▶ 0:15:40>> welcome. I know that senator blumenthal is running a few minutes late. I assume we will have a number of our colleagues join us. We will have to figure out the circumstance as well. I appreciate our witnesses joining us today and for the important work that you all do to support our veterans and their families. As we know, our nation owes veterans the assurance of receiving safe, high-quality, and effective care through the department of veterans affairs.
▶ 0:16:09This includes making certain the medications being prescribed are designed to support recovery from trauma, pain, and mental health challenges and are being paired correctly with the right support system. This responsibility is central to this committee's mission and is the focus of today's discussion. Recent reporting by the wall street journal has raised concerns about the use of multiple central nervous system and medications among veterans often referred to as combat cocktail. These stories raise the question of how widespread these practices are, their origins, how the v.a.
▶ 0:16:39Is addressing these issues, and what the oversight and accountability mechanisms are in these instances. Medication is critical to the overall care and well-being of many veterans and nothing from today's hearing should suggest veterans should hesitate to seek treatment or the evidence-based medications are unsafe or unwelcome in any way. Over the past decade, the v.a.
▶ 0:17:00Has made significant progress in reducing opioid prescriptions through promoting safer options, expanding programs and support, holistic health and implement a new oversight measures to identify high risk medication combinations. This hearing, however, provides hearing to assess progress, discuss effective strategies, identify gaps that still remain. Veterans deserve the trust in the system and that is exactly why we are here today. This includes understanding how the v.a.
▶ 0:17:30Trains clinicians, monitors prescribing practices, and implement's policy to make sure veterans have access to non-medication options like therapy, pain management, and community programs. Along with discussing whether private models or technologies can offer insights. And ultimately helping the v.a. To better serve veterans. Today, we will hear from officials who oversee prescribing practices and mental health policies across the system.
▶ 0:17:57The goal is simple, understanding the scope of the issue and understanding what steps the v.a. And congress can take to guarantee that veterans receive safe, effective, and personalized care the. . Men and women who have served our nation deserve nothing less. As I indicated, senator blumenthal is expected to join us shortly. We are going to proceed with the first panel.
▶ 0:18:21Testifying on this first panel, -- what are you telling me? -- testifying on the first panel, on my sheet, the second panel, Dr. juliekroviak, deputy assistant inspector general for the department of veterans affairs. Accountability office -- director hundrup.
▶ 0:18:53And -- erin fletcher, wounded warrior project. I appreciate you witnesses willing to testify and we will begin with miss hundrup. >> chairman moran, ricky member blumenthal, members of the committee. Thank you for the opportunity to discuss our work related to medication management at the v.a.. My testimony covers various related gao report findings and recommendations.
▶ 0:19:22Effective medication management is essential to ensure veterans receive safe and cumbrian's of treatment. This is particularly important for veterans experience in mental health conditions which have been a consistent and growing issue. Many veterans also live with chronic pain often because of injuries from their military service. Veterans may receive medications such as antidepressants for mood stabilizers as well as opioids for pain management.
▶ 0:19:47Some veterans have multiple chronic and mental health conditions, which may necessitate the use of numerous medications. Increasing the risk of pharmacy. If managed improperly, polypharmacy can lead to adverse health outcomes or even overdose or death. As such, it is critical the v.a. Ensure it is offering effective treatment, including medication, as well as nonpharmacological options to reduce risk of negative outcomes. We examined v.a.
▶ 0:20:13Providers treatment plan decisions for veterans with mental health conditions. A range of treatments, including top therapy, one or more psychiatric medications, such as antianxiety or antidepressants or a combination of the two. The v.a. Did not have guidance or monitor providers documentation of required treatment options in the plants. We made two recommendations to adjust these issues. Since then, the v.a.
▶ 0:20:42Agreed with and took action to implement the recommendations. Specifically, the v.a. Providers are now required to record mental health treatment plans as separate easily identifiable documents and medical records. The plans are to clearly show what treatment is being provided . The different treatments that were considered, and whether any changes may need to be further considered going forward. The v.a. Also developed an approach for monitoring the consideration of different evidence-based treatments.
▶ 0:21:12Including both the prescribing of medications and therapy options. With this approach, the v.a. Is in a better position to ensure providers are considering all available options and providing the most appropriate treatment to each veteran. Importantly, with this information, the v.a. Is also in a position to evaluate the prevalence and appropriateness of polypharmacy and minimize the risks it can bring, including overdose or death. Additionally, we've examined issues related to the v.a.
▶ 0:21:42Implementation of its opioid safety initiative. At the time of our report, the v.a. Had reduced prescribing rates that we found the v.a. Did not always consistently follow some risk mitigation strategies. Such as conducting annual urine drug screening, or requiring consent for long-term prescribing. We made recommendations to address these issues.
▶ 0:22:11Documenting each of the risk of strategies and veterans medical records. With this tool, the v.a. Providers are following the strategies. In light of the very serious risks that opioids pose, including addiction and overdose, it is critical that v.a. Ensure it is maintaining careful oversight of prescribing so that it is done in the safe and effective manner.
▶ 0:22:36Lastly, the availability of mental health services is especially important for servicemembers transitioning out of the military as this is a particularly vulnerable time. The transition period can bring stressors related to housing, employment, and family reintegration. And these veterans are susceptible to mental health conditions. Such a separation counseling.
▶ 0:23:07The departments have not assessed the effectiveness of their collective efforts. And we recommend they do so. The v.a. Has also agreed with this recommendation and stated it will coordinate to establish a plan of action to implement it, including identifying any gaps in services or duplicate of efforts. It is important for v.a. To take action to address our recommendation and we will carefully monitor the steps that the v.a. Takes going forward.
▶ 0:23:34Addressing our recommendation will help to ensure the department's are most effectively offering mental health services to veterans as they readjust the civilian life. I would be happy to answer any questions you may have. Dr. kroviak, welcome, thank you for your testimony. Oversight conducted by the office of the inspector general regarding the v.a.
▶ 0:24:02Medication management practices. A fundamental health care activity is a medication reconciliation process involving providers, patients, and their caregivers that ensures they are aware of all medications a patient has prescribed and taking, including over-the-counter and supplements. Medication reconciliation required by v.a.
▶ 0:24:24Can be time and labor intensive, but it helps verify that patients are taking their medications as prescribed and each medication's risk and potential side effects are understood. It can also reveal or prevent duplicate of treatments, contraindications due to allergies and potentially dangerous drug interactions. Medication reconciliation is most critical during care transitions, such as when a patient is discharged from a hospital, moved from different levels of care, or receives v.a.
