[Senate Hearing 118-247]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 118-247

                 FOUNDATION OF CARE: EXAMINING RESEARCH
                 AT THE DEPARTMENT OF VETERANS AFFAIRS

=======================================================================

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                    ONE HUNDRED EIGHTEENTH CONGRESS

                             FIRST SESSION

                               __________

                            NOVEMBER 1, 2023

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
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        Available via the World Wide Web: http://www.govinfo.gov
        
                               __________

                   U.S. GOVERNMENT PUBLISHING OFFICE                    
55-025 PDF                  WASHINGTON : 2024                    
          
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                 SENATE COMMITTEE ON VETERANS' AFFAIRS

                     Jon Tester, Montana, Chairman
Patty Murray, Washington             Jerry Moran, Kansas, Ranking 
Bernard Sanders, Vermont                 Member
Sherrod Brown, Ohio                  John Boozman, Arkansas
Richard Blumenthal, Connecticut      Bill Cassidy, Louisiana
Mazie K. Hirono, Hawaii              Mike Rounds, South Dakota
Joe Manchin III, West Virginia       Thom Tillis, North Carolina
Kyrsten Sinema, Arizona              Dan Sullivan, Alaska
Margaret Wood Hassan, New Hampshire  Marsha Blackburn, Tennessee
Angus S. King, Jr., Maine            Kevin Cramer, North Dakota
                                     Tommy Tuberville, Alabama
                      Tony McClain, Staff Director
               David Shearman, Republican Staff Director
                            
                            
                            C O N T E N T S

                              ----------                              

                            November 1, 2023

                                SENATORS

                                                                   Page
Hon. Jon Tester, Chairman, U.S. Senator from Montana.............     1
Hon. Angus S. King, Jr., U.S. Senator from Maine.................     7
Hon. Joe Manchin III, U.S. Senator from West Virginia............     9
Hon. Bill Cassidy, U.S. Senator from Louisiana...................    12
Hon. Mazie K. Hirono, U.S. Senator from Hawaii...................    14
Hon. Marsha Blackburn, U.S. Senator from Tennessee...............    17
Hon. Richard Blumenthal, U.S. Senator from Connecticut...........    19

                               WITNESSES

Rachel Ramoni, DMD, ScD, Chief Research and Development Officer, 
  Office of Research and Development, Department of Veterans 
  Affairs; accompanied by Patricia Hastings, DO, MPH, FACEP, RN, 
  Chief Consultant, Health Outcomes Military Exposures; and 
  Sumitra Muralidhar, PhD, Director, Million Veteran Program.....     2

Matthew J. Kuntz, JD, MHA, Executive Director, National Alliance 
  on Mental Illness for Montana..................................     4

                                APPENDIX
                          Prepared Statements

Rachel Ramoni, DMD, ScD, Chief Research and Development Officer, 
  Office of Research and Development, Department of Veterans 
  Affairs........................................................    25

Matthew J. Kuntz, JD, MHA, Executive Director, National Alliance 
  on Mental Illness for Montana..................................    32

                        Questions for the Record

Department of Veterans Affairs response to questions discussed 
  during the hearing by:

  Hon. Mazie K. Hirono...........................................    45

Department of Veterans Affairs response to questions submitted 
  by:

  Hon. Marsha Blackburn..........................................    46
  Hon. John Boozman..............................................    48
  Hon. Margaret Wood Hassan......................................    50
  Hon. Mazie K. Hirono...........................................    50
  Hon. Angus S. King, Jr.........................................    52
  Hon. Joe Manchin III...........................................    59
  Hon. Kyrsten Sinema............................................    62
  Hon. Thom Tillis...............................................    65
  Hon. Tommy Tuberville..........................................    66

                       Statements for the Record

Hon. Kyrsten Sinema, U.S. Senator from Arizona...................    71

National Association of Veterans' Research and Education 
  Foundations (NAVREF)...........................................    72

NeuroFlow, Inc., Letter from Christopher Molaro, CEO and Chairman    75

Vietnam Veterans of America (VVA), Jack McManus, National 
  President......................................................    78

 
                          FOUNDATION OF CARE:
                       EXAMINING RESEARCH AT THE
                     DEPARTMENT OF VETERANS AFFAIRS

                              ----------                              


                      WEDNESDAY, NOVEMBER 1, 2023

                                       U.S. Senate,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 3:42 p.m., in 
Room SR-418, Russell Senate Office Building, Hon. Jon Tester, 
Chairman of the Committee, presiding.

    Present: Senators Tester, Brown, Blumenthal, Hirono, 
Manchin, Sinema, Hassan, King, Cassidy, Blackburn, and 
Tuberville.

            OPENING STATEMENT OF CHAIRMAN JON TESTER

    Chairman Tester. I'll call this hearing to order. Good 
afternoon everybody. This hearing is on research activities of 
the VA. While veteran oriented research is an integral part of 
veteran specific care, the product of VA's research clearly 
impacts each and every one of us. For decades, VA has been at 
the forefront of our Nation's research efforts. Because of 
their work, we have access to new and innovative cancer 
treatments, life-saving vaccines, the pacemaker, and others.
    VA remains in a unique position to spear breakthroughs in 
our medical and scientific knowledge, with access to data from 
the Nation's largest integrated healthcare system. We know 
countless lives depend on expanding our understanding of and 
treatment options for mental health conditions. That is why 
mental health treatment must always be a top priority of VA 
research. It has been three years since the passage of 
Commander John Scott Hannon, Veterans Mental Health Improvement 
Act, and just last year research provisions in the STRONG Act 
were signed into law.
    These legislative accomplishments have a direct impact on 
research projects and funding, including in my home State and 
Matt Kuntz's home State of Montana. And in that regard, I want 
to welcome Matt Kuntz, who is a friend of Scott Hannon, the 
person that the John Scott Hannon Veterans Mental Health Care 
Improvement Act was named after. Matt Kuntz is the head of NAMI 
Montana. He has incredible knowledge of what goes on the 
ground, both from a VA perspective and a civilian perspective. 
He's also on the National VA Research Advisory Committee. 
Thanks for being here, Matt.
    It's been over a year since we passed the Sergeant First 
Class Heath Robinson Honoring our PACT Act. This law sets up a 
framework to better understand the illness, treatments, and 
connections between military service and toxic exposures. Now, 
while the PACT Act outlines specific research requirements, it 
also creates an interagency toxic exposure research working 
group.
    This working group must guide future research efforts, such 
as the effect of toxic exposure on the descendants of veterans. 
Research must translate to real world improvements in veteran 
care. Veterans must have access to the newest and most current 
treatment options for conditions they're more likely to 
experience through clinical trials offered through VA.
    And the VA needs to do more to ensure that our rural 
veterans, like those in Montana, are not left behind. This also 
requires the VA to prioritize research as a whole, ensuring 
that clinician researchers get an ample opportunity to expand 
our medical and scientific knowledge. I look forward to hearing 
from everyone here on how to best accomplish this critical 
mission. And if you'll just help me pause for a second.
    [Pause.]
    Chairman Tester. Senator Moran is on his way. As you guys 
know, the reason I was late, and I think many of the others 
were late, is they were voting, and the ones that are here on 
time are voting now.
    Senator Tuberville. So we voted earlier.
    Senator Tester. It's exactly right. So I want to welcome 
our witnesses. We've got Dr. Rachel Ramoni. Doctor, good to 
have you here. You're the Chief Research and Development 
Officer for VA's Office of Research and Development. She is 
accompanied by Dr. Patricia Hastings. Patricia is the Chief 
Consultant of the Health Outcomes for Military Exposures Office 
and Sumitra Muralidhar. Sorry about that. I butchered it up 
pretty bad. She is the Program Director for the Million Veteran 
Project.
    As I mentioned in my opener, we're also joined by Matt 
Kuntz, who's the Executive Director of the National Alliance on 
Mental Illness for the Treasure State. Dr. Ramoni, you may 
begin. You have 5 minutes, and please know that your entire 
written testimony will be made a part of the record.

