Veterans Affairs & Military Medicine Fall 2019 Edition

75th Anniversary of the G.I. Bill Transforming Pain Care for Veterans Disaster Response

Interviews John H. Windom

Executive Director of the VA Office of Electronic Health Record Modernization

U.S. Rep. Gus M. Bilirakis

2019 FALL EDITION

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CONTENTS

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INTERVIEWS

HEALTH RECORD STATUS AND 8 ELECTRONIC MODERNIZATION

An interview with John H. Windom, Executive Director of the VA Office of Electronic Health Record Modernization

By J.R. Wilson

DENTAL CARE IN CONGRESSIONAL 28 VETERANS’ SPOTLIGHT An interview with U.S. Rep. Gus M. Bilirakis

By Gail Gourley

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CONTENTS FEATURES

14 DISASTER RESPONSE

The role of the military health system in providing medical staff, equipment, and scientific expertise in the event of natural disasters or disease outbreaks

By Scott R. Gourley

21 TRANSFORMING PAIN CARE FOR VETERANS 36 VA PROSTHETICS: STATUS AND ADVANCES 44 IMAGING TECHNOLOGY 52 THE G.I. BILL

By Gail Gourley

By J.R. Wilson

WIKIMEDIA COMMONS

By Scott R. Gourley

On the landmark law’s 75th anniversary, a look at the once and future dividend for military service members

By Craig Collins

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Published by Faircount Media Group 4915 W. Cypress St. Tampa, FL 33607 Tel: 813.639.1900 www.defensemedianetwork.com www.faircount.com www.vamilmedoutlook.com EDITORIAL Editor in Chief: Chuck Oldham Managing Editor: Ana E. Lopez Senior Editor: Rhonda Carpenter Contributing Writers: Craig Collins Gail Gourley, Scott R. Gourley, J.R. Wilson DESIGN Art Director: Robin K. McDowall ADVERTISING Advertising Sales Manager: ​Steve Chidel Advertising Team Lead: Beth Hamm Representatives: ​Art Dubuc, Geoffrey Weiss OPERATIONS AND ADMINISTRATION Chief Operating Officer: Lawrence Roberts VP, Business Development: Robin Jobson Business Development: Damion Harte Accounting Manager: Joe Gonzalez Intern: Emily Falcone FAIRCOUNT MEDIA GROUP Publisher: Ross Jobson

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INTERVIEW

ELECTRONIC HEALTH RECORD STATUS AND MODERNIZATION An interview with John H. Windom, Executive Director of the VA Office of Electronic Health Record Modernization

By J.R. Wilson EHR system, provided by Cerner Corp. DOD’s new Military Health System GENESIS (MHS GENESIS) is currently in its pilot phase, while the first component replacing the VA’s 40-year-old Veterans Health Information Systems and Technology Architecture (VistA) is being installed in the Pacific Northwest.

John H. Windom, executive director of the VA’s Office of Electronic Health Record Modernization, spoke with Veterans Affairs & Military Medicine Outlook’s J.R. Wilson about the new EHR system, how the transition is going, and what it will mean for veteran health care in the future.

Veterans Affairs & Military Medicine Outlook: What is the status of the EHR modernization (EHRM) effort?

John H. Windom: We’re on time and on budget and will go live in March 2020 at our initial operating capability site, the Mann-Grandstaff VA Medical Center [VAMC] in Spokane, Washington, and the VAMC’s four community-based outpatient clinics [CBOCs], part of its satellite network. We have migrated successfully, moving an incredible amount of data successfully.

We’ve also completed seven of eight national workshops, where we’re training in excess of 500 clinicians and users at any point of time on the Cerner Millennium solution.

We continue to work collaboratively with DOD to solidify best practices, not only industry but benchmark practices, as part of the DOD deployment, [to] ensure the lifetime seamless movement of information as part of the longitudinal health record we’re seeking to establish in support of interoperability objectives.

John H. Windom, executive director of the Department of Veterans Affairs’ Office of Electronic Health Record Modernization.

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At what point do you anticipate the entire effort being completed?

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PHOTO COURTESY OF U.S. DEPARTMENT OF VETERANS AFFAIRS, OFFICE OF ELECTRONIC HEALTH RECORD MODERNIZATION

n ELECTRONIC HEALTH RECORDS (EHRs) are one of those technologies that came out of the shadows in the 21st century to become virtually ubiquitous in U.S. health care. Nowhere has their adoption been more extensive than in the Department of Defense (DOD) and the Department of Veterans Affairs (VA). But, until now, these two giant agencies maintained separate EHR systems, even though everyone in the DOD system ultimately winds up in – or is at least eligible for – VA care.

That is now coming to an end. In September 2018, DOD and the VA announced they will be adopting the same Millennium®

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John H. Windom talks to an attendee during an industry day event May 29, 2019, at the Crystal Gateway Marriott in Arlington, Virginia. The industry day was an opportunity for the Office of Electronic Health Record Modernization to provide attendees with an update about VA’s effort to replace its current electronic health record systems with the commercial-off-the-shelf solution – Cerner Millennium – now being deployed by the Department of Defense (DOD). The EHRM initiative will leverage an existing commercial solution to achieve interoperability within VA, with DOD, and with community care providers. A single interoperable solution across VA and DOD will facilitate the secure transfer of active-duty service members’ health data as they transition to veteran status.

VA PHOTO BY EUGENE RUSSELL

The contract projects nine years and six months since the May 2018 contract award – 2028 – but we’re always looking for a way to accelerate. In addition, we will be deploying a best-of-suite module of the solution separately at sites that are further down the road [first in Columbus, Ohio].

We think we can get the scheduling solution deployed in five years to those areas that have not received the entire package within that five years. We want to give the entire enterprise some form of Cerner capability sooner, so an entity does not have to wait the entire nine years and six months to get anything.

Will the new EHRs be available to private physicians as well as VA clinicians?

EHRM is focused on getting the right data to the right place at the right time, ensuring continuity of care and patient safety. It will provide interoperability across the VA, DOD, and community sites of care. The VA community care providers will be able to share data through a health information exchange [HIE] network called CommonWell, which is used by many community providers, and another HIE called Carequality, a framework that enables health data sharing between and among networks.

Will veterans have access to their personal EHRs to review, copy, and, if necessary, request information be updated or corrected?

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Absolutely. VA is establishing a new patient portal as part of the EHRM for veterans to access, review, and make copies of their own health records as well as work with the VA to update or correct those records. The new patient portal will be available to veterans after their VA medical center goes live and the new EHR is activated in conjunction with the go live of a VA medical center.

Veterans who receive care at sites that have not gone live with the new EHR will continue to use the current My HealtheVet patient portal until their facility goes live. The Office of Electronic Health Record Modernization is currently working with Mann-Grandstaff and the VA Puget Sound Health Care System in Seattle to ensure veterans and their health care teams receive timely access to tools and resources for the new patient portal.

This has been referred to as an “enlistment-to-grave” system, incorporating all medical information about the individual from initial physical to exit physical by his or her service branch, then picking up with all subsequent VA data. Is that still the case and how well is the integration proceeding?

DOD and VA remain committed to working together in support of the transition throughout a person’s military and veteran history to provide a single longitudinal health record from DOD and VA that incorporates all health encounters while serving in the active or veteran community. The initial migration of VA data – 23.5 million veterans’ health records and over four decades’ worth of patient information – was transferred into the Cerner data center, where DOD health care data is stored, this past summer.

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The new EHR solution will be a single source of Veteran health information for patients and providers The new EHR solution will: Eliminate the cumbersome manual transfer of records when a service member transitions from military service to Veteran status.

Present clinicians with role-based information to drive better health outcomes and provide Veterans with enhanced access to their complete health record.

Enhance collaboration and improve health information sharing with DoD and community providers.

IMAGE COURTESY OF U.S. DEPARTMENT OF VETERANS AFFAIRS, OFFICE OF ELECTRONIC HEALTH RECORD MODERNIZATION

When will the Cerner Millennium system be fully activated for the VA and integrated with its DOD counterpart?

We have that projected for 2028.

Does this also cover National Guard members, reservists, and Coast Guard personnel?

National Guardsmen and reservists are included as part of the DOD rollout. The Coast Guard recently announced their intent to join the rollout as well and have been added to the DOD contract. So as those locations are deployed, the health records of Guards, reserves, and Coast Guard members will be accessible to VA providers as well.

Will immediate family members (spouses and children) also have VA EHRs under the modernization program?

The veteran’s spouse and dependents who are eligible and receiving VA health care benefits or become eligible at a later date will have their records included in the EHRM solution. Those who are outside that community will not have their records moved into the VA portfolios.

provided with an improved experience that leverages improvements in interoperability between VA, DOD, and VA community care providers; increases care provider efficiency; and data analytic innovations that will equip VA providers with tools and information for advanced clinical decision-making.

Does the new EHR system impact or change any health care benefits veterans currently have?

No. The EHRM does not change veteran benefits as they relate to eligibility.

By establishing a single EHR, DOD will be able to keep more accurate and complete health records for each service member, providing the VA with better information to make decisions regarding benefit eligibility. That’s a key element.

The EHRM solution will impact the way VA delivers care. Veterans will be

How will it affect the speed with which a veteran receives health care from the VA after transitioning from the military?

EHRM does not affect the speed of the established process to determine eligibility for VA care and benefits.

However, it will be far more efficient for the active-duty service member’s transition. Because the EHRM solution aligns VA and DOD to a single instance, veterans will not experience lag time associated with health records being delivered

Veterans will also no longer have to carry paper records from DOD to VA “providers, which means there will be no time required to manually transfer information into VA’s EHR from hard-copy documents. ” www.defensemedianetwork.com

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from DOD to VA after separating from service. Veterans will also no longer have to carry paper records from DOD to VA providers, which means there will be no time required to manually transfer information into VA’s EHR from hard-copy documents.

When you say speed, there are efficient mechanisms that will drive decision-making to be more efficient. It is still about benefits determination, but access to that determination will be more readily available.

If a veteran left military service before the creation of EHRs or other computerized health care records, what is their status within the new system?

Have EHRs already been created for them?

Veterans who left military service prior to the advent of EHRs but have since engaged with the VA for health care have an EHR as part of VistA. Any veteran eligible for VA care, but who has not previously engaged the VA for health care and does not have an EHR will be provided with an EHR upon engaging with the VA. We have data going back to 1981.

There has to be a benefits consideration made when a veteran enters into the VA system (no matter how long it has been since leaving military service). So if you’ve ever interacted with the VA, your data will be there. If you’re eligible to use the system, records will be created and care provided.

How easy will it be to update – or even replace – the Cerner system in the future?

VA remains confident in our decision to replace VistA with an EHRM solution provided by Cerner. It generates that movement towards interoperability we’re seeking between VA, DOD, and the community providers who support us. We are on track for successful implementation.

Innovation is a critical aspect of the contract with Cerner. Not only will the system be updated regularly, it will be continually upgraded as technology advances and the needs of veterans

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I’ve watched the movement of thought from skepticism, to uncertainty, to now excitement to be part of the solution set that is so highly thought of in the commercial environment, that supports their care provisions.

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evolve. Updates to the system will be made more easily and without disruption to veteran care. With every VA center on the same platform, updates are more efficient and there is no loss of productivity or additional training required. It also helps control costs – every implementation is not different. Innovation will not cease; we are in a very innovative environment here. Cerner is seeking to capitalize on what we know as well as we capitalize on the things they know.

Does the new system accommodate differences between military EHRs and the VA version (diagnosis and treatment codes, prescription records, private health care data, etc.)?

The new system will accommodate differences. The EHRM program is facilitating the requisition interactions between the VA, DOD, and Cerner, working collaboratively at both the national and local levels. The design of the new EHR solution will be a by-product of that collaborative effort. We’re leveraging best practices and what DOD already has experience doing.

Our movement is toward a commercial EHR, the crosspollenization and alignment of SMEs [subject matter experts] on all sides to understand what the workflow requirements are in support of our veterans. We have workshops that include clinicians and other SMEs from across the continuum working in support of those interoperability objectives. The system absolutely

allows for differences between the departments when necessary to meet workflow or mission variations.

However, the underlying datasets will have the appropriate commonality to support our interoperability objectives.

What feedback have you gotten from clinicians and veterans?

We’ve held a series of workshops demonstrating the product across the enterprise to expose the various stakeholders to the new system. I’ve watched the movement of thought from skepticism, to uncertainty, to now excitement to be part of the solution set that is so highly thought of in the commercial environment, that supports their care provisions.

The excitement is there, [and] it will be increased in the education process we’re employing.

We know uncertainly breeds concern, and we owe it to our veterans to put them at ease as much as we possibly can. The general consensus is people are eager and anxious and very much desire to be part of this implementation process. The veterans we have interviewed about EHRM have expressed excitement and relief that they will no longer need to keep multiple paper records from multiple providers and that their VA providers will be able to access their complete medical history in real time. And that’s huge.

Is there anything else you want to add?

This effort is about our veterans, about delivering the best care and capabilities we can. We’re proud of the effort ongoing today. We know we owe a solution set that will support our veterans, their transition from active duty to veteran service, and allow them to take their minds off of whether their information is accurately moving into their veteran lifetime of care. The VA will have a service member for a large portion of their lives, and we want them to have the most accurate information to support the best possible care.

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DISASTER RESPONSE

The role of the military health system in providing medical staff, equipment, and scientific expertise in the event of natural disasters or disease outbreaks

By Scott R. Gourley

n WHILE SOME STILL MIGHT DEBATE THE EXISTENCE of cause and effect relationships, by most quantifiable standards, natural disasters – and the subsequent need for government disaster response efforts – are on the rise. Along with the better-known natural disasters like hurricanes, fires, or tornadoes, additional response demands may stem from the possibilities of either natural or extremist-directed pandemic crises or other attacks. Reflective of its available personnel resources, unique equipment inventories, and dedicated training programs, the Department of Defense (DOD) plays and will continue to play a critical supporting role in those response and recovery efforts.

DISASTER RESPONSE As evidence of the rising needs for military disaster response, one recent report prepared by the U.S. Government Accountability Office (GAO) noted that fall 2017 included three of the top five costliest hurricanes on record, pointing to four sequential disasters – hurricanes Harvey, Irma, and Maria as well as massive California wildfires – with creating “an unprecedented demand for federal disaster response and recovery resources.”

While the primary mission of the DOD is to defend the nation, through its Defense Support of Civil Authorities (DSCA) responsibilities, the department is frequently asked to play a prominent role supporting civil authorities during disasters and declared emergencies.

