[House Hearing, 111 Congress]
[From the U.S. Government Publishing Office]
THE VISION CENTER OF EXCELLENCE:
WHAT HAS BEEN ACCOMPLISHED
IN THIRTEEN MONTHS?
=======================================================================
HEARING
before the
SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED ELEVENTH CONGRESS
FIRST SESSION
__________
MARCH 17, 2009
__________
Serial No. 111-7
__________
Printed for the use of the Committee on Veterans' Affairs
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COMMITTEE ON VETERANS' AFFAIRS
BOB FILNER, California, Chairman
CORRINE BROWN, Florida STEVE BUYER, Indiana, Ranking
VIC SNYDER, Arkansas CLIFF STEARNS, Florida
MICHAEL H. MICHAUD, Maine JERRY MORAN, Kansas
STEPHANIE HERSETH SANDLIN, South HENRY E. BROWN, Jr., South
Dakota Carolina
HARRY E. MITCHELL, Arizona JEFF MILLER, Florida
JOHN J. HALL, New York JOHN BOOZMAN, Arkansas
DEBORAH L. HALVORSON, Illinois BRIAN P. BILBRAY, California
THOMAS S.P. PERRIELLO, Virginia DOUG LAMBORN, Colorado
HARRY TEAGUE, New Mexico GUS M. BILIRAKIS, Florida
CIRO D. RODRIGUEZ, Texas VERN BUCHANAN, Florida
JOE DONNELLY, Indiana DAVID P. ROE, Tennessee
JERRY McNERNEY, California
ZACHARY T. SPACE, Ohio
TIMOTHY J. WALZ, Minnesota
JOHN H. ADLER, New Jersey
ANN KIRKPATRICK, Arizona
GLENN C. NYE, Virginia
Malcom A. Shorter, Staff Director
______
SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS
HARRY E. MITCHELL, Arizona, Chairman
ZACHARY T. SPACE, Ohio DAVID P. ROE, Tennessee, Ranking
TIMOTHY J. WALZ, Minnesota CLIFF STEARNS, Florida
JOHN H. ADLER, New Jersey BRIAN P. BILBRAY, California
JOHN J. HALL, New York
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
official version. Because electronic submissions are used to prepare
both printed and electronic versions of the hearing record, the process
of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
__________
March 17, 2009
Page
The Vision Center of Excellence: What Has Been Accomplished in
Thirteen Months?............................................... 1
OPENING STATEMENTS
Chairman Harry E. Mitchell....................................... 1
Prepared statement of Chairman Mitchell...................... 38
Hon. David P. Roe, Ranking Republican Member..................... 3
Prepared statement of Congressman Roe........................ 39
Hon. Zachary T. Space............................................ 4
Hon. Timothy J. Walz, prepared statement of...................... 39
Hon. John Boozman................................................ 5
Hon. Harold Rodgers.............................................. 5
WITNESSES
U.S. Department of Veterans Affairs, Madhulika Agarwal, M.D.,
MPH, Chief Officer, Patient Care Services, Veterans Health
Administration, and James Orcutt, M.D., Ph.D., Chief of
Ophthalmology, Office of Patient Care Services, Veterans Health
Administration................................................. 21
Prepared statement of Dr. Agarwal and Dr. Orcutt............. 50
U.S. Department of Defense, Jack W. Smith, M.D., M.M.M., Acting
Deputy Assistant Secretary for Clinical and Program Policy, and
Colonel Donald A. Gagliano, M.D., USA, Executive Director,
Vision Center of Excellence.................................... 23
Prepared statement of Dr. Smith and Colonel Gagliano......... 52
______
Blinded Veterans Association, Thomas Zampieri, Ph.D., Director of
Government Relations........................................... 11
Prepared statement of Dr. Zampieri........................... 44
Fugate, Specialist Travis, USA (Ret.), Hindman, KY............... 6
Prepared statement of Specialist Fugate...................... 40
Kinney, Sergeant David William, III, USA (Ret.), Duland, FL...... 7
Prepared statement of Sergeant Kinney........................ 41
Magallanes, Sherry, on behalf of Master Sergeant Gilbert
Magallanes, Jr., USA (Ret.), Clarksville, TN................... 8
Prepared statement of Mrs. Magallanes........................ 42
MATERIAL SUBMITTED FOR THE RECORD
Background Material:
Text of Language from sections 1623 and 1624 of the National
Defense Authorization Act for Fiscal Year 2008............. 54
Vision Center of Excellence Organizational Structure Chart,
Draft as of February 20, 2009.............................. 56
Allen W. Middleton, Acting Deputy Assistant Secretary of
Defense, Health Budgets and Financial Policy, Office of the
Assistant Secretary of Defense (Health Affairs), U.S.
Department of Defense, to Hon. Harry Mitchell, Chairman,
Subcommittee on Oversight and Investigations, Committee on
Veterans' Affairs, letter dated March 12, 2009, regarding
the FY 2009 Defense Health Program Operation and
Maintenance Budget for the establishment and operation of
the Vision Center of Excellence............................ 56
Post-Hearing Questions and Responses for the Record:
Hon. Harry E. Mitchell, Chairman, and Hon. David P. Roe,
Ranking Republican Member, Subcommittee on Oversight and
Investigations, Committee on Veterans' Affairs, to Hon.
Hon. Eric K. Shinseki, Secretary, U.S. Department of
Veterans Affairs, letter dated April 22, 2009, and VA
responses.................................................. 57
Hon. Harry E. Mitchell, Chairman, and Hon. David P. Roe,
Ranking Republican Member, Subcommittee on Oversight and
Investigations, Committee on Veterans' Affairs, to Hon.
Robert M. Gates, Secretary of Defense, U.S. Department of
Defense, letter dated April 22, 2009 and DoD responses..... 61
THE VISION CENTER OF EXCELLENCE:
WHAT HAS BEEN ACCOMPLISHED IN THIRTEEN MONTHS?
----------
TUESDAY, MARCH 17, 2009
U. S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Oversight and Investigations,
Washington, DC.
The Subcommittee met, pursuant to notice, at 10:06 a.m., in
Room 334, Cannon House Office Building, Hon. Harry E. Mitchell
(Chairman of the Subcommittee) presiding.
Present: Representatives Mitchell, Space, Walz, and Roe.
Also present: Representatives Buyer, Boozman, and Rodgers
of Kentucky.
OPENING STATEMENT OF CHAIRMAN MITCHELL
Mr. Mitchell. Welcome to the Subcommittee on Oversight
Investigations Hearing on the Vision Center of Excellence.
We will begin, and I would like to ask unanimous consent
that Mr. Boozman be invited to sit at the dais for the
Subcommittee hearing today. Hearing no objection, so ordered.
This hearing is now in order, and we will begin with
opening statements.
In April of 2008, this Subcommittee held a hearing on
Traumatic Brain Injury (TBI)-related vision issues. In that
hearing, there was an extensive discussion with the U.S.
Department of Veterans Affairs (VA) and U.S. Department of
Defense (DoD) about the Vision Center of Excellence mandated by
the National Defense Authorization Act of 2008 (NDAA). We heard
from both agencies that they were working hard on this
initiative. Today, we will receive an update on the product of
that hard work and how it has affected veterans in need of
vision care.
We will also discuss the future needs of both of these
agencies that we can assure that the center will be worthy of
our veterans.
Last August, we were assured by the DoD that funding for a
Vision Center of Excellence (VCE) would be distributed in
fiscal year 2009. I applaud Congressman Space and Congressman
Walz for urging Chairman of the Defense Appropriations
Subcommittee, John Murtha, to set aside $5 million for the
Vision Center. This demonstrates how important this issue is
for the Members of this Subcommittee.
We now know that the fiscal year 2009 Defense Health
Program Operation and Maintenance Budget allocated $3 million
to the Vision Center of Excellence. However, it troubles me
that even with this funding and appointment of a director and
deputy director, whose testimonies we will receive shortly, the
center is still without offices, computers, phones, and staff.
To put these delays in perspective, we will hear from a
number of veterans and their families about the difficulties
they have experienced receiving vision care.
Kentucky National Guardsman, Travis Fugate, suffered
grievous injuries in Iraq in 2005. He lost his right eye and
much of the vision in his left, and recently he lost what
little vision remained.
The Vision Center of Excellence would have included the
Military Trauma Eye Injury Registry that is designated to
provide a seamless transition of information which could have
preserved at least some of Travis' vision. This is a reminder
of the cost in delaying interoperability between the
departments.
Although Travis' story is troubling, unfortunately he is
not alone. Sergeant David Kinney's involvement in an improvised
explosive device (IED) explosion in 2005 forced him into
treatment for headaches and a vision-related injury. He is here
today to tell us what has happened since his injuries and the
tribulations he has faced while seeking treatment.
We will also hear from Gil Magallanes, a Green Beret in
Afghanistan who was seriously injured in 2001. His wife Sherry
will be sitting beside him to help tell his story.
I am confident that none of us in this room would actively
choose continuous delays or failures that needlessly hurt our
veterans, yet we have seen time and again our veterans being
left in a void where they don't know where to turn for
treatment.
It took almost 7 years for Gil Magallanes to be introduced
to his vision impairment speech team coordinator. That is
unacceptable, and the Vision Center of Excellence would have
provided a means to provide the specific care that is needed.
Planning for the Vision Center of Excellence has been under
way for years, and I have no doubt that our second panel, which
includes Colonel Donald Gagliano and Dr. Claude Cowan, will
testify that VA and DoD are eager to get to work.
I expect today's hearings to be followed by speedy action
from DoD and the VA to open the Vision Center of Excellence.
Travis, David, and Gil, thank you for your service, and for
appearing before this Subcommittee today. Your testimony will
be very helpful to us as we work to ensure that your colleagues
in arms receive the care they deserve.
And thank you Dr. Zampieri for appearing here today and for
your endless advocacy on behalf of our Nation's veterans.
And thanks also to DoD and VA for coming to the Hill to
provide us with an update.
One of our Subcommittee Members, Mr. Walz had to attend to
family business back home, but will be joining us shortly. He
had the distinct honor of meeting Specialist Fugate at Walter
Reed last week, and would like to extend his thanks to all
witnesses, for being here today.
And before I recognize the Ranking Republican Member for
his remarks, I would like to swear in our witnesses. I would
ask all witnesses to stand and raise their right hand.
[The prepared statement of Chairman Mitchell, and
additional background documents, appear on pps. 38, 54, and
56.]
Mr. Mitchell.
[Witnesses were sworn.]
Mr. Mitchell. Thank you, you may be seated.
I now recognize Dr. Roe for opening remarks.
OPENING STATEMENT OF HON. DAVID P. ROE
Mr. Roe. Thank you, for yielding, Mr. Chairman, and before
I begin, I would like to recognize one of my closest personal
friends, Dr. David Jones, who is a veteran from my district who
is attending here today.
The Vision Center of Excellence, and accompanying Military
Eye Injury Registry, were included as provisions in the
Military Eye Trauma Treatment Act introduced last Congress by
my colleague, Dr. John Boozman, an optometrist and Member of
this Committee. These provisions were also included in the
fiscal year 2008 National Defense Authorization Act, which
passed in late January 2008, but was not funded at that time.
Funding for this program was approved with passage of the
fiscal year 2009 Military Construction Veterans Affairs
Appropriations Bill in late September 2008 when $6.9 million
was allocated for this purpose through the Department of
Veterans Affairs. The Subcommittee staff asked the Department
of Defense over a month ago about when the funding would be
available for the VCE.
We were informed last Friday, March 13, 2009, that the
Department of Defense authorized effective March 12, 2009, $3
million for the establishment of the Vision Center of
Excellence.
I am pleased that this funding has been finally identified
and provided by the Department of Defense.
Mr. Chairman, I would like to ask that the letter from the
Department of Defense dated to you March 12, 2009, be submitted
into the official hearing record.
I agree with the Chairman, that it is important that this
Committee take a look at the process being made in implementing
this legislation, and closely follow the interaction between
the DoD and the Department of Veterans Affairs.
It is no secret to this Committee that these two
departments have not always played well together in the past;
however, with the increasing numbers of servicemembers
returning from Iraq and Afghanistan, with what has become one
of the signature injuries of the war or terrorism, traumatic
brain injury, and the related comorbid ocular injuries, it is
critical that Congress conduct strict oversight into how this
program is developed and implemented to assure that our
Nation's servicemembers and veterans are well served.
This hearing is not the end of our oversight in this
matter. In the very near future Dr. Boozman intends on
scheduling a round table to further discuss the issues with
Members of the Armed Services Committee and other stakeholders,
including Blind Veterans Association, other veteran service
organizations, and medical specialty organizations to be
invited to the table for an open discussion of the progress
being made and where we can address possible improvements.
I am looking forward to delving into this subject matter in
greater detail, and appreciate Chairman Mitchell's interest on
this issue.
I look forward to listening to the testimony today, and I
am encouraged there will be future discussions and oversight on
this matter as well. Again thank you, Mr. Chairman, and I yield
back.
[The prepared statement of Congressman Roe, and the DoD
letter of March 12, 2009, appear on pps. 39 and 56.]
Mr. Mitchell. Thank you.
Mr. Space.
OPENING STATEMENT OF HON. ZACHARY T. SPACE
Mr. Space. Thank you, Mr. Chairman.
Thank you for calling this hearing and for your leadership
on this issue.
I would like to thank also those veterans and family
members who are here today to tell your stories so that we can
better understand and help other soldiers and veterans keep and
regain their sight. I appreciate how difficult it must be to
speak publicly about your struggles, and I want to commend you
for such a selfless action.
I also appreciate the testimony from the representatives
from the Department of Defense, the VA, and from Colonel
Gagliano on the progress that has been made on setting up the
Vision Center for Excellence and the Eye Registry. Of course,
as we all know progress has been slow.
As we will hear today it has been too slow for many
veterans who are returning home to a broken system that is
unable to effectively treat the injuries they have sustained
defending our country. This has to change. And like others here
today, I am frustrated that the solution that was debated and
vetted and ultimately put forth by Congress more than a year
ago has not been implemented.
The Congressional intent behind the Vision Center of
Excellence is clear. With hundreds of injured soldiers
experiencing eye trauma, we must have a comprehensive store of
information about the particular injuries incurred, options for
treatment, and rehabilitation, and the ability to simply share
information between facilities.
When any servicemember goes into battle, he or she does so
knowing the risk of bodily injury. That is an inherent part of
the obligation incurred when you defend your country. What he
or she may not expect is to return home and watch his or her
condition deteriorate as a result of gaps in knowledge and
incomplete paperwork.
It is simply unacceptable that these soldiers and veterans
have lost their vision not on the battle field, but here at
home under our watch. In some cases their vision is a casualty
not of warfare, but of bureaucracy.
Some may say that we have here a tragedy of errors in which
none of the various government entities are blameless and none
are solely at fault. I believe that we can, and we must, do
much more to serve these veterans by establishing the Vision
Center of Excellence that was authorized in appropriated funds
for last year.
Yet, instead of pointing fingers, I hope that this hearing
will provide the impetus for immediate action to begin setting
up these Vision Centers of Excellence, and ultimately I hope
that hearing the stories of veterans who have been affected by
the delay in implementation will shed light on what is at stake
in this situation.
I regret very deeply, Mr. Chairman, that I will have to
depart after making this opening statement. I have conflicting,
actually three hearings set for 10:00 this morning, but I
wanted to make a point to be here to emphasize those issues
that I, my colleague, Mr. Walz, and our Chairman feel so
strongly about.
I am very eager to see this project move forward and
anxiously await news of its progress. I yield back.
Thank you, Mr. Chairman.
Mr. Mitchell. Thank you.
Mr. Boozman.
OPENING STATEMENT OF HON. JOHN BOOZMAN
Mr. Boozman. Thank you, Mr. Chairman, very briefly. I will
just be very brief, because I want to go ahead and hear what
everyone has to say. But I see Mr. Rogers here. I want to thank
you for your, you know, doing a tremendous job of advocating
this. You are here as a Republican, and yet I know that you
represent the Appropriators, and this has been a very
bipartisan thing, and we do appreciate your help and appreciate
your advocacy in recognizing how valuable this was early on.
So thank you, Mr. Chairman.
Mr. Mitchell. Thank you. I ask unanimous consent that all
Members have 5 legislative days to submit a statement for the
record. Hearing no objection, so ordered.
At this time I would like to welcome Panel One to the
witness table. I now recognize Mr. Rogers of Kentucky to
introduce our first witness, Specialist Fugate.
OPENING STATEMENT OF HON. HAROLD ROGERS
Mr. Rogers. Mr. Chairman, Ranking Member Roe, and
distinguished Members of the Subcommittee, thank you for
letting me have the chance to say a few brief words this
morning, and introduce to you a constituent of mine, who is
your first witness on the panel this morning.
I am sorry that I can't stay as well for the entire
hearing. My Subcommittee on Appropriations is meeting as we
speak, and I have to run back to that session, at which I am
the Ranking Member.
But I am very, very pleased to see your Subcommittee
conducting this very important hearing and timely hearing and
initiation of the Vision Center of Excellence.
As I am sure you will hear from today's testimonies, it is
imperative that the Department of Defense and VA work together
quickly to firmly establish this center and valuable Eye Trauma
Registry to assist our young men and women in uniform facing
vision challenges.
So many of us take for granted driving to the grocery
store, watching a ball game, reading a good book. Sight affords
us such simple things.
Our brave soldiers, sailors, airmen who have lost their
vision will survive and can thrive, but if we can prevent
vision loss, we ought to do everything possible to make that
happen.
The Vision Center of Excellence is a part of ensuring that
we are doing our job as they go about doing their job on our
behalf.
I met U.S. Army Specialist Travis Fugate, the extraordinary
young man and soldier sitting to my left 2 weeks ago when he
came in my DC office. I learned about his family back in
Kentucky where I know his family. They live in a small town
called Hindman in Knott County, coincidentally the home of
former Congressman Carl Perkins, whom some of you may remember.
Small town.
I was extremely moved by his story, his personal
experience, and I think probably most importantly his positive
attitude on life. Despite perhaps some failures on our part, he
has not given up on himself or our country.
Travis is a native of Knott County, Kentucky, located in
the heart of my district in the mountains of east Kentucky. He
entered the Kentucky National Guard in December of 2003, he
deployed to Iraq in February 2005 with Co. B 206th Engineers.
What unfolded there was no less than a series of tragic events,
and yet you will see his truly American spirit. A spirit that
overcomes obstacles and conquers life's setbacks.
And I will let Travis tell his story, as I could not do it
justice. But I do want to commend him for his courage and thank
him for his service and sacrifice for our country, and in this
selfless campaign he is assisting all of us in, in trying to
help people like himself throughout the service of our country.
And with that, Mr. Chairman, I am honored and pleased to
introduce to you Travis Fugate.
Mr. Mitchell. Thank you, Mr. Rogers for your introduction.
Also joining us on our first panel is Sergeant Kinney, U.S.
Army retired, an Operation Enduring Freedom/Operation Iraqi
Freedom (OEF/OIF) veteran from Deland, Florida, Master Sergeant
Magallanes, U.S. Army retired, and his wife Mrs. Magallanes
from Clarksville, Tennessee, and Dr. Tom Zampieri, the Director
of Government Relations from the Blinded Veterans Association.
I ask all witnesses to stay within 5 minutes of their
opening remarks. Your complete statements will be made part of
the record.
First let me just say that at the end of 5 minutes you will
all hear a beep, so hopefully we can keep within that so all
people can be heard.
At this time I would like to recognize Specialist Fugate to
begin.
STATEMENTS OF SPECIALIST TRAVIS FUGATE, USA (RET.), HINDMAN, KY
(OIF VETERAN); SERGEANT DAVID WILLIAM KINNEY III, USA (RET.),
DULAND, FL (OEF/OIF VETERAN); MASTER SERGEANT GILBERT
MAGALLANES, JR., USA (RET.), AND SHERRY MAGALLANES,
CLARKSVILLE, TN (OEF VETERAN AND SPOUSE); AND THOMAS ZAMPIERI,
PH.D., DIRECTOR OF GOVERNMENT RELATIONS, BLINDED VETERANS
ASSOCIATION
STATEMENT OF SPECIALIST TRAVIS FUGATE, USA (RET.)
Specialist Fugate. Thank you Chairman and Congressman Roe
and other distinguished Members for letting us come up here and
talk to you guys.
It is really exciting here in how all that is being said.
Everyone seems to be moving in the right direction with our
Vision Center of Excellence. But I remember feeling the same
excitement last January when I got the e-mails describing what
was being given to us veterans, and I hope this time that
excitement and energy doesn't dwindle to the halt that is has
been at for the past year.
I submitted a written testimony which has the dates and
times and everything, and I couldn't sit up here and tell you
how everything happened, but I will tell you that I was injured
in 2005 on May the 18th. I was hit by an IED just south of
Baghdad, and there I lost my vision. And vision is the second
leading injury only behind hearing loss. A lot of people don't
know that.
I came home and I received great treatment here at Walter
Reed, and even as a transition into the VA it was a lot of
work. I had to do a lot of work myself to get through it all,
but I made it. I made it through. And the doctors up here sent
me with a job. I had to tell the Ears, Nose and Throat doctors
back in Lexington, Kentucky, that I needed an issue addressed
on my frontal sinus.
When I got enrolled in the VA and requested to have it
addressed, due to my records being scattered and inaccessible
to the doctors, they couldn't go in and do what they needed to
do. Without the records they couldn't really determine the
anatomy of my face, as the inside was so severely injured by
the blast.
So the doctor, making a wise decision not just to cut in
there not knowing what is what, told me to just wait and see
what happens. And I trusted that decision, because I had gained
a great trust in all the medical professionals on DoD and the
VA side.
Well anyway, with the VA's rehabilitation I got a lot of
devices, a lot of good technology. I really gained a hope that
I could be successful, but then I got this infection and then
it pretty much led to the loss of the rest of my vision.
And that is it, thanks.
[The prepared statement of Specialist Fugate appears on p.
40.]
Mr. Mitchell. Thank you. Next Sergeant Kinney.
STATEMENT OF SERGEANT DAVIS WILLIAM KINNEY III,
USA (RET.)
Sergeant Kinney. Thank you, Mr. Chairman, everybody on the
panel up there.
Like Travis said, our statements are in the record. And a
short version, in Afghanistan, Mazar-e Sharif, Afghanistan in
the north an IED went off, I banged the back of my head on the
back of the seat real hard, caused bruising, and cracked the
two top vertebrae in my neck right at the base of the brain
stem. All right?
Trying to get doctors to understand that I was having
severe headaches--my vision started to blur almost immediately
afterward, within a month it started to blur. Trying to get
doctors to understand that, you know, there was something going
on, all I heard was that you are 40 years old, you shouldn't be
running around with 20 year olds. Okay? That is unacceptable.
We are out there training people, we are training the guys, we
can't be that way.
To start getting glasses issued. I have had six pairs of
glasses issued. My last eye exam says that I don't need any
more prescriptions, they won't do me any good. Okay?
This happened in November of 2005 where I have had
different eye exams. And the records, if I didn't carry them
with me and get a copy from each place I went from Landstuhl to
Eisenhower Medical Center, to the Tampa VA, Daytona VA, carry
these records with me there would be no track record of showing
what is going on. And every time I go to a new facility, you
get new treatment. Everybody wants to change the direction of
which way the wheel is turning.
We need to get one roof where everybody can get together
and our records are tracked, a database of some sort where our
records can be tracked and our care can be under one roof, one
facility somewhere that when you have this type of vision and
you are having these problems, they can be addressed in a way
that would be done right.
I had a civilian doctor say I had a closed head trauma.
Anybody who has been in a car wreck, you know, what that is,
where you bang your head real hard. Okay? And that is what
happened to me. I didn't have a blast that would cause any
scarring or anything like that, so it was real hard to see my
injury. Is that me? I was going to say, I didn't talk that
much, did I?
Mr. Mitchell. No, that's something else. I'm sorry. No,
that's not you.
Sergeant Kinney. But we have got to have somewhere to track
this stuff. We have got to get the Vision Center of Excellence,
TBI studies, and get everybody on the same ball program.
I mean, I know there are new programs starting. The VA has
been a great help, the Wounded Warrior Program has. I have
gotten good care, but it is just not--nobody is talking to each
other, and you can't get the care if nobody is talking to each
other.
You know, if it was you or your son out here that was
sitting on this side of the desk, how would you feel and what
would you do for him?
Thank you.
[The prepared statement of Sergeant Kinney appears on p.
41.]
Mr. Mitchell. Thank you very much.
Master Sergeant Magallanes.
STATEMENT OF SHERRY MAGALLANES ON BEHALF OF MASTER SERGEANT
GILBERT MAGALLANES, JR., USA (RET.)
