits of added technical capacity are not
    just clinical. This also enables personal connectedness for
    veterans residing in community living centers or even
    hospitalized to connect with loved ones.
        VA has continued to work with Tribes and Indian Health
    Service to develop standardized processes to ensure that
    veterans who require care among the various health care systems
    receive one coordinated approach in getting the services they
    need in the environment they choose. VA is planning a Tribal
    Consultation later this summer with the Tribes to deploy the
    approved plan.
        VA appreciates the continued support of Congress regarding
    telehealth, including through the recent Coronavirus Aid Relief
    and Economic Security Act, which provided the supplemental
    funding needed for VA to invest in enhancing and expanding our
    systems and technology.
        Recent legislation such as the MISSION Act, which
    authorized Anywhere to Anywhere telehealth, has also been
    pivotal to that advancement.
        VA is committed to providing excellence for each veteran in
    our care, even and especially during these unprecedented times.
    We will continue to lead the way forward, and we are grateful
    for your continued support, as it is essential to provide care
    for veterans and their families.
        This concludes my testimony. My colleagues and I are
    prepared to answer any questions that you may have.
        Chairman Moran. Doctor, thank you very, very much, and
    thank you to your colleagues for joining you.
        I want to ask my question to Dr. Galpin, at least my
    initial question.
        Could you detail for the committee the amount of CARES Act
    funding that has been spent to date on the total allocated for
    VA telehealth services?
        And in addition to that, I have been exploring with the VA
    for several months now, the issue of the amount of money that
    was allocated to the VA in the CARES Act, which gave the VA
    authority to form agreements with telecommunication companies
    to provide short-term complimentary internet services to rural
    veterans, and generally, when I have those conversations--let
    me get an answer to your first question, and then I will
    follow-up with my second one related to that topic. So total
    amount of money spent compared to what was allocated under the
    CARES Act?
        Dr. Galpin.
        [inaudible]--providers during the pandemic. So far, since
    March 1st and through July 15th, we have spent over $69 million
    on COVID-related requirements, of which $57.8 million came from
    the CARES Act funding.
        We have used that to provide over 30,000 4G-connected iPads
    to veterans. For providers, we have bought 12,000 iPads, 24,000
    webcams, 22,000 headsets, 10,000 speakers. We have expanded our
    help desk. That was a big challenge for us early on. It was
    just the amount of calls we were getting to the help desk as we
    expanded. We practically quadrupled the staff there.
        We are funding some research to make sure we learn from
    this event, and we are expanding our telecritical care program
    with that funding as well. So, yes, that has been critical, but
    the number, I think you are looking for is just over $57
    million so far.
        Chairman Moran. $57 million so far out of the amount that
    was appropriated which was what?
        Dr. Galpin. Ours was about $250 million. It included
    teleradiology as well, and a large chunk of that was for the
    telecritical expansion, which we are just about to undertake.
        Chairman Moran. Thank you very much.
        The second part of this question is, when I have raised
    these topics before, I generally hear about iPads and Walmart.
    What I have not found an answer to is, How did the VA utilize
    that provision to create agreements with telecommunications
    company to provide services to rural veterans?
        Dr. Galpin. Yes, it is a great question. Fortunately, we
    have an office, a Strategic Partnership Office, and we have
    been working really for a while now to develop partnerships
    with organizations, with internet service providers or cellular
    providers to try and expand connectivity to veterans in rural
    communities, wherever they may be.
        In telehealth, we realized when we were trying launching
    our Anywhere to Anywhere initiative that that was critical. We
    could build these fantastic programs, but if a veteran cannot
    receive it on the other end, it does not make a difference.
        So we already have partnerships with T-Mobile, with Sprint
    which is owned by T-Mobile, with Verizon, with SafeLink by
    TracFone help support veterans. We are using VA Video Connect
    to make data.
        As you know, as you mentioned, we have partnerships with
    Walmart, with veterans service organizations, and with Philips
    to develop our ATLAS sites in rural communities where veterans
    do not have internet access or therapeutic environment.
        We have partnerships with Microsoft. Microsoft is helping
    us outline the areas in the country using both our data and FCC
    data when we have a population of veterans that do not have
    access to internet, and then they are going to help us go and
    identify additional partnerships to bring in Airband internet
    into those areas and help with digital scaling.
        Following the CARES Act, we did actually get some companies
    from the committee who are interested in partnering with us. We
    have met with those. A lot of them are interested in helping
    out with the ATLAS program. I think that seems to be a real
    strong concept that people want to support.
        The other area, which is great, is helping us co-promote
    the FCC Lifeline program. FCC Lifeline is a program a lot of
    veterans qualify for. We think it may be underutilized in the
    veteran population, and so we want to make sure veterans get
    that benefit. It is a subsidy of $9.25 a month for their
    internet or phone service, but if they are in Tribal or Native
    land, they can get up to $34.25 a month.
        So we are trying to reach out to more partnerships. In the
    next couple weeks, we are going to be releasing an RFI, Request
    for Information, to go out publicly to look for other companies
    that want to partner with us. We feel there is probably more
    people out there than we have been able to identify so far that
    would like to help out the scenario.
        I mean, it is amazing. Honestly, since we started the work
    with the Partnership Office, many companies are just absolutely
    ready to say yes when we talk about supporting veterans in the
    digital divide. It is an issue that people recognize really
    needs a broad coalition and a lot of support.
        Chairman Moran. Thank you, Dr. Galpin.
        Let me ask you. I assume that if I ask my staff to delve
    deeper into the details of those partnerships, you and your
    team would be cooperative in providing us that information.
        Dr. Galpin. Yes. We would love to collaborate with you and
    your team on this. Again, this is a big issue and very
    important to us.
        Chairman Moran. Thank you for your efforts and your
    testimony.
        Let me ask just a question that is worth more than the time
    I have. But, Dr. Matthews, can you explain how expanded
    telehealth services will impact access standards for community
    care?
        Dr. Matthews. Sure. This was----
        Chairman Moran. Go ahead.
        Dr. Matthews. Sorry.
        Chairman Moran. You anticipated my question.
        Dr. Matthews. Yes. This was actually a very early
    conversation, actually, that I had with Dr. Galpin and others
    in VA, how could--how should, actually, we approach the
    eligibility standards.
        Currently, telehealth, unfortunately, does not impact them,
    and unfortunately, I mean, in the sense that it actually would
    take some regulatory change, so we could not do really any
    quick changes during the pandemic.
        The idea is that telehealth is offered. If a veteran
    accepts that care, it will, of course, be coordinated, but
    otherwise it does not affect their eligibility. Eligibility is
    only determined by face-to-face services at this point.
        Chairman Moran. Thank you very much.
        When you say at this point, you are suggesting there is a
    change coming?
        Dr. Matthews. There is always at least reconsideration. I
    think you would expect us to continue to improve upon how we
    provide access, and if telehealth--especially in specialty
    services is available and especially with our quality of care
    and when, of course, it is clinically appropriate. I think
    there is always going to be consideration that perhaps
    telehealth would be a major, meaning primary form of delivery.
    It could never replace face-to-face 100 percent. That is in no
    way the concept there, but perhaps initial consultation,
    follow-up visits, and the like. So it would be actually as the
    MISSION Act promotes more of an integrated platform with face-
    to-face care in the community.
        Chairman Moran. Thank you. Senator Manchin?