▶ 0:24:54And community care. For those patients with chronic or difficult to treat conditions, including mental health conditions, the risk of policy front -- polypharmacy, being prescribed multiple medications, is real. It is not always mean a patient is receiving for care. Veterans are at higher risk for psychotropic polypharmacy that is being prescribed more than two medications that affect mind, mood, and behavior.
▶ 0:25:21This can occur because of their distinct military experiences that lead to complex and treatment resistant mental health diagnoses. The ag has noted deficiencies in medication management in several of our reports in v.a. Health care. We uncovered noncompliance with required processes for patients being discharged from health care settings. Only 37% of electronic health records at the philadelphia v.a.
▶ 0:25:49Included a clear discharge medication instructions, which are essential to prevent medication errors post hospitalization and ensuring continued recovery. Patients must also be educated on potential risks associated with their prescriptions. Many antidepressants, for instance, carry black box warnings due to their increased risk of suicidal thoughts. Particularly in young adults.
▶ 0:26:14When -- one tragic case showed serious deficiencies when a young veteran who ultimately died by suicide was prescribed an antidepressant without being educated on the risks and was not provided timely follow-up care to evaluate responses to this new medication. This case highlights the critical value of patient education and timely follow-up care. In addition to challenges prescribing with the nda, say prescribing for veterans receiving community care.
▶ 0:26:45A significant troubling area remains the oversight of opioid prescriptions written by community care providers. The v.a. Is required to ensure community providers review and acknowledge the opioid safety initiative guidelines. However, we found inadequate oversight in the v.a. Third-party administrator certification that community providers review these guidelines. When community providers are not even aware of the v.a. Expectations for opioid prescribing, the v.a.
▶ 0:27:15Cannot guarantee the safety of those veterans referred to the community for chronic and acute pain management. Our review of the v.a. Eastern kansas health care system highlighted further inadequacies in coordination and oversight and medication management involving community providers.
▶ 0:27:32Among other issues related to patient safety for veterans referred to the community, we found incomplete documentation verifying safe open the prescribing practices and a lack of documented medication reconciliation by community providers. In conclusion, the v.a. Dedicated clinical staff worked tirelessly to provide high-quality care tailored to each veterans needs, such care can involve multiple treatment modalities and medications.
▶ 0:28:01Patients and caregivers must be empowered to manage their care with accurate medication instructions and understanding of treatment expectations and knowledge of potential side effects for each medication. The oag is committed to independent oversight. Our teams have dedicated medical professionals are uniquely positioned to assess and drive meaningful improvements in the quality of care delivered by both va and community providers.
▶ 0:28:28Chairman moran, ranking member blumenthal, and committee members, I am happy to take any questions you may have. >> thank you, doctor. Aaron fletcher, welcome again, your testimony will be received. >> distinguished committee members, thank you for today's hearing and the honor to join you on behalf of wounded warriors project in the families we serve.
▶ 0:28:51Our vision to foster the most successful well-adjusted generation of wounded service members in our nation's history brings with it the responsibility to identify, address, and serve the mental health needs of veterans who reach out for help. In our most recent warrior survey, 77 percent of warriors reported ptsd, and more than half presented with moderate to severe ptsd symptoms at the time of the survey. Nearly two and three reported one or more mental health conditions.
▶ 0:29:18And for many of the warriors, the mental health challenges can be worsened further by poor sleep, chronic pain, and feelings of isolation. Recent reporting about polypharmacy has highlighted how over medication can be one of the many challenges veterans face on the road to recovery. Poor access to therapy, canceled appointment, and stigma can also frustrate even those who are most motivated to find care.
▶ 0:29:44There is reason for hope, and we can frame strategies for improvement around stopping over medication, increasing access to care and embracing innovation. Regarding over medication, recent research has shown that 28 percent of post-9/11 veterans receiving v.a. Mental health care met criteria for central and nervous system polypharmacy. One way to help reverse these trends will be for congress and v.a. To continue their investment in precision medicine.
▶ 0:30:11By moving beyond one-size-fits-all care, precision medicine enables more accurate decisions that improve outcomes and reduce unnecessary or ineffective treatments. Congress have launched v.a.'s initiative precision mental health to identify and validate brain and mental health biomarkers and translate those findings into improved clinical care for veterans. With consistent support and funding as well as expansion to consider low level blast injuries.
▶ 0:30:41This initiative can transform the way medication can supplement evidence-based therapy. Increasing access to care will help move away from what some veterans observed to be a medication first approach at va, in which prescriptions are offered before therapy, or without consistent access to evidence-based treatment. As they are struggling to treat providers for increased mental health care, we can broaden our perspective on access.
▶ 0:31:12Veterans increasingly express interest in nonpharmacological and complement -- comp lament three therapies to supplement their treatment. Mindfulness, yoga, acupuncture, tai chi, and other integrated approaches provide coping skills, stress reduction, and support between therapy sessions. Congress and v.a. Can help extend more access to approaches like these by renewing commitment to the v.a. Whole health program. Even with over 100 whole health locations, availability still widely varies across v.a.
▶ 0:31:44Facilities. Without a consistent centralized implementation model, many veterans remain unaware of available resources or encounter barriers in accessing them. Moreover, capacity constraints and frontline clinical treatment make access to these services even harder to obtain. These barriers can leave veterans relying solely on pharmacological interventions. Lastly, innovation can help set new strategies to ensure veterans have access to evidence-based treatment.
▶ 0:32:13Forward thinking approach to case management are one area where we can drive change. We found success with offering veterans a regular touch points to reduce frustration, ease confusion, and help them stay engaged while they navigate the clinical system. In a v.a. Context, one example we have found extremely effective is the post 9/11 military to be a management program.
▶ 0:32:37This public-private partnership model allows v.a.'s to place liaisons at certain partnership sites as veterans complete specialized treatment in the community. For example, v.a. Liaisons are on-site in our warrior care network academic medical centers, where veterans receive intensive outpatient care. The v.a. Liaisons help veterans obtain v.a. Medical records, schedule follow-up appointments after discharge, and serve as a direct point of contact should the veteran have questions about their v.a. Care in the future.
▶ 0:33:09At these sites, 90 percent of participating veterans returned to v.a. For ongoing care, which is evidence that is structured, proactive, and collaborative transition support that helps prevent veterans from falling through the cracks and helps maintain gangs -- games achieved in treatment. I would like to recognize v.a.'s are most important partner in helping veterans access the care and support they need. It is critical we give v.a. The tools they need to succeed and with congress' health, v.a.
▶ 0:33:38Has made progress in recent years to reduce over prescriptions, include -- improve oversight, embrace innovation, and strengthen its mental health care system. We are hopeful the challenge is being discussed today will be the focus of more effort to ensure veterans receive the best possible support when seeking mental health care. Thank you for this invitation to testify, and I welcome your questions. >> before we go to questions, let me turn to the ranking member, senator blumenthal for his opening statement.
