STATEMENT OF
REAR ADMIRAL PATRICK W. DUNNE, USN (RET)
ACTING UNDER SECRETARY FOR BENEFITS
AND ASSISTANT SECRETARY FOR POLICY AND PLANNING
U.S. DEPARTMENT OF VETERANS AFFAIRS
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES

June 11, 2008

Good morning Chairman Filner, Ranking Member Buyer, and Members of the Committee. Thank you for inviting me here to update the Committee on the Department of Veterans Affairs' (VA) progress in implementing the wounded warrior provisions in the National Defense Authorization Act of Fiscal Year 2008. I also would like to thank the Committee for its work in passing this important legislation, and I am pleased to report VA and the Department of Defense (DoD) are making demonstrable progress in implementing the provisions of the Wounded Warrior Act, title XVI of Public Law 110-181, which addresses those matters that require VA and DoD cooperation to improve the care, management and transition of recovering service members. I will describe VA and joint VA/DoD efforts with respect to eight specific sections of the law in which this Committee has particular interest. I am accompanied today by Dr. Madhulika Agarwal, Chief Patient Care Services Officer for the Veterans Health Administration (VHA), and Dr. Paul Tibbits, Deputy Chief Information Officer, Office of Enterprise Development.

Section 1611. Comprehensive policy on improvement to care, management, and transition of recovering service members
Section 1611 requires VA and DoD to:

• Jointly develop and implement a comprehensive policy on improvements to the care, management, and transition of recovering service members.
• Jointly and separately conduct a review of all policies and procedures of VA and DoD that apply to, or shall be covered by, the comprehensive policy described above.

As part of our comprehensive policy, VA is working on two handbooks: one for our Federal Recovery Coordinators, and another for Transition Assistance and Case Management of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) Veterans.

VA, in collaboration with DoD, is developing a Federal Recovery Coordinator (FRC) handbook, which will significantly improve care for veterans and service members. The FRC Handbook describes primary approaches and available resources to Federal Recovery Coordinators (FRCs) and other care managers. This handbook will guide the FRCs in the delivery of all needed programs and services to recovering service members and veterans. In an effort to comply with Section 1611 and to maintain the handbook's value, VHA's Care Management and Social Work Service will be responsible for the final review of the FRC Handbook. The target date for completion of this handbook is summer 2008.

VA completed a separate handbook on the Transition Assistance and Case Management of OEF/OIF Veterans on May 31, 2007. VA will continue to review and update the Handbook as necessary.

Another effort currently underway is a charter group comprised of specialty care managers across VA including OEF/OIF teams, spinal cord, blind rehabilitation, mental health, polytrauma and others. This group will be making recommendations for a system wide approach to care management with emphasis on the coordination between programs. This charter group is expected to submit its report to VA leadership in July 2008. In addition, this charter group will assist in the development of VHA policy for care management.

Section 1612. Medical evaluations and physical disability evaluations of recovering service members
Section 1612 requires:

• The Secretary of Defense shall, no later than July 1, 2008, develop a policy on improvements to the processes, procedures, and standards for the conduct by the military departments of medical evaluations of recovering service members.
• The Secretary of Defense and the Secretary of Veterans Affairs shall, no later than July 1, 2008, develop a policy on improvements to the processes, procedures, and standards for the conduct of physical disability evaluations of recovering service members by the military departments and by the Department of Veterans Affairs.
• The Secretary of Defense and the Secretary of Veterans Affairs shall jointly submit to the appropriate committees of Congress a report on the feasibility and advisability of consolidating the disability evaluation systems of the military departments and the disability evaluation system of the Department of Veterans Affairs into a single disability evaluation system.

Section 1614. Transition of recovering service members from care and treatment through the Department of Defense for the care, treatment, and rehabilitation through VA
Section 1614 requires VA and DoD to jointly develop and implement processes, procedures, and standards for the transition of recovering service members from DoD to VA.

