Veterans Affairs & Military Medicine Outlook, Spring 2020 Edition by Faircount Media Group

Veterans Affairs & Military Medicine Outlook Supports

NATIONAL NURSES WEEK 2020

West Point for Doctors Enhancing Specialty Care for Veterans Keeping Personnel and Patients Safe

Interview Dr. Rachel Ramoni

Chief Research and Development Officer (CRADO), Veterans Health Administration

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CONTENTS VA AIMS TO ENHANCE SPECIALTY 6 THE CARE FOR VETERANS By Charles Dervarics

12 KEEPING PERSONNEL AND PATIENTS SAFE

The VA’s Safe Patient Handling and Mobility program protects nurses and patients. By Gail Gourley

PROGRAM BENEFITS NURSING 20 VALOR STUDENTS AND THE VA By Gail Gourley

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PREPARATION, RESPONSE, RECOVERY: THE VA’S “FOURTH MISSION” VA emergency responders attend to veterans in every phase of a natural disaster. By Craig Collins

VA RESEARCH

DR. RACHEL RAMONI, CHIEF 34 INTERVIEW: RESEARCH AND DEVELOPMENT OFFICER (CRADO), VETERANS HEALTH ADMINISTRATION By Craig Collins

42 PUTTING THE “D” IN R&D

Increasing the real-world impact of VA research By Craig Collins

THE VA AND CLINICAL TRIALS The VA’s Cooperative Studies Program (CSP) is the linchpin for increasing veterans’ access to high-quality clinical trials. By Craig Collins

52 PUTTING DATA TO WORK FOR VETERANS By Craig Collins

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58 MILITARY HEALTH SYSTEM TRANSFORMATION

Administration and management of all U.S. military medical facilities are shifting to the Defense Health Agency. By J.R. Wilson

POINT FOR DOCTORS: THE UNIFORMED 66 WEST SERVICES UNIVERSITY OF THE HEALTH SCIENCES By J.R. Wilson

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THE VA AIMS TO ENHANCE SPECIALTY CARE FOR VETERANS By Charles Dervarics

that took effect in June 2019. Among other provisions, the law set new guidelines for how veterans can see specialists outside the VA system. Under the act, a veteran can seek private-sector care if he or she must wait more than 28 days for a VA appointment or drive more than 60 miles to a VA facility. The agency says this policy may mean 1.5 million veterans will gain access to private care, up from 560,000 under previous department choice initiatives. So far, VA leaders say the law has produced gains for specialty care. “Ninety percent of the increase in consultations going out to the community are in specialty care,” Richard Stone, MD, administrator of the Veterans Health Administration, told a Capitol

President Donald Trump signed the MISSION Act in 2018. Its provisions – including changes in how veterans access specialty care – went into effect in June 2019.

Hill audience in February 2020. With these options now more readily available, he said, “It appears veterans have improved access to specialty care.” However, there is still ample evidence – despite the new flexibility – that many veterans prefer to use VA facilities and staff for their specialty care. “The MISSION Act has afforded the veterans the opportunity to receive speedier care,” said Terrence Hayes, a spokesman for the Veterans of Foreign Wars (VFW). “However, our members’ preference remains the VA medical

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n IN EUREKA, MONTANA, NEAR THE Canadian border, a telehealth initiative brings together a veteran with a physician five hours away. In Pittsburgh, a Department of Veterans Affairs (VA) oncologist conducts video visits with patients 100 miles to the east, coordinating care with a technician who helps ease patients into this new approach. And across the country, veterans have flexibility to see specialists outside VA thanks to a new law with provisions on everything from telemedicine to increased patient choice. These are among many new developments to enhance specialty care for veterans, particularly those living in less-populated areas and those who face more complex challenges or deal with new challenges as they age. Spanning more than 20 disciplines, VA’s specialty care includes cardiology, critical care, dermatology, diabetes, eye care, infectious disease, neurology, nutrition, and oncology, and other areas described in full at www. patientcare.va.gov/specialtycare.asp. With many new activities underway, one common thread across these initiatives is the goal “to ensure that veterans are spending their time getting care instead of driving to it,” said Lesly Roose, a program manager at the VA’s Office of Connected Care. VA specialty care is changing under the MISSION Act, the comprehensive legislation signed into law in 2018

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VA PHOTO

Veteran Cedric Boswell greets a nurse in the cardiology clinic at the Atlanta VA Medical Center. A study published in 2019 in the Journal of the American Medical Association found no statistically significant difference between private sector and VA wait times for cardiac specialty care.

centers and clinics, where they believe they will receive more specialized care due to their military service needs.” Research has shown that veterans were able to access VA specialists at the same or faster rates than they could secure such care in the community. A 2019 study in the Journal of the American Medical Association found no statistically significant difference between private sector and VA wait times for primary care and two major areas of specialty care: cardiology and dermatology. While the VA had statistically significant longer wait times for a third area of specialty care included in the study – orthopedics – compared with private providers, researchers said the findings “should help to disabuse the unfortunate yet widely held belief that access in the VA is substantially inferior to that in the private sector.” However, regional variations within the large VA system mean the situation can look different on the ground depending on the location. Recently, the VA’s Office of Inspector General (OIG) found the process of obtaining care in the community was particularly difficult in the southern U.S. region including Florida, Puerto Rico, and parts of Georgia. The OIG said it took 10 days to refer potential outside consultations and another 18 days to process the request. That meant “28 days of administrative wait before a veteran was able to begin the scheduling and appointing process,” said William “Doc” Schmitz, VFW’s national commander in chief. “With standards of 20 days for primary care and 28 days for specialty care, the access standards were surpassed before the process of scheduling and receiving care could begin.” At one site, ophthalmology referrals took 66 days to complete care delivery, with 34 days spent waiting to create

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authorizations. If community care is to succeed for a large segment of the veteran population, he added, “it must work seamlessly and quickly to deliver needed care.” One reason behind the delays is the many VA staff vacancies that go unfilled. In fall 2019, the OIG reported that 131 of 140 VA medical facilities had severe shortages of medical officers and 102 had severe nurse shortages. The inspector cited lack of qualified applicants, non-competitive salaries, and staff turnover among the reasons for the large number of vacancies. In specialty care, shortages also can lead to overworked staff who remain on the job. For example, data showed that nurses who specialize in spinal cord injury or disorder (SCI/D) worked more than 105,000 overtime hours in one year, David Zurfluh, national president of Paralyzed Veterans of America, said at a March 2020 hearing. Such trends also indicate that underqualified staff must provide more care. “A system that relies on floating nurses, not properly trained to handle SCI patients, overworks existing SCI/D nursing staff,” Zurfluh said. “This leads to burn out, injury, and loss of work time

or staff departure and is unacceptable. In some circumstances, it even jeopardizes the health care of veterans.” At recent 2020 hearings, members of Congress chimed in with their concern about VA staff shortages. “Vacancies continue to be the biggest barrier to primary, specialty, and mental care for veterans across the country,” said Sen. Jon Tester, D-Mont., a member of the Senate Veterans’ Affairs Committee. One potential answer to these challenges is greater use of technology to deliver high-quality specialty care. One such innovation is the Specialty Care Access Network – Extension for Community Healthcare Outcomes (SCAN-ECHO) program, which links primary and specialty care physicians to improve patient care in the VA system. SCAN-ECHO is a provider-to-provider connection, where specialists provide professional development to increase the knowledge and skills of primary care physicians in rural or isolated communities. Webinars, small-group training, and even mini-residencies are options used to deliver the training. In a 2019 report, the Department of Health and Human Services (HHS) cited a study finding that veterans with

VA PHOTO

Above: VA spinal cord injury (SCI) nurses and veterans on Veterans Day Weekend at the VA Boston Healthcare System. Staff shortages in specialty care areas can lead to overworked staff and delays in veterans’ access to care. Right: A room equipped with Tele-ICU capability at the North Las Vegas Medical Center. Below right: A treatment room at the nation’s first remote chemotherapy clinic, located at the James E. Van Zandt VA Medical Center in Altoona, Pennsylvania.

VA PHOTO

PHOTO BY KELLY D. SKINNER

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chronic liver disease showed much stronger outcomes if their primary care physicians participated in the program. “Those receiving the intervention were much less likely to die than those who had no SCAN-ECHO consultation over the same time period,” the agency reported. Other research showed that providers with at least one SCAN-ECHO consultation improved treatment for patients with hepatitis C. Overall, HHS said based on the most recent data, SCAN-ECHO was used most heavily to improve care for diabetes, pain management, and hepatitis C. While SCAN-ECHO is a long-time tool of VA, more recent advances in telehealth – with patients interacting directly with specialists via video – are driving a rapid expansion in remote patient consultations. Telehealth provided 2.6 million episodes of care to more than 900,000 veterans in fiscal year 2019, an increase of 17 percent over the previous year, the VA reported. “This extraordinary progress gives veterans more convenient care options without traveling to their provider’s office,” VHA’s Stone wrote in a post in January 2020 on VAntage Point, the VA’s blog. The MISSION Act also contains many provisions to support telehealth. It specifically authorizes “anywhere to anywhere” telehealth, which in effect “can bring provider expertise across state lines and into veterans’ own living rooms,” Stone added. Such innovations include the nation’s first remote chemotherapy clinic from the VA Pittsburgh Healthcare System. From their base in Pittsburgh, oncologists monitor the care of patients as they visit the James E. Van Zandt VA Medical Center in Altoona, Pennsylvania, two hours to the east. Staff in Altoona use a camera to send images and live video to the oncology team in Pittsburgh. The Altoona clinic can conduct lab work, testing, and radiology services, and clinic staff work with oncologists to create a patient’s individualized treatment plan.

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“Patients and caregivers tell me, ‘We love this technology because it saves us so much travel, time, and money,’” said Vida Passero, MD, an oncologist and head of VA Pittsburgh’s hematology and oncology division, in a recent post on the VA’s blog. One key element to success is having a welltrained, caring technician on site in Altoona to introduce the patients and their families to the concept of visiting with a physician via a TV screen. Oncology is just one of many initiatives underway to enhance specialty care via telehealth: • Later this year, the VA Pittsburgh Healthcare System also plans to roll out tele-gynecology for outpatient clinics in western Pennsylvania and eastern Ohio, part of an effort to deliver care to a fast-growing population of women veterans. • VA teledermatology solutions are helping patients get quicker access to board-certified dermatologists. Under this program, a primary care provider on site orders imaging, which is then transferred to a remotely located dermatologist via the VA’s electronic health record. Mobile app solutions also are underway to enhance care in this specialty. • A Tele-ICU program allows specialty providers to access intensive care unit rooms via video to improve care. Rooms

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Combating the Impact of High-Stress Environments We face daily challenges that can “destabilize the delicate balance of bacteria in the gut, such as eating processed food, environmental chemicals, heavy metals, and stress,” says Dr. Gerda Edwards, PhD, DNM, FDN1, a United States Navy veteran and now doctor of natural medicine. However, service men and women face even more pressure on the gut microbiome from high-stress training and combat situations, and from acute and chronic pain resulting from active duty injuries. Over time, these conditions can lead to an increase in the “bad” bacteria that release chemicals causing inflammation. This weakens the intestinal wall causing leaky gut. Toxins more easily enter the blood stream, eventually causing disease conditions and weakened immunity. A 2017 study* with 73 soldiers in a military training environment determined that “Changes in intestinal microbiota composition and metabolism coincide with increased intestinal permeability in young adults under prolonged physiological stress.” The authors of the 2017 study suggest “targeting the microbiota before stress exposure” to maintain a healthy gut. The importance of the gut microbiome to military health and performance was confirmed by the 2017 creation of the Tri-Service Microbiome Consortium (TSMC) to enhance collaboration among Army, Navy, and Air Force scientists.**

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“We support our military’s mission to reduce both acute and chronic pain with less reliance on opioids and restore function and improved immunity. By integrating more non-pharmaceutical approaches like Prebiotin, we can improve the care of our soldiers and veterans while using low-risk care options that are cost effective and offer long-term health benefits.” – F.Wilson Jackson, MD, FACP, FACG, AGAF, Prebiotin Medical Director

Journal References: *Karl JP et al. Changes in intestinal microbiota composition and metabolism coincide with increased intestinal permeability in young adults under prolonged physiologic stress. DOI: 10.1152/ajpgi.00066.2017. **Glaven S et al. The Current and Future State of Department of Defense (DoD) Microbiome Research: a Summary of the Inaugural DoD Tri-Service Microbiome Consortium Informational Meeting. DOI: 10.1128/ mSystems.00086-18. Pain Research Forum.org. Symptoms of Opioid Dependence Linked to Gut Microbiota. Nov 26, 2018.

Dr. Edwards served in the US Navy for 27 years, retiring with the rank of Captain after three tours in the Gulf, and was awarded the Defense Superior Service Medal (DSSM) and three Legion of Merit (LOM). Learn more at www.prebiotin.com/military-gut-microbiome-unique-universal/

Yoo BB, Mazmanian SK. The Enteric Network: Interactions between the Immune and Nervous Systems of the Gut. DOI: 10.1016/j.immuni.2017.05.011. This product is not intended to diagnose, treat, cure, or prevent any disease. Copyright © 2007-2020. Jackson GI Medical. All rights reserved.

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in the tele-ICU typically include TV screens, cameras, and call buttons used to contact specialists. Providers review charts, speak with patients, make notes, and confer with on-site care teams to chart patient care. • A TeleStroke initiative supports VA facilities without round-the-clock acute stroke coverage. Under this initiative, neurologists can examine patients through a video tool and help local providers diagnose conditions and propose treatments. Another emerging innovation is the Accessing Telehealth through Local Area Stations (ATLAS) initiative, where VA and partners are creating dedicated space in local communities for veterans to visit with their health care providers. One of the new locations is 7 miles from the Canadian border in Eureka, Montana, where veterans face a five-hour drive to the nearest VA hospital. At its office in Eureka, VFW Post 6786 provided a dedicated office space plus an internet connection so that veterans can communicate with their medical providers. “By providing convenient locations for veterans to access VA care in their communities, ATLAS saves veterans travel time and transportation costs, increases their access to care, and provides a convenient solution for aging, underserved,

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Philips provided a demonstration of its Project ATLAS Remote Telehealth exam rooms to VA Secretary Robert Wilkie, Dr. Leonie Heyworth, and Dr. Kevin Galpin during the Veterans of Foreign Wars (VFW) 120th National Convention, on July 23, 2019. The ATLAS initiative is improving access to quality health care by providing remote VA Telehealth exam rooms for veterans who live in rural areas.

or rural veterans,” said Roose, the ATLAS program manager within the Office of Connected Care. The VFW, the American Legion, and veterans’ service organizations offer locations for these local stations, and Philips Healthcare has donated telehealth equipment and expertise to make them fully operational. Aside from Eureka, Phase 1 ATLAS sites include Linesville, Pennsylvania, and Los Banos, California. For each site, Philips created an exam room that was customized based on feedback from veterans who participated in role-play activities to determine the best layout and structure to promote patient ease and comfort. ATLAS pods have blood pressure cuffs, glucose meters, electronic scales, and other resources to facilitate a quality health care visit. The local VA facility associated with the ATLAS site determines the clinical

services offered at each site. Each site has the ability to link veterans with VA providers through VA Video Connect, a secure video conferencing software. Patients also have no co-pay for VA Video Connect appointments. For the next phase of the project, the VA is working with other partners to stand up exam rooms in more sites such as local Walmart stores. Leaders recently cut the ribbon on a new ATLAS facility inside a Walmart in Asheboro, North Carolina. The retailer also will provide space for ATLAS sites in Boone, North Carolina; Howell, Michigan; Keokuk, Iowa; and Fond du Lac, Wisconsin. “ATLAS is enhancing the veteran experience by offering a convenient and personalized health care option for veterans that face long travel times to VA facilities or have limited internet connectivity at home,” Roose said. Overall, the VA says nearly 1.9 million veterans have sought care via the MISSION Act’s various initiatives since June 2019. A recent survey of 7,000 VFW members also found that 74 percent saw improvements at their local VA facility, up from 64 percent in 2018. Overall, Roose added, “The MISSION Act has greatly expanded the choices veterans have when it comes to their health care.”

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KEEPING PERSONNEL AND PATIENTS SAFE The VA’s Safe Patient Handling and Mobility program protects nurses and patients. By Gail Gourley

n AS THE OPENING MONTHS OF 2020 reveal the increasingly devastating developments of the COVID-19 pandemic, images of health care workers caring for skyrocketing numbers of patients are prevalent. A shortage of personal protective equipment is just one example highlighting their safety requirements, and those of their patients. Underlying the crisis and inherent in all patient care, both as part of the pandemic as well as other ongoing health care functions, is the always-present need to transport, move, and reposition patients with limited mobility. The overexertion and bodily reaction from motions like lifting, bending, twisting, and reaching place nurses and other health care workers at high risk for injury, underscoring additional safety concerns. The Department of Veterans Affairs (VA) has placed emphasis on protecting nurses and patients with its Safe Patient Handling and Mobility (SPHM) program. Jill Earwood, MSN-HCQ, CSPHP, RN, VHA Office of Nursing Service liaison for SPHM and Asheville VA SPHM coordinator, explained the significance of injuries to nurses. Referring to a November 2018 article in the U.S. Bureau of Labor Statistics journal Monthly Labor Review, Earwood said, “Previous research on hospitals

demonstrated that hospital workers have a higher-than-average incidence rate of injury and illness. And historically, RNs have experienced some of the highest injury and illness rates in health care and the social assistance sector.” In anecdotal terms, Earwood noted that nursing colleagues observe, “We’re the only profession that looks at a hundred pounds as ‘light weight.’ And it’s because we’ve been expected to manually handle that amount of ‘light weight,’ more than a hundred pounds, repeatedly, every day that we work.” She continued, “The VA committed to stopping this culture of thinking that we had to lift, and do things differently than a factory worker or construction worker; that we should have equipment to do the work that we’re doing.” Another issue is that the percentage of bariatric patients continues to increase. “They have more co-morbidities than the average person in the hospital, so they’re even more dependent on us,” Earwood said. “They need us for the activities of daily living.” An additional factor highlighting the necessity to keep nurses safe, Earwood added, is that “the American Association of Colleges of Nursing says that the U.S. is projected to have a shortage of nurses that’s intensifying

as baby boomers age and the need for health care grows. So, all of these things make patient handling a significant issue for nurses.” Tony Hilton, DrPH, MSN, FNP, CRRN, Veterans Health Administration SPHM national program manager, explained the importance to staff and patients of utilizing technology for patient mobility, stating that all the evidence shows the benefits of “mobilizing patients very early in admission, starting in the ICU.” She continued, “It’s so clear in the literature and in practice that it’s important to get our patients moving very quickly and very early. The problem is that we’ve manually done it for years and years, and we have been taught to do this using our physical bodies. That has been proven through a lot of literature that the human body is not built to withstand these kinds of tasks that result not only in acute incidents of injury, but chronic injuries. … So we really started looking at it in the VA from a protecting staff perspective. But then we realized all of the benefits to the patients. So, in terms of utilizing the technology, it’s a win-win for our patients and our staff.” Hilton pointed to VA research in reducing nurses’ injuries, beginning in the 1990s with pilot projects and demonstration sites. “Over time, this initial research group and those pilot facilities started to do work with our regulators and Congress to ask for funding,” she said. “In 2008, we were provided over $200 million in capital funds for overhead ceiling lifts and technology,” showing that “the VA has a serious commitment to really making sure we protect our staff and our patients.” That initial funding began the VA’s national SPHM program, utilizing proven methods and the latest technology and devices to maximize the safety of patients and staff when moving or lifting patients. As one example, ceiling lift devices utilize a sling to transfer a person from point to point along an overhead track. “The VA invested a lot of money into ceiling lifts and other technology that

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Sling seats attached to ceiling lifts are one method utilized by the VA to safely move patients in inpatient and outpatient settings.

