VA Testimony of Robert H. Roswell, MD before Congress on March 25, 2003

United States Department of Veterans Affairs

STATEMENT OF
THE HONORABLE ROBERT H. ROSWELL, M.D.
UNDER SECRETARY FOR HEALTH
DEPARTMENT OF VETERANS AFFAIRS
BEFORE THE
COMMITTEE ON GOVERNMENT REFORM, SUBCOMMITTEE ON NATIONAL SECURITY,
EMERGING THREATS, AND INTERNATIONAL RELATIONS ON
"PROTECTING THE HEALTH OF DEPLOYED FORCES: LESSONS LEARNED FROM THE PERSIAN GULF WAR"

March 25, 2003

Mr. Chairman, I am pleased to be here to testify before the Subcommittee on "Protecting the Health of Deployed Forces: Lessons Learned from the Persian Gulf War." With me today is Dr. Craig Hyams, VA's Chief Consultant for Occupational and Environmental Health.

Since nearly 250,000 U.S. troops are engaged in renewed conflict in the Gulf region, I am grateful for the opportunity to emphasize that VA today is better prepared to provide high quality health care and disability assistance than at any other time in our history. Since Operations Desert Shield/Desert Storm in 1991, VA has developed and implemented the following policies and programs in response to the lessons learned from that conflict.

Health Care, Surveillance, Education, and Outreach

Health Care following Combat

It is critical to provide informed, knowledge-based health care after every war. Congress has shown an appreciation for the importance of providing health care for combat veterans. Under 38 U.S.C. § 1710(e)(1)(D), added by Public Law 105-368, VA is authorized to provide health care for a two-year period to veterans who serve on active duty in a theater of combat operations during a period of war after the Gulf War, or in combat against a hostile force during a period of hostilities after November 1, 1998. Under this provision, all veterans of conflicts now have a two-year period of access to VA health care for any illness, regardless of whether there is sufficient medical evidence to conclude that the illness is attributable to that service. An exception to this general rule occurs when VA has found that a particular condition is not due to the period of service in question. Veterans of the current conflict with Iraq will be eligible for health care under this provision of law. Although they may be deemed to be serving in the Southwest Asia Theater of Operations during the Gulf War era, our special authority to provide treatment to such veterans expired December 31, 2002 (38 U.S.C. 1710(e)(1)(C)).

In addition to providing needed health care, VA has the capability to collect and analyze information on the health status and health care utilization patterns of veterans. The capability to collect this basic health information helps us evaluate specific health questions, such as determining the causes of difficult-to-explain symptoms experienced by some veterans returning from certain combat theaters or areas of hostilities. VA's medical record system now permits patient health information to be tracked for special groups of veterans. Moreover, standard health care databases allow VA to evaluate the health care utilization of veterans every time they obtain care from VA, not just on the one occasion that they elect to have a registry examination, as was the practice in the past. This will provide a much broader and longer-term assessment of the health status of these veterans because many veterans return frequently for VA health care and are often seen in different clinics or even different parts of the country for specialized health care.

Ensuring High Quality Post-Deployment Health Care

Specialized health care during the post-deployment period can help prevent long-term health problems. Therefore, VA has developed evidence-based clinical approaches for treating veterans following deployment. Newly developed Clinical Practice Guidelines (CPG's), which are based on the best scientifically supported practices, give health care providers the needed structure, clinical tools, and educational resources that allow them to diagnose and manage patients with deployment-related health concerns. Two post-deployment CPG's have been developed in collaboration with DoD, a general purpose Post-Deployment CPG and a CPG for unexplained fatigue and pain. Our goal is that all veterans who come to VA will find their doctors to be well informed about specific deployments and related health hazards. Information on Clinical Practice Guidelines are available online at www.va.gov/environagents. This web site also contains information about unique deployment health risks and new treatments.

Assessment of Difficult-to-Diagnose Illnesses

We have learned that sustained clinical care and research is needed to understand post-deployment health problems. Congress also understood this need and in legislation enacted as Public Law 105-368 required establishment of a plan to develop national centers for the study of war-related illness and post-deployment health issues. Subsequently, in 2002, VA established two such centers, known as "War-Related Illness and Injury Study Centers" (WRIISC's), in East Orange, NJ, and Washington, DC, to provide specialized health care for veterans from all combat and peace-keeping missions who suffer difficult-to-diagnose but disabling illnesses. These centers are available through referral to veterans from all eras, including veterans of a future war with Iraq. These centers also provide research into better treatments and diagnoses, develop education programs for health care providers, and develop specialized health care programs to meet veterans' unique needs, such as the National Center for PTSD.

The majority of veterans returning from combat and peacekeeping missions are able to make the transition to civilian life with few problems. Most who come to VA for health care receive conventional diagnoses and treatments, and leave satisfied with their health care. Nevertheless, VA has learned that some veterans have greater problems on their return to civilian life, and a small percentage of them develop difficult-to-diagnose symptoms. The two WRIISC's focus on determining the causes and most effective treatments for difficult-to-diagnose symptoms, problems seen in veterans of all wars. More information on the WRIISC's can be found at the VA website, www.va.gov/environagents.

