[Senate Hearing 117-]
[From the U.S. Government Publishing Office]




 
 VA TELEHEALTH PROGRAM: LEVERAGING RECENT INVESTMENTS TO BUILD FUTURE 
                                CAPACITY

                              ----------                              


                       WEDNESDAY, APRIL 28, 2021

                           U.S. Senate,    
     Subcommittee on Military Construction,
             Veterans Affairs, and Related Agencies
                               Committee on Appropriations,
                                                    Washington, DC.
    The subcommittee met at 3:00 p.m. in room SD-138, Dirksen 
Senate Office Building, Hon. Martin Heinrich (chairman) 
presiding.
    Present: Senators Heinrich, Manchin, Boozman, Hoeven and 
Capito.

                     VETERANS HEALTH ADMINISTRATION

STATEMENT OF DR. STEVEN L. LIEBERMAN, ACTING DEPUTY 
            UNDER SECRETARY FOR VETERANS HEALTH 
            ADMINISTRATION

              OPENING STATEMENT OF SENATOR MARTIN HEINRICH

    Senator Heinrich. Good afternoon, everyone.
    This hearing of the Military Construction, Veterans 
Affairs, and Related Agencies Appropriation Subcommittee is now 
called to order.
    Well, that is a mouthful, is it not, Ranking Member 
Boozman.
    I would start by saying what an honor it is to serve as the 
chairman of this subcommittee.
    And I would like to thank Ranking Member Boozman for his 
leadership on this subcommittee as well. I look forward to 
working with you on a bipartisan basis to deliver for our 
Nation's veterans and their families.
    And I am proud to have several veterans in my family 
myself, and to serve a state that has one of the highest rates 
in military volunteerism in the country. Veterans deserve far 
more than just words of gratitude for their service when they 
come home. They deserve the quality of care and the benefits 
that they have earned with that service.
    In my chairmanship I will be especially focused on ensuring 
a robust COVID-19 vaccination program through the entire VA 
system, and providing better healthcare and housing assistance 
for veterans experiencing homelessness. Most are committed to 
improving the telehealth services that so many rural veterans 
in New Mexico and all across the country rely upon to receive 
their critical care.
    I would like to thank our witnesses for participating in 
today's hearing that will address VA's telehealth program: Dr. 
Lieberman, Acting Deputy Under Secretary for Health; Dr. 
Galpin, the Executive Director for Telehealth; and Mr. Galvin, 
the Associate Deputy Assistant Secretary in the Office of 
Information Technology.
    We very much appreciate all of your participation, thank 
you for being here today.
    And just a few logistical items up front as this is a 
hybrid hearing, senators participating virtually should mute 
their microphones when they are not under recognition, for the 
purposes of eliminating inadvertent background noise. After a 
year, we are finally starting to learn how to use these 
platforms. When we get to the question portion of the hearing 
we will use the standard five-minute rounds and senators will 
be recognized in seniority order.
    VA has been expanding utilization of telehealth programs 
over the past several years, though, as we saw across the 
country, the COVID pandemic led to a significant increase in 
patients seeking access to care through online platforms.
    And I am glad that the VA was well-positioned to provide 
this service to veterans who needed access to their providers, 
and has effectively responded to an increase of over one 
million patients engaged by telehealth since fiscal year 2018.
    In New Mexico alone, the number of veterans connected to VA 
by telehealth has tripled in that time, which is pretty 
remarkable. Part of the reason VA was able to do this so 
quickly was due to the work of this committee in producing the 
CARES Act, providing VA with resources to purchase devices for 
use by veterans and providers to expand services, and to enter 
into partnerships with telecom providers to give access to 
additional veterans.
    The funding in the CARES Act, the continued funding in the 
American Rescue Plan, and the increases provided by Congress 
over the last several years, have demonstrated significant 
interest and investment in this treatment modality.
    Despite funding increases of nearly 165 percent since 
fiscal year 2019, however, barriers to accessing telehealth 
remain. Unfortunately, it is often the same veterans who 
already face barriers to receiving in-person health care, who 
also have issues accessing telehealth services.
    I want us to discuss these gaps and how we can work to keep 
America's promise to all of our returning service members and 
their families.
    As VA continues to utilize resources provided to expand 
telehealth capacity and bridge the digital divide, we must be 
absolutely sure that these resources are going where they are 
needed most. That means, in many cases, highly rural and remote 
veterans, including those in Indian Country. That means 
veterans who face other barriers to getting the care that they 
need in person.
    We also need VA to do everything they can to enable those 
veterans to utilize the technology available to them, including 
digital literacy training and other support as needed.
    Broadband access remains an issue in many areas of this 
country, including many communities in New Mexico. While VA is 
in some cases stepping up to provide devices with cell service 
and a data package to veterans, in many cases that just is not 
enough to overcome widespread lack of access to basic broadband 
infrastructure in rural and tribal communities.
    VA cannot solve the country's challenges with broadband, 
but in order to care for all of the veterans that they are 
charged to serve, VA has a responsibility to engage with 
Federal agencies and other partners in support of the effort to 
bring broadband connectivity to every single American.
    As the country continues to get the pandemic under control, 
clinics and healthcare facilities across the country will 
reopen further. And we are already seeing that people are 
feeling more comfortable seeking in-person care.
    VA will and should prioritize treating veterans who have 
delayed care during the pandemic. And much of that will be done 
in person. At the same time, the VA must not scale back on 
efforts to expand telehealth initiatives, while many veterans 
may no longer have a need or preference for in-home access when 
the pandemic ends, there are also veterans who still will not 
have the same ability to access VA in person, or using 
telehealth, VA should redirect its focus to veterans who may 
need it more than most.
    I look forward to hearing about the Department's long-term 
vision for integrating telehealth into the way VA provides 
healthcare to veterans and how VA will leverage the investments 
that Congress has made in this area.
    And with that, I will turn it over to our ranking member.

               OPENING STATEMENT OF SENATOR JOHN BOOZMAN

    Senator Boozman. Thank you, Mr. Chairman, and welcome to 
the subcommittee. We look forward to working and partnering 
with you and your staff, our staff, in service to our veterans.
    We appreciate the witnesses coming today to discuss the 
Department of Veterans Affairs telehealth programs. For years 
this committee has supported expanding and enhancing VA 
telehealth's efforts, particularly for rural and highly rural 
veterans.
    The VA was already experienced in providing telehealth 
services when the pandemic hit and the dramatic expansion of 
services offered during COVID should be commended, very much 
so. It is not easy to institute this type of change in any 
large organization, and the speed with which the VA did so is 
truly remarkable.
    In January 2020, VA provided just over 41,000 patient 
visits using video telehealth straight to their home, by April 
that number had increased to more than 393,000, and by January 
of 2021, the number was 798,000. Again, 41,000 to 798,000.
    From January to January this represents a 1,831 percent 
increase in the number of telehealth visits. Just last month, 
VA in-home telehealth visits totaled more than 965,000. So this 
growth trend is continuing.
    Between emergency supplemental and fiscal year 2021 base 
funding, Congress has provided VA with roughly $5 billion to 
enhance telehealth services.
    Clearly this has been a successful effort to date. But as 
this committee looks forward to the fiscal year 2022 budget and 
beyond, we want to know more about how VA plans to harness the 
momentum and broaden access to their services.
    Behind the enormous growth we have seen over the last year 
are some statistics that show there are still challenges ahead 
that need to be addressed. In a non-pandemic environment 
telehealth is a valuable tool to enhance access to healthcare 
for veterans in rural, highly rural and underserved areas.
    When we look at the utilization numbers of the last year, 
we see that much of the growth has been realized in more urban 
and populous areas.
    So I look forward today to learn more and hear more about 
what VA is going to do to address this and what barriers our 
rural veterans still face to access telehealth services.
    So thank you, Mr. Chairman. And, I yield back.
    Senator Heinrich. I suspect we are going to have a lot of 
similar interests in care delivery in rural America.
    Thank you, Senator.
    And Dr. Lieberman, your full written testimony is going to 
be included in the record. But you are recognized now for five 
minutes to sort of summarize those remarks.

