SUSAN MATHER, MD, MPH
CHIEF PUBLIC HEALTH AND ENVIRONMENTAL HAZARDS OFFICER
DEPARTMENT OF VETERANS AFFAIRS
BEFORE THE SUBCOMMITTEE ON
NATIONAL SECURITY, EMERGING THREATS, AND INTERNATIONAL RELATIONS
COMMITTEE ON GOVERNMENT REFORM
U.S. HOUSE OF REPRESENTATIVES
HEARING ON "OCCUPATIONAL AND ENVIRONMENTAL SURVEILLANCE OF DEPLOYED FORCES: TRACKING TOXIC CASUALTIES"
July 19, 2005
Mr. Chairman and members of the Committee, I appreciate the opportunity to appear before you today to describe some of the major initiatives of the Department of Veterans Affairs (VA) in response to the health care and other needs of veterans returning from Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF).
VA’s goal is to ensure that every service man and woman returning from combat has access to world-class services, and in every way possible, to hold open the doors to an uncomplicated passage from soldier to citizen.
Achieving this transition goal is dependent in part upon the seamless transition of a wide range of basic data about these new veterans from the Department of Defense (DoD) to VA. Access to this information helps VA provide services to veterans in many different ways, which I will describe today.
To begin with, I am pleased to be able to tell you today that VA and DoD together are finding better ways to move these data more efficiently between our two Departments. This includes electronic sharing of medical information that can be critical for health care and timely processing of benefits claims, and for evaluating potential environmental and occupational health issues among troops stationed in areas where environmental hazards may pose a threat.
As we have testified at previous hearings, VA and DoD are continuing our partnership to meet the needs of our newest veterans – the men and women who served in OIF and OEF – and to assist them with a smooth transition from active duty to civilian life. In this regard, VA has successfully developed, with DoD’s assistance, a roster of the men and women who have returned from serving in OIF and OEF and then separated from military service.
Our most recently updated roster of May 17, 2005, contains 360,674 OIF and OEF veterans who have left active duty many who have already sought VA health care services. We anticipate serving about 103,000 of these veterans for health care and related services in FY 2005. This roster has proven to be invaluable for tracking these newest veterans and their use of VA services, and for providing outreach about the range of benefits they have earned.
VA’s OIF/OEF veteran roster is also invaluable for ensuring that these newest veterans have full access to VA’s world-class services. In addition to health care, VA offers a spectrum of programs for veterans and their survivors, including disability compensation, dependency and indemnity compensation, vocational rehabilitation, life insurance, pension, education benefits, specially adapted housing and automobile grants, and burial benefits.
In this regard, we are providing each VA VISN with the names of those OIF and OEF veterans in the geographic areas served by that VISN. This means that local VA staff can now easily identify service members from Iraq or Afghanistan for the purpose of local outreach efforts. In addition, Iraqi Freedom and Enduring Freedom coordinators at each VA benefits office and medical center coordinate with DoD discharge staff to ensure a smooth transition to VA services at locations nearest to the veteran’s residence after discharge, based in part on these data. Through this coordination, veterans are recognized at their local VA facilities that process their benefits claims, and continuity of their medical care, including medications and therapy, is ensured.
VA has also been working closely with DoD to identify those OIF and OEF veterans who have been seriously injured or who suffer from deployment related illnesses to ensure their seamless transition into VA. I am very pleased to be able to tell you today that VA and DoD have just signed an MOA that will serve as the basis for giving VA access to DoD’s listings of seriously injured service members, known as the Physical Evaluation Board (PEB) database. Access to these data will help ensure that any veteran who was seriously wounded or injured or has become ill while in defense of our country will have seamless access to the timely and highest-quality services they need and deserve, regardless of where they are in the transition process.
Environmental and Occupational Health Data
In your invitation to testify today, you asked about how occupational and environmental health surveillance data collected by DoD will be used to address health issues of returning service members. We know from previous experience how important it is to have credible answers to questions from veterans, their families and others about possible health problems from exposure to potential environmental and occupational hazards during military deployments. Therefore, we have been pleased to hear from DoD about their activities monitoring occupational and environmental exposures in the current conflicts in Iraq and Afghanistan, and their willingness to share this data with VA in the future.
In two briefings from DoD’s Deployment Health Support Directorate to the DoD/VA Deployment Health Working Group (a working group of the DoD/VA Health Executive Council), DoD has described an active environmental surveillance program. This program is collecting routine data on air, water and soil samples, as well as data for specific incidents of concern, such as a sulfur mine fire that occurred recently at Al Mishraq, Iraq, which exposed troops to sulfur dioxide and hydrogen sulfide.