On August 31, 2007, the Deputy Secretaries of Defense and Veterans Affairs signed a Memorandum of Understanding establishing the Federal Recovery Coordination Program (FRCP) as a joint VA/DoD Program. This program was implemented in January 2008. VA and DoD continue to jointly review and develop this program through recurring meetings and initiatives.

On January 7, 2008, the newly identified FRCs completed a comprehensive VA and DoD training program, which included specialized training on the newly developed Federal Individualized Recovery Plan (FIRP). FRCs are already developing FIRPs for severely injured service members and veterans. As of June 1, 2008, this program has enrolled and is currently serving 80 service members and veterans. Presently, an ongoing, iterative approach to enhance the FIRP is underway to ensure those needs identified by recovering service members and veterans are included as the program matures. Over time, the FRCP will take increasing advantage of onsite mentoring and online delivery of training resources to ensure our Coordinators are employing best practices and are responsive to the needs of America's brave wounded warriors.

Sections 1618, 1621, and 1622 of the 2008 National Defense Authorization Act (NDAA) assign DoD primary responsibility for establishing Traumatic Brain Injury (TBI) and Post Traumatic Stress Disorder (PTSD) Centers of Excellence and for establishing a comprehensive plan to deal with TBI and mental health conditions. VA is collaborating with DoD to support these efforts.

Section 1618. Comprehensive plan on prevention, diagnosis, mitigation, treatment, and rehabilitation of, and research on, traumatic brain injury, post-traumatic stress disorder, and other mental health conditions in members of the Armed Forces
Section 1618 requires joint planning between VA, DoD, and the military departments regarding the prevention, diagnosis, mitigation, treatment, research, and rehabilitation of TBI, PTSD, and other mental health conditions in members of the Armed Forces. This planning will cover the continuum of care from DoD to VA for those in need of this care. Section 1618 also specifically requires the Secretary of Defense, with VA consultation, to provide to the Congressional defense committees a comprehensive plan for DoD programs and activities to prevent, diagnose, mitigate, treat, research, and otherwise respond to TBI, PTSD, and other mental health conditions in members of the Armed Forces. This plan should assess current DoD capabilities, identify gaps in current capabilities, and identify the resources required to address those gaps.

Section 1621. Center of excellence in the prevention, diagnosis, mitigation, treatment, and rehabilitation of traumatic brain injury
Section 1621 requires the Secretary of Defense to establish, within the Department of Defense, a center of excellence in the prevention, diagnosis, mitigation, treatment, and rehabilitation of traumatic brain injury, including mild, moderate and severe TBI. The Secretary of Defense is to maximize collaborative efforts with various private and public entities, including VA, to carry out the responsibilities enumerated in Section 1621.

Section 1622. Center of excellence in prevention, diagnosis, mitigation, treatment, and rehabilitation of post traumatic stress disorder and other mental health conditions
Section 1622 requires the Secretary of Defense to establish, within the Department of Defense, a center of excellence in the prevention, diagnosis, mitigation, treatment, and rehabilitation of post traumatic stress disorder, including mild, moderate and severe PTSD. The Secretary of Defense is to maximize collaborative efforts with various private and public entities, including VA, to carry out the responsibilities enumerated in Section 1622.

VA and DoD Collaborations on TBI and PTSD
In response to sections, 1618, 1621 and 1622, VA provides expertise and experience to the DoD Center of Excellence for TBI and Psychological Health. VA's contribution will include providing a Deputy and two subject matter experts, one in TBI and one in PTSD. VA's Acting Deputy Director for the Center of Excellence is already in place.