ALL PHOTOS COURTESY OF VA

was deployed over a few years, from 2008 to 2010 and 2011,” Earwood said. She explained that the best option is the presence of full room coverage, which “allows for staff to be able to mobilize patients from corner to corner, wall to wall, and to the bathroom, without having barriers to care.” In comparison to floor-based lifts, Earwood said ceiling lifts are preferred because they require less force to push them. “If you have a floor-based lift, you have to actually use force to push the patient that’s in it. Also, the ceiling lifts require zero space for storage. And we know that in hospitals, space is definitely at a premium.” Ceiling lift usage is widespread in the VA. “The good news is that the majority of VA [hospitals] have ceiling lift coverage in at least 50 percent of all the rooms; most are at 75 percent, and some at 100 percent, in the 24/7 spaces,” Earwood said. “But, we’re fortunate to also have ceiling lifts in other departments, like outpatient therapy, imaging, the EDs [emergency departments] – which are 24/7 but we consider those outpatients – and our community-based clinics. “Ceiling lifts are definitely the choice of technology for those patients who are completely dependent,” Earwood continued, “or if we’re trying to create early ambulation for patients who can’t bear weight, you can actually use a ceiling lift to get them upright, feet touching the floor, but the ceiling lift is actually bearing the weight of the patient. So, patients are able to ambulate earlier with the use of special slings and harnesses.” The VA also uses technology for fall recovery. “They have several air-assisted devices that raise [patients] off the ground so that we’re not using a backboard and the strength of as many people as we can get to lift someone off the ground, which is safer for staff, obviously, and safer for patients,” Earwood said.

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Left: Stand-assist technology facilitates early mobility, which evidence shows is beneficial to patients. Below: A ceiling lift for gait training enables patients who can’t bear weight to ambulate earlier using special slings and harnesses.

Devices also function to assist patients out of their vehicles when they arrive for emergency care or routine appointments, as well as to help them back into their vehicle. “These devices range from a ceiling lift in a covered area outside, to floor-based equipment that will do this, to using air-assisted technology in an emergency situation where we just need to use that technology to move them from the vehicle to a stretcher,” she said. “We also have stand-assist devices,” she continued. “Our therapy partners agree, and our therapy partners are definitely onboard. We’ve had conferences where we’re collaborating with therapists – physical therapists, occupational therapists, and kinesiotherapists. We don’t want to limit patients, and we don’t want to do more than we need to when it comes to assisting them, so we have stand-assist devices, both powered and non-powered, for those patients who are able to bear weight and able to use some upper body strength.” There are also multiple devices for assisting with hygiene. Earwood described mechanical-lift seat toilets. “They function much like the recliners you see in a home, where the recliners raise so that the person can kind of

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perch on it, and then it lowers so they can sit. These toilets do the same,” she said, adding that this device is especially helpful for postoperative patients following knee or hip surgery. “If they’re struggling with toileting, this is a device that’s great to use for getting them out of bed, getting them to the restroom on their own, and then advancing them on.

“And we also have mechanical shower chairs now, which are wonderful,” Earwood enthused. Primarily used for residents in long-term care, shortstay rehab, and hospice settings, these shower devices recline, raise and lower, and have protective seatbelts. Earwood said she’s heard story after story from nurses across the country referencing patients who were unable to be in a regular shower chair, and with this device, they “were able to get a shower, instead of maybe a whirlpool bath or a bed bath, for the first time in years.” Earwood also described simple, friction-reducing devices like slide sheets, which are very effective in moving patients laterally and up and down the bed, or to help move patients’ legs across their car seat if they only need help getting their legs turned. Motorized stretchers and beds are other technologies that have an impact, as many injuries occurred in the past, Earwood noted, with staff pushing heavy equipment with a patient in them. “Motorized stretchers and beds have definitely made ease of transport accessible to the staff.” Additionally, Hilton described a powerlift device available for emergency medical services staff, who are also at high risk for injury. The system connects to the floor of the ambulance and lifts the patient on a stretcher into the ambulance, instead of personnel lifting the patient and stretcher manually. There are many opportunities for innovation in utilizing these devices, Hilton said, such as adapting much of this technology for veterans not only in hospitals but across all settings, including home and community. With the ability to participate in recreation and sports and improve their quality of life, she said, “we think that makes a big difference when it comes to reducing depression scores. All of this has such a huge impact on

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Training personnel to utilize Safe Patient Handling and Mobility technologies is accomplished using several methodologies, including competency development with peer leaders, didactic instruction, and simulation.

patients and their families, not only in the acute care setting, but also in the home and the community setting.” To assist health care providers by bringing information about this safety technology and its use to the point of care, the VA developed its Safe Patient Handling App. Hilton said that the app, utilized in VA, non-VA, and international settings, includes video clips of how the technology works, patient assessment algorithms, and other SPHM resources useful at the bedside, adding, “This has been extremely helpful by making the algorithms that we’ve created over the last few years into a much simpler way to get to the answer of ‘How do you do this?’” Another method for assessing which equipment to use during patient care or movement is the Bedside Mobility Assessment Tool (BMAT), an industrydeveloped instrument widely used in the VA under a national agreement. Earwood said, “Objective screenings are necessary so that we can decide what [equipment] patients may need at any given moment during care or during movement. BMAT is the only tool that we have now that marries the patient’s response to screening to the equipment.” Using this tool, a nurse can perform an objective assessment of a patient’s capabilities, asking them to perform physical tasks and observing their response. Based on that response, Earwood said, “you know which equipment you need.” Training the staff in the use of these SPHM devices is based on the directive requirement, Hilton said, “which includes some very specific criteria that we expect their facility to utilize so we can measure our program outcomes.” She explained that they use several separate methodologies, including an electronic system, new employee orientation with hands-on exposure,

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and training with a unit peer leader to ensure competency. Hilton continued, “We have a national conference for [SPHM] facility coordinators, and this is where we not only provide didactic [instruction], but we focus on the simulation of competency within all of our technologies that we offer. This is done at our SimLEARN center in Orlando, at our simulation hospital. It’s a three-day training program where we have simulation happening within multiple settings. … We walk small groups through each of those scenarios so that they can see how they actually use the technology.” Asked about the biggest barriers and challenges in utilizing this technology, Hilton pointed to traditional nursing culture, which has focused on manual patient handling for years, as well as the fact that traditional body mechanics training was based on moving “boxes,” which are very different from humans. Also, she said, it is not a standard of care in the schools of nursing, where students are still taught manual handling techniques. “We try to mitigate that by participating in community and university

hospitals as faculty speakers, and by getting our staff to really engage with modern-day life technology. One good example is to look at your smartphone. How long did it take to get familiar with your smartphone? And now, you can’t be without it,” she said. Looking toward the future, Hilton enthused over the exciting potential of the VA’s five-year strategic plan, which will address “improving the employee experience with safe patient handling and all of the components that include ergonomic, education, and learning how to buy equipment,” as well as quantifying improved patient outcomes associated with that care. The benefits of this technology to personnel and patients are evident. “We’ve been monitoring our staff injuries and found that our injuries have been reduced by 50 percent in 10 years, which is incredible,” Hilton said. “We know that if you don’t take care of your caregivers, the patients’ care is being affected. So, it is ultimately for the patients’ benefit … and improving our patient outcomes.”

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SPONSORED BY NURSES ORGANIZATION OF VETERANS AFFAIRS (NOVA)

VA NURSES: STORIES FROM THE FRONT LINES OF A PANDEMIC By Teresa Morris, Director of Advocacy & Government Relations, and Kelly D. Skinner, NOVA President

n 2020 IS THE YEAR OF THE NURSE AND MIDWIFE, a time to celebrate Florence Nightingale’s 200th birthday (May 12), while recognizing Nurses worldwide for the dedication and care they provide their patients. Acknowledging the tireless work of our health care professionals on the front lines has never been more important or timely during this global pandemic. VA Nurses provide a unique kind of care, one that includes a wholehealth model designed to provide personalized and proactive care that is both physical and psychological. They are trained to understand military culture and the service-related injuries and illnesses – both physical and mental – that often come with it. They are uniquely qualified to combat this “war against COVID-19.” The almost 3,000 members of the Nurses Organization of Veterans Affairs (NOVA) are among those providing care at the over 1,243 VA health care facilities within the U.S. and its territories. They are on the front lines during this pandemic and stand ready to take care of Veterans and their communities as VA activates its 4th Mission* in areas where there are a high number of COVID-19 cases. As this article went to print, VA hospitals in New York, New Jersey, Massachusetts, Michigan and Louisiana have opened beds to non-Veteran patients, and others may follow as cases surge in known “hot

spots.” During a national emergency/health crisis, VHA facilities and their health care professionals provide a safety net for the nation’s hospitals – the following are some of the nurses who will be caring for Veterans and nonVeterans in communities around the country. These are their stories: Cecilia McVey, MHA, RN, FAAN, is the Associate Director for Nursing and Patient Care Services at the VA Boston Healthcare System. “As a Nurse Executive of one of the largest VA health care systems, I am honored to care for our Veterans and staff for the past 50 years. We are living in unprecedented times and I am seeing staff go above and beyond despite the risk to themselves and their families to provide the best care anywhere! We are nurses that, unlike many other professions, dedicate ourselves to saving lives … in floods, tornados, blizzards, sunshine, and rain. 2020 is The Year of the Nurse and never has it been more important for the need for nursing care across the United States. It matters when we don’t go to work. I am privileged to work among the most amazing staff of nurses, physicians and others. It is because of all of them that our Veterans get the best in clinical care. We will always be there for our Veterans and our communities. We are VA STRONG!” Kelly D. Skinner, DNP, APRN, NP-C, GNP-BC, CRRN, WCC, CFCN, the Spinal Cord Injury Clinical Specialist at the VA Boston Healthcare System, is

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PHOTO BY KELLY D. SKINNER

VA Nurses at VA Boston Healthcare System stand ready to serve Veterans and their community. This photo: VA Nurses on a Spinal Cord Injury Unit. Opposite page: VA Nurses in the Community Living Center.

PHOTO BY ANASTASIA ARYEE

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tasked to help ensure staff competency and adequate staffing amid the coronavirus pandemic. As the VISN 1 Nurse Professional Standards Board (NPSB) Consultant and NPSB Chairperson at her facility, she is doing ad hoc local boards and started conducting nurse applicant screening interviews. Kelly admits that, “This is not business as usual. We all need to be collaborative and flexible during these unprecedented times to assure an adequate and highly qualified nursing workforce.” Catherine Giasson, DNP, MHA, RN, NE-BC, is the Associate Nurse Executive at the VA Central Western Massachusetts Healthcare System. She is serving as the Chief of Operations for the Incident Command Center, which was activated in response to COVID19. The Incident Command Center Leadership Team is responsible for the operations of services system-wide and managing efforts to continue service levels. Catherine commented, “In my role, I am leading teams with others in the fight against the coronavirus outbreak. As the situation swiftly evolves, we are utilizing the published protocols and guidance to maintain health care services. The safety of the Veterans and staff is our top priority.” Michelle Salazar, BSN, RN, has been busy at the Black Hills VA Health Care System as one of the Bed Management Solution (BMS) Coordinators and Transfer Coordinator. According to Michelle, “BMS is so important to VA during this pandemic as it allows the nation to coordinate bed availability to assist with patient overload within VA, and if needed, with civilian overcrowding.” Michelle is working diligently to manage bed availability to ensure the VA is ready to provide care and services as part of the VA’s 4th Mission. Taryn-Janae Wilcox-Olson, MHS, RN, the Patient Safety and Risk Awareness Operations Manager at the VA Portland Healthcare System, was charged with screening patients and visitors at the entrances. She reported, “My department staff was asking everyone entering the facility if they had experienced fever, cough or shortness of breath within the last week. Having the designated screening stations helped to limit the spread of COVID-19.” Laurel Ghose, MSN, RN, NE-BC, Acting Facility Telehealth Coordinator at the VA Boston Healthcare System, revealed how “Clinical Telehealth engages real-time interactive exchanges between patients and clinicians.

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During the COVID-19 pandemic, virtual care makes continued care possible while maintaining appropriate distancing. Ongoing care is being provided via VA Video Connect (VVC). Both clinicians and Veterans are connecting for their routine and follow-up care by utilizing telehealth appointments. We are in the process of providing the ER, urgent care, and units with patients who have a potential or positive COVID-19 diagnosis with iPads. This has been expanded to long-term care and mental health.” Molly Maloney, BSN, RN, a registered nurse on an acute spinal cord injury (SCI) unit, shared, “As this crisis continues to evolve, we are faced with a lot of questions and mostly concern for our already compromised patients. It is our responsibility to keep them safe. Therefore, we are working hard to minimize the risk of exposure and spreading the virus; doing our best to plan for the worst-case scenarios. As a team, we are willing to do what it takes to support one another, and first and foremost provide the best care to our Veterans.” Danielle Newman, MSN, RN, is a Clinical Resource Nurse for Specialty and Outpatient Clinics. She described how “It is challenging and at times frightening, but through it all there is hope for health care workers on the front lines of the coronavirus pandemic. The lack of proper equipment, particularly the N95 masks,

gowns, gloves and sanitizer, could be a real possibility. Another hurdle is the protocols and CDC guidance changing minute to minute and the increasing patient ratios. COVID-19 has turned American hospitals into a ‘combat zone.’ Our core values focus our minds on our mission of caring and thereby guide our actions toward service to others. I was called to serve, I was called to be a nurse – not to look at the problem from far away, but to be down in the trenches helping people fight the fight. And that is where I plan on staying until we get through this together.” Let us all pause as we move through the next weeks and months and be reminded of Florence Nightingale and her call to service – service that she passed on to all Nurses, empowering them to care for the sick and wounded during times of global crisis. We owe all of them our thanks and gratitude. The Nurses Organization of Veterans Affairs (NOVA) is a professional membership organization for nurses employed by the Department of Veterans Affairs (VA). For more about NOVA, visit their website: www.vanurse.org For VA COVID-19 information: www.va.gov/

*VA 4th Mission ensures continued service to Veterans, while supporting national, state, and local emergency management, public health, safety and homeland security efforts.

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VALOR PROGRAM BENEFITS NURSING STUDENTS AND THE VA n THE TRANSITION FROM STUDENT to a real-world job setting can be difficult in any arena, and that is certainly true for the nursing profession, where the potential for reality shock among new nurses is significant. In an effort to ease that transition for newly graduated registered nurses (RN) entering the workforce, as well as augment the number of nurses joining the ranks in caring for the nation’s veterans in Department of Veterans Affairs (VA) health care facilities, the VA Learning Opportunities Residency (VALOR) program provides nursing students an opportunity to enhance their skills in a VA health care setting. And, the VA looks for a significant percentage of program participants to stay on and begin their nursing careers in the VA, helping to stem the current and projected nursing shortage.

The VALOR program was initiated in 1990, according to program specialist Glenda Fuller, PHR. “This is a program that provides unique learning opportunities for outstanding students,” she said, adding that participating students must have a 3.0 GPA and have completed their junior year in an accredited baccalaureate nursing program. Selected candidates for this paid internship work in an approved VA facility a total of 400 hours during the summer months, and they can work an additional 400 hours spread over their senior year while accommodating their school schedule. Currently, 124 VA-approved health care facilities participate in the VALOR program, Fuller said, and since 2007, the program has seen 5,197 nursing student participants. Nursing students in the program engage in didactic or classroom experiences, clinical conferences, and

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SPOTMATIKPHOTO VIA 123RF.COM

By Gail Gourley

CATHY YEULET

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competency-based clinical practice with a qualified RN preceptor. “Each one of the [participating] facilities has a different curriculum,” explained Patrick Youngblood, DBA, SPHR, Health Professional Scholarship program manager and VALOR program manager. The students work with a preceptor on an assigned unit, but also may have the opportunity to rotate to other specialties for additional learning experiences. For example, he said, “Maybe it’s a [medical-surgical unit], or maybe they do some rotations in psychiatry or telemetry, or whatever the other disciplines are at the hospital.” The students gain valuable experience in the VALOR program, augmenting traditional classroom instruction, Youngblood said. While they learn skills in nursing school, for example, how to start an IV, he said, “By the time you pass the NCLEX [National Council Licensure Examination – a nationwide examination for the licensing of nurses] and go out there, it’s totally a different environment. This [program] brings you into that environment to experience nursing in a real-world setting.” “The VA affords them the opportunity to get real-life experience with a preceptor and a developed curriculum to hone their skills,” he said. “Not only are they coached and mentored about their bedside [skills], but they also learn and get the experience of being in the different units within the hospital in a training environment.” Additionally, “Those 800 hours that an individual can add to their resume enhances their hireability,” said Youngblood. “Whether it’s at the VA or in the private sector, it’s just valuable training that they’ve received to make them more marketable.” A research study reinforces the program’s value to nursing students. In a July 2016 article published in the monthly, peer-reviewed clinical journal Federal Practitioner titled “The Unique Value of Externships to Nursing Education and Health Care Organizations,” study authors Debra

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Opposite page: The VA’s VALOR program provides an opportunity for nursing students to learn and gain valuable experience in a health care setting before entering the workforce. Above: VALOR participants engage in didactic experiences, clinical conferences, and competency-based clinical practice with a qualified RN preceptor.

Shipman, PhD, RN, Jack Hooten, MHA, MSN, RN, and Linda Lea, MBA, PA-C, “investigated RNs’ experience in the VALOR prelicensure externship during the nurses’ senior year of coursework and the impact of this experience on their nursing practice,” according to the abstract. In their discussion of findings, they wrote, “The present study found that nursing students who had been in the VALOR externship felt confident in their clinical skills when they were transitioning to the RN role. Other studies similarly have found that externship students were self-confident assuming the RN role, owing to their additional clinical experience. … The RNs interviewed in the present study discovered that, unlike nursing school, VALOR provided a realistic view of full-time work as an RN.” The VALOR program also provides benefits to the VA. “The reason the program was established was to create a pipeline of newly graduating students to fill vacancies throughout the VA,” Youngblood explained. Currently, the

retention rate for program participants to stay with the VA after graduation is 47 percent. “Some changes were made probably two to three years ago to increase that number,” he said. “The VA’s point of view is that we would like to see that retention rate exceed 60 percent, so the facilities that participate in the program are encouraged, or almost mandated, to sign a commitment-to-hire letter stating that they will hire their students. Therefore, we anticipate that that retention rate will change over the next couple of years.” In addition to a source to fill nursing vacancies, Youngblood explained that the VALOR program helps to fulfill the mission of the VA Office of Academic Affiliations. That mission, according to the VA, is to conduct “an education and training program for health professions students and residents to enhance the quality of care provided to veteran patients within the Veterans Health Administration (VHA) healthcare system. In accordance with this mission, ‘To educate for VA and for the nation,’ education and training efforts are accomplished through coordinated programs and activities in partnership with affiliated U.S. academic institutions.” “We mirror their goal in the mission to educate and train those students,” Youngblood said. “Our hospitals that have these affiliations with the

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universities thrive off of that relationship with the university.” Moreover, prospective employers at VA health care facilities are able to become familiar with VALOR participants’ skills and strengths while they are students, allowing for the most appropriate hiring and placement decisions, Youngblood added. One of the specific challenges regarding the VALOR program, Youngblood explained, is that “most of these are in urban locations, where the universities are. So, as with the rest of medicine, we have challenges in the rural locations with this program,” he said. Additionally, Youngblood said, “Hiring students at VA facilities prior to them passing their NCLEX can be a challenge,” highlighting efforts to educate the facilities about utilizing all the available hiring flexibilities. “There’s a high turnover in human resources,” he said, “so we always endeavor to inform and advise them of the hiring practices and encourage them to get involved in hiring these individuals. “The process to credential a newly licensed nurse can sometimes take longer than what a recruiter or a new candidate might want,” he added.

