VA Secretary press conference March 26, 2024

Terrence Hayes (VA Press Secretary): Good afternoon, ladies and gentlemen. It's great to see you all again. Today we have Under Secretary for Health, Dr. Shereef Elnahal and VA Boston Healthcare System Chief of Staff, Michael Charness, joining Secretary McDonough to share how we have expanded access to care across the nation. Also, just a heads up as well, the National Disabled Veterans Winter Sports Clinic is in two weeks. If you have not witnessed our world class instructors working alongside the nearly 400 disabled Veterans from every corner of the country, I encourage you to do so. So, all right. I appreciate each of you attending today. I will now turn the floor over to Secretary Denis McDonough. Mr. Secretary.

Denis McDonough (VA Secretary): Terrence, thanks very much. Good afternoon, everybody. Thanks for coming out again this month. Really good. At VA, we're celebrating Women's History Month by honoring our women Veterans who've defended our freedom in every conflict since the Revolutionary War and the women who are still defending our freedom around the world today. And we're honoring more than 310,000 of our women VA colleagues. We're grateful for everything they do, caring for our Veterans, their families, caregivers, and survivors. So, I want to take a moment to tell you about one of those VA teammates out of North Providence, Rhode Island, Iona Bussiere. You see, Iona has two jobs. She's a Veteran service representative, which we call VSR, here at VA, meaning she processes Vets' benefit claims. And Iona is also serving as a citizen soldier, a sergeant first class in the United States Army Reserves. In just a couple of weeks, she'll celebrate her 20th anniversary of service to the country. Iona deployed to Iraq in '07 and '08 and to Kuwait from 2010 to 2011. She remembers that during those deployments, burn pits were everywhere, filling the air with clouds of toxic smoke. Well, last year, Iona was hit with some devastating news. A friend and fellow soldier from her deployment to Iraq had been diagnosed with terminal breast cancer. Iona was turning 40 herself, so she decided to go in for a toxic exposure screening and her very first mammogram. That's where the doctors discovered that she had breast cancer. Treatable, thank God. Stage three on one side, stage two on the other. Like so many Vets, Iona is a fighter. She's undergone a flurry of treatments, including months of grueling chemotherapy and a recent mastectomy. But because of the PACT Act, President Biden's toxic exposure law, Iona's cancer is service-connected, presumed to be caused by our exposure to burn pits overseas. She's covered. Most importantly, she's getting the VA care and treatment she needs, earned, and so richly deserves.

There's a lot to take away from that story. First, I'm praying for Iona and her family as she goes through one of the most important battles of her life. Second, VA is filled with dedicated public servants just like her, and her experience, as scary as it has been, has only made her believe more in VA's mission. She says, 'When I see a claim, I think about it as if it were my own. I make sure to review each claim as thoroughly and accurately as I can because every single claim offers a chance to help a fellow Veteran.' Third, and finally, to women Vets and all Vets, if you're not already getting your care from VA, please consider us. We're delivering record levels of care and benefits to women Vets, but this is just the beginning. We're going to continue to do better for women Veterans. We're going to continue to be better for women Veterans. We want to serve you, and we won't rest until every single women Veteran is coming to VA. So please come to VA to get your toxic exposure screenings and mammograms as soon as you can. And don't wait. Apply for the care that you deserve and have earned at VA.gov/PACT. Even if you don't need this care today, you might tomorrow or the next day or 30 years from now. It's quick, it's easy to apply, and once you're in, you have access for life. With that, let me turn the mic over to Dr. Shereef Elnahal, who's dialing in from Chicago at the ACAG conference, and Dr. Michael Charness, who's joining us from Boston. They're going to talk about the work we've been doing to open VA's doors even wider, expanding access to VA care whenever and wherever Vets need it. Shereef, Michael, welcome. Over to you.

Dr. Shereef Elnahal (Under Secretary for Health): Thank you, Mr. Secretary, and good afternoon, everyone, beaming to you from the Jesse Brown VA Medical Center here in Chicago with Director Cliff Smith and his excellent team who run a great operation here. I want to thank you, sir, for that really important story. Iona is a Veteran who we work for every single day. And as a clinician who has treated patients with cancer, including Veterans, that time between understanding that you have a cancer diagnosis and getting a new appointment with an oncologist to figure out the plan is an anxiety filled time. But it's also a really important time clinically, because we know that time to treatment can often matter. And sometimes it's a life and death matter for Veterans to get that care as soon as possible. And it's for that very reason that expanding access to VA care is a top priority for the VA and for the entire Biden-Harris administration with the Cancer Moonshot Initiative. Also, because VA has proven to be the best care in America for Veterans. Last year, the PACT Act gave us the opportunity to bring even more Veterans into VA for care. And already solely due to the PACT Act, we have enrolled more than 100,000 new Veterans into VA who otherwise would not necessarily have qualified, and we are looking forward to welcoming many more as eligibility for health care enrollment expands. In fact, earlier this month we just launched eligibility that is universal for every deployed post 9/11 Veteran, deployed Gulf War Veteran, and any toxic exposed Veteran across the world. We're expanding access to care because we know that the influx of new demand for care will be greater because of the PACT Act and because we are welcoming so many more Veterans into our doors. Veterans who receive VA healthcare have better health outcomes than non-enrolled Veterans, and VA hospitals have dramatically outperformed non-VA hospitals in overall quality ratings and patient satisfaction ratings. Additionally, VA healthcare is often more affordable than non-VA healthcare for Veterans, and so solving for expanded and fast access to care, especially for new problems, is exactly what we focused on with an initiative called the Access Sprints. The Access Sprints were part of an overall strategy to expand access to our healthcare system in primary care, specialty care, and mental health, and the aim was to improve timeliness, efficiency, capacity, as well as Veteran and healthcare worker experience. And since the sprint kicked off last year, local VA facilities and regional networks have spent months designing and implementing locally driven innovations and tried and true practices, practices like scheduling more Veterans into a typical schedule than we have before, offering night clinics, weekend clinics, more telehealth and virtual care, expanding both the modalities and the volume of care that we've been offering to Veterans. And today, I am proud to share some of the key outcomes of these efforts. As of March 11 of this year, the Access Sprint has enabled a total of 32,000 new patient visits across primary, specialty, and mental health care at participating VA medical centers, over and above the volume of appointments that we saw just last year. And the largest impacts we've seen to wait time so far are in primary care, a 15% reduction in wait time on average, followed by mental health, which experienced a 5% reduction for new patient appointments, and in gastroenterology, which saw also a 5% improvement in wait times for new patient visits. Further, VA saw approximately 25,000 more new patients from October of '23 to February of '24, compared to the same period last year. And 81% of VA medical centers saw more new patients than they did just the year prior. So not only was this impactful across the country in terms of total Veterans who benefited, the impact has been distributed across the majority of our VA medical centers. 12% fewer new patients, as a result, have waited more than 20 or 28 days for a new appointment, 20 in the case of primary care and mental health, and 28 days in the case of specialty care. And 14% fewer new patients were waiting for appointments with a community provider due to wait time eligibility because we were able to bring them into VA for their care. These results are not only making a difference in Veterans' lives right now by providing sooner access to care, they're also setting us up at VA for continued success by ensuring that we have best practices in place to sustain the incredible outcomes we saw during the Access Sprints. Our VA leaders and staff are to be credited for this unprecedented expansion in capacity and the significant progress we have made in offering access to care. And I'm very proud to introduce one of our most effective clinical leaders in the system. Dr. Michael Charness serves at the VA Boston Medical Center and also is leading a really important effort to make sure that as we expand the volume of appointments and offer greater care to Veterans across the country, that we protect our clinicians from burnout. So, Dr. Charness, over to you.