▶ 0:34:09>> thank you, Mr. chairman. My apologies for my lateness. I'm going to put my statement in the record. Let me just thank you and the witnesses for being here today.
▶ 0:34:29Polypharmacy often is a symptom of long wait times for care or other factors that may result in multiple medications that conflict with each other or cause damage to the individual in sufficient clinical capacity, fragmented care, and lack of accessible alternatives to medication. It may lead to overreliance or mismanagement of pharmaceuticals .
▶ 0:34:59And unfortunately, what we have seen is longer waiting time for access to care, reports indicate there is a serious deviation from the v.a.'s commitment to evidence-based veteran centered mental health care and I have written to secretary collins about it. I'm going to put that letter in the record as well. The v.a.
▶ 0:35:26Has lost a lot of its staff, which could count for those delays. And it needs to be in the position to have the resource to restore its mental health care network. Let me just say finally by way of this introductory statement that Dr. fletcher, I was concerned that v.a.
▶ 0:35:51Has instituted a copayment for holistic treatment like yoga, fitness classes, meditation, whole health coaching that allow veterans to rely on treatment other than just medication. I think that is really counterproductive. I look forward to the questions, and my thanks, Mr. chairman.
▶ 0:36:18>> let me begin with a broad question to each of you. In part, what precipitated the hearing was the reporting from wall street journal that highlighted troubling the examples of veteran medication experiences. From each of your perspectives, how closely do those cases align with what your office or organization is seeing and where do they differ?
▶ 0:36:43In other words, tell me what you see is what was reported in the article and what we should know about that. >> thank you. In our work, we found a number of factors influence provider decisions to prescribe. They ranged from the resources at a medical center to complexity of the conditions the comfort level was prescribing, as well as availability and the types of treatments. There's a lot that can influence it.
▶ 0:37:12We did find at the time of our work, which was based on fiscal year 2018 data, so it is a little bit dated. There are 37% of veterans with one mental health condition that were prescribed psychiatric medication, either alone or in combination with therapy.
▶ 0:37:32In focusing even more, those with ptsd taking medications, of those taking medications, where polypharmacy comes in, taking two or more classes range from 32% from a primary care provider, to upwards of 61%. As has been stated, polypharmacy in and of itself is not necessarily problematic.
▶ 0:37:58In preparation for the hearing, we were looking to see if there was updated data on where the v.a. Is in terms of just polypharmacy. Not to say that that alone is bad, it does increase risks. That was not available, so I would encourage the v.a. To make those data available. And it is worth examination.
▶ 0:38:16But we did recommend making sure the treatment plans have clear identifiable information so that they can monitor that and see where there are risks and mitigate those risks, such as if the provider is doing a lot of prescribing and you see a lot happening, you can look into that and see if there is appropriate to make sure they are mitigating risks or taking action if that may be the case. >> is it a suggestion so we can compare what takes place at the v.a.
▶ 0:38:45With other health care providers? >> just to have a number to update where we were, a lot has changed since 2018. Just to understand veterans with ptsd or other mental health conditions, what kinds of prescribing and classes of medications they are getting. For a while, there was concern about opioids in combination with benzodiazepines. That was reduced greatly in something the v.a.
▶ 0:39:15Made great strides in. But where are we today? Has it continued to decrease? I think some of these allegations don't have the data, so we don't know. I think the first order of business is really updated data. >> thank you. Doctor, anything to add or suggest? >> I was disappointed in the article. It was devastating to read about the patient experiences. Those are real. >> it is. How about now?
▶ 0:39:44>> I found the article disappointing. The cases were devastating, the patient experiences are real. What I didn't and would not expect to have is what the medical records show, with the provider on health care team, what their response would have been and how we supported the patient. These were complicated patients. It is easy to understand that from reading the article. Va treats very complicated patients.
▶ 0:40:12I was also very disappointed that the suggestion is that the v.a. Providers are handing out medications to avoid providing adequate care. That is not what we have seen. We have been in every facility, vet center, clc, this is not what we are seeing. We are seeing compassionate, dedicated providers managing incredibly complicated patients. >> great to hear, thank you.
▶ 0:40:42Dr. fletcher. >> thank you for the opportunity. What we hear from the warriors we serve is they often encounter medication recommendations before therapy is offered or even accessible. So we know this does not happen everywhere. We've heard it consistently enough that it suggests an opportunity to increase access to first-line psychotherapies and more shared decision-making at the treatment planning process. >> is what you are saying different than what Dr.
▶ 0:41:10Kroviak was saying? >> there's a lot of similarities. >> senator blumenthal? >> thank you. Dr. fletcher. To what extent have waiting times for mental health appointments been due to diminished staff? I will ask the same question of our other witnesses as well. >> thank you for that question. What we heard from the warriors we serve is they are experiencing access to care difficulties.
▶ 0:41:44And that can create problems. We know that warriors with the best outcomes have access to evidence-based treatment, well informed about the medications that they are taking, and again, are active participants in the treatment planning process. >> we are aware of shortages in mental health providers and access to care within mental health and v.a.. That is not unique to the v.a. Health care system.
▶ 0:42:10So the wait times we are seeing are also reflected in the wait times that veterans are experiencing one being referred to the communities. So it is a much bigger problem than just va. >> it is not unique, but what is unique, certainly unusual to the v.a. Health care system, is it is discouraging talented mental health professionals from coming to the v.a. Through policies of furloughs and firings. Would you agree?
▶ 0:42:37>> I will say through our cyclical reviews, where we go out to facilities not for cause, to try and get a feel for culture and quality of care practices. We are getting more feedback that morale is going down because of the uncertainty within the federal government. So yes, while they aren't participating in drp, or did not participate in the crp or other programs, and a clinical staff are exempted from that. They are still losing clinical staff because of morale.
▶ 0:43:08>> it means if you are talented and skilled professionals are going to come to the va, or stay. They are going to be leaving. >> I have to say, these are discussions we have with leaders. We are not asking them to validate their data or what they are sharing in a conversation the concerns at the local level. >> did you have anything -- >> I would quickly echo what Dr.
▶ 0:43:36Kroviak said about the nationwide shortages inside as well as outside. In terms of distinguishing between mba care and outside care, for the v.a., there is a timeliness standard for care in a v.a. Facility. They don't have that for receiving care in the community. Which means v.a. Is limited in its understanding how long it takes a veteran to be seen in the community. And what the challenges are, how best to address them. And we do have an outstanding work imitation for v.a.
▶ 0:44:05To establish a timeliness standard which would help give us more information about the differences. Of course timeliness of care is to care issue because the longer a veteran has to wait, that can exacerbate health issues. >> of course the wall street journal article the chairman referred to, combat concho, how america over medicaid's its veterans.