Veterans Health Initiative

VA has built upon the lessons learned from our experiences with Gulf War and Vietnam veterans' programs to implement an innovative new approach to health care for veterans. The Veterans Health Initiative ( VHI) is a comprehensive program designed to increase recognition of the connection between military service and certain health effects, to better document veterans' military and exposure histories, to improve patient care, and to establish a database for further study.

The education component of VHI prepares VA healthcare providers to better serve their patients. We have completed modules on spinal cord injury, cold injury, traumatic amputation, Agent Orange, the Gulf War, PTSD, blindness/visual impairment and hearing loss, and radiation. We are currently developing modules on infectious disease health risks in Southwest Asia, sexual trauma, traumatic brain injury, and military occupational lung disease. These important tools are integrated with other VA educational efforts to enable VA practitioners to more quickly and accurately arrive at a diagnosis and to provide more effective treatment.

Enhanced Outreach

Outreach is critical, and the Gulf War made clear the value of timely and reliable information about wartime health risks for veterans and their families, elected representatives, the media, and the nation at large. VA has already developed a brochure that addresses the main health concerns for military service in Afghanistan and is preparing another brochure for the current conflict in the Gulf region. These brochures answer health-related questions that veterans, their families, and health care providers have about these hazardous military deployments. They also describe relevant medical care programs that VA has developed in anticipation of the health needs of veterans returning from combat and peacekeeping missions abroad.

Another challenge for outreach is to address the specific concerns of veterans and their families over the potential health impact of environmental exposures during deployment. Veterans also have questions about their symptoms and illnesses following deployment. These concerns are addressed through newsletters and fact-sheets to veterans covering health and compensation issues, including environmental health issues; regular briefings of veterans service organizations; organization of national meetings on health and research issues; media interviews; other educational material and websites with information, like www.va.gov/environagents.

Recruit Assessment Program (RAP)

Based on the Department's experience providing health care and benefits to Gulf War veterans, VA recognizes the critical importance of health documentation and life-long medical records that cover pre-, during-, and post-deployment period. Previously, new health problems among Gulf War veterans were not readily verifiable due to a lack of detailed computerized records documenting enlistment and pre-deployment health status. Research efforts to understand Gulf War veterans' illnesses were also hampered by inadequate base-line health information, and inadequate documentation of health status during active duty.

DoD and VA have recognized these shortcomings and are attempting, through development and implementation of the Recruit Assessment Program ( RAP), to collect comprehensive baseline health data from all U.S. military recruits. The RAP is a DoD program, which is under development with the support of VA. The goal is for the RAP to be the first module of a life-long health record for military personnel and veterans. The RAP will help DoD and VA to evaluate health problems among service-members and veterans after they leave military service, to address post-deployment health questions, and to document changes in health status for disability determination.

It is important to note that during the last two years all U.S. Marine Corps recruits initially trained on the West Coast have completed a RAP questionnaire as part of a pilot RAP development program. Therefore, baseline health data is available for over 31,000 Marines, many of whom are currently serving in the Gulf region.

VA Vet Center Program

VA's Vet Centers, originally conceived to provide a wide variety of readjustment services to Vietnam veterans, have been invaluable in providing similar services to veterans from more recent combat and peacekeeping missions. More than 115,000 veterans of Operations Desert Shield/Desert Storm have made use of their services. We fully expect that the VA Vet Centers will be available to help both veterans of the current hostilities in Afghanistan and Iraq and veterans of future conflicts elsewhere in the world.

Disability Compensation

To assist in disability determinations, VA has actively worked with DoD to develop separation physical examinations that thoroughly document a veteran's health status at the time of separation from military service and that also meet the requirements of the physical examination needed by VA in connection with a veteran's claim for compensation benefits. VA has also worked to provide fair compensation for Gulf War veterans with difficult-to-diagnose illnesses. Under 38 U.S.C. § 1117 (as amended by Public Law 107-103), VA has authority to compensate Gulf War veterans for chronic disabilities resulting from an undiagnosed illness or certain medically unexplained chronic multisymptom illnesses. It is our belief that servicemembers serving in the Southwest Asia Theater of Operations during the current conflict with Iraq would, as veterans, also be eligible for compensation for disabilities resulting from undiagnosed illnesses.

Coordination with the Department of Defense

Enhanced Interagency Collaboration

One of the important lessons learned from addressing Gulf War health issues was the need to significantly increase intergovernmental coordination among VA, DoD, and Department of Health and Human Services ( HHS). The initial Government response to Gulf War veterans' concerns about their illnesses was not effectively coordinated among these Departments. As a consequence, the Persian Gulf Veterans Coordinating Board (PGVCB) was established in January 1994. This board, consisting of representatives from VA, DoD, and HHS, was created to coordinate Federal efforts in the areas of research, clinical care, and benefits. The initiation in 2000 of the tri-agency Military and Veterans Health Coordinating Board (MVHCB), replacing the PGVCB, served to institutionalize future interagency cooperation. In 2002, the MVHCB was disbanded and a special deployment-health working group of the VA-DoD Health Executive Council was established to further its work and ensure continued interagency coordination for all veteran and military deployment health issues. Governmental coordination will continue to play a critical role in addressing health problems among veterans in future conflicts and peacekeeping missions.

