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10
Health and Exposure Data Infrastructure to Improve the Scientific Basis of Presumptions

INTRODUCTION

This chapter addresses the implementation of a system of data collection to support surveillance and research, as well as to track the exposures of individual military personnel. The long-term goal is a system that would improve or complete many of the evidence gaps that now lead to presumptions. Information on exposure is needed to conduct studies that will provide data for calculating attributable fractions and for determining exposure groups of particular individuals.

Once a causal relationship has been established or presumed between a specific disease and a type of exposure, it becomes crucial to establish whether the Service member was exposed during military service. When data are not sufficient to describe a specific Service member’s service-exposure history, presumptions are needed to give guidance about what to assume as exposure magnitude is considered. One clear path toward reducing the need for presumptions in decision making is to accurately document and provide Service member-specific exposure and health data to those making decisions regarding that Service member’s case. Thus individuals determined by an adequate exposure surveillance system not to be exposed to an agent of concern would not be at risk for the particular health outcome(s) caused by that specific exposure. The availability of exposure data would provide evidence to support a veteran’s claim that the exposure occurred while in military service. The availability of exposure data will allow more informative epidemiological studies to be performed and a more accurate determination of service-attributable fraction (SAF).



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10 Health and Exposure Data Infrastructure to Improve the Scientific Basis of Presumptions INTRODUCTION This chapter addresses the implementation of a system of data col- lection to support surveillance and research, as well as to track the expo- sures of individual military personnel. The long-term goal is a system that would improve or complete many of the evidence gaps that now lead to presumptions. Information on exposure is needed to conduct studies that will provide data for calculating attributable fractions and for determining exposure groups of particular individuals. Once a causal relationship has been established or presumed between a specific disease and a type of exposure, it becomes crucial to establish whether the Service member was exposed during military service. When data are not sufficient to describe a specific Service member’s service- exposure history, presumptions are needed to give guidance about what to assume as exposure magnitude is considered. One clear path toward reducing the need for presumptions in decision making is to accurately document and provide Service member-specific exposure and health data to those making decisions regarding that Service member’s case. Thus individuals determined by an adequate exposure surveillance system not to be exposed to an agent of concern would not be at risk for the particular health outcome(s) caused by that specific exposure. The availability of exposure data would provide evidence to support a veteran’s claim that the exposure occurred while in military service. The availability of exposure data will allow more informative epidemiological studies to be performed and a more accurate determination of service-attributable fraction (SAF). 

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 IMPROVING THE PRESUMPTIVE DISABILITY DECISION-MAKING PROCESS The need for having better exposure data has been recognized repeatedly in numerous external reviews of Department of Defense (DoD) and Depart- ment of Veterans Affairs (VA) activities regarding Service member health protection and veteran health care and disability determination (GAO, 1999, 2000a,b, 2005a,b, 2006; IOM, 1996a, 1999b, 2000c). Detailed health status data collected throughout a Service member’s active duty and veteran experience, coupled with individual exposure data collected during that period, would provide the data needed to make better decisions about an individual’s likelihood of service-related disease cau- sation and thus minimize the need for presumptions. As the Institute of Medicine (IOM) noted in 1996, The DoD, the branches of the armed services, and the DVA should con- tinue to work together to develop, fund, and staff medical information sys- tems that include a single, uniform, continuous, and retrievable electronic medical record for each [S]ervice member. The uniform record should include each relevant health item (including baseline personal risk factors, every inpatient and outpatient medical contact, and all health-related interventions), allow linkage to exposure and other data sets, and have the capability to incorporate relevant medical data from beyond DoD and DVA institutions (e.g., U.S. Public Health Service facilities, civilian medical providers, and other health-care institutions). . . . (IOM, 1996a, p. 10) DoD and VA have been working together since 1998 to improve shar- ing of medical information for active-duty military personnel and veterans. The agencies have developed a short-term plan to improve their existing health information systems and a long-term plan to create a modern health information system based on computable data. However, as GAO points out, DoD and VA lack a detailed project management plan to guide their efforts (GAO, 2007). In 1997, President Clinton issued a directive to DoD and VA “to create a new Force Health Protection Program. Every soldier, sailor, airman, and Marine will have a comprehensive, life-long medical record of all illnesses and injuries they suffer, the care and inoculations they receive, and their exposure to different hazards. These records will help us prevent illness and identify and cure those that occur” (DoD, 2006a, p. 2). Also in 1997, coincident with the presidential directive described above, DoD issued an instruction describing the “Implementation and Application of Joint Medical Surveillance for Deployments.” This document defined initial expectations for more detailed medical surveillance and exposure assessment data collection systems for both deployment and in-garrison or nondeployment settings. This plan laid the groundwork for systems that would “eventually be capable of linking deployment and nondeployment