▶ 0:44:33I think it indicates the care for them, mental health care, or other kinds of care, is really important to prevent over medication that often results from the cocktail of pharmaceutical drugs that may be prescribed sometimes wrongly or inadvertently.
▶ 0:45:04And I wonder if -- you can say Dr. fletcher -- whether there should be stronger safeguards, oversight to prevent that kind of problem? >> thank you for that.
▶ 0:45:26What we hear from our warriors is they want to spend more time with their providers, they want to process through their systems, they want to be informed about the medications they are being prescribed.
▶ 0:45:43We know that consistent follow-up increases his chances of treatment adherence and treatment compliance, consistent follow-up allows providers and veterans to identify medications that may not be working properly, avoid symptoms that may become too uncomfortable. That consistent oversight is important to successful clinical outcomes. >> again, my time is about to expire.
▶ 0:46:11Let me just say I appreciated both of the oig and gao findings, which are tremendously important. As one example , 33% ofvha facilities were not in full compliance to have a management team. That seems like a really basic failing. And again, you can't have pain management without the personnel to do it.
▶ 0:46:38And I think unfortunately, the va is sacrificing that tremendously important capability. Thank you, Mr. chairman. >> thank you, Mr. chairman. Thank you for being here. Good to see you all. Very important issue. We have a lot of problems in my state of alabama with overprescribing.
▶ 0:47:03Dr., you and miss hu spoke aboutndrup -- hundrup spoke about managing at the v.a., and health related issues. A better hold on medical professionals accountable for overprescribing harmful medications. Do we have a plan for that? If both of you could answer. >> ultimately the plan is va's.
▶ 0:47:32But our oversight work has shown a lot of critical leaders in the body that exists to oversee the facilities, do not have defined roles and responsibilities and clear lines of authority. So va has a plethora of directives and policies that are based in evidence.
▶ 0:47:52However, it is the consistent application of those policies and practices where we find most of the issues we report on with structured oversight roles where leaders know what is their responsibility, it is written down, and they own it. And a certain staff and procedures and practices are there that can really help in force.
▶ 0:48:16We feel it could really help enforce the more consistent application of these directives and policies and practices that they have plenty of. >> thank you. >> I would also echo Dr. kroviak . We have similar findings and share the same sentiments. I would add in our work, I think by having v.a.
▶ 0:48:35More clearly document the treatment plans and be easily identifiable as well as document that what evidence-based treatment options were considered. Obviously in many cases it is very complex, there is not a straightforward answer. There does need to be adjustments specific to the individual that change over time. And you might have multiple medications involved.
▶ 0:49:04By having that documented and clear in the record, it sets up v.a. To be in a position to monitor that. They have committed to reviewing individual provider plans, a sample of plans on an annual basis just to make sure -- I think as Dr. kroviak, the policies are only as good as implemented. I would be interested to see what v.a.
▶ 0:49:27Is doing to continue to monitor and look for outliers and take action with providers that may not have the best education or may not be making the best decisions for their veterans. >> do you think we should have oversight on foreign manufactured drugs that we give our veterans? Is there any thought on that?
▶ 0:49:51>> I think when the warrior project would stand on we want it to be as informed as possible about the medications they are taking. We want treatment recommendations to be evidence-based research informed and prescribed in the safest manner possible.
▶ 0:50:11>> I don't have a specific comment on oversight, -- >> foreign manufactured. Which most of them are, by the way anyway. >> this whole medication reconciliation process I emphasized in my testimony is more about the interaction between the prescriber, provider, and the patient. I think that is where all of this action has to happen to where everybody is on the same page. It is really outside of the v.a.
▶ 0:50:42To where the question you're asking would be put into play and absolutely I would not speak against increased scrutiny over the safety of the medications we are buying and prescribing. >> that is not something I have familiarity with, but it is an important topic that v.a. Should be closely looking at. >> 45 seconds.
▶ 0:51:08I hosted a field hearing in alabama this spring talking about psychedelic assisted therapy. You think that expanded access through fda approval in these types of therapies could and would help address -- >> thank you for that question, I think that access in research on alternative treatments is something that a lot of warriors
▶ 0:51:40We serve. That they have tried and more eager to pursue the nontraditional therapies when they have that success. But we would want these treatment recommendations to be based on patient safety and evidence informed. >> thank you, Mr. chairman. >> thank you very much for this panel.
▶ 0:52:11We have millions of veterans and a rather large percentage of them have ptsd. According to the wall street journal article, nearly 60% of v.a. Patients with ptsd, I don't know what that translates into numbers, but they say that is over half a million patients. Are each of these veterans with ptsd supposed to have an individual treatment plan?
▶ 0:52:40I don't know who to ask this question two. Yes, no? >> yes, I think having an individualized approach to treatment yields better outcomes. >> that is not my question. Do each of these -- over half a million, let's just focus on the veterans with ptsd, do they each have a treatment plan?
▶ 0:53:04Who is supposed to come up with a treatment plan for each -- >> if they are diagnosed with ptsd and being treated, they will be required to have a treatment plan that is created and monitored by their health carting -- their health care team. >> you deal directly with the veterans of the two other panel members. Do they have treatment -- individualized treatment plans? >> I would say that varies across veterans.
▶ 0:53:36I can't speak necessarily for all of the veterans. We typically hear that when they are afforded the opportunity to have access to this evidence-based treatment, that it can be individualized, but it is not always. >> when you think about the number of veterans we have and their medical needs, it is just astronomical. The needs are astronomical.
▶ 0:54:06At a time when there have been pretty significant cuts to v.a., which always had a shortage of providers, is that true? In hawaii we always said they are trying to hire people for the v.a. There has always been a shortage, it is exasperated with this regime. Isn't that so? That shortage. Somebody?
▶ 0:54:30>> the oig publishes a report annually on critical staffing shortages for the past eight to 10 years, I cannot remember exactly. But you are correct. We have noticed the most significant increases. >> at the same time as -- I think Dr. fletcher -- gao, I think you said that there needs to be more oversight?
▶ 0:55:03And when you have staffing cuts, etc., who is supposed to provide the oversight that you are recommending? This is for miss hundrup. You say more oversight is needed, but there are massive cuts to v.a. Who is supposed to provide the oversight for the medical care of the veterans? >> I think that is where there is a level of oversight.
▶ 0:55:32If you have a policy requirement -- you say that they need more oversight. But there is less because there have been cuts to the v.a.. The v.a. Capacity to provide care. What I'm seeing is I commend you all for pointing out the needs, but how are the needs supposed to be met when the v.a. Is actually making pretty significant cuts to an already strapped health care system, the biggest health care system in the country?