Increased collaboration has also extended beyond America's borders and strengthened coordination with Military and Veterans Affairs agencies in other countries. On post-war health issues, such as those arising after Operations Desert Shield/Desert Storm, VA scientists and policy makers collaborate and share lessons learned with their counterparts in Canada, the United Kingdom, and Australia. Because of the similarity of health problems among war veterans of different countries, these collaborations have focused on difficult-to explain-symptoms that consistently arise among military personnel returning from hazardous deployments.

Transmission of Health Data between DoD and VA

VA and DoD are closely collaborating to develop the ability to share medical information electronically. Recently, the VA/DoD Joint Executive Council and Health Executive Council approved the adoption of the Joint VA/DoD Electronic Health Records Plan. This Plan provides for the exchange of health data and development of a common health information infrastructure and architecture supported by common data, communications, security and software standards, and high performance health information systems. Since June 2002, the Departments have successfully been sharing electronic medical information. Key initiatives in the Electronic Health Records Plan are the Federal Health Information Exchange (FHIE) and HealthePeople (Federal).

FHIE (formerly known as the Government Computerized Patient Record) provides historical data on separated and retired military personnel from the DoD's Composite Health Care System (CHCS) to the FHIE Data Repository for use in VA clinical encounters, and potential future use for aggregate analysis. Patient data on laboratory results, radiology reports, outpatient pharmacy information, and patient demographics are now being sent from DoD to VA via secure messaging. This first phase of FHIE is fully deployed and operational at VA medical centers nationwide. The next phase is currently being deployed and includes admission discharge transfer data, discharge summaries, allergies, and consult tracking.

HealthePeople (Federal) is a strategy to achieve full interoperability among Federal health information systems, starting with the ability to provide a two-way exchange of health-related information between VA and DoD by 2005. VA and DoD are collaborating on several important health information applications in moving toward HealthePeople (Federal). Taken together, they will permit the Departments to offer a seamless electronic medical record.

Clinical Data Repository/Health Data Repository (CHDR): This project seeks to ensure the interoperability of the DoD Clinical Data Repository with the VA Health Data Repository by FY 2005.
Consolidated Mail-Out Pharmacy: The Departments are testing a system that allows VA to refill outpatient prescription medications from DoD's Military Treatment Facilities.
Lab Data Sharing and Interoperability: VA and DoD are testing an application that will allow both Departments to combine resources and provide laboratory services to one another.
Credentialing: A project team has identified common credentialing data to be exchanged between the DoD and VA. Software is being jointly developed and there are plans to begin testing at three sites by 4th Quarter FY 2003. This will decrease the time and resources needed to credential providers who need to practice in both health care systems.
Scheduling: VA and DoD are sharing technical requirements to ensure interoperability between scheduling applications of each Department. This will allow providers to see all appointments a patient might have scheduled at both VA and DoD facilities and, where authorized, to schedule appointments in each other's clinics.
E-portal Systems: The Departments are collaborating on a joint acquisition of health content for their electronic web portal systems. This will provide uniform patient health information to VA and DoD beneficiaries.

Deployment Health

VA applauds the efforts of DoD to prevent health problems among deployed troops and to provide immediate care for combat casualties. However, just as DoD has made substantial progress preventing morbidity and mortality on the battlefield, we also need to focus greater attention on the long-term health problems of veterans after the war. The trauma of warfare has lasting effects. The physical and psychological wounds of war can heal slowly, and toxic exposures on the battlefield may have enduring health consequences long after the actual war has ended.

The key to addressing the long-term needs of veterans is to improve medical record-keeping and environmental surveillance. To provide optimal health care and disability assistance after the current conflict with Iraq, VA needs the following:

a complete roster of veterans who served in designated combat zones; and
data from any pre-deployment, deployment, or post-deployment health evaluation and screening of deployed troops.

Furthermore, in the event Iraq uses weapons of mass destruction against U.S. troops, it will be vital for VA to have as much health and environmental information as possible on potential exposures and their health effects in order to provide appropriate health care and disability compensation for veterans of this conflict. Ideally, information would be available from representative environmental samples, biological samples obtained from exposed troops, clinical data from exposed troops who seek medical care, and data from an epidemiological survey of symptoms and illnesses among potentially exposed troops.

Summary

A veteran separating from military service and seeking health care today will have the benefit of VA's decade-long experience with Gulf War health issues. VA has successfully adapted many existing programs, improved outreach and education, and readjustment counseling services for Gulf War veterans. VA now has significance experience with the special provisions in law authorizing disability compensation for Gulf War veterans. In collaboration with other federal agencies, VA has additionally initiated new programs for developing and coordinating federal research on veterans' health questions. The Department of Veterans Affairs has learned many lessons since Operations Desert Shield/Desert Storm. The Federal government is committed to caring for deployed service members both during deployment and after they leave military service.

Mr. Chairman, this concludes my statement. Dr. Hyams and I will be happy to respond to any questions that you or other members of the subcommittee might have.