Dr. Joel Kupersmith is the former Chief Research and Development Officer (CRADO) for the Veterans Health Administration (VHA), U.S. Department of Veterans Affairs (VA), and is now the CEO of Kupersmith Associates, a medical research and healthcare consulting firm. He is a graduate of New York Medical College. Kupersmith was a professor and director of clinical pharmacology at the Mt. Sinai School of Medicine; chief of cardiology at the University of Louisville; chairman of Michigan State University’s Department of Medicine; and dean of Texas Tech University’s School of Medicine and Graduate School of Biomedical Sciences, as well as the university’s vice president for clinical affairs and CEO of faculty practice. He was a scholar in residence at both the Institute of Medicine and the Association of American Medical Colleges. Kupersmith became CRADO at the VA in 2005, and his eight-year tenure in the position has been longer than any of his predecessors. During his tenure, VA Research expanded its portfolio on critical areas such as post-deployment health and women’s health, launched the Million Veteran Program (MVP), and developed the VA’s Central Institutional Review Board. Before he stepped down from his position on May 31, he was kind enough to conduct an interview about the evolution of VA research and development, the changes seen during his tenure, and his own role in the organization.

 

Chuck Oldham: There are a lot of veterans and members of the military who may not be familiar with the VA research program. What are the important things that they should know about the program?

Dr. Joel Kupersmith: It’s a very broad program, but I think one of the distinguishing characteristics is that it’s veteran-centric; that is, we emphasize conditions related to veterans. Now, that would include conditions related to deployment, like post-traumatic stress disorder [PTSD], traumatic brain injuries [TBIs], spinal cord injury, prostheses, these sorts of things. But also, because veterans get the same diseases everybody else gets – heart disease, lung disease, cancer, and diabetes, particularly – we have research programs in those areas. So, we are focused on the veteran and in turn all the things health-wise that will affect veterans over the years.

The second distinguishing feature is that we are embedded in a healthcare system [VHA] and that is very important, because we continually relate to that healthcare system. Over 60 percent of our researchers also see patients – that is, they are clinicians. They see veterans, and we are very close to seeing what research needs there are based on clinical experience, and how to apply it in hospitals and medical centers and so forth within the VA.

Also, VA Research has been a very illustrious program over the years. It has three Nobel Prize winners, and now seven Lasker Award winners. VA Research has led to many advances in heart disease, for example. High blood pressure research has been one of the key areas we pioneered. More recently, we’ve been making strides in research on diabetes, PTSD, TBI, various prostheses, and brain/computer interfaces. So I think all these features – being focused on the veteran, the fact that most of our researchers are practicing clinicians, and also being an intramural program – are major aspects.

VA Research has been a very illustrious program over the years. It has three Nobel Prize winners, and now seven Lasker Award winners. VA Research has led to many advances in heart disease, for example. High blood pressure research has been one of the key areas we pioneered. More recently, we’ve been making strides in research on diabetes, PTSD, TBI, various prostheses, and brain/computer interfaces.

 

If there is a continuum of research that ranges from the very pie-in-the-sky theoretical to the very practical, where would you say the VA’s research falls?

All along the continuum. We do a lot of basic science research, including hormonal research, cancer research, and genetic research. We also conduct clinical trials through our Cooperative Studies Program. One area where we’ve been placing greater emphasis is health services, health systems research.

I think we have one of the best health systems research programs; we are at the top of that area. And, that’s really partly because we have a [healthcare] system that we’re aligned with – VHA. We’ve developed new ways of doing health services research over the past few years, and we have a lot of people who are leaders in the field.

 

It seems that because of the organization you’re working with that you have a very large cohort available. How much of an advantage is that?

It’s a tremendous advantage. Add to that an electronic health record where we have 15 years of data, actually, and that’s a big thing. We are actually now reorganizing our computer databases so that we can more effectively use that information. That’s going to be a major asset, because there’s a lot of interest now in the White House, and in the research community, in how to make use of these large databases, not only for research, but also for quality of care. These are going to be great sources of information for us, and that is a major asset.

The other asset, I think, is that veterans are very altruistic, and I can give you an example of that in our Million Veteran Program, which aims to collect genetic data on a million veterans. One of the developments we’ve seen in recruitment is that many veterans who’ve signed up for it have done so on the basis of hearing about it from another veteran. About 15 or 16 percent have heard about the program and have come in and signed up for it. In other words, they were not asked to be in the program, they just heard about it. I think that’s a pretty impressive number, and I think it shows the altruism of veterans. They know that they may not directly benefit from this research study, but they know they are helping their community. So that’s another aspect of the program that I think is important to remember: the veterans themselves.

 

How did the Million Veteran Program come about? Could you speak a little bit about that sort of personalized medicine?