According to the GAO, the DOD has two primary avenues of support: when requested by a federal agency – such as the Federal Emergency Management Agency (FEMA), Department of Health and Human Services, Department of Homeland Security, Department of Agriculture [Forest Service], or U.S. Agency for International Development (USAID) – and approved by the secretary of defense; and when the U.S. Army Corps of Engineers serves as the DOD coordinating and primary federal agency for public works and engineering-related response efforts. Separate from the DOD efforts, National Guard units can be brought on State Active Duty to support their own governors or other governors through state-to-state emergency management assistance agreements.

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FROM HURRICANES TO WILDFIRES September 2017’s Hurricane Maria (Sept. 16-Oct. 2/ landfall on Puerto Rico Sept. 20], a Category 5 hurricane that devastated Dominica, the U.S. Virgin Islands, and Puerto Rico, provides a number of excellent representative examples that reflect the broad scope and capabilities of military disaster response capabilities.

The Hurricane Maria military response effort was coordinated in large part by U.S. Army North (ARNORTH) under Lt. Gen. Jeffrey S. Buchanan, then U.S. Northern Command’s (USNORTHCOM’s) Joint Force Land Component Command commander.

One small glimpse of the scope of that response effort was provided by ARNORTH public affairs representatives in a late October 2017 summary: Noting the command team’s initial arrival in Puerto Rico on Sept. 28, they offered that activeduty and Reserve forces peaked in mid-October at more than 15,000.

Just over one week later, there were still more than 13,000 personnel on the ground and a total of 59 helicopters (down from 72 at the height). On the medical side, DOD support included an Army combat support hospital, an Air Force Expeditionary Medical Support System (EMEDS), and the hospital ship USNS (U.S. Naval Ship) Comfort. At the height of the response, Comfort was joined by three U.S. Navy vessels: USS Wasp; USS Oak Hill; and USS Kearsarge. Although Wasp and Oak Hill departed in mid-October as the support effort transitioned from response to recovery, the military effort retained the Kearsarge and its aircraft, along with some Seabees and a Marine Expeditionary Unit (initially the 26th MEU followed by 24th MEU).

Significantly, many of the assets noted had been “on the ground” since Hurricane Irma (Aug. 30-Sept. 13/eye passed just north of Puerto Rico on Sept. 6) and stayed to respond to the devastation of Maria.

Moreover, at roughly the same time that this critical support was being delivered across those areas affected by the hurricanes, DOD personnel were also responding to the 2017 California wildfires. Much like the damage caused by hurricanes,

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U.S NAVY PHOTO BY MASS COMMUNICATION SPECIALIST 3RD CLASS KATIE COX

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the California fires that year included five of the 20 most destructive wildland/ urban interface fires in the state’s history.

According to the recent GAO report, DOD officials noted that, while National Guard personnel in State Active Duty status primarily provided wildfire fighting capabilities, additional DOD commodity support and access to military bases ranged from the Defense Logistics Agency fulfilling 3,500 U.S. Forest Service orders for emergency equipment and supplies, including 5 million AA batteries, to access provided at both Travis and Beale Air Force Bases to stage ambulances and their crews.

2019 HURRICANE DORIAN As of this writing, the most recent example of a growing DOD disaster

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U.S. Navy sailors and Coast Guard personnel transport a patient in response to Hurricane Dorian in the Bahamas, Sept. 6, 2019. In support of foreign disaster relief efforts in the Bahamas, the secretary of defense authorized U.S. Northern Command to provide transportation logistics for the movement of USAID and third-party humanitarian commodities and personnel throughout the region and to conduct assessments of critical transportation nodes to facilitate the delivery of humanitarian assistance and maximize the flow of disaster relief into the area.

response can be found in the immediate aftermath of Hurricane Dorian. Following initial landfall over the Bahamas’ Abaco and Grand Bahama islands from Sept.

1-2 with sustained wind speeds of approximately 180 miles per hour, the deadly system became nearly stationary.

Based in part on satellite-based data and resulting estimates, the National

Aeronautics and Space Administration (NASA) reported that as of the early hours of Sept. 3, Hurricane Dorian had been “stationary over the island of Grand Bahama for 18 hours, most of the time as a Category 5 hurricane,” with stormtotal rain accumulation over parts of Grand Bahama and Abaco islands having already exceeded 24 inches.

Amazingly, it continued to get worse. By the next day, Sept. 4, NASA researchers estimated that, in addition to the massive direct storm damage, rain accumulation had exceeded 36 inches in an area that included parts of Grand Bahama Island and Abaco Island.

That same day, USAID’s Office of U.S. Foreign Disaster Assistance (OFDA) issued its initial response report, stating, “Hurricane Dorian severely damages homes and infrastructure and causes

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FLOATING MEDICAL SUPPORT

U.S. NAVY PHOTO BY BILL MESTA

A view of the U.S. Navy Hospital Ship USNS Comfort (T-AH 20) as it gets underway from Naval Station Norfolk, June 14, 2019. Comfort got underway to begin its deployment to South America, Central America, and the Caribbean in support of humanitarian and partner-building efforts. extensive flooding in Abaco and Grand Bahama,” and adding that U.S. Chargé d’Affaires Stephanie Bowers had declared a disaster in the Bahamas on Sept. 2, prompting USAID to activate a Disaster Assistance Response Team (DART) to lead the U.S. government (USG) response, as well as a Washington, D.C.-based Response Management Team (RMT) to support the DART. The DART and RMT are responding to the situation in coordination with other USG counterparts, Government of Bahamas (GoB) representatives, and humanitarian partners.

While not officially part of the DOD, an early glimpse of potential capabilities that could be applied came from the U.S. Coast Guard (USCG), which provided immediate response efforts by conducting helicopter search and rescue activities. As of Sept.

4, USCG reported the rescue of 39 individuals in Abaco and three individuals in Grand Bahama from flood-inundated areas. Along with coordinating aerial search and rescue operations, the service began to ship 250 rolls of plastic sheeting

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– sufficient to support shelter requirements for approximately 12,500 people – to the Bahamas aboard five Coast Guard cutters that would arrive on Sept. 5.

In terms of direct U.S. military support, the Sept. 4 briefing added that the DOD had already “made available up to $5 million in Overseas Humanitarian, Disaster, and Civic Aid funds to support USAID/OFDA-led response operations in the Bahamas, including through military air transport for humanitarian personnel and cargo.”

Three days later, on Sept. 7, 2019, the USAID/OFDA daily briefing explained, “In addition to working closely with the USCG, USAID is working with the U.S. Department of Defense (DoD) and has requested the unique capabilities of [USNORTHCOM] to provide airlift and logistics support for USAID-led humanitarian response activities. U.S. military helicopters began transporting members of the DART and critical response equipment to Abaco on September 7.”

[Footnote: In 2018, the commander of USNORTHCOM formally received the expanded role as the DOD Synchronizer for DSCA.] USAID’s Sept. 8 update noted the successful application of the DOD helicopter transport capabilities, stating: “With the support of the U.S. Department of

In his Sept. 8, 2019 letter to USAID Administrator Mark Green, U.S. Sen. Marco Rubio, R-Fla., urged Green to request that the DOD reposition the hospital ship USNS Comfort to support hurricane relief efforts in the Bahamas.

But the fact is that the East Coasthomeported Comfort, along with her West Coast-homeported sister ship, USNS Mercy, do far more than disaster response. The two ships represent key DOD capabilities for delivering medical assistance, humanitarian assistance, subject matter exchanges, and partnership building.

In fact, mid-September 2019 found Comfort completing its seventh medical mission in Central America, South America, and the Caribbean, departing Grenada on Sept. 21. During the port call, the Comfort team included military and civilian personnel from the United States and partner nations, including Argentina, Brazil, Canada, Costa Rica, Chile, the Dominican Republic, Mexico, and Peru, as well as several nongovernmental organizations.

During Comfort’s six-day medical mission in St. George’s, Grenada, 800 medical professionals from those partner nations and organizations joined U.S. Navy, U.S. Air Force, U.S. Army, and U.S. Public Health Service representatives to provide care for 5,060 patients at two separate shore-based medical sites as well as performing 96 surgeries aboard the ship.

Defense (DoD), members of USAID/ OFDA’s Disaster Assistance Response Team (DART), along with other relief actors, conducted aerial and on-theground assessments of storm-affected

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U.S ARMY PHOTO BY SPC. JENNILY LEON RODRIGUEZ

U.S. Army soldiers unload equipment from a U.S. Army CH-47 Chinook helicopter in the Bahamas, Sept. 9, 2019, in the wake of Hurricane Dorian. In the days following the storm’s landfall in the Bahamas, DOD ships and helicopters transported response personnel and tons of supplies between Nassau and storm-affected areas.

areas of Abaco and nearby cays on September 7 and 8. The assessments found that predominant humanitarian needs include safe drinking water, shelter support, and measures to restore power and enable access to hard-toreach communities.”

Along with transport, Sept. 8 seemed to reflect a transition of sorts to think about the growing medical needs being identified. Following his own visit to some of the devastated areas, U.S. Sen. Marco Rubio, R-Fla., sent a letter to USAID Administrator Mark Green, urging him to request that the hospital ship USNS Comfort be repositioned to the Bahamas as soon as possible.

Rubio shared observations from his recent trip, stating: “There remains an immediate need for medical attention and communications, however, accessibility and resources are limited, and a lack of electricity continues to plague recovery efforts. Vertical-lift of those who are injured and require treatment by trained professionals is the only solution until debris is cleared and on-shore resources can be stood up. The USNS Comfort, and its crew of trained medical staff, flight deck and ability to desalinate water, would be ideal in helping the Bahamian people. While it is currently assigned to U.S. Southern Command’s Area of Responsibility, the USNS Comfort, if requested, could be reassigned to the Bahamas and provide short-term medical treatment as runways and ports come back online. Additionally, the Bataan Amphibious [Ready] Group, already in the area, has ships that are also capable of providing air lift and medical support.”

Meanwhile, DOD support to ongoing operations continued to grow. In its Sept. 10 briefing, USAID observed that DOD was “operating daily flights to transport humanitarian actors and

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relief commodities between Nassau and storm-impacted islands,” adding, “As of September 9, DoD ships and more than 20 helicopters had transported approximately 72 metric tons of supplies and 180 response personnel.

“DoD continues to provide extensive logistic support for humanitarian operations, with [USNORTHCOM] operating daily flights for NGO [nongovernmental organization], UN [United Nations], and DART staff, as well as humanitarian supplies, from Nassau to affected areas of Abaco and Grand Bahama,” it elaborated.

“On September 10, [USNORTHCOM] helicopters supported the movement of International Medical Corps emergency medical team staff and medical supplies, as well as a joint assessment team – comprising staff from UN Office for the Coordination of Humanitarian Affairs (OCHA) and UK Department for International Development (DFID) – to Freeport. On the same day, [USNORTHCOM] facilitated a health assessment by staff from the GoB and the Pan American Health Organization in northern Abaco’s Coopers Town.”

“PROACTIVE RESPONSE” Just as the DOD has to attempt to prepare for and position itself to face the challenges of unknown battlefields, military resources would also be applied in response to either natural or man-made crises ranging from globally spread pandemics to domestic chemical, biological,

radiological, nuclear, or high-yield explosive (CBRNE) incidents to the growing threats of cyber-intrusion into our domestic security.

In the case of CBRNE preparations, the bulk of the effort falls within USNORTHCOM’s Joint Task Force Civil Support (JTF-CS). Consisting of active, Guard, and Reserve military members drawn from all service branches, as well as civilian personnel, the task force is commanded by a federalized National Guard general officer and has the responsibility to plan and integrate DOD support to the designated Primary Agency for domestic CBRNE consequence management operations.

As noted in USNORTHCOM descriptions, “When approved by the secretary of defense and directed by the commander of USNORTHCOM, JTF-CS deploys to the incident site and executes timely and effective command and control of designated DOD forces, providing support to civil authorities to save lives, prevent injury, and provide temporary critical life support.

“The mission of supporting civil authorities is not a new one for DOD,” it adds.

“The U.S. military has a long history of providing assistance to civil authorities during emergencies. U.S. military forces have assisted federal, state, and local agencies during natural disasters such as hurricanes, floods, and earthquakes. The role of JTF-CS in providing assistance to the Primary Agency after a CBRNE incident is in keeping with this long and proud tradition.”

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TRANSFORMING PAIN CARE FOR VETERANS

By Gail Gourley

n MANY VETERANS ARE IN PAIN. It affects their lives, and their families, every day.

Recognizing the needs of its patients, the Veterans Health Administration (VHA) continues to take a system-wide proactive role in managing pain. Moreover, recent years have seen a shift in pain management techniques and approaches in the context

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of the ongoing opioid crisis, emphasizing reduced reliance on medication and increased utilization of a variety of alternative pain therapies. This shift also incorporates a holistic, teambased approach to patient care. “Talking about the current state of pain management in the VA [Department of Veterans Affairs], clearly we are in

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the process of transforming our health care approach to pain management,” explained Friedhelm Sandbrink, MD, national program director for pain management, VHA, and director, Pain Management Program, Department of Neurology, Washington DC VA Medical Center.

Pain is a significant and complex issue in the veteran population. “In veterans, it’s often in the context of significant mental health and often medical comorbidities, which really contribute to the challenge,” Sandbrink said. “If it’s in the setting of somebody, for example, with PTSD [post-traumatic stress disorder], you have to really coordinate the mental health [aspect] with the medical and the pain approach. It requires coordination of care.”

Sandbrink said that, in general, chronic pain is more common in veterans than in non-veterans, and more often severe, citing data from a National Health Interview Survey published in 2017 that compared veterans to non-veterans in

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Charles Brill, a physician’s assistant at the Fort Campbell Intrepid Spirit Center, uses acupuncture to relieve a patient’s pain March 20, 2017. The Department of Veterans Affairs is in the process of transforming its health care approach to pain management, moving away from reliance on opioid medication to incorporating complementary and integrative health approaches that include, for example, acupuncture, yoga, and cognitive behavioral therapy.

the United States. Survey results indicated severe pain in veterans is 40 percent more common than in non-veterans, 9.1 percent of respondents versus 6.4 percent respectively, and especially in veterans who served in recent conflicts.

Additionally, of veterans enrolled in VA primary care, Sandbrink said 1 in 3 has a chronic pain diagnosis, 1 in 5 has persistent pain, and 1 in 10 has severe persistent pain. “And we know also from data comparing 2008 to 2015 that both pain diagnoses as well as mental health diagnoses actually have increased in prevalence,” he added.