Dr. Michael Charness (Chief of Staff, VA Boston Healthcare System): Thank you and good afternoon. So, as we were preparing for these Access Sprints, we recognized that our efforts needed to be sustainable if the outcome was going to be meaningful. You can't sprint very far with a heavy backpack, and we were mindful that clinicians everywhere bear heavy administrative burdens. Many clinicians experience burnout, and reducing administrative burdens is one way to decrease burnout and increase professional fulfillment. Our task force came together with the goal of reducing administrative burdens so that clinical teams could focus on what matters to them most, caring for Veterans. We reviewed feedback from clinical teams around the country to understand better their administrative burdens. One common burden is managing view alerts and inboxes full of clinical messages. Clinical teams manage hundreds of these daily, but some alerts are not clinically important. Our task force identified a few simple tweaks to VA's electronic health record that quickly eliminated clinician view alerts related to appointment scheduling. Implementing just a few of these changes produced a quick drop in view alerts in Boston, and clinicians noticed the difference. The task force has shared these improvements with VA clinicians across the country. Freeing up more time for clinical care will improve clinic access while increasing clinician engagement in the most rewarding part of their jobs. Thank you.

Terrence Hayes (VA Press Secretary): Thank you, gentlemen, for joining us. We'll open the floor up to questions. Leo?

Leo Shane (Military Times): Yeah. Thank you for doing the press conference. A question for you, Secretary, and for Dr. Elnahal. Given that the Access Sprints you've seen such success, is there any concern about the plans to draw down the number of staffers over the course of the year? You talked about that as part of the budget presentation that we're looking at maybe pulling back about 10,000 folks, a lot of that coming from medical. Is there concern that even with the efficiencies you've outlined, do you think that that could take away some of the opportunities to keep that momentum going?

Denis McDonough (VA Secretary): Fair question. Shereef, do you want to take a first swipe at this and then I'll pile on?

Dr. Shereef Elnahal (Under Secretary for Health): Absolutely, sir. So, we are focused overwhelmingly on making sure that we retain the clinicians that we hired, especially as we hired a record number of healthcare workers just last year, but also the clinicians who've been at VA for many years, who've dedicated much of their careers to serving Veterans. Where we see the most opportune target in overall FTE reductions, which, by the way, will be through attrition and voluntary separation from employment. We're not considering anything involuntary. We think there is opportunity to cut our workforce by 10,000, especially in those roles that are not directly Veteran facing. So, we're talking about more managerial, programmatic individuals, supervisory roles that aren't necessarily over the point of care directly. That is the category of employees that we think can attrit down to a level where we're not compromising capacity for clinical care. And so, we think we have the room to do that. And we think we have the overall end strength to be able to build on the Access Sprints as a result of the record hiring year we just had in fiscal year '23.

Denis McDonough (VA Secretary): Yeah, I don't think I have much more to add to that, Leo, unless you want to follow up on it. But I do think that it's really important that one of the things that Dr. Charness pointed out, that one of the things I hear constantly in the field is, in fact, I heard this in very stark relief when I was in Wyoming, is the inefficiencies that are created by the administrative burden for our employees. So, the clinical reminders that Dr. Charness is talking about are really important. Efficiency gains, they're really important for provider morale. Believe me, I heard that loud and clear in Wyoming. But it ultimately increases their ability to see additional patients, additional Veterans. And so, the last thing I'd just say is, you know, I just spent yesterday in Atlanta with Emory where we have a really terrific joint program to educate and train new nurses or give existing nurses path to further education opportunities and skills development. I got to tell you, the difference between the conversation yesterday with our regional nurse leads as it related to access to nursing expertise as opposed to a year and a half ago when I met with a couple of the same leaders was night and day. And that's because we did just have a really positive year and a half or so of hiring nurses. That's because we got these additional authorities, which is to say we've had a good couple of years on hiring nurses, which gets us in the position to provide the kind of care that Dr. Charness and Dr. Elnahal just talked about. Lastly, I also heard last week when I was in Asheville, Johnson City, and Knoxville that the experience that they've had in the last year in those three facilities, three high growth and high performing facilities, has been very positive as it relates to retention of providers, as Shereef has just indicated. And to a person they talked-well, not to a person. In each setting where we talked about this, they credited the hiring authorities and the retention authorities that Congress has given us over the course of the last years, be that either the Raise Act for nurses or the Title IX authorities under PACT Act expressly called out in Asheville, for example, the importance of CSIs in maintaining frontline staff, which, as you know, we had been facing a challenge with retention of everybody to include very highly compensated specialists, but also, especially in this moment of pretty substantial wage growth, frontline providers. So, to hear that testimony about the impact of policy decisions that we've taken and that Congress has taken in the course of the last couple of years has been really important.

Leo Shane (Military Times): Okay. And just a point of clarification, the Access Sprints are still-that initiative is still going on, correct? We're still going to see-so if I'm a Veteran in an area that hasn't seen or hasn't engaged yet, and I haven't seen some expanded nighttime offerings or weekend offerings, is there still a chance that I'll see that in coming months?

Dr. Shereef Elnahal (Under Secretary for Health): Every medical center in our system, Leo, is doing what they can now to see what is sustainable after that sprint of increased volume that we were able to accomplish between October and the beginning of March. And so hopefully a lot of that will stay in place. We have to be mindful of overall staffing, our authorities, and ability to pay things like overtime, et cetera. And so not all of it will be sustained but we're asking every medical center and network to look very closely about what we can continue, especially since we discovered that we can see that many more Veterans in a defined period of time. So, the picture, in other words, will be variable geographically, medical center by medical center. But we do hope to sustain a lot of that and expand capacity in the coming months.

Denis McDonough (VA Secretary): It's been useful for me to see where I've been, obviously, talking to Shereef about the results of the Access Sprints, but having just had a series of good trips in the last several weeks, including this one to eastern Tennessee and western North Carolina, where-let's be really clear that in eastern Tennessee, for example, there are not a lot of additional providers. You know, there's in each market, maybe one big additional provider. So, it's not like we have great access opportunities outside of VA. And I saw there the great work that they're doing, the radiology techs, for example, with access to MRI on nights and weekends, it makes a huge difference. And what we heard is it makes a big difference not only for the Veteran patients, but also for the family members and caregivers for those Veteran patients, because all of a sudden now you don't have to take time off work to get your dad or get your mom to their appointment. And so, it's decreased wait times, increased access. But also, this is where, as Shereef was saying, the Veteran experience, the Veteran trust signal and the employee signal, the E signal, are two sides of the same coin, right? Which is if we can ease access for everybody, it ends up leading to, obviously, higher Veteran satisfaction and higher employee satisfaction, less burnout, as Michael was saying.

Leo Shane (Military Times): All right, great. Thank you both.

Terrence Hayes (VA Press Secretary): We'll go to David next. Good afternoon, David.

David Elfin (cyberFEDS): Hey, Terrence. Hey, everybody. Sorry I can't be there. I've got two questions. The first one's for Dr. Elnahal. We are about six months, halfway through the fiscal year, and mental health has been the issue that both you and Secretary McDonough have talked about where you want to do some hiring. And I just wonder if you have a good sense this far into the fiscal year, how it's going with that.

Dr. Shereef Elnahal (Under Secretary for Health): Well, I'll just say, David, that mental health overall is one of our top priorities, clinically. It feeds directly into our suicide prevention priority, which is our top clinical and public health priority. And on top of that, we know that there are healthcare worker shortages in mental health across the country for any healthcare provider, not just the VA. And so, when we say strategic hiring, we call out mental health as a specialty, where we expect continued hiring, because we know that the need is only going to go up over time. And we know that there are staffing needs almost universally across the system to be able to meet the demand that Veterans have for that care. And so, we are still focused on getting mental health clinicians on board and those who support them. And we're happy to send you updates on how many we've hired so far this year. But we continue to hire in mental health because we know that demand signal is only going to go up commensurate with Veterans' needs.

