Department of Veterans Affairs VA A Primer on Telehealth July 26 2019 Congressional Research Service https crsreports congress gov R45834 SUMMARY Department of Veterans Affairs VA A Primer on Telehealth R45834 July 26 2019 Victoria L Elliott The Veterans Health Administration VHA of the Department of Veterans Affairs VA is Analyst in Health Policy leveraging the use of telehealth with the goal of expanding veterans’ access to VA care Telehealth generally refers to the use of information and communication technology to deliver a health care service It is a mode of health care delivery that extends beyond the “brick-andmortar” health care facilities of the VHA VA telehealth services are generally provided on an outpatient basis and supplement in-person care Such services do not replace VA in-person care The VA copay requirements for telehealth are the same as for VA in-person care but in some cases may be lower than the copays for VA in-person outpatient health care services delivered through the VHA President Trump and Congress have recently enacted measures such as the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks of 2018 VA MISSION Act P L 115-182 that aim to address the access barriers that veterans may experience when accessing VA telehealth services across states lines The VA MISSION Act among other things removes all geographic and licensing barriers to VA telehealth thereby allowing veterans to access VA telehealth services in their communities from any location in the United States U S territories District of Columbia and Commonwealth of Puerto Rico VA Telehealth Modalities In FY2018 more than 9 3 million veterans were enrolled in VA care In that same fiscal year the VA provided 2 29 million telehealth episodes of care to 782 000 veteran patients collectively using the following three VA telehealth modalities 1 home telehealth 2 store-and-forward telehealth and 3 clinical video telehealth The VA has developed VA mobile applications apps which refer to software programs that run on certain operating systems of mobile devices e g smartphones and tablets and computers that transmit data over the internet that veterans can access as telehealth applications Veterans can access VA mobile apps on cellular and mobile devices that operate using either a web-based platform an iOS platform or an Android operating platform VA Telehealth Partnerships and Access According to the VA it cannot meet the health care demands of veteran patients in-house and therefore it has established partnerships with private sector vendors to help address veterans’ demand for VA care For example the VA’s partnership with the wireless service provider T-Mobile would allow a veteran who has T-Mobile as a cellular wireless service provider to access the VA Video Connect app without incurring additional charges or reducing plan data allotments VA Teleconsultations VA providers can use telehealth platforms and applications to consult with one another which is referred to as a teleconsultation by section 1709A b of title 38 of the U S Code The VA has adopted and modified the Project Extension for Community Healthcare Outcomes Project ECHO learning model which the Expanding Capacity for Health Outcomes Act P L 114-270 required the Secretary of the Department of Health and Human Services to examine and report on to create a Specialty Care Access Network-Extension for Community Healthcare Outcomes SCAN-ECHO learning model The VA’s SCAN-ECHO is a similar approach that aims to connect underproductive providers to assist access-challenged providers using the hub-and-spoke model which refers to a structure whereby a central point referred to as the “hub” disseminates information to different connecting points referred to as the “spokes” Topics Covered in This Report This report provides background information on VA telehealth including veteran eligibility and enrollment criteria VA telehealth copayment requirements and VA providers’ authority to provide telehealth services anywhere The report also discusses the components of VA telehealth It also discusses three issues that Congress could choose to consider 1 access barriers to in-person VA care 2 lack of access to the internet and 3 conflicting guidelines for prescribing controlled substances via telehealth across state lines Congressional Research Service Department of Veterans Affairs VA A Primer on Telehealth Contents Introduction 1 VA Telehealth Overview 1 Rural Veterans 2 Integration with the Private Sector 2 Report Roadmap 3 VA Telehealth Programs and Requirements 3 Veteran Eligibility Enrollment and Access 4 Telehealth Copayment Requirements 5 VA Provider Eligibility and Training on Telehealth 6 VA Telehealth Components 7 The Internet and Wireless Data 7 Potential Cybersecurity and Privacy Risks 8 Telehealth Modalities 8 Home Telehealth HT 9 Store-and-Forward Telehealth SFT 10 Clinical Video Telehealth CVT 12 VA Mobile Health VA Mobile 13 VA App Store 14 Required Login Credentials 14 Required Operating Platforms 15 VA Video Connect VVC 16 The VA’s Partnerships with Philips Healthcare and T-Mobile 16 VA Telehealth Services 17 The VA’s Partnership with Walmart 18 VA Teleconsultations 19 Issues for Congress 20 Access Barriers to In-Person VA Care Continue to Exist 21 Some Veterans Lack Access to the Internet 21 Conflicting Guidelines for Prescribing Controlled Substances via Telehealth across State Lines 22 Figures Figure 1 Distribution of Services That Transpired via the Home Telehealth HT Modality for those Veterans who Received Telehealth Services FY2009-FY2018 10 Figure 2 Distribution of Services That Transpired via the Store-and-Forward Telehealth SFT Modality for Those Veterans who Received Telehealth Services FY2009FY2018 11 Figure 3 Distribution of Services That Transpired via the Clinical Video Telehealth CVT Modality for those Veterans who Received Telehealth Services FY2009FY2018 13 Figure 4 Selected VA Mobile Apps from the VA App Store 14 Congressional Research Service Department of Veterans Affairs VA A Primer on Telehealth Tables Table D-1 Total Number of Veteran Patients Who Had Received VA Telehealth Services and Accessed the Services Through Each VA Telehealth Modality FY2009-FY2018 31 Table D-2 Total Number of Telehealth Encounters that Transpired Through Each VA Telehealth Modality FY2009-FY2018 31 Appendixes Appendix A Abbreviations Used in This Report 24 Appendix B History of VA Telehealth 26 Appendix C VA Provider Authority to Provide Telehealth Services Anywhere 29 Appendix D Total Number of Veteran Patients who Had Received VA Telehealth Services and Total Number of Telehealth Encounters that Transpired FY2009-FY2018 31 Contacts Author Information 32 Congressional Research Service Department of Veterans Affairs VA A Primer on Telehealth Introduction In FY2019 an estimated 20 million veterans were living in the United States of which 9 3 million were enrolled in care through the Department of Veterans Affairs VA 1 Chapter 17 of Title 38 U S C requires the VA to provide health care services to eligible veterans through the Veterans Health Administration VHA of the VA which is one of the largest integrated health care systems in the United States The VHA is composed of nearly 1 700 VA medical facilities 2 VA care is not a health insurance program it is primarily a direct provider of care Meeting veterans’ demand for care has been challenging for the VA Some veteran patients who seek health care services from the VHA experience barriers to receiving in-person care for example by being unable to schedule VA medical appointments in a timely manner or having to travel long distances to reach health care facilities 3 In conjunction with the Veterans Choice Program VCP the recently enacted VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018 VA MISSION Act P L 115-182 and other measures that aim to expand veterans’ access to care the VA has attempted to address barriers to in-person care using telehealth in VA health care facilities 4 According to the VHA telehealth refers to the use of health informatics disease management and t elehealth technologies to enhance and extend care and case management to facilitate access to care and improve the health of designated individuals and populations with the specific intent of providing the right care in the right place at the right time 5 VA Telehealth Overview VA telehealth is a mode of health care delivery that extends outside of the “brick-and-mortar” health care facilities of the VHA Telehealth in contrast to in-person care functions using information and communication technology ICT to transpire an episode of care to a veteran patient without requiring the patient to visit a service provider in person Although telehealth generally supplements in-person care it does not replace VA in-person care In this context the use of ICT to deliver telehealth services does not disrupt a veteran patient’s daily life activities such as working and going to school Veterans do not need to meet their VA provider in-person to receive VA health care services This type of nondisruptive access to health 1 Department of Veterans Affairs VA FY2020 Budget In Brief 2020 Congressional Submission pp BiB-3 10 VA FY2020 Funding and FY2021 Advance Appropriations Volume II Medical Programs and Information Technology Programs p VHA-277 3 VA Quality of Care https www va gov QUALITYOFCARE new-approach improving-access asp and Steve Walsh Patricia Murphy and Stephan Bisaha “VA Hospitals Still Struggling with Adding Staff Despite Billions From Choice Act ” National Public Radio NPR January 31 2017 Morning 4 CRS Report R44562 The Veterans Choice Program VCP Program Implementation and CRS Report R45390 VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018 VA MISSION Act P L 115182 5 VHA Patient Care Data Capture Directive 1082 March 23 2015 p 8 This report uses the term “telehealth ” as does the VA even though the Congress uses the term “telemedicine ” The term “telehealth” generally refers to the delivery of clinical and nonclinical health care services via a technological method This term is often used interchangeably with the term “telemedicine ” which generally refers to the delivery of only clinical health care services via a technological method See 38 U S C §1730C and Office of the National Coordinator for Health Information Technology within the Department of Health and Human Services HHS What is telehealth How is telehealth different from telemedicine https www healthit gov faq what-telehealth-how-telehealth-differenttelemedicine 2 Congressional Research Service 1 Department of Veterans Affairs VA A Primer on Telehealth care services is likely more convenient than the traditional in-person care services used by veteran patients and their civilian counterparts 6 Telehealth encourages veteran patients to be actively involved in their health care decisions because it requires veterans to perform telehealth-related tasks such as downloading mobile applications apps to connect with VA providers and staff A mobile app refers to a software program that runs on certain operating systems of mobile devices e g smartphones and tablets and computers that transmit data over the internet 7 See the “VA Mobile Health VA Mobile ” section in this report Rural Veterans Legislation and regulations that aim to expand veterans’ access to VA telehealth services generally focus on the U S population of rural veterans Many of these veterans experience geographic barriers to accessing in-person VA care such as having to travel long distances to reach their nearest health care facilities 8 Of the estimated 9 2 million veterans who were enrolled in the VA health care system in FY2019 approximately 33% of them were rural veterans 9 According to the VA “ the U S population of rural veterans is older 56% are over 65 poorer 52% earn less than $35 000 per year and sicker a greater number of co-morbidities than their urban counterparts ”10 In addition to having to travel long distances to reach their nearest health care facilities rural veterans may experience access barriers to VA telehealth services because they lack access to broadband internet in their communities 11 Similarly veterans who live in urban areas also experience access barriers to VA care such as having to wait more than 30 days to receive care through the VA 12 Integration with the Private Sector According to former Under Secretary of the VHA David J Shulkin MD who later became the VA Secretary “ t he fact is that demand for v eterans’ health care is outpacing VA’s ability to supply the health care services in-house ”13 President Trump and the Congress have acknowledged