Spotlight on Women's Health- 16 -Department of Veterans Affairs

**Department of Veterans Affairs**

**Spotlight on Women's Health**

**Cyberseminar 05-09-2012**

**Women Veterans Health Strategic Health Care Group Research Priorities**

**Dr. Patricia Hayes**

Susan Frain:  It's with the greatest pleasure that I introduce Dr. Patricia Hayes, who's the chief consultant for the Women Veterans Health Strategic Health Care Group in the Office of Patient Care Services for the Department of Veterans Affairs.  In this role, she oversees the delivery of VA health care services for the more than 300,000 women Veterans who use VA care.  

Dr. Hayes received her Ph.D in clinical psychology from Catholic University in 1984 and joined the VA in the early 1980s as a clinical psychologist seeing Vietnam era veterans with PTSD.  She became the women Veteran program manager for VA Pittsburgh and later was the lead for [Division] 4.  

Recently, Dr. Hayes has successfully worked across VHA to expand initiatives for women Veterans health care into a broad range of areas of importance, including cardiac health, reproductive health and a comprehensive evaluation of health care provision to women Veterans.  She chaired the Undersecretary for Health Workgroup on the enhancement of primary care to women veterans.  she's also frequently called to testify on the needs of women veterans before Congress.  She's collaborated with VA researchers on topics, including organization of care delivery, satisfaction with care and evaluation of quality disparity.

On a personal note, I've been moved by how tirelessly Dr. Hayes works on behalf of the women Veterans we serve and I'm delighted that all of us will have the opportunity to hear her speak today.  Dr. Hayes?

Dr. Patricia M. Hayes:  Okay.  Good afternoon or good morning, I want to thank Susan for that gracious introduction and Susan and I have a consistenly great history of working together on women's health research.

Today, what I have been asked to do is to go over in depth the strategic planning and the strategic goals of our program for women Veterans in order that researchers may be able to recognize and join in in the areas in which we have some of the greatest need for the expertise of research.  

Many of you have seen this slide, it has to do with the population of women Veterans increasing and the red bar obviously is tied to the scale on the right, the number of women Veterans.  These are actuarial predictions from the Vet pop and we already know from the fact that we have over two million Social Security numbers in the computers from DOD, this population of Women Veterans is actually greater than this and the message behind that really is that there's a significant population to study and the number of women coming VA is going to continue to rise very dramatically.

Here's another way to look at sort of what has happened and I thank Susan Frain's group, the Women's Health Evaluation Initiative for all the data and Sourcebook work that they have been doing for us.  You can see that the population has doubled in the last ten years, so these are the users of VA.  We also know that the population of women Veterans has increased rapidly in the same kind of line that we just showed in the prior slide.

So why has this population increased?  It is not solely because we have a war going on or that we've had some recent conflicts.  The real reason why the population has gone up so dramatically is because of the number of women on active duty military, 18% of the National Guard and the Reserves are female, 11.6% of the OEF/OIF are female and currently 6 percent of VA health care users.  

Now how does that compared when we think about the history of women in the military, 3 1/2 to 4% during World War II, then there was a 2% cap on women serving in the military until after Vietnam.  Gulf War I was 11% female, so it's very similar to the current deployment group and it really speaks to the pipeline when we think about the number of women that are on our doorstep that will continue to flow into VA for use of VA health care.

On Slide 5 the overall sense and the face of who we're serving has also changed rather dramatically.  Of course, we all kind of knew that there were young women with these frequent visits—and if you haven't had access to the Sourcebook that Dr. Frain has published with us, you can get a copy online on HSR&V and on our Web site, you may want to look at the current demographics that we have for women veterans.  

One of the things we learned is that on average women come at least one more visit per year than men do and it kind of makes sense when you think about reproductive health care, but also because our women have fairly high mental health needs.  Women proportionately have a higher percent and there's a higher proportion of women Veterans with service-connected disabilities, compared to male Veterans.  So we're serving a population in the VA that has a high amount of service-connected—and obviously this fits very critically with our mission.

We provide maternity care and that has expanded recently and we're seeing more and more women coming in for OB care.  Most of our women who are under age 50 are working and we need to think about accomodating them in our clinics and we have high mental health needs, which I'll go into a bit more in a moment.

One of the things we learned from looking at the recent demographics is that our aging and older women are actually still our largest sub-population of women in the age 45 to 65.  We have to think about menopausal needs, the emerging geriatric care needs.  They'll be in more for inpatient and extended stays and they will present more in terms of pain management.  This, again, is the overview of what we're seeing for VA patients.

The mission of my office is really twofold.  It is to insure that all women veterans receive equitable, high quality and comprehensive health care in a sensitive and safe environment at all VA facilities.  Now if we break that mission out a little bit, it seems kind of simple and straightforward, but each and every element is an element that we need to continuously evaluate and that we've actually collected a lot of data on and for which we have some strategic objectives.

We want all the care for women Veterans to at least be equitable to that that we provide to men.  It must be high quality and we have been moving to make sure that it is a comprehensive health care.  The sensitive and safe environment in some ways has been one of our greatest challenges.

We also have a mission to be a national leader in the provision of health care for women veterans.  Thereby raising the standard of care for all women.  You can see that we're not just saying we want our care of women to be as good as the care of men in VA, but rather we really see ourselves as developing a health care system that is a best practice, that shows the country how to provide good health care to women and we sincerely engage in that mission.

