Veterans Affairs & Military Medicine OUTLOOK, 2020 Fall Edition

THE COVID-19 INSIGHTS PARTNERSHIP

A new collaboration leverages federal expertise, health data, and computing power in the fight against the novel coronavirus

The Other Enemy in World War I The U.S. Navy vs. the 1918 Spanish flu

Combating COVID-19

The U.S. military goes to war against the novel coronavirus

CONTENTS 6

THE VA MISSION ACT An update

By Craig Collins

15 THE JOINT HEALTH INFORMATION EXCHANGE Streamlining data access for community providers

By Craig Collins

VA RESEARCH

18 THE COVID-19 INSIGHTS PARTNERSHIP

A new collaboration leverages federal expertise, health data, and computing power in the fight against the novel coronavirus.

By Craig Collins

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THE NATIONAL ARTIFICIAL INTELLIGENCE INSTITUTE The VA’s new institute aims to improve veterans’ lives through advanced analytics.

By Craig Collins

32 THE VA’S NATIONAL PRECISION ONCOLOGY PROGRAM Building a System of Excellence for cutting-edge cancer care

By Craig Collins

38 VA TELEHEALTH RESPONDS RAPIDLY TO PANDEMIC 44 THE OTHER ENEMY IN WORLD WAR I

By Gail Gourley

The U.S. Navy vs. the 1918 Spanish flu

By Dwight Jon Zimmerman

52 COMBATING COVID-19

The U.S. military goes to war against the novel coronavirus.

By Craig Collins

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MEDICAL MODELING AND SIMULATION 60 MILITARY SHIFTS ORGANIZATIONS WHILE RETAINING FOCUS

By Scott R. Gourley

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THE VA MISSION ACT An update

By Craig Collins

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hen it was signed into law with overwhelming bipartisan support on June 6, 2018 – the 74th anniversary of D-Day – the VA MISSION Act was celebrated as a long-overdue expansion of the partnership between the Veterans Health Administration and the non-Veterans Affairs (VA) health care community. The new law promised to increase access to health care, both in VA facilities and in the community; reduce wait times; expand benefits for caregivers; and improve VA’s ability to recruit and retain quality medical professionals.

Historically, the VA has made considerable efforts to ensure veterans receive care in the community when VA cannot provide the care needed. Beginning in 1920, Congress authorized the VA to contract with community providers in “exceptional cases.” The series of laws passed over the ensuing decades – authorizing certain inpatient, outpatient, and urgent-care services to veterans with and without service-connected disabilities through non-VA community providers – resulted in a complicated network of programs, each with its own eligibility requirements.

The Choice program, which allowed veterans to receive care outside the VA system under certain conditions (i.e.,

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excessively long wait or drive times to receive care at VA facilities), along with other fee-based community care programs, was replaced by the provisions of the VA MISSION (Maintaining Internal Systems and Strengthening Integrated Outside Networks) Act, which establishes a permanent community care program and requires VA to build and administer a high-performing, integrated network of VA and non-VA providers that seamlessly provides high-quality care.

The VA MISSION Act also expanded veteran access to care in other ways, beyond a focus on community care: increasing support and assistance to family caregivers of disabled veterans; establishing a new urgent care benefit; and authorizing “anywhere to anywhere” telehealth visits across state lines.

VA leadership conducted in-person visits to facilities across the country in the lead-up to implementing the law’s provisions, and the regulations were finalized a year later. The rollout of the law’s provisions – beginning with its new Veterans Community Care Program – began on June 6, 2019, and extends out beyond 2030.

COMMUNITY CARE The MISSION Act’s changes to VA community care have required completion of a considerable number of interrelated tasks. Community Care Program access is tied to a set of eligibility requirements based on a veteran’s place of residence and the availability of VA services in their region. Whether a veteran meets established drive-time and wait-time standards, they may be eligible to receive care under other conditions, all of which were set in the actual legislation: They may be eligible for the “grandfather” provision that, under the Choice Act, allowed them to receive care if they lived more than 40 miles from the nearest VA care facility. On a case-bycase basis, a veteran may be referred to a community health care provider when the patient and the referring doctor or agency agree it’s in the patient’s best interest.

These new eligibility criteria continue to depend, first and foremost, on a veteran’s individual needs or circumstances. A detailed overview of the law’s provisions and eligibility requirements can be accessed at www.missionact.va.gov.

According to Dr. Kameron Matthews, VA’s chief medical officer and Assistant Under Secretary for Health for Clinical Services, this new list of requirements is a combination of those explicitly legislated and others published through regulation. “We’ve used the sense of urgency and transformation that the MISSION Act promoted to update a lot

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VA IMAGE

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of the business processes around community care,”she said.

The community care contracts that will assist in the implementation of the requirements of the MISSION Act, Matthews said, resulted in a more veteran-centric arrangement, with the VA assuming a role of coordinator for patients receiving care at VA-approved providers within its Community Care Network (CCN), which comprises six regions managed by third-party administrators (TPAs). As of late 2020, TPAs for five of the six regions had been selected, expanding the CCN throughout the continental United

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The Department of Veterans Affairs’ Community Care Network comprises six regions that are managed by third-party administrators (TPAs). This graphic shows the TPAs for regions 1, 2, 3, and 4.

The TPA for region 5, TriWest Healthcare Alliance, was announced in October 2020.

States, Alaska, Hawaii, the U.S. Virgin Islands, and Puerto Rico.

Not all of these regional networks had been fully deployed by the fall of 2020, Matthews said – and the COVID-19 pandemic has caused minor local delays in the deployment schedule. As the pandemic worsened in the spring of 2020, the VA began reviewing referrals to community

care providers on a case-by-case basis, weighing the clinical needs and safety of veteran patients with the risks of inperson visits. While the VA stayed open for all care that rose above the risk of COVID-19, both at VA facilities and in the community, this had the effect of temporarily decreasing in-person visits to community providers. In addition, community providers were decreasing services and negotiations with individual providers for enrollment in the network slowed.

“We deployed facility by facility,” said Matthews, “and by the end of the fiscal year [2020], we’d fully deployed regions 1, 2, 3, and 4” – an area covering providers

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The VA MISSION Act expands the Program of Comprehensive Assistance for Family Caregivers in two phases to support caregivers of Vietnam and older veterans injured in the line of duty on or before May 7, 1975 (the first phase, launched in October 2020), and caregivers of veterans injured in the line of duty between May 7, 1975, and Sept.

10, 2001 (the second phase, anticipated to launch in fall 2022).

throughout the lower 48 United States and Hawaii.

The VA has been working closely with community providers to ensure a positive experience for veterans. By taking responsibility for coordinating community care appointments, the VA is making the process as seamless and trouble-free as possible. It has been working closely with community providers – providing training and education, for example, about the challenges confronted by veterans – to ensure a positive experience for veteran patients.

The MISSION Act directs the VA to establish rigorous quality standards for the Community Care Program, and to make comparative quality scores for the VA and community care available to both veterans and their providers.

VA PHOTO

URGENT CARE One of the MISSION Act’s new provisions is the urgent (non-emergency) care benefit “for the treatment of minor injuries and illnesses, such as colds, sore throats and minor skin infections.”

This benefit is offered in addition to the opportunity to receive same-day services from a VA primary care or mental health provider. Urgent care options are available from care providers that belong to the VA’s contracted network of community providers, without prior VA authorization.

The availability of same-day service at an urgent care or retail clinic (for uncomplicated illnesses, such as a sore throat, or for more pressing illnesses or injuries requiring splinting, casting, or wound treatment) has been a concern of several veterans service organizations (VSOs), including the American Legion, which argued for a more streamlined

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experience for veterans seeking urgent and emergency care.

The VA is continuing to expand its contracted urgent care network, so that most veterans will be within a 30-minute drive of an urgent care center – though veterans should verify that the center is an in-network facility before visiting. According to Katie Purswell, the American Legion’s deputy director of health policy, “You can call the VA and they’ll tell you: ‘You need to go to an urgent care center, and here’s a list of the closest ones to your area that accept VA payments.’ I know the VA is continuing to make those relationships.

The partnership is best for everybody, especially the veterans who aren’t able to get the care they need without having to drive three hours to get to an emergency room.” A list of in-network urgent care providers – or of any VA or community providers – is also available online at www. va.gov/find-locations.

For those unfamiliar with the language of health care insurance and claims, it’s important to distinguish between the terms “urgent care” – which is for nonlife-threatening illnesses or injuries – and “emergency care,” which is for an injury, illness, or symptom so severe that a “prudent layperson” (according to VA policy) reasonably believes a delay in seeking immediate medical attention would be a threat to the life or health of the patient.

The VA implemented a new business process in June 2020 that allows

emergency room visits to providers in the VA’s third-party network to be covered by community care if certain conditions are met. These conditions are detailed online at https://www.va.gov/ communitycare/programs/veterans/ emergency_care.asp. This process has streamlined the approval and claims submission process for emergency room visits.

CAREGIVER SUPPORT Before passage of the MISSION Act, the VA offered general support for family caregivers of any veteran enrolled in VA health care: training, education, respite care services, a Caregiver Support Line, self-care courses, and other benefits. An augmented Program of Comprehensive Assistance for Family Caregivers (PCAFC) offered expanded benefits – including a monthly stipend, a beneficiary travel allowance, mental health counseling, and enhanced respite services – to caregivers of veterans injured in the line of duty on or after Sept. 11, 2001.

The VA MISSION Act expands eligibility for the PCAFC in two phases. After successfully installing and certifying a new information technology system to help administer the program, the VA launched the first phase – accepting applications from family caregivers of veterans who were injured in the line of duty on or before May 7, 1975 – in October 2020.

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Left: Dr. Janeen Smith of the San Francisco VA Health Care System speaks with Navy veteran John Bartlett, who lives in Hawaii, using VA Video Connect. The “anywhere to anywhere” authority granted by the VA MISSION Act has made it possible for licensed health care providers to see patients using telemedicine regardless of their location. Left, below: Nathan Naylor of Philips, left, and Dr. Neil Evans, chief officer for the VHA Office of Connected Care, demonstrate ATLAS to U.S. Sen. Shelley Capito, R-W.Va., in November 2019. The goal of ATLAS is to extend VA telehealth to rural and underserved veterans.

VA PHOTO BY SHAWN GRAHAM

VA PHOTO

TELEHEALTH

“We’ve expanded the program to include Vietnam and older veterans,” said Matthews. “And we, of course, will continue to support general caregiver resources and education for all veterans, but now the comprehensive assistance program provides more financial support for caregivers of older veterans.” The VA had accepted thousands of applications by the end of the first week of October.

A second phase of PCAFC expansion, to caregivers of veterans who were injured in the line of duty between May 7, 1975, and

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Sept. 10, 2001, is anticipated for the fall of 2022. According to Purswell, focusing first on caregivers of older veterans was the right move. “Knowing we have an aging veteran population, it’s really important to us to make sure they are getting quality care,” she said. “And supporting caregivers is the best way we can make sure that is happening – making sure they are getting the benefit, first of all, and then that they’re trained and they’re capable, and that we’re looking back in on them and making sure they are staying qualified and have all the tools they need.”

One of the earliest and most conspicuous changes to veteran health care enabled by the MISSION Act was the expanded use of telemedicine. The law states that a covered and licensed health care professional may practice “at any location in any state,” regardless of where they or the patient are located, if they are using telemedicine.

“Typically telehealth is constrained by state lines,” explained Matthews. “The MISSION Act actually gave us, VA – a federal entity not restricted by state lines – what we call ‘anywhere to anywhere’ authority.” Matthews can now practice telemedicine anywhere in the VA network.

This “anywhere to anywhere” authority had an immediate effect: More than 900,000 patients used VA telemedicine services in fiscal year 2019, an increase of 17 percent. When the COVID-19 pandemic hit, said Matthews, and in-person visits presented health risks, VA’s telemedicine infrastructure was able to take up the slack. “Since the start of the COVID-19 pandemic, in a matter of months, we’ve increased the number of video visits by 1,800 percent,” Matthews said. “Through the MISSION Act, we have the capacity in our health system to support it.”

This capacity has been boosted further by partnerships – for example, a new program known as Project ATLAS, which is a collaboration between the VA, Philips Healthcare, T-Mobile, and two of the nation’s largest VSOs: the American Legion and Veterans of Foreign Wars

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(VFW), which have offered up their posts as hubs where veterans – whether they are members of that particular VSO or not – can access telehealth services.

Project ATLAS (Accessing Telehealth through Local Area Stations) aims to improve access to care for the nation’s 20 million veterans – particularly the roughly 5 million who live in rural areas where health care access is limited.

In September 2020, American Legion Post 176 in Springfield, Virginia, hosted one of the first ATLAS sites, the rollout of a five-site pilot, where veterans will, with technical assistance from volunteer staff, meet with providers through VA Video Connect on equipment provided by Philips. For Purswell – herself a VA patient who, before moving to Washington, D.C., lived in a rural area where she drove three-and-a-half hours each way to appointments for treating and rehabilitating a traumatic brain injury – Project ATLAS is an exciting development.

“I can only imagine, for some of our other rural veterans that are homebound or wheelchair-bound, how difficult it is for them to find a ride or drive themselves to these locations, for appointments that could have been done via telehealth,” she said. Veterans in rural areas often don’t have great internet access – and some

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may not even have access to a computer.

“So to be able to allow veterans to go to a local post and see their medical provider and not have to worry about the bandwidth dropping out, or not to have video, or not to have someone there to be able to help them walk through the steps of doing a virtual appointment – we’re excited to make that available to veterans.”

LOOKING TO THE FUTURE OF VETERAN CARE Expanded access to community care, urgent care, caregiver support, and telehealth are among the MISSION Act’s most significant provisions, but the law contains several others aimed at improving the quality of the VA for decades to come. It requires the VA to establish mobile deployment teams of medical personnel, for example, who will provide health care at underserved VA facilities.

As Matthews pointed out, it’s difficult for any health care organization to recruit staff clinicians in some parts of the United States, and the VA, despite its collaborations with other agencies, sometimes encounters resource and personnel constraints. So far, pilot deployments of mobile teams have been undertaken at three different sites to establish what

Matthews called clinical resource hubs – outposts to supplement the care provided at these locations, both in-person and via telemedicine. To date, the VA’s mobile care teams at these pilot sites have provided more than 94,000 visits.

With provisions that extend out to 2034, the MISSION Act also looks to the future of veteran health care, giving the VA tools to recruit and retain the nation’s best health care providers. The law increases the amount of education debt reduction available to VA physicians, expands the number of medical residencies in the VA and other federal health care facilities, and establishes a pilot program for medical scribes – personal assistants who help physicians document and coordinate patient visits.

Under MISSION Act authority, the VA recently launched a scholarship pilot program, Veterans Healing Veterans, for veterans pursuing a medical education through historically black colleges and universities (HBCUs) and five other Teague-Cranston medical schools that were established in conjunction with VA medical centers. Eighteen veteran medical students were enrolled at nine medical schools through this program in 2020.