Mrs. Magallanes. I am Sherry Magallanes, and I am honored
to be speaking on behalf of my husband----
Mr. Mitchell. Very good.
Mrs. Magallanes [continuing]. Who is retired Master
Sergeant Gilbert Magallanes. He is a veteran of the United
States Army who served in both the Gulf War and Operation
Enduring Freedom. He is a Green Beret that served with Fifth
Special Forces Group at Fort Campbell, Kentucky, and now
medically retired after 21 years of active-duty service due to
combat wounds that he sustained in Afghanistan during Operation
Enduring Freedom.
He sustained his injuries actually from a friendly fire
accident on December 5th, 2001, while his Special Forces team
was guarding Hamid Karzai, the President of Afghanistan, and he
incurred an open traumatic brain injury with loss of skull and
brain matter around the occipital lobe, that is actually larger
than a 50 cent piece. The skull has actually been repaired by
craniotomy, but the brain damage is obviously permanent.
He also has numerous other injuries, including homonymous
hemianopsia, which is complete loss of his left field of vision
bilaterally. He has slight left-sided hemiparesis, a cognitive
thinking dysfunction and disorder, migraine disorder, and
seizure disorder. He has lost two digits and part of his palm
of his left hand, he has nerve damage to the left wrist, severe
hearing loss, and he is now in stage three kidney failure and
will require a transplant.
He spent over 1\1/2\ years in the hospital having multiple
surgeries, recovering, numerous hospitalizations since. He has
had to relearn how to walk and learn his left from his right,
and so forth.
After his wounds were stabilized in Landstuhl, Germany, he
was sent to Walter Reed where he resided in intensive care in a
coma for several weeks.
At the end of January, he was sent for traumatic brain
injury rehabilitation at the Palo Alto VA in California. After
that, he was sent to a community reentry program that was a
civilian-based unit in Sharps Medical Rehab in San Diego. It
was our understanding he would obtain vision training for him
to adapt for the vision loss and improve his independent living
skills. However, once he completed the course in San Diego,
they did the craniotomy to repair the skull deficit and he was
sent back to Fort Campbell, Kentucky.
I assumed his care would be transferred to the Blanchfield
Army Community Hospital at Fort Campbell at that time; however,
his records were not completely transferred each time he was
transferred between a military medical facility and a veterans
medical facility, therefore, causing a break in his continuity
of care.
The case manager he was assigned to when he reached
Blanchfield Army Community Hospital in Fort Campbell was not
aware of the extent of his injuries, and the hospital could not
provide the adequate care that he needed. At the time, they did
not have a neurologist on staff to treat the effects of the
traumatic brain injury, the seizure disorder, the migraine
disorder, or anything else.
He was assigned a staff physician who in turn told us
traumatic brain injury and neurological disorders were not her
specialty, but she would do the best that she could, and she
did.
When the seizure disorder actually worsened, we had to go
to his commander at Fifth Special Forces Group to arrange for
him to be sent to Walter Reed so he could be treated by an
actual neurologist.
We were not married at the time. I had no knowledge of the
military, how to handle a medical board proceeding, or the
procedure for retirement. I do not have a background in the
medical field to understand the extent of Gilbert's injuries,
diagnosis, or required treatment, and the proper protocol for
therapy. Therefore, a lot of phone calls were made to his
commander at the time and he was added to the temporary
retirement disability list upon the findings of the Army
Medical Evaluation Board.
At this time, all of his care was to be transitioned to the
Department of Veterans Affairs. Since my husband's medical
records were not transferred with him each time he transferred,
we had to request copies and begin the process of compensation
and pension exams as ordered by the Department of Veterans
Affairs to identify all of his injuries and ongoing medical
problems as defined by the findings of the Army Medical
Evaluation Board.
At the time, he had a vision exam to confirm field vision
loss and told him to be happy that at least the vision he does
have is good.
After he was assessed and given 100-percent disability
rating through the Department of Veteran Affairs, we were told
that any care he needed would be provided. However, when I
called to get him an appointment with the vision clinic,
because his vision seemed to be changing, they told us he
couldn't be seen. There was a certain protocol that had to be
followed. I went to the hospital administrator. They told me
that he needed to be seen by his primary care, referral had to
be made, even though he was already rated for vision loss.
In 2008, we attended a paralympic sporting event, which we
were fortunate to meet Travis Fugate, and at that time he
forwarded our information to the Blind Veterans Association.
And in turn, Ms. Christina Hitchcock with the BVA contacted us
and invited us to their convention in Phoenix this past year.
And it is 7 years post injury. We finally were introduced to
our Visual Impairment Services Team (VIST) coordinator at the
Nashville VA.
We now get to go to blind vision rehab to make him more
independent and so forth on March 25 of this year in Palo Alto.
Although his vision impairment stems from the loss of brain
matter and brain damage, not an actual disease or damage to his
eyes, I still feel things may have been easier for him and our
family if he was taught how to compensate for the visual loss
in the beginning. I feel, and actually thought, there to be
some process to prevent events like that. I know from our
experience I was wrong. If we had not met Travis and the BVA,
he would still not be receiving the vision testing and so forth
that we have waited almost 7 years for.
It is our hope there will be a plan implemented not only to
traumatic brain injury, but also for vision impairments and
care coordination. We would like to see a system that tracks
and follows patients through their course of care and during
active duty and as they transition to retired members of the
Department of Veterans Affairs to ensure that they are
receiving the proper care and training as their injuries
indicate. Therefore, no one would have to wait for 7 years to
receive care and training as we did.
This, in turn, would mean additional educational training
and research in visual impairments caused by traumatic brain
injury for the staffs of both military facilities and the
Department of Veterans Affairs.
In closing, I would just like to say that my husband, being
the loyal and dedicated ranger that he is, has absolutely no
regrets about his service to our great country. He would be
back in uniform and on the front lines if he was medically able
to do so, but he is not.
It is our hope that he be offered the necessary training
and medical care to help him live his life as independently as
he can with the injuries that he did sustain.
Thank you for your time.
[The prepared statement of Mrs. Magallanes appears on p.
42.]
Mr. Mitchell. Thank you very much.
Mr. Zampieri.
STATEMENT OF THOMAS ZAMPIERI, PH.D.
Dr. Zampieri. Ranking Member and Chairman Mitchell and
Congressman Boozman and other Members of the Committee, on
behalf of Blinded Veterans Association we appreciate that you
scheduled this hearing today.
For our part we want to thank each of the Members of the
Committee and the Committee staff who have followed this issue
since the NDAA was passed a year ago, and I think you obviously
all know my frustration with this slow process, and I am being
kind in describing it that way, I think.
You know we started off with a lot of excitement because
the physicians, the ophthalmologists in the military and the
ophthalmologists in the VA and the optometrists in both the
military and the VA actually started planning and talking about
the great things that could be accomplished with this Vision
Center of Excellence right around the same time that the
original legislation was introduced in the Congress to create
this in the Wounded Warrior section of the NDAA, which included
the TBI and the Post-Traumatic Stress Disorder (PTSD) Centers
of Excellence. And we thought that the train would all pull out
together. That these three centers would all be established at
the same time. They would be equally funded, equally staffed,
they would all deserve the same amount of resources and
support. Well, could fool me.
What happened was somewhere along the lines after the--soon
after the NDAA passed, I started being told by different
sources that, the famous story of ``there is no money.'' This
was not included in the specific line item in the
Appropriations for fiscal year 2008. And when I went to the
Armed Services Committee and Defense Appropriations Committee
and the VA Committee and various people, they said there was
plenty of money that was not only included in the War
Supplemental for wounded warrior care, but there was money that
was also included in regular Defense Appropriations for the
Centers of Excellence. Meaning all three centers, not two.
However, we now know that that wasn't, or at least according to
different sources, the case.
What happened was, as time went on in April, in fact a year
ago, April 2nd, we had a hearing in this very room. DoD
witnesses came and they talked about all the excitement of what
they were going to do and how they were going to do it, and yet
nobody in writing ever promised how much they were going to put
into this.
There were public statements made by senior leadership at
the end of April about how they were having funding challenges
in trying to establish the Vision Center of Excellence. And at
the same time, I would point out that Congress was in the
middle of examining the War Supplemental request to cover the
remaining part of 2008 and the beginning of 2009, and there was
a vehicle there where someone could have simply asked for the
$5 million if that was indeed the issue.
Then again in May, I was told again that there was no
money. June there was a hearing in this room by the full
Committee, and Mr. Dominguez came over to testify about
seamless transitions and meeting the requirements of the NDAA.
And if you go back and review his testimony, he talked
extensively about the TBI Center of Excellence, the PTSD Center
of Excellence, and he has one paragraph about the Vision Center
of Excellence and no mention of funding, and that should have
set off all sorts of red flags.
Basically, where we are at today is I was astounded and not
amused that suddenly last Friday, the Chairman gets a letter
from the Pentagon saying we have mysteriously found $3 million
for the Vision Center of Excellence. And you have to excuse my
sarcasm here, but I don't believe that that suddenly was just
found. There is no reason at all, with all of the other
Appropriations that have come through, that someone could not
have simply asked if that truly was the issue.
The Vision Center of Excellence is going to play a very
critical part of ensuring that research is coordinated, that
these individuals that have had eye trauma or traumatic brain
injury and vision disorders are tracked, that their diagnoses,
their tests, their surgical reports are collected, examined,
outcome studies will be developed.
And just briefly, the Vision Center of Excellence is not
one big hospital. The idea is that it is a virtual center that
will work across both the VA and DoD systems in finding
literally thousands of these individuals who have come back
with different types of either TBI vision dysfunction or with
penetrating eye trauma.
I will end it here.
Again, thank you very much, I look forward to your
questions.
[The prepared statement of Dr. Zampieri appears on p. 44.]
Mr. Mitchell. Thank you very much.
And first I just want to thank all of you for the service
that you have given to our country and the service that you
have rendered in the past and your attitude today. It is just
terrific.
The first questions I have are for Travis Fugate.
First of all Travis, have you been happy with the overall
care that you have received from the VA and the DoD?
Specialist Fugate. What was that again, sorry?
Mr. Mitchell. Have you been happy with your overall care
from the VA and DoD?
Specialist Fugate. In combination, no. Individually, each
entity individually, yes. I have encountered wonderful doctors,
wonderful staff, and wonderful rehabilitation, numerous
devices, the newest technologies to assist me in my daily
living, and going to school. I have used the vocational
rehabilitation program that the VA offers to go back to school,
and begin a new life as a blinded individual.
So for both of them as a whole no, but each individual
entity I have been happy. Yeah, I have been happy.
Mr. Mitchell. Thank you.
Travis, can you describe what the transition was like
between the VA and the DoD facilities?
Specialist Fugate. It was a lot of paperwork, a lot of
time. This was in 2005, or excuse me 2005/2006, that I
transitioned, and since there have been a couple programs that
has been implemented to help. I am not sure how they are doing
now.
But during the transition, once I got to the VA, they
seemed that they were completely unfamiliar with the way things
were working with DoD. It was obviously just two completely
different entities. And had there been some sort of central
access point or hub to medical records and documentation and
things like that, educational information for the staff
regarding blindness and other things, I think it could have
been a lot better, a lot easier.
Mr. Mitchell. Okay.
Travis, how far is your home to the nearest VA facility?
And also I want to ask a couple other questions. Who is
your primary caretaker in Kentucky? And along with that, how
have your injuries affected your family, especially your dad?
Specialist Fugate. Currently, I use a VA home loan to buy a
home, and I have lived just by myself. Luckily my mother, my
sister, and my father all live in a close proximity, so I have
daily assistance. So their lives have been affected greatly in
that a lot of their time and care goes into making sure that I
am getting by and I am living comfortably.
My dad has made great sacrifices in that he has risked
losing multiple jobs working in the coal mines of the
Appalachian mountains in order to drive me 2\1/2\ hours to the
closest VA that is in Lexington, Kentucky. Several times a
month occasionally.
So if that answers your question.
Mr. Mitchell. Let me just ask a question of Dr. Zampieri.
If the Vision Center of Excellence was fully operational,
how could this Center have potentially changed the stories of
Travis, David, and Gil?
Dr. Zampieri. I think the big thing would have been having
the ability of any ophthalmologist, either in the VA or DoD
system, be able to go in and see the surgical reports.
And I think one of the most complex problems that providers
have, and I am sure that the Ranking Member appreciates this as
a physician, and I know Congressman Boozman does also, is all
of these individuals suffer multiple traumas, multiple
different types of injuries where they have had multiple
surgeries. In Travis' case he was in a coma for a month, so he
doesn't even remember any of the surgeries that he had.
So having the Vision Center of Excellence Eye Trauma
Registry set up and operational, a physician could see Travis,
go to the VCE's site, look at the different types of surgeries
that were done on his retina, and he has had multiple
surgeries, and be able to quickly figure out this is, you know,
what I need to do next, you know, in my clinical decision
making. And I think that is the big thing with all of them, not
just with Travis.
You know, because David described to me yesterday about how
he went through multiple different tests at multiple different
hospitals and they are repeating the same tests over and over,
which is not only inefficient and expensive, but having those
diagnostic tests in one registry, eye registry, would
efficiently, you know, improve that.
Mr. Mitchell. Thank you.
Dr. Roe.
Mr. Roe. Thank you, Mr. Chairman.
First of all, I just want to tell you, Travis and all of
you, we appreciate your service to your country. And secondly,
you made a statement earlier that you appreciated what had been
given to you. Nothing has been given to you. You earned every
bit of it and we need to make sure that we understand that in
this room and in this country, I think.
And I also want to thank the family members. You mentioned
your family, Travis, and certainly other family members that
have stood by their family members and have assisted them in
what they needed to do. And I found it astonishing last night
when I read this entire testimony that we had let this go on
for as long as it had, and the nonsense that this government
funds every day and then not to fund this very needed program
was appalling to me.
I believe this hearing, Mr. Chairman, is very much needed,
and I appreciate your doing this, to bring this to light.
This incident, and I am going to call you Sergeant Gil so I
won't step all over your name. I am from Clarksville,
Tennessee, and we had a Sergeant Davis I believe from
Elizabethton, Tennessee, who was Special Forces that was killed
in that very incident I recalled when I was reading the
testimony last night, it just tripped my memory, and so I am
very familiar with where you were injured.
I think in all the testimony I have heard screams for a
seamless electronic transferable, easy readable, electronic
medical records where when you go from one point to another
point for care, that it is seamless. And it looks to me like
that would have prevented many of the problems that each of you
have experienced in the 7 years that you all went through not
to get to the point where you could get care was amazing to me
when I read that.
And I think the injuries that each of you all have
sustained, loss of vision--I am a surgeon, and it would have
prevented me from doing any of that, and I admire and
appreciate what you all have done.
One of the things that we noticed in testimony from a year
ago, and I will just read it briefly and then ask each of you
to answer this question.
This was testimony from 1 year ago.
``It is important to emphasize, however, that neither the
transfer between health care systems, that is DoD or VA, is a
linear path to ensure every veteran or servicemember receives
the care or benefits they deserve.
The VA has created a case management program for Operation
Enduring Freedom/Operation Iraqi Freedom veterans. The VA, DoD,
Federal Recovery Coordination Program further provides needed
assistance in support for veterans and servicemembers.''
The question that each of you can answer. Have any of you
worked with a Federal Care Coordinator to assist you in your
treatment plan, and when did that care begin or has it?
Sergeant Kinney. I can say no for me, I haven't met anybody
in that way.
Mr. Roe. Okay, Sergeant Kinney.
And Sergeant Fugate?
Specialist Fugate. For me there has been--I have heard some
rumors of case managers, but I don't know any names or I
haven't personally--there is a couple social workers, but I
think that is a whole different thing. So no.
Mrs. Magallanes. In regards to us, we had a case manager
when he first arrived in Blanchfield Army Community Hospital,
but again she wasn't aware of the extent of his injuries or
were able to provide any services that he really needed. In
regards to Federal case management, no.
Our local VA, which is an hour from us, which is Nashville,
actually started their own little polytrauma unit, a little
over a year ago, and called us in, and again we reiterated that
it was 6 years. We understand he was injured early in the war
and they were not prepared for the extent of the injuries, but
they had him again go through a series of different clinics,
vision, speech, and identified all of his injuries, but in
regards to getting therapy he still wasn't offered it.
So they still don't contact him or follow up in regards to
making sure that he gets the necessary treatment he needs. It
basically falls upon the patient. And a lot of them, I know in
my husband's case, I don't have a medical background, so to
have to understand what he needs and to understand a traumatic
brain injury and that a cognitive disorder requires ongoing
treatment. It is not just something you can have once and then
be done with, because the brain needs repetitiveness. And to
understand, I didn't know that, I was not aware of it. And I
honestly thought that someone would be there to help us guide
through this, but now hopefully, you know, we are going to get
the care that we need and this will just prevent someone going
through the same situation, you know, that they won't have to
do the same things we did.
Mr. Roe. The bottom line answer is no.
Mrs. Magallanes. Yeah, pretty much, yeah. Which we did have
a case manager, like I said, but it is just not the same thing.
They didn't actually do anything for us.
Mr. Roe. Okay, thank you.
Thank you, Mr. Chairman.
Mr. Mitchell. Thank you.
Mr. Boozman.
Mr. Boozman. Thank you, Mr. Chairman, and again thank you
and the Ranking Member for being such a leader in this effort
to try and resolve the problem that we have got.
I want to thank all three of you guys. My dad retired as a
master sergeant in the Air Force, so he was an enlisted guy, so
I feel very comfortable around you all. But I do appreciate
your sacrifice, not only of you, but of your families. And I
know that you have gone through a very difficult situation, and
you really do exemplify the cost, the true cost of the
endeavors that we are involved in now, and we really do
appreciate your service.
Tell me, I guess you know, you eluded to--my concern is you
all have had a tough time in the area of vision, and what we
are trying to do is establish this Center of Excellence to
prevent, as just was said, you know, so that people wouldn't go
through this in the future by trying to, you know, this center,
giving best management practices being an advocate in that way.
And as you have learned it has really been a very frustrating
experience.
Mr. Zampieri, I don't want to put you on the spot, but
where is the bottle neck? Where do you see things? You are a
guy that has been around here for a long time advocating for,
you know, vision problems and things, where do you see the
bottle neck in this thing?
Dr. Zampieri. I seriously question, some folks will get
angry about this, but the Senior Oversight Committee (SOC) was
supposed to be responsible for the implementation of the NDAA,
and you know, I think, you know, their function was to be able
to cut through, identify problems, make solutions to those,
advise both Secretary Gates and now Secretary Shinseki, and
this never seemed to get to their level of well okay, if
somebody says, if it is Dr. Casells or I don't care who it is,
says we can't find the money, you know, I assume that was the
SOC's responsibility.
And I think there was, you know, mentioned in the earlier
start of the testimony, there was $6.9 million that Senator
Johnson and Congressman--Chairman Chet Edwards put into the
MilCon/VA budget specifically for helping to get this started.
And you know, I question why is it no one went and identified
that and said okay, this is some resources that we could put
into this.
I hope that helps, you know, help point one finger in one
direction.
Mr. Boozman. No, very good, thank you.
Let me ask you all. You had your injuries, and at what time
did you start receiving any sort of mobility training?
Sergeant Kinney. I didn't get mine until last year, because
everybody wouldn't combine the TBI with eye injury. I think I
said it in my statement, it is like saying a bad word in
church. You just couldn't say TBI and vision, nobody would
believe that there was a conflict between the two.
Mr. Boozman. Right.
Sergeant Kinney. And it took till last year and they got me
to the Birmingham BRC down there.
Mr. Boozman. Uh-huh.
Sergeant Kinney. The Blind Rehabilitation Center in
Birmingham. And I learned a lot there, but just getting the
people to understand that there is a problem----
Mr. Boozman. So once you got down there that was very
beneficial in helping you to navigate.
Sergeant Kinney. Oh, yes, sir.
Mr. Boozman. How about you, Mr. Fugate?
Specialist Fugate. I was injured in May of 2005. I started
planned rehabilitation in August of 2005, so that was pretty
quick.
But I will say that in the time, that I sat up here at
Walter Reed waiting to recover from other injuries, I had no
information on blindness or no one to come and tell me that it
is going to be okay, that there is accessible computers and
that there are other blind people in the world.
Mr. Boozman. Right.
Specialist Fugate. I was really alone. I had my mother
trying to Google blindness basically.
So I understand now the VA has the BROS (Blind
Rehabilitation Outpatient Specialist), the blind--I always--I
will just say BROS, because I always mess it up--that comes out
and works with the soldiers.
So hopefully that is addressing that particular issue on a
small scale.
Mr. Boozman. Thank you.
So your mom is trying to figure it out, which is a sad
situation.
Specialist Fugate. Yeah, yeah.
Mr. Boozman. I am Boozman or Boozman you all are----
Mrs. Magallanes. Magallanes.
Mr. Boozman. Magallanes.
Mrs. Magallanes. Uh-huh.
Mr. Boozman. Okay.
How about very quickly can you tell us as far as when you
started getting your mobility.
Master Sergeant Magallanes. For actual vision training I
have had no training at all. I have just used my Special Forces
training for teaching my myself. I had a great occupational
therapist down in San Diego who helped me work with my scanning
capabilities, and quit making me use my head back and forth for
turning, because I am half blind, I don't see any to my left.
Mr. Boozman. Yeah.
Master Sergeant Magallanes. So I always walk like this. I
mean just completely.
Mr. Boozman. Right.
Master Sergeant Magallanes. And so now as soon as I walk in
the room, I scan and I just scan with my eyes and try to walk
normal, and that is the way it was. But now I am going March
25th to the trauma center in California.
Mr. Boozman. Very good.
Yeah, I think as the other two indicated, that is something
that really will be very helpful. Even though you are a tough
guy and were able to, you know, figure out a lot of this
yourself, I think that training will be very useful.
Thank you, Mr. Chairman.
Mr. Mitchell. Thank you.
I would like to ask two questions very quickly of Dr.
Zampieri.
And you were talking with Mr. Boozman, and in your
testimony you also indicated in several places the lack of
funding available for the Vision Center of Excellence. Do you
feel that that is still a concern today?
Dr. Zampieri. Thank you for asking that.
Yeah, the $3 million I have some serious questions. I don't
know what is in the testimony of the DoD representative here
today, but I would ask--I don't get to ask--but I will ask you
to ask, you know, how much money is it going to cost for
information technology support for the Vision Center of
Excellence? Because I have been told, off the record, that it
is at least $2 million.
I would also want to know how are you going to cover the
construction costs, because there has been concerns about
space--office space for the Vision Center of Excellence out at
Bethesda at the National Naval Medical Center, that is where
the Vision Center of Excellence is supposed to be
headquartered, and they have identified space, but they need
some construction money, and I don't ever in the past year, I
have never seen a figure for that. Is it $5 million that they
need for space renovation?
And the third thing is, you know, the original estimates
last May were $5 million to get this up and running, because
there are going to be four clinical sites, Bethesda, Brook Army
Medical Center, Madigan Army Medical Center, and Balboa
National Naval Medical Center are supposed to be designated as
quote, ``four Clinicalized Centers of Excellence.'' And how do
you fund and staff with $3 million? You know, those four sites,
plus the headquarters, none of that still adds up.
Hope that helps.
Mr. Mitchell. Yes, and one last question really quickly.
To your knowledge, is DoD utilizing the Blind
Rehabilitation Centers for vision-impaired active-duty members
awaiting medical boards, and do you think we could be providing
this training to those members sooner to assist with the
transition from the DoD to the VA system?
Dr. Zampieri. Briefly, you know, the VA has taken a lot of
positive steps. As Travis mentioned now, they do have blind
rehabilitative outpatient specialists who do early intervention
now, and they have for the last few years, at both Walter Reed,
Bethesda, Brook Army Medical Center, and so that has been a
positive step. That helps them with the initial education about
blind rehab training and orientation mobility training.
And then those BROS and the VIST coordinators, Visual
Impairment Service Team coordinators from the VA, they can help
expedite and make sure that the individuals get transferred
into one of the ten VA blind centers for their training.
And so I think one of the things too that I identified as
sort of a failure, I think is the case managers and the Federal
Recovery Coordinators don't always even understand that there
are these VA resources available.
I know that it is a big system, it is complex, you are
dealing with a lot of different people, a lot of turnover, but
I think that, you know, part of the--hopefully the Vision
Center of Excellence mission will be in educating, you know,
the staff, the case managers. That if you have a servicemember
with TBI with vision problems or with penetrating eye injuries
that the first thing they should do is initiate a consultation
with VA's blind rehabilitative services, because they do an
excellent job. But if they aren't told, we are going to
continue to have people fall through the cracks.
Sergeant Kinney. Sir?