Well, this is the wave of the future. I think a lot of people believe it’s a situation where you’re going to predict some disease that somebody’s going to have 40 years from now, but that person is not going to be able to do anything about it – but really it’s very different. There are a lot of aspects to it.

One is so-called pharmacogenomics. Everybody has different sorts of reactions to drugs and handles them differently. Some people have adverse effects, others none, and a lot of that is genetic, and so we will be able to predict that, and tailor the drug therapy.

But even more important, I think one of the most significant outcomes of MVP is that based on new knowledge about what genes do, we are going to be able to create designer treatments. It’s already happening in cancer treatment. We also have a drug for schizophrenia that’s being developed on this basis, and others are beginning to develop other drugs. That’s where we’re going to change medicine.

Coincidentally, just recently there was major publicity about a finding that certain kinds of breast and ovarian cancer have the same genetic makeup. In other words, we will reclassify the way diseases are thought about based not on what organs they are in, but based on the genes that caused them; and based on what those genes do, we can design treatments. That’s really the future, and that’s why it will change medicine.

So here we have this opportunity; we have an important mission in caring for veterans, and it’s their genes that we are looking at, to focus on diseases that happen to veterans in that light. This program [Million Veteran Program] is a little different from what the VA has done before, and the first thing I thought we should do is get veterans’ opinions on it. So we had an outside group do a survey, and 83 percent of veterans thought we should do it. We asked many other questions about it. They were very concerned about privacy – which everybody is with large databases – and some other issues, but the survey gave us an impetus to do it. It takes a lot of collaboration with the healthcare system because of the way we do it.

What we do is we send a letter out – and we are now in, I believe, 50 medical centers – to the medical center’s population asking if they would like to opt in or opt out of this. So they can opt out immediately. If they opt in, we make an appointment during their next scheduled hospital visit, and at that time we draw blood and get consent to look at their electronic health record, their medical records. That’s all.

Then based on what studies we’re going to do, we will recontact them … we’ll have software that will look through the data and see who would be a good candidate.

For example, one of the first things we’re going to do is look at PTSD – not only what might be associated with susceptibility to it, but what might also be associated with resilience against it. So we will be looking at who has PTSD and then contacting those people.

 We have a number of new programs and new ways of doing research. We have a whole new way of doing health services research that will make it more easily translate into care and systems improvement. It has forced a kind of collaboration and engagement of the clinical system and the research, and is already being copied by others.

 

Is there any particular additional effort to try to encourage more women veterans to participate in the Million Veteran Program?

Yes, we are focusing on that. Minorities definitely. This is, of course, an issue, in that we have a smaller women’s population. But we do have 500,000 women who are in the Veterans Healthcare System, so out of that, if we get substantial agreement to participating in the program, we’ll still have a pretty large women’s database.

 

In what ways would you say that VA Research as a whole has changed during your tenure?

Well, I think in several ways. The Million Veteran Program is one way. We’ve also made a lot of administrative improvements, like the Central IRB, which is the Institutional Review Board for the whole system rather than the former situation, where if you wanted to do a study in 30 different hospitals, you had to go to review boards in each hospital. This way it’s “one-stop shopping.”

We have a number of new programs and new ways of doing research. We have a whole new way of doing health services research that will make it more easily translate into care and systems improvement. It has forced a kind of collaboration and engagement of the clinical system and the research, and is already being copied by others.

We have a new way of doing clinical trials within the system, which is a little bit technical, but the person’s own physician actually does the trial and the records are stored in the person’s own electronic health record.

We’ve had a lot of great research studies that have come along, like the brain/computer interface, where people move prosthetic limbs with their thoughts. We have some new prostheses – a new arm prosthesis that we’re working on, for example – that are excellent. We have better treatments for PTSD, and at least a better understanding of TBI. We’ve done many chronic disease studies over the years since I’ve been here – prostate cancer and diabetes, for example. We’ve done an important study on coronary bypass surgery, another on a shingles vaccine, and many others.

We’ve made a lot of other administrative improvements that I think have been important. We have a much better communications program and much better relationships with Veterans Service Organizations, with specialty societies, and with academic societies – very close relationships.

We deal a lot with the Veterans Service Organizations. We are telling them what’s going on, and they have been very helpful. In fact, they’re offering to help work with the Million Veteran Program, and they’ve been helpful in other studies too, and in forming them. They were helpful in helping us with veterans for focus groups we conducted prior to MVP’s launch. So, we work very closely with them, and that’s something that’s been very good.

Also, there has been a much greater collaboration, particularly in the last two years, with DoD [the Department of Defense], to the point where we’re actually going to do collaborative projects that hadn’t been done before. We’ve developed a close relationship with NIH [the National Institutes of Health] also. The VA has always collaborated with NIH, but I think it’s been greatly elevated. Another change is infrastructure improvement. We have the same infrastructure issues that a lot of government does, and a lot of the country does now. We’ve made some real improvements in that over the last, I’d say, three years.