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 HEALTH AND EXPOSURE DATA INFRASTRUCTURE environmental and occupational exposure and data to health hazard and/or health risk assessments to individual medical records and medical outcome databases” (DoD, 1997, p. 5). The vision for a more comprehensive and continuous surveillance sys- tem was articulated in DoD Directive 6490.2 issued in 2004. It proposed that Health surveillance systems shall be continuously in effect throughout each [Service member]’s career, capturing data about individual health status; instances of disease and injury; medical interventions such as immuniza- tions, treatments, and preventive medications; and exposures to potential and actual health hazards associated with occupation, deployment, and lifestyle. (DoD, 2004, p. 3) It also dictated policy that “[s]urveillance data collected on individual [Service member]s during their careers shall be provided to VA upon their separation or retirement from the military” (DoD, 2004, p. 4). Defining and developing the mechanisms and systems to implement these goals has been an iterative process that has taken years—largely due to the magnitude and complexity of the issues being addressed. Those efforts are now bringing action as a series of systems and expectations are being implemented. DoD Instruction 6490.03 of 2006, which replaced the 1997 DoD Instruction 6490.3, sets clear expectations that deployment exposure assessment and monitoring data be submitted to individual health records and to a DoD-wide database (DOEHRS—the Defense Occupational and Environmental Health Readiness System) (DoD, 2006c, p. 21). The remainder of this chapter reviews the current state and future plans for DoD and VA collection and use of health and exposure data throughout a Service member’s span of service. The availability of such data would enable studies to better understand potential linkages between service- connected exposures and future health status and would reduce reliance on presumptions in decision making. DOD HEALTH AND EXPOSURE ASSESSMENT DATA COLLECTION DoD Health Assessment and Medical Surveillance Overview Opportunities for health assessments of Service members on active duty occur at obvious service milestones throughout the Service member’s span of service. These milestones include the initial medical evaluation at acces- sion, or entry into the service, and subsequent periodic health assessments

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0 IMPROVING THE PRESUMPTIVE DISABILITY DECISION-MAKING PROCESS that continue until separation or retirement from the service. These mile- stones are displayed in Figure 10-1. Additional surveillance may precede or follow specific deployments with assessments tailored to the particular hazards of a deployment. Routine Health Assessments Throughout the Span of Service Elements of the health data collected for each of the assessments per- formed over the span of a Service member’s service are found in Table 10-1. They may include responses to a health history questionnaire, physical examination findings, and laboratory test results. The degree of detail and areas of emphasis in each assessment vary based on the specific point in the span of service or on the purpose of each individual assessment. Generally, a self-completed questionnaire contains a core set of questions regarding physical and mental health, and history of environmental and occupational exposures and stressors. This is intended to follow the recommendations of the U.S. Preventive Health Services Task Force’s Guide to Clinical Preven- tive Services (AHRQ, 2006). Data are collected in a combination of written and electronic formats. All new recruits and enlisted Service members undergo an initial evalu- ation at the time of accession. This is the most comprehensive of the assess- ments and provides the baseline set of data that is updated at the time of each future assessment. As in all assessments, the nature of the responses and test results partly determine what additional evaluation or screening is performed. At this time, data from this evaluation are generally saved only in a hard copy format. The Health Assessment Review Tool (HART) is an electronic and standardized implementation of the self-reporting question- naire that is currently being pilot tested at Ft. Jackson (Army) and San Diego (United States Marine Corps); the HART-A (the accession version) is expected to be more generally available in the next few months (Personal communication, Col. K. Cox and C. Postlewaite, Department of Defense, November 1, 2006). The periodic health assessments (PHAs) are episodic (generally annual) follow-up evaluations primarily employing self-completed questionnaires. Positive responses on this questionnaire, or additions to previously col- lected information, trigger a more detailed assessment. In following the U.S. Preventive Health Services Task Force recommendations, the PHAs are ideally targeted based on gender, age, disease risk factors, medical history, and exposure history (DoD, 2006d). The PHA is currently being instituted by the Army, but it has been established in the Navy and Air Force for several years. The separation, retirement, or deactivation assessment is the final rou- tine evaluation that all Service members undergo. Whereas previously a