Mr. Mitchell. Yes, sergeant?
Sergeant Kinney. Sorry, I don't mean to interrupt, but the
seamless transition. We can't get into the VA system 6 months
prior to us getting discharged. Some of us, our care has lasted
up until--I was injured November 2005, I didn't retire until
June of 2008, okay? I started trying to get into the VA system
as non-service connected. You can't get care that way. They
won't give you medicine, they won't start your stuff for you
until you are all the way into the VA system. There is no
seamless transition. You start everything over when you retire.
When you get your DD-214 in hand is when you retire, that is
when you get into the VA system. Before that it is not
seamless. It is non-service connected. You don't get care. You
get seen and that is it. And I have got records to prove that.
Mr. Mitchell. Thank you.
Dr. Roe, did you have any other?
Mr. Boozman, any other questions?
Mr. Walz.
Mr. Walz. Well thank you, Mr. Chairman, I apologize for
being a little late here. Thank you to each of our witnesses
who are here today. Thank you for your service and thank you
for your continued service by coming here and pointing out what
we can do better.
Specialist Fugate, I had the opportunity to meet you.
Travis, this is Congressman Walz, and again I was deeply
inspired by your willingness to try and help us figure out what
we need to do to make this work.
You mentioned something to me, Travis, last week I have
thought about all this weekend. You mentioned something that
sometimes we forget here. You said your only desire is to try
and live as independently as you possibly can.
Are you going to be able to do that back in Kentucky the
way it is now? You talked to me about the little place you
bought on the hill and how you'd like to go back there and do
some things. What do you think, is it possible?
Specialist Fugate. No, unfortunately it is not. I bought
the place, it is beautiful up there in the mountains, but for
me the house that I bought I quickly realized that it was more
like a cell or a prison, because I have no way of leaving
there. You can't just get a sidewalk--hop on a sidewalk and go
down the street. There is no public transit. So now I am forced
to change my life plans and move to a more urban area so that I
can adapt and try to live independently.
Mr. Walz. Travis, if I can ask, and you are thinking one of
the urban areas may be DC or something like that. You are
probably finding out like the rest of us, it is a lot more
expensive than Kentucky.
How about your retirement plan and your disability? How is
that impacted by you being basically unable to make that choice
to go to Kentucky, you just simply can't, as you have spoken
about. Where is your disability pay at and retirement pay and
how does that affect your decisions?
Specialist Fugate. I have realized since being up here in
the hospitals since January, I have made a lot of good contacts
and good friends, and I have realized that what I am getting
currently, which is less than $3,000 a month, is definitely not
going to support me moving up here and living efficiently. I
will have to get some sort of part-time job, which I am excited
about, I want to get back out into the working environment.
But I have also realized since talking to my fellow
veterans here that there are several types of pay and assisted
pay through the VA that I haven't even been informed about in
nearly 4 years. Apparently I am not getting what I deserve.
So maybe after the changes I can reevaluate the financial
situation, but as for now, I am really nervous about the
transition, but unfortunately it is a requirement for me to be
independent, regardless of the cost.
Mr. Walz. Well thanks, Travis.
Sergeant Kinney, you brought up something, if I can just
raise one more thing, and I could not agree with you more. We
talk about seamless transition but it doesn't seam to exist
anywhere except in words, and it is something I have been
deeply concerned about because of exactly the things you
stated.
There was an initiative we started last year, the Eye Care
Centers of Excellence, that was supposed to be a joint
initiative between DoD and the VA system to try and deal with
this very same thing, to make sure that you are receiving the
care on the DoD side and the totally seamless transition in
these shared facilities or shared initiative to switch you
over, and it has not been done.
If we get that done do you think that is going to make a
big difference in terms of your care, quality of life, and
those types of things?
Sergeant Kinney. Well in my care it would, because the VA
doctors would be able to talk to the DoD doctors, okay? They
would be able to track what the Army doctor started at
Landstuhl and Fort Gordon Eisenhower Medical Center, then the
VA would be able to pick up from there.
I also have a civilian neurologist that needs to see these
records, because he is closer to where I live. And he is the
one that found out that I had TBI and he is the one that put
everything together. But the VA and the DoD don't want to have
nothing to do with him because he is civilian, but I am
outsourced by the VA to go see him and DoD. So it does not make
sense.
If we can start something up to get to my records, okay? If
I give a doctor permission to look at my records or through the
DoD, just like signing into a bank account or something like
that, somebody--we were talking about this last night, if they
are able to get into like an access account to access my VA
records like an account, he would be the only one able to do
it, and he would be able to see what is being tracked and what
is being done. He has asked for tests to be done and they were
never done, because the VA won't approve them or the DoD
wouldn't approve them. He is a civilian, he does not know what
he is talking about. And you hear things like this.
And I can get into a big story about it all, but it is not
worth it. But one department does not talk to the next and then
they outsource you and you still can't get the care that you
need.
Mr. Walz. Well, and I appreciate it, I know, I can hear the
frustration in your voice being a veteran myself----
Sergeant Kinney. Sorry.
Mr. Walz. No, no, don't be sorry about it. This is exactly
what we are trying to alleviate, and it is absolutely
diminishing the care of our warriors, and I am absolutely
convinced it is costing us a lot more money, not to mention it
is creating a culture of frustration with our warriors who are
willing to go and serve and be injured and then our care is not
what it needs to be. So I am incredibly frustrated by that.
I know talking to Travis, his doctors were a little
frustrated with him and the VA because they kept asking him how
many surgeries he had, and as you have heard him he is very
well spoken and kind of a mild mannered kid, and he said--he
finally had to tell them ``It was pretty hard to know how many
surgeries I had when I was in a coma and don't remember
those.'' So you would like to think that those records might
have been passed on.
So you can rest assured that this Committee is absolutely
committed to putting this in the past, and your being here is
helping us do that. So thank each of you.
I yield back, Mr. Chairman.
Mr. Mitchell. Thank you very much.
And again, I want to thank you on behalf of all of us and
the American public, the service you have given. We appreciate
your testimony.
And like I have said before, this isn't just for you that
you are doing this today. This is for a lot of other people so
that we can avoid the mistakes that have been made in the past
and we can correct it so other people won't have to go through
what you have done.
So thank you very much, and we appreciate your service.
I would like to welcome Panel Two to the witness table.
For our second panel we will hear from Dr. Madhulika
Agarwal, Chief Officer of Patient Care Services for the
Department of Veterans Affairs, Dr. James Orcutt, Chief of
Ophthalmology for the Veterans Health Administration,
Department of Veterans Affairs, and they are accompanied by Dr.
Claude Cowan, Deputy Director for Vision Center of Excellence,
U.S. Department of Veterans Affairs. Also joining this panel
are Colonel Donald Gagliano, Executive Director of the Vision
Center of Excellence, and Dr. Jack Smith, Deputy Assistant
Secretary for the Clinical Program Policy for the Department of
Defense.
I would like to begin by recognizing Dr. Agarwal, if she
would begin, and then we will continue with Dr. Orcutt, Dr.
Cowan, and Colonel Gagliano and Dr. Smith.
Each of you have 5 minutes, and if you could keep it
between that. We have your written testimony that will be
entered into the record.
STATEMENTS OF MADHULIKA AGARWAL, M.D., MPH, CHIEF OFFICER,
PATIENT CARE SERVICES, VETERANS HEALTH ADMINISTRATION, U.S.
DEPARTMENT OF VETERANS AFFAIRS; JAMES ORCUTT, M.D., PH.D.,
CHIEF OF OPHTHALMOLOGY, OFFICE OF PATIENT CARE SERVICES,
VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS
AFFAIRS; ACCOMPANIED BY CLAUDE COWAN, M.D., DEPUTY DIRECTOR,
VISION CENTER OF EXCELLENCE, U.S. DEPARTMENT OF VETERANS
AFFAIRS; JACK W. SMITH, M.D., M.M.M., ACTING DEPUTY ASSISTANT
SECRETARY FOR CLINICAL AND PROGRAM POLICY, U.S. DEPARTMENT OF
DEFENSE; AND COLONEL DONALD A. GAGLIANO, M.D., USA, EXECUTIVE
DIRECTOR, VISION CENTER OF EXCELLENCE, U.S. DEPARTMENT OF
DEFENSE
STATEMENT OF MADHULIKA AGARWAL, M.D., MPH
Dr. Agarwal. Good morning.
Good morning, Mr. Chairman, and respected Members of the
Subcommittee. Thank you for the opportunity to discuss VA's
collaboration and accomplishments with DoD concerning the
Vision Center of Excellence or VCE.
Dr. Jim Orcutt, National Director of Ophthalmology and I
are accompanied by Dr. Cowan, Deputy Director of the Vision
Center of Excellence.
I would like to request our written statements be submitted
for the record.
Mr. Chairman, before I begin my statement I would like to
acknowledge the service and sacrifice of the members of the
first panel. We as a Department and a Nation appreciate the
courage they have displayed both on the battlefield and here
today.
I would like to thank them and you Mr. Chairman, for
allowing us to hear their concerns and to provide an update to
you about our work in addressing visual impairment and vision
loss in veterans and servicemembers.
VA has been working jointly with DoD to implement the
components of the 2008 National Defense Authorization Act to
establish a Vision Center of Excellence in prevention,
diagnosis, mitigation, treatment, and rehabilitation of
military eye injuries, to implement a defense and veterans Eye
Injury Registry and coordinate care and benefits between DoD
and VA. We appreciate Congress's support in this area.
During the summer of 2008, VA began discussing the Eye
Trauma Registry with DoD. The registry will include veterans
and servicemembers with direct eye injury from service in
Operation Enduring Freedom and Operation Iraqi Freedom, as well
as other servicemembers and veterans who have sustained TBI
with resulting visual symptoms.
Of note, VA's polytrauma centers conduct comprehensive
assessments of TBI related visual function, ensuring a
comprehensive approach to identification, treatment, and
rehabilitation of visual impairment.
VA and DoD have outlined the requirements for a concept of
operations (CONOPS) for a registry. The CONOPS address the
registry structure, the competence required within the
registry, and the system requirements to make the registry
functional. We have agreed to use a central database with input
from the Joint Theater Trauma Registry, VA's electronic health
record, and the DoD's electronic health record. We approved
this concept in January 2009, and VA's Office of Information
and Technology is providing critical support for this effort.
The VCE will maintain the registry and continue monitoring
and improving it. While the registry is not designed to be a
real-time care management system, the registry's strength is in
its ability to follow patients long term and look at the nature
of an injury and the process of care from as early in the
sequence as possible.
Care management is, and always will be, the responsibility
of VA and DoD staff who work with other facilities to
anticipate, identify, and address the patient's needs.
DoD is the lead agency for developing the Vision Center of
Excellence or VCE.
In November 2008, DoD and VA appointed Colonel Don Gagliano
and Dr. Claude Cowan as Director and Deputy Director,
respectively, of the VCE. They eagerly accepted their
responsibilities and are currently recruiting additional staff.
The VCE will monitor patterns of care and create standard
protocols to ensure consistency of care, it will help to
identify gaps in care delivery, and to find areas for improved
collaboration and coordination.
The VCE will also support the full continuum of care from
both departments, extending rehabilitation services to those
with vision loss by leveraging existing services already in
place.
VA blind rehab services, include 10 intensive inpatient
blind rehab centers, 157 visual impairment service team
coordinators, 75 blind rehab outpatient specialists, and 55
newly established low vision and blind rehab outpatient
clinics. Veterans and servicemembers will be able to receive
vision rehab services at these sites.
VA has assigned a blind rehab outpatient specialist at
Walter Reed Army Medical Center and Bethesda National Naval
Medical Center to receive referrals and coordinate and provide
direct rehab care for veterans and active duty servicemembers.
Through the Eye Registry, the VCE will identify
servicemembers with visual injuries and will work with both VA
and DoD researchers to support new advances in knowledge and
care. This work will allow the VCE to educate providers about
new findings on eye trauma and the visual symptoms of TBI.
VA and DoD are organizing a second conference in December
2009 to educate providers in VA and DoD on the visual
consequences of traumatic brain injury.
Thank you again for the opportunity to speak about VA's
role in supporting the VCE and the Eye Injury Registry.
We are here and happy to answer your questions.
[The prepared statement of Dr. Agarwal and Dr. Orcutt
appears on p. 50.]
Mr. Mitchell. Thank you very much.
The next person that I want to call on is Dr. Jack Smith.
Thank you.
STATEMENT OF JACK W. SMITH, M.D., M.M.M.
Dr. Smith. Chairman Mitchell, Ranking Member Roe, Members
of the Subcommittee, thank you for the opportunity to discuss
the Department of Defense and Department of Veterans Affairs
Vision Center of Excellence current initiatives.
I would like to thank the panelists from Panel One for your
service and for sharing your stories with us today. Certainly
you help us to identify areas in which we still need to
improve, and we are committed to continuous improvement and to
ensuring that our warriors receive excellent quality care,
especially for vision, threatening injuries, and illnesses
across the continuum of care from prevention, to diagnosis,
mitigation, treatment, rehabilitation, and research from the
Department of Defense to the Veterans Administration or the
private sector.
In August of 2008, the Assistant Secretary of Defense for
Health Affairs solicited nominations from the services and from
the VA, and in November he appointed Colonel Don Gagliano as
the Director, and Dr. Claude Cowan as Deputy Director of the
Vision Center of Excellence.
DoD has also allocated $3 million in funding from the
Defense Health Program for fiscal year 2009.
And if I may make a clarification, this funding has been
available since the beginning of the fiscal year in October.
The memorandum that was referred to dated March 12th was
provided at the request of Veterans Affairs Committee staffers
and simply validates that Mr. Middleton has had that money
allocated for the Vision Center of Excellence.
Together, and with ongoing DoD and VA support, Colonel
Gagliano and Dr. Cowan have already begun the challenging work
of strategic planning of establishing better linkages and
communication between DoD and VA vision treatment and research
assets, and have started identifying their near, intermediate,
and long-term requirements for space and other support for the
center.
DoD's primary focus is to provide expert services for our
servicemembers and their families in all areas of vision care.
Developing and implementing innovative ways of managing eye
injuries is crucial.
The Department is committed to improving the quality of
care for our wounded warriors who deserve the very best
treatment for their sacrifices they have made for our Nation.
We thank the House Veterans' Affairs Committee for your
continued interest and support for the Vision Center of
Excellence, and we are pleased to be here to talk about this
significant initiative.
I welcome your questions. Thank you.
[The prepared statement of Dr. Smith and Colonel Gagliano
appears on p. 52.]
Mr. Mitchell. Thank you.
I think you can tell by the testimony before that the
results of all your planning and your talk and so on really
hasn't been very fruitful for these soldiers that were before
us.
Let me just ask a question for all of you.
In a meeting that this Subcommittee had regarding funding
in February of this year, it was stated that DoD reallocated $3
million for the Vision Center of Excellence, and you provided
this Subcommittee with a memo dated March 12th with the
official documentation of this reallocation.
Now some questions about this. When exactly was the money
allocated for the Center of Excellence? And when we hear
testimony from veterans like we just had from the first panel,
who could have been helped by the Center of Excellence, I
wonder how DoD came up with $3 million, and why wasn't this $3
million allocated 14 months ago when the authorizing language
was enacted? And how much of this money has actually been spent
to date and on what?
Dr. Smith. Sir, let me try that.
I am not sure that I can answer all of the questions. The
allocation of the money was part of the allocation process for
this fiscal year and was set aside for the Vision Center of
Excellence. The $3 million is still largely remaining. I think
some $7,000 has been spent at this point.
And I can't answer the exact date question, I will have to
take that for the record, sir.
[The following information from DoD was subsequently
received:]
The Department of Defense (DoD) is committed to improving the
quality of vision care for our wounded warriors and veterans, who
deserve the very best for the sacrifices they have made for our Nation.
During the past year, Optometry and Ophthalmology Consultants from the
Armed Services and the Department of Veterans Affairs created the plan
that lays the foundation for the Vision Center of Excellence (VCE). The
DoD analyzed and reviewed the necessary requirements and identified $3
million in funding that was available at the beginning of FY 2009 to
commence initial operating activities.
To achieve the objectives of the VCE, Colonel Donald Gagliano,
Executive Director, and Dr. Claude Cowan, Deputy Director, have made
significant progress in the Center's strategic and operational planning
efforts and have identified primary resource requirements (personnel,
registry and operational costs) to appropriately obligate the funding
available.
The Defense and Veterans Eye Injury Registry (DVEIR) is key to
achieving the Center's goals because it will provide data necessary to
measure rates of injuries and longitudinal outcomes; this data will
also support improvement in clinical care and care processes, and
ensure consistency across the entire continuum of care. The remainder
of the funds will be used for necessary operational tasks such as
space, travel and equipment. The VCE will expedite the strategic and
operational planning efforts identified by the VCE leadership.
We have embarked on a mission to address the issues of the
visually disabled and to enable our wounded warriors and veterans to
return to a fully functional status; anything less is unacceptable.
Mr. Mitchell. Let me ask this. How much money has the VA
and DoD spent so far on information technology (IT) support?
Dr. Agarwal. The VA has allocated $2 million for the Office
of Information Technology (OIT) support.
Mr. Mitchell. And what has the money been spent on?
Dr. Orcutt. Maybe I can respond to that a bit.
The process of developing the concept of operations began
well over a year ago, and during the process developing that we
have used IT dollars to support the contractors who worked with
us to develop the concept of operations. That was even paid for
that operation before the $2 million was allocated, so it is
not out of IT dollars.
I can't tell you the exact amount of contracts, since I am
not on that side of the fence, but that whole operation was
funded internally by Office of Information Technology within
the VA.
The $2 million is now allocated to the implementation. A
project manager has been assigned to this. They have the money
ready to go, and we are actually having a meeting next April--
the 1st of April this coming month in Seattle to actually
develop coding and operational planning for the implementation,
and the $2 million is being used to set up that particular
meeting.
I hope that answers your question.
Mr. Mitchell. And my understanding has been there is no
staff so far, there is no computers, there is no secretary.
There is no staff at all for the Centers of Excellence for
vision; is that correct?
With all this money that is been spent or allocated we are
not serving the veterans yet are we?
Dr. Smith. Sir, the staff that we have are the Director and
Deputy Director, and Dr. Gagliano does have some statement that
he would I think like to share with the Committee concerning
what has been done already.
If I may return to your question about the $3 million.
There had been working groups between DoD and VA, and the $3
million requirement was a recommendation of some of those
working groups that were originally headed by General Gale
Pollock, who testified before this Subcommittee back last
April. So there has been work ongoing to identify the
requirements.
As to space, there has been space allocated for the
immediate needs of the center. There are some intermediate and
longer term plans that are being looked at programmatically,
but we do have computers for Dr. Gagliano and communication
devices and space available to get started. There are some
hiring actions also.
Mr. Mitchell. And I am just curious, why there has only
been $7,000 spent in 6 months when these veterans need this
help. You said only $7,000 has been spent out of the $3
million.
Dr. Smith. Yes, sir. The director and deputy director have
been spending time largely in strategic planning, in connecting
the Clinical Centers of Excellence, working with the programs
for research--clinical research in eye injuries, and that
hasn't been very expensive so far. Certainly we expect those
requirements to ramp up substantially as we get additional
staff members on board.
Mr. Mitchell. And as we have more hearings I assume too
about these issues.
Let me ask, you know a comment that Sergeant Kinney made at
the last panel. He talked about his VA and DoD doctors and the
consultants that he had back and forth and he finally went to a
private neurologist, and as a result of dealing with a private
neurologist there is no consultation at all, sharing of records
or anything with the VA and DoD doctors and a doctor that was
actually recommended or approved by the VA and DoD. How could
that happen?
Dr. Smith. Sir, I am not familiar with the details of his
case. We could certainly look into that.
[The following information from DoD was subsequently
received:]
Sergeant Kinney's experience is unfortunate and regrettable. To
ensure our servicemembers and veterans never have to go through what he
did, the Department of Defense (DoD) and the Department of Veterans
Affairs (VA) have continued to develop and improve continuity of care
programs. In May 2007, the VA expanded the Case Management Program for
Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans
to enhance and improve case management procedures, coordination of
services, and overall case management. Now, the VA screens all OEF/OIF
veterans and automatically assigns case managers to veterans with
severe injuries.
In late 2007, the VA and DoD established the joint Federal
Recovery Coordination Program. The Federal Recovery Coordinator (FRC)
serves all seriously injured servicemembers and veterans to ensure a
continuum of world-class lifelong care. FRCs coordinate care with VA,
DoD, and private health practitioners and facilities to ensure veterans
have access to the right services at the right time.
The Vision Center of Excellence is taking steps to ensure members
of the armed services and veterans who are visually impaired receive
appropriate blind/vision rehabilitation quickly and effectively,
including assuring that appropriate clinical information about patients
follows them from one system to another for uninterrupted care.
As we identify opportunities to better address the health care
needs of our armed services and veterans, we will continue to enhance
access to care.
Mr. Mitchell. It is not just him, I have heard that from
others as well, so it is not a stand alone case.
Dr. Agarwal. Sir, if I may just address the issue of the
records for a moment.
We certainly have access using the bidirectional health
information exchange to information when it is available from
the DoD. And it is available in the form of remote data view or
VistA web.
One of the issues has been on making all the clinicians
aware of it and also in training them. We are taking that with
the Joint Information Interagency Board, so there is a group
that is going to help us move that information further.
Mr. Mitchell. Thank you.
Dr. Roe.
Mr. Roe. Thank you, Mr. Chairman.
I spent 31 years practicing medicine and looking and taking
care of patients, and quite frankly--and you all are bright
people in here and not totally responsible, but I find this
embarrassing to have treated our veterans this way. I really
truly do.
And doing a registry, I have been familiar with tumor
boards and for years, and this is not rocket science, it is
just somebody needs to get the bull by the horns and get the
job done, and I think that these folks need to know where to
go.
I know when you are a primary care physician you direct the
care of the patient. And I forget which person it was that said
their doctor tried to do the best they could, and I am sure
they did with the limited knowledge they had, and I have done
the same thing. I was in the military and did the best I could,
but I wasn't the right person many times to have seen.
I can't imagine walking around for 5 minutes without my
sight, I have used it so much. And the limitation it puts on
lives, we should be jumping through every hoop we could, and I
think someone needs to be in charge of this problem, and we
don't ever need to hear of this again. It needs to work for
these folks. And they certainly have earned our help, I think.
And you have listened to the testimony, Dr. Agarwal or Dr.
Smith or whomever, to this. It is compelling to me, very
compelling testimony, these three brave soldiers who made
almost the supreme sacrifice, and it's obviously changed their
lives forever, how they live forever, and what they went
through.
And what do we have in place right now? What can you tell
me to satisfy me right now that this is not going to continue
to happen? We are not going to be sitting here a year from now
listening to the same thing again.
Colonel Gagliano. Ranking Member Roe, thank you. I am
Colonel Gagliano and the Director of the Vision Center of
Excellence, and it is really a great honor, and I really am
thankful to have heard the testimony of my fellow warriors. I
have been there, done what they have done, and I know what they
have experienced and what they have been through.
I have been an ophthalmologist in the Army for close to 30
years. As a matter of fact, I am facing retirement here in a
couple of weeks, and I hope to come back in order to do this
job as a retiree recall because I am so passionate about what
we need to do to address this issue. I have been working in
vision care my entire career essentially.
So what I can tell you is that I totally concur with
everything you are saying about what needs to happen. I will
say that everybody who works in the system recognizes that
there is a problem, and the problem is not just in vision care,
it is a deep problem. And vision care will actually be the
leader, I believe, of resolving this problem. We will take this
to the ability to exchange records in a way that probably
hasn't happened in any other specialty before because it is
such a serious consequence of injury.
We have been able to break many barriers, as a matter of
fact just in the short time that I have been working on this in
the last few months. I think we are making progress, and I
think we will continue to make process. And the best thing I
can do today is assure you that we do have a strategy in place
that will track these cases. We have a strategy in place to
implement the bidirectional health information exchange, and we
also have a strategy in place to drive innovation and research
so that we cannot only take care of them the way we are taking
care of them today, but do it better tomorrow.
Mr. Roe. Colonel, thank you.
I guess what I am thinking as I am putting my doctor hat
on, is that when Travis Fugate comes to my office or comes
somewhere and gets evaluated, are his needs going to be met? In
other words, he is now here on his own, and will there be
through this registry and so forth to identify these folks,
then a treatment plan that they can leave there with, or is
this left with the VA or who is it left with? So when they
leave knowing what is going to happen, one, two, three, four,
not bounce them pillar to post.
Colonel Gagliano. The registry will actually be rather
unique. We intend to design this so we will be able to look at
longitudinal outcomes and track patients and get statistics and
data on the kinds of injury mechanisms as I talked about
before. That will help us understand where the gaps in care
are.
