[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]
VA HOME TELEHEALTH: LOOKING BEHIND THE NUMBERS
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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
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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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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
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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
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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 <=6
months).
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.
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\9\ Healthcare Inspection, Care of an Urgent Care Clinic Patient,
Tomah VA Medical Center, Tomah, Wisconsin (June 18, 2015).
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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.
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\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).
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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.
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\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.
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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]