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Annual Periodic Health Assessments (PHA) Health Pre-deployment Post-deployment Post-deployment Separation/ Initial medical assessment health health health retirement health evaluation before entering assessment assessment reassessment assessment ser vice Medical Surveillance Data Deployment Tr aining Separation/ Accession retirement Pre- Post- deployment deployment Daily location tracking and exposure monitoring (occupational and environmental) Exposure data from Exposure Data Occupational and post-deployment health Environmental Health assessment and Site Assessment reassessment Routine industrial hygiene and environmental exposure assessments by operation and/or job/task Service FIGURE 10-1 Timeline for medical surveillance and exposure data collection. 1 Landscape view FIGURE 10-1 reduced to final size to show type size in book

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TABLE 10-1 Timeline for Medical Surveillance and Exposure Data Collection  In Service After Training Post- Before Throughout Pre- Post- Deployment Separation/ Accession Service Service Deployment Deployment Deployment Reassessment Retirement Routine Medical Surveillance Dataa Self-Administered Questionnaire Family history of chronic X X diseases Personal habits X Past medical history X Medications X X X X Allergies X General health status X X X X Significant events since last X X periodic health assessment On a profile, light duty, or X undergoing a medical board Medical or dental problems X X Pregnancy X Counseling or care for mental X health in past year Questions or concerns about X health Health changes during X X deployment In sick call during deployment X X Nights spent as a patient in a X X X hospital during deployment Vaccinations X

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Health changes during X X deployment In sick call during deployment X X Nights spent as a patient in a X X X hospital during deployment Vaccinations X Symptoms now or developed X X anytime during this deploymentb See anyone wounded, killed, or X dead during this deployment Engaged in direct combat X where discharged weapon During deployment, feel like in X great danger of being killed Interested in receiving help for X X X a stress, emotional, alcohol, or family problem Little interest or pleasure in X X doing things Feeling down, depressed, or X X hopeless Thoughts that you would be X better off dead or hurting yourself in some way Nightmares due to an X X experience so frightening, horrible, or upsetting Constantly on guard, watchful, X X or easily startled Numb or detached from X X others, activities, or your surroundings  continued

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TABLE 10-1 Continued  In Service After Training Post- Before Throughout Pre- Post- Deployment Separation/ Accession Service Service Deployment Deployment Deployment Reassessment Retirement Self-Administered Questionnaire (continued) Concerns of serious conflicts X X with spouse, family members, or close friends Concerns of hurting or lose X control with someone Having problems if wounded, X injured, or assaulted during deployment Alcohol use X Difficulty working, taking care X X of things at home, or getting along with other people Illnesses or injuries that caused X you to miss duty for longer than 3 days Treated by a healthcare X provider, admitted to a hospital, or had surgery Injuries or illnesses while on X active duty for which you did not seek medical care Other questions or concerns X about your health Intend to seek Department of X Veterans Affairs disability

