```

[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]

             VA HOME TELEHEALTH: LOOKING BEHIND THE NUMBERS

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

                               FIELD HEARING
                               
				BEFORE THE

              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

                                 OF THE

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                     ONE HUNDRED FIFTEENTH CONGRESS

                             FIRST SESSION

                               __________

                       WEDNESDAY, AUGUST 30, 2017

                        TRAVERSE CITY, MICHIGAN

                               __________

                           Serial No. 115-27

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
       
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         Available via the World Wide Web: http://www.fdsys.gov
                     
                   
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                    U.S. GOVERNMENT PUBLISHING OFFICE                    
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                     COMMITTEE ON VETERANS' AFFAIRS

                   DAVID P. ROE, Tennessee, Chairman

GUS M. BILIRAKIS, Florida, Vice-     TIM WALZ, Minnesota, Ranking 
    Chairman                             Member
MIKE COFFMAN, Colorado               MARK TAKANO, California
BRAD R. WENSTRUP, Ohio               JULIA BROWNLEY, California
AMATA COLEMAN RADEWAGEN, American    ANN M. KUSTER, New Hampshire
    Samoa                            BETO O'ROURKE, Texas
MIKE BOST, Illinois                  KATHLEEN RICE, New York
BRUCE POLIQUIN, Maine                J. LUIS CORREA, California
NEAL DUNN, Florida                   KILILI SABLAN, Northern Mariana 
JODEY ARRINGTON, Texas                   Islands
JOHN RUTHERFORD, Florida             ELIZABETH ESTY, Connecticut
CLAY HIGGINS, Louisiana              SCOTT PETERS, California
JACK BERGMAN, Michigan
JIM BANKS, Indiana
JENNIFFER GONZALEZ-COLON, Puerto 
    Rico
                       Jon Towers, Staff Director
                 Ray Kelley, Democratic Staff Director

              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

                    JACK BERGMAN, Michigan, Chairman

MIKE BOST, Illinois                  ANN MCLANE KUSTER, New Hampshire, 
BRUCE POLIQUIN, Maine                    Ranking Member
NEAL DUNN, Florida                   KATHLEEN RICE, New York
JODEY ARRINGTON, Texas               SCOTT PETERS, California
JENNIFER GONZALEZ-COLON, Puerto      KILILI SABLAN, Northern Mariana 
    Rico                                 Islands

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

                              ----------                              

                       Wednesday, August 30, 2017

                                                                   Page

VA Home Telehealth: Looking Behind The Numbers...................     1

                           OPENING STATEMENTS

Honorable Jack Bergman, Chairman.................................     1
Honorable Ann Kuster, Ranking Member.............................     3

                               WITNESSES

Kevin Galpin, M.D., Executive Director, Telehealth Services, 
  Office of Connected Care, Veterans Health Administration, U.S. 
  Department of Veterans Affairs.................................     5
    Prepared Statement...........................................    23

        Accompanied by:

    Alan R. Constantian, Ph.D., Deputy Chief Information Officer, 
        VHA Account Manager for Clinical Functions, Office of 
        Information & Technology, U.S. Department of Veterans 
        Affairs

    Pamela J. Reeves, M.D., Director, John D. Dingell Detroit VA 
        Medical Center, Veterans Health Administration, U.S. 
        Department of Veterans Affairs

Dr. Thomas Wong, D.O., Senior Physician, Office of Inspector 
  General, U.S. Department of Veterans Affairs...................     7
    Prepared Statement...........................................    27

 
             VA HOME TELEHEALTH: LOOKING BEHIND THE NUMBERS

                              ----------                              

                       Wednesday, August 30, 2017

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
                      Subcommittee on Disability Assistance
                                      and Memorial Affairs,
                                                   Washington, D.C.
    The Subcommittee met, pursuant to notice, at 9:02 a.m., in 
the Garfield Charter Township Board Room, 3848 Veterans Drive, 
Traverse City, MI, Hon. Jack Bergman [Chairman of the 
Subcommittee] presiding.
    Present: Representatives Bergman and Kuster.

          OPENING STATEMENT OF JACK BERGMAN, CHAIRMAN

    Mr. Bergman. Good morning, everyone. This hearing will come 
to order.
    I really want to thank everybody and welcome you to today's 
field hearing on VA telehealth. I especially want to thank 
Ranking Member Kuster for joining us here in this beautiful 
part of the world that we call home here in northern Lower 
Michigan. Again, I am so glad you are with us.
    Prior to getting started, I would like to ask unanimous 
consent that a statement to be provided by the Manistee County 
Veterans Council be entered into the hearing record.
    Hearing no objection, so ordered.
    Mr. Bergman. The VA has been using telemedicine for 
decades, and it is an increasingly important part of VA health 
care. I am proud that here in Michigan we have a concentration 
on some of the most tech savvy VA hospitals in the country. 
Hospitals and Health Networks Magazine recently released its 
annual ``Most Wired'' list. That used to mean different things 
at different times.
    [Laughter.]
    Mr. Bergman. This is a good thing.
    Five VA medical centers around the country made the cut, 
and three of them are in the State of Michigan--Saginaw, Battle 
Creek, and Detroit.
    Now, as the President and Secretary Shulkin announced at 
the White House earlier this month, VA telehealth is poised for 
another expansion. There are actually several distinct 
telehealth programs, each with its own purpose and needs. Today 
we will examine home telehealth, which is when VA puts 
technology into a veteran's home to help him or her manage a 
chronic health condition and remotely consult with a physician. 
The Anywhere-to-Anywhere initiative, which will increase VA 
doctors' abilities to practice beyond state licensing 
boundaries, and a VA Connect app, which enables video 
conferencing with doctors on a smart phone, should boost home 
telehealth.
    Of all the telehealth programs, home telehealth perhaps has 
the most impact on improving health outcomes, generating 
savings, and keeping thousands of elderly veterans out of 
nursing homes. Home telehealth is especially helpful in highly 
rural areas such as we have here in the 1st District, 
especially as you get into the Upper Peninsula.
    VA's clinic network is impressive, but they cannot be 
everywhere. In many cases, like the UP, it is just not 
practical to drive an hour each way for a routine consultation.
    Home telehealth also seems to be the most challenging for 
the VA. The complexity of care can be high, and managing IT 
equipment and medical devices in a veteran's home is 
necessarily more difficult than doing so in clinics. There is 
also an elaborate supply chain to distribute the equipment and 
extensive IT infrastructure in which any glitch may cause 
cascading disruptions.
    VA also has a rocky history, which we all hope is behind us 
now and going forward, with home telehealth enrollment. The 
Office of Inspector General audited enrollment nationally and 
found a pattern of less vulnerable, less challenging patients 
being targeted for enrollment, to the detriment of more 
vulnerable, more challenged patients.
    OIG also examined complaints about the Detroit Medical 
Center and substantiated that employees recorded hundreds of 
veterans as enrolled in home telehealth when they had, in fact, 
received no equipment for telehealth services. The employees 
even entered telehealth monitoring notes in these people's 
health records when no monitoring had happened. In both 
instances, the employees were attempting to hit targets in 
their performance evaluations in the easiest possible way. That 
is wrong.
    While other telehealth programs are growing, home 
telehealth enrollment has declined over the last few years. 
There is no indication that wrongdoing is to blame, but I am 
concerned about this trend. I hope our witnesses today can 
explain that.
    Another important service for rural veterans is VA's mobile 
medical units. They are trucks, tractor trailers, RVs and other 
vehicles outfitted as traveling clinics. In 2014, OIG found 
pervasive problems with their management. VA did not know how 
many mobile units it had, where they were located, what they 
were used for, and how many patients they served. Some were 
permanently parked, meaning in reality they were not mobile at 
all.
    In the Choice Act, Congress mandated reforms and better 
reporting, and today there are nearly twice as many mobile 
medical units, but too many of them are inactive. They are not 
providing services often enough to meet the Congress' goal, and 
only a few provide telehealth. There is still quite a long way 
to go until the mobile medical units are being utilized to 
their full potential.
    There are over 700,000 unique veterans served by VA 
telehealth every year, and that is impressive, and it is 
growing fast. Most of them are in clinics using video 
conferencing and imaging to communicate with specialists at 
other locations. VA seems well equipped to handle these 
telehealth programs, and the track record is good. I want to 
make sure that home telehealth is working properly for the 
roughly 150,000 veterans now enrolled.
    I also want to be confident that the program will grow to 
serve more people, and the supply chain and IT can keep up with 
that growth.
    Mr. Bergman. I now yield to Ranking Member Kuster for her 
opening statement.

        OPENING STATEMENT OF ANN KUSTER, RANKING MEMBER

    Ms. Kuster. Thank you, Chairman Bergman, and thank you for 
hosting here in Michigan. My husband and I have had a wonderful 
time in your beautiful district, and we are delighted to be 
here.
    I really do enjoy working so closely with General Bergman 
to address many of the issues that our veterans face, and I 
hope your constituents understand your leadership role and the 
fact that our Subcommittee and our Full Committee are among the 
most bipartisan and productive in the whole Congress.
    So, like Chairman Bergman, I represent a mostly rural 
district in New Hampshire, the western side of New Hampshire, 
from the Massachusetts border up to Canada, and by holding this 
field hearing here in Traverse City we have the unique 
opportunity to learn about the concerns of veterans in rural 
Michigan and how we share their concerns with rural veterans in 
New Hampshire.
    When Chairman Bergman and I learned about common issues 
that our veterans faced, we worked together, and our goal is to 
solve these issues. So that is why we are so thankful to have 
the VSO's with us, as well as advocates, families, and 
caregivers to spend their morning with us and learn about how 
we can do an even better job with telehealth.
    In New Hampshire and Michigan our veterans face significant 
geographical barriers to VA health care, sometimes traveling 
long distances, and I can say sometimes not in the best 
weather, and waiting too long to receive care due to a shortage 
of doctors or lack of hospitals or clinics in some communities. 
Treating veterans via telehealth has the potential to help 
veterans get the care they need in rural areas by saving 
veterans the time and often the expense of traveling to a VA 
facility, and we support the VA's decision and the current 
administration and Secretary Shulkin in their decision to 
expand telehealth.
    However, infrastructure is a very real barrier for 
expansion of telehealth initiatives in rural areas. In both 
rural New Hampshire and rural Michigan, the IT infrastructure, 
the high-speed broadband and cellular service that is 
necessary, just simply might not exist or may be inadequate. 
Without this basic infrastructure to support the use of 
telehealth, rural veterans are still going to face barriers to 
accessing care.
    That is why I am eager to learn more about the plan to 
expand home telehealth programming and whether the VA has plans 
to address the rural infrastructure barriers or is aware of 
other challenges that could slow or stop expansion of the 
program.
    I want to know if other successful programs designed to 
provide care to rural veterans face barriers that could prevent 
their expansion in rural communities all across the country, 
and I want to understand what the VHA is doing on the local and 
national level to overcome these barriers.
    We also want to ensure that the proper processes are 
followed so that veterans receive quality care. Telehealth is 
not appropriate in many care settings, and some veterans do not 
want to receive telehealth treatment. Veterans should always 
have the ability to say yes or no to treatment via telehealth.
    That is why I was alarmed to learn of the actions taken by 
the Associate Chief of Nursing Services at the John Dingell 
Medical Center in Detroit. It is a violation of VA policy and 
unacceptable to add patients to the home telehealth program 
without their consent.
    I am very concerned about performance goals being tied to 
home telehealth enrollment and worried that this created a 
perverse incentive for employees to care only about enrollment 
numbers so that they could receive a bonus and not about what 
was best for our veterans. We want to know what VA has done to 
ensure that employees are not incentivized to repeat this 
behavior under the new telehealth expansion initiative.