The trend away from medication reliance, especially opioid medication, began more than five years ago, Sandbrink said. “We initiated our Opioid Safety Initiative [OSI] as a pilot in 2012 and took it nationally in 2013. The [OSI] supports our approach of implementing pain care transformation, moving away from relying on medication itself, but including and providing additional access to nonpharmacological strategies – approaches that include complementary and integrative health [CIH] modalities,” he said, including, for example, cognitive behavioral therapy (CBT), yoga, and acupuncture.

Sandbrink added that the VA approach aligns very well with the findings of the Department of Health and Human Services Pain Management Best Practices Inter-Agency Task Force report, released in May 2019. “It truly supports our approach to pain care, which is an integrated, collaborative approach to pain management that relies on these different modalities and relies on teams

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PHOTO BY LEEJAY LOCKHART

V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

VA IMAGE

The VA’s whole health approach incorporates complementary and integrative health practices – including non-pharmacological ways to manage pain – in its effort to provide veterans with more patient-centered, holistic care.

Additionally, Sandbrink identified that high-dose opioid prescribing, associated with higher risk of overdose and death, in this case tracking as 100 or more morphine milligram equivalents per day, saw a 74 percent reduction from 2012 to currently. “So we still have about 15,000 patients on a high-dose regimen, but we used to have close to 60,000,” he said.

Another component of the OSI is the Overdose Education and Naloxone Distribution program, which educates veterans, families, and caregivers about overdose and aims to prevent death by treating and reversing a life-threatening opioid overdose with naloxone administration. Naloxone is provided to veterans identified as being at risk for opioid overdose. “They may be patients on high-dose opioid medication, or who maybe stopped opioid medication recently, or are on an opioidbenzodiazepine combination,” said Sandbrink. “We have now issued naloxone to more than 200,000 veterans at no cost to the veteran, and we have had over 700 successful reversals of an overdose with this medication. So, I think in many ways, the VA is a leader in naloxone distribution.”

Concurrently with the VA moving away from reliance on opioid medication to treat pain, greater emphasis has been directed toward non-pharmacological CIH approaches. In 2016, the VHA Office of Health Services Research and Development held a state-of-the-art (SOTA) conference titled “Non-pharmacological Approaches to Chronic Musculoskeletal Pain Management.” At this VA-sponsored research conference, Sandbrink said, “We looked at what is the best evidence that we have for non-pharmacological pain treatments for musculoskeletal pain, which is the most common pain conditions that veterans have.” He added that they determined there’s “good evidence” for the

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effectiveness of behavioral and psychological therapies such as CBT; exercise and movement therapies such as yoga and tai chi; and manual therapies such as acupuncture and massage.

The evidence-based findings and recommendations from this SOTA conference were published in a 2018 article in the Journal of General Internal Medicine. The article stated that participants recommended the following nine non-pharmacological therapies “be implemented across the VHA system as part of pain care: cognitive behavioral therapy; acceptance and commitment therapy; mindfulness-based stress reduction; exercise therapy; tai chi; yoga; acupuncture; manipulation; and massage.”

The article continued, “Integration of these non-pharmacological approaches into primary care, pain care, and mental health settings should be a policy priority, and these treatments should be offered early in the course of pain treatment.”

Sandbrink said, “We now make these treatment approaches available to our veterans whenever it’s clinically indicated. And if we can’t do it at the VA facility itself, then we make that information available through the community care program.”

Sandbrink reflected on the significance of the VA’s emphasis on the whole health approach, which he characterized as “a reorientation of how the VA engages with veterans.”

“The VA is moving towards a more patient-centered care approach – a more holistic, whole health approach,” Sandbrink explained. “It’s being rolled out nationwide, supported by the Comprehensive Addiction and Recovery Act, the CARA legislation from 2016, that not only supported the [OSI] in the VA, but also actually mandated that VA expand the use and the research and the education about integrative health modalities. The VA has taken this further and has implemented a whole health approach that is integrated into our health care at all facilities.

In 2018, we actually established 18 flagship sites for [CIH] and whole health in the VA. Every VISN [Veterans Integrated Service Network] has a dedicated flagship site. By 2020, we expect to bring on two more sites in each VISN, so another 36 that have the whole health approach will be added.

“What we mean by that is that not only do we build an integration of CIH modalities into our clinical care, and we have whole health clinicians and teach all providers about that, but we also include a much greater effort to educate and train veterans and their families in self-care and self-management,” Sandbrink continued.

“This is really about empowering the veteran,” he said. “What is really important for you in your situation in your life, and how can we as a health care system support you to reach your goals and be as functional as possible?”

Sandbrink also highlighted the VA’s efforts to fully implement a 2017 VA mandate that every facility have an interdisciplinary pain team – including a medical provider, an addiction specialist,

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A counselor meets with a veteran. The VA’s patient-centered, whole health approach entails that a veteran and care providers work together to form a personal care plan, which guides not only a strategy to manage pain but the veteran’s health care altogether.

a rehabilitation professional, and a provider who can deliver evidence-based behavioral approaches – at their site.

“This demonstrates how seriously we take this as a system to make sure that we not only provide medication but a truly comprehensive team approach,” he said.

Furthermore, Sandbrink emphasized, “One of the things that we do in the VA is truly target our resources to the veterans who need it most. So we need to have a population-based approach that makes sure that every veteran has access to the pain care they need. We also realize that there are veterans who are at particularly high risk for an opioid overdose or for suicide, and we know that chronic pain is one of the most commonly identified risk factors for suicide.”

In an effort that is both from mental health as well as from pain management, Sandbrink explained, information about veterans identified at highest risk is provided to the facility, and every facility now has a risk review team consisting of primary care, pain clinic providers, and mental health providers. “They discuss the care of these patients who are at highest risk in order to coordinate their care and make sure they get engaged by the right providers,” he said. “They may, for instance, see that a patient who is on opioid medication hasn’t been seen yet by the pain clinic, but may benefit from that, or they see that a patient may have a high risk for a mental health concern, and they proactively reach out to the veteran to engage them. The goal is really to integrate across our different stakeholders so that the teams who work with a veteran all work together to develop one care plan that includes pain care and mental health.”

As part of the ongoing effort to provide the best pain care for veterans, Sandbrink said the VA has a large pain research effort. “A lot of it is in regard to understanding the impact of opioid medication, and the impact of our non-opioid approach to pain care in regard to patient satisfaction and outcomes.

We also have a lot of efforts to increase understanding of how we can better engage the veteran in this transformation of pain care, and for veterans who have opioid use disorder, how we can better actively engage them with the treatment program for that.”

For example, Sandbrink said the VA recently held a SOTA research conference specifically regarding opioid medication

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and opioid use disorder, bringing in external stakeholders, subject matter experts from all over the nation, and VA leaders to enhance research and understanding regarding patients who are on long-term opioid therapy; improving access to opioid use disorder treatment; and examining challenges for patients who have both pain conditions as well as substance use disorder.

Asked about the biggest challenges in addressing pain management for veterans, Sandbrink identified “moving away from reliance on opioid medication to multimodal pain care” and emphasized the need to engage veterans, their families, and their caregivers.

“It’s reflective of our whole health effort,” he said. “We’re transforming our approach to care, which is really a huge endeavor, but we are not changing pain care alone. We’re actually changing our entire health care approach. And one of the challenges is for everyone involved to work together collaboratively, speaking the same language and developing a care plan together.”

While pointing to “huge strides” made to date in opioid prescribing, he acknowledged, “Some patients are still on highdose long-term opioid therapy, and we realize the challenges that come with making that pain care transformation. We also realize that a significant number of the veterans who have been on opioid medication long term may have developed opioid dependence or opioid use disorder. Across the United States, we have more than 2 million people who are believed to have opioid use disorder. And we know that many veterans are affected by that.”

He continued, “One thing that we need to make sure [of] is that we adjust the care of those veterans that takes the whole person into account. And that means not just thinking about what is the safest from a pain care standpoint, but also possible addiction treatment.

“There’s a lot of stigma associated with opioid use disorder or receiving the medication for that,” he summarized. “So that needs to be considered as well.”

Sandbrink emphasized, “We want to make sure that veterans know that we are here to listen to them and that we offer a truly comprehensive pain care approach with multiple modalities. We want to encourage veterans to make use of what we offer, to make use of our behavioral therapies, our rehabilitation approaches, our integrative health modalities, because the best pain care can only happen if the patients are actively engaged with implementing it.

“This is something where the providers and the patients work in collaboration as a team,” he said. “And the most important team member is the veteran.”

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INTERVIEW

VETERANS’ DENTAL CARE IN CONGRESSIONAL SPOTLIGHT

An interview with U.S. Rep. Gus M. Bilirakis

By Gail Gourley n ONE ASPECT OF VETERANS’ HEALTH CARE receiving heightened attention involves dental care. A clear example of expanded congressional focus on this topic emerged at a recent hearing before the Health Subcommittee of the House Committee on Veterans’ Affairs. During that September hearing, Rep. Gus M. Bilirakis, R-Fla., highlighted legislation he introduced in May 2019 in an ongoing effort to expand the Department of Veterans Affairs’ (VA) existing dental care services to an increased number of veterans.

The Veterans Early Treatment for Chronic Ailment Resurgence through Examinations Act of 2019 (H.R. 2628), or the VET CARE Act of 2019, would authorize administrative support for community providers of dental care and establish a pilot program providing dental services to 1,500 eligible enrolled veterans who currently receive no periodontal care.

This pilot program would serve to determine whether there is a correlation between receiving these services and experiencing fewer complications of chronic ailments.

Increasing evidence supports a link between periodontal disease and chronic conditions including cardiovascular disease, stroke, and diabetes, and indicates it is a contributing risk factor in pregnancy for premature birth and/or low birthweight. While

Veterans Affairs & Military Medicine Outlook: Before discussing the details of the legislation that you introduced, how would you describe the current state of VA dental care for veterans?

U.S. Rep. Gus M. Bilirakis: Well, it’s not adequate. This is [based on] hearing from veterans in my district, but veterans all over the country are having a very difficult time getting dental care. We do have several nonprofits in the Tampa Bay area, where I’m from, that help out veterans, and we actually partner with the dental association here in Pasco County. They see as many veterans as they possibly can, but it’s never enough.

And right now, it’s very limited in what they can do, as far as who qualifies for

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the VA does provide outpatient dental services to certain eligible veterans as defined in Title 38 of the U.S. Code, eligibility requirements differ from those for most other VA medical benefits, resulting in many veterans receiving no dental care.

At the Health Subcommittee hearing, Bilirakis said, “If we’re able to improve the VA health care system by providing preventive dental services that lead to fewer complications of chronic ailments, it not only shows that we are looking at the long-term outlook of our veterans’ health, but it could also prove to be done in a cost-effective manner. The VET CARE Act is a practical, commonsense way to demonstrate this approach for dental services, replicating already-established research in the community.”

Bilirakis represents Florida’s 12th Congressional District. Elected in 2006, he serves on the Energy and Commerce Committee and the Veterans’ Affairs Committee. He is the ranking member of the Veterans’ Affairs Economic Opportunity Subcommittee and a member of the Disability Assistance and Memorial Affairs Subcommittee. In the week prior to the Health Subcommittee hearing on H.R. 2628, Bilirakis spoke with Veterans Affairs & Military Medicine Outlook about the importance of the VET CARE Act of 2019 and expanding dental services for veterans.

dental care. You have to be 100 percent disabled, or a [former] POW [prisoner of war], or it has to be a service-connected [dental] injury, meaning if someone gets injured in the mouth during combat. It’s certainly not enough.

You introduced the VET CARE Act of 2019 earlier this year. In broad terms, how do you hope to change things with this bill?

First of all, our veterans deserve the dental care. And we want to prove to the VA that you can save money on the back end. If we treat these veterans, who are so worthy, then they won’t develop exacerbated health complications, in a lot of cases, including those associated

with diseases such as diabetes. A study was presented to me by a dentist in my area, [Zacharias Kalarickal, DDS], who knew a good friend from the University of Pennsylvania, Dr. [Marjorie] Jeffcoat, [DMD], the former dean of the dental school. She conducted a study having to do with heart disease, diabetes, and other chronic diseases. We feel that we can make our point by passing this pilot project, and comparing those who have type 2 diabetes and receive dental care to those that have type 2 diabetes that do not receive dental care, proving that, in the long run, you can keep veterans with diabetes healthier if you provide preventative oral health care, and that treating their underlying diabetes is less

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We feel that we can make our point by passing this pilot project, and comparing those who have type 2 diabetes and receive dental care to those that have type 2 diabetes that do not receive dental care, proving that, in the long run, you can keep veterans with diabetes healthier if you provide preventative oral health care, and that treating their underlying diabetes is less costly when the veteran has access to dental care.

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Rep. Gus M. Bilirakis, R-Fla.

FACEBOOK PAGE OF REP. GUS M. BILIRAKIS

costly when the veteran has access to dental care.

Specifically, what would Section 2 of the bill, “Administrative Support for Community Providers of Dental Care,” do? Could you explain how this would work?

This section would ensure that VA providers are entitled to advise patients in the pilot program of opportunities

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for dental care through the VADIP [VA Dental Insurance Program] and other community partners for low- to no-cost dental care. Currently, the VA is prohibited from advising its patients to go to nonprofit and other providers in the community for dental [care].

My bill would allow VA to have that conversation with these veterans who go through the pilot program by giving them a list of those potential providers in the community. It’s really common sense, and they should be allowed to do so anyhow, but this assures them that they can do this; they can make these referrals for our veterans.

We have community providers for those who are participating in the pilot

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We have community providers for those who are participating in the pilot project – 1,500 veterans who have type 2 diabetes and are chosen, not by me, but in accordance with the legislation. project – 1,500 veterans who have type 2 diabetes and are chosen, not by me, but in accordance with the legislation.

Veterans who have a service-connected disability will be given preference with regard to this pilot project. But we also want to inform them in the meantime, until we can get dental coverage for all veterans, or at least those who are disabled or have these chronic illnesses.

We want to make sure that they know about the [dental] resources available in the community.

There also is something that the Congress passed a few years ago. It’s really not sufficient according to the veterans that I speak to, but there is a discounted insurance program [VADIP] that will help. It provides discounted, low-cost insurance by private insurers such as Delta Dental [and MetLife]. The cost is a little lower, but still much too expensive for a lot of veterans to afford.

