[House Hearing, 118 Congress]
[From the U.S. Government Publishing Office]
IOWA: A LEADER IN VETERAN
HEALTHCARE INNOVATION
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON HEALTH
OF THE
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED EIGHTEENTH CONGRESS
SECOND SESSION
__________
MONDAY, MAY 13, 2024
__________
Serial No. 118-62
__________
Printed for the use of the Committee on Veterans' Affairs
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Available via http://govinfo.gov
__________
U.S. GOVERNMENT PUBLISHING OFFICE
55-930 WASHINGTON : 2025
-----------------------------------------------------------------------------------
COMMITTEE ON VETERANS' AFFAIRS
MIKE BOST, Illinois, Chairman
AUMUA AMATA COLEMAN RADEWAGEN, MARK TAKANO, California, Ranking
American Samoa, Vice-Chairwoman Member
JACK BERGMAN, Michigan JULIA BROWNLEY, California
NANCY MACE, South Carolina MIKE LEVIN, California
MATTHEW M. ROSENDALE, SR., Montana CHRIS PAPPAS, New Hampshire
MARIANNETTE MILLER-MEEKS, Iowa FRANK J. MRVAN, Indiana
GREGORY F. MURPHY, North Carolina SHEILA CHERFILUS-MCCORMICK,
C. SCOTT FRANKLIN, Florida Florida
DERRICK VAN ORDEN, Wisconsin CHRISTOPHER R. DELUZIO,
MORGAN LUTTRELL, Texas Pennsylvania
JUAN CISCOMANI, Arizona MORGAN MCGARVEY, Kentucky
ELIJAH CRANE, Arizona DELIA C. RAMIREZ, Illinois
KEITH SELF, Texas GREG LANDSMAN, Ohio
JENNIFER A. KIGGANS, Virginia NIKKI BUDZINSKI, Illinois
Jon Clark, Staff Director
Matt Reel, Democratic Staff Director
SUBCOMMITTEE ON HEALTH
MARIANNETTE MILLER-MEEKS, Iowa, Chairwoman
AUMUA AMATA COLEMAN RADEWAGEN, JULIA BROWNLEY, California,
American Samoa Ranking Member
JACK BERGMAN, Michigan MIKE LEVIN, California
GREGORY F. MURPHY, North Carolina CHRISTOPHER R. DELUZIO,
DERRICK VAN ORDEN, Wisconsin Pennsylvania
MORGAN LUTTRELL, Texas GREG LANDSMAN, Ohio
JENNIFER A. KIGGANS, Virginia NIKKI BUDZINSKI, Illinois
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
official version. Because electronic submissions are used to prepare
both printed and electronic versions of the hearing record, the process
of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
----------
MONDAY, MAY 13, 2024
Page
OPENING STATEMENTS
The Honorable Mariannette Miller-Meeks, Chairwoman............... 1
The Honorable Julia Brownley, Ranking Member..................... 3
WITNESSES
Panel 1
Dr. Carolyn Clancy, M.D., Assistant Under Secretary for Health,
Office of Discovery, Education and Affiliate Networks, Veterans
Health Administration, U.S. Department of Veterans Affairs..... 4
Accompanied by:
Dr. Victoria Sharp, M.D., Deputy Chief of Staff, Iowa City VA
Healthcare System, U.S. Department of Veterans Affairs
Panel 2
Dr. Mahsaw Mansoor, M.D., Resident, University of Iowa,
Department of Ophthalmology.................................... 12
Mr. Brandon Blankenship, Chief Technology Officer, ProCircular... 14
APPENDIX
Prepared Statements Of Witnesses
Dr. Carolyn Clancy, M.D. Prepared Statement...................... 23
Dr. Mahsaw Mansoor, M.D. Prepared Statement...................... 27
Mr. Brandon Blankenship Prepared Statement....................... 37
Statement For The Record
American Optometric Association Prepared Statement............... 39
IOWA: A LEADER IN VETERAN
HEALTHCARE INNOVATION
----------
MONDAY, MAY 13, 2024
Subcommittee on Health,
Committee on Veterans' Affairs,
U.S. House of Representatives,
Washington, DC.
The subcommittee met, pursuant to notice, at 10:02 a.m.
Central Time, in University of Iowa, University Capitol Center,
Room 1117, Iowa City, Iowa, Hon. Mariannette Miller-Meeks
[chairwoman of the subcommittee] presiding.
Present: Representatives Miller-Meeks and Brownley.
OPENING STATEMENT OF MARIANNETTE MILLER-MEEKS, CHAIRWOMAN
Ms. Miller-Meeks. Good morning. This field hearing for the
Subcommittee on Health for the U.S. House of Representatives'
Committee on Veterans Affairs will come to order.
My name is Mariannette Miller-Meeks, and it is my pleasure
to serve as the Congresswoman for Iowa's 1st congressional
District and the chairwoman of this subcommittee.
Before we begin, I want to thank the students, faculty, and
staff at the University of Iowa for providing us with this
space to host this field hearing. It is a great day truly when
I get to spend it in the Hawkeye State and the Hawkeye
community here in Iowa, and also part of the University of Iowa
where I did my residency and was the first woman on faculty at
the University of Iowa's Department of Ophthalmology.
I also want to thank my colleague and friend,
Representative Julia Brownley, from California, the ranking
member of the subcommittee, for traveling to the district for
today's hearing, as well as Dr. Clancy. I look forward to
visiting Representative Brownley's district in a few months for
a field hearing with California veterans and stakeholders.
I also want to thank the VA for being with us here today.
Our U.S. Department of Veterans Affairs (VA) here in Iowa City
is known for its quality and expert care, and as residents at
the University of Iowa, we train at the VA as well. Many of the
faculty have dual appointments, but it really is an institution
of excellence and proud to have our VA Hospital in my district.
If I could just pause for a moment, there may be some
veterans in the audience. Could you raise your hands or stand
if you are a veteran.
Could we applaud them, please.
[Applause.]
Ms. Miller-Meeks. Thank you so much for your service to our
Nation. Both Representative Brownley and I feel that it is a
pleasure and an honor to serve you in Congress.
First, I am going to point out that some members of my
staff are here, both my district staff and my DC staff, so if
they will stand. They will point themselves out to you, and if
any of you have veterans'-related issues, please feel free to
stop by and ask them questions when you are leaving.
The format for today's hearing is set up to allow the
audience to listen to the proceedings and the testimony of a
congressional hearing as if we were in Washington, DC. This is
not a town hall. It is not a campaign event, just to make sure
everyone understands. This is an official hearing. If you do
have issues or concerns, my staff can help you with any of the
following issues you may have at the end of the hearing.
As a physician and a 24-year Army veteran, it is my top
priority to ensure that the VA delivers state-of-the-art modern
healthcare to veterans nationwide. I know firsthand how
important technical advances in healthcare can be in ensuring
that we accomplish our duty as clinicians. This mission
requires constant oversight and attention to keep moving the
ball forward.
During today's hearing we will discuss the transformative
work that is being done in the veterans' healthcare space, work
that the VA healthcare system is a leader in, as well as
hearing from some of the constituents in my district who are
leading the way in healthcare and veterans' entrepreneurship.
We will also discuss the partnerships the VA has made with
private healthcare providers in Iowa to ensure that every
veteran has access to the care that works for them.
Finally, we will examine the breakthroughs in artificial
intelligence and ophthalmology that were pioneered right here
in our State, as well as discussing artificial intelligence
that is used throughout. There are some entities that are not
yet at VA, and we know Dr. Clancy is working on that.
Recently I have had the pleasure to visit with a group
called the ClearForce which is using suicide risks, behavioral
modifications, and artificial intelligence to help us to
identify people earlier than when they get to the point for
having to call. It is a proactive way of reaching out to
veterans who may be at risk for suicide.
There is also work that is being done with augmented
reality, or virtual reality, for treatment of Post-Traumatic
Stress Disorder (PTSD) and depression and avoidance of suicide,
which we know that the VA's--one of its top priorities is to
reduce the numbers of veteran suicides.
As I previously stated, innovation in healthcare is a topic
that is very close to me, and I support pushing the technology
envelope to reach new heights in quality medicine for veterans
and all Americans. The University of Iowa Healthcare System, in
partnership with the VA's Central Iowa Healthcare System, has
done exactly that. The Iowa City VA Medical Center is ranked 33
out of 154 training sites for clinicians VA-wide, and the
University of Iowa is also ranked highly when it comes to
research and funding among U.S. public institutions.