David Elfin (cyberFEDS): Getting that data would be great. And, Secretary McDonough, this is an unrelated question, and I'm sure you and everybody else at the department are breathing a sigh of relief that we didn't have a shutdown last weekend. President Biden has already released his FY '25 budget, and you are an agency that's going to get a pretty decent boost, maybe the biggest I actually saw. And I wondered what you made of that. And how confident are you how things are going to go in the next fiscal year, which, sad to say, is just in six months.

Denis McDonough (VA Secretary): Yeah, David, thanks so much. And we will get you that data. I was just kind of going through my mental Rolodex here, which is a little rusty, as you've all witnessed many times. But I get regular reports, maybe not as regular as Shereef on our strategic hiring goal. So that's a gettable number. We'll make sure that we share that with you guys. I think it's a good question.

Secondly, the good news is that when Congress passed the first tranche of FY '24 full year funding about three weeks ago, we were breathing a sigh of relief. So, we were happy about that three weeks ago. We were also happy that the other half of the government didn't shut down over the weekend. That was good progress, of course. I feel really good about our FY '25 budget. And I just started my hearing prep this morning with our team. We have four hearings coming up, two the first two weeks after Congress comes back, week after next, and then two in May. House first, then Senate. So, I look forward to the opportunity to engage with Congress on that. We've been briefing them, following up. We did kind of administration by administration deep dives and then program office by program office deep dives up on the hill. That's really important. And so, I feel good about it. I think it's also important to just keep in mind both what we've experienced and what we've accomplished in the course of the last number of years. And I've hastened to say a number of years because I'm not going to just talk about the time that I've been in this job, because notwithstanding me being here, this agency continues to perform at a very high level. Just think about the monumental change in VA, going back to, say, 2018. Implementation of the Mission Act, fundamentally enhancing something that the VA has done for a long time, which is provide care in the community, but fundamentally enhancing that, even hypercharging it. Secondly, the pandemic, the largest public health crisis in the country in 100 years. And then third, the PACT Act, which can be the largest expansion of VA benefits in a generation, if not ever. Those are three monumental changes, contextually, really important to keep in mind as we're debating our budget, for example. So, I really look forward to the chance to engage with Congress on this. I think the president and OMB have done us a major solid in the budget, and I look forward to discussing it more broadly with Congress. And to just close out that last point about those three really important contextual changes, notwithstanding those, as I say, kind of generational statutory changes in the first and third, and then a multi-generational public health challenge in the second, VA has continued to perform at a very high level, now providing more care and more benefits to more Veterans than at any time. So, I really like our arguments. I really like our budget. Really looking forward to making sure that we defend it appropriately before Congress and that we make sure that this broader context and perspective is included in that defense.

David Elfin (cyberFEDS): Thank you both very much.

Terrence Hayes (VA Press Secretary): Thank you, David. We'll go to Patricia.

Patricia Kime (Military.com): Thank you for doing this. This question is probably for Dr. Elnahal, but also for the secretary. Last week, the VA office of inspector general had a report about the electronic health record system and linked a possible death of a Veteran to a missed appointment as a result of that electronic health record system that has been rolled out in Ohio. And I'm wondering if you could give us an update on the rollout at the Lovell Federal Health Center and how that went and whether you would care to comment on the OIG report and how that rolls into your expectation to jumpstart that program again.

Denis McDonough (VA Secretary): Good. Shereef, you want to take a first step, or I'm happy to take a first swipe, too.

Dr. Shereef Elnahal (Under Secretary for Health): Happy to, sir. So, the first thing I want to say is reading that OIG report in full, you know, this is a Veteran who served this country and deserved the best health care he could get from us. And so, every single time this happens, we have to learn from it. I know for a fact that the Columbus VA Medical Center, as well as VISN 10, have done a deep dive into this, have done a root cause analysis, and are making and have made already significant changes to our processes as we interface with the new electronic health record to prevent this from ever happening again. And that's consistent with our movement to high reliability, which is a philosophy that says the system overwhelmingly is the reason that patient errors happen. And we have to support our frontline workers and employees in raising these issues so that we can jump on it as a team and fix them. And so, I'm grateful to the inspector general for also doing a deep dive into this. Our teams have been very focused on it, and we will work through it. Regarding the James A. Lovell deployment, so far so good. We are seeing deep and meaningful engagement, firstly from the deputy secretary, who's been a tremendous leader responsible for the program, but also Dr. Neil Evans, working with the Department of Defense, their team that deploys EHRs, and, of course, the most important collaboration between Dr. Buckley and the VA staff and the Navy personnel at Lovell. And so, we're continuing to see again the high reliability principles in action. We're seeing tickets filed when problems are noticed with quick action. And we're also seeing patient safety incident reports, thankfully, not meaningfully increased predeployment, but still something that we see in every medical center with a real culture around patient safety and solutioning those issues. And so, so far, we're seeing this as the most successful deployment we've had. Now, we're going to watch this closely, and we're going to be on top of it, not just in the next few weeks, but in the coming months when we start to roll back the direct support and get to normal operations. At Lovell, we'll be watching closely about what these trends are, and we'll be very transparent when problems arise and we'll jump on any issue to fix it. But so far, I think part because of the incredible teamwork between VA and DoD, but also the learnings we've had, significant learnings over the last several years, we think the deployment is going quite well so far.

Denis McDonough (VA Secretary): Yeah, I think I can only add maybe three points to what Shereef has said. I think one indicator of the experience so far at Lovell is that this is now middle of last week that I got this most recent update, and I've been on the road a lot since. But DepSec is staying on top of this. She updated us that as of middle of last week, that facility was at about 60% of pre go-live appointment manifestation, meaning they were fulfilling 60% of the appointments. That was a little bit ahead of what they had assessed would be the likely outcome. Remember that in each of the go-lives there's expected to be a substantial productivity loss as we work through the training and the deployment of the new system. So that's an important number. It's a kind of early, strong indicator. But as DepSec has reminded us every day on this and Dr. Evans has reminded us and Shereef just underscored, you know, if we had stopped watching at Columbus, for example, after the first couple of weeks, we would have felt okay about that, too. But in fact, we saw major problems thereafter. So, we're going to stay on top of this. That's at Lovell.

Second, it's really really important that the IG dedicates the kind of attention and time and resource to EHR that he has dedicated so far. We really, really appreciate it. We learn a lot from each of his new studies. Now, we've been going back and forth with him now for several weeks on these three new studies, so much so that we were in a position to begin to address some of the really fundamental concerns in the pharmacy report, for example, in particular, and I think we've kept you updated of the fact that we're going to be communicating to Veterans in the five go-live sites that we want to work directly with them on their existing prescriptions and just double check to make sure that everything is in good standing.

And then third and last is there's a reason we're in reset. And these are hard learned lessons. We're going to stay in reset until we are confident that we are making the system work in a way that improves Veteran outcomes and improves the provider experience in those five sites before we go live any farther. So, this is directly in response to your question about jumpstarting again, the system. We're not looking to jumpstart and do any fast movements here. I think you see that in our budget request. We're very eyes wide open. We're trying to make sure that we are rolling forward consistent with what the experience of our providers and of our Veterans and those five important go-live sites tells us.

Patricia Kime (Military.com): Just a follow-up. When do you feel like you'll have enough data and information to even make that assessment?

Denis McDonough (VA Secretary): Yeah, I'm not going to jump ahead of that now and put an artificial marker on that. I know Neil and his team, led by DepSec and Dr. Elnahal are watching that very closely and making those judgments as we proceed. But it's also, that's why it was so important, I think, to deputy secretary and to Shereef to make sure that the five go-live sites were also watching with us, helping us learn from their experience as Lovell went live, right. And so, each of these experiences is really important to us, and we'll make that judgment when we're ready to make that judgment. I don't want to put a timeline on it yet.