The VA has stood up a new Innovation Center, intensified its focus on underserved facilities through programs such as the mobile teams pilot, and launched a veteran peer support program for primary care in VA medical centers.

These provisions of the MISSION Act will serve to nourish and reinforce the ongoing transformation of the VA’s efforts, drawing a growing number of quality health professionals into its ranks to help plot a course for the future of American health care – and above all, to provide veterans with the level of care a grateful nation has determined is their due.

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MARK ADAMS 123RF

The VA MISSION Act includes provisions aimed at recruiting and retaining high-quality health care providers, such as increased education debt reduction, increased numbers of medical residencies at VA and other federal health care facilities, and the recently launched Veterans Healing Veterans scholarship pilot program.

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THE JOINT HEALTH INFORMATION EXCHANGE Streamlining data access for community providers

By Craig Collins

ADOBE STOCK

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hen the departments of Defense and Veterans Affairs (DOD and VA) announced in the spring of 2020 that they had established a joint health information exchange (HIE), allowing them access to patient data from each other’s community providers, it was a big deal – but that may not have been obvious to many outside the community who provide medical care to service members and veterans.

Before the joint HIE, the DOD and the VA built their own HIEs through which they exchanged patient data with different community health care providers.

A community health care provider had to join each HIE separately to access patient data from both departments. Thus, a community provider, caring for a VA patient, may not be able to access previous record information from the Military Health System (MHS), or from any community provider who cared for the veteran when he or she was in service.

Bill Tinston is the director of the Federal Electronic Health Record Modernization program office, chartered by the DOD and the VA to implement a single, common federal electronic health record (EHR).

The joint HIE is part of this larger effort.

The joint HIE, Tinston said, breaks down the last obstacle community providers face in accessing the data they need to

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inform and provide care for patients.

“We’ve shifted away from our homebuilt information gateways,” he said, “to a single commercially provided gateway that serves both departments, so that a community provider, or a health information exchange that a community provider belonged to, would only have to sign up with the departments once, and both departments would have the advantage of that bidirectional exchange of data.”

It’s easy for civilians to imagine why a VA community care provider might need access to MHS community records, but the way in which health care delivery is evolving makes it imperative for information to flow in other directions, Tinston said. One of his colleagues at the Defense Health Agency, for example, is a retired Army officer who was injured in an accident two years ago. “He sees the VA for certain things,” Tinston said. “He goes to community providers for certain things. And he goes to the Military Health System for some things. ... If you’re a beneficiary who retired or left the service, you can see whatever community provider you want. You could be referred to those community providers either from the Military Health System or the Veterans Health Administration. And community providers can refer patients to one another.”

The whole point of the joint HIE is to not make distinctions about who is providing care to a military or veteran patient, or where the care is delivered. “It’s about getting the right data about the patient to the provider to support the health care encounter where and when it needs to happen,” Tinston said. While the joint HIE honors all existing provisions protecting patient health care data, the DOD and the VA also honor patient consent by allowing any patient who is not an active-duty service member to opt out of sharing data through the joint HIE. About 46,000 community partners had joined the joint HIE by October 2020, when it expanded dramatically: CommonWell Health Alliance, a nonprofit network of more than 15,000 hospitals and clinics, signed onto the network, moving the DOD and the VA one step closer to a nationally interoperable network of data with community providers.

The joint HIE, Tinston said, not only simplifies the retrieval of health record information, “It improves the active usability and availability of the patient data, and gets it to the providers on whatever side it needs to be shared, commercially or within the federal government. Providers will be able to make the right clinical decision and deliver better patient care.

That’s why it’s a big deal.”

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VA RESEARCH

THE COVID-19 INSIGHTS PARTNERSHIP

A new collaboration leverages federal expertise, health data, and computing power in the fight against the novel coronavirus.

By Craig Collins

IMAGE BY HELLERHOF VIA WIKIMEDIA COMMONS

that revealed what were described as “ground-glass opacities,” or abnormally hazy areas, in patients’ lungs. For this reason, an early – and incomplete – concept of COVID-19 emerged: It was a respiratory disease.

Over time, a more complex and bewildering picture has developed. COVID-19 isn’t limited to the respiratory system.

Patients with the disease experience a variety of symptoms that can include muscle and joint pain, extreme fatigue, cardiac arrythmias, blood clotting, skin

Top: An X-ray of a COVID-19 victim’s lungs, showing pneumonia. Over time, it has become apparent that the effects of the virus aren’t limited to the respiratory system. Above: A 3D medical illustration of the 2019 novel coronavirus, derived from a CDC-released image, explaining the ultrastructural morphology. This virus has four surface proteins – E,S,M, and HE – labeled in the image. The S protein gives the crown-like appearance for which the virus is named. The crosssection shows the inner components of the virus.

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here are still more questions than answers. For the first months of the COVID-19 pandemic that swept across the globe in the spring of 2020, doctors and researchers were mostly stumbling in the dark as they fought a new and sometimes deadly infectious disease. One of the most conspicuous symptoms among patients infected with SARS-CoV2, the novel coronavirus that causes COVID-19, was respiratory distress: difficulty breathing, pain or pressure in the chest, and CT scans

U.S. NAVY PHOTO BY MC2 SARA ESHLEMAN

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IMAGE BY MIKAEL HÄGGSTRÖM, MD, VIA WIKIMEDIA COMMONS

Above: Lt. j.g. Natasha McClinton, an operating room nurse, prepares a patient for a procedure in the intensive care unit (ICU) aboard the hospital ship USNS Comfort (T-AH 20) in New York, New York, April 23, 2020, during the coronavirus disease (COVID-19) pandemic. Comfort was working with Javits New York Medical Station as an integrated system to relieve the New York City medical system. Right: Common and uncommon symptoms of coronavirus disease 2019 (COVID-19), the disease seen in the 2019–20 coronavirus outbreak, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

rashes, nausea, vomiting, diarrhea, headaches, and decreased cognitive functioning or “brain fog.” In the spring and summer of 2020, several reports of younger COVID-19 patients with a mysterious and dangerous array of symptoms, known as multisystem inflammatory syndrome, emerged.

Equally puzzling are the variations in how the disease affects infected people: A large percentage – according to the U.S. Centers for Disease Control and Prevention (CDC), up to 70 percent, with a most recent “best estimate” of 40 percent – experience no symptoms at all.

Many patients experience it as a mild upper respiratory infection, with a fever and slight cough; many suffer more severe symptoms, often in clusters; and a

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significant number of people are killed by COVID-19. The high percentage of asymptomatic patients makes it difficult to estimate an accurate infection fatality rate for the disease, but the number of deaths so far – by October 2020, more than a million people worldwide, including more than 220,000 Americans – is far greater than the annual deaths associated with seasonal influenza.

Why such a wide array of symptoms?

Why such variation in the complexity

and severity of symptoms? Why such a vast difference in patient outcomes?

In April 2020, it began to look as if disease experts were approaching some answers: Intriguing results began to emerge from studies conducted by a team of clinicians and systems biologists who had fed patient data from publicly available datasets into supercomputers at the Department of Energy’s (DOE) Oak Ridge National Laboratory. This group’s findings have offered insights

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This transmission electron microscope image shows SARS-CoV-2 – the virus that causes COVID-19 – isolated from a patient in the United States. Virus particles are shown emerging from the surface of cells cultured in the lab. The spikes on the outer edge of the virus particles give coronaviruses their name.

scale, we were able to show there’s great variance in the expression of these key genes across the population,” Jacobson said. “So that’s probably a combination of underlying genetic variance, as well as environmental effects.”

IMAGE BY NIAID-RML

A NOT-SO-NEW PARTNERSHIP

into disease pathways in the body, possible explanations for the multitude of COVID-19 symptoms, and – most important – ideas for how existing drug therapies might be adapted to counteract these symptoms.

The Oak Ridge team was led by computational systems biologist Daniel Jacobson, PhD, with clinical insights supplied by doctors including Amy Justice, MD, PhD, a staff physician and clinical epidemiologist at the Department of Veterans Affairs (VA) Connecticut Healthcare System and professor of medicine and public health at the Yale School of Medicine. The team began by analyzing gene expression patterns in the lung fluid cells of COVID-19 patients and, using the lab’s Summit supercomputer, comparing them with the genes of uninfected patients. These computational analyses suggested that genes involved in regulating the release of bradykinin – a peptide hormone that promotes inflammation, dilating blood vessels to lower blood pressure – appear to be excessively “switched on” in the lung cells of those with the virus.

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The resulting “bradykinin storm,” if it occurred in other organs, could explain the wide variety of symptoms experienced

by COVID-19 patients. The team promptly turned its attention to how the bradykinin system and the renin-angiotensin system (RAS) – the peptide system involved in regulating blood pressure, degrading bradykinin, and contributing to other imbalances – react to SARS-CoV2 infection. The follow-up study was a population-scale deep dive, comparing gene expression in 57 different tissues in an uninfected group of 1,300 people – a study of 17,000 RNA-sequence datasets overall.

“There’s just a really good matchup between what we would predict from the bradykinin in different tissues and the range of symptoms we see in COVID-19, which everybody has been scratching their heads about,” said Jacobson. “How does this virus give us this whole collection of symptoms that are not typical of most viruses, and why do some people have one symptom and not others?”

One explanation, he said, may be that viral colonization of tissues are localized; infection may take different routes in different people. “At the population

Armed with a molecular model for how the RAS-bradykinin pathway responds to the novel coronavirus, and with the computing power to apply it to different populations and scenarios, researchers are poised to investigate a multitude of questions. If the model proves accurate, it can provide a template for how, and when, the disease can be treated, perhaps with existing U.S. Food and Drug Administration (FDA)-approved drugs. In their report on the study, Jacobson’s and Justice’s team identified drugs or supplements that might be used to treat COVID19: medications such as stanozolol or ecallantide that reduce bradykinin production; bradykinin receptor inhibitors, such as icatibant; and vitamin D, which is involved in the RAS system and could attenuate or prevent a bradykinin storm.

Several studies are already underway within the COVID-19 Insights Partnership, a framework launched in April 2020.

The new initiative joins the DOE’s computing power with the federal agencies overseeing the largest repositories of health data in the nation: The VA and the Department of Health and Human Services (HHS).

Collaboration between the DOE and VA isn’t new. Justice’s participation in the Oak Ridge project was established, in part, because discussions about forming the COVID-19 Insights Partnership had begun months earlier, when VA’s chief research and development officer, Rachel Ramoni, PhD, floated the idea of combining federal health data resources

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IMAGE BY JASON SMITH/ORNL, U.S. DEPT. OF ENERGY

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with DOE’s high-performance computing and artificial intelligence capabilities to explore questions about the COVID-19 pandemic. VA’s Office of Research and Development, the FDA, HHS, and DOE, recognizing the enormous potential of this data to study and perhaps solve some of the mysteries of COVID-19, began discussing a partnership in March 2020, when U.S. cases numbered in the hundreds.

The speed with which the new partnership was launched is due in part to the fact that VA electronic health record data was already mirrored on servers at Oak Ridge: Four years ago, the two agencies launched an initiative, MVP-CHAMPION, to apply DOE’s supercomputing, artificial intelligence, and data analytics to VA’s unparalleled health care data and genomic data compiled by the VA’s Million Veteran Program (MVP). Since 2017, computing and clinical experts have been working to gain insights into three topics important to veteran health: cardiovascular disease, cancer, and suicide.

The outcomes of these ongoing projects will provide better predictors of disease and improved clinical decision support for VA care providers and patients.

As Justice pointed out, moving VA data onto DOE servers required a lot of work to get all the permissions and privacy protections in place. “All of that happened before COVID-19 hit,” she said.

“If it hadn’t, none of this would have happened.” Justice compared the unexpected benefit of the MVP-CHAMPION initiative to NASA’s Apollo program, which ushered in a sequence of unforeseen technological innovations. “When COVID-19 hit,” she said, “all of a sudden there was an immediate use for that data that no one could have anticipated when we first started the collaboration.”

According to Molly Klote, MD, who directs the VA’s Office of Research Protections, Policy, and Education, MVPCHAMPION was formed for the benefit of both agencies: “The Department of Energy needed to practice modeling with the use of their supercomputers, and they needed an enormous data set,” she said. Genomic data from the MVP

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A normal blood vessel, shown at top, is compared with a blood vessel affected by excess bradykinin.

A hyperactive bradykinin system permits fluid, shown in yellow, to leak out and allows immune cells, shown in purple, to squeeze their way out of blood vessels.

– obtained so far from about 500,000 of the 830,000 veterans participating in the program – comprises the largest such database in the United States.

It’s been Klote’s job to navigate a new set of regulatory and privacy concerns, to unlock this data trove for analysis of COVID-19. “The enclave at the Department of Energy where all the VA data sits is a VA enclave that meets all of VA’s standards for privacy and security,” she said. Disclosure of a veteran patient’s data requires a series of permissions, usually including the signature of the veteran, but because the COVID-19 pandemic is a public health emergency, the Partnership has received permission under HHS Public Health Authority to pool health record data from the VA and

the Centers for Medicare and Medicaid Services (CMS).

Because the RAS-bradykinin computational study was formulated while Klote and her office were securing this public health authority, veteran data was not used to develop the mechanistic model developed at Oak Ridge – but as Jacobson pointed out, the COVID-19 Insights Partnership is about more than sharing data; it’s also about sharing expertise.

“The partnership with Amy [Justice], and getting her perspectives on the mechanism, was extremely helpful,” he said.

“This was a good outcome of the Insights collaboration, and it’s leading to a lot of what we hope will be very productive interactions with the VA.”

NEXT STEPS Studies are underway both within and outside of the COVID-19 Insights Partnership. Three studies of existing drugs, each targeting a different part of the RAS-bradykinin pathway – icatibant;

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GRAPHIC BY OUR WORLD IN DATA

A world map of total confirmed COVID-19 cases per million people as of September 2020.

dexamethasone; and calcifediol, a vitamin D analog – have yielded early results that support the team’s disease model, and the partnership is working to facilitate clinical trials of other drugs identified by the Oak Ridge team. According to Justice and Jacobson, it’s likely that therapies for COVID-19 will combine two or more of these drugs, in courses targeting the needs of individual patients, to shut down the mechanisms of COVID-19 pathogenesis.

The COVID-19 Insights Partnership’s earliest studies of VA and CMS data have been straightforward analyses of questions posed by the FDA, many of which don’t require complex algorithms and artificial intelligence: Some have focused on operational questions (i.e., the usage rate of existing drugs), while some examine treatment outcomes (the safety and efficacy of drugs such as anticoagulants and hydroxychloroquine).

According to Justice, priorities among the list of questions being explored by the Insights Partnership are adjusted as new findings are revealed. “We have agreed that this group, the Insights group, can arbitrate what questions will be addressed and how they will be prioritized,” she said. “For example, hydroxychloroquine initially was on the list of

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things they wanted to look at. Then, over time, the antithrombotics became very important, because of all the thrombosis that we’re seeing. So the group asked to add antithrombotics to the list. We’ve completed an analysis of hydroxychloroquine, which we fed into a larger collaborative analysis of several other groups involved with the FDA.” These analyses, said Justice, have focused exclusively on data from the VA, which, as one of the nation’s largest health care systems, also has one of the largest samples of COVID-19 patients – as of October 2020, the VA health care system had treated more than 65,000 people for the disease. Much work remains to be done; these early studies have been mostly limited to data that could be extracted and studied by Justice’s group from VA records. Over time, as DOE frees up more resources – people and time – to devote to the Partnership, it will enable more ambitious computational studies.