              SUMMARY STATEMENT OF DR. STEVEN L. LIEBERMAN

    Dr. Lieberman. Good afternoon, Chairman Heinrich, Senator 
Boozman, and members of the committee.
    I appreciate the opportunity to discuss the Department of 
Veterans Affairs telehealth program.
    I am accompanied today by Dr. Kevin Galpin, executive 
director, Telehealth Services; and Mr. Jack Galvin, associate 
deputy assistant secretary, Development, Security and 
Operations in the Office of Information and Technology.
    VA is honored to provide healthcare and services to the 
more than 9 million veterans who entrust us with their care, 
the pandemic has challenged VA and has shown the world what VA 
is made of. We remained open for in-person care when clinical 
urgency rose above the risk of COVID-19. VA has long been 
considered a national telehealth leader.
    Expansion of telehealth has been an essential part of VA's 
strategy to enhance the accessibility, capacity, quality and 
experience of healthcare for veterans, their family members and 
their caregivers. VA's commitment to the innovative application 
of technology to engage patients remotely through telehealth, 
for well over a decade, provided a solid foundation for VA's 
agile and effective response to COVID-19.
    At the pandemic's onset VA quickly pivoted to a virtual 
first healthcare delivery model, meeting veterans at the 
location of their choosing and ensuring delivery of high-
quality care, following safe social-distancing principles.
    This care delivery paradigm shift has led to unprecedented 
levels of telehealth use. VA appreciates congressional support, 
including via the Coronavirus Aid, Relief and Economic Security 
Act and the American Rescue Plan Act, to provide VA the ability 
to enhance and expand the systems and technologies used to care 
for veterans virtually.
    The MISSION Act and the recent National Defense 
Authorization Act have also been pivotal with advancing this 
mode of care delivery to help veterans to optimally manage 
their health, and receive care from the right provider, at the 
right time, and at the place the veteran prefers irrespective 
of their location in the country.
    Through telehealth and other virtual services, like My 
HealtheVet, veterans may access the information needed to help 
manage their health, engage with professionals all over the 
country, and receive remote healthcare monitoring services, 
coordination of care, and tailored education about their 
chronic conditions.
    In support of telehealth expansion in all settings, 
including the home, outpatient clinic and acute care hospital, 
VA is investing in the necessary technology and supporting 
infrastructure as a foundation for these services.
    This includes the development and maintenance of web, 
mobile, and telehealth applications used by veterans, and VA 
staff alike, to support care delivery at a distance, including 
in underserved areas, such as rural locations.
    Healthcare is increasingly becoming consumer- and 
technology-driven, VA must continue leading in this area to 
ensure veterans are provided access to a modern, technology 
optimized healthcare system.
    These efforts must include advancing telehealth 
technologies on a scalable information technology 
infrastructure, constructing digital tools that welcome 
veterans to engage with their healthcare services at any time, 
leveraging advanced analytics to gain insights on how to 
optimize care, and incorporating these solutions into VA's new 
electronic health record.
    Through these efforts, VA will deliver healthcare without 
walls, and realize its connected care vision are providing 
veterans with trusted care anytime and anywhere.
    VA continues to see high levels of veteran engagement with 
Connected Care technologies, and anticipates continued 
acceleration of their use as we move forward from the pandemic. 
VA remains committed to providing safe, high-quality care to 
veterans, especially during these unparalleled times.
    VA is grateful for your continued support and collaboration 
with our shared mission. Because of your support, as well as 
the dedication of our committed workforce, we continue to 
expand the reach and effectiveness of the healthcare system, 
caring for veterans wherever they are.
    I believe that as we emerge from the pandemic that many 
U.S. healthcare systems will continue to do more virtual care. 
I have further confidence that VHA is positioned to lead the 
way in U.S. healthcare clarifying the new normal for post-
pandemic health care.
    This concludes my testimony. My colleagues and I are 
prepared to answer any questions you may have.
    [The statement follows:]
               Prepared Statement of Dr. Steven Lieberman
    Good afternoon Chairman Heinrich, Senator Boozman and distinguished 
Members of the Subcommittee. I appreciate the opportunity to discuss 
VA's telehealth activities during the Coronavirus Disease 2019 (COVID-
19) pandemic. I am accompanied today by Dr. Kevin Galpin, Executive 
Director, Telehealth Services, VHA, and Jack Galvin, Associate Deputy 
Assistant Secretary, Development, Security and Operations, Office of 
Information and Technology (OIT).
                              introduction
    VA strives to enhance the accessibility, capacity, quality and 
experience of VA healthcare through the implementation of virtual care 
technologies that are effectively integrated into the lives of VA staff 
and the Veterans they serve. During the unprecedented challenge of the 
COVID-19 pandemic, VA is proud of the dedication and resilience of our 
workforce who have remained steadfast with their commitment to provide 
excellence to the Veterans who entrust us with their care. For many 
years, virtual care has been a critical component of VA's healthcare 
delivery system, and this has never been a more important modality for 
care than during the pandemic.
    VA has long been considered a national leader in telehealth, and 
expansion is an essential part of VA's strategy to increase Veteran 
access to healthcare. VA's early commitment to the innovative 
application of technology to engage patients remotely (e.g., through My 
HealtheVet--VA's personal health record; mobile and other connected 
applications; and an extensive and multi-faceted telehealth program) 
provided a solid foundation for an agile and effective response to the 
COVID-19 pandemic. The Department moved immediately to meet Veterans 
where they are and to ensure continued care delivery, including the 
increase of the telehealth capacity to unprecedented levels.
    In response to the pandemic, VHA worked closely with OIT to address 
and stay ahead of the anticipated increase in demand for virtual care. 
OIT stabilized the existing environment by monitoring and addressing 
potential issues; enhanced the capability by improving telehealth visit 
performance and quality; and expanded access to telehealth by tripling 
the concurrent use capacity of VA's platform for clinical video 
telehealth known as VA Video Connect (VVC). VA achieved over a 1900 
percent increase in video visits from VA to home, going from 10,645 
visits the first week of March 2020 to 220,790 visits at the end of 
February 2021. In May 2020, VA recorded its first day with 2 million 
minutes of VVC visits. Now that this system has expanded to our VA 
Commercial Cloud (commonly known as Care2 Cloud), the Department 
continues to scale capacity to meet the exponential increase in demand 
for telehealth appointments.
    Another key example of technology directly supporting VA's clinical 
demands during the pandemic has been the expansion of VA's Tele 
Critical Care program, increasing Veteran virtual access to critical 
care specialists in intensive care units (ICU) across the system. Since 
the onset of the pandemic, VA has deployed 265 mobile Tele-Critical 
Care carts to 97 VA Medical Centers (VAMC). Along with the VAMCs that 
already had Tele-Critical Care technologies in place, every VA facility 
with Intensive Care beds is now capable of receiving virtual access to 
critical care specialists.
    VA appreciates the support of Congress regarding telehealth, 
especially through the recent Coronavirus Aid, Relief and Economic 
Security Act and the American Rescue Plan Act, which provided the 
additional funding VA needed to invest in enhancing and expanding the 
systems and technology used to care for Veterans. Recent legislation 
such as Section 151 of the VA Maintaining Internal Systems and 
Strengthening Integrated Outside Networks (MISSION) Act of 2018, 
enables VA-employed healthcare professionals with an active, current, 
full and unrestricted license, registration, or certification in any 
state to care for Veterans regardless of where the healthcare 
professional or Veteran is located, if the covered healthcare 
professional is using telemedicine to provide treatment to the 
individual. The MISSION Act has been a pivotal advancement for this 
mode of care delivered to Veterans. These actions have provided 
significant benefit, addressing what had been barriers to the continued 
rapid expansion of telehealth.
                           population covered
    VA leverages technology to augment care for Veterans within VA 
healthcare facilities, in Veterans' homes and anywhere there is access 
to an Internet-connected computer, mobile phone, or tablet. VA's 
connected care footprint was significant prior to the COVID-19 pandemic 
and has grown even more remarkably since the onset of the pandemic.
    VA's online patient portal, My HealtheVet, is accessible through 
VA's modernized web presence at www.VA.gov and had over 5.5 million 
registered users at the conclusion of fiscal year (FY) 2020, as 
compared to 5.1 million users in fiscal year 2019. This represents 8 
percent growth. VA's video telehealth program was utilized by more than 
1.3 million Veterans in fiscal year 2020, a growth of more than 175 
percent over fiscal year 2019. Telehealth services are available at 
over a thousand VA sites of care, and care is delivered through video 
telehealth in more than 50 specialties: including mental healthcare, 
primary care, specialty care and rehabilitation services.
                       type of services provided
    Telehealth can enhance the Veteran experience and the delivery of 
healthcare for Veterans in their homes and communities; at VA clinics; 
and as they access hospital-based and emergency services.
    For Veterans at home, telehealth capabilities can help Veterans 
better manage their own health and enhance access to VA healthcare 
services irrespective of a Veteran's location in the country. Examples 
of VA's expansion in this type of Veteran engagement include delivery 
of care remotely through video visits through the VVC application; 
connecting with Veterans in their communities through the Accessing 
Telehealth Through Local Area Stations (ATLAS) initiative; supporting 
Veterans with chronic conditions through the Remote Patient Monitoring-
Home Telehealth Program; and providing Veterans with the technology 
they need to connect with VA through the Veteran tablet loaner 
initiative. VA also continues to leverage web-based and mobile tools 
like My HealtheVet and VA's mobile applications to support Veterans as 
they self-manage their own health at home. Through these efforts, 
Veterans and their caregivers can access the information they need to 
help manage their health and can access their providers, mental health 
specialists, nurses and other healthcare professionals using real time 
video or asynchronous communication from their homes or home 
communities. Veterans can also receive remote healthcare monitoring and 
care coordination services, and tailored education about their chronic 
conditions.
    VA continues its expansion of clinic-based telehealth services. 
Initiatives in this category enable VA to provide more accessible 
services at clinic locations, build clinical capacity in underserved 
areas and connect Veterans with the right clinical expert for their 
personal circumstance and condition. In addition, clinics are often the 
location where Veterans learn about services available to them from 
home. Examples of expansion in the clinic-based telehealth include the 
growth of regional clinical resource hubs for primary care, mental 
health and specialty care. The Clinical Resource Hubs (CRH) are 
Veterans Integrated Services Network (VISN) level resources that 
provide Primary Care, Mental Health, and specialty services to Veterans 
in underserved areas and sites that are experiencing staffing gaps. 
These sites that receive CRH services are often referred to as spoke 
sites. Other examples of expansion include the development and 
expansion of targeted specialty telehealth initiatives such as tele-
dermatology, tele-sleep medicine, and tele-oncology and the expansion 
of a national expert consultation center model.
    VA is also enhancing the quality of hospital and emergency services 
through the adoption of telehealth technologies. Technology can help 
provide Veterans timely access to the healthcare professional services 
they need in acute care and emergency situations, even when the 
specialty provider is not immediately available locally. Examples of 
this type of care include programs such as Tele-Stroke, which ensures 
Veterans presenting to participating VA emergency rooms with symptoms 
suggestive of a stroke can receive an urgent neurology assessment by a 
remote stroke specialist who can provide evidence- based 
recommendations for treatment to the in-person team. Another example is 
VA's Tele-Critical Care program, which ensures critically ill Veterans 
in VA ICUs have real time access to board certified intensivists and to 
experienced critical care nurses. A further example is the telehealth 
emergency management program, which provides remote clinical services 
following a declared emergency (e.g. hurricane, natural disaster, 
pandemic).
    During the COVID-19 pandemic, both tele-critical care and 
telehealth emergency management have been an important part of VA's 
response.
    Finally, in support of the expansion of telehealth in all settings 
(home, clinic, hospital), VA is investing in the necessary technology 
and supporting infrastructure as a foundation for these services. This 
investment includes the development and maintenance of mobile health 
and telehealth applications that are used by VA staff and Veterans 
alike to support care delivery at a distance, as well as VA's My 
HealtheVet patient portal. Other key investments include necessary 
training, implementation support, program office staffing, equipment 
maintenance and modernization, communications, evaluation/research, and 
provider and Veteran-facing help desk support.
                            va video connect
    VVC is VA's video telehealth platform that allows Veterans, their 
families and caregivers to meet virtually with their VA care teams on 
any computer, tablet, or mobile device with an Internet connection and 
web camera. VVC is one of the largest and most successful digital 
health platforms in the Nation and helps VA provide close to 30,000 
virtual appointments to Veterans at home each day. Daily video visits 
to home or other locations that the Veteran chooses have increased from 
around 2,000 a day since February 2020 to more than 47,500 a day in 
mid-February 2021. This rapid increase in video appointments was 
necessary to maintain safe clinical services in the setting of the 
COVID-19 pandemic and was made possible by the expansion and 
reengineering of select portions of VA's information technology 
infrastructure, as well as by rapid adoption of VVC by VA healthcare 
professionals.
    To further increase Veteran connectedness, VA is taking strides to 
bridge the digital divide for Veterans who lack the technology or 
broadband Internet connectivity required to participate in VA 
telehealth. More than 99,000 cellular-enabled tablets and 20,000 
cellular phones have been distributed to Veterans to help them connect 
to their VA services.
    Additionally, major wireless carriers such as Verizon, T-Mobile, 
SafeLink by Tracfone and AT&T have partnered with VA to support 
Veterans' access to VA telehealth services through the Zero Rating 
program, allowing Veterans, their families and caregivers to use VA 
Video Connect without incurring data fees, with some limitations, while 
on their networks.
    Further, VA has implemented a national digital divide consult 
through which VA social workers assist qualifying Veterans apply for 
Federal subsidies for their needed technology.
          specific connected care/telehealth covid-19 efforts
    In an effort to expand video-to-the-home services for all Veterans, 
VA has used remote patient monitoring services to help monitor higher 
risk Veterans who need to be isolated or quarantined at home. 
Additionally, VA has leveraged video telehealth on inpatient hospital 
wards to enhance infection control among Veterans in isolation rooms; 
supported increased utilization of VA's online capabilities on VA.gov 
and My HealtheVet; and launched specific text-messaging interventions 
to support Veterans who are concerned about COVID-19 and those who are 
isolating at home after possible exposure.
    In addition, VA has extended the use of video telehealth in 
intensive care units to provide remote intensive care consultation at 
sites that may have limited or overwhelmed intensive care specialty 
resources; and focused efforts of the Office of Veterans Access to Care 
and Office of Connected Care on maximizing telehealth into Specialty 
Care Services at healthcare facilities to improve capacity and 
productivity moving forward.
                             recent trends
    Healthcare is increasingly becoming consumer and technology driven. 
VA must continue to provide Veterans access to a modern technology-
enhanced healthcare system. These efforts must include continued 
advancement of Internet-enabled virtual care and telehealth 
technologies; integration of advanced analytics into these products; 
and incorporation of these solutions into VA's new electronic health 
record platform.
    VA continues to see high levels of Veteran engagement with 
connected technologies and anticipates continued acceleration of the 
use of these technologies, integrated into routine care delivery, as we 
lead the way forward following the COVID-19 pandemic.
    The VA patient portal, My HealtheVet, leads the industry in 
customer satisfaction scores and in the percentages of patients who use 
the portal. And, it has seen consistently increasing utilization, with 
a dramatic incline since the beginning of the COVID-19 pandemic. On the 
portal, VA processed over 12 million prescription refill requests and 
managed over 15 million secure messages between Veterans and their 
healthcare teams from October 2020 to March 2021. In the context of the 
COVID-19 pandemic, compared to the same period in fiscal year 2020, 
this represents an approximately 10 percent increase in prescription 
refill requests and a 51 percent increase in secure messages initiated 
by VA patients and their healthcare teams.
    Utilization of video telehealth services had also been increasing 
at a rapid rate prior to the pandemic and shifted to exponential growth 
during the pandemic. The use of VA telehealth services overall in 
fiscal year 2019 increased more than 14 percent over fiscal year 2018. 
The recently established Clinical Resource Hub Program, which currently 
provides primary care and mental healthcare, is adding specialty care 
to support underserved locations as yet another example of expansion. 
Statistics from the program's early success show that tele-mental 
health hubs served 257 spoke sites and provided over 174,000 visits to 
more than 39,000 Veterans. Additionally, video to the home or a non-VA 
location had also been increasing prior to the pandemic, with more than 
99,000 Veterans engaging in a video healthcare session at home or at 
another offsite location in fiscal year 2019. This represents a 246 
percent growth over the prior year.
                               conclusion
    Caring for veterans is our mission. We are committed to providing 
high-quality healthcare to all Veterans in our care, especially during 
these unprecedented times. VA is grateful for your continued support, 
as it is essential to providing this care for Veterans and their 
families.