the challenges the VA has faced in supplying VA care in-house by enacting 6 Medicare Payment Advisory Commission MedPAC Mandated Report Telehealth Services and the Medicare Program March 2018 pp 475 491-495 7 130 Stat 1460 The U S Food and Drug Administration FDA of HHS classifies some mobile apps as “medical devices” and thus regulates the safety and effectiveness of those mobile apps See FDA Medical Devices Mobile Medical Applications https www fda gov medicaldevices digitalhealth mobilemedicalapplications default htm and FDA Examples of Mobile Apps for Which the FDA Will Exercise Enforcement Discretion https www fda gov medicaldevices digitalhealth mobilemedicalapplications ucm368744 htm 8 For example see Representative Gus M Bilirakis “Veterans E-Health and Telemedicine Support Act of 2017 ” remarks in the House Congressional Record daily edition vol 163 part 81 November 7 2017 p H8557 9 VA FY2020 Budget In Brief 2020 Congressional Submission pp BiB-10 16 10 VA FY2020 Funding and FY2021 Advance Appropriations Volume II Medical Programs and Information Technology Programs p VHA-127 11 Federal Communications Commission FCC Wireline Competition Bureau Seeks Comment on Promoting Broadband Internet Access Service for Veterans Public Notice September 12 2018 p 2 12 For example see Senator Johnny Isakson “Veterans Healthcare ” remarks in the Senate Congressional Record daily edition vol 163 part 209 December 21 2017 p S8194 and Representative Jeff Fortenberry “Year-End Report ” remarks in the House Congressional Record daily edition vol 165 part 4 January 9 2019 p H353 13 VA “Debunking the VA Privatization Myth ” press release April 5 2018 Congressional Research Service 2 Department of Veterans Affairs VA A Primer on Telehealth measures such as the VA MISSION Act 14 The VA has since established new partnerships with private sector vendors such as Philips Healthcare T-Mobile USA Inc T-Mobile and Walmart Inc Walmart under the VA’s Advancing Telehealth through Local Access Stations program The VA established these partnerships with the goal of reducing veterans’ access barriers to VA in-person care by expanding their access to VA telehealth services 15 Report Roadmap To assist Congress as it considers measures on VA telehealth this report  provides an overview of VA telehealth programs and requirements including veteran eligibility and enrollment criteria and VA telehealth copayment requirements     discusses VA providers’ authority to provide telehealth services anywhere discusses the components of VA telehealth provides an overview of VA teleconsultations discusses three issues that Congress could choose to consider 1 access barriers to in-person VA care 2 lack of access to the internet and 3 conflicting guidelines for prescribing controlled substances via telehealth across state lines provides in Appendix A a summary table with all abbreviations used in the report provides in Appendix B the history of VA telehealth and a high-level overview of at least one legislative provision that was enacted into law and aims to address VA telehealth beginning with the 109th Congress provides in Appendix C a discussion on the VA providers’ authority to provide telehealth services anywhere and     provides in Appendix D the total number of veterans who received VA telehealth services and the total number of telehealth encounters that transpired during each of the fiscal years FY2009-FY2018 VA Telehealth Programs and Requirements On July 12 2016 the VA established the Office of Connected Care OCC within the VHA The goal of OCC is to “deliver information technology IT health solutions that increase a v eteran’s access to care and supports a v eteran’s participation in their health care ”16 OCC administers the following four VA telehealth programs 17 14 38 U S C §1730C VA “National Telehealth Summit to Increase Health Care Access for Veterans ” press release December 6 2018 and VAntage Point Telehealth Adapting Tech to Improve VA Health Care New Partnerships Set Stage for VA Telehealth Innovation and Expansion VA December 20 2018 https www blogs va gov VAntage 55049 vatelehealth 16 VA “Telehealth Services and Connected Care ” VHA Telehealth Quarterly January 2016 p 2 Winter Edition 17 This list was adapted from VA Connected Care https connectedcare va gov terms connected-health single About 15 Congressional Research Service 3 Department of Veterans Affairs VA A Primer on Telehealth 1 According to the VA VA Telehealth Services “ improve convenience to v eterans by providing access to care from their homes or local communities when they need it ” 2 My HealtheVet is the web-based electronic health record EHR for veteran patients through which veterans can view and download electronic protected health information ePHI 3 VHA Innovation Program is an annual competitive program that allows VA staff and key stakeholders in the private sector to submit innovative ideas on enhancing VA care and 4 VA Mobile Health VA Mobile develops mobile apps 18 For its telehealth programs the VA has requested an appropriation of $1 1 billion for FY2020 and an advanced appropriation of $1 7 billion for FY2021 19 Veteran Eligibility Enrollment and Access Not all veterans are eligible to receive VA care and not every veteran is automatically entitled to medical care from the VHA 20 Veterans’ eligibility for enrollment in the VHA is based on veteran status i e previous military service service-connected disability and income 21 Veterans enrolled in the VA health care system can receive a range of health care services including primary care and specialty care via telehealth as authorized under the VA’s medical benefits package The VA medical benefits package refers to a suite of health care services that are covered for eligible veterans generally at no cost under certain circumstances 22 In a given year however not all enrolled veterans receive their care from the VA—either because they do not need services or because they have other forms of health coverage such as Medicare Medicaid or private health insurance 23 In FY2018 more than 9 3 million veterans were enrolled in VA care 24 A veteran generally must be enrolled in the VA health care system to access VA telehealth services which are typically provided on an outpatient basis A veteran who is not enrolled in VA care can access VA telehealth services under certain circumstances For example a veteran who is not enrolled in VA care but who is “tentatively” eligible for VA care could access VA telehealth services on an outpatient basis 25 Of the 9 3 million veterans who were enrolled in VA care in FY2018 the VA provided 2 29 million telehealth episodes of care to 782 000 veteran patients 26 130 Stat 1460 The U S Food and Drug Administration FDA of HHS classifies some mobile apps as “medical devices” and thus regulates the safety and effectiveness of those mobile apps See FDA Medical Devices Mobile Medical Applications https www fda gov medicaldevices digitalhealth mobilemedicalapplications default htm and FDA Examples of Mobile Apps for Which the FDA Will Exercise Enforcement Discretion https www fda gov medicaldevices digitalhealth mobilemedicalapplications ucm368744 htm 19 VA FY2020 Funding and FY2021 Advance Appropriations Volume II Medical Programs and Information Technology Programs p VHA-134 20 CRS In Focus IF10555 Introduction to Veterans Health Care 21 38 C F R §17 46 22 38 C F R §17 38 23 CRS in Focus IF 10555 Introduction to Veterans Health Care 24 VA FY2020 Budget In Brief 2020 Congressional Submission p BiB-10 25 38 C F R §17 42 26 U S Congress House Committee on Appropriations Subcommittee on Military Construction Veterans Affairs and Related Agencies The State of Veterans Affairs Statement of the Honorable Robert L Wilkie Secretary of Veterans 18 Congressional Research Service 4 Department of Veterans Affairs VA A Primer on Telehealth An episode of care generally refers to all of the health care services that a VA provider provides to a veteran patient to treat the veteran’s health condition disability 27 The Faster Care for Veterans Act of 2016 P L 114-286 required the VA among other things to ensure that veterans could schedule their own telehealth appointments 28 A recent U S Government Accountability Office GAO report found that neither the Veteran Appointment Request System nor the On-line Patient Self-Scheduling System OPSS had the capability to allow veterans to schedule their own telehealth appointments 29 According to the VHA access to VA telehealth services is a joint decision between the veteran and his or her care team of VA providers and clinical staff 30 The care team tells the veteran which clinically appropriate VA care services he or she can access through the VHA There may be instances when it is clinically appropriate for a veteran to receive in-person care rather than a telehealth service When the care team decides that it is clinically appropriate for a veteran to receive telehealth services the veteran would need to opt into accessing VA telehealth services The veteran patient would then be able to schedule his or her telehealth appointment Telehealth Copayment Requirements A telehealth copayment refers to the out-of-pocket costs that a veteran patient pays for a telehealth encounter 31 A veteran patient generally pays $15 per primary care outpatient visit and $50 per specialty care visit at VA medical facilities 32 According to the VA copay amounts for telehealth are usually less than for VA in-person care 33 The VHA does not require veterans to pay a copay for health care services to treat a serviceconnected disability condition nor is a copay required if a veteran meets at least one of the following four main criteria 34 1 The veteran patient has a service-connected disability condition that is rated at 50% percent or more 2 The veteran patient is a former prisoner of war 3 The veteran has an annual income that is below the income limit 4 The veteran is a recipient of the Medal of Honor Other veteran patients can receive free VA care when they receive care under certain circumstances such as care for military sexual trauma care that is part of a VA research project and care that is provided for compensation and pension examinations 35 Affairs 116th Cong 1st sess February 26 2019 pp 8-9 27 Based on an email that CRS received from the VHA January 14 2019 28 130 Stat 1460 29 U S Government Accountability Office GAO VA Health Care Independent Verification and Validation of Patient Self-Scheduling Systems Was Consistent with the Faster Care for Veterans Act of 2016 GAO-18-442R June 13 2018 p 3 30 Based on an email that CRS received from the VHA January 14 2019 31 38 U S C §1701 32 38 C F R §17 108 c 2 33 Based on an email that CRS received from the VHA January 14 2019 34 38 C F R §17 108 d 35 Ibid Congressional Research Service 5 Department of Veterans Affairs VA A Primer on Telehealth Veteran patients who are not exempt from paying VA copays incur the costs of their VA care The VA determines a veteran patient’s copay by evaluating the rendered telehealth encounter against two factors 1 the location of the veteran patient when the telehealth encounter transpired and 2 the VA’s internal business office protocols on copay amounts for VA care 36 The Honoring America’s Veterans and Caring for Camp Lejeune Families Act of 2012 P L 112154 among other things allows the VA Secretary to waive veteran patients’ copay requirements for telehealth 37 In March 2012 the VA Secretary began waiving copays for telehealth services provided to veteran patients in their homes VA Provider Eligibility and Training on Telehealth The Department of Veterans Affairs Codification Act P L 102-83 requires the VA Secretary among other things to establish interrelationships and coordinate the delivery of VA health care services with the public and private sectors 38 Therefore a health care provider who is either seeking a government position within the VA referred to as a VA-employed provider or seeking to remain as a private sector provider while working with the VA under a contract referred to as a VA-contracted provider is eligible to provide VA care to veterans A VA provider either VAemployed or VA-contracted must hold at least one full active current and unrestricted state39 license to be eligible to work for or with the VA 40 The provider can use his or her license to deliver in-person care and telehealth services through the VHA Each VA provider can decide whether he or she wants to provide VA telehealth services to veteran patients across state lines The VA MISSION Act among other things allows a VA-employed health care provider to provide telehealth services