Fuller elaborated, “The facilities now provide the next step for when the students graduate,” she said. “For instance, we have some facilities where [participants] go directly from being a valid student to being a graduate nurse technician until they become licensed. And once they become licensed, then they rotate into whatever that next logical step is at that facility, whether the ‘transition to practice’ program or whatever specific program they have at that facility to help them better become prepared to be an RN.” Typically, Fuller indicated, there are more applicants than can be accommodated in the program. “I have facilities that will normally say, ‘I have two slots and I have 40 applicants,’” she said. For fiscal year 2020, Fuller noted that 259 nursing students are approved for the VALOR program. “What I think would surprise someone is that we don’t have to do that much advertising for the VALOR program, because normally word gets out by word of mouth from previous VALOR students. I had gone on an on-site audit last year, and one of the students at the facility, when we interviewed her, said, ‘I told everybody at the school about the VALOR program.’ If they have good,

positive experiences, then they have no problem telling other students at their school, or wherever they are, about the VALOR program,” she said. Fuller added that feedback from participants reflects the positive experiences. “We do an annual satisfaction survey with the students, and 98 percent of VALOR participants would recommend this program to someone else. The most recent one was done in September 2019, and that’s pretty standard,” she said. “They’re always above 95 percent.” Elaine R. Sherman, MSN, RN, VA nurse professional development specialist and VALOR coordinator, shared her experience as a former VALOR program student participant. Describing her motivation to apply for and participate in the program, she explained, “I am a veteran, and this was an opportunity for me to give back. Also, I had not worked in a hospital before, and I am a visual learner, so this was a chance for me to put together all the information I had learned in nursing school, such as completing a head-to-toe assessment. Or, when seeing a diagnosis of CHF [congestive heart failure], this was an opportunity to see the signs and symptoms in real time. “It was a great experience,” she continued. “I shadowed nurses and floated to all the units, which provided me an opportunity to see nursing in real time and decide what specialty I would like to choose. I would recommend the VALOR program to every nurse,” she daid, adding that in her position at a teaching hospital, “I promote this to all nursing students who train in our building.” Sherman summarized the overall value of her participation in the program, asserting that it provided a strong foundation for her ensuing professional nursing career.

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CATHY YEULET

Not only do participating nursing students benefit from the VALOR program in the experience they gain; the program also serves as a source of potential candidates to fill the VA’s nursing vacancies.

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SPONSORED BY UNIVERSITY OF ILLINOIS AT URBANA-CHAMPAIGN

UNIVERSITY OF ILLINOIS AT URBANACHAMPAIGN DEVELOPS INTERACTIVE MIXED REALITY SOFTWARE FOR SEPSIS DIAGNOSIS

n IT’S RARE TO FIND SOMEONE IN AMERICA whose life has not been impacted by sepsis, whether themselves or a loved one. Michelle Osborne, an employee of the University of Illinois, recalls her father passing away from sepsis in 2012: “The symptoms progressed so quickly that it was difficult for doctors to determine he had it until it was too late.” The same year in Central Illinois, 5-year-old Gabby Galbo died from sepsis from an undetected tick bite, prompting her parents to fight for legislation to develop evidence-based protocol for early recognition and treatment in statewide hospitals. “Gabby’s Law” was signed into effect by Governor Bruce Rauner in 2016 and has been followed by legislation in Ohio and Wisconsin. While sepsis can affect anyone, the very young and very old are often most at risk. In deployed field hospitals, soldiers with abdominal trauma and significant tissue loss are at greater risk of developing sepsis, according to an article published by BMJ Military Health in 2013. Collaboration efforts have led to a 16% decrease in mortality-associated sepsis since 2013 according to the CDC, yet the disease remains notoriously difficult to identify and treat quickly. The CDC estimates that at least 1.7 million adults in the United States annually develop sepsis, which is the body’s response to an infection. Sepsis can be difficult to diagnose and is often fatal if not treated in a timely manner. Out of those 1.7 million adults, nearly 270,000 die from sepsis: that’s nearly one out of every three patients who die in a hospital. Symptoms are ambiguous and can include a fever and chills, shortness

Student’s view of Interactive Mixed Reality Trainer during simulation performed in summer 2019, showing the 360-degree video recording component. The simulated patient is a 35-year-old female complaining of fever after a recent surgery.

of breath, and high heart rate, progressing to cognitive impairment and organ shutdown. To improve sepsis outcomes, a new Interactive Mixed Reality (IMR) training tool has been developed by OSF HealthCare and the University of Illinois at Urbana-Champaign. IMR encompasses both virtual and augmented reality (VR and AR), merging real and virtual worlds to produce new learning environments. This tool makes it easier for healthcare providers to diagnose by directing them through sepsis prevention protocol with a 360-degree video recording and annotation, proving the efficacy of new simulated environments in training novice medical professionals. “Simulation technologies such as virtual and augmented reality are becoming more common in medical training,” said T. Kesh Kesavadas, Director of the Health Care Engineering Systems Center (HCESC) at the University of Illinois. VR and AR are a major focus of HCESC, a research center that fosters collaboration between engineers and physicians. Other areas of focus for HCESC are surgical robotics, health data analytics, and smart health. Kesavadas states, “Our center is at the forefront of developing these technologies as well as software that makes it possible for faculty without programming skills to create IMR scenarios.”

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ALL IMAGES: HEALTH CARE ENGINEERING SYSTEMS CENTER AT THE UNIVERSITY OF ILLINOIS AT URBANA-CHAMPAIGN, 2019

Virtual and Augmented Reality helps train medical professionals

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Right: The sepsis IMR trainer features four components: an introduction to the scenario, direction through a patient evaluation, directions on administering protocol to a patient in septic shock, and suggestion of additional tests to perform on the patient. Below right: The sepsis IMR trainer displays questions about patient statistics to direct a student through determining if sepsis is present. The inset on the right is a zoomed-in reading of the patient’s heart rate and body temperature readings.

HCESC’s goal is that increasing usability of VR and AR technologies for instructors will make them more widespread in training novice medical professionals and improving existing healthcare processes. These technologies allow students to practice techniques more thoroughly prior to practicing on a simulated or actual patient but are not easy to create; lack of effective software for instructors to easily develop VR curriculum content is a hurdle that HCESC is working diligently to overcome. In partnership with OSF HealthCare, HCESC has created a software platform that simplifies the creation of IMR. The sepsis protocol training referenced above is comprised of three parts: an integrated, 360-degree video recording of a clinical encounter to provide firstperson perspective, rich annotated content, and an assessment questionnaire. “An important part of simulation is including real-world parameters: patient physiology, emotions, and clinical team behaviors all contribute to how successful an encounter might be. Our software platform allows instructors to easily include all these parameters,” Kesavadas said. “OSF HealthCare is testing VR as a replacement for traditional simulation training for nurses. VR-based software has made this training accessible to nurses in a timely manner at their workstation,” added John Vozenilek, M.D., Vice President and Chief Medical Officer for Innovation and Digital Health at Jump Trading Simulation and Education Center at OSF HealthCare. “We are planning to develop a comprehensive set of curriculum for nursing staff and other health professionals using the new IMR technology.” HCESC’s sepsis prevention education scenario demonstrates the potential of enhancing simulated medical training by accelerating clinical exposure for novice students. “We conducted an IRB-approved study with 28 novice

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students to evaluate its efficacy, and proudly concluded that our IMR software is a usable technology,” Kesavadas said. The participants provided feedback by answering demographics, NASA-TLX, and system usability scale questionnaires. “It’s a step towards improving VR-based education content development.” The Health Care Engineering Systems Center at the University of Illinois is a research center housed under the Grainger College of Engineering, with a focus on fostering collaboration between engineers and physicians to improve healthcare technologies and patient outcomes such as sepsis recovery. Simulation technology using VR and AR is a huge focus of HCESC, especially as its use becomes more viable as an educational tool in hospitals such as the OSF HealthCare system. A large part of HCESC’s mission is collaboration: their partnership with Jump Simulation Center provides training on the latest mannequin-based simulators and virtual reality tools to meet the needs of the new Carle Illinois College of Medicine and other medical and allied health organizations in central Illinois. Their partnership with OSF HealthCare in Peoria, Jump ARCHES, provides direct access and competitive grants for engineers and clinicians of every discipline to work

together and solve healthcare problems. Over the last four years, this endowment has provided $3 million to affiliates at the University of Illinois at Urbana-Champaign, University of Illinois College of Medicine in Peoria, and OSF HealthCare systems. In 2019, the partnership was expanded to foster further collaboration between investigators in areas beyond engineering, such as applied health sciences and veteran’s affairs at the University of Illinois. While sepsis remains difficult to diagnose and may rapidly turn fatal, the University of Illinois is hoping that this Interactive Mixed Reality technology will prompt healthcare providers to ask the right questions and perform the correct assessments quickly. The portable nature of IMR sepsis training allows for quick and easy adoption, ultimately benefitting patients from large hospital complexes to deployed field hospitals with limited resources. Osborne adds, “This technology may have saved my father’s life had doctors been using it in 2012, but I’m hopeful that it can save countless lives as HCESC moves forward with it in the future.” Twitter: @ILHealthEng Facebook: Health Care Engineering Systems Center at Illinois Hashtags: #VR #Health

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PREPARATION, RESPONSE, RECOVERY: THE VA’S “FOURTH MISSION” VA emergency responders attend to veterans in every phase of a natural disaster. By Craig Collins

n IT’S HARD TO ARGUE ANYONE WAS READY for what happened in Northern California on the night of Oct. 8, 2017, when a series of wildfires broke out in and around the Napa-Sonoma wine country – but the San Francisco VA Health Care System (SFVAHCS) was readier than most. The fires, stoked by dry conditions and high winds, swept through much of the area, destroying an estimated 8,400 homes and buildings. About 100,000 people were evacuated from the area, and 117 veterans lost their homes or reported fire damage, along with 16 SFVAHCS staff members. All told, 793 veterans in the region were affected by the fires. At around 8:00 a.m. on Monday, Oct. 9, as the fires were still burning, Mary Ann Nihart, MA, APRN, PMHCNS-BC, PMHNP-BC, associate director of Patient Care Services at SFVAHCS, received a call from Bonnie Graham, SFVAHCS director, informing her she was the incident commander for the VA’s response to the fires. Her first task was to assemble her team and find out what was going on. Nihart had recently participated in the VA’s response to another huge wildfire, in nearby Lake County, so she knew what to do. “You get the phone bank going, and

then you have your first call, and that’s when you begin to get the situational information and what you’re going to need to deploy to provide services,” she said. “It’s the acute phase, when we’re evacuating people.” The San Francisco VA had up-to-date lists of vulnerable veterans associated with each clinic in the area. “When they are shutting off electricity, you’ve got to begin to think about who is out there who relies on a ventilator, who uses oxygen,” said Nihart. “You’re thinking about all of those elements for your veterans.” The VA response team reached out to every veteran in the region to see what they needed, and then issued a call for volunteers. One of the fires – the Tubbs fire, which burned through several residential areas of Santa Rosa – came dangerously near the Santa Rosa VA Clinic, which serves 9,400 Northern California veterans. The clinic was closed for several days,

and Air Force veteran Victor Negron, a clinic administrative officer, showed up for work on Monday to begin monitoring the air quality inside the clinic and help in the response. Negron spent much of the next several days driving around in shorts and a T-shirt – he and his family had fled in the middle of the night with only the clothing on their backs, before losing their home to fire – to make contact with other veterans and inform them of the clinic’s closure. By Tuesday, the response team had set up phone lines for veterans to call for information and began arranging shelter for those who had been evacuated or lost their homes. One of the most significant issues for evacuees, Nihart said, was medication. “When you get awakened at 2 o’clock in the morning and told you have to evacuate immediately,” she said, “you forget things like your CPAP [continuous positive airway pressure machine] and your medicines.

One of the fires – the Tubbs fire, which burned through several residential areas of Santa Rosa – came dangerously near the Santa Rosa VA Clinic, which serves 9,400 Northern California veterans.

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VA employees load a C-5 cargo aircraft with supplies in response to Hurricane Maria in 2017. The VA’s Comprehensive Emergency Management Program (CEMP), its standardized procedure for disaster response and recovery, is administered by the VA Office of Emergency Management.

With the clinic pharmacy closed down, the response team entered into agreements with local pharmacies, such as Walgreens and CVS, to provide emergency refills. To avoid too much disruption in the delivery of medical care, the San Francisco VA team called upon a Mobile Medical Unit: a clinic on wheels, accessed through the regional Veterans Integrated Service Network (VISN). “We offered up clinic space so we could send providers out to see veterans with specific needs in some of the shelters,” said Nihart. The team in the field was in constant interaction with veterans displaced or otherwise affected by the fires, tuned in to their every need even as the fires were brought under control and operations moved into the recovery phase. “You start thinking about recovery about midway through a response,” said Nihart. “You start thinking about the total impact, and what you are going to need to bring people back to a place that is whole.” To ease the burden for evacuees and those who had lost their homes, VA volunteers tapped local resources to secure clothing and Walmart gift cards. Mental health experts and social workers stepped in to offer post-trauma support. “You’re thinking about how you are going to get resources to those folks, to help them get back to a normal state, and about how you can best support them, whether they’re going to need housing or anything else. You know, we’re full service. We’re not just a medical organization. We provide social services – whatever’s needed.”

PHOTO COURTESY OF VA

THE VA’s OFFICE OF EMERGENCY MANAGEMENT

You don’t think of picking up everything you’re going to need. ... A lot of our job is to find those folks when they’ve just

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been scattered across the county and make sure that they get connected back to emergency medication services.”

The lightning-fast response in Northern California was possible because the Veterans Health Administration (VHA) is a large, integrated health care system with the

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The Tubbs fire came close to the VA’s Santa Rosa Clinic in October 2017. VA personnel went into action within hours of a series of wildfires breaking out in Northern California that month, reaching out to veterans in the area and assessing how best to provide medical or social services to them in the wake of the disaster.

infrastructure and expertise to deliver supplies, information, and clinical staff support to a population whose needs and whereabouts can be determined quickly – mostly because their local VA staff already know them and can help direct and coordinate the activities of volunteers who surge in to meet demand during response and recovery. As it is throughout the nation, disaster response and recovery is a standardized procedure within the VA, known as the Comprehensive Emergency Management Program (CEMP). The program is administered at VA headquarters – with field offices placed strategically throughout the United States and its territories – through the VA’s Office of Emergency Management (OEM). The VA’s emergency response capabilities have evolved since the 1980s, when the first elements of the National Incident Management System began to develop. At the time, VA’s charter assigned it three primary missions: to deliver clinical care to veterans; to conduct research that benefits veterans and all Americans; and to educate the nation’s health care workforce in the best clinical practices. In 1982, a new law, the VA/DOD Health Resources Sharing and Emergency

Operations Act, assigned it a fourth mission: to serve as the principal health care backup to the Department of Defense (DOD) in time of war. According to Paul Kim, MD, director of the OEM, this fourth mission was expanded in preparation for Operations Desert Storm and Desert Shield in 1990, when the Federal Emergency Management Agency (FEMA), the Department of Health and Human Services (HHS), the VA, and DOD wanted to position the nation’s health care system to prepare for mass casualties and fatalities. “So, the four of us – VA, FEMA, DOD, and HHS – got together and started doing the planning,” Kim said, “and that’s when the National Disaster Medical System [NDMS] was born.” The NDMS is a federally coordinated initiative to assist state and local responses to the medical and public health effects of major disasters and emergencies, as well as to support the military medical system in caring for casualties resulting from overseas conflicts. “So our fourth mission is that we are the primary backup to both DOD and HHS in times of emergency,” said Kim, “and that emergency could cover a variety of manmade disasters. We’ve responded to the Oklahoma City bombing, the World Trade Center attacks, hurricanes, earthquakes – you name it.” Much of the VA’s emergency response work happens out of the public eye, in the form of proactive planning and exercises designed to reduce the impact of a disaster before it strikes. These efforts

are both strategic and tactical. In the VA’s Caribbean Healthcare System, for example, where more than 90,000 veterans live in Puerto Rico and the U.S. Virgin Islands, emergency management committees – composed of departmental supervisors and partners from local, state, and federal agencies, as well as other community members – meet monthly to identify the probability of certain disasters in the current calendar year, and how efforts and resources might be coordinated. According to Cosme Torres-Sabater, emergency manager for the VA Caribbean Healthcare System, the region’s biggest risks are posed by hurricanes and seismic activity. At VA facilities – the main medical center in San Juan and 10 outpatient clinics on the islands of Puerto Rico, St. Croix, and St. Thomas – employees undergo periodic training in emergency management and are frequently led through drills and tabletop exercises. “We invite the National Weather Service,” said TorresSabater. “We invite the community medical centers. We invite the Department of Health and other agencies, emergency management people at the municipal or other local level to discuss what happens if we have a major hurricane.” On the heels of these exercises, officials identify areas for improving readiness: personnel needs, supplies such as water and meals, likely equipment rentals, shelter and other spaces. In the spring of 2017, in San Juan – one of the federal government’s coordination centers for the National Disaster Medical System – the VA Caribbean

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VA PHOTO

Much of the VA’s emergency response work happens out of the public eye, in the form of proactive planning and exercises designed to reduce the impact of a disaster before it strikes.

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PHOTO COURTESY OF VA

Dr. Paul Kim (right), director of the VA Office of Emergency Management, briefs VA Secretary Robert Wilkie on response capabilities.

Healthcare System also took part in a full-scale, three-day multiagency exercise, which included partners from FEMA, HHS, and DOD, that simulated a Category 5 hurricane striking the region in September of that year. As it turned out, the exercise was well chosen; from early to mid-September, U.S. islands in the Caribbean were devastated by not one, but two Category 5 hurricanes: Irma, which killed seven people and caused more than $2 billion in damage, and Maria – the worst natural disaster in recorded history to affect the U.S. Caribbean islands – which swept through just two weeks later. The VA Caribbean Healthcare System began its tactical preparations early – a routine practice when a known disaster, such as a hurricane, is approaching. “If we’re tracking ... a hurricane or something that we can predict,” Kim said, “we look at our vulnerable patient population. We have nine categories of vulnerable patients we need to respond to quickly: those who are on home oxygen, those who are dependent on electricity. Our critical mental health patients, our dialysis patients, our spinal cord injury patients – those who, if there is an evacuation or the power goes out or they lose critical infrastructure, we’ve got to get to them quickly.” As Irma approached, said TorresSabater, the NDMS was activated and teams activated the plan devised during the full-scale exercise: Teams from the VA San Juan Medical Center – the only federal health care facility in Puerto Rico – were deployed to the San Juan airport to receive 91 veteran evacuees from the Virgin Islands with medical conditions, who were sent to predetermined public and private health care facilities. Ten days later, as it became clear that Puerto Rico lay directly in Maria’s path, the VA worked with the local Department of Health to evacuate those and other vulnerable veteran patients to Atlanta. Each

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of the VA’s Caribbean clinics, equipped with backup power, water, and satellite communications equipment, was secured for the coming storm, and closed down two days in advance of expected landfall. VA patients needing special care were kept safe at the hospital in San Juan.

RESPONSE AND RECOVERY It’s hard to convey the scale of the damage Hurricane Maria did when it slammed into Puerto Rico on Sept. 20, 2017. Torres-Sabater has compared it to a nuclear bomb. The 155-mile-per-hour winds killed nearly 3,000 people on the island, destroyed or damaged thousands

of homes, and left most of Puerto Rico without power or water. The winds and floods knocked out 85 percent of the island’s cell phone towers and 90 percent of its phone and internet cables, and blocked roads all over the island. Through it all, however – even as 20 inches of rainfall flooded downtown San Juan – the VA Medical Center remained open, operating on backup generator power. When the storm had passed, all but two VA clinics on the island immediately reopened. VA’s incident response team sprang into action, activating a distinct Patient Assistance and Family Branch within the hospital’s incident command system. The hospital opened a shelter for employees

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VA PHOTO

Left: A Mobile Medical Unit from the Orlando VA Medical Center deployed to Puerto Rico in the aftermath of Hurricane Maria. Below left: David Barron, at right, a nurse with the El Paso VA Health Care System, was dispatched to Houston, Texas, in the wake of Hurricane Harvey to provide medical assistance through the Disaster Emergency Management Personnel System (DEMPS). DEMPS volunteers play a critical role in VA’s disaster and emergency response efforts.

and veterans, and their families, who’d been left homeless by the storm. Teams of nurses and social workers reached out to veterans who were in need of medicine, oxygen, or other support, and arranged for some to be transferred to the main hospital in San Juan. The team deployed new satellite communications equipment to make and maintain contact with veterans, and enabled some to connect with family members on the mainland to assure them of their safety. With its FEMA, HHS, and DOD partners, the VA ferried food, water, medical supplies, communications, and other equipment around the island. A priority for the VA, of course, was maintaining or re-establishing the ability to provide medical care in hardhit areas far from the San Juan hospital. With support from the mainland, said Torres-Sabater, “We deployed vehicles that we used as Mobile Medical Units, and we received other vehicles as resources for contingencies. We had

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a mobile pharmacy unit, and we also received additional tents that we used to create mobile clinics in different areas.” In the northeast, a part of Puerto Rico hit particularly hard by the storm, where flooding washed out a bridge to the VA’s clinic in the town of Utuado, VA and HHS set up a 70-bed Federal Medical Station. These response efforts, played out in the weeks following the storm, could not have been undertaken with the VA’s Caribbean staffing levels alone. One of the key features of VA’s disaster response capability is the Disaster Emergency Management Personnel System (DEMPS), a program that surges volunteer VA staff in from other parts of the country. From September through December, in Puerto Rico and the U.S. Virgin Islands, a total of 691 VA employees from different disciplines – doctors, nurses, social workers, and others – left their positions to put in twoweek rotations. Throughout its response,

the VA’s Caribbean Healthcare System, with the help of DEMPS volunteers and other agency partners, served nearly 1,900 vulnerable veterans with medical needs. Given the damage to the island and the unprecedented challenges, it was unlike any emergency response Torres-Sabater – a former Army officer who has served the VA for more than 17 years – has ever seen. “Being a veteran, and seeing how our employees, regardless of the challenges they had at home, reported to duty to serve our veterans ... I am proud to work here and see that devotion.” A growing number of volunteers throughout the VA, Kim said, are signing up to serve in the DEMPS, which is run by a national coordinator through the OEM. Volunteers – professional VA employees who are paid for their service during an emergency response – undergo training, both online and through hands-on experiences. From just under 3,000 volunteers prior to Hurricane Maria, the number of DEMPS volunteers has grown to around 15,000. “Because of what these folks experience during these deployments,” said Kim, “we have people who come back and say: ‘That was the most rewarding adventure I’ve ever had, and I want to do more of this.’ So we really benefit from the spirit of the VA employee, that their mission is to care for veterans and anyone else in need who may come to us during some of these catastrophic disasters. ... It’s always a very emotional experience meeting these folks after they’ve come back from two weeks, or sometimes more, of seeing people when they need us the most.”