    Senator Heinrich. Thank you, Dr. Lieberman.
    We will start with a round of questions using the standard 
five-minute rounds. And I will start by recognizing myself.
    Dr. Lieberman VA reported to committee staff that it 
obligated $2.2 billion towards telehealth in fiscal year 2020, 
including a much larger than originally planned investment in 
base funds. VA also received $300 million in CARES Act 
appropriations for telehealth activities of which it has only 
obligated about $120 million so far to date.
    Although it is important to track the different sources of 
funds separately, it is also important to have a full picture 
of the significant investment that has been made in VA's 
telehealth initiative.
    Can you describe how the Department will execute the 
remaining CARES Act and base funding before the end of the 
year? And further, what is the Department's plan for growth 
over the next few years, and how do you measure success?
    Dr. Lieberman. So, first off I just--I cannot emphasize 
enough, I made in my opening remarks, about how much we 
appreciate the support of Congress during these challenging 
times. There was already a lot of generosity even before the 
pandemic, but it really helped us to jumpstart and rapidly 
accelerate forward.
    And this is new territory in the pandemic. And so we have 
been judicious and careful in making the right decisions on how 
to execute the dollars. We fully anticipate executing all of 
the dollars, the CARES dollars and as we move forward. And we 
have really spent on a lot of programs that have benefited 
veterans across this country on both infrastructure and 
equipment.
    And at this point I will turn it over to Dr. Galpin, and 
then also leave some time, briefly, for Mr. Galvin also to just 
describe what--to respond to your questions.
    Dr. Galpin. Yes. Thank you for that question. And again, 
very much appreciate the support of Congress and helping us 
take care of veterans during this pandemic.
    Just to provide some context on this, VA has been a leader 
in telehealth for a while. In 2019 and we provided 2.6 million 
episodes of telehealth care.
    And the reasons we do telehealth in the VA are multiple. So 
one, as Dr. Lieberman mentioned, it increases the accessibility 
of care. We can bring care that is far away closer to the 
veteran. It enhances the capacity of care, particularly in our 
rural locations. So we can hire a provider in an urban setting 
to take care of a veteran in a rural facility or underserved 
area.
    It also enhances the quality of care. We can add another 
set of eyes to our ICU services, to make sure that there is 
coverage overnight for critical care physicians. We can make 
sure the stroke neurologist is available to the ER when the 
veteran shows up with symptoms, and then we can enhance the 
experience of care.
    Things changed for us during the pandemic. And I think this 
is, you know, a really important part of the story. Suddenly we 
had a new priority, and that was safety. And that really became 
the main driver of why we were doing telehealth during the 
pandemic. And what that did, that led to a complete change in 
the location of care.
    So just to provide the context on this, before the pandemic 
as a telehealth program, 78 percent of our video appointments 
were being done from one VA clinic to another, which means that 
22 percent were being done in the home. To adhere to social 
distancing guidelines and still provide quality services, we 
completely made a shift to the home. So if you look at today, 
97 percent of our visits are being done to the home, 3 percent 
clinic.
    That was a huge shift in operations. And we did not just 
shift the location of care for veterans, we also shifted the 
location of care for providers. So providers have become 
comfortable working out of their home, and taking care of 
veterans in their home.
    All of this was not simple, and it required the funding of 
the CARES Act to purchase the IT infrastructure to scale it 
quickly. We purchased, you know, over--we have distributed over 
47,000 webcams to providers 28,000 headsets, thousands of 
iPads, monitors, speakers, for veterans. We recognized, because 
of the digital divide, if we did not help them with the 
technology, that they were not going to be able to participate, 
so we distributed over 84,000 iPads, 20,000 cellular phones.
    We initially found that we needed to expand our help desk. 
Our help desk helps veterans and providers alike with the 
technology, through our help desk veterans can do a test call. 
We had to increase that staff by about 500 percent.
    So there was a tremendous amount of investment to make that 
transition in the location of care. But in addition to that, we 
continued with our plans to grow programs that also benefit 
specifically rural veterans.
    So these are programs like our clinical resource hubs. We 
are making a tremendous investment there, using ORH funding as 
well as funding from our core budget. And the Clinical Resource 
Hubs program is really significant. This is where we very 
specifically look to hire providers in the urban locations so 
we can match supply and meet the demand for the veterans in 
rural locations.
    This program continues to grow. I think at the end of last 
year, we had less than 575 health care professionals in that 
program, now we are over 700, so, again, significant investment 
there.
    We are also investing in growing our Tele-Critical Care 
Program. This has been an incredibly valuable program during 
the pandemic, but it was also important during the normal 
times. Through this program we can hire providers that have 
hubs where we have the critical care providers sitting in one 
location, and they can monitor the rural facility overnight 
when there is an absence of a provider. They can help a trainee 
overnight when a new veteran comes in and needs intensive care 
services.
    We are expanding our Tele-Stroke program to make sure 
neurologists are available to veterans in the ER. We are 
investing in our Tele-Oncology program to fill in gaps in our 
oncology service and provide more consistent access to some of 
the nation's experts in oncology. So there is a lot of 
significant investments in a lot of different areas.
    And, you know, I would say that is a high-level summary of 
some of the things we are doing with those funds, which has 
just been absolutely critical, particularly to help during the 
pandemic.
    Let me turn it over to Mr. Galvin to talk about some of the 
IT investments?
    Mr. Galvin. I know we are over time, but I would also like 
to echo the gratitude.
    On the OIT side, we received $2.1 billion in CARES Act 
funding. We have obligated and committed about 1.8 billion of 
that already, and are on track to expend all of that by the end 
of September.
    As Dr. Lieberman and Dr. Galpin indicated one of our first 
calls was to the Office of Connected Care, and Dr. Galpin and 
I, talking about what it is that we can help with in terms of 
the underlying infrastructure.
    And two key themes came out of that discussion. One was the 
obvious one, which was we had to stabilize our existing VA 
Video Connect solution, and we had to expand it, and we did 
that with the help of the CARES Act. Not only did we expand our 
existing, but we also introduced a new scalable technology in 
the cloud, and that has helped us stay ahead of demand.
    For stabilization we also use the CARES Act to help 
increase visibility tools, to help to respond proactively if 
the system had stability issues, or for security to audit it. 
And the other key element that came out of that discussion was 
critical care. We knew that if we were going to see patients 
that they were going to be in critical condition. If that was 
the case we wanted to leverage telehealth, and specifically our 
tele-ICU capabilities.
    We have two central hub tele-ICU facilities, one in 
Minneapolis and one in Cincinnati, and we were able to extend a 
solution to every single VA ICU bed in the country to be able 
to tap into that Minnesota and Cincinnati coverage.
    There was a great deal of other investments made, of 
course, with those CARES Act funds, including some of the 
fundamental things necessary for rural health connectivity in 
VA space. It helped us to accelerate our modernization of 
bandwidth. We were able to reach over 2,100 locations with 
increased bandwidth on modernized platforms, on fiber that we 
can advance the acceleration of capacity if necessary in about 
75 percent less time than when it was on its old technology of 
copper.
    So I will stop there. I know we are a little bit over.
    Senator Heinrich. No. Thank you so much.
    Senator Boozman.
    Senator Boozman. Thank you, Mr. Chairman.
    And I want to follow up on the digital divide that we are, 
you know, discussing now. And, I mean, the reality is in fiscal 
year 2019 the breakdown of telehealth usage was 45 percent 
rural and 55 percent urban. Now, in fiscal year 2020, and 
certainly this had to do with--you know, somewhat with the 
pandemic and all of the things that have gone on with but the 
telehealth nearly doubling the increased utilization seems to 
have skewed towards urban veterans, 68 percent, fiscal year 
2020 usage in urban with only 32 percent being rural.
    So I guess the question is, is that, again, you know, we 
had the pandemic, we are getting through that, and you all have 
done a tremendous job of that. But do we expect the numbers to 
go back more like they were? And what barriers exist that 
prevent rural veterans from taking advantage of telehealth and 
what is VA doing to address them?
    Dr. Lieberman. So, certainly, for many appointments 
veterans prefer face-to-face or have to be face-to-face because 
there has to be examination that can occur. And so we expect 
some of--to continue to see an increase in the face-to-face 
appointments.
    Rural health has always been a priority for us and 
continues to be, and we really look at it that we provide a 
menu of options to meet the challenges that are occurring in 
rural America. And so certainly we do have clinics in rural 
America, and now that as we are, hopefully, getting past the 
pandemic that more and more people will be able to go to the 
clinics in rural America.
    We certainly, for those locations that have broadband 
access, we provide a VA Video Connect in the home, just like we 
would to anyone else. We started piloting the ATLAS program, 
which are rooms which were designed based upon input from 
veterans, where they can go if they do not have broadband in 
their homes, to these locations. We also have them in different 
clinics, including in Indian Health Service locations. Those 
have not been as active during the pandemic, just because of 
safety issues again. And then certainly we have implemented in 
recent times our Digital Divide Consult.
    And I will let Dr. Galpin cover that topic.
    Dr. Galpin. Thank you. This is a critical question for us 
and a critical topic and just--I am going to just bring us back 
to 2018.
    So in 2018 after the MISSION Act was passed, that allowed 
us to take care of our veterans anywhere in the country. That 
was a huge piece of legislation for us. We set out, within a 
week, a very ambitious goal. We said by the end of 2020 all of 
our ambulatory care healthcare professionals would be capable 
to deliver care to veterans into their home using our VA Video 
Connect product.
    Now at the time we recognized that that would be great for 
some veterans but not for all veterans. So we concurrently 
launched our Digital Divide efforts, and we have developed 
several work streams to try and address that. It is a very 
difficult project for us to address all on our own. This is a 
government-wide project, something that we need to work on with 
government, but also community and private sector.
    One of the biggest things that we did was implement what we 
call our Digital Divide Consult. So we felt we needed a 
systematic way when we identified a veteran that did not have 
Internet or technology to participate in our telehealth 
programs, that we could get them assistance.
    And so right now, at almost all of our medical centers, if 
a provider identifies a veteran in that category, they can 
refer the veteran to a social worker. Social workers have now 
been trained to help veterans overcome the digital divide.
    One tool in their tool belt is our iPad program. So through 
the Digital Divide Consult social workers can see if veterans 
qualify for one of our Internet-connected devices. And that 
could be sent to a veteran, essentially loaned to them so that 
they can take advantage of our telehealth services. Again, we 
have distributed 84,000, more than 84,000 of those iPads since 
the beginning of the pandemic.
    The other big thing we do, though, is we help them apply 
for Federal subsidies. So we take advantage of the FCC's 
Lifeline program. So through Lifeline, a veteran, and as well 
as many others, may qualify to get a subsidy, a $9.25 subsidy 
on their Internet bill. For a veteran--for Native veterans who 
live on tribal lands, that could be up to $34.25, so a bigger 
impact. So we will help veterans apply for that so they can get 
their own technology and their own Internet.
    We are also very excited now to add the emergency broadband 
benefit (EBB) into that same process. The EBB is something that 
will provide great benefit to veterans. This now provides, at 
least temporarily, up to $50 for most veterans, and if you are 
on tribal land additional $75. And those two programs build on 
top of each other. So a veteran on tribal lands could get 
almost $110 per month to help get connected. So we are excited 
about that.
    So that is our systematic process. We have also done other 
efforts. We have partnered with cellular companies to zero rate 
our VA Video Connect app. So for veterans, for instance, who 
use that $9.25 benefit through Lifeline and get a Lifeline 
subscription, usually have very limited data with that. But if 
you have a zero-rated app, like VA Video Connect, you can do as 
much video with us as you need without running out of data.
    So that is really critical, you know, to help veterans who 
have Internet but maybe it is insufficient quantity of Internet 
to really participate with us at the levels needed.
    And then for veterans who live in areas where there is just 
no affordable Internet option, as Dr. Lieberman mentioned, you 
know, we have the ATLAS program, and that is where we partner 
with community centers, with Walmart, veteran service 
organizations, Philips. You know, leverage the great work being 
done in the private sector to donate services to us that we can 
create spaces where veterans can go. The technology is already 
set up with them. We already have the Internet there, and they 
can book out that space and get an appointment.
    It is the beginning of a program. We have just started 
that, and we had to shut down, partially, during the pandemic, 
but another exciting option as a way, amongst many ways that we 
can help veterans in the rural locations.
    I did not get to the second part of your question, but I 
know my time is up. So if you wanted to come back to that.
    Senator Boozman. Well, we will come back. Again, we 
appreciate that very much.