to veteran patients across state lines using only one state license even in states where the provider is not licensed to practice 41 Appendix C provides an overview of the VA-employed providers’ authority to provide telehealth services across state lines using one state license A VA-employed provider who chooses to use a single license in this manner must meet the following four statutory requirements of a covered health care professional 42 1 the VA provider must be an employee of the VA 2 the VA Secretary must have authorized the VA provider to provide telehealth services across state lines 3 the VA provider must agree to adhere to all standards for quality relating to the provision of medicine that is consistent with VA policies and 4 the VA provider must hold an active current full and unrestricted license registration or certification in at least one state to practice in his or her field of medicine 36 Based on an email that CRS received from the VHA January 14 2019 38 U S C §1722B 38 38 U S C §523 39 The term “state” means each of the 50 States territories and possessions of the United States the District of Columbia and the Commonwealth of Puerto Rico See 38 U S C §101 40 38 U S C §1730C b 4 41 38 U S C §1730C 42 This list was adapted from 38 U S C §1730C b 37 Congressional Research Service 6 Department of Veterans Affairs VA A Primer on Telehealth This authority does not extend to VA-contracted providers Current law43 does not allow a VAcontracted provider to provide VA health care services including telehealth to veteran patients across states lines using a single license in states where the VA-contracted provider is not licensed to practice A VA-contracted provider in contrast to a VA-employed provider must hold a license in each state where the provider chooses to practice Neither type of provider is required to obtain a specialty license registration or certification to practice his or her field of medicine via telehealth through the VHA The VA encourages its providers to complete the Telehealth Master Preceptor Certification Program 44 This program offers an educational curriculum on the delivery of VA telehealth including the VA telehealth modalities used to deliver telehealth services see the “Telehealth Modalities” section below The VHA Telehealth Services National Training Center which is a nationally accredited training center oversees the program and other telehealth trainings In FY2018 according to the VA more than 56 000 VA providers and staff completed at least one training session on telehealth 45 In that same fiscal year the VA had provided more than 100 720 telehealth trainings VA Telehealth Components VA telehealth encompasses four general components 1 the internet and wireless data 2 telehealth modalities 3 VA Mobile Health and 4 VA teleconsultations Each of these components is discussed below Health informatics and data visualizations are not discussed because they are beyond the scope of this report The Internet and Wireless Data A veteran patient who chooses to access VA telehealth services must be willing to perform telehealth related tasks such as accessing a health care service and obtaining his or her ePHI electronic protected health information using the internet—the vehicle for which a telehealth episode of care transpires A veteran patient must have access to the internet to access VA telehealth services on mobile devices and computers In 2017 according to a VA study of 43 600 veteran enrollees 77% reported using the internet on an occasional or more frequent basis 46 Of those 77% of veteran enrollees who reported using the internet the enrollees performed the following telehealth related tasks 47    33% scheduled medical appointments 45% accessed their EHRs electronic health records and 77% searched for information on health The VA’s findings reveal that veterans who are enrolled in the VA health care system are using the internet to perform telehealth-related tasks However veteran patients do not necessarily have to have their own internet service to perform telehealth related tasks and access VA telehealth 43 38 U S C §1730C Based on an email that CRS received from the VHA January 14 2019 and Office of Enterprise Integration OEI within the VA FY2019 FY2017 Annual Performance Plan and Report February 2018 p Appendix-3 45 Based on an email that CRS received from the VHA January 14 2019 46 Grace Huang Ph D Benjamin Muz M P P Sharon Kim M P P et al 2017 Survey of Veteran Enrollees’ Health and Use of Health Care Data Findings Report Westat April 2018 p xvll 47 Ibid 44 Congressional Research Service 7 Department of Veterans Affairs VA A Primer on Telehealth services For example veteran patients can access the internet from a VA medical facility a family member’s home or a local library access to high-speed internet service typically yields the best internet performance 48 In addition a veteran who chooses to access VA telehealth services via a mobile device e g smartphones and tablets must have adequate cellular data storage The amount of wireless data storage on a mobile device determines whether the veteran will be able to download and use certain components of VA telehealth such as VA mobile apps Potential Cybersecurity and Privacy Risks A veteran patient who chooses to perform telehealth-related tasks on a personal mobile device and computer must consider the potential cybersecurity and privacy risks associated with accessing VA telehealth services 49 During a telehealth encounter for example a veteran patient can view download and transmit their ePHI over the internet According to the Federal Bureau of Investigation mobile devices and internet connections can be compromised when accessed by an unauthorized party 50 The VHA cannot ensure that a veteran is accessing VA telehealth services on a trustworthy device via a trustworthy connection—that responsibility falls upon the user when the user is accessing the service on their personal device According to the VA it “will coordinate restoration activities” with internal and external key stakeholders when veteran patients experience cybersecurity and privacy threats 51 Certain veteran patients can access VA telehealth services on VA issued mobile devices According to the Federal Communications Commission the VA provided 6 000 tablets with 4G LTE connectivity to low-income and rural veterans with the goal of reducing the veterans’ broadband infrastructure barriers to telehealth in their homes 52 These veterans are accessing telehealth services on trustworthy devices via trustworthy connections The VA’s Cybersecurity Program ensures that among other things ePHI and personally identifiable information that are transmitted via VA devices and systems are protected against cybersecurity and privacy threats 53 Of course cybersecurity and privacy risks are not limited to the U S veteran patient population 54 Telehealth Modalities A telehealth modality refers to the mode in which a telehealth episode of care transpires 55 VA providers offer telehealth services to veteran patients via one of the following three telehealth modalities 1 home telehealth 2 store-and-forward telehealth and 3 clinical video 48 There are seven types of high-speed internet services 1 Digital Subscriber Lines 2 cable modems 3 fiber optic service 4 satellite 5 mobile wireless 6 fixed wireless and 7 Wi-Fi hotspots To learn about each type of highspeed internet service see Federal Trade Commission Shopping for High-Speed Internet Service https www consumer ftc gov articles 0022-shopping-high-speed-internet-service 49 CRS In Focus IF10559 Cybersecurity An Introduction 50 U S Federal Bureau of Investigations What We Investigate Cyber Crime https www fbi gov investigate cyber 51 VHA VA Cybersecurity Program VHA Directive 6500 January 23 2019 p 19 https www va gov vapubs viewPublication asp Pub_ID 1003 FType 2 52 Federal Communications Commission Report on Promoting Broadband Internet Access Service for Veterans Pursuant to the Repack Airwaves Yielding Better Access for Users of Modern Services Act of 2018 May 2019 https docs fcc gov public attachments DOC-357270A1 pdf 53 VHA VA Cybersecurity Program VHA Directive 6500 January 23 2019 p 4 https www va gov vapubs viewPublication asp Pub_ID 1003 FType 2 54 CRS In Focus IF10473 Digital Health Information and the Threat of Cyberattack 55 Center for Connected Health Policy What is Telehealth http www cchpca org what-is-telehealth Congressional Research Service 8 Department of Veterans Affairs VA A Primer on Telehealth telehealth 56 The three VA telehealth modalities are described in more detail below Note that the VHA does not consider VA Mobile Health as a telehealth modality even though veterans can use this technology to access telehealth services 57 The VA considers VA Mobile Health as an “essential element of health care” delivery rather than an ICT tool used to deliver telehealth services 58 In FY2019 the VA is to begin measuring the VHA’s performance in addressing the health care needs of eligible veterans who receive telehealth services via these three VA telehealth modalities For example one new measurement would analyze the ratio of “the number of unique v eterans served through telehealth services numerator and the number of unique v eterans that receive care through the VHA denominator ”59 Using this measurement the VA anticipates that at least 15% of eligible veteran patients will access VA telehealth services in FY2019 Home Telehealth HT The home telehealth HT modality allows a VA provider who is not located in the same location as a veteran patient to provide the patient with daily case management services for his or her chronic medical conditions such as chronic heart disease or diabetes 60 The HT modality allows the VA provider to view medical data and information from a medical device such as a heart monitor that the veteran patient wears Telehealth episodes of care via the HT modality generally have no location restrictions unless the veteran patient is on bed rest From FY2012 to FY2018 the VA provided 6 7 million telehealth encounters via the HT modality to 1 0 million veteran patients 61 In FY2018 the VA provided 872 705 telehealth episodes of care to 136 741 veteran patients through the HT modality According to the VA the case management service that VA providers most often provide to veteran patients via the HT modality is the management of hypertension commonly known as high blood pressure Figure 1 illustrates the distribution of services that transpired via the HT modality for those veterans who received telehealth services for each of the fiscal years FY2012-FY2018 56 VA FY2017 Funding and FY2018 Advance Appropriations Volume II Medical Programs and Information Technology Programs p VHA-252 57 U S Congress House Committee on Veterans’ Affairs Subcommittee on Health Statement of Keven Galpin M D Acting Executive Director for Telehealth hearing on Technology and Treatment Telemedicine in the VA Health Care System 115th Cong 2nd sess August 9 2016 H Hrg 3 Washington DC GPO 2016 58 VA About VA Mobile Health https mobile va gov about# 59 OEI FY2019 FY2017 Annual Performance Plan and Report February 2018 pp Appendix-2 3 60 U S Congress House Committee on Veterans’ Affairs Subcommittee on Health Statement of Keven Galpin M D Acting Executive Director for Telehealth hearing on Technology and Treatment Telemedicine in the VA Health Care System 115th Cong 2nd sess August 9 2016 H Hrg 4 Washington DC GPO 2016 61 Based on an email that CRS received from the VHA January 14 2019 See Table D-1 in Appendix D Congressional Research Service 9 Department of Veterans Affairs VA A Primer on Telehealth Figure 1 Distribution of Services That Transpired via the Home Telehealth HT Modality for those Veterans who Received Telehealth Services FY2009-FY2018 Source Figure prepared by CRS based on data from an email that CRS received from the Veterans Health Administration VHA of the Department of Veterans Affairs VA January 14 2019 Notes A single veteran could have received more than one telehealth service via the HT modality See Appendix D for the total number of veterans who received telehealth services and the total number of telehealth encounters that transpired during each of the fiscal years FY2009-FY2018 According to the VA the telehealth encounter data on the HT telehealth modality is unavailable for FY2009-FY2011 The number of veteran patients who have accessed telehealth services via the HT modality has increased even though Figure 1 shows a downward trend for the percentage of veteran patients who accessed VA telehealth services via the HT modality The total population of