           STATEMENT OF RACHEL RAMONI ACCOMPANIED BY
            PATRICIA HASTINGS AND SUMITRA MURALIDHAR

    Dr. Ramoni. Thank you so much, and good afternoon, Chairman 
Tester. On behalf of my colleagues, Dr. Patricia Hastings and 
Dr. Sumitra Muralidhar, I want to express our gratitude for the 
opportunity to discuss how VA's research programs improve the 
health of those who served, and express my gratitude for the 
wind that you put in our sails through the Hannon Act, and 
through the STRONG Act, and through the PACT Act.
    VA's Office of Research and Development, which I am so 
privileged to lead, has the primary responsibility for managing 
the department's research appropriation and sets policy for 
department research activities. For nearly a century, VA has 
had a research program dedicated to enhancing the well-being of 
veterans through scientific discovery. We are embedded within 
the VA healthcare system, both operationally as well as 
culturally.
    As an intermural program that exclusively funds eligible VA 
employees qualified to do research, the science we support is 
firmly grounded in the experience of clinicians and researchers 
working directly with veterans in 104 of our 170 medical 
centers nationwide. It is truly, truly an extraordinary system 
in which to conduct biomedical research. Our greatest 
distinction and honor, of course, is our mission to serve 
veterans.
    Over 9 million former service members are enrolled in VA 
healthcare. Caring for these individuals and those who 
preceeded them has resulted in one of the richest healthcare 
data sets in the entire world. The VA informatics and computing 
infrastructure, also called Vinci, houses billions of records 
for over 25 million patients. Moreover, the Million Veteran 
Program Genomic Database is poised to achieve 1 million veteran 
contributors under Dr. Muralidhar's stewardship.
    When our data powerhouse is paired with skilled 
researchers, modern scientific computing and analytic tools, 
and now the potential of AI, the opportunities for veteran 
centric discovery are vast. The Office of Research and 
Development's capacity to do good extends well, well beyond 
data science. We support the full range of research approaches, 
from basic science to rehabilitation research.
    Today, VA researchers are fulfilling our mission through a 
range of impactful research, including shedding light on the 
impacts of military exposures, refining the diagnosis and 
treatment of brain and mental health conditions, and advancing 
precision cancer care.
    VA research also plays an essential role in interagency 
efforts. We are deeply involved in the Cancer Moonshot, 
including co-leadership of working groups on decentralized 
clinical trials, that bring trials to veterans wherever they 
live, data and data safeguards.
    In addition, as specified in the PACT Act, we have formed 
and are leading, as Chairman Tester mentioned, an interagency 
toxic exposures research working group under the Office of 
Science and Technology Policy. Every year, VA researchers make 
tremendous contributions to expanding our body of knowledge.
    In fiscal year 2022, for example, our scientists authored 
nearly 14,000 research articles. Their work fuels the 
continuous cycle of research, evidence-based policymaking, 
clinical care and evaluation, which steadily improves veterans 
care. In the realm of military environmental exposures, Dr. 
Hastings' health outcomes and military exposures team is also 
integral to the process of using scientific evidence to inform 
policy and healthcare.
    We thank you for your support with the PACT Act, which 
dramatically accelerated this work. The President's fiscal year 
'24 budget requests $938 million in appropriations for VA 
medical and prosthetic research to continue the investment in 
VA's capabilities as a national research enterprise sustaining 
your investments from prior years.
    Research flourishes in the context of steady funding rather 
than in a setting of fluctuations between increasing and 
decreasing investment. Our research is conducted by highly 
specialized teams that can take years for a medical center to 
assemble. With the exception of the clinician researchers who 
lead research teams, most of the staff who conduct this 
research are hired on term or temporary basis rather than by 
permanent appointments.
    This means that when funding contracts, those teams must be 
disbanded and their expertise is lost to the system. Your 
sustained investment is critical to ensuring that our vital 
research can continue as we address the physical, mental, and 
social needs of those who have borne the battle. We are so 
grateful for your enduring dedication and support.
    In conclusion, I want to reiterate that at the heart of VA 
research lies our unwavering commitment to our veterans. Every 
discovery, every innovation, every advancement is a tribute to 
their sacrifices and a step toward fulfilling our mission to 
improve veterans' lives. I look forward to answering your 
questions.

    [The prepared statement of Dr. Ramoni appears on page 25 of 
the Appendix.]

    Chairman Tester. Doctor, thank you for your testimony. Next 
we'll have Matt Kuntz from Montana. Matt, 5 minutes. Your 
entire statement will be part of the record.

                 STATEMENT OF MATTHEW J. KUNTZ

    Mr. Kuntz. Chairman Tester, Ranking Member Moran, and 
distinguished Members of the Senate Veterans Affairs Committee, 
on behalf of NAMI Montana, the National Alliance on Mental 
Illness for Montana, I would like to extend our gratitude for 
the opportunity to share with you our views and recommendations 
regarding veterans' healthcare research.
    The entire NAMI community applauds the Committee's 
dedication, addressing the critical issues around mental health 
and veterans' suicide. I also express gratitude for the 
Committee's rescue of the VA's Research Program in the Cleland-
Dole Act last year. Without the Committee's decisive action to 
prevent the bureaucratic conflict of interest implosion, VA 
research around the country would've shut down, and we would be 
having a much different hearing today.
    As NAMI Montana's executive director, I serve on the NRAC 
Commission and have also served on the COVER Commission. I'm 
not speaking on behalf of NRAC or the COVER Commission today. 
Based upon that background and experience, I believe it's time 
for Congress to step in and give ORD clear legislative 
purposes, and realign its granting process to improve veterans' 
healthcare outcomes.
    Specifically, I'm respectfully asking for two purposes and 
three funding categories, and I invite you to check my work. 
It's really easy to find the NRAC reports and ORD annual 
reports. It's about 60 pages annually a year. Some of the staff 
can read through 20 years in no time. And hopefully they'll see 
that I'm right.
    The VAs ORD's current purposes are muddled by a variety of 
missions, objectives, and priorities. This lack of focus makes 
it difficult to determine what outcomes VHA, VA, ORD or its 
congressional funders are looking for.
    So the purposes that I'm suggesting are, one, to serve 
veterans through large scale research and commercialization 
support in veteran specific healthcare areas such as toxic 
exposure, spinal cord injuries, prosthetics, and brain health, 
including mental health, suicide prevention, substance use 
disorders, and geriatric issues.
    Two, to support implementation research and quality 
improvement throughout the Veterans' Healthcare Administration. 
Those purposes require a prioritization that I believe is 
necessary, and it leads to three categories of funding.
    The first is large healthcare studies of veterans' issues, 
like the Million Veteran Program, the Hannon Initiative, and 
precision oncology. This is what VA research does best. We need 
to double down on these programs.
    The second one is new. It's commercialization matching 
grants. We need to help the VA research insights find 
commercial partners to bring them through the FDA process. 
Well-designed matching grants of VA search resources can 
further the transition to real world care, while keeping the 
funds inside the VA healthcare system. We need to explore this.
    And then finally, the third category, implementation and 
quality improvement grants. Making sure VA healthcare is 
scientifically adopting the best currently available methods 
and operations. These categories take the best of what the VA 
is currently doing and expands upon it.
    These categories feed into each other to create a true 
learning system within VA healthcare. These categories honor 
the value of intramural research without single-mindedly being 
shackled to it.
    In conclusion, ORD has taken clear steps to move to become 
an outcome-oriented organization, but it needs Congress to 
clarify its purpose, and strategic funding methodologies. Thank 
you again for the opportunity to testify in front of this 
honorable Committee. Your attention to this issue means a lot 
to NAMI Montana, and the people that we serve. We look forward 
to working with you in continuing to improve veterans' 
healthcare in the future. Thank you.