    One thing we might do, Mr. Chairman, is maybe you all could 
visit with our staffs in maybe 6 months, you know, some 
timeframe where things are settled down. And then again, just 
give us a report on the numbers again.
    And then two, I think we can be helpful in that area in 
regard to maybe breaking down some of the barriers that you are 
having and, you know, see how we can be helpful that way, 
either legislatively or just, you know, through coercion, you 
know, whatever we need to do. But it is very, very important.
    Thank you, Mr. Chairman.
    Senator Heinrich. Thank you, Ranking Member Boozman.
    Do we have Senator Hoeven on the remote team?
    Senator Hoeven. We do. Yes, we do, Mr. Chairman.
    Senator Heinrich. Go right ahead.
    Senator Hoeven. Thanks. Thank you.
    Dr. Lieberman, how has the congressional action through the 
CARES Act helped VA scale up its telehealth capacity?
    Dr. Lieberman. So this has been a great help to us, the 
CARES funding for care in general at VA, but also for the 
growth of the telehealth program.
    And Dr. Galpin, do you want to go into more detail on that?
    Dr. Galpin. Yeah, no--I mean, it is an important question. 
So I am going to specifically refer to just what we have done 
in the telehealth program with the CARES Act funding. It has 
been critical.
    Again, at the beginning of the pandemic we made some pretty 
dramatic shifts in the way that we provided care, providing 
care really to a new location, delivering care from our 
providers' homes to the veterans' homes. Because of that we had 
to invest in technology.
    I will let Mr. Galvin speak to some of the IT investments 
that were needed there.
    But we had to outfit our providers with technology. We had 
to purchase them, webcams, monitors, speakers, headsets, iPads, 
to give them the capability of delivering telehealth services.
    And then again for the veterans, we needed to get them 
technology in some cases so they could participate if they did 
not have technology or Internet from their home. We 
dramatically expanded our help desk, help desk provides 
veterans, and providers alike, services to make sure that they 
feel comfortable with technology and answers technology 
questions. That was another big investment.
    We also made significant investments in purchasing Tele-
Critical Care equipment. Tele-Critical Care is a program where 
a provider at one facility can help oversee and contribute to 
the care of a veteran in an ICU at another facility.
    At the beginning of the pandemic we were very concerned 
that one of our ICUs could get overwhelmed with COVID cases, 
and they were going to need additional support. We also worried 
that there was a possibility that we could lose staff at an 
ICU. And so making sure that all of our facilities have the 
capability of connecting back to our physicians and nurses in 
some of these ICU hubs that can provide support was critical.
    We also see that as a critical aspect for fortifying our 
system going forward into the future against a future 
emergency, whether it be a pandemic or something else. So, 
again, it has been critical from the telehealth side.
    And let me turn it over to Mr. Galvin to talk about how we 
leveraged it from the IT side.
    Mr. Galvin. Thank you, Dr. Galpin.
    Yes. So I mentioned some of the things specific to 
telehealth but also--benefiting telehealth, but also all folks 
in a remote user setting. We have had to double the bandwidth 
at our gateways. We have four trusted Internet connected 
gateways, typically pre-pandemic we were handling anywhere 
between 40- and 50,000 people in a remote user telework 
environment during the pandemic, and now nominally we are at 
about 100- to 120,000 a day.
    So we increased the bandwidth to those, the hardware for 
those, we procured 200,000-plus laptops, and that helped us to 
help the activation of various different locations and 
different workflows. Things like COVID screening centers, 
testing centers, vaccination.
    We were able to use, through the CARES Act, the funding and 
the scale that we got from that, and the infrastructure, to be 
able to outfit over 700 small, medium and large vaccination 
centers across the country. And that has enabled our clinicians 
to be able to vaccinate millions of veterans and hundreds of 
thousands of employees.
    We also deployed a new kiosk solution that offers any VA 
connected workstation to be converted into a secure veteran 
access point for a video connect encounter. There was countless 
application developments that helped with immunization, vaccine 
tracking, scheduling COVID screening. We even developed a 
virtual agent called Annie that we use for chat bot, that helps 
veterans navigate to important information and changes to their 
care, frequently asked questions that helps them to help 
navigate to, you know, get access to some of the services they 
need throughout the pandemic.
    We leveraged our texting solution to reach millions of 
veterans at once to give them important information about their 
care and appointments. So we did a number of things that CARES 
Act funding certainly helped us tremendously for pandemic 
relief.
    Senator Hoeven. Are there additional telehealth 
flexibilities that we should extend, you know, even beyond the 
pandemic, Dr. Lieberman?
    Dr. Lieberman. Dr. Galpin.
    Dr. Galpin. Yeah, no--that is a great question. I think it 
speaks to the way forward. I can tell you this just bottom 
line. So prior to the pandemic we were a leader in telehealth 
and we expect to be a leader in the telehealth after the 
pandemic. We think it is the right thing to do for veterans 
that gives them great options for their healthcare delivery.
    One of the things that we were able to do in the past year 
is actually formalized a five-year strategic plan for 
telehealth, and it is an exciting vision for where we are going 
in the future. It talks about delivering care without walls, 
making sure we can bring care to the veterans wherever they 
choose to reside, irrespective of physical boundaries or 
geographic distance.
    It talks about building, engaging digital tools for 
veterans that welcome them to connect with us at any time when 
they want to engage with their healthcare services.
    It talks about capacity, leveraging programs like our 
clinical resource hubs where, again, we match supply and demand 
across the organization to make sure we fill in gaps in rural 
locations.
    And it talks about making sure we give veterans access to 
some of our nation's experts of experts when they have a rare 
or complicated disease, and they need that type of expertise.
    And we think this is exciting. And we, you know, talking 
about flexibilities, some of these things are things you can 
only do in an integrated healthcare system, like the VA. And 
that gets us really excited.
    Now, going back to flexibility, because I think this is 
also important. Because of the past year, we have had an 
opportunity to learn a great deal about our telehealth 
operations and get great feedback. We have also learned how 
important it is to have that flexible workforce. So because of 
all this transition, and change in location of care, we 
probably have the most flexible workforce we have ever had 
before.
    Providers now are comfortable working out of their home, 
taking care of veterans in their home. So you imagine the next 
time we have a severe weather emergency where veterans or 
providers cannot get to a clinic location, how much easier it 
will be for us to continue operations.
    So one of the things we need to think about flexibility, 
going forward, is how do we maintain that? How do we make sure 
our providers maintain that muscle memory? They have the 
technology at home; that we give them that experience so that 
we are ready for what happens next.
    So flexibility is important but, again, very excited about 
the future.
    Senator Heinrich. Thank you, Senator Hoeven.
    We have a two vote series that has just started. And so I 
want to get to Senator Manchin, and then I think, so that 
everyone can get over and vote, we will probably wrap things up 
at that point, but I know there is a lot more ground here that 
members were not able to get to. And we are going to submit a 
number of questions for the record.
    Senator Manchin.
    Senator Manchin. Thank you, Mr. Chairman.
    Dr. Galpin, since we are facing so challenges with 
broadband access in states like mine, West Virginia, rural 
state, one solution the VA is offering is to store clinical 
information and forward it electronically to another site for 
evaluation, or basically your ATLAS program.
    So my question would be is, when do we expect, it has only 
been in five states, and ours is as rural as they can possibly 
get. I have so many people that are not connected. As a matter 
of fact, we could not even use telehealth in so many parts of 
our rural state that we had to use telephone, the old 
telephone, because doctors could not connect with them. And 
then we had to have a whole another code that they could bill 
off that, and we had to get a special permit from the HHS.
    That is how remote, we have so many areas. So I do not know 
what your intentions are there, or when you think you might be 
expanding or trying in state such as rural as ours, would be 
very helpful.
    Dr. Galpin. So it is, again, another really important 
questions for us, the digital divide, which is what, you know, 
really----
    Senator Manchin. I think I was asking also with the money 
that, you know, you all had extra money from the COVID, and we 
thought that would really help expand that more rapidly.
    Dr. Galpin. Yes. So I will speak to the digital divide in 
general, and then talk some specifically about ATLAS, because 
the digital divide is really critical. We cannot deliver our 
services to veterans through telehealth unless they have the 
connectivity.
    Senator Manchin. Right.
    Dr. Galpin. And so that is a huge challenge for us. And 
that is why we have implemented the Digital Divide Consult. 
That is why we put so much investment in trying to help 
veterans get the technology. And again, through the help of 
this committee and the CARES Act funding, we have been able to 
meet that demand, at least for the tablets, getting them the 
iPads.
    To your point, though, it is very difficult when you are on 
a location where you do not have cellular service. I can give 
you a cellular-connected iPad, but it is not going to work if 
you are outside the area of the cellular company, and so when 
you get into real rural locations, we need different types of 
solutions.
    Senator Manchin. That aligns into the hotspot theme. We put 
money in for hotspots too. Are you all taking advantage of 
that?
    Dr. Galpin. So let me talk about the ATLAS. ATLAS is one of 
the unique opportunities that we have that fits into, you know, 
kind of a broad spectrum of things we can do in rural 
locations. So if we identify a location in a rural community 
where there is a population of veterans that do not have 
affordable access to Internet, this is where the ATLAS program 
comes in.
    Right now we have 11 of them. We were just getting started 
and were really excited about the program before the pandemic 
hit. We had to shut it down for a while to redo our infectious 
disease program protocols.
    We have activated them, we expect to expand to 15 this 
year, and we are doing a lot of evaluation trying to figure 
out, well, where is the best place to put this? How do we 
operate these most successfully, so they provide value to 
veterans?
    In the meantime, while we are rolling out that program and 
taking advantage of the John Scott Hannon legislation, that 
allows us to develop a grant program to actually fund those 
sites, we are working on the other parts of the digital divide 
initiative and work stream.
    One of the things we are doing is looking at hotspots. Can 
we work with some companies again? We have the authority to 
work with private sector and get donations. Can we work with 
some of the private sector companies to put in hotspots for 
veteran places where they can go to access the Internet that is 
in their communities?
    And so that is one of the efforts we are looking at now. 
And I have had some really good meetings with a company, even 
over just the past couple of weeks on that.
    Senator Manchin. Are we running out? I mean, basically the 
funding seems to be adequate. It is just a matter of finding 
the vendors, and people can do this. Is that is your biggest 
challenge you have right now?
    Dr. Galpin. Yes, I mean, right now, yes, absolutely. The 
funding has been critical, we have been able to meet the demand 
and, and what we continue to do is just look for opportunities 
of ways to get the services out.
    Senator Manchin. And your distributing device is trying to 
help veterans basically access. A lot of them would not have 
the technical knowledge, you know. Are you able to have the 
personnel that can help them, bring them up to speed so they 
have the ability to use them and to facilitate them?
    Dr. Galpin. Absolutely. So we have a couple of ways we 
address that. So for the devices that we distribute, one of the 
things that we certainly learned is that the veterans did need 
education. That was some of the early feedback we got.
    So we did contract with a service, and so now when a 
veteran gets one of our iPads, there is a technician that calls 
them. We called it our White Glove service, to offer them help 
setting up the device, as well as doing an initial test call to 
make sure that they are comfortable with the technology.
    For veterans that we are not distributing the device to, we 
are setting up at every facility that same capability. So the 
conversation when someone is considering a telehealth is not, 
hey, do you want to do video? It is, would you like to do 
video. We have a way to help you if this is something you are 
not comfortable with.
    And that is the type of experience we want to provide. So 
we are approaching that both for the devices we distribute as 
well as for every veteran that wants to participate, but may 
not feel comfortable, again, with the technology to do that.
    Senator Manchin. My state of West Virginia has a high 
percentage of veterans, as you know. I mean it is a tremendous 
participating state. And with that, we are not that far from 
you. We would hope you would consider because it would be an 
area that if you can basically overcome the challenge of the 
terrain that we have, and also the realness, population 
sparseness, things of that sort, it could help you anywhere in 
the country. And we are only about three or four hours away. So 
we will take your right there to come and help us.
    Dr. Galpin. Great, absolutely.
    Senator Manchin. Okay. Thank you, sir.
    Dr. Galpin. Important.
    Senator Heinrich. Thank you Senator.
    Again, thank you to all the witnesses and senators for 
participating in this hearing today, while VA greatly increased 
telehealth capabilities over the past couple of years there is 
much more that needs to be done to sustain those capabilities 
and reach the hardest-to-serve areas and populations.
    This committee looks forward to working with VA to develop 
a plan to support telehealth, including increased access to the 
unserved.