veteran patients accessing VA telehealth services via the HT modality increased by 142 1% from 56 484 veteran patients in FY2009 to 136 741 veteran patients in FY2018 However the number of telehealth encounters that transpired via the HT modality has fluctuated see Figure 1 and Table D-2 The VA provided its financial obligations for the delivery of telehealth services via the HT modality in the agency’s FY2020 funding and FY2021 advanced appropriations budget request to the Congress 62 In FY2019 the VA estimates that $270 6 million was obligated to the delivery of telehealth services via the HT modality 63 The VA has requested an appropriation of $279 8 million for FY2020 and an advance appropriation of $291 million for FY2021 to deliver telehealth services via the HT modality Store-and-Forward Telehealth SFT The store-and-forward telehealth SFT modality facilitates the interpretation of patients’ clinical information by allowing a VA provider who is not located in the same location as a veteran patient to assist another VA provider who is located in the same location and has provided in- 62 The VA does include the obligatory requirements for the other two telehealth modalities store-and-forward telehealth and clinical video telehealth in the agency’s FY2020 funding and FY2021 advanced appropriations budget request to Congress 63 VA FY2020 Funding and FY2021 Advance Appropriations Volume II Medical Programs and Information Technology Programs p VHA-134 Congressional Research Service 10 Department of Veterans Affairs VA A Primer on Telehealth person care to the veteran patient 64 Examples of the clinical information include data images sound and video medical records from the veteran patient’s radiology and dermatology examinations The veteran patient does not have to be present during the electronic transfer of his or her clinical information After receiving the clinical information the VA provider interprets the clinical information for the other VA provider and provides follow-up care instructions for the veteran patient From FY2009 to FY2018 the VA provided 2 7 million telehealth encounters via the SFT modality to 2 5 million veteran patients 65 In FY2018 the VA provided 344 853 telehealth episodes of care to 314 487 veteran patients through the SFT modality According to the VA it provides captures stores and forwards clinical information mostly for teleretinal imagining via the SFT modality to screen for diabetic eye disease in veteran patients According to the VA teleretinal imaging refers to a VA provider’s use of a special camera to take a picture of a veteran patient’s eye 66 The picture is electronically sent to an eye care specialist After reviewing the picture the specialist then reports his or her findings to the veteran patient’s primary care provider Figure 2 illustrates the distribution of services that transpired via the SFT modality for those veterans who received telehealth services for each of the FY2009-FY2018 Figure 2 Distribution of Services That Transpired via the Store-and-Forward Telehealth SFT Modality for Those Veterans who Received Telehealth Services FY2009-FY2018 Source Figure prepared by CRS based on data from an email that CRS received from the Veterans Health Administration of the Department of Veterans Affairs January 14 2019 Notes A single veteran could have received more than one telehealth service via the SFT modality See Appendix D for the total number of veterans who received telehealth services and the total number of telehealth encounters that transpired during each of the fiscal years FY2009-FY2018 U S Congress House Committee on Veterans’ Affairs Subcommittee on Health Statement of Keven Galpin M D Acting Executive Director for Telehealth hearing on Technology and Treatment Telemedicine in the VA Health Care System 115th Cong 2nd sess August 9 2016 H Hrg 4 Washington DC GPO 2016 65 Based on an email that CRS received from the VHA January 14 2019 See Table D-1 66 U S Congress House Committee on Veterans’ Affairs Subcommittee on Health Statement of Keven Galpin M D Acting Executive Director for Telehealth hearing on Technology and Treatment Telemedicine in the VA Health Care System 115th Cong 2nd sess August 9 2016 H Hrg 7 Washington DC GPO 2016 64 Congressional Research Service 11 Department of Veterans Affairs VA A Primer on Telehealth The increase in the number of telehealth encounters that have transpired via the SFT modality seems to indicate that VA providers are increasingly seeking the expertise of their peers VA providers are presumably seeking additional expertise due to the lack of a given expertise in their respective geographic area and the VA’s overall shortage of health care providers 67 Clinical Video Telehealth CVT The clinical video telehealth CVT modality allows a VA provider who is not located in the same location as a veteran patient to view diagnose monitor and treat medical conditions of the veteran patient in real-time 68 The CVT modality functions by allowing the VA provider and the veteran patient to see each other via an interactive live video technology Telehealth episodes of care via the CVT modality transpire between different VA sites of care such as from a VA medical center VAMC to a veteran patient’s home or from a veteran patient’s home to a VA provider’s home office From FY2009 to FY2018 the VA has provided 5 7 million telehealth encounters via the CVT modality to 2 1 million veteran patients 69 In FY2018 the VA provided 1 074 422 telehealth episodes of care to 393 370 veteran patients through the CVT modality According to the VA the telehealth service that veteran patients accessed the most via the CVT modality is telemental health which refers to the delivery of a mental health service via telehealth 70 Figure 3 illustrates the percentage of veterans who received telehealth services and the number of telehealth encounters that transpired via the CVT modality for each of the fiscal years FY2009-FY2018 67 VA FY2020 Funding and FY2021 Advance Appropriations Volume II Medical Programs and Information Technology Programs pp VHA-174-175 68 U S Congress House Committee on Veterans’ Affairs Subcommittee on Health Statement of Keven Galpin M D Acting Executive Director for Telehealth hearing on Technology and Treatment Telemedicine in the VA Health Care System 115th Cong 2nd sess August 9 2016 H Hrg 3 Washington DC GPO 2016 69 Based on an email that CRS received from the VHA January 14 2019 See Table D-1 70 VA Fact Sheet TeleMental Health in the Department of Veteran Affairs February 2018 https www va gov anywheretoanywhere docs TeleMental_Health_factsheet PDF Congressional Research Service 12 Department of Veterans Affairs VA A Primer on Telehealth Figure 3 Distribution of Services That Transpired via the Clinical Video Telehealth CVT Modality for those Veterans who Received Telehealth Services FY2009FY2018 Source Figure prepared by CRS based on data from an email that CRS received from the Veterans Health Administration of the Department of Veterans Affairs January 14 2019 Notes A single veteran could have received more than one telehealth service via the CVT modality See Appendix D for the total number of veterans who received telehealth services and the total number of telehealth encounters that transpired during each of the fiscal years FY2009-FY2018 The upward trends in both the percentage of veterans who received telehealth services and the number of telehealth encounters that transpired via the CVT program seem to illustrate that veteran patients are increasingly interested in receiving VA telehealth services via this modality Veteran patients’ interest in the CVT program might stem from it being well established and publicized The program is the VA’s oldest method of telehealth delivery Additionally veterans have been able to access telemental health care services via the CVT modality since the VA started providing telehealth services This report discusses the history of VA telehealth in Appendix B VA Mobile Health VA Mobile VA Mobile allows veterans to access certain health services and ePHI via VA mobile apps on mobile devices e g smartphones and computers 71 According to the National Center for Veterans Analysis and Statistics NCVAS 97 9% of veterans who were enrolled in the VHA in 2016 owned a smartphone and 78 3% owned a computer i e a laptop desktop or notebook computer 72 Veterans can access the VA mobile apps at any time regardless of where the veteran is located According to the VA “VA Mobile Health aims to improve the health of v eterans by providing technologies that expand clinical care beyond the traditional office visit via mobile apps ”73 71 VA VA Mobile Health FAQs https mobile va gov content va-mobile-health-faqs NCVAS Profile of Veterans Internet Use Deep Dive Data from the 2016 American Community Survey April 2018 p 2 73 VA About VA Mobile Health https mobile va gov about 72 Congressional Research Service 13 Department of Veterans Affairs VA A Primer on Telehealth VA Mobile has four overall functions first it allows veteran patients to connect and schedule medical appointments with VA providers second it provides veterans with access to health care information on topics such as mental health and weight management third it allows VA providers to provide case management of veteran patients’ disabilities illnesses from afar and fourth it allows VA providers to disseminate best practices among themselves with the goal of improving the health outcomes of veteran patients As a reminder the VA does not consider VA Mobile to be one of the three modalities for the delivery of health diagnostics or health services VA App Store VA mobile apps such as those illustrated in Figure 4 are located in the virtual VA App Store 74 The VA App Store is a public-facing web-based store that offers 47 mobile apps available to veterans their caregivers and VA providers About two-thirds of the mobile apps in the virtual VA App Store are for veterans and their caregivers The remainder of the apps are for VA providers Veterans who are not enrolled in the VHA may access some of the VA mobile apps Figure 4 Selected VA Mobile Apps from the VA App Store Not all of the mobile apps are specific to health care VA mobile apps provide veterans with access to a range of VA benefit services and information such as conferring with a VA pharmacist reviewing current disability benefits and obtaining information on Source Figure prepared by CRS using information depression Veterans who are not enrolled in from the Department of Veterans Affairs VA VA the VHA for example can also access social App Store https mobile va gov appstore apps such as the VA-Department of Defense DOD Veteran Link app which is a secure social networking app for veterans and current servicemembers Required Login Credentials The public can view the different VA mobile apps in the VA App Store however only veterans their caregivers and VA providers with certain access accounts can download and use the apps To download VA mobile apps a veteran must have login credentials for at least one of the following three accounts 1 a DOD Self-Service Logon DS Logon account 2 a My HealtheVet account or 3 an ID me account 75 A general overview of each of the three accounts which are all free to veterans is provided below 76 DOD Self-Service Logon DS Logon Account is a federal account that authenticates a veteran’s affiliation with the VA and DOD 77 This secure self-service account allows the veteran to access 74 To view the virtual VA App Store see VA VA App Store https mobile va gov appstore VA Get Your Secure Logon Logging into VA Apps https mobile va gov login-information#info-dslogon 76 Ibid 77 Department of Defense DOD My Access Center Your DS Logon Self-Service Site https myaccess dmdc osd mil identitymanagement authenticate do execution e8s1 75 Congressional Research Service 14 Department of Veterans Affairs VA A Primer on Telehealth multiple VA and DOD websites and apps The veteran can request either a Level 1 Basic or a Level 2 Premium account both of which are free   Level 1 Basic Account allows a veteran to view general information located on a VA and DOD website Level 2 Premium Account allows a veteran to view personal information on VA and DOD websites The veteran must prove his or her identity to get a Premium Account by answering a set of questions MyHealtheVet Premium Account is a federal account that authenticates a veterans’ enrollment in VA care 78 It authorizes a veteran patient to complete health care-related tasks such as viewing his or her electronic health record reordering medications and contacting his or her health care provider via