    [The prepared statement of Mr. Kuntz appears on page 32 of 
the Appendix.]

    Chairman Tester. Matt, we appreciate you being here. We 
appreciate your comments to this Committee. We'll do 5-minute 
rounds of questions. Dr. Ramoni, could you tell me what the 
VA's current research priorities are?
    Dr. Ramoni. Yes, sir. I can tell you what our current 
research priorities are. We have five strategic priorities. One 
is to increase veterans' access to high quality clinical 
trials. The second is to increase the substantial real-world 
impact of VA research. The third is to put VA data to work for 
veterans. The fourth is to proactively promote diversity, 
equity, and inclusion within our sphere of influence. And the 
fifth is to promote community using VA research. And that is 
community with our veterans, as well as other agencies, and 
internally to VA.
    Those are our strategic priorities. We also have priorities 
that are focused on health conditions. And those health 
conditions include military exposures and toxic exposures 
including Gulf War illness, precision oncology, mental health 
and suicide prevention, and pain and opioid use disorder.
    Chairman Tester. You heard when it comes to community which 
is one of your priorities, you heard Matt Kuntz talk about 
quality improvement grants and matching grants for 
commercialization. Two questions. Are there any available, 
number one, and number two, are they being utilized?
    Dr. Ramoni. So sir, to the first point regarding quality 
improvement and implementation grant I would first point out 
that there is a research appropriation and a clinical care 
appropriation. The research appropriation cannot itself be used 
for implementation, but this is why we work closely with 
clinical partners such as the oncology program office to 
collaboratively implement research findings into practice.
    We do have within our office a group called the Quality 
Enhancement Research initiative or QUERY that does have 
clinical dollars, and they work to implement evidence-based 
findings across VA. And in fact, our driving force in the 
Evidence Act within our entire organization. So those are a 
couple of the ways in which we promote implementation.
    On top of that, the funding though is also infrastructure 
that promotes implementation. So our prototype for this is the 
precision oncology program under the Lung Precision Oncology 
Program. We have over 100 sites across the country. And by 
interacting with these medical center by medical center, we 
find that we can more proactively implement. We don't just 
publish and hope people implement, but we work closely with 
them to implement.
    Chairman Tester. Let me come back to this in the second 
round, but I want to ask Matt Kuntz a question before my time 
runs out. And that is, how can we best improve access to 
research projects for veterans in Montana?
    Mr. Kuntz. Senator Tester, I think it's by doubling down on 
those big projects, Million Veteran Program. I got an email as 
a Montana veteran's last week asking me to sign up. We're not 
going to have all of the fancy research infrastructure that the 
VA wants or needs to come to our State. I've given up on that 
after a decade of trying.
    But I do believe that those big studies, like the Hannon 
Initiative, the Million Veteran Program, need to be able to be 
decentralized enough where you can demand that they be 
available to your veterans. That it is not the VA's choice 
whether or not to come to our State. It's just a matter of when 
and how.
    Chairman Tester. So I'm going to go back to--and I don't 
want to get a fight on the panel. You guys don't have to punch 
it out or nothing. But the truth is, when it comes to research 
as per mental health, as per the Hannon Act, rural America 
tends to rise to the top when it comes to suicides. Whether 
you're in Alaska or Montana or any other rural State, they tend 
to be higher there. Are you guys doing research in rural areas 
on that?
    Dr. Ramoni. So our ability Senator Tester, honestly, to do 
research in rural areas, in particular clinical trials, is 
limited by the absence of academic affiliates there. But we are 
working as previously mentioned, on decentralized approaches, 
including the regulatory changes necessary to facilitate 
outreach to those areas. In addition to leveraging teleclinical 
trials and our pharmacy unit.
    Chairman Tester. Thank you. I'll come back to this, but 
there's got to be a way. I mean, we've got internet, we've got 
broadband, we've got the university system in Montana that's 
pretty damn good that has everything from PA to nurse programs 
that are pretty doggone good.
    I think it's a big mistake to say you guys don't have the 
big university. We don't have the, you know, we don't have the 
Ivy League schools and all that stuff when, especially when it 
comes to mental health, rural America's afflicted by it more. I 
believe more than anywhere else on a per capita basis. Senator 
King.

                   SENATOR ANGUS S. KING, JR.