As the partnership grows, said Klote, and new data sets are added to the sample for analysis, it will be important to focus on the diversity of the data: Despite their immensity, the VA and CMS data sets represent a pretty narrow sample of Americans. “About 60 percent

of our population is Vietnam veterans, almost exclusively men,” she said. “We just don’t have a very diverse population. So we can say certain things about the data, but we’re limited, in a lot of ways, about what we can say. That’s why we were trying to pull all these different data sources onto the Department of Energy servers.” Klote is enthusiastic about the prospect of accessing data from the military health care system, which treats not only active-duty service members but also their spouses and kids, as well as military retirees.

“We don’t have any kind of population like that in VA,” she said.

Amid the worst pandemic the world has seen in a century, the architects of the COVID-19 Insights Partnership are focused on throwing everything they have at increasing our understanding of the disease and improving outcomes for patients. “One of the things we’re learning by trying to do this collaboration is how can we most effectively do it in a way that is respectful, protecting individual privacy, but also capitalizing on the fact that we have this information that can help both veterans and non-veterans,” said Justice. “It’s been a steep learning curve, but we’re hoping we’re going to be better positioned to be able to do this even more effectively in the future, particularly if there is another wave of the COVID-19 epidemic.”

Klote, who spent 13 years overseeing Army medical research programs before joining the VA, believes the COVID-19 Insights Partnership is a groundbreaking collaboration, with the potential to impact the future of American medicine. “If we can put all these data in the same place, it will be a model for future public health emergencies, such as suicide or opioid addiction,” she said. “If we can get agreements together and work through this process – because it’s never been done before – we will have a model to solve some major medical issues going forward.”

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THE NATIONAL ARTIFICIAL INTELLIGENCE INSTITUTE

The VA’s new institute aims to improve veterans’ lives through advanced analytics.

By Craig Collins

I

n the spring of 2020, as the nation’s COVID-19 pandemic continued to confound doctors’ efforts to predict patient outcomes, the Department of Veterans Affairs’ (VA) new National Artificial Intelligence Institute (NAII) stepped up to the plate: In collaboration with the Washington DC VA Medical Center, a predictive model was developed that would incorporate patient data from the department’s Corporate Data

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Warehouse (CDW) with demographic and other community data. This data, analyzed by artificial intelligence (AI) software using machine-learning algorithms, would predict prognostic risks for various outcomes, including whether or not an individual patient would succumb to the disease within 30 days.

The work showcased a new type of collaboration and worked through various policy and computational issues. The

experimental tool consisted of two main elements: the mortality model itself, which performed better than existing models; and a COVID-19 dashboard for VA clinicians, which would display a patient’s risk score, along with the individual and environmental factors driving that risk.

The COVID-19 dashboard, piloted at the Washington DC VA Medical Center, is available to VA clinicians, offering two distinct views: Primary care teams can filter datasets by patient’s health care provider, track COVID-19 testing, and view the mortality risk scores – probabilities generated by the model. Inpatient care providers can filter datasets by hospital location and specialty.

Hospitalists at the DC VA Medical Center were all given access to the model to assess its potential for ensuring, prior to a patient’s discharge, that no hidden or unusual factors might affect the prognosis. Though still in the pilot phase, the new predictive model is already leading to good results: Clinicians tested the model on a COVID-19 patient with a kidney disorder. The hospitalist believed the model would overweight the preexisting conditions and predict mortality on a patient who was recovering – but this was not the case; the patient had a relatively low mortality risk score (0.31) when factors such as oxygen saturation and platelet levels were factored into the prediction.

THE VA’S NEW INSTITUTE The COVID model and dashboard pilot at the DC VA Medical Center, along with other VA AI capacity-building efforts, demonstrate something that may not be widely known outside the VA health care system: AI is already being applied in many circumstances to improve the diagnosis and treatment of veteran patients.

It’s no wonder: AI works best when algorithms can process a lot of underlying, interrelated information, and the Veterans Health Administration operates the largest integrated health care system in the United States, serving more than 9 million patients at more than 1,200 medical facilities. Through its Million Veteran Program, it has collected and curated

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VA PHOTO

VA PHOTO BY ROBERT TURTIL

Left: Gil Alterovitz, PhD, leads the Department of Veterans Affairs’ National Artificial Intelligence Institute. Left, below: James A. Haley Veterans’ Hospital pathologists Dr. Andrew Borkowski, left, and Dr. Stephen Mastorides examine tissuesample slides under a microscope. Borkowski and Mastorides are training a machine-learning module to differentiate between cancerous and healthy cells in images taken from specimen slides.

genomic data from about 800,000 donated blood samples, the largest such database in the nation.

VA medical records also contain more than a billion images from scans, X-rays, and other technologies – a rich potential resource for AI applications. Earlier this year, for example, Drs. Stephen Mastorides and Andrew Borkowski of the James A. Haley Veterans’ Hospital in Tampa, Florida, began training a machine-learning module to recognize the difference between cancerous and healthy cells in images taken from specimen slides. In their earliest studies, machine-learning software was able to diagnose cancer with accuracies above 95 percent.

The VA trains more doctors and nurses than any other health care entity in America, and R&D emerging among VA investigators and clinicians reveal the enormous potential of AI to transform research and care. The key to unleashing

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this potential will be the ability to focus and coordinate the explorations and uses of AI in order to apply a strategic, veteran-centered focus to VA research and clinical care.

To help achieve this focus, the NAII was formally established last fall – in November, National Veterans and Military Families Month. Gil Alterovitz, PhD, FACMI, FAMIA, who was one of the core writers of the updated “National AI R&D Strategic Plan” released in 2019, is leading the new institute. He is also a Harvard Medical School faculty member in the Department of Medicine and has led national and international initiatives in the innovative use of health care data and technology.

The institute is a joint effort between the VA’s Office of Research and Development and the Secretary’s Center for Strategic Partnerships; the NAII will combine the resources and expertise of the VA and partners in the public

and private sector. It will look at partnerships, policy, pilots, and community engagement around AI. For example, VA collaborations have included a partnership between VA and DeepMind working on predicting the onset of deadly kidney disease. The institute is working across offices and industry to enable leveraging this and other models at the VA for AI R&D and education.

Less than a year old, the new institute is working on a strategy that begins, Alterovitz explained, with two primary components: “We want to make a difference for the veterans, their health and well-being,” he said. “So we’ll need to know the veterans’ priorities, and that’s one of the things we’re working to discover.” In order to use AI to meet those priorities, VA will bring different offices and a veteran engagement board together to determine priorities and pilot the use of these cutting-edge technologies.

“There are a number of offices that are working on different applications related to artificial intelligence,” Alterovitz said, “so we established an AI Task Force that is bringing together offices across the VA – and not just in research. That way, we can work together to combine and leverage some of these applications, and make a difference for the veterans directly.”

Earlier this year, the institute was cited as one of the early national AI successes in the first annual report of the American AI Initiative (link: https://www.whitehouse.gov/wp-content/uploads/2020/02/American-AIInitiative-One-Year-Annual-Report.pdf).

AI MEETING VETERAN NEEDS The careful work of coordinating and strategizing is important to AI’s future

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High school students (from left) Ethan Ocasio, Neeyanth Kopparapu, and Shreeja Kikkisetti developed the Clinical Trial Selector, which won honorable mention at the NAII’s inaugural AI Tech Sprint.

could be adapted or scaled up to have a huge effect for both veteran patients and VA investigators. Alterovitz imagines a search engine that might allow veteran patients to log in and find – and sign up for – trials matching their medical information. “The VA researcher who is recruiting patients for a trial will automatically have another patient,” said Alterovitz. “And, most importantly, the patient benefits, because they get this experimental treatment – which they might not have been able to access otherwise – that could work for their condition.” The team later received production access to VA data for veterans to use the app, and feedback was used to enhance VA health information available to veterans.

The Clinical Trial Selector won honorable mention at the Tech Sprint, whose overall winner was a team from the digital consulting company Composite Apps.

The application developed by this team, CURA Patient, is a web-based platform for coordinating care and making care plan details available to patients and their families; providers; specialists; and payers. The platform is a complex, multifunctional tool – for example, Alterovitz pointed out, it can apply machine learning to imagery and function as a

THE FUTURE OF AI IN VETERAN CARE As it encourages novel interactions with organizations outside the VA, the NAII is working to build interdisciplinary partnerships in AI research and development. “We’re looking at doing different collaborations and leveraging different types of data that traditionally have not been used for veterans.”

For example, an NAII team consisting of Alterovitz and Christos Makridis, PhD, collaborated with professor Cosmin Bejan, PhD, from Vanderbilt University, Stanford University computer scientist David Zhao, and the polling firm Gallup to examine machine learning ap-proaches that could quantify the role of socioeconomic factors on veterans’ physical well-being.

While some socioeconomic data can be found in VA medical records, it’s not typically a focus – but responses to survey questions, carefully crafted by Gallup, have the potential to add detail and discover connections that medical records alone may not be able to reveal. “This is thinking of novel ways to apply AI,” said Alterovitz, “using new processes and partnering approaches. It’s based on data gathered from outside the VA, but focuses on how that data, with AI, can help improve veterans’ well-being.”

As the NAII continues to gather information about how AI is being applied

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VA PHOTO

in the VA, but the NAII is also actively working to encourage the exploration and implementation of AI to solve urgent problems.

The NAII has pioneered what it calls AI Tech Sprints: time-limited competitions, conducted in partnership with the Department of Commerce, designed to encourage collaboration with potential partners in the academic, industrial, and nonprofit sectors. The approach earned a Government Innovation Award for public-sector innovations in 2019. Teams that compete in AI Tech Sprints are charged with designing AI-enabled tools that address veteran needs, all while interacting with VA researchers.

More than 10 teams, most of them representing leading software and health care companies, participated in the institute’s inaugural AI Tech Sprint that showcased results in December 2019, an event that produced several promising innovations – one of which was developed by three high school students from Virginia.

The students’ Clinical Trial Selector used natural language processing to draw patient information from records, applied AI to sort through characteristics of cancer patients – including age, gender, lab values, and types of cancer – and then ran that information through an interface with the National Cancer Institute to match eligible patients with clinical trials.

Today, matching veterans to clinical trials can be a tedious, frustrating process. This new tool, developed in a short period of time by high school students,

virtual caretaker: A patient could take a picture of their pills for the day with a smartphone, send it to the cloud for processing, and receive immediate feedback. “It might tell you: ‘Oh, you’re missing this medication right now. You should be taking this twice a day, and you don’t have it in your hand.’”

In addition to optimizing care for individual patients, said Alterovitz, CURA Patient can be scaled up to steward the cost and efficacy of care throughout a health care system. “It has different phases for how it can be integrated into different systems,” he said, “and at each level, there are different pieces of AI that contribute to it.”

VA PHOTO BY ADAN PULIDO

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throughout the VA, a picture is emerging of what kind of AI is most needed by VA researchers. One of the NAII’s first tasks has been to define the challenges VA researchers and clinicians may encounter in developing and implementing AI R&D, and to identify key areas for advancing AI R&D at the VA. Specifically, the NAII has identified five key areas for cutting-edge AI research and development: 1) deep learning, 2) trustworthy AI, 3) privacypreserving AI, 4) explainable AI, and 5) multiscale AI analysis.

Deep Learning. Deep learning is modeled after how our brains function. It utilizes artificial neural networks with specialized, multi-layered architectures, and can learn tasks by analyzing training examples. “It’s a technique that is especially useful when you have noisy data sets in related pieces of information,” said Alterovitz. “And that’s exactly what we see many times in the VA: You’ve got imaging. You’ve got language that is processed from clinical notes, which can include typos. Some of these are quite messy. They are noisy and large – the largest integrated health care system in the country, all running essentially the same overall software.”

The VA/DeepMind collaboration to predict the onset of deadly kidney disease – and to enable prophylactic treatment – is an example of deep learning at work.

Trustworthy AI. Trustworthy AI is developed around the nation’s laws and values – which may seem a selfevident characteristic of AI, but some

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Dr. Thomas Osborne is chief medical informatics officer at the VA Palo Alto Health Care System and leader of a trial there to evaluate the artificial intelligence model developed by the VA/DeepMind partnership to predict the onset of deadly kidney disease.

machine-learning algorithms, despite the intentions of their designers, can produce untrustworthy results. For example, last fall, a research group reported a study in Science that found a health insurance algorithm employed by major U.S. hospitals was biased to determine that Black patients were less likely to need care.

One important assertion of trustworthy AI is that the training data used to develop algorithms must be representative of the people the algorithm is designed to help. VA data, which represents the multitude of experiences, attitudes, and ethnic, geographic, and gender composition among veterans, will encourage researchers to train algorithms that are fair and equitable to all veterans.

Privacy-preserving AI. The tremendous amount of veteran health data collected by the VA creates a challenge when that data is accessed by researchers and partners: Information is essential for training powerful AI algorithms to serve veterans, but VA data often contains sensitive health details, and it is important to obtain results without violating privacy by identifying individual patients.

One option is a cutting-edge technique known as homomorphic encryption,

which allows a program to perform analysis or calculations on encrypted health information without revealing any information about a patient’s identity.

Explainable AI. Another priority, particularly for clinicians, is explainable AI: Physicians want to understand why a machine made a decision that will affect a patient’s health. Feeding data to an algorithm and getting an answer – for example, recommending a certain medication for treatment of a patient – without any insight into how that recommendation was reached is an experience known as the “black box” phenomenon.

Many physicians – understandably – approach such results with skepticism.

The Prediction Modeling Unit at the Ann Arbor VA Center for Clinical Management Research (CCMR) encountered this problem when developing an AI model for predicting symptomatic flareups associated with inflammatory bowel disease (see sidebar, page 31). “Some of the statistical methods we’ve used in the past,” said Ann Arbor VA gastroenterologist Akbar Waljee, “are easily understood. We do confront some barriers or challenges with people adopting some of these machine-learning methodologies, because some are likely to say: ‘Well, you just threw data into a computer, and it came up with something. How do you know why it came up with that?’”

Explainable AI, said Waljee, produces more than just a decision or rec-ommendation; it presents users with a list of decision points during the processing of a given algorithm – an illustration of how it arrived at its conclusions.

Likewise, said Alterovitz, the new COVID-19 dashboard pilot makes the AI behind its model explainable to clinicians, who do not have to take its risk scores at face value. They can see all the inputs that were included in – and excluded from – the model, and how they were interrelated and considered, in order to decide whether they need to leverage its findings and/or seek more information to inform their treatment of a patient.