▶ 0:56:02Let me move on -- I don't know how the veterans are supposed to receive the kind of care they need when there are cuts to the provider base. Ms. fletcher, I was in -- intrigued by you saying veterans should have alternative kinds of care. Is that a fruitful avenue for us to support and pursue if we are not going to have all of the mental health providers that are necessary? You are nontraditional services -- your nontraditional services. Are we doing something to provide those kinds of programs?
▶ 0:56:35Dr. Fletcher: I think there is absolute value in pursuing research to support these alternative therapies. What we have typically heard is most of the warriors we serve are willing to avail themselves to the front line treatments that are already available. We hear that they seek these alternative therapies when what they have tried has not worked. And so a commitment to innovation in mental health care is absolutely needed.
▶ 0:57:05Dr. Fletcher: >> do you think that is a fruitful way to go? The v.a. System lacks providers. Especially I would say mental health providers, but if we can create an environment where alternative kinds of support -- is that a fruitful way for us to proceed? >> yes, I do believe there is value in pursuing alternative therapies. >> that may be one of the ways to go when we lack resources.
▶ 0:57:38Dr. Fletcher: Thank you, Mr. chairman. >> thank you all for coming, I appreciate your commitment to this important cause. As a combat veteran myself, I take very personal stake in all of these matters. Thank you for your commitment to the cause.
▶ 0:58:00Dr. Fletcher: I think to respond to some of my colleagues, scum of the reason why the community care model was is more critical ever, which is the v.a. Has perpetually been under resourced, especially in rural states like montana, where you cannot have a v.a. Clinic in every town. Most towns are tutor treat -- two to three hours apart. The expectation that a v.a. Clinic will be available within reasonable driving distance in a -30 degrees snowstorm is unlikely.
▶ 0:58:30Dr. Fletcher: Taking advantage of the community care options and investing in community care, especially in our rural states is important now more than ever. You made a great point, Dr. fletcher, that I want to reinforce. The alternative care model that we are seeing so many veterans flying to mexico, the middle east, going to turkey to get psychedelic treatment that they are finding immediate relief from ptsd, tbi.
▶ 0:58:56Dr. Fletcher: They are finding it to be safer, healthier, and far more effective for them and their families. Yet that type of treatment is not only not provided by the v.a. Are all health care system, it has been stigmatized and in some cases treated as illegal even though it is working far better. Whether it is acupuncture, dry meat -- dry needling, alternative psychedelics, we need to be open minded about how we can adopt these therapies.
▶ 0:59:23Dr. Fletcher: Unfortunately, this is not a knock on the v.a., but they will not be an innovative entrepreneurial creative place. It is just not. And we should not fight back, we should welcome that and say outside groups like other nonprofit organizations can be those hotbeds of innovation and we should be able to welcome those in and welcome their creative thought process. At the end of the day it is about the outcomes, not the process.
▶ 0:59:50Dr. Fletcher: Veterans, not victims, patients, not bureaucracy, outcomes over process. That is what we have to focus on. Thank you for your comments. I want to go back to a comment you made, incredibly relevant, no matter what the legislation and policies, if they are not executed properly, none of that matters. I think that is the government in a nutshell at the end of the day.
▶ 1:00:14Dr. Fletcher: We can pass laws, but if the people we employ to enact those policies are not the right ones or not doing it properly, it will fail. Written informed consent law we are trying to pass has broad support across the veteran, nonprofit, and the health care industries and communities. I would like your thought on how this should pass, how we ensure when and if it passes, we enact it properly.
▶ 1:00:44Dr. Fletcher: >> informed consent is important because it is an explicit way to ensure the patient knows about the risks of the medications they may be taking. We did find that the informed consent was lacking and recommended the v.a. Take steps to implementing our recommendation. They implement a tool.
▶ 1:01:04Dr. Fletcher: In the medical record there is a flag to show whether or not, my understanding, that informed consent for long-term opioid therapy was discussed and signed by the patient. I would suggest a similar approach in the medical record if it is expanded to others for informed consent. If there can be a similar flag, if it flips up on the medical record and they can have that discussion with a patient including the date it was had.
▶ 1:01:37Dr. Fletcher: >> do you feel the v.a. Is structured to effectively implement this rule? >> I will acknowledge it has been a while since we looked at this. But I do understand -- what I understood was that too was in place in the medical records. A lot has happened with the medical records and the transition. But should what we understood to take place when the implement at our recommendation in 2020 still be utilized, it is worth asking.
▶ 1:02:08Dr. Fletcher: My understanding is it can be a simple process to add that and providers would be continuing to do that. I've not heard any cases where it has been lacking but it is up to each provider in the medical record to document that for that individual. >> on its face, unrelated, but all things relate to this.
▶ 1:02:26Dr. Fletcher: Do you think it is yet another reason why we must reemphasize electronic health records linking dod health records that have a seamless pass-through so we don't have to continue to waste billions of dollars, years, and lives losing medical records from years in service for combat injuries meticulously documented and we throw them in the trash and rebuild from scratch for the v.a.
▶ 1:02:50Dr. Fletcher: Which takes years, missing treatments, missing symptoms, and failing veterans. Is it finally time to have a dod that is seamless and there is no delay and no ledge that people fall off of? >> absolutely. >> thank you.
▶ 1:03:08Dr. Fletcher: >> senator, you might want to tell our colleagues about the plan for a roundtable you have asked me to conduct, to have a conversation about a topic you described in some of your questioning. Next tuesday at 2:00, you might tell us what you have in mind. >> thank you, chairman. We will talk about our treatment ecosystem. After I was wounded, I was privileged to undergo some processes at walter reed that were eye-opening to me.
▶ 1:03:39Dr. Fletcher: We talked about psychedelics, sleep therapy, but the availability of psychedelics and how we can bring those into the v.a. System into the broader veteran health care ecosystem as we are seeing a tremendous caseload of feedback from veterans and patients who benefited from that treatment very specifically and come back and testify that these treatments are having incredible impact on them. And the side effects so far are minimal to negligible.
▶ 1:04:09Dr. Fletcher: Thank you for the opportunity to bring that up. Hopefully it will be an insightful session. >> thank you for your leadership and interest in this topic. We have not invited every committee member, but you are all invited. We invited everybody who is on this committee that has been engaged in this psychedelic treatment aspect of pursuing policy. But if anybody, and all are welcome to come, it is next tuesday at 2:00. Now, senator king.
▶ 1:04:41Dr. Fletcher: >> I want to emphasize what senator sheehy just said. As I looked over my notes and questions, it comes back to these electronic medical records. We talked about coordination with community care. Good electronic medical records. Coordination with veterans coming out of the defense department. And everything comes back to that.