    Senator King. I just want to follow up on that, Senator. I 
think it's very important because, you may well have different 
typologies and different pathologies in rural areas than you 
have in urban areas, and if the standard is a major research 
university, you're going to be missing a lot of the issues.
    So I would agree. There's a university in Montana that's, I 
think you said pretty damn good. There's also one in, in the 
State of Maine that's pretty damn good. And we also have some 
important research institutions in Maine, the Jackson 
Laboratory, Maine Medical Center.
    So the point is, I hope you'll rethink where these clinical 
trials take place, because if you're not doing them in rural 
areas, you may be missing some important information that could 
be informative because that's where a lot of veterans are.
    Dr. Ramoni. Yes, Mr. King, I absolutely agree. I want to 
bring these trials to where the veterans are. Nothing gladdens 
my heart like when we learn that our research has saved a life. 
It is going to take some extra work, and I think it's 
worthwhile work.
    And as I was talking to my colleague here, Dr. Muralidhar, 
I come here to learn. And what I'm hearing today is that we 
need to do better at getting clinical trials into our rural 
areas. And we'll have to do that by working with the medical 
center directors in those areas.
    While I oversee the research program here from Washington, 
DC, it is the medical center directors who can really work with 
us and help to foster the research in those areas. In addition 
to steps that we're taking to allow for remote trials and 
leveraging the broadband that Chairman Tester raised.
    Senator King. Terrific resources. Thank you for that. You 
may be the first person that ever came here to learn something.
    [Laughter.]
    Senator King. I appreciate that. Sorry, Mr. Chairman. We 
had a hearing several months ago on suicide prevention, and I 
talked to Dr. Miller. And it turns out that there are a number 
of sort of nonclinical factors affecting veteran suicide. One 
high on the list was financial insecurity, another was food 
insecurity.
    I hope that this can be a focus. That this isn't only about 
mental health problems, but about those nonclinical items, 
because we need to know what's causing this, and therefore we 
can hopefully start to deal with it. Will you pursue that 
issue?
    Dr. Ramoni. Yes, sir, on two fronts. One, I can get back to 
you with a list of what we are doing in that area. And then 
second we can certainly look to expand the work that we're 
doing. That takes a more holistic view. And I think it really 
is a strength of VA because we are, as a unified organization, 
we include benefits, and we include healthcare. So we perhaps 
are uniquely able not only to understand, but also to intervene 
on those factors. Whereas other healthcare systems are not.
    Senator King. You have a national scope. You have urban, 
rural. You have a tremendous opportunity. I should have begun 
with a mention. We've got VA researchers in Maine working on 17 
different projects from opioid use to workforce burnout. So I 
appreciate the work that you're sponsoring.
    Geriatric research, education, and clinical centers. It 
certainly makes sense as our veterans age that you're looking 
at those geriatric issues. My only concern here is to be sure 
that ORD and GRECC are also coordinating with NIH and other 
agencies, so that we're not duplicating. We're spending a lot 
of money here. And if NIH is leading an enormous effort on 
Alzheimer's, for example, let's not duplicate it. Let's work 
with them. Add your expertise, and knowledge, and database to 
what they're doing.
    Dr. Ramoni. Yes, you are really speaking to my heart there. 
We work extremely closely with the National Institute on Aging, 
and I think it serves as paradigm for how we should work with 
other institutes. At NIH, we meet at least twice yearly. Dr. 
Richard Hodes, who leads that institute and I are in regular 
communication. We collaborate----
    Senator King. Let's make it more than twice yearly.
    Dr. Ramoni. Yes.
    Senator King. Can you accelerate that a little bit?
    Dr. Ramoni. Yes. Well, yes. I'm one person and there are a 
lot of NIH institutes, so I'm going to have to open up my 
calendar. But yes, I would love to meet with them more 
regularly. We certainly have the senior program manager within 
our office who is the liaison, speaks with them much more 
regularly than that. But the two leadership teams come together 
twice yearly and we collaborate.
    They are, let me tell you, most interested in our 
capabilities at having a clinical research infrastructure to 
both conduct clinical trials and data----
    Senator King. And the nationwide database.
    Dr. Ramoni. Yes. And MVP is working very closely with a 
National Institute on Aging.
    Senator King. Now, Mr. Chairman, may I be indulged for an 
extra minute? If you learned of a disease that affected one out 
of four elderly veterans, an epidemic that caused significant 
harm, hospitalization costs, and often death, would you 
consider that worthy of research?
    Dr. Ramoni. Yes, sir.
    Senator King. What I'm referring to is falls.
    Dr. Ramoni. Yes.
    Senator King. And it is an epidemic among seniors in our 
country, and certainly among veterans. And my concern is that 
A, we don't know enough about it. And B, once we learn more 
that we learn how to prevent falls, it's a preventable 
epidemic, at least to some extent. And my frustration is that 
Medicare, for example, will pay for a hip replacement, but they 
won't pay for grab bars in your shower.
    So I hope that this is an area that GRECC can focus upon, 
because this is an epidemic just like any other disease because 
it's killing people. I hope you'll put some emphasis on that.
    Dr. Ramoni. Yes, sir. My own mother passed away following a 
fall. And a dear friend of mine lost her father following a 
fall. I think it is certainly worthy of study. And again, we 
will get back to you with the work we're currently doing, and 
then would love to have discussions about where we could do 
more.
    Senator King. And prevention is where we should be headed.
    Dr. Ramoni. Absolutely. Absolutely. Because once you've 
fallen----
    Senator King. It's too late.
    Dr. Ramoni. The damage is done.
    Senator King. That's right. Thank you, Mr. Chairman.
    Chairman Tester. The man from WVU Center Mansion.

                    SENATOR JOE MANCHIN III

    Senator Manchin. Thank you very much Mr. Chairman. It's 
pleasure to be with you as always. And so Dr. Ramoni, I'd like 
to focus on the VA's National Artificial Intelligence 
Institute. There's no reason that the VA shouldn't be the world 
leader in adopting AI into healthcare practices.
    If implemented properly, it could be revolutionary. Easing 
our staffing issues, monitoring our patient's safety, 
predicting diseases, mental illness, all the things that go 
with that, creating novel treatments, and thousands of other 
applications we know. So how is the work at the VA's AI 
Institute being prioritized by the VA? How far along are you?
    Dr. Ramoni. Yes, so thank you, Senator. We started up the 
National AI Institute a few years ago, not knowing that the 
generative AI revolution was just around the corner. But we are 
fortunate to have as our leader of that AI Institute, Gil 
Alterovitz, and a team of people around the country in 
different medical centers doing that work.
    Because we were able to lay that foundation, we have been 
able to participate in a number of national efforts, including 
in the most recent Executive order, ensuring that VA is on the 
map for AI. And to ensure that trustworthy AI principles----
    Senator Manchin. Have you all basically briefed Secretary 
McDonough and Deputy Secretary Bradsher?
    Dr. Ramoni. Have we briefed them?
    Senator Manchin. Are they briefed?
    Dr. Ramoni. Oh yes, they certainly are.
    Senator Manchin. They're on top of it?
    Dr. Ramoni. Yes. Yes, they are certainly read into the AI--
--
    Senator Manchin. Let me just say this, through my AI work 
on my other committees, and Armed Services is one where I'm 
chairman of the Subcommittee on Cyber, I learned that AI is 
useless and truly useless without accurate, massive database.
    So does the VA own all its own data? Are you including what 
is created by contractors? And do you own that access to all 
contractors' data that will go into your database? And who is 
that managed by? Who is managing that for you?
    Dr. Ramoni. Well sir, for a complete answer we will have to 
get back to you, but I can tell you speaking as researchers who 
love nothing more than access to data, I can tell you that 
because of the work that our corporate data warehouse team has 
done on both the clinical and research sides, we have access to 
quite a bit of data.
    Senator Manchin. Okay.


------------------------------------------------------------------------
 
-------------------------------------------------------------------------
VA Response: All data generated within the VA for the purpose of
 research is owned by the VA. Aside from VA investigators, only VA
 contractors can conduct VA studies. Any data from these studies also
 belong to VA. The VA manages its own research data through on premise
 storage solutions and cloud storage. The stored data are subject to all
 applicable VA information security and privacy controls.
------------------------------------------------------------------------