Patricia Kime (Military.com): Okay. Thank you.

Terrence Hayes (VA Press Secretary): Orion.

Orion Donovan-Smith (The Spokesman Review): Thanks. Good to be here with you guys again in person. Mr. Secretary, thank you.

Denis McDonough (VA Secretary): Your presence was felt even though you weren't here for that.

Orion Donovan-Smith (The Spokesman Review): I'm sure glad to be in the room. And I want to follow up on something Patricia asked, but also sort of tie this back into the Access Sprints. And I've got a couple other nerdy questions about that I might come back for later after somebody else has had a chance, but I was struck in reading that the OIG report that deals with the death by accidental overdose that I was reminded of the extraordinary level of care VA provides relative to the private sector, the number of follow up calls and attempts to reach a Veteran that wouldn't happen otherwise, and that didn't happen as normal in this case, according to the IG. I wonder-and, of course, the report attributes that, at least in part, to the new-the Oracle Health EHR. So, my question for you, Mr. Secretary, and for Dr. Elnahal, is just is that system forcing VA to reduce, to lower that standard of care by virtue of either design issues or just the overall slowdown? Is VA having to do less than you ordinarily would?

Denis McDonough (VA Secretary): Yeah, we won't accept any change to make us do less. I think study after study shows that Veterans in our care have better health outcomes, and I think that's something that's been proven time and again over time for VA. It's something we're proud of. So, I think the OIG's findings are really important and consistent, as Shereef said, with our conduct as an HRO, we obsess about failure. And when we have failures, we dig in to make sure that we learn from them and do not repeat them. And we want to make sure that we're an agency that our providers can speak their minds when they confront a situation like that. The OIG helps us with that, obviously. And so, I think we'll continue to conduct ourselves in that way.

Orion Donovan-Smith (The Spokesman Review): I don't know if Dr. Elnahal wants to add to that, but I have another question more generally on the Access Sprints, too.

Denis McDonough (VA Secretary): Shereef, do you want to add on EHRM or you want to go to Access Sprints?

Dr. Shereef Elnahal (Under Secretary for Health): I'll just very briefly add, sir, that, you know, Orion, I think you do make an astute observation that we have higher standards than many other healthcare providers on the degree to which we follow up with Veterans if they miss appointments, especially in mental health, because we know that the mental health risk overall in terms of conditions is higher, but then the risk of dying by suicide is also higher. And so, the standard of trying three times to get back in touch with that Veteran is in policy. And as the secretary said, when we find that that system or any system that we have isn't allowing us to meet our standards in policy, we do not lower our standards in policy. We create the processes needed to follow the policy that allows us to deliver that excellent care and that higher standard. And so that's exactly what Columbus has done. It's exactly what we've learned from across the five sites. And so, we are making sure that every Veteran who comes in for mental health, if they don't show up, we follow that policy.

Orion Donovan-Smith (The Spokesman Review): A quick follow up on that, this came up in the recent House VA committee hearing, but Dr. Evans was asked if VA has, in any other instances, lowered its standards as a result of the EHR. Can you address that question?

Dr. Shereef Elnahal (Under Secretary for Health): I'm not aware of any standards that we have lowered, especially on quality and our processes for care that we've determined lead to superlative care. And I think the outcomes have proven both in the overall star ratings for quality that are published and peer reviewed literature. They derive directly from our over and above efforts to make sure Veterans are following through with their care and that we're reaching out and bringing Veterans into the care. So, I'm not aware of any policies or standards that we've lowered, in any case, for this EHR.

Orion Donovan-Smith (The Spokesman Review): Okay. Thank you. And Dr. Elnahal, question. I'll hold the rest of my questions on the Access Sprints, but one question on that. You mentioned the fact that VA provides, according to all this research, an exceptionally high quality of care and at lower overall cost. Is it fair then to say that the increasing reliance on community care over the past, that we've seen over the past decade necessarily means lower quality care at higher cost to taxpayers?

Dr. Shereef Elnahal (Under Secretary for Health): Well, what I'll say, Orion, is that Veteran by Veteran, we are making sure that they get the best quality care possible, including when they have to get care in the community. And we rely on the community much more for rural Veterans, for example, and in areas where we don't have services or capacity to be able to meet the needs. So, I don't want Veterans to come away with a concern if they have to get care in the community, we're on top of it, and we want to make sure they get that care. Writ large, our quality that we offer in VA, when we can offer that care, is better. And so that is why we are doing the Access Sprints. The overwhelmingly first reason we are doing it is because it's added that many more opportunities to offer VA care, which means that we know that the Veteran is getting the best quality care. So, I'd say at the population level, that's an observation. And we're trying to calibrate ourselves as much as possible to expand our capacity, most importantly, because we offer superior quality.

Orion Donovan-Smith (The Spokesman Review): All right, thank you.

Denis McDonough (VA Secretary): If I can just add a point to that if it's okay, and Shereef can edit me if I screw it up. But I think one of the reasons that VA care is better, and I think the studies prove this, is the integration of the care for the Veteran. A Veteran can get care, you know, get mental health care, obviously, can get preventative primary care, can get specialty care, and we really pride ourselves in making sure that we integrate that care. And so that's why I've said to you that it's a huge priority for us, and this is why I've been meeting with our community care partners on my trips to find out how can we be in a better position to make sure, for example, that we get records of a Veteran's appearance in the community back more quickly so we can then integrate the results of that test or the results of that care into the overall health picture, which we really pride ourselves on. And docs like Shereef and especially a doc like Michael Charness really wants to be able to see that whole picture. And so, it just requires us to really make sure that we're on top of integrating that care. And it's just as we've said to you in the past, and I think you've heard from our community partners, too, that sometimes they wrestle with the administrative burden of working with us as well. And we're eyes wide open about that. But we just got to get on top of that as a general matter so we can integrate the care, because, like a Veteran who goes into the community for one portion of his care, he or she may be coming to us for two or three other portions of their care, right. And so that's the whole point of an integrated healthcare system.

Orion Donovan-Smith (The Spokesman Review): All right. Thank you. Terrence, I'd appreciate a chance to come back if there's time. Thanks.

Terrence Hayes (VA Press Secretary): We'll circle back, my brother. We'll go to Lucy. Good afternoon, Lucy.

Lucy Bustamante (NBC Philadelphia): Good afternoon. Thank you for doing this. Mr. Secretary, if you could start off. I have two questions. And if we could circle back as well, Terrence. Our sister station in Miami is working on a specific case of a Veteran that took a very long time to get his service-connected, and they had learned that the average time from beginning to end of processing a disability claim is averaging about four months right now. Can you talk about just the amount of time that it's taking and the efforts to be able to get that to go a little faster?