                     ADDITIONAL COMMITTEE QUESTIONS

    Finally, I will keep the hearing record open for a week. 
Committee members who would like to submit written questions 
for the record should do so by 5:00 p.m., Wednesday, May the 
5th. And we certainly appreciate the department responding to 
them in a reasonable period of time.
              Questions Submitted to Dr. Steven Lieberman
             Questions Submitted by Senator Martin Heinrich
                              future goals
    Question. The Veteran Health Administration's Connected Care 
Strategic Plan, 2021-2025, which outlines three goals and eight 
strategies to leverage technology to enhance the accessibility, 
capacity, quality and experience of VA healthcare for veterans, their 
families and their caregivers. Ideally, behind this strategic plan are 
performance goals, performance measures, and quantifiable targets. What 
specific metrics will VA use to measure the success of the telehealth 
program over the coming years?
    Answer. VA has established a five-year strategic vision for 
connected care, which will be supported by yearly updates to operating 
targets and metrics, informed by lessons learned from the Coronavirus 
Disease 2019 (COVID-19) pandemic. Post pandemic, telehealth success 
metrics will be constructed to include data focused on Veteran and 
provider experience, access to services, utilization, health equity and 
clinical outcomes.
                 tribal veterans' access to telehealth.
    Question. Historically, some of the hardest to reach populations 
for access to care include those who live in highly rural areas or on 
tribal land, and those with limited English proficiency. Based on the 
first half of fiscal year 2021, there has been more than a 300 percent 
increase in the number of veterans seeking telehealth in New Mexico 
compared to all of fiscal year 2019. What specific steps has VA taken 
to improve access to telehealth for Veterans in Indian Country?
    Answer. VA is taking strides to bridge the digital divide for 
Veterans who lack the technology or broadband Internet connectivity 
required to participate in VA telehealth services irrespective of their 
location in the country.
    VA has implemented a national digital divide consult process. This 
program allows VA providers to refer Veterans who would benefit from 
video telehealth services but do not have Internet access or video-
capable devices to a social worker who can help them determine 
eligibility for programs to access the Internet service or technology 
needed for VA telehealth. VA can lend Veterans Internet-connected 
devices or help them in applying for Federal Communications Commission 
(FCC) administered Internet subsidies. The FCC subsidies are available 
through the Lifeline and Emergency Broadband Benefit (EBB) programs.
    The Lifeline and EBB programs can combine to provide many 
qualifying Veterans $59.25 per month for their Internet services. 
Veterans on tribal lands can receive $109.25 per month through these 
programs.
    VA has completed over 62,000 digital divide consultations between 
the beginning of fiscal year (FY) 2021 and August 31, 2021. VA has also 
distributed more than 110,870 Internet connected tablets to Veterans 
since March 1, 2020.
    Additionally, major wireless carriers such as Verizon, T-Mobile, 
SafeLink by Tracfone and AT&T have partnered with VA to support 
Veterans' access to VA telehealth services through the Zero Rating 
program, allowing Veterans, their families and caregivers to use VA 
Video Connect with fewer worries about data fees.
    VA is also continuing collaborations with Walmart, Philips, the 
Veterans of Foreign Wars, and American Legion to establish a total of 
fifteen telehealth access stations in Veteran communities. The 
Accessing Telehealth through Local Area Stations (ATLAS) sites allow 
Veterans to receive VA telehealthcare at a convenient location close to 
their home. VA currently has 12 ATLAS locations nationally that are 
open and available for scheduling. By the end of 2021, it is 
anticipated that a total of 13 ATLAS sites will offer clinical services 
by telehealth from VA providers. As part of its future expansion, VA is 
collaborating with Navajo Nation and Navajo Health Foundation--Sage 
Memorial Hospital in Ganado, Arizona to establish an ATLAS site.
     accessing telehealth through local area stations (atlas) pilot
    Question. VA's ATLAS pilot seems promising as a way to reach 
underserved veterans in concept, but based on data to date, very few 
veterans are utilizing this model. One site that has been in operation 
for over 15 months reported only one telehealth visit.
    Provide an update on the pilot, including activation dates, usage, 
satisfaction, any plans for expansion, and performance metrics.
    Answer. VA has collaborated with public and private organizations, 
including Philips, Walmart, Veterans of Foreign Wars, and The American 
Legion, to provide private telehealth-equipped space in communities 
with poor broadband connectivity and a long drive time to VA medical 
facilities. At this time, all Philips donations have been allocated 
with expansion plans to include Emporia, Kansas; Wellston, Ohio; and 
West Virginia. Additional opportunities have been identified with 
federally Qualified Health Centers (FQHC), Navajo Health Foundation, 
and National Association for Veteran County Service Officers. As 
required by section 701 of the Commander John Scott Hannon Veterans 
Mental Health Care Improvement Act of 2019 (Public Law 116-171), VA is 
working to enter into agreements, and expand existing agreements, with 
organizations that represent or serve Veterans, nonprofit 
organizations, private businesses, and other interested parties for the 
expansion of telehealth capabilities and the provision of telehealth 
services to Veterans through the award of grants.

 
------------------------------------------------------------------------
              Site                  Activation Date    Total Encounters
------------------------------------------------------------------------
Walmart ATLAS Sites:
    Asheboro, NC................  12/11/2019........  9
    Boone, NC...................  12/15/2019........  1
    Howell, MI..................  2/17/2020.........  4
    Keokuk, IA..................  10/15/2020........  3
    Fond du Lac, WI.............  10/29/2020........  6
American Legion ATLAS Sites:
    Springfield, VA.............  9/22/2020.........  2
    Wickenburg, AZ..............  3/9/2021..........  12
    Emporia, KS.................  TBD...............  n/a
    Ohio........................  TBD...............  n/a
    West Virginia...............  TBD...............  n/a
VFW ATLAS Sites:
    Gowanda, NY.................  6/22/2021.........  10
    Athens, TX..................  3/29/2021.........  1
    Los Banos, CA...............  3/29/2021.........  15
    Eureka, MT..................  12/20/2019........  36
    Linesville, PA..............  1/25/2021.........  5
Additional ATLAS Locations Under
 Consideration:
    Ganado, AZ (Sage Memorial     TBD...............  n/a
     Hospital).
    Huron County, OH VSO........  TBD...............  n/a
    Greene County, PA VSO.......  TBD...............  n/a
    Heart of Kansas (federally    TBD...............  n/a
     Qualified Health Center--
     FQHC).
------------------------------------------------------------------------

    Prior to the COVID-19 pandemic, the ATLAS Program had established 
six ATLAS sites. These stations were temporarily closed during the 
COVID-19 pandemic while appropriate precautions in accordance with 
COVID-19 guidelines from the Centers for Disease Control and Prevention 
(CDC) and the Environmental Protection Agency guidelines were put in 
place. In addition to reopening these sites in June 2020, the ATLAS 
Program has opened six new sites. Additional new ATLAS sites are 
planned through the end of the 2021 calendar year and beyond to 
continue to further extend opportunities for Veterans to access care by 
telehealth (see chart above). Demand for ATLAS appointments is expected 
to grow as Veterans' concern for COVID-19 exposure is reduced via 
vaccination and easing of pandemic-related restrictions. VA has 
developed a communication strategy to market new and existing ATLAS 
sites in conjunction with the local VA medical center (VAMC) Public 
Affairs Team.
    The Office of Rural Health and the Office of Connected Care have 
sponsored a partnered evaluation of ATLAS to examine qualitative and 
quantitative outcomes, as well as Veteran satisfaction, associated with 
the pilot. In addition, VA is performing an evaluation of quality of 
care and experience specifically for care occurring in ATLAS spaces led 
by the VA Collaboration Evaluation Center Team and Veterans' Experience 
Office. The care at ATLAS locations is being provided by VA clinicians 
via telehealth. The usual VA policies and processes regarding 
assessment and oversight of clinical quality of care still apply. To 
date, Veterans who have completed an evaluation after completing an 
ATLAS appointment have generally expressed high satisfaction and an 
excellent telehealth experience.
    Question. Based on the data to date, does VA remain committed to 
ATLAS as an effective model to reach veteran populations?
    Answer. VA continues Veteran outreach regarding the new ATLAS 
initiative and remains committed to the ATLAS concept as an opportunity 
to bridge the digital divide through both public and private 
collaborations. ATLAS affords Veterans the option to receive convenient 
telehealthcare in their community saving them time and mileage while 
providing them with a secure and private space for a telehealth 
experience.
    Question. Has VA evaluated the effectiveness and feasibility of 
placing an ATLAS on tribal land? If so, please share VA's findings.
    Answer. VA is collaborating with Navajo Health Foundation in 
Arizona to bring an ATLAS site to fruition at the Sage Memorial 
Hospital in Ganado, AZ. Ganado is a town in Apache County, AZ. Apache 
County is one of the top counties with more than 1,000 Veterans lacking 
access to broadband connectivity. The nearest VA facility in this 
geographic area is in Gallup, NM with an average drive time of 104 
minutes. There are 141 Veterans who reside in Ganado, AZ and 340 
enrollees within 30 minutes of Ganado. Additionally, there are 686 
enrollees within 60-minute drive time of Sage Memorial Hospital.
    Question. What steps is VA taking to encourage veterans to take 
advantage of these sites?
    Answer. A comprehensive communication strategy has been developed 
for each existing ATLAS site to encourage Veterans to take advantage of 
this opportunity. The communication strategy has been shared with each 
VAMC Public Affairs Officer(s) supporting an ATLAS site.
            asset and infrastructure review (air) commission
    Question. The MISSION Act established the Asset Infrastructure 
Review Commission, which required VA to review where its facilities 
are, as well as the surrounding healthcare market, and determine if 
changes should be made across the enterprise to improve access to care 
for veterans. VA was still in the process of conducting market 
assessments when VA dramatically increased telehealth usage. While 
helpful in reaching some veterans, telehealth is not an absolute 
substitute for in person care.
    How has the increased shift to telehealth affected VA's market 
assessments or how it determines the demand for facilities?
    Answer. VA is leading the country in standardizing the use of 
telehealth for routine doctor visits. Telehealth has become even more 
critical as the COVID-19 pandemic upended normal ways of life and 
altered typical interactions in healthcare between patients and 
providers. From March 1, 2020, to May 1, 2021, VA saw a 1,698 percent 
increase in home or off-site telehealth visits. In February 2021, VA 
averaged nearly 45,000 such visits per day. While the increase of 
telehealth services was necessary due to the COVID-19 pandemic, 
telehealth cannot be a substitute for in-person care; telehealth is 
only one tool in delivering care to Veterans.
    The market assessments have reviewed telehealth data, including the 
types of care being accessed through telehealth and the level of 
adoption in each market. Additionally, VA is conducting a National 
Planning Strategy (NPS) focused on telehealth. The Telehealth NPS aims 
to document how telehealth is nationally organized and delivered, 
define services that may or may not be most impacted by telehealth, and 
estimate, at a high level, the impact Telehealth will have on future 
infrastructure requirements. Results from the Telehealth NPS will 
influence VA's final recommendations to the Asset and Infrastructure 
Review (AIR) Commission.
    Question. How is VA factoring in telehealth, in its determination 
of whether a facility, or an individual clinic within a facility, is 
needed in a community?
    Answer. The need for new sites of care depends on a range of 
factors that include: consideration of current and projected demand, 
current and projected Veteran population and availability of care 
within VA's network of community providers through Community Care, and 
ability to recruit and retain qualified staff. Local leadership will 
work with Veteran Integrated Service Network (VISN) leadership and VA 
central office colleagues when gaps in care are identified. Requests 
for modernization of new sites of care are reviewed in conjunction with 
needs across regions and nationally. The use of telehealth has expanded 
both within VA and within community providers and has created options 
for serving Veterans that go beyond establishing capital solutions.
    Telehealth deployment can be carried out in a variety of models, 
which could either increase or decrease VA's infrastructure needs 
depending on format and the locations of both provider and patient. For 
instance, if both the Veteran and healthcare provider connect via 
telehealth from their homes, then the need for infrastructure would be 
reduced. However, this scenario requires adequate Internet bandwidth 
between both homes to support the telehealth modality. Alternatively, 
if a Veteran were to connect via telehealth from a properly equipped VA 
exam room and the provider connects from a different VA space, such as 
an office or exam room, then two VA spaces are required. This scenario 
increases the need for infrastructure, utilizing two VA locations 
rather than one space for a typical face-to-face encounter.
    It stands to reason that the U.S. healthcare industry across the 
public and private sectors will require less physical space for care 
that may be provided remotely, given technology-enabled trends towards 
outpatient and virtual care that have been present in U.S. medicine 
since well before the pandemic. VA will continue to evaluate how to 
optimize its infrastructure as this landscape evolves.
   integration w/electronic health record modernization (ehrm) effort
    Question. The Office of Connected Care's new strategic plan notes 
``VA will pursue full integration of VA's connected care capabilities 
with VA's [EHRM] efforts.'' This includes developing interfaces and 
clinical pathways to support continuity of care.
    How has VA's revised vision for telehealth been incorporated into 
VA's EHRM efforts?
    Answer. To facilitate ease of telehealth in the modernized 
electronic health record being deployed through VA's EHRM efforts, VA 
and Cerner have integrated VA Video Connect scheduling into the new 
electronic health record. To make it easier to schedule telehealth 
appointments between sites on Cerner and sites not yet on Cerner, VA is 
collaborating with Cerner to make interfacility EHR telehealth 
scheduling easier and more efficient by creating functionality in the 
Telehealth Management Platform that allows the bidirectional exchange 
of telehealth appointment information.
    VA Remote Patient Monitoring-Home Telehealth (RPM-HT) vendors and 
Cerner are partnered to leverage an Application Programming Interface 
(API) to allow Veterans' vital sign data to populate into the new 
Cerner Electronic Health Record (EHR). The ability for providers to 
view RPM-HT vital sign data and blood glucose values directly in the 
record was not available in VistA/CPRS (Computerized Patient Record 
System). Viewing vital sign and blood glucose data in the EHR for 
Veterans enrolled in RPM-HT enhances the provider experience with the 
RPM-HT program by allowing efficient viewing of data collected by RPM-
HT technologies in a Veterans home within a provider's daily workflow.
    Moving forward, providers and licensed clinical personnel will be 
able to easily view Veterans' vital sign data (blood pressure, pulse 
rate, oxygen saturation, weight, temperature) as well as blood glucose. 
The data will be securely and seamlessly integrated into the EHR and 
labeled as ``self'' to differentiate it from vital sign information 
collected by healthcare professionals in clinics. RPM-HT Care 
Coordinators will also have their own separate view for ease of use 
while working in the Veteran's record.
    Question. Is expanded telehealth, including any additional 
interfaces required, being considered during VA's strategic review of 
its EHRM rollout?
    Answer. VA and Cerner are continuing ongoing communications and 
working toward VA's strategic vision of integrating telehealth 
operations into the Cerner medical record where needed and valuable to 
Veterans or healthcare professionals. The strategic review has afforded 
VA and Cerner additional time to progress down its integration roadmap 
but has not changed its strategic direction.