                          SENATOR JOE MANCHIN

        Senator Manchin. Thank you, Mr. Chairman. I appreciate it
    very much, and thank you, Doctor, for being here.
        I have introduced the HOTSPOTS bill, which would expand our
    Government's ability to purchase and distribute internet-
    connected devices to libraries and low income in rural areas,
    and I encourage my Senate colleagues really to look into this.
    And, hopefully, we get this into the next package we are
    working on right now for the COVID relief package.
        So many rural areas, especially rural Appalachia, does not
    have any connectivity whatsoever, but we have been able to
    hotwire, basically, a wireline into all rural libraries. This
    would allow--if a hotspot could be given to a veteran, they
    would be able to connect for telehealth. Right now, they
    cannot. All they are doing is audio health.
        So my question, can you give me a sense of where all
    these--you spent $38.9 million, I am understanding, from the
    CARES Act on telehealth initiatives and equipment for both
    veterans and providers. You all reported distributing more than
    46,000 iPads to veterans and providers for accessing and
    facilitating telehealth appointments and also reported an
    additional 22,000 iPads are on order.
        So my question would be, Can you give me a sense of where
    all the devices are going? Are they all network-enabled? I want
    to make sure that, hopefully, my State of West Virginia is
    getting its fair share, and can you share a full report of
    where they have been distributed?
        Can anybody speak to that?
        Dr. Galpin. I can speak to that. I do not have that data
    with me, but we have--we can get that breakdown for you after
    the hearing, if we can take that back for the record as to
    where they are distributed.
        Senator Manchin. Can you also determine where the VA
    telehealth infrastructure resources are going and how you are
    helping veterans with high-speed internet access? That is what
    we are having problems with. There is no use to have an iPad if
    you have no connectivity. So I hope you are looking at----
        Dr. Galpin. Correct.
        Senator Manchin [continuing]. the challenges that we have.
    Whether it is rural West Virginia, rural Arkansas, rural North
    Carolina, rural Kansas, wherever it may be, we have got
    problems, and to get quickly to help these people, HOTSPOTS
    would be the quickest way we can get them set up to something.
        Dr. Galpin. Yes. Let me provide some feedback on that. I
    think that was a question about what we are doing. So let me go
    through the broader list because you are absolutely right. This
    is a critical issue for us, and it is impossible for us to
    deliver telehealth services where there is not internet
    connectivity.
        There was an FCC report that was released last year that
    said 2.2 million veteran households do not have fixed or mobile
    broadband internet.
        Senator Manchin. First of all, if I can correct you on one
    thing. We have proven the FCC maps are totally incorrect. They
    are totally incorrect. That is why we are holding up some of
    their money until they get the maps corrected. So I hope you
    are not working off of their old maps because they have even
    agreed they are incorrect.
        Dr. Galpin. Well, I think irrespective of whether we are
    looking at the maps, we recognize that this is a problem. I
    mean, for the reason that you just described, when we talk to
    our providers and get their satisfaction surveys back--we just
    had one from one of our VISNs where they interviewed or got
    feedback from 1,600 providers, and one of the biggest
    challenges they face is the veteran not having the internet or
    the equipment on their end. And that is, again, why we launched
    an initiative to bridge the digital divide for veterans.
        I can tell you it is something we cannot do alone. I mean,
    this is a huge issue, and the VA is not going to solve it
    alone. That is why we need cross-administration, collaboration
    with Congress, public-private sectors. There is a tremendous
    amount of work to do.
        Senator Manchin. Well, I know you have all used solutions.
    One of your solutions was offering veterans to use store for
    telehealth options at places like Walmart, VFWs, American
    Legion halls through the ATLAS technology. The idea is that
    since a veteran does not have access to broadband at home,
    their local Walmart, VFW, American Legion would have better
    broadband.
        While it sounds promising, you have only opened six ATLAS
    sites in five States, and unfortunately----
        Dr. Galpin. That is correct. So----
        Senator Manchin. So what is the VA's plan to expand these
    telehealth sites?
        Dr. Galpin. So the ATLAS program, we think is very
    promising. Again, that is a public-private partnership that we
    have been working on.
        What we have done--and going back to your library concept--
    we have created a scheduling package, a scheduling system so
    that we can identify if there is an ATLAS site near a veteran.
    So we can set up libraries via a set of sites, Walmart sites.
    Wherever we have a therapeutic environment, internet
    connection, and veterans in that area, we can establish this.
        Now, we were beginning to open these sites, and we had a
    plan to get, I think, 11 prior to COVID. We did temporarily
    shut them down due to infectious disease concerns. We are now
    beginning to open them back up. The first one that opened was
    in Eureka, Montana. The Walmart sites are expected to open up
    by mid-August, and then we will continue on with the
    progression.
        But we agree. I mean, this is a huge issue. We need to get
    the services out there, and there is a lot of veterans that
    either do not have the connectivity in their home or the home
    is not a therapeutic environment. And these type of ATLAS
    locations that can be in their community, if not their home,
    would serve both needs.
        So this is a huge issue for us, and we are on the same
    page, as we need to solve it.
        Senator Manchin. Well, let me just say as a State with a
    high percentage, one of the highest percentages of veterans,
    and a very patriotic State like all of our States are, but West
    Virginia has a very high percentage. If you want to try
    something and see if it works, try West Virginia because if it
    will work in our hills and mountains and valleys, it will work
    anywhere.
        Dr. Galpin. I appreciate that. Thank you.
        Chairman Moran. Senator Manchin, thank you.
        I recognize Senator Boozman.