The University of Iowa Healthcare System was also the first
hospital to offer patients access to Artificial Intelligence
(AI) technology in the field of ophthalmology with technology
that diagnoses diabetic retinopathy pioneered by Iowa's own Dr.
Michael Abramoff. One of our witnesses, Dr. Mansoor, who works
with Dr. Michael Abramoff, is here today and will be speaking
more on this later.
I would also like to take a minute to expand a bit on
another important AI venture, the VA's Recovery Engagement and
Coordination for Health-Veterans Enhanced Treatment (REACH VET)
program. REACH VET is a predictive AI model that identifies
veterans who may clinically benefit from enhanced care,
outreach, and assessment of suicide risk. It then flags these
veterans for further care. This program is active in 28 VA
sites and has been able to identify around 6,700 veterans per
month. It is with breakthrough technology like this that we are
able to make a difference and save veterans' lives. In a rural
State like Iowa, being able to have predictive models and
outreach without necessarily having a footprint in the
community is very important. It is with this breakthrough
technology like this that we are able to make a difference and
save veterans' lives.
I really am excited to be here. I look forward to this
discussion we will have today. Once again, I want to thank
Ranking Member Brownley for traveling to my district, Dr.
Clancy as well. I yield time to her for other opening
statement.
OPENING STATEMENT OF JULIA BROWNLEY, RANKING MEMBER
Ms. Brownley. Thank you, Chairwoman Miller-Meeks.
I want to thank you really for inviting me to your home
State and for the hospitality we have received so far. It is
really a privilege to be here.
I always appreciate the opportunity to hear directly from
local VA medical centers and the stakeholders and innovators
that are working with them to provide the best possible care
for our veterans. VA Medical Centers and facilities do not
exist in a vacuum, and the partnerships that VA creates with
local communities are extraordinarily crucial. I am glad to be
here to hear more from the VA and from the local community
members about the partnerships that have been created and how
we can continue to leverage those to innovate and improve care
for our veterans.
In a community like Iowa City, where a university is the
lifeblood and center point of the community, those partnerships
and opportunities for innovation are the most evident.
I have enjoyed learning more about the relationship between
the University of Iowa and the VA in my preparation for this
hearing, and I am impressed by the research and innovation you
have been able to accomplish thus far.
Great ideas and innovations can come from many different
places, and it is important that we support and encourage VA to
take those ideas in, whether they come from the private sector,
academia, veterans, or from VA's own employees. It will also be
important for the VA to have set processes in place to evaluate
these ideas and determine which ones add value and quality to
veterans' care.
I am very impressed by the research program at the Iowa
City VA Healthcare System, and in particular, the work of the
Research Center for the Prevention and Treatment of Vision
Loss. While the breakthroughs in treatments discovered by the
center can and should primarily benefit veterans, it is also
true that its work will benefit the general population as well.
We should make sure that VA can communicate with its community
partners to share those innovations.
I am looking forward to hearing more from Dr. Mansoor and
Mr. Blankenship about their experiences and successes, and I
hope to hear more about their ability to coordinate with the VA
to share those innovations.
Thank you all very much. Again, thank you, Madam Chair. I
am delighted to be here, and I look forward to hearing from all
of you.
Ms. Miller-Meeks. Thank you very much, Ranking Member
Brownley.
I would now like to introduce the witnesses. On our first
panel, we have Dr. Carolyn Clancy, Assistant Under Secretary
for Health for the Office of Discovery, Education, and
Affiliate Networks at the Veterans Health Administration (VHA);
and Dr. Victoria Sharp, Deputy Chief of Staff at the Iowa City
VA Healthcare System.
Dr. Clancy, you are now recognized for 5 minutes to deliver
your opening statement.
STATEMENT OF CAROLYN CLANCY
Dr. Clancy. Good morning, Chairwoman Miller-Meeks and
Ranking Member Brownley. Thank you so much for the opportunity
to join you in the Hawkeye State today to discuss the status of
veteran healthcare in Iowa, and the State's leadership in
healthcare innovation, especially around ophthalmology.
I am accompanied today, as you just noted, by Dr. Victoria
Sharp, and I do want to acknowledge our two extraordinary
medical center directors, Ms. Lisa Curnes from Central Iowa,
and Ms. Judith Johnson-Mekota from Iowa City.
The Department takes great pride in providing a
comprehensive range of healthcare services to veterans across
the State through one of the leading healthcare systems serving
veterans in the Midwest healthcare network for more than 50
years.
Veterans in Iowa have access to a wide range of care and
support options through in-person visits, telehealth services,
community partnerships, and affiliation agreements with local
universities making it easier for veterans to access routine,
chronic, and preventative care closer to home.
The Iowa City VA Medical Center itself is equipped with
state-of-the-art technology and staffed by a team of
experienced and dedicated healthcare professionals committed to
delivering high-quality care, offering a wide array of primary
and specialty care services, including veteran directed care,
internal medicine, kidney and pancreas transplants, and more.
The Iowa City VA Healthcare System's dedicated network of
facilities and clinics across the State, including 12
participating universities in Iowa, and over 21,000 active
providers, ensures veterans have access to high-quality medical
care, including primary care, mental health, orthotic and
prosthetic clinical services, and rehabilitation programs.
Community resource and referral centers also provide services
to address the diverse needs of veterans, including housing,
vocational rehabilitation, and personalized support.
In Fiscal Year 2023, nearly 500,000 community care
outpatient appointments were made, a 75 percent increase over
the last 5 fiscal years. The healthcare system has also
successfully integrated telehealth to improve access and
deliver specialized care to veterans. Tele-Emergency Care, or
Tele-EC, is just beginning to be rolled out in this network,
offering acute unscheduled episodic medical care virtually to
veterans who are determined to meet an emergent or urgent level
of care. In other words, these veterans get access to what my
family gets because they can call me, right? They can speak to
a clinician 24/7-I am worried--do I need to see someone right
now? Should I be in the emergency room, or should I make an
appointment as soon as I can?
The platform triages over 15,000 calls with a median wait
time under 10 minutes. Nearly 70 percent of veterans using
Tele-EC are less likely to need community care, reducing costs,
and over 85 percent are very satisfied and trust using it.
Our strong partnerships support research in various
diseases, including immunology, transplantation, pulmonary, and
diabetic diseases. With 102 active researchers, VA has advanced
patient-focused clinical trials for cancer, kidney and liver
diseases, traumatic brain injuries, and post-traumatic stress.
Investigators in Iowa City have also identified vulnerabilities
for veterans with chronic pain and PTSD, partnering with
relevant centers to educate providers. Another recent
innovative approach focuses on virtual reality exposure
therapy, allowing patients with multiple sclerosis to
participate in safe exercise and mobility assessments.
Speaking to ophthalmology just for a moment or two and
setting up the stage for our expert coming later, since 1998,
the ophthalmology service in Iowa City has witnessed a
significant increase in patient visits and surgeries with over
8,000 visits a year. The eye clinic is comprised of experienced
and renowned nurses, optometrists, ophthalmologists, residents,
technicians, and clerks, providing top-notch ophthalmological
care. VA also supports education with three University of Iowa
residents stationed at the nearby VA Medical Center.
The Iowa City Center for the Prevention and Treatment of
Visual Loss is a cutting-edge research facility, as you
mentioned, dedicated to advancing ophthalmology and finding
innovative solutions for various eye conditions. Funded by VA's
rehabilitation, research, and development positions, the Center
receives an annual core funding of $1.2 million, which is
leveraged into additional Federal grants from other entities of
around $7 million a year. The Center applies a
multidisciplinary approach exploring areas such as
telemedicine, computer-aided diagnosis, neuro protection, and
neurotrophic growth factors.
Let me just thank you again for the invitation to join you
for this important discussion. VA remains dedicated to
providing exceptional healthcare to our Nation's heroes in Iowa
and beyond, and these initiatives really underscore or underpin
our Under Secretary's initiatives, placing a high priority on
innovation as a strategic driver for his priorities, including
at the top of the list, soonest and best care, as well as
suicide prevention.
As we navigate this evolving landscape of healthcare, we
strive to learn from leaders in Iowa and elsewhere and are
committed to upholding the mission of those who have served by
continuously striving for innovation and excellence.
Thank you very much.
[The Prepared Statement Of Carolyn Clancy Appears In The
Appendix]
Ms. Miller-Meeks. Thank you so much, Dr. Clancy.
We will now proceed with questioning. As is my protocol
when we are in DC, I typically will do questions last. I am
going to turn to Ranking Member Brownley for any questions she
might have.
Ms. Brownley. Thank you, Madam Chair.