▶ 1:05:09Dr. Fletcher: Overprescribing, or prescribing polypharmacy where there's conflicts and danger, that won't happen if you have decent medical records. So every practitioner that sees a veteran sees the same information about what they are taken, what they have been prescribed, what their history is, all of that necessary background. The development of electronic medical records for the department of defense and the v.a. Has been a debacle.
▶ 1:05:40Dr. Fletcher: We are spending billions of dollars, it is still not working, it has been tested, people don't like it. I never understood frankly while we did not use the same system that is already on the shelf for thousands of hospitals across the country. Why are we inventing a new system for these patients? Sorry about the speech, but the senator provoked it because he's absolutely right. A personal story. Just recently I talked to an elderly -- elderly friend.
▶ 1:06:08Dr. Fletcher: I realized she was much sharper and more engaged and with it than had been the case a month or two before. I didn't really think too much about it until I later talked to her husband who said she had a fall, she had a broken knee, went into the hospital, her physicians looked at her prescription record and changed the prescriptions and she is a different person.
▶ 1:06:33Dr. Fletcher: Nothing else happened other than taking her off certain drugs, putting her on others, and adjusting the volume, if you will. So this was totally obvious. And all it was was somebody seeing cohesively with the prescription record was. One question I have is it seems to be a primary where ai could help. Ai could tell you whether there are contradictions and problems.
▶ 1:07:02Dr. Fletcher: I think that is one area where everyone is talking about ai. But it is something where he can quickly and instantly analyze and would have every drug in the world and you put in what would happen if these person are taking these drugs and we do this, we get an answer. You are nodding, nodding does not show up in the record. You have to say yes senator, that was a brilliant comment. >> yes, senator. That is not a topic we have looked at.
▶ 1:07:31Dr. Fletcher: But I do think you are absolutely right in terms of even some of the record sharing. We understand from v.a. And stating their intent to implement our recommendations that they anticipate using medical technologies like ai. Just to move back from the need for oversight and more people, there is promise ai could alleviate some of that. We are very early and that is not something the gao has looked at specifically. I think it has a lot of promise.
▶ 1:08:02Dr. Fletcher: >> one of my questions is is there any part of the v.a. Routine that involves an annual checkup of your medications? Is it something the v.a. Does routinely? It seems like a useful tool. >> I can take that question. Including the old cprs the v.a.
▶ 1:08:23Dr. Fletcher: Uses and the new record, when you prescribe a new medication, the software itself is taking that one medication against the list of medications a patient has already prescribed, or against unknown allergy the patient has reported. What you are saying is happening in even the most basic e hr function.
▶ 1:08:44Dr. Fletcher: The issue is an alert can pop up that describes the risk level of that interaction so that the provider has to make a determination like yes, I know this risk exists, but I'm taking the risk because it is worth whatever outcome or treatment plan established. What you are saying it is happening. It does not require new technology. >> there are regular reviews of medication?
▶ 1:09:12Dr. Fletcher: >> every time you see a patient the medication for consilium process should be happening between provider and patient. But the software they are using when you enter a new medication will run it against the inventory of what is already being prescribed to make sure those interactions are not happening that you are worried about. >> one of the things you mentioned was possible lack of communication and coordination with community care.
▶ 1:09:41Dr. Fletcher: That is a gap we should be paying attention to. >> it is a massive gap we have reported on frequently. There is a technological solution when all e hr's communicate with each other, that is the ultimate solution. We are nowhere near that. >> there is no excuse for being nowhere near that in this day and age. But I deeply appreciate your testimony. I hope you will follow up as a result of our questions and what the committee is after. Let us know what we can do to help.
▶ 1:10:11Dr. Fletcher: That is our job. You can be our eyes and ears in the field and say here is a gap, here is a problem. Oversight by this committee or legislation by this committee could help fill those kinds of gaps. Thank you for your testimony. >> senator hassan. >> thanks and to our witnesses, thank you for your support of veterans.
▶ 1:10:38Dr. Fletcher: As you highlighted in your testimony, veterans often experience hardships in the transition period where they leave the military and reenter civilian life. The gao recommended the dod and be a joint executive committee, which oversees in the coordination of health care and benefits between the military and the v.a., assess the effectiveness of doj and v.a. Efforts to facilitate access to mental health services for these transitioning service members.
▶ 1:11:08Dr. Fletcher: Can you discuss why it is important to make these kinds of assessments and how they can help lead to potentially improving the health care our veterans are receiving during this critical time? >> thank you. In our work we identified a number of helpful touch points across the transition continuum, one year before separation to one year after. There was often times some confusion about which program they need to, or how it works. Sometimes lack of awareness.
▶ 1:11:39Dr. Fletcher: Some of the programs we found were late. For example, two programs, solid start and in transition. Both noble programs with good intent. They were identifying the veterans two to three months after separation, which is already very late in the process. There was also potential duplication getting similar phone calls, resulting in confusion on the part of the veteran may be being overwhelmed, not knowing.
▶ 1:12:06Dr. Fletcher: Not only was it late in the process, but looking across, there are different programs. I think each individually have noble goals and provide critical services. But looking across, some places that might be -- >> assessing this, especially for mental health care, what is the value of this assessment in terms of mental health access?
▶ 1:12:32Dr. Fletcher: >> the value of this assessment will be to look across and identify the timing, whether there are gaps, whether certain things could be done earlier, whether for instance, the separation health assessment is supposed to have health assessment. That is not happening now. I think they could identify where there are gaps. Maybe there is overlap or duplication, and really look systematically across, which can result in some savings on the part of dod or v.a.
▶ 1:13:01Dr. Fletcher: Or both, and they can shift those so it is coming at the right time in a clear manner for the veteran that is better understandable. I think it will result in a more cohesive, holistic approach. >> I think it is critically important as somebody who advocated and worked on this, solid start program, day one of the transition there would be these things in place. That means organizations have to start planning before the veteran separates.
▶ 1:13:33Dr. Fletcher: Dr. kroviak, let me follow-up in a way on what senator king was just talking about. One of the issues he raised is medication management for veterans receiving community care. You've discussed it is really important veterans who receive community care have their opioid prescriptions coordinated and monitored by the v.a..
▶ 1:13:59Dr. Fletcher: The coordination and oversight can be lifesaving for veterans struggling with pain and mental health conditions. In 2023, the inspector general's office looked into the v.a. Oversight of community care oversight prescriptions and found gaps in care coordination, documentation, and the use of risk mitigation strategies for system patients receiving community care. In your testimony, you stated two of the seven recommendations from the 2023 report still have not been implemented.