a secure messaging technology ID me Account is a private sector account that in this context authenticates a veterans’ affiliation to the VA and DOD This account “provides secure identity proofing authentication and group affiliation verification for government and businesses across sectors ”79 It is also free to veterans Required Operating Platforms The veteran’s electronic device must operate using either a web-based platform an iOS platform or an Android platform for a VA mobile app to work on the device 80 A web-based platform refers to an operating system that has a web-browser such as Internet Explorer and Google Chrome 81 A VA web-based app such as MyHealtheVet which is the electronic health record EHR for veterans is accessible over the internet An iOS platform refers to the operating system installed on Apple Inc Apple electronic devices such as the iPhone and iPad 82 A VA iOS-app is available to veterans who use Apple devices A veteran who has an Apple device can download VA iOS apps from the VA App Store and from the Apple App Store 83 A veteran who does not have an Apple electronic device will not be able to access a VA iOS app on a non-Apple device An Android platform refers to the operating system installed on non-Apple electronic devices e g companies such as Samsung and LG 84 A VA Android app is available to veterans with devices that do not have the iOS operating platform installed on them A veteran who has an electronic device with an Android operating system can download VA Android apps from the VA App Store and the Google Play Store which is a mobile app on an Android device 85 A veteran who does not have an Android device will not be able to access a VA Android app on a nonAndroid electronic device 78 VA Login to My HealtheVet https www myhealth va gov mhv-portal-web user-login and VA FY2020 Funding and FY2021 Advance Appropriations Volume II Medical Programs and Information Technology Programs p VHA136 79 ID me Inc About Us https www id me about 80 VA VA App Store https mobile va gov appstore 81 VA Apps for Web Browsers https mobile va gov appstore web 82 VA Apps for iOS Devices https mobile va gov appstore iOS 83 Ibid 84 VA Apps for Android Devices https mobile va gov appstore android 85 Ibid Congressional Research Service 15 Department of Veterans Affairs VA A Primer on Telehealth VA Video Connect VVC The VA Video Connect VVC is a mobile app that veteran patients can download from the virtual VA App Store The VVC app functions by allowing a veteran patient to connect via live video with a VA provider regardless of where the veteran or provider is located through the CVT modality 86 The veteran patient can use the VVC app on a mobile device To access the VVC app the veteran patient’s mobile device must contain a web camera speakers and microphone 87 In addition the device must be able to connect to and have access to the Internet According to the VA the VVC “uses encryption to ensure privacy in each session ”88 The VA launched the VVC app in August 2017 and has recorded 105 300 telehealth visits via the VVC app from October 2017 to September 2018 89 The VA’s Partnerships with Philips Healthcare and T-Mobile The VA has partnered with private sector vendors Philips Healthcare and T-Mobile to expand veterans’ access to the VVC app Philips Healthcare currently partners with the VA by providing veterans with a “virtual connected care” through the company’s Virtual Medical Center 90 This new partnership with Philips Healthcare aims to place telehealth information and communication technology equipment in 10 posts at the facilities of two veteran service organizations VSOs recognized by the President Congress and the VA Secretary for the representation of veterans Veterans of Foreign Wars and the American Legion 91 The placement of the equipment in the VSO posts would expand VA telehealth services to veterans who are likely to be members of and who frequently visit those two VSOs However the program would not exclude non-VSO members from accessing VA telehealth services at the VSO sites A positive outcome from this pilot program could encourage veterans who are not members of VSOs to visit VSO sites to access VA telehealth services The VA’s partnership with T-Mobile would allow veterans with this wireless service to access the VVC app via their mobile device without incurring additional charges or reducing plan data allotments 92 According to a VA press release “veterans will be able to connect to appointments on their mobile devices for no extra charge regardless of their current data plan ”93 The VA did not provide in its press release the amount of the “extra charge” that veteran patients would have incurred from accessing the VVC app on their mobile devices It is likely that other veterans who U S Congress House Committee on Veterans’ Affairs Subcommittee on Health Statement of Keven Galpin M D Acting Executive Director for Telehealth hearing on Technology and Treatment Telemedicine in the VA Health Care System 115th Cong 2nd sess August 9 2016 H Hrg 4-3 Washington DC GPO 2016 and VA VA Video Connect https mobile va gov app va-video-connect 87 VA Frequently Asked Questions What Type of Equipment Do I Need to Use VA Video Connect https mobile va gov app va-video-connect#AppFAQ 88 VA VA Video Connect https mobile va gov app va-video-connect 89 VA “VA Video Connect Expands Veterans’ Access to Health Care ” press release April 30 2018 and VA “VA Exceeds 1 Million Video Telehealth Visits in FY2018 ” press release February 7 2019 90 Philips Healthcare Virtual Medical Center https www usa philips com a-w government va-telehealth html gclid EAIaIQobChMIusOR0cWn3wIVEo_ICh1DCQ0BEAAYAyAAEgICpfD_BwE gclsrc aw ds 91 38 U S C §101 38 U S C §5902 and VAntage Point Telehealth Adapting Tech to Improve VA Health Care New Partnerships Set Stage for VA Telehealth Innovation and Expansion VA December 20 2018 https www blogs va gov VAntage 55049 va-telehealth 92 VAntage Point Telehealth Adapting Tech to Improve VA Health Care December 20 2018 https www blogs va gov VAntage 55049 va-telehealth 93 Ibid and VA VA Video Connect App Description https mobile va gov app va-video-connect#AppDescription 86 Congressional Research Service 16 Department of Veterans Affairs VA A Primer on Telehealth do not have T-Mobile as their wireless service provider would incur the unknown extra charge for accessing the VVC app The VA has not yet announced any plans to partner with all wireless service providers to ensure that veteran patients who access the VVC app on their mobile devices will not incur additional charges VA Telehealth Services The telehealth services that the VA provides to veteran patients align with their respective VA inpatient care services A VA health care service does not change when a VA provider delivers the service via telehealth For example a veteran patient who chooses to access telemental health services via the VVC app on a mobile device would receive the same type of mental health services he or she would have received in-person According to the VA Secretary the VHA is the largest U S provider of telehealth services having provided 2 29 million telehealth episodes of care to 782 000 veteran patients in FY2018 94 Of those 782 000 veteran patients 9% of them were female and 45% of them live in rural areas 95 Veteran patients can access a range of telehealth services through the VHA These telehealth services can be grouped into the following seven categories in alphabetical order 96 1 2 3 4 5 6 7 consultative and evaluative telehealth services disease and illness-specific telehealth services gender-specific telehealth services preventative telehealth services rehabilitative telehealth services rural-specific telehealth services and wellness telehealth services According to the VA the agency will provide general VA health care services to veteran patients and refer them to private health care providers for health care services that those providers provide “most effectively and efficiently ”97 The VA’s decision to refer such services to the private sector might stem from the agency’s shortage of VA providers 98 A veteran can access VA telehealth services from various VA sites of care such as VA medical facilities mobile telehealth clinics and non-VA sites of care such as the homes work places and schools of veterans A veteran who seeks VA care including VA telehealth services at non-VA medical facilities and nonfederal facilities from non-VA providers must receive prior authorization from the VA before accessing such services The VA generally authorizes a veteran to seek VA care from a non-VA provider when 94 U S Congress House Committee on Appropriations Subcommittee on Military Construction Veterans Affairs and Related Agencies The State of Veterans Affairs Statement of the Honorable Robert L Wilkie Secretary of Veterans Affairs 116th Cong 1st sess February 26 2019 pp 8-9 95 Ibid and based on an email that CRS received from the VHA January 14 2019 96 CRS developed these categories based on the VA’s research on telehealth See VA Health Services Research and Development Research Topics eHealth Telehealth https www hsrd research va gov research_topics ehealth cfm 97 VA FY2019 Budget In Brief 2019 Congressional Submission p BiB-6 98 VA FY2020 Funding and FY2021 Advance Appropriations Volume II Medical Programs and Information Technology Programs pp VHA-174-175 Congressional Research Service 17 Department of Veterans Affairs VA A Primer on Telehealth the existing VA facilities or other government facilities are not capable of furnishing economical hospital care or medical services because of geographic inaccessibility or are not capable of furnishing care or services required 99 The VA continues to develop new telehealth services to meet the needs of veterans According to the VA FY2019 funding and FY2020 advanced appropriations budget request to Congress for example the Comprehensive Opioid Management in Patient Aligned Care Teams COMPACT team is “testing a telehealth-based self-management training system to promote improved care for v eterans receiving chronic opioid therapy ”100 The VA’s Partnership with Walmart On December 6 2018 the VA announced a new partnership with Walmart that aims to reduce access barriers to VA care that underserved veterans experience 101 Through this partnership which is part of the VA’s Advancing Telehealth through Local Access Stations program the VA is establishing a pilot program whereby underserved veterans in certain locations would access VA telehealth services in donated spaces at Walmart retail stores 102 Walmart would provide the VA with operational support According to Walmart the prospective locations will be based on “the number of veterans and the health resources offered ”103 The VA has stated that its decision to partner with Walmart is based on the fact that more Americans live near a Walmart store than a VA medical center VAMC According to the VA 90% of Americans live within ten miles of a Walmart Ninety percent of veterans do not live within ten miles of a VAMC 104 The VA reported to Congress that there were an estimated 172 VAMCs in 2019 105 For that same calendar year the VA also reported to Congress that there were other VA medical facilities within the VA health care system including 23 health care centers 300 vet centers and 728 communitybased outpatient clinics The VA has not yet stated how many veterans live near other VA medical facilities in relation to Walmart stores This information would be helpful to Congress as it considers measures relating to the use of existing VA spaces 106 This prospective pilot program 99 38 C F R §17 52 a VA FY2019 Funding and FY2020 Advance Appropriations Volume II Medical Programs and Information Technology Programs p VHA-464 101 VA “National Telehealth Summit to Increase Health Care Access for Veterans ” press release December 6 2018 and VAntage Point Telehealth Adapting Tech to Improve VA Health Care New Partnerships Set Stage for VA Telehealth Innovation and Expansion VA December 20 2018 102 Kendra Weaver Psy D VA Telemental Health Innovations Improving Access to Care VA PowerPoint Presentation May 2018 p Slide 52 103 Walmart “U S Department of Veteran Affairs and Walmart Announce Telehealth Collaboration to Research Underserved Veterans ” press release December 6 2018 https news walmart com 2018 12 06 us-department-ofveteran-affairs-and-walmart-announce-telehealth-collaboration-to-reach-underserved-veterans 104 VAntage Point Telehealth Adapting Tech to Improve VA Health Care New Partnerships Set Stage for VA Telehealth Innovation and Expansion VA December 20 2018 https www blogs va