Thank you, Dr. Clancy. It is great to see you again. I
never thought that I would come together with you in Iowa City,
but here we are. Thank you so much for being here.
I was struck in reading your written testimony that you
said that here in Iowa, that community care has increased 75
percent over the last 5 years. That is a striking number. The
good news is lots of veterans asking for services for their
healthcare, but I think the point of your testimony is to talk
about all of the different innovations that are here,
particularly here in Iowa where there are lots of rural
communities that have barriers to their access to healthcare,
so forth and so on, things like telehealth and VA Health
Connect.
I guess I am trying to understand all of these great
innovations--and there are lots of them here--all these great
innovations, and yet at the same time, to really address so
many veterans in rural settings, you know. Here we have all of
these innovations and yet, community care continues to increase
75 percent over 5 years.
Can you talk a little bit about that?
Dr. Clancy. Absolutely. First, our overarching priority for
VA is ``soonest and best care.'' If veterans need help, we want
to help them right now, as rapidly as we can, and we want to
get them to the best possible care. Getting that right balance
between care that we can provide because we are more finely
attuned to the unique needs of those who have served, versus
getting them in faster in the community. At a time when the
healthcare labor market is, I think to put it politely, in
flux, I think there has been a lot of dynamics that no one
fully understands just yet, some of that attributable perhaps
to the pandemic and many, many other shifts.
We are struggling. I think VA has got the huge advantage of
having deployed telehealth since about 2005 or 2006. Now,
historically, this was almost a separate line of activity. I
mean, literally separate accreditation and all kinds of things
like that. The pandemic changed that quite dramatically, so
that we are trying to be able to meet veterans where they are
in as close to real-time as possible. This is why I think Tele-
Emergency Care is such a game-changer. If I am worried now at 8
o'clock on Saturday night, I should not have to think, great, I
have to wait until first thing Monday morning. I can actually
pick up the phone now and be getting advice from a clinician in
very short order. That is the direction that we are headed.
I hope that helps.
Ms. Brownley. Thank you.
I think when the Chairwoman had her opening comments she
talked about veterans at risk for suicide and a program that is
now identifying 6,700 at risk veterans on a per-month basis,
which I had not heard that statistic before. I am pretty
impressed.
I am curious to know, of 6,700 veterans who are identified
on a per-month basis, do you have any data, statistics to say,
you know, what happens to that 6,700 population? I am assuming
there is a lot of screening that goes on in each one of those
cases, and we get to a place of maybe medication or something,
but we might find that some veterans are really at risk for
suicidal ideation.
Do you have any data on that?
Dr. Clancy. We do, and I would be happy to get you a more
detailed readout for the record.
What I can tell you with complete confidence is that we
have seen decreased incidents in suicidal ideation and suicide
attempts, which we think is extremely important. To be clear,
this particular model is for veterans who have been getting
their care within our system. Although we feel fully
responsible for all veterans, whether they are connected to us
or not, this is only for veterans in our system. It really is
taking care to the next level, which is saying, you know,
instead of, like, responding to phone calls, if you will, you
remember the old pink slips that would be sitting on a pile,
you are actually using AI to prioritize those at the highest
risk. That, I think, is the game-changer, and I think we are
going to see a lot more of that in healthcare. We track this on
a monthly basis. In fact, our two directors are very quick to
show me their statistics, and so forth, but we can get you all
that.
Ms. Brownley. Thank you.
I yield back.
Ms. Miller-Meeks. Thank you very much, Ranking Member
Brownley.
I am just going to dovetail on that. When speaking about
community care--and I think Dr. Sharp could even elucidate that
more. The power of AI to be able to deliver care remotely, to
increase access to prevention and affordability, all of those
things which we are all concerned about in healthcare in
general, but also at the VA, I think that the power of
artificial intelligence, or augmented intelligence, really is
that innovative breakthrough that we are looking for and I
think can help with a lot of that, especially in rural areas,
which is one of the reasons that we are talking about this
today.
Dr. Sharp, I am going to ask you something. We had a
hearing, the Health Subcommittee, in DC on artificial
intelligence and VA healthcare. We had the chair of the
Oversight Subcommittee who had brought up that he thought that
if we are using AI, that we should get a consent from a veteran
every time we use AI.
In your experience as the Deputy Chief, I am sure that you
can tell us of where--you know, some places where AI is being
utilized. Would this be something that would be feasible to do,
to get permission from a veteran every time AI is used? Would
it be cumbersome? Would you have some thoughts on that? Because
as we make policy, this would be very important in actual
delivery of care.
Dr. Clancy. I am just going to start this off a little bit
just to say we are fully committed to being very transparent
with all of our veterans about everything that we are doing.
Clearly, if it involves personally identifiable information or
their health information, yes, informed consent will be part of
it.
As you know, the President issued an Executive Order last
October, and we are now working through it very, very
carefully--I mean, very carefully--how do we go about all of
this and when is it that we need consent and when is it that we
do not.
Just to give you an example where we might not, some of our
colleagues at another facility in California, but not your end
of the State, Representative Brownley, were using a kind of AI
to use an enterprise scheduling approach for nursing, right.
Rather than having every single unit do their own scheduling,
they were looking at how much can we shift off and also,
frankly, making needed changes, who is going to be the next
person who has to work overtime in a much fairer way. You do
not need informed consent from veterans for that, but that is
an application for you.
I will leave it to you, Dr. Sharp.
Ms. Miller-Meeks. Yes, ma'am. Dr. Clancy, I did not mean to
imply that the VA was not being transparent.
Dr. Clancy. Yes.
Ms. Miller-Meeks. It is more from delivering clinical care,
especially when you have manpower shortage or person shortage,
when you have a healthcare workforce shortage, how cumbersome
would it be and does it need to be consent for every time you
are using artificial intelligence as you detailed beautifully,
so----
Dr. Clancy. I will just mention we are, I think, as you
know, going to be doing some test sprints in the near future
with some very carefully thought-through pilots. Those by
definition--this is using ambient dictation, right--veterans
will have to give informed consent to be part of this. We will
learn on the ground how onerous it would be or not.
Ms. Miller-Meeks. Thank you so much.
Dr. Sharp.
Dr. Sharp. Thank you.
For now, you know, we have limited use of AI, and we are
looking at many applications going forward. I mean, currently,
we have our AI research, and so we definitely get the veteran's
consent for that. As we move forward, then I think we will have
to evaluate it, right? We will want to make sure veterans are
protected. We will in the situations that we need to, just like
we get consents for--you know, when we do surgical procedures,
we always just want to make sure that everything--you know, the
veterans are protected. We will just have to see as we go
forward to the situation.
Ms. Miller-Meeks. Thank you.
Dr. Sharp, can you expand on some of the areas where the VA
has improved its quality of healthcare delivery to veterans in
Iowa in the last few years.
Dr. Sharp. I can talk about a couple of our programs that
we built. We are--our veterans, many of them are in rural
areas, so I just want to bring up a couple of things that we
are doing, because we want to take the care to them. We think
that we provide great quality care, and so we want them to get
their care in the VA, although getting it wherever they need,
you know, in their communities.
A couple of things, though, that we have done is we have
home-based cardiac and pulmonary rehabilitation programs, and
we have the cardiac rehabilitation program going currently, and
then we are going to do the pulmonary soon. It is a tele
program, and they work with their cardiologist or pulmonologist
at the VA, and then we found it is like a 12-week exercise,
nutrition program. We are doing that. We have got great results
from the veterans. They are very happy about it.
A couple of other things we have done, recently in our
cardiology electrophysiology service line, we implanted our
first cardiac contractility modulation device, which is for
heart failure therapy, and it improves their outcomes and their
quality of life. Also, we are just among a small number of
hospitals in the State that are able to provide that therapy.
The other thing is we just recently had approval to implant
a leadless pacemaker. It is the smallest pacemaker on the
market, and it has got a battery life of 16 to 17 years.
By doing these things, we think we can increase the
procedures we do. We have an Electrophysiology (EP) lab that we
are working to get--it will be ready for us to improve these--
or expand these procedures soon. We think it is great that we
are doing these great things.
Ms. Miller-Meeks. There is remote monitoring with those?
Dr. Sharp. I think so.
Dr. Clancy. Yes.
Ms. Miller-Meeks. Thank you.
I will now recognize Representative Brownley for some
additional questions.
Ms. Brownley. Thank you, Madam Chair. I appreciate that.
Dr. Sharp, I just wanted to ask you from your perspective
why you think community care has increased so significantly
here over the last 5 years?