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active duty for which you did not seek medical care Other questions or concerns X about your health Intend to seek Department of X Veterans Affairs disability Laboratory Tests Urinalysis (albumin, sugar, X X X HCG) H/H X X X Blood type X X X Drugs and alcohol X X X Serum sample X X X X HIV testing X X CBC X Hemoglobin X Hematocrit X Vaccination status X Clinical Screening and Measurements Height X X X Weight X X X Temperature X X X Pulse X X X Blood pressure X X X Distant vision, near vision X X X Refraction by autorefraction or X X X manifest Heterophoria X X X Color vision X X X Depth perception, field of X X X vision, night vision  continued

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TABLE 10-1 Continued 6 In Service After Training Post- Before Throughout Pre- Post- Deployment Separation/ Accession Service Service Deployment Deployment Deployment Reassessment Retirement Clinical Screening and Measurements (continued) Intraocular tension X X X Audiometer X X X Pap smear X X X Allergies X Tobacco use X Alcohol abuse and stress X management Chronic illnesses X Medications X Cholesterol X Breast exam, mammogram X Fecal occult blood X Sigmoid X Colonscopy X Immunizations X Clinical Evaluations Head, face, neck, and scalp X X X Nose, sinuses X X X Mouth and throat X X X Heart X X X Lungs and chest, vascular X X X system Anus and rectum X X X

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Nose, sinuses X X X Mouth and throat X X X Heart X X X Lungs and chest, vascular X X X system Anus and rectum X X X Abdomen and viscera X X X External genitalia X X X Upper and lower extremities X X X Spine, musculoskeletal system X X X Body marks, scars, tattoos X X X Skin X X X Neurologic and psychiatric X X X disorders Pelvis X X X Endocrine system X X X Routine Exposure Dataa Industrial Hygiene Exposure X Assessment of Operations, Jobs/Tasks Qualitative Exposure X Judgments Occupational Exposure X Monitoring Routine Environmental Health X Programs  continued

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 HEALTH AND EXPOSURE DATA INFRASTRUCTURE 4. Develop DoD policy to ensure that classification/declassification (secrecy) issues are managed appropriately for both DoD and the veteran. There are clearly times when national security or mission success depends on maintaining secrecy regarding certain aspects of a Service member’s military experience. However, every effort should be made to find mechanisms for characterizing Service member exposure and health histories in manners that do not interfere with the broader issues of national security or mission success. DoD should develop procedures that ensure full or partial declassification of sensitive information for the timely provision of that Service member’s or veteran’s health care. When such declassification is not possible, DoD should establish procedures whereby blinded data relevant to the Service member’s health and exposure history are provided. In some instances where national security and secrecy issues cannot be resolved, DoD and VA may need to establish mechanisms involving experts with appropriate security clearances to monitor affected registry cohorts for potential health outcomes and define surveillance or research activities that may need to be conducted within appropriate secrecy clearances. An interagency agreement could be developed between DoD and VA address- ing the secrecy issue. Since both agencies have used the classification system in the past this agreement would address the policy development process and the exchange of classified information between the two agencies. The process would include establishment of a joint DoD-VA board comprised of individuals who have sufficient security clearance to discuss classified data. The access to classified information process would be contained in a written document outlining a mechanism to identify, monitor, track, and medically treat individuals who were part of research activities involving human sub- jects and whose research design and results have been classified. Recommendation: Establish registries of Service members and veterans based on exposure, deployment, and disease histories. Recommendation: DoD and VA should establish and implement mechanisms to identify, monitor, track, and medically treat individuals involved in research and other activities that have been classified and are secret. 5. Strengthen the assessment of psychological stressors and symptoms. Psychological and combat-related stressors may detrimentally impact the long-term mental and emotional well-being of military personnel and should be thoroughly assessed at key points during the military career of men and women. Currently, basic clinical evaluations for neurological and psychiatric disorders are made at accession, after training, and throughout