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INTERVIEW

DR. RACHEL RAMONI,

CHIEF RESEARCH AND DEVELOPMENT OFFICER (CRADO), VETERANS HEALTH ADMINISTRATION By Craig Collins

Veterans Affairs & Military Medicine Outlook: You came to VA in 2017. How did you go about identifying the Office of Research and Development’s (ORD) top research priorities: increasing veterans’ access to high-quality clinical trials, increasing the real-world impact of VA research, and putting data to work for veterans? Rachel Ramoni, DMD, ScD: I came up with a first draft of these priorities

Rachel previously served on the faculty at New York University College of Dentistry in the Department of Epidemiology and Health Promotion and at the Department of Biomedical Informatics at Harvard Medical School. While at Harvard, Rachel established and led the Undiagnosed Diseases Network (UDN) Coordinating Center. The UDN, funded by the National Institutes of Health, brings together clinical and research experts from across the United States to solve challenging medical mysteries using advanced technologies. The Boston Globe called the network a “powerful new way to diagnose mystery illnesses.” Prior to her work with the UDN, Rachel was executive director of the Substitutable Medical Applications, Reusable Technologies project, or SMART. It resulted in the SMART on FHIR (Fast Healthcare Interoperability Resources) technology, which enables electronic health record apps to be developed once and run across disparate systems. This technology is now broadly used by companies like Apple, Cerner, and Epic. Rachel earned a Doctor of Medicine in Dentistry degree from the Harvard School of Dental Medicine, as well as a Master of Science and Doctor of Science in epidemiology from the Harvard School of Public Health. She also holds certificates in dental public health and oral epidemiology.

in 2018, about a year after I joined VA. In the previous year, I got to know the organization well, both in the central office, where I work, and in the VA medical centers, where the research takes place. I shared the priorities with members on the Hill and also with leadership in VA. Perhaps it’s because they are so obviously rooted in things that we should be doing that they were quite directly embraced. It was in 2018 that these were first articulated.

Was there anything about your previous experience in research and health care that informed the process of determining these priorities? Most of my career has been spent in the field of informatics. Prior to starting my job at VA, I worked on a project called the Undiagnosed Diseases Network, which is focused on diagnosing individuals with mysterious medical conditions. In terms of the first priority – increasing veterans’ access to high-quality clinical trials

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VA PHOTO

n RACHEL B. RAMONI, DMD, ScD, is the chief research and development officer (CRADO) for the Department of Veterans Affairs (VA). Rachel assumed her role in January 2017. She is responsible for developing and executing the strategy for VA’s nationwide research enterprise, which encompasses more than 2,200 active projects at more than 100 sites. VA research is supported by a nearly $2 billion budget (fiscal year 2019), which includes both direct VA support and research funding from outside entities, such as the National Institutes of Health (NIH), other federal agencies, and nonprofit and private organizations. Rachel has a longstanding commitment to patient-centered return on investment. This is reflected in her three strategic research priorities: (1) increasing veterans’ access to high-quality clinical trials, (2) increasing the substantial real-world impact of VA research, and (3) putting VA data to work for veterans. She has overseen the implementation of an array of initiatives to advance these priorities, including joint efforts with the National Cancer Institute (NCI), Department of Energy, Prostate Cancer Foundation, and numerous other federal and non-federal partners.

VA PHOTO BY EUGENE RUSSELL

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– in the world of undiagnosed diseases, oftentimes clinical trials offer people the only hope. And we now have a big focus on precision oncology, particularly on prostate cancer. There are no approved drugs to treat metastatic prostate cancer. These trials offer hope to people when standard clinical care has been exhausted as a possibility. The second priority, which is to increase the substantial real-world impact of VA research, is also informed by other work that I have done, which has been aimed at getting research to the point where you can help people. This is well tied in with the history of VA. We are embedded in one of the largest health care systems in the country, so we have a special responsibility to make sure that our research is not only published but creates innovations and discoveries that benefit our veterans. That also draws from my work with the Undiagnosed Diseases Network, where it was always so exciting when a new discovery was made, but then the next question would be: “How does this help people?” And the third priority, putting VA data to work for veterans, is quite directly drawn from my experiences at the Department of Biomedical Informatics at the Harvard

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Opposite page: Dr. Rachel Ramoni. Above: Ramoni addresses attendees of the VA Research Fair held on June 19, 2018, in the foyer of the Rayburn House Office Building in Washington, D.C. VA scientists were on hand to showcase their medical research advances aimed at improving the lives of veterans.

Medical School. There, I saw firsthand the power of data to improve people’s lives. I want veterans to benefit from that. Were there other reasons why you identified access to clinical trials as a priority? VA has a long history of conducting multisite clinical trials. The Cooperative Studies Program has brought great innovations to the world, such as aspirin as a preventive measure for secondary heart attack, and the massive clinical trial that led to the first shingles vaccine being approved for use in the United States. And we’re now conducting trials, for example, on non-pharmacologic approaches for pain, as well as sleep in the context of PTSD. At the same time, I’ve heard from pharma companies, which are the source of a lot of these treatments, that VA had a reputation for being difficult to work with. I thought: Well, that is not great news

for the veterans who could benefit from these studies. Difficult how? For instance, the average time it took to start up an industry-sponsored VA trial was 285 days, when the average around the country for academical medical centers was around 150 days. We have committed to be a hundred days faster by the end of fiscal year 2021, to even the playing field and make sure people see VA as a place where they can bring their most innovative treatments to veterans. What are some of the things VA needs to do to make that happen? I think one of the things that makes us such an important partner is also what has made us more challenging to work with – which is just the scale of VA. There are 170 medical centers, and they often develop some of their own ways of doing things. A lot of what we’ve been working on is rolling out more standardized approaches. For example, we are putting into place a VA-wide system for IRB [Institutional Review Board] review, to review studies for human subjects’ protection. This system will ensure standardized forms and processes across all VA medical centers, so that if you want to start up a

VA PHOTO BY CHRISTOPHER PACHECO

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VA PHOTO BY LAMEL HINTON

study at 10 different sites, you don’t have to fill out 10 different sets of forms. This reflects my emphasis on creating a research enterprise that looks at the VA as a whole, rather than having 170 separate medical centers. VA’s budget proposal also mentions partnerships, such as the new NAVIGATE partnership with the National Cancer Institute, to get more veterans into trials that aren’t necessarily funded by VA. Are there similar projects in the works? We have two strategies for increasing veterans’ access to high-quality trials. One is to make the process of starting a trial more efficient. The other is to strengthen the support and infrastructure you need to nourish these clinical trials. One of the partnerships we made was with the National Cancer Institute, which awarded funding to 12 sites across the VA to help support staff and to enroll more veterans into NCIsponsored clinical trials. At the same time, the Prostate Cancer Foundation made a commitment to VA of $50 million to do the same thing for our prostate cancer trials. That project is called POPCaP – the Precision Oncology Program for Cancer of the Prostate. At this time, there are 10 POPCaP sites around the country. POPCaP’s initial focus is metastatic prostate cancer, cancer that’s spread to other parts of the body. It’s first of all ensuring that these men get genetic testing – it’s been found that a significant proportion of men with metastatic prostate cancer have genetic variations that predispose them to the cancer and also make them more likely to respond to certain treatments.

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Left: Dr. Bruce Montgomery, an oncologist at the VA Puget Sound Health Care System in Seattle, Washington, meets with Navy veteran Allen Petchnick, whose metastatic prostate cancer has been effectively treated to date with targeted therapy. The advanced level of medical care Petchnick received was made possible by a partnership between the VA and the Prostate Cancer Foundation. Below: In this 2015 photo, World War II Marine veteran Stanley Frable, who took part in the COURAGE trial, meets with Dr. Steven Sedlis, then the chief of the cardiology section at the Manhattan VA Medical Center. The VA is working to implement findings from the COURAGE trial.

We’re making sure these men get the sequencing they need so they can get access to the promising treatments through clinical trials. For the second priority you’ve identified – increasing the substantial real-world impact of VA research – how well do you think VA research translates into practice, compared to the work of other institutions? I think VA is actually at an advantage in terms of getting research findings into practice, because we are a large research program embedded in a health care system. Often, the research ideas we get come from clinicians who practice in the VA. And a lot of those clinical leaders are being brought in early in the planning phase of the study to make sure that when it’s done, it’s ready to transition over to the clinic.

“I think VA is actually at an advantage in terms of getting research findings into practice, because we are a large research program embedded in a health care system.” For example, this is something we’re working on now to implement findings of two studies: the VA COURAGE trial, and another funded by NIH called the ISCHEMIA trial. Those studies both found that in certain circumstances, with chest pain, it’s no worse to have intensive medical management, rather than get a stent, which can be associated with complications. We’ve started working with our national program director in cardiology, Dr. Richard Schofield, and talking about what this means for VA patients – how we can make sure this research goes on to benefit people – and at the same time isn’t inappropriately understood to mean that stenting is never the answer, because of course there are many circumstances in which that’s the best possible treatment. I used to be an academic at Harvard. There, I didn’t have the advantage of being able to call up the head of cardiology at one of the largest medical health care systems in the country to say, “Gosh we have this finding, so how should we

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A transmission electron micrograph image of particles of SARS-CoV-2, the virus that causes COVID-19. The VA Office of Research and Development’s response to COVID-19 is being guided by its strategic principles: increasing veterans’ access to clinical trials, increasing the real-world impact of VA research, and putting VA data to work for veterans.

change our care on this basis?” It’s incredibly powerful to be able to bridge research and clinical care just by picking up the phone. How do you envision the VA increasing this kind of impact? A few ways. Number one, working more closely with the clinical teams at VA. We’re getting to know our clinical colleagues ever better. The second is that we have a very active Technology Transfer Program in terms of generating intellectual property and ultimately leading to products. So, we – the Office of Research and Development – are focusing some of our funding now on developing some of the inventions made in VA. For instance, Tech Transfer has been working with the Human Engineering Resource Laboratories up in Pittsburgh to prototype some VA inventions, and working on getting more licensing agreements for these products – because you may have developed an important innovation, but unless somebody is going to produce it at scale, it’s not going to benefit people. There is a new law called the Evidence-Based Policy Act that requires every agency to have a plan to use evidence in informing its budget and its policies. People on my team are working closely with the Office of Finance to bring their evidence to the budget decision-making process at VA. Just having a seat at that table is another way we’re using research and evidence to have an impact on how VA does its business.

NIAID

The VA’s third strategic research priority is to put data to work for veterans. The VA probably collects more data than any other health care system. Where is it in terms of putting that data to work? What we’re excited about is the potential to bring in expertise, both within the VA but also outside the VA, in a way, obviously, that respects privacy of our veterans and all the rules and regulations about the use of these research and health care data. We’re in the process of setting up a VA Data Commons, where de-identified research and clinical data will be made available to qualified researchers. The thinking is that if you bring the best minds to the data, then they are going to make discoveries that will benefit veterans. And we’ve certainly found that to be true in our initial and ongoing studies in the Million Veteran Program. Some of the early research articles that have come out from that project have been recognized as among the most influential of the year. How are your priorities informing ORD’s response to COVID-19? Prior to the COVID-19 outbreak, ORD was pursuing three strategic priorities, and we have continued focusing on these

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goals: increasing veterans’ access to high-quality clinical trials, increasing the substantial real-world impact of VA research, and putting VA data to work for veterans. These priorities have allowed us to rapidly respond to COVID-19 demands. In line with our first priority, enhancing veteran access to clinical trials, ORD has committed its resources to work closely with industry partners to expedite clinical trials that seek to understand and treat COVID-19. We are coordinating with federal agencies like the National Institute of Allergies and Infectious Diseases [NIAID] on national studies to understand COVID-19 and to develop new treatments. Part of this effort includes collecting specimens from veterans infected with COVID-19 to aid in vaccine and therapeutics development. Another example of current research: The VA medical centers in Palo Alto, Denver, and New Orleans are participating in an NIAID-sponsored clinical trial of remdesivir, one of the more promising medications for COVID-19. VA is also part of a clinical trial with Regeneron Pharmaceuticals, to study the use of a drug called Kevzara to treat COVID-19. We started up that clinical trial site in under a week, thanks to the work that we have done over the last two years to streamline our processes.

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“It’s our job to take those findings and walk them along the research and development pipeline, to transform those insights into treatments or products that benefit veterans.”

Photo by Carrie Martin/LLNL

From left: Pat Falcone, Lawrence Livermore National Laboratory (LLNL) deputy director for Science and Technology; LLNL Director Bill Goldstein; Rachel Ramoni, VA’s chief research and development officer; Morgan Luttrell, a senior adviser of veterans relations at the Department of Energy (DOE); and Dimitri Kusnezov, National Nuclear Security Administration’s chief scientist, are pictured at LLNL in February 2018 during a two-day gathering of officials and top scientists with VA, DOE, and several national labs to discuss using supercomputing, machine learning, artificial intelligence, and other emerging technologies to solve major challenges facing veterans.

Our second priority, increasing the real-world impact of research, is especially meaningful in the context of a new disease like COVID-19. It’s both motivating and humbling to know that it is only through research that we, the human race, will defeat this virus. We are working closely with our clinical partners across the Veterans Health Administration [VHA] to ensure that the clinical care we provide is based upon the best evidence available. Guided by our third strategic priority, putting VA data to work for veterans, ORD is analyzing VHA health care data to provide important real-world evidence about whether drugs that have been developed for other purposes are effective in treating COVID-19. What other opportunities do you see within the VHA, or in ORD, to capitalize on the potential of big data to transform care and improve veterans’ lives?

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There is so much potential. We’ve chartered the National Artificial Intelligence Institute, a collaboration between our office and the Secretary’s Center for Strategic Partnerships. One of the things that we are looking at, for instance, is the ability to process images. In oncology, the hope is that you can use image processing to tell you something about which treatment a person may or may not respond to, based on those image characteristics. And there are some early data from researchers, both inside and outside the VA, that indicate this is a promising line of research. There is a tremendous amount of data in those pictures that our eyes alone can’t detect; that’s a really promising area for research. We also want to develop our ability to partner with industry or with private entities. And one way the National AI Institute did this was through a Tech Sprint they recently ran to encourage outside entities to create applications to effectively use open data. Putting data to work requires technology, and technology costs money – and for government agencies, funding always seems to be an uncertainty. How does VA plan to leverage its expertise to stay on the cutting edge of analyzing and putting data to work? We do this, in part, by working with other government agencies. For instance, we have a collaboration with the Department of Energy to help us analyze and draw knowledge from Million

Veteran Program data. The VA Data Commons, which I previously mentioned, is another approach to ensure access to up-to-date, cloud-based infrastructure that can expand with our needs. Our IT office has been very supportive of our developing this cloud-based platform. So, these partnerships, and these new technologies, are helping us approach this work in the context of IT budgets that naturally have limits. Sometimes, when we talk about Big Data, the conversation can seem kind of abstract. So, let’s remind readers: In what ways has VA’s big data enterprise, things such as the Million Veteran Program, improved health care and the quality of life for veterans? I always say I’m a very patient woman – and it’s a good thing, because research unfolds over time. Because of the large number of individuals that we have in the Million Veteran Program, for example, we’re able to identify new genetic markers for conditions – say, for cardiovascular disease. And that’s the beginning of a process that we hope leads to either new treatments or to more precise diagnostics for people. We cover the full spectrum of research, obviously, from basic science all the way through to health services research. Our commitment to veterans is that when we find that basic science discovery, we say: “Well, how the heck is this going to help me, knowing that this variation is associated with cardiovascular disease?” It’s our job to take those findings and walk them along the research and development pipeline, to transform those insights into treatments or products that benefit veterans.

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VA Research

PUTTING THE “D” IN R&D

Increasing the real-world impact of VA research By Craig Collins

n AMONG THE THOUSANDS OF STUDIES conducted at Department of Veterans Affairs (VA) medical centers, outpatient clinics, and nursing homes every year, innovations abound. In 2006, for example, when a high percentage of military service members returning from Iraq and Afghanistan suffered from post-traumatic stress disorder (PTSD), VA mental health researchers and clinicians attacked the problem with an evidence-based intervention, cognitive-processing therapy (CPT), that VA clinical psychologist Patricia Resick, PhD, had been researching since 1988. The initiative to disseminate CPT throughout the VA brought relief not only to veterans, but to other Americans suffering from PTSD. Today, CPT is considered a leading cognitive-behavioral treatment, a frontline intervention for PTSD. The expansive, integrated structure of the Veterans Health Administration (VHA), with more than 9 million patients treated at about 1,240 facilities, presents a unique opportunity for its more than 20,000 mental health professionals to move the work of investigators such as Resick into clinical practice. But the size and scope of the VHA can also present some challenges. Amy Kilbourne, PhD, MPH, director of the VHA’s Quality Enhancement Research Initiative (QUERI), is a national expert in implementation science: the study of methods and strategies to promote the uptake of proven interventions into routine practice. Following on the success of the CPT initiative, she said, VA’s Health Services Research and Development Service (HSR&D) turned its focus to getting more veterans into treatment for depression – one of the most common mental health conditions facing veterans and a condition associated with greater suicide risk. In 2008, the VA estimated that about 1 in 3 veterans who visited primary care clinics had some symptoms of depression; 1 in 5 had serious symptoms that required further evaluation; and 1 in 8 had major depression requiring treatment with psychotherapy or antidepressants. The challenge for VA clinicians wasn’t that they didn’t know how to treat these veterans, Kilbourne said – it was that its mental health experts often weren’t interacting with the veterans who needed help. “We had great programs,” she said, “but they were all in psychiatry.” In most VA facilities, mental health clinicians were “embedded” in departments distinct from the primary care settings that accounted for the majority of patient interactions. “VA saw right away that essentially confining depression treatment into a mental health specialty was not going to make a realworld impact,” said Kilbourne, “because most veterans were not going to a mental health specialist first to get depression care. They were going to their primary care doctor.”