Dr. Sharp. Well, the reason that I think that it has
increased, I think--well, one, is we have an increased number
of veterans that we are caring for. Also, you know, in
healthcare, the pandemic probably played some role with
staffing shortages, things like that. We are working to look at
the veterans that we serve. We want to make sure that they get
the care that they deserve and that they want. We are trying to
do things to help them, so we are doing, you know, telehealth.
We are doing these VA Video Connect (VVC) visits. We are doing
those types of things. We have our community care outreach
clinics, and we are--traditionally it was primary care, mental
health. We are really working to expand our specialty care
services there. We have cardiology, orthopedics. We are looking
to expand all the services we can. We want to take the care to
them as best we can.
Yes, so we are trying to help and----
Ms. Brownley. If you work and extrapolate COVID, because I
can see how COVID would impact a 5-year data situation, if you
were going to look at that, you know, for the last 2 years
anyway, do you still see that kind of increase or can you--is
it flat? Is it declining? Do you have any sense of what is
happening in community care?
Dr. Sharp. Well, in our facility we watch it. You know, we
monitor it, and we try to make sure we have the services. We
are looking at a number of our operations, things like that. We
are kind of getting back to that prepandemic level. Also, just
the referrals, is how we look at it--our referrals to the care
in the community was rapidly going up. It is not going up as
much anymore. We are really looking internally, talking to the
veterans, you know, because many of them prefer to get their
healthcare within the VA, so trying to make sure that we have
the access, looking at all of those components to make sure
that they can get the care they want and where they want it.
We hope--I mean, you know, there is no way to predict the
future, but we are trying all we can to get them the care where
they want, and many of them prefer the VA for that.
Ms. Brownley. Yes. I mean, my conversations with veterans
is that they would prefer to get their healthcare within the VA
and, once they are in the VA, find that the healthcare is
pretty extraordinary.
I know for women veterans, there are a lot of services that
the VA does not offer, pregnancy, for example--I know
pregnancy, but deliveries of babies have to happen outside of
the VA. There are a lot of different services for--specialized
services for women that do not happen in the VA. You might have
more services here that I am not aware of. I know that that is
a requirement to go out to the community. There is not a choice
there.
Anyway----
Dr. Clancy. If I could just add----
Ms. Brownley [continuing]. you know, it is something that
is--you know, with community care being on the rise, I agree, I
do believe that the VA cannot offer all of its services without
the help and support of community services. I absolutely
believe in that. On the other hand, we want to make sure that
we are maximizing those services within the VA to the degree
that we can. Care outside of the VA is more expensive, and we
would like to be using those resources to continuously improve
those services, you know, within the VA. That is the reason I
am asking.
Dr. Sharp. Yes. One comment about that are women's health
services. I mean, we have really worked hard, you know, in
trying to provide services. We, you know, really try to have a
full suite of services for our women veterans. You know, we
have gynecologists, and we have urologists and, you know,
breast surgeons, so we have really a full suite. The maternity
care, we help them get--you know right, we do not deliver their
babies, but we do keep in touch with them during their
pregnancy. We help them get whoever they want, but we also do
baby showers, and we do all kinds of things. We do not want
them to feel that they are no longer connected to the VA during
that time of their pregnancy.
We really try hard, and we have a number of women veterans
who really love to get their care with us here in Iowa City,
and also in the Des Moines VA.
Ms. Brownley. Do you know the ratio for the maternity care
for the person who is responsible for these young women who are
getting their care in the community? Is it 1-to-10? Or 1-to-
100? Or--I mean, I have been to some VA hospitals where it has
been well over a hundred per--I cannot remember what they are
called--maternity coordinators perhaps.
Dr. Clancy. Yes. That has actually become sort of an
enterprise function.
Last summer, VHA had its first ever Maternal Health Summit,
which was just unbelievable to be there, because it turned out
across our system many, many coordinators were trying to do
slightly different things. Together, they have made a shared
commitment to follow women for a year after they have
delivered, particularly on the lookout for mental health issues
which tend to be more common in the women that were serving,
but also to let them know we are here, we have got you, and we
are following, and it is not like we are saying goodbye because
you had a baby and had the baby delivered elsewhere.
Ms. Brownley. Yes. One last quick question, just one more.
She runs a tight ship. I am just saying. Just one quick
question.
Can you roughly give me an idea of all of your veterans who
are, you know, under the category of rural veterans who
distance or, you know, there are other barriers to access to
that care, sort of what percentage of those veterans in your
overall veteran population?
Dr. Sharp. I do not have the specific numbers, but I do
know there is a large number.
Ms. Brownley. I mean, just roughly, like, would you say
half?
Dr. Sharp. I do not even think I can guess.
Ms. Brownley. Yes. You cannot guess.
Dr. Sharp. There is a lot of them, but, yes, I do not want
to give a number when I do not really know.
Ms. Brownley. All right. Thanks. Great.
I yield back, Madam Chair.
Dr. Sharp. We can get that information to you.
Ms. Miller-Meeks. I was going to try and answer that
question. The 1st congressional District has over 50,000
veterans. We have the Iowa City VA facility, and the next
closest would be in Des Moines. Those are just the veterans
that are registered for care within the VA system, so 50,000,
one institution. We do have certainly clinics and other
opportunities throughout the State. Most of our counties have a
clinic as well, but it is a large population--we have a large
population of veterans in Iowa and in the 1st congressional
District.
Maybe that will help a little bit, but certainly we can get
that breakdown for you as well.
I have no further follow-up questions.
Thank you, Ranking Member Brownley.
On behalf of the subcommittee, I want to thank you both for
your testimony and for joining us today. We are going to seat
the next panel. You are now excused, and we are going to wait
for a moment while the second panel comes to the witness table.
[Discussion off the record.]
Ms. Miller-Meeks. Thank you very much.
Welcome everyone, and thank you for the participation in
today's field hearing.
Joining us today is Dr. Mansoor, resident at the University
of Iowa, Department of Ophthalmology; Brandon Blankenship,
chief technology officer at Pro Circular.
Dr. Mansoor, you are now recognized for 5 minutes for your
opening statement.
STATEMENT OF DR. MAHSAW MANSOOR
Dr. Mansoor. Chairwoman Miller-Meeks, Ranking Member
Brownley, and distinguished members of the subcommittee, on
behalf of the University of Iowa Health Care, thank you so much
for the opportunity to appear before you here today to discuss
innovations in veterans' healthcare in the State of Iowa.
I am Mahsaw Mansoor, a resident physician at the university
completing my training proudly in ophthalmology. I have also
proudly been training in the veterans' affairs healthcare
system for the past 8 years.
Before we discuss the exciting progress here in Iowa, I
would like to share why this topic is deeply personal to me. As
a second generation Iranian-American, I cherish the values of
the American heartland. We are a community rooted in unspoken
truths of integrity, self-sufficiency, and hard work. This, of
course, lends naturally to the American dream and the immigrant
values that were instilled in me by my parents.
Much of our very beautiful State is composed of rural farms
and small-town communities, and I promise you it is the heart
of America that lives in these small towns. This means,
however, our patients travel very far to access care. The
social determinants of access to care quickly then become
apparent. Transportation, loss of a day's wages, inability to
tend to the farm, and unpredictable weather, are few among
many. This translates to missed appointments, delayed care, and
economic impacts that are immeasurable.
That is why I am here before you today to share the impact
of autonomous AI in deconstructing these barriers. No veteran,
Iowan, or American should ever fall into the ranks of an
invisible population that does not have access to care.
Complications from diabetes are the leading cause of
blindness in working age adults in our country. In Iowa, about
10 percent of the adult population has been diagnosed with
diabetes, and it is estimated that the economic burden in our
State alone is greater than $2.5 billion each year.
Despite the obvious economic and health implications, many
are surprised to actually learn that diabetic eye disease can
be prevented with screening and early detection. In most
settings this involves a minimum of an annual visit to an
ophthalmologist. Yet the social determinants we discussed are a
barrier to adequate screening, both nationally and globally.
This is where we have led the way in developing autonomous
AI that allows for enhanced screening in a safe, and
importantly, ethical manner even to the smallest rural
communities of our State.
Let me share the story of Digital Diagnostics, an Iowa-
founded AI company. Digital Diagnostics was founded in 2010 by
my colleague and mentor, Dr. Michael Abramoff, right here down
the street in Coralville. As a healthcare tech company, Digital
Diagnostics designs and implements AI systems that can diagnose
eye disease by analyzing high-quality images.
Our flagship product, LumineticsCore, is an AI system
designed to diagnose diabetic-related eye disease but without
needing a physician to ever look at the images. It is the
fastest growing patient-facing medical AI in the world.