Right now we are facing a new type of injury mechanism.
Blast injuries are relatively unknown to the field, and we are
already starting to make great progress in addressing these
by--in fact having meetings a couple a weeks ago in laying out
these priorities for the announcements for this year's research
funding. So that is one part of what the registry do.
Will the registry be able to communicate with every
provider in the system? We hope so, that is the intent, that is
what we are looking for.
The idea of allowing that information to be exchanged with
the private sector is another one, but that is going to be
pretty hard. At the moment we don't really know how to do it.
I will tell you that we have designed this along the lines
of the private-sector registry so we not only can have the data
from our registry, but the data from the U.S. Eye Injury
Registry. As a matter of fact we call ours the Defense and
Veterans Eye Injury Registry in order to align it with the
bright people who have put in place a registry for eye trauma
in the past, both internationally and nationally.
We are looking at the moment for the data fields required
in order to provide the kinds of information that I just
mentioned. And this meeting we are having in April will help us
identify what data elements actually don't exist in the current
health records so that we can get to the longitudinal outcomes
and we can make some decisions for the process of care and what
the new requirements are in terms of research.
Making it visible to the care providers in the DoD and VA
system I think is achievable, and achievable in the near term.
Mr. Roe. Thank you, Mr. Chairman.
May I have just one quick question?
Colonel, I can't understand how it is so hard to get
information from a private doctor to the VA and vice versa. For
good patient care it requires information, and all we did was
sign a records release and we had that information, and why is
that so hard?
Colonel Gagliano. Locally it is not, and it is based on
relationships and it is happening, but it is not happening
nationally. And I think a little bit of that has to do with
some of the perceptions of Health Insurance Portability and
Accountability Act (HIPAA) rules and registrations, and some
people even interpret HIPAA as an obstacle. I think we just
have to work through some systems realignment in order to get
that not to be an obstacle, but actually to be an opportunity
to share that data.
Mr. Roe. Thank you, Colonel.
Thank you, Mr. Chairman.
Mr. Mitchell. Thank you.
Mr. Walz.
Mr. Walz. Well thank you, Mr. Chairman, and thank you to
our panelists for your service to our veterans. I can assure
you there is no pleasure in us asking all the questions. We are
here as partners, and each of us up here represents 700,000
Americans that want nothing more than the best possible care
for our veterans.
So when we see three of them come up here it is just the
nature of our business, I say it time and time again, if there
were three that were not cared for properly that is three too
many. This is a zero sum proposition that has no room for
error, and all of us understand that.
So I guess what you are hearing out of this, and you will
continue to hear it, is frustration, because we all know we are
in this together. And we will accept responsibility for our
side of things. We want to see that that responsibility is
being shared all the way around. But the end result is, and I
understand and I have seen this and I keep saying it, DoD
produces and is the best war fighters the world has ever seen.
The VA provides the best care in the world. The problem is
sometimes figuring out how to talk to each other.
I have to tell you, it is a milestone achievement to have
both DoD and VA at the same table today, that I am happy about.
I am not happy about how slow it's been in getting there.
So just a couple things I would ask is, how often is the
Committee that is sitting in the strategic planning, including
the BVA, the Blind Veterans Association, a group that knows
more about this than almost anyone out there, are they being
included in any of this? If I can ask anyone who has an answer
on that.
Colonel Gagliano. I would be happy to answer that.
We are committed to engaging with the veteran support
organizations.
I think the first effort I did the first day I was
appointed was to set up a meeting to hear what they had to say
about what their perceptions are of what was needed, and I have
met on several occasions with Mr. Zampieri and Mr. Miller from
the Blind Veterans Association and other veteran associations
to hear what they are hearing from their members, because that
is where we will be able to gather information about what is
really happening. Sometimes you have to look externally to find
what is happening internally, and that is one of the ways we
plan to do that, is to continue that relationship.
Mr. Walz. Just one more question, if I could, Mr. Chairman.
And I would associate myself with Dr. Roe, who by the way is a
great addition to this Committee, a great area of expertise and
very insightful and helps us understand and coming from a
physician, Dr. Roe's personal practice transferred over to
electronic medical records, has been helping all of us talk
through that.
My question is, the Centers of Excellence on TBI and PTSD
were up and running at a much shorter rate. Is it the nature of
the vision issue, the eye care issue, or why did it take so
long for us to get yourself in, Colonel and others to get
going? I am just asking why does it seem like this was an
incredible lag as opposed to the other two joint Centers of
Excellence?
Dr. Smith. Sir, the Congress did appropriate over $900
million in funding for traumatic brain injury and for post-
traumatic stress disorder, which was very helpful in
accelerating the process of standing those up.
Mr. Walz. So this is a funding issue? If we had given more
money these guys would have received better care?
Dr. Smith. Not primarily, sir, no, sir.
I would say that the challenge has been somewhat different.
We had already Centers of Excellence in clinical care around
the country, and the challenge here with the Vision Center of
Excellence is to link those together and to establish better
communication and collaboration between those than has
previously existed, along with the VA centers. So the nature of
the challenge is different.
The Center of Excellence for traumatic brain injury and
psychological health had rockets put on it basically to launch
and to fill a void that I think was larger than has existed for
vision.
Still, many challenges to be met, and certainly we
acknowledge that and are committed to improving on this.
Mr. Walz. Well, I appreciate that, but now I feel even
worse for our three veterans sitting here, knowing that we
didn't strap the rockets on this one then and get it going, and
if there are experts out there who could have helped us know
that that was going to be the problem we failed them, if that
is the case. So that is frustrating.
And I will come back as a final comment on HIPAA. I agree
with you and I see this happen in VA cases with my county
veteran service officers. The HIPAA issue, I do believe at
times it poses an obstacle, but I do believe at times it is
been there as a crutch for a failure to deliver at times. It
cannot be allowed to be that. We need to figure out how to
protect privacy, but at the same time not hinder you from doing
your job.
So I yield back.
Mr. Mitchell. Thank you.
And I would like to say something very quickly to add on to
what Congressman Walz said.
Looking at your organizational chart for the Vision Center
of Excellence. Based on this since it was authorized there are
only two people that have been hired. No wonder it is so slow.
The only ones that are on here are Colonel Gagliano and Dr.
Claude Cowan. Nothing else has been done.
Mr. Buyer.
Mr. Buyer. Thank you very much, Mr. Chairman, and I thank
the Members for your leadership, in particular Dr. Boozman.
Following up the question by the Chairman, I would like to
ask Secretary Smith. What resources were used to reallocate the
$3 million from DoD to the VCE? In other words, how much has
been obligated so far? One person, no space, no furniture, no
IT.
Dr. Smith. Sir, the allocation of the $3 million has been
from the Operations and Maintenance (O and M) funds for the
Defense Health Program, and the space allocation has been
solved as a temporary measure. There is strategic planning
ongoing for an intermediate and long-term plan.
Does that answer your question?
Mr. Buyer. Then according to this plan, what additional
funding has been requested in the President's fiscal year 2010
budget request for both VA and DoD?
Dr. Smith. I will have to take that for the record, sir. We
support the President's budget, though.
Mr. Buyer. Well, we are going to get it here in a few days.
You know the answer, right?
Dr. Smith. I don't have an answer today, sir. I will have
to take that for the record.
[The DoD response is included in the answer to Question #4
in the Post-Hearing Questions and Responses for the Record,
which appears on p. 64.]
Mr. Buyer. All right.
Well then let us do this, maybe this will be the best thing
to be productive. Let me ask Dr. Agarwal?
Dr. Agarwal. Agarwal.
Mr. Buyer. All right, thank you.
How many active duty soldiers have been through the VA's
blind rehabilitation centers to date?
Dr. Agarwal. Sir, I will have to get back to you on that
information.
Mr. Buyer. We are on a roll.
Well, let me finish with this.
I would like for you, since you are going to be providing
information to the Committee, please provide a timeline for the
full implementation of the Vision Center of Excellence Program,
including the following items.
Number one, completion of the concept of operations.
Number two, sharing VA and DoD electronic records in an
interoperable manner.
Number three, coordination of care between VA and DoD for
blind veterans and servicemembers.
With that I would like to yield the balance of my time to
Dr. Boozman.
[The DoD response is included in the answer to Question #5
in the Post-Hearing Questions and Responses for the Record, and
the VA response is included in the answer to Question #11 in
the Post-Hearing Questions and Responses for the Record, which
appears on pps. 64 and 61.]
Mr. Boozman. Thank you, very much.
You know when this all started this really was a thing that
started from the ground up, and you all are part of them, Dr.
Cowan, Dr. Orcutt, Dr. Gagliano, you are an ophthalmologists.
But what people were seeing were people like the three
individuals that we had testifying earlier that go through the
system, because they have other injuries many times. The eye
part is just forgotten to a large degree, and then somebody
eventually, an optometrist or ophthalmologist or whatever, an
eye care practitioner would acquire these individuals and then
have to figure out who was going on and move them in the right
direction.
So there is a lot of excitement, you know, about getting it
done, this and that, and so we get it enacted and then nothing
happens. The only time that anything seems to happen at all is
when we have a hearing.
A year ago we had a hearing, everybody was excited, the
colonel that was here then said you know it is time for action,
you know we have been sitting around we need to get on the
stick. But as we can see, the reality is very little has been
done.
Now I say that, VA has done a good job, and we appreciate
you. DoD, the best I can tell has done very, very little.
And again, nobody is more supportive of you guys than I am,
but in this particular case you either don't want to do it or
you are incompetent. I think that is the only two conclusions
that we can draw.
You mentioned the money. Were you aware Dr. Gagliano that
you had $3 million? When did you find out that there was $3
million in the budget?
Colonel Gagliano. Yes, sir. Shortly after I was appointed I
was informed that $3 million had been set aside for the Vision
Center of Excellence.
Mr. Boozman. It has got to be a record just spending $7,000
in any agency of government as far as moving forward. I mean,
if we are actually doing anything.
The other thing I would say, Mr. Smith, is there is really
a lot of contention as to you are saying that there is money
funded for the other vision--not other visions, but other
Centers of Excellence.
Mr. Murtha and Mr. Young don't agree with your
interpretation. They feel like that money was supposed to be
spent for all three. They talk about money above the neck. And
again, like I say, that just hasn't been done. So our
Appropriators, they are not saying the same thing that you are
saying, okay?
Dr. Smith. Thank you, sir.
Mr. Boozman. I would like know really just some basic
things, you know, if we had money problems, as you attested,
why didn't you ask for more?
Dr. Smith. Sir, I didn't mean to suggest that we have money
problems. What I have suggested is that the requirements for
establishing the Vision Center of Excellence are different from
the requirements for establishing the TBI and Psychological
Health Vision Center of Excellence.
And in fact, the $3 million that has been allocated for
this fiscal year was based upon recommendation jointly from a
work group that was from the services and the VA.
Mr. Boozman. Now in the USA Today article, in that article
it said that there was no money.
Dr. Smith. I am sorry, who said that, sir?
Mr. Boozman. In the USA Today. They reported that somebody
from DoD said there was no money appropriated.
Dr. Smith. That is not correct, sir. There has been $3
million allocated from the Defense Health Program.
Mr. Boozman. So if we have had money and things, why like
the concept of operations and things like that, why haven't we
been able to do those things?
Dr. Smith. We haven't had the benefit of a full-time
director and deputy director.
Mr. Boozman. Well if we had money, why haven't we got a
full-time director and why don't we do the other?
Dr. Smith. I am sorry, I don't understand the question.
Mr. Boozman. You said if we have the money, if we have the
resources, why don't we have the manpower to do the job?
Dr. Smith. I understand that there are hiring actions
underway to get additional staff for the center.
Mr. Boozman. So why didn't we do that a year ago?
Dr. Smith. I think that a year ago there were actions
underway to identify where was the best location, what were the
strategic objectives for the center. So work has been ongoing,
but that is the point to which we have come today.
Mr. Boozman. Since the NDAA was enacted in January of 2008
there were specific funding requirements due within--I am
sorry--specific reporting requirements due within 180 days on
staffing, funding, activities of the three Defense Centers of
Excellence. The first report came was delayed. Came to the
report in mid-November, did not meet the Committee's
expectations on the Vision Center of Excellence.
The fiscal year 2009, NDAA also required a specific report
within 30 days, not only on the staffing, funding, and plans
for the VCE for fiscal year 2009, but also 2010, 2011, 2012
within 30 days. But it has been 100 days later and we still
haven't seen any report.
Dr. Smith. Sir, I will have to check on the status of that
report. I know there has been some work done to produce that.
[The final report regarding the establishment of the Joint
Department of Defense/Department of Veterans Affairs (DoD/VA)
Vision Center of Excellence was sent to the House and Senate
Armed Services Committees on April 30, 2009. The report
entitled, ``Report on: The Joint Department of Defense/Veterans
Affairs Vision Center of Excellence,'' dated March 2009, is
being retained in the Committee files.]
Mr. Boozman. I guess the problem is this. You know, again
we enact the law--I mean, do you all agree that we have a
problem based on the testimony of the three and from the field?
I mean, do you not want to do the center, is that the problem?
Dr. Smith. No, sir, that is not the problem. Certainly we
acknowledge that there is a need for this center. We think that
we need to push ahead and get this business done and see how we
can best improve the care that we provide. So we certainly
acknowledge that and thank the Committee for your interest and
support.
Mr. Buyer. Will the gentleman yield?
Mr. Boozman. Yes.
Mr. Buyer. I have this great sense that there was just a
different priority, Dr. Boozman. I think there was a great
sense here, but for DoD to focus more on the TBI and the PTSD
and this is an issue that they didn't embrace as strongly as
you embrace. And when you look at the pure ``numbers,'' and
where their focus should be, I think their energies and
priorities were somewhere else. I mean that is quite obvious
here in my assessment today. That is unfortunate.
You know, Colonel, I just read your bio, you have an
extraordinary career, and I want you to be able to walk out
that door with your head held high. And you are having to
salute your civilian led leadership, and I feel really
uncomfortable here that you have had such a remarkable career,
and please don't get smacked on the backside as you end that
career. You have had a wonderful career, and hopefully you can
step back through the door and provide the leadership that we
are looking for someone to do.
And it is unfortunate that the Committee here is using some
pretty tough language and they are pretty firm, because I think
the Members here are very upset. And the reason they are very
upset, is because they wanted specific things to happen and
that did not happen. And I think this panel has gotten the
message. We don't need to keep bringing veterans in here to
tell their stories of how that care had not been fulfilled, and
I think that is what you are hearing here today.
I yield back to the gentleman.
Mr. Boozman. The only thing I would say is this. I agree
totally with the comments of Mr. Buyer. And again, you know,
nobody is more supportive of you than I. But in this particular
case, and I really do understand this in the sense my brother
was an ophthalmologist, I started a low vision program at the
Arkansas School for the Blind, worked with Eleanor Faye in New
York, so I really do understand, you know, the things that you
get into with this. And I do understand too how easy it is to
overlook things when you are dealing with all these other
multiple injuries and this and that. And then too, many times
it doesn't matter in the military or whatever, the individuals
just don't have the training to recognize.
So when I visit with the Appropriators, when I visit with
whoever, again, this is something that everybody agrees, I
think, you know, would be an outstanding thing to do, the
problem is it is not getting done.
And you know, we talk about funding, you know, the funding
appears. But if there is a funding problem, I guess my
frustration is that nobody is really asking for that. Nobody is
coming forward and saying we need this or that.
Again, there is a real differences in opinion with the
Appropriators as to whether or not funding has been
appropriated or not, but it all comes down to priorities, and
there is a lot of money, you know, circulating through the
defense. It is not like Congress, it is not like I haven't been
very supportive in giving a tremendous amount of funding to the
effort, and yet, you know, this not doing the concept of OPS,
that doesn't cost any money, it doesn't cost any resources. It
does cost resources, but that is something that VA has gotten
on the stick and done and DoD hasn't done.
So again, I yield back, and I hope that we can move forward
and show some progress.
Mr. Mitchell. You know, just before we ask some other
questions here, because there is some other questions that want
to be asked.
This is for Dr. Orcutt. We had a hearing April 2nd on last
year traumatic brain injury related vision issues. That was the
whole purpose of the hearing. And I want to quote part of your
statement.
You said, ``For the seriously injured, ill, or wounded, VA
and DoD have created a new Federal Recovery Coordinating
Program that will assign coordinators capable of working within
and between VA and DoD and the private sector to monitor and
support our severely wounded veterans and servicemembers. VA's
OEF and OIF Case Management Program provides a fully integrated
team approach at every VA Medical Center.''
And listening to what these gentlemen had said at the first
panel, they didn't get that service. What has happened?
Dr. Orcutt. Yes, that was part of our joint statement, and
that is what the polytrauma directors have set up in the system
to have this case coordination.
In terms of what happened to these patients on an
individual basis I have no idea, since I can't track their
individual processes. But it is certainly my understanding from
the polytrauma folks that we in fact have those case
coordinators set up at all these sites.
I don't know if Dr. Agarwal would have more comment on that
or not.
Mr. Mitchell. Well, I would just assume first of all if
these three fell through the cracks and didn't get the services
that are at every VA Medical Center, there is a lot others, and
somebody is not checking on them.
Yes?
Dr. Agarwal. Sir, we are committed to providing the full
scope of services for the entire continuum of care and also for
coordinating the care when the transitions happen from DoD.
It is true that it is very unfortunate, and I totally agree
with you, that none of what transpired with the previous panel
members should have ever happened. But as a system we have
tried our best to address it, especially over the course of the
last 18 to 12 months.
The Federal Recovery Coordinator Program that you have
mentioned, which is intended to navigate between the VA and
DoD, as well as outside of the two systems for our
servicemembers, and veterans who are going to need lifelong
care.
We have a case management system, a very comprehensive case
management system of the OEF, OIF program managers, case
managers, transition patient advocates. This team has been set
up at each of our Medical Centers.
We have 27 military treatment facility (MTF) coordinators,
the MTF liaisons stationed at the 13 MTFs. So in essence, there
is a system which is fairly comprehensive that has been in
motion for the last 12 to 18 months where a referral is made to
the MTF liaison, the VA liaison who is stationed at one of the
military treatment facilities who in turn gets in touch with
the OEF/OIF case manager at a facility when the veteran--or the
servicemember I should say, is being transferred to the VA.
Within the VA system we also have lead case managers for
four areas, which are fairly complex. The polytrauma system of
care, the blind rehab system, the spinal cord injury, and for
mental health.
There is a lot of interconnectivity between the case
managers and the liaisons, and this is to ensure that we
coordinate the care to the extent that is possible.
Mr. Mitchell. I have heard all this, and I understand that.
I am just saying that it hasn't worked in the case of the three
people that came before us on the first panel, and I assume
there are others in the same category.
Dr. Roe, do you have anything else to ask?
Mr. Roe. No further questions.
But first of all it is obviously extremely complex--it is,
and having to get these systems for the numbers of people you
all are having to treat is enormous. But as all of you
physicians know, it all comes down to what happens to one
patient at one time. And for them it is 100 percent if it
doesn't work. So we have got to try to make that system work.
And Colonel, thank you for your service and for what you
have done for almost 30 years for your Nation.
And Mr. Chairman, thank you for bringing this to the
attention of myself certainly, and to the Congress.
Mr. Mitchell. Thank you.
Mr. Walz.
Mr. Walz. Thank you, Mr. Chairman.
Well, I am sure not going to pile on, because I have the
Minneapolis Polytrauma Center, which is I think the best
facility in the system, and I would argue I have also the Mayo
Clinic in my district, and I would compare the two any day of
the week.
And so I will say it again, I am the biggest supporter of
what we do for our veterans, but I would be remiss to say how
incredibly disappointed I am.
And it is seldom that I hear the Members up here, and Dr.
Boozman has got a lot of experience. He is also a very mild
mannered guy, but I can hear the upset in his voice, and he
understands this.
These three didn't come here for pity or for handouts or
for anything. They simply wanted care that this Nation has the
ability to deliver, and the thing that is most frustrating to
me is for a Congress that anticipated something ahead of time,
or at least in the midst of it and tried to put things into
place to deal with it. And so here we are, and I just shudder
to think of the number of these individuals who could have been
treated differently had we got this up and running.
So I think much has been said here, and I think it has been
very clear to all of you, there is going to be a very, very
bright eye watching this from now on. I believe we have been
there before, but it is going to be like nothing you have seen
yet. And all I can say is, this thing has got to run. It is got
to go. We have got to see the things that Mr. Buyer asked for
in the plan, and you have been charged with the mission to do
it. And so I fully expect as I have seen time and time again,
you will rise to the occasion, you will get it done, and we
will provide excellent care for our warriors, and that is all
of us in this together.
So I do appreciate all of you being here. I appreciate the
complexity of what you are going through, and I know also,
don't think for a minute I don't know the disappointment you
all share that we are at this. The difference is, is that you
all possess some ability to change that, and I hope you take
that advantage.
So I yield back.
Mr. Mitchell. Mr. Boozman, any final words?
Mr. Boozman. Just one thing.
I did pull up the USA Today article, and you might want to
look at that. Mr. Kelly was quoted in that as saying, ``No
money was appropriated for a vision center,'' Kelly says.
So again, you know, you might need to visit with him and
see if you guys are on the right track.
But I would just encourage you, you know, what we are here
to do is really to try and help move this thing forward, and
you have got tremendous support. I know Mr. Walz wrote a letter
to our Appropriators requesting money in visiting with Mr.
Murtha and Mr. Young. Again, if we need more resources we can
work and help you get those things, but we do have to get on
the stick and move forward. And it is some of the things that
haven't been done on the DoD side really haven't required
money, they have just required doing. And I don't think there
is any excuse for not getting the concepts of OPS done so that
we can move forward. And you know, you just can't do these
things until you do the basic things, and we just aren't
getting that.
So I appreciate your efforts. Nobody appreciates it, you
know, anymore than I do, and the rest of the Committee, this is
a very bipartisan group that really just has the heart of our
veterans and our servicemembers at heart. And like I say, I am
here to help you. But on the other hand, I think if you don't
accept that help, you know, and let us help you, then we are
going to hold you accountable, and I think that that is
important, and I know, you know, that you want that of
yourselves.
So thank you very much, Mr. Chairman, I appreciate you and
the Ranking Member again for going this, taking the time, and I
think we made some real head way.
Mr. Mitchell. Thank you very much, and thank all of you for
appearing today. I appreciate it, and hopefully as a result of
all this we will see some real changes in the lives and the
future of our veterans.
With that, this hearing is adjourned.
[Whereupon, at 12:06 p.m., the Subcommittee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Hon. Harry E. Mitchell, Chairman,
Subcommittee on Oversight and Investigations
In April of 2008, this Subcommittee held a hearing on TBIRelated
Vision issues. In that hearing, there was an extensive discussion with
the VA and DoD about the Vision Center of Excellence mandated by the
National Defense Authorization Act of 2008. We heard from both agencies
that they were working hard on this initiative. Today we will receive
an update on the product of that hard work and how it has affected
veterans in need of vision care. We will also discuss the future needs
of both agencies so we can ensure that the Center will be worthy of our
veterans.
Last August, we were assured by DoD that funding for a Vision
Center of Excellence would be distributed in FY 2009. I applaud
Congressman Space and Congressman Walz for urging Defense
Appropriations Chairman John Murtha to set aside $5 million for the
Vision Center. This demonstrates how important this issue is to the
Members of this Subcommittee. We now know that the FY 2009 Defense
Health Program Operation and Maintenance Budget allocated $3 million to
the Vision Center of Excellence. However, it troubles me that even with
this funding and the appointment of a Director and Deputy Director,
whose testimony we will receive shortly, the Center is still without
offices, computers, phones, or staff.
To put these delays in perspective, we will hear from a number of
veterans and their families about the difficulties they have
experienced receiving vision care. Kentucky National Guardsmen Travis
Fugate suffered grievous injuries in Iraq in 2005. He lost his right
eye and much of the vision in his left, and recently, he lost what
little vision remained. The Vision Center of Excellence would include
the Military Trauma Eye Injury Registry that is designed to provide a
seamless transition of information which could have preserved at least
some of Travis's vision. This is a reminder of the cost in delaying
interoperability between the Departments.
Although Travis' story is troubling, unfortunately, he is not
alone. Sergeant David Kinney's involvement in an IED explosion in 2005
forced him into treatment for headaches and vision related injuries. He
is here today to tell us what has happened since his injuries and the
tribulations he has faced while seeking treatment.
We will also hear from Gil Magallanes, a Green Beret in Afghanistan
who was seriously injured in 2001. His wife Sherry will be sitting
beside him to help tell his story.