In response, the VA launched an effort similar to the one that made CPT more widely available to veterans. Investigators and practitioners created and tested, through a series of rigorous studies, a model to link veterans in primary care to mental health services: The collaborative care model, in which a team of professionals – including a primary care physician, a mental health clinician, a nurse, a social worker, and other team members – helps patients deal with depression symptoms. “Then they tested techniques to improve the process by which depression treatment was occurring,” Kilbourne said, “and finally, they actually looked at the costeffectiveness of it and then tested different strategies to maintain the depression treatment in primary care programs in the VA. And then it became a nationalized program.” The wide-scale implementation and adoption of CPT for treating PTSD, and of the collaborative care model for relieving depression symptoms, are clear victories for VA research – the aim of which, after all, is to improve the health and lives of veterans. Many VA innovations are likewise validated by research, but there’s often a lag between proving their value and actually making them valuable. An often-cited study by health informatics experts at the University of Missouri suggested that despite the growth in medical research, it takes an average of 17 years for evidence-based findings to reach clinical practice – and only about 1 in 5 proven practices ends up being used regularly in the real world. “We’re wasting a lot of research dollars,” Kilbourne said, “when we’re not able to provide to our patients all the innovations that research has found to be effective in regular routine care.” Why does it take so long for evidence to make its way into practice? There are multiple reasons: Many investigators publish in peer-reviewed journals and get back to work, and it can take a long time for an idea to make it from the pages of a journal out into the real world, if it makes it at all. If it does, it will probably need to be adapted across different

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settings – which is why the VA invests in translational centers to push early adoption of innovations. “You might have a great innovation, but it might have been developed at three large VA hospitals,” Kilbourne said. “Maybe it doesn’t work in community-based outpatient clinics, because they simply don’t have the resources or the manpower to do it.” Along with this “capacity” barrier, she said, there’s also the stubborn resistance of inertia, of sticking to the way things have always been done.

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CLOSING THE 17-YEAR GAP The QUERI is an element of VHA’s HSR&D, which is just one corner of the vast research enterprise administered by the Office of Research and Development (ORD). VA research covers the continuum of medical science, from basic biomedical science to system-wide service

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In 2006, VA mental health researchers and clinicians treated the high numbers of Iraq and Afghanistan veterans with PTSD using cognitive-processing therapy (CPT), an evidence-based intervention that had been studied since 1988 by VA clinical psychologist Patricia Resick, PhD, and that today is considered a frontline intervention for PTSD. The wide-scale implementation and adoption of CPT for treating PTSD is the kind of translation of evidencebased VA innovations into practice that the VA is working to speed up and streamline.

care delivery, with the help of three other research services: Biomedical Laboratory Science Research and Development Service (BLRD), Clinical Science Research and Development Service (CSRD), and Rehabilitation Research and Development Service (RR&D). Translation into practice has always been a focus for each of these services, but VA’s 2021 budget proposal includes initiatives to accelerate

the translation of VA innovations – to put them to work in the real world, faster, and maximize their benefits. Christopher Bever, MD, who directs BLRD, is a neurologist who began his research career with the VA, studying the effects of certain drugs on multiple sclerosis in animal models. His group studied a specific immune function in a mouse model, using a molecule that has since been patented by an investigator at Emory University in Atlanta, who is developing it for use in treating stroke and, possibly, neurodegenerative diseases such as Parkinson’s. It’s often the case that no matter how promising this kind of work – such as studying the function of cell receptors at the molecular level – the excitement can fizzle if nobody picks up the torch. The mechanism that funded Bever’s work, the Merit Award, is VA’s principal means of supporting basic preclinical biomedical

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Samuel Kuna, MD, VA physician and director of the Crescenz VA Sleep Center, pictured at right, discusses the benefits of the REVAMP app, which enables veterans to play a primary role in tracking sleep data and adjusting sleep habits to mitigate the effects of obstructive sleep apnea, with Army veteran Walter Broadnax at the Corporal Michael J. Crescenz VAMC. Kuna, who led the development of REVAMP, is a core investigator with the VA Center for Health Equity Research and Promotion (CHERP), and in 2012 was awarded a VA Employee Innovation Award to translate his research into practice. In August 2017, REVAMP launched as a pilot at 10 sites across the country and has since expanded to additional sites within the VA health care system.

Award program is strictly intramural, marshaling the expertise of VA investigators; in the intermediate term, he sees the possibility of co-funding collaborations between investigators with the VA and the National Institutes of Health (NIH). Merit Awards are based on hypotheses posed and pursued by investigators. But before a drug or treatment can be cleared for clinical trials, Bever explained, it has to clear several hurdles for approval by the U.S. Food and Drug Administration (FDA): “You have to show that the drug doesn’t have some undesirable toxicity. You have to show that it doesn’t cause cancer, and you have to show that it doesn’t cause fetal malformation. And then you have to characterize how it behaves in the body. You can pay people to do those things. But they are not hypothesis-driven.” Another new BLRD/CSRD funding mechanism, for drug and biologic development, is designed to clear these regulatory requirements and support preclinical studies that will move a drug or treatment toward clinical trials. So far, about a half-dozen of these have been awarded to accelerate the translation of VA innovations. A clinical trial, of course, isn’t the ultimate goal of VA research – it’s implementing a drug or treatment that has proven successful in those clinical trials. The VA’s large-scale, multicenter trials

are coordinated by ORD’s Cooperative Studies Program (CSP), which until recently had no formal mechanism for moving proven drugs or treatments into VA health care. “We would develop a study,” said CSP Director Grant Huang, MD, “and we would tell people about it, and hopefully they would say: ‘Yeah, that’s a great idea. Let me do something with that.’” A recently launched initiative, the CSP Implementation Program, loops in VA’s implementation experts at the beginning of the trial design process, before a study is launched. The new process, Huang said, is a way of not only weighing all the standard concerns involved in trial design, but also “starting to think about the implementation requirements up front, and then building that into the design of the study so that when the results are available, they are useable in a way that then can be more readily deployed in the health care system.”

THE VA’s IMPLEMENTATION SCIENTISTS: RESEARCH MEETS THE WORLD Meanwhile, Kilbourne and the VA’s implementation experts continue to explore new ways of moving the VA’s evidence-based discoveries into the mainstream of clinical care. HSR&D alone funds 18 distinct Centers of Innovation (COINs) around the country,

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and behavioral studies. A Merit Award typically supports an investigator for a period of three to four years, after which his or her discoveries may form the basis of further VA investigations that may carry it to the next stage of development. The timing of these follow-on studies, however, varies. Too often, investigators work in silos, with intense focus on their own pieces of the puzzle. It takes a number of Merit Awards – about 10 to 15 years’ worth – to produce an innovation that translates to clinical care. One of the ways the VA aims to accelerate this translation and fit pieces of the bigger puzzle together is to encourage and support researchers to join forces in areas of high-priority research. In the spring of 2020, BLRD and CSRD launched a cycle of Collaborative Merit Awards to support linked studies aimed at translational activities. “The idea,” said Bever, “is getting investigators together to talk about what they are trying to do and to look at where they are trying to go with this, and then to define steps that are needed to get to, in this case, clinical trials of something in humans. And then how can we structure our Merit Awards so that maybe Chris gets a Merit Award on this part, and Dr. Smith gets one on a different part?” The process actually began several years ago, with high-level meetings that produced research roadmaps that will lead to clinical trials in priority areas. In its first iteration, Bever said, the linked Merit

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Dr. Sara Landes, a psychologist at the Central Arkansas Veterans Healthcare System, is leading a study evaluating the implementation of REACH VET, a program aimed at increasing suicide prevention outreach for veterans at highest risk for suicide, at 28 VA medical centers. The study will make it possible to identify and address potential barriers to implementation so the program can run as smoothly as possible.

each dedicated to ensuring a particular area of research has the greatest possible impact on VA health care practices and health outcomes for veterans. VA implementation scientists hope to build on these efforts. ORD’s recent budget proposal recommends new Translational Science Initiatives, such as the efforts that broke CPT and the collaborative care model out of their silos and made them standards of VA mental health care. “A lot of our innovations haven’t really been tested in broad populations,” Kilbourne said. Implementing the Translational Science Initiatives, she said, will compel investigators, early in the validation process, to move their innovations beyond smaller, more controlled settings – “and maybe do some further testing and validation of these innovations in a broader population. And that could include going out to smaller VA facilities or community-based outpatient clinics. We want to make sure that frontline providers feel comfortable in using the new innovation, and ensure that it’s actually effective [in a variety of settings].” These proposed initiatives will work in tandem with HSR&D’s Implementation Research Initiatives: multicenter studies of implementation strategies for moving innovations into practice. These studies focus on one intervention, randomized at different VA sites whose providers

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receive either standard implementation training or training along with facilitation services. “You need about 40 or 50 sites to do a study like this,” said Kilbourne, “to really understand if the added facilitators make a difference in helping frontline providers use that intervention properly.” As Kilbourne points out, VA’s frontline providers are often the best judges of what will work and what won’t in a particular setting – but they often don’t have the tools they need to succeed. Sometimes this is due to a lack of familiarity with the basics of implementation science, of how to introduce new practices to an existing system. The QUERI recently established the VA’s first fixed training programs in implementation, coordinated by its Center for Evaluation and Implementation Resources (CEIR). There are currently six of these Implementation Strategy Training Hubs, two in California and one each in Michigan, Massachusetts, Texas, and Arkansas. “We want to be able to support providers who want to use the innovations, but who may need additional guidance, training, or resources to use that innovation,” Kilbourne said. One area of implementation research that Kilbourne is particularly excited about, she said, is the domain of “usercentered design,” such as the investigation conducted in the mid-1990s by entrepreneur Jeff Hawkins, who had

an idea for a personal digital assistant (PDA), but wanted to spend time imagining how it would be used before he built an expensive prototype. Hawkins carved a block of wood and carried it around in his pocket for several weeks, pretending it was a working device, in order to get insights into how he would use it. If somebody asked to set up a meeting, for example, he’d pretend to schedule it on his block of wood. The resulting PalmPilot became a digital repository for addresses, calendars, memos, and to-do lists. A similar process – getting patients and providers in a room together to talk about an innovation and how it might be adapted to fit their needs and priorities – is often used in the design of prosthetics, and Kilbourne would like to see it applied to other innovations as a way to prevent early missteps. “You want to start with an intervention that is halfbaked, and seems like a promising intervention,” she said, “coming from a translational scientist, someone who is just really tinkering with things still, and then you give it to patients and providers and let them design it for you. That’s a new and cutting-edge area in implementation science.” The VA has long been on the cutting edge of medical science – and through its host of new translation initiatives, it aims to push more of these groundbreaking discoveries into everyday care. “We’re probably one of the few federal agencies that has really prioritized the need to implement innovations into routine practice,” said Kilbourne, “and the need ... to decrease that 17-year gap between research and practice. I think in many respects the VA is at the forefront of doing that.”

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VA Research

THE VA AND CLINICAL TRIALS

The VA’s Cooperative Studies Program (CSP) is the linchpin for increasing veterans’ access to high-quality clinical trials.

Dr. Kathleen M. Chard, co-chair of Cooperative Study #591, “Comparative Effectiveness Research in Veterans with PTSD” (CERV-PTSD), is pictured with a research staff member modeling a therapy session.

n EARLY IN THE 21ST CENTURY, AFTER YEARS of study and clinical work, mental health clinicians and investigators in the Veterans Health Administration (VHA) helped to develop and validate the success of two highly effective treatments for veterans with post-traumatic stress disorder (PTSD). The first, prolonged exposure therapy, involves a patient’s vivid and repeated recollection of a traumatic event, until the emotional response to the event is diminished. The idea is for the patient to gradually extinguish overwhelming emotions associated with the traumatic memory. The second treatment, cognitive processing therapy, works in a similar way. With the guidance of a therapist, patients are taught to evaluate and change the upsetting thoughts they’ve had since their trauma – and in turn, to change their emotional response to these thoughts. This type of therapy, developed in the 1980s by an investigator who later joined the VHA, involves the appraisal of patients’ memories, dialogue, and introspection, and teaches coping skills to challenge negative or upsetting thoughts. While investigations have provided solid evidence that both prolonged exposure (PE) and cognitive processing therapy (CPT) are effective, there isn’t much evidence to

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By Craig Collins

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A pharmacist prepares a dose of the shingles vaccine to be administered at Blanchfield Army Community Hospital’s Town Center Pharmacy, Fort Campbell, Kentucky. The VA led the clinical trial that resulted in Food and Drug Administration approval for a shingles vaccine. The trial involved 39,000 people (veterans and non-veterans) at 16 VA medical centers, the National Institutes of Health, and five universities.

indicate which might have better results. A study comparing them would require a sizeable cohort of PTSD patients who have access to both treatments within a large integrated health care system, staffed by clinicians and investigators experienced in both treating PTSD and in recruiting, planning, coordinating, and executing a large, randomized, multisite clinical trial. The VHA – the largest integrated health care system in the United States, serving more than 9 million veterans at more than 1,200 health care facilities – may well be the only organization in the United States positioned to do this, in large part due to the experience, resources, and expertise of its Cooperative Studies Program (CSP), a division of the VHA’s Office of Research and Development. The CSP is internationally renowned for its large-scale, innovative clinical trials and epidemiological studies. In 2014, VA Cooperative Study #591, Comparative Effectiveness Research in Veterans with PTSD (CERV-PTSD), began comparing PE and CPT outcomes among 900 male and female veterans with PTSD related to their military service. As investigators record and process the results of this study, they expect it to advance PTSD care by providing conclusive information about whether one treatment is better than the other – overall, and for different types of patients. Since it was formally established in 1972, the CSP has conducted large, multicenter clinical trials such as CERV-PTSD – studies aimed at evaluating the effectiveness of medical, surgical, or behavioral interventions – as well as observational epidemiological studies, which evaluate causes or risk factors for disease. According to Grant Huang, PhD,

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MPH, director of the CSP, the VA actually established the use of multisite cooperative study within the United States. At the conclusion of World War II, when about 10,000 American veterans suffered from tuberculosis, the VA partnered with the United Kingdom’s Medical Research Council (MRC) in evaluating the effectiveness of streptomycin and other drugs in treating the disease. This study, the first VA-armed forces clinical trial, was conducted at seven VA and two military hospitals. “The U.S. and British were trying to tackle the problem of tuberculosis in returning veterans,” said Huang, “and at the time, we had clinicians, scientists, and biostatisticians who came together and said, ‘Let’s rigorously study what treatments work best.’ That became known as a cooperative study.” One of the most famous VA cooperative studies was launched nearly two decades later by Dr. Edward Freis: the first multicenter, double-blind, randomized placebo-controlled trial to determine the

effectiveness of antihypertensive drugs in preventing or delaying serious cardiovascular events and organ damage. The study was conducted among more than 500 patients at 17 centers, and the success of the trial earned Freis a Nobel Prize nomination. He has been referred to as the father of the first multisite clinical trial of cardiovascular drugs. On the heels of this landmark study, the VA officially established the CSP in 1972, and charged it with coordinating multicenter clinical trials that evaluated novel therapies or new uses for existing treatments. In its first decade, the basic form of the program took shape, with the establishment of CSP Coordinating Centers and a Clinical Research Pharmacy Coordinating Center. “Since the 1970s,” Huang said, “we’ve developed some new capabilities – for example, in addition to clinical trials, we also conduct large-scale observational studies.” In the late 1990s, the CSP established four Epidemiological Research and

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PHOTO COURTESY OF THE DEPARTMENT OF VETERANS AFFAIRS COOPERATIVE STUDIES PROGRAM CLINICAL RESEARCH PHARMACY COORDINATING CENTER

The Cooperative Studies Program’s awardwinning Clinical Research Pharmacy Coordinating Center participates in CSP studies involving drugs or medical devices and has the ability to manufacture drugs and look-alike placebos for certain trials.

Information Centers (ERICs) for this purpose. Prior to VHA launching a genomic medicine initiative in 2006 to advance knowledge of how genes affect health and how medicine might be personalized for veterans, the CSP established a DNA bank and a biospecimen repository to support genomic studies within its trials. This effort helped form the foundation of the Million Veteran Program (MVP), the world’s largest biobank of genetic material, to anchor studies comparing genes, survey responses, and health records of 850,000 veterans (and counting). To date, the MVP has provided the basis for numerous studies of the risk factors for PTSD, Gulf War illness, substance use disorder, cardiovascular disease, macular degeneration, anxiety disorder, and others – as well as for pharmacogenomic studies, or studies of how patients with certain genetic profiles respond to different medications.

TODAY’S CSP From its origins in the 1940s, the CSP has completed more than 200 studies, and today conducts trials at more than 80 VA medical centers around the country. CSP investigators and their partners have evaluated treatments for a variety of conditions, including psychiatric disorders, cancer, neurologic disorders, infectious diseases, diabetes, and cardiovascular disease. These multicenter trials are conducted in partnership with other VA investigators as well as university affiliates, private-sector partners in the pharmaceutical and biotechnology industries, and government agencies such as the National Institutes of Health (NIH) and the Department of Defense. CSP has also partnered internationally to conduct studies with investigators in the United Kingdom, Canada, and Australia.

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Two distinct research branches, focused on clinical trials and observational studies, have evolved in parallel within the CSP. Randomized clinical trials are the purview of five CSP Coordinating Centers, located at VA medical centers in Boston, Massachusetts; Hines, Illinois; Palo Alto, California; Perry Point, Maryland; and West Haven, Connecticut. These centers provide study design, data management, statistical analysis, quality management, and administrative support to cooperative studies performed by VA investigators. “These five Coordinating Centers are teams of experts who can design, manage, and run clinical trials, and all the things involved with that,” said Huang. “They have project managers, quality assurance experts, research

administrators, and some clinicians as well. They receive the data from all our study sites, and there is a group of statisticians who analyze the data and clean it to make sure the quality is good.” A unique feature of the CSP is its Clinical Research Pharmacy Coordinating Center (CRPCC) in Albuquerque, New Mexico, which participates in CSP studies involving drugs or medical devices. “I don’t know of any major federally funded center that handles what they do,” Huang said. “They have a lot of capabilities.” CRPCC experts develop drug-handling protocols, negotiate with pharmaceutical companies, distribute and keep track of drugs used in trials, and work with the Food and Drug Administration (FDA) to ensure regulatory compliance. They can

From its origins in the 1940s, the CSP has completed more than 200 studies, and today conducts trials at more than 80 VA medical centers around the country. CSP investigators and their partners have evaluated treatments for a variety of conditions, including psychiatric disorders, cancer, neurologic disorders, infectious diseases, diabetes, and cardiovascular disease. 49

CONFIRM study coordinator Elaine Nevins explains a colorectal cancer screening procedure to Navy veteran Alex Pryor at the VA Puget Sound Health Care System in 2012. CONFIRM, which is evaluating the two most common types of colorectal cancer screening among 50,000 veterans, is the largest single clinical trial in VA history.

also, Huang said, manufacture drugs for use in certain trials, as well as look-alike placebos. The CRPCC’s excellence has earned it an international reputation; in 2009, its rigorous quality assurance protocols earned it a Malcolm Baldrige National Quality Award – and it remains one of only two federal agencies to have won the honor. Observational research among veteran populations is conducted and disseminated by the CSP Epidemiology Centers, located at VA medical centers in Boston; Seattle, Washington; and Durham, North Carolina. A fourth recently established center in Palo Alto, California, also has expertise in genetic data and analysis. These centers also work with a pharmacogenomics laboratory located in the Little Rock, Arkansas VA medical center. Experts at these centers provide scientific expertise, data, and research infrastructure to conduct large-scale epidemiological evaluations of veterans’ health and disease burdens. They also, Huang pointed out, create and maintain data resources to support VA research. “Our Boston center is the hub of the Million Veteran Program,” he said, “so they collect data about health behaviors and lifestyle from now more than 800,000 veterans, get information from their medical records, and then tie it to the genetic data we’re collecting from their blood.” The Seattle center maintains the Vietnam-Era Twin Registry, a collection of data gathered from studies and biospecimens of more than 14,000 Vietnam-era veteran twins and more than 3,400 selected family members, the largest of its kind. The Durham center specializes in the health effects of Gulf War service, and the Palo Alto center focuses on studies of pharmacogenomics. Much of the CSP’s work is funded through the VA Office of Research and Development’s (ORD) intramural funding program: Eligible VA clinician investigators come up with an idea for

a study and submit a description to Huang’s CSP headquarters in Washington, D.C. After a review, staff at one or more of the Coordinating Centers design and develop a study and launch it through the VA health care system. This same basic process happens for both clinical trials and observational studies. “Both our trial centers and our epidemiological centers will work with clinical investigators to fully develop a quality study or protocol,” he said. “They’ll design the study. They determine how they would recruit the veterans, how many they need, where they would get them from, and then how they would collect their data. Furthermore, they will determine the logistics and other requirements for conducting the study within the VA health care system. And then they analyze it and produce results with our clinical investigators.” CSP often partners with the Health Economics Resource Center, a facility formally aligned with ORD’s Health Services Research and Development Service, to analyze the cost-effectiveness of a treatment or intervention – whether a drug that performs well might save the VA money, for example, or might be more effective than existing treatments over the long run. One current clinical trial, CONFIRM, is the largest single clinical trial in VA history, evaluating the two most common types of colorectal cancer screening among 50,000 veterans. CONFIRM is expected to provide definitive guidance on the best methods for colorectal cancer screening to prevent death. The CSP’s ability to conduct trials on this scale benefits veterans, the VHA, and clinical practice everywhere. The most obvious benefit for veterans is that these large-scale trials offer access to cuttingedge diagnostics and treatments, administered by skilled clinicians who are tuned in to their needs. “A major benefit of our program,” Huang said, “is that we provide definitive evidence that influences health care decisions.” A landmark VA study, conducted in the 1980s, showed that aspirin can reduce heart attacks, and CSP studies have helped establish clinical practice guidelines for treating several other diseases and disorders. The scope of the VHA also enables the CSP to partner with numerous public and private partners. A collaboration with Merck & Co., a pharmaceutical manufacturer, evaluated the effectiveness of a new shingles vaccine among 39,000 veterans and other patients at 16 VA medical centers, the NIH, and five universities. “We performed the definitive trial,” Huang said, “and our partnership with Merck led to the ultimate approval of the shingles vaccine by the FDA.” The VHA is uniquely suited to form such partnerships and conduct trials because it is both a research and a clinical care institution. Most research organizations aren’t able to have a direct impact on patient care, Huang said. “They fund scientists and investigators, and they publish. Afterwards, they don’t have the capability [to help patients] because they don’t have the other components that we have. We’re taking advantage of the fact that we have, all within one health care system, the capability to conduct research and provide clinical care, policy, and decisionmaking, and we’re trying to capitalize on those capabilities.”