So, we think that the opportunities within the VA and even outside the VA, even though they’re well intentioned, are just not adequate. Not enough veterans would be covered.

Could you please elaborate on Section 3 of the VET CARE Act, which outlines the “Pilot Program for the Provision of Dental Care to Certain Veterans”?

This is a four-year pilot program serving 1,500 veterans who have type 2 diabetes, giving preference to those who are disabled – not necessarily 100 percent disabled, because they already qualify for dental care, but those who are disabled. Those veterans will receive dental care with periodic visits to the dentist. After the pilot program is completed, we will measure those results – how the veteran is doing with the dental care provided as opposed to not having any dental care at all. And in this way, we [intend to] prove to the

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VA and the federal government that it does make a difference. We feel it will save a lot of money on the back end with this prevention. And that’s what it is – it’s preventive services. In general, I know that going to the dentist provides many benefits, and I know that there have been studies linking certain oral diseases to factors that will ultimately affect your heart, for example, and we want to prevent heart disease, obviously. So first, the veterans deserve this care, without question. And, secondly, we’re going to save money in the long run if we provide preventative dental treatments to veterans. We want people to know that [by expanding dental coverage], we’ll save the VA money that could be used elsewhere in the long run – for mental health care, for example.

How were the eligibility criteria determined regarding which veterans would be included in the pilot study?

We had to limit it to a certain extent, and we chose diabetes. Type 2 diabetes is very rampant and it is a chronic disease, so we thought that we could measure that as opposed to a chronic disease that is not as common. I’ve always relied on experts’ [input], and we’ve fine-tuned the bill over the years, including fiscally. You can have the best bill possible, but if it’s not heard in the VA Committee and doesn’t get on the floor of the House of Representatives and the Senate, it’s not going to go anywhere and it’s not going to do good. So sure, I would like to file a bill to cover all veterans with regard to [dental] care, or at least those who qualify to receive medical care in the VA system. I would like to cover all of them to make sure that we provide dental care, but I know that we would face a lot of dissent [in some circles], and I know that more than likely the comprehensive bill wouldn’t go anywhere at this point. So, I thought this was a good way to start. But

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ultimately, we want all our veterans who qualify for health care within the VA to receive dental care.

PHOTO COURTESY OF THE OFFICE OF REP. GUS M. BILIRAKIS

What are some of the possible outcomes after the pilot study concludes?

If we can prove that we’re saving money in the long run and treating our heroes – and it’s not costing us a lot of money for the pilot project; I understand the expense is very negligible – then we’ll file subsequent legislation. As a matter of fact, I’ve spoken to [U.S. Rep.] Julia Brownley, [D-Calif.], chair of the Veterans’ Affairs Health Subcommittee, and she has a comprehensive bill to cover VA [dental] care. I don’t think that

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I’ve participated in several town hall meetings, particularly veteran meetings, and vets come up to us and, case by case, they say, “We need surgery. We need dental care. We need a root canal, or a crown,” and we’ll refer them, we’ll try to get them help individually, and in a lot of cases we’ll find a dentist that will do it.

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it would go [forward currently], because you’re taking away some money possibly from another program, an existing program. I don’t really think that we can get all that. This [pilot study] will show the VA and members of Congress that we’ll prove that prevention will definitely save money in the long run, and we’ll file a bill to have our veterans covered.

What would passage of this bill mean for veterans?

It gives them hope. First of all, the 1,500 [veterans in the pilot study] would get dental care, those who are selected, and again, not by me. But secondly, it gives the veterans hope that we’re working towards solving this issue. I’ve participated in several

Rep. Gus M. Bilirakis pictured with three veterans in August 2019. In May 2019, Bilirakis introduced the VET CARE Act, legislation that aims to expand existing dental care services to an increased number of veterans.

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For the most part, in our VA Committee – and I’ve been on there since 2007 – we’ve worked in a bipartisan fashion. We want to prove to fiscal conservatives that this is a worthy program, and of course, save money in the long run.

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town hall meetings, particularly veteran meetings, and vets come up to us and, case by case, they say, “We need surgery. We need dental care. We need a root canal, or a crown,” and we’ll refer them, we’ll try to get them help individually, and in a lot of cases, we’ll find a dentist that will do it. Or we’ll have a one-, two-, or three-day clinic that’s open to all veterans.

But we want to solve this problem for every veteran that qualifies.

What would passage of this bill mean for the VA? It will prove to the VA that this service is affordable.

The bill has a bipartisan group of cosponsors. Is there anything you’d like to highlight about the bipartisan nature of this bill’s cosponsors?

For the most part, in our VA Committee – and I’ve been on there since 2007 – we’ve worked in a bipartisan fashion. We want to prove to fiscal conservatives that this is a worthy program, and of course, save money in the long run.

What do you see as the biggest challenges in passing this bill?

Because we’re having a hearing on the bill next week, I think that we’ve convinced the chairman and the ranking member and committee staff that this is something that’s doable. So, I think we’ve gone through that. We’ve overcome those hurdles with regards to challenges. Again, preventive dental services and better health lead to better health outcomes. This is definitely a worthy goal.

To summarize, is there a message you would like to convey to America’s veterans?

Yes. I want them to know that it’s a priority on the Health Subcommittee, and the VA Committee, and it definitely is my top priority to get our veterans the services that they need and have earned.

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ORGANIZATIONS EXPRESS SUPPORT FOR THE VET CARE ACT OF 2019 While addressing key questions posed by Rep. Gus M. Bilirakis, R-Fla., during a recent House Veterans’ Affairs Committee Health Subcommittee hearing about H.R. 2628, the VET CARE Act of 2019, representatives from three veterans service organizations offered strong support for the bill, which would expand the Department of Veterans Affairs’ (VA) dental care services for veterans.

Referencing written remarks supporting the legislation, Roscoe Butler, associate legislative director, Paralyzed Veterans of America (PVA), stated during the hearing that a person’s “oral health has a major impact on their physical health, and gum disease is often associated with diabetes, heart disease, and many other serious medical conditions. A large number of veterans who receive care from the VA are not getting the appropriate dental care needed, which could later add to other health complications.” The written PVA statement continued, explaining, “The VET CARE Act would require VA to establish a four-year pilot program for older veterans with type 2 diabetes. Since the VA spends most of its health care costs on treating veterans with chronic conditions like diabetes, expanding dental coverage to these individuals will help improve their overall health and may bring those costs down.”

Joy J. Ilem, national legislative director, Disabled American Veterans (DAV), said, “DAV has been a long-time advocate of dental care for all veterans being within a comprehensive care package.” She added, “I think [this] bill is very reasonable in terms of a start to look at the conditions, as Mr. Butler indicated, that are prevalent in the veteran population,” utilizing the pilot program study “as a first step of really offering that benefit.”

DAV written testimony affirmed the organization’s strong support for the legislation as a “measured and reasonable way to assess the full costs and benefits associated with regular and preventive dental care for service-connected veterans,” and to assist policymakers in improving VA dental services in the future.

In his written statement of support for the bill, Jeremy Butler, chief executive officer, Iraq and Afghanistan Veterans of America (IAVA), referred to the legislation’s “pilot program to expand dental care to veterans that have certain chronic conditions. This type of care has been proven to increase overall health and reduce health care costs. It is for these reasons that IAVA supports this legislation.”

At the hearing, Jeremy Butler referred to the existing “disconnect between dental care and medical care,” adding, “we’re all in agreement here that it’s [veterans’] whole health that is the important part, and these should be seen as one thing.”

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VA PROSTHETICS: STATUS AND ADVANCES

By J.R. Wilson

n ANCIENT TEXTS – POETRY, HEROIC TALES, HISTORIES – make reference to prosthetic limbs dating back as far as 1500 B.C., although the oldest physical evidence is an artificial leg dated at around 300 B.C. Unearthed at Capua, Italy, in 1858, the bronze and iron device, with a wooden core, appears to have been used after a below-the-knee amputation.

For the next 1,500 years, little progress was made and prosthetics primarily were cosmetic in nature, aside from those designed to help a horse-mounted knight hold a sword or lance.

The only “advances” were the development of the peg leg and hook hand during the “Dark Ages” (476 B.C. to 1000 B.C.).

The Renaissance (14th-17th centuries) saw a renewed emphasis, based on resurrected Greek and Roman medical texts, to fit amputees with more functional prosthetic legs and hands, most made of iron, steel, copper, and wood. Increased functionality and lighter, more adaptable materials led to the first real advances during the 16th century. The next three centuries saw incremental improvements in articulation, materials, and functionality, but artificial limbs essentially remained little more than “placeholders” for the amputated limbs.

It was not until post-World War II military amputees began demanding greater functionality that researchers again improved the weight and durability of prosthetics and, with the development of transistors and microprocessors, began the modern evolution of technologically advanced components and systems.

While significant advances were made in both design and functionality from 1950 through the post-Desert Storm era of the 1990s, all of the factors for a “perfect storm” in prosthetics – from smaller, faster electronics to advanced new lightweight materials to high demand to strong public support – came together at the turn of the century and the beginning of America’s longest war in Southwest Asia.

Improved, ubiquitous body and vehicle armor, universal basic medic training for all warfighters, medics trained to EMT levels, and the presence of surgical teams on the front lines made Operation Iraqi Freedom and Operation Enduring Freedom (Afghanistan) the lowest killed in action (KIA) conflicts in history.

But they also led to more amputations and more major loss of limb functionality than at any time since the U.S. Civil War. The Department of Veterans Affairs (VA), the Department of Defense (DOD), and civilian academic and medical research

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facilities all are involved in – and cooperating with each other on – the constant advancement in prosthetics, especially lower limbs, arms, and hands, the latter being by far the most difficult.

Prosthetic legs have advanced to the point where some wounded warfighters, told advanced battlefield care has saved their legs – but with only 80 to 90 percent of the functionality they originally had – have asked DOD or VA surgeons to amputate and give them the latest prosthetic leg, which may offer more than 100 percent of a natural leg’s functionality.

Even so, artificial legs still are not perfect, with different people experiencing different levels of pain and difficulty adapting to them.

Although the number of U.S. warfighters now deployed to Southwest Asia is only a fraction of those there at the peak of the war, interest in further prosthetic technology development and funding for it has remained relatively stable, as has the pace of research, development, test, and evaluation (RDT&E).

“Some areas are moving faster than others at different points in the development pipeline,” according to Brian Schulz, PhD, scientific program manager, VA Office of Research and Development. “Multigrasp hands have come a long way, microprocesser knees and ankles have made advances. Most [of those advances] have been on the inside [of the prosthesis], such as neural interfaces and a lot of surgical techniques that show immense promise for the future.

“It’s more a steady process of small advances than a big leap.

There are some things on the cusp, such as modular implantable neural prosthetic systems that interface the nerves with the prosthetic limb. That doesn’t have full FDA [Food and Drug Administration] approval yet, but once it and others are approved, they will come together in the future to enable much more capability.”

The level of funding and research, combined with advances in other technologies that are applicable to improving some part of prosthetic development, such as smaller, faster microprocessers, also have led researchers to take another look at ideas previously shelved because all of the necessary technologies were not there to support them.

“A fair amount of funding has gone into trying to improve the socket interface due to the discomfort and skin issues prosthetic users experience. Despite a lot of effort and some incremental advances, I don’t think we’ve really solved the

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intended issues, which is why some of the internal efforts have become more attractive,” M. Jason Highsmith, PhD, national director, VA Orthotic & Prosthetic Clinical Services, told Veterans Affairs & Military Medicine Outlook.

“There may be some additional things [impacting the future evolution of prosthetics], such as the concept of wearable technology. Another is the smartphone, where you can connect to an app to make an adjustment.”

The vast majority of military amputees from Southwest Asia have been in their late teens or early 20s, raising another concern for researchers and clinicians.

“These largely impact the younger end of the spectrum, and we don’t really have a good handle on what will happen as they grow older,” Highsmith warned.

“We need more studies.”

That is one reason it takes so long to move a new technology or prosthesis from the lab to the FDA to the wounded warrior. And the amount of red tape involved will only increase as

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Despite great strides in prosthetic technology, especially since the turn of the century, the process of adapting to and property fitting prosthetics can still be challenging. researchers seek to link new levels of prosthetic electronics to the human nervous and muscle systems.

That is why translating implantable and invasive systems to market is slower than developing the enabling technologies.

“So many advances in the lab look promising, but take so long to get out to the patient. Any implantable device requires full FDA approval as a Class 3 implantable device, which is far more difficult,” Schulz said. “Some level of red tape is necessary because these are invasive devices, but they also are a hurdle we have not had to get past with simpler external devices.

“The implants would be permanent, with the prosthetic attaching to it. The problem there is you have a hole in your skin with metal coming through it that could be an avenue for infection.”

This slower, more difficult process also will have an impact on public perception and the expectations of amputees. Advances in artificial limbs, especially legs, have been so fast and dramatic since the turn of the century that those outside the development chain have come to expect new, sci fi-level capabilities on a regular, fast-track basis.

Lately, however, new technologies under investigation are facing a much longer and more rigorous approval cycle before becoming commercially available.

Which is not to say there are no exceptions, the most notable of which is the LUKE Arm, under development for the past 15 years by DEKA Research & Development Corp., a New Hampshirebased company founded by Segway inventor Dean Kamen. Named for the prosthetic hand given Star Wars hero Luke Skywalker after a light saber battle with Darth Vader, it became the first invasive prosthesis approved by the FDA in May 2014.

The arm translates signals from the wearer’s muscles to perform multiple

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U.S. AIR FORCE PHOTO BY AIRMAN 1ST CLASS ABBIGAYLE WAGNER

V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

RIGHT: A prosthetic 3-D printed hand is made by Tech Sgt. Zachary Zilm, 582nd Operation Support Squadron NCO in charge of group training, July 3, 2018, on F.E. Warren Air Force Base, Wyoming. Zilm works through the organization Enabling the Future, a global network of passionate volunteers using 3-D printing to give the world a “helping hand.” The hands go to children who do not have the option for traditional prosthetic devices. Additive – or 3-D – printing and the ways it can potentially be used to improve care for patients with prostheses is of great interest to the VA. BELOW: Utah Gov. Gary Herbert meets with Enduring Freedom and Iraqi Freedom veterans Ed Salau, left, and Bryant Jacobs, right, in February 2016 at the VA Salt Lake City Health Care System. In December 2015, Salau and Jacobs became the first Americans to undergo surgery – part of an FDA-approved study – to receive percutaneous osseointegrated prostheses (POPs), titanium implants in their residual limbs to which prosthetic limbs attach.