I'm confident that none of us in this room would actively
countenance delays or failures that needlessly hurt our veterans, yet
we have seen time and again our veterans being left in a void where
they don't know where to turn for treatment. It took almost 7 years for
Gil Magallanes to be introduced to his Vision Impairment Services Team
coordinator. That's unacceptable and Centers of Excellence provide a
means to provide the specific care that is needed.
Planning for the Vision Center of Excellence has been underway for
years, and I have no doubt that our second panel, which includes
Colonel Donald Gagliano and Dr. Claude Cowan, will testify that VA and
DoD are eager to get to work. I expect today's hearing to be followed
by speedy action from DoD and the VA to open the Vision Center of
Excellence.
Travis, David, and Gil--thank you for your service and for
appearing before the Subcommittee today. Your testimony will be very
helpful to us as we work to ensure that your colleagues in arms receive
the care they deserve. Thank you Dr. Zampieri for appearing here today
and for your endless advocacy on behalf of our Nation's veterans.
Thanks also to DoD and VA for coming to the Hill to provide us with an
update.
One of our Subcommittee Members, Mr. Walz had to attend to family
business back home, but will be joining us shortly. He had the distinct
honor of meeting Specialist Fugate at Walter Reed last week, and he
would like to extend his thanks to all the witnesses for being here
today.
Prepared Statement of Hon. David P. Roe, Ranking Republican Member,
Subcommittee on Oversight and Investigations
Thank you for yielding, Mr. Chairman.
The Vision Center of Excellence (VCOE) and the accompanying
Military Eye Injury Registry were included as provisions in the
Military Eye Trauma Treatment Act (METTA), introduced last Congress by
my colleague, Dr. John Boozman, an Optometrist and a Member of this
Committee. These provisions were also included in the FY 2008 National
Defense Authorization Act, which passed in late January 2008, but was
not funded at that time. Funding for this program was approved with
passage of the FY 2009 Military Construction/Veteran Affairs (MILCON/
VA) appropriations bill in late September 2008 when $6.9 million was
allocated for this purpose through the Department of Veterans Affairs.
The Subcommittee staff asked the Department of Defense over a month
ago about when the funding would be available for the VCOE. We were
informed last Friday, March 13, 2009, that the Department of Defense
authorized, effective March 12, 2009, $3 million for the establishment
of the Vision Center of Excellence. I am pleased that this funding has
been finally identified and provided by the Department of Defense. Mr.
Chairman, I would like to ask this letter from the Department of
Defense to you, dated March 12, 2009 be submitted into the official
hearing record.
I agree with the Chairman that it is important that this Committee
takes a look at the progress being made in implementing this
legislation, and closely follow the interaction between the Department
of Defense and the Department of Veterans Affairs. It is no secret to
this Committee that these two departments have not always ``played
well'' together in the past. However, with the increasing numbers of
servicemembers returning from Iraq and Afghanistan with what has become
one of the signature injuries of our war on terrorism, traumatic brain
injury (TBI) and related co-morbid ocular injuries, it is critical that
Congress conducts strict oversight into how this program is developed
and implemented to assure that our Nation's servicemembers and veterans
are well served.
This hearing is not the end of our oversight into this matter. In
the very near future, Dr. Boozman intends on scheduling a Roundtable to
further discuss this issue with Members of the Armed Services
Committee, and other stakeholders, including the Blinded Veterans
Association, other veteran service organizations, and medical specialty
organizations to be invited to the table for an open discussion of the
progress being made, and where we can address possible improvements. I
am looking forward to delving into this subject matter in greater
detail, and appreciate Chairman Mitchell's interest on this issue.
I look forward to listening to the testimony being presented today,
and am encouraged that there will be future discussions and oversight
on this matter as well.
Again, thank you Mr. Chairman, and I yield back.
Prepared Statement of Hon. Timothy J. Walz
Chairman Mitchell, Ranking Member Roe, Members of the Subcommittee,
and our witnesses, thank you so much.
I want to immediately recognize the brave young veterans who are
here today to speak with us. I commend your service and I thank you for
helping to educate us today. I had the true honor to meet Travis
Fugate, an exceptional young man, the other day and it would be hard to
express how impressed by him I was. I look forward to hearing his story
in his own words today.
It is always useful to hear directly from our veterans on such
important issues as the Center of Excellence in Prevention, Diagnosis,
Mitigation, Treatment, and Rehabilitation of Military Eye Injuries, as
well as related programs to address visual dysfunction among our
servicemembers and veterans established by section 1623 of the Fiscal
Year 2008 National Defense Authorization Act (NDAA).
Military eye injuries have not been as high-profile as some other
forms of injuries prevalent in our current conflicts. But this is a
very important project. There is good evidence that a substantial
number of TBI patients are reporting vision problems. More generally,
the Eye Center of Excellence would enable the DoD and VA to gather and
disseminate important information on the diagnosis, treatment and
follow-up for all significant eye injuries among members of the Armed
Forces on active duty and veterans.
Unfortunately, the NDAA did not provide funding for the Eye Center
of Excellence. I have been working on this issue for quite some time.
It is one part of what I think is absolutely essential--ensuring a
seamless transition from DoD to VA for our servicemen and women,
particularly our injured servicemen and women. Nothing is more
important than to establish real and substantial cooperation across DoD
and VA as our troops make the transition to civilian life and veteran
status. This is complex, it involves two huge and complex
organizations. And quite frankly, I think what we know about the Eye
Center illustrates not just how important ensuring that seamless
transition is, but how difficult it is.
I will be honest. VA has made a real commitment to this project. I
have not seen the same commitment on the part of DoD. We are, of
course, entering a new era with a new Administration, so I look forward
to hearing from DoD about its part in this legislatively mandated
project, and about its cooperation with VA. I approach this unhappy
with the lack of progress thus far, and willing to listen and work with
DoD. Thank you.
Prepared Statement of Specialist Travis Fugate, USA (Ret.),
Hindman, KY (OIF Veteran)
My name is Travis Fugate. I am 25 years old, and I am a retired
specialist in the U.S. Army.
I served as a member of the Kentucky National Guard starting
December 5, 2003, until April 2, 2006, when medically retired because
of my OIF injuries. While in support the 18th Military Police Brigade I
was mobilized on active duty December 13, 2004, then deployed to Iraq
February 2005 . . . I was severely injured on patrol on May 18, 2005,
from IED blast. So on May 18, 2005, when I was hit in the face by an
IED, I remember telling myself to stay calm. We had been on a routine
mission just south of Baghdad, and I had been in the turret of our
vehicle. My buddies told me, ``The bird is on its way,'' and as soon as
I heard the helicopter, I knew I'd be all right. I had that much trust
and confidence in the medics who were about to take my life in their
hands.''
The initial blast caused severe facial injuries with loss of my
right eye, traumatic brain injury, and penetrating injuries to left eye
resulting in severe visual impairment to left eye. Initial emergency
surgery done in Green Zone, then to Landstuhl Germany, then evacuated
to Walter Reed Army Medical Center. I was in coma at WRAMC for over a
month, and had several surgeries during this time on facial injuries,
and left eye.
I was home from Walter Reed, living in Kentucky. I had lost my
right eye, and I had a limited field of vision from my left eye--about
20/200 which is legally blind. But I could still see colors, shapes,
large print and shadows. I could see which girls were pretty and which
ones weren't.
In 2006, I went for a follow-up visit with an ENT doctor at the
Lexington VA Medical Center. The nurse brought him a big stack of my
files, and he told her, ``There's absolutely nothing relevant that I
need in there.'' He told me the anatomy of my sinuses was so
disfigured, he didn't know what in my face tissue was, what was natural
and what was artificially implanted. He said he wouldn't feel
comfortable going in there and messing around, and he said let's wing
it and wait for an issue to arise, then address it. I trusted that
decision immediately, because my experience was that the medics and
Army doctors are all professionals, and I was used to putting my faith
in them.
For 2 years, things were OK. I went back to community college, and
I started being active with many different disabled sporting events and
programs where I had chance to meet other injured OIF veterans, and
attended the Blinded Veterans Association national convention in August
2007.
Last November, 3 weeks before finals, I had to call my dad at 10
p.m. to tell him I thought I had one of those headaches that the
doctors at Walter Reed warned me about. They said it would come from
directly over my left eye and could lead to a severe infection and
possible brain injury. He took me to the ER, and I was in the hospital
for 10 days with a serious infection. The upper left hemisphere of my
face was so swollen that my eyelids swelled together. And that was the
last time I had any sight.
In January, I returned to Walter Reed, where the doctors would have
better access to all my surgery records. I saw a retina specialist, and
within 5 minutes, he'd scheduled a 5-hour surgery the following day for
detached retina and bleeding in left eye. My situation was that severe.
Since then, I have had several more surgeries, including one just over
a week ago March 6th 2009 where they again tried to save my retina
because of another detachment.
I am on many medications with some strong pain medication; I am
still in some constant pain. While inpatient at Walter Reed Medical
Center I was constantly visited by a VA Blind Rehabilitative Specialist
who helped me with orientation and mobility training while an
inpatient, and helped arrange my transfer to the Hines VA Blind
Rehabilitation program in Chicago that I will start this week on March
18, 2009.
With the rehabilitation I have already completed, I understand that
special devices and adaptive technology can make nearly anything
achievable for a person who has lost his vision. But because of a lack
of my electronic surgery files being accessible from the WRAMC, the VA
medical doctors in Kentucky might not have had all the information
needed about my very complex eye injury and surgery facial
reconstruction treatment in various military medical centers.
My sister recently reminded me that I wrote her a letter from Iraq
before I was injured. I told her that if I was hurt, I'd rather die
than go on living without my sight. I don't feel that way anymore.
Today, I am happy to be alive, and I'm excited about my future. But
just like everyone else in this room, and everyone else in this
country, I want to live a life that's full and bright and rich. I need
your support to do so.
The reason I am here today is to tell my story and let you know
that the Vision Center of Excellence that this congress established a
year ago, is critical to ensuring that all the combat eye injured and
TBI with visual impairments are entered into a registry where the
surgery records and treatments can be tracked from both military and VA
eye care providers. I am disappointed that after a year, they have not
set this up and I asked Congressman Rogers to ensure this isn't delayed
any longer.
I want to stress that my retinal surgeon at Walter Reed Medical
Center was one of the best in the world, he is well respected by
everyone, and cares deeply about me and other combat eye injured, so
want to make clear that my military medical care was top notch in this
story. I am sad that Dr. Weichel is going to soon leave the Army this
next week, but him like others have been waiting for this Vision Center
of Excellence for a long time, and he can't keep waiting forever for
this support.
The Vision Center of Excellence will help thousands of those
returning with eye injuries by coordination of there follow-up care,
developing vision research plans for both medical and technology
research to help all of us and previous generations of war injured
veterans who need these things. Why they can not find $ 5 million to
get this set up is beyond me, and funding should not be an excuse now,
for not doing this today!
Prepared Statement of Sergeant David William Kinney III, USA (Ret.),
Duland, FL (OEF/OIF Veteran)
I joined the Army in June 1979 as a Parachute Rigger and heavy
weapons specialist. After years of dedicated service I enlisted in the
Florida Army National Guard as an Anti-Armor Specialist and Infantryman
in 1983. In 2003 my Florida national Guard Unit was deployed to Iraq.
During my tour in Iraq my unit was assigned to guard the Bagdad
Convention Center. In the coming months we would be barraged with
countless explosions in and around the parameter that we were
stationed. Not only were these explosions deadly, but were so loud that
they would shatter nearby glass and throw fellow guard members to the
ground. Although I was never hurt, my unit experienced heavy mortar and
rocket fire throughout my stay.
I was sent to Afghanistan for my second tour of duty in April of
2005. During a local mail run in February of that year, an Improvised
Explosive Device (IED) detonated between the lead HUMVEE and my
vehicle. The impact of the explosion caused my HUMVEE to roll over. As
the HUMVEE was rolling, I reached over to pull the gunner stationed
above the HUMVEE inside the vehicle. This action caused me to slam the
back of my neck into the seat back bar. Thankfully everyone in the
HUMVEE survived with only minor bruises, cuts, and headaches.
A few days later I visited the Troop Medical Center (TMC) to see
why I was still sore and experiencing mild head aches. I was advised by
the senior medic on staff that I was a forty-3 year old man and
therefore, my injuries would take longer to heal. I was prescribed
Motrin and returned to duty.
In December 2005, I received my second injury when I was assigned
to a security detail that detonated three 1,000 lbs bombs found in a
farmers field. Before the detonation of the bombs, we moved back the
safest distance possible due to the village's location and local
terrain conditions. Although we moved to the safest area possible, we
were still not within the maximum safe distance needed, but the Officer
in Charge (OIC) stated that we were at a safe distance. This however,
was not the case. The explosion reached my position and caused us to
lose our balance and to become disoriented as well as causing our ears
to bleed. I was a couple weeks later I was treated at the Troop Medical
Center because my vision had started to become blurry, my headaches
became more frequent, and with greater intensity. These headaches began
to affect my sleep, causing me to be able to accumulate a maximum of 1
to 3 hours of sleep a night.
Since 2005, my medical troubles have continued to rise. I was
medically retired from the Army June 2008 and received a disability
rating of 80 percent combined from MEB. I am on TDRL status and not
permanent status. Since then I have received my VA pension in Feb.
2009, my eye sight has worsened, I am being treated for post traumatic
stress disorder (PTSD), and my headaches continue to inhibit my ability
to sleep.
Since leaving Afghanistan I have been shuffled around to various
locations around the globe including hospitals and research
institutions in Germany, Georgia, Florida, and Alabama. With each visit
I am greeted with the same barrage of tests that still have not
correctly diagnosed my condition. My eye sight continues to worsen. No
doctor, technician, or researcher has been able to tell me why I am
losing my vision. When I started my Eye Care in Tampa VA, where on my
first visit I was told not to drive anymore due to my eye's poor
condition! I was given no explanation and no written reason why. I was
told to see a low vision specialist. Nothing was done after that eye
exam. I received a letter for legal blindness after completion of the
BRC and I was taught about my new lifestyle I was going to live. I am
currently on my 6th pair of eye glasses.
I have endured MRIs, spinal taps, numerous exams, and x-rays, but
still do not have answers to my symptoms. This has become very
frustrating because I must continue these tests and exams on a daily
basis to be eligible to receive basic needs such as new prescriptions
and now I am beyond more glasses. Many times doctors have false
diagnosed me. In one instance Florida Eye Clinic, one doctor said that
there was nothing they could do for me and I was a difficult patient.
Another doctor at Bascom Palmer Eye institute said I might be
malingering.
In summary, I have no reason or explanations on why my eyes have
continued to deteriorate. I have been to countless doctors'
appointments, exams, many of my family members, and friends have had to
request for time off from work to drive me to my appointments. In
addition my appointments sometimes exceed 10 to 15 appointments a month
at various locations. I try to schedule multiple appointments in the
same day in order to cut down the number of days needed for visits, but
many times this is not an option. I believe if we had a center
specializing in vision and TBI Injury out of one central location a
patient could either be admitted or out--patient care could be given
under one roof. This would eliminate the countless exams and testing
that had to be redone due to not being able to get medical records
released from one doctor to the other in a timely manner. Testing could
range from 1 month to the end of a patients testing and then evaluated.
Then if necessary, the center could bring a patient back for follow-up
exams for further evaluation and to listen to patient about what is
going on with his/her concerns of their conditions. A central database
accessible to VA, DoD and any Civilian Doctor that care is outsourced
to by VA or DoD would also be extremely beneficial to people in my
condition. And this will spot a lot of unnecessary exam and may be able
to diagnose the patient condition sooner.
If this was you, when would you say enough is enough, with
countless doctors, exams, and testing with no results because of the
government inability to start a TBI/Vision Center.
Prepared Statement of Sherry Magallanes, on behalf of
Master Sergeant Gilbert Magallanes, Jr., USA (Ret.), Clarksville, TN
(Spouse and OEF Veteran)
My husband is Retired Master Sergeant Gilbert Magallanes Jr; he is
a 45-year old veteran of the United States Army who served in both the
Gulf War and Operation Enduring Freedom. He is a Green Beret that
served with 5th Special Forces Group at Fort Campbell, KY. He is now
medically retired after 21 years of active duty service due combat
wounds he sustained in Afghanistan during Operation Enduring Freedom.
He sustained his injuries from a friendly fire incident where the
U.S. Air Force dropped a 2000 pound JDAM (smart bomb) on his Special
Forces Team (ODA574) while they were guarding the President of
Afghanistan, Hamid Karzai on December 05, 2001. My husband, Gilbert
incurred an open traumatic brain injury with a loss of skull and brain
matter around the occipital lobe that was larger than a 50 cent piece,
the skull has been repaired by craniotomy, but the brain damage is
permanent; resulting in homonymous hemianopsia (complete loss of his
left field of vision bilaterally), slight left sided hemi paresis,
cognitive thinking dysfunction and disorder, seizure disorder, migraine
disorder, loss of digits 2 and 3 and part of his palm on the left hand,
nerve damage to his left wrist, severe hearing loss, and he is now in
Stage 3 Chronic Kidney Failure.
My husband, Retired Master Sergeant Gilbert Magallanes, Jr., spent
over 1\1/2\ years in hospitals having multiple surgeries and
recovering, and have had numerous hospitalizations since. He has had to
relearn how to walk, had to learn his left from his right and just how
to cope with his injuries. At first he was very angry, depressed and
mad at the world. He had no motivation or want to do anything, much
less set goals for any achievements. He felt he was at the top of his
game, a Green Beret, in the best shape of his life with a goal of
promotions in the Army and having his own Special Forces Team. That
goal/dream was taken away from him when that 2000 pound bomb landed on
December 05, 2001.
After his wounds were stabilized in Landstuhl Germany, my husband,
Gilbert was sent to Walter Reed Army Medical Center where he resided in
the Intensive Care Unit in a coma for several weeks. At the end of
January he was sent for traumatic brain injury rehabilitation at the
Palo Alto VA in California. In April he was sent to Sharps Medical
Rehab in San Diego, CA for a community re-entry course for his
Traumatic Brain Injury. It was our understanding that he would obtain
vision training for him to adapt for his vision loss and improve his
independent living skills. However, once he completed the course in San
Diego he had the craniotomy to repair the skull deficit at Balboa Navy
Medical Center in San Diego and was then sent back to Fort Campbell,
Kentucky. I assumed his care would be transferred to the Blanchfield
Army Community Hospital at Fort Campbell, Kentucky at this time.
However, my husband, Gilbert's records were not completely transferred
each time he was transferred between a military medical facility and a
Veterans Affairs medical facility therefore causing a break in his
continuity of care. The case manager my husband was assigned when he
reached Blanchfield Army Community Hospital in Fort Campbell, Kentucky
was not aware of the extent of his injuries and Blanchfield Army
Community Hospital could not provide the adequate care he needed. At
the time Blanchfield Army Community Hospital did not have a Neurologist
on staff to treat the effects of the Traumatic Brain injury or
neurological disorders. My husband, Gilbert was assigned to a staff
physician who in turn told us traumatic brain injury and neurological
disorders were not her specialty but she would do the best she could.
He was no longer followed by Speech therapy, occupational therapy,
physical therapy, vision care, nor did he receive any additional
cognitive training. When his seizure disorder worsened we went to
Gilbert's Company Commander at 5th Special Forces Group, Colonel
Mulholland who helped arrange, at the expense of 5th Special Forces
Group for Gilbert to return to Walter Reed Army Medical Center to be
treated by a Neurologist.
We were not married at the time; I had no knowledge of the
military, how to handle a medical board proceeding or the procedure for
retirement. I do not have a background in the medical field to
understand the extent of Gilbert's injuries, diagnosis or required
treatment and proper protocol for therapy. Therefore a lot of phone
calls where made to his Commander at the time. My husband was added to
the Temporary Retirement Disability List (TDRL) upon the findings of
the Army Medical Evaluation Board (MEB) and the Physical Evaluation
Board (PEB) in 2004. At this time all of his care was to be
transitioned to the Department of Veterans Affairs. Since my husband's
medical records were not transferred with him each time he transferred
to a different medical facility, we had to request copies to begin the
process of the compensation and pension exams as ordered by the
Department of Veterans Affairs to identify all of his injuries and on
going medical problems as defined in the findings of the Army Medical
Evaluation Board and Physical Evaluation Board. Gilbert was seen at the
Veterans Affairs Medical Center in Nashville, Tennessee for each injury
and diagnosis. At that time he had a vision exam to confirm the field
vision loss, and told him to be happy that at least the vision he does
have is good. After he was assessed and given a 100 percent disability
rating through the Department of Veterans Affairs, we were told that
any care he would need would be provided by them. Later he felt that
his vision was changing, I called the vision clinic at the Veterans
Affairs Medical Center in Nashville, Tennessee for an appointment, and
I was told Gilbert couldn't be seen in the vision clinic. I then went
to the hospital administration office to find out the problem, and was
told my husband required a visit to his primary care doctor at the
Veterans Affairs Outpatient Clinic, a referral, and then he would be
given an appointment. It took quite a while to get him into the clinic.
No one ever asked us if Gilbert had vision training/rehab or if he was
assigned a coordinator with the Vision Impairment Services Team (VIST)
at our local Veterans Affairs Medical Center; when he was finally seen
in the vision clinic they only did a routine exam. Gilbert was also not
assigned to the speech clinic, occupational therapy or physical therapy
for additional treatment.
In 2008, we attended a paralympic sporting event for soldiers with
vision impairments in Alabama where we were fortunate enough to meet
Travis Fugate. He forwarded our contact information to the Blind
Veterans Association we got a call from Christina Hitchcock who invited
us to the Blind Veterans Association conference in Phoenix, Arizona in
August of 2008. It was then that we were told that he could and should
have been able to attend one of the blind centers that would teach my
husband how to compensate for his vision loss.
Although it took almost 7 years, we were finally introduced to our
Vision Impairment Services Team (VIST) coordinator at the Nashville VA
in 2008. We were also sent back to the Palo Alto VA in November 2008
for some extensive vision testing by Dr. Cockerham who identified a
dimple in Gilbert's optical nerve and now has to be watched closely for
glaucoma due to the Traumatic Brain Injury, when normally he would not
have been a candidate for glaucoma. We are currently scheduled to
attend the Blind Center in Palo Alto on March 25th 2009 for vision loss
training.
Although my husbands vision impairment stems from the loss of brain
matter and brain damage not an actual disease or damage to his eyes, I
still feel things may have been easier for him and our family if he was
taught how to compensate for the visual loss in the beginning. I feel--
and actually thought there to be some process to prevent events like
this. I know from our experience, I was wrong. If we had not met Travis
Fugate and been introduced to the Blind Veterans Association my
husband, Gilbert still would not be receiving the vision testing and
training that he has waited almost 7 years for.
It is our hope there will be a plan implemented not only for
Traumatic Brain Injury but also for Vision impairments and care
coordination. We would like to see a system that tracks and follows
patients through their course of care during active duty, and as they
transition to the retired ranks of the Veterans Administration to
ensure they are receiving the proper care and training as their
injuries indicate. Therefore, no one would have to wait for 7 years to
receive care and training as we did. This in turn would mean additional
educational training in visual impairments caused by Traumatic Brain
Injury for the staffs of both the military facilities and the
Department of Veterans Affairs facilities providing the care.
In closing, I would just like to say that my husband, being the
loyal, and dedicated Ranger that he is, has absolutely no regrets about
his service to our great country, he would be back in uniform and on
the frontlines if he was medically able to do so, but he is not. It is
only our hope that he be offered the necessary training and medical
care to help him live his life as independently as he can with the
injuries that he has sustained.
Thank you for your time and for allowing me to speak on this
matter.
Prepared Statement of Thomas Zampieri, Ph.D.,
Director of Government Relations, Blinded Veterans Association
INTRODUCTION
Chairman Mitchell, Ranking Member Roe, and Members of the House
Veterans Affairs Subcommittee on Oversight and Investigations, on
behalf of the Blinded Veterans Association (BVA), thank you for this
opportunity to present our testimony regarding the large numbers of
military vision injuries and the bureaucratic problems associated with
implementing the Congressionally mandated National Defense
Authorization Act (NDAA) of 2008. The legislation established the joint
Department of Defense (DoD) and Department of Veterans Affairs (VA)
Vision Center of Excellence (VCE) and Eye Trauma Registry.
Established in 1945 and Congressionally chartered in 1958 as the
only Veterans Service Organization exclusively dedicated to serving the
needs of our Nation's blinded veterans and their families, BVA
sincerely appreciates the invitation extended to our organization to
present testimony. We are also grateful that the Operation Iraqi
Freedom (OIF) and Operation Enduring Freedom (OEF) blinded veterans
present this morning, and who will later share their stories, have also
been welcomed.
