VA Testimony of Madhulika Agarwal, M.D., MPH and James Orcutt MD, PH.D. before Congress on March 17, 2009

United States Department of Veterans Affairs

STATEMENT OF
MADHULIKA AGARWAL, M.D., MPH
CHIEF OFFICER, PATIENT CARE SERVICES
AND JAMES ORCUTT, MD, PH. D.
CHIEF OF OPHTHALMOLOGY
OFFICE OF PATIENT CARE SERVICES
VETERANS HEALTH ADMINISTRATION
DEPARTMENT OF VETERANS AFFAIRS
BEFORE THE
HOUSE COMMITTEE ON VETERANS' AFFAIRS
SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

March 17, 2009

Good morning, Mr. Chairman and Members of the Subcommittee. Thank you for the opportunity to discuss the Department of Veterans Affairs’ (VA’s) collaborations and accomplishments with the Department of Defense (DoD) concerning the Vision Center of Excellence. We are accompanied today by Dr. Claude Cowan, Deputy Director of the Vision Center of Excellence.

VA has been working jointly with DoD to implement the components of the 2008 National Defense Authorization Act to: 1) establish a Vision Center of Excellence (VCE) in prevention, diagnosis, mitigation, treatment and rehabilitation of military eye injuries; 2) implement a Defense and Veterans Eye Injury Registry; and 3) coordinate care and benefits between DoD and VA. We appreciate Congress’ support in this, area and we are proud to say the broad concepts of a VCE and registry were already in development prior to the passage of this landmark piece of legislation.

DoD has been an important partner in developing the VCE, and is the lead agency in the implementation process. In the summer of 2008, the Office of the Assistant Secretary of Defense for Health Affairs accepted a joint VCE proposal from both VA and DoD. By August of the same year, applications were solicited for the VCE Director position. Shortly thereafter, a Deputy Director was named. Colonel Don Gagliano and Dr. Claude Cowan have accepted these respective responsibilities. With leadership from both DoD and VA, the Departments have institutionalized our commitment to cooperate, and is emblematic of the new culture of collaboration between the two agencies. This leadership team is currently recruiting additional staff members (including administrative staff, an optometrist and a blind rehabilitation specialist) to supplement and support the mission.

The primary goals of the VCE are to monitor patterns of care and the utilization of standard protocols (such as the traumatic brain injury, or TBI, specific eye exam) to ensure consistency of care, to identify gaps in care delivery, and to find areas where collaboration and coordination can be improved. This includes not only care for ocular injuries sustained during active duty and management of patients with visual symptoms related to TBI, but also the full continuum of care extending rehabilitation services for those with vision loss. VA blind rehabilitation services include 10 intensive inpatient Blind Rehabilitation Centers, 157 Visual Impairment Service Team Coordinators, who provide care management, 75 Blind Rehabilitation Outpatient Specialists, who serve in Veterans’ homes and communities, and 55 newly established low vision and blind rehabilitation outpatient clinics across the United States. Both Veterans and active duty personnel will be able to receive vision rehabilitation services at these sites.

Follow-on care and family re-integration training for Veterans are important issues to VA and these efforts undergo constant revision and expansion as needs dictate so that when Veterans leave our facilities, they and their family are better prepared for adjusting to life at home.

The VCE is not only focused on supporting facilities that provide treatment, diagnosis and the continuum of care, it will also work to identify servicemembers with visual injuries as early as possible. Since 2002, VA has assigned a Blind Rehabilitation Outpatient Specialist at Walter Reed Army Medical Center and Bethesda National Navel Medical Center to identify, coordinate and provide direct rehabilitative care for Veterans and active duty servicemembers. The VCE will also work to facilitate care coordination within and between VA and DoD for those with multiple injuries, including vision loss, and to ensure that appropriate eye assessments are provided. VA’s Polytrauma Centers continue to conduct comprehensive assessments of TBI-related vision function – this ensures a comprehensive approach to visual impairment identification, treatment and rehabilitation.

The VCE will review the existing literature for strong practices that will provide guidelines for management of patients with ocular injuries and visual symptoms related to TBI. Through review of existing literature and the assessment of the effectiveness of current DoD and VA treatment protocols, the VCE will identify and refine strong practices for the management of patients with ocular injuries or visual disability. In addition the VCE will facilitate the dissemination of these practices through the use of written guidance documents and combined conferences with VA and DoD.

Where the literature has not identified essential components of appropriate management, the VCE will work with both VA and DoD research programs to provide guidance and to support new research. The VCE will educate providers about new findings on eye trauma and the visual symptoms of TBI. VA and DoD organized a joint meeting in San Antonio in December 2007 on the visual consequences of TBI and are planning a second conference in December 2009 to educate providers in VA and DoD on the Visual Consequences of Traumatic Brain Injury. Research priorities were defined during a consensus validation project in December 2008. In addition, VA’s Office of Research and Development sponsored a State of the Art Conference on TBI in June 2008. This led to a request for applications for research in traumatic brain injury, including research specifically related to vision and hearing loss.

During the summer and fall of 2008, VA began developing the eye trauma registry. In VA and DoD discussions, participants began outlining the requirements for a Concept of Operations for the registry, which included participants from VA, DoD and the Joint Theater Trauma Registry. The Concept of Operations addresses the registry structure, the components required within the registry, and the system requirements to make the registry functional. VA and DoD have agreed to endorse using a central database with input from the Joint Theater Trauma Registry, VA’s electronic health record, and DoD’s electronic health record. Essential to this plan was the commitment that this registry would be accessible and updated by VA and DoD providers and end users. VA approved this concept in January 2009, and DoD’s approval is pending.

The Departments recognized the registry needed to include more than just Veterans and servicemembers with direct ocular damage from service in Operation Enduring Freedom or Operation Iraqi Freedom (OEF/OIF). We also needed to include Veterans and servicemembers who sustained TBI with resulting visual symptoms. The VCE will maintain the registry and will continue monitoring and improving it while ensuring care for injured Veterans and servicemembers.

VA’s Office of Information and Technology (OI&T) is providing critical support for the development of the registry and has assigned an implementation program director for this effort. Participants from VA, DoD and the Joint Theater Trauma Registry will meet in early April, 2009 to begin implementation of the registry.

VA is financially committed to the initiation of the registry project. VA’s OI&T provided funding for a consultant to develop the Concept of Operations; similarly, DoD extended support to their providers who helped develop the Concept of Operations. The 2009 VA budget included $2 million for the registry and $6.9 million for the VCE. The registry funding was provided to OI&T to support the implementation of the registry. The VCE’s funding supported hiring staff and fully administering the educational conferences noted above.

Thank you again for this opportunity to speak about VA’s role in supporting the VCE and the eye injury registry. These are exciting programs that hold great promise for providing the highest quality care our nation expects and our Veterans and servicemembers deserve. Our medical health care system is recognized as one of the best in the world, and we will continue to lead in all areas, including specialized care.