▶ 1:14:28Dr. Fletcher: What problems remain in terms of ensuring community care providers and the v.a. Are working together to ensure that veterans, especially those being prescribed opioids, are getting the best care they can and what can we do in congress to help? >> those recommendations yourefg >> those recommendations yourefe >> those recommendations youreft information sharing. We have been working with ivc, the integrated veterans care program office.
▶ 1:14:56Dr. Fletcher: It is a struggle to ensure that communication and oversight, the sharing of information, and it will require changes to the contract, modifications to the contract that ba has with thethr contract that ba has with theths very seriously and we are meeting with them quarterly to discuss how we can move forward with ensuring those things happen.
▶ 1:15:26Dr. Fletcher: >>I'm about out of time so I wil follow-up in writing, but I continue to be really concerned about the issue of veterans especially with mental health issues being given the right kind of follow-up instructions about their medications when they are discharged. I will follow-up with a question in writing on that. >> senator hassan, thank you.
▶ 1:15:56Dr. Fletcher: We have another panel and we have not yet called the vote, so we might be in good shape for the hearing to conclude. I will quit talking to improve the chances. I don't have time to ask these questions, but I am very interested, Dr. kroviak, in community care. It seems like other members are.
▶ 1:16:17Dr. Fletcher: I don't know whether the problem, because we don't have the information, the ordination, we don't know whether there has been realized problems for the veterans or a lack of ability to demonstrate whether that exists. I will follow-up with my staff to have that conversation. Our veterans at real risk we don't know and it's not just a paperwork issue? I don't mean just because records are important, information matters.
▶ 1:16:45Dr. Fletcher: I am interested in the eastern kansas report you alluded to and want to hear more about that. I think it was you, Dr. fletcher, that said something about the prescription first image. I want to know whether the prescription first image has a basis in fact or whether it is just something that is said.
▶ 1:17:11Dr. Fletcher: Also there is an impression that ba has been successful in overprescribing opioids, and I would like to know the facts about that belief. Those are the things I want to follow up, and I will ask my staff and you to have those conversations. I knew senator blumenthal would think he was entitled as well. >> just a quick question, which I neglected to ask before.
▶ 1:17:38Dr. Fletcher: The wall street journal article says only 15% of veterans diagnosed with depression, ptsd, or anxiety are offered psychotherapy in lieu of medication, according to a 2019 report by the government accountability office. Is that percentage still accurate? >> unfortunately I don't have updated data on where we are with that.
▶ 1:18:06Dr. Fletcher: To my earlier point, it's worth following up with the v.a. Since publicly available data is not out there. >> if you could follow-up, I would appreciate it. But you know of no reason that number has changed. >> I don't know that that would necessarily change. >> senator blumenthal, thank you . Thank you all for your testimony. I appreciate your commitment to this cause. With that you are dismissed, quickly. I welcome our second panel, quickly.
▶ 1:18:35Dr. Fletcher: Testifying today on the second analyst is Dr. ilse wiechers. Deputy director for health for patient care services, veterans affairs. Company advised thomas emmendorfer. Thank you both very much for your presence. Dr. wiechers, you are recognized for your testimony.
▶ 1:19:06Dr. Fletcher: >> good afternoon, chairman moran, ranking member blumenthal , and members of the committee. I am the acting deputy assistant undersecretary for health for patient care services at the veterans health administration. I am joined by Dr. tom emmendorfer, executive director of pharmacy benefits management services. Thank you with you about how the v.a. Ensures safe, effective, and veteran centered management and share our view on the three bills under consideration.
▶ 1:19:38Dr. Fletcher: As a practicing be a psychiatrist, I am aware of the complexity of medication management for veterans. Many veterans live with chronic conditions like ptsd, chronic pain, and substance use disorders which often require complex treatment. While multiple medications may be necessary, we recognize the risks of polypharmacy and are committed to reducing unnecessary prescribing. V.a. Has built a strong base for this.
▶ 1:20:09Dr. Fletcher: We use real-world data, not market incentives, to guide decisions. One example is our use of pharma co. Genomics, which helps taylor medications to a genetic profile. This has proven to reduce adverse drug events. We have also made progress in opioid safety. Since launching the initiative in 2013, we have reduced opioid describing by 68% and cut current opioid and benzodiazepine prescribing by 90%.
▶ 1:20:40Dr. Fletcher: Tools like the storm dashboard help us identify veterans at high risk and coordinate care to prevent overdoses. V.a. Has made it easier for veterans to achieve naloxone. We distribute naloxone widely, over 1.8 million prescriptions to date, as well as providing overdose education to veterans and caregivers. Naloxone is free of charge to veterans. It can be accessed through v.a.
▶ 1:21:07Dr. Fletcher: Premises, mobile units, community events, and by messaging care teams through the v.a. App. We are advancing the psychotropic drug safety initiative, a decade-long quality improvement effort focused on safer prescribing of medications for mental health. Pdsi has reduced use of benzodiazepines and antipsychotics, especially among veterans with substance use disorder. We acknowledge there is more work to be done.
▶ 1:21:37Dr. Fletcher: That's why v.a. Issued a request for information to identify innovative software solutions that can support individualized medication review and de-prescribing. This is part of our effort to address polypharmacy and ensure every medication has a clear purpose. Now I turned briefly to the legislation, noting that our full views are detailed in my written statement. V.a. Supports the end veterans overdose act, subject to amendments.
▶ 1:22:05Dr. Fletcher: We agree with the goal of expanding access to naloxone but are concerned about removing prescription requirements entirely. Prescriptions help ensure accountability and stewardship of government resources. We have already made steps to make naloxone widely available, including preventing standing prescriptions for any veterans at risk of overdose. We remain committed to increasing the availability of overdose reversal medications. V.a. Supports the protecting veteran access to telemedicine services act with amendments.
▶ 1:22:38Dr. Fletcher: V.a. Appreciates the committee's engagement and attention, as well as the willingness to discuss technical issues v.a. Has identified. V.a. Recommends amendments to ensure this new authority effectively addresses the two significant barriers to ensure providers can furnish care, including prescribing controlled substances to veterans through telehealth, restrictions with the csa and within the csa, and variability in state law prescribing requirements.
▶ 1:23:06Dr. Fletcher: A clear federal framework would help deliver care to veterans wherever they live. V.a. Has concerns with the written informed consent act. Well we support informed decision-making, requiring signature consent for medications could lead to unintended consequences such as a delay in access to care and increased mental health stigma. Our current policies already require completion of informed consent discussions and recommendation in the electronic health record.
▶ 1:23:36Dr. Fletcher: V.a. Is committed to ensuring safe, effective, veteran centered medication management that helps improve the lives of our nation's heroes. We are proud of the progress we have made but we know there is more to do. We will refine processes, expand access, and put veterans first in everything we do. Thank you for your time and your continued support. We look forward to your questions. >> Mr.