    Dr. Ramoni. But I can tell you that there are some 
challenges in getting data back. For instance, in the case 
where genetic testing is sent to outside laboratories, that 
data is not specified in the contract always to come back to 
the VA.
    Senator Manchin. So, I mean, have you looked at your 
contracts to make sure that they, basically, you need this to 
do the accurate work you need with AI for it to be effective? 
Have you started recommending those changes be made, so when 
you have outside contractors, you do own that, or you have 
rights to that database?
    Dr. Ramoni. I know that in the conversations I've been 
privy to, which are in the context of oncology, that those are 
active discussions about ensuring that we get data back from 
those data providers.
    Senator Manchin. Thank you. Mr. Kuntz, if I could talk to 
you because it's just a horrible situation. I know and I thank 
you for your work you're doing in mental illness and all the 
suicide----
    Mr. Kuntz. Thank you.
    Senator Manchin [continuing]. And all the problems that 
we're having with our veterans. I was always interested, when 
someone is basically retiring out, coming back from either 
service, coming back from combat, and they're basically been 
diagnosed with some challenges. Is that forwarded on to you if 
they come back to Montana, in Montana? Are you made aware of 
all the medical conditions and records upon discharge that that 
soldier may have?
    Mr. Kuntz. Sir, I don't work for the Veterans' 
Administration, but I know that that's been something that 
we've been working with----
    Senator Manchin. I mean, do you know if there's a problem 
there? Because it seems like to me, they're coming back home in 
West Virginia, we should have been notified that there was some 
serious problems we could have intervened and helped them with. 
And we're not seeing that until it's almost too late.
    Mr. Kuntz. Sir, I agree with you. I mean, it feels like 
it's something that's always talked about and it feels like 
from the DoD side, if you could lean on those folks and make 
sure----
    Senator Manchin. Let me ask you this. Do you all, any of 
you all from the Department of Veterans, VA know anything about 
this? Are we able to access those records? Is my four hospitals 
in West Virginia going to have access to the medical records 
coming out and discharge records of a soldier coming out of 
service?
    Dr. Ramoni. So sir, I am going to have to take that 
question back, but I want to make sure that I understand. Are 
you asking whether the VA receives the records from all 
discharged military?
    Senator Manchin. I would say that if I'm coming out of the 
military and I'm discharged, okay. So you checked me out and 
I've had some problems. I've had some conditions.
    Dr. Ramoni. Yes, sir.
    Senator Manchin. And you all have treated me while I've 
been in service, while I was fully deployed. Now I'm discharged 
and you would ask me, what hospital do I want to go to? And I'd 
say, I want to go to the Woody Williams VA Center in 
Huntington, West Virginia. And would they be aware, would you 
make them aware of all of the conditions and all the prior 
treatments I've received, so they know that I might have some 
substance abuse problems?
    Dr. Ramoni. Thank you, sir. We will take that question.
    Senator Manchin. I don't, but I want to say I'm just 
hypothetically. Okay. And we're just----
    Dr. Ramoni. Yes. We will take that question and get back to 
you because now I have a sense of----
    Senator Manchin. What I'm trying to get to?
    Dr. Ramoni [continuing]. Of what you're asking, yes.


------------------------------------------------------------------------
 
-------------------------------------------------------------------------
VA Response: The Department of Veterans Affairs (VA) has a long-standing
 partnership with the Department of Defense (DoD) to coordinate the
 transition of care for service members leaving the military and needing
 ongoing care from the Veterans Health Administration (VHA). VHA has 43
 VA Liaisons for Healthcare, advanced practice social workers and
 registered nurses, stationed at 21 Military Treatment Facilities (MTFs)
 and DoD installations, as well as five (5) Regional VA Liaisons for
 Healthcare to provide virtual transition assistance at DoD
 installations that do not currently have VA Liaisons located onsite. VA
 Liaisons for Healthcare provide direct access and coordinate
 individualized VA health care for service members from DoD to VA prior
 to discharge from the military. VA Liaisons for Healthcare collaborate
 with MTF treatment teams to identify ongoing health care needs then
 communicate those health care needs to the Post-9/11 Military2VA (M2VA)
 Case Management team at the VA health care facility closest to the
 service member's home or most appropriate location for the specialized
 services the medical condition requires. This includes information
 about substance abuse problems if applicable to the individual
 transitioning service member/Veteran. This formal transition process
 between the VA Liaisons for Healthcare and the Post-9/11 M2VA Case
 Management teams bridges the gap during the vulnerable time of
 transition. This specialized part of the military-to-civilian
 transition, namely the transition of health care from DoD to VHA, is
 accomplished by assessing individualized needs, expediting the
 transitioning service member's/Veteran's initial registration/
 enrollment for VA health care, scheduling initial VHA appointments, and
 ensuring screening for ongoing case management.
 
Post-9/11 M2VA Case Management teams are located at every VA health care
 facility and provide comprehensive transition assistance and
 longitudinal case management for Post-9/11-era wounded, ill, and
 injured service members and Post-9/11 era Veterans. The Post-9/11 M2VA
 Case Management team at the transitioning service member's/Veteran's
 home VA health care facility (such as the Woody Williams VA Center in
 Huntington, West Virginia) would receive the information provided by
 the VA Liaison for Healthcare and also has access to view DoD medical
 records through the Joint Longitudinal Viewer to gain a complete
 picture of the new Veteran's DoD health history. Post-9/11 M2VA Case
 Managers are social workers and nurses who provide case management to
 meet the clinical and non-clinical needs of the transitioning service
 member/Veteran and coordinate with the other members of the Veteran's
 VHA treatment team to ensure responsive, synchronized, and integrated
 care benefits and services.
------------------------------------------------------------------------


    Senator Manchin. I'm saying we can----
    Unidentified Speaker. Do you know when you can get the 
medical records from the VA?
    Dr. Ramoni. Well, I know that once somebody is enrolled in 
the VA, that the VA does have access to DoD records. I'm not 
certain if prior to the enrollment those data are available. 
I'm also aware that there are a number of transition activities 
that occur upon discharge from the DoD to facilitate enrollment 
in VA.
    But again, I'm not certain then whether if somebody doesn't 
enroll, then does VA have access to those records? And I think 
furthermore, Mr. Manchin, if I understand your question, then 
is there some proactive way to identify----
    Senator Manchin. I'm just saying if we can intervene and--
--
    Chairman Tester. Gentlemen, I've got to get to Senator 
Cassidy. We're over quite a bit. But these are the researchers. 
I think we need to be talking to the clinicians to get that 
information. Okay. And she will, she'll get them.
    Senator Manchin. I saw you had the gentleman from Montana.
    Chairman Tester. Kuntz is top flight, but he's in the 
private sector. Right on. So it's good. Senator Cassidy.

                      SENATOR BILL CASSIDY

    Senator Cassidy. Hey, hello. I'm going to ask just some 
basic questions. Perhaps Dr. Ramoni, you're the one who would 
answer. How much of the funding that you put out there is for 
basic research versus clinical research?
    Dr. Ramoni. Yes, sir. I'm going to have to get back to you 
on that question. I know that among our--we have four major 
research services, basic science, clinical science, health 
service research, and rehab. That among the four, basic science 
is the largest.


------------------------------------------------------------------------
 
-------------------------------------------------------------------------
VA Response: ORD funds research through four major research service
 areas: basic biomedical science, clinical science, health services
 research, and rehabilitation. Our funding for basic biomedical research
 constitutes approximately 39% of our total funding portfolio across all
 four services. The table below provides are actual funding amounts for
 FY2022 and 2023, and our requested budget for 2024.
------------------------------------------------------------------------



------------------------------------------------------------------------
 Obligations by Service (Dollars       2022         2023         2024
          in thousands)              Actuals      Actuals      Request
------------------------------------------------------------------------
Biomedical Laboratory R&D (821)        208,492      216,339
-----------------------------------------------------------------212,012
Rehabilitation R&D (822)               116,567      116,782
-----------------------------------------------------------------120,924
Health Services R&D (824)              123,604      120,743
-----------------------------------------------------------------125,691
Clinical Science R&D (829)              90,898       94,627
rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr104,021
Service Obligations Totals             539,561      548,491      562,648
------------------------------------------------------------------------