                          SENATOR JOHN BOOZMAN

        Senator Boozman. Thank you, Mr. Chairman, and thank you all
    for being here with your testimony.
        I want to give you a pat on the back. I believe in Central
    Arkansas, the VA there, it is up 1,000 percent, and the
    Veterans Health Care System of the Ozarks, I think it is up
    approximately almost 4,400 percent in regard to their ability
    to do telemedicine. So they truly are leading in the area, and
    we appreciate your support as we go forward.
        Senator Manchin was talking about the partnerships and
    things. Dr. Galpin, in the areas where the partnerships exist,
    even though there is not that many, are you seeing an increase
    in veterans using VHA to receive their health care? Is it
    working in the areas that are actually set up?
        [No response.]
        Senator Boozman. Maybe our technology is not working.
        Chairman Moran. Dr. Galpin, are you there?
        [No response.]
        Chairman Moran. Dr. Matthews?
        Senator Boozman. Yes.
        Dr. Matthews. I unfortunately cannot speak to numbers.
        Dr. Galpin. I do not know if anyone is having an issue, but
    we have not heard the questions or any of the comments in the
    last few minutes.
        Mr. Klobucar. I have not either.
        Chairman Moran. Can you hear now?
        Mr. Klobucar. I have not heard this time.
        Chairman Moran. Can you hear now?
        Senator Boozman. It is the story of my life.
        Dr. Galpin. Yes.
        Mr. Klobucar. We got it now. We can hear now.
        Senator Boozman. Okay. Good enough.
        What I was saying was that, first of all, we have had a
    tremendous increase in Arkansas. We are very proud of that.
    They are doing a great job, and we just appreciate all that is
    being done in that area.
        Senator Manchin talked about the partnerships. We would
    like to have more. In the areas, though, that we are actually
    doing the partnerships, what are the results? Are we seeing a
    significant increase in veterans using VHA as a result of that
    to get their health care?
        Dr. Galpin. I think I can address that, that question.
        Senator Boozman. Yes.
        Dr. Galpin. The partnerships for the past couple years have
    been focused on getting more video telehealth services out to
    veterans, and we had a strong program prior to this year. Last
    year, we did over 2.6 million episodes of telehealth care to
    over 900,000 veterans.
        But what you have seen happen this year has been just
    incredible growth with the pandemic. So already this year--and
    as we all know, this year is not over yet--we have already done
    3.6 million episodes of care to 1.2 million veterans. We have
    seen our use of Video Connect into the home, which is our
    platform that does deliver the video telehealth to the veteran.
    We have seen that grow by about 2,000 encounters a day to over,
    now touching, 32,000 encounters a day. It is over 1,000 percent
    increase.
        Fortunately, with the public-private partnerships, we have
    been able to advertise. We have been able to purchase more
    equipment. So we are seeing the growth out there. We are seeing
    that veterans are adopting the technology.
        We had some really nice feedback. The Veterans Experience
    Office just interviewed several veterans, about 43 in hour-long
    interviews. Overwhelmingly like telehealth, they prefer it over
    telephone because it makes them feel more connected to their
    providers and more comfortable with the visit.
        So I think we are getting the word out there. The public-
    private partnerships have been critical in helping us
    communicate, to advertise, and again, getting the veterans some
    of the services that they otherwise might struggle to get.
        Senator Boozman. Right. So you are truly the industry
    leader in the sense of doing telehealth and doing a great job.
    Your numbers are way up.
        I guess my next question--and you partly addressed it--but
    do we have enough data? Do we have the metrics? Not just the--
    you know, I like this on-the-phone type approach, but do we
    have the metrics on telehealth services to know that the
    quality of care and the outcomes of that care are better,
    worse, or equivalent to traditional in-person care?
        Dr. Galpin. Yes. There has been a good amount of research
    on this. So when you look at an area that I think is really
    important to us like telemental health, there is consistent
    research that shows that the quality of the telemental health
    visit is equivalent to care in person, and that crosses
    populations in the studies from civilians to veterans.
        We also have regular feedback from our veterans. So we do
    veteran satisfaction surveys to see how their experience is,
    and that is a little different than the outcome.
        But, in general, particularly pre-COVID, we saw very high
    satisfaction scores in telehealth: 96.9 percent in quality this
    year prior to March 1st, 87.9 in overall satisfaction, 87.3 in
    trust.
        Now, we have seen some dips in some of those satisfaction
    scores since COVID in the 3 to 5 percent range, but we had some
    action to help out with that going forward that we are excited
    about.
        In addition, we just, at one of our VISNs, interviewed
    providers and they asked about the quality there as well, and I
    think it was about 77.4 of the providers that do telehealth
    care was equivalent or better quality than delivering care in
    person with masks, and 81 percent felt that the care was more
    efficient or equal to delivering care in person with masks. And
    that actually exceeded the efficiency, exceeded care via
    telephone.
        So there are a lot of people that have studied this in the
    area--particularly in the area of mental health, and they do
    see that it is equivalent to traditional in-person care.
        Senator Boozman. Thank you, Dr. Galvin.
        Thank you, Mr. Chairman.
        Chairman Moran. Thank you, Senator Boozman.
        Senator Hirono?