Multiscale AI Analysis. A system with the size and scope of the VA, said Alterovitz, will need AI applications

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USING AI TO PREDICT IBD FLARE-UPS AT THE VA’S ANN ARBOR HEALTHCARE SYSTEM in Michigan, gastroenterolo-

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gist Akbar Waljee, MD, is building a better way to predict flare-ups in symptoms associated with inflammatory bowel disease (IBD).

More than a million Americans – including, according to a VA study, more than 60,000 to 80,000 veterans (2000-2019) – suffer from IBD, an umbrella term for chronic conditions that include Crohn’s disease and ulcerative colitis. According to the Crohn’s and Colitis Foundation, IBD-related hospitalizations and outpatient drug therapies cost between $11 billion and $28 billion annually.

Periods of symptom flares and remission are typical of IBD, and flare-ups are often painful and debilitating enough to require hospitalization, surgery, or treatment with steroids – which can involve side effects and increase the risk of other disorders, such as infections, bone loss, blood clots, and high blood pressure, among other side effects. In some cases, IBD can lead to lifethreatening complications such as blood clotting and liver damage.

Biomarkers that help predict IBD flares are most commonly identified through blood or stool tests, which are expensive and vary widely in availability and accuracy. Better predictive models, Waljee believes, would help patients avoid disabling aggravations of this disease and keep them in remission – and in remission, avoid long periods of ineffective or unnecessary therapies with other drugs. By keeping veterans out of hospitals, a better predictor could also greatly reduce IBD-associated health care costs.

Waljee is exceptionally capable of devising this new predictive tool: In addition to being a staff physician, he’s an investigator in the Ann Arbor VA’s Center for Clinical Management Research (CCMR). With research health scientist Wyndy Wiitala, PhD, he co-directs the CCMR’s Prediction Modeling Unit (PMU), which uses machine learning to collect and analyze patient data for the purpose of informing clinical decisions.

that can simultaneously analyze items at multiple scales: integrating deep learning models across several modes of medical imagery, for example, from the molecular level to gross anatomy.

Multiscale analysis can also refer to time: using an observation or lab value from a given moment in time to predict trends over days, months, or even years.

“Integrating information from multiscale analysis can give you a better picture of a patient,” Alterovitz said. “It’s very useful for finding relationships – say, inputs from different specialists,

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Using machine-learning algorithms to analyze patient record data, including histories of flares and commonly available bloodwork values, the PMU team, along with University of Michigan statistician Ji Zhu, PhD, came up with a set of criteria for deciding which patients to watch more closely and which may need to begin taking non-steroidal medications to forestall flares. Because some of these drugs take two to three months to take effect, Waljee said, it’s important to identify a coming flare at least three months in advance. “We decided to take all of the relevant information from a patient’s prior history, the longitudinal data, and then predict their need for steroids in the next few months,” he said.

The model produced by the Ann Arbor team – which is updated over time to integrate new patient data – has outperformed traditional tests, predicting flare-ups among veteran patients with about 80 percent accuracy. The next step, Waljee said, will be to validate the model in an external cohort of patients, and then to develop a platform for deploying the model throughout the VA.

such as radiologists and pathologists, who may not normally interact with each other that much.” AI also, he said, can be applied to VA care systemwide, to reveal outcomes in terms of quality, efficiency, and cost – a better picture of how the entire VA health care system is performing.

Wyndy Wiitala, PhD, who co-directs the CCMR’s Prediction Modeling Unit in Ann Arbor with Waljee, believes the NAII, with its focus on coordinating resources and expertise, could help unlock the vast potential of data contained within veterans’ medical records. “The VA has such

rich data,” she said. “There are a lot of opportunities to use that data for different prediction models in different situations, to understand patient trajectories and to improve patient care. I think there is a lot of work to be done in that area, and I think it would be great to collaborate with others.”

Given its size, complexity, and emphasis on data-driven clinical decision-making, AI may become the most powerful tool available to VA researchers, clinicians, and administrators: the key to putting the VA’s unique resources to work to help veterans.

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THE VA’S NATIONAL PRECISION ONCOLOGY PROGRAM Building a System of Excellence for cutting-edge cancer care

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ven among medical professionals, it can be difficult to appreciate the speed at which the field of oncology – the study and treatment of cancer – has transformed in the 21st century. Before 2003, when the international Human Genome Project completed identifying and mapping all of the genes in the human genome, oncologists mostly fought cancer with the three blunt instruments at their disposal: surgery, chemotherapy, and radiation.

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With the ability to sequence the genes of humans and tumor cells, researchers began investigating ways to block or disrupt the disease pathways of specific cancer types. Within a year of the Human Genome Project’s completion, for example, investigators discovered a mutation in a particular gene, the EGFR gene, which could lead to overexpression of hormone receptors, tumor development, and growth. The receptor activated by this gene, researchers discovered,

could be targeted at the molecular level with new EGFR-inhibiting drugs such as gefitinib and erlotinib.

Over the next decade, researchers discovered many more gene alterations that predicted cancer patients’ responses to specific drugs. This new paradigm for treating cancer – patientspecific molecular testing of tumors to determine whether they will respond to certain treatments, particularly with safe and effective anti-tumor

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V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

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Patient-specific molecular testing of tumors enables doctors to determine how they will respond to certain treatments and to prescribe more targeted therapies.

(antineoplastic) drugs – is known as precision oncology.

The ability to sequence the genes of individual patients and the opportunity to develop drugs targeting these mutations have revolutionized the study and treatment of cancer – a disease that is, fundamentally, a failure to regulate cell growth.

A program of molecular testing sprang up quickly within the nation’s largest integrated health care system, the Veterans Health Administration (VHA), and a regional precision oncology program, based primarily in VHA’s New England Healthcare System, began to emerge.

The National Cancer Institute (NCI), meanwhile, as part of the White House’s 2016 Cancer Moonshot initiative, began

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supporting clinical trials at hundreds of hospitals and clinics around the country to evaluate the responses of certain tumors to both existing drugs and experimental drugs that showed promise for treatment.

Part of the VA’s contribution to the Cancer Moonshot Initiative was the formation, in 2016, of what’s now known as the National Precision Oncology Program (NPOP). NPOP began as an effort to expand the New England program into a nationwide capability and to maximize the access of veteran patients to clinical trials of precision cancer drugs. Its core purpose is to make genetic testing available to VA cancer patients for whom testing may determine either a prognosis or a course of treatment, but NPOP

extends more than the program’s geographic reach; it offers consultative services to VA oncologists, helping to interpret the often complex results of genetic sequencing, and an informatics system that supports research and a learning health care system. Clinical care is supported by VA’s sophisticated telehealth delivery system, which makes precision oncology available to a growing number of veteran patients.

The establishment of NPOP led to a rapid increase in the number of VA facilities participating in the program and the number of tumor samples being submitted for molecular analysis. Many of these first samples were of certain types of lung tumors, which were not only common among VA cancer patients, but also associated with a high number of mutated genes that resulted in sensitivity to anti-cancer drugs. More recently, metastatic prostate cancer tumors were added as a focus for molecular analysis.

Prostate and lung cancer are the leading types of cancer among veteran patients; of the approximately 50,000 veterans who are diagnosed with cancer each year, about 15,000 are diagnosed with prostate cancer, and about 7,700 with lung cancer. For VA’s oncology care teams, dashboards are available at the NPOP website to help identify veterans at their facilities with either lung or prostate cancer who may be appropriate for testing. Other solid tumors may be sent for testing through NPOP, as well, if patients have advanced-stage cancer and are candidates for drug therapy. To date, the VA’s NPOP has sequenced more than 13,000 samples, and the program is utilized by nearly every oncologist practicing within the VA.

FROM HUBS OF EXPERTISE TO A SYSTEM OF EXCELLENCE According to Michael Kelley, MD, VA’s national program director for oncology,

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the NPOP was designed from the beginning to be a platform with research built into it.

As the program rolled out, VHA’s Office of Research and Development (ORD) launched its Research for the Precision Oncology Program (RePOP) and a Precision Oncology Data Repository (PODR) to advance the knowledge and capabilities necessary to improve care for veteran cancer patients. These programs work to recruit more veteran patients to trials, increasing the amount of data and tumor tissue available for study, while using that data to develop predictive models, analytic techniques, and clinical applications.

An important research initiative prompted by the Cancer Moonshot is the APOLLO (Applied Proteogenomics Organizational Learning and Outcomes) program, a collaboration between the VA, the Department of Defense, and the NCI to classify tumors (with an initial focus on lung tumors) not only by genetic changes, but also by levels of certain proteins, which can also be biomarkers associated with cancer. APOLLO, which performs molecular analyses of every possible gene mutation and protein expression, provides new insights into the biology of various cancers and treatments that can be targeted and evaluated in clinical trials.

Because prostate and lung cancers account for about half of the cancers diagnosed among VA patients annually, the NPOP’s early focus was devoted to these two types of cancer. VA research

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Dr. Bruce Montgomery, co-lead for the Precision Oncology Program for Cancer of the Prostate, meets with Navy veteran Allen Petchnick, whose prostate cancer has been effectively treated to date with targeted therapy.

into precision medicine for veterans with prostate cancer was given an enormous boost when, shortly after the NPOP had been established, the VA formed a $50 million partnership with the Prostate Cancer Foundation (PCF). The initiative established by this partnership, the Precision Oncology Program for Cancer of the Prostate (POPCaP), aims to deliver precision oncology to all veterans with prostate cancer.

POPCaP has grown dramatically since it was first funded in 2018. It consists of a network of 12 hubs of expertise with the capacity to perform precision oncology, as well as a searchable data core that includes clinical notes, pathology reports, radiology and laboratory reports, and more. POPCaP provides veterans with metastatic prostate cancer access to genetic testing and genetic counseling, clinical trials, and access to on- and off-label use of U.S. Food and Drug Administrationapproved drugs matched to specific mutations.

The VA-PCF partnership funded a large pilot program called PATCH (Prostate Cancer Analysis for Therapy Choice), which attempts to leverage NPOP’s sequencing capabilities into studies. The goal of PATCH is to match

each possible mutation in a veteran with prostate cancer to a different trial – ultimately, to increase the number of VHA facilities involved in precision prostate cancer clinical trials; to improve veteran access to those trials; and to increase the number of clinicians providing care and working in prostate cancer research.

According to Rachel Ramoni, DMD, ScD, VA’s chief research and development officer, PATCH isn’t really a “study,” but rather “an infrastructure for us to rapidly run through precision oncology trials for prostate cancer, so that as new ideas emerge, we don’t have to look for sites to run the trial, because we have really well-oiled machinery to be able to launch and conduct those trials. And in VA, we certainly have the scale to do that. ... PATCH is all about getting those trials open and completed as quickly as possible, so you don’t have to set up an entire system every single time; you can rapidly go from one trial to the next, or run parallel trials.”

Like most VA clinicians, Michael Kelley, the VA national program director for oncology, is also a research scientist: He’s chief of hematology-oncology at the Durham, North Carolina VA Medical Center and a professor of medicine at Duke University. POPCaP has provided a template, Kelley said, for how the VA can bring precision oncology to every veteran who needs it. “I think a lot of us have a vision of the type of care we’d want for a loved one with cancer – the quality of care, the efficiency of its delivery, and ready accessibility. That is what we were thinking about when we were establishing – initially, through our partnership with the Prostate Cancer Foundation – the Precision Oncology Initiative as an integrated clinical and research system in combination with our precision oncology and telehealth expertise.”

POPCaP provides precision oncology through a hub-and-spoke model, with NPOP sequencing and delivering services through regional hubs of expertise, and one of the things the VA has learned, Kelley said, was that with its cuttingedge telehealth capabilities – recently

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expanded with a $4.5 million dollar grant from the Bristol Meyers Squibb Foundation to establish a national teleoncology center aimed at more effectively reaching veterans living in rural communities – it can deliver those services anywhere. “If you look at the map of the patients who have participated [in NPOP], you’ll see it’s essentially a distribution map of where veterans are in this country. NPOP is one component of what excellent oncology care looks like, but it’s very clear that similar expertise could be in one place, or a small number of places, and we could distribute that across our system.”

Today, every veteran with prostate cancer can be tested and have DNA examined not only from somatic cells – tumor cells with DNA damaged by mutation – but also “germline” or “constitutional” DNA, which is the DNA passed down from parents to offspring, and that can contain mutations that elevate cancer risk for patients or their family members.

POPCaP sites provide access to appropriate trials, precision oncology care, genetic counseling, and other services.

“These POPCaP sites are doing a great job of implementing those services,”

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Army veteran Roger Lupkes, who has been diagnosed with prostate cancer, lung cancer, and colon cancer, and his wife, Henrietta, travel 100 miles from their home in rural Minnesota to the Sioux Falls VA Medical Center, where he is able to see his oncologist, Dr. Michael Kelley, who is 1,400 miles away in North Carolina, via a telehealth visit. The VA’s robust telehealth infrastructure is making it possible for veterans to receive cutting-edge precision oncology care regardless of where they live.

said Kelley. “But we’re not satisfied with that. We want that to happen everywhere. Our thinking about these sites, delivering care across the system, has evolved. Now we’re thinking we don’t need only a center that delivers excellent clinical care. We need a system of excellence.”

The successes of POPCaP have catalyzed a VHA initiative to create a Precision Oncology System of Excellence: an enterprise-wide capability to deliver precision oncology care to veterans regardless of where they are or what type of cancer they have. Both Kelley and Ramoni, when asked to describe their vision for what this System of Excellence will look like, speak in terms of defining clinical pathways for precision oncology:

evidence-based care plans established to reduce variation, improve the quality of care, and optimize outcomes for patients.

“The System of Excellence we envision,” Kelley said, “is that as soon as an improvement or change in clinical care comes about, and there is a consensus that this improvement should happen in a center – well, it should happen everywhere. Veterans shouldn’t have to travel to one of the 12 centers. They should be able to get it where they are.”

They should also, Ramoni said, immediately benefit from the latest research findings. “What you need to know about this effort is that it’s really an integration of the research and clinical areas around precision oncology,” she said.

ORD works closely with clinical partners to both make these clinical pathways available everywhere, and also to support and update their implementation.

“Beyond simply sharing the pathways as information about best-practice care, we want to ensure that the care is available and is being provided to our veterans. We want to know when there are places in the VA where they might need help in living up to the expectation that we provide the best care wherever a

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VA PHOTO BY CHRISTOPHER PACHECO

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V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

Navy veteran and cancer survivor Patrick McGuire, who was diagnosed with stage IV lung cancer, benefited from DNA sequencing of his tumors; the testing revealed a particular gene mutation for which the VA was able to prescribe a targeted drug.

veteran may be.” Ramoni describes the System of Excellence as a learning organization fueled by research findings: “All top cancer care centers feature clinical trials,” she said, “and those inform the care pathway – so that what we learn over time leads us to provide ever better care to our veterans.”