VA anticipates using this environmental data in several ways after it is provided by DoD, including evaluating whether there is a scientific basis for service connecting certain conditions based on exposure to environmental and occupational hazards, diagnosing health problems among veterans, and conducting research on long-term health effects among service members.
These data will be most important for deciding disability compensation claims and for long-term health research. It will be useful, but less important, for diagnosing and treating health problems. For example, for an OIF veteran suffering from asthma, diagnosis and treatment would not depend very much on whether he or she was exposed to sulfur dioxide from the sulfur fire at Al Mishraq – treatment would be the same regardless of the cause. On the other hand, if that veteran wanted to file a disability claim based on a exposure to hazardous materials, then information about his/her exposure could be essential to support the claim, provided that there is also sound scientific and medical evidence of an association between the exposure and the disability. Similarly, if a researcher wanted to determine whether asthma rates were greater among all service members exposed to sulfur dioxide at Al Mishraq, access to these environmental data would be essential.
It is our understanding that DoD is currently collecting these data, but that they will need time to assemble all of the large number of individual data points they have collected into an electronic database that can be readily searched by time, geographic location, or service member’s identity. Compiling all of this separate data into a useable electronic format is essential to making this information to be useful for VA.
I would emphasize that access to what must be enormous amounts of raw, uncorrelated environmental surveillance data, without being able to track it by individual, location or other means, would not be very useful to VA or for veterans.
DoD has assured us that they are taking the steps needed to assemble these raw data into a useful database, and that they will make that database available to VA to help us provide services to veterans. We look forward to achieving that goal and applaud DoD’s efforts.
VA recognizes the importance of outreach to veterans about deployment-related environmental and occupational health issues. To this end, VA has produced a brochure that addresses the primary health concerns for service members in Afghanistan, a similar brochure for those serving in Iraq, and a third brochure on health care for women veterans returning from the Gulf region. These are available at www.va.gov/EnvironAgents.
These brochures answer health and environmental hazards-related questions that veterans, their families, and their health care providers may have about these military deployments. They also briefly describe relevant medical care programs that VA has developed in anticipation of the health needs of veterans returning from combat and peacekeeping missions abroad. These are widely distributed to VA medical centers, military contacts, veterans service representatives and through VA’s websites including www.va.gov/EnvironAgents.
Seamless Transition Activities
In January of this year, VA established the Seamless Transition Office to ensure the smooth transition of service members from DoD to VA. The new office is composed of representatives from the Veterans Health Administration (VHA), Veterans Benefits Administration (VBA), and National Cemetery Administration (NCA), as well as two active duty Marine Corps officers. They are charged with identifying OIF and OEF veterans, ensuring their priority access for VA health care, developing processes that will ease the transition from the military to VA care and benefits, coordinating case management for patients with significant health care and benefit needs, educating VA staff on transition procedures and the tools available to assist staff and clinicians, and improving our outreach to returning service members.
Points of Contact
Although VA’s OIF/OEF veteran roster is an excellent tool for tracking most veterans, it has been less effective for tracking seriously injured service members as they return from the combat theater and transition to the VA system. To meet that need in part, VA has collaborated with DoD to ensure seamless and timely transition for the most seriously injured service members. To that end, VA has detailed two full-time VBA Veterans Service Representatives (VSRs), a contract vocational rehabilitation counselor, and two full-time VHA social workers to the Walter Reed Army Medical Center, which is one of the military treatment facilities (MTFs) receiving the largest numbers of OIF and OEF casualties. VHA social workers and VBA Veterans benefits counselors have also been assigned as VA/DoD liaisons to the Brooke, Eisenhower, and MadiganArmyMedicalCenters, DarnallArmyCommunityHospitalat FortHood, the NationalNavalMedicalCenterin Bethesda, and CampPendletonNavalHospitalin San Diego.
These individuals work closely with military medical providers and DoD social workers to assure that returning service members receive information and counseling about VA benefits and programs, as well as assistance in filing benefit claims. They also coordinate the transfer of active duty service members and recently discharged veterans to appropriate VA health care facilities. Through this collaboration, we have improved our ability to identify and serve returning service members who sustained serious injuries or illnesses while serving our country.
VA recognizes that making available world-class services to veterans is only the first step – we must also do everything we can to get the word out to veterans and their families about the services they have earned. In this regard, as VA identifies new OIF and OEF veterans who have separated from the military based on names and addresses provided by DoD, the Secretary of Veterans Affairs mails new veterans a letter welcoming them home, thanking them for their service to their country, and briefly explaining the VA programs that are available to them.