    The veterans in Michigan, New Hampshire, and all across our 
country deserve high-quality, accessible care, and I believe 
that the VA should be using technology to achieve these goals. 
However, the VA must ensure it is using telehealth and 
technology to best serve our veterans, which is why it is 
important for the VA to follow policies and why we must 
continue to hold oversight hearings on these issues.
    I thank you, Chairman Bergman, and I yield back the balance 
of my time.
    Mr. Bergman. You know, you can tell I have been back in the 
district for about a month. I just realized there was a 
microphone in front of me, because up here we don't have a 
whole lot of electrons. The point is when we get out to talk, I 
have gotten in the habit of using my Marine command voice. So 
if I cause anybody to put earplugs in, I apologize for that.
    [Laughter.]
    Mr. Bergman. By the way, Representative Kuster and I have 
been talking about this trip for a long time.
    Ms. Kuster. I have been bugging him.
    [Laughter.]
    Mr. Bergman. It is great that we have been able to finally 
make this happen, and just know that we are headed to New 
Hampshire in about three weeks.
    Ms. Kuster. Thank you very much.
    Mr. Bergman. To go up there to do it, because the more you 
know about what is going on outside of your own backyard and 
how it compared, the better we become in actually delivering 
the services that our veterans so--I mean, they earned them, 
they deserve them, and, by golly, we need to get them to them.
    Now I would like to welcome our panel seated here in front 
of us at the--I hate to say the witness table. The bottom line 
is we are going to call it the presentation table today.
    On the panel we have Dr. Kevin Galpin, who is the Executive 
Director of VHA Telehealth. Welcome.
    He is accompanied by Dr. Pamela Reeves, Director of the 
Detroit VA Medical Center; Dr. Alan Constantian, Deputy Chief 
Information Officer and VHA Account Manager for Clinical 
Functions of VA's Office of Information and Technology; and we 
also have Dr. Thomas Wong, who is the Senior Physician with the 
VA Office of the Inspector General.
    Dr. Galpin, you are now recognized for 5 minutes.

                STATEMENT OF KEVIN GALPIN, M.D.

    Dr. Galpin. Good morning, Chairman Bergman, Ranking Member 
Kuster. Thank you for the opportunity to discuss VA telehealth, 
telehealth information technology, and our home telehealth 
program. I am accompanied today by Dr. Pam Reeves, Medical 
Center Director of the John D. Dingell VA Medical Center in 
Detroit, Michigan; and Dr. Alan Constantian, Deputy Chief 
Information Officer for the Office of Information and 
Technology.
    VA Telehealth is a modern veteran- and family-centered 
health care delivery model. It leverages information and 
telecommunication technologies to connect veterans with their 
clinicians and allied or ancillary health care professionals, 
irrespective of the location of the provider or the veteran. It 
bridges enhanced access and expertise across the geographic 
distance that would otherwise separate some veterans, including 
those in rural areas, from the providers best able to serve 
them.
    VA is recognized as a world leader in the development and 
use of advanced telehealth technology. In Fiscal Year 2016, of 
the more than 5.8 million veterans that used VA care, 
approximately 12 percent received an element of their care 
through telehealth. This represented more than 702,000 veterans 
and over 2.17 million telehealth episodes of care.
    VA's telehealth portfolio allows for advanced clinical care 
delivery in over 50 clinical specialties. Services are 
delivered primarily through one of VA's three broad categories 
of telehealth.
    The first, clinical video telehealth, is the use of real-
time interactive video conferencing to assess, treat, and 
provide care to veterans remotely. As an example, this can be 
used to provide mental health counseling to veterans closer to 
their home, or even in their home.
    The second category of telehealth is store-and-forward. 
This is the use of technology to asynchronously acquire and 
store clinical information such as a picture, a sound, or a 
video, which is then sent and assessed by a provider at another 
location for clinical evaluation. This can deliver services 
such as dermatology and retinal screening.
    The third broad category is home telehealth. This is a 
technology-enabled remote monitoring program where clinical 
data and information is collected through a VA-provided home-
based device or through the patient's own mobile device or home 
computer. This allows a VA provider to monitor the veteran's 
health status, provide clinical advice, and facilitate patient 
self-management as an adjunct to the veteran's traditional in-
person health care. This service can help veterans continue to 
live independently, reduce hospitalization, and spend less time 
and money for medical visits.
    Between 2013 and 2014, the VA Office of the Inspector 
General audited VA's home telehealth program, providing their 
final report to us in 2015. The OIG analyzed outcomes for over 
15,000 veterans in the home telehealth program and concluded 
that the program was successful in reducing in-patient 
admissions for all three main patient categories of care, 
inclusive of the non-institutional category of care, what we 
call the NIC category, chronic care management category, and 
health promotion and disease prevention category.
    The OIG described the program as a transformational 
modality for delivering quality health care that is convenient 
and accessible to veterans who cannot travel or live hours away 
from the medical facility.
    While the OIG found the overall program to be successful, 
they also concluded that the VA missed opportunities to expand 
enrollment for the non-institutional, or NIC, category, the 
category of enrollment with the best outcomes based on their 
analysis methodology. In response they recommended, and the VHA 
agreed, to system enhancements that would help identify demand 
for NIC enrollments and establish new performance measures to 
promote enrollment of NIC patients into the home telehealth 
program.
    In response, VHA has revised its care assessment needs 
score report so it automatically flags patients at risk for 
institutional care who might benefit from the home telehealth 
program as a NIC patient.
    VHA also created and implemented national home telehealth 
templates and revised their dialogues that remind home 
telehealth staff to reassess patients' category of care at 
specified intervals.
    Finally, VHA has proposed a NIC enrollment metric for the 
home telehealth program. The proposal has been presented to the 
Performance Accountability Work Group and National Telehealth 
Advisory Board, with the expectation of enacting the new 
targets in 2018.
    VA has plans to dramatically enhance the telehealth program 
going forward. Related to the announcement on August 3rd by the 
President and VA Secretary Dr. David Shulkin, VA has sent a 
proposal to the Office of Management and Budget to address 
barriers that are adversely impacting our ability to deliver 
telehealth services to our Nation's veterans. Once OMB is done 
reviewing the proposal, VA will make it public so it can be 
commented upon.
    Also noted at the White House announcement and part of 
VHA's new Anywhere-to-Anywhere telehealth initiative, VA is 
initiating the rollout of a new telehealth application called 
VA Video Connect. It provides a secure and web-enabled video 
service and makes it easy for veterans and providers to connect 
over video from any location with sufficient Internet services 
and any capable video device.
    In conclusion, VA is a leader in providing telehealth 
services, which remains a critical strategy in ensuring 
veterans connect with health care when and where they need it. 
With the support of Congress, we have an opportunity to shape 
the future and ensure that VA remains a leader in leveraging 
cutting-edge technology to provide convenient, accessible, 
high-quality care to veterans through telehealth.
    Mr. Chairman, this concludes my testimony. Thank you for 
the opportunity to testify before the Committee today. We do 
appreciate your support and look forward to responding to any 
questions either of you may have.

    [The prepared statement of Kevin Galpin, M.D. appears in 
the Appendix]

    Mr. Bergman. Thank you.
    Dr. Wong, you are recognized for 5 minutes.

                 STATEMENT OF THOMAS WONG, D.O.

    Dr. Wong. Good morning. Mr. Chairman and Ranking Member 
Kuster, thank you for the opportunity to discuss the OIG's work 
regarding home telehealth and documentation concerns at the 
John D. Dingell VA in Detroit, Michigan. My written statement 
has been submitted.
    Home telehealth technology and its implementation answers a 
fundamental question asked by many, if not all, primary care 
providers and their staff: How is my patient doing in-between 
office visits? Home telehealth can answer that question, but 
can also make care better for our patients.
    Telehealth technology can also bridge the barrier of 
distance that prevents patients from accessing specialists. A 
video link paired with telehealth equipment can provide 
necessary information for a specialist to help a patient that 
can be hundreds of miles away. This program must have proper 
oversight for these important functions to occur.
    We received allegations that in the last two weeks of 
Fiscal Year 2013 there was improper patient enrollment of over 
900 patients in home telehealth. There was use of overtime to 
produce end-of-year enrollment numbers regardless of whether 
patients wanted to be enrolled, or even contacted.
    What we found is that in that period alleged, the home 
telehealth program enrolled 836 new patients, and the majority 
of those patients were enrolled in the last two days of Fiscal 
Year 2013. For those 836 patients, we expected to see 836 
consults, 836 screening notes, 836 assessment notes, 836 
monthly monitoring notes, all in this sequence, to properly 
enroll a patient for telehealth care.
    What we found was 828 patients who did not have the proper 
enrollment sequence, and many monthly monitoring notes were 
written without the required previous steps of enrollment. 
Monthly monitoring notes capture and generate workload for a 
facility. The monthly monitoring note should be the last note 
entered for a patient to be enrolled in a home telehealth 
program. In the Detroit facility, monthly monitoring notes were 
entered into patients' electronic health records regardless of 
proper enrollment sequence, missing consults, missing screening 
notes, and missing assessment notes.
    We also determined that without the use of overtime for the 
last two days of Fiscal Year 2013, the facility could not have 
surpassed their workload encounters.
    We made several recommendations to the facility based on 
re-education of home telehealth staff on enrollment procedures 
and better oversight of home telehealth documentation. We asked 
VA to evaluate administrative action to the individual and 
allowing these notes to be entered in this manner.
    In summary, telehealth technology is an innovative way to 
care for patients. For those front-line staff caring for 
patients, telehealth allows for the processing of information 
to affect the lives of patients for the better, and no doubt 
can save lives in the long run. But to be effective, the 
program must be administered responsibly so that we can affect 
as many lives as possible.
    Mr. Chairman, this concludes my statement. I would be happy 
to answer questions you or Ranking Member Kuster may have.

    [The prepared statement of Thomas Wong, M.D. appears in the 
Appendix]

    Mr. Bergman. Thank you, Dr. Wong.
    The written statements of those who have just provided oral 
testimony will be entered into the hearing record.
    We will now proceed to questioning, and we are going to 
start--Ranking Member Kuster is going to start with her first 
question.
    Ms. Kuster. Thank you. Thank you very much.
    I am going to just go to our witness here from Detroit to 
give you an opportunity to respond, Dr. Reeves, on what steps 
have been taken both with regard to retraining and oversight to 
overcome the incident that was discovered, or apparently there 
were allegations that were investigated by the Inspector 
General.
    Dr. Reeves. Sure. We retrained staff in 2015. We had the 
Office of Telehealth come and give training to all of our 
staff. They have ongoing training that they have to do. When 
any new staff join, there are some critical things that they 
need to know. Again, this is from the Office of Telehealth in 
terms of training that is done before they can see any patient, 
and then some other training that is done within 30 or 60 days 
of the start of their training.
    Ms. Kuster. And does part of that training include the 
concept of informed consent for a patient to enter into a 
telehealth program?
    Dr. Reeves. Kevin?
    Dr. Galpin. I can address that. Any time a veteran is being 
considered for telehealth, they have to provide at least verbal 
consent to participate in the program. That is one of our 
program requirements, not just for home telehealth but all 
telehealth.
    Ms. Kuster. And is there some record of that?
    Dr. Galpin. It should be documented with a note by the 
provider doing the referral or by the care coordinator or the 
provider who is receiving the referral.
    Ms. Kuster. Okay. Were there any disciplinary proceedings?
    Dr. Reeves. Yes. The Associate Chief Nurse received a 21-
day suspension, unpaid suspension.
    Ms. Kuster. Okay. So moving on, I think I would like to go 
to Dr. Galpin just in terms of what the opportunities are with 
this technology. Could you just expound upon what some of the 
new initiatives will be under this Anywhere-to-Anywhere? If you 
could expand upon that and whether or not there is action 
needed by Congress to effectuate the goals of this policy.