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VA PHOTO BY CHRISTOPHER PACHECO

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NATIONAL CANCER INSTITUTE

GETTING MORE VETERANS INTO CLINICAL TRIALS By participating in VA clinical trials, veterans – particularly those with conditions beyond the reach of routine clinical care – are given access to potentially life-saving or life-enhancing treatments that wouldn’t otherwise be available. This is one of the primary reasons why increasing veterans’ access to highquality clinical trials has been identified as a strategic priority in the VA’s 2021 budget proposal. Despite the many advantages enjoyed by the VHA’s research and health care system, its scope sometimes presents challenges to external partners, and veterans remain underrepresented in clinical trials funded by non-VHA organizations. Clinical trials conducted at VHA sites tend to take longer than at non-VHA centers, for several reasons. Another significant challenge for partners, said Huang, is simply that the VHA has different ways of doing things – and that these differences are not system-wide, but can vary from center to center. Huang envisions the CSP as the key facilitator for these potential partners, helping them negotiate these differences and ease the way toward greater veteran participation in multicenter clinical trials. “We’re developing a process where we say, if you’re an external partner in industry or maybe even another federal agency, we will work with you to help navigate our system: figure out what you need to work and coordinate with multiple VA medical centers, and then provide access for veteran patients to clinical trials of, let’s say, new drugs or new therapies that industry might want to be testing or developing. So that’s now a more externally focused set of priorities that we’re dealing with.” This external focus will necessarily specialize, like CSP’s overall structure, along two parallel lines, for both industry and federal partners. One template for how the CSP might increase opportunities for veterans emerged in the summer of 2018, when

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Under the NAVIGATE partnership between the VA and the National Cancer Institute (NCI) aimed at increasing veteran enrollment in cancer trials, NCI is building infrastructure at 12 VA sites for clinical trials of cutting-edge cancer therapies.

the VA formed a partnership with the National Cancer Institute (NCI): the NCI and VA Interagency Group to Accelerate Trials Enrollment (NAVIGATE). “NAVIGATE was actually based on a model we developed at CSP for recruiting within the VA for CSP studies,” said Huang. When the NCI reached out to VA to encourage more veteran enrollment in cancer trials, the CSP shared this model with them. “And they said, ‘We want to do that, too. Can we fund a group of sites using that model, but then be more focused on NCI-funded trials?’” Under the NAVIGATE partnership, the NCI is building infrastructure at 12 VA sites for clinical trials of cutting-edge cancer therapies, including precision medicine therapies based on patients’ genetic profiles and immunotherapies that channel patients’ own immune systems to fight the disease. Similar partnerships may be in the works, Huang said; the National Institute on Aging (NIA) has approached the CSP about a partnership focusing on diseases of aging, such as Alzheimer’s. Another NIH organization, the National Center for Advancing Translational Sciences,

has discussed teaming up to enhance the work of NIA’s PREVENTABLE trial (Pragmatic Evaluation of Events and Benefits of Lipid-Lowering in Older Adults). “They have a network of university-based sites,” Huang said. “And VA has about 60 sites where we’re going to contribute to this large-scale, 10,000-patient study looking at the effect statins have on dementia.” CSP and the NIA are discussing ways in which the two might share ideas, expertise, and practices. When he speaks of “expertise,” Huang points out that he’s not just talking about scientific and clinical expertise; CSP has developed decades’ worth of expertise in every aspect of large, multicenter clinical trials: operations, finances, administration, safety, and the rigorous technical and regulatory standards involved in planning, coordinating, and conducting trials that may involve tens of thousands of veteran participants. “This whole initiative,” he said, “is about leveraging that expertise, to be part of a larger national clinical research enterprise and do studies that will really benefit veterans – and all Americans, for that matter.”

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VA Research

PUTTING DATA TO WORK FOR VETERANS By Craig Collins

n IN THE ERA OF BIG DATA, there aren’t many public entities with bigger data than the Veterans Health Administration (VHA). The nation’s largest integrated health care network, serving about 9 million veterans, was an early adopter of electronic medical records, beginning in the 1970s. This digital platform has evolved over the years and now constitutes an electronic health record that contains inpatient and outpatient diagnoses and procedures, lab results, prescriptions, and other veteran medical data. In total, VHA has compiled more than 78 billion records from all of its VA medical centers. At the same time, the VHA’s groundbreaking efforts to understand how genes affect health and illness continue to grow. The most prominent of these efforts, the Million Veteran Program (MVP), was launched in 2011 to learn how genes, lifestyle, and military exposures interact to affect health and illness. To date, about 850,000 veteran volunteers have donated genetic samples – vials of blood – to aid in studies that look for associations between genes and medical record data, as well as self-reported survey data on lifestyle and military exposures. The investigations enabled by the collection of genetic material are generally of two types. The first, genotypic or “candidate gene” studies, focus on associations between pre-specified genetic variations and disease states. VHA investigators were pioneers in these kinds of studies; beginning in the mid-1990s, investigators at the Puget Sound Health Care System made a series of discoveries linking genetic mutations to Werner’s syndrome (a hereditary disease that causes premature aging and death), schizophrenia, and dementia. When the international Human Genome Project showed how to map the entire sequence of chemical base pairs that make up human DNA, it opened the door to a new kind of investigation: the genome-wide association study, or GWAS, in which entire genomes from a large cohort of people are scanned for common genetic variations. With the help of powerful supercomputers, investigators discovered which genes appear in one group – such as people with breast cancer – and not another.

A useful GWAS requires several elements: a large sample of genetic material, the infrastructure necessary to store and examine it, and powerful computational tools for comparing hundreds of thousands, maybe even millions, of variants. Samples from MVP participants are collected and stored in a massive freezer at the Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC) within the Boston VA facility. The 850,000 DNA samples, taken from veterans enrolled in MVP, are sorted, stored, and retrieved by a sophisticated robotic system. Great pains have been taken to guarantee the security of this data and the anonymity of donors. Names are removed from samples immediately; each participant becomes an anonymous blood vial, and data collected from other potentially identifying information, such as surveys, are assigned codes. According to Sumitra Muralidhar, PhD, who directs the Million Veteran Program, the point of building such a massive trove of genetic samples is to enable comparison studies on a scale that will reveal hidden secrets. “We’ll have sufficient numbers of people with a disease and without a disease,” she said, “and we’ll compare their genetics, so we can then identify what genetic risk factors may be associated with a certain disease.” Most MVP studies to date have compared genotypes – differences in the DNA sequences stored in the MAVERIC – with phenotypes, which Muralidhar defines as simply any observable characteristic or trait. “A phenotype could be as simple as the color of your hair or the color of your eye,” she said. “It could be a disease like diabetes. PTSD is a phenotype.” Post-traumatic stress disorder is a complex phenotype with many variations, Muralidhar said, as is a multi-variable condition like cardiovascular disease. “Lipid level, blood pressure – all of these are what we call phenotypes: biochemical, biomedical characteristics that result from the genes we have.” In less than a decade of existence, the power of the VHA’s considerable data stockpile has been made evident in landmark studies comparing genetic information to the phenotypes described in electronic health records and other data sources.

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Left: Joe Shanks, a medical technician at the San Francisco VA Medical Center, draws a blood sample from Air Force veteran Matt Parsons during enrollment in the Million Veteran Program (MVP). Below left: To date, about 850,000 veterans have donated genetic samples – vials of blood – through the MVP.

and lifestyle for each person. In the future, VA clinicians will take what’s learned from these large-scale genomic studies and either prevent diseases entirely or optimize treatments. But it remains to be seen how soon that future will arrive.

PHOTO BY FRANK CURRAN, VA BOSTON HEALTHCARE SYSTEM

VA PHOTO

BUILDING ON THE MVP’s POTENTIAL

In January 2020, for example, VA researchers reported new evidence of the underlying biological causes of anxiety disorder, which affects about 10 percent of all Americans. Derived from the genetic and health data from 200,000 MVP volunteers, the study was the largest GWAS of anxiety traits to date. In 2019 alone, said Muralidhar, MVP investigators “had 19 high-impact papers released.” In December 2019, when the American Heart Association published its annual list of the 10 greatest advances in heart- and stroke-related research, it included two MVP studies that offered insights into the genetic basis of both venous thromboembolism (VTE) and peripheral artery disease (PAD). Identifying risk factors, Muralidhar said, is only a starting point in putting this data to work for veterans. “Being associated with something doesn’t mean there’s a cause and effect,” she said. “You have to then do more functional studies to actually show how that change in your DNA is making you more susceptible to an illness or more responsive to a medication.” The ultimate goal of the MVP is to practice what’s known as “precision medicine,” an approach for disease treatment and prevention that takes into account individual variability in genes, environment,

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Putting data to work for veterans is one of the strategic priorities identified by the Department of Veterans Affairs’ (VA) Office of Research and Development (ORD) in the department’s 2021 budget proposal – an acknowledgement that the vast, rich datasets at the VA’s disposal are resources that remain largely untapped. Because these datasets hold information that will benefit veterans and all Americans, VA is taking steps to accelerate the pace at which this data can be discovered, extracted, and used for research that will unlock advances in precision medicine. There’s a good reason, said Muralidhar, that most studies of MVP genetic data are genotypic studies that scan DNA for changes called single nucleotide polymorphisms, or SNPs. “Genotyping is the first level,” she said. “We’re only looking at certain points along the DNA.” Depending on how a test is designed, investigators can look for any number of markers – but it’s still scanning for variations, rather than mapping the entire sequence of the genome. Obviously, having the complete picture of variants across the genomes of many individuals is likely to yield better results than scans of candidate segments. But moving to this next level is exponentially more expensive: Genotyping costs about $45 per sample, plus some additional costs for analysis, compared to about $1,000 to $1,200 for a research-grade whole-genome sequence. At that rate, the VA obviously will not be able to sequence a million genomes – but it has invested in a significant increase in investigators’ ability to conduct genome-wide association studies. “We have done about 53,000 [whole-genome sequences], so we are halfway there,” Muralidhar said. “We’ve already invested the funding and committed to doing 100,000 whole genomes.” A fuller picture of genetic data is one piece of the puzzle. VA investigators also need a more complete picture of the phenotypes against which these genes are being compared. “We’re looking now at how we can translate some of these findings, move them along the pipeline to actually become useful in the clinic ... and that will involve functional studies and validation of the research findings,” said Muralidhar. The most basic indicator of a phenotype in the electronic health record is a six-character code known as the ICD

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(International Classification of Diseases) code, which is a fairly blunt instrument; as Muralidhar pointed out, many conditions, such as PTSD, are so multi-faceted that a single code is insufficient for any but the most basic analysis. A primary care physician’s entry of the PTSD code into a record, for example, doesn’t necessarily mean the patient has PTSD; it’s a diagnosis that must be confirmed in follow-up visits to mental health clinicians. The VA is fortunate in that it has one of the most complete and accessible electronic health records in the world. “They are deep and go back almost 30 years,” said Muralidhar. “We know what medications people are on. We know when they were diagnosed with certain illnesses, from their labs what kind of tests were done, what the results of those were – all of that information is there.” To unlock the potential contained within the VA’s datasets, the ORD has launched an ambitious effort to establish a centralized VA Phenotype Library that processes and curates phenotypic data and associated “metadata,” such as statistics or references that describe or otherwise help to understand that data. As it happens, a team of VA data experts have curated the PTSD phenotype for studies of the condition: They developed an algorithm that combed through all available data and metadata including natural language processing that could read, decipher, and understand clinicians’ written notes – and used it to identify patients with the PTSD phenotype – essentially, digging the phenotype out of the medical

record, whether or not there had been an official diagnosis. Follow-up calls to about 200 clinicians validated the instrument. “So now with great confidence – 95 to 98 percent confidence,” Muralidhar said, “we can say that if you use this algorithm, you’ll pick out all the people who have that illness.” Curating phenotypes using artificial intelligence and algorithms, unsurprisingly, is a meticulous and lengthy process, but Muralidhar said the VA’s data experts have already curated more than 200 phenotypes to the Phenotype Library – which will make things considerably easier for new studies. “You don’t have to go and reinvent the wheel,” Muralidhar said. “You can look at our library and say: ‘Here it is, and this is how they did it, so I’m going to use that same algorithm to find the patients I need for a clinical trial,’ or for any purpose you may want to identify patients with a certain illness. ... In the future, the VA Phenotype Library will be available even to external researchers – but we are going to start with VA researchers.”

UNLOCKING THE POTENTIAL OF THE VA’s COMPUTING INFRASTRUCTURE One of the challenges associated with maintaining such vast datasets, obviously, is making them more widely available to researchers while protecting data security. The anonymity of MVP volunteers is protected by the data platform, GenISIS, and investigators search through that data using the VA’s specialized health

services research platform, essentially a set of servers known collectively as VINCI (VA Informatics and Computing Infrastructure). From the outset, said Muralidhar, MVP leaders decided that genetic data would not be distributed to researchers. “We put the data in a central secure repository,” she said, “and we bring researchers to the data.” The man in charge of VINCI is Scott DuVall, PhD, who describes it as “a central, secure platform that allows veteran data, mostly medical record data, to be accessed in a controlled way where we are limiting people to just what is approved and just what’s necessary to perform a certain study. And that data is combined with tools that allow people to analyze and explore the data looking for scientific discoveries.” VINCI also includes analytical tools that help researchers evaluate this data in a computing environment. DuVall is leading the effort to put data to work for veterans and, ultimately, for all Americans. The first step, he said, is to prepare the data to go to work. “The VA has some of the most complex and comprehensive medical record data in the entire world, and it’s spread across a national health care system with close to 400,000 employees,” he said. “Of those, there are tens of thousands of physicians, and 100,000-plus nurses and other personnel. These are all people who are authoring new data on our veterans. And the veterans themselves submit information, or the devices they wear, like cardiac devices and others that collect and author data. We’ve got more than 20 years’ worth of longitudinal medical record data.” Getting this data ready for work, DuVall said, is akin to brushing its teeth and sending it to the shower and driving it to the office, where it’s ready for action. “What that means,” he said, “is

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VA PHOTO FOR ILLUSTRATIVE PURPOSES ONLY

The ultimate goal of the MVP is to enable the practice of precision medicine, an approach that takes into account individual variability in genes, environment, and lifestyle and tailors disease screening, treatment, or prevention measures – such as frequency of mammograms for breast cancer screening – for each person.

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VA PHOTO BY EUGENE RUSSELL

One of the challenges associated with maintaining such vast datasets, obviously, is making them more widely available to researchers while protecting data security.

PHOTO COURTESY OF VA

Above: Sumitra Muralidhar, PhD, far left, is pictured at the 2018 VA Research Fair on Capitol Hill. Muralidhar directs the Million Veteran Program. Right: Scott DuVall, PhD, who oversees VINCI (VA Informatics and Computing Infrastructure), the VA’s specialized health services research platform, is working to improve researchers’ access and ability to analyze VA data while also ensuring veterans’ privacy and data security.

we’re standardizing data across time, and standardizing across different parts of the country.” Though it seems like common sense for “diabetes” to mean the same thing in Salt Lake City, where DuVall works, as it does in Atlanta – or to mean the same thing today that it did 10 years ago – codes and conventions often vary from place to place (i.e., in clinical and administrative settings) and from time to time. Preparing VA data for work means transforming and mapping it onto a community-supported common data model – the Observation Medical Outcomes Partnership model, developed by the Food and Drug Administration. “Doing it like this allows us to use the same code sets that they use at Harvard, and the same ones they use at Johns Hopkins and the Mayo Clinic,” DuVall said, “so that we can run the same type of studies that

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they do and we can share our studies with them.” A common data model also allows for data to be retrieved from sources such as the Centers for Disease Control and Prevention, the National Institutes of Health, the Department of Defense (DOD), and, for veterans who are receiving care outside the VA, from the Centers for Medicare and Medicaid Services. According to Grant Huang, PhD, director of VHA’s Cooperative Studies

Program, a common data model will help VA investigators more precisely design multicenter clinical trials from its five Coordinating Centers. If the CSP is developing a study of a diabetes treatment, for example, it may help to target veteran patients who share certain genetic or lifestyle characteristics. “So, what we can do from an informatics standpoint,” Huang said, “is work with Scott’s team and say: ‘We need to know not only which patients have diabetes, but which patients have diabetes and some other characteristics.’ And he has the data that can tell us where they are. So that helps us to be a little more precise and target, say, the 20 sites where the data show us that’s where the veterans are.” Brushing data’s teeth and getting it to the office is only the first step outlined by DuVall; VA’s data experts also want to expand data’s workplace, building a computing environment beyond GenISIS and VINCI to include cloud-computing environments such as the VA Enterprise GovCloud and the VA Data Commons, a pilot project conducted in collaboration with the University of Chicago to integrate clinical, genomic, imaging, and other data from VA records within a scalable infrastructure. As the electronic health record evolves into a shared platform with the DOD’s medical records, researchers will be able to capitalize on some of the built-in capabilities of the vendor, Cerner, for accessing and sorting complex data sets. For certain applications, such as the complex algorithms involved in accessing the Phenotype Library, the VA has an agreement with

OAK RIDGE NATIONAL LABORATORY PHOTO

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the Department of Energy (DOE), to make use of the expertise and supercomputing capacity at several national laboratories. “They have the horsepower needed to make scientific discoveries with as much data as we have,” DuVall said. One VA/DOE project involves building a predictive model that takes into account all pieces of information that may indicate suicide risk – not primarily for research but in order to enable early interventions to provide support. “You combine codes, medications,” said DuVall. “You combine that with genetic data. And then you combine that with the language written in clinical notes and mental health notes, discharge summaries and depression surveys, and all of these other pieces. And you put it in these supercomputers and crunch it, looking for some

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The Summit supercomputer at the Department of Energy’s (DOE) Oak Ridge National Laboratory. The VA has an agreement with DOE to make use of the expertise and supercomputing capacity at several national laboratories to assist in secure data analysis.

associations.” Additional DOE projects are underway to assess risks for cardiovascular disease and metastatic prostate cancer. The VA is forming numerous such partnerships, to support planning and policy related to artificial intelligence and data science. These efforts include subject matter experts from universities, nonprofit foundations, health care systems, and industry partners to accelerate discovery and enhance the VA’s ability to analyze data. In DuVall’s data

workplace analogy, these are data’s coworkers, laboring every day to read and interpret data in ways that will improve clinical care – making it more streamlined, cohesive, and effective – and unravel the mysteries that remain encoded in veteran’s genes and documentary records. “Everything we do in research,” DuVall said, “is trying to connect the dots: why people get sick, and when they do, which treatments or medications or lifestyle changes can help them feel better. The more we can look at the whole picture, the more accurately those associations can be made.” And as the VHA becomes increasingly able to turn its data into knowledge, the more it will be able to improve the health and well-being of American veterans.