PHOTO COURTESY DEPARTMENT OF VETERANS AFFAIRS

complex, simultaneous, powered movements. Individual motors in the wrist and fingers enable it to adjust its positions to perform six different user-selectable grips, while force sensors allow precision control of its grasp.

Continuing development of the LUKE Arm also has given the wearer a rudimentary sense of touch by tying sensors in the artificial fingers to nerves at the point of amputation. Special software translates the signals to mimic those coming

from a real hand, enabling the patient to “feel” and send signals back to the hand with the appropriate movements and pressure to open an envelope or pick up an egg without breaking the shell.

Hands and feet/ankles are the most difficult to replicate, although feet/ ankles, when part of a complete leg prosthetic, have shown significant improvement in recent years.

“The anatomic level of amputation matters greatly, especially what

happens at the foot level versus the legs.

Prosthetic feet began moving out in the 1990s, and in the last decade and a half, we’ve seen powered feet and ankle systems and microprocessor knee systems.

Upper limbs also have incorporated more of those during that time, reintegrating large muscle groups to have more control over the terminal device, such as a hand,” Highsmith noted.

“A lot of advancements have been made in a lot of areas. Sadly, the partial foot amputation problem has not moved as much as other areas. There were some advancements a decade ago, but nothing recently. The other levels have seen significant advancements, but there is always both an up and downside, in terms of cost, training, pain, etc.”

Research to advance and improve the sense of touch and balance – which are closely linked in feet and legs – reduce pain, and give the patient a greater sense of “wholeness” remain primary goals in improving the patients’ ability to reintegrate into their routines and lives.

As with many new technologies, an advance in one area often leads to advances in others. Such is the case with sensor restoration for lower-limb amputees. Schulz said the same technology could be used to restore sensation in Continued on page 43

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DOD PHOTO BY SUN L. VEGA

The LUKE Arm prosthesis translates signals from the wearer’s muscles to perform complex, simultaneous, powered movements. In May 2014, it became the first invasive prosthesis to receive FDA approval.

neuropathic feet, a growing problem among veterans.

The success of any new technology also depends on determining the best balance between accommodation and training.

“Folks have been paying more attention to this, looking at how much training is actually needed to fully and maximally use these technologies and be sure you’re actually studying the patient’s utilization to see if there is a real difference between the current technologies and previous technologies,” Highsmith said.

“Some higher technologies may be issued without proper training, and we’re very interested in making sure if we are going to issue technology that has novel features, the patient is getting the training to understand what the technology is capable of and how to properly use it. That could be understanding

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specific modes, for example, such as running or climbing.”

Other fast-evolving technologies not directly related to prosthetics also will have an impact on future VA and DOD efforts to improve patient care. One of those is additive – aka 3-D – printing.

“From a material science perspective, conventional methods and materials will likely be a strong product, but we have a number of clinicians who use this technology to make their delivery of care more efficient,” Highsmith said.

“That may not be the actual product, but check-fits along the way.

“There could be lots of different ways to integrate 3-D printing, and we don’t want to limit what our clinicians can imagine for using these techniques. We have a group looking at where these tools are around the network, how many clinicians are using it, what it is doing for practice in the VA. It’s of great interest.”

The materials available for 3-D printing today are not of sufficient quality for the rigors of a prosthetic limb, but new, stronger materials are being developed at a fast pace. And there are some applications where current materials might play a role.

“There are some circumstances where having a softer material is better, such as printed airsoles that are softer in some areas than others,” Schulz noted.

“Another group is looking at 3-D printing methods that would allow women to wear high heels, which standard prosthetics are not designed to do.”

Mechanical and biomechanical orthotics are not likely to be the only avenue of treatment for amputees in the future. Transplants of hands or feet, for example – not from another person but using replacements grown in the lab from the patient’s own cells – also are a growing part of 21st century medical research as is regeneration, where the body is stimulated to regrow a severed part. But both are far behind mechanical and even biomechanical prosthetics.

“Hand transplants will improve as technology and immune suppression improve, but in the forseeable future, it’s too difficult a problem to really take over.

It can be done, but not without challenges and setbacks,” Schulz said. As to what will be the dominant approach by mid-century: “I would say neural mechanical, increasing integration with our neural system. Possibly with some elements of regeneration.

“The future will see better integration of bio, improved control, improved neural interfaces, better skeletal attachments, more durable, commercial external components. Many of these advances can be used together to restore a limb. When people can feel, they tend to call it ‘their’ hand, not the ‘prosthetic’ hand.”

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V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

IMAGING TECHNOLOGY

By Scott R. Gourley

n FEW AREAS OF MILITARY MEDICINE are evolving faster and more dramatically than medical imaging.

And few locations reflect this evolution better than Brooke Army Medical Center (BAMC) in San Antonio, Texas. Comprising 10 separate organizations, BAMC has been described as “the Flagship of Army Medicine.” In addition, ongoing coordination with both veteran and civilian medical facilities provides BAMC practitioners with a unique perspective across a broad spectrum of medical care.

In terms of medical imaging, Col. James Wiedenhoefer, USAF, chief of BAMC’s Department of Radiology, points to “the full scope of radiologic services” and related imaging technologies.

“We span everything from the most basic, which is just plain film, to some of the more complex nuclear medicine and MRI [magnetic resonance imaging] imaging,” he explained. “So we do plain film, ultrasound, CT [computerized tomography], MRI, and nuclear medicine imaging, some of which is fused with cross-sectional imaging such as CT. And along those same lines, we also do interventional radiology work with angiography, fluoroscopy, and mammography.”

Elaborating on the example of mammography imaging, he offered that it uses “basic X-ray technology” that has been “modified slightly and specifically for imaging breast tissue.”

He noted that recent mammography developments at BAMC involve the introduction of 3-D breast tomosynthesis, which applies computer technology to achieve 3-D imaging of the breast tissue, which he characterized as a significant enhancement over “plain film 2-D imaging.”

Wiedenhoefer pointed to CT scanning as “the workhorse” of imaging at BAMC, largely due to the fact that “it’s quick and it’s detailed.”

“With our radiology services, we probably do more here than anywhere else in the DOD,” he said, adding, “and we have a lot of specialty applications that we also use for both CT and MRI.”

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Asked for an example of those specialty applications, he pointed to “functional cardiac MRIs.” “That’s basically like looking real time at the function of the heart, while using MRI,” he said. “And that’s been a big thing added just in the last year, where we’ve been able to identify disease states that we previously couldn’t.”

He pointed to the recent example of a service member who was attempting to reclassify specialties to become an air traffic controller.

“Through our functional MRI program, we found a condition that’s called cardiac non-action, which is basically where the heart muscle isn’t as dense as it should be and predisposes this kid to be like one of these cases of just sudden cardiac death in a young person. … Our functional MRI program has allowed us to identify some of these cases and really make a big difference,” he said.

Col. Kyle Walker, MC, USA, chief of Diagnostic Radiology and Trauma/ER Radiology at BAMC, highlighted the use of dual-energy CT, identifying it as “where different strengths of photons are utilized to characterize specific types of pathology and actually render a specific diagnosis.”

Walker said that the amount of patient radiation exposure in CT scans “is always an issue,” and that it is always addressed through practice of the “as low as reasonably achievable” (ALARA) radiation principle.

“ALARA means balancing the amount [of radiation] given versus the optimal diagnosis,” he said. “In reality, the equipment does a lot of that for us because it basically modulates the strength of the beam based upon the thickness of the person. But we’re also cognizant of that with the techniques we pick and the number of times a patient is scanned. So the fact that we have modern equipment really cuts down on the dose given.

“But every dose that’s administered is actually documented with the scan,” he added. “It’s part of the medical record. It’s accessible and can be quantified.”

In parallel with this documentation, BAMC plans to acquire new software that will monitor and track the

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U.S. ARMY PHOTO BY LORI NEWMAN

V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

amounts of radiation doses on patients that may be reoccurring into the system.

Walker said that the recent introduction of new CT technologies at BAMC didn’t change employment of the technology but did serve to make CT scanning more efficient.

“That’s because the new technology takes advantage of a wide number of detectors on the scanner, which means virtually half of the dose is administered for each scan, with computer programming basically reconstructing the other part for us,” he said.

In addition to reducing radiation dosages, Walker offered that another advantage is the ability to get very detailed information on complex anatomic structures that would otherwise be susceptible to motion.

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Air Force Lt. Col. Penny Vroman, Brooke Army Medical Center Nuclear Medicine Department chief, looks at scans of a patient with neuroendocrine tumors June 26, 2019, to ascertain if a radiopharmaceutical that was administered is targeting the tumors.

“The best example of that is the heart. I mean, we can essentially freeze the heart with a heartbeat and be able to visualize all the detailed anatomic structure,” he said. “That also goes for the brain, for the solid organs, and for the gastrointestinal tract.”

Walker described BAMC as “on the cutting edge in the sense that we actually use alternative imaging techniques for fertile-age females,” stating, “For acute abdominal pain, for example, we use a lot more MRIs than are used in the

civilian sector to diagnose those disease processes rather than exposing them to radiation with CT. And that’s also true with kids.”

Noting his own background as an obstetrician-gynecologist with a fellowship in women’s imaging, Wiedenhoefer echoed those sensitivities to radiation exposure for fertile-age females, adding that other recent changes include new breast biopsy techniques that utilize the Affirm® breast biopsy system, which allows patients to sit upright during the procedure.

“So we’re applying many of the technologies that we have had in the past,” he said. “We just have better equipment.”

Reflecting on coordination efforts between BAMC and the Veterans Health Administration (VHA), Walker

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U.S. AIR FORCE PHOTO BY STAFF SGT. KEVIN IINUMA

Cardiac magnetic resonance imaging technologists observe a patient during a cardiac MRI scan at Wilford Hall Ambulatory Surgical Center, Joint Base San Antonio-Lackland, Texas. Cardiac MRI is noninvasive, takes approximately 20-45 minutes, and enables an assessment of the function and structure of the heart.

highlighted the area of interventional radiology.

“We treat a lot of the patients with the Y90 Radioembolization,” he said.

“Basically they have liver cancer and they can have an endovascular treatment for their liver cancer that has a relatively low side-effect profile and pretty good efficacy. And that’s a good joint venture. Those collaborations occur, but it’s kind of more driven by the subspecialists that are out there rather than us specifically. But we do collaborate with them frequently.”

While acknowledging that cooperation, Wiedenhoefer offered his personal belief that there is room for improvement.

“We had a case just recently where someone from the VA reached out to us to try and help acquire some imaging for an inpatient at the VA,” he explained.

“They didn’t have a table that was able to support the weight of the particular patient. And we were working with them, trying to coordinate getting the patient over here. But it didn’t work out for that particular incident, meaning that they just ended up taking them over to university hospital. However, there are more and more circumstances where we’re trying to cover all of San Antonio and all of these military-related

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components working better together to take care of our patients.”

Looking at the possible evolution of imaging technologies over the next five years, Lt. Col. Nathan E. McWhorter, DO, a nuclear medicine physician at BAMC and assistant professor of radiology at the Uniformed Services University of the Health Sciences, pointed to the hope for the release of new “theranostic” imaging and treatment agents.

“Theranostic combines the words ‘therapy’ and ‘diagnostic’ into one word,” he said. “We call it a radiopharmaceutical, where it’s just designed to target a specific type of tumor. And you can put one type of radioactive particle on it, inject it into the patient, and then do imaging. And then, once your diagnosis is made and that this patient indeed has that treatable type of cancer, then we put a different type of radioactive particle on the exact same radiopharmaceutical – you can just think of it as a medication, really – and it goes in the same way by injection and kind of bombards the tumor from the inside while the patients just kind of sit there in the chair and really don’t feel anything.”

McWhorter said that BAMC currently uses a theranostic called Lutathera®, offering, “Our hospital was the first to do this in the DOD and the first here in

San Antonio as well. It’s for a specific type of carcinoid tumor, where we have the agent, the best type of PET [positron emission tomography] imaging for diagnosing it, and can categorize where the disease is throughout their body. Then from that, we follow up and treat them with a very small radioactive dose of a medication.”

He continued, “This was a huge breakthrough. We’re at a new age in nuclear medicine. In fact, there’s hopefully another type of theranostic coming up for treating prostate cancer. It’s under research right now, but it’s showing some very promising results. And as it achieves FDA approval, we will be looking to adapt that capability very quickly.”

In his own perspective on future developments, Wiedenhoefer noted an expansion of breast-specific gamma imaging to look at metabolically active breast tumors as well as the use of elastography, which can be applied in both MRI and an ultrasound to assess the stretchiness, sponginess, or compressability of an organ.

“We’re doing that with ultrasound and with MRI,” he said. “And that helps lower the number of biopsies that need to be done for these tissues and may actually reduce the number of invasive diagnostic tests that need to be done.”

However, Wiedenhoefer was quick to assert that few areas hold greater promise than the introduction of new information technologies (IT).

“Everything is computer-based now,” he observed. “It’s all ones and zeros. It’s no longer a photograph. It’s all digital information. And because of that, it can be transmitted over much larger distances and manipulated

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U.S. ARMY PHOTO BY JASON W. EDWARDS

U.S. AIR FORCE PHOTO BY SENIOR AIRMAN ASHLEY PERDUE

Left: U.S. Air Force Airman 1st Class Faith Brown, a diagnostic imaging phase II student assigned to the 6th Medical Support Squadron, uses the brand-new General Electric Revolution HD computed tomography (CT) machine at MacDill Air Force Base, Florida, June 13, 2019. The images produced during scans from the new CT machine are more detailed than before, allowing radiologists to better diagnose more patients.

Below: Ezra Poetker, radiology informatics system administrator, monitors radiology information systems for irregularities at Brooke Army Medical Center, Fort Sam Houston, Texas, Oct. 4, 2019. Radiology Informatics supports all radiology sections and is essential in the interpretation of more than 275,000 patient studies each year.

better. We’re merging more and more of that and our doctors are working more and more together. We’re covering a larger scope of things, and really trying to consolidate those, with the hope that in the next five years what is now limited to San Antonio could be more throughout CONUS and the world, where these subspecialty radiologists like Dr. McWhorter or Dr. Walker can actually provide support to other places just by sending the images to them.”

As the chief of the Informatics Division in the BAMC radiology department, Rik Guinther was also quick to highlight digital benefits ranging from the continuity of information from the battlefield to a reduction in medical errors or misdiagnoses.

