You mentioned in passing the change in the nature of VA’s collaboration with the DoD. I wonder if you could expand on that? How has that changed as far as collaboration with research?

There is a certain kind of collaboration that’s been around for a long time, in the interchange of ideas and in our peer review system – it’s called merit review. We’ve had DoD people involved for a long time.

What we did in the past two years was start a process where we collaborate directly with DoD on specific projects, and we first undertook a joint program review with them in TBI and PTSD, looking for gaps, overlaps, etc. We identified areas in which we thought there should be joint research, and we both are putting money in – approximately $100 million – to form two major research consortia that are going to be collaborative.

One consortium is going to be in TBI and one on PTSD. So there will actually be joint projects. That’s never been done.

 

Obviously a lot of things happened between 2001 and today as far as the veteran population. What do you see as the greatest healthcare challenges facing returning veterans, and what occurred during your tenure to address those challenges?

Today’s service members have direct contact now, and they have no buffers of time between the time they are in battle and the time they come home. Remember the old movies, where they’d be sitting on the ship coming back and reading letters? It’s very different today. They are in contact by email and telephone, and so in a way that’s great – they get the support of their family – but also, they can get problems, and it’s a whole different form of adjustment that we have to get used to.

Well, there are a few answers to that. One is that veterans, by and large, get the same diseases everybody else does, so their future is going to include heart disease, cancer, lung disease, and diabetes. That’s going to happen. They are an older population than previous veterans. In a sense, you can say they are closer to some of these conditions than the 19- and 20-year-olds who came out of World War II, so that’s a difference.

As far as their direct experiences, there’s a combination of medical and social issues that I think are important. The medical issues – PTSD, TBI – which are considered the signature issues of [Operation Enduring Freedom and Operation Iraqi Freedom] are the big things. They are going to require the kind of research we’ve done. We’ve had a number of projects related to new treatments for PTSD, for example – prolonged exposure therapy, and cognitive therapies, and now Prazosin for nightmares. We’ve done a lot of studies to try to determine the causes of PTSD, because those are things that they are going to face.

One of the issues that they face now, and I don’t know how this is going to play out in the future, is that there’s a big difference between the relationship between people in battle and those back home than there was during World War II. Today’s service members have direct contact now, and they have no buffers of time between the time they are in battle and the time they come home. Remember the old movies, where they’d be sitting on the ship coming back and reading letters? It’s very different today. They are in contact by email and telephone, and so in a way that’s great – they get the support of their family – but also, they can get problems, and it’s a whole different form of adjustment that we have to get used to.

As far as the VA, that kind of adjustment is going to spill over into a number of healthcare issues – mental health and probably other health conditions – and I think that’s going to be part of the future as far as research we have to look at.

For example, one of the efforts we’ve undertaken is to increase our research in homelessness, trying to look at some of those things that are related to PTSD and substance abuse and mental illness and all these things that coalesce in one person. The same with suicide. Suicide is uncommon, but it’s there and it’s a major issue, and so we are studying that area. As a matter of fact, we’re in the process of looking at a suicide prevention study. Those are the kinds of things that I think veterans will face in the future.

And there’s the healthcare services issue, how it’s going to relate to the Affordable Care Act, how veterans’ care relates to that, and how the system is going to relate to it. How is the system going to relate to the fact that we don’t take care of families? That will also spill over as far as research is concerned, in terms of health services and systems research, and how we should design care for veterans in concert with the kind of care that everybody else is providing.

 

What are some of the ways that VA research has been working with patient care and services within the VA?

One of the ways is that we’re looking at Patient Aligned Care Teams [similar to civilian patient-centered medical homes], and we will be studying them. What we’ve changed in health services research is that we’ve created two programs. One is called CREATE, and the other is called COIN. COIN is Centers of Innovation and CREATE is Collaborative Research to Enhance and Advance Transformation and Excellence.

What that means is, in order to get funding now, especially in the health services research centers, you have to engage with a healthcare system in jointly designed programs. You have to jointly design programs, not just projects. So instead of doing scattered projects, you have to design a system of projects, a group of projects. For example, let’s say the topic is women’s health: You have to design a group of projects in women’s health, or access.

So, we’re forcing early engagement, and then a continuous engagement with the healthcare system, so that those in the system can have input into what kind of research we do. With these intiatives, our researchers can also have input into the system, explaining what we do in research, how we go about it, and what kinds of things will come out of it, so there will be a smoother translation of findings into the system when studies are complete. We’ve just started these intiatives, so we haven’t tested them yet, but that’s how we’re dealing with trying to improve the relationship with the healthcare system. Not that the relationship needs improvement, but we’re trying to engage it in a more focused way.

 

What’s the nature of the Learning Health Care System that you’ve written about in recent years, and what is its relevance to VA research and patient care?

The Learning Health Care System means essentially that every contact you have with a patient, you learn from somehow. Now obviously, that’s an insurmountable task – every contact – but we have a number of things in the VA that help this process.

One is the electronic health record, so that we can accumulate information from patient contacts and use it. We have this program [MVP] that I just mentioned, and that will contribute to it, and we have a research program in the system that can design this learning in a more rigorous way so that the research can contribute to it. That’s pretty much our idea of how the VA can approach it. The facts that are important are that we are in the healthcare system and that we have an electronic health record, and those are things that are unique.