    Dr. Galpin. Thank you. Actually, we may need to spend about 
10 minutes on that because I think this is--
    Ms. Kuster. I have two-and-a-half. I have a good 
relationship with the General.
    Mr. Bergman. We have some flexibility.
    Ms. Kuster. I am feeling good about the flexibility.
    Dr. Galpin. So let me just start by talking about the 
direction we are going, because I think it is an incredibly 
exciting direction. It is hard to kind of talk about everything 
we are doing unless I can kind of break it up into categories.
    So the way I think of it--and there are all different ways 
to think of it--is the things we are doing at the facility 
level, the things we are doing at the regional level, the 
things we are doing at the national level.
    So, first of all at the facility level, our expectation is 
that telehealth is just going to be integrated into all the 
services we provide to make it more accessible. So when you 
look across the broad spectrum of clinical services that we 
provide in the VA, or any health care provides, every specialty 
can add telehealth as a component of their care. Some can do 
pretty much all their care through telehealth. Some can do a 
portion of their care through telehealth.
    So we want to make it so easy to do telehealth that it is 
like picking up the phone, and that is where our VA Video 
Connect application comes in. We want to make it easy. I want 
to be able to send a link to a veteran and say, hey, let's jump 
on a video call because you called in, said you have a rash, 
and I would like to look at it; or I got your x-ray back today, 
and I want to show it to you, not just describe it to you.
    We also want providers to be able to say, instead of coming 
back to see me in two weeks for your follow-up, would you 
rather have a video appointment so you do not have to leave 
your home? So that integration of just the day-to-day 
operations is key, and that is going to happen at the facility 
level.
    We also think, for some of our very large medical centers 
that have maybe 10 community-based outpatient clinics, they 
have challenges with meeting surge demand. So any given day you 
can have a provider out at a remote CBOC or community-based 
outpatient clinic. They may be two hours away from the main 
facility. You cannot figure out a way to staff up for that 
surge or contingency. But with telehealth you can have some 
centralized providers who, at a moment's notice, can be 
directed to that CBOC saying we have a provider out, let's have 
them work there and take care of refills, anything that they 
can do through telehealth through the day to cover for that out 
provider.
    We can also have, if we have a bunch of same-day sick 
patients coming to that clinic, we can say we have 20 patients 
waiting here and it is two hours away from anywhere else, let's 
focus our resources there today to decrease that wait time for 
same-day sick.
    We also think, because it is really, really important, and 
I am sure anyone who has ever taken care of a family member 
realizes, when you have someone who has a lot of medical 
comorbidities, it is really important to have family members or 
caregivers attend appointments, hear what the doctors are 
saying, help with the medications.
    And so with telehealth, not just getting care more 
accessible for the veterans and patients but actually saying if 
you want to attend this appointment remotely because you have a 
full-time job and it is hard to leave for the whole day, or you 
have sick children at home, we want to give you an opportunity 
to attend virtually so you can participate in the conversation.
    So at the facility level it is a lot about accessibility. 
It is about making that care more convenient, bringing it into 
the home, bringing the family members of caregivers, and 
helping to share clinical resources in the local area.
    At the regional level we start looking at capacity. So 
there are parts of the country, rural communities, where it is 
very challenging to hire a provider. A provider leaves, maybe 
it is a year-and-a-half, two years before we can really replace 
them in person.
    Through telehealth what we can do is we can say, all right, 
that rural community is close to a major metropolitan city, we 
are going to hire contingency staff in that location. When you 
lose your provider locally, we are going to fill in by 
telehealth so we have consistency in our access. When you can 
hire a provider, we will pull out. But in the meantime, the 
veterans' care is not going to be impacted. We are going to 
have a regular provider filling in for that person.
    So on the regional level, it is really important that we be 
able to share clinical resources, and that is where the 
Anywhere-to-Anywhere authority comes in, because we are not 
aligned where every rural community has a metropolitan city 
right next to them in their state that has authority to provide 
telehealth. Sometimes we have to go across state lines.
    At the regional level we also want to work on our telephone 
systems and add telehealth into what we are doing with call 
centers. So in the middle of the night, or anytime, 24 hours a 
day, we would like to see it, if a veteran calls in and they 
have a concern or a complaint that can be addressed with a 
provider, we would like to have a provider available who can 
get on a video call or an audio call with them and say let me 
take care of this so we are not sending you to the emergency 
room if we don't need to, or we are sending you to a clinic 
where you would have to wait because there are 10 other people 
who showed up on the same day.
    At the national level, it is a lot about quality. So what 
we can do with telehealth is I can take the expert provider who 
is maybe one of the top researchers on a rare condition who 
works in VA Connecticut, and I can make their services 
available to the small number of veterans anywhere in the 
country that has that rare condition. That is another place 
where we need Anywhere-to-Anywhere authority. We can't license, 
maintain licenses in every state. So to be able to provide that 
level of service and be able to do it in the home or the places 
that are most convenient for veterans, we need to have the 
authority to be able to say we should not have barriers. If I 
have a provider who can deliver a service, if I have a veteran 
who needs a service, we should be able to connect them simply, 
no questions asked.
    That is why that initiative is so important for us.
    Ms. Kuster. And just a last question. Is there legislation 
that is required for that initiative to do this Federal 
licensing or cross-border licensing?
    Dr. Galpin. We have the authority in the VA to get us most 
of the way there, and that is what the Secretary and the 
President were talking about at their event. The VA has the 
authority if we put out regulations. We have always preferred a 
legislative approach to this. It is the best solution. 
Legislation can take us farther than regulations can. We can 
develop new authorities through that. There are veterans that 
we will not be able to reach because they live across the 
border in Canada. They drive in for service to a VA, but then 
they go back home. They are now in another country. Our 
regulations would not allow us to treat those veterans through 
Anywhere-to-Anywhere.
    There are also other things with controlled substances that 
are Federal laws that we can't impact with our VA regulations. 
We can get to a 90 percent solution. We can do certainly a lot 
more with regulations than our existing authority. Legislation 
would be, by far, the preferred choice.
    Ms. Kuster. I yield back.
    Mr. Bergman. Thank you.
    Dr. Galpin, you seem to be the first name on here. By the 
way, I would like to tell Ranking Member Kuster that that 
question and your response was probably the most relevant and 
motivating interaction that I have heard in all of our hearing 
testimonies to date, since we have been together as a Committee 
for the last six-plus months, because what I heard you say, Dr. 
Galpin, is that you had the ability to redirect assets out of 
the CBOCs whatever happens to be. The provider is out for the 
day, something is wrong, connect someone via telehealth and 
still provide the capability. In previous hearings I have 
talked about using the military method of the surge. This is a 
different form of that, but it is a redistribution of assets to 
get the job done. I commend you for that type of attitude and 
proactive response.
    So let me ask you a slightly different question here, Dr. 
Galpin. VA provided figures that indicate that the telehealth 
enrollment overall is growing, but home telehealth is 
shrinking. Can you explain, give me some whys on that?
    Dr. Galpin. Yes. Let me provide a little bit of context of 
what we describe as home telehealth, because I think there are 
two different programs that need to be considered here.
    One is our monitoring program, and that is what we 
traditionally call home telehealth. Then we have video into the 
home, which is the VA Video Connect.
    Mr. Bergman. Can you describe the monitoring? How are we 
monitoring in the home telehealth?
    Dr. Galpin. So what we do is we enroll veterans in a 
program, and in most cases, about two-thirds of cases we will 
provide them a device in their home, and that device can 
connect by Internet, but it can also connect by telephone line.
    We enroll them in what we call a Disease Management 
Protocol. So let's say they have diabetes and hypertension. The 
equipment has protocols in it that asks them questions: How are 
you feeling today? Did you take your medications? They can put 
in their blood pressure. They can put in their blood sugar 
records. And then there is a nurse on the other end or some 
care coordinator--it doesn't have to be a nurse, but in most 
cases it is--who is monitoring that data and the parameters. If 
the blood pressure gets up to this high, the system gives you a 
red flag.
    So that care coordinator works with the veteran, 
essentially a conduit between them and the organization. If 
they see parameters going outside the control, they see 
something happening with the veteran that is concerning, they 
call them up. They can educate them, they can connect them with 
a provider.
    So it is a group of nurses essentially that have 
dashboards, and they have regular information that is coming in 
from veterans who are in their home to make sure that they are 
staying on a good pathway in their disease management. That is 
the monitoring program. So it is daily monitoring.
    The video into the home program is more episodic care. This 
is when someone calls in and says, oh, I would like to have an 
appointment for this rash, and I say, great, let's get on a 
video. It is a one-time event. Maybe it is a scheduled event. 
Maybe it is an ad hoc event. We connect by video. We are seeing 
each other, we are hearing each other. That is video into the 
home.
    The video into the home, when we looked at the end of 
quarter 3 data, that program has grown by over 70 percent over 
the last year's growth. That is the program that we are seeing 
expanded.
    The remote monitoring program, as you say, those numbers 
have declined over the last several years. That is a resource-
constrained program. Nurses can only manage so many patients 
and monitor them successfully and safely. Unless we add nurses 
to the program, those numbers will stay static, and that has 
been the situation that we have been in for several years.
    On top of that, I think it was in 2014, our community got 
together and wanted to put standards for the amount of veterans 
that could be safely monitored through that program. Previously 
there were about 90 to 150 veterans that could be monitored. 
When that group got together and they said, well, we can do 
that; however, when we cross-cover, when someone is out, 
suddenly we are monitoring 200 to 300 veterans, that is not a 
safe practice.
    So they created a panel-sized calculator that, based on the 
complexity of the panels and what you anticipate to be your 
panel make-up of complex versus non-complex patients, it 
produces recommendations on what your panel size should be, and 
that produced an average panel size of, I think, 80 to 85 
veterans per nurse. So it kind of decreased the total number of 
veterans that we can enroll based on the existing staff. So we 
are not seeing heavy growth in that program at this point.
    Mr. Bergman. Okay. You know, I think since it is just the 
two of us, we can go back and forth with questions if we 
decided we have asked enough questions. Is that okay?
    Ms. Kuster. That is perfect.
    Mr. Bergman. Okay. Do you want to go again?
    Ms. Kuster. I am happy to, yes.
    So, just to pick up on that before we leave it, more 
resources, more personnel resources would be needed.
    What about the equipment in the home? What are the 
constraints on that, and are there recommendations about 
equipment in the home for participation?
    I mean, I just want to say I have been surprised and very, 
very impressed, for example, that mental health treatment can 
be provided very effectively by telehealth. I did not 
anticipate that. Up north in my district, not far from the 
Canadian border we have a CBOC, but we also have veterans 
centers that are just for mental health, and they were able to 
provide care as long as a veteran was sitting comfortably in a 
chair in a room with privacy, on the television with their 
mental health provider.
    But how do we address the equipment in order to bring that 
kind of treatment into the home?
    Dr. Galpin. I am going to separate again. Again, we have 
the remote monitoring program, and that is something that we 
can supply. So we have a central distribution mechanism where 
the veteran gets enrolled in the program. They can be 
distributed out equipment for home monitoring. We also have an 
option where they can use their own phones or their own 
Internet, though it is a much smaller percentage of veterans 
that actually use their own devices for home monitoring.
    For the video into the home--I think that is the category 
you are focusing on most--I break it down into three categories 
of accessibility for the veteran in the home in that case. So 
we have veterans that live in areas where they can get 
broadband or high-speed Internet, they subscribe to it, and 
they have devices that are video capable. In that case, we can 
use that VA Video Connect application, send them a link, and we 
can connect them, we can do video conferencing.
    What you are saying about mental health is true. It is also 
true for many other specialties. I mean, imagine the amount of 
specialties that don't require any physical examinations, or 
the amount of appointments that don't require physical 
examination other than visual. So mental health, social work, 
pharmacy, speech therapy--there is a long list where a very 
complete appointment can be provided through video 
conferencing.