VA and DoD continue to collaborate on a number of projects related to mental health and TBI. Some examples include:

• VA and DoD are developing revisions to medical coding for TBI for submission to the International Classification of Diseases revision 9. These will be submitted in September 2008 and should become effective October 1, 2009.
• VA and DoD are developing clinical practice guidelines for TBI for use by both Departments, to be completed by September 2008.
• VA assigned Polytrauma Rehabilitation Nurse Liaisons at Walter Reed Army Medical Center and the National Naval Medical Center at Bethesda.
• VA establishing a five-year Assisted Living Pilot project for veterans with TBI for implementation between April 2008 and June 2013.
• Since 2004, VA and DoD have operated a Mental Health Work Group to improve collaboration and clinical coordination between the two Departments. This Group identifies issues and develops policies for improving care for veterans with mental disorders, including support for disseminating evidence-based Cognitive Processing Therapy and Prolonged Exposure Therapy for PTSD and collaborating on PTSD research.
• VA, DoD, and the National Institute of Mental Health began meeting in January 2008 to improve research methodology regarding effective treatments for PTSD. On January 22 and 23, 2008, VA, DoD, and the Department of Health and Human Services convened a group of scientific experts and research administrators to develop methodological guidance for conducting treatment studies for patients with PTSD. This is particularly significant because this will allow our researchers to have identified objectives and measures for any study on PTSD, which will enable them to make comparisons between studies, meaningfully analyze results, and advance our understanding of the field. This group will publish and distribute a report this summer. VA is aggressively pursuing numerous activities to improve treatment for PTSD, including:
  • Interagency coordination with the National Institute of Mental Health, National Institute of Drug Abuse, National Institute on Alcohol Abuse and Alcoholism, and DoD, including the Congressionally Directed Medical Research Program, Defense Centers of Excellence, and the Office of the Assistant Secretary of Defense for Health.
  • Ensuring research priorities are identified and addressed by working with the federal research funding agencies.
• Recently, a joint VA/National Institutes of Health solicitation for proposals was issued entitled, "Network(s) for Developing PTSD Risk Assessment Tools." Discussions continue about other ways to collaborate to answer important treatment questions. Proposals are due August 2008, and the review will be complete in Fiscal Year 2009. VA and the National Institutes of Health may each fund up to three projects.
• VA is disseminating evidence-based psychotherapies for PTSD, including Cognitive Processing Therapy and Prolonged Exposure Therapy, throughout the VA system and to DoD clinicians. As of May 28, 2008, 1,168 VA Mental Health providers have been trained in Cognitive Processing Therapy: 839 of these were trained as part of the national rollout, while the others were trained through locally arranged and funded training. In addition, 607 DoD clinicians separately participated in a two-day training seminar on Cognitive Processing Therapy similar in format to VA's training.
• VA continues to work with identified DoD PTSD experts in an effort to continually improve clinical care and enhance research programs on PTSD. VA will fully collaborate with DoD's Center of Excellence for TBI and Psychological Health on research and educational programs including, but not limited to, projects involving VA's National Center for PTSD.

Section 1623. Center of Excellence in Prevention, Diagnosis, Mitigation, Treatment, and Rehabilitation of Military Eye Injuries
Section 1623 directs DoD to establish a Center of Excellence in the prevention, diagnosis, treatment, and rehabilitation of eye injuries, and requires VA to collaborate to the maximum extent practicable with the activities of the Center. It further requires a comprehensive plan and strategy for a registry and establishes several conditions the registry must achieve. Finally, Section 1623 requires VA and DoD to jointly provide for a cooperative program on traumatic brain injury post traumatic visual syndrome, including vision screening, diagnosis, rehabilitative management, and vision research, including research on prevention and visual dysfunction related to traumatic brain injury.

VA and DoD began working together to address eye injuries before the passage of the NDAA. In November 2007, VA's Director of Ophthalmology began meeting with DoD ophthalmologists and optometrists to discuss approaches for improving care and coordination. In December 2007, VA and DoD participated in a conference on the visual consequences of TBI, which was well attended by representatives from VA Polytrauma Rehabilitation Centers and blind rehabilitation specialists, as well as optometrists and ophthalmologists from both Departments. This conference provided an opportunity to initiate a consensus validation process, which will identify and disseminate the most effective strategies for treatment and services when they are known and to determine where additional research is needed. VA has also assembled teams of specialists, to develop questions for determining evidence-based treatments; we anticipate this process will be complete in the summer.