gov VAntage 55049 vatelehealth 105 VA FY2020 Funding and FY2021 Advance Appropriations Volume II Medical Programs and Information Technology Programs p VHA-277 106 The 109th Congress for example passed the Veterans Benefits Health Care and Information Technology Act of 2006 P L 109-461 which required the VA Secretary among other things to expand veterans’ access to telehealth services by increasing the number of readjustment counseling service centers commonly referred to as “Vet Centers” that link to VA medical facilities See 38 U S C §1712A note 100 Congressional Research Service 18 Department of Veterans Affairs VA A Primer on Telehealth has raised some concerns however because according to the Veterans Rural Health Advisory Committee VRHAC Walmart is encountering some of the same challenges that the VHA has met when expanding telehealth services to rural veterans such as keeping pace with technology for virtual care and the expansion of bandwidth 107 However such challenges could be locationspecific and not representative of all Walmart retail store locations VA Teleconsultations Current law Chapter 17 of Title 38 of the U S Code 108 refers to teleconsultation as “the use by a health care specialist of telecommunications to assist another health care provider in rendering a diagnosis or treatment ” The law defines teleconsultation in relation to VA’s delivery of mental health and traumatic brain injury assessments The VA extends its use of teleconsultations in the delivery of VA care with the goal of improving veteran patients’ health care outcomes particularly those of rural veterans For example the VA has adopted and modified the Project Extension for Community Healthcare Outcomes Project ECHO learning model which the Expanding Capacity for Health Outcomes Act P L 114-270 required the HHS Secretary to examine and report on to create a Specialty Care Access Network-Extension for Community Healthcare Outcomes SCAN-ECHO learning model 109 110 Project ECHO is a global technology-enabled collaborative learning model whereby medical educators and specialty care health care providers disseminate best practices to primary care and rural health care providers with the goal of improving the health outcomes of rural and underserved patients 111 The best practices are disseminated through different modalities such as teleECHO which is the delivery of medical education such as patient case-based learning through a virtual network TeleECHO is delivered through a hub-and-spoke model which refers to a structure whereby a central point the “hub” disseminates information to different connecting points the “spokes” The VA launched SCAN-ECHO in 2011 with the goal of expanding VA care to rural veterans and veterans that live in medically underserved areas 112 According to the VA SCAN-ECHO refers to an approach to provide specialty care consultation clinical training and clinical support from specialty care teams to rural primary care providers PCPs using video teleconferencing equipment 113 VA teleconsultations generally transpire under SCAN-ECHO using the hub-and-spoke model The “hubs” are the specialty care providers who are on specialty care teams and the “spokes” are 107 Veterans Rural Health Advisory Committee VRHAC Presentation Veteran Integrated Service Network 16 South Central VA Health Care Network Meeting Notes May 23 2018 p 2 108 38 U S C §1709A 3 b 109 HHS Report to Congress Current State of Technology-Enabled Collaborative Learning and Capacity Building Models February 2019 https aspe hhs gov system files pdf 260691 ECHOAct-ConsolidatedReportToCongress pdf 110 VA VA Uses Technology to Provide Rural Veterans Greater Access to Specialty Care Services In the Spotlight https www patientcare va gov In_the_Spotlight asp 111 University of New Mexico School of Medicine About Extension for Community Healthcare Outcomes ECHO https echo unm edu about-echo-2 To see where Project ECHOs are located in the United States and globally see University of New Mexico School of Medicine Locations https echo unm edu locations-2 112 VA VA Uses Technology to Provide Rural Veterans Greater Access to Specialty Care Services In the Spotlight https www patientcare va gov In_the_Spotlight asp 113 Office of Rural Health within the VHA Rural Expansion of Specialty Care Access Networks Extension for Community Health Care Outcomes SCAN-ECHO Request for Proposals November 2012 p 1 Congressional Research Service 19 Department of Veterans Affairs VA A Primer on Telehealth the PCPs who are on patient aligned care teams PACTs According to the VA SCAN-ECHO transpires when PCPs present a patient’s case using multi-site videoteleconferencing equipment Providers then take information back to the patient for discussion and collaborative decision making The specialty care team collaborates culminating in a recommended treatment plan In addition to case presentations formal clinical education is provided 114 The Expanding Capacity for Health Outcomes Act ECHO Act P L 114-270 required the HHS Secretary to examine technology-enabled collaborative learning and capacity-building models and report the findings to Congress no later than two years after enactment 115 In February 2019 the Office of the Assistant Secretary for Planning and Evaluation ASPE within HHS submitted the required report to Congress ASPE retrieved information about SCAN-ECHO from the VA and found that the VA has evaluated the use of SCAN-ECHO for medical conditions and health care services such as chronic liver disease diabetes and women’s and transgender health care services 116 For example ASPE found that the VA studied the difference in health outcomes of 62 750 veterans with chronic liver disease between 2011 and 2015 117 Of those 62 750 veteran patients 513 of them had received virtual teleconsultations with VA providers who were participating in SCAN-ECHO According to ASPE “those receiving the intervention were much less likely to die than those who had no SCAN-ECHO consultation over the same time period ”118 SCAN-ECHO is an example of the VA’s efforts to expand the capability of VA telehealth to “underproductive providers to assist access-challenged providers ”119 Issues for Congress The VA is leveraging the use of telehealth with the goal of expanding veterans’ access to VA care Based on its experience with telehealth to date the VA has stated that increased access to telehealth could reduce the use of VA travel benefits by veterans and reduce hospital admissions 120 Telehealth is not a new form of health care delivery It is a multibillion dollar industry in both the federal and private sectors showing upward trends in telehealth access utilization innovation and spending 121 114 VA VA Uses Technology to Provide Rural Veterans Greater Access to Specialty Care Services In the Spotlight https www patientcare va gov In_the_Spotlight asp 115 130 Stat 1395 116 Office of the Assistant Secretary for Planning and Evaluation ASPE within HHS Current State of TechnologyEnabled Collaborative Learning and Capacity Building Models Report to Congress February 2019 pp 79-100 117 Ibid p 39 118 Ibid 119 VA FY2019 Funding and FY2020 Advance Appropriations Volume II Medical Programs and Information Technology Programs p VHA-70 120 VA VA Telehealth Services Fact Sheet https www va gov COMMUNITYCARE docs news VA_Telehealth_Services pdf 121 Grand View Research GVR Inc Telemedicine Market Size Trend Analysis By Product Hardware Connectivity Network By Region North America Europe Asia Pacific Latin America Middle East Africa and Segment Forecasts 2018-2025 Report ID GVR-1-68038-313-3 April 2017 VAntage Point Telemedicine An Important Tool for Veterans Health September 13 2017 https www blogs va gov VAntage 41153 telemedicineimportant-tool-veterans-health and MedPAC Mandated Report Telehealth Services and the Medicare Program March 2018 p 480 Table 16-1 Congressional Research Service 20 Department of Veterans Affairs VA A Primer on Telehealth Discussed below are three issues that Congress may choose to examine while considering additional topics related to veterans and telehealth services 1 access barriers to in-person VA care continues to exist 2 some veterans lack access to the internet and 3 VA providers’ guidelines for prescribing controlled substances via telehealth are different Access Barriers to In-Person VA Care Continue to Exist According to the VA the agency cannot meet veterans’ demand for VA in-patient care 122 Congress and the VA have considered measures and initiatives to expand veterans’ access to VA care using telehealth 123 The expansion of VA telehealth does not address the access barriers that veteran patients’ face when seeking in-person VA care Instead telehealth provides veterans with an alternate way to access health care services through the VHA The VA is predicting that the U S veteran population will decrease by 32%—from 20 0 million veterans in 2017 to 13 6 million veterans in 2037 124 This prediction does not equate to a lower number of veterans seeking enrolling in and accessing VA care in the future For example more than three-fourths of the 13 6 million veterans that the VA projects will be in the U S veteran population in 2037 might choose to enroll in and access care through the VA health care system Congress may consider whether the VA should continue to expand veterans’ access to VA inperson care in VA brick-and-mortar buildings and or through VA telehealth services by assessing how such modes of delivery effect the cost and quality of care in addition to timely access Some Veterans Lack Access to the Internet The overarching goal of the MISSION Act and VA final rule on telemedicine is to expand veteran patients’ access to care using telehealth The use of telehealth services requires that veteran patients have access to the internet to connect to VA telehealth providers Veteran patients who do not have readily accessible internet connections would likely have difficulty reaching their VA providers According to the National Center for Veterans Analysis and Statistics NCVAS an estimated 20 1% of veterans did not have internet access in 2016 125 In April 2018 for example the GAO found that some veterans who live on the U S Pacific Islands such as Guam and American Samoa could not access the internet because of damaged cables and equipment failures that occurred during inclement weather 126 The VA is investigating ways to expand veteran patients’ access to VA telehealth services to address veterans’ lack of access to the internet Specifically the agency is evaluating the feasibility of non-VA facilities e g libraries schools and post offices serving as internet online hotspots and retaining VA kiosks where veteran patients can access telehealth services 127 VA “Debunking the VA Privatization Myth ” press release April 5 2018 Appendix B provides a brief narrative summarizing at least one legislative activity that aims to address VA telehealth for each of the 109th-115th Congresses 124 National Center for Veterans Analysis and Statistics NCVAS of the VA Veteran Population Projections 20172037 https www va gov vetdata docs Demographics New_Vetpop_Model Vetpop_Infographic_Final31 pdf 125 NCVAS Profile of Veterans Internet Use Deep Dive Data from the 2016 American Community Survey April 2018 p 2 126 GAO Veterans Health Administration Opportunities Exist for Improving Veterans’ Access to Health Care Services in the Pacific Islands GAO-18-288 April 12 2018 p 45 127 VA Visualizing Health Care for Rural Veterans with GIS PowerPoint July 11 2017 p slide 8 and Jared Serbu “VA Wants to Make Telehealth Part of Its Day-to-Day Business But Says State Licensing Laws Stand in the Way ” Federal News Radio May 8 2017 https federalnewsradio com veterans-affairs 2017 05 va-wants-to-make122 123 Congressional Research Service 21 Department of Veterans Affairs VA A Primer on Telehealth Congress and the President have responded to this divide by enacting measures such as the Repack Airwaves Yielding Better Access for Users of Modern Services Act of 2018 P L 115141 RAY BAUM’s Act of 2018 The RAY BAUM’s Act of 2018 required among other things the Federal Communications Commission FCC to submit a report to Congress on promoting broadband internet access to veterans particularly to rural veterans and veterans with low incomes The FCC submitted the report to the Senate Committee on Commerce Science and Transportation and the House Committee on Energy and Commerce in May 2019 128 According to the FCC’s report the 2 2 million veteran households that do not have access to broadband internet experience barriers when adopting broadband such as the inability to pay for the