    The second category of veteran is veterans who live in an 
area that maybe has broadband 4G connectivity, but they may not 
have their own device or they may not subscribe to that 
bandwidth. So VA in this case has a program where we can 
distribute out a connected tablet. It has 4G connectivity. We 
ship it to the veteran. They can use it. We have distributed 
about 6,000 of those, or over 6,000 of those. That is certainly 
an area where we could get assistance. I don't know if the 
right answer is a public-private partnership, but that is a 
resource limit. There is a point where we do run out, we have 
to buy more.
    Ms. Kuster. Are the VSOs involved in that program at all? 
Do you know?
    Dr. Galpin. In the distribution--
    Ms. Kuster. The Veteran Service Organizations in the 
distribution or the purchase?
    Dr. Galpin. Not that I am aware of.
    Ms. Kuster. Maybe that is something we could look into.
    Dr. Galpin. I could look into that, but I am not aware of 
that.
    Ms. Kuster. Okay.
    Dr. Galpin. So we do have a way to get the veterans the 
connectivity and the device for that service, and we think that 
is certainly a great opportunity. We would like to be able to 
do more of that where it is needed.
    The third category is the most challenging. We looked at 
this, and these are not official numbers, but we asked rural 
health at the beginning of the year to give us a list of where 
veterans are located, how many veterans do we have in 
communities that have no broadband, no 4G connectivity.
    Ms. Kuster. That would be my district.
    [Laughter.]
    Ms. Kuster. This is why we have come together on this 
issue.
    Dr. Galpin. These are approximate numbers. But nationally, 
at least in that initial data query, we have about 40,000 
veterans living in those areas, and in Michigan it's about 
1,500, in New Hampshire it was like 300.
    Ms. Kuster. Forty thousand nationally?
    Dr. Galpin. Yes.
    Ms. Kuster. Oh, we should be able to correct this.
    Dr. Galpin. Yes. So these are preliminary numbers, again. I 
wasn't asking for--
    Ms. Kuster. No, but it is not like 4 million.
    Dr. Galpin. Yes. So those are the most challenging because 
we can't ship them a connected tablet and have it work, and 
this is where I think local community and the VA need to be 
working together--public-public partnerships, public-private 
partnerships--to say, okay, here is a veteran community or a 
community that has 11,000 veterans in it that don't have 
connectivity. We can't provide the services we want to provide 
into the home or close to their home. Let's find a building 
like this, maybe a rural community that has satellite 
connectivity. Let's see if we can reserve rooms. We can then 
send them a tablet and they can schedule a time in a room at a 
library, at an academic site, at a town center, just so they 
can connect to their local VA port or their distant VA 
provider.
    That is a real opportunity. In the meantime--well, that is 
probably the thing we need to do first. But where Congress can 
help with this--I heard you ask that question earlier. I really 
didn't address it. I would certainly like some more time to 
talk about where we could get help from Congress, but making 
bandwidth, making Internet more of a utility. I know that is a 
bad word to some people, a utility, but more like a utility in 
that it is available everywhere.
    Maybe there is a combination where there are different 
levels. I know, again, it is a touchy area, a utility versus a 
commodity, but we really should have that service everywhere, 
and we have got to figure out ways and support companies that 
want to do that. VA can't set up Internet connectivity all over 
the country, but there are people who can, and that is a big 
area, and that will help us tremendously.
    Ms. Kuster. Well, a lot of veterans--and I am sure General 
Bergman has seen this--in my district, they are choosing to 
live a rural life, and many of our Vietnam-era veterans came 
back and chose to live in a more rural area, and mental health-
wise that is probably healthy for them. They get out, they go 
hunting and fishing and snowmobiling, and it works well for 
them. But it is not just their health that would benefit from 
the connectivity; it is their economic opportunities, it is 
their personal opportunity for staying connected to family and 
friends. So I think it is definitely something worth looking 
into.
    I will yield back.
    Mr. Bergman. Thank you.
    Dr. Wong, in your home telehealth enrollment audit, you 
found that less sick and younger veterans were being targeted 
for enrollment, and the sicker and more elderly vets were being 
deemphasized. Can you put some more meat on that bone, give 
further explanation and what effect it had on the home 
telehealth enrollment overall?
    Dr. Wong. So, the meat on those bones was done by audit, 
and that is why I can't speak to that. I am from the health 
care division, and so I can speak to the Detroit issue with the 
home telehealth. But as far as that number and that report 
goes, that goes to the audit division of IG, which I was not 
involved with.
    Mr. Bergman. So I need to go find the audit division of IG 
to answer that?
    Dr. Wong. I can get that.
    Mr. Bergman. You can direct me--
    Dr. Wong. Absolutely.
    Mr. Bergman. Are they in D.C.?
    Dr. Wong. And I will. They are in D.C., yes.
    Mr. Bergman. Oh, good. Then when we get back there, I will 
have a little direct meeting.
    Dr. Wong. I will get that question to them, actually.
    Mr. Bergman. Good. So then let me go to an extra one. In 
your Detroit report, you made recommendations to ensure that no 
one manipulates any more enrollment records, okay? The 
recommendations were to retain everyone, make sure policy is 
followed, correct the veterans' telehealth records, and to 
consider taking personnel action.
    Have those recommendations been resolved?
    Dr. Wong. The education has been resolved. We are still 
waiting for the facility to give us data on the surveillance of 
notes that confirm or do not confirm that telehealth has been 
delivered appropriately and documented.
    The administrative action is still in process. We know that 
action has been taken, but we need VA to provide official 
documentation of that.
    Mr. Bergman. Okay. And I am going to ask one more question 
and then yield back.
    Ms. Kuster. That is fine.
    Mr. Bergman. Dr. Reeves, the Associate Chief of Nursing 
received a 21-day suspension?
    Dr. Reeves. Yes.
    Mr. Bergman. Was that with or without pay?
    Dr. Reeves. Without pay.
    Mr. Bergman. Without pay. In your opinion or that of those 
you have consulted with, was that appropriate, or did that send 
a strong enough message throughout the system that that kind of 
behavior would not be tolerated?
    Dr. Reeves. I think it sent a strong message. We have 
never--I have never given anyone a 21-day suspension, a manager 
a 21-day suspension without pay. And so we thought it was 
appropriate.
    Mr. Bergman. Okay. I yield back.
    Ms. Kuster. I just want to follow up before we leave here 
on one issue that we haven't covered, and I will start with Dr. 
Wong, but if anyone wants to follow up on that.
    This is with regard to the mobile medical units, another 
way of servicing rural communities. Two questions. Are you 
aware that the VA has a better accounting system at this time 
to locate these mobile medical units and keep track of them? 
And secondly, I would just ask you, given the situation down 
south in Texas and Louisiana, are they able to bring these 
units in in an emergency to provide care for both veteran and 
non-veteran populations?
    Dr. Wong. The mobile medical unit, again, was a different 
audit report.
    Ms. Kuster. Oh, okay.
    Dr. Wong. It was an audit report. It wasn't an inspection 
report, so I cannot speak for that.
    Ms. Kuster. Okay. Is anyone else on the panel able to speak 
to that, the mobile units?
    Dr. Galpin. I will qualify by saying I am not the subject-
matter expert for mobile medical units.
    Ms. Kuster. Sure.
    Dr. Galpin. I can help with some of the responses, and I 
will have to take some of it back for the record.
    Ms. Kuster. Okay.
    Dr. Galpin. The mobile medical units are under emergency 
management. Basically, new recommendations, a new policy was 
developed that was just actually published in July that gives 
criteria for managing the mobile medical units, and I 
understand that a report is going to Congress yearly on the 
number, connectivity, use of those mobile medical units.
    I know last year, for instance, we had 27 reported clinical 
workload. They produced approximately 27,000 encounters, did 
about 4,000 telehealth encounters. So they are being tracked 
much more closely under a program under policy now. But it is 
emergency management.
    Regarding the question, I think it is a great question as 
far as how can we help Texas right now, how can we help the 
Houston area. There has been a tremendous amount of 
conversation over the last couple of days about what can 
telehealth do, and we had providers jumping out of their seats 
saying I want to help, how can I help, how can I get involved.
    I know we have mobile vet centers. I think we have one 
mobile medical unit and vet center in the area. The manager for 
the mobile vet center said they have, I think, nine mobile vet 
centers within a one-day drive, if needed, to bring into the 
area. So at this point we are working with our central command 
trying to figure out exactly what needs to happen.
    So there will be a lot more to come on this, and we can 
certainly give you an after-action.
    Ms. Kuster. Like I said, we had a flood in our Manchester, 
New Hampshire facility last month, and a number of mobile units 
were brought in from surrounding areas and have been very, very 
helpful for all different types. I think it would be useful, 
actually, for our Committee to tour and get a handle on how 
these are useful for all different types of--again, it was 
mental health, it was primary care, it was different clinics 
that were able to continue even after this flood. So it was 
good.
    I am just going to go to Dr. Constantian, who came all the 
way out here. Is there anything that you would like to add from 
your area of expertise, anything that we should know or 
anything that Congress can be doing with regard to IT? I guess 
my biggest question has to do with the change in the electronic 
health record and how that would impact telehealth, and is 
there an off-the-shelf option here where we would be able to 
move forward quickly, or are we going to have a--I won't use 
the technical term in terms of what is going to happen next 
with the new electronic health record and our intent to expand 
telehealth.
    Mr. Constantian. Thank you, Ranking Member Kuster. I know 
probably the arrangements that we are trying to move forward on 
with Cerner based on Secretary Shulkin's determination and 
findings from early June are probably of greatest interest to 
you and Chairman Bergman. However, those negotiations have not 
resulted yet in a contract, so it would be premature probably 
for me to comment on that, specifically what the software would 
bring to the table in terms of telehealth support.
    I would say, though, that IT and the Office of Information 
Technology and Veterans Health Administration, my office, 
partnering with another element, the Enterprise Program 
Management Office in particular and Dr. Galpin's office in VHA 
have formed a very tight partnership in terms of the vision for 
telehealth and what the IT supports are that are required to 
undergird that. Many of those, not all but many of those, I 
would say even most, are not electronic health record-specific. 
It is more in the area of infrastructure and capacity to build 
out that strategy.
    So assuming we go forward with Cerner and the contract is 
let, we will have some work that interfaces with Cerner, but a 
lot of the work that we have in terms of expanding 
infrastructure is independent of the electronic health record 
choice that we take.
    Ms. Kuster. I will yield back, but we may take back to our 
Committee. I would suggest that we have a presentation for the 
Full Committee on telehealth and the expansion of telehealth, 
and then maybe if we do it in a way that is timely to the 
announcement about where we are headed with the electronic 
health record, and then you could describe that infrastructure. 
I think that would be of interest certainly as we--we have some 
big hearings coming up this fall about the future of the VA and 
what it looks like in terms of facilities and care in the 
community and care in the home. I think it is going to be 
important for our Members to have a thorough understanding of 
what is possible, and potentially the VA can be on the cutting 
edge, as the VA has been in so many other areas. It would be 
really exciting to see the VA be leading the way in telehealth.
    Thank you. I appreciate you taking the trip, and I 
definitely appreciate the testimony.
    I will yield back.
    Mr. Bergman. Thank you.
    I guess I have never heard this question asked in a hearing 
like this, but this is your opportunity, any of the four of 
you, to offer to myself and Ranking Member Kuster your thoughts 
on where Congress either could be more helpful or, in some 
cases, less helpful.
    I will open it up to anyone who would like to offer a 
comment on that.
    Dr. Galpin?
    By the way, we don't shoot the messenger here.
    [Laughter.]
    Dr. Galpin. I will be respectful.
    Mr. Bergman. And I appreciate that.
    Dr. Galpin. I appreciate that question, but I think this is 
a partnership. I mean, we look to you all for leadership and 
direction as much as we do from our own agency. So it is 
important that we are all working together and you understand 
where we have challenges and can look to you for help in those 
areas.