VA PHOTO BY ASHLEIGH BARRY

PHASING IN When he announced the effort to establish a Precision Oncology System of Excellence last year, VHA’s executive in charge, Richard Stone, MD, explained that it would be phased in over time, beginning with a nationwide system of precision oncology for lung cancer that will likely first be rolled out in a nationwide network of sites, analogous to those implementing the POPCaP program as both clinical and research centers. The process of selecting and operationalizing these VA medical center hubs to conduct genetic lung cancer screening and to lead precision oncology clinical trials, as part of this larger lung cancer precision oncology plan, is scheduled to occur in 2021 and 2022.

Over the longer term – beginning around 2022 – the VHA will phase in infrastructure to support precision oncology for breast cancer and rare cancers. Breast cancer isn’t one of the

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most common types of cancer among veterans – but that’s because 97 percent of veteran cancer patients are men. According to Kelley, there are about 700 new diagnoses of breast cancer annually in the VHA, a number expected to rise as more women serve, and as more women veterans age. The VHA, Kelley pointed out, is committed to serving all veterans. He envisions a system of cutting-edge precision oncology for breast cancer delivered from a single virtual center.

“It’s going to be making sure that there is good care coordination and case-tracking, to ensure that patients get the right care at the right time, and that there is an opportunity to talk to a group of experts in breast cancer for the VA providers who are seeing and caring for patients,” Kelley said. “These experts can be directly involved in that patient’s care, if that is appropriate, or they can be overseeing what is happening through their own sets of data in the electronic medical record – or both.”

A focus on rare cancers is more logical than it sounds: “Rare cancers,” Kelley said, “are not rare, believe it or not.” As a group, they account for about 16 percent of all cancers, and gene sequencing for some rare cancers has led to seminal advances in targeted therapies not only for those cancer types, but for other

types as well. Kelley foresees a likely rare cancer precision oncology partnership with the NCI and the Defense Department, to build the knowledge base necessary to produce actionable results from research.

Meanwhile, ORD is laying the groundwork for the research that will underpin clinical advances in precision oncology for breast cancer and rare cancers: establishing mechanisms to allow veterans with breast cancer greater access to clinical trials, and building networks to advance research and initiate new programs with partner agencies such as the NCI and the National Institute of Dental and Craniofacial Research.

Because of the comparatively smaller number of both of these cancer types in the VHA, Ramoni said, both will likely involve virtual clinical trials: “That simply means you don’t have to be in, say, Seattle to participate in the trial. To the extent possible, these trials will be available to people wherever they are. When we’re researching oral medications, for example, we’ll mail the medications directly to people’s homes and conduct a kind of tele-clinical trial.”

Taken together, these efforts will help expand the National Precision Oncology Program’s System of Excellence, fostering an enterprise-wide culture conditioned to push itself toward advancements in research and care, to remove any disparities in access to the VA’s cutting-edge cancer treatments, and to inform veterans – and their families – what their genes might be saying about their risk for cancer.

“I view this as not only helping the veterans, but their family members as well, to understand their risk of cancer – which may add years of healthy life for them all,” Ramoni said. “And the scale of the VA obviously means we’re going to touch a lot of American families.”

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VA TELEHEALTH RESPONDS RAPIDLY TO PANDEMIC D

uring the COVID-19 pandemic, many Americans are experiencing telehealth for the first time, as health care systems offer opportunities and encourage patients to connect remotely with their providers. This allows them to safely stay at home, limiting their exposure to the coronavirus while continuing to access care.

The same is true for the nation’s veterans, who are in vast numbers

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increasingly participating in telehealth services during the pandemic.

But in fact, for many veterans, telehealth is nothing new. Recognized as a world leader in the development of telehealth services, the Department of Veterans Affairs (VA) has led the way in telehealth innovation for more than 50 years.

In 1968, closed-circuit television connected specialists at the University of

Nebraska Medical Center with veterans at VA hospitals in Grand Island, Lincoln, and Omaha, Nebraska. In the five decades since, the VA has provided an increasing array of telehealth services, enhancing accessibility and quality of care for veterans anywhere in the country.

That expertise has positioned the VA to quickly increase its capacity and ability to provide these services during the pandemic.

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By Gail Gourley

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U.S. ARMY PHOTO BY VISUAL INFORMATION SPECIALIST JASON JOHNSTON

Opposite and left: While many Americans were forced to use telehealth services for the first time due to the COVID-19 pandemic, many VA patients had been taking advantge of telehealth services for years.

application that we call Annie,” she said, which delivers automated text messages like medication reminders or healthrelated notifications and can be helpful used in conjunction with telehealth modalities.

EXPANDING TELEHEALTH CARE

CATEGORIES OF TELEHEALTH SERVICES Current VA telehealth falls into three overlapping categories: remote patient monitoring/home telehealth; asynchronous telehealth; and synchronous telehealth.

According to Leonie Heyworth, MD, MPH, the VA national synchronous telehealth lead and primary care provider at San Diego VA Healthcare System, “In 2003, the home telehealth program, which was the original telehealth product, provided care for our more fragile homebased veterans in remote monitoring of vital signs, for example, and transmitting them under the supervision and care of a nurse.”

Remote patient monitoring continues functioning as an important telehealth category, utilizing advanced technology to collect and send health data for care management.

A second category, asynchronous telehealth, uses technologies to acquire and store clinical information – data, images, or sounds – that is later evaluated by a VA provider at another location.

“An example of this would be teledermatology or tele-eye, where images are taken by a technician and reviewed by a provider asynchronously; that is, the images may be taken at a different time from the time that the images are reviewed by the provider,” Heyworth

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explained. “It may be that whoever is reviewing those images doesn’t actually meet with that particular veteran, and it’s another provider who’s facilitating that care. That allows us to provide dermatology care or ophthalmology care in areas where they may not exist, by taking the same information that you would get in person but having that interpreted by an expert somewhere else.”

The third category, synchronous telehealth, uses real-time, interactive video conferencing to assess, treat, and provide care to veterans in a separate VA clinical location, and increasingly at home or another non-VA location.

“We evolved over the years, particularly in the 2011-2013 window, to doing more and more clinic-based telehealth, putting clinic-based telehealth staff in our clinics across the country to facilitate this care, and really building on that concept of providing the care where it’s needed,” Heyworth said. This has been implemented in more than 900 VA locations, allowing veterans to connect with VA specialist providers nationwide from local community clinics.

Each of the telehealth categories also weaves in mobile applications to deliver care, Heyworth said. “For example, asynchronous telehealth is coming out with a mobile application to allow veterans to take high-resolution images and short video clips to transmit to their providers from home. And we have a text-based

While the concept of delivering telehealth care to veterans in the clinic space had matured, Heyworth said, efforts turned to providing that care in veterans’ homes, or other non-VA locations of their choice.

In 2018, a new federal rule allowed VA providers to deliver telehealth care to veterans regardless of where in the United States the veteran or the provider are located, including across state lines or outside a VA facility. “That was really a pivotal moment,” said Heyworth.

“It really opened things up for us at VA for telehealth, because essentially with that [rule], which we call ‘Anywhere to Anywhere,’ we can have a VA provider in any state, in any town anywhere, deliver care to where it’s needed most, by telehealth.”

With the authority to deliver care essentially anywhere, Heyworth continued, “That has really expanded over the past couple of years, but particularly over the past couple of months due to the pandemic, because of many veterans preferring to stay home for their care, concerned about COVID exposure, and [for] other veterans, because care is potentially easier for them to access at home, particularly those who live a distance from a VA facility.”

Veterans access telehealth in their home or other non-VA location by utilizing the VA Video Connect application, allowing live video on any computer, tablet, or mobile device with an internet connection.

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PHOTO COURTESY OF DEPARTMENT OF VETERANS AFFAIRS

“The goals and objectives are really to provide patient-centered care and to allow veterans to access care in a way of their choosing,” said Heyworth.

“Uniquely, VA enrolls veterans in locations where we have no facilities, so for those veterans, it may mean that they have to travel a certain distance to get to a VA facility in order to receive care. The concept of being able to deliver care remotely, and particularly into the home, by the use of video telehealth, through the use of mobile applications to monitor conditions in veterans’ homes, not only makes sense because of how VA delivers care geographically and how veterans are enrolled, but also speaks to the assets in this new digital era and our desire as a VA to make sure that our veterans are getting the most innovative services and products.”

Heyworth added, “The exciting thing about being at VA and doing telehealth is that we have a whole geographic enterprise of providers from which we can draw to provide VA services,” including to veterans who live in rural areas far from a VA facility or academic center.

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The VA has been providing an increasing array of telehealth services over five decades.

“We really are positioned uniquely to be able to [deliver that care], and I think we will see this concept of sharing expertise grow significantly across all our categories of care.”

TELEHEALTH IN EMERGENCIES Along with standard care, emergency and urgent care situations can also be managed with the VA Video Connect platform. Heyworth explained that if, during a video visit with a patient, the provider determines there is a medical or psychiatric emergency such as a heart attack or suicide threat, the built-in E911 feature allows the provider to contact the veteran’s local emergency service, identifying the patient’s location and the nature of the emergency.

“VA Video Connect is a VA-built product, and we identified early on the

E911 feature being a key need as far as the effective management of emergencies,” Heyworth said. “So functionally, in a video visit, the provider has tools to manage those emergencies.”

For urgent-care situations, Heyworth said, “There is a growing movement across VA to be able to offer same-day services by telephone and video, and there are multiple sites that have established this and attached these services to their call centers.” With providers attached to the call centers, she continued, “We have the ability, in cases and conditions that need to be seen right away and can be done virtually, to offer veterans that option.”

COVID-19 RESPONSE Heyworth attributes the VA’s ability to deliver the increased volume of telehealth services since the pandemic began to its early and ongoing efforts dating back to the original programs, and having staff across facilities familiar with these services.

“We had the benefit of having [telehealth] rolled out, having a system

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Annie is a VA mobile app that delivers automated text messages with health-related reminders or notifications.

Another factor in the growth, Heyworth said, has been recognition of “the need for veterans to have the equipment and the connectivity to participate. And to do that during the COVID months, we distributed over 7,000 tablets to veterans without their own devices and without connectivity to enable them to connect with us.”

While tablet distribution expanded since the onset of the pandemic, more than 50,000 tablets have been distributed to veterans since the program’s inception in 2016. Heyworth said that the Coronavirus Aid, Relief, and Economic Security Act (CARES Act) also provided funding for veterans enrolled in the VA supportive housing program to receive smartphones to further increase connectivity.

Since the pandemic began, Heyworth said, VA providers are increasingly enthusiastic about the capabilities of doing a remote physical examination using peripheral Bluetooth-connected devices such as a digital stethoscope, blood pressure cuff, thermometer, or pulse oximeter. “They enable a VA

ACCESS AND INCLUSION Looking ahead regarding VA telehealth, Heyworth said, “I think the

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VA PHOTO

to schedule it, and having providers trained and educated on it, and an initiative underway since 2018 with the goal of having every ambulatory provider at VA capable of doing a VA Video Connect visit,” Heyworth said. With the “Anywhere to Anywhere” rule granting the ability to provide telehealth services to veterans in their homes no matter where they live, she added, “We were positioned legally with the authority, and operationally with the tools and the training of our frontline staff, to be able to pivot quickly.”

Heyworth added that another component in delivering the exponential growth was the ability of their IT partners at the VA to rapidly expand the capacity of VA Video Connect and accommodate the demand surge in a matter of weeks.

For example, the volume of video telehealth to home visits exceeded 167,000 for the week of Aug. 16 to Aug. 22, 2020.

“That really speaks to the growth that we’ve seen over the course of the pandemic, because that is almost a 1,400 percent increase in the weekly volume of VA Video Connect visits to home from the end of February 2020,” Heyworth said. “So, VA really leveraged virtual care with the onset of the pandemic and continues to do so. … The growth is going strong.”

provider to do a more comprehensive exam, with the tools that they’re familiar with using in person in the clinic space,” said Heyworth. “The range of options that we have – from a simple video telehealth setup to using our digital stethoscope and actually seeing the rhythm strip like you would see on an EKG across the video screen – really speaks to a breadth of applications for the use of video, and something that has been surprising in a really great way during this pandemic, as people try and push the limits of understanding how they can do more and more video telehealth.”

With the huge increased use of telehealth since the pandemic began, the VA is offering support to providers.

Heyworth said, “Our goal of getting every provider to do one visit first has been a good strategy in making sure that people are comfortable and that we’re not saying, ‘Here’s a certain minimum volume we want you to achieve.’ We’re saying, ‘Let’s get you comfortable just doing one. Let’s make sure that you have the training.’ We encourage people to do a test call with the telehealth team or with their colleagues to make sure they have what they need in order to do the visit. We have a national telehealth technology help desk so people can call if they have any difficulties with the technology or if they need any help with troubleshooting.”

That support is also available to veterans, Heyworth continued. “We are beginning a process where we’ve asked facilities to establish a test call program for veterans, understanding that some veterans may need more support than others, particularly veterans who may be less familiar with the technology, or don’t use it as much as other veterans, to make sure that they feel confident ahead of their first visit in the use of the technology.”

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VA TELEMENTAL HEALTH Telehealth encompasses a wide spectrum of health care, including mental health.

TELEMENTAL HEALTH IN THE DEPARTMENT OF VETERANS AFFAIRS (VA)

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increases access to care and provides a broad scope of mental health services for veterans that includes every diagnosis, every type of therapy, and multiple locations, according to Linda Godleski, MD, Veterans Health Administration lead for telemental health, and director, VA National Telemental Health Center, and professor, Department of Psychiatry, Yale School of Medicine.

“In terms of being used for every diagnosis, it’s at the clinical discretion of the mental health clinician whether telemedicine is the optimal modality for any given patient, but there are no absolute exclusion criteria,” Godleski said. “We have patients with PTSD [post-traumatic stress disorder], depression, schizophrenia, and substance use disorder who are all being treated by telemental health.”

“Where [telemental health] is really useful is in preventing hospitalizations,” said Godleski. “It can be used to assess and address patients who are in an acute crisis, even at times suicidal, so that whereas in the past, the veteran would have to physically go to the emergency room to be evaluated to see whether or not they needed to be hospitalized, now they can go to the community-based outpatient clinic or even be seen in their home.”

In 2010, the VA launched the National Telemental Health Center (NTMHC).

“The purpose was to deliver the highest level of care to veterans no matter where they were located,” explained Godleski. This nationwide model, composed of clinical experts in diagnoses such as bipolar disorder, substance use disorder, and psychosis, and who are located throughout the country, provides teleconsultations to veterans anywhere. “[Veterans] don’t have to live right outside of a medical center or in a big city to be able to access the same level of expertise,” she said.

Against a backdrop of more than 6 million VA telemental health visits since the early 2000s, according to Godleski, the volume has “exponentially grown,” with a huge increase since the onset of the COVID-19 pandemic. Cumulatively, FY 20 year-to-date figures as of Sept. 24 show that the VA has provided telemental health services to nearly 534,000

future is that of inclusion. We want to make sure that every veteran has this opportunity.

“To that end, we’ve done a number of things,” she continued. “We have our ‘zero-rating’ option for those veterans who have internet connectivity, but are concerned about data use and cost of the video visit. We’ve worked with select mobile carriers on a so-called ‘zero rate,’ to identify the VA Video Connect domain name and not charge veterans against their personal data for

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veterans during almost 2.3 million visits, with more than 428,500 of those veterans receiving over 1,983,500 total telemental health sessions directly into their homes or other place of choice. Telemental health visits into the home comprised 86 percent of all telemental health visits, compared to 26 percent in FY 19.