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MILITARY HEALTH SYSTEM TRANSFORMATION

Administration and management of all U.S. military medical facilities are shifting to the Defense Health Agency. By J.R. Wilson

n IN THE MOST SIGNIFICANT DEVELOPMENT in military health care since its founding in 1775, the National Defense Authorization Act of 2017 (NDAA 2017) directed the Defense Health Agency (DHA) to bring all U.S. military medical treatment facilities for all service branches together under a single Department of Defense (DOD) organization. It was an action that had been recommended by several studies since World War II to reduce duplication and redundancy and increase proficiency and health care solutions. Until NDAA 2017, each service was responsible for ensuring a ready medical force and its own medically ready force. As a result, there were no inter-service standardization processes, just a great deal of variation. The transition to DHA is intended to standardize all aspects of health care and ensure consistency throughout the U.S. military. That transition began on Oct. 1, 2018. A year later in October 2019, an article on the Military Health System’s official website by DHA’s director, Army Lt. Gen. Ronald J. Place, addressed what the transition means to Army, Navy, and Air Force hospitals and clinics. “Many are questioning what this change really means. Let me first tell you what it’s not about: It’s not about ownership. It’s not about control. It’s not about one Service is better than another. As a matter of fact, it’s because of the great work the Services have done to advance and elevate the quality of care for our warfighters and their families that bring us to this day,” he wrote. “This is all about the patient. It’s about harvesting decades of best practices from across the Army, Navy, and Air Force – along with what we can learn from the civilian community – to build a global standard with one focus: Make our system better to improve health outcomes that matter to our patients.” DHA originally was stood up on Oct. 1, 2013, as the nation’s military medical combat support agency – a joint, integrated organization enabling the services to provide a medically ready

force and ready medical force to combatant commands in both peacetime and war. Working with the Joint Staff Surgeon and military department medical organizations, DHA maintains a global network of military and civilian medical professionals at nearly 450 military hospitals and clinics, supporting health care delivery to 9.5 million active-duty service members, retirees, reservists, National Guardsmen and women, and their families. The movement of all military health care delivery to DHA – both CONUS and OCONUS – is scheduled for completion by October 2021. A primary goal is to standardize the business side of health care delivery while improving patient experiences, such as making the process for scheduling appointments or getting a referral for specialty care the same across all facilities. DHA has assigned military health care facilities to individual markets, based on size: 21 large markets; 16 small markets; and 66 facilities which, because they do not fit into either of those segments, are being designated as a “stand-alone” segment and will be managed by the same office that manages the small markets. Some 75 U.S. military treatment facilities (MTFs) in Europe and the Indo-Pacific region eventually will be placed into similar markets and transitioned to DHA no later than Sept. 30, 2021. “Common patient safety and clinical quality policies mean the very best practices in one clinic become the norm within every clinic, raising our performance across the board. A single agency accountable for all the health care we provide – whether in one of our facilities or through a civilian provider in our TRICARE managed care network – means we will be more effective in finding the best possible source for the best care for each patient,” according to Place. “In the months ahead, we’ll set up market organizations in regions across the country, allowing hospitals and clinics in the same geographic area – regardless of Service – to share and target resources where our patients need them. In the next year, our work focuses on getting this right in the United States

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U.S. AIR FORCE PHOTO BY STAFF SGT. CEAIRA TINSLEY

PHOTO BY DALE DAVIS

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Above: Sailors and staff observe morning colors at Naval Health Clinic Corpus Christi prior to a CO’s call with Capt. Eric Evans to commemorate the command’s official transition to the Defense Health Agency (DHA) on Oct. 1, 2019. All U.S. military medical treatment facilities will transition to the Defense Health Agency by the end of September 2021. Right: U.S. Army Lt. Gen. Ronald Place, DHA director, addresses members of the 99th Medical Group at Nellis Air Force Base, Nevada, Feb. 28, 2020. During the visit, Place discussed the future of military health care and new advances such as MHS GENESIS, the military’s new electronic health record.

and [preparing] for the transition of overseas facilities.” The transition also will make the new military electronic health records (EHR) system – MHS GENESIS – available across the full spectrum of both DHA-run military health care facilities and those run by the Department of Veterans Affairs. This seamless availability of EHRs to both patients and caregivers, regardless of service, status, or location, not only relieves the patient of the need to copy and carry their records

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with them when visiting a new facility, but also ensures different providers will not need to repeat the same tests multiple times because they can’t access earlier test results.

U.S. ARMY At a Jan. 28 forum of 350 Army medicine leaders at Fort Belvoir, Virginia,

Army Surgeon General Lt. Gen. R. Scott Dingle warned the attendees they had to rapidly gain “a better understanding of the breadth and depth of change” from the transition. “Things are changing at the speed of relevance,” he said. “As leaders, it is imperative that we understand the changes that are going on, and that we are also responsive to these changes,

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U.S. ARMY PHOTO BY SGT. CRAIG JENSEN

U.S. Army and Ghanaian medical professionals discuss medical practices during Medical Readiness Exercise (MEDREX) 19-3 at Accra, Ghana, on June 10, 2019. MEDREX exercises in support of U.S. Army Africa allow U.S. forces to train in an alternatively resourced environment, share medical practices, and build lasting relationships with medical professionals from participating African partner nations.

because if you are not responsive to the changes, you lose the relevance. And so, fasten your seat belts, batten down the hatches, be ready to make these supersonic speed changes.” Dingle’s office, in a statement on the Army’s medical website, assured service members the transfer of Army hospitals to DHA is designed to create a more integrated health care system, improve patient outcomes, and enable the readiness of the Army to support the Joint Force by ensuring medical readiness, supporting wartime requirements, and enhancing the quality of care for soldiers and their families. “As we reform and reorganize, we are committed to providing ready and responsive health services and force health protection,” Dingle told the House Armed Services Committee’s Subcommittee on Military Personnel in December 2019, speaking on behalf of the Army’s 130,000 health care providers. “The Army is continually assessing the risks with changes to medical end strength. Personnel changes currently under review are a necessary part of our modernization and our force shaping,” he said. “For the service and sacrifice of our soldiers and their families, we must get this right. This is our solemn obligation to our nation,” he added. At the Defense Committee on Trauma (DCOT), Committees on Surgical and En Route Combat Casualty Care (CCC) Conference in San Antonio, Texas, on Nov. 13, 2019, Dingle also said the transition is an opportunity to bring real change to combat trauma care. That is a major goal of the Army Ready Surgical Force Campaign Task Force (ARSFC TF). ARSFC TF wants to ensure larger roles and training opportunities in

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military exercises such as the Medical Readiness Exercises (MEDREX) in support of U.S. Army Africa (USARAF), Expeditionary Resuscitative Surgical Team (ERST) in support of U.S. Africa Command (AFRICOM), Expeditionary Health Readiness Platform-Honduras (EHRP-H) in support of U.S. Army South (ARSOUTH), and Global Health Engagement (GHE) Medical Readiness Training Exercise (MEDRETE) in support of ARSOUTH. “Things are moving at the speed of relevance and if we aren’t relevant to today’s fight, then we’ll become extinct,” Dingle told the conference. “I can’t change the past, but together we can change the future. We can get it right, but it’s not me – it’s we. It’s going to take all of us to bring change.”

U.S. AIR FORCE “The Air Force is fully committed to the vision of an integrated system of military health and making that process as seamless as possible,” according to Lt. Gen. Dorothy A. Hogg, Air Force surgeon general. “DHA will have responsibility for the administration and management of military treatment facilities operations related to delivering the health care benefit. The Air Force Medical Service

retains our readiness mission, ensuring airmen are fit to carry out their mission and delivering deployable medical assets to meet combatant commander requirements.” Maj. Nicole Ward and Capt. Matthew Muncey are program managers with the Air Force Medical Service (AFMS) Transition Cell, which serves as an information clearinghouse, facilitating communication and collaboration within AFMS as well as externally to the Army, Navy, and DHA. “We work closely with DHA and the TIMO [Transition Intermediate Management Office] program management offices to ensure clear communication flows to build support and deliver guidance to Air Force and our service partners’ MTFs. Each service brings its own best practices and approaches to make this process possible. This collaboration furthers the MHS high-reliability organization journey, reflecting and enhancing our own Air Force Trusted Care principles,” Ward said in a January 2020 interview with the Air Force Surgeon General Public Affairs Office. “It also means the Air Force lends its expertise to the transition process and DHA’s implementation efforts,” Muncey added. “The first example to demonstrate the value of our

Left: Air Force Maj. Nicole Ward (left) and Air Force Capt. Matthew Muncey, program managers with the Air Force Medical Service Transition Cell. The Transition Cell interfaces with DHA and represents the Air Force position on the development of policy and plans for the transition of military treatment facilities (MTFs) to DHA. Below: Naval Medical Center Portsmouth (NMCP) hosted the Future of Military Medicine panel on Nov. 14, 2019, to discuss the MTFs’ transition to DHA. The panel participants were, from left to right: Capt. Joel Schofer, deputy chief of the Medical Corps at the Navy Bureau of Medicine and Surgery (BUMED); Capt. Lisa Mulligan, NMCP’s commanding officer; and Capt. Guido Valdes, Navy Medicine East’s deputy commander.

be paramount – providing exceptional, high-quality trusted care and improving the readiness of our airmen.”

U.S. NAVY The newly established Navy Medicine Readiness and Training Command (NMRTC) is assisting the transition of health care delivery and business operations to DHA, while enabling Navy Medicine to retain command and control of the uniformed medical force and responsibility and authority for the operational readiness of sailors and Marines, as well as the clinical readiness of the medical force. “The transition is going well,” Capt. Joel Schofer, deputy chief of the Medical

Corps at the Navy Bureau of Medicine and Surgery (BUMED), told a Nov. 14, 2019 Future of Military Medicine panel at Naval Medical Center Portsmouth (NMCP), Virginia, the Navy’s oldest continuously operating military hospital since 1830. “DHA is building its bench. What BUMED is doing is taking personnel and putting them into what is called the direct support cell … the portion of BUMED that is helping DHA run MTFs.” BUMED’s position is simple: The readiness of the Navy Medicine team is paramount to combat survival in the future. The focus will be on getting and keeping the team ready.

U.S. NAVY PHOTO BY SEAMAN IMANI N. DANIELS

partnership is the AFMS memorandum of agreement with DHA to provide direct support to the MTFs. This agreement allows us to maintain uninterrupted operations supporting Air Force MTFs, freeing up DHA to develop and mature its processes. Air Force’s early and frequent engagement with the DHA yielded positive results for the Air Force and the entire enterprise.” The Transition Cell was created by AFMS in 2018 to be the primary interface with DHA and represent the Air Force position on the development of policy and plans in transition of the MTFs to DHA, according to Muncey. The cell has representation from both the Air Force Medical Readiness Agency (AFMRA) North in Falls Church, Virginia, and AFMRA South in San Antonio, Texas. “DHA recognizes it doesn’t have all the answers to these questions and is very open and transparent about that. So it relies heavily on the services to lend our time and talent toward trying to figure out these problems,” Muncey said. “That’s really where the Transition Cell offers up a lot of the benefits of this productive partnership. We focus on making the transition as seamless as possible by working with DHA to make sure we meet Congress’ intent, while preserving what we already do well at the MTF.” Hogg said the transformation will “provide us an opportunity to really shape the future of the Air Force Medical Service. Our core mission continues to

U.S. AIR FORCE PHOTO BY JOSH MAHLER

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US. ARMY PHOTO BY PATRICIA DEAL, CRDAMC PUBLIC AFFAIRS

Carl R. Darnall Army Medical Center (CRDAMC) emergency medicine (EM) resident Capt. Katey Bettencourt examines a simulated casualty while Air Force Maj. Chris Pitotti, EM residency program associate director, University of Nevada, observes during CRDAMC’s Joint Emergency Medicine Exercise held May 28-31, 2019. The exercise tested the Tactical Combat Casualty Care readiness of Army, Air Force, and Navy EM residents in a simulated realworld, joint operational medicine environment. The transition to DHA will facilitate the implementation throughout the Military Health System of best practices in military medical care from all the services.

“The way we think about our mission has changed more than the actual mission,” said Capt. Lisa Mulligan, NMCP’s commanding officer. “We need to start thinking, in the terms of Navy Medicine, the mission is being more focused on readiness, but still includes the things that we have been doing all along,” Mulligan said. “DHA transition is a big change, but we have the culture to deal with change,” added Capt. Guido Valdes, deputy commander of Navy Medicine East. “If anybody can get through the new journey, Navy Medicine can.” “Military Health System (MHS) transformation has provided Navy Medicine an unmatched opportunity to refocus on our true mission – the reason why we have uniformed medical personnel – which is achieving maximum future life-saving capabilities and survivability along the continuum of care,” according to Rear Adm. Bruce L. Gillingham, Navy surgeon general, in his statement to the House Appropriations Committee Subcommittee on Defense on March 5, 2020. “When a sailor or Marine goes into harm’s way, Navy Medicine is with them. The CNO [Chief of Naval Operations] and CMC [Commandant of the Marine Corps] have expressed a sense of urgency for Navy Medicine to meet the demands of the rapidly changing security environment. Our commitment: Optimizing Navy Medicine for the warfighter.” In a Feb. 19, 2020 report to Congress, DOD announced it had concluded a review of 343 U.S. military medical facilities

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and is now beginning to restructure 50 of those “to better support wartime readiness of military personnel and to improve clinical training for medical forces who deploy in support of combat operations around the world.” Of those being restructured, 37 outpatient clinics now open to all beneficiaries eventually will see primarily only active-duty personnel. Active-duty family members, retirees, and their families who currently receive care at those facilities will transition over time to TRICARE’s civilian provider network, a process MHS said may take several years as each is assessed for individual requirements and alternative providers. Place said the MHS transition also requires a change of mindset within DHA. “We’ve largely been an agency that is a legacy of TMA – TRICARE Management Activity – and we’re very good at that. We’re very good at carefully and slowly looking at information and coming up with the right answer. That mindset doesn’t work as we support hospitals, medical centers, and clinics in action. When a question arises, we need to respond quickly,” he said. “We have to transition from being good at thoughtful, deliberate work, to also being an organization of action that takes in information and rapidly gets the right people involved. We still have to be absolutely accurate managing the TRICARE benefit, but we have to be nimble, agile, flexible, and supportive on the direct care delivery side. So, in our culture, we have to transition to balancing both of those things.” Place also tried to dispel some rumors that have swirled around the transformation. “The reason for this transformation has nothing to do with this idea that Army Medicine, Air Force Medicine, or Navy Medicine weren’t doing a good enough job,” he said. “That’s not what this is about. This is about taking the great work that people have been doing and finding those best practices across the entirety of the military health care system and bringing everyone up to that level. We have to find ways to make the process user friendly, irrespective of service, for every single beneficiary that we have,” he said. “Every single person in senior leadership across the services, everyone in Congress who is writing these laws, fundamentally understands the great work that is happening in military medicine, and the whole idea behind this is how to take that great work and make it better. Our ultimate goal is to strengthen our ability to provide ready medical forces to support global operations and improve the medical readiness of combat forces.”

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WEST POINT FOR DOCTORS: THE UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES By J.R. Wilson

n THE UNIFORMED SERVICES UNIVERSITY of the Health Sciences (USUHS), founded in September 1972 by an act of Congress, is a unique and critical, yet comparatively little known, component of the U.S. military. Located on 100 acres of wooded land on the grounds of the National Naval Medical Center, 3 miles from Washington, D.C., and across the street from the National Institutes of Health, it is the premier medical education and research center for all the U.S. armed services. “We’re unique in many ways, as far as being a medical school,” USUHS President Dr. Richard W. Thomas told Veterans Affairs and Military Medicine Outlook. “Having a university focused on developing military physicians – a West Point for doctors – has proven its value over the years, providing a steady stream of high-quality physicians for the armed services. We were established as a medical school and grew into a university, which is the opposite of how most evolve. We recently created a College of Health Sciences that, for the first time, allows us to award undergraduate degrees. “I didn’t graduate from this university and was on active duty before I went to med school. Even when I was on active duty, I wasn’t familiar with what the university did. USUHS is the foundation for a lot of capabilities, and the advantage we bring is resident capabilities the services can reach back to and take advantage of. We are supporting the services so they can accomplish their mission by ensuring the medical readiness of our forces. We don’t want to be the best med school in the country you’ve never heard of; we’re becoming more well known for what we do, which is a positive trend.” About 60 percent of the university’s students have had no prior medical training. With a better than 95 percent graduation rate, USUHS provides from 15 to 18 percent of new military

doctors each year. As they become more senior, that grows to about 25 percent of all active-duty doctors and 35 percent of senior physicians in key billets, influencing medical operations as well as policy. Currently, one service surgeon general, two deputy surgeon generals, the Joint Staff Surgeon, and a number of command surgeons are USUHS graduates. “Our strategic plan comprises three domains. The first is education and training, the second is research, and the third is leadership development. What makes us unique from other medical schools is we are focused on leadership development. I want military health care facilities, not just doctors and nurses who happen to wear a uniform,” Thomas said, adding that plan and the university’s structure have proven invaluable in dealing with COVID-19, which he believes will have a long-lasting impact on USUHS and its graduates. “One of the advantages we have in the military, since the foundation of military medicine in 1775, is catching and learning from experience so we can improve. We have a mandate to improve the medical health of the force, and to do that we have to look at where we’re coming from. When this [COVID-19] happened, we pulled the after-action reports on what happened with previous outbreaks, such as H1N1. But this one is unique, so we are in the process of adapting to meet those challenges. This is about force medical readiness, and we want to make sure we can optimize our medical response so we can minimize the impact on the force.” Since its first graduating class of 29 doctors 40 years ago, USUHS has produced more than 5,000 doctors, 70 dentists, 660 nurses, and 1,300 biomedical sciences medical research doctors. It has continuously expanded and now houses four schools, 13 research centers, and the Armed Forces

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U.S. NAVY PHOTO BY MASS COMMUNICATION SPECIALIST 3RD CLASS WILLIAM PHILLIPS

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

U.S. NAVY PHOTO BY MASS COMMUNICATION SPECIALIST 2ND CLASS LAURA BAILEY

Above: The Uniformed Services University of the Health Sciences (USUHS) located in Bethesda, Maryland, is the premier medical education and research center for the U.S. armed forces. Right: First-year medical students at USUHS’s F. Edward Hébert School of Medicine receive more than 140 pounds of books each inside the school’s anatomy lab in August 2016. USUHS educates, trains, and prepares uniformed services health professionals, officers, and leaders to directly support the Military Health System, U.S. national security and national defense strategies, and the readiness of the armed forces.