    I will go through just a couple. The first is legislation, 
that Anywhere-to-Anywhere legislation, that and overcoming some 
of the issues with our ability to provide comprehensive care 
through telemedicine, so with the Controlled Substance Act, the 
portion of that which is the Online Pharmacy Consumer 
Protection Act of 2008. These are things where we need action 
from somewhere to help overcome.
    I think legislation is, again, still the best approach. It 
is the most comprehensive. It could potentially still be done 
faster than we can get regulations through comment periods. 
That is still something we need to put out through the public. 
So that is an area that we would certainly love very 
comprehensive support.
    The other is IT infrastructure. I am going to put that in 
the category of both IT and community IT. In the VA, our IT is 
separate. They have a separate budget from us. Sometimes we 
have needs in our program, and I will give you the figures I 
have. We did an assessment of what we wanted to do with VA 
Video Connect, the services in the home, and to do what we felt 
we wanted to do, it was going to require an additional $25 
million of IT funds per year to make that happen. That is 
something that currently we don't have funds for, and those 
monies sit in a very different pocket from the other money that 
we may have.
    Mr. Bergman. Are those funds restricted? In other words, 
restricted within that pot? Is that by legislative or by what 
means restricted? What put up the barrier?
    Mr. Constantian. In 2006 there was legislation to create a 
separate IT appropriation for IT expenditures, and there was a 
rationale for that. There was the ability to account across the 
Department for whatever IT expenditures there were. It had 
perhaps an unintended consequence, by separating out the 
monies, whereby there might be enough money in situations like 
telehealth where you need medical funds for clinicians, for 
some of the infrastructure that is not IT, but you also need to 
partner those funds with IT.
    In terms of responding to your question, Chairman Bergman, 
I was going to say that one thing we experience in the Office 
of Information Technology in health care is that there are so 
many excellent ideas that require IT funding, often between 
three times and five times the amount of money that we have 
available for development of those services. So we have to make 
very difficult choices. There are safety issues, there are 
suicide prevention demands, other demands for that IT support, 
and we can't fund all of the good ideas that the Veterans 
Health Administration has in terms of benefitting veterans.
    Dr. Galpin. Yes. So I will sort of skip ahead and come back 
to the IT infrastructure, because the appropriations thing, 
this falls under the big category of let's make government more 
simple and intuitive. So I have a budget, but it is split into 
three pockets. I may have plenty of money in this pocket, but I 
need to buy something that requires this money and I can't do 
it.
    Mr. Bergman. Because of legislation.
    Dr. Galpin. Because of legislation. I believe it is 
legislation. It is separate appropriations, and there is a lot 
of anxiety and fear in the government over this. If I use this 
for the wrong purpose--
    Mr. Bergman. So I am going to put words in your mouth here. 
You are the boots on the ground. You are in the middle of a 
fight. You have assets over here, and you have assets over 
here, and you are being limited from using the assets to do the 
right thing for the right reason at the right time because of 
legislation. Did I get that right?
    Dr. Galpin. Correct. And in the area of telehealth, it is 
particularly confusing because we have a clinical bucket of 
money and we have a technology IT bucket of money, and where do 
we sit? When I buy a tablet for a veteran, is it IT money? Is 
it clinical money? And depending on the situation, it could be 
either. So that confuses people. And if you buy it for one 
purpose and want to re-purpose it for another, then you have 
used the wrong type of money. It is confusing.
    Mr. Bergman. So the legislation is inhibiting or preventing 
you as a leader who is in the fight, boots on the ground, from 
basically winning the battle--
    Dr. Galpin. Doing the right thing.
    Mr. Bergman [continued].--that you are in the middle of.
    Dr. Galpin. Correct.
    Mr. Bergman. Okay. I just wanted to make sure that I was 
hearing what you were saying.
    Mr. Constantian. Sir, I would add that there are mechanisms 
for transferring between those buckets of money, but they are--
    Mr. Bergman. Who created the mechanisms?
    Mr. Constantian. Sorry I can't comment on that in terms of 
different appropriations. But what I would say is that it 
requires notification of Congress. So the shifts between the 
appropriations can't be done quickly. There is some lag period.
    Mr. Bergman. Okay. So the process exists.
    Mr. Constantian. Yes.
    Mr. Bergman. Okay.
    Dr. Galpin. But that creates for us a lot of challenges in 
the telehealth space, and along with simplifying government, I 
think our ability to buy things in the government is incredibly 
complex. Sometimes we go through years of contracting and 
protests and after-actions, and it becomes incredibly 
challenging.
    So you start out, again, working with the buckets of money. 
You have a budget that comes for one or two years at a time, 
and then the time to actually act on something you are trying 
to act on is incredibly complex and long. So I think for us in 
telehealth, that is another area. When we are trying to move 
things quickly and we are in an area of significant growth, and 
we want to be the leader in this area, having to wait for a 
couple of years to get new technology in is an incredible 
challenge. And again, there is a lot of anxiety about how do 
you do it right, how do you make sure you follow all the rules.
    So just, again, simplifying.
    I would say hiring is in the third category of that. Again, 
we just need to simplify the way we do things so we have an 
intuitive system that people can--if they are doing the right 
thing that should be in line with the laws and regulations. I 
think that is a huge area of opportunity.
    Going back to the initial question, though, about what we 
can do for telehealth right now, the legislation, the IT 
infrastructure, helping with that Internet expansion in the 
community, helping with our IT expansion in the VA to support 
what we are trying to do, and then simplification of policies 
and procedures that just make our system very complex to move 
quickly.
    Mr. Bergman. Okay. Well, we have had a little discussion up 
here amongst the Ranking Member and myself, and I believe you 
are all set and satisfied. We are going to move forward, if you 
will.
    Do you have any closing statements or anything that you 
want to say? Because I am just going to close the hearing off.
    Ms. Kuster. Just to say thank you, and I have had a 
wonderful time in Michigan. Thank you for the invitation. Thank 
you to all of you for traveling here as well.
    Mr. Bergman. I am going to just, again, echo the Ranking 
Member's words and thank you for making the effort to be here. 
Thank you for the continuing education on both parts, because 
in good business group, it doesn't make any difference what the 
unit of measure is, interactions, everybody works together, 
everybody knows what their responsibilities are, everybody 
should know what they are being held accountable for. But 
probably most importantly, we need to feel as though we are in 
an environment where we can clash in a collaborative, positive 
way and come out maybe a little bit bloodied in the short term, 
but nonetheless nothing that is going to cause permanent 
damage, and our mission moves forward because of the fact that 
we tangled with one another. So I thank you for that.
    Roles and missions we talk a lot about in the military, and 
I was kind of alluding to it in my comments there about what is 
the role of Congress, what is the role of the VA, what is the 
role here and there. Roles and missions is something that is 
continuing based on the fight you are in and based on the 
capabilities you have been assigned to bring to the table.
    I will tell you, Dr. Reeves, as someone in the military who 
holds people accountable, I really don't think a 21-day 
suspension was enough. I just want to let you know that. That 
has stuck somewhere in my system right now because no matter 
what you are doing, in the end if somebody gets hurt because 
somebody didn't do the right thing, there is no excuse for that 
and you have to send a message that is so strikingly clear that 
if anyone even considers doing something like that again, it 
means that the message wasn't right on the front end. So I 
would just offer that advice as a former military commander.
    I just wanted to thank you all, all of you witnesses today 
for being with us and for your thoughtful testimony.
    The panel is now excused.
    The VA has long recognized the opportunities that 
telehealth presents to bridge the distances not only between 
its facilities and its veterans in rural areas but utilizing 
these techniques to build on what the expectations will be for 
future veterans who have yet to even--if you will, the folks we 
are talking about now are the ones who haven't even signed up 
to join the military, yet they are the toddlers using their 
screens at home that have their Fitbit on who will know their 
provider through some type of device, and that is the future 
that we are looking at.
    But we have an opportunity as veterans' health care 
especially and providers of services to our veterans to be on 
the leading edge, and we cannot miss that opportunity. So after 
rolling out the telehealth nationally in 2003 and significantly 
expanding it in 2011, I believe the Department is at another 
key moment for growth, for opportunity. Telehealth is already a 
billion-dollar enterprise for the VA. It seems to be headed 
into the multi-billions. We have to make sure that those 
administrative systems and enabling technologies keep up with 
the needs, if you will, in such a way that there is such a 
thing as being on the leading edge but not so far out on the 
edge that you are assuming unnecessary technological risk, if 
you will. We are not going to be the R&D in some ways, but yet 
we will be the implementers of good R&D.
    We also have to stay mindful of previous incidents of well-
intentioned performance metrics motivating bad behavior. We 
already talked about that. VA is engaged in a very 
consequential planning for its future. So the big issues are 
where and how new hospitals should be built, if at all; what is 
the best mix of in-house and community care, what that looks 
like; and how to move forward with an optimal technology for 
the moment, because we know when we put something in place, it 
is going to change.
    Telehealth touches every issue, and I want to make sure 
that that is always part of our conversation. As you heard 
Ranking Member Kuster talk about the rural nature of her 
district, the rural nature of my district, if it will work in 
our districts, it will work anywhere. We look forward to being 
that test bed, if you will, in some ways, to see what works and 
what doesn't, because I will guarantee our constituents don't 
beat around the bush. They will get to it very quickly. So 
thanks for making that part of the conversation.
    I look forward, as always, to working with Ranking Member 
Kuster, and I am also looking forward to talking with her back 
in D.C. and hearing of her exploits here in our beautiful 1st 
District and all the hospitality she enjoyed.
    We are going to be all in this together to make telehealth 
what it can be.
    I ask unanimous consent that all Members have five 
legislative days to revise and extend their remarks and to 
include extraneous material.
    Without objection, so ordered.
    Again, once again, thank you to all of you.
    And to those of you in the audience who came today, thanks 
for joining us here this morning.
    With that, this hearing is now adjourned.

    [Whereupon, at 10:10 a.m., the Subcommittee was adjourned.]

                            A P P E N D I X

                              ----------                              

                Prepared Statement of Kevin Galpin, M.D.
    Good morning, Chairman Bergman, Ranking Member Kuster, and Members 
of the Committee. Thank you for the opportunity to discuss VA 
telehealth, telehealth information technology (IT), and our home 
telehealth program. I am accompanied today by Dr. Pam Reeves, Medical 
Center Director of the John D. Dingell VA Medical Center (VAMC) in 
Detroit, Michigan and Dr. Alan Constantian Deputy Chief Information 
Officer for the Office of Information and Technology and VHA Account 
Manager for Clinical Functions.

Introduction

    VA Telehealth is a modern, Veteran- and family-centered health care 
delivery model. It leverages information and telecommunication 
technologies to connect Veterans with their clinicians and allied or 
ancillary health care professionals, irrespective of the location of 
the provider or Veteran. It bridges enhanced access and expertise 
across the geographic distance that would otherwise separate some 
Veterans, including those in rural areas, from the providers best able 
to serve them.
    Telehealth is mission-critical to the future of VA care. Its 
potential to expand access and augment services is both vast and 
compelling. While telehealth is capable of enhancing the health care 
system in multiple ways, three are specifically essential for the 
successful operation of our national, integrated VA enterprise.
    First, telehealth increases the accessibility of VA care. It brings 
VA provider services to locations most convenient for Veterans, 
including for those Veterans with mobility or other health challenges 
that make travel difficult. Through telehealth, Veterans are able to 
receive care in their community-based clinic and at home.
    VA is committed to increasing access to care for Veterans and has 
placed special emphasis on those in rural and remote locations. This 
means transitioning from older systems and a health care delivery model 
that has been in place for decades to a system that works for Veterans 
and is focused on contemporary practices in access. VA is empowering 
Veterans and their caregivers to be in control of their care and make 
interactions with the health care system a simple and exceptional 
experience.