Denis McDonough (VA Secretary): Yeah. Thanks so much, Lucy, for the question. Right now, just in terms of updating you all, the total disability claims inventory is 997,028. Sorry, 208. That is to say 979,208 claims. The backlog portion of that, that is to say those claims that are more than 125 days old are 348,203. That's as of Saturday. And that has us in-I'm not going to do the math on the percentage, but that'll give you a sense of it. That's one. Two-as a general matter right now, we are-we are-even though we are receiving more claims this year than we received last year. And remember, last year was a record year. So even though we are receiving more claims this year than we received last year, we are reducing the backlog because about 75% of the cases that we're working on right now are backlogged cases. And that goes directly to your question about how we are speeding the time to completion on those claims. The average number of claims-I think you're right. It's all a question about how you define months. But I think the average number of days, I think the last I remember is about 128 days, which is about 17 days faster than a year ago. And that is all a function, Lucy, of the fact that we have dramatically increased the number of trained Veteran service representatives and rating Veteran service representatives who are working these cases. We've increased that workforce by about 20%, and we have goals in the budget, as you've seen, to continue to add to that workforce over the course of this next year. Now, let me just take PACT Act as an example. We've had about 1.5 million claims filed under the PACT Act, and we've granted 862,000 PACT Act claims. So, of the 1.5 million claims received, we've granted 862,000. It's really important for purposes of definition to understand that even though we've granted, in some cases, in some of those 862,000 claims, we may have granted to one Veteran one claim, but he may have two other claims in his package, which is to say that we may have granted that Veteran in one instance, but we're still working the other two. So, the way we measure it is until all of the claims are closed, it's considered open. And so that's, I think, probably the fairest way to do it. But it is also worth kind of keeping in mind that as we measure the backlog, it's not that a Veteran is waiting for all of the contentions in his filing until he gets that service-connection. In fact, we're able to establish it as we're working through each of the claims. Lastly, all of these are averages, Lucy, and unless we're going to start doing median, we basically operate under the mean here. And so, averages really smooth out those numbers, which really isn't fair because we actually consider each individual claim the most important thing. So just yesterday down in Atlanta, I was told by one of our partners in the NAB that they were at an event over the weekend, a one VA event up in South Carolina, where he said three Veterans came to that event, had never been, and never filed a claim at VA, never been to VA, left that event with 100% service-connection. And that's great, except that's not the median experience either, right. So, I guess what I'm trying to say is my heart goes out to that Vet in Miami. I wish we would have gotten it done faster. If there's something we can do, if you can put him or her in touch with us, let's make sure that we've done everything we can. But it is true that in a big system like this, where we're getting now 60% more claims over the course of the last two years than we got in the year prior. And that year was an historic year. Even though that's the case, we're continuing to work through these and bringing that backlog down. I'm really proud of that work. But that does not hide the fact that there are still Veterans who wait too long for a claim. And for those guys, we really want to make sure that we're improving that experience.

Lucy Bustamante (NBC Philadelphia): Thank you, sir. I will definitely pass it on to my counterpart Alina Machado there and let her know. A very quick follow up on this. And obviously, circling back on the back end, we also have our military Veterans and journalism fellow on the call as well in our newsroom. So, the PACT Act, obviously, is still expanding. You all are constantly doing work on including more locations, more timeframes, speeding up different sections of the PACT Act, as we saw on March 5th. If you could talk about any conversation happening to include bases that have been on the BRAC committee, such as our base in our area, Willow Grove. We managed to get some video very recently of the half a million dollar water filter that's filtering out PFAS from the water currently under the base that goes into the creeks that civilians fish in, such as children on spring break, for example. So, if you could talk about what's being done to include the bases that we know have PFAS and other toxins that maybe just yet are not included in the PACT Act and how that's being thought about behind the curtain.

Denis McDonough (VA Secretary): Yeah. Well, first and foremost, if there is a Veteran who feels like they have been exposed to toxins during their deployment, during their active duty service, whether they deployed overseas or not, this is the importance of Section 103 of the PACT Act. If you feel that you have been exposed to toxins during training, while you're active duty stateside, for example, you're exposed to lead or asbestos, please go to VA.gov/PACT. Let's get you enrolled for VA care. Under Section 103, we can now do that, and we've seen a good number. You heard Shereef give some of those numbers earlier, but we'll be able to update on those numbers, I think, relatively soon here on expanded access for new enrollees at VA. And remember, then, the other promise of the PACT Act is Veterans getting a higher priority group rating by virtue of additional service-connections that come from the PACT Act. And so, first and foremost, if you feel like you've been exposed, whether it's at Willow Creek-I talked recently down in the canteen to one of our great employees, a Marine Veteran. She talked about the experience that she had at a Marine base in California that is now a super fun site. So, we are constantly getting input on those sites. We're constantly working with our expert teams, including at the health exposures from the health outcomes and military exposures team, the HOME team, to make sure that we are using the other part of the act, which allows us to add new conditions to the list of service-connections, to expand that list. So, we are constantly working that. And then my last point is to those Veterans as it relates to access to benefits. If there are Veterans in Philadelphia who feel like they're exposed and are now suffering those conditions, please come file a claim and let us do the work on establishing where you were. So, yes, we are constantly looking at new geographies. As I said, I just had a conversation with our team about this particular Marine facility, but that should not, even as we work through our process, that should not stop Veterans from going ahead and filing a claim and let us work those claims. And lastly, let me just reiterate my first point. Under Section 103 of the PACT Act, if you were exposed to that kind of activity, even here in training stateside, you now qualify and are eligible for VA care. So please come in and get the care, then go ahead and file a claim, and let's get us working on establishing that service-connection and establishing benefits.

Lucy Bustamante (NBC Philadelphia): Thank you, sir. If you can circle back, Terrence at the end. Appreciate that as well.

Terrence Hayes (VA Press Secretary): Will do, Lucy. And if you can have your colleague perhaps reach out to me about the claim situation and also to hopefully get a hold of that Veteran, please circle back with me.

Lucy Bustamante (NBC Philadelphia): I will let you know.

Terrence Hayes (VA Press Secretary): Appreciate it. We'll go to Ellen.

Ellen Milhiser (Congressional Synopsis): Hello. Good to see you in person. This question is actually for Dr. Elnahal. The last time you were mentioning the Access Sprints, you mentioned that there were some specialties for which you actually had more access available than was used by the Veterans. And I was wondering if that's still true with any of the specialties and if that's helping gauge where attrition needs to occur in FTEs going forward.

Dr. Shereef Elnahal (Under Secretary for Health): Follow up with you, Ellen, on what you mean by that. These are delivered appointments to Veterans over and above the appointments we delivered last year across these services. So, I'm not concerned about having over capacity, the more capacity we have, knowing the influx of new enrollees we're getting from the PACT Act, as the secretary just mentioned, but also increased demand for care per Veteran, we can fill our clinician schedules and we can see those Veterans. I'm not concerned about being over capacity, especially when it comes to outpatient services, mental health, the key services that we offer.

Ellen Milhiser (Congressional Synopsis): Second question, the military health service-Lieutenant General Crosland from the Defense Health Agency wants to bring more complex patients back into the MHS and into the military treatment facilities. Are y'all talking with them directly about creating pilot projects to send Veterans over? And if Veterans were to receive care at DoD facilities, is that considered community care or in-house?

Denis McDonough (VA Secretary): Yeah. I mean, so we've been talking about this a lot with you guys, Ellen. The answer is, are we talking to them directly? Absolutely. And I think to Shereef's good credit and to his team led by those network directors-talk about making the Access Sprints work. It's network directors, it's VA medical center directors, and then it's those great clinicians like Michael Charness making that happen. So, I'm thrilled about that. The other thing they're doing is they're innovating on points of care, and they're deepening our collaboration with DoD and increasingly with USDA. But we'll have more to say about USDA in coming months. But we are deepening that collaboration to increase points of care for Veterans closer to those Veterans. So, we do that in a place for example, you know, Shereef talked to you guys at length about Pensacola. We do that at Fort Sill in Oklahoma. We do that at Tinker Air Base in Oklahoma. We do that in Shaw Air Base in California, where we basically in large measure staff the MTF on Shaw, and we see both active duty and Veteran patients there. And then we're really trying to make this happen at Joint Base Elmendorf-Richardson up in Alaska. Those are some of the near term targets, and it really depends how we do it. Shereef can talk-maybe reattack his recent visit in Kentucky and Tennessee with the new CBOC on base there. But what kind of care it is, in some instances, it's going to be community care. In some instances, it's an interagency exchange of services. So, we actually don't end up getting into color of money issues. We can, in effect, exchange the provision of care for access to the care point to provide that care. So that might be like an interesting appearance at one of our upcoming press conferences to talk about how we manage the money in each of those individual cases, because in each one it's going to be a little bit different. But Shereef, do you want to talk about your recent trip with the ribbon cutting on the new CBOC?