LumineticsCore effectively allows specialty service care to be
performed by a minimally trained camera operator to detect
diabetic retinopathy at the point of care, such as a primary
eye--primary care clinic, not an eye care clinic. This allows
for only those who have positive diabetic retinopathy diagnosis
to then be referred to see the specialist to establish a care
management plan. The burden is thusly reduced for both the
patient and the specialist.
Digital Diagnostics has also helped pave the path for the
use of AI diagnosis in healthcare. Our Iowa-led team was
pivotal in establishing many firsts, including the first U.S.
Food and Drug Administration (FDA) approval of an autonomous
diagnostic system in 2018, and then the creation of the first
ever autonomous AI Current Procedural Terminology (CPT) code
for billing and payment in 2019.
Encouragingly, emerging evidence from randomized control
trials highlights the impact of autonomous AI for diabetic eye
exams in primary care patients to improve health equity, reduce
access disparities, increase physician productivity, and
improve adherence to care.
We have shown at Iowa that autonomous AI is a scalable
solution to a problem long considered intractable. In our State
and others, AI diagnosis will increase our reach and allow
greater access to our rural communities.
Currently Digital Diagnostics has more than 600 sites under
contract with about 100,000 exams performed annually in the
United States. Through the pioneering efforts of Dr. Abramoff,
Centers for Medicare and Medicaid Services (CMS) has created a
reimbursement model for LumineticsCore which allows patients to
continue to access this incredibly important exam.
In Iowa, we have a team dedicated to bridging the gap to
deliver care to those that need it most. Our group has paved
the way for autonomous AI in an ethical way. Through continued
vision research, we are committed to improving access to Iowans
and veterans across this State.
Again, our group would like to thank Chairwoman Miller-
Meeks, Ranking Member Brownley for allowing an opportunity to
testify before you today. We have no greater priority than
ensuring our veterans have access to the highest quality care,
and we are privileged to continue in a path that benefits our
veterans and our Iowans.
[The Prepared Statement Of Mahsaw Mansoor Appears In The
Appendix]
Ms. Miller-Meeks. Thank you, Dr. Mansoor. I will tell Dr.
Abramoff you did very well. If only we had the device and we
could show everyone here, it is quite impressive.
Dr. Mansoor. Yes.
Ms. Miller-Meeks. Mr. Blankenship, you are now recognized
for 5 minutes to deliver your opening statement.
STATEMENT OF BRANDON BLANKENSHIP
Mr. Blankenship. Thank you.
Good morning, ladies and gentlemen. Thank you for the
opportunity to testify today.
Although I am the chief information security officer for
Pro Circular, a cybersecurity services firm based out of Iowa,
I believe that my value to the subcommittee can be best
vocalized as a recipient of VA care.
I am an Iraq War veteran that led a squad of Marines in the
Triangle of Death in 2004. Upon my return in 2005, I
experienced some of the scheduling and administrative
challenges navigating the VA.
On the AI topic, as a cybersecurity professional, in recent
years, I have seen, firsthand, the incredible benefits of using
artificial intelligence and machine learning in cybersecurity,
not only to enhance the accuracy and speed and detection models
to identify threatening malware behaviors, but to automate
research tasks. As others have articulated, the VA has
mountains of data at its disposal. This data can be used by
doctors, nurses, administrative staff to better serve veterans.
However, the issue is that much of this data is either
unstructured or difficult to query. Effectively this data is
unavailable to the staff and doctors to use in any meaningful
way in a timely manner simply because they are drowning in
data. AI, or machine learning algorithms, are fantastic at
pattern recognition, and will continue to improve as results of
those patterns are used to train the models further.
Imagine how beneficial it would be for a doctor to have the
top five recommended issues ready for review before seeing a
patient. Those potential diagnoses and remediations would be
based on decades of hard data and thousands of discreet data
fields rather than fallible human bias and individual best
effort.
The Artificial Intelligence Markup Language (AIML) could be
seen as a genius intern that excels in processing large amounts
of data quickly and accurately making correlations based on
historical facts and individual patient history. These
recommendations could be given to the doctor as a force
multiplier without cutting out the expert human judgment. It
would allow the doctors to make use of currently unusable data
to make real-time, fact-based decisions and ultimately better
serve veterans.
My personal experience with the VA centered on
administrative problems. After returning from a war zone, I
went to the VA to get my hearing checked within weeks. The
visit took most of the day, and the only thing that was
accomplished was to get into the system and have an opportunity
to be scheduled for a hearing test. I was not allowed to
negotiate the date for scheduling like a normal doctor's
office.
I later received a letter in the mail informing me that my
hearing test appointment was the following day, which I was
unable to attend because of a conflict, and that was 19 years
ago, and I have never been back. I fully acknowledge that I
chose not to use the VA because of my frustration with the
scheduling process. However, multiply my personal experience
times millions of veterans to understand the scope. If the
scheduling process is frustrating and counterintuitive,
effectively veterans are being denied care.
Because it has been two decades since I have experienced
fire Fights and suicide car bombs with no hearing protection,
it is unlikely I will be able to prove that my hearing loss is
as a result of military service. I want to say this super
clearly. The focus is not about my personal journey, but
rather, acknowledging that AI and chatbots or scheduling
personal assistants can be used to streamline and achieve
efficiency gains for the Department of Veterans Affairs. If we
can do better to cut down cycle time and defects in scheduling
and navigating a complicated system, fewer veterans will self-
select out of the care they need and deserve.
AI can be used for predictive analysis, for resource
allocation by analyzing historical data, and AI can predict
demand for healthcare services enabling the VA to allocate
resources effectively and ensure timely access to care for
veterans.
It can also be used for faster diagnosis and treatment, and
research and development. However, I believe that by simply
improving the administrative process, we can provide an
enhanced and better experience.
Thank you very much.
[The Prepared Statement Of Brandon Blankenship Appears In
The Appendix]
Ms. Miller-Meeks. Thank you very much, Mr. Blankenship.
It is really incredible the opportunities I think that we
have, and as Members of Congress, we have the very difficult
task of making regulations and laws and legislating an area
which we may not be as intimately familiar with as both of you
are.
I will now recognize Ranking Member Brownley for any
questions that she might have.
Ms. Brownley. Thank you very much.
I must say, Mr. Blankenship, you are not the first to
inform us that you have had issues with getting appointments
and interacting with the VA, so apologize for that.
I think that, you know, in terms of the services that you
are providing currently in your job, but AI in general could be
a huge--and I believe this very, very strongly--could be a huge
piece of the puzzle in terms of improving all of these systems,
you know, within the VA. We have all of these old systems. I
mean, one of my frustrations having been on this committee now
for 12 years is whenever we stand up a new program, we need a
system to support it, some automated, computerized system, and
that is always the delay of standing up these new innovations.
I wish you would come to the VA and head up this idea of
looking at systems throughout the larger enterprise of the VA
and show us how we can improve all of those systems. I mean,
the VA back in the day was a leader in electronic health
records. Now we are sort of behind in that in following what
private industry is trying to do and improve our legacy system
that has been there for a long, long time.
We really need you and folks like you to help the VA move
in this direction in a very precise way. Your point about
mountains of data, I mean, this is the one advantage, I think,
that the VA has over any other institution across the country
is that we have an inordinate amount of data, and that is why
so many researchers are attracted to working with the VA
because there is so much data there. You know, how we can
improve upon that is also, I think, very, very important.
Thank you for your testimony today, and thank you for
pointing out where we can do a much better job to serve our
veterans. I appreciate it.
Dr. Mansoor, thank you for your testimony. I wish we could
replicate you across the VA. I love your enthusiasm. I think
you are the first resident that has ever testified in front of
this committee, at least in my 12 years, so thank you certainly
for being here.
You mentioned--there are two areas that I want to ask you.
One is, you said this can all be provided--AI can be provided
in an ethical way. Back to the Chairwoman's original question,
I want to hear a little bit about that. Also, I am interested
to know if you have any data in terms of--I understand that the
population in Iowa, there is about 10 percent that are
suffering from diabetes, and how--you know, if you have data to
show how you improve those percentages.
Dr. Mansoor. Thank you so much. It is truly a privilege to
be here today.
To your first question, delivering AI in an ethical way,
probably less than a decade ago, we did not even--the landscape
was completely different. You know, this is not a hype cycle.
This is not something that is here and then going to be gone
and we are on to the next thing.
In order to have technology that is going to do those
things we want it to do, increase access to care, reduce these
barriers that we have all talked about, it has to be deployed
in an ethical way, right? There are two comments on that.