                          SENATOR MAZIE HIRONO

        Senator Hirono. I was just listening to you, Dr. Galpin,
    talking about surveying veterans. Have you surveyed any
    veterans in Hawaii as to how they feel about telehealth?
        Dr. Galpin. I am fairly positive we have. We distribute
    surveys after our video visits. I do not have the breakdown
    here, but we can provide a breakdown. I think it is by VISN
    facility. So we can certainly get that information to you.

        [Please see page 80 for response]

        Senator Hirono. I would be curious to know, because I
    remember when the veterans are first given the option of doing
    remote telemedicine or some fashion of it. And I remember
    talking with veterans, albeit this was maybe a decade ago, and
    a number of them were quite resistant. And I think that what
    you are seeing, what you are telling me is that more of them
    are becoming used to this form of getting care, and that they
    consider it to be good, if not adequate.
        Dr. Galpin. Yes. Again, I will point to that Veterans
    Experience Office survey. That the veterans they interviewed,
    again, it was a small number, and I do not think that survey
    included anyone in Hawaii, but there was an overwhelming
    positive response to telehealth. Again, they preferred it over
    telephone because it made them feel more connected to the
    providers.
        In general, I would say that this pandemic has been eye-
    opening to people, I think providers and veterans alike. I
    mean, we have had thousands of providers do this for the first
    time, thousands--hundreds of thousands of veterans do it for
    their first time, and I think people have recognized the value.
    And they appreciate the type of services you can get through
    the video modality.
        Senator Hirono. So Senator Joni Ernst and I really pushed
    for telehealth across State lines, so providers across State
    lines could provide those services, and that this provision was
    included in the MISSION Act.
        This is for Dr. Matthews. In your testimony, you noted that
    this authority to go across State lines to provide services is
    pivotal for telehealth delivery for veterans.
        So could you provide a little bit more detail on how this
    kind of authority has extended access to health care, and is
    there any particular type of health care that particularly
    benefits from telehealth? And how many providers across State
    lines have utilized this authority to provide services to
    people outside of the State in which they practice? Dr.
    Matthews?
        Dr. Matthews. Sure. I will definitely need to defer the
    majority of that question back to Dr. Galpin, but overall, just
    to note within the Community Care program, we had at the onset
    of the pandemic in similar timing with CMS, did extend
    telehealth coverage within our Community Care episodes of care.
    So while we are also organizing it at massive quantities within
    the VA, it is available through our Community Care network as
    well too, including urgent care.
        But, Dr. Galpin, if you want to speak more about the
    provider concerns?
        Dr. Galpin. Yes, absolutely. And I will start out by just
    saying that the MISSION Act was absolutely critical for
    allowing us to move forward. That authority, which we call our
    Anywhere to Anywhere authority, allows us to feel comfortable
    delivering care on and off Federal property.
        So when we look at VA Video Connect, irrespective of the
    State laws, our providers are able to deliver care into a
    veteran's home. So it allows us to make care more accessible.
    It allows us to take the care that was being delivered in a
    community outpatient clinic and do it at that Walmart site,
    take it to the veteran's home, help them get health care in the
    community.
        The other big thing, though, and--oh, go ahead.
        Senator Hirono. Well, I wanted to know. Do you have a sense
    of how many providers are doing, providing this kind of care
    across State lines?
        Dr. Galpin. I do not have that number specifically.
        Senator Hirono. Are there participants?
        Dr. Galpin. I do not have that----
        Senator Hirono. Do you know whether there are thousands? If
    you have some idea? But if you do not, we move on because the
    fact is that it has expanded, telehealth accessibility.
        So for Dr. Matthews again--I am sorry.
        Did you want to add something else before I go on to the
    next question? If not, I am going to the next question.
        One of the questions I have--I think I am running out of
    time. So if you do not mind. Citizens of the Freely Associated
    States--that would be the Republic of Marshall Islands,
    Federated States of Micronesia, Republic of Palau--they serve
    in the U.S. military, and do so and retire then like the U.S.
    citizens, yet the VA cannot provide direct services to these
    veterans because they are prohibited from doing so in foreign
    nations, that this includes prohibition against providing
    telehealth services.
        So I would like to know. I mean, we need to do a statutory
    change in order to enable at least telehealth services to be
    provided to these citizens; is that correct? And have you----
        Dr. Galpin. Yes.
        Senator Hirono [continuing]. considered the feasibility of
    making that statutory change so at least telehealth services
    can be provided?
        Dr. Galpin. So I can address that. So, yes, it would
    require statutory change, starting with USC 1724. At present,
    we are prohibited from providing care internationally, and that
    is any type of care.
        We have thousands of veterans who utilize the VA system,
    who live internationally. They come to a State or to a
    Territory to get care, but then they return home. And to those
    veterans, we cannot provide the same type of service that we
    provide to a veteran in a State. They have to come for care in
    a State. So it would require----
        Senator Hirono. Yes, I understand all that.
        Dr. Galpin [continuing]. statutory change.
        Senator Hirono. Would you support--would the VA support a
    statutory change to enable this kind of service to be provided?
        Dr. Galpin. I can tell you that we have certainly looked at
    it. I really cannot get ahead of the Department's opinion on
    it. So I think that is something we would have to take back and
    have a broader discussion with our leadership on.
        Senator Hirono. Please do that because I think it is what
    we owe the citizens of these countries to provide them some
    level of health care.
        So one more question. I do not know what my time is, Mr.
    Chairman.
        Senator Boozman. [Presiding.] It is out.
        Senator Hirono. Well, there you go.
        Do you mind if I just ask one more short question, Mr.
    Chairman?
        Senator Boozman. One really short one. Thank you. Go ahead.
        Senator Hirono. This is for Dr. Klobucar about connectivity
    in Pacific Islands, and while that has improved, many
    communities in the Pacific--while it has improved, many
    communities--sorry--in the Pacific Islands still lack
    sufficient connectivity for telehealth. What is the VA doing to
    improve internet connectivity for extremely remote and rural
    island locations like those in the Pacific Islands? Very
    briefly, are you doing anything to address that concern?
        Mr. Klobucar. Hi. I am hoping you can hear me.
        As Dr. Galpin outlined before, we are seeking to work with
    community partners to make an attempt to do that and also
    investigating the possibility for local hotspots.
        Senator Hirono. Uh-huh.
        Mr. Klobucar. But that work is ongoing, and I do not know,
    Dr. Galpin, if you can elaborate any more on that.
        Dr. Galpin. I do not have too much to offer beyond what you
    said.
        I think the key is that this really needs a broad
    leadership coalition. I do not think we can take this on and
    get to where we need to be for veterans. I think we need to
    collaborate with Congress, committee, across administration,
    other Federal agencies to really reach the end zone on this
    really critical issue.
        So we would look forward to working with you all more on
    this, again, to get to where we need to be.
        Senator Hirono. Thank you very much.
        Thanks, Mr. Chairman.
        Senator Boozman. Thank you, Senator Hirono.
        Senator Cassidy?