                                 ______
                                 

           Questions Submitted by Senator Senator Jon Tester
    Question. What progress has VA made in implementing Section 701 of 
the Hannon Act to expand telehealth access at non-VA sites?
    Answer. VA is working to build a grant program to support non-VA 
sites in the establishment of ATLAS sites. VA is currently drafting 
regulations and is establishing an ATLAS Grant program office.
    Question. How will you incorporate any best practices and views 
from partner organizations, like the VFW, who have hosted these ATLAS 
sites?
    Answer. VA's ongoing evaluation at ATLAS Veterans Service 
Organization (VSO) pilot locations has yielded insight and perspective 
from Veterans, local and national VA leadership, and VA staff. VA has 
also engaged in discussion with the Veterans of Foreign Wars to 
identify areas of concern to address in the new program. This knowledge 
will inform plans for growth at ATLAS sites and be integrated into 
standard operating procedures for new locations.
    Question. Many rural communities lack adequate broadband access for 
telehealth and other online or video services. For Montana veterans, 
telephone visits are the main way they access VA telehealthcare. What 
steps is VA taking to ensure that veterans, such as in my home state of 
Montana, are able to access VA telehealth in all forms--including 
video?
    Answer. VA is taking strides to bridge the digital divide for 
Veterans who lack the technology or broadband Internet connectivity 
required to participate in VA telehealth services irrespective of their 
location in the country.
    VA has implemented a national digital divide consult process. This 
program allows VA providers to refer Veterans who would benefit from 
video telehealth services, but do not have Internet access or video-
capable devices, to a social worker who can help them determine 
eligibility for programs to access the Internet service or technology 
needed for VA telehealth. VA can lend Veterans Internet-connected 
devices or help them in applying for Federal Communications Commission 
(FCC) administered Internet subsidies. The FCC subsidies are available 
through the Lifeline and Emergency Broadband Benefit (EBB) programs.
    The Lifeline and EBB programs can combine to provide many 
qualifying Veterans $59.25 per month for their Internet services. 
Veterans on tribal lands can receive $109.25 per month through these 
programs. VA has completed over 62,000 digital divide consultations 
between the beginning of fiscal year 2021 and August 31, 2021. VA has 
also distributed more than 110,870 Internet connected tablets to 
Veterans since March 1, 2020.
    Additionally, major wireless carriers such as Verizon, T-Mobile, 
SafeLink by Tracfone, and AT&T have collaborated with VA to support 
Veterans' access to VA telehealth services through the Zero-Rating 
program, which allows Veterans, their families and caregivers to use VA 
Video Connect with fewer worries about data fees.
    VA is also continuing to work with Walmart, Philips, the Veterans 
of Foreign Wars, and The American Legion to establish fifteen 
telehealth access stations in Veteran communities. The Accessing 
Telehealth through Local Area Stations (ATLAS) sites allow Veterans to 
receive VA telehealthcare at a convenient location close to their home. 
VA currently has 12 ATLAS locations nationally that are open and 
available for scheduling. By the end of 2021, it is anticipated that a 
total of 13 ATLAS sites will offer clinical services by telehealth from 
VA providers. As part of its future expansion, VA is collaborating with 
Navajo Nation and Navajo Health Foundation--Sage Memorial Hospital in 
Ganado, Arizona to establish an ATLAS site.
    Question. VA has publicized a partnership with Microsoft's Airband 
Initiative to establish or enhance broadband connectivity in select 
rural areas. Which areas are a part of this partnership and what is the 
criteria for selection?
    Answer. VA, in collaboration with the Microsoft ``Airband 
Initiative,'' used data mapping tools to identify areas with large 
concentrations of Veterans who have limited broadband access. Below are 
the top 10 identified priority areas:

                          Top 10 Priority Areas
------------------------------------------------------------------------
                   State                               County
------------------------------------------------------------------------
Oklahoma..................................  McCurtain
Louisiana.................................  Vernon
Arizona...................................  Yavapai
Florida...................................  Dixie
Arizona...................................  La Paz
Oklahoma..................................  Pushmataha
Louisiana.................................  Beauregard
Alabama...................................  Marengo
Michigan..................................  Newaygo
Oklahoma..................................  Choctaw
------------------------------------------------------------------------

    Question. Have Montana Veterans been given access to Microsoft 
Airband via VA? If not, are there any plans for expansion to Montana, 
given the significant broadband access issues there?
    Answer. As Microsoft Airband develops the necessary infrastructure 
to deploy their novel connectivity, partnerships in areas of need can 
leverage the technology when it becomes available. Microsoft Airband 
has an established partner in the rural area near Helena, Montana and 
recently added a new partner, Anthem Broadband.

                                 ______
                                 

             Questions Submitted by Senator Lisa Murkowski
    Question. Dr. Lieberman, in your testimony you spoke about efforts 
to expand video-to-the-home services by utilizing remote patient 
monitoring services for Veterans at higher risk, those who need to be 
isolated or quarantined at home, and for those who are concerned about 
COVID-19 exposure. Are Veterans receiving adequate Mental Healthcare 
via telehealth?
    Answer. Rigorous research consistently supports that mental health 
services, including psychotherapy and psychiatry, delivered over video-
to-clinic and video-to-home are as clinically effective as traditional 
in-person care for treating a range of mental health conditions in 
Veterans. Patient and provider satisfaction, therapeutic alliance, and 
retention have also been demonstrated. Quantitative data show that 
Veterans perceive high quality in their telehealth visits, and 
qualitative interview data show that Veterans overwhelmingly like the 
use of video telehealth. Internal VA survey data (July 2020-January 
2021) showed that 33 percent of Veterans in mental healthcare preferred 
video care over in-person or telephone care.
    In fiscal year 2020, throughout the COVID-19 pandemic, Veterans 
Health Administration (VHA) Mental Health Services maintained 92 
percent of previous fiscal year outpatient workload. Telemental health 
to home (TMH-to-Home) increased across the population to include: 
clinics, rural/urban, gender, age, race, and the mental health 
continuum of care (outpatient, residential, inpatient, and emergency 
department). VHA used multiple ways of reaching Veterans via technology 
(e.g., clinical video telehealth into clinics, homes, and other non-VA 
locations; Clinical Resource Hubs for staffing and service gap 
coverage; National Telemental Health Center expert consultations; Home 
Telehealth/remote monitoring; mobile apps such as Posttraumatic Stress 
Disorder (PTSD) Coach; secure messaging, etc.).
    In fiscal year 2020, VA provided TMH services to nearly 550,000 
Veterans during more than 2.4 million visits (1.6 million more TMH 
visits than in fiscal year 2019--a 207 percent increase). Of this 
fiscal year 2020 total, more than 444,000 Veterans received nearly 2.1 
million TMH visits directly into their home or location of choice (a 
932 percent increase in visits over fiscal year 2019). TMH-to-Home 
visits averaged 27,000 per month pre-COVID. In March 2021, there were 
over 551,000 TMH-to-Home visits (the highest monthly TMH-to-Home volume 
to date). TMH-to-Home group therapy averaged 150 group visits per month 
pre-COVID and increased to more than 145,500 visits in March 2021 (the 
highest TMH-to-Home group utilization to date).
    Question. Has there been an increase in Mental Healthcare needs 
amongst Veterans during the pandemic?
    Answer. Overall utilization of mental health services does not 
suggest an increase in mental health needs during the pandemic. In the 
quarter following the declaration of the COVID-19 pandemic (fiscal year 
2020, Quarter 3), there was a decrease of approximately 60,000 unique 
Veterans seeking mental healthcare. Unique Veterans seeking mental 
healthcare has increased steadily each quarter since this initial 
decline. In the last complete quarter (fiscal year 2021, Quarter 2), 
the number of unique Veterans seeking mental healthcare has returned to 
pre-pandemic levels.
    Question. Have you seen an increase in Veteran suicide rates over 
the past 13 months? And if so, what measures is the VA taking to ensure 
those who need Mental Healthcare are receiving proper care that is 
customized to their individual needs?
    Answer. VA conducts ongoing surveillance to assess potential 
pandemic-related trends in suicide-related indicators. These include 
tracking by week of the following:

  --VHA site-reported Veteran suicides;

  --VHA patients with new indications of a non-fatal suicide attempts;

  --On-campus suicide attempts and deaths; and

  --Emergency department visits for suicide attempts.