The one is machine learning and deep learning AI, assisted
AI, all of these technologies have--we want to make sure that
they are not inherently becoming biased, because you can run
the danger of actually exacerbating issues that we are here
talking about today.
To that end, you know, I am very grateful for the support
both, of course, from the university but from our VA as well,
that has allowed us and, of course, Dr. Abramoff who cannot be
here today to lead this landscape. You know, we have to analyze
all of this, and a lot has been written now in the literature
of what does it mean to be ethical. We go back to kind of our
principles in medicine where do no harm, right? Nonmaleficence,
beneficence autonomy. You have to respect a patient's right for
self-determination and then, very importantly, justice.
By engaging in a discussion with ethicists and really
experts and thought leaders in this field, Dr. Abramoff and the
team at Digital Diagnostics has really led the conceptual
bioethical framework that has allowed for deployment of AI
successfully.
I think, you know, our motto is AI the right way, and we
really mean that. You know, none of this is going to be helpful
if we cannot find a way to do it ethically in a manner that
protects our patients first and foremost. That is kind of to
that end.
Then I knew this question would come up about the data in
Iowa, and I actually pushed internally for a lot of that. I
think, unfortunately, it is a bit--you know, it is
confidential. I will tell you this: We talked about 10 percent
of our patients in the State of Iowa, about 10 percent--and
really that is kind of reflected nationally as well, but 10
percent, so one in 10 Americans has diabetes. I will tell you
over 85 percent of those patients are not getting their annual
eye exam, and we know that of those, probably 10 percent at
least have diabetic retinopathy.
I cannot speak to the specific numbers in our own county, I
wish--or county or State. I really wish I could. I want that
data too. I will say when you look at the more granular numbers
that are there, you really realize what is happening in our
country, in our State. You know, my parents immigrated from an
impoverished, you know, frankly, Third-World area. This is why
I have this enthusiasm, because I am here to stay, and people
like me are here to stay, and we are going to make this
difference.
Right now, greater than 25 percent of counties in this
country, the population does not have access to an eye care
provider. If we can deconstruct that work, especially in a
State like Iowa where the majority are coming from, rural
areas, small towns, I think it is hard to imagine a reality
where we are not going to be improving the status quo.
Ms. Brownley. Thank you.
Ms. Miller-Meeks. Thank you very much.
I would say Dr. Abramoff and I have had this conversation
for well over 20 years.
Dr. Mansoor. Yes.
Ms. Miller-Meeks. To see this come to fruition and the
primary impetus, as you said, was to get access to care so this
particular device can be placed in any place without an eye
care provider and have an undilated exam. If an individual is
at a pediatrician's office and it is Type 1 diabetes, and so,
they have--the course of the disease, the length of disease is
important in the severity or development of diabetic
retinopathy, but if it is accessed at a clinic where they are
with their family practitioner, with their internist, they do
not have to see the ophthalmologist, but the AI part of that
which allows that to occur through machine learning, through
repetitive images that were--you know, all of those were
collated, examined, and then developed into an algorithm that
says this individual needs to have further care, not just an
eye exam in a year.
The ability to disperse that districtwide, statewide,
nationwide I think is extremely powerful, and it has both, as
we said to begin with, prevention, affordability, and access,
so those things that are critically important to us in
healthcare.
Dr. Mansoor, can you expand a little bit more on AI
research projects being conducted at the Iowa City Center for
Prevention and Treatment of Blindness?
Dr. Mansoor. Absolutely.
Thank you to the VA system, of course, for supporting this
research that we do here, and many kudos and thanks and
gratitude to Dr. Randy Kardon, who is also not here, but also
hopefully soon to be colleague and mentor.
We are doing quite a bit. Right now, there are eight open
grants that are funding a myriad of projects, a myriad of
projects. We have--I think at the core, if I can boil it down,
we are leveraging AI deep learning to our imaging modalities,
which we have the state-of-the-art here for our veterans in our
Iowa City VA. We are using the power of the machine learning in
developing spatial recognition patterns of both the optic nerve
and then areas of the retina as well. You know, we have talked
a lot about diabetic eye disease, of course, because the
implications are massive, but it does not stop there.
Our team led by Dr. Kardon is also investigating actively
blood flow to the retina that may be affected in age-related
macular degeneration, of course, which affects many people,
many veterans, of course, and then internationally as well.
Other sight blinding diseases, like glaucoma, which I am
sure you have heard of, multiple sclerosis, radiation-induced
retinopathy, which is a disease that impacts the retina after
having radiation treatment for cancer, and really, one of the
areas of particular interest, especially in patients who are
combat veterans, is eye movement related disorders. One just
quick word about a project where we are actually using a
virtually reality headset to capture the eye movement of our
veterans in real-time and then using our machine learning
algorithms to better understand how these eye movement
disorders are actually then causing symptoms, and how we can
mitigate all of that. The point being, right now with this
immense data, we want to not just prognosticate and treat, but
we want to prevent, so all of that coming out of our center
here, which we are very proud of.
Ms. Miller-Meeks. Thank you very much.
Mr. Blankenship, I can see you smiling as we are discussing
this, so it is definitely where your passion is. I am going to
ask you to expand a little bit on the barriers you have
experienced while working with the VA Healthcare System, not in
a negative way. You are an entrepreneur. You use some of the
challenges you have had to make a system better, and I think it
is important for us to understand how we can help the VA to
incorporate AI and AI that is going to help us with, you know,
again, affordability, access, and prevention?
Mr. Blankenship. Absolutely.
I think a quick win that we could have is just using large
language models, Chat Generative Pre-trained Transformer
(ChatGPT), something very simple. I know that ChatGPT is not
the depth and breadth of AI machine learning, but it is
something that is very low hanging fruit. If we use something
like that to establish patterns in correspondence with people
seeking care and using that to draft letters and using a
scheduling assistant from some large language model, I think
that would have pretty immediate beneficial effects. That would
be one.
The other concept that crosses my mind is ensuring that we
protect the back-end data. Any time we use--we train an AI
model, there has to be a repository where all of the data
points are stored. If those data points are used to train
models that are outside of our system, then we lose control of
those data points. It is effectively personally identifiable
information and Health Insurance Portability and Accountability
Act (HIPAA) data.
The downside if we do not keep control of that data--it is
a data governance issue--is that those diagnoses or those data
points might show up in other models. We have to be very
careful of that in our business where we do not want a client's
name showing up on another report.
Although it is a lower risk for our organization, it would
be a higher risk for VA.
Ms. Miller-Meeks. I think that is one of the areas that we
are all concerned about, which is data governance and privacy.
Thank you both very much, Dr. Mansoor and Mr. Blankenship,
for your testimony, answering our questions.
Ranking Member Brownley, would you like to make any closing
remarks?
Ms. Brownley. I think I just want to say it is delightful
to be here. I am very impressed with everything that is going
on here in the Medical Center and the State in general. I just,
you know, appreciate all of you in this room who are committed
to supporting our veterans and making sure that they get the
very best healthcare that they have earned and deserved. We
feel very, very strongly about that, and we are continuously
trying to improve upon that.
You know, any feedback that you can give us in terms of
what we can be doing to help you, and what you are trying to do
to help our veterans, we certainly want to hear. It does not
always have to come through a hearing. You can contact us at
any time, and certainly you can contact me at any time. Please
do that.
Again, I just thank you from the bottom of my heart for all
of the services that you provide to our veterans and the
quality healthcare that you provide.
Ms. Miller-Meeks. Thank you, Ranking Member Brownley.
It has really been a pleasure to be with you all here in
Iowa's 1st congressional District. I want to thank everyone for
coming out today, our witnesses, the VA, and also especially
thanks to the staff both on the Democrat side and the
Republican side, as well as my district staff. Thank you all
for that.
Innovation in veterans' healthcare space is an important
topic, and it is a duty of ours. Iowa is doing amazing work in
this space, and I am proud to highlight it. We owe it to our
veterans to ensure that they receive quality healthcare and
access to that quality healthcare.
Again, I would like to thank Ranking Member Brownley for
coming out to my district, and I look forward to going to hers
later in this year. I hope to continue working with our
colleagues across the aisle to ensure that we do our duty as
Congress and serve those who served us.
The complete written statements of today's witnesses will
be entered into the congressional hearing record.
I ask unanimous consent that all members have 5 legislative
days to revise and extend their remarks and include extraneous
material.
Hearing no objection, so ordered.
Thank you all so very much for your participation in
today's hearing.
This hearing is now adjourned.
[Whereupon, at 11:03 a.m., the subcommittee was adjourned.]