▶ 1:24:04Dr. Fletcher: Chairman, I have to leave for another meeting but I want to complement the department for the dramatic reduction in opioid prescriptions. >> I am happy to yield to you if you want to ask -- >> that's all. Thank you. >> let me ask, Dr. wiechers, I notice you are on the faculty at yale. So you are familiar with our v.a. Facility in connecticut.
▶ 1:24:37Dr. Fletcher: Secretary collins has repeatedly stated that access to v.a. Care has not been affected by staffing reductions, but the v.a.'s own data tells a different story. Wait times for new mental health appointments have increased sharply since january in my home state, connecticut. The most recent data shows the current wait time for a new patient mental health appointment at the orange v.a.
▶ 1:25:08Dr. Fletcher: Clinic in connecticut, outpatient facility specializing in mental health, is 208 days, nearly six months. Given these kinds of wait times, how does the v.a. Plan to prevent overreliance on medication when veterans can't access these timely appointments ? And what steps are necessary to address this issue? >> thank you for the question.
▶ 1:25:41Dr. Fletcher: I agree that access to timely mental health care is one of our top priorities. We continue to actively be recruiting and hiring mental health providers across the system. We are working to address the access challenges you have noted, and it does vary from facility to facility, so acknowledge there are differences based on location.
▶ 1:26:10Dr. Fletcher: We are doing work now to identifiy ways we can improve our efficiencies -- >> you don't dispute the data showing those wait times? >> I acknowledge there are wait times at some facilities that are beyond what our expectations and standards -- >> I have also heard credible reports that some v.a.
▶ 1:26:34Dr. Fletcher: Psychologists are being instructed to cap the number of sessions they can offer patients , even when in their professional judgment additional sessions are clinically necessary. I don't know how you justify that kind of practice. >> there is on the number of psychotherapy appointments a veteran can have.
▶ 1:27:01Dr. Fletcher: There is no national policy -- >> so you dispute there are any caps that psychologists have been instructed to impose? >> we support the implementation of evidence-based psychotherapies. Many of those are a course of treatment that occurs, sometimes eight to 12 treatments, sometimes 12 to 20 treatments.
▶ 1:27:28Dr. Fletcher: The individual provider working with that veteran is the one determining the course of treatment and when it is appropriate to complete that work. There is set, there is no policy indicating a cap in the number of treatments available.
▶ 1:27:47Dr. Fletcher: >> so the answer to my question is yes, you dispute that any instructions have been provided that there should be a cap imposed -- >> there is no national policy -- >> are psychologists ever told they have to impose caps? >> I can't speak to what every individual psychotherapist across the country has been told, but we don't have a policy that states that and I wouldn't support it. >> I'm going to cut through the verbiage in the interest of time.
▶ 1:28:17Dr. Fletcher: We have been told by multiple sources that caps have been imposed on psychologists. If you are not hearing it, I think the v.a. Leadership needs to do a better job of listening to these psychologists and others who are actually providing care. In the interest of time, I'm going to yield. >> thank you, senator blumenthal. I would suggest, Dr.
▶ 1:28:47Dr. Fletcher: Wiechers, that you take senator blumenthal's commentary to heart and actually explore within the v.a. Whether there is a policy or a written national policy, a practice that is limiting the ability for treatment that the provider believes is necessary in some fashion. Does that make sense to you? >> it does.
▶ 1:29:15Dr. Fletcher: Senator blumenthal, I would like to continue the conversation with you and your staff further so I can make sure I understand why you are hearing. >> I welcome that opportunity and I want to say this is not personal to you. I recognize you are not in charge of the v.a. Health care system, and both of you have long histories of service in the v.a., which I appreciate. I thank you for your service and I know you have ultimately the goal of serving our veterans.
▶ 1:29:47Dr. Fletcher: I want to be helpful to you in serving that goal. >> thank you, sir. >> Dr. emmendorfer, let me ask you a question. I was able to attend the launch of the phaser pilot program in 2019 at the national press club with secretary wilkie, which introduced the idea of using a patient's dna to prevent side effects and reduce the use of ineffective medications.
▶ 1:30:17Dr. Fletcher: I understand that program is successful. I would like to have that confirmed. And is now available in nearly every v.a. Medical center. How is the v.a. Training providers to use this? How is the v.a. Integrating results into electronic health records? Tell me about this program and whether it matters. >> I'm happy to report it is a success.
▶ 1:30:42Dr. Fletcher: Earlier this leak -- this week, we learned another medical facility has admitted the pharmicogenomics program and we expect the remaining seven facilities to implement the testing by the end of 2026. For the training, we have over 1000 v.a.
▶ 1:31:02Dr. Fletcher: Providers that have participated in the continuing education program, pharmicogenomics, and we also have our academic detailing services program, which is trained pharmacists that have conducted outreach with around 7000 providers to help promote pharmicogenomics. It is integrated into our electronic health record, so it's part of the clinical support system.
▶ 1:31:31Dr. Fletcher: There's about 100 medications that are evidence-based with the pharmicogenomic testing. At the time of prescribing, our electronic health record will flag an alert on the pharmicogenomics testing and that helps guide appropriate medication selection and therapy. >> tell me, as the laymen on so many things, what does the dna tell us?
▶ 1:31:59Dr. Fletcher: What is it capable of indicating to avoid treatment of a patient? >> it's helpful with the dna because it will tell us as health care providers of how we expect that medication to behave when it's in your system and being metabolized by your body.
▶ 1:32:22Dr. Fletcher: That information helps make the upfront selection for the medication, so in the past where we may have to do some trials and the patient's trial on the medication wasn't optimal, and you may have to stop that medication and try another. Pharmicogenomics takes that guesswork out. >> senator blumenthal, anything you want to cover? >> I would like to submit additional questions for the record.
▶ 1:32:52Dr. Fletcher: >> you also indicated you had something to submit for the record. >> I'm going to submit my statement and the letter I wrote to. >> the senator without objection. I'm sorry to cut this hearing sciorra. Senator blumenthal and I probably have access to more conversation with you.
▶ 1:33:14Dr. Fletcher: I see you nodding your heads and we will follow-up with staff to make sure anything we may have missed because of the vote is covered. I want to thank you for your testimony, thank the committee members for their participation, for the audience. Each member has five legislative days to submit statements or questions for the record.
▶ 1:33:35Dr. Fletcher: Any senator who would like to submit a question should do so in a timely manner, and likewise I ask our witnesses to respond to every question in a timely manner as well. With that, our committee hearing is adjourned. [captioning performed by the national captioning institute, which is responsible for its caption content and accuracy. Visit ncicap.org]