    Second, telehealth increases quality of care. It enables VA to 
model its services so that national experts in rare or complex 
conditions can effectively care for Veterans with those conditions, 
regardless of the Veterans' location in the country. Telehealth 
leverages health informatics, disease management principles, and 
communications technologies to deliver care and case management to 
Veterans. Telehealth changes the location where health care services 
can be provided, making care accessible to Veterans in their local 
communities and their homes.
    Third, telehealth enhances the capacity of VA clinical services for 
Veterans in rural and underserved areas. The mission of VA Telehealth 
Services is to provide the right care in the right place at the right 
time through the effective, economical, and responsible use of health 
information and telecommunications technologies. This is accomplished 
by empowering VA to hire providers in major metropolitan areas, where 
there is a relative abundance of clinical services, for the purposes of 
serving Veterans in rural and even frontier communities where medical 
services may be insufficiently available.
    Leveraging telehealth technologies affords VA an opportunity to 
increase access to care for Veterans, especially for those in rural or 
underserved areas. It allows Veterans access to VA health providers or 
services that may otherwise be unobtainable locally. Telehealth is now 
considered mission-critical for effectively delivering quality health 
care to our Veterans. VA remains committed to ensuring that America's 
Veterans have access to the health care they have earned through their 
service, and we will continue to expand telehealth services to meet the 
growing needs of our Veterans.

VA Telehealth By The Numbers

    VA is recognized as a world leader in the development and use of 
telehealth technology. To ensure excellence in care delivery, VA 
aspires to elevate and expand telelehealth in the coming years. VA has 
substantially increased access to care for Veteran patients using 
telehealth services and is a recognized pioneer in the practice of 
telehealth. Since 2002, over two million Veterans have accessed VA care 
through telehealth services, and Veterans are utilizing more telehealth 
services from VA than ever before. In fiscal year (FY) 2016, of the 
more than 5.8 million Veterans who used VA care, approximately 12 
percent received an element of their care through telehealth for a 
total of 2.17 million telehealth visits. This represented more than 
702,000 Veterans, with 45 percent of those Veterans served living in 
rural areas. In total, this amounted to over 2.17 million telehealth 
episodes of care.
    VA recognizes three broad category types of telehealth to deliver 
services to Veterans in 50 clinical specialties. The first of the three 
categories, Clinical Video Telehealth, is defined as the use of real-
time interactive video conferencing to assess, treat, and provide care 
to a patient remotely. Typically, Clinical Video Telehealth links a 
Veteran at a clinic or his or her home to a provider at a VA medical 
center in another location. Clinical Video Telehealth allows clinicians 
to engage patients in the comfort and convenience of their homes and 
facilitates delivery of a variety of clinical services including 
primary and specialty care. Clinical Video Telehealth means that 
instead of having the cost and inconvenience of the Veteran traveling 
by road, rail, or air to see a provider, the VA provider delivers care 
through telehealth to the Veteran. VA Video Connect represents the next 
step for Clinical Video Telehealth. It provides fast, easy, encrypted, 
real-time access to VA care. It allows for video health care visits, 
such as telemental health visits, where a hands-on physical examination 
is not required. It also makes it easier for Veterans to choose where 
they'd like to receive services, whether those services are in their 
home or any other place the Veteran desires.
    Cumulative Veterans using the Real Time/Clinic Based Video 
Telehealth program:

 
------------------------------------------------------------------------
      Fiscal Year                  July                    EOFY
------------------------------------------------------------------------
             FY15                  247,942                 282,319
------------------------------------------------------------------------
             FY16                  269,135                 307,985
------------------------------------------------------------------------
             FY17                  293,291
------------------------------------------------------------------------

    The second category of telehealth is Store-and-Forward Telehealth, 
which is the use of technologies to asynchronously acquire and store 
clinical information (such as data, images, sound, and video) that is 
then assessed by a provider at another location for clinical 
evaluation. VA's national Store- and-Forward Telehealth programs 
deliver services such as Dermatology and Retinal Screening, where a 
health care provider can use a photo or a series of photos for 
diagnosis or triage.
    Cumulative Veterans using the Store and Forward Telehealth Program:

 
------------------------------------------------------------------------
      Fiscal Year                  July                    EOFY
------------------------------------------------------------------------
             FY15                  249,489                 298,802
------------------------------------------------------------------------
             FY16                  254,018                 304,760
------------------------------------------------------------------------
             FY17                  257,282
------------------------------------------------------------------------

    In FY 2016, the number of Veterans treated by Clinical Video 
Telehealth and Store and Forward Telehealth in Michigan was more than 
11,800. This was accomplished via more than 33,000 telehealth 
encounters. Compared to the previous fiscal year, these two telehealth 
modalities in Michigan grew by approximately 13 percent in encounters 
and 14.5 percent in unique Veterans treated.
    The third broad category of telehealth is Home Telehealth. Home 
Telehealth uses VA-provided devices via regular telephone lines, mobile 
broadband, or cellular modems, or Veteran-owned devices using landline 
or mobile phones for interactive voice response, or Veteran-owned smart 
phones, laptops, or tablets via secure web browser, to connect a 
Veteran with a VA care coordinator, most often a registered nurse. 
Overall, 68 percent of Veterans participating in VA Home Telehealth use 
a VA-supplied home telehealth vendor contracted device and 29 percent 
use their own personal device (3 percent are not yet assigned at time 
of data capture). There are none using a mix of both at this time. For 
the 29 percent Veterans utilizing their own device, 24 percent use 
Interactive Voice Response (IVR) using Veteran's own landline or mobile 
phone and 5 percent use Web-Enabled Browser using Veteran's PC, laptop, 
smartphone or tablet to access a secure vendor website.
    Using Home Telehealth technologies, the VA care provider can 
monitor the Veteran's health status, provide clinical advice, and 
facilitate patient self-management as an adjunct to traditional face-
to-face health care. The goal of VA's Home Telehealth program is to 
improve clinical outcomes and access to care while reducing 
complications, hospitalizations, and clinic or emergency room visits 
for Veterans who are at high-risk due to a chronic disease (e.g., 
Diabetes). Not every patient is suitable for this type of care; 
however, for those Veterans who are, Home Telehealth can help them live 
independently and spend less time on medical visits. Over 85,000 
Veterans are regularly using Home Telehealth services. VA found that 
patients easily learn how to use their Home Telehealth technologies and 
are highly satisfied with the program. Home Telehealth makes it 
possible for Veterans to become more involved in their medical care and 
more knowledgeable about their conditions, providing an opportunity to 
more effectively self-manage their health care needs.
    All Veterans enrolled in the Home Telehealth program are assessed 
and assigned to a Category of Care. This assessment is completed using 
the Continuum of Care Form and is based on the Veteran's behavior, 
symptoms, cognitive status, living situation, caregiver support, 
functional ability (activities of daily living), and prognosis. The 
Veteran is reassessed every six months and when there is any change in 
status.
    The Categories of Care (in descending order of health care 
complexity) include:

      Non-Institutional Care (NIC) - Includes Veterans with 
deficits in three activities of daily living (ADL), one or more 
behavioral / cognitive deficits, or less than six months to live. If a 
Veteran does not meet one of these requirements but has two or more ADL 
deficits in combination with three or more deficits in instrumental 
activities of daily living (IADLs) or is age 75 or older, lives alone, 
or has 12 or more clinic encounters in the past 12 months, they also 
meet NIC criteria
      Chronic Care Management (CCM) - Includes Veterans who do 
not meet NIC criteria but who have one or more chronic illnesses 
amenable to Home Telehealth care and require on-going intensive case 
management, monitoring, and interventions.
      Acute Care Management (ACM) - Includes Veterans with 
short-term clinical needs such as, but not limited to, post-operative 
care, transition management, or post-hospital care (enrollment   Health Promotion / Disease Prevention (HPDP) - Includes 
Veterans who have a primary need for health promotion, disease 
prevention, and self-management education for maintaining healthy 
behaviors. This category also includes any enrolled Veterans (including 
those who meet NIC criteria) who respond less than 70% of the time 
through the technology for at least 90 days.

    The categories of care represent different levels of workload for 
the care coordinators. Based on the national recommendations, care 
coordinators monitoring more complex patients are expected to monitor 
fewer patients than a care coordinator with less complex patients. The 
needs of the Veterans served at a local VA facility help determine the 
strategy for the panel size mix and the panel size for the Care 
Coordinators.
    Cumulative Veterans using the Home Telehealth program:

 
------------------------------------------------------------------------
      Fiscal Year                  July                  September
------------------------------------------------------------------------
             FY15                  145,720                 156,016
------------------------------------------------------------------------
             FY16                  140,429                 150,620
------------------------------------------------------------------------
             FY17                  136,650
------------------------------------------------------------------------

VA OIG Reports

    Between 2013 and 2014, the VA Office of the Inspector General (OIG) 
audited the management of VHA's Home Telehealth program and provided 
their final report in 2015. As part of their audit, the OIG analyzed 
outcomes for about 15,600 patients in the six months following their 
enrollment in the Home Telehealth Program, and concluded that ``the 
program was successful in reducing inpatient admissions for all three 
main patient categories'' of enrollment, inclusive of the Non-
Institutional Care (NIC), Chronic Care Management (CCM), and Health 
Promotion/Disease Prevention (HPDP) enrollment categories. In its 
conclusion, the OIG described the program as a ``transformational 
modality for delivering quality healthcare that is convenient and 
accessible to veterans who cannot travel or who live hours away from 
the medical facility.''
    However, the OIG also concluded that the VA ``missed opportunities 
to expand enrollment for Non-Institutional Care,'' the category of 
enrollment with the best outcomes based on their analysis methodology. 
In response, they recommended, and VHA agreed, to system enhancements 
that would help identify demand for NIC enrollments and establish new 
performance measures to promote enrollment of NIC patients into the 
Home Telehealth Program. In response, VHA addressed the following three 
OIG Action Items such that OIG closed its report on December 2, 2016:

    1. Revised Care Assessment Need (CAN) Score Report: In February 
2016, VA completed modifications to the CAN score report so that it 
would automatically identify patients at risk for institutional care 
who might benefit from Home Telehealth (HT) as a NIC patient. The CAN 
score is a tool used by PACT teams to identify patients at highest risk 
of health care decline so that appropriate care and services can be 
targeted to intervene appropriately to improve outcomes and reduce 
utilization. Guidance and training regarding this modification was 
communicated nationally to VHA Patient Aligned Care Teams (PACT) and 
other appropriate services/providers so they can use the CAN score 
report to identify and refer patients to Home Telehealth that 
potentially meet NIC criteria. This training was also provided to HT 
staff so they could proactively identify patients at risk for 
institutional care who likely fall under the NIC Category of Care for 
HT.

    2. Created and Implemented HT National Templates: In addition to 
the modification to the CAN Score report, national HT reminder dialog 
templates were completed and have recently been released to the field. 
The reminder dialog templates help standardize home telehealth 
documentation but also remind home telehealth staff to reassess their 
enrolled patients at specified intervals to ensure they are in the most 
appropriate category of care, including the NIC category of care. In 
addition to correctly assigning Veterans to the correct enrollment 
category, the templates will facilitate the creation of national home 
telehealth reports because they include nationally standardized data 
elements. As an example of a potential report, VA Telehealth services 
would be able to assess the overall percentage of Veterans enrolled in 
the program who have not had their category of care assessed in a 
designated time period.

    3. Defined NIC Quality Indicators: At the start of FY 2017, VHA 
proposed NIC quality indicators that employed a population-based model 
analyzing the number of Veterans from the previous year to determine 
specific number-related NIC performance indicators for each VISN. This 
proposal was presented on the national VISN leads Program Manager call 
in August 2016 and was included in a report to the OIG.

    This proposal, however, raised concerns among Telehealth field 
staff and was ultimately not enacted. VHA recognized that the initial 
proposal for FY2017 clinical indicators needed revision to help avoid 
unintended consequences of a new metric.