=======================================================================
A P P E N D I X
=======================================================================
Prepared Statements of Witnesses
----------
Prepared Statement of Carolyn Clancy
Good morning, Chairwoman Miller-Meeks, Ranking Member Brownley, and
Members of the Subcommittee. Thank you for this opportunity to join you
in the ``Hawkeye State'' today to discuss the status of Veteran health
care in Iowa and the state's leadership in health care innovation,
especially around ophthalmology. I am joined today by Dr. Victoria
Sharp, who serves as the Deputy Chief of Staff at the VA Iowa City
Healthcare System (VAICHS).
Status of Health Care in Iowa
The Department takes pride in providing a comprehensive range of
health care services to Veterans in Iowa through one of the leading
health care systems serving Veterans in Veterans Integrated Service
Network (VISN) 23: VA Midwest Health Care Network. The Iowa City VA
Medical Center (VAMC), rated 5 stars by the Centers for Medicare and
Medicaid Services, offers a wide array of primary and specialty care
services, including Veteran-directed care programs, internal medicine,
surgery, mental health, kidney and pancreas transplants, and more. The
facility is equipped with state-of-the-art technology and staffed by a
team of experienced and dedicated health care professionals committed
to delivering high-quality care to the Veterans they serve. VA Central
Iowa Healthcare System also offers innovative technology such as the
virtual reality treatment used within the Physical Therapy (PT)
department to treat multiple sclerosis. This treatment allows Veterans
to safely exercise and regain mobility while measuring range of motion,
perform assessments, work on strength training, and improve balance.
Additionally, Iowa delivers care at 15 community-based outpatient
clinics (CBOC) throughout the State, making it easier for Veterans to
access care closer to home. These clinics provide services like routine
check-ups, chronic disease management, and preventive care. Our
dedicated network of facilities and clinics across the State ensures
Veterans have access to high-quality medical care, including primary
care, mental health services, specialty care, and rehabilitation
programs.
Access to Diverse Care and Support Modalities
Through a combination of in-person visits, telehealth services, and
community partnerships, Veterans have more options than ever before to
receive high-quality, timely care when and where they need it.
Universities are important partners in delivering care to Veterans
through the Community Care Network (CCN). There are 12 universities
actively participating in the CCN throughout Iowa. When eligible,
Veterans can access care in the community through the CCN, which has
21,224 active providers. In Fiscal Year (FY) 2023, Veterans in Iowa had
nearly 500,000 Community Care outpatient appointments, a 75 percent
increase over the last 5 fiscal years.\1\
---------------------------------------------------------------------------
\1\ Between Fiscal Year 2019 and Fiscal Year 2023, Community Care
outpatient appointments in Iowa have increased by 75 percent, rising
from 371,603 to 497,931.
---------------------------------------------------------------------------
Community Resource and Referral Centers also play a vital role in
supporting Veterans and their families. These Centers provide a wide
range of services and resources to address the diverse needs of the
Veteran community. One key service offered is the U.S. Department of
Housing and Urban Development (HUD)-VA Supportive Housing (VASH)
program, which combines HUD housing vouchers with VA supportive
services to help homeless Veterans and their families find and sustain
permanent housing. Additionally, the Grant and Per Diem program assists
in providing transitional housing and supportive services to homeless
Veterans. Another service that homeless veterans are referred to is the
Department of Labor's (DOL) Homeless Veterans' Reintegration Program
(HVRP), a competitive grant program whose sole purpose is to work with
veterans who are experiencing homelessness, or who are at risk of
homelessness. DOL's Veterans' Employment and Training Service (VETS)
funds two HVRP grantees in Iowa, Vocational Rehabilitation Specialists
Inc. and Goodwill Industries of the Heartland.
Beyond housing and outreach, these Centers connect Veterans with
Vocational Rehabilitation programs to help them develop job skills and
find employment opportunities. Many Centers maintain a food pantry,
clothing closet, and facilities for showers and laundry, ensuring basic
necessities are met. Equally important are the regular visits and
personalized support provided by dedicated staff. They work tirelessly
to assess each Veteran's unique situation and connect them with
appropriate resources and services to address their specific needs.
Innovative Uses of Telehealth
VAICHS has taken significant strides to strategically incorporate
telehealth, enhancing access and delivering specialized care to
Veterans across its service area. Notably, the system implemented a
robust telehealth program for audiology and speech pathology services,
providing diagnostic and treatment services to Veterans in CBOCs and
patient homes. The Mobile Audiology Clinic serves over 1,000 Veterans
annually, while the cochlear implant surgical site offers specialized
services for deafened Veterans.
An additional telehealth program was developed and piloted to
deliver infectious disease (ID) physician expertise to rural VAMCs. The
pilot program reduced unnecessary antibiotic use in three Community
Living Centers by 30 percent and was well----received by frontline
providers due to its user-friendly design, seamless integration into
workflows, ease of administration, and ability to connect experts with
their patients.
The Department also launched VA Health Connect, modernizing the
Veteran health care experience by offering a 24/7 virtual care option
on the phone, through VA Video Connect or through chat with a real
person. It offers Veterans in Iowa the opportunity to speak with a
nurse, schedule, confirm or cancel medical appointments, talk to a
medical provider about an urgent or developing medical issue, refill
and request medication renewals, and check on the status of medications
with the help of pharmacy professionals.
As part of VA Health Connect, VA developed a Tele-Emergency Care
capability known as Tele-EC, which will be available in VISN 23 by the
final quarter of Fiscal Year 2024. Tele-EC is similar to a nurse advice
line that many Veterans with private insurance may have experienced.
VA's Tele-EC model utilizes Health Connect clinical contact centers to
triage and connect Veterans or caregivers to a licensed emergency
medicine practitioner. They address the Veterans' acute medical needs
over video or phone or direct them to the appropriate resources based
on their situation. Since last year, Tele-EC has triaged over 15,000
calls, with a median wait time to speak to a provider under 10 minutes.
The data show that Veterans utilizing Tele-EC are less likely to need a
Community Care appointment because nearly 70 percent of Veterans'
concerns were resolved over the phone, ultimately reducing Community
Care costs. Over the past year, nearly 85 percent of Veterans who have
used Tele-EC say they were satisfied with their visit, and the same
percentage of Veterans trust using Tele-EC in the future.
Orthotic, Prosthetic, and Pedorthic Clinical Services
VA has also increased its Orthotic, Prosthetic, and Pedorthic
Clinical Services (OPPCS) staff in Iowa from three to eight clinicians
to better serve the needs of Iowa Veterans. The facility expanded its
services in 2023 to include in-facility custom orthotic and prosthetic
care, attracting positive responses from Veterans. Des Moines'
Knoxville CBOC now offers custom orthotic and prosthetic care to
Veterans, while the Mobile Prosthetic and Orthotic Care program is
being rolled out in Iowa City, offering VA-provided care in Dubuque,
Waterloo, and Ottumwa CBOCs starting in May 2024. These expansions aim
to improve accessibility and quality of care for Iowa's Veteran
community by increasing the number of clinicians and establishing new
facilities.
Beyond direct care, OPPCS is partnering with the University of
Iowa's Human Performance and Clinical Outcomes Lab to improve
understanding and treatment of musculoskeletal and neurological
conditions. The collaboration aims to use advanced biomechanical
analysis techniques and clinical expertise to explore innovative
approaches to orthotic and prosthetic design, rehabilitation protocols,
and patient-centered care strategies. The lab will utilize
revolutionary motion capture and analysis capabilities to evaluate gait
patterns, joint mechanics, and functional performance in individuals
with limb loss or musculoskeletal impairments. This data-driven
approach will guide the development of tailored orthotic and prosthetic
interventions. The collaboration will also facilitate the integration
of clinical expertise from VA OPPCS, ensuring research findings are
directly applicable to real-world patient scenarios and aligned with
the latest clinical practices.
Rehabilitation Therapies
The Iowa City VAMC is actively collaborating with local
universities and research institutions to stay at the forefront of
rehabilitation research. It is making strides in incorporating
complementary and integrative health approaches into rehabilitation
therapies, including PT and occupational therapy (OT), benefiting
approximately 61,000 Veterans. Central Iowa, in particular, is leading
in embedding PT into primary care, which has resulted in noticeable
reductions in wait times and opioid prescribing.
VA is also producing virtual reality content for PT/OT and
implementing a tele-wheelchair clinic, utilizing clinical telehealth
technology for wheelchair assessments. These data can help therapists
personalize treatment plans and track progress more effectively. Other
rehabilitative initiatives include piloting home health agency
programs, hiring physical therapists and chiropractors into community-
based offices, establishing a Geriatric Accredited Emergency
Department, participating in the Enhancing Pelvic Health Across the
Continuum, and expanding its Home-Based Primary Care Teams.