                          SENATOR BILL CASSIDY

        Senator Cassidy. Thank you all.
        Dr. Galpin, I am interested in the--we have spoken about
    outcomes. An earlier question was about the outcomes of
    telemental health, for example, versus those in person.
        In some institutions, I know there has been a real problem
    with missed appointments, and I am interested whether
    compliance has actually improved or not. Is the reason for the
    noncompliance formally because someone just could not get there
    on time, but now they have taken care of that with telemental
    health, or is it just that their life is too disorganized to
    show up on time for anything? What have you all learned about
    that?
        Dr. Galpin. There is probably a good amount of studies on
    that, that I cannot quite today, but that is something we could
    find for you and bring back for the record.
        I was just going to look up--because I know we did a study
    for our tablet program, and let me just provide some of the
    data here that I have in my notes. So tablet recipients
    experienced an increase of 1.94; for psychotherapy encounters,
    an increase of 1.05; medication management visits, an 18.5
    percent increase; and their likelihood of receiving recommended
    mental health care necessary or continued care in the 20.24
    percent increase in their missed opportunity rate in a 6-month
    period following the receipt of a tablet.
        Senator Cassidy. I am sorry. So there is an increased
    missed opportunity rate or a decreased missed opportunity rate?
        Dr. Galpin. Decrease. I am sorry. I misquoted my own
    reading here. Decrease, 20.24 percent decrease in their missed
    opportunity rate in that 6-month period.
        Senator Cassidy. Now, is there any----
        Dr. Galpin. So, you know, again, their----
        Senator Cassidy. It is pretty soon to tell, but I would be
    curious. Clearly, veteran suicide has been a risk, and we have
    had different strategies of how to reach people. The ability to
    reach online might be something which would augment a telephone
    hotline. Has there been any effort to look at that, or is it
    too soon? But any kind of implications regarding that issue?
        Dr. Galpin. Well, I think the one thing we can say is that
    to help improve and decrease veteran suicide, we need to get
    the care to the veteran, and so however the veteran wants to
    get care, I think we need to provide as many options as
    possible. So, you know, telehealth is a great option----
        Senator Cassidy. I accept that. I am just wondering if this
    is--if all--if all avenues of providing care are created equal,
    and I think that is what we are trying to figure out here is
    the--empirically, on some of our biggest public health issues,
    suicide, for example, among veterans, is this something which
    just sounds good, or is it really going to pan out? But it may
    just be that it is too soon.
        Let me ask you as well, and this may be for you or Dr.
    Klobucar. We have obviously put a lot of money to expand the
    telehealth mental--the infrastructure. My hope is that that
    would decrease your unit cost of delivering care. It is a lot
    cheaper to have somebody in an office looking at a computer
    screen and going very efficiently one patient to the next than
    having a big waiting room and having all the attendant costs of
    clerks and aides, et cetera.
        So is there any chance that this initial investment will
    result in cost reduction opportunities after next fiscal year?
        Mr. Klobucar. Hi. Yes. I cannot really speak to cost
    reduction, although we can find out what that looks like and
    get back with you with those data.
        I think it is important to note and just to briefly refer
    back to what you said earlier that there are a number of
    programs that are Web-based programs that provide support for
    veterans online that are suffering from depression and post-
    traumatic stress disorder, and we have seen some significant
    uptake in that area. These are relatively new programs that the
    VA started in Fiscal Year 2019 or Fiscal Year 2018. So we
    expect those to continue to grow, particularly as our younger
    veterans grow older and our veteran population grows younger
    over time.
        So we are making a significant effort with several online
    programs that we hope will have some advantage in helping those
    veterans with post-traumatic stress disorder.
        As far as the numbers and the data and the cost per unit, I
    will definitely look into that for you and get back.
        Senator Cassidy. Maybe one last question. Are there any
    telehealth visits that are not appropriate? I am a physician.
    So, immediately, I think of the physical exam. You are quite
    limited what you can do for a physical exam, but are there any
    visits in which--somebody told me they want to do orthodontia
    by telehealth. How do you do orthodontia by telehealth?
        So what is out there that we kind of learned, ``Oh, it is
    better to have the people seen in person''?
        Dr. Galpin. The way we approach that--and I would say that
    every specialty could add a telehealth component now. Some
    specialties can do more of the care through telehealth, so
    telemental health. One of the reasons why it is so successful
    is they can do the vast majority of their care by that route.
    If you look at surgery, they can do pre-visit, post visit,
    obviously not the surgery itself.
        So it is less about that we find a specialty or type of
    care that we cannot delivery through telehealth. It is more
    about what portion of that care can we deliver through
    telehealth.
        Senator Cassidy. And let me ask you----
        Dr. Galpin. So there is really no absolute----
        Senator Cassidy [continuing]. one more question.
        Dr. Galpin [continuing]. yes or no.
        Senator Cassidy. Doctor, one more thing, I am a
    gastroenterologist. I think I knew at one time, the VA required
    somebody to drive in to be consented. Even if they lived 100
    miles away, they would have to drive in, get consented, return
    home, and then come back from the colonoscopy. It seemed very
    impractical, as anyone who has taken a colonoscopy prep can
    imagine.
        So the question is, will VA regulations allow people to be
    consented for a procedure like a colonoscopy remotely by a
    telehealth visit as opposed to having to drive in?
        Dr. Galpin. I believe the answer is yes to that, but I need
    to check back and make sure I am being consistent with the
    regulation. But, yes, I believe the answer is yes to that.
        Senator Cassidy. Please let us know that.