Radiobiology Research Institute (AFRRI), the nation’s research and response facility for radiation-related events. Reflecting on that anniversary, Thomas cited the value the doctors and nurses who have graduated from USUHS have added to both military and overall national medical care. “If you look at the value proposition of the university and our alumni, we have folks who have gone on to serve only in the federal systems – military and otherwise – but others have taken their talents to the civilian medical care community,” he noted. “Most of our students came from the health professions scholarship side, so we got a predictably high-quality product who have had a tendency to serve longer than the average medical professional coming in from other sources.” The F. Edward Hébert School of Medicine, the original medical school, offers doctorate degrees in medicine, doctorate and master’s degrees in public health and related disciplines, doctorate degrees in medical and clinical psychology, and interdisciplinary PhD degrees in three military-relevant areas of science: molecular and cell biology, neuroscience, and emerging infectious diseases. The school supports 19 departments and 13 centers, programs, and initiatives. At present, 687 students are enrolled. The Daniel K. Inouye Graduate School of Nursing, with 179 current students, offers a PhD in Nursing Science, Doctor of

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Nursing Practice (DNP) in Nurse Anesthesia, Family Nurse Practitioner, Women’s Health Nurse Practitioner, and Psychiatric Mental Health Nurse Practitioner. It also offers a Master of Science in Nursing (MSN) and a Doctor of Nursing Practice in Adult-Gerontology Clinical Nurse Specialist. The Postgraduate Dental College incorporates more than 29 programs from Army, Navy, and Air Force dental schools. It offers its current enrollment of 242 students a master’s degree in Oral Biology and unique research opportunities. The recently established College of Allied Health Sciences awards transferable college credits that can lead to undergraduate degrees for corpsmen and medics completing one of four military medical training programs at the Department of Defense’s (DOD’s) joint Medical Education and Training Campus (METC). It has 170 students enrolled in 2020. Under a program begun five years ago and graduating its first students this year, enlisted personnel wanting to become military physicians can attend a two-year postgraduate pre-med program. Graduates of the Enlisted to Medical Degree Preparatory Program (EMDP2) can apply to any medical school in the country,

USUHS PHOTO BY SHARON HOLLAND

Left: Retired U.S. Public Health Service Rear Adm. (Dr.) Kenneth Moritsugu, a member of the Uniformed Services University of the Health Sciences board of regents, watches as students in the medical laboratory technologist (MLT) training program at the Medical Education and Training Campus in San Antonio, Texas, practice blood draw skills. The MLT program is one of several programs that are eligible for college credit under USUHS’s College of Allied Health Sciences. Below left: Army Sgt. 1st Class Joshua Richter listens to a lecture at George Mason University-Prince William Campus, Manassas, Virginia, as a student in the Uniformed Services University of the Health Sciences’ Enlisted to Medical Degree Preparatory Program in 2014. Richter was among the first 10 enlisted members accepted into the program, which has expanded each year since it began.

including USUHS, where they are promoted to junior grade officers. On graduating from USUHS with their MDs, they become O-3s (Army or Air Force captains or equivalent Navy lieutenants). “There is a lot of interest in growing this program, because we have a lot of enlisted members interested in becoming military doctors. It originally was established due to interest from senior members of the services,” Thomas noted. “The program has been highly successful and has been expanded each year. The class that came in this year is about 30. We’ll have to make some major investments to expand our footprint here for that, but you’re getting experienced military personnel from all work areas. “Following World War II, the military saw a need to develop and retain highly qualified doctors, so they established the Military Graduate Medical Education Program. About 40 percent of all military

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graduates from that program go through here. As we look at a shortage of civilian doctors, it is more essential than ever that the military maintain these graduate medical programs to ensure a pipeline for high-quality physicians.” The university’s 13 centers enable faculty and students to collaborate with leading experts from around the nation to push the boundaries across a wide range of biomedical sciences to advance and shape military medicine and world health. The USUHS centers are the: • Center for Deployment Psychology • Center for Global Health Engagement • Center for Neuroscience and Regenerative Medicine • Center for Rehabilitation Sciences Research • Center for the Study of Traumatic Stress • Consortium for Health and Military Performance

• Defense and Veterans Center for Integrative Pain Management • Infectious Disease Clinical Research Program • Murtha Cancer Center Research Program • National Center for Disaster Medicine and Public Health • Surgical Critical Care Initiative • Tri-Service Center for Oral Health Studies • Center for Health Professions Education “Right now, we’re in the top 10 percent in the nation in medical research dollars – medical rehabilitation, human optimization, suicidality, and other areas – in response to areas that have been identified to us by the services,” Thomas said. “The foresight of some of our founders has helped us facilitate medical research, giving us a unique statutory ability to shorten key research in areas important to the services and our service members. “We continue to do that research, in partnership with non-federal agencies, as DOD’s foundation for health care education and research. The university exists to support the services, not only training and graduating health care professionals, but also through our ongoing research efforts.” USUHS has come a long way since its first three years, when its classrooms,

U.S. NAVY PHOTO BY MASS COMMUNICATION SPECIALIST 2ND CLASS LAURA BAILEY

PHOTO BY PETTY OFFICER 1ST CLASS JACOB SIPPEL

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laboratories, and offices were housed on the third floor of a small office building in downtown Bethesda, Maryland, above a drug store and a bank. “We’re a moderately sized university. We are looking seriously at growing from our current class size of about 170 to up to 200 per class; beyond that, we would have to do some significant new construction,” Thomas said. “But we have been asked to grow. We have more than 3,000 applicants for each new class, so we can be highly selective, giving us very high-quality students. If we don’t take someone, we work closely with the services to make sure they are linked up with the right folks to talk about health professionals scholarships. “We have more than 730 foreign and domestic active patents from our research side and a large number of partnerships with other nations. When we do our field training exercises, we invite students from other nations to come in and train with our students; we always get more applicants than we can handle. That is consistent with the joint, interagency, intergovernmental, and multinational [JIIM] environment.” As might be expected, with its heavy emphasis on biomedical research, USUHS is heavily involved in – and affected by – the COVID-19 pandemic. “We have been significantly impacted. As a federal agency, we’re following the guidance given us by DOD, so we’re going

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Left: Cmdr. Kevin Michel, a certified registered nurse anesthetist at Naval Hospital Jacksonville, who earned a Master of Science in Nursing degree from USUHS, prepares anesthesia in the main operating room. USUHS provides highquality health care professionals it graduates into military medicine. Right: First-year USUHS medical students at the F. Edward Hébert School of Medicine participate in the Advanced Combat Medical Experience (ACME) training exercise at USUHS. ACME is designed to test medical students’ knowledge in a simulated combat situation, and volunteer role players wearing latex cut suits that simulate battle injuries allow medical students to apply simulated medical interventions such as hemorrhage control, IV insertions, and tracheostomies. USUHS ensures its graduates can provide care whether in a hospital or on a battlefield.

to distance learning, which isn’t a big jump because we’ve used that already, and it is a great opportunity to enhance that capability,” Thomas said. “DOD also turned to us immediately on the research side, and our IDCRP [Infectious Disease Clinical Research Program], which is heavily involved in helping manage COVID-19 in select military centers across the nation, putting us at the leading edge of research on the virus. Some of our experts in public health and occupational medicine are working to refine the clinical practice guidelines on how to handle patients infected with the virus.” Looking to the future, Thomas is confident USUHS will continue to provide

the highest quality of new doctors and nurses it graduates into military medicine and in its contributions to the nation’s warfighters. “I think we’ll continue to grow and evolve as we’ve done over the 45 years since our founding. The Institute for Defense Analyses just did a study I commissioned looking at the cost and value of the university. Since its founding, the USUHS has evolved into a critical capability for DOD and the nation, and I think we will continue on that path. It is mandatory for the force medical readiness to maintain a cadre of top-level medical professionals. There is a shortage of civilian doctors in the U.S. and there is some talk about us growing to take in more students, such as increasing our capacity to educate more nurses,” he said. “The reason the U.S. can deploy forces around the globe, in austere environments, and fight and win is because we have a medical force that can deploy side by side with them. The university provides the environment to not only establish centers of excellence, but to maintain and sustain that capability, always there for the services to reach back and tap into … so we can help them react and adapt for the readiness of the force. We are both an academic and a military organization – academic is the noun, but military is the modifier.”

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ARMY WELLNESS CENTERS FOCUS ON REDUCING MUSCULOSKELETAL INJURY RISK By Gail Gourley

n THE THEME OF READINESS IS PROMINENT in the 2020 Posture of the United States Army Statement, in which senior Army leaders emphasized to the Senate Armed Services Committee that warfighting readiness remains the Army’s top priority as it increases lethality to prepare for the future. A key element is that soldiers must be ready to deploy and able to train. Injuries, and specifically musculoskeletal (MSK) injuries, are the most significant medical non-readiness factor in the U.S. Army, according to Army Public Health Center (APHC) experts and the Army’s “2018 Health of the Force” report. Research has shown that these are primarily due to cumulative trauma, or overuse injuries, including stress fractures, Achilles tendonitis, patellar-femoral syndrome, plantar fasciitis, and back and knee pain syndromes. They are mostly sustained from training and strenuous operational activities, reflecting actions necessary for mission preparedness, with running the leading cause of MSK injuries. To tackle this problem, Army Wellness Centers (AWCs), an integrated network of 35 facilities located across the United States and overseas, are utilizing research combined with technology, health promotion, and wellness programs to minimize soldiers’ MSK injury risk factors. AWC services include metabolic testing, fitness testing, body composition analysis, biometrics, biofeedback, health coaching, and health education. The AWCs were designed and implemented around 2005, with the last implementation completed about 2018, according to Laura Mitvalsky, director of Health Promotion and Wellness, APHC. “It was the Army’s response to fragmented health

promotion program delivery,” she said. “We actually did a largescale evaluation looking at health promotion and wellness programs across the Army, and they’ve done that in the DOD [Department of Defense] as well. What they found was that there are a lot of programs out there, but they can’t be evaluated because they don’t have the component pieces in place to be evaluated.” The AWCs were devised to address that fragmentation, Mitvalsky explained, by building a standardized model to look at not only the facilities, but also programs, staffing, and equipment. “That standardized model delivers key readiness support capabilities to soldiers and community members. And they do that in several ways,” she said. “Typically, health promotion and wellness programs are based on the disease, like a high blood pressure class or a high cholesterol class or weight management. But that’s not how the wellness centers program standardized model is designed. It’s based upon targeting the behaviorally modifiable factors most likely to result in chronic disease, injury, and/or performance issues. So, our core programs are based upon, ‘How do we get after the behaviors that lead to those problems?’” In addition to the distinctive program model, Mitvalsky also described AWC staff as unique, composed of a variety of allied health sciences professional backgrounds and national certifications, and cross-trained in health coaching applications “so that they have competencies in all of the assessments that we do in the wellness center.” So, for example, an exercise physiologist can also do the metabolic testing, or

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PHOTO BY MIKE STRASSER, FORT DRUM GARRISON PUBLIC AFFAIRS

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a registered dietician is cross-trained to do exercise testing. Along with active-duty service members, the AWCs also provide standardized primary prevention programs to adult family members, retirees, and Department of the Army civilians. In 2019, the wellness centers served more than 58,000 unique clients with approximately 119,000 combined total visits. The majority of those were active-duty soldiers at about 77 percent, followed by family members at about 11 percent. Decades of Army injury prevention research have led to knowledge of the scope of the injury problem and its risk factors that are addressed by the capabilities of the AWCs. Bruce Jones, MD, MPH, senior scientist in the APHC Clinical Public Health and Epidemiology Directorate, described the magnitude of the injury problem: “Musculoskeletal injuries are the biggest health problem in the Army, resulting in over 2 million medical encounters annually, and accounting for very close to 10 million limited duty days,” he said, adding that the second leading problem, behavioral health, is about a million visits, and less than 2 million days of limited duty. “So,

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Kale Panetti, a health educator at the Fort Drum Army Wellness Center, administers a VO2 max assessment that tells clients how well their muscles use oxygen. Army Wellness Centers can provide soldiers with scientifically validated assessments and personalized plans for how they can improve components of their health and performance.

this is really the Army’s biggest health concern.” Research shows the strong connection between both aerobic fitness and body composition as related to increased risk for MSK injury. The risk factors can be quantified in terms of slow 2-mile run times and body mass index ratings out of compliance with the Army Body Composition Program, Army Regulation 600-9, either too low or too high. But the primary MSK risk factor is slow run time, meaning males with a 2-mile run time greater than 15 minutes or females with a 2-mile run time greater than 18 minutes. “Low aerobic fitness is the most consistent risk factor that we found,” Jones said. “We also know that high and low body fat are risk factors, especially when coupled with low aerobic fitness,” but, he added, there are also other risk factors, including smoking, poor sleep, and

stress. “We’ve shown over the years that the more you smoke, the more you get injured, and those who are heavy smokers have risks that are one-and-ahalf to two times higher than soldiers who don’t smoke. We also know that individuals who sleep less than four hours a day have a 50 percent higher risk than those who sleep eight or more. And we can show that individuals who have higher-than-usual stress have a one-anda-half times higher risk than those who have less-than-usual stress.” Jones said that the AWCs addressed many of these risk factors because they relate to long-term health as well, “but now we have a focus on something that’s much more immediate and has a bigger impact on the Army – and that’s musculoskeletal injuries. “We realized in working together that many of the most important [MSK] risk factors that we have found, low aerobic fitness for instance, and high or low body composition, were things that the wellness centers were already looking at. So, it really became an ideal partnership to begin working together,” Jones said, “because in the wellness centers, we have a platform to build on and get the

PHOTO BY SPC. BRITTANY GARDNER

U.S. ARMY PHOTO BY GRAHAM SNODGRASS

Left: Megan Amadeo, Army Wellness Center project officer, Army Public Health Center, assists U.S. Army Capt. Zachary Schroeder, Headquarters and Headquarters Company commander, Army Public Health Center, with putting on the new K5 metabolic testing unit May 9, 2019, as part of his training to compete in the Army Ten Miler in October 2019. The K5 portable VO2 unit, which is available at certain Army Wellness Center locations, allows soldiers and athletes to measure how well their muscles use oxygen, and can be used to optimize performance and train for events. Below left: Lt. Col. Shawn J. Scott, 86th Combat Support Hospital supporting the 297th Area Support Medical Company, examines the knee of Spc. Eric S. Adams, 297th ASMC, on June 22, 2011, on Contingency Operating Base Basra. Musculoskeletal injuries are the most significant medical non-readiness factor in the U.S. Army and are commonly sustained from training and strenuous operational activities.

information out, especially to the highest risk populations.” Mitvalsky added, “When we started the wellness centers, we were focused on chronic disease and long-term health outcomes, and as the [MSK research] data has become more available, we can actually target those soldiers with those risk factors and get them into the wellness centers. And that’s our focus now. “We’re trying to make it really easy for commanders to know who to send to the wellness centers,” she said. “What the wellness centers provide to individual soldiers is a place that they can go for a personalized assessment that’s scientifically validated and get a personal prescription for how to improve multiple components of their health and their performance,” Jones explained. “Because not only will these things reduce injury risks, but also by improving your run times, you’re going to improve your military performance. And we know that performance on military obstacle courses,

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for instance, is better among soldiers who have higher aerobic fitness. So, there are multiple benefits to the individual soldier.” Luis Omar Rivera, PhD, Army Wellness Center lead program evaluator in the APHC Health Promotion and Wellness Directorate, explained how the AWCs work to reduce soldiers’ risk of MSK injuries. “We know from multiple years of Army injury prevention research that low aerobic fitness and poor body composition – having too high or too low body fat percentage – are very strong predictors of musculoskeletal injury,” he said. “The wellness centers are applying the knowledge that we have from that [research] to help soldiers prevent musculoskeletal injuries before they occur, and it really all starts with the Army Wellness Center health educators’ use of technology. The health education staff within the wellness centers use cutting-edge aerobic fitness testing and body composition technology to assess where soldiers currently

stand on those measures and to provide soldiers with feedback about where they stand. Staff then work with soldiers on an individual basis to help them make improvements to the underlying behaviors that we know contribute to low aerobic fitness and poor body composition.” Rivera continued, “This includes what the Army refers to as the performance triad of sleep, physical activity, and nutritional behaviors. These are three key behaviors that have a synergistic effect on soldier health and readiness outcomes, and the wellness center staff use health education and health coaching techniques to help soldiers create an improvement plan around these behaviors, to help them ultimately reduce their musculoskeletal injury risk.” Jones added, “And if you think about it, you can increase your aerobic fitness by training not only on the track, but also at the dinner table. So, they can get in one place both coaching on improving their physical activity and thereby their fitness, and also on nutrition as well. And not only can these high-risk soldiers go there, but if commanders are aware of soldiers who are concerned about sleep or smoking cessation or stress, they have a place that they can go to address their concerns on an individual basis. “I think a surprise to many is the fact that activity, body composition, sleep,

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tobacco, are all related to injuries, and how big an impact they have,” Jones continued, adding that it’s also important to realize that you don’t have to wait 30 or 40 years to experience the ill effects of smoking or being overweight. The AWCs continue to expand their capabilities with the new K5 technology, a research-grade assessment device currently being tested at many of the facilities. Rivera explained, “The wellness centers are in the process of taking their aerobic fitness assessment capabilities truly to the next level, partnering with university researchers to implement the latest in wearable metabolic testing technology to assess aerobic fitness in field-based settings. Currently, wellness centers are limited to assessing aerobic fitness in the facility, in the actual center itself. With this new wearable, portable technology, they’ll be able to do that in the field,” and, he added, better support readiness by delivering this fitness testing capability to soldiers in their training environments. Mitvalsky added, “We are cutting-edge right now and developing the protocols with the universities that we’re partnered with, so not only will the Army have this technology, but industry will have this technology as well.” “We should also be able to identify the components of what the AWCs do that are the most effective,” said Jones. In utilizing

the K5s in field assessments, “it may be that we don’t just look at running, but we could also look at activities like marching [to ascertain] who are the soldiers who are going to have difficulty carrying a 70-pound rucksack. So, there is great potential, not only from a health promotion perspective, but actually from a scientific perspective, knowing what works best.” For all the program and research components, a key aspect of the AWCs is that they are standardized and function with a centralized database, where every facility is executing the programs’ components in the same manner and on the same equipment. That’s essential, Jones said, “because if you don’t have standardization, you can’t move from installation to installation as soldiers do, and know whether you’re improving, and have the providers who are seeing you know whether you’re improving, as a basis for counseling. And the other factor that’s very critical is a centralized database.” Echoing that concept, Rivera said, “We really take an enterprise-level perspective to evaluation, where we are able to look at the soldier’s experience with the wellness centers regardless of where they are physically located. So, as they move from installation to installation, and they continue to come to the wellness center, we can continue to track that trajectory. The value of that is that we see a more comprehensive picture of how soldiers are changing over time.” Noting that the AWCs are based on a standardized, replicable model, and moreover, that “commanders love the wellness centers, and we are constantly getting requests to put up more,” Mitvalsky said one challenge, as with many things, is: “How do we resource those?” She added that it’s imperative to continue reinforcing to commanders that “if you send your soldiers to that wellness center, that is going to be a good use of their time.” Mitvalsky indicated that, as additional evidence of AWC acceptance, the Navy and the Air Force have inquired about developing wellness centers using the same model. “So, do we export across the DOD so that no matter whether a soldier, sailor, airman, Marine, they could get these services wherever they go? We’re starting to have [those] discussions,” she said. “I believe the key message is that the Army Wellness Centers are an investment in the health of our force, not only as a whole, but also at the individual soldier level,” Mitvalsky concluded. “Because it’s really at the individual level that we can provide specific information on their physiology to help them improve their performance. The foundation of all of that is the Army’s ability to deploy, to fight, and to win against any adversary, and that comes down to the individual soldier being able to do what they need to do when they need to do it. The components of the Army Wellness Center, the assessments that we do, are going to help them achieve that goal.”

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U.S. ARMY PHOTO BY SGT. HENRY VILLARAMA

A U.S. Army paratrooper assigned to the 173rd Airborne Brigade runs to the woodline after conducting an air assault mission during Exercise Saber Junction 2019 in Hohenfels Training Area, Germany, Sept. 26, 2019. Army Wellness Centers are using research combined with technology, health promotion, and wellness programs to minimize soldiers’ musculoskeletal injury risk and help them achieve warfighting readiness.

Veterans Affairs & Military Medicine Outlook, Spring 2020 Edition

Articles inside

University of Illinois at Urbana-Champaign Develops Interactive Mixed Reality Software for Sepsis Diagnosis

VA Nurses: Stories from the Front Lines of a Pandemic

Army Wellness Centers Focus on Reducing Musculoskeletal Injury Risk

West Point for Doctors: The Uniformed Services University of the Health Sciences

Military Health System Transformation

VA Research: Putting the "D" in R&D

Preparation, Response, Recovery: The VA's "Fourth Mission"

VA Research: The VA and Clinical Trials

The VA Aims to Enhance Specialty Care for Veterans

VALOR Program Benefits Nursing Students and the VA

Keeping Personnel and Patients Safe

Interview: Dr. Rachel Ramoni, Chief Research and Development Officer (CRADO), Veterans Health Administration

VA Research: Putting Data to Work for Veterans