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

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

                                APPENDIX

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