    Senator Cassidy. And is that money extramural or is it by 
researchers who are on a VA campus? Or are you contracting with 
somebody who is at a med school someplace, or?
    Dr. Ramoni. These all are individuals who are at least 
five-eighths VA. And the work can be done either on the VA 
campus or through agreement or lease with academic affiliates 
or other lease space.
    Senator Cassidy. Now, do you have a sense of the percent 
that you're leasing off the campus versus on, and is there any 
difference in the productivity of the researcher who is 
physically situated on a VA campus versus one who is not?
    Dr. Ramoni. I do not have that information at present.
    Senator Cassidy. How do you measure productivity of the 
people who receive these grants? Because I come from academic 
medicine and it's publish or perish, or you have to get a 
certain number of grants, or you've got to have, you know, you 
name it.
    Dr. Ramoni. Yes.
    Senator Cassidy. How do you measure the productivity of the 
people whom you are funding?
    Senator Cassidy. So, to me, the ultimate part of what drew 
me to the VA and is different from where I was in academic 
medicine, is that I ultimately view the productivity of our 
researchers as making their way back to the veterans. So for 
instance, in the Lung Precision Oncology Program, it's, do we 
update the lung cancer screening guidelines on the military 
exposure.
    Senator Cassidy. I accept that. I have limited time. I 
accept that. But nonetheless, if it's really high quality work, 
it's going to be copied by others.
    Dr. Ramoni. Yes. And so we do publish, we had 14,000 
publications back in fiscal year '22. In addition to----
    Senator Cassidy. That must include abstracts too, right? 
Not peer reviewed.
    Dr. Ramoni. I will have to go back and check for the 
record, but there are a large number of VA researchers.


------------------------------------------------------------------------
 
-------------------------------------------------------------------------
VA Response: The 14,000 publications Dr. Ramoni reported are all peer-
 reviewed, scholarly publications. It does not include news coverage nor
 reports of the studies; abstracts and summaries may be provided as part
 of an article and are not counted as distinct articles. Abstracts and
 summaries are not counted as stand-alone items.
------------------------------------------------------------------------


    Senator Cassidy. So let me go back to--because we're 
interested in how do you know that somebody's going to work? So 
publications is one way. Getting something licensed is another. 
Doing a clinical trial, enrolling 5,000 people is a third. Do 
you have kind of metrics that if we wanted to look at, we could 
say, ``Whoa, this is really working,'' or, ``Hmm, is anybody 
doing anything there?'' You see what I'm saying? We need to 
have that, sort of, kind of----
    Dr. Ramoni. Yes. And so what I would say is, prior to us 
implementing this effort to treat VA as a research enterprise, 
each center has its own way of tracking things. Each of the 107 
medical centers that conducted research. We are now instituting 
systems across all of those systems that allow us to better 
understand what research is happening, what funding are they 
bringing in from outside sources, how many people are they 
enrolling in clinical trials, whether they're funded by VA or 
not. For VA funded research, we get progress reports, of 
course, on a yearly basis.
    Senator Cassidy. Now are you all funding researchers or are 
you funding a research proposition?
    Dr. Ramoni. We fund proposals.
    Senator Cassidy. I see. So Dr. Jon Tester might bring you a 
proposal to do something on traumatic brain injury and you 
would look at it and see if it's good.
    Dr. Ramoni. We conduct peer review, like NIH does.
    Senator Cassidy. Got you. Okay. And the clinical work that 
you are doing, do you have a sense of how many veterans are 
enrolled in clinical trials sponsored by your research?
    Dr. Ramoni. For our research, we can gather information 
about how many people are enrolled in the trials. For trials 
that are sponsored by outside parties, we do not yet have that 
information at our fingertips.
    Senator Cassidy. So I think you're telling me that if a 
pharmaceutical company has a new treatment, they may be 
enrolling patients at a VA, but that would not necessarily be 
VA sponsored research. It would just be going through your 
institutional review board, enrolling VA patients.
    Dr. Ramoni. Not necessarily going through our institutional 
review board, going through a review board----
    Senator Cassidy. Someplace?
    Dr. Ramoni [continuing]. On which we rely, yes.
    Senator Cassidy. Now, in terms of though, going back to my 
question, do you have a number of veterans who are enrolled in 
clinical research that the VA sponsors?
    Dr. Ramoni. Yes. We can get that number to you.


------------------------------------------------------------------------
 
-------------------------------------------------------------------------
VA Response: For VA Office of Research and Development funded clinical
 trials, it is estimated that about 932,000 Veterans are enrolled or
 will be enrolled in studies that are currently recruiting, completed
 recruitment but active, or enrolling by invitation. Over 40,500 more
 Veterans are expected to be recruited for clinical trials that have not
 yet begun recruitment.
------------------------------------------------------------------------


    Senator Cassidy. Okay. I'm almost out of time, but let me 
just say this. I'm going to put it plugin, Mr. Chair. We've 
been working on something called a VetPAC idea, modeled after 
MedPAC and MACPAC from Medicaid and Medicare analysis to give 
us a tool by which to evaluate these programs.
    And we are not there yet, but I'd like to eventually bring 
it to the Committee and hopefully on a bipartisan basis, it'll 
give us a way to have more insights into what we're trying to 
learn.
    Chairman Tester. I look forward to that, Senator Cassidy, 
and I appreciate the work in that effort, because 
accountability is really important. We want to make sure the 
dollars that are spent, actually people are utilizing them in a 
way that provides benefits one way or the other. Thank you. 
Senator Hirono.

                    SENATOR MAZIE K. HIRONO

    Senator Hirono. So I'm curious about this, the Million 
Veteran Program. So is this Dr. Muralidhar? I think I'm 
mispronouncing somebody's name. Your name. Okay. So I'm curious 
about this MVP Program, soon approaching the goal of collecting 
genetic information of 1 million veterans. So how did you get 
this information from 1 million Veterans? When they access VA 
services? Do they somehow get tested for genetic information? 
How is this working?
    Dr. Muralidhar. So, thank you for that question, Senator. 
So Million Veteran Program is really a voluntary research 
program that we actively consent veterans. So we reach out to 
them and invite them to participate in the program, and if 
they're interested, then they would consent to it.
    And it's generally a 20-minute visit at the VA hospital. If 
they're coming in person, they provide a sample of blood, 10 ml 
for genetics and other molecular data. And they complete 
surveys on health and lifestyle, military experience, and 
exposures. And they also give us access to their health records 
for research and agree to be recontacted.
    That's the general premise of the participation. They can 
also enroll online. In 2019, we actually launched an online 
portal. So they can either come into a VA hospital where we 
have a site for enrollment, or they can enroll online.
    Senator Hirono. So what is the hope and expectation of 
having a million people's genetic information? What is it that 
the VA hopes to do with all of this? And is this the largest 
collection of this kind of voluntary genetic information?
    Dr. Muralidhar. Yes, it is the world's largest cohort. 
Right now, we are just under 8,000 more to go to get to a 
million veterans. This is a partnership that we actually 
established with veterans right from the beginning. And the 
goal was really to understand how genetics, lifestyle, and 
military experiences and exposures, impact health and well-
being.
    And so we clean and curate the data, both from the 
electronic health record and the surveys. We curate all the 
molecular data, the genetic data that we generate from the 
biospecimen, and these are provided in a secure way to 
researchers within the VA at this point.
    And now we have over a hundred projects doing work with 
this data set. We have over 350 publications and very high 
impact journals so far.
    Senator Hirono. And so with these hundred projects that you 
have, such as? Because the whole idea is to provide, I take it, 
better healthcare for veterans?
    Dr. Muralidhar. Yes. So the ultimate goal is really to take 
these research findings and bring it back into the healthcare 
system. And so initially we focused several years on the 
recruitment and enrollment piece, and then we cleaned the data 
and started providing them for research. And now we are 
starting to see some initial projects that are bearing fruit in 
terms of clinical translation.
    For example, we have one project where a polygenic risk 
score was identified for increasing risk in men to metastatic 
prostate cancer in African Americans. So that polygenic risk 
score is now being tested in a clinical trial to see if it 
improves when compared to standard of care to predict the risk 
for metastatic prostate cancer better.
    Senator Hirono. I don't imagine that you have a lot of 
Asian Native Hawaiian cohorts in this 1 million population.
    Dr. Muralidhar. So we do have quite a bit of diversity. So 
we have about 18 percent African American, that's over 175,000 
African Americans in the cohort. The largest in the world of 
its kind right now. We have 8 percent Hispanic ethnicity 
represented. We do have very low Asians, and you know Native 
Americans, and Pacific Islanders, about 1 percent or so.
    So our goal is after we get to the million, beyond that, we 
will start diversifying the cohort more. We will have focused 
campaigns to recruit more of the underrepresented populations 
in this program.
    Senator Hirono. So you were asked--someone was asked the 
question of how many veterans are enrolled in clinical trials? 
And I don't know that we got the answer to that. We don't have 
that answer?
    Dr. Ramoni. No, I will get that answer for you in response. 
I will be able to get that answer for VA funded trials. We will 
not have the information at this point for non-VA funded 
trials.