OBSTACLES TO VCE IMPLEMENTATION
OIF and OEF servicemembers with both penetrating eye trauma and
Traumatic Brain Injury (TBI) visual impairment have had to wade through
a DoD bureaucracy. DoD has given us the impression that, for them, an
entire year's time to create an organizational charter is actually not
that long. Persistent excuses for lack of action range from ``no plan
was approved for VCE'' to, of course, ``no funding has been found to
create VCE.''
When NDAA was enacted in January 2008, an immediate reaction from
senior level Assistant Secretary of Defense for Health Affairs
officials was that VCE was an ``unfunded mandate by Congress'' that
would cost ``an estimated $5 million that we do not have built into
this year's budget.'' If this were the case, Congress should have then
asked why these funds were not requested in either last year's May 2008
War Supplemental (H.R. 2462) when $162 billion was provided for, among
other things, ``wounded warrior care'' or, better yet, in the FY 2009
Defense Appropriations to cover this year's startup costs. Instead,
both in June and again in early August at the Skyline Drive office of
the Assistant Secretary of Defense for Health, and then once again on
September 24, senior officials repeated the claim that finding even the
bare minimum of $3 million to fund startup costs for the Vision Center
of Excellence presented a very tough challenge.
For 4 years, BVA has attempted to bring to the attention of the
Armed Services Committees, the Defense Appropriations Committees, both
VA Committees, DoD Health Affairs, and the Veterans Health
Administration (VHA) the ever-increasing prevalence of combat eye
trauma and TBI visual dysfunction among servicemembers. We have become
increasingly concerned about the growing numbers of both the battle
wounded who have penetrating direct eye trauma (13 percent of all
evacuated wounded have experienced eye trauma) and/or TBI-related
visual complications (64 percent with TBI have tested positive for
visual dysfunction).
Responses to these pleas have included ``the need to wait until the
next plan is approved,'' ``NDAA reports come late for review,''
``inability to find office space,'' and the aforementioned ``lack of
requested funding.'' The cumulative result of these responses has been
delayed action.
The Pentagon did appoint the first Director of VCE in November
2008. Colonel Donald Gagliano is a highly qualified and dedicated 29-
year Army career ophthalmologist who served in Iraq for 1 year. Also
appointed was an equally well-qualified VA Deputy Director of VCE, Dr.
Claude Cowan. BVA fully supported both appointments. The two officials
have entered these challenging positions with virtually no office
space, little staffing support, zero funding for 3 months, no
organizational charter, and thousands of combat eye-wounded
servicemembers and veterans spread across various military medical
facilities and VA medical centers. Thanks to MILCON/VA Appropriations
Chairman Chet Edwards, VA received a $2 million appropriation for IT
support. Although Senate MILCON/VA Appropriations Chairman Tim Johnson
also helped provide an additional $6.9 million to VHA, questions
persisted for months regarding a plan on how to use these funds.
The OIF and OEF eye wounded who have recently enrolled in the VA
health care and benefits system never should have encountered this
difficult process. Quick action by Secretary Gates, in cooperation with
Secretary Shinseki and with the full attention of the Senior Oversight
Committee, is now vital to correct this mess.
BVA emphasizes that the clinical skills of the DoD professional eye
care providers, both ophthalmology and optometry, have been excellent.
In many cases, they have been no less than outstanding. Ophthalmology
surgery not possible during previous wars has saved the vision of many
Soldiers and Marines. Nevertheless, the system that organizes and
administers such treatment must become accountable for all battle eye
wounded and TBI patients affected. It must answer for the lack of
action inherent in its failure to begin staffing procedures that will
eventually reach 12 positions, failure to locate office space, and
failure to address the issue of construction renovation funding for the
National Naval Medical Center.
PREVALENCE AND INCIDENCE OF VISUAL IMPAIRMENTS
As of September 2008, VHA reported 8,747 diagnoses of TBI with
approximately 7,500 in diagnostic testing for possible TBI. Improvised
Explosive Device (IED) blasts contributed to more than 64 percent of
these injuries. As of January 30, 2009, a total of 43,993
servicemembers had been wounded or injured by accidents in Iraq. The
number of those wounded in hostile operations and requiring air medical
evacuation from Iraq between March 19, 2003 and January 30, 2009 from
one early report was 9,375, of which an estimated 13 percent (1,219)
had sustained combat penetrating eye trauma. Some 135 of this number
have enrolled in VA Blind Rehabilitation Service (BRS) programs. This
past November, however, the Military Surveillance Monthly Report
contained an article from DoD on eye injuries among members of active
components (U.S. Armed Forces, 1998-2008) that detailed, by ICD,
diagnostic code searches turning up 4,970 perforating and penetrating
eye trauma cases, 4,294 chemical or thermal burns, and 686 damaged
optic nerves, most of which were from among OIF and OEF injured.
The number of direct battle eye injuries does not include estimates
of all moderate-to-severe TBI servicemembers or veterans who have
visual dysfunction, according to VA research of those tested by either
neuro-ophthalmologists or low-vision optometrists at a few military and
VA centers. We stress that while only a small percentage of the eye
injured meet the legal blindness definition of 20/200 or less of visual
acuity, those with neurological vision dysfunction from mild, moderate,
or severe TBI will require long-term VA eye care follow-up in low-
vision clinics. Veterans with a history of ocular battle injuries are
also at high risk of developing retinal detachments, traumatic
cataracts, glaucoma, and other delayed TBI neuro-visual complications
that can occur years after the initial injury.
The top three contributors to combat eye injuries have been
Improvised Explosive Devices (IEDs), Rocket-Propelled Grenades (RPGs),
and Mortars, with IEDs causing 56.5 percent of all eye injuries in
Iraq. Just how many servicemembers have actually sustained moderate-to-
severe TBI injuries to the extent that they are experiencing neuro-
sensory visual complications is anyone's guess. The estimates in
professional journals and other publications indeed change from month
to month. The 64 percent figure (those with TBI who have experienced
visual dysfunction) represent those with associated neurological visual
disorders of diplopia, convergence disorder, photophobia, ocular-motor
dysfunction, color vision loss, and an inability to interpret print.
Some TBIs result in visual field defects with enough field loss to meet
legal blindness standards. We are also finding ever increasing numbers
of TBI-caused ``functionally blinded'' OIF and OEF veterans who, while
not legally blind, are unable to perform normal daily activities
because of loss of vision. More TBI visual screening, diagnosis,
treatment, and new outcome studies should be initiated without delay.
One early VA research study (2005) of OIF and OEF servicemembers
who had entered the VA system with an ICD-9 (diagnostic code) search
found 7,842 individuals with a traumatic injury of some kind.
Consistent with recent media articles and VA reports, the most common
traumatic injury diagnoses were hearing loss and tinnitus (63.5
percent). We now know that 94,191 of the more than 1.3 million troops
who have served in OIF and OEF are now service-connected for tinnitus
while 78,076 are service-connected for hearing loss. A major cause of
this hearing loss (60 percent of the cases) is exposure to IEDs. The
second most common VA diagnostic code was for visual impairment (27.9
percent). We submit to this Subcommittee that the cases of sensory loss
of hearing and visual impairment as a result of TBI constitute a
``silent epidemic'' not widely reported by media. They are,
nevertheless, the #1 and #2 injuries from OIF and OEF combat.
NEUROLOGICAL IMPACT OF TBI DYSFUNCTION
Perception plays a major role in an individual's ability to live
life. Although all senses play a significant role in perception, the
visual system is critical to perception, providing more than 70 percent
of human sensory awareness. With hearing being another critical
component, IED blast injuries can obviously impair markedly these two
key sensory systems.
Vision provides information about environmental properties. It
allows individuals to act in relation to such properties. In other
words, perceptions allow humans to experience their environment and
live within it. Individuals perceive what is in their environment by a
filtered process that occurs through a complex, neurological visual
system. With various degrees of visual loss comes greater difficulty to
clearly adjust and see the environment, resulting in increased risk of
injuries, loss of functional ability, and unemployment. Impairments
range from loss in the visual field, visual acuity changes, loss of
color vision, light sensitivity (photophobia), and loss of the ability
to read and recognize facial expressions.
Although one can acquire visual deficits in numerous ways, one
leading cause is injury to the brain. Damage to various parts of the
brain can lead to specific visual deficits. Some cases have reported a
spontaneous recovery but complete recovery is unlikely and early
intervention is critical. Current complex neuro-visual research is
being examined in an attempt to improve the likelihood of recovery. The
re-training of certain areas and functions of the brain has improved
vision deficits in some disorders. Nevertheless, the extent of the
recovery is often limited and will usually require long-term follow-up
with specialized adaptive devices and prescriptive equipment.
The brain is the most intricate organ in the human body. The visual
pathways within the brain are also complex, characterized by an
estimated two million synaptic connections. About 30 percent of the
neocortex is involved in processing vision. Due to the interconnections
between the brain and the visual system, damage to the brain can bring
about various cerebral visual disorders. The visual cortex has its own
specialized organization, causing the likelihood of specific visual
disorders if damaged. The occipitotemporal area of the brain is
connected with the ``what'' pathway. Thus, injury to this ventral
pathway leading to the temporal area of the brain is expected to affect
the processing of shape and color. This can make perceiving and
identifying objects difficult. The occipitoparietal area (posterior
portion of the head), is relative to the ``where,'' or ``action''
pathway. Injury to this dorsal pathway leading to the parietal lobe
will increase the likelihood of difficulties in position (depth
perception) and/or spatial relationships. In cases of injury,
individuals find it hard to determine an object's location and may also
discover impaired visual navigation.
It is highly unlikely that a person with TBI will have only one
visual deficit. A combination of such deficits usually exists due to
the complexity of the organization between the visual pathway and the
brain. The most common cerebral visual disorder after brain injury
involves visual field loss. The loss of peripheral vision can be mild
to severe and requires specific visual field testing to be correctly
diagnosed. In turn, a number of prescribed devices are frequently
necessary to adapt to this loss.
Accompanying such complex neurological effects on the patient is
the overwhelming emotional impact of brain injury on the patient and
his/her family. BVA would ask Members of the full House Committee to
seriously consider the ramifications of such injuries. Brain injuries
are known for causing extreme distress on family members who must take
on the role of caregivers. According to a New England Journal of
Medicine report of January 30, 2008, TBI ``tripled the risk of PTSD,
with 43.9 percent of those diagnosed with TBI also afflicted with
PTSD.''
At present, the current system of screening, treatment, tracking,
and follow-up care for TBI vision dysfunction is inadequate. Adding
visual dysfunction to this complex mix, especially if undiagnosed,
makes attempts at rehabilitation even more daunting and potentially
disastrous unless there are significant improvements in the screening,
treatment, tracking, and follow-up care through the proposed and
legislated Vision Center of Excellence.
VCE TO ADDRESS CRITICAL ISSUES
BVA believes that the VCE Eye Trauma Registry is where vital
components for research, best practices, outcome measures, and
education can be developed and refined for the eye trauma wounded and
those with TBI vision dysfunction. Critical vision research coordinated
with the Defense Veterans Brain Injury Centers (DVBIC) and Defense
Centers of Excellence for TBI can facilitate effective eye trauma
research between DoD and VA. We predict that the number of TBI-injured
will again increase beginning this spring as the troop surge into
Afghanistan gets underway.
BVA wishes to clear up false misinformation about VCE that has
recently become commonplace: First, VCE is not to be one large clinical
eye treatment center for all combat eye injured. It is better
understood as ``a virtual center with connectivity'' to the four major
military trauma centers (National Naval Medical Center, Brooke Army
Medical Center, Madigan Medical Center, and San Diego Naval Medical
Center), the soon-to-be five VA Polytrauma Centers, and the hundreds of
other medical centers where the highest proportion of eye-injured and
TBI-wounded are already receiving high quality, specialized surgery
care and low-vision optometric services.
Second, VCE is not a DoD blind center or rehabilitation facility.
It will, however, coordinate its work with the already existing,
skilled, multidisciplinary VA Blind Rehabilitation Centers (BRCs) and
low-vision clinics with decades of experience treating blinded
veterans. The VCE Eye Trauma Registry will track all eye injured and
TBI visually impaired, coordinate joint vision research, promote best
practices, and develop educational information on vision services for
both providers and families.
VA BRS AND LOW-VISION SERVICES
A positive note is that the challenges inherent in the growing
number of returning OIF and OEF servicemembers needing screening,
diagnosis, treatment, and a coordinated Seamless Transition of services
can be met, at least to some extent, by the existence of world-class VA
BRCs. The programs provided at such centers now have a 60-year history.
In the larger picture of VA programs for blind and visually impaired
veterans, BVA began working more than 4 years ago to ensure that VA
expand its current capacity to serve blinded veterans. Such expansion
became necessary as the aging population of veterans with degenerative
eye diseases requiring specialized services has continued to increase.
As a result of efforts to broaden and increase services, 54 new
outpatient intermediate low-vision and advanced blind rehabilitation
outpatient programs already have specialized staffing in place. Many of
these new programs are opening with veteran-centered, low-vision
specialized teams providing the full range of basic, intermediate, and
advanced rehabilitation services. Accompanying these gains is special
VA emphasis on outcome measurements and research projects within VHA.
The VA approach of coordinated team methods for rehabilitation care has
unlocked strategies for new treatments and provided the most updated
adaptive technology for blinded veterans. The new, specialized low-
vision and blind programs already existing within the VA system must be
utilized by DoD through VCE. The eye injured must receive high quality
health care with proven outcomes that include constantly emerging
vision research.
The mission of each Visual Impairment Services Team (VIST) program
is to provide blinded veterans with the highest quality of vision loss
services and blind rehabilitation training that truly help them adjust
to the major changes they have experienced in their lives. To
accomplish this mission, VISTs have established mechanisms to
facilitate more completely the identification of blinded veterans and
to offer a review of benefits and services for which they are eligible.
The VIST concept was created in order to coordinate the delivery of
comprehensive medical and rehabilitation services for blinded veterans.
VIST Coordinators can assist not only newly blinded veterans with
timely and vital information leading to psychosocial adjustment, but
can also provide similar assistance to their families.
Seamless Transition from DoD to VA is best achieved through the
dedicated work of VIST Coordinators and Blind Rehabilitation Outpatient
Specialists (BROS). They are in a unique position to provide
comprehensive case management services to returning OIF/OEF service
personnel for the remainder of their lives. VIST Coordinators are now
following the progress of 135 recently blinded veterans who are being
served on an outpatient basis. The VIST system currently employs 112
full-time and 43 part-time Coordinators. There are 39 full-time BROS
teams who also manage cases and serve as blind instructors for OIF and
OEF blinded veterans.
The VA BROS is a highly qualified professional. Many BROS hold
Masters Degrees in both Orientation and Mobility and Rehabilitation
Teaching. BROS also receive extensive cross-training at one of the ten
BRCs nationwide. The training prepares such individuals to provide, in
the veteran's home environment, the full range of mobility, living,
adaptive, manual, and other skills essential to blind rehabilitation.
VIST/BROS teams are also well equipped to provide excellent local
services on a continuing basis when a veteran returns home from an
inpatient stay at a BRC.
Advanced Outpatient Rehabilitation Programs occur in ``Hoptel''
settings, as VA calls them. Hoptel sleeping arrangements function
perhaps more like hotels than hospitals. Such programs offer Skills
Training, Orientation and Mobility, and Low-Vision Therapy for veterans
who need treatment with prescribed eye wear, magnification devices, and
adaptive technology to enhance remaining vision. Those returning from
blind centers benefit from these outpatient services when they require
additional training. A VIST Coordinator with low-vision credentials
manages the program with other key staff consisting of certified BROS,
Rehabilitation Teachers, Low-Vision Therapists, and a part-time Low-
Vision Ophthalmologist or Optometrist. Medical, surgery, psychiatry,
neurology, rehabilitative medicine, pharmacy, physical therapy, and
prosthetics services can all be consulted as needed within the VA
Medical Center, effectively providing the full continuum of care for
the OIF and OEF veterans. DoD and VA are in the process of developing a
bi-directional electronic health care record that exchanges medical
records and clinical eye trauma surgery information. Private agencies
that offer blind rehabilitation would rarely have full medical
services, surgical subspecialties, and psychiatry all co-located within
one facility, meaning veterans and families would have to travel
additional distances to obtain needed outpatient care for other
conditions, adding to wait times for consultants, delays in obtaining
prescribed medications, or waiting on new treatment plans. BVA strongly
recommends that private agencies utilized for services provide outcome
studies. We also recommend that they be accredited by the Commission on
Accreditation of Rehabilitation Facilities, that they be required to
utilize VA electronic health care records for clinical care, and that
they meet specific outcome measures for future contracts.
Another important model of service delivery that does not fall
under VA BRS is the VICTORS program, or the Visual Impairment Center to
Optimize Remaining Sight. VICTORS is an innovative program that has
been operated by VA Optometry Service for more than 18 years. The
program consists of specialized services to low-vision veterans who,
though not legally blind, suffer from visual impairments. Veterans must
generally have a visual acuity of 20/70 through 20/200 to be considered
for VICTORS. The program, entirely outpatient, typically lasts 3-5
days. Veterans undergo a comprehensive, low-vision optometric
evaluation. They receive prescribed low-vision devices and are trained
in the use of adaptive technology to optimize functional independence.
The Low-Vision Optometrists employed in the Intermediate Low-Vision
programs are ideal for the highly specialized skills necessary for the
assessment, diagnosis, treatment, and coordination of services for Iraq
and Afghanistan returnees with TBI visual symptoms. This is because
such veterans often require long-term follow-up services. The programs
also assist the aging population of veterans with degenerative eye
diseases. Such programs often enable working individuals to maintain
their employment and retain full independence in their lives. They also
provide testing for and research into the effectiveness of adaptive
low-vision technology aids that have recently become available through
training, review, and research. In conjunction with a wide network of
VA eye care clinics existing in VA medical centers nationwide, combined
VIST/BROS teams and Intermediate/Advanced Outpatient programs can
provide a wide network of specialized services for veterans and their
families in.
All of these programs test the effectiveness of new adaptive low-
vision technology aids through training, review, and research. Programs
requiring long-term follow-up services, such as the new Advanced and
Intermediate programs, are cost effective for high-need, low-vision
OIF/OEF veterans with residual vision from TBI. Combined VIST/BROS
teams and Intermediate/Advanced Outpatient programs can provide a wide
network of specialized services for servicemembers and their families
in coordination with existing VA Eye Care clinics within VA medical
centers. VCE is critical to the success of all of the aforementioned
specialized VA services.
CONCLUSIONS
Serious combat eye trauma and visual dysfunction associated with
TBI among OIF and OEF service personnel have become the second most
common injury resulting from the two conflicts. More than 9,940 visual
injuries have occurred and thousands more have visual dysfunction
stemming from TBI. We urge Members of the full House Committee to
demand compliance with the existing NDAA requirements. Both DoD and VA
should provide the $5 million funding for the remainder of FY 2009 for
joint professional and administrative staffing, joint office space for
no fewer than 12 staff members, construction, information technology,
and funding oversight of all activities of the Vision Center of
Excellence and Eye Trauma Registry. Congress indeed expected compliance
13 months ago. The establishment of the Defense Intrepid Center of
Excellence for Mental Health and the TBI Center of Excellence, along
with VCE, would substantially improve the multidisciplinary
coordination, treatment, rehabilitation, and research into eye trauma
and TBI-related visual impairment experienced by servicemembers and
veterans throughout the DoD and VA systems.
BVA again expresses sincere gratitude to this Subcommittee for the
opportunity to present our testimony. We hope that you understand the
deep sense of frustration we have felt over the course of the 13 months
since NDAA established VCE. Simply put, the time for DoD and VA to
implement VCE, as intended by the 110th Congress, is now. With the
large numbers of veterans suffering direct eye injury from battle and
TBI visual dysfunction, further delay is unacceptable. Because the
population of war wounded servicemembers and veterans is widely diverse
geographically, it is not appropriate or reasonable that one military
or VA medical treatment facility become a clinical center for all eye-
wounded servicemembers or for TBI patients with visual dysfunction.
Depending on such an idea would be cost prohibitive and delay care for
literally thousands of men and women.
We request that the House VA Committee require that both Secretary
Gates and Secretary Shinseki get VCE on track again. The Defense
Appropriations War Supplemental in April should present the next
feasible and excellent opportunity to add additional directed funding.
RECOMMENDATIONS
The Secretary of Defense and Secretary of Veterans
Affairs must immediately direct the Senior Oversight Committee
Executive Director to approve the organizational structure and charter
for VCE and provide DoD/VA clinical/administrative staff teams. He must
oversee the securing of temporary office space for at least 12 staff
members and see that financial resources are in place to begin to begin
full implementation of the operations of VCE. He should then report
back to this Committee within 30 days. VHA was directed to spend $6.9
million in FY 2009 for VCE. These funds should be utilized now for at
least some of the expenses associated with VCE's establishment.
The military director of VCE, Colonel Gagliano, and VA
Deputy Director Dr. Cowan need immediate administrative and information
technology staff support, office equipment, travel funding, and
educational support resources from both DoD and VHA to implement the
new VCE joint program, with no less than $5 million to cover FY 2009.
Congressional oversight should ensure that MILCON/VA and
Defense Appropriations Chairmen and Ranking Members review budgets for
FY 2010 to ensure that they provide no less than $6.5 million for
staffing, $10 million for FY 2010 vision research, and no less than $2
million for information technology. Some $6 million is urgently needed
at present to fund a Navy construction project that will renovate
office space and other facilities at National Naval Medical Center in
Bethesda, Maryland, where VCE Headquarters is to be located. All
Program Operational Management initiatives should then be funded for FY
2011, FY 2012, and FY 2013 as mandated by the reporting clause in the
National Defense Authorization Act of 2009.
VCE must be patient and family centered, comprehensively
coordinated, and compassionate. It should be a virtual center providing
real Seamless Transition that ensures electronic bi-directional
registry exchange of both inpatient and outpatient eye care clinical
records that both DoD and VA eye care staff can update and share with
the Veterans Benefits Administration so that benefits for service-
connected injuries can be assessed.
All DoD/VA case managers need educational updates on the
various VA specialized vision programs for eye trauma and TBI visual
dysfunction. Veterans and family members need information on locations
of vision services within DoD and VA. VIST/BROS teams must be notified
early in the treatment process of transfers to their local area of any
eye-injured servicemember. All DVBIC and VA TBI Centers must report
data to VHA on eye trauma or TBI vision dysfunction cases.
Private agency involvement in the treatment and
rehabilitation process should be narrowly limited to those meeting
strict accreditation, certification, educational, and university peer--
reviewed research criteria. Such agencies should be equipped with
multidisciplinary staff support and meet all Health Insurance
Portability and Accountability (HIPPA) requirements.
VCE should become involved in the DoD peer-reviewed
Congressionally Directed Medical Research Program (CDMRP) in order to
encourage additional TBI visual dysfunction research. More eye trauma
research in conjunction with DoD, VA, NIH, and universities with VA
academic affiliations is desperately needed now. Potential long-term
consequences of mild-to-moderate TBI in OIF/OEF veterans are still
unknown. Discoveries of such consequences will require new technology
and diagnostic research support. BVA, supported by the current Veterans
Service Organization Independent Budget, requests $10 million for CDMRP
in FY 2010 as directed vision research.
Prepared Statement of Madhulika Agarwal, M.D., MPH,
Chief Officer, Patient Care Services, Veterans Health Administration,
and James Orcutt, M.D., Ph.D., Chief of Ophthalmology,
Office of Patient Care Services, Veterans Health Administration,
U.S. Department of Veterans Affairs
Good morning, Mr. Chairman and Members of the Subcommittee. Thank
you for the opportunity to discuss the Department of Veterans Affairs'
(VA's) collaborations and accomplishments with the Department of
Defense (DoD) concerning the Vision Center of Excellence. We are
accompanied today by Dr. Claude Cowan, Deputy Director of the Vision
Center of Excellence.
VA has been working jointly with DoD to implement the components of
the 2008 National Defense Authorization Act to: 1) establish a Vision
Center of Excellence (VCE) in prevention, diagnosis, mitigation,
treatment and rehabilitation of military eye injuries; 2) implement a
Defense and Veterans Eye Injury Registry; and 3) coordinate care and
benefits between DoD and VA. We appreciate Congress' support in this,
area and we are proud to say the broad concepts of a VCE and registry
were already in development prior to the passage of this landmark piece
of legislation.
DoD has been an important partner in developing the VCE, and is the
lead agency in the implementation process. In the summer of 2008, the
Office of the Assistant Secretary of Defense for Health Affairs
accepted a joint VCE proposal from both VA and DoD. By August of the
same year, applications were solicited for the VCE Director position.
Shortly thereafter, a Deputy Director was named. Colonel Don Gagliano
and Dr. Claude Cowan have accepted these respective responsibilities.