        [Please see page 81 for response]

        Okay. Thank you.
        I yield back. Thank you, Mr. Chairman.
        Senator Boozman. Thank you.
        Senator Blumenthal?

                       SENATOR RICHARD BLUMENTHAL

        Senator Blumenthal. Thank you, Mr. Chairman.
        We have a vote, which I understand has been called. So I am
    going to try to be brief.
        I know that the VA has provided some national statistics.
    Specifically, the telehealth video visits have increased by
    1,132 percent since February, rising from about 11,000 to
    138,700 appointments per week between February and June 2020,
    which is quite remarkable. Do you have statistics State by
    State specifically for Connecticut?
        Dr. Galpin. I do not have it with me for this hearing. I
    believe we can get those State by State.

        [Please see page 84 for response]

        Senator Blumenthal. Yes.
        Dr. Galpin. I believe we can.
        Senator Blumenthal. That would be great.
        Can you tell me--maybe you will have to get back to me
    about this one too--how well Connecticut is doing, VA in
    Connecticut is doing in terms of telehealth?
        Dr. Galpin. Again, I do not have State-specific information
    with us today.
        Senator Blumenthal. Okay. Can you tell me what--I know that
    you answered the question about generally the need to form a
    coalition to get different groups together to bridge the
    digital divide. My guess is it affects veterans not only in
    rural areas, but throughout the country, because it affects our
    general population throughout the country. It affects school
    students, the homework gap.
        I have been a major advocate of extending the Lifeline
    program, funding it more adequately. Commerce Committees had
    hearings on this issue.
        Is the VA working with the FCC on this issue?
        Dr. Galpin. Yes. The Lifeline program is actually something
    that we are very excited about. We have talked to them. We have
    had FCC representatives at our meeting.
        One of the things we are going to be doing in the next
    month is lodging a digital divide consult. So when a provider
    identifies that a veteran does not have technology or internet
    access, they can refer that veteran to a social worker.
        And one of those tools a social worker will have in their
    tool belt is the Lifeline program. They are going to do an
    assessment, assuming the veteran is interested, to see whether
    the veteran qualifies and then help them get connected to those
    benefits. Again, it is $9.25 a month for veterans, and if you
    are on Native land or Tribal land, it is $34.25.
        We would be interested in discussing what you are
    describing there as potentially an expansion of the benefits
    for veterans. That is something we would love to collaborate on
    and work together to discuss.
        Senator Blumenthal. Do you have an estimate as to what
    percentage of the veteran population lack connectivity? We hear
    about telehealth, but does the VA have an estimate on the
    percentage of its constituency?
        Dr. Galpin. Yes. So we have the data that the FCC provided
    last year in their report. In that report, they talked about
    2.2 million veterans of the veteran population they had as 18
    million not having access to fixed or mobile internet in their
    home. About 15 percent of veteran households do not subscribe
    to it, and there is about 364,000 veterans, about 0.2 percent
    of the veteran population that live in an area where they
    cannot get fixed or mobile broadband or fixed or mobile
    internet at sufficient speeds.
        So it is a large population out there, which is why it is a
    big concern for us.
        Senator Blumenthal. And just going back to the line of
    questions that Senator Cassidy asked, specifically concerning
    veteran suicide, does telehealth offer potential means of
    reaching out, providing counseling that so far have not been
    used as well as they should?
        Dr. Galpin. Well, I think specifically telehealth is one of
    the ways that we can make mental health care more accessible.
    Again, it is a lot about can we get services out to the
    veterans who need them in a way that they want to receive them.
        For some veterans, taking time off work is challenging,
    trying to find child care, to get to appointments, traveling
    the long distances. So telehealth is one of the ways that we
    can create quality visits where they can feel connected to
    their provider, but we can do it in an accessible way so that
    we are really lowering the activation energy threshold for a
    veteran to seek help.
        There is also value in the sense that some veterans, they
    do not want to get care in their community. They might be
    concerned about getting care from the mental health provider
    that they are going to see in a store. This allows them to get
    care at a distance in a therapeutic environment.
        So I think it is a huge way that we can get mental health
    care out to the veterans in a way that they want it. It does
    not mean it is going to work for everyone. Some people will
    prefer to come in, in person. Some people are going to prefer
    telephone, but again, we want to make sure all veterans have
    that option so they can get the care when they need it and they
    want it.
        Senator Blumenthal. Thank you. These topics are very, very
    important. My time has expired. Thank you for having this
    hearing, Mr. Chairman.
        Senator Boozman. Thank you, Senator Blumenthal.
        Senator Blackburn?
        [No response.]
        Senator Boozman. Senator Sinema?
        [No response.]
        Senator Boozman. We have got a vote going on. So we may
    have people who have left and will come back.
        Senator Loeffler?