“The digital information is also important in 3-D reconstruction,” Wiedenhoefer echoed. “In fact, just this past week, Rik Guinther and his team were working with the maxillofacial surgeons here. The current technology that we have allows us to do better 3-D reconstructions and allows them to do their surgery better.

Orthopedics is similar. They can do a lot of 3-D reconstructions just to make sure that alignment of joints and so forth, and fracture planes, are well

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visualized and conceptualized before they go and take them to do surgical repair.”

The same imaging technologies and approaches that hold so much promise also present new challenges for the medical community. One of those challenges involves what some might see as information overload.

Wiedenhoefer explained that 10 or 15 years ago, a CT scan of the head

involved 16 images reflecting slice thicknesses of 1-1.5 centimeters.

“But now the slices look at every millimeter, and that same exam might result in 2,000 images. And they all need to be looked at. So it’s easier for us to acquire images at a lower radiation dose, but yet they become more complex in the interpretation of them.”

He added, “Right now, when we have a trauma patient come in, they’ll get a head CT, neck CT, and CT of aorta, chest, abdomen, pelvis, cervical spine, thoracic spine, and lumbar spine. When one person comes through, they may easily have 10,000 images for radiologists to

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look at. With that same patient 10 years ago, it would have been 115 images – maybe. So patients are coming through and the radiologists are having to read, in an eight-hour shift, maybe 130 exams or more. It’s really getting to a point where they may not be able to get through all the images. So, from that standpoint, we are better and better, but we also have a ton more to do. And it’s getting to the point where we are maxed out in what we can get through in the interval of time.”

Moreover, Walker pointed out that the reality for radiologists reading that imagery is that it is a 24/7 requirement.

“It never ever stops,” he said. “And the problem is the complexity doesn’t change regardless of time of day or night. So a big challenge is having personnel to keep up.”

“That’s absolutely true,” Wiedenhoefer added. “And that person has to be skilled enough to do the work and to get through it. And that’s going to continue.

The technology is going to continue to get more complex.”

He referred to the application of new IT “imaging modalities,” and BAMC’s use of systems called Vitrea and TeraRecon, to break the CT scans into individual elements.

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Army and Air Force doctors assess a simulated trauma patient at Brooke Army Medical Center, Fort Sam Houston, Texas, Sep. 4, 2019. A trauma patient today might generate 10,000 images for a radiologist to look at.

“So if we were interested in just looking at the bone or looking at the heart or something, we can take that and then do 3-D reconstructions of that thing,” he explained. “Nuclear medicine does this a lot with cardiac exams.

But then it requires somebody skilled enough to do all the post-processing in order to make usable information out of that. … It takes some really skilled people to do it. And meanwhile the patients are coming through faster than we’re able to even do the processing.”

In addition to the processing, Guinther highlighted associated IT challenges based on both digital storage and the bandwidth necessary to open the images to other providers and other hospitals as necessary.

“We went from 16 images on a piece of film to a couple of thousand digitally and now we’ve got to transfer these to another hospital or to other workstations around the hospital,” he said.

“So storage becomes a big issue as we

continue with digital mammography and those types of things. That’s one of our biggest challenges on the IT side, just to make sure that we keep up with the amount and volume of information that we acquire, and to present it back to the radiologist in a timely fashion. And it’s not just radiologists today; it’s anybody that needs to see that image. And that can be hundreds of clinicians a day viewing thousands of studies.”

Wiedenhoefer closed with acknowledgement of one more potential issue hovering on the digital horizon.

“I have read about, and we haven’t had any direct issues here, but one thing I could see becoming a problem in the future involves malware and viruses incorporated into imaging systems,” he said, “because it’s all computer software now. And there are reports actually of people who have added malware and viruses into the system that then falsely place tumors into organs. So people get cross-sectional imaging and they’re interpreted as a tumor, when in reality it isn’t a tumor. It’s a virus that’s intentionally in there to look like a tumor. They insert false tumors into these things to wreak havoc within the systems. Again, we haven’t had any issues with that, to my knowledge, but they are out there.”

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THE G.I. BILL

On the landmark law’s 75th anniversary, a look at the once and future dividend for military service members

n TODAY IT’S HARD TO FIND ANYONE WILLING TO SPEAK against a law often described as one of the most important items of domestic legislation in the history of the United States. But the provisions codified in the Servicemen’s Readjustment Act of 1944 – the original G.I. Bill of Rights – were far from universally accepted when the country debated how it would reintegrate American military service members who had been sent to fight in World War II and who numbered, by the time war had ended, nearly 15 million.

The United States had learned painful lessons from its earlier large-scale military mobilizations. The pension systems

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enacted to compensate Civil War combatants and their survivors proved so complicated, costly, and divisive that when the next big war came around – World War I – the government was more circumspect, scaling back veteran benefits and offering no assistance for non-battle injuries or age-related ailments.

Instead, veterans were promised, in 1924, a deferred “bonus,” payable in 20 years. During the Great Depression, of course, World War I veterans, many of whom were standing in bread lines, desperately needed these bonuses, a crisis that eventually led to the debacle known as the “Bonus March,” in which active-duty service members were sent to forcibly remove

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WIKIMEDIA COMMONS

By Craig Collins

V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

LIBRARY OF CONGRESS, PRINTS & PHOTOGRAPHS DIVISION

Opposite page: President Franklin D. Roosevelt signs the Servicemen’s Readjustment Act of 1944, known as the G.I. Bill, in the Oval Office on June 22, 1944. Right: World War I veterans, many carrying American flags, march across the east plaza of the U.S. Capitol in 1932, demanding immediate payment of their bonuses, which were not redeemable until 1945. Protesting veterans who formed encampments were violently ousted in what became known as “the Battle of Anacostia Flats.”

protesting veterans from the capital. One of President Herbert Hoover’s final missteps, the “Battle of Anacostia Flats,” led by hard-charging Douglas MacArthur, further dimmed Hoover’s prospects for re-election.

Because it was signed into law by President Franklin D. Roosevelt, architect of the New Deal, the G.I. Bill is often thought of as a broad-based welfare program designed to expand the American middle class. This was certainly one of the law’s most important consequences, but it wasn’t designed primarily as a tool for social mobility. Roosevelt wanted to acknowledge the service of veterans and reintegrate them into the economy, but he knew the American job market wouldn’t be able to accommodate such a sudden shock: In June 1943, the government’s Conference on Post-War Adjustment of Civilian and Military Personnel reported that the first year of demobilization would probably result in 8 or 9 million unemployed Americans.

In October 1943, the president asked Congress to enact legislation that would finance educational or vocational training for all who served in World War II. He foresaw long-term benefits: “rich dividends in higher productivity, more intelligent leadership, and greater human happiness. We must replenish our supply of persons qualified to discharge the heavy responsibilities of the postwar world.”

To craft this new benefit package, the White House and Congress sought input from veterans and their advocates. A leading voice was Harry W. Colmery, the former national commander of the American Legion who’d been an Army Air Corps pilot instructor during World War I. In December 1943, in a room at the Mayflower Hotel, Colmery, who’d been asked by the American Legion to serve on a special bipartisan committee, began drafting the outline of a bill. Over the next three weeks, he and other committee members met with education, banking, and employment experts and used these conversations to craft a bill that went beyond Roosevelt’s vision, to include loans for homes, farms, and small businesses; unemployment assistance; prompt settlement of disability claims; and the concentration of these and other veteran programs into an adequately staffed Veterans Administration (VA).

The bill was officially titled the “Servicemen’s Readjustment Act,” but the American Legion’s public relations head, Jack Cejnar, knew this name was too dull to sell the public on its provisions. On Jan. 8, 1944, the organization unveiled its proposal for a “G.I. Bill of Rights,” an ingenious title that appeared to put members of Congress in the position of either voting for these rights or against them.

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Ironically, much of the bill’s strongest public criticism came not from legislators, but from other veteran advocacy groups, including the Veterans of Foreign Wars and Disabled American Veterans. These groups believed the G.I. Bill failed to prioritize the needs of veterans who’d suffered physical and psychological wounds from their service. Beyond a one-time bonus payment dismissed by lawmakers as too expensive, however, these organizations failed to provide a viable alternative proposal.

As the bill made its way through the House and Senate committees, several of its provisions – including those related to unemployment assistance, education, and training – were threatened by legislators who questioned whether they would encourage or discourage veterans from finding jobs. Some criticized it as a reckless spending bill that would simply expand the nation’s welfare system. Colmery, a Republican who wasn’t a fan of Roosevelt’s New Deal, resented the idea that veterans would become a drain on the nation’s resources. For one thing, the bill placed time limits on the benefits, to keep it from becoming an open-ended program such as Social Security.

Some of the nation’s most prominent academics, poised to receive an influx of millions of new veteran college and university students, weren’t crazy about the idea. Harvard University President James Bryant Conant complained the bill would benefit “the least qualified of the wartime generation.” Robert M. Hutchins, president of the University of Chicago, argued that “colleges and universities will find themselves converted into educational hobo jungles. ... Education is not a device for coping with mass unemployment.’’

The Servicemen’s Readjustment Act of 1944 passed by a slim congressional majority and was signed into law on June 22, 1944, just 16 days after American troops stormed the beaches at Normandy. Over the next decade, more than 2 million veterans would attend college with G.I. Bill assistance, including books, tuition, and a monthly stipend; by 1947, veterans accounted for 49 percent of American college students.

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The G.I. Bill signed in 1944 and every iteration of it since has afforded funds to assist veterans in pursuing education or training.

Years later, a repentant Conant would concede that the students who came to Harvard with the help of the law – mostly urban and rural working-class men – were “the most mature and promising students Harvard has ever had.”

U.S. NATIONAL ARCHIVES AND RECORDS ADMINISTRATION

BUILDING A MIDDLE-CLASS NATION The G.I. Bill’s three main provisions – grants for education or training; federally guaranteed home, farm, and business loans with no down payment; and unemployment compensation – were administered by the Veterans Administration, and were immediately successful, securing opportunities for veterans and economic stability for the nation. Less than a year after the war finally ended with Japan’s surrender to the Allies on Sept. 2, 1945, the largest demobilization in history, Operation Magic Carpet, had repatriated millions of American military personnel from the European,

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Pacific, and Asian theaters. Seventy percent of these veterans were employed.

Almost a million were in school; another million were receiving assistance to supplement farm work; more than 400,000 were participating in on-the-job training programs; and more than 300,000 were receiving assistance to establish their own businesses or professional practices.

Colmery and his friends at the American Legion didn’t know it at the time, but these numbers – which would continue to grow and extend help to millions more – achieved far more than merely softening the landing for returning veterans. Before World War II, college and home ownership were mere fantasies to the average American, and the G.I. Bill freed up energy and ambition that had remained shackled throughout the Great Depression and the war. It’s no exaggeration to say the law transformed American society; as much as any event

in American history, it democratized the American Dream. More than half the 15.3 million World War II veterans took advantage of the law’s education and training provisions.

Access to low-interest mortgages provided by the G.I. Bill reflected Colmery’s belief that veterans deserved to own their own homes, and by the time the law had expired in 1956, the VA had guaranteed 5.9 million home loans, totaling $50.1 million, to veterans, enabling many to move from urban apartments to homes in areas outside cities that had, prior to the war, been reserved for the wealthy and upper-middle class. The word “suburbs,” in fact, did not become a part of the American lexicon until the postwar era when developers, striving to meet demand, carved out these new enclaves.

Many historians have claimed the G.I. Bill was a leading factor in transforming America from a working-class, largely agricultural society into the world’s first predominantly middle-class nation. In his book When Dreams Come True: The G.I. Bill and the Making of Modern America, author Michael J. Bennett argues that the law’s overall effect was “a social revolution even greater than Henry Ford’s.”

Bennett wrote: More than any other law, the G.I. Bill was responsible for the postWorld War II explosion in college graduates, the education of leaders of the civil rights movement, the growth and dominance of the suburbs, and the proliferation of interstate highways, supermarkets, and franchise stores and restaurants.

Quite literally, the G.I. Bill changed the way we live, the way we house ourselves, the way we are educated, how we work and at what, even how we eat and transport ourselves.

In taking special notice of the education of civil rights leaders, Bennett was acknowledging an uncomfortable

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Left: A home in the suburb of Levittown, New York. The G.I. Bill provided veterans with access to federally guaranteed home, farm, and business loans with no down payment, enabling millions to purchase homes outside dense urban areas. Below: Rep. G.V. Montgomery, D-Miss., speaks about the G.I. Bill to Marine Corps recruits in 1987.

truth about how its provisions were implemented: While the bill’s American Legion sponsors insisted the law’s provisions should apply to every veteran who had served, regardless of race or gender, the reality was that many veterans, and particularly AfricanAmericans, were unable to take advantage of the G.I. Bill’s opportunities until the passage of civil rights legislation two decades later. Many schools, for example, remained closed to women and African-Americans, and many postwar housing developments – including Levittown, New York, the archetype of American suburbia – remained racially segregated.

When the original G.I. Bill expired in 1956, it had provided education or training benefits to a total of 7.8 million veterans. Twenty-nine percent of veterans had taken out low-interest loans to purchase homes, farms, or businesses, while only 14 percent had made full use of the bill’s most controversial provision: unemployment compensation, in the form of $20 weekly payments for a maximum of 52 weeks.

A 1965 study by the Veterans Administration found that G.I. Bill college graduates, with their increased earning power, had increased federal tax revenues by more than a billion dollars annually and driven increased demand for goods and services – benefits far in excess of the law’s total $14.5 billion cost.

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UPDATES: THE FOREVER G.I. BILL In the 75 years since its passage, the G.I. Bill has been updated and modified to match economic and political realities. In response to several cases of overcharging and fraud associated with the original G.I. Bill, for example, the benefit package for veterans of the Korean War authorized payments to veteran students to subsidize tuition, fees, books, and living expenses, rather than direct payments to colleges and universities.

About 2.4 million Korean War veterans used these education benefits, about half of them to attend higher education academies. More than 1.5 million Korean War veterans obtained home loans. In 1956, the VA extended educational assistance to the dependents of veterans who were killed or disabled due to their service.

The Vietnam G.I. Bill, first enacted in 1966, underwent several modifications before it ended in 1976; by then, a higher proportion of Vietnam-era veterans had used their benefits for higher education than any previous generation: Of the 10.3 million eligible, 6.8 million veterans took advantage of the bill’s education and training provisions.

After 1973, when the nation’s military became an all-volunteer force, VA benefit programs were designed in part to aid in the recruitment of military personnel.