    To date, we have not observed increases in documentation of these 
indicators. Definitive assessment of trends in Veteran suicide rates 
since the start of the pandemic will be conducted when vital status and 
cause of death data for 2020 become available from the CDC's National 
Death Index (NDI).
    The onset of the COVID-19 pandemic beginning in March 2020 resulted 
in drastic changes in the delivery of mental healthcare across the U.S. 
To ensure mental healthcare was available to all Veterans in need, at 
the pandemic onset, VHA immediately outlined a strategic plan to 
address the full continuum of care. The COVID-19 Response Plan for 
mental health and suicide prevention has been based on a public health 
model focusing on comprehensive community and clinically based 
strategies organized across the following three domains: universal, 
selective and indicated services. In addition to rapidly developing and 
disseminating self-help app protocols specific to COVID-19 impact, VHA 
enhanced targeted strategies for identifying and reaching Veterans at 
increased risk for suicide and mental health challenges, as well as 
enhancing efforts to bolster operational protocols to ensure continued 
operation of its mission in the face of increasing demand and potential 
risks for staff who work in close proximity. A thorough description of 
our COVID-19 response plan as related to suicide prevention is 
available online in our 2020 National Veteran Suicide Prevention Annual 
Report (Available here: Veteran Suicide Data and Reporting--Mental 
Health (va.gov)).
    Question. One of the challenges that Alaska's Veterans trying to 
use telehealth services face is the fact that a significant portion of 
Alaska lacks broadband access.
    How many Veterans are unable to access telehealth services due to 
lack of broadband access? What is the VA doing to ensure that all 
Veterans, including those in rural and remote locations, have access to 
telehealth?
    Answer. Based on December 2019 estimates from the VHA Office of 
Rural Health, Geospatial Outcomes Division (GSOD), approximately 
416,000 (or 14 percent of) VA-registered Veterans residing in rural, 
highly rural, and insular island areas lack access to telehealth 
capabilities because broadband connectivity is unavailable.
    VA is taking strides to bridge the digital divide for Veterans who 
lack the technology or broadband Internet connectivity required to 
participate in VA telehealth services irrespective of their location in 
the country.
    VA has implemented a national digital divide consult process. This 
program allows VA providers to refer Veterans who would benefit from 
video telehealth services but do not have Internet access or video-
capable devices to a social worker who can help them determine 
eligibility for programs to access the Internet service or technology 
needed for VA telehealth. VA can lend Veterans Internet-connected 
devices or help them in applying for FCC administered Internet 
subsidies. The FCC subsidies are available through the Lifeline and 
Emergency Broadband Benefit (EBB) programs.
    The Lifeline and EBB programs can combine to provide many 
qualifying Veterans $59.25 per month for their Internet services. 
Veterans on tribal lands can receive $109.25 per month through these 
programs.
    VA has completed over 45,500 digital divide consultations since the 
beginning of fiscal year 2021 and has distributed more than 84,000 
Internet connected tablets since the start of the pandemic.
    Additionally, major wireless carriers such as Verizon, T-Mobile, 
SafeLink by Tracfone, and AT&T are working with VA to support Veterans' 
access to VA telehealth services through the Zero-Rating program, which 
allows Veterans, their families, and caregivers to use VA Video Connect 
with fewer worries about data fees.
    VA is also continuing collaborations with Walmart, Philips, the 
Veterans of Foreign Wars, and American Legion to establish a total of 
fifteen telehealth access stations in Veteran communities. The 
Accessing Telehealth through Local Area Stations (ATLAS) sites allow 
Veterans to receive VA telehealthcare at a convenient location close to 
their home. VA currently has 12 ATLAS locations nationally that are 
open and available for scheduling. By the end of 2021, it is 
anticipated that a total of 13 ATLAS sites will offer clinical services 
by telehealth from VA providers. As part of its future expansion, VA is 
collaborating with Navajo Nation and Navajo Health Foundation--Sage 
Memorial Hospital in Ganado, Arizona to establish an ATLAS site.
    Question. How does the rate of Veterans utilization of telehealth 
services in Alaska compare to other states and the national average?
    Answer. Clinical video telehealth visits in Alaska numbered 2,862 
in fiscal year 2019 and 7,348 in fiscal year 2020, representing a 156 
percent year over year growth. This is compared to 231 percent growth 
at the national level for clinical video telehealth between fiscal year 
2019 and fiscal year 2020.
    Question. Can money spent to reimburse travel be spent on a 
telehealth bill? In other words, if I have to pay a premium for 
Internet because I live in a remote location where broadband is not as 
accessible, can I, if I were a Veteran, be reimbursed for that usage 
fee? Please tell me how this will work as I know in Alaska both 
connectivity and the cost and difficulties associated with traveling to 
and from an appointment and then getting reimbursed have been points of 
contention.
    Answer. Under 38 U.S.C. Sec. 111, VA may pay the actual necessary 
expense of travel, or in lieu thereof an allowance based on mileage, of 
any eligible person to and from a VA medical facility or other place 
for the purpose of, among other things, examination, treatment, or 
care. 38 U.S.C. Sec. 111(a); 38 C.F.R. Sec. 70.32. VA lacks the 
authority to reimburse Veterans for Internet usage fees under the 
program described above that reimburses Veterans for travel.
    However, VA can assist Veterans in obtaining Internet service and 
avoiding data charges in order to access telehealth through its digital 
divide initiatives. VA works with Internet service providers to reduce 
concerns about data fees when using VA Video Connect for telehealth 
appointments. For Veterans that do not have a device with Internet 
access, VA may be able to lend certain eligible Veterans an Internet-
connected iPad or smartphone to connect with VA through telehealth. VA 
also works with American Legion, Philips North America, Veterans of 
Foreign Wars, and Walmart to bring telehealthcare into select 
communities through ATLAS. ATLAS sites provide private spaces for 
Veterans to have video appointments with their VA providers. In 
addition, the FCC's Lifeline program subsidizes the cost of home 
broadband and phone service. Many Veterans are eligible for Lifeline 
benefits, including Veterans with lower incomes and those participating 
in Medicaid, Supplemental Nutrition Assistance Program, Supplemental 
Security Income, Federal Public Housing Assistance, VA pension, VA 
Survivors Pension, and tribal programs and residents of federally-
recognized tribal lands. To benefit from these services, Veterans 
should speak with their providers who can make a referral to a social 
worker. Social workers can help Veterans get the Internet or technology 
needed to access VA telehealth.
    Question. Section 20011 of the CARES Act directed the VA to ensure 
that telehealth capabilities be available for homeless Veterans and 
their Case Managers that participate in the Department of Housing and 
Urban Development--Department of Veterans Affairs Supportive Housing 
program. How has the VA been working to ensure that Veterans utilizing 
this program have access to telehealth services?
    Answer. For the homeless Veteran population, VA purchased over 
31,000 smartphones with pre-paid cellular Internet service and 
distributed them through the Homeless Veterans Program.

                                 ______
                                 

              Questions Submitted by Senator Bill Hagerty
    Question. In 2020 and 2021 Veterans' use of virtual medicine 
increased dramatically--more than 1,900 percent as compared to 2019. 
Some of the advances you have described in your opening statement are 
incredible. However, in order for veterans to take advantage of these 
powerful tools, they must have access to broadband--this is a bigger 
challenge for veterans in rural areas--and one that is being addressed 
across multiple Federal agencies. In response, the Department of 
Veterans Affairs (VA) has partnered with private industry and other 
Federal agencies to provide broadband infrastructure and the necessary 
technology to Veterans. Specifically, the VA has provided more than 
110,000 cell phones and tablets to Veterans and certain wireless 
providers to allow Veterans to receive virtual care without incurring 
data fees through the Zero-Rating program. Can you provide more details 
about the partnership with private industry through the Zero-Rating 
program?
    Answer. T-Mobile, Verizon, AT&T, and SafeLink by TracFone are 
supporting Veterans' connections through video and VA Video Connect by 
zero rating the VA Video Connect application. Zero rating helps Veteran 
subscribers of these carriers avoid data charges when using VA Video 
Connect on the carrier networks. This enables Veterans to access their 
VA care teams through telehealth with fewer worries about data fees.
    Question. What lessons has the VA learned about partnering with 
private industry to provide technology to veterans and how can the VA 
expand these efforts to better serve veterans?
    Answer. VA believes there are opportunities to continue expanding 
public private collaborations to support Veterans' access to healthcare 
through the Accessing Telehealth through Local Area Stations (ATLAS) 
program as an example. ATLAS is a pilot designed to bridge the digital 
divide and reach rural and underserved Veterans in areas with limited 
access to healthcare. Through this initiative, VA is currently working 
with Philips, Walmart, Veterans of Foreign Wars (VFW), and American 
Legion to provide convenient locations within Veterans' communities 
equipped with the broadband and telehealth technology necessary to 
access VA healthcare. Going forward, VA envisions expanding ATLAS to a 
variety of locations, including academic institution, community 
centers, and federally-qualified health centers.
    VA additionally believes there are opportunities to work with 
additional cellular providers to zero rate VA Video Connect on their 
networks if State-based legal barriers are addressed. Zero rating 
allows Veterans to access their VA care teams through VA Video Connect 
with fewer worries about data charges.
    By combining government and private sector expertise, VA believe it 
can achieve its connected care vision of providing Veterans with 
trusted care, anytime and anywhere.
    Question. During the pandemic, we've seen a rise in mental health 
cases--due to isolation, increased anxiety and stress--across the 
general population. Mental health issues are even more prevalent among 
service members and the veteran community. Suicide rates among 
veterans, for example, is 1.5 times higher than the general population. 
According to VA data, about 20 veterans a day commit suicide and nearly 
three quarters of them are not under VA care. In your testimony, you 
mentioned a host of initiatives aimed at curtailing this alarming rate. 
How can the VA more proactively reach out and identify veterans that 
are at risk of suicide?
    Answer. NOTE: Per the most recent VA suicide report, the most 
recent data indicates that on average there were 17.6 Veteran suicides 
each day in 2018. In 2018, the average of 17.6 Veteran suicides per day 
comprised 6.5 Veterans with recent VHA use and 11.1 Veterans without 
recent VHA use. Previous reports had indicated that the number was 20, 
however, evolving practices in surveillance and clarification on the 
definition of ``Veteran'' and all that is encompassed in that 
definition have allowed us to appropriately update that number.
    VA's suicide prevention efforts are guided by the National Strategy 
for Preventing Veteran Suicide (2018), which provides the framework for 
identifying priorities, organizing efforts, and contributing to a 
national focus on Veteran suicide prevention over the next decade. The 
Strategy calls for community-level interventions to conduct outreach to 
all Veterans regardless of their engagement with VA. Full details about 
the National Strategy for Preventing Veteran Suicide and our public 
health approach are available at the following link: https://
www.mentalhealth.va.gov/suicide_prevention/strategy.asp.
    In 2020, VA translated the vision of the 10-year National Strategy 
and its four major domains into operationalized plans of actions: 
Suicide Prevention 2.0 (SP 2.0), started in 2018, combined with the 
Suicide Prevention Now initiative. SP 2.0 is a six-year strategic plan 
with national reach focused on the implementation of clinical and 
community-based prevention, intervention, and postvention services that 
reflect the National Strategy's four pillars. The SP 2.0 community-
based domain focuses on enacting the four pillars through the VISN-
Based Community Coalition and Collaboration Building, Veteran-to-
Veteran Coalition Building, and State-Based Coalition and Collaboration 
Building models described below.
    Community-Based Interventions in SP 2.0: To reach Veterans both 
inside and outside VA care, SP 2.0 aims to move suicide prevention 
beyond a one-size-fits-all model to a blended model combining community 
prevention strategies and evidence-based clinical strategies that will 
empower action at the national, regional, and local levels. Community-
Based Interventions for Suicide Prevention (CBI-SP) migrates and 
expands three legacy initiatives into a comprehensive approach to 
community-based suicide prevention to address needs at state and local 
community levels, covering 2,381 counties including 13.2 million 
Veterans:

  --For state-level prevention, the Office of Mental Health and Suicide 
        Prevention (OMHSP), in collaboration with our partners at the 
        Substance Abuse and Mental Health Services Administration 
        (SAMHSA), is supporting expanding the Governor's Challenges to 
        Prevent Suicide Among Service Members, Veterans, and their 
        Families, where State-level policymakers will partner with 
        local leaders to implement a comprehensive suicide prevention 
        plan, with a goal to invite all 50 states to participate by the 
        end of fiscal year 2022. Currently 35 States are actively 
        involved in the Governor's Challenge.

  --For local community action, OMHSP is supporting expansion across 
        all Veterans Integrated Service Networks (VISNs) of a Community 
        Engagement and Partnerships--Suicide Prevention (CEP-SP) 
        program focused on community coalition-building coupled with 
        targeted outreach and education, as well as the Together With 
        Veterans (TWV) program, a VA Office of Rural Health program 
        focused on empowering and supporting Veteran leadership for 
        suicide prevention.

  --The community-based interventions expand the capacity of VISNs to 
        engage in community-based suicide prevention efforts in their 
        region, thereby reducing population suicide rates among 
        Veterans.

  --This includes a comprehensive strategy to hire and train Community 
        Engagement and Partnerships Coordinators (CEPC), who will 
        collaborate at the community, regional, and state levels, to 
        implement evidence-informed community-based suicide prevention 
        interventions. Four VISNs, identified as early adopters, began 
        implementation of SP 2.0 community-based intervention 
        strategies. In fiscal year 2021, the National Suicide 
        Prevention Program initiated a Request for Letters of Intent 
        (LOI) approach, which helped to facilitate our phased 
        implementation of this effort. Five additional VISNs were 
        selected to start in the second quarter of fiscal year 2021 and 
        the remaining VISNs will be starting in the first quarter of 
        fiscal year 2022.

  --By the end of the phased roll out in fiscal year 2023, the 
        Community Engagement and Partnerships--Suicide Prevention will 
        have expanded to all 18 VISNs and all 50 States will have been 
        invited to participate in the Governor's Challenge.

    Clinically Based Interventions in SP 2.0:

  --For the clinically based strategy of SP 2.0, in partnership with 
        VA's Clinical Resource Hubs (CRH), implementation of evidenced-
        based interventions for suicide prevention via telehealth is 
        underway.

  --As indicated in the 2019 VA/DoD Clinical Practice Guideline (CPG) 
        on the Assessment and Management of Patients at Risk for 
        Suicide, the focus in fiscal year 2021 has been on the roll out 
        of the following: 1) Cognitive Behavioral Therapy for Suicide 
        Prevention (CBT-SP), which was initially piloted under SPP's 
        ``Demonstration Projects'' line item; 2) Problem-Solving 
        Therapy for Suicide Prevention (PST-SP); 3) Dialectical 
        Behavior Therapy (DBT), conducted in a small pilot; and 4) the 
        Advanced Training in the Safety Planning Intervention (ASPI).

  --SP 2.0 Clinical Telehealth interventions target Veterans with a 
        history of suicidal self-directed violence. This initiative 
        will include 100+ hires across all telehubs to reach all 
        healthcare systems, targeting care for 20,000 Veterans at high 
        risk for suicide.