                         SENATOR KELLY LOEFFLER

        Senator Loeffler. Hi. Can you hear me?
        Senator Boozman. Yes, perfectly.
        Senator Loeffler. Wonderful. Thank you so much, and thank
    you all for being here for this really important topic.
        Obviously, the COVID-19 pandemic really demonstrated the
    value of telehealth across the VA throughout so many areas in
    the health care system and continues to, and it is vitally
    important we continue to ensure that veterans regain access to
    the full spectrum of in-person care. But, obviously, for now,
    the demand for telehealth will continue to remain high, and
    that is why it is imperative that residents, fellows, interns,
    and other VA health care trainees are given the chance to
    experience the needed ability to provide care via telehealth
    during their supervised training instead of having to learn on
    the job or in person.
        And that is why I partnered with my Georgia colleague,
    Representative Buddy Carter, to introduce the VA MISSION
    Telehealth Clarification Act. It is a basic bill that allows
    supervised training to utilize telehealth technology throughout
    the delivery of care, and my version goes a step further by
    providing additional clarity on the types of qualified VA
    providers that can actually provide care through telehealth
    under the law. So it helps expand the VHA's capacity to provide
    much needed care through its existing work force. So I want to
    thank Congressman Carter for his partnership on that.
        My question really relates to, Dr. Galpin, if you could
    comment on any of the steps that are being taken by VHA to
    ensure that providers are trained to provide care, effective
    care really, through telehealth as well as any limiting factors
    that we need to be aware of as we start to integrate telehealth
    more into our delivery of health care to our veterans to go
    forward.
        Dr. Galpin. I appreciate that question and certainly
    appreciate the bill that has been proposed.
        Regarding your question about how we are working with
    providers to make them capable of doing telehealth, just to
    provide some context, last year as part of our Anywhere to
    Anywhere initiative, we set an objective that by the end of
    this year, 2020--this is pre-COVID--that all of our primary
    care clinicians and our mental health clinicians would be
    capable of offering video to the home.
        Last year, we got to about 60 percent, and now we are at
    just about 90 percent in both categories. The goal is always to
    have all of our ambulatory care providers capable of delivering
    video to home by the end of the next year.
        So what we are doing to that, we have national trainings
    the providers are taking. We are purchasing equipment for them.
    We are making sure their schedulers are capable of doing it,
    and so solely--well, not solely anymore, but we are moving
    toward, again, 100 percent capability there.
        When you talk about some of the things that we need to do,
    we still have a lot of work to do on enhancing the experience.
    We want to make this as simple as possible for both veterans
    and providers. So we are taking feedback from both groups and
    making sure we are updating our processes, updating our
    software to make sure it works for everyone.
        Some of the challenges, I think, you mentioned, what is
    hard, what needs to be done, this is an area where I think,
    again, we need collaboration with Congress. We are still
    navigating a very complex legal environment, despite the
    MISSION Act. Even with the MISSION Act, Clarity Act, which
    would be outstanding in letting us use all of our clinical
    resources, all of our clinicians to participate in telehealth,
    there is still a challenging combination of Federal and State
    laws that limit us in providing comprehensive care to veterans
    through the modality or are confusing to our providers and so
    in some ways makes it challenging for them to participate in
    certain types of care where they would otherwise like to.
        So I appreciate the question. I hope that I answered it and
    see if there is a followup.
        Senator Loeffler. That is very helpful. Thank you, Doctor,
    and obviously, we would be interested to learn about some of
    the challenges as they relate to Federal laws that would limit
    your ability to deliver care. So thanks so much for everything.
        I yield my time.
        Senator Moran. [Presiding.] If I understand where we are
    at, at the moment, it is Senator Sinema. Senator Sinema?