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 IMPROVING THE PRESUMPTIVE DISABILITY DECISION-MAKING PROCESS the service career. Very brief structured assessments for some psychiatric symptoms occur during the post-deployment periods only. Assessment of exposure to combat and of psychological stress during deployment is a particularly challenging element of the Committee’s pro- posed approach to tracking factors influencing the health of veterans. Scales have been developed to assess exposures during combat and the validity and reliability of these instruments has been assessed (Friedman et al., 1986; Janes et al., 1991; Keane et al., 1989; Laufer et al., 1984; Lund et al., 1984; Wessely et al., 2003). These instruments have been used in investigations of Vietnam veterans (Buydens-Branch et al., 1990; Frueh et al., 2005; Green et al., 1989; Yehuda et al., 1992) and more recently for personnel deployed in Iraq and Afghanistan (Hoge et al., 2004). A 2004 study carried out by military investigators addressed mental health problems and combat duty in personnel deployed to Iraq and Afghanistan (Hoge et al., 2004). This study demonstrates the feasibility of investigations directed at troops in relation to combat deployment. A follow-up study of Vietnam veterans, the National Vietnam Veterans Readjustment Study, incorporated an exposure measure based on military records (Dohrenwend et al., 2006). Onset of posttraumatic stress disorder (PTSD) was associated with combat exposure, with evidence for a positive close-response relationship. These studies show that combat exposure and related stress can be measured. They also show the feasibility of informative research on neuro- psychiatric disorders among veterans. Further development will be needed to achieve the type of surveillance proposed by the Committee. Psychiatric disorders, particularly PTSD, depression, and alcohol abuse and dependence are common. More data systematically collected using validated and structured instruments pre- and post-deployment will aid DoD and the VA to better identify stressors that may predispose individuals to develop these disorders, identify Service members to whom early inter- vention should be provided, and track individuals exposed to emotional trauma and with psychiatric symptoms in specialized registries. A number of brief validated instruments are available for PTSD, major depression, and alcohol abuse and dependence—three common psychiatric disorders experienced by veterans. A dedicated, face-to-face interview by an experienced clinician, recognized to be the most valid method of assessing PTSD, is likely not feasible in the post-deployment or separation/retirement medical evaluations. While a host of instruments are available for assessing PTSD, realistically the only feasible instruments that might be useful in this context would be one of several available screening questionnaires. These include (1) the 4-question Primary Care PTSD Screen (Prins et al., 2003), (2) a 7-question scale keyed to the DSM-IV criteria for PTSD (Breslau et al., 1999), (3) the 17-question PTSD Symptom Scale Self-Report (Coffey et al., 1998), (4) the Screen for Posttraumatic Stress Symptoms (Carlson, 2001),

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 HEALTH AND EXPOSURE DATA INFRASTRUCTURE and (5) the PTSD subscale of the large Psychiatric Diagnostic Screening Questionnaire (Zimmerman and Mattia, 2001). Only the first of these, the Primary Care PTSD Screen, has been validated on combat veterans. Also, while these screening instruments may be useful in identifying veterans who may have PTSD, they are not adequate for diagnosing PTSD. There are also a host of screening instruments for major depression including the 2 item Prime-MD, the 9 item Patient Health Questionnaire, and the 20 item Centers for Epidemiological Studies Depression (CES-D) scale, among others. Alcohol abuse and dependence can be screened with a number of instruments including the RAPS-QF, the AUDIT, and the CAGE, among others. These instruments vary in length and sensitivity and specific- ity in different populations. Studies that employ these screening instruments for prospective research will need to account for some degree of misclassification of the health out- come. In spite of these shortcomings, data from a screening instrument on an unselected population of veterans obtained in a systematic manner would be very valuable for the type of prospective studies envisioned in this report to better understand service-related morbidity. 6. Establish registries of Service members and veterans based on exposure, deployment, and disease histories. The Committee recommends that VA and Congress consider the initia- tion and prospective follow-up of specific veteran populations who may share a common exposure history as a viable surveillance tool. Creating a registry that may include initial demographic, exposure, and health infor- mation is a reasonable interim response to veterans with unexplained or underexplained health complaints that are temporally but not scientifically related to military service. A registry would allow the formation of a pool of veterans who are linked by some shared attribute of military service, such as combat cam- paign, theater location, or catastrophic event (e.g., Khamisiyah, Iraq), to be identified and actively followed forward through regular follow-up contacts from the registry staff. Trends in health of the registrants could be followed forward, and communication with registrants about new health information or treatment recommendations could be facilitated. As well, the registrants could be invited to participate in scientific studies to elucidate the cause or proposed mechanism of health harm they may have experienced. Such a model is being used to follow the World Trade Center responders, workers, and neighborhood population. This model differs somewhat from existing VA registries (e.g., Gulf War or Agent Orange) in that these tend to be cross- sectional assessments, with little regular follow-up or interaction with staff. Although registry costs can be high, so are the costs of presumptions. Enrollment in a registry may offer the veteran access to some of the medi-