service and the lack of broadband development in their geographic location 129 In future discussions regarding this issue Congress may consider the costs associated with deploying broadband infrastructure in underserved geographic areas 130 According to the VA some veteran patients are given tablets “that operate over 4G LTE mobile broadband to support VA Video Connect ” where infrastructure is lacking 131 Conflicting Guidelines for Prescribing Controlled Substances via Telehealth across State Lines Congress continues to address concerns regarding the prescribing of controlled substances such as opioids 132 The VA MISSION Act and the VA’s final rule do not address the prescribing of controlled substances to veteran patients who are not receiving services from within VA medical facilities or who are not in the same state as the prescribing physician as permitted under the Ryan Haight Online Pharmacy Consumer Protection Act of 2008 Ryan Haight Act P L 110425 Section 311 h 1 of the Controlled Substance Act CSA 133 which was added by Section 3 of the Ryan Haight Act authorized the special registration for telemedicine with the goal of increasing patients’ access to practitioners that can prescribe controlled substances via telemedicine in limited circumstances 134 Current law defines a practitioner as a physician dentist veterinarian scientific investigator pharmacy hospital or other person licensed registered or otherwise permitted by the United States or the jurisdiction in which he practices or does research to distribute dispense conduct research with telehealth-part-of-its-day-to-day-business-but-says-state-licensing-laws-stand-in-the-way 128 FCC Report on Promoting Broadband Internet Access Service for Veterans Pursuant to the Repack Airwaves Yielding Better Access for Users of Modern Services Act of 2018 May 2019 https docs fcc gov public attachments DOC-357270A1 pdf 129 Ibid pp 12-13 130 CRS Report RL30719 Broadband Internet Access and the Digital Divide Federal Assistance Programs 131 VA FY2020 Funding and FY2021 Advance Appropriations Volume II Medical Programs and Information Technology Programs p VHA-135 132 CRS Report R44987 The Opioid Epidemic and Federal Efforts to Address It Frequently Asked Questions 133 The primary federal law governing the manufacture distribution and use of prescription and illicit opioids is the CSA a statute that the Drug Enforcement Administration DEA is principally responsible for administering and enforcing See CRS Report R45164 Legal Authorities Under the Controlled Substances Act to Combat the Opioid Crisis 134 CRS Report R45240 The Special Registration for Telemedicine In Brief and Letter from Senator Claire McCaskill Senator Lisa Murkowski and Senator Dan Sullivan to Robert W Patterson Acting Administrator DEA January 30 2018 Congressional Research Service 22 Department of Veterans Affairs VA A Primer on Telehealth respect to administer or use in teaching or chemical analysis a controlled substance in the course of professional practice or research 135 The registration would enable a practitioner to deliver distribute dispense or prescribe via telemedicine a controlled substance to a patient who has not been medically examined in person by the prescribing practitioner 136 While the CSA authorized the special registration for telemedicine practitioners have not been able to apply for this special registration The Drug Enforcement Administration DEA has yet to finalize a rule on the registration’s application process and procedures and the limited circumstances that warrant it 137 The Ryan Haight Act expressly exempts VA providers and VA-contracted providers from needing to obtain a special registration in each state where the providers choose to practice if they meet two conditions First the providers must prescribe the controlled substance within the scope of their employment at the VA Second the providers must either 1 hold at least one state registration to prescribe a controlled substance or 2 prescribe in a VA health care facility while using the registration of that facility The special registration though not implemented yet by the DEA the MISSION Act or the VA’s final rule on telehealth might confuse VA providers about whether they must hold a license in each state where they intend to prescribe controlled substances to veteran patients The special registration would allow a VA provider to prescribe a controlled substance in a state where the provider is not licensed to practice The MISSION Act and the VA’s final rule on telehealth in contrast to the special registration do not preempt state laws regarding the prescribing of controlled substances VA providers must be licensed in each state where the provider intends to prescribe a controlled substance 138 Congress could consider encouraging the VA to develop guidelines on how its providers would prescribe controlled substances to veteran patients who are not receiving telehealth services from within VA health care facilities 135 21 U S C §802 21 21 U S C §831 h and 21 U S C §829 e 137 21 U S C §831 h 2 138 38 U S C §1730C e and VA “Authority of Health Care Providers to Practice Telehealth ” 83 Federal Register 21904 May 11 2018 136 Congressional Research Service 23 Department of Veterans Affairs VA A Primer on Telehealth Appendix A Abbreviations Used in This Report ASPE Office of the Assistant Secretary for Planning and Evaluation of the Department of Health and Human Services HHS ASPPB Association of State and Provincial Psychology Boards ATLAS Advancing Telehealth through Local Access Stations CCTV Closed-circuit television CMOP Consolidated Mail Outpatient Pharmacy CMS Centers for Medicare and Medicaid Services of HHS COMPACT Comprehensive Opioid Management in Patient Aligned Care Team CSA Controlled Substance Act P L 91-513 as amended CVT Clinical Video Telehealth Modality DEA Drug Enforcement Agency DHP Digital Health Platform DOD Department of Defense DOJ Department of Justice DS Logon Department of Defense Self-Service Logon DSL Digital Subscriber Lines DTC Direct-to-consumer telehealth ECHO Extension for Community Healthcare Outcomes EHR Electronic health record ePHI Electronic protected health information FCC Federal Communications Commission FDA Food and Drug Administration of HHS GPO Government Publishing Office HHS Department of Health and Human Services HRSA Health Resources and Services Administration of HHS HT Home Telehealth Modality IMLC Interstate Medical Licensure Compact IT Information technology MAT Medication assisted therapy MGH Massachusetts General Hospital NCVAS National Center for Veterans Analysis and Statistics NTIA National Telecommunications and Information Administration OAI White House Office of American Innovation OCC Office of Connected Care ORH Office of Rural Health PACTs Patient Aligned Care Teams Congressional Research Service 24 Department of Veterans Affairs VA A Primer on Telehealth PCPs Primary Care Providers Project ECHO Project Extension for Community Healthcare Outcomes PSYPACT Psychology Interjurisdictional Compact PTSD Posttraumatic stress disorder RAY BAUM’s Act of 2018 Repack Airwaves Yielding Better Access for Users of Modern Services Act of 2018 P L 115-141 RVAP Rural Veterans Health Access Program SCAN-ECHO Specialty Care Access Network-Extension for Community Healthcare Outcomes SFT Store-and-Forward Telehealth Modality VA Department of Veterans Affairs VAMC VA Medical Center VA MISSION Act The VA Maintaining Internal Systems and Strengthening Integrated Outside Networks of 2018 P L 115-182 VA Mobile VA Mobile Health VVC VA Video Connect VHA Veterans Health Administration VRHAC Veterans Rural Health Advisory Committee VSO Veteran Service Organization Congressional Research Service 25 Department of Veterans Affairs VA A Primer on Telehealth Appendix B History of VA Telehealth For decades the VA has provided telehealth services to veteran patients to improve health care access and to address delivery challenges such as shortages of in-patient beds and health care providers skilled in the delivery of veteran-centric care In the 1950s and 1960s for example the VA had difficulties in recruiting psychiatrists and neurologists 139 In FY1961 there were 18 722 eligible veterans on a waiting list to receive VA inpatient care for psychiatric and neurological health care conditions 140 That same year the VA started testing the use of telehealth with the goal of addressing the aforementioned challenges that veteran patients were experiencing when trying to access VA in-person care for psychiatry and neurology services According to the VA’s Annual Report for FY1961 the VA tested the use of telehealth by using the closed-circuit television CCTV technology as a telehealth modality The CCTV technology refers to a system that “links a camera to a video monitor using a direct transmission system ”141 VA physicians and therapists at a VA medical facility in Oklahoma City OK had used the CCTV technology to disseminate best practices and trainings on therapy and psychiatry with the goal of improving veteran patients’ health care outcomes 142 According to the VA its use of telehealth using the CCTV technology was a success because t he results indicate that this form of communication can be a valuable tool in the treatment of psychiatric patients and in the training of personnel in psychiatric service In addition it shows the potential in a number of other medical applications such as for example an education technique in surgical training 143 Since then the VA has aimed to address veterans’ access barriers to VA in-person care using updated telehealth technologies and equipment which are discussed under the “VA Telehealth Components” heading in this report Legislative History of VA Telehealth144 The Congress has passed several laws that address VA telehealth Provided below is a high-level legislative history of VA telehealth to help inform any future congressional discussion on this issue For each Congress beginning with the 109th January 3 2005 to January 3 2007 there is a brief narrative summarizing at least one legislative provision that aims to address VA telehealth This list may not be comprehensive 139 VA Annual Report for Fiscal Year Ending June 30 1954 March 15 1955 p 41 and VA Annual Report 1961 January 5 1962 p 170 140 VA Annual Report 1961 January 5 1962 p 30 141 CCTV technologies are generally used for security surveillance activities See Department of Homeland Security CCTV Technology Handbook July 2013 p 1 142 VA Annual Report 1961 January 5 1962 p 170 143 VA Annual Report 1962 January 9 1963 p 159 A year after completing the CCTV technology testing in another example the VA began testing telehealth using telephone lines as a telehealth modality in 1962 Using the telephone lines the VA had electronically transmitted veteran patients’ electrocardiograms between a VA medical facility in Brooklyn NY and a VA medical facility in Baltimore MD See VA Annual Report 1962 January 9 1963 pp 159160 144 Carol D Davis a Senior Research Librarian in the Domestic Social Policy Division performed the legislative search for this report Congressional Research Service 26 Department of Veterans Affairs VA A Primer on Telehealth Veterans Benefits Health Care and Information Technology Act of 2006 109th Congress The Veterans Benefits Health Care and Information Technology Act of 2006 P L 109-461 among other things required the VA Secretary to increase the number of VA medical facilities that are capable of providing readjustment counseling services via telehealth 145 Veterans’ Mental Health and Other Care Improvements Act of 2008 110th Congress The Veterans’ Mental Health and Other Care Improvements Act of 2008 P L 110-387 among other things required the VA Secretary to develop a pilot program to assess the feasibility and advisability of providing certain veterans with peer outreach peer support readjustment counseling and other mental health services using telehealth to the extent practicable 146 Caregivers and Veterans Omnibus Health Services Act of 2010 111th Congress The Caregivers and Veterans Omnibus Health Services Act of 2010 P L 111-163 among other things allows the VA Secretary to contract with community mental health centers and other qualified health entities with the goal of expanding veterans’ access to VA telehealth services 147 Honoring America’s Veterans and Caring for Camp Lejeune Families Act of 2012 112th Congress The Honoring America’s Veterans and Caring for Camp Lejeune Families Act of 2012 P L 112154 among other things allows the VA Secretary to waive veteran patients’ copay requirements for telehealth 148 The Veterans