When the pandemic began and clinics were shut down, Godleski said they needed to quickly get mental health services to their patients, including very seriously mentally ill patients.

“In the COVID world, it was even more important to reach out to provide support and decrease isolation, decrease anxiety,” she said. “What we learned from COVID is that telehealth has been an enormously useful tool to deliver mental health services to patients, even with the most severe illnesses, under the most unpredictable and stressful circumstances.

“VA telemental health care is really a game-changer in the delivery of mental health services,” Godleski said. “With telemental health, we can bring the necessary services right to the individual without disrupting their life, without disrupting their day, and exactly when they need it.”

the use of VA Video Connect as a health service.”

And for those veterans who don’t have connectivity in their home, Heyworth said, an initiative called ATLAS, Accessing Telehealth through Local Area Stations, places telehealth access points in select Walmart and veterans service organization locations, further increasing convenient access to care. There are currently seven pilot sites across the country.

“If we can’t bring care services to your home, let’s at least bring them to ‘Main

Street,’ so that care is more accessible to every veteran, and every veteran who is enrolled in VA services really has the opportunity to fully use them,” said Heyworth.

“Our hope is that veterans will give [telehealth] a try and really let us know what they think about it. Our goal is to make this veteran-centric,” concluded Heyworth, “and we’re very committed to making sure we understand their experiences and are positioned to respond meaningfully to them.”

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The U.S. Navy vs. the 1918 Spanish flu

By Dwight Jon Zimmerman

THE PANDEMIC BEGINS On March 4, 1918, Pvt. Albert Gitchell, a cook at Camp Funston in the Fort Riley, Kansas military reservation, was admitted to sick bay, the diagnosis: flu.

His was the first recorded military case of what would come to be called the Spanish flu, one that, when it had run its course, would infect hundreds of millions of people worldwide and kill more than 50 million.

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Though contagious, because the cases were mild – and with the French and British armies in desperate need of fresh troops from their new ally the United States in order to finally bring to an end the Great War (World War I) – Fort Riley’s commander ordered the flow of men entering and leaving for Army bases throughout the country to continue uninterrupted. Only flu victims requiring hospitalization were exempt.

Wherever they went, from Army camps to points of departure, to naval bases and elsewhere, infected soldiers passed on the disease, leaving in their wake an evergrowing number of victims to this new strain of flu. Once in Europe, infected soldiers soon spread the virus across France. From there, it was carried into England, over the trenches into Germany, and throughout Europe.

Ironically, because so many of the nation’s top medical professionals had either enlisted or were drafted when America declared war against Germany, soldiers, Marines, and sailors were able to receive the best medical care. But with flu vaccines yet to be invented, the only effective weapon doctors had against the spread of infectious diseases was the quarantine. Unfortunately, with the nation on war footing and having to fasttrack training and deployment of troops, medical professionals in the military, from Army Surgeon General Maj. Gen.

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NATIONAL MUSEUM OF HEALTH AND MEDICINE PHOTO

THE OTHER ENEMY IN WORLD WAR I

Military patients in an emergency hospital in Camp Funston, Kansas, in the midst of the Spanish flu pandemic. Camp Funston recorded the first military case of the Spanish flu on March 4, 1918.

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NAVAL HISTORY AND HERITAGE COMMAND PHOTO

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Left: Gen. John J. Pershing and Rear Adm. Albert Gleaves on the deck of USS Seattle in the harbor of Brest, France, 1918. The Spanish flu was transported across the Atlantic on troopships, and some 12,000 troops actually died of the flu while aboard them. Left, below: Rear Adm. William C. Braisted, Surgeon General of the U.S. Navy during the pandemic. He estimated that 40 percent of the Navy’s personnel ultimately were infected with the Spanish flu. Bottom: Superintendent of the U.S. Navy Nurse Corps Lenah Higbee was the first woman to earn a Navy Cross, for her service during the Spanish flu pandemic.

William Gorgas – the conqueror of malaria in Panama – to Surgeon General of the Navy Rear Adm. William C. Braisted, were helpless to stem what they knew would be a tidal wave of flu cases.

Yet only the most senior political and military leaders on both sides knew of the threat posed by the epidemic. Because they were afraid such news would devastate civilian morale and abet the enemy, the Allies and Central Powers both maintained strict censorship of the media. Such news of the virus that existed consisted of local newspaper reports, giving the impression that the problem was isolated or regional. The exception was Spain,

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a neutral country. When infected migrant workers returned home from France, the Spanish press’ extensive reporting caused the virus to get the mis-applied nickname that would be forever associated with the pandemic: Spanish flu.

By early summer 1918, when it appeared that the Spanish flu had run its course, top military authorities on both sides felt confident the problem was well in hand, if not over, and they could focus attention on their new offensives that would, one way or another, win the war.

The news that they were wrong was contained in the opening lines of a weekly status letter dated Sept. 7, 1918, from Navy Surgeon General Braisted to Secretary of the Navy Josephus Daniels.

Braisted’s message began with an optimistic opening sentence: “The health of the Navy continues excellent in that admission rates for all causes continue lower than average peace time rates.”

This optimism was undercut by the next sentence, which ominously stated, “However, the incidence of influenza is increasing.” By the end of the month, the U.S. Navy Bureau of Medicine and Surgery (BUMED) would face the greatest challenge of its existence, one that when it was over would see seven of its members – Superintendent Lenah H. Sutcliffe Higbee, Lt. Cmdr. Lee McGuire, Lt. William Redden, Nurse Marie Louise Hidell, Nurse Lillian Murphy, Nurse Edna Place, and Hospital Apprentice 1st Class Carey Miller – receive the Navy Cross for their heroic efforts fighting the Spanish flu.

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The interior of an isolation ward at Naval Training Camp Gulfport, Mississippi, during the Spanish flu pandemic. With no vaccine available at the time, the only recourse to mitigate the virus’ spread was quarantine.

NAVAL HISTORY AND HERITAGE COMMAND PHOTO

NAVY NURSES STEP UP In 1918, the U.S. Navy Nurse Corps celebrated its 10th birthday. Superintendent Lenah Higbee, a plankowner – one of the “Sacred Twenty” as the original 20 nurses were called – had 160 nurses ready for duty when America entered the war in April 1917. Fifteen months later, the Nurse Corps had 1,082 nurses, and none too soon. In late August-early September 1918, the flu’s violent, deadly second wave struck. In naval hospitals across the nation and overseas, Navy nurses found themselves on the medical front lines, working under appalling and dangerous conditions to save the lives of their patients, with many falling victim as well and some paying the ultimate price.

Because it received men from all over the nation, the sprawling Great Lakes Naval Training Base located north of Chicago became an epicenter of this second wave. When nursing school graduate Josie Brown reported for duty there, she was stunned by the flu’s effect on patients. She recalled that many victims suffered projectile nosebleeds.

“Sometimes the blood would just shoot across the room,” she said. “You had to get out of the way, or someone’s nose would bleed all over you.”

The influx and turnover of patients was so great that hospital staff was forced to

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organize them into queues going from beds to stretchers on the floor beside the beds, with more continuing down the hall.

In the morning, the staff removed those who had died the night before, replacing them with the next-closest patient.

Another area that became an epicenter was Philadelphia. Despite second-wave cases recorded as early as August, city leaders allowed a Liberty Loan Drive war bond parade to proceed as scheduled on Sept. 28. More than 200,000 attended, raising $600 million. Three days later, the flu’s second wave exploded in the city and nearby Navy Yard with such violence that within days, and in a move reminiscent of the Black Death plague of the Middle Ages, men in horse-drawn wagons traveled the streets calling for citizens to bring out their dead for burial.

Marie Louise Hidell and Edna Place were stationed at the naval hospital in Philadelphia. Like the rest of the staff, they worked grueling shifts. One night alone, Hidell admitted 188 patients.

Brushing off warnings about how they were putting their lives at risk, they contracted the virus and within hours of each other died on Sept. 29, the first two Navy nurses to succumb to the flu.

Navy nurse Lillian Murphy was stationed at the hospital in Naval Operating Base Hampton Roads, Virginia, another hard-hit second-wave epicenter because it was a dispatch location for soldiers

going to France. By Oct. 8, the base hospital had treated more than 3,500 cases.

Like her sister nurses elsewhere, Murphy worked tirelessly day and night treating her patients. She contracted the disease and died on Oct. 10.

On the second anniversary of Armistice Day, Nov. 11, 1920, the Navy officially recognized the courage and sacrifice of these nurses. Higbee became the first woman to be awarded the Navy Cross “for distinguished service in the line of her profession and unusual and conspicuous devotion to duty.” Place, Hidell, and Murphy received Navy Crosses posthumously for “distinguished service and devotion to duty.” These four are the only women to date to receive the Navy’s highest decoration.

THE TRAGEDY OF THE USS PITTSBURGH The autumn outbreak of the Spanish flu’s second wave struck just as convoys of troops from America to Europe were reaching their peak. Ultimately, more than 12,000 troops died on transports before reaching France. So devastating was that second wave that it forced a temporary suspension of troop convoys.

Of all the Navy ships to suffer from the outbreak, none equaled that of the USS Pittsburgh, the only major Navy warship to be put out of action by the disease.

The Pittsburgh entered the history books on Jan. 18, 1911, when, as the USS Pennsylvania, Eugene Ely conducted the first complete landing and take-off cycle from the armored cruiser’s makeshift flight deck. Re-named the Pittsburgh in 1912 to make available the state’s name for the lead ship in a new battleship class, in 1917 Pittsburgh became the flagship of Commander in Chief, Pacific Fleet, Adm. William Caperton.

In late 1917, Caperton was ordered to form the South Atlantic Squadron and

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NAVAL HISTORY AND HERITAGE COMMAND PHOTO

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conduct anti-submarine warfare patrols off the coast of eastern South America.

Because of the large Royal Navy presence already patrolling those waters, Caperton’s stated military mission was a cover for his unstated one: “showing the flag” diplomatic events with local dignitaries to keep Brazil, Uruguay, and Argentina in the Allies’ camp. By summer 1918, his squadron had shrunk from four armored cruisers to just the Pittsburgh, making the military mission moot.

Experience in handling the mild first wave of Spanish flu had made local health officials complacent when the Pittsburgh arrived at Rio de Janeiro in the beginning of October, where the ship prepared to enter a floating dry dock for scheduled repairs and maintenance. On Oct. 4, the passenger ship SS Dannemara arrived and discharged its passengers. Though some were infected with the flu, the city’s health authorities did not impose a quarantine. Nor did the Pittsburgh’s skipper, Capt. George Bradshaw, suspend shore liberty for the crew as a precautionary measure. By Oct. 7, the flu’s second wave began cutting a familiar deadly swath through citizens and sailors. When the Pittsburgh entered dry dock on Oct. 10, more than 90 sailors had fallen ill. The

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Left: USS Pittsburgh in drydock at Rio de Janeiro, Brazil. By the time the ship left the drydock, virtually her entire crew had been infected, and 58 had died. Right: The Liberty Loans Parade in Philadelphia, Pennsylvania, on Sept. 28, 1918, attended by 200,000, was a superspreader event that became known as the deadliest parade in American history. More than 17,000 Philadelphians subsequently died.

next day the case count had skyrocketed to 418. On Oct. 13, Seaman E.L. Williams became the first flu fatality.

When the number of dead reached 16, Caperton contacted city authorities to arrange burial arrangements.

On Oct. 21, he led ashore a funeral party. Upon reaching their destination, Caperton later wrote, “Conditions in [Sao Francisco Xavier Cemetery] beggared description. Eight hundred bodies in all states of decomposition, and lying about in the cemetery, were awaiting burial. Thousands of buzzards swarmed overhead.” Graves dug for the dead sailors had been taken over by others, forcing shipmates to dig new graves.

Simple wooden crosses with their names were affixed over them. Ultimately, the Pittsburgh suffered 663 cases (80 percent of the crew) on the sick list, with 58

fatalities. Forty-one were buried ashore, with all eventually returned for re-burial in the United States. In their memory, a 20-foot-high white granite obelisk carved with the names and ratings of the sailors was erected. On it was the inscription: “Erected by the crew of the USS Pittsburgh, in memory of their shipmates who died from the influenza, OctoberNovember 1918.”

AMERICAN SAMOA DODGES A BULLET American Samoa is an unincorporated territory in the South Pacific about 2,500 miles southwest of Hawaii and 2,000 miles north-northeast of New Zealand.

During World War I, U.S. Navy Cmdr. John Poyer was naval governor of American Samoa. His counterpart in Western Samoa, a British colony administered by New Zealand and located 40 miles west, was Lt. Col. Robert Logan. Logan had led the force that captured Western Samoa from the German occupiers, and with the victory became the military governor, a post he held throughout the war. He was, however, apparently an easily offended martinet. In November 1918, the Spanish flu pandemic would test to the utmost the

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NAVAL HISTORY AND HERITAGE COMMAND PHOTO

WIKIMEDIA COMMONS

Left: The SS Talune, which brought the Spanish flu to Western Samoa. Below left: American Samoa’s Naval Governor Cmdr. John Poyer. His strict quarantine saved American Samoa from the disaster that befell its British neighbor.

administrative skills of the two men, with one rising to the challenge and becoming a hero, and the other failing, with tragic consequences.

Contact with the outside world for these remote island territories was through radio and ship. The SS Talune regularly worked the route between Auckland and the Samoas and nearby islands.

The second wave of the Spanish flu arrived in New Zealand from infected British Commonwealth ships in early October 1918, and rapidly spread, with devastating consequences. As the Talune prepared for its scheduled run at the end of the month, despite two of its crew hospitalized with the flu, local health authorities cleared the ship for travel on Oct. 30.

Meanwhile, in American Samoa, Poyer had read about the pandemic through a radio bulletin from the news syndicate Press Wireless. Deciding not to await instructions, Poyer seized the initiative.

He summoned the Samoan matais (chiefs) to a council and together they worked out a quarantine for the territory. Any ship arriving had to either discharge passengers, crew, and cargo on Goat Island in the inner harbor near the capital, Pago Pago, or enter the hospital for a two-week quarantine. The matais organized native patrols to watch the beaches and intercept any vessel, even those carrying relatives from other islands.

The Talune arrived at Apia, Western Samoa’s capital, on Nov. 7, with some

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crewmembers and passengers already exhibiting flu symptoms. Their condition downplayed by the ship’s captain, the quarantine officer allowed infected passengers to disembark. Only after the Talune had departed and he was reading newspapers brought by the ship did Logan discover the flu’s severity.

By then it was too late. Meanwhile, at American Samoa, the Talune’s captain found in Poyer an informed official not to be fooled, resolute with his quarantine.

In late November, with the flu raging out of control in Western Samoa, Logan dispatched a mail boat to rendezvous with a mail steamer at American Samoa.