Dr. Shereef Elnahal (Under Secretary for Health): Yeah. And thanks, sir, for summarizing the extensive partnerships we have with the DoD. We're really seeing effective and excellent partners in that agency. Assistant Secretary Martinez Lopez, General Toleda Crosland, who's over the Defense Health Agency, they're setting an agenda that is very complementary to ours. And I was just in Fort Campbell, as the secretary mentioned, serving Veterans in both Tennessee and Kentucky with a new activation where it's multiple primary care teams, but also several other outpatient based services that we are now offering. And when it comes to the readiness mission, the assistant secretary tells me that the serving Veterans is in and of itself a very fulfilling thing for active duty clinicians who work side by side with our VA employees in these partnerships. And it also enhances the readiness mission that they have to best prepare those clinicians for anything they have to do in their service. And so, these are really complementary efforts. We think that thousands of additional Veterans will benefit just from that Fort Campbell activation. I was also in Pensacola just a couple of months ago. Pensacola, Florida has a full scale acute care hospital operated by DoD without a single inpatient bed filled with an active duty service member. And we think that opportunity has significant potential to be able to bring more and more complex care to that region. It's a very high Veteran population in that region of Florida, and we think that it's also complementary for what the DoD's goals are with their uniform services. And so, we're going to be doing this as much as we possibly can, especially since the infrastructure challenges are only going to go up when our average age of plan is around 60 years. So, we have to make use of these partnerships. And by the way, we have a really willing partner in the Defense Health Agency and the uniform service clinicians in working with us on this.

Ellen Milhiser (Congressional Synopsis): Thank you.

Denis McDonough (VA Secretary): We'd love to see you write more about this. I think this is like a total win-win, and it's an efficiency move. It's, you know, really great for VA providers, it's really great for VA providers, for DoD providers, and ultimately really great for Veterans. So, we think it's a really good opportunity.

Ellen Milhiser (Congressional Synopsis): Thank you.

Terrence Hayes (VA Press Secretary): Jory.

Jory Heckman (Federal News Network): Good afternoon. Thanks as always for doing this. With respect to the hiring that VA and VHA is looking to do this year, clearly, you guys aren't hiring at the same volume from last year or recent years, but where do you guys stand with the time to hire, time to fill goals? Are you guys on pace with that? And if not, what kind of levers are you guys looking to pull to get there?

Denis McDonough (VA Secretary): I'll take a first crack at it and I'll see if Shereef wants to add. I think it's uneven, and I'm still super frustrated at how long it takes to hire. I just heard about it again on the road yesterday in Atlanta, heard about it in Knoxville last Friday. And we just have to get better. There's great-there's places where we're seeing really good improvement, mostly by deploying Tiger teams on a very regular basis. For example, the nurses in Atlanta have a once a month, weeklong, kind of five day check in in the midst of their other work to see how they're working through every single one of those cases, case by case. I heard the same thing in Knoxville, where they just had a multidisciplinary team that would meet once a month and check in on every single package of people hiring. Where is it? Who's got it next? You know, who's in touch with the employee? It's that kind of elbow grease that it just requires, and we lose too many very high quality and high quality and highly qualified providers to our competitors by being slow and we can't afford to keep doing that. Anything you want to add, Shereef?

Dr. Shereef Elnahal (Under Secretary for Health): Definitely agree with your assessment of where we are on that, sir. I think we still have a lot of room to grow and reducing time to fill. One additional thing on top of all of the training and standardized process work that we're trying to do is that we're actually doing a friendly competition between the networks to see who can get to the lowest time to fill for the critical hires that we need to make. And so, we hope that that will have some benefit here, but we've got to get better, and we're very focused on it.

Denis McDonough (VA Secretary): My early money is on 23 because that's where Minnesota is and Minnesota routinely leads the nation and everything important.

Jory Heckman (Federal News Network): Eager to see how that all shakes out.

Denis McDonough (VA Secretary): That's on the record.

Jory Heckman (Federal News Network): Total subject change. But last month Senator Tester sent a letter out to the postal service specifically about delays with medication in the mail specifically going to Veterans. Obviously, you know, there's that dialogue between USPS and the senator, but I just wondered if that rose to the level of VA having a focus on that, if they're seeing that being an issue nationally or regionally, and if so, if you guys are reaching out to the postal service about those delays in Veteran medication in the mail.

Denis McDonough (VA Secretary): We-I think both Shereef and I routinely reach out to our mail order pharmacy teammates to see how that's going and whether we have any evidence. Most recently actually was a report in Minnesota that was as we headed into the holidays. The report that we got back at the time was very reassuring. I did hear about this in Georgia yesterday, and I saw news reporting on Senator Tester's question, but I don't have an update on that for you guys right now. We can surely get you one. But Shereef, is there anything you have more recent than I have?

Dr. Shereef Elnahal (Under Secretary for Health): I think you covered it, sir. The only thing I'll add is that in addition to our pharmacy benefits management team, which tracks these metrics on fulfilled deliveries and time to deliver very closely, by the way, our standard is in a short number of days to get Veterans their medication through our mail order pharmacy program, two to three days. And our medical centers on top of that make sure that Veterans get their medications. And so inasmuch as we talk about our higher standards for follow up when Veterans can't make it to clinic, we also have a very high standard here. And we've got teams both locally and nationally paying attention to this.

Jory Heckman (Federal News Network): All right. Thank you. Good. Appreciate it.

Terrence Hayes (VA Press Secretary): We'll go to Caron. Good afternoon.

Caron Lenoir-Kelly (NBC Universal): Good afternoon. Thank you. So much for being here. My name is Caron Lenoir-Kelly. I am the military Veteran fellow at NBC 10 in Philadelphia. And I have two questions for you. I have a question and a follow-up, but my first question is we've talked a lot about the touch for Veterans within the VA system, and full disclosure, I am a Vet as well as a journalist. But has the grievance process changed for Veterans who've had negative medical experiences in surgical care at the VA? The VA still has not directly addressed years of over medication of Veterans. So has the ability to self-advocate, have advocates within the system, and cut through the red tape, has it changed?

Denis McDonough (VA Secretary): You know, I just had an opportunity to join all of the patient advocates across the country. They have a routine. They call it Tea with Annie. So, with their program lead in headquarters, and they get together as a group on a regular basis to check in on best practices, what people are experiencing. I've now met with them twice in my VA time just because I think the patient advocates are a very unique service at VA and a very important service at VA. And so, I'm not aware of any change in either the grievance or in the Veteran advocacy program. I can tell you that when I talked to the Veteran advocates, they were not uniformly happy with our performance, as you might suspect, and they are no wilting violets when it comes to them advocating on behalf of their Veterans, directly with their facility leadership and where they need to, directly with us at the agency leadership here in VACO. So, I'm not sure I know precisely what you mean in terms of the change in the grievance process, but I just want to underscore to our Veterans that every facility has a patient advocate. Those patient advocates work for you. They, believe me, are a tough and very dedicated group of people, which I can speak to from experience. And if that is not working for Veterans, then we are always open to additional ideas to make sure that we can be responsive to our Veterans' needs, including by the Veterans contacting us here directly at VACO.

Caron Lenoir-Kelly (NBC Universal): Thank you for that response. My follow-up question is, why are decision reviews for Veterans, women Veterans specifically, that have been denied for military sexual trauma or PTSD related or unrelated to military sexual trauma only allowed if the decision was dated on or after February 19, 2019? Doesn't that exclude the tens of thousands of women that actually gave military sexual trauma a name?