------------------------------------------------------------------------
 
-------------------------------------------------------------------------
VA Response: For clinical trials funded through the VA Office of
 Research and Development, it is estimated that about 932,000 Veterans
 are enrolled or will be enrolled in studies that are currently
 recruiting, completed recruitment but active, or enrolling by
 invitation. Over 40,500 more Veterans are expected to be recruited for
 clinical trials that have not yet begun recruitment.
------------------------------------------------------------------------


    Senator Hirono. So when you say the VA funded clinical 
trials, how many VA funded clinical trials are there? Because 
there aren't a lot of the clinical trials done in a hospital, 
regular hospital setting.
    Dr. Ramoni. So if I am to look--I'm sorry, I'm looking for 
the numbers of clinical trials that we fund. I may have to take 
that question also for the record.


------------------------------------------------------------------------
 
-------------------------------------------------------------------------
VA Response: As of November 21, 2023, the VA Office of Research and
 Development is funding 591 trials that are at various stages of
 activity (e.g., not yet recruiting, recruiting, active but not
 recruiting). The VA Office of Research and Development has also funded
 over 1,433 clinical trials that have been completed since it started to
 require clinical trials to be registered in Clinicaltrials.gov since
 2007.
------------------------------------------------------------------------


    Senator Hirono. I would be very interested in knowing how 
many, because it seems to me that clinical trials is one of the 
ways that people sign up for these trials. You can really make 
some determinations as to whether a particular protocol is 
working or not, depending on whatever the factors are. And it's 
not always a genetic kind of an identifier----
    Dr. Ramoni. That's right. There are----
    Senator Hirono [continuing]. That is at play.
    Dr. Ramoni. I apologize.
    Senator Hirono. So I'm curious to know the figures, because 
I do think that clinical trials is one of the very specific 
ways that we can make some determinations as to best 
treatments.
    Dr. Ramoni. Yes, ma'am. And I was able to find the number. 
There are 2,029 clinical trials that are active across VA that 
we have a record of. And 617 of those are funded by us.
    Senator Hirono. Okay. And are these mainly cancer trials?
    Dr. Ramoni. No. They cover a full range of conditions. So 
for instance, one of the largest trials that we're conducting 
is a comparison of fecal immunohistochemical testing. Like a 
Cologuard type test versus colonoscopy of 50,000 people 
followed for 10 years to see which is more effective in 
preventing death.
    Senator Hirono. Okay. Well, thank you.
    Chairman Tester. Rachel, could you send us the research 
projects that are being asked. Send it to me and I'll 
distribute to the Committee?
    Dr. Ramoni. Yes.


------------------------------------------------------------------------
 
-------------------------------------------------------------------------
VA Response: A current list of research projects funded by the VA Office
 of Research and Development (except for those funded by VA's
 Cooperative Studies Program) can be found on the National Institutes of
 Health RePORTER website (https://reporter.nih.gov/search/f4fehWMR-
 0Kj75mk2ik5MA/projects). A list of active Cooperative Studies Program
 projects can be found at: https://www.research.va.gov/programs/csp/
 studies.cfm.
------------------------------------------------------------------------


    Chairman Tester. So that the Committee has an idea, at 
least on those 617 that are VA funded, what they're about. 
Okay? Senator Blackburn.

                    SENATOR MARSHA BLACKBURN

    Senator Blackburn. Thank you. I appreciate that, Mr. 
Chairman. And as I told you all before the hearing started, I 
appreciate so much that you all are here today and to work with 
us on this. Dr. Ramoni, we talked a little bit about the CB 
program there at Vanderbilt, and the research work that is 
being done there. I had a question, as we were working on the 
hearing, the R and D office is embedded within the VA health 
system. So that means that the funds for research are available 
only to VA employees. Is that correct?
    Dr. Ramoni. Yes, ma'am. That is correct.
    Senator Blackburn. Okay. Now we know that the VA in 
Nashville is on the campus of Vanderbilt University, and the VA 
is right across from the hospital there, which is a research 
hospital, which has done some pretty amazing work.
    So why would we not allow those funds to be used with some 
of the researchers that are really right across the street 
there at Vanderbilt and expand the opportunities for getting to 
an answer on CB and how that is going to be treated?
    Dr. Ramoni. So thank you for the question, ma'am, which as 
I understand it, it's about why are we an intramural funding 
organization instead of sending funding extramurally, like 
let's say NIH or others?
    So there are a few responses to that question. One is that 
A, given the amount of funding that we have we want part of our 
work in funding research within VA is it serves as both a 
recruitment and retention tool for clinicians. So research is 
one of the reasons why people come to work in VA. The second 
point is that the ideas then bubble up directly from the people 
who work with veterans on a day-to-day basis. The third is, of 
course, we encourage people to come and get a VA appointment. 
Meaning you can apply for funding with a promise of getting a 
VA appointment. It's not a sort of catch-22, where you have to 
have a VA appointment in order to apply for funding. But you 
need funding to sort of get an appointment.
    And the third is that we actively collaborate, as I was 
mentioning previously with the primary extramural funding 
agencies like NIH, DoD, and others.
    Senator Blackburn. Okay. Let me stop you at that. We've had 
a lot of success with our military service with the Pathfinder 
Program. Senator Rosen and I did a lot of work on this, and it 
allowed active duty to actually partner with engineers in our 
research institutions. We have had that program on campus at 
Vanderbilt, and it has been very successful.
    And when you talk about the constricted bronchiolitis and 
Dr. Hastings was talking about how invasive the surgery is, the 
biopsy process is, it just seems that when you're doing this, 
you would have a portion of that funding that would allow you 
to partner with research institutions in hopes of getting to a 
faster resolution on this.
    We've put so much work into dealing with toxic exposure. A 
big part of that is what happens with the respiratory system. 
So if we need to look at that allowance, we should do that, Mr. 
Chairman, and allow them to use some of those funds.
    Before my time runs out, I do want to ask you about the 
data security efforts for the Million Veteran Program. And we 
want our veterans to feel safe knowing that their data, their 
information, their medical history, all of their PII is going 
to be safe. And we've seen the VA go through cyberattacks and 
information being leaked.
    And the concern on this is not just cybersecurity, physical 
security is also a part of this. And I would like to know what 
you're doing to enhance that physical and that cybersecurity, 
so that veterans that are in that Million Veteran Program are 
going to be protected.
    Dr. Muralidhar. Thank you for that very important question, 
Senator. So protecting the privacy and security of our 
veterans' data is paramount for us. It's our highest priority. 
So right from the time we collect the data from veterans, till 
the point that the data is used for research, we've put in 
place number of mechanisms to protect the data.
    First and foremost, we code the data. There is no direct 
identifier like name, or date of birth, or social security 
number.
    Senator Blackburn. So you're anonymizing----
    Dr. Muralidhar. Yes.
    Senator Blackburn [continuing]. All of that? Okay.
    Dr. Muralidhar. Yes. And second of all, the environment, 
the computing environment in which we store the data and make 
it available to researchers is isolated from the VA network, 
for example. So if there are perturbations, even to the VA 
network, it will not impact this structure where the data is 
stored and used.
    We don't send out data to researchers. We bring them to the 
data in a central secure scientific computing environment, and 
we provide the tools for them to do their analysis, and they're 
only able to take away the results. They cannot take any level 
data out.
    And the last thing is, when you provide data to 
researchers, again, we code them and anonymize them. So 
researchers can't tell who it belongs to.
    Senator Blackburn. Okay. That's helpful. Thank you.
    Chairman Tester. If you'll just bear with me a little bit, 
Senator Blumenthal. I want you to enlighten me because we 
started out this hearing and you talked about research has to 
be done in areas where there are major universities. Senator 
Blackburn just talked about Vanderbilt, which is a major 
university, and how did the VA funded projects were solely for 
VA and didn't utilize the university.
    So, enlighten me why more of this isn't done in rural 
America, because what you just told her is that you don't need 
the universities. And what you told us earlier, if I heard this 
correctly, is that you need to do research where there is major 
universities.
    Dr. Ramoni. Yes, Chairman Tester. Thank you for that 
question. Most of our researchers have dual appointments. They 
both are like Dr. Miller, Bob Miller, is both a Vanderbilt 
professor and a VA researcher. And that is true for the vast 
majority of our researchers. So it really is that academic 
affiliation that----
    Chairman Tester. So in fact, you are bringing in the 
information that the universities have because they have two 
jobs, one with the university and one with the VA.
    Dr. Ramoni. That's the same for many of our clinicians as 
for our researchers, yes.
    Chairman Tester. Okay, thank you. Senator Blumenthal.