                         SENATOR KYRSTEN SINEMA

        Senator Sinema. Yes. Thank you, Mr. Chairman and Ranking
    Member Tester, for holding this hearing. And thank you to all
    of our witnesses for being here today.
        Since the start of the pandemic, the CDC and health experts
    have emphasized the need to social distance, wear face
    coverings, and wash hands frequently to minimize the spread of
    the disease. Our daily lives look very different now than they
    did earlier this year.
        Increased telework, distance learning, socializing, and
    telehealth have become more commonplace, but for many, access
    to broadband and devices still remains a challenge.
        In Arizona, the VA health system covers a lot of rural
    areas, and access to telehealth can be a major resource for so
    many in these areas, but telehealth cannot work without access
    to broadband.
        In addition to being a cosponsor of the Access to Broadband
    Act that was passed by the Commerce Committee a few months ago,
    I have repeatedly highlighted the importance of expanding
    broadband services, particularly during this pandemic.
        So my first question is for Dr. Klobucar. According to the
    Department of Commerce, 22 percent of American households do
    not have access to the internet from home, and this issue
    disproportionately affects Indian Country where 53 percent of
    homes do not have access to broadband networks.
        As VA expands telehealth services during the pandemic, what
    is the VA learning about broadband needs in rural and Tribal
    areas, and are barriers to access due to limitations of
    broadband a lack of devices or other critical infrastructure
    needs?
        Mr. Klobucar. Thank you for that question, Senator Sinema.
        I think as Dr. Galpin indicated before, this is an area
    that is a constant challenge for us in VA, especially when we
    talk about Tribal areas. We have expanded telehealth services
    into some Tribal facilities across the country, but those
    opportunities present themselves locally as local VA medical
    centers look for solutions to deliver care to these Tribal
    communities.
        Again, as Dr. Galpin said, this is something we cannot do
    alone. We do need the support of other agencies such as the
    U.S. Department of Agriculture Rural Utilities Service, such as
    the Federal Communications Commission, and others to try to
    reach into these Tribal lands where internet, broadband access
    is limited.
        The President's Broadband Interagency Working Group that
    formed about 2 and-a-half years ago was an attempt to address
    some of those problems, and as a result, the NTIA has
    established some Web resources for local internet providers to
    help them access Federal funds, but certainly more is needed.
        We are now with FEMA in Regions 1 and 2 to look for
    solutions in the region, and they are bringing together
    partnership with VA with USDA and with other national
    organizations to try to address some of these burning issues.
    This is an important issue for us, and it is something that we
    have been working with partners to try to address for a number
    of years. And we hope that the pandemic has made it
    increasingly evident that more needs to be done.
        Senator Sinema. Thank you.
        Dr. Matthews, my office is hearing from veterans in Arizona
    who have been seen via telehealth appointment, and they have
    concerns that they did not get the same level of care they
    would have gotten in person. How is the VA addressing these
    concerns among veterans who might be hesitant or concerned
    about the care they are receiving virtually, and what processes
    do you have in place to collect feedback from veterans in these
    appointments so we can improve the process?
        Dr. Matthews. Thanks so much for that question. I will
    definitely defer to Dr. Galpin about the different processes
    the veterans can use to change their different platform.
        We have instituted, even during this pandemic, a new
    Veterans Experience Survey focused on care associated with
    during this pandemic, and we are collecting that data now
    regularly. That survey just started July 10th, and we are
    getting information about their experience, both face-to-face
    care and telehealth, what their preferences would be for next
    visit and the like.
        So we will continue to improve upon how veterans'
    experiences are actually reflected. A lot of the questions even
    get down to their technology concerns. Were they able to see
    their provider clearly? Could they hear them clearly? Do they
    feel that their privacy concerns were addressed?
        So we are definitely taking the veteran experience into
    account, but, Dr. Galpin, if you want to go into some of the
    processes on how veterans can actually receive this care?
        Dr. Galpin. Yes. This is a really important area for us.
    Improving the veteran's experience, the family members, the
    caregiver's experience, that is part of our vision for
    telehealth in the VA.
        We regularly collect--we have surveys that go out to
    veterans post their telehealth visit. So we can see the data,
    what the experience is. We can see that for providers as well,
    and so this is something that we take very seriously.
        We are working with the Veterans Experience Office now.
    They were conducting interviews--I think I mentioned those
    before--that overwhelmingly veterans like telehealth, and they
    prefer it over a telephone. But we want to work with them to
    really map out the entire experience. From the moment that
    someone talks to them about telehealth and when someone is
    offering them help with the equipment to ask them do they have
    the right internet, would they want to do a test call, if
    things do not work during the appointment, then obviously the
    experience in the level of care is not going to be good.
        So our goal is to keep working on these areas, enhancing
    the processes, integrating the processes, and enhancing the
    technology so that we do meet expectations, but ultimately, we
    want this to be a choice for veterans.
        We are in a really unusual time right now, but if this is a
    modality that does not work for an individual veteran, we want
    there to be an option for them to say, ``I want in-person care.
    That works better for me,'' and that is really the right way to
    treat the individual, allow them to make their health care
    choices and to find their preferences.
        Senator Sinema. Thank you.
        Mr. Chairman, I have additional questions I will submit for
    the record. Thank you. I yield back.
        Senator Moran. Thank you, Senator Sinema.
        I think Senator Tillis is returning for an additional
    question, and I have a couple of additional questions. And then
    we will be close to wrapping up.
        Let me make certain--that Senator Sinema's question caught
    my attention, and I want to make certain that the answer is
    that a veteran who does not feel comfortable, does not want to
    utilize telehealth is not in any way coerced to do so.
        Dr. Matthews. Correct, sir.
        Senator Moran. Thank you.
        This would be Dr. Klobucar. Would you speak directly to the
    challenges the Department faces in providing virtual care to
    veterans in highly rural and frontier areas? What is the update
    that you would have on the VA Video Connect for a rural Native
    veteran project?
        Mr. Klobucar. Yes, sir. The Office of Rural Health's
    Veterans Rural health Resource Center in Salt Lake City has
    established a VA Video Connect project, and the goals behind
    this are to educate providers on delivering mental health care
    to Tribal nations, culturally sensitive mental health care, and
    also to deliver training for veterans who may wish to engage in
    that care.
        This is an ongoing program. We have trained dozens of
    providers so far. It is a relatively new program, and it is
    designed to enhance the VA Video Connect effort as we expand
    out into more and more Tribal areas. There is ongoing expansion
    planned for next year and the following years, and we are
    seeing positive results already.
        Senator Moran. Thank you.
        Dr. Galpin, I want to understand about the ATLAS telehealth
    pods. My understanding was they were closed at the start of the
    pandemic, and do you have an update on when those pods might be
    reopened?
        Dr. Galpin. Yes. The one in Eureka, Montana, has opened.
    The other ones, the Walmart sites, the plan is to open them in
    mid-August, and then we have another VSO site that we
    anticipate or we target for the end of September.
        As you noted, they were closed down, and we were concerned
    about infection risk. We have worked with infection control,
    with Walmart, to make sure that we have new protocols in place.
    They will maybe feel a little bit different. Hopefully, people
    will feel safe going to them, and that we do want to then
    reopen them and expand. But that is the timeline.
        Senator Moran. Thank you.
        This is not a filler question while we wait for Senator
    Tillis question, but I always give--at least I always attempt
    to give our witnesses an opportunity. Is there anything that
    you would like to make certain that I and the Committee hears,
    anything you would like to correct or wish that someone had
    have asked you that you would now like to answer?
        Dr. Matthews. Thank you for this opportunity, sir.
        I think I just want to echo really what our executive in
    charge, Dr. Stone, almost builds into his message. He builds a
    video message every day during the pandemic. It is actually
    something that has caused a great deal of just positive energy
    throughout VHA, and one of his messages that is regularly
    shared is just one of great gratitude for our VA staff.
        What it took for the administration to really respond to
    the pandemic, particularly in the March-April timeframe of
    converting to a very acute responsive mode, that took a great
    deal of energy. Even within my own office, the Office of
    Community Care is administrative completely. We are nowhere
    near the front line of actually taking care of patients.
        My own deputy, three of my staff actually volunteer to go
    to the front line to assist with emergency management, and that
    is just one office. There were others as well.
        So I would be remiss if I did not really recognize on the
    record just unbelievable commitment of the VA staff during this
    response.
        Senator Moran. Doctor, you are right and appropriate to do
    so, and I would be remiss if I did not agree with what you said
    and express gratitude on behalf of this committee and members
    of the U.S. Senate, but most importantly, our veterans for the
    efforts that were made to care for them during this time, which
    we wish would end sooner than it has. But we are grateful for
    those, and many of them are veterans themselves helping other
    veterans. So please express our gratitude for that
    circumstance.
        Let me see if we are going to conclude this meeting, and I
    am ready to do so, unless you tell me otherwise. Done.
        I thank our witnesses for being here, and thanks for
    bringing us some education and enlightenment. We have
    additional questions that would be submitted for the record. I
    would ask that the VA respond to those as soon as possible. The
    committee members should have those questions to the committee
    within 5 days.
        With that, our hearing is concluded.
        [Whereupon, at 3:17 p.m., the committee was adjourned.]

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