[Senate Hearing 117-548]
[From the U.S. Government Publishing Office]
S. Hrg. 117-548
VA TELEHEALTH PROGRAM: LEVERAGING RECENT INVESTMENTS TO BUILD FUTURE
CAPACITY
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HEARING
before a
SUBCOMMITTEE OF THE
COMMITTEE ON APPROPRIATIONS UNITED STATES SENATE
ONE HUNDRED SEVENTEENTH CONGRESS
FIRST SESSION
__________
SPECIAL HEARING
APRIL 28, 2021--WASHINGTON, DC
__________
Printed for the use of the Committee on Appropriations
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: https://www.govinfo.gov
__________
U.S. GOVERNMENT PUBLISHING OFFICE
50-338 PDF WASHINGTON : 2023
COMMITTEE ON APPROPRIATIONS
PATRICK J. LEAHY, Vermont, Chairman
PATTY MURRAY, Washington RICHARD C. SHELBY, Alabama, Vice
DIANNE FEINSTEIN, California Chairman
RICHARD J. DURBIN, Illinois MITCH McCONNELL, Kentucky
JACK REED, Rhode Island SUSAN M. COLLINS, Maine
JON TESTER, Montana LISA MURKOWSKI, Alaska
JEANNE SHAHEEN, New Hampshire LINDSEY GRAHAM, South Carolina
JEFF MERKLEY, Oregon ROY BLUNT, Missouri
CHRISTOPHER A. COONS, Delaware JERRY MORAN, Kansas
BRIAN SCHATZ, Hawaii JOHN HOEVEN, North Dakota
TAMMY BALDWIN, Wisconsin JOHN BOOZMAN, Arkansas
CHRISTOPHER MURPHY, Connecticut SHELLEY MOORE CAPITO, West
JOE MANCHIN, West Virginia Virginia
CHRIS VAN HOLLEN, Maryland JOHN KENNEDY, Louisiana
MARTIN HEINRICH, New Mexico CINDY HYDE-SMITH, Mississippi
MIKE BRAUN, Indiana
BILL HAGERTY, Tennessee
MARCO RUBIO, Florida
Charles E. Kieffer, Staff Director
Shannon Hutcherson Hines, Minority Staff Director
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Subcommittee on Military Construction, Veterans Affairs, and Related
Agencies
MARTIN HEINRICH, New Mexico, Chairman
BRIAN SCHATZ, Hawaii JOHN BOOZMAN, Arkansas, Ranking
JON TESTER, Montana MITCH McCONNELL, Kentucky
PATTY MURRAY, Washington LISA MURKOWSKI, Alaska
JACK REED, Rhode Island JOHN HOEVEN, North Dakota
TAMMY BALDWIN, Wisconsin SUSAN M. COLLINS, Maine
CHRISTOPHER A. COONS, Delaware SHELLEY MOORE CAPITO, West
JOE MANCHIN, West Virginia Virginia
MARCO RUBIO, Florida
BILL HAGERTY, Tennessee
Professional Staff
Michelle Dominguez
Joanne Hoff
Jason McMahon
Patrick Magnuson (Minority)
Jennifer Bastin (Minority)
Lucy Gardner (Minority)
Administrative Support
Drew Platt
C O N T E N T S
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Page
Opening Statement of Senator Martin Heinrich..................... 1
Opening Statement of Senator John Boozman........................ 3
Summary Statement of Dr. Steven L. Lieberman..................... 4
Prepared Statement of Dr. Steven Lieberman................... 5
Introduction............................................. 6
Population Covered....................................... 6
Type of Services Provided................................ 7
VA Video Connect......................................... 7
Specific Connected Care/Telehealth COVID-19 Efforts...... 8
Recent Trends............................................ 8
Conclusion............................................... 9
Additional Committee Questions................................... 18
Questions Submitted to Dr. Steven Lieberman...................... 19
Questions Submitted by Senator Martin Heinrich................... 19
Future Goals................................................. 19
Tribal Veterans' Access to Telehealth........................ 19
Accessing Telehealth through Local Area Stations (ATLAS) Pilot 19
Asset and Infrastructure Review (AIR) Commission............. 21
Integration w/Electronic Health Record Modernization (EHRM)
Effort..................................................... 22
Questions Submitted by Senator Senator Jon Tester................ 22
Questions Submitted by Senator Lisa Murkowski.................... 24
Questions Submitted by Senator Bill Hagerty...................... 26
VA TELEHEALTH PROGRAM: LEVERAGING RECENT INVESTMENTS TO BUILD FUTURE
CAPACITY
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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.]
[all]