In February 2008, VA's Directors of Ophthalmology and Optometry met with their DoD counterparts to begin preparing a presentation on the concept of the Center of Excellence; VA and DoD appreciate the importance of the Center and have even agreed to call it a joint Center of Excellence. The following month, VA and DoD began developing an interoperative plan that will help establish the registry and allow a bidrectional flow of information. Throughout the month of April, VA and DoD continued discussing both the Center of Excellence and the registry. In May, VA and DoD workgroup members began reviewing draft documents on Systems Requirements and Concept of Operations for a Military Eye/Vision Injury Registry.

From April 30 to May 2, 2008, VA's Office of Research and Development held a State of the Art meeting in Arlington, Virginia examining the latest advances and research on diagnosis and management of traumatic brain injury and put forth an agenda for research to explore currently unanswered questions. One session of this meeting was devoted to sensory changes (i.e., hearing and vision) and the results of this meeting will soon be published to guide future research.

Any OEF/OIF veteran seen at a VA medical facility is automatically screened for TBI. Veterans for whom the screen is positive are referred for a full, in-depth evaluation. The evaluation process includes a standardized evaluation template of common problems following brain injury. This template includes checks for visual impairment. Our visual treatment specialists conduct full visual examinations including, but not limited to, acuity, full visual field testing, pressures within the eye, and imaging of both the retina and the cornea to assess damage to these structures. In all, this screening process includes a 22-item checklist, including an evaluation for visual impairment and presence of visual symptoms. VHA is currently drafting policy to initiate eye examinations for active duty service members and veterans who are currently receiving care or who previously received care at a VA Polytrauma Rehabilitation Center.

For veterans and active duty personnel with visual impairment, VA provides comprehensive Vision Rehabilitation services. Currently, 164 Visual Impairment Service Team (VIST) Coordinators provide lifetime case management for all legally blind veterans, and all OEF/OIF patients with visual impairments. Additionally, 38 Blind Rehabilitation Outpatient Specialists (BROS) provide blind rehabilitation training to patients who are unable to travel to a blind center. These Polytrauma Blind Rehabilitation Specialists have certification in two areas, low vision rehabilitation and orientation and mobility training. They work in close collaboration with our neuro-ophthalmologists and low vision optometrists who evaluate, diagnose, and recommend treatment for our patients with visual impairments. Each Polytrauma Rehabilitation Center and Polytrauma Network Site has dedicated funding for a BROS on the Polytrauma team.

Blind Rehabilitation Service involvement often begins while the injured service member is still a patient at a military treatment facility. The patient is transferred to a VA Blind Rehabilitation Center as soon as it is medically needed and at the patient's request. There is no waiting time for OEF/OIF veterans for this service.

Section 1635. Fully interoperable electronic personal health information for the Department of Defense and Department of Veterans Affairs
Section 1635 requires VA and DoD to jointly develop and implement electronic health record capabilities that allow for full interoperability of personal health care information by September 2009. Section 1635 also requires development of a VA/DoD Inter-Agency Program Office to act as a single point of accountability. This office will oversee the rapid development of capabilities that will allow for full interoperability of personal health care information between VA and DoD. The office will then implement those developed capabilities while continuing to accelerate information exchanges.

Fully Interoperable Electronic Personal Health Information
VA and DoD have been, and will continue to be, extremely committed to achieving the goal of health information interoperability. To that end, on April 17, the Departments formed the Interagency Program Office (IPO) and appointed an Acting Director from DoD and an Acting Deputy Director from VA. Shortly thereafter, on April 29, VA and DoD delivered a joint National Defense Authorization Act (NDAA) Implementation Plan to Congress regarding interoperability of electronic health records. The Implementation Plan includes a detailed schedule for developing electronic health record (EHR) requirements, acquisition and testing activities, and implementation milestones for the interoperable EHR. The Implementation Plan also documents the intended course of action for the IPO, and builds upon the already significant success achieved by the Departments toward sharing health information used in the care and treatment of all VA and DoD shared patients. The Implementation Plan also expands our vision for sharing essential viewable data - as depicted in Exhibit 1 and Exhibit 2 - by identifying improvements VA and DoD could make to meet the goal of interoperability by September 2009, as well as further improvements to our EHR capabilities in years beyond.