Access Choice and Accountability Act of 2014 113th Congress The Veterans Access Choice and Accountability Act of 2014 P L 113-146 among other things requires the VA Secretary to improve veterans’ access to VA telehealth via mobile vet centers and mobile medical facilities 149 The Faster Care for Veterans Act of 2016 114th Congress The Faster Care for Veterans Act of 2016 P L 114-286 among other things requires the VA Secretary to ensure that veteran patients can schedule their own medical appointments for VA telehealth services 150 145 120 Stat 3411 122 Stat 4116-4117 147 124 Stat 1150 148 38 U S C §1722B 149 128 Stat 1778 150 130 Stat 1460 146 Congressional Research Service 27 Department of Veterans Affairs VA A Primer on Telehealth John S McCain III Daniel K Akaka and Samuel R Johnson VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018 115th Congress The John S McCain III Daniel K Akaka and Samuel R Johnson VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018 P L 115-182 VA MISSION Act of 2018 among other things removes all geographic barriers to VA telehealth and therefore allows veterans to access VA telehealth services in their communities from any location in the United States U S territories District of Columbia and Commonwealth of Puerto Rico 151 151 38 U S C §1730C Congressional Research Service 28 Department of Veterans Affairs VA A Primer on Telehealth Appendix C VA Provider Authority to Provide Telehealth Services Anywhere Veteran patients who cannot access telehealth because of provider shortage gaps may benefit from having access to out-of-state telehealth providers in non-VA health care facilities Generally states determine whether a health care provider can provide a health care service across state lines because states handle provider licensure Each state has the authority to establish its own licensure requirements and each state licensing board has its own eligibility requirements for health care providers Due to state-specific licensing laws a health care provider licensed and certified in one state may not be able to provide health care services to patients located in another state where the provider is not licensed State licensing laws can cause some health care providers to experience geographical and licensing-related barriers to providing health care services across state lines to rural and underserved populations On August 3 2017 the White House and the VA announced the Anywhere to Anywhere initiative which aims to remove the geographic barriers that veterans might experience when accessing VA care Under this initiative a veteran patient can access VA telehealth services anywhere from a VA provider located outside of a VA health care facility The initiative is a joint effort between the VHA the White House Office of American Innovation 152 and the Department of Justice 153 The VA’s attempt to expand veterans’ access to VA care via telehealth under this initiative was threatened by its providers’ experiences of geographic and licensing barriers to delivering the services across state lines 154 On October 30 2017 a House Committee on Veterans Affairs report found that the continued expansion of telemedicine across the VA health care system is constrained by restrictions on the ability of VA providers to practice telemedicine across state lines without jeopardizing their state licensure and facing potential penalties for the unauthorized practice of medicine 155 152 President Donald J Trump established the White House Office of American Innovation OAI in 2017 The OAI provides the President with recommendations on how to improve government operations and polies See U S President Trump “Presidential Memorandum on the White House Office of American Innovation ” 115th Cong 1st sess March 27 2017 153 The Department of Justice DOJ is responsible for enforcing federal laws in the United States To learn more about DOJ see CRS Report R44424 FY2017 Appropriations for the Department of Justice by Nathan James The White House and the VHA “Telehealth Technology ” press release August 3 2017 154 Jared Serbu “VA Wants to Make Telehealth Part of Its Day-to-Day Business But Says State Licensing Laws Stand in the Way ” Federal News Radio May 8 2017 155 U S Congress House Committee on Veterans’ Affairs VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018 report to accompany H R 5674 115th Cong 2nd sess H Rept 115-161 Washington DC GPO 2018 pp 13-14 The VA has identified the following seven situations when its providers’ practice of telehealth may be inconsistent with state laws 1 the veteran patient and VA provider are physically located in different states during the telehealth episode of care 2 the veteran patient is receiving a VA telehealth service from a VA provider in a state where the provider is not licensed to practice 3 the VA provider is delivering a VA telehealth service to a veteran patient in a state where the provider is not licensed to practice 4 the VA provider is delivering a telehealth service on a non-VA property 5 the veteran patient is receiving a telehealth service on a non-VA property 6 the veteran patient has not been previously assessed in person by the VA provider who is delivering the telehealth service and 7 other state requirements would prevent or impede the practice of health care providers delivering telehealth to veteran patients See 38 C F R § 17 417 b 2 Congressional Research Service 29 Department of Veterans Affairs VA A Primer on Telehealth On May 11 2018 the VA published a final rule in the Federal Register to exempt its providers who deliver care via telehealth from certain state licensing laws and regulations 156 Two major elements of the final rule changed the VHA’s existing practice delivery 1 VA providers may deliver telehealth services outside of VA health care facilities and 2 state licensing boards may no longer deny or revoke a VA provider’s license if he or she provides a telehealth service in a state where the provider is not licensed to practice in non-VA health care facilities According to the VA the prohibition addresses the concerns of some VA providers that chose not to provide telehealth services across state lines in non-VA health care facilities because their state licensing boards might take action against their licenses for doing so 157 In March 2018 for example the VA Pacific Island Health Care System reported to the GAO that it had concerns about delivering a telehealth service to a veteran patient in his or her home because a state could require VA providers to be licensed in the state where the patient resides 158 The final rule does not preempt state laws regarding the prescribing of controlled substances nor does it extend beyond the telehealth provider’s employment at the VA or extend to VA-contracted providers 159 A VAcontracted provider must continue to practice under the laws and regulations of his or her state of licensure The rule became effective on June 11 2018 five days after the enactment of the VA MISSION Act The VA MISSION Act among other things removed all geographic barriers to VA telehealth and therefore allowed veterans to access VA telehealth services in their communities from any location in the United States U S territories District of Columbia and Commonwealth of Puerto Rico 160 According to Chapter 17 of Title 38 of the U S Code d Relation to State Law 1 The provisions of this section shall supersede any provisions of the law of any State to the extent that such provision of State law are inconsistent with this section 2 No State shall deny or revoke the license registration or certification of a covered health care professional who otherwise meets the qualifications of the State for holding the license registration or certification on the basis that the covered health care professional has engaged or intends to engage in activity covered by subsection a 161 The VA MISSION Act codified the core principles of the above-mentioned final rule with the goal of protecting VA providers against possible liability issues stemming from state licensure laws 162 This authority is given only to VA providers that meet the statutory requirement of a “covered health care professional ” According to the VA nearly 10 000 VA providers gained the authority to provide out-of-state telehealth services to veteran patients in non-VA health care facilities in states where the provider is not licensed to practice 163 VA “Authority of Health Care Providers to Practice Telehealth ” 83 Federal Register 21897-21907 May 11 2018 VA “Authority of Health Care Providers to Practice Telehealth ” 82 Federal Register 45757 October 2 2017 158 GAO Veterans Health Administration Opportunities Exist for Improving Veterans’ Access to Health Care Services in the Pacific Islands GAO-18-288 April 12 2018 p 46 159 VA “Authority of Health Care Providers to Practice Telehealth ” 83 Federal Register 21904 May 11 2018 160 38 U S C §1730C 161 38 U S C §1730C d 162 VA “Authority of Health Care Providers to Practice Telehealth ” 83 Federal Register 21901 May 11 2018 163 Kevin Galpin MD Impact Analysis for RIN 2900-AQ06 VA May 14 2018 p 5 156 157 Congressional Research Service 30 Department of Veterans Affairs VA A Primer on Telehealth Appendix D Total Number of Veteran Patients who Had Received VA Telehealth Services and Total Number of Telehealth Encounters that Transpired FY2009-FY2018 Table D-1 Total Number of Veteran Patients Who Had Received VA Telehealth Services and Accessed the Services Through Each VA Telehealth Modality FY2009FY2018 VA Telehealth Modalities Fiscal Year Home Telehealth HT Store-and-Forward Telehealth SFT Clinical Video Telehealth CVT 2009 56 484 166 633 58 600 2010 66 175 172 505 72 600 2011 91 281 191 388 96 900 2012 119 368 232 164 148 400 2013 143 043 257 904 202 800 2014 156 822 277 871 248 800 2015 155 446 282 929 282 300 2016 150 237 292 130 307 000 2017 145 318 297 472 336 000 2018 136 741 314 487 393 370 1 220 915 2 485 483 2 146 770 Totals Source Table prepared by CRS using data from on an email that CRS received from the Veterans Health Administration of the Department of Veterans Affairs January 14 2019 Note None of the data were rounded by CRS Table D-2 Total Number of Telehealth Encounters that Transpired Through Each VA Telehealth Modality FY2009-FY2018 VA Telehealth Modalities Fiscal Year Home Telehealth HT Store-and-Forward Telehealth SFT Clinical Video Telehealth CVT 2009 Data are unavailable 194 750 149 500 2010 Data are unavailable 192 445 189 700 2011 Data are unavailable 212 056 250 200 2012 786 697 256 476 387 500 2013 941 440 274 430 542 600 2014 1 068 313 297 135 659 600 Congressional Research Service 31 Department of Veterans Affairs VA A Primer on Telehealth 2015 1 071 569 300 133 758 000 2016 1 007 709 314 048 837 900 2017 956 000 322 851 898 000 2018 872 705 344 853 1 074 422 6 704 433 2 709 177 5 747 422 Totals Source Table prepared by CRS using data from on an email that CRS received from the Veterans Health Administration of the Department of Veterans Affairs January 14 2019 Notes None of the data were rounded by CRS According to the VA the telehealth encounter data for the HT modality is unavailable from FY2009-FY2011 Author Information Victoria L Elliott Analyst in Health Policy Acknowledgments The U S Department of Veterans Affairs provided information and data on VA telehealth for this report Amber Wilhelm CRS Visual Information Specialist created the data charts and the graphic illustrated in this report Carol D Davis CRS Senior Research Librarian performed the legislative search and provided valuable resources on VA telehealth for this report Mariam Ghavalyan CRS Research Assistant provided invaluable assistance with the data presented in this report Disclaimer This document was prepared by the Congressional Research Service CRS CRS serves as nonpartisan shared staff to congressional committees and Members of Congress It operates solely at the behest of and under the direction of Congress Information in a CRS Report should not be relied upon for purposes other than public understanding of information that has been provided by CRS to Members of Congress in connection with CRS’s institutional role CRS Reports as a work of the United States Government are not subject to copyright protection in the United States Any CRS Report may be reproduced and distributed in its entirety without permission from CRS However as a CRS Report may include copyrighted images or material from a third party you may need to obtain the permission of the copyright holder if you wish to copy or otherwise use copyrighted material Congressional Research Service R45834 · VERSION 1 · NEW 32