From 1976 through 1987, veterans received assistance under the Veterans

Educational Assistance Program (VEAP).

Unlike previous programs, VEAP required participants to contribute to their education benefits from their own salaries, after which the VA matched contributions at a rate of 2 to 1. Nearly 700,000 veterans used VEAP benefits for education and training – but by the mid-1980s, it was clear that military recruitment was falling short of expectations. Congress, with leadership from Mississippi Congressman G.V. “Sonny” Montgomery, enacted the Veterans’ Educational Assistance Act of 1984, more commonly known as the Montgomery G.I. Bill or MGIB. The MGIB kept the same basic structure and pay-in requirement as VEAP, but offered benefits to more veterans, including eligible reservists. The program offered up to 36 months of assistance to cover tuition, fees, and living expenses. More than 2 million service members have earned higher education degrees with MGIB assistance.

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PHOTO BY LANCE CPL. AARON BOLSER

U.S. AIR NATIONAL GUARD PHOTO BY TECH. SGT. DAN HEATON

Left: Senior Airman Jamie Foster, a member of the Michigan Air National Guard’s 127th Wing and a second-year law student at the University of Michigan Law School, works on homework during a flight aboard a KC-135 Stratotanker en route from Michigan to Alaska, Aug. 25, 2019. Foster is using her military educational benefits to pay for law school and then hopes to become a lawyer in the U.S. Air Force Judge Advocate General Corps. The Forever G.I. Bill expands eligibility to a wider group of service members, including National Guard members, and eliminates a previous 15-year time limit on benefits. Below: Cpl. Eduardo Villalobos, academic instructor, teaches recruits of Delta Company, 1st Recruit Training Battalion, about the various tuition assistance programs available, such as the Post-9/11 G.I. Bill and the Montgomery G.I. Bill, on Aug. 26, 2015, on Parris Island, South Carolina. The class covered the benefits of and differences between each G.I. bill.

The largest expansion of veterans’ educational benefits since the original G.I. Bill began in August 2009, with the implementation of the Post-9/11 G.I. Bill. Veterans who had served after Sept. 11, 2001, were eligible for benefits including the full cost of any public college in their state, a housing allowance, and a $1,000 annual stipend for books. The Post-9/11 law was also the first to allow beneficiaries to transfer their entitlements to a dependent. An updated version of the bill, passed in 2011 and known as a “G.I. Bill 2.0,” expanded benefits to eligible National Guard members, and expanded benefits to include non-degree-granting institutions, flight training programs, onthe-job training, and certain licensure, certification, or placement tests.

The changes and fixes continue to evolve. The people who drafted the Post-9/11 G.I. Bill did not foresee that the war that began on Sept. 11, 2001, would last longer than the 15-year “use-it-or-lose-it” time limit they had placed on veteran benefits. Under the law, veterans had 15 years after their discharges to use the money. But – as it did for many Americans – the economic recession that began in 2008 introduced greater fluidity into the lives of veterans; after years of relative stability, many found themselves compelled to move, look for work, or seek training opportunities in a changing job market.

The G.I. Bill’s most recent update is aimed at these and other 21st-century issues. Officially named for the man who drafted the first G.I. Bill, the Harry W. Colmery Veterans Educational Assistance Act of 2017 implemented more than 20 new provisions, many of which were simple tweaks, expansions, or cuts.

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The most noteworthy feature was the elimination of time limits to use benefits for new enlistees. The new law, known also as the Forever G.I. Bill, also expands eligibility to a wider group of service members, including National Guard members, reservists, and Purple Heart recipients; provides additional money to students in STEM (science, technology, engineering, and math) programs; and includes pilot programs to encourage enrollment in high technology programs.

While many of the details are different, the intent of the Forever G.I. Bill is the same as that devised by the men who composed the original law 75 years ago. As Colmery wrote, while corresponding with the colleagues who helped him draft the bill, “We recognize that the burden of war falls upon the citizen soldier, who has gone forth, overnight, to become the answer and hope of humanity; we seek to preserve his rights to see that he gets a square deal.”

To Warren Atherton, who commanded the American Legion from 1943 to 1944, the G.I. Bill was far more than a reward to be paid for military service; it was a tool that could be used by returning service members to further the growth and prosperity of the United States. “The continuing duty of citizenship is to apply the lessons of this war to the establishment of a better and stronger nation,” he said. “As these veterans have led in war, so must they lead in peace.”

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VA Research

CARDIOVASCULAR CARE

By Craig Collins

n CARDIOVASCULAR DISEASE (CVD) IS THE LEADING cause of death among American men and women, killing about 610,000 people every year. In the Department of Veterans Affairs (VA) health care system, it’s the leading cause of hospitalization, and it’s of particular concern to the veteran population because of its association with a number of other diseases or disorders, including diabetes, hypertension (high blood pressure), spinal cord injury, and post-traumatic stress disorder (PTSD).

CVD is defined as a condition that arises from problems of blood flow, many of which are related to narrowed or blocked blood vessels, and which can lead to heart attack, coronary heart disease, stroke, or chest pain (angina). Risk factors for the disease include: age; obesity/overweight; smoking; lack of exercise; diet; high blood pressure; diabetes; alcohol use; stress; high LDL or low HDL cholesterol; and heredity. Eighty percent of veterans have two or more risk factors for CVD. This may be partly attributable to the fact that veterans are older, on average, than other Americans, but a recent study, published in The Journal of the American Board of Family Medicine in January 2019, found that veterans also reported higher numbers of CVD conditions at younger ages than nonveterans.

Researchers in VA’s Office of Research and Development (ORD) examine hereditary and lifestyle risk factors for CVD and conduct studies ranging from lab experiments to large clinical trials, involving thousands of patients, in search of new or improved treatments. For example,

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using data from its ambitious nationwide Million Veteran Program, which links patient health records and biospecimens with DNA from veteran volunteers, VA researchers have identified potential genetic markers for CVD risk factors, including cholesterol levels and high blood pressure. These findings may lead to new, targeted treatments that can prevent or effectively treat CVD. When new treatments are devised, it’s up to VA’s health services researchers to discover the most effective and efficient way of implementing them in a VA health care system that serves more than 9 million veterans. Within the ORD, the Health Services Research and Development (HSR&D) Service funds investigations into the factors that affect health care quality and outcomes for veterans with CVD, including the effectiveness of telemedicine in managing CVD risk factors for rural veterans; the impact of CVD on operating costs; and differences in CVD risk among groups of veterans. The overall aim is to optimize care for veterans who are either at risk for CVD or living with CVD conditions.

HSR&D investigators have pioneered evidence-based practices and approaches that have reduced risks for veterans and extended the reach of VA resources – for example, peer coaching and support. In the Seattle area, Karin Nelson, MD, a core investigator with HSR&D’s Center of Innovation and a professor of medicine at the University of Washington, is evaluating the effectiveness of a peer coaching program she developed for veterans with

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DEPARTMENT OF DEFENSE PHOTO

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LEFT: A veteran gets his blood pressure checked at the VA North Texas Health Care System. High blood pressure, or hypertension, is a risk factor for cardiovascular disease (CVD), which can lead to heart attack, coronary heart disease, or stroke. BELOW LEFT: Smoking is another risk factor for CVD. In addition to looking at systolic blood pressure changes, the Vet-COACH study will also measure reductions in CVD risks like tobacco use or cholesterol levels.

high blood pressure. The Vet-COACH (Veteran Peer Coaches Optimizing and Advancing Cardiac Health) study will test whether trained veteran coaches, visiting other veterans in their homes, can help improve blood pressure control and at least one other risk factor for CVD. Nelson designed the approach based on her previous collaborations with community health workers to reduce veterans’ risk for chronic diseases. “We’re using a community health worker model,” Nelson

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said, “where people who are not health professionals get training in coaching and some basic health education, and then they do community-based visits.”

During these visits and telephone support sessions, coaches in the program talk with veterans about their daily lives and help them set goals for managing high blood pressure and reducing CVD risks – through physical activity, healthier eating, taking medications, smoking cessation, or other approaches that fit the veterans’ lifestyles. Veteran

coaches in the program will also connect participants with communitybased and clinical resources.

Nelson will compare results from program participants to those of veterans receiving regular VA primary care. The primary outcome to be compared is systolic blood pressure, from the beginning of the study to a one-year follow-up, but Nelson will also measure reductions in other cardiovascular risks such as tobacco use or cholesterol. The study is ongoing and it’s too early to tell whether the peer coaching program will lower blood pressure, but “We’ve had some really positive responses to the program,” said Nelson.

“People really like the fact that they’re working with another veteran, and they feel like they can talk to that person in a different way than to a doctor.”

Studies such as Nelson’s Vet-COACH investigation are aimed, ultimately, at working closely with at-risk veterans to reduce their risk of worsening disease, improving their health and quality of life, and making optimal use of VA resources.

Another ongoing HSR&D study, implemented on a broader scale, is similarly designed to evaluate a project for improving the quality of care for veterans with transient ischemic attack (TIA). The project is known as PREVENT (Protocol-guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms).

TIA occurs when a temporary blockage of blood flow to the brain causes neurological symptoms such as slurred speech, numbness, or paralysis.

While it’s sometimes referred to as a “minor stroke,” a TIA is a major warning: About a quarter of the people who have a TIA go on to have a more severe stroke

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PREVENT hub data has yielded valuable information, revealing gaps between the care veterans receive and what VA researchers have identified as without-fail care.

or other serious adverse health event within a year. According to PREVENT program manager Barbara Homoya, MSN, a research nurse at HSR&D’s Center for Health Information and Communication (CHIC) at the Richard L. Roudebush VA Medical Center in Indianapolis, Indiana, the mortality for people with TIA is similar to that of patients who present to an emergency department with chest pain. “About 11 to 12 percent of them die within a year,” she said. “And the problem with TIA is these patients look fine. They’re not clutching their chests.

So there’s often a lack of urgency.”

A previous VA-funded study by Dawn M. Bravata, MD, a CHIC core investigator and professor of medicine at Indiana University, showed that only 1 in 4 veterans with TIA receive “without-fail care”: all of the care for which they are eligible among processes that have been proven effective and should be routinely available to patients with TIA. After collecting data from the VA’s Corporate Data Warehouse, the research team composed algorithms to calculate which processes of care would provide the most improvement for veterans with TIA, in terms of recurrent events or mortality. The algorithms yielded seven processes that should be considered “without-fail care” for patients with

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Transient ischemic attack, sometimes called a “minor stroke,” occurs when a temporary blockage of blood flow to the brain causes neurological symptoms such as slurred speech or paralysis. The VA’s PREVENT program aims to provide VA facilities and health care providers with the resources and information necessary to ensure veterans receive the best possible treatment for TIA.

TIA, Homoya said. “They are brain imagining, carotid artery imaging, neurology consultation, antithrombotics, high and moderate potency statins, anticoagulation for those veterans who have atrial fibrillation, and hypertension control,” she said. “And what we’ve found is that timely care – which means within the first few days, when the highest mortality occurs – can reduce recurrent events by 70 percent, and mortality can be reduced by about one-third. This is the kind of improvement that you very rarely see in medicine.”

The goal of the PREVENT program is to provide VA facilities and care providers with the information and resources they need to ensure veterans with TIA receive the kind of care that will yield these outcome improvements.

PREVENT resources include professional education and support, clinical support, and data resources to close knowledge gaps. “One of those is an interactive web

platform that we call the PREVENT hub,” said Homoya. “It provides data to the sites that previously was not available to them, on over 20 processes of care as well as outcome measures such as mortality, percent of admission, and followup visits within 30 days.” These data are collected from all VA health care facilities nationwide.

PREVENT hub data has yielded valuable information, revealing gaps between the care veterans receive and what VA researchers have identified as without-fail care. For example, Homoya said, it showed that while many veterans with TIA were prescribed statins, not all were receiving the moderate- to highintensity statins recommended in TIA care guidelines. “There was a real deficit there,” she said. “Educating pharmacists and providers about the guidelines was a really key piece for them to improve care to those veterans.”

PREVENT began in July 2017 as a pilot project at six sites in the VA, where nurse facilitators guided local care teams in reviewing the available evidence that supported the importance and urgency of TIA care, formulating goals based on self-identified quality of care and existing barriers, and then implementing their customized quality improvement programs. The dramatic improvement in TIA care at these six sites led to the VA’s attempt to roll it out to all VA facilities nationally. Homoya and PREVENT staff members have been meeting in information sessions with chiefs of neurology, emergency department

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VA PHOTO

Emergency department staff and simulation trainers participate in the TeleStroke Program go-live training at the Las Vegas VA Medical Center on Jan. 18, 2018. The TeleStroke program connects veterans with VA stroke neurologists through live bedside telehealth video feeds. The National Evaluation of the VHA TeleStroke Program is currently underway to measure the success of the program’s implementation and to identify any areas for improvement.

directors, and chief medical officers and providing support to patient-aligned care teams (PACTs). “We’ve been getting the word out,” said Homoya. “And we now have almost 80 additional sites that are utilizing the PREVENT hub. We have almost 200 new users. There are a couple of VISNs [Veteran Integrated Service Networks, or regional divisions of VA care facilities] that have made it a requirement for their facilities to do this quality improvement project.”

The PREVENT project, then, transformed midstream from one type of investigation – measuring the effectiveness of a newly designed treatment, process, or protocol – into a study of how an already validated process is implemented throughout the VA. The rapid translation of research findings and evidence-based treatments into clinical practice is a key mission of HSR&D’s Quality Enhancement Research Initiative (QUERI), which for more than 20 years has been committed to ensuring that research is used to sustain improvements in care for veterans. The PREVENT project was one of five conceived under a nationwide QUERI program, the Precision Monitoring to Transform Care (PRIS-M) QUERI, which focuses on using existing data from VA patients’ electronic health

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records to improve health care quality and outcomes.

Another PRIS-M QUERI project, led

by Linda Williams, MD, a CHIC core investigator and professor of neurology at Indiana University, is aimed at expanding the access of veteran stroke patients to the expertise of stroke specialists. The focus of this investigation, the National Evaluation of the VHA TeleStroke Program, is an intervention launched in 2017 to connect VA stroke neurologists to deliver services remotely through a live telehealth video feed at veterans’ bedsides in more than 30 VA medical centers. More than 1,000 emergency consults have been conducted via iPad tablets since the TeleStroke program began.