Poyer intercepted the vessel at the

harbor’s entrance and ordered it to quarantine or turn back. The steamer’s captain requested permission to put his mail cargo directly on the mail boat. Poyer refused. The ship turned away, its cargo still on board.

When informed of what had taken place, Logan took umbrage and cut off all contact with American Samoa. Later, when Poyer offered medical assistance from the first graduates of a nursing school established for natives, Logan refused. Thanks to Logan’s incompetence, 90 percent of Western Samoa’s population became sick, with about 8,500 fatalities.

Poyer, meanwhile, received the Navy Cross “for the extraordinarily successful measures by which American Samoa was kept absolutely immune.” The grateful natives whose lives he saved honored him as well. In 1919, they built a high school and named it Poyer School, and composed a song. Set to the tune of “The Star-Spangled Banner,” it contrasted what happened between Western and American Samoa. It ended with the line: “God in heaven bless the American governor and flag.”

Two more waves of the Spanish flu would occur before the pandemic ended in 1920. When it was over, the Navy recorded 5,027 deaths and more than 106,000 hospitalized, out of a roster of 600,000 sailors – an undercount, as mild cases were not recorded. Braisted estimated a sickness rate in the Navy of 40 percent. Though the Navy’s primary responsibility was treating infected sailors, medical staff stepped up in local communities, in some cases taking full control from overwhelmed officials. Yet despite its devastating impact, for the general public, the horror of trench warfare soon came to overshadow the fact that more American soldiers, sailors, and Marines died of the flu than were killed in action in the war.

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The U.S. military goes to war against the novel coronavirus.

By Craig Collins

I

t was in late February 2020 that the first American military service member, a young soldier stationed at Camp Carroll near Daegu, South Korea, was infected with the novel coronavirus, SARS-CoV-2, that causes the disease now known as COVID19. By then, the Department of Defense (DOD) had already been working, for weeks, on the effort to protect service members and all Americans, at home or overseas, from the unpredictable and often deadly virus that has made its way around the world.

As the virus continued to sicken people in China, where the global pandemic began, the DOD’s earliest activities were directed at keeping military and civilian Americans safe. The federal officials, service members, and civilians evacuated from China in the early weeks of the pandemic, when many

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commercial flights had been grounded, were brought home on military aircraft, and many were temporarily housed at military bases. Civilian evacuees from China, or from passenger cruise ships that had suffered outbreaks at sea, were lodged at DOD facilities under an agreement with the U.S. Department of Health and Human Services (HHS).

The U.S. military and its federal and international partners were called upon to do more as the pandemic spread across the globe, and the Global Pandemic Campaign Plan issued by the Pentagon on January 30 has grown in scope and complexity to reflect the challenge of fighting a pernicious enemy that attacks indiscriminately. The DOD’s response to the coronavirus has been truly global in scale and comprehensive in scope, tapping into military expertise in everything from logistics to medicine to vaccine development.

Brian Lein, MD, joined the campaign in May 2020, as the Defense Health Agency’s new assistant director for health care administration. Before that, Lein spent 30 years in the Army, commanding some of the nation’s most important medical, research, and educational facilities before retiring with the rank of major general.

“In just about every aspect of the nation’s COVID-19 response,” Lein said, “you see the fingerprints of the Department of Defense.

It’s been at the forefront of a lot of what’s been done.”

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U.S. AIR NATIONAL GUARD PHOTO BY MASTER SGT. MATT HECHT

COMBATING COVID-19

U.S. Army Chief Warrant Officer 2 Timothy Jardinico works in the New Jersey National Guard’s Joint Operations Center in the Homeland Security Center of Excellence, Lawrenceville, New Jersey, April 22, 2020. New Jersey soldiers and airmen, as well as active duty personnel and civilians from U.S. Northern Command, were working together in the center to support the state’s response efforts to COVID-19.

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Right: Tech. Sgt. Travis Pruett, 134th Air Refueling Wing Medical Technician, Tennessee Air National Guard, tests a patient at a COVID-19 drive-up testing station in Blount County, Tennessee, April 9, 2020. Below, right: A view of patient care units under construction inside the Jacob K. Javits Convention Center in New York City.

U.S. ARMY CORPS OF ENGINEERS PHOTO

U.S. AIR NATIONAL GUARD PHOTO BY SENIOR MASTER SGT. KENDRA M. OWENBY

A HEALTHY AND MISSIONREADY FORCE From the start, the DOD’s response to the COVID-19 pandemic was focused on three priorities laid out by Secretary of Defense Mark Esper: first, to protect service members, DOD civilians, and their families; second, to maintain the military’s mission capabilities; and third, to provide full support to the whole-of-government interagency response to the pandemic.

The Pentagon’s first moves to protect the health of the armed forces were issued in a series of memos outlining force health protection guidance for service members and their commanders – focusing first on quarantines for those who had been to mainland China, and then on travel restrictions for service members and their families to and from countries based on risk classifications assigned by the U.S. Centers for Disease Control and Prevention (CDC). In March, all domestic travel, including duty travel and permanent changes of station, was temporarily halted, and in hard-hit countries such as Italy and South Korea, force health protection plans, which included modified training, quarantining, social distancing, and promoting good hygiene, kept infection rates lower at U.S. military installations than in much of the surrounding areas.

Communications technology has helped to keep many DOD personnel safe: Civilians have turned increasingly to telework, and a virtual recruiting environment has been established to protect recruiters. The pandemic has introduced significant changes to the way health care is delivered in the Military Health System.

“Using digital solutions,” said Lein, “has allowed us to continue providing care but decrease the requirement of patients to actually come in and have a face-to-face

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encounter with the pharmacy or with a provider.”

At the same time, the Defense Department has striven to remain agile, flexible, and responsive, adapting to conditions as they emerge. Initial stop-movement orders – which involved mission-critical exemptions from the start – have been updated and altered as more has become known about the novel coronavirus and how it’s transmitted. Even as it battled COVID-19, the DOD continued global military operations: conducting counterterrorism missions in Africa and the Middle East; assuring freedom of navigation in operations around the world; monitoring and protecting U.S. airspace; monitoring North Korean weapons tests, and more.

Force health protection and readiness, Lein said, “go hand in hand. It’s not an either-or. We haven’t compromised one for the sake of the other; we’ve been able to do both to make sure we’re still able to respond to any international crisis.”

SUPPORTING THE INTERAGENCY RESPONSE When the DOD issued its Global Pandemic Campaign Plan in January, it put the U.S. Northern Command (NORTHCOM) at the forefront of the battle. By early April, a major federal disaster declaration had been issued in all 50 states for the first time in American history, and the DOD’s support to the response nationwide was mobilized within several existing frameworks, including the National Response Plan.

“Under the National Response Plan,” said Lein, “DOD has certain requirements that we’re meeting – but we also have, through our liaison officers and through our trusted relationships that we’ve had with the Centers for Disease Control and Prevention, Health and Human Services, the Department of State, and others, […] been able to develop a really strong interagency platform at the secretary

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U.S. NAVY PHOTO BY MASS COMMUNICATION SPECIALIST 1ST CLASS SCOTT BIGLEY

V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

Right: The Military Sealift Command hospital ship USNS Comfort (T-AH 20) provided medical relief to New York City. Comfort cared for trauma, emergency, and urgent care patients without regard for their COVID-19 status. Comfort worked with the Javits New York Medical Station as an integrated system to relieve the New York City medical system, in support of the U.S. Northern Command’s Defense Support of Civil Authorities as a response to the COVID-19 pandemic. Below, right: Capt. Lana Clouser, a certified registered nurse anesthetist, sedates a patient prior to surgery aboard the hospital ship USNS Mercy (T-AH 19) on April 29, 2020. Mercy deployed in support of the nation’s COVID-19 response efforts, and served as a referral hospital for non-COVID-19 patients admitted to shore-based hospitals. This allowed shore-based hospitals to focus their efforts on COVID-19 cases. The DOD is supporting the Federal Emergency Management Agency, the lead federal agency, as well as state, local, and public health authorities in helping protect the health and safety of the American people.

with National Guard Civil Support Teams were instrumental in augmenting the capacity of civilian laboratories in processing patient samples for testing.

U.S. NAVY PHOTO BY MASS COMMUNICATION SPECIALIST 3RD CLASS JAKE GREENBERG

THE LOGISTICS OF PANDEMIC RESPONSE of defense level through the secretary’s COVID-19 Task Force.”

Military medical support to regions of the country hard-hit by the virus have included embedding Defense Department providers directly into civilian hospitals or treatment facilities. Deployable augmentation teams from the Army, Navy, and Air Force have assisted providers in the fight against COVID-19. In the spring, as the pandemic accelerated throughout the United States, service branches put out a call to retired and reserve members to help shore up the capabilities of civilian medical providers. By mid-April, for example, about 25,000 former soldiers from various backgrounds had volunteered to join the Army team, either as medical providers or support staff.

DOD medical professionals have added modular capability to civilian health care facilities – staffing entire hospital wings, for example – and established alternate care facilities such as the field hospitals established by the U.S. Army Corps of Engineers in Seattle and at the Javits Convention Center in New York City.

Overall, the Corps of Engineers added more than 15,000 beds to civilian health care facilities by converting hotels,

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dormitories, and convention centers into alternative care sites.

The Navy hospital ships Comfort and Mercy were dispatched to New York and Los Angeles, respectively, to add 1,000 additional beds each and expand those cities’ capacity to deliver care. The Navy also established its own expeditionary medical facility at the Morial Convention Center in New Orleans.

The military medical community shared generously from its stock of medical supplies and personal protective equipment (PPE) – an effort that has been aided nationwide with the assistance of as many as 45,000 National Guard service members, who transported and distributed supplies and food, set up and supported community-based testing sites, created additional medical capacity, and dispatched infection control teams to help nursing home staff prevent the spread of COVID-19. Specialists

The importance of the National Guard to the domestic COVID-19 response helps illustrate an important aspect of the DOD’s pandemic campaign: logistics.

The tasks of moving people and equipment around, and keeping personnel supplied with the material they need to fight the disease, have been monumental undertakings, and military expertise has been critical. NORTHCOM and the U.S. Transportation Command (TRANSCOM) have delivered millions of test swabs and N95 respirator masks, along with thousands of personnel, to where they’re needed, and their efforts have been supplemented by National Guard units – in April, for example, when airmen from the California Air National Guard transported 500 ventilators and medical supplies to New York and other states in need. Air Force aircrews moved hundreds of personnel and nearly 8 tons of cargo to the Army field hospitals set up in New York and Washington state, evacuated COVID19-positive patients from remote areas, and helped hundreds of American citizens return home from abroad.

By June, the Defense Logistics Agency (DLA) had procured a massive stockpile of material for the nation’s COVID-19 fight: more than 13 million nonmedical and

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A scientist with the Emerging Infectious Disease Branch at the Walter Reed Army Institute of Research conducts studies on the novel coronavirus. The Emerging Infectious Diseases Branch, established in 2018, has the explicit mission to survey, anticipate, and counter the mounting threat of emerging infectious diseases of key importance to U.S. forces in the homeland and abroad.

surgical masks; 5.9 million N95 masks; more than 118 million exam gloves; 2.7 million isolation and surgical gowns; 8,000 ventilators; and more than 821,000 test components. According to Lein, the job of staying on top of where all this equipment goes, and when, is handled within the Office of the Secretary of Defense, by the COVID-19 Task Force established in February.

The Army, Navy, and Marine Corps also stepped up by producing critical equipment, partnering to produce 3D-printed face shields and test swabs to assist in the response.

U.S. ARMY PHOTO BY SHAWN FURY

MILITARY RESEARCH AND TECH AID THE FIGHT From the beginning of the pandemic, when the DOD used its sophisticated disease modeling platform to inform its own planning and personnel decisions, military science and research have contributed to the national response. In May, when the White House announced Operation Warp Speed, the administration’s program to accelerate the development, manufacture, and distribution of COVID-19 vaccines and other countermeasures, the Pentagon joined the public-private partnership to lend support in diagnostics, therapeutics, vaccines, production, distribution, and security. By September, five DOD medical treatment facilities had been identified for Phase 3 COVID-19 vaccine trials.

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In addition to the clinical research conducted at military medical facilities, Lein pointed out, the DOD also conducts basic bench research at its laboratories. For example, in May, the Air Force Genetics Center of Excellence at Keesler Air Force Base in Biloxi, Mississippi, joined with the CDC and the National Institutes of Health to begin sequencing the genome of the SARS-CoV-2 virus to track its evolution and identify targets for treatment and vaccines.

In addition to the vaccine trials being conducted at DOD medical facilities, said Lein, military laboratories are contributing to clinical research in various ways. “The research and development that goes on at the Army, Navy, and Air Force labs includes everything from vaccine development to working on various treatment algorithms and medications,” he said. “The Walter Reed Army Institute of Research has worked with the Food and Drug Administration [FDA] and other partners to get some of these testing devices up and available for testing across the United States.”

Several military-developed technologies have contributed to the COVID-19 response: The Army has used stand-off thermal imaging devices, for example, to create safe distance between operators and subjects being screened for fever. In May, the FDA authorized the emergency use of a device developed by the U.S. Army Medical Research and Development Command: the COVID-19

Airway Management Isolation Chamber (CAMIC), which had been used in the Military Health System as an extra layer of protection for health care workers. “The CAMIC has been used to prevent aerosolization of the virus during airway procedures and during treatment and intubation of patients,” said Lein. “And that came directly out of our research.”

Some promising technologies are still in the experimental phase. The Defense Threat Reduction Agency (DTRA), for example, is adapting a technology it has been developing in partnership with the company Royal Philips – a wearable device programmed to detect, with the use of artificial intelligence and machine-learning algorithms, the early signs of bacterial or viral infection – to be COVID-19-specific.

AN INTERNATIONAL EFFORT As part of an international effort to mitigate the effects of SARS-CoV-2, both in terms of public health and global security, the DOD has been involved in several international efforts. The DTRA’s Cooperative Threat Reduction (CRT) Program supported requests from more than a dozen nations seeking help with COVID-19 – an extension of the international partnership to mitigate weapons of mass destructionrelated threats to the United States and its allies. Laboratories built or renovated in partner nations through this program are playing a crucial role in COVID-19 testing or research. Through the CRT program, the DOD also contributed other forms of support – including subject matter expertise, diagnostic support, and PPE – to foreign partners.

The DOD has also extended aid to allies and partners through its humanitarian assistance programs. By October,

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the Pentagon, through its Humanitarian Assistance and Response Operations Team, had contributed more than $105 million overall to 139 countries to aid in testing, diagnostic support, infection control, PPE, contact tracing, and more.

Each of the six combatant commands has played a role in this process. In September, the U.S. Southern Command (SOUTHCOM), for example, transported a large mobile field hospital to Kingston, Jamaica, as a donation on behalf of the American people to support Jamaica’s ongoing COVID-19 response. NORTHCOM shipped a field hospital to Mexico and helped Mexican officials reconfigure it to handle COVID-19 patients, and both the European and African Commands (USEUCOM and AFRICOM) contributed funding and subject matter expertise to Italy and the African Union. The U.S. Indo-Pacific Command (USINDOPACOM) worked with the U.S. Agency for International Development to deliver ventilators to Indonesia and train field epidemiologists in Cambodia.