Now, everybody is developing electronic health records, but we have 15 years of data already, and nobody has the kind of research system that we have that’s embedded in healthcare. Other people do research, but this kind of comprehensive research program, which goes from basic genetics, genetic findings, and brings that into testing in the healthcare system – whether these findings are going to be of use and then testing therapies – those are the essential things that are unique about VA research, and those are all related to the healthcare system.

 

Could you explain comparative effectiveness research?

Yes. We do a lot of that. We’ve been doing that for 35 years, actually, but haven’t necessarily called it that. Essentially, it’s comparing two types of treatment that are already in use.

For example, there were three major studies done on diabetes, looking at close versus less intensive control of diabetes. Of those three major studies, we did one of them. What the studies found was that for somebody who has suffered from diabetes for many years, and is already starting to have complications or having complications, less intensive control was better, and close control was more of a danger to low blood sugar. In a younger person who does not have complications yet, and in whom you can prevent those complications, tighter control is probably better, because the danger obviously is in the complications. So that’s a kind of comparative effectiveness study.

Other comparative effectiveness studies that we’ve conducted include prostate cancer. We looked at whether, in prostate cancer that hasn’t spread, it is better to just monitor it, or better to perform surgery. Both are treatments that are in the system. Both are being done, and we found that outcomes are equivalent, actually, and that you can just observe. The study lasted about 17 years. The median length of follow-up was 10 years. So those are the kinds of comparative effectiveness studies the VA has done for years.

There’s another point about that, and this is another point about VA research, actually: These are studies that a government agency could do, or would do, whereas industry wouldn’t necessarily pick these topics.

 I think continuation of making administrative improvements. We started on administrative simplification. Our main handbook was reduced from roughly 110 pages to approximately 48 or 52 pages. Those kinds of things absolutely need to be done, and I think that will facilitate research.

 

Have there been efforts over the years to fast-track certain research?

That’s difficult, but, again in health services research, one of the ways to fast-track research is to fund it differently. You know, a lot of times the old way of doing [research] is to begin with a pilot study, come back with the results, apply for another grant, and then do the next, bigger study, and so forth.

Now we’re looking at just saying, “OK, if this works, you’re going to get the next step automatically. You can just start it right away.” So, that’s one of the ways of fast-tracking it.

We’re also looking at various methods of this kind of database approach, to look within our database to see whether we can get new studies within the database that will make it go more quickly than having to enter patients over the years.

 

What do you see as the next big issue on the horizon for VA research?

I think making use of the Million Veteran Program and making use of these large databases, how we can effectively get rigorous studies out of them, is going to be a big issue.

Just having a database and the information is really not enough. We have to figure out how we’re going to essentially enact or re-enact a kind of randomized trial within a database – whether it’s by randomization or some other way – how we can get good scientific evidence from them. That’s going to be a big issue, not only for the VA, but for everybody.

 

You had mentioned the brain/computer interface for amputees. What kind of potential do you see there for prosthetics?

Oh, it’s tremendous. That’s just the beginning of a long process, and it’s going to take many years before that approaches a level of day-to-day usefulness, but it’s a great feat to actually be able to sort out what happens in the brain to move a limb, and then translate moving that prosthetic limb. That will have great utility, but it’s going to be a long time coming.

It’s going to be a long time for many of these things. A lot of the genetic things will go on for 50 years. When is this brain/computer interface going to reach day-to-day clinical use? It’s going to be a while.

 

What would you say are the things that you’ve wanted to accomplish that remain to be done?

I think continuation of making administrative improvements. We started on administrative simplification. Our main handbook was reduced from roughly 110 pages to approximately 48 or 52 pages. Those kinds of things absolutely need to be done, and I think that will facilitate research. There needs to be continuation on improving the infrastructure, which the VA is doing and just needs to continue doing.

It’s important that people remember that we are here, in part, to create an atmosphere where creative individuals can accomplish things, and whatever you do, that has to be part of what you’re thinking about. That’s the kind of thing that people have to continue to remember. I haven’t done research since I’ve taken this job, but we create an atmosphere for it, we create resources for it, and those kinds of things have to continue and improve as we go on.

 

What have been the most enjoyable aspects of your role?

Seeing the research, going to visit medical centers, seeing people do their research and seeing what research they do. Talking to them, interacting, and discussing their research are probably the most fun. Just seeing the Million Veteran Program, seeing the more than 200,000 people signed up – it’s nice to see some things that you’ve accomplished. I think those are the rewarding parts of it.

But, you know, I’m a researcher. I started as a researcher myself, and a clinician, and then I started doing administrative work, so I understand very much what it takes to do research on the part of the researcher and what they have to do not only to be creative, but also be entrepreneurial; to put together programs, and to have to hire people, and bring in the resources, so these are things that I’m very aware of and have been very aware of all during the time I’ve been here.

I’ve tremendously enjoyed this time, and feel very positive about the past eight years. I’m optimistic about the research program’s future, and feel it’s poised for many outstanding contributions in coming years.

This article first appeared in the The Year in Veterans Affairs & Military Medicine 2013-2014 Edition