Access to expert care is critical for patients who suffer an acute stroke and who may benefit, for up to 4.5 hours after onset, from alteplase, a thrombolytic drug that breaks up blood clots. During every minute acute stroke care is delayed, an average of 1.9 million brain cells die, so access to a stroke specialist is critical. According to Holly Martin, project manager of the National TeleStroke Evaluation, TeleStroke began as a program to serve rural VA facilities that didn’t have access to acute stroke care, but it has

since expanded beyond rural sites to reach veterans at any facility that does not have access to a stroke-trained neurologist. About 18 VA stroke neurologists are currently available to teleconference with veterans and VA providers around the country.

Measuring the success of TeleStroke implementation includes measures of baseline encounter rates between stroke patients and stroke specialists; whether stroke patients are being treated or transferred to facilities with stroke specialists; and how many acute stroke patients are treated (and how quickly) with alteplase. “This is a quality improvement project,” Martin said. “At this point, they’re wanting simply to count how many patients are served ... and even to see how many patients are eligible for treatment, because we didn’t have that information before. Because some had to immediately send patients with stroke symptoms to another hospital, the team will also eventually look at the impact of TeleStroke on transfer rates and cost savings for the VA. Our role as the evaluation team is to provide information as it’s being implemented so they can make changes, in real time, to improve the quality of the program.”

It will never be possible for the VA, or any large health care system, to have cardiovascular care experts at every one of its 153 medical centers, more than 700 outpatient, community, and outreach clinics, and 126 nursing home units, but through measuring the effectiveness of evidence-based interventions such as TeleStroke, VA health services researchers are working to ensure this expertise reaches as many veterans as possible.

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VA Research

DIABETES CARE

By Craig Collins

n DIABETES MELLITUS – A CHRONIC DISEASE in which the body can’t produce or properly use insulin, the hormone that transfers sugar from the bloodstream into cells – is a serious and worsening public health issue in the United States, where it’s the seventh-leading cause of death. More than 30 million Americans, including more than 7 million who remain undiagnosed, have the disease. According to the U.S. Centers for Disease Control and Prevention (CDC), 84 million more Americans are at risk to develop the disease, and 1.5 million more are diagnosed every year.

Ninety percent of the people with diabetes suffer from the type 2 form of the disease, in which the pancreas fails to meet the body’s demand for insulin. High blood sugar levels can eventually damage blood vessels and organs, and diabetes is a leading cause of blindness, end-stage renal disease, and amputation for Department of Veterans Affairs (VA) patients.

One of the most common diagnostic tools for diabetes is the hemoglobin A1c test, which estimates an average level of blood sugar over three months. A1c levels of 6.5 percent or more indicate a diabetes diagnosis; levels between 5.7 and 6.4 – above normal, but not yet meeting the criteria for type 2 diabetes – indicate a diagnosis of prediabetes.

For a number of reasons, veterans have a much higher risk for diabetes than the general population: 25 percent of veterans have diabetes, compared to about 10 percent of Americans overall. A major risk factor for diabetes is obesity, and nearly 80 percent of veterans are overweight or obese.

Care providers in the Veterans Health Administration (VHA) are focusing resources and expertise on the nearly 1.5 million veterans with diabetes – and also on the millions more with prediabetes, whom research has shown can prevent or delay onset of the disease through healthy diet, weight loss, and exercise. To help guide these efforts and optimize outcomes for veteran patients, researchers in the VA’s Health Services Research and Development (HSR&D) Service evaluate diabetes care from every angle, examining

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patients’ access to care as well as the most effective and efficient means of delivering it.

These studies of health care delivery are particularly important for veterans with diabetes, said the VA’s Matthew Crowley, MD, because, “Diabetes is a profoundly self-managed disease.

The patient is responsible for taking care of their own diabetes for 99.9 percent of their time. Most days, weeks, and months, they are not interfacing with their care providers.” The VA, to maximize interaction between diabetes patients and its health care system, has been a leader in telemedicine: provider/ patient contact through telecommunications technology.

While the efforts of researchers and clinicians have improved control of diabetes overall across the VA, veterans with persistent poorly controlled diabetes (PPDM) haven’t benefited from these efforts. Despite receiving clinic-based care, 12 percent of veterans with type 2 diabetes have PPDM and are at greater risk of complications.

Crowley, an endocrinologist at the Durham, North Carolina VA and an associate professor of medicine at Duke University, recently launched a study that will examine an intensive telemedicine intervention, known as PRACTICE-DM, designed for delivery within the VA’s existing telemedicine infrastructure. Crowley’s team defined PPDM as a hemoglobin A1c level greater than 8.5 percent, persisting for more than a year despite engaging with standard VA diabetes care.

The study will compare outcomes between two groups of veteran patients with PPDM, at sites in Durham and Richmond, Virginia. One group will receive the standard home-telehealth care coordination and telemonitoring, and another will receive the PRACTICE-DM. The difference between the two programs, Crowley said, is significant. While the standard telemedicine protocol focuses largely on telemonitoring and data collection, “PRACTICE-DM is a comprehensive approach that combines a number of different telehealth-based approaches, all for delivery by clinical VA telehealth staff.” Bundled into the program are five different

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PHOTO BY ALAN LEVINE

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activities: telemonitoring; a self-management support module for educating patients; diet and activity support, which will help patients develop individualized plans for nutrition and exercise; depression support, linking patients with active depression symptoms to VA resources; and medication management, done in coordination with a VA provider. “It’s very comprehensive,” Crowley said, “and targets many of the factors that typically underlie persistently poor control in veterans with type 2 diabetes.”

Crowley’s team is on track to complete enrollment by the end of 2019 and begin reporting data sometime next year. While his team is working blind and can’t predict what they’ll see, he said, “We would consider a clinically significant difference between the two

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An at-home hemoglobin A1c testing device. Diabetes is largely managed by the patients themselves, but research is underway to determine the most effective ways the VA can help patients control the illness.

interventions to be about half a point in A1c. In some of our pilot work, we saw improvements that were substantially greater than that, so we hope we’ll see similar results in this larger study.”

DIABETES CARE FOR WOMEN AND MINORITY VETERANS VA’s attempt to optimize diabetes care for veterans is complicated by the fact that differences – in incidence of the disease, access to care, and outcomes – persist among subgroups of

the veteran population. Researchers throughout the VA conduct numerous studies devoted to mitigating or eliminating these disparities.

The fastest-growing segment of VA health care users is women. In 1988, when the VA established its Women Veterans Health Program, a little over 4 percent of veterans were women. Today, the VA estimates that percentage to be 10 percent. Much of what VA investigators have learned about diabetes care for women veterans has been revealed in their examinations of different interventions and models of care.

Tannaz Moin, MD, an endocrinologist at the VA Greater Los Angeles Healthcare System, core investigator at the HSR&D Center for the Study of Healthcare Innovation, Implementation

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and Policy (CSHIIP), and an assistant professor of medicine at the University of California-Los Angeles, has studied VA’s diabetes programs for years now, including comparisons of the Diabetes Prevention Program (DPP) – an intensive, structured, in-person program Moin has called the “gold standard” of prevention programs for adults with prediabetes – and the MOVE! program, which has fewer sessions, is designed for flexibility, and does not specifically focus on adults with prediabetes. Moin’s research has already yielded important discoveries, such as the finding that online diabetes programs are as effective as in-person sessions for weight loss – and that weight loss and patient satisfaction outcomes are generally better among veterans enrolled in the DPP than among those enrolled in MOVE! When Moin and colleagues recruited participants for one of her initial comparison studies, she noticed that despite the fact that more than 7,000 women veterans were receiving care in the Los Angeles VA System, very few women – two, to be exact – signed on for her study.

In response, Moin designed a study that became one of several administered through a new VA Quality Enhancement Research Initiative (QUERI) program known as Enhancing Mental and Physical Health of Women through Engagement and Retention (EMPOWER). “In EMPOWER,” Moin said, “our philosophy is that while VA is doing amazing things, delivering evidencebased preventive services … women are still considered a vulnerable population with unique needs.”

Moin’s team found that many women veterans weren’t comfortable working in predominantly male group-based programs such as the DPP and MOVE! When they offered a prevention program in a woman-only group, they had greater success recruiting participants.

Women veterans were screened for overweight and prediabetes, a process that led to an unforeseen result: Very few women veterans with prediabetes were aware of it, and the medical record review and patient notification process

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A study conducted by Tannaz Moin, MD, an endocrinologist at the VA Greater Los Angeles Healthcare System, revealed that female veterans showed more interest in participating in the VA’s in-person Diabetes Prevention Program (DPP) when a women-only group was available, and appreciated having the option to choose an online version of the DPP.

itself resulted in a 187 percent increase in the number of women aware of their prediabetes diagnosis. Women participants were then offered the choice of participating in an in-person, womenonly DPP group led by another woman coach or a remotely delivered online version of the DPP. The aim of this study – Tailoring VA’s Diabetes Prevention Program to Women Veterans’ Needs – wasn’t really to measure the weight loss outcomes, which have been demonstrated by the prior work of Moin’s team, but at increasing enrollment. And by this measure, it was a success. “This was supposed to be a tiny pilot,” said Moin, “with 40 women.

And we were able to recruit three times that number – 120 participants. The enthusiasm of the women was high

because they got a choice, and believed the VA cared about them enough to say: ‘You choose what works better for you.’”

Two-thirds of the participants preferred the online version.

Moin and her team are in the process of submitting a proposal for a larger-scale study. While women-only in-person groups are a feasible option for densely populated areas such as Los Angeles, women veterans living elsewhere – Bakersfield, for example – may benefit from the online option.

“Eventually we’d like to see the online DPP more broadly available,” Moin said.

“I believe in providing choice.”

Choice is a key principle of HSR&D investigations, many of which aim at expanding access to care among veterans overall, and particularly at expanding access for vulnerable populations. According to the CDC, rates of diagnosed diabetes are higher among African-Americans, Native Americans, and Hispanic Americans than they are among white and Asian Americans.

VA health care researchers are still trying to pin down the reasons for these disparities. Brian Neelon,

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PhD, a research health scientist at the Charleston VA Medical Center and associate professor of biostatistics at the Medical University of South Carolina, is leading an ambitious analysis of personal and environmental factors that, over time, affect outcomes for veterans with diabetes. He and other researchers have already gathered data suggesting that disparities in uncontrolled blood sugar and length of diabetes-related hospital stays are explained in part by where veterans live, but demography and residential location don’t provide the full picture.

Neelon is studying other factors, essentially overlaying multiple data sets, beginning with the identification of “hotspots,” or geographic clusters of high or low HbA1c, health care costs, emergency room visits, and other outcomes among veterans with type 2 diabetes. “By identifying locations with poor diabetes-related outcomes,” said Neelon, “policymakers and health providers can begin to design targeted interventions” – such as additional community-based outpatient clinics

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A veteran and a nurse interact with a provider using telehealth technology during a clinic visit.

Telemedicine could potentially be implemented in areas that VA research identifies as having poor diabetes-related outcomes, whether due to neighborhood or workforce deprivation factors.

or telemedicine systems – “to improve outcomes in these communities.”

Neelon’s analysis will also involve developing a “neighborhood deprivation index” of factors – such as income, education, employment levels, neighborhood walkability, and access to healthy food – to see whether more deprived areas correlate with poorer outcomes. Finally, he and his colleagues will develop a new “workforce deprivation index” that will comprise information such as average wait times for primary care, the overall availability of primary care, and the presence of team care, in addition to basic access measures such as distance to a VA medical center. His team will use this index to identify facilities that may benefit from increased staffing, efficient patient portals, or telehealth programs to reduce

patient demand. Ultimately, they want to determine how neighborhood and workforce deprivation impact the long-term health of veterans with type 2 diabetes and to identify resource-deprived areas that are ideal targets for health promotion efforts. “The overarching premise of our grant is that some areas may be doing well,” he said, “while others could potentially benefit from interventions to improve health outcomes. Our aim is to pinpoint areas that are in greatest need of such interventions.”

Donna L. Washington, MD, directs the Office of Health Equity-QUERI National Partnered Evaluation Center and leads the women’s health-focused research area at the CSHIIP. She’s devoted her career to addressing the health care needs of vulnerable and underserved patient populations. Veterans from racial or ethnic minority groups with diabetes carry what she calls a “double burden”: Not only do they have diabetes at higher rates, but among patients who have diabetes – both within and outside the VHA system – they are less likely to have their blood sugar under control.

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These two factors are the starting point of one of Washington’s recent studies, launched last year: “Mitigating Racial/Ethnic and Socio-economic Disparities in VA Care Quality and Patient Experience.” The investigation will be an observational study of a national cohort of veterans, correlating “social determinants” of health care outcomes (such as socio-demographics and residential characteristics) with health care data, characteristics and behaviors of health care providers (i.e., prescribing habits), and system-level data, including sitelevel implementation of patient-aligned care teams (PACTs) and VA quality measures of patient experiences.

Understanding how better-performing systems deliver diabetes care can help other facilities or systems improve monitoring and controlling blood sugar among racial/ethnic minority veterans. “This is really one of the very unique aspects of the study I’m leading,” said Washington.

“We believe health care systems can

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LaCresha Mitchum, a registered nurse, certified diabetes educator, and diabetic coordinator at the Williams Jennings Bryan Dorn VA Medical Center in Columbia, South Carolina, listens to U.S. Army veteran William Baker, a patient with type 2 diabetes, as he describes some health issues. An investigation launched last year, “Mitigating Racial/Ethnic and Socio-economic Disparities in VA Care Quality and Patient Experience,” aims to understand how betterperforming VA systems provide diabetes care to racial/ethnic minority veterans, with the hope that systems with better health outcomes can help other facilities or systems improve.

vary how they deliver care, so that even if there are social determinants of health present, we believe some health care systems are more successful in figuring out how to account for them and get better outcomes for their patients.”

The VA has been a pioneer in developing and field-testing evidence-based interventions that reduce disparities in health care outcomes among vulnerable patient populations. “VA studies have

found that a peer coach or peer support improves control of diabetes and reduces disparities,” Washington said, “and that’s one of many different examples of evidence-based practices to help with diabetes control.”

The way in which these interventions are implemented may differ outside the controlled environment of a study group, however, and these differences are part of what Washington and her team plan to evaluate. “In other words,” she said, “how have some sites translated these evidence-based findings into practice, and what are some of the lessons that can be applied to other sites?”

It’s an ambitious research undertaking, involving several layers of data, and is likely to take at least a couple of years to complete – but it’s an ambition in line with the VA’s mission to provide the highest-quality diabetes care, and achieve the best possible outcomes, for all veterans regardless of who they are or where they live.

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