Denis McDonough (VA Secretary): That's a really important question, and I'm not aware of what that policy limitation is. So, why don't we make sure that we follow up directly with VBA and we'll work with Terrence to get an answer right back to you. Let me just say how awesome it is that I think-to know that there's another Veteran going into journalism, there's an amazing history of Veteran journalists. I think-I hope you all feel that we admire each of you. I have to say I have particular admiration for a number of Veteran journalists as well. So, I'm really thrilled that you're taking this fellowship.

Caron Lenoir-Kelly (NBC Universal): Thank you so much. I've been a journalist for a long time and I have the great privilege of working with Lucy Bustamante at NBC 10 and I thank you for that comment. We need more Veterans in our newsrooms to give perspective because in all of this, what I haven't heard-I've heard you talk about numbers and really pretty numbers, but I'm wondering who you're talking to when you're asking these questions because my lived experience is that it can't possibly be Vets that you're talking to.

Denis McDonough (VA Secretary): I think that's really a really important challenge and I really appreciate that. And I think one example is our V signal, which is our survey at VA which has return rates of 12% to 14% which rival all industry performance on surveys. And the V signal is really important to us and by no means do I think we've got it right. And by no means have I talked to every Veteran in the country and by no means is every Veteran I talked to satisfied. But the voice of the Veteran is really really important to us here at VA and so we will continue to endeavor to get to each Veteran to hear their experience and most importantly hear how we can improve their experience.

Caron Lenoir-Kelly (NBC Universal): Thank you so much.

Terrence Hayes (VA Press Secretary): Orion.

Orion Donovan-Smith (The Spokesman Review): All right. Well, thanks again for the chance. As always, I want to say I appreciate you guys taking the time to answer all these questions. Not to disparage, but over other side of Lafayette Square they usually kick us out a little bit quicker. So, I don't take it for granted. I'll try to keep my questions quick and feel free to answer them as quick as you want. But following up on some of the access stuff, one thing I hear from both Veterans and providers at some of the Oracle Cerner EHR sites is that they'll tell a Veteran that they would have to wait, let's say two months for an appointment there. And so, then they give them the chance to go to the community. But they don't necessarily say you're going to have to wait maybe four or five or six months to see that same kind of provider in the community. Obviously this is a long running issue where VA has more transparency than the rest of the medical system with respect to wait times for the last decade or so, and that gives you the chance of getting a bad rap for that. But does VA have the ability, and would you provide that information to Veterans and say, sorry, we can't see you for two months, but still, that might be quicker than the private sector.

Denis McDonough (VA Secretary): Shereef, do you want to talk this through? I think it's kind of right up your alley.

Dr. Shereef Elnahal (Under Secretary for Health): Absolutely. So, Orion, I think you highlight a really important phenomenon which I think has basically two root causes. One root cause of why Veterans often have to wait longer in the community is that there are capacity issues in the community. Healthcare workforce shortages affect a lot of different health systems across the country, not just some of our VA medical centers. And it's often the case that when we don't have a particular service, especially in rural areas, we are often the most accessible provider, even if wait times are longer than certainly Veterans want or any of us want. And so, I think overall access challenges in the community are partly the reason. Another part of the reason is that, you know, when we have to coordinate care in the community, that is always a live ball back and forth between the VA and that provider, getting that Veteran a confirmed appointment, communicating back with the Veteran on their availability, appointment availability at that provider. And so, the blocking and tackling just to get a confirmed appointment much too long when I arrived here. We're making some improvements in that. We've seen reductions universally at almost every medical center and the time that it takes to schedule, because in our view, when a Veteran needs care in the community, we have to do everything in our power to get that care as fast as possible. But I also think we have more work to do on improving the processes for scheduling in the community. We have some pilots happening right now with direct scheduling into the community, the particularly successful one in Columbia, South Carolina, where one of the few major providers work directly with us who often see a high volume of care. And we took a new technology that could get right into their scheduling grids, and we saw substantial improvements in the time to schedule. So, I think those are two main reasons, and we're focused on tackling both.

Orion Donovan-Smith (The Spokesman Review): Thank you. Just to be clear, does VA have the ability to provide that information on community care wait times to an individual Veteran?

Dr. Shereef Elnahal (Under Secretary for Health): That's the other issue, Orion, it's like a very apt question. We often can't tell a Veteran accurately how long they're going to need to wait to get care in the community because that timeframe in coordinating that care, we can estimate it, we can give historical averages, but we can't say for certain when that appointment will be confirmed until that appointment is confirmed. And so, at the time when we make the referral into the community, it's often not possible to be able to tell the Veteran how long they're going to have to wait. By contrast, in the VA, we can schedule that Veteran an appointment within a matter of days. So, the time to schedule in the VA is a lot faster. And more often than not, they can be seen in the VA when we have that offering faster, which is why the Access Sprints are so important. By expanding capacity even more, and by the way, orienting our operation in a way where we reliably offer that VA option to every Veteran we possibly can, we'll be able to deliver more timely care if we're able to do that. So, we're very focused on capacity expansion, but also the processes by which we get Veterans confirmed scheduled appointments.

Orion Donovan-Smith (The Spokesman Review): Okay. Thank you. I don't know if Dr. Charness is still on the line, but I was struck by one thing he said about the changes to the EHR, in this case CPRs, the Legacy EHR that you all were able to make and that improved efficiency in this one instance. It struck me because that's something I continue to hear from users of the new EHR, that when they've raised concerns about inefficiencies that reduce their ability to see patients, kind of cutting against what you're trying to do with the Access Sprints. Those changes haven't been implemented for many months. I wonder if Dr. Charness wants to speak to the value of implementing a change like that quickly, and if that's something that you're giving up potentially with this new EHR.

Dr. Michael Charness (Chief of Staff, VA Boston Healthcare System): So, the change that we made is not a change to the architecture of the EHR, it's really a change to use. Our EHR has been around for a long time, but there are all sorts of tricks that people don't know about, and we're able to sometimes socialize those so that people who haven't learned how to take advantage of certain tricks, like turning off scheduling notifications, can learn how to do so, but we're not fundamentally modifying the EHR when we do that.

Orion Donovan-Smith (The Spokesman Review): Thank you. One more quick question on EHR, and then I'll let you guys go. But I'm being told that providers at some of the Oracle Health-Oracle Cerner EHR sites, after being allowed to have longer appointment times, like one hour slots for patients because of some of the reduced efficiencies, they're now being asked to shorten those into half hour slots to see more patients. Is that part of the Access Sprint initiative? And how do you weigh that, you know, know the quality of care issue against access to care? I know that's a tough question.

Denis McDonough (VA Secretary): Good question. Shereef, you want to take that? Michael may have you on, too.

Dr. Shereef Elnahal (Under Secretary for Health): Sorry about that. So, I'd say a couple things, Orion. It would be interesting to know the timing of when you got that information. Part of the Access Sprints were to try and schedule more Veterans into any given clinic grid to be able to see what our potential was, to be able to see more Veterans in a timely way. So, if that issue came up over just the last several weeks, it could be related to the Access Sprints. It also might be related to the general efforts we are trying to make in the five sites to restore productivity to predeployment levels. And we're getting closer and closer to that. I wonder if those are being mapped to our standard appointment length determinations, which we made shortly before I arrived in VA. So, they're not too old in terms of the standards that we've set. But we did try to set a range of appointment lengths for each service to ensure that we're maximizing capacity to see Veterans. And so, I think it could be a combination of things. Trying to restore predeployment productivity, our bookability effort, which requires our clinicians to fill their schedules to the 80% level. And often appointment lengths have to be changed in order to meet that. But also, the Access Sprints challenged us to see even more Vets. Could be any one of those things. Happy to work with you offline to determine which one.

Orion Donovan-Smith (The Spokesman Review): All right, thanks again. I appreciate the time.

Terrence Hayes (VA Press Secretary): I think we got Quil on.