    Following discussions in the third and fourth quarter of FY 2017, a 
new proposal for a NIC enrollment quality indicator has been developed 
that targets 50 percent NIC enrollment by mid-year FY 2018 and 55 
percent by the end of FY 2018.
    The proposal has been presented to the Performance Accountability 
Work Group (PAWG), VISN Telehealth Leads council, and National 
Telehealth Advisory Board with the expectation of enacting the new 
quality indicators in FY 2018.

Future of VA Telehealth

    As recently announced on August 3rd, 2017, by the President and VA 
Secretary Dr. David Shulkin, VA has begun several initiatives using 
telehealth technology and mobile applications to connect with more 
Veterans and provide services where they live.
    VA has sent a proposal to the Office of Management and Budget (OMB) 
to address barriers that are adversely affecting our ability to deliver 
telehealth services to our Nation's Veterans. Once OMB is done 
reviewing this proposal, VA will make it publicly available for 
comment. We encourage all affected stakeholders to send in comments, 
and we look forward to working with all parties to make this proposal 
as workable and effective as possible for all Veterans who seek VA 
health care services.
    VA is also initiating the nationwide rollout of a new application 
called VA Video Connect. VA Video Connect provides a secure and web-
enabled video service that makes it easy for Veterans to connect with 
their VA providers by video on their own mobile phones or personal 
computers. VA Video Connect is currently being used by more than 300 VA 
providers at 67 hospitals and their associated clinics. It will be 
rolled out to more VA providers and Veterans across the country over 
the next year.
    Dr. Shulkin also announced the nationwide roll-out of an 
application to make it easier to schedule or change appointments with 
VA. The Veteran Appointment Request (VAR) app, is an application that 
makes it possible for Veterans to use their smartphone, tablet, or 
computer to schedule or modify appointments at VA facilities. The VAR 
capability is currently available to Veterans at several locations 
nationwide. During its initial rollout, Veterans used the app to book 
more than 4,000 appointments with their providers. VA will continue to 
roll out the application nationwide - bringing the capability to all VA 
facilities and clinics.

Conclusion

    VA is a leader in providing telehealth services, which remains a 
critical strategy in ensuring Veterans can access health care when and 
where they need it. With the support of Congress, we have an 
opportunity to shape the future and ensure that VA is leveraging 
cutting-edge technology to provide convenient, accessible, high-quality 
care to Veterans.
    Mr. Chairman, this concludes my testimony. Thank you for the 
opportunity to testify before the Committee today. We appreciate your 
support and look forward to responding to any questions you and Members 
of the Committee may have.

                                 
                Prepared Statement of Thomas Wong, D.O.
    Mr. Chairman and Ranking Member Kuster, thank you for the 
opportunity to discuss the Office of Inspector General's (OIG) work 
regarding VA's Home Telehealth (HT) program. My statement today focuses 
on the results of our healthcare inspection reviewing allegations 
related to the documentation of patient enrollment in HT at the John D. 
Dingell VA Medical Center, Detroit, Michigan.

VA HOME TELEHEALTH

    In July 2003, the Veterans Health Administration (VHA) established 
Telehealth Services within the Office of Patient Care Services to 
support the development of new models of care in VA using health 
information technologies to address patient needs. The goal was to 
improve quality, convenience, and access to care for patients via 
health informatics, telehealth, and disease management technologies 
that enhance and extend care and case management while reducing 
treatment costs, complications, hospitalizations, and clinic or 
emergency room visits, for veterans in post-acute care settings and 
patients with chronic diseases. \1\ The Office of Connected Care is 
responsible for implementing telehealth throughout VA. \2\
---------------------------------------------------------------------------
    \1\ VHA Office of Connected Care Home Telehealth Operations Manual, 
April 2017.
    \2\ Ibid.

    According to the Office of Connected Care's Home Telehealth 
Operations Manual (HT Operations Manual), the term Home Telehealth 
``applies to the use of telecommunication technologies to provide 
clinical care and promote patient self-management as an adjunct to 
traditional face-to-face health care.'' \3\ The exchange of health 
information between the veteran's home or other location to the VA care 
setting alleviates the constraints of time and distance. \4\
---------------------------------------------------------------------------
    \3\ Ibid.
    \4\ Ibid.
---------------------------------------------------------------------------
    Since its inception, use of HT services has grown exponentially 
from approximately 2,000 to more than 96,000 enrolled patients at the 
conclusion of fiscal year (FY) 2015. \5\ On August 3, 2017, the 
President and the VA Secretary announced three new initiatives-one 
regulatory and two technological-designed to expand the use of 
telehealth nationwide. \6\ As the use of telehealth services expand, 
the need to provide proper surveillance and oversight is required so 
that telehealth can be delivered effectively to those patients who are 
enrolled in this program.
---------------------------------------------------------------------------
    \5\ VHA Office of Connected Care Home Telehealth Operations Manual 
(April 2017).
    \6\ The Anywhere to Anywhere VA Health Care initiative will create 
a regulation allowing VA providers to administer telehealth care to 
veterans anywhere in the Nation using VA Video Connect, a video 
conferencing service to connect patients and providers virtually, and 
the Veteran Appointment Request application, which will allow veterans 
to schedule or modify appointments using their mobile devices. See: 
President Trump and Secretary Shulkin Announce Veteran Telehealth 
Initiatives. The White House. https://www.whitehouse.gov/blog/2017/08/
03/president-trump-and-secretary-shulkin-announce-veteran-telehealth-
initiatives. Published August 3, 2017. Accessed August 21, 2017.

HEALTHCARE INSPECTION-DOCUMENTATION OF PATIENT ENROLLMENT CONCERNS IN 
    HOME TELEHEALTH, JOHN D. DINGELL VA MEDICAL CENTER, DETROIT, 
    MICHIGAN \7\
---------------------------------------------------------------------------
    \7\ Our report is available online at: https://www.va.gov/oig/pubs/
VAOIG-14-00750-143.pdf.

---------------------------------------------------------------------------
    Allegations

    In October 2013, the OIG received allegations regarding 
inappropriate documentation of patient enrollment in the HT program at 
the facility. Specifically, the concerns were:

      Documentation of enrollment in HT monitoring services was 
entered in the electronic health records (EHRs) of over 900 patients 
without their knowledge or consent from September 14, 2013 until 
October 1, 2013. Specifically, notes were written in patients' EHRs 
stating they were enrolled in and monitored by HT when they were not.
      ``In order to make her numbers for the end of the FY,'' 
the Associate Chief of Nursing Service (ACNS) required staff to work 
overtime (OT) for several weeks to produce documentation on the 
enrollment of patients in HT, regardless of whether these patients 
wanted to be enrolled or even contacted.

    We conducted our review from January 2014 through March 2016. We 
made an initial site visit June 25-26, 2014 and conducted a follow-up 
visit with facility leadership and HT coordinators on March 23, 2016. 
We conducted more than 20 interviews with the complainant, facility 
leadership, and others with knowledge of the allegations. We reviewed 
numerous VA records, policies, and procedures relevant to the 
allegations.

HT Enrollment Process

    HT enrollment involves a six-step sequential process delineated by 
the HT Operations Manual involving: 1) a referral or consult to the HT 
program; 2) screening for eligibility and suitability; 3) an initial 
assessment and treatment plan; 4) patient or caregiver education; 5) 
activation in VA and vendor computer systems; and 6) the initial 
monthly monitor note (MMN). An MMN is a progress note written by HT 
program staff to document a patient's progress in the HT program that 
occurred in the 30 days prior to the entering of the note. An initial 
MMN should be the last note written in the HT steps of enrollment. It 
is not intended to function as a clinical note, but rather is a 
workload capture of the activity of daily monitoring by the HT Care 
Coordinator. We understood the HT Operations Manual to indicate, and 
VHA officials agreed, that enrollment of a patient into the HT program 
does not occur until after completion of all steps outlined in the 
Operations Manual.

Performance Goals

    Each FY, VHA establishes performance goals and measures and tracks 
achievement of each performance goal by facility. For FY 2013, one of 
the performance goals for the facility was to enroll a total of 6,778 
or more unique patients into telehealth-based services. Another 
performance goal for this facility was to increase the total number of 
telehealth encounters to 11,724 or more. These HT performance goals 
were also part of the ACNS' individual performance goals.
    The facility's telehealth programs provided telehealth services to 
3,317 unique patients during FY 2013 and therefore did not meet the 
performance goal for enrollment of unique patients. However, the 
facility managers documented 12,295 telehealth encounters during FY 
2013, exceeding the performance goal for encounters by 571. For FY 
2013, the ACNS received an award of $5,000 for her performance rating. 
The rating was based, in part, on achieving the number of HT patient 
care encounters, in addition to over 30 other objectives.

Findings

    We substantiated that from September 14, 2013 until October 1, 
2013, HT program staff entered MMN documentation for the purpose of 
initiating the enrollment process for 836 new HT patients and worked OT 
in order to do so. We found that 828 of the 836 new patients were not 
properly enrolled in HT according to the sequence outlined in the HT 
Operations Manual. An initial MMN should be the last step of HT 
enrollment; however, the data showed that initial MMNs were entered in 
patients' EHRs regardless of proper enrollment sequence, missing 
consults, screening notes, and assessment notes. The 828 patients had 
not been issued HT monitoring equipment and had not received HT 
monitoring in the 30 days prior to the entering of the MMN. \8\
---------------------------------------------------------------------------
    \8\ We did not specifically address whether patients' consents were 
obtained. We noted that since the MMNs were entered as the initial 
documentation, any consent post MMN would not be relevant to the 
inspection as the procedures delineated in the HT Operations Manual 
require that consent be obtained prior to HT services.
---------------------------------------------------------------------------
    Further, we substantiated that the entry of the MMNs in the new 
patients' EHRs by HT staff during OT met the criteria for patient care 
encounters that contributed to the facility's and ACNS' ability to meet 
one of two FY 2013 performance measures for telehealth services. 
Without the use of OT during the last 2 days of FY 2013, which allowed 
the entry and completion of 634 MMNs, the facility and ACNS would not 
have reached or surpassed the performance goal of 11,724 HT encounters. 
However, we did not find that HT staff were required to work OT as 
alleged. Rather, HT staff informed us that they voluntarily worked OT 
to complete patient enrollment and clean up missing notes during this 
timeframe.
    The ACNS denied that staff worked OT in order to meet the HT 
performance goal. She stated she approved OT for HT staff near the end 
of FY 2013 to start HT patients' enrollment process. HT staff informed 
us that their practice was to enter the MMN first to capture workload 
and that Veterans Integrated Service Network (VISN) managers had 
directed them to use the MMN as the first note. However, the ACNS and 
HT staff were unable to provide written documentation from the VISN 
with instructions to enter the MMN first. VISN managers we interviewed 
did not indicate that a MMN could be used as the first note for HT 
enrollment. The VISN managers stated that they did not direct facility 
HT staff to use the MMN as the first note in order to capture workload.
    The ACNS also described a documentation ``clean-up'' process during 
which staff would enter missing MMNs prior to the end of the FY 2013. 
We requested that the ACNS clarify this clean-up process in the context 
of entering 828 new MMNs for patients who had no previous HT care 
during the year. The ACNS reported that the entry of missing MMNs at 
the end of the FY was for enrolled patients; however, the data showed 
that the majority of notes written from September 14, 2013 until 
October 1, 2013 were MMNs for new HT patients.

Recommendations

    Based on our findings, we recommended that the Facility Director:

      Ensure that HT staff be retrained and follow the Veterans 
Health Administration HT process of care and documentation 
requirements.
      Ensure that documentation accurately reflects patients' 
HT enrollment status as described in this report.