Outreach to returning members of the Reserves and National Guard is a special concern for VA, and we have significantly expanded our collaboration with DoD to enhance outreach to this group. For example, during FY 2003, the Veterans Benefits Administration (VBA) conducted over 800 briefings attended by almost 47,000 reserve and guard members. During FY 2004, VBA conducted over 1,300 briefings attended by more than 88,000 reserve and guard members. In FY 2005 through May, VBA has conducted almost 1,000 briefings attended by over 68,000 reserve and guard members. In addition, working with DoD, we developed a new brochure, “A Summary of VA Benefits for National Guard and Reserve Personnel.” The brochure summarizes the benefits available to this group of veterans upon their return to civilian life. We have distributed over a million copies of the brochure to ensure the widest possible dissemination through VA and DoD channels. It is also available online at www.va.gov/EnvironAgents/docs/SVABENEFITS.pdf.
Benefits Delivery at Discharge (BDD)
VA also actively participates in discharge planning and orientation sessions for returning service members. Outreach activities include the distribution of flyers, posters, and information brochures to VA medical centers, regional offices, and Vet Centers. These various publications help to explain VA services available to separating veterans.
Current joint VA-DoD initiatives involves helping separated service members file for and receive service-connected disability compensation benefits more quickly than in the past. Our goal is to adjudicate claims within 30 days of separation by conducting cooperative separation physical examinations with DoD as part of the separation process. By comparison, VA's national average processing time is 163 days for claims requiring a disability rating. In the Benefits Delivery at Discharge program, the medical information needed to begin the VA claims process is seamlessly transferred from DoD to VA. In addition, if a service member is found to be disabled, additional applicable vocational and employment services may be quickly initiated.
VA is sensitive to the increased familiarity with the internet among younger veterans. Today, we are making a wide selection of basic information available over the internet to OIF and OEF veterans and their families. For example, our new “Iraqi Freedom” link from VA’s Internet page provides information on VA benefits, including physical and mental health services, DoD benefits, and community resources available to regular active duty service members, activated members of the Reserves and National Guard, veterans, and veterans’ family members.
Here is a listing of VA brochures and other information for veterans of Operation Iraqi Freedom and Operation Enduring Freedom that are now available on the Web.
Veterans Benefits Information
Information for Iraqi Freedom Veterans
PTSD and IraqVeterans
VA Health Care Enrollment Information
Brochures and Publications, Including:
Online Benefits Applications
Women Veterans Health and Benefits Information
Training and Education
To ensure that a thorough understanding and appreciation for the needs of these newest combat veterans is shared across every level of the Department, VA has developed a number of training materials and other tools for front line staff.
For example, VA’s Veterans Health Initiative (VHI) is a program designed to increase recognition of the relationship between military service and certain health effects; better document veterans' military and exposure histories; improve patient care; and, establish a database for further study. The education component of VHI prepares VA health care providers to better serve their veteran-patients. One new independent study guide module created under this program called “Treating War Wounded,” was adapted from an April 2003 VHA satellite broadcasts designed to help VA clinicians manage the clinical needs of returning wounded from the war in Iraq.
Additional training modules and independent study guides for health care providers have been prepared on spinal cord injury, cold injury, traumatic amputation, Gulf War veterans’ illnesses, Post Traumatic Stress Disorder (PTSD), prisoners of war (POW), blindness/visual impairment and hearing loss, and exposure to radiation are also available. Training modules on infectious disease risks in Southwest Asia and on health effects from Weapons of Mass Destruction were released in January 2004. The most recent modules developed under this program cover military sexual trauma, traumatic brain injury, blast injuries, and pulmonary diseases of military occupational significance. All are available online at www.va.gov/VHI.
In addition to the VHA training modules on PTSD, VA’s National Center for PTSD has developed the Iraq War Clinician’s Guide for use across VA. The website version, which can be found at www.ncptsd.org, contains the latest fact sheets and available medical literature and is updated regularly. The first version of the Iraq War Guide was published in June 2003. It is now being revised in collaboration with DoD based on our experience with returning casualties. These important tools are integrated with other VA educational efforts to enable VA practitioners to arrive at a diagnosis more quickly and accurately and to provide more effective treatment.
For returning service members who are experiencing emotional and behavioral problems, VA has programs specifically developed to assess and address emotional and behavioral problems associated with the military experience. The training programs cited above will ensure that our skilled clinicians will be better able to identify and treat problems presented by the newest generation of combat veterans. The VHI module on PTSD in Primary Care mentioned above is designed to increase recognition of PTSD in medical primary care settings. Within these mental health programs, VA operates a comprehensive continuum of clinical care for PTSD in its medical centers and clinics. This is accomplished both through special PTSD programs and through PTSD specialists in general mental health programs.