Local Partnerships
VA consistently prioritizes community engagements and effective
partnerships to provide Veterans and their beneficiaries with well-
rounded care and support. One of the most successful collaborations to
date includes the National Disabled Veterans Golf Clinic (NDVGC), a
week-long adaptive golf program presented by VA and Disabled American
Veterans (DAV). This annual event promotes rehabilitation by
instructing Veterans with specific life-changing disabilities in
adaptive golf. VA and DAV began partnering with the University of
Iowa's Department of Physical Therapy and Rehabilitation Science in
2019 and have continued to collaborate each year since. The NDVGC
Director works directly with the Clinical Assistant Professor and Co-
Director of Clinical Education to connect University of Iowa students
with the program. These students are supervised throughout their
involvement, supporting registration, fall risk assessments, seating
stations, and alternative activities offered at NDVGC. In 2023, these
activities included cycling, kayaking, rock wall climbing, disc golf,
bowling, water aerobics, and cornhole. Through this collaboration,
NDVGC not only provides the opportunity to earn college credit toward
coursework completion but also offers participating university students
an intimate introduction to the populations of Veterans they serve.
Other partnerships include affiliation agreements with local
universities for audiology, speech pathology, PT/OT, chiropractic, and
nurse practitioner programs. Additionally, there are collaborations
with Des Moines University and UnityPoint Health Care System on stroke
camps and stroke support groups. In 2023, the National Veterans Golden
Age Games was hosted by the VA Central Iowa Health Care System, who
partnered with many local sponsors and volunteers. Over 600 Veteran
athletes aged 55 and older, from 107 VAMCs, competed in 19 medaled
sports and 4 exhibition events, demonstrating their commitment to
``Fitness for Life.''
Cutting-Edge Research
The VAICHS has been a top VA system for over 50 years, funding
research in infectious diseases, immunology, transplantation,
dermatology, and pulmonary, cardiovascular, and diabetic diseases.
Presently, VA has 102 active researchers in Iowa, working on 254
projects funded by approximately $34 million through VA's Office of
Research and Development. Through the system, VA has advanced patient-
focused clinical trials for cancer, kidney, and liver diseases, and
developed projects to better understand and manage patients with
traumatic brain injuries (TBI) and post-traumatic stress disorder
(PTSD).
Specifically, Iowa City investigators have identified
vulnerabilities for Veterans with chronic pain and PTSD, partnering
with the National Center for PTSD and the Pain Management, Opioid
Safety, and Prescription Drug Monitoring Programs to educate providers.
Jointly, they have evaluated a short message service (or SMS) messaging
intervention system, named Annie, to improve antidepressant adherence
and depression outcomes in Veterans. They are also exploring innovative
approaches to address the complex challenges faced by Veterans with
chronic pain and PTSD, such as virtual reality exposure therapy and
advanced neuroimaging techniques.
Artificial Intelligence in Ophthalmology
Since 1998, the VA Ophthalmology service in Iowa City has witnessed
a significant increase in patient visits and surgeries, with over 8,000
visits per year. This growth has provided opportunities for the service
staff, residents, and faculty to deliver top-notch ophthalmologic care.
The Eye Clinic boasts a dedicated team of experienced nurses, an
optometrist, an ophthalmic technician, and a clerk, all committed to
serving Veterans and the Veteran community. VA prioritizes education,
supporting three University of Iowa residents and stationing three
residents directly at the VAMC.
Complementing Iowa City's direct care efforts, the Iowa City Center
for the Prevention and Treatment of Visual Loss is a cutting-edge
research facility dedicated to advancing ophthalmology and finding
innovative solutions for various eye conditions. Significantly funded
by VA's Rehabilitation Research and Development Division, the Center
receives an annual core funding of $1.2 million, leveraged into
additional Federal grants totaling around $7 million per year. This
funding supports faculty members, pilot grants, equipment, and research
personnel, fostering innovation and advances in ophthalmologic care,
ultimately benefiting Veterans and the broader medical community.
Currently, the Center has two active awards involving deep learning
and artificial intelligence (AI) in ophthalmology. The first focuses on
improving glaucoma diagnosis, progression monitoring, and treatment
outcomes using structural imaging and visual field testing. The second
aims at developing automated assessment of ocular misalignments and
enhancing diagnosis through AI and eye-tracking devices. With a strong
focus on early detection and treatment of blinding disorders like
retinal disease, glaucoma, and TBI, the Center employs a
multidisciplinary approach. It explores areas such as telemedicine,
computer-aided diagnosis, neuroprotection, and neurotrophic growth
factors. One project aims to develop automated image analysis
approaches to determine the severity and cause of optic nerve edema
using machine learning on clinically acquired imaging data. The
approach will predict measures of severity and causation from novel
image-analysis-based parameters, utilizing optical coherence tomography
volumes and fundus photographs across multiple visits.
Conclusion
Madam Chair, Ranking Member, thank you again for the invitation to
join you for this important discussion. VA remains dedicated to
providing exceptional health care services to the Nation's heroes in
Iowa and beyond. As we navigate the evolving health care landscape, VA
is committed to upholding its mission of serving those who have served
by continuously striving for excellence, innovation, and accessibility
in the services we provide.
Prepared Statement of Mahsaw Mansoor
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Prepared Statement of Brandon Blankenship
Good morning, ladies and gentlemen,
Although I am the chief information security officer for
ProCircular, a cybersecurity services firm based out of Iowa, I believe
my value to this subcommittee can be best vocalized as a recipient of
VA care. I am an Iraq war veteran, that led a squad of Marines in the
Triangle of Death in 2004. Upon my return, in 2005 I experienced some
of the scheduling and administrative challenges navigating the VA.
In recent years I have seen firsthand the incredible benefits of
using AI/ML within cybersecurity, not only to enhance accuracy and
speed in detection models to identify threatening malware behaviors,
but to automate research tasks.
As others will likely articulate, The VA has mountains of data at
its disposal. This data can be used by doctors, nurses, and
administrative staff to better serve veterans; however, the issue is
that much of this data is either unstructured or difficult to query.
Effectively this data is unavailable to the staff and doctors to use in
any meaningful way or in any timely manner, simply because they are
drowning in data. AI or machine learning algorithms are fantastic at
pattern recognition and will continue to improve as the results of
those patterns are used to train the model further.
Imagine how beneficial it would be for a doctor to have the top
five recommended issues ready for review before seeing a patient, and
those potential diagnosis and remediations would be based on decades of
hard data and thousands of discrete data fields, rather than fallible
human bias and individual best effort. The AI/ML could be seen as a
genius intern that excels at processing large amounts of data and
quickly and accurately making correlations, based on historical facts
and individual patient history. These recommendations could be given to
the doctor as a force multiplier, without cutting out expert human
judgment. It would allow the doctors to make use of currently unusable
data to make real-time fact-based decisions, and ultimately better
serve veterans.
My personal experience with the VA centered on administrative
problems. After returning from a war zone, I went to the VA to get my
hearing checked within weeks. The visit took most of the day, and the
only thing that was accomplished was to get into the system and have an
opportunity to be scheduled for a hearing test. I wasn't allowed to
negotiate the date for scheduling like a normal doctor's office. I
later received a letter in the mail informing me that my hearing test
appointment was the following day, which I was unable to attend because
of a conflict. That was 19 years ago, and I've never been back. I fully
acknowledge that I chose not to use the VA, because of my frustration
with the scheduling process, however, multiply my experience times
millions of veterans to understand the scope. If the scheduling process
is frustrating and counterintuitive, effectively veterans are being
denied care.
Because it's been two decades since I have experienced firefights
and suicide car bombs with no hearing protection, it is unlikely I will
be able to prove that my hearing loss is the result of military
service. The issue isn't my personal journey, but rather acknowledging
that AI, chatbots or scheduling personal assistants can be used to
streamline and achieve efficiency gains for the Department of Veterans
affairs. If we can do better cut down on cycle time and defects in
scheduling and navigating a complicated system, fewer veterans will
self-select out of the care they need and deserve.
AI can be used for predictive analytics for resource allocation. By
analyzing historical data, AI can predict demand for healthcare
services, enabling the VA to allocate resources effectively and ensure
timely access to care for veterans. It can also be used for faster
diagnosis and treatment, and research and development; however, I
believe that by simply improving the administrative process, we can
provide an enhanced veteran experience.
Statement for the Record
----------
Prepared Statement of American Optometric Association
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
[all]