Quil Lawrence (NPR): Yeah. Thanks as ever, you all, for providing all this access. Appreciate it. I wanted to get an update on VASP if I could. Still talking to Veterans who are-they've been told that they won't be foreclosed on, but May is the deadline you've given us for VASP to roll out. That's a very short time. They're wanting to know if they'll have a solution then. They're still getting all of this pressure for poisonous to take a poisonous mod. They're holding out. In the meantime, they can't pay down their mortgages. Any update on VASP?

Denis McDonough (VA Secretary): I think Quil, Josh talked at length about this last week with you guys. I don't have anything more to add to what Josh added. Believe me, I'm on this several times a day, at least twice a day. So let me not exaggerate. I'm on this twice a day and keeping a very close eye on it. But I don't have anything more to add to what Josh added to you guys last week, if that's okay.

Quil Lawrence (NPR): Yeah, that's fine. Just one follow-up. If there is anything in terms of working with Congress on this. I mean, Congressman Van Orden in particular, was very emphatic that he wasn't going to accept what seemed to be the solution that was in the works-emphatic even for him. And I'm wondering, do you need Congress to fix this? And how is that conversation going?

Denis McDonough (VA Secretary): I have a lot of respect for Congress as a general matter. I have a lot of respect for Mr. Van Orden, too, for two reasons, obviously-three. One, he's the elected member from his district. Two, he is a very battle deployed sailor, in fact, a seal. And three, he actually represents the district right across the bridge from where I grew up. And so, I've really appreciated his views and his experience. And Josh, same. And Josh has stayed in very close touch with him and with the committee, including with our chairman, including just over the course of the last couple of weeks, making sure that we're engaging directly with them. So that's by way of introduction to my answer. I think my answer remains what we've said to you guys, which is that we believe we have the statutory authority already to carry out what we need to carry out here. We think it's in the best interest of Veterans and we think, actually, over time, it will be not only less disruptive to Veterans' lives, but will also be a cost saver for our taxpayers. And so, we'll stay in very close touch with Congress. I underscored not only my institutional respect for Congress, but also my personal respect for Mr. Van Orden, and we'll make sure that we continue to understand their concerns and do what we can to address them. But I also think we feel good about the authorities that we have to address this challenge.

Quil Lawrence (NPR): And if you could just clear up one date, because I've heard May. I've heard May 31, and I've heard you say by summer, all of those things could be the same date. But could you tell me when you think VASP will roll out?

Denis McDonough (VA Secretary): I'm afraid of giving you a fourth answer. So why don't we have Terrence talk directly with VBA and if we can get more precise than any of those three answers, then we'll come back to you. Is that okay, Quil, rather than me add a fourth, and add greater confusion. As you guys know, as a general matter, I'm not as clear as I should be and often more confusing than I should be.

Quil Lawrence (NPR): I'm not trying to trip you up.
Denis McDonough (VA Secretary): No, I know you're not. I know you're not trying to trip me up, but I don't also want to confuse anybody. So let us get you the most concise answer from our team, who actually knows stuff rather than me.

Quil Lawrence (NPR): Thank you all very much.

Terrence Hayes (VA Press Secretary): Thanks, Quil. We'll circle back to Lucy.

Lucy Bustamante (NBC Philadelphia): Very quick guys. Thank you so much. And, Mr. Secretary, Ms. Kelly keeps me very honest as well. Just for the record there.

Denis McDonough (VA Secretary): I have no doubt about that having heard from her just today for the first time.

Lucy Bustamante (NBC Philadelphia): She's fantastic. No doubt. Okay. Question about post 9/11 Veterans. As a result of the PACT Act, what's going on with the cancer screenings? Any outcomes from the screenings that you all have said or have been able to identify? We know that a lot of Veterans, post 9/11 Veterans, are dying very young, in their 30s. Have these screenings led to any actionable items and anything that the VA is doing to prevent these deaths because of the screenings from PACT?

Denis McDonough (VA Secretary): Yeah. So let me disaggregate one thing, and then I'll answer your question more fully. First of all, what the PACT Act allows for is what we call a toxic exposure screening. We've now administered more than 5 million of such toxic exposure screenings in the last year and a half since the law was signed in-since that provision was signed into law. And we'll go to Shereef and Dr. Charness to see if they want to add more about what that toxic exposure screening includes. I do remember that Terrence gave us his brief after he had his toxic exposure screening. But in large measure, it's to make sure that the Veteran's primary care provider understands more about what that Veteran has experienced, and it may, in fact, lead to additional screening. And I have encountered, obviously talked about Iona today, who made a decision in light of what she learned from one of her battle buddies. I've also run into a senior enlisted sailor who explained the situation that his wife went through, and she got a screening for throat cancer after having her MOS overseas be managing a burn pit in Iraq, which led to early discovery of throat cancer at stage zero. So, I've heard those anecdotal experiences, Lucy, but I don't know that we have aggregated information about cancer screening. Last point, and then we'll go to Shereef and Dr. Charness from a provider's perspective, what I want to say to Veterans, though, is if you feel like you have been exposed, please get your toxic exposure screening, one. And two, if there's further follow up that you want to ensure happens. For example, we do now under VA practice, especially for deployed Veterans, work with them to get earlier access to mammography screens for example. Please talk to your primary care provider about getting additional screens. We are very proud of our oncology work at VA. We are a leading agency in the president's cancer moonshot. We are determined to make continued strides on oncology on beating cancer. And as our team, which is based out of Durham, says, at VA, we beat cancer every day. So, if you're encountering Veterans and you're reporting, Lucy, please urge them to work with their primary care providers to get additional screening. Shereef or Michael, anything to add?

Dr. Shereef Elnahal (Under Secretary for Health): I think that's excellent messaging, sir. And the only thing I'll add is that every one of these toxic exposure screenings that is done which know a simple questionnaire asking about some of the more common exposures and questions to the Veteran about what they think they may have been exposed to in their service, that ends up being a permanent part of that Veteran's medical record and decisions on when and how to screen for things like breast cancer, cervical cancer, number of the other evidence based cancer screenings, take the individual Veteran's risk profile and conditions into account, and there is now a permanent documentation of that concern over an exposure that could lead clinicians to make a different decision. And that's exactly why we are doing these screenings in the first instance, to just deliver better care, give clinicians more information to do more screening if they feel that it's clinically necessary in conversation with the Veteran. I think the point the secretary made is really important. The Veteran should feel empowered to advocate for screening, knowing that their exposures, having gone through the screening and a number of other factors, might want them to get screened. And so, our clinicians are always available to you if you want to have that conversation. We'll follow the evidence, but we're also going to listen to Veterans on this, make sure that we're giving them the care they deserve. I don't know if I missed anything. Dr. Charness, feel free to weigh in.

Dr. Michael Charness (Chief of Staff, VA Boston Healthcare System): So, just to the question of premature death in Veterans from the post 9/11 era, cancer, obviously as a result of exposures, would be one. But research that's going on here and elsewhere is showing that repeated traumatic brain injury and post-traumatic stress also leads to accelerated heart disease and other conditions. And so, it's a more complex problem than just the exposures that is being sorted out through longitudinal research that VA has sponsored. So, it was a complicated war because so many Veterans had so many deployments, and some of the issues related to traumatic brain injury and post-traumatic stress may have been greater than in some of the earlier wars. So that's just something to keep in mind also.

All right. Thank you all for your time today. Terrence, if you can email me a list of the latest claim sharks as well that you all have identified. I'll leave that to our email exchanges and let everyone have a good afternoon.

Terrence Hayes (VA Press Secretary): I'll definitely circle back with you, Lucy. I think that concludes everything. Thank you to Drs. Elnahal and Charness for joining us this afternoon. Truly appreciate you sharing time with us, gentlemen. With that said, we'll see everybody again next month. Thank you, everybody.

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