With leadership from both DoD and VA, the Departments have
institutionalized our commitment to cooperate, and is emblematic of the
new culture of collaboration between the two agencies. This leadership
team is currently recruiting additional staff members (including
administrative staff, an optometrist and a blind rehabilitation
specialist) to supplement and support the mission.
The primary goals of the VCE are to monitor patterns of care and
the utilization of standard protocols (such as the traumatic brain
injury, or TBI, specific eye exam) to ensure consistency of care, to
identify gaps in care delivery, and to find areas where collaboration
and coordination can be improved. This includes not only care for
ocular injuries sustained during active duty and management of patients
with visual symptoms related to TBI, but also the full continuum of
care extending rehabilitation services for those with vision loss. VA
blind rehabilitation services include 10 intensive inpatient Blind
Rehabilitation Centers, 157 Visual Impairment Service Team
Coordinators, who provide care management, 75 Blind Rehabilitation
Outpatient Specialists, who serve in Veterans' homes and communities,
and 55 newly established low vision and blind rehabilitation outpatient
clinics across the United States. Both Veterans and active duty
personnel will be able to receive vision rehabilitation services at
these sites.
Follow-on care and family re-integration training for Veterans are
important issues to VA and these efforts undergo constant revision and
expansion as needs dictate so that when Veterans leave our facilities,
they and their family are better prepared for adjusting to life at
home.
The VCE is not only focused on supporting facilities that provide
treatment, diagnosis and the continuum of care, it will also work to
identify servicemembers with visual injuries as early as possible.
Since 2002, VA has assigned a Blind Rehabilitation Outpatient
Specialist at Walter Reed Army Medical Center and Bethesda national
Navel Medical Center to identify, coordinate and provide direct
rehabilitative care for Veterans and active duty servicemembers. The
VCE will also work to facilitate care coordination within and between
VA and DoD for those with multiple injuries, including vision loss, and
to ensure that appropriate eye assessments are provided. VA's
Polytrauma Centers continue to conduct comprehensive assessments of
TBI-related vision function--this ensures a comprehensive approach to
visual impairment identification, treatment and rehabilitation.
The VCE will review the existing literature for strong practices
that will provide guidelines for management of patients with ocular
injuries and visual symptoms related to TBI. Through review of existing
literature and the assessment of the effectiveness of current DoD and
VA treatment protocols, the VCE will identify and refine strong
practices for the management of patients with ocular injuries or visual
disability. In addition the VCE will facilitate the dissemination of
these practices through the use of written guidance documents and
combined conferences with VA and DoD.
Where the literature has not identified essential components of
appropriate management, the VCE will work with both VA and DoD research
programs to provide guidance and to support new research. The VCE will
educate providers about new findings on eye trauma and the visual
symptoms of TBI. VA and DoD organized a joint meeting in San Antonio in
December 2008 on the visual consequences of TBI and are planning a
second conference in December 2009 to educate providers in VA and DoD
on the Visual Consequences of Traumatic Brain Injury. Research
priorities were defined during a consensus validation project in
December 2008. In addition, VA's Office of Research and Development
sponsored a State of the Art Conference on TBI in June 2008. This led
to a request for applications for research in traumatic brain injury,
including research specifically related to vision and hearing loss.
During the summer and fall of 2008, VA began developing the eye
trauma registry. In VA and DoD discussions, participants began
outlining the requirements for a Concept of Operations for the
registry, which included participants from VA, DoD and the Joint
Theater Trauma Registry. The Concept of Operations addresses the
registry structure, the components required within the registry, and
the system requirements to make the registry functional. VA and DoD
have agreed to endorse using a central database with input from the
Joint Theater Trauma Registry, VA's electronic health record, and DoD's
electronic health record. Essential to this plan was the commitment
that this registry would be accessible and updated by VA and DoD
providers and end users. VA approved this concept in January 2009, and
DoD's approval is pending.
The Departments recognized the registry needed to include more than
just Veterans and servicemembers with direct ocular damage from service
in Operation Enduring Freedom or Operation Iraqi Freedom (OEF/OIF). We
also needed to include Veterans and servicemembers who sustained TBI
with resulting visual symptoms. The VCE will maintain the registry and
will continue monitoring and improving it while ensuring care for
injured Veterans and servicemembers.
VA's Office of Information and Technology (OI&T) is providing
critical support for the development of the registry and has assigned
an implementation program director for this effort. Participants from
VA, DoD and the Joint Theater Trauma Registry will meet in early April,
2009 to begin implementation of the registry.
VA is financially committed to the initiation of the registry
project. VA's OI&T provided funding for a consultant to develop the
Concept of Operations; similarly, DoD extended support to their
providers who helped develop the Concept of Operations. The 2009 VA
budget included $2 million for the registry and $6.9 million for the
VCE. The registry funding was provided to OI&T to support the
implementation of the registry. The VCE's funding supported hiring
staff and fully administering the educational conferences noted above.
Thank you again for this opportunity to speak about VA's role in
supporting the VCE and the eye injury registry. These are exciting
programs that hold great promise for providing the highest quality care
our Nation expects and our Veterans and servicemembers deserve. Our
medical health care system is recognized as one of the best in the
world, and we will continue to lead in all areas, including specialized
care.
Prepared Statement of Jack W. Smith, M.D., M.M.M.,
Acting Deputy Assistant Secretary for Clinical
and Program Policy, U.S. Department of Defense, and
Colonel Donald A. Gagliano, Executive Director,
Vision Center of Excellence
Mr. Chairman, Members of the Committee, thank you for the
opportunity to discuss with you the Department of Defense (DoD) and
Department of Veterans Affairs (VA) Vision Center of Excellence (VCE)
current initiatives and way forward. Vision complications, such as loss
of vision and blindness, are the ``silent epidemic'' of Operation Iraq
Freedom and Operation Enduring Freedom, but there are also typical eye
injuries and diseases affecting our soldiers and Veterans that must be
addressed.
DoD's primary focus is to provide expert services to our
servicemembers, our Veterans and their families in all areas of vision
care (prevention, diagnosis, mitigation, treatment, rehabilitation and
research). Developing and implementing innovative ways of managing eye
injuries is crucial. The Department is committed to improving the
quality of care for our wounded warriors, who deserve the very best for
the sacrifices they have made for our Nation. We are pleased to be here
to talk about this significant initiative.
Establish a Vision Center of Excellence
Due to the increase in vision injuries and diseases sustained by
the men and women of our Armed Services, Congress directed that the
Department establish a Vision Center of Excellence to ensure the full
spectrum of care is fully supported. It is our duty to protect our
servicemembers and assist them with all their medical needs, including
vision.
There is much to accomplish, establish, implement, and set in
motion in order to achieve the goals and objectives of the VCE. I want
to share with you some of the VCE accomplishments to date.
The Department envisions that the VCE's permanent headquarters will
be integrated with the vision capabilities in the National Capital
Region. The current goal is to secure long--term space in the same area
as the Eye Clinic (Ophthalmology and Optometry) in the new Walter Reed
National Military Medical Center. This will allow for synergies between
vision care providers and patients in the National Capital Area, and
will benefit from proximity to the new National Intrepid Center of
Excellence building and to the National Eye Institute.
VA and DoD have developed a process for collaboration at Walter
Reed Army Medical Center (WRAMC) for blind rehabilitation care while
servicemembers are still receiving DoD care. This effort will enhance
the continuum of care and better integrate a continuum of care across
the DoD and VA for vision rehabilitation. The next steps are:
Finalize a Memorandum of Understanding (MOU) for
collaboration at WRAMC for blind rehabilitation care while
servicemembers are still receiving DoD care; and
Establish approval for privileging rehabilitation care
providers in DoD facilities.
To enhance continuity of care between DoD and VA vision centers, we
have worked together to define common vision care data exchange
protocols for the DoD Bilateral Health Information Exchange developers.
We also plan to develop a training program for the use of the DoD/VA
Bilateral Health Information Exchange to continue the collaboration
effort to support optimal DoD/VA transitional vision care. We will
continue to do this since health information exchange is key to
successful collaboration.
We have established priorities for vision research based on
identified requirements by working with the Congressional Special
Interest Vision Research Administrators and the Congressionally
Directed Medical Research Program (CDMRP). We plan to host a meeting
with vision research entities to establish priorities for vision
research through the Congressional Special Interest Vision Research
Administrators and CDMRP.
The VCE involves the coordinated effort of the DoD, VA,
institutions of higher education and various commercial, academic and
non-profit entities. The VCE will have the opportunity to transform the
way we provide vision care through these collaboration efforts. We plan
to:
Promote affiliation with research institutes, including
the National Eye Institute, FDA, and other academic institutions; and
Develop an eye trauma training center affiliated with an
academic institution with a high volume of trauma patients to enhance
the readiness of the vision care teams.
Implement the Defense and Veterans Eye Injury Registry
Currently, we do not have an optimal mechanism to capture long-term
data for eye injuries and diseases that are affecting our
servicemembers returning from theater and our Veterans undergoing long-
term care. This registry will support care coordination for
servicemembers and Veterans with significant eye injuries, provide data
necessary to measure longitudinal outcomes, and provide statistical and
accurate data requested by Congress and Veterans Service Organizations.
VA and DoD developed a Defense and Veterans Eye Injury Registry
Concept of Operations (CONOPS). Included in this CONOPS is the
development of an eye trauma module that will be incorporated into the
Joint Trauma Tracking Registry (JTTR). The next step is to begin
populating the Defense and Veterans Eye Injury Registry by late 2009.
The Defense and Veterans Eye Injury Registry will drive innovation
forward. It will provide those with eye injuries, diseases and those
with visual loss associated with Traumatic Brain Injury (TBI) many
opportunities as it will allow for sharing studies outcomes,
establishing best practices and clinical guidelines.
Conclusion
The VCE is designed to improve the care of American military
personnel and Veterans affected by combat eye trauma, to bring back
those suffering from vision loss, injuries and vision anomalies to a
fully functional capability, and to create a Joint Defense and Veterans
Eye Injury Registry that will drive research and innovation in vision
care. We are working diligently to ensure the VCE becomes the leader in
vision care as we understand how important this mission is for our
servicemembers and Veterans.
We are grateful to the Members of the House Veterans' Affairs
Committee for your efforts to assist our soldiers. We have come a long
way, but now our work intensifies.
Thank you for your time and the opportunity to update you on the
VCE. We look forward to answering your questions.
MATERIAL SUBMITTED FOR THE RECORD
SEC. 1623. CENTER OF EXCELLENCE IN PREVENTION,
DIAGNOSIS, MITIGATION, TREATMENT,
AND REHABILITATION OF MILITARY EYE INJURIES.
(a) In General--The Secretary of Defense shall establish within
the Department of Defense a center of excellence in the prevention,
diagnosis, mitigation, treatment, and rehabilitation of military eye
injuries to carry out the responsibilities specified in subsection (c).
(b) Partnerships--The Secretary shall ensure that the center
collaborates to the maximum extent practicable with the Secretary of
Veterans Affairs, institutions of higher education, and other
appropriate public and private entities (including international
entities) to carry out the responsibilities specified in subsection
(c).
(c) Responsibilities
(1) IN GENERAL--The center shall----
(A) implement a comprehensive plan and strategy for the
Department of Defense, as developed by the Secretary of Defense, for a
registry of information for the tracking of the diagnosis, surgical
intervention or other operative procedure, other treatment, and follow-
up for each case of significant eye injury incurred by a member of the
Armed Forces while serving on active duty;
(B) ensure the electronic exchange with the Secretary of
Veterans Affairs of information obtained through tracking under
subparagraph (A); and
(C) enable the Secretary of Veterans Affairs to access the
registry and add information pertaining to additional treatments or
surgical procedures and eventual visual outcomes for veterans who were
entered into the registry and subsequently received treatment through
the Veterans Health Administration.
(2) DESIGNATION OF REGISTRY--The registry under this subsection
shall be known as the `Military Eye Injury Registry' (hereinafter
referred to as the `Registry').
(3) CONSULTATION IN DEVELOPMENT--The center shall develop the
Registry in consultation with the ophthalmological specialist personnel
and optometric specialist personnel of the Department of Defense and
the ophthalmological specialist personnel and optometric specialist
personnel of the Department of Veterans Affairs. The mechanisms and
procedures of the Registry shall reflect applicable expert research on
military and other eye injuries.
(4) MECHANISMS--The mechanisms of the Registry for tracking
under paragraph (1)(A) shall ensure that each military medical
treatment facility or other medical facility shall submit to the center
for inclusion in the Registry information on the diagnosis, surgical
intervention or other operative procedure, other treatment, and follow-
up for each case of eye injury described in that paragraph as follows
(to the extent applicable):
(A) Not later than 30 days after surgery or other operative
intervention, including a surgery or other operative intervention
carried out as a result of a follow-up examination.
(B) Not later than 180 days after the significant eye injury
is reported or recorded in the medical record.
(5) COORDINATION OF CARE AND BENEFITS--
(A) The center shall provide notice to the Blind
Rehabilitation Service of the Department of Veterans Affairs and to the
eye care services of the Veterans Health Administration on each member
of the Armed Forces described in subparagraph (B) for purposes of
ensuring the coordination of the provision of ongoing eye care and
visual rehabilitation benefits and services by the Department of
Veterans Affairs after the separation or release of such member from
the Armed Forces.
(B) A member of the Armed Forces described in this
subparagraph is a member of the Armed Forces as follows:
(i) A member with a significant eye injury incurred while
serving on active duty, including a member with visual dysfunction
related to traumatic brain injury.
(ii) A member with an eye injury incurred while serving on
active duty who has a visual acuity of 20/200 or less in the injured
eye.
(iii) A member with an eye injury incurred while serving on
active duty who has a loss of peripheral vision resulting in 20 degrees
or less of visual field in the injured eye.
(d) Utilization of Registry Information--The Secretary of Defense
and the Secretary of Veterans Affairs shall jointly ensure that
information in the Registry is available to appropriate
ophthalmological and optometric personnel of the Department of Defense
and the Department of Veterans Affairs for purposes of encouraging and
facilitating the conduct of research, and the development of best
practices and clinical education, on eye injuries incurred by members
of the Armed Forces in combat.
(e) Inclusion of Records of OIF/OEF Veterans--The Secretary of
Defense shall take appropriate actions to include in the Registry such
records of members of the Armed Forces who incurred an eye injury while
serving on active duty on or after September 11, 2001, but before the
establishment of the Registry, as the Secretary considers appropriate
for purposes of the Registry.
(f) Traumatic Brain Injury Post-Traumatic Visual Syndrome--In
carrying out the program at Walter Reed Army Medical Center, District
of Columbia, on traumatic brain injury post-traumatic visual syndrome,
the Secretary of Defense and the Department of Veterans Affairs shall
jointly provide for the conduct of a cooperative program for members of
the Armed Forces and veterans with traumatic brain injury by military
medical treatment facilities of the Department of Defense and medical
centers of the Department of Veterans Affairs selected for purposes of
this subsection for purposes of vision screening, diagnosis,
rehabilitative management, and vision research, including research on
prevention, on visual dysfunction related to traumatic brain injury.
SEC. 1624. REPORT ON ESTABLISHMENT OF CENTERS OF EXCELLENCE.
(a) In General--Not later than 180 days after the date of the
enactment of this Act, the Secretary of Defense shall submit to
Congress a report on--
(1) the establishment of the center of excellence in prevention,
diagnosis, mitigation, treatment, and rehabilitation of traumatic brain
injury under section 1621;
(2) the establishment of the center of excellence in prevention,
diagnosis, mitigation, treatment, and rehabilitation of post-traumatic
stress disorder and other mental health conditions under section 1622;
and
(3) the establishment of the center of excellence in prevention,
diagnosis, mitigation, treatment, and rehabilitation of military eye
injuries under section 1623.
(b) Matters Covered--The report shall, for each such center--
(1) describe in detail the activities and proposed activities of
such center; and
(2) assess the progress of such center in discharging the
responsibilities of such center.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
U.S. Department of Defense
Office of the Assistant Secretary of Defense for Health Affairs
Washington, DC.
March 12, 2009
Hon. Harry Mitchell
Chairman, Subcommittee on Oversight and Investigations
Committee on Veterans' Affairs
U.S. House of Representatives
Washington, DC 20515
Dear Mr. Chairman,
In accordance with section 1623 of the National Defense
Authorization Act for Fiscal Year 2009 (P.L. 110-181) to establish a
center of excellence in prevention, diagnosis, mitigation, treatment
and rehabilitation of military eye injuries, the Fiscal Year 2009
Defense Health Program Operation and Maintenance Budget for the
establishment and operation of the Vision Center of Excellence is $3
million. The Director, Vision Center of Excellence, is authorized to
incur financial obligations as a result of hiring civilian personnel,
acquiring contractual services and supplies, and conducting travel
requirements necessary to ensure mission accomplishment. The Director's
funding needs will be monitored throughout the fiscal year to ensure
that funding is available to support mission requirements.
My point of contact is the Director, Program, Budget and Execution
Division, Dave Moonan, 703-681-4341.
Sincerely,
Allen W. Middleton
Acting Deputy Assistant Secretary of Defense
Health Budgets and Financial Policy
Committee on Veterans' Affairs
Subcommittee on Oversight an Investigations
Washington, DC.
April 22, 2009
Honorable Eric K. Shinseki
Secretary
U.S. Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20420
Dear Secretary Shinseki:
Thank you for the testimony of Madhulika Agarwal, M.D., Ph.D.,
Chief Officer, Patient Care Services, Veterans Health Administration,
James Orcutt, M.D., Ph.D., Chief of Ophthalmology, Veterans Health
Administration and Claude Cowan, M.D., Deputy Director of the Military
Eye Trauma Vision Center of Excellence, U.S. Department of Veterans
Affairs at the U.S. House of Representatives Committee on Veterans'
Affairs Subcommittee on Oversight and Investigations hearing that took
place on March 17, 2009, on ``The Vision Center for Excellence: What
Has Been Accomplished in Thirteen Months?''
Please provide answers to the following questions by June 2, 2009,
to Todd Chambers, Legislative Assistant to the Subcommittee on
Oversight and Investigations.
1. When did the four Polytrauma Centers begin tracking eye
injuries? Please explain why the tracking has not been a focus as it
has with TBI and PTSD patients.
2. Other types of injuries such as the 817 amputees, 580 burns,
8,780 VA diagnosed TBI, 43,000 PTSD, are and have been reported,
published, and briefed in the past year. Why has there not been any
briefings or reports on eye injuries?
3. Are the four VA Polytrauma Centers staffed with vision teams
of Optometry and Ophthalmological with Blind Rehabilitative Outpatient
Specialists and Visual Impairment Service Team (VIST) Coordinators? If
so, please provide the dates of implementation of the VIST Team
Coordinators.
4. When are servicemembers with Vision Impairment being referred
to VA VIST Coordinators?
5. What are the current requirements for continuing education of
DoD and VA medical staff (to include VIST and VA Bros) on screening for
vision complications from TBI?
6. Please outline individually the plans, timeline and estimated
costs for the VCE to perform the functions as stated in the NDAA.
Specifically address the areas of research, registry and family and
patient education.
7. Those with visual dysfunction and legal blindness should be
reported by DoD to VA. Explain how this is being reported between
departments today. How will compliance be assured so that
servicemembers with eye injuries are accounted for and care provided by
the VA?
8. Replication of the Palo Alto VAMC Vision Screening program for
TBI seems to be a key priority across the VA polytrauma sites. How is
VHA going to ensure that this occurs? What is the timeline of
implementation for each of the three other polytrauma centers?
9. Are there plans on having key TBI/PTSD military staff visit
and train at the VA blind centers to begin the process of sharing
resources and information? If so please provide a timeline for when
this will occur.
10. Who has been designated by the Secretary to be the OI&T
implementation director for the Vision Center of Excellence program
(VCE), and have the appropriate resources been allocated to support the
program?
11. Please provide a timeline for the full implementation of the
VCE program, including the following items: 1) completion of the
Concept of Operations; 2) sharing VA and DoD electronic health records
in an interoperable manner; and 3) coordination of care between the VA
and DoD for blinded veterans and servicemembers.
12. Will additional funding be requested in the President's FY
2010 budget request for VA to support the Vision Center of Excellence?
13. From the testimony received at the hearing, it appears that
there is still a lack of contact between severely injured
servicemembers and the Federal Care Coordination Program. What is the
status on this program, and how is the Department reaching out to these
servicemembers to make them aware of the services and benefits
available to them?
14. Please provide the Committee with the names of Case Managers
and the Federal Care Coordinators who have been assigned to the three
veterans who testified at this hearing. Please also provide the dates
in which these individuals were assigned to assist the veterans.
15. Please provide the planned budget obligations for the $6.9
million appropriated to the Department of Veterans Affairs for the
Vision Center of Excellence.
Thank you again for taking the time to answer these questions. The
Committee looks forward to receiving your answers. If you have any
questions concerning these questions, please contact Subcommittee on
Oversight and Investigations Staff Director, Martin Herbert, at (202)
225-3569 or the Subcommittee Republican Staff Director, Arthur Wu, at
(202) 225-3527.
Sincerely,
David P. Roe
Harry E. Mitchell
Ranking Republican Member
Chairman
0_________
Questions for the Record
Hon. Harry E. Mitchell, Chairman
Hon. David P. Roe, Ranking Republican Member
House Committee on Veterans' Affairs
Subcommittee on Oversight and Investigations
The Vision Center of Excellence: What Has
Been Accomplished in 13 Months
March 17, 2009
Question 1: When did the four Polytrauma Centers begin tracking eye
injuries? Please explain why the tracking has not been a focus as it
has with TBI and PTSD patients.
Response: Initial discussions with the Department of Defense (DoD)
began in September 2007 during a joint meeting at the Madigan Army
Medical Center in Tacoma, WA. During this meeting, the need for an eye
injury registry was identified. Subsequent meetings were conducted in
December 2007 at the Visual Consequences of Traumatic Brain Injury
conference and at the American Lake Department of Veterans Affairs (VA)
Medical Center in April 2008. At this meeting, VA and DoD determined
DoD would be able to track eye injuries through the DoD joint trauma
theater registry staff. As a result, the Defense and Veterans eye
injury registry (DVEIR) is now being developed as part of the vision
center of excellence (VCE) action plan. Polytrauma rehabilitation
centers (PRC) are tracking their patients with blindness and vision
loss, but VA currently does not have an effective mechanism for
tracking eye injuries except for patients admitted to the PRC. Patients
admitted to the PRC have always had their eye injuries identified,
annotated in the electronic medical record and treated. VA also
identifies and treats all other associated injuries and conditions and
provides ongoing follow-up care and services as appropriate for their
condition. In 2008, VA implemented policies and procedures to perform
Traumatic brain injury (TBI) specific eye examinations for every TBI
patient admitted at each PRC [VHA Directive 2008-065, Performance of
Traumatic Brain Injury Specific Ocular Health and Visual Functioning
Examinations for Polytrauma Rehabilitation Center Patients, October 20,
2008]. A standardized template was developed and deployed to Veteran
Health Administration (VHA) eye care practitioners to document the
examination. For patients with TBI admitted to the PRCs prior to 2008,
the PRCs are contacting each patient to coordinate to perform the TBI-
specific eye examination for them. Reports on completion of the TBI
specific ocular health and visual functioning exam for prior and
current patients are submitted monthly by each PRC to VHA Office of
Rehabilitation Services. This exceptional step of performing TBI-
specific eye examinations was implemented based upon work by VA
clinical providers at Palo Alto PRC, who first reported in 2007 that
patients with blast-related TBI may be at higher risk for visual
function abnormalities than might be found by conventional visual
acuity testing.
Question 2: Other types of injuries such as the 817 amputees, 580
burns, 8,780 VA diagnosed TBI, 43,000 PTSD, are and have been reported,
published, and briefed in the past year. Why has there not been any
briefings or reports on eye injuries?
Response: VA blind rehabilitation service and visual impairment
service teams currently track 596 unique Operation Enduring Freedom/
Operation Iraqi Freedom (OEF/OIF) servicemembers and Veterans with eye
injuries, and/or visual conditions following TBI. A total of 101 unique
OEF/OIF servicemembers and Veterans have been served in inpatient blind
rehabilitation centers, of which:
48 were active duty at the time of treatment;
52 were discharged from the military at the time of treatment
and;
1 was an active duty foreign military servicemember.
As additional Veterans with eye injuries are identified, either
through delivery of medical care at VA or through referral from the
DoD, VA will continue to add and track these Veterans as appropriate.
As discussed in response to question # 1 the existence of a
systems-wide eye registry that includes all TBI patients is presently
not available and thus data for reports or briefings related to eye
injuries will not be available until the full implementation of DVEIR.