VA’s 207 Vet Centers also play an important role complementing VA health care services. Our mental health clinical activities are linked to and supportive of Vet Center activities. Vet Center staff members actively pursue outreach to military installations and family support centers to assist veterans and their eligible family members in the veterans’ return to civilian life. Last year, Vet Centers began extending readjustment counseling services to all OEF and OIF veterans. To date, VA’s Vet centers have served 18,000 of these new veterans.
New Clinical Tools
Earlier I discussed the Veterans Health Initiative (VHI) as a program designed to increase recognition of the relationship between military service and certain health effects. VA has also developed additional tools to assist the clinician when treating OIF and OEF veterans.
A screening instrument, in the form of a clinical reminder, is being implemented for returning OIF and OEF veterans who come to VA for health care. This assessment tool will prompt the provider with specific screening requirements to assure that veterans are evaluated for medical and psychological conditions that may be related to recent combat deployment.
VA has also developed evidence-based clinical approaches for treating veterans following deployment. These clinical practice guidelines (CPGs) 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 CPGs 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 will find their VA doctors well-informed about specific deployments and related health hazards. The VA website contains these CPGs as well as information about unique deployment health risks and new treatments.
VA and DoD recently released a new CPG on the management of traumatic stress. This guideline pools DoD and VA expertise to help build a joint assessment and treatment infrastructure between the two systems in order to coordinate primary and mental health care for the purpose of managing, and, if possible, preventing acute and chronic PTSD.
DoD-VA Data Sharing Improves VA Services to Veterans
VA and DoD have made significant progress toward interoperability of health information that will improve service to veterans and support occupational and environmental health surveillance. Since Memorial Day 2002, the VA clinicians have had access to military health data through the Federal Health Information Exchange (FHIE). FHIE presently supports the one-way transfer of electronic military health data (Note: This data is limited and does not amount to an electronic version of the service member’s complete health treatment record) on separated service members to the VA Computerized Patient Record System (CPRS) for viewing by VA clinicians treating veterans. Since FHIE implementation, DoD has transferred records for over 3.07 million unique DoD patients to the jointly operated FHIE repository. Over 8,000 new DoD separatee records are added monthly.
These historical health data are currently used for clinical care and are being examined for use in aggregate analysis. Data being shared, through one-way transmission from DoD to VA, include laboratory and radiology results; outpatient pharmacy data from military treatment facilities, retail network pharmacies, and DoD mail order pharmacy; allergy information; discharge summaries; admission, disposition, and transfer information; consult reports; standard ambulatory data record; and patient demographic information.
VA also has worked closely with DoD to implement Cycle I and Cycle II of the real-time Bi-directional Health Information Exchange (BHIE) at two locations: between the Madigan Army Medical Center (Tacoma, WA) and VA Puget Sound Healthcare System and the William Beaumont Army Medical Center (El Paso, TX) and VA El Paso Health Care System. Cycle I of BHIE permits DoD military treatment facilities and VA facilities to share patient demographic data, DoD and VA outpatient pharmacy data, and allergy information when a shared patient presents for care. BHIE Cycle II functionality supports the sharing of additional elements of data including laboratory results, lab order data, and radiology report data.
VA and DoD are now developing the Clinical Data Repository/Health Data Repository (CHDR) which will support the real-time bi-directional exchange of computable data between the DoD Clinical Data Repository (CDR) and the VA Health Data Repository (HDR), known as Clinical Data Repository/Health Data Repository (CHDR). In September 2004, VA and DoD successfully demonstrated a CHDR pharmacy prototype in a lab environment that supported the capability to conduct drug/drug and drug/allergy interaction checking across VA and DoD systems. The departments are actively developing CHDR for production and anticipate completing the interface by October 2005.
VA is also working with DoD to develop functionality to support the transfer of pre- and post-deployment health assessment data to VA physicians and claims examiners.
I have briefly described how DoD’s data on new OIF and OEF veterans helps VA provide better services to veterans in many different ways. The roster of separated OIF and OEF veterans is useful for patient tracking, outreach and future research. We clearly look forward to receiving a complete roster of all deployed personnel (both separated and those remaining on active duty) and environmental and occupational surveillance data that DoD is collecting today in Iraq and Afghanistan as soon as it is available in a usable electronic format.
Finally, I want to emphasize that a service member separating from military service and seeking health care through VA today will have the benefit of VA’s decade-long experience with Gulf War health issues as well as the President’s commitment to improving collaboration between VA and DoD. VA has successfully adapted many existing programs, improved outreach, improved clinical care through practice guidelines and educational efforts, and improved VA health provider’s access to DoD health records.
This concludes my statement. My colleague and I will be happy to respond to any questions that you or other members of the Subcommittee might have.