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0 IMPROVING THE PRESUMPTIVE DISABILITY DECISION-MAKING PROCESS cal services a presumption provides, but under a different mechanism that could allow time for the clinical and epidemiologic evidence to accumulate so as to make a more evidence-based decision about a presumption. Recommendation: Develop a plan for an overall integrated surveillance strategy for the health of Service members and veterans. It is critical that DoD and VA work together to define a common strat- egy for integrated health surveillance of Service members and veterans. Fully leveraging the Service member-veteran exposure and health data is critical to the full understanding of disease etiology and causation, the establishment of relative risk, the adjudication of disability claims, and the treatment of disease. It is also critical to appropriate deliberations regarding presumptions in disability decision making. The need for surveillance can be identified at any point in a Service member’s or veteran’s experience history. Surveillance studies begun dur- ing a Service member’s service career may need to extend into his or her post-service experience. Data needs for the specific surveillance activity may have been generated during either the Service member experience or the veteran experience or both. Therefore this activity must be jointly well managed by DoD and VA. A strong central organization, staffed jointly by DoD and VA with external expert advisors, should be given responsibility for the ongoing evaluation of health and exposure data quality, the regular review of registry and surveillance activities, the definition of surveillance and research strategies, and the coordination of surveillance and research projects. This joint DoD-VA Service member and veteran exposure and health surveillance organization would have broad responsibility for over- sight of all DoD and VA surveillance and research activities whether they are conducted internally or externally by those organizations. Recommendation: Improve the data linkage between the electronic health record data systems used by DoD and VA—including capabili- ties for handling individual Service member exposure information that is included as part of the individual’s health record. Although there are efforts underway to electronically transfer Service member health records from DoD to VA, these efforts are moving slowly and the timeline for completion of a seamless interface is unclear. DoD and VA should increase attention to this effort with a clear integration plan, timetable for implementation, metrics for tracking implementation prog- ress, and annual reporting of metric results. To date there has been little discussion regarding electronic transfer of Service members’ exposure information in their health records to VA. As the