Status of the Interagency Program Office
VA understands the imperative to form a joint IPO and is working closely with our DoD partners to ensure our commitments are fulfilled. Based on our Implementation Plan, the IPO is now implementing other activities and milestones identified in the Implementation Plan, including efforts to secure permanent shared facilities and infrastructure for the IPO. We believe our Implementation Plan is both aggressive and achievable. By October 2008, we anticipate we will complete much of the initial staffing and facilities activities, including appointing a permanent Director and Deputy. While we do not have a permanent IPO facility and staff yet, we continue to make progress toward our goals. As of last week, the IPO facilities and space requirements are being finalized in the format required by the DoD Facilities personnel. In addition, the IPO budget submission is being finalized for inclusion in the Wounded Warrior Program Object Memorandum, which covers FY 2010 to FY 2015.

IPO and Joint Activities Governance
The mission of the IPO will evolve over time. Initially, the IPO will provide a forum for high level coordination and guidance to ensure the Departments achieve full interoperability of the electronic health record data. Moving forward, the IPO will work in parallel with and build upon the successes already achieved by the VA/DoD Joint Executive Council (JEC) and the Senior Oversight Committee. This will ensure necessary IPO activities are captured and incorporated into the JEC's Joint Strategic Plan as measurable objectives. Operationally, the IPO will report to, and receive guidance from, the JEC and its co-chairs.

Strategy to Achieve an Interoperable Electronic Health Record
VA and DoD are already sharing some viewable health information one-way and some bidirectionally. Some selected data elements can be used as computable data. For example, the Departments now share computable allergy and pharmacy information that checks for drug or allergy interactions using data from each other's systems. We continue to take steps to expand our bidirectional sharing of viewable data. For example, VA and DoD are already sharing pharmacy, radiology, laboratory, progress notes, problems and procedures, theater data and limited inpatient data in bidirectional viewable format. This month, we will begin to share vital sign information, such as heart rate, temperature and blood pressure readings, to our existing capabilities. We will add history data and questionnaires by September 2008. Additionally, throughout 2008, we are expanding a successful bidirectional image sharing pilot beyond the William Beaumont Army Medical Center and El Paso VA Health Care System, our initial test sites, and we will continue to expand our image sharing program in 2009. These steps will address the Dole-Shalala Commission's Recommendation to ensure that all essential health information is viewable and sharable by October 2008.

VA and DoD have formed a VA/DoD Joint Clinical Information Board. This Board is essential to our overall acquisition strategy for a fully interoperable EHR and is composed of clinical experts and physicians tasked with prioritizing the data needs of an interoperable EHR. The Board's work includes defining what information must be shared and determining how that information will be shared. The Board will serve as a bridge between our current capabilities in viewable format and our future needs for full interoperability.

The Joint Clinical Information Board has already defined and validated EHR requirements, which should be approved by the end of the month. Following this, and contingent upon funding, the Departments will proceed with acquisition, development, testing, and implementation of interoperable EHR capabilities. VA is confident we will achieve full interoperable electronic health record capability with DoD by September 2009.

Beyond the 2009 Target for Interoperability
VA recognizes "interoperability" does not have a discrete end point, since technologies and standards continue to evolve. VA and DoD remain leading stakeholders in the effort led by Office of the National Coordinator for Health Information Technology and the Department of Health and Human Services. VA and DoD will advance the identification and implementation of standards and will achieve a national framework for sharing health information with other key health providers.

This concludes my prepared statement. I would be pleased to answer any questions you or any of the members of the Committee may have.