U.S. AIR FORCE PHOTO BY SR. AIRMAN JONATHON CARNELL

MOVING FORWARD: LESSONS LEARNED Everyone who joins the Department of Defense, active duty or civilian, takes an oath to defend the nation “against all enemies, foreign and domestic.” The DOD’s fight against SARS-CoV-2 has deployed 61,000 people – including about 4,400 doctors, nurses, and other medical personnel – around the country to fight the pandemic and lend support: to deliver health care, manufacture PPE, distribute equipment and food, create and staff alternative care sites, support community-based testing, and more. Eventually, the United States and its allies will defeat SARS-CoV-2, and the efforts of service members and DOD civilians will have played a critical role in keeping the already grim death toll lower than it might have been.

But the fight is far from over: By the end of October 2020, as military and civilian medical research communities worked apace to develop vaccines, treatments, and other countermeasures, American public

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Airmen assigned to the 60th Aerial Port Squadron secure pallets loaded with U.S.-made ventilators onto the cargo floor of a C-17 Globemaster III at Travis Air Force Base, Aug. 27, 2020. The United States provided brand-new, high-quality ventilators to the government of Indonesia to fight COVID-19.

health officials continued to struggle in their efforts to contain the virus. On Oct. 23, the United States reported its highestever number of new COVID-19 cases – more than 83,000. Health officials warned of a long, dark winter.

As the DOD and its partners redouble their efforts, Lein and the DHA remained focused on the priorities initially outlined by Secretary Esper. The Military Health System will continue to refine how it engages with patients, after its early experiences in expanding its telemedicine capabilities. “We’re building a digital patient platform that will be standardized across all the Department of Defense,” he said, “because when this hit, we had lots of pockets of excellence, and now are trying to standardize that excellence across the Department of Defense.” This platform will be used not only for routine appointments, Lein said, but for critical care. “When you have a critical care patient, the ability to reach back to a subject matter expert, especially during COVID, is crucial.”

The mobilization of Guard and Reserve units called forward to help civilian health care organizations, Lein said, will likely be more streamlined in the future – as will nearly every aspect of the DOD response.

“We’re still learning as we go,” Lein said.

“A lot of these things were unknown: How do we quarantine people with COVID? How do we isolate people? What are quarantine and isolation, and how long do we need to do them? Using all the science, we’re continuing to learn these things.” Every military branch, in conjunction with the DHA and the Uniformed Services University of the Health Sciences, is working through discussions of medical lessons learned – all the challenges and issues identified during the COVID-19 response so far – and developing long-term solutions for them.

“This has been an opportunity for us to integrate what we’ve learned in the Military Health System with our civilian partners, and vice versa,” said Lein. “It has been an incredibly collaborative process between the Department of Defense and all of the other agencies, in support of the soldiers, sailors, airmen, Marines, and their family members. Ensuring the readiness of our troops has been a priority. I really want to thank our nation for its continued support to the military throughout, because they’ve been doing a lot of the heavy lifting behind the scenes for COVID19, while continuing to serve on the front lines around the world.”

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MILITARY MEDICAL M0DELING AND SIMULATION SHIFTS ORGANIZATIONS WHILE RETAINING FOCUS

By Scott R. Gourley

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Surgeon Maj. (Dr.) Ian Cassaday, 250th Forward Surgical Team, left, utilizes a Telehealth in a Bag kit and a Transportable Exam Station to simulate a craniectomy (performed by a non-neurosurgeon) during testing of virtual health capabilities in a field and operational environment during Joint Warfighting Assessment 2019.

for medical simulation and training for DHA. Tomasello, who previously served as deputy JPM MMS, explained that the organizational change reflected, among other things, the fact that the former office, under PEO STRI, was perceived as something of an “Army-centric” organization.

“The office originally planned to migrate to DHA, but we were going to do it more slowly, piece by piece, over

a three-year period, eventually culminating in FY 22,” he said. “But the Army, for several reasons, came along and said that they would like us to do that in one year as opposed to three.

“We said, ‘OK, fine,’” he continued.

“You know, ‘rip the band aid off.’ There are some advantages to that, so ‘let’s get on with it.’ And so we did. We got all the planning and other arrangements in place. And I am now chartered by Dr. Butler [Barclay P. Butler, PhD, MBA, serves as the J4, Component Acquisition Executive (CAE) and the head of contracting actions for DHA] as a component acquisition executive, and I reside in the CAE organization at DHA.” Noting a few additional organizational changes, he summarized, “In terms of what we do and how we do it, that really hasn’t changed. It’s just a shift organizationally

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U.S. ARMY PHOTO

O

ne significant addition to military health care training across the joint services involved the establishment of the office of Joint Project Manager for Medical Modeling and Simulation (JPM MMS). Created in 2013 by the assistant secretary of defense for health affairs (ASD(HA)) in partnership with the Defense Health Agency (DHA) and the U.S. Army’s Program Executive Office Simulation, Training and Instrumentation (PEO STRI), JPM MMS was created to fulfill the services’ shared medical training requirements across the continuum of care.

Stated goals for the organization included fulfilling the services’ shared medical training requirements, standardizing medical modeling and simulation capabilities, centralizing life cycle management, and establishing a single transition office for medical modeling and simulation science and technology.

As part of a process designed to further expand these activities and capabilities across the continuum of medical care, the summer of 2020 witnessed the “stand down” of JPM MMS, which had been organizationally structured under PEO STRI, and simultaneous activation of the office of Program Manager for Medical Simulation and Training (PM MST), now organized under DHA. “We may have changed our name, but the mission is the same,” said Jude M. Tomasello, program manager

from the Army’s PEO STRI over to the DHA Component Acquisition Executive.”

U.S. ARMY PHOTO BY VISUAL INFORMATION SPECIALIST JASON JOHNSTON

SIMULATION AND TRAINING EFFICIENCIES Asked about the advantages of maintaining centralized multi-service medical simulation and training requirements in a single office, Tomasello said, “There is a lot of commercially available technology, especially in the medical simulation field.

And there are a few folks out there who might be inclined to ‘do their own thing.’

They’ll go to a trade show. And if their organization happens to have a little bit of money, they’ll buy the shiniest object at that trade show.”

Such an approach might include some “near-term benefits,” Tomasello said.

“But if you’re looking at things holistically at an enterprise level, you really need to look at total ownership costs: the acquisition cost, technology, obsolescence, sustainment, economic order quantities, and all those things that a Department of Defense [DOD] program manager is chartered to look after.

“You really need to look after those things,” he continued. “So centralizing those requirements into a single office

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Multinational soldiers treat a simulated casualty during the final field training exercise of a sixmonth medical training course hosted by the International Special Training Centre in which 24 special operations forces soldiers from 10 different nations participated, March 1, 2017. The intent of the training course was to raise the competencies and capabilities of the NATO special operations forces medics, further enhancing medical support of our fighting soldiers.

gives that DOD advantage in terms of cost and efficiency while also giving users benefits in terms of longer sustainment, planned upgrade cycles, and things like that, to keep their capabilities viable.”

He offered the analogy of an Army base buying different gunnery trainers from different manufacturers with different standards, sustainment requirements, and funding.

“It doesn’t take a rocket scientist to see how inefficient that is all the way around,” he said. “But when you do things from an approach with efficiencies, in the case of hospitals, you’re giving them a product where all they literally do is show up and train on their programs of instruction.

They don’t have to worry about whether they have enough money to buy this

capability or dedicate one of their clinicians or nurses to run the simulation and do the ordering. That’s all done for them in a centralized manner, just as the Army does for its forces.”

PROGRAM EXAMPLES Tomasello said that the office supports programs across the medical continuum of care, from Level I, the point of injury on the battlefield, up to Level IV, which involves hospitals.

“I’ve got a whole team of acquisition professionals that can analyze requirements, condense those requirements, get those capabilities on contract, and eventually deliver them,” he said. “And we not only support across the continuum of care, we also support across the acquisition life cycle: from science and technology, through development, and all of the way through sustainment.”

Asked for examples of this ongoing support, he related, “In one case, we’re doing a medical training center for the special forces in NATO. That’s over in Mons, Belgium [NATO Special Operations headquarters]. They basically drew it on a piece of paper, and we said, ‘Yes, we can do that.’”

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U.S. ARMY PHOTO BY STAFF SGT. STEVEN FLORES

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Another representative program is the Special Operations Command Purposed Emergency Access Response, Point of Injury and Trauma Simulation (SPEARPOINTS). Government solicitations have outlined the SPEARPOINTS Prolonged Field Care Training System as “provid[ing] a capability for Special Operations Forces (SOF) teams to train collectively on SOF Medical Critical Tasks, in a mission scenario that replicates in-theater safe house/team house environment.”

“SPEARPOINTS is a medical simulation training center at Fort Campbell that is kind of like the Army ‘mystic’ [Medical Support Training Center (MSTC)] on steroids,” said Tomasello. “They are going to use it for training the special ops folks, but they are also going to use it for things like assessments of new equipment, which they tend to do on a regular basis.

They will be able to go into SPEARPOINTS and test that equipment out under realworld scenarios.”

As of this writing, he observed that plans are in place to have the SPEARPOINTS contract awarded by late October 2020.

Along with those representative examples, Tomasello pointed to “existing

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Spc. Myles Leedahl, center, an animal care specialist assigned to Public Health ActivityHawaii, Hickam Branch, and Spc. Olamide Fagbohun, right, a combat medic assigned to Headquarters and Headquarters Company, 2nd Brigade, 35th Infantry Regiment, 25th Infantry Division, inject air into an endotracheal tube to provide breathing assistance for a simulated military working dog during the Canine Tactical Combat Casualty Course at the Medical Simulation Training Center (MSTC), Schofield Barracks, Hawaii. The course is instructed by veterinary technicians and officers from Public Health Activity-Hawaii to offer medics from across the Pacific region an opportunity to train with military working dogs and simulators to become more familiar with canine first aid skills.

contract vehicles” that were written over the past few years by JPM MMS. “They’re still active contracts,” he noted. “One, for example, is the Virtual Patient Simulator. That’s where people can come from any element of the Department of Defense or virtually any other government agency and order whole-body high-fidelity manikins as well as canine simulators off of this contract.

We also have another contract called MS3, for medical simulation supplies and services. And that was originally developed for the VA [Department of Veterans

Affairs] to buy a lot of items, ‘kit them,’ and then send them to the VA hospitals.

So that is more like a commodity contract, and we had that available to us if folks need one of those particular products or services.

“As I said earlier, our capabilities run the gamut from [Level I] to [Level IV] and anything from science and technology all the way through sustainment. We’ve got the flexibility and the tools in our toolbox to do that,” he summarized.

THE PM MST TEAM Tomasello said that service requirements for medical modeling and simulation capabilities are presented to the PM MST office “in a couple of different ways.”

“The SOCOM [U.S. Special Operations Command] representatives tend to come straight to us,” he said. “We have a relationship with them and we work with them directly. Otherwise, if it’s coming through the services, we have an organization within DHA under the J7 education and training folks called the Defense Medical Modeling and Simulation Office [DMMSO]. They serve as our ‘requiring’ activity. They will take requirements

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from the services or the hospitals and condense those. First, they’ll look at them and they might say, ‘You know, you already have a huge supply of these manikins, so you don’t really need them.’ So they provide that kind of function. If the requirement is validated, then they will send it to us to do the acquisition and to provide the capability. So DMMSO is our partner, just like TRADOC [U.S. Army Training and Doctrine Command] is with PEO STRI. They come up with the requirements and then the materiel developer provides and sustains the capability.”

Noting that some hospitals or training centers might occasionally try to bring requirements directly to his team, he added that, when that happens, they will be referred to DMMSO, “where they will go through the normal requirements vetting process.”

Describing his 15-person team, located in Orlando, Florida, as “small but fierce,” he asserted, “When you’re like that, you tend to do a lot of repurposing. You know, ‘Hey, I know you were working on this one thing, but this other thing came up with a higher priority.’ You don’t have additional people to assign to those projects. So the members of our team are flexible and know that they’re going to need to stay flexible for a while.”

The PM MST includes Tomasello – who lacks a deputy – a DHA business manager, six Army civilians who will finish administratively transitioning to DHA civilians by the end of October, engineers, cyber professionals, a logistician, financial and administrative professionals, assistant program managers, and subject matter experts in the form of retired combat medics.

“Those former combat medics are invaluable to us, because many of us, as lifelong acquisition professionals, don’t really have that combat medic experience,” he said. “And we need that.”

Asked about the presence of cyber professionals on the team, he replied, “That’s checking all the blocks and doing everything you need to do. With acquisitions there are statutory requirements that include considering all the cyber elements of a program. That’s a must-do.”

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U.S. Army Spc. Echo Lile and U.S. Army Sgt. Rodney Espinal, 307th Brigade Support Battalion, 1st Brigade Combat Team, 82nd Airborne Division, assess and operate on a simulated casualty using the Tactical Combat Casualty Care Exportable (TC3X) model of medical training manikin in the U.S. Central Command region on Feb. 12, 2020.

The TC3X is a state-of-the-art medical training device used to simulate an actual casualty that could be found on the battlefield.

MEETING TOMORROW’S REQUIREMENTS Summarizing his message to today’s service members about the work being performed by DHA’s PM MST team, Tomasello offered, “DHA is a big place, and the medical health system is a big enterprise. But, as I outlined earlier, whenever some aspect [of that enterprise] involves training or simulation, either as a system or a product or service, we’ve got the skills and experience that we can use to contract for an acquisition. We always say that everything starts with a requirement.

So, if that requirement is vetted through the proper channels, we are reactive and responsive to those requirements.

I should say that we don’t make our own requirements – what some people have described as the whole ‘self-licking ice cream cone’ thing. But when those properly vetted requirements come along, we have the people with the experience to

contract for it. It could be an item like a manikin. Or it could be a complete turnkey solution that would be provided as a service where clinicians or combat medics would only need to show up and train. And we would take care of all the risks and everything in between.”

He concluded, “We’re coming into the Defense Health Agency with a wealth of acquisition experience. And DHA, thankfully so, is already tapping into that.

Myself and one of my other team members are on a team to help DHA [get] its arms around becoming an acquisition organization. And there’s a lot to that. It’s training. Its processes. It’s regulations. It’s all of those things that the services have embraced for years.

The DHA is still relatively young in the whole acquisition realm. They haven’t really got that foundation built yet.

But I’m on a team and a working group that’s helping to do that. And I’m very happy about that. I’m also happy that we’re influencing processes on science and technology transfer. We’ve got a lot of folks doing great things in the labs. But for years, it was just that they would develop something and then it had nowhere to go. There was no transition agent or funding or requirement.

And we’re instilling discipline in that process as well, so that the great work that these folks are doing can end up as a capability in the hands of a clinician that really needs this capability.”

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U.S. ARMY PHOTO BY PFC. ANDREW ZOOK

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