      Review the circumstances surrounding the entry of HT 
Program monthly monitor notes in electronic health records of patients 
as discussed in this report with the Office of Human Resources and the 
Office of General Counsel and take appropriate action as necessary.

    The VISN and Facility Directors concurred with our recommendations 
and provided an acceptable action plan. We consider Recommendation 1 
closed based on information we received from the facility prior to the 
publication of our report. However, we consider Recommendations 2 and 3 
open pending receipt of evidence from the facility that they have 
completed all activities outlined in their corrective action plan, 
which is detailed in Appendix B of our report. We will continue to 
follow up with the facility until all actions are complete.

OPPORTUNITIES TO EXPAND THE APPLICATION OF TELEHEALTH

    In addition to HT, there are many other opportunities to exploit 
the benefits of telehealth. One use of telehealth that has not been 
vigorously applied by VA is the use of telehealth to inform providers, 
often in emergency room (ER) settings, who diagnose a patient with a 
very recent cerebral stroke. Veterans who present to a VA or non-VA ER 
with this condition may not have the good fortune to be evaluated 
immediately by a stroke neurologist. In this scenario, telehealth is a 
modality that can be used by the ER provider to convey imaging of the 
brain, lab data, and physical exam results to the stroke neurologist 
and, if appropriate, receive expertise in the use of time sensitive 
``clot busting'' agents. If time sensitive therapy is appropriate, then 
it can be administered in the ER and the patient may then be stabilized 
at the facility or transported to a hospital with more capability to 
treat a cerebral intravascular event.
    In a recent report, the OIG recommended and the Under Secretary for 
Health agreed, that VHA would review current acute stroke treatment 
policies and assess the use of telehealth evaluation and more 
aggressive local treatment in patients presenting to rural and/or low 
complexity VHA facilities with signs and symptoms of acute stroke. \9\ 
VA completed the assessment and provided evidence of a plan to 
establish a variety of stroke-related support services including a 
network linking expertise in acute stroke management at high complexity 
medical centers to rural and/or low complexity medical centers. We 
consider this recommendation closed.
---------------------------------------------------------------------------
    \9\ Healthcare Inspection, Care of an Urgent Care Clinic Patient, 
Tomah VA Medical Center, Tomah, Wisconsin (June 18, 2015).
---------------------------------------------------------------------------
    This technology can be used not only to advise VA providers in VA 
facilities on the use of time sensitive stroke treatments but could 
also be made available to non-VA providers presented with a veteran 
with a presumed very recent cerebral stroke.

CONCLUSION

    HT is an innovative care model that leverages advancements in 
modern technology to improve the quality, access, and convenience of 
health care delivery to veterans across the nation, particularly those 
located in geographically remote areas. We anticipate that the need for 
and use of HT will continue to grow in parallel to both the demand for 
VA health care and the incorporation of digital technologies in our 
daily lives. In addition to the application of telehealth to the home 
environment, there are numerous opportunities to exploit this 
technology to improve the delivery of health care, as with the example 
of acute stroke, to veterans who live a great distance from tertiary 
medical centers.
    As with any information system, poor data integrity can generate 
significant consequences and poor decision making. VA relies upon 
workload capture to evaluate programs for clinical outcomes, 
achievement of performance targets, and funding decisions. \10\ For 
example, resource allocations for two of the four categories of care 
within the HT program are tied directly to the workload capture 
generated by the MMNs. \11\ As the HT Operating Manual points out, 
``This can provide a significant source of revenue for VISNs enabling 
them not only to sustain [HT] programs but to expand and grow these 
with additional staffing resources.'' \12\ Without data integrity, 
there is limited assurance that the resultant decisions represent the 
best interests of our Nation's veterans.
---------------------------------------------------------------------------
    \10\ VHA Office of Connected Care Home Telehealth Operations Manual 
(April 2017).
    \11\ Ibid.
    \12\ VHA Office of Connected Care Home Telehealth Operations Manual 
(April 2017).
---------------------------------------------------------------------------
    Mr. Chairman, this concludes my statement. I would be happy to 
answer any questions you or Ranking Member Kuster may have.

            OIG OVERSIGHT REPORTS REGARDING HOME TELEHEALTH

 Review of Alleged Wasted Funds at Consolidated Patient Account Centers

                    for Windows Enterprise Licenses

          Report Number 16-00790-417, Issued December 16, 2016

Summary:

    In November 2015, the OIG received an allegation that employees at 
Consolidated Patient Account Centers (CPACs) were required to use two 
Windows enterprise licenses when thin clients \13\ were converted to 
computers. We conducted our review of CPACs' utilization of Windows 
enterprise licenses from December 2015 through March 2016.
---------------------------------------------------------------------------
    \13\ A device with only a few locally stored programs that depends 
on networked resources and typically does not have auxiliary drives or 
most software applications. Thin clients discussed in this report did 
not require local Windows enterprise licenses.
---------------------------------------------------------------------------
    According to the complaint, CPACs operated within a virtual desktop 
infrastructure (VDI) environment that required CPAC employees to log 
onto a virtual machine that had its own Windows enterprise license to 
perform their work-related functions. Allegedly, employees were using 
computers that required Windows enterprise licenses only as a gateway 
to access a virtual machine that also required a license. The complaint 
further alleged that the Windows enterprise licenses on the computers 
were not necessary because the computers were being underutilized.
    We substantiated the allegation that VA's Office of Information and 
Technology (OI&T) wasted VA funds at CPACs to purchase underutilized 
computers that also required Windows enterprise licenses to operate. 
Specifically, CPAC employees used these computers only as gateways to 
access virtual machines on the network server that had individual 
Windows enterprise licenses. This occurred because OI&T mandated that 
CPACs replace thin clients which depend on networked resources to 
operate with computers.
    However, OI&T did not consider the CPACs' operating framework 
before purchasing the computers or mandating the replacement. Because 
CPACs did not change their operating framework when they converted from 
thin clients and only used computers as gateways, OI&T paid for 
underutilized computers and avoidable licenses. As a result, OI&T 
wasted about $7.2 million in VA funds converting CPACs from thin 
clients to computers.

Recommendation:

    We recommended the Assistant Secretary for Information and 
Technology implement a policy to ensure cost-effective utilization of 
information technology equipment, installed software, and services and 
ensure coordination of acquisitions with affected VA organizations. 
This will help ensure VA's operating framework and organizational needs 
are considered prior to acquisitions.

    Status: Open. We anticipate receiving VA's next status update on/
about October 1, 2017.

                  Audit of the Home Telehealth Program

            Report Number 13-00716-101, Issued March 9, 2015

Summary:

    We conducted this audit to determine whether VHA managed 
effectively its HT Program. Specifically, the audit focused on VHA's 
effective management of the Home Telehealth Program and its mission to 
improve access to care and to reduce patient treatment costs. We 
conducted our audit work from February 2013 through December 2014. The 
audit included a review of home telehealth funds and management 
controls over the program during FY 2012 at six randomly sampled VISNs. 
We used FY 2012 data because it was the most current data available at 
the time.
    We found that VHA can expand HT Program enrollment opportunities 
for Non-Institutional Care (NIC) patients. NIC telehealth patients 
showed the best outcomes, in terms of reduced inpatient admissions and 
bed days of care (BDOC). However, in FY 2012, the number of NIC 
patients-served grew by only about 13 percent. In FY 2013, the number 
of NIC patients-served declined by 4 percent, while the number of 
Chronic Care Management (CCM) and Health Promotion/Disease Prevention 
(HPDP) patients-served grew 51 and 37 percent, respectively.
    The significant change in the mix of patients receiving care in 
this program occurred due to a change in the performance methodology. 
VHA began to measure program performance by the total number of 
patients-enrolled, rather than focusing on the increase in enrollment 
for NIC patients. This change in performance metrics encouraged VHA to 
enroll more HPDP participants. These participants would likely need 
less intervention from Primary Care physicians, because their health 
care needs would be less complex. VHA was successful in reaching its 
new performance metric. However, obtaining this goal did not result in 
more patients with the greatest medical needs receiving care under the 
program.
    As a result, VA missed opportunities to serve additional NIC 
patients that could have benefited from the Home Telehealth Program. VA 
could have potentially delayed the need for long-term institutional 
care for approximately 59,000 additional veterans in FY 2013.
    VHA needs to expand the Home Telehealth Program to better meet the 
projected health care needs for an aging veteran population and reduce 
the need to place veterans in more costly, long-term institutional 
care.

Recommendations:

    1. We recommended that the Interim Under Secretary for Health 
implement mechanisms that effectively identify demand for Non-
Institutional Care services to ensure that veterans who need these 
services are provided the opportunity to participate in the Home 
Telehealth Program.

    Status: Closed effective November 18, 2016

    2. We recommended that the Interim Under Secretary for Health 
develop specific performance measures to promote enrollment of Non-
Institutional Care patients into the Home Telehealth Program.

    Status: Closed effective November 18, 2016

                     Audit of Mobile Medical Units

            Report Number 13-03213-152, Issued May 14, 2014

Summary:

    The House Committee on Appropriations requested the Office of 
Inspector General to conduct a review of VA's use of Mobile Medical 
Units (MMUs) to assess whether the Veterans Health Administration (VHA) 
is fully utilizing MMUs to provide health care access to veterans in 
rural areas. We conducted our audit from July 2013 through March 2014. 
The scope of our audit included the estimated 47 MMUs that operated in 
FY 2013.
    We found that VHA lacks information about the operations of its 
MMUs and has not collected sufficient data to determine whether MMUs 
improved rural veterans' health care access. VHA lacks information on 
the number, locations, purpose, patient workloads, and MMU operating 
costs.
    We determined VHA operated at least 47 MMUs in fiscal year 2013. Of 
these, 19 were funded by the Office of Rural Health (ORH) and the 
remaining 28 were funded by either a Veterans Integrated Service 
Network or medical facility. Medical facilities captured utilization 
and cost data in VHA's Decision Support System (DSS) for only 6 of the 
estimated 47 MMUs. If VHA consistently captured these data, it could 
compare MMU utilization and costs with other health care delivery 
approaches to ensure MMUs are providing efficient health care access to 
veterans in rural areas.
    These weaknesses occurred because VHA did not designate specific 
program responsibility for MMU management, define a clear purpose for 
its MMUs, or establish policies and guidance for effective and 
efficient MMU operations.
    As a result of limited MMU data, we were unable to fully address 
the Committee's concerns. However, it is apparent that VHA cannot 
demonstrate whether the almost $29 million ORH spent, as well as 
unknown medical facility funding for MMUs, increased rural veterans' 
health care access and the extent to which MMUs can be mobilized to 
support its emergency preparedness mission.

Recommendations:

    1. We recommended the Under Secretary for Health withhold funding 
for new mobile medical units until a comprehensive assessment is 
conducted to assess factors, such as the current composition of the 
mobile medical unit fleet, services provided, operational days and 
costs, and the effect on rural veterans' access to health care.

    Status: Closed effective July 13, 2015

    2. We recommended the Under Secretary for Health assign 
responsibility for developing mobile medical unit policies, objectives, 
and strategy, and for providing program oversight.

    Status: Closed effective July 13, 2015

    3. We recommended the Under Secretary for Health assign 
responsibility for maintaining operational data on mobile medical units 
to ensure mobile medical unit resources can be used as part of VHA's 
emergency preparedness plan.

    Status: Closed effective July 13, 2015

    4. We recommended the Under Secretary for Health publish necessary 
policy and guidance to provide for effective and efficient mobile 
medical unit operations.

    Status: Closed effective December 22, 2015

    5. We recommended the Under Secretary for Health implement a 
mechanism to ensure that mobile medical unit-specific operations and 
financial data, such as patient workload, services provided, and costs, 
are collected in the Veterans Health Administration's Decision Support 
System.

    Status: Closed effective July 13, 2015

                                 [all]
```