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1 HEALTH AND EXPOSURE DATA INFRASTRUCTURE inclusion of exposure data in employee health records is a key DoD strategy for ensuring that exposure information is available for individual Service members, this appears to be a major weakness in the system. DoD and VA should explicitly include the integration of these individual exposure data into the health record transfer integration plan, implementation timetable, metrics, and annual reporting. Reports on progress of these plans should be included in the annual report to Congress on DOEHRS progress. Recommendation: Ensure implementation of the DoD strategy for improved exposure assessment and exposure data collection. The DOEHRS program is a major undertaking that has potential for dramatically increasing the availability of exposure data. However, DoD has many important priorities, and short-term funding pressures have the potential to delay implementation activities. Because of the importance of these efforts, not only to DoD but to VA as well, we recommend that additional steps be taken to ensure that DOEHRS is fully implemented as planned. In addition, because of the importance of adequately trained indi- viduals to the success of DOEHRS, we further recommend that these steps specifically include detail on the training of individuals needed to make the accurate professional judgments and generate appropriate exposure data critical to DOEHRS. These additional steps are as follows: 1. Include a specific DoD budget line item for DOEHRS that includes funding for system development and enhancement, system implementation, and training of personnel. 2. Develop clear metrics for tracking the effective deployment and uti- lization of DOEHRS throughout DoD. 3. Require an annual status report to Congress on DOEHRS develop- ment and implementation progress and related training activities. Recommendation: Develop a data interface that allows VA to access the electronic exposure data systems used by DoD. DoD is investing heavily in DOEHRS and other improved exposure data systems that are standardized across the various armed services. In the Committee’s interviews with people responsible for development and deployment of these systems, we did not encounter anyone with knowledge of activities by DoD or VA to develop a VA interface with these systems that will allow use of the Service member-specific and longitudinal exposure data by VA. VA should move quickly to develop plans for interfaces to these new DoD exposure data systems. This should not require massive new data

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 IMPROVING THE PRESUMPTIVE DISABILITY DECISION-MAKING PROCESS systems within VA but instead consist of appropriate interfaces and views to the data within DoD systems that are accessible by VA. The first step would be a VA team embedded within the DoD implementation team at the Army’s Center for Health Promotion and Preventive Medicine where the VA team can examine the system capabilities and data structures so that appro- priate interfaces can be defined and developed to meet the needs of VA. Recommendation: Consider interim interventions for affected veterans while data are collected or more thoroughly analyzed to resolve scien- tific uncertainty. It can take significant time to collect and analyze data needed to ade- quately resolve scientific uncertainty in establishing causal relationships between exposure and disease. VA should consider interim interventions in instances where veterans are severely affected during the time it takes to conduct the needed research. These measures might consist of provisional health care for affected veterans during the interim period. REFERENCES AHRQ (Agency for Healthcare Research and Quality). 2006. Guide to clinical preventive services. Recommendations of the U.S. Preventive Services Task Force. AHRQ Publica- tion No. 06-0588. Rockville, MD: AHRQ. ASTM (American Society for Testing and Materials). 2003. Standard guide for environmental health site assessment process for military deployments. Designation E 1-0. West Conshohocken, PA: ASTM International. ATSDR (Agency for Toxic Substances and Disease Registry). 2003. What Is the National Exposure Registry (NER)? http://www.atsdr.cdc.gov/NER/index.html (accessed April 6, 2007). Breslau, N., E. L. Peterson, R. C. Kessler, L. R. Schultz. 1999. Short screening scale for DSM- IV posttraumatic stress disorder. American Journal of Psychiatry 156(6):908-911. Buydens-Branch, N. D., and M. Branchey. 1990. Duration and intensity of combat exposure and posttraumatic stress disorder in Vietnam veterans. Journal of Nervous and Mental Disease 178:582-587. Carlson, E. B. 2001. Psychometric study of a brief screen for PTSD: Assessing the impact of multiple traumatic events. Assessment 8(4):431-441. CDC VES (Centers for Disease Control and Prevention Vietnam Experience Study). 1989. Health status of Vietnam veterans. Synopsis. Vol. 1. Atlanta, GA: Centers for Disease Control. http://www.cdc.gov/nceh/veterans/default1c.htm (accessed April 9, 2007). Coffey, S. F., B. S. Dansky, S. A. Falsetti, M. E. Saladin, K. T. Brady. 1998. Screening for PTSD in a substance abuse sample: Psychometric properties of a modified version of the PTSD Symptom Scale Self-Report. Posttraumatic stress disorder. Journal of Traumatic Stress 11(2):393-399. Cohen, B. M., and M. Z. Cooper. 1954. A follow-up study of World War II prisoners of war. VA Medical Monograph. Washington, DC: U.S. Government Printing Office.

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