                   SENATOR RICHARD BLUMENTHAL

    Senator Blumenthal. Thanks, Mr. Chairman, and thank you for 
holding this hearing, which quite honestly is one of the more 
enlightening of our hearings. I'm learning a lot about stuff I 
never knew, like the MVP program, which as you observe in your 
testimony, is ``The largest database of genetic information on 
African Americans in the world.''
    Seems to me there's probably a wealth of information in the 
MVP that you have already. You observe here that you've, 
``Identified 12 DNA variants associated with the risk of 
suicide and highlights the genetic link between suicide and 
factors such as impulsivity, chronic pain, attention deficit 
hyperactivity disorder, and heart disease.''
    Those conditions are associated with certain genetic 
makeups, and you have evidence as to the statistical links, and 
the potential for treating them. When will this information be, 
in a sense, weaponized into treatment that's available to the 
thousands, maybe millions of veterans who could benefit?
    Dr. Muralidhar. So thank you for the question, Senator. So 
the paper just came out recently, and so we've identified 
associations, meaning that a genetic change is associated with 
certain conditions. So there are several steps that need to 
happen before it actually becomes a biomarker or a new drug is 
discovered because of it, or a drug can be repurposed because 
of that.
    So we have to validate these results and then see if there 
is a way--if there's already a drug that's approved by FDA, 
that could be used for any of these conditions that can be 
repurposed you know, for preventing suicide. And so that's a 
longer step working with FDA and others to get to that point. 
But there are a few steps from the initial discovery to making 
it available.
    Senator Blumenthal. Well, how soon? You know, veterans are 
committing suicide every day, there's a real potential to save 
lives. We talk about this issue probably, I don't know how 
often at our meetings here, but as recently as this morning, we 
had a meeting with some of the Veterans Service Organizations. 
The Chairman was there, raised this issue. A number of us 
raised this issue right off the bat. And never once was this 
study mentioned.
    I don't know whether you can tell us whether this process 
can be accelerated, whether there can be a priority on it. You 
note also that ``Researchers are looking at numerous health 
conditions such as PTSD, depression, diabetes, and heart 
disease that are also associated with certain genetic 
factors.''
    So I think there's a potential here that is very important. 
I've been on this Committee for 12 years. I'm learning about it 
for the first time. Shame on me. But what more can we do to 
publicize it, and also to enable more veterans or persuade more 
veterans to be a part of it?
    Because self-selection, I would guess the voluntary aspect 
of it may skew it somewhat. A veteran who is depressed on the 
verge of suicide, probably isn't going to enlist in the MVP 
program. So again, I just want to throw that question out 
there.
    Dr. Muralidhar. Yes, thank you, Senator. So any veteran in 
the country can enroll in the program, either at a VA hospital 
or through our online portal. It is mvp.va.gov. It's simple to 
go there and learn more about it and enroll. We also recently 
launched a sub cohort within MVP, and this is really a very in-
depth mental health survey that's sent out to veterans who are 
in the program to, to learn more about these conditions, the 
serious mental illness and substance use disorders.
    And we launched about six sites this year. And roughly 
about 500 veterans have actually joined MVP and completed that 
survey. And so that's going to go on over the next few years so 
we can learn more and validate the findings that we get from 
one observation.
    Senator Blumenthal. I don't think I'm making myself clear. 
I'd like to know in a month, 3 months, 5 months, so we can help 
people, what you're finding and how to actualize it in 
treatment. If you're talking about years away, I think that's 
good, if your only objective is research. But we want practical 
solutions. I know I'm sounding oversimplistic, highly 
unscientific, but that's the instinct that will drive people 
like Matthew Kuntz, and he's nodding, anyone who is dealing 
with clinical depression that could cause suicide next week.
    Dr. Muralidhar. Yes, and I completely agree with you. And I 
think that is our goal. The whole purpose of this program is to 
not just do research and discover something, but then to find 
ways to take it back to our veterans. And so we will work hard 
to take anything, any discovery that comes out of this program, 
to take it in toward the clinic.
    Senator Blumenthal. Thank you. My time has expired, but 
obviously my interest in this topic has not. And thank you, Mr. 
Chairman for having this hearing.
    Chairman Tester. Thank you, Senator Blumenthal. There was a 
vote call. It may last 15 minutes, it may last an hour and a 
half, who knows? But we're going to close this meeting out. And 
I want to thank you Dr. Ramoni, for being here and your two 
supporters, and Matt Kuntz. It's always good to see you, man. 
Keep up the good work. We appreciate you holding the fort down 
in Montana.
    For those folks who want to put questions in for the 
record, I would ask that you would answer them in a timely way. 
Thank you for participation. The record will be kept open for a 
week and we are adjourned.
    [Whereupon, at 4:43 p.m., the hearing was adjourned.]

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