    Communications: VA has multiple efforts underway to proactively 
reach out to veterans

  --Make the Connection is VA's award-winning mental health public 
        awareness campaign. The primary objectives are to highlight 
        Veterans' true and inspiring stories of mental health recovery 
        and to connect Veterans and their family members with mental 
        health resources in their communities. Hear stories of recovery 
        at https://maketheconnection.net/. Since its launch in 2011, 
        the campaign has achieved the following, high-level outcomes: 
        over 27 million visits to the website; over 299 million video 
        views; over 1.3 million uses of campaign website resource 
        tools; over 3 million fans on Facebook, with over 258 million 
        social engagements (likes, shares, and comments), and well over 
        10 billion impressions on social media; and, over 510,000 
        airings of Make the Connection's 18 public service 
        announcements (PSA), for over 3.6 billion impressions, equaling 
        more than $48 million dollars in equivalent paid media value.

  --Media Outreach: VA's paid media campaigns for Veteran mental health 
        and suicide prevention include experts in digital marketing, 
        social media, and strategic communications, as well as writers, 
        graphic designers, researchers, and subject matter experts 
        familiar with Veteran mental health. VA communication campaigns 
        focus on mental health literacy, crisis intervention, suicide 
        prevention, reducing the stigma associated with mental health 
        challenges and encouraging help-seeking behavior among all 
        Veterans. VA continues to adjust campaign tactics and 
        performance measures, based on data or in response to emerging 
        platform opportunities or advancements, to increase engagement 
        with target audiences and to continue providing the right 
        messages at the right time to support Veterans. Campaign 
        content includes Lethal Means Safety, #BeThere supporter, 
        Veterans Crisis Line and Suicide Prevention Month (September) 
        messaging.

      --OMHSP uses a data-driven approach to reach Veterans where they 
            are online and in-person. Data capture and evaluation are 
            part of OMHSP's continual measurement and optimization of 
            campaign performance against campaign goals, beginning with 
            the first effort launched in 2010.

      --The Suicide Prevention Program has invested $8.5 million 
            towards its paid media efforts in fiscal year 2021, which 
            supports VA's requirement to inform Veterans about 
            available resources and services by distributing accurate 
            and responsible information using the most effective and 
            impactful platforms available online.

      --Paid media efforts started in February of 2020 focusing on 
            three campaigns: Lethal Means (encouraging behavior change 
            with an emphasis on lethal means safety), Be There (raising 
            awareness about suicide and suicide prevention) and 
            Veterans Crisis Line (taking action when a Veteran is in 
            crisis).

      --Since launch through the end of March 2021, ads have generated 
            over 1.09 billion impressions, over 2.8 million website 
            visits, over 393 million completed video views, and over 
            82,000 resource engagements.

    Other Programs for Outreach:

  --Recovery Engagement and Coordination for Health--Veterans Enhanced 
        Treatment (REACH VET) program: REACH VET uses predictive 
        (statistical) modeling to identify Veterans at risk for suicide 
        and other adverse outcomes. The breadth of predictive factors 
        that identify those Veterans at greatest risk for suicide or 
        other significant adverse event take into account both medical 
        and social determinants of health and, as such, may be 
        sensitive to identifying Veterans at increased risk due to 
        COVID-related stressors. As the result of an ongoing effort to 
        engage Veterans identified by the REACH VET predictive model in 
        a comprehensive review of their care that continued during the 
        pandemic, the percentage of individuals who were identified by 
        REACH VET as being at the greatest risk who had their care 
        reviewed by a VHA provider rose from 91 percent in March 2020 
        to 99 percent in April 2021. Similarly, outreach attempts to 
        those Veterans to collaboratively review their care rose from 
        89 percent in January 2020 to 99 percent in April 2021.

  --Safety Planning in the Emergency Department (SPED): The Emergency 
        Department (ED) is also an area in which individuals who are at 
        significant risk for suicide are encountered. Though a Veteran 
        may present to an ED for non-suicide or mental health related 
        reasons, all Veterans who are encountered in the ED are 
        screened for risk of suicide. In order to better serve these 
        Veterans, VA has implemented Safety Planning in the Emergency 
        Department (SPED) for Veterans who go home following a visit to 
        the ED during which they are found to be at intermediate or 
        high chronic or acute risk for suicide. From March 2020 to 
        March 2021, 3,583 SPED-eligible visits completed a Suicide 
        Prevention Safety Plan within 24 hours of the visit. The 
        overall success rate that shows plans are collaboratively 
        developed within 24 hours of a visit to the ED rose from 62 
        percent in March 2020 to 86 percent in March 2021.

  --Coaching into Care (CIC): VA provides a national telephone service 
        for Veterans, their family members, and other loved ones 
        seeking services at local VA facilities and in the community. 
        Coaching is provided free-of-charge by licensed psychologists 
        or social workers to family members and friends who are seeking 
        care or services for a Veteran family member. Site: https://
        www.mirecc.va.gov/coaching/. In the third quarter of fiscal 
        year 2020, CIC maintained an active call center during the 
        entire initial period of remote operations due to COVID-19 and 
        completed 1499 calls with family members.

  --Veterans Crisis Line: VA provides 24-hours per day, 7-days per 
        week, and 365-days per year continuous crisis intervention 
        services through the Veterans Crisis Line (VCL). VCL connects 
        Veterans in crisis and their families and friends with 
        qualified, caring VA responders through a confidential toll-
        free hotline, online chat, or text. The VCL is an important 
        resource for outreach and access to care. Its mission is to 
        supplement local suicide prevention efforts.

  --VA Solid Start: Launched in December 2019, Solid Start proactively 
        calls newly separated Veterans three times during their first 
        year after separation from active-duty military service (at 90, 
        180, and 365-days post-separation). Specially trained VA 
        representatives offer resources and information concerning 
        specific VA benefits and services, as well as partner 
        resources, based on issues or challenges identified by the 
        Veteran during the call. In addition to calls, transitioning 
        Servicemembers receive information on benefits and eligibility 
        in written format (by email or mail) about the variety of VA 
        benefits and healthcare resources available, including mental 
        healthcare, and a caring contact with each Veteran regardless 
        of VA eligibility. Solid Start prioritizes calls to eligible 
        Veterans who had a mental health appointment within their last 
        year of active-duty service. Representatives are trained to 
        connect Veterans in crisis to the Veterans Crisis Line through 
        a warm transfer, remaining on the line until the Veteran is 
        connected. Please visit https://www.benefits.va.gov/transition/
        solid-start.asp for additional information.

  --Local Facility and Community Outreach and Activities: VA has just 
        under 500 dedicated employees for suicide prevention efforts, 
        located at every VA medical center (VAMC) to connect Veterans 
        with care and educate the community about suicide prevention 
        programs and resources. An essential role of local suicide 
        prevention teams is to participate in outreach activities in 
        their communities to increase awareness of suicide prevention 
        and the resources available in the local community (a minimum 
        of five events per month). These outreach activities include 
        the following: (1) community suicide prevention trainings and 
        other educational programs; (2) exhibits and material 
        distribution to a wide variety of organizations and 
        populations; (3) meetings with State and local suicide 
        prevention groups, and collaborations with Vet Centers and 
        local Veteran of Foreign Wars (VFW) and American Legion posts; 
        and (4) suicide prevention work with Active Duty/Guard/Reserve 
        units, college campuses, and American Indian/Alaska Native 
        groups.

    Question. An anecdotal lesson, part of the stigma of mental health 
is that reaching out for help could be incorrectly perceived as 
weakness--especially in rural communities where everyone knows what 
truck you drive. One of the unforeseen advantages of telemedicine is 
that veterans can reach out for help without having to travel to a 
clinic. Have you seen improvements with veterans reaching out for help 
virtually? What more can be done to highlight available services for 
veterans with mental health issues? Are there opportunities to partner 
with private industry?
    Answer. Utilization of VA Video Connect (VVC), which allows 
Veterans to complete a mental health appointment at the location of 
their choosing, has increased dramatically throughout the COVID-19 
pandemic. In March 2021, VHA completed over 550,000 mental health VVC 
appointments. In comparison, prior to the pandemic declaration 
(February 2020), VHA completed just over 29,000 VVC mental health 
appointments. Increased VVC utilization includes over 1,000 percent 
increase with those Veterans living in rural locations. Ongoing 
national campaigns, such as 1 Step Today (https://www.va.gov/opa/
pressrel/pressrelease.cfm?id=5661) and Make the Connection (https://
www.maketheconnection.net/) remain critical in addressing the stigma 
associated with mental health and asking for help. VA will use 
opportunities to expand VVC and video technology through work with non-
VA parties to leverage mental healthcare opportunities and ease 
initiating and receiving care.
    Question. A synchronous and clear video quality is significantly 
more important when it comes to mental health. Health professionals can 
identify body language and facial expressions that can be signs of 
serious trouble. How have the VA mobile apps helped in this, what can 
be improved?
    Answer. Virtual Care Manager (VCM), VA's application used to create 
video visits, is updated incrementally over time to promote efficient 
video visits (e.g., features include being able to create, view and 
join video visits; re-send email notifications to Veterans; and create 
group visits). VA Video Connect (VVC), VA's video application, is 
continually updated to ensure it remains a state-of-the-art video 
platform providing a high-quality video experience for providers and 
Veterans (during the pandemic, the group layout feature was expanded). 
VVC promotes safe, effective, and efficient care by having several, 
important features, as follows:

  --e911: Patient's physical location is available to 911 operators in 
        the patient's local area in the event of an emergency.

  --Secure and Encrypted: End-to-End encryption helps to ensure patient 
        privacy is protected.

  --Scheduled: Allows patients to invite caregivers and families from 
        multiple locations into the telehealth encounter (which helps 
        support for those at risk).

  --Provider Privacy: The provider's phone number is not revealed to 
        the patient.

  --Patient Privacy: The patient's data become part of the medical 
        record and are not given or sold to any third parties.

  --Zero Rating: Depending on the patient's phone carrier, encounters 
        may not count against the patient's mobile data.

  --Anonymity: Personal contact information is not shared while using 
        VVC Group encounters.

    The ``VVC Now'' application allows providers to create ``on 
demand'' VVC links and send to patients via email or text message in 
order to create a virtual medical session for ad hoc video visits. The 
suite of applications (VCM, VVC, VVC Now) promotes secure, high-
quality, and efficient video care. A continuous communication feedback 
loop between facility staff and the Office of Mental Health and Suicide 
Prevention and the Office of Connected Care promotes sharing of what's 
going well and what needs improvement, and technology updates address 
field feedback (e.g., requested upcoming addition of audio-only option 
for VVC).
    Addressing the digital divide is still an area of concern. Some 
Veterans need access to devices and broadband Internet to participate 
effectively in a high-quality video session, and VA has been 
implementing solutions to address this.
    Question. The advantage the VA Health System has over the private 
health system is that the VA has sole jurisdiction over the licensing 
requirement regulations. The CARES Act in particular gave the VA more 
flexibility and expanded authority to provide telehealth services to 
veterans.
    Has the VA been able to quantify the changes in cost for the 
expanded use of telemedicine at the VA?
    Answer. In fiscal year 2020, VA leveraged telehealth to maintain 
the safe delivery of high-quality outpatient VA services in the context 
of pandemic-related physical distancing guidelines. This resulted in a 
dramatic shift from in-person visits and on-site telehealth visits at 
VA facilities to video visits in Veterans' homes. This also resulted in 
emergent expenditures needed to quickly modernize VA automation systems 
and purchase additional equipment to permit and effectively handle the 
exponential growth of teleworking VA staff members. A clear 
illustration of the exponential growth is the over 3.8 million video 
visits provided by VA to Veteran's homes in fiscal year 2020, an 
increase of greater than 1,200 percent compared to fiscal year 2019. 
Any changes in cost for overall Veteran care based on the increased use 
of telehealth is not yet fully understood.
    Question. What lessons has the VA learned through the expanded 
telemedicine effort? How can the VA further partner with private 
industry to better serve veterans?
    Answer. VA learned that its prior investments and vision for 
telehealth services were invaluable in the face of an emergency. Prior 
to the pandemic, VA had a national telehealth platform to serve 
Veterans in their homes, a national remote patient monitoring program, 
a large tele-critical care program, and a field-based telehealth 
workforce on which to rely. By leveraging these strong foundational 
elements, VA was able to transition its services within the pandemic 
care delivery paradigm.
    Despite its strong foundations, VA faced hurdles in scaling its 
programs at the rapid pace needed during the early days of the 
pandemic. VA recognizes the need to balance its traditional lean 
operations against a requirement for flexibility. Going forward, VA 
must invest in sustaining a more robust and expansible technology 
infrastructure so it can immediately execute sharp pivots in its 
operations when needed.

                          SUBCOMMITTEE RECESS

    Senator Heinrich. We stand adjourned. Gentlemen, thank you 
very much.
    [Whereupon, at 3:45 p.m., Wednesday, April 28, the 
subcommittee was recessed, to reconvene at a time subject to 
the call of the Chair.]