Question 3: Are the four VA Polytrauma Centers staffed with vision
teams of Optometry and Ophthalmological with Blind Rehabilitative
Outpatient Specialists and Visual Impairment Service Team (VIST)
Coordinators? If so, please provide the dates of implementation of the
VIST Team Coordinators.
Response: Yes, the four VA PRCs are staffed with vision teams that
include: optometry and ophthalmology (including low vision optometry,
and neuroophthalmology), blind rehabilitative outpatient specialists
(BROS), and visual impairment service team (VIST) coordinators. VIST
coordinators are at each PRC, and these positions have existed at each
PRC location since before 2005 when the VA polytrauma system of care
was established (prior to 2005, the PRCs existed with designation as
lead traumatic brain injury centers).
Question 4: When are servicemembers with Vision Impairment being
referred to VA VIST Coordinators?
Response: Servicemembers with vision impairment are being referred
to VIST coordinators when first identified so that they can benefit
from visually impaired services through the VA. This happens at several
possible stages:
At the military treatment facilities (MTF) where VA
liaisons are located, the liaisons participate with the
interdisciplinary military treatment teams and upon discussion of
patients with vision impairments, liaisons may suggest treatment
options within VA.
As identified and appropriate, VA liaisons collaborate
with the MTF treatment team and enlist the services of a VIST
coordinator or BROS to begin working with a servicemember onsite at the
MTF.
If a person is obtunded and the discovery is not
determined until their cognitive skills improve, then referral to a
VIST coordinator may occur at a later stage, possibly when at a PRC.
As a servicemember transitions from the MTF to VA, the VA
liaison coordinates health care, including visual impairment services
at a health care facility closest to the servicemember's home or most
appropriate for their condition.
Question 5: What are the current requirements for continuing
education of DoD and VA medical staff (to include VIST and VA BROS) on
screening for vision complications from TBI?
Response: VA has provided, and continues to provide, training to
medical staff and VIST and BROS through several VA conferences: visual
consequences of TBI (December 2007); blind rehabilitation service
national conferences (August 2008, August 2009); blind rehabilitation
continuum of care conference (February 2009); and the visual
consequences of TBI II conference (scheduled for December 2009). Newly
hired VIST and BROS staff are provided training through national
program consultants, and receive ongoing mentoring for continued
education and professional preparation specific to vision conditions in
TBI. Additionally, Blind Rehabilitation Service hosts monthly
conference calls for VIST and BROS, and maintains a Web-share access
site addressing questions and distributing information about this
topic.
Question 6: Please outline individually the plans, timeline and
estimated costs for the VCE to perform the functions as stated in the
NDAA. Specifically address the areas of research, registry and family
and patient education.
Response: VA and DoD are conducting discussions to finalize a
timeline for full implementation of the VCE. The budget is being
revised as additional information becomes available related to
staffing, supplies, travel and training. DoD was provided $1 million in
fiscal year (FY) 2008 and $3 million in FY 2009 for the VCE. VA had
provided funding for the VCE for staffing and set up costs (office
equipment, etc) of $1.6 million for FY 2009. Congress provided the VA
$6.9 million for VCE and $2 million for DVEIR. The $2 million is
budgeted for IT costs thru early FY 2010. VA funding is for staffing,
infrastructure and educational meetings for providers, and will be will
be used to fund the VCE approximately thru FY 2013. The Director (DoD)
and Deputy Director (VA) are collaborating on the identification of
areas that will require additional research opportunities to assist
with improving overall services and treatment options. The consensus
document from blind rehab and the technical advisory group is nearing
completion and outlines what is needed in research with an anticipated
date of approval by no later than December 31, 2009. (draft document in
the review stage).
The Office of Research and Development held the ``state-of-the-
art'' meeting in June 2008 which led to the request for proposal for
research in this area. Funding for the registry is proceeding. VHA held
a teleconference with the Office of Information and Technology (OI&T)
program manager on May 12, 2009 and is proceeding with a proof of
concept registry document while waiting for the concept of operations
(CONOPS) from DoD.
Patient and family education will be a continuous process and will
be implemented to meet the individual needs of each Veteran from a
multi-disciplinary perspective.
Question 7: Those with visual dysfunction and legal blindness
should be reported by DoD to VA. Explain how this is being reported
between departments today. How will compliance be assured so that
servicemembers with eye injuries are accounted for and care provided by
the VA?
Response: At the major continental United States sites, such as
Walter Reed Army Medical Center (WRAMC) and Naval Medical Center San
Diego, there are VIST coordinators in place and the eye care
professionals refer patients directly to them. In the past,
coordinators were asked to participate in medical staff rounds for
inpatients to help identify referrals, however due to potential Health
Insurance Portability and Accountability Act violations, DoD requested
this be re-evaluated and that practice has not been reinstated. DoD has
stated that they would begin credentialing VIST coordinators to include
them in staff rounds in the future, and VA is negotiating with DoD to
begin credentialing VIST as soon as possible.
Currently, the only formalized method of reporting servicemembers
with visual dysfunction and legal blindness from DoD to VA is through
the VA liaison for health care referral process. The VA blind
rehabilitation outpatient specialist who services WRAMC and the
National Naval Medical Center (NNMC) has participated in the inpatient
multidisciplinary trauma/blast team meetings at those two MTFs. The VA
BROS continues to attend these meetings as needs arise.
Question 8: Replication of the Palo Alto VAMC Vision Screening
program for TBI seems to be a key priority across the VA polytrauma
sites. How is VHA going to ensure that this occurs? What is the
timeline of implementation for each of the three other polytrauma
centers?
Response: Since December 1, 2008, all patients admitted to a PRC
with a diagnosis of TBI are provided a TBI-specific ocular health and
visual functioning examination that was first established at Palo Alto
PRC. VA has implemented policies and procedures to perform TBI specific
eye examinations for every TBI patient admitted at each PRC [VHA
Directive 2008-065, Performance of Traumatic Brain Injury Specific
Ocular Health and Visual Functioning Examinations for Polytrauma
Rehabilitation Center Patients, October 20, 2008]. A standardized
template was developed and deployed to VHA eye care practitioners to
document the examination. Since December 2008, 113 such patients have
been in the PRCs, of which 96 have completed the examinations; 17 are
currently unable to complete testing due to their medical condition.
For patients with TBI admitted to the PRCs prior to December 1,
2008, the PRCs are contacting each patient to coordinate to perform the
TBI-specific eye examination for them. Reports on completion of the TBI
specific ocular health and visual functioning exam for prior and
current patients are submitted monthly by each PRC to VHA Office of
Rehabilitation Services. Between February 2005 and December 2008, a
total of 652 patients with TBI went through the PRCs; a total of 481 of
these patients were discharged without having completed the examination
prior to discharge. A total 419 of these patients have been referred
for examination, and 219 have completed the TBI eye examinations so
far. The remainder have either been contacted and provided referral
(201), or declined referral or are deceased (61).
Question 9: Are there plans on having key TBI/PTSD military staff
visit and train at the VA blind centers to begin the process of sharing
resources and information? If so please provide a timeline for when
this will occur.
Response: DoD staff have visited 5 of the 10 VA inpatient blind
rehabilitation centers at Chicago, IL; West Haven, CT; American Lake,
WA; Augusta, GA, and Palo Alto, CA. While there are currently no DoD
visits planned to VA blind rehabilitation centers, VA remains open and
readily accessible to DoD sending staff who work with TBI or post-
traumatic stress disorder patients to visit and train at VA blind
rehabilitation centers. VA and DoD typically collaborate to provide
joint training at conferences such as the visual consequences of TBI
conference (December 2007), and the upcoming visual consequences of TBI
II conference (December 2009).
VA also provides staff at major MTFs to support the provision of
services, training and interaction with regard to blind rehabilitation.
Since 2002, a BROS has supported blind rehabilitation services to WRAMC
and NNMC. This has entailed the VA BROS attending the WRAMC TBI
meetings and NNMC trauma rounds, and providing in-service training to
staff at NNMC and WRAMC on multiple occasions. Since February 2009, the
BROS have been attending the weekly TBI clinic at the WRAMC Military
Advanced Treatment Center (MAT-C) to work with patients who are blind,
visually impaired, or have visual disturbances as the result of a TBI.
VA social work care liaisons at Naval Medical Center San Diego and
Brooke Army Medical Center work with VIST coordinators at supporting VA
medical centers in San Diego or San Antonio to coordinate services or
referrals for visually impaired servicemembers as appropriate. The
supporting BROS at VA medical centers will also provide blind
rehabilitation care on site at these DoD medical centers.
Question 10: Who has been designated by the Secretary to be the
OI&T implementation director for the Vision Center of Excellence
program (VCE), and have the appropriate resources been allocated to
support the program?
Response: There is a program manager, and a development manager for
VA's OI&T efforts in support of the DVEIR. VA received $2 million for
fiscal 2009, which should be sufficient. A support contract was awarded
to Patriot Technologies in September 2008 for all VA registries. These
contract resources are in place and provide support for VA's portion of
the DVEIR.
Question 11: Please provide a timeline for the full implementation
of the VCE program, including the following items: 1) completion of the
Concept of Operations; 2) sharing VA and DoD electronic health records
in an interoperable manner; and 3) coordination of care between the VA
and DoD for blinded veterans and servicemembers.
Response: VA and DoD are collaborating to finalize a timeline for
full implementation of the vision center of excellence (VCE). The
initial draft of the timeline allows for a period of 3 years for full
activation of the VCE, however it may take longer to meet all
milestones. A fully developed timeline is scheduled to be presented for
approval in the fourth quarter of FY 2009, with initial actions in the
1st Quarter of FY 2010.
The Director (DoD) and Deputy Director (VA) are closely
collaborating on VCE implementation, to include hiring the Deputy Chief
of Staff and administrative support, which will positively impact the
ability to move forward with the program. Agreement on the development
of standards and requirements for a blind rehabilitation specialist and
optometrist are complete and the recruitment process has begun.
Progress has been made on defining the standards and requirements for
the Chief of Staff position as well as initiating the recruitment
action. Temporary space has been identified since the testimony of
March 17, 2009. VA completed the CONOPS for the registry. It was
reviewed by DoD and is being used as a guide to develop a DoD CONOPS
for the establishment of the eye registry.
VA has allocated staff to prepare the CONOPS and other requirements
documents. Significant VCE and DoD technical approach decisions are
pending and ultimately will define our project efforts. VA and DoD
maintain close coordination and discussion on the VCE and the structure
of the required registry. VA is coordinating care as noted above
through BROS, VIST and care coordinators.
Question 12: Will additional funding be requested in the
President's FY 2010 budget request for VA to support the Vision Center
of Excellence?
Response: VA has no current plans to request additional funding in
the President's FY 2010 budget request for the Vision Center of
Excellence.
Committee on Veterans' Affairs
Subcommittee on Oversight an Investigations
Washington, DC.
April 22, 2009
Honorable Robert M. Gates
Secretary of Defense
U.S. Department of Defense
1000 Defense Pentagon
Washington, DC 20301
Dear Secretary Gates:Thank you for the testimony of Jack Smith,
M.D., Deputy Assistant Secretary of Defense for Clinical Policy and
Programs, U.S. Department of Defense and Colonel Donald A. Gagliano,
USA, M.D., Executive Director for the Military Eye Trauma Center of
Excellence, U.S. Department of Defense at the U.S. House of
Representatives Committee on Veterans' Affairs Subcommittee on
Oversight and Investigations hearing that took place on March 17, 2009
on ``The Vision Center for Excellence: What Has Been Accomplished in
Thirteen Months?''
Please provide answers to the following questions by June 2, 2009,
to Todd Chambers, Legislative Assistant to the Subcommittee on
Oversight and Investigation.
1. Plans reported to this Committee in June 2008 by Mr. Michael
Dominguez, Principal Deputy Under Secretary for Personnel at DoD,
regarding the new Vision Center of Excellence (VCE), included four
designated clinical Vision Centers of Excellence at Bethesda NNMC,
Brooke Army Medical Center, Madigan Army Medical Center, and Balboa
Naval Medical Centers, all military major polytrauma centers. What are
the specific staffing, funding, and space costs approved and when will
those be implemented?
a. What are the estimated IT costs for FY09 and FY10?
b. What are the estimated costs to renovate office space?
c. What are the cost projections for the Center in FY09, FY10
and FY11?
2. Please provide the numbers of servicemembers with TBI visual
impairments that DoD is tracking? Currently, how is data being
collected so research or clinical outcomes can be tracked?
3. How much of the $3 million that was obligated from DoD to the
VCE has been used?
4. Will additional funding be requested in the President's FY 2010
budget request for DoD to support the Vision Centers of Excellence?
5. VA has already approved the Concept of Operations in January
2009. When will the Department of Defense approve the Concept of
Operations? Please provide to the Committee a timeline for execution of
the Vision Centers of Excellence with key milestones highlighted.
Thank you again for taking the time to answer these questions. The
Committee looks forward to receiving your answers. If you have any
questions concerning these questions, please contact Subcommittee on
Oversight and Investigations Staff Director, Martin Herbert, at (202)
225-3569 or the Subcommittee Republican Staff Director, Arthur Wu, at
(202) 225-3527.
Sincerely,
David P. Roe
Harry E. Mitchell
Ranking Republican Member
Chairman
0_________
Questions for the Record
Hon. Harry E. Mitchell, Chairman
Hon. David P. Roe, Ranking Republican Member
House Committee on Veterans' Affairs
Subcommittee on Oversight and Investigations
The Vision Center of Excellence: What Has
Been Accomplished in 13 Months
March 17, 2009
Question 1: Plans reported to this Committee in June 2008 by Mr.
Michael Dominguez, Principal Deputy Under Secretary for Personnel at
the Department of Defense (DoD), regarding the new Vision Center of
Excellence (VCE), included four designated clinical VCEs at Bethesda
national Naval Medical Center (NNMC), Brooke Army Medical Center,
Madigan Army Medical Center, and Balboa Naval Medical Centers, all
military major polytrauma centers. What are the specific staffing,
funding, and space costs approved and when will those be implemented?
Response: Initial plans envisioned a single Vision Center of
Excellence (VCE) in Bethesda, with satellite treatment centers. Our
vision is still to have the headquarters office of the VCE in the
Walter Reed National Military Medical Center (WRNMMC) in Bethesda,
alongside the Ophthalmology Clinics and the Refractive Surgery Center.
The VCE is developing the Defense and Veterans Eye Injury Registry
(DVEIR) to track occurrences and outcomes and it will be accessible to
all DoD and Department of Veterans Affairs (VA) polytrauma centers such
as Brooke Army Medical Center, Madigan Army Medical Center, and Balboa
Naval Medical Centers.
To establish the VCE headquarters, it will cost approximately $4.0
millionth renovate existing spaces at WRNMMC and relocate existing
tenants. An additional $0.3 million in initial operations and
maintenance costs will be required to purchase equipment and furniture.
The DoD analyzed and reviewed necessary requirements and identified
$3 million in funding that was available at the beginning of FY 2009 to
commence initial operating activities. Since their selection in
November 2008, Colonel Donald Gagliano, Executive Director, and Dr.
Claude Cowan, Deputy Director, have made significant progress in
strategic and operational planning and identified primary resource
requirements. The funding for FY 2009 will be used for personnel,
temporary duty (TDY) travel, and equipment.
The VCE is taking steps to ensure members of the Armed Services and
veterans who are visually impaired receive appropriate vision
rehabilitation quickly and effectively.
Question 1(a): What are the estimated IT costs for FY 2009 and FY
2010?
A portion of the $3 million allocated for the VCE in FY 2009 will
be used for DVEIR requirements. The VA allocated $2 million in FY 2009
for the implementation of the DVEIR, including IT support and hardware.
The $6.8 million requested for the VCE in the Defense Health Program
(DHP) FY 2010 budget includes funding for the VCE IT initiatives.
Question 1(b): What are the estimated costs to renovate office
space?
Response: DoD has determined that space at the present NNMC can be
renovated to house the VCE, such that it can be collocated with the
WRNMMC. This location allows for collaboration and synergies with the
vision care providers and patients in the National Capital Region and
will allow the VCE to best meet its congressional mandate by being in
close proximity to the new National Intrepid Center of Excellence for
Traumatic Brain Injury, the National Eye Institute of the National
Institutes of Health (NIH), the Uniformed Services University, and the
National Military Advanced Training Center, a facility for the
reintegration and rehabilitation of injured servicemembers. The current
estimate is $4.0 million in military construction the first fiscal year
and $0.3 million in operations and maintenance the next fiscal year to
outfit the facility.
Question 1(c): What are the cost projections for the Center in FY
2009, FY 2010 and FY 2011?
Response: The DoD identified $3 million in funding during FY 2009
to provide for the VCE's initial operating activities, specifically for
personnel, DVEIR support, operational costs, TDY travel, supplies and
services necessary for administration and support.
The DoD requested $6.8 million in FY 2010 for the VCE in the DHP
budget request, specifically, full-time equivalents to carry out
initiatives and support each directorate in the areas of Research and
Surveillance, Rehabilitation and Restoration, Informatics and
Information Management (the DVEIR), Clinical Care and Global Outreach,
and to support the Chief of Staff in operational development and
program management activities; maintenance and support for the DVEIR;
TDY travel to participate in conferences and perform outreach; and
other operational requirements.
Question 2: Please provide the numbers of servicemembers with
traumatic brain injury (TBI) visual impairments that the Department of
Defense is tracking? Currently, how is data being collected so research
or can clinical outcomes be tracked?
Response: The Vision Center of Excellence (VCE) is developing the
congressionally mandated Defense and Veterans Eye Injury Registry
(DVEIR) to assist in research and data collection to provide accurate
statistics. The DVEIR is a critical component of the VCE's plan to meet
the needs of our wounded warriors. At this time, there is no
standardized way to track information on our servicemembers who have
visual impairments and TBI.
The DVEIR is an ongoing project planned under the authority of the
VCE Executive Director, Colonel Don Gagliano. The DVEIR will support
care coordination for servicemembers and veterans with significant eye
injuries and visual dysfunction from TBI and provide statistics
necessary to measure longitudinal outcomes. The specific requirements
for an interoperable eye injury registry are currently under active
development. Once complete, the DVEIR will contain statistics for
members of the Armed Forces who incurred an eye injury while serving on
active duty on or after September 11, 2001.
Question 3: How much of the $3 million that was obligated from the
Department of Defense (DoD) to the Vision Center of Excellence (VCE)
has been used?
Response: The DoD analyzed and reviewed the necessary requirements
and identified $3 million in funding that was available at the
beginning of Fiscal Year (FY) 2009 to commence initial operating
activities. VCE leadership has identified primary resource
requirements, including personnel, Defense and Veterans Eye Injury
Registry, temporary duty travel expenses, equipment, and operational
support to appropriately obligate the funding available. Twenty
thousand dollars has been obligated to date; however, the VCE is
expediting the expenditure of the remaining funds as the resource
requirements are now clearly defined. We expect to obligate most of the
remaining funds by the third quarter of FY 2009.
Question 4: Will additional funding be requested in the President's
Fiscal Year (FY) 2010 budget request for the Department of Defense
(DoD) to support the Vision Center of Excellence?
Response: A budget was proposed for FY 2010 through FY 2015 for
Vision Center of Excellence (VCE) requirements that included projected
costs of VCE personnel, necessary office space and professional
equipment, temporary duty travel expenses, Defense and Veterans Eye
Injury Registry support, and other operational expenses. The proposal
was reviewed by the Wounded, Ill, and Injured Senior Oversight
Committee Staff Office and approved by the DoD's senior level review
and governance body, the Deputy's Advisory Working Group.
Question 5: The Department of Veterans Affairs (VA) has already
approved the Concept of Operations in January 2009. When will the
Department of Defense (DoD) approve the Concept of Operations? Please
provide to the Committee a timeline for execution of the Vision Center
of Excellence (VCE), with key milestones highlighted.
Response: The VCE has taken a leadership role in the development of
implementation strategies for the Congressionally mandated Defense and
Veterans Eye Injury Registry (DVEIR). The DVEIR will support the
coordination of care between the DoD and VA for servicemembers and
veterans with significant eye injuries and visual dysfunction traumatic
brain injury and provide the data necessary to accurately measure
longitudinal outcomes.
An ophthalmology, optometry, and information technology workgroup
from the VA and the DoD has been meeting since March 2008 and has
developed a Concept of Operations for the DVEIR. The Concept of
Operations examines development options and details a recommended
approach to implementing the DVEIR. Ongoing coordination efforts
between the VCE, DoD, VA, and other established trauma registries will
provide further guidance for the refinement of the Joint Concept of
Operations and the development and implementation of the DVEIR. The DoD
is hosting a meeting with VA in June for further development and
implementation of the Joint Concept of Operations and the DVEIR. The
DoD estimates the Joint Concept of Operations will be approved by the
fourth quarter of Fiscal Year (FY) 2009.
KEY MILESTONES
The DoD and VA established the Congressionally directed VCE in
recognition of the increased rate of ocular injuries and visual
impairment incurred during Operation Iraqi Freedom and Operation
Enduring Freedom conflicts. The VCE has made significant progress to
fulfill its mission of improving the health and quality of life for
members of the Armed Forces and veterans through advocacy and
leadership in the development of initiatives focused on the prevention,
diagnosis, mitigation, treatment and rehabilitation of disorders of the
visual system. Specifically:
Operations: The VCE directors are developing a plan to align
priorities with strategic objectives and establish the foundation of
the VCE. The strategic plan is an iterative process that will provide
the proper structure needed to fulfill the VCE's mission with maximum
efficiency and emphasize its importance. This comprehensive approach
will consider VCE requirements, National Defense Authorization Act
mandates, and industry best practices. Creation of the VCE strategy is
moving forward with the development of drafts of the VCE Charter and
the DoD Directive. The documents have been sent forward for approval.
These governance documents will identify the high-level roles of the
VCE and are required to ensure funding, manpower, and the future
development of the VCE.
As part of the strategic planning efforts, the VCE will finalize
position descriptions for the initial hiring actions for submission and
approval by the third quarter of FY 2009.
DVEIR: The DVEIR will provide data necessary to measure rates of
injuries and longitudinal outcomes. This will support the VCE efforts
to ensure the ongoing improvement in care and care processes and to
foster consistency across the entire continuum of care. As mentioned
before, the Joint DVEIR workgroup will finalize a joint strategy for
the DVEIR and Joint Concept of Operations by the fourth quarter of FY
2009. The DoD is hosting a meeting with the VA in June for further
development and implementation of the Joint Concept of Operations and
the DVEIR.
Research and Surveillance: VCE leadership established research
priorities for the Congressional Special Interest Vision Research
Programs and the Congressionally directed Medical Research Program
through collaboration with health professionals from the DoD, VA,
National Institutes of Health (NIH), Food and Drug Administration,
other Federal health entities, and the private sector. Grant funding
will be awarded based on those priorities. In June 2009, the VCE
Executive Director is hosting the Vision Research Scientific Steering
Committee meeting to finalize the Request for Proposal announcements
for the FY 2009 Congressional Special Interest Vision Research Program
grants. The VCE will continue to work with DoD, VA, and other external
entities to move research forward and assist those in need.
Outreach: VCE staff members interact with visually impaired
warriors and veterans to identify unaddressed needs and help close
those gaps. Colonel Don Gagliano and Dr. Cowan have visited wounded
warriors and veterans at Walter Reed National Military Medical Center
(WRNMMC) and other vision care centers and listened to their concerns
and experiences. VCE leadership has solicited input from other centers
of excellence, related Federal health agencies, multiple vision/
veterans advocacy organizations, and affected members of the Armed
Services and veterans for the VCE way ahead. VCE leadership has
participated in numerous meetings and conferences on visual impairment
for warriors, including the Defense Centers of Excellence Strategic
Planning Summit. The VCE Executive Director was appointed as the DoD ex
officio member of the NIH National Eye Advisory Council, which will
further expand the VCE's outreach efforts. Additionally, the VCE is
coordinating with the VA Blind Rehabilitation Service to establish a
Memorandum of Understanding.
Rehabilitation and Restoration: A process was developed for
collaboration between the VA and Walter Reed Army Medical Center for
blind rehabilitation care while servicemembers are still receiving care
from the DoD. Efforts are underway to establish this collaboration
across other vision centers to enhance the continuum of care and better
integrate seamless care across the DoD and VA for vision
rehabilitation.
Facilities: The VCE acquired short-term space near the TRICARE
Management Activity Headquarters in Falls Church, VA, to begin initial
operations and is working to secure funding for a long-term facility in
WRNMMC. The $4.052 million military construction (MILCON) project was
not finalized in time to be included in the FY 2010 medical MILCON
budget and will now be considered for the FY 2011 MILCON budget.