What are some of the strategic goals?  I will run through some of them and then talk a little bit about some of the research areas that head directly to these strategic goals.  We have a goal to transform the health care delivery for women Veterans.  Transforming it from a system that really has in many ways neglected the needs of women and focused primarily on the health care needs of men to a transformational health care service for women.

We also have a strategic goal of developing, implementing and influence all VA policy as it relates to women Veterans.  So we are looking at the policies that come out from every office and checking to make sure that there's equitable treatment of women Veterans in these policies.  

We also are developing, implementing and influencing VA education initiatives across the board and particularly in terms of delivery of women's health care and we are driving a focus and setting the agenda for a very particular goal and that is to increase our understanding of the effects of military service on women's lives.  I see this as a particularly opportune era because we have so many women, who have a different military experience now than many of their counterparts in the past.  We have so many women who are actively engaged in combat areas and we need to understand the effects of this service, both positive effects and challenges and vulnerabilities that have been created on the basis of military service.  So we have a very wide possible agenda here in terms of research.

Our end goal is to make sure the needs of women Veterans are always considered across program offices, including research and in policy and key decisionmaking.  So those are our main goals and ones that we have [run out] strategically, so I will go through the goals.

Implementing comprehensive primary care means complete primary care from one designated women's health care provider at one site.  It must include the care for primary care and acute chronic illnesses, all that we know about primary care.  It must include PACT and we are measuring this with our women's health primary care evaluation tools, which we have in my office and we have considerable data on those called the WATCH Tool.  

So, as Becky [Yano] and other folks working in this area of management and HSR&D kinds of research now, we now have some ongoing prospective and retrospective measures of imlementation of primary care of women.  What we don't have in this area yet are any measures of behavior changes that happen in terms of things like proficiency and the care of women in terms of our training.  We don't have measures of the outcomes.  We don't know if patients are more satisfied and we don't know about clinical care outcomes by implementing this type of systematic care for women.  So those are really critical points that are big questionmarks for us.  

One of the other clinical research needs that I wanted to mention here: We know that there is considerable research that goes on for men and women outside the VA, but we don't have as many researchers as we need and as we would want to have in the areas that we have the highest morbidity and mortality for women.  So we've begun to have a cardiac disease work group and if anyone out there is interested particularly in issues around research on cardiac disease, hypertension, these are issues that the work group is beginning to generate.  We're looking at all the data on how cardiac disease manifests itself in women Veterans and also on testing and treatment of women in the VA.  

Obviously lung cancer is the next big morbidity issue for women in the country.  We do not yet see that there may be differences for Veterans, but we certainly know that young Veterans, male and female, who go into deployment do tend to increase smoking and we have very little activity in the area of research on smoking cessation by gender and whether VA can provide some specific types of smoking cessation treatments that may be particularly effective and, therefore, be used as evidence-based.

Colon cancer also has a high morbidity for women and men and we haven't looked at things like patterns of test compliance.  We haven't looked at the role of mental health issues in getting your testing for any of the preventive measures and particularly for an invasive procedure like for colon cancers, whether MSP and other types of burden of trauma have an effect.

Some of the other areas that we have clinical research needs are the expanding area of cervical and breast cancer.  We don't yet have data on whether there are or are not differences in rates of HPV virus in women or of cervical cancer, breast cancer in women.  So that's another open area.

We also have some researchers who are beginning to look at pregnancy and pregnancy outcome, including unplanned pregnancies, or preconceptions behaviors, but we simply haven't had the data in the past, nor the alliance with researchers to look at specifically pregnancy outcomes in all women Veterans.  Of course, stratified by many things, including race, ethnicity, combat exposure, all other kinds of stressors, et cetera.  So we're very interested in these areas and we're really actually interested in all the areas as they are related to mental health conditions, combat exposure, et cetera.  So I'm hopeful there will be some questions about these areas, but even as we just sort of spin off and say as we're doing excellent care, how can we look at particularly the mental health components and the combat experiences of women Veterans? 

So a second goal in trying to do coordinated care was to install the Full-time Women Veterans Managers programs system-wide.  This is another one where we haven't actually done anything to study the implementation of this—it may be a lost opportunity, but it's important to know, I think about the Women Veteran Program Managers because not only do they serve as a lynchpin for improved women's health services, but they can be involved in research activities and help in terms of women Veterans participating in research activities.

Slide 13—you may have heard a good bit about the Transformation Initiatives at VA and VA central office.  We are a part of what is called the New Models of Care.  There are particular areas in particular where we have been involved very directly, which would have impact in terms of research opportunities.  

We do have some folks working on homelessness.  In fact, Donna Washington has helped look at risk factors for homelessness in women and has developed a Vulnerability Screening Tool, that's being rolled out right now and there's certainly opportunity with Dr. Washington to look at some of the aspects of training screeners.  What are we able to do by screening?  Are we able to do earlier intervention and prevention of homelessness that is one of the key areas for transformation.  

We have a women's Veterans Call Center, where we're doing outreach calls to women Veterans and we do have one researcher looking at some of the qualitative issues about when we reach women, what were some of the reasons why they either used VA and left?  Why they may never have used VA in the past or what some of their other qualitative experiences were with VA health care?

Privacy and environment of care is the correction of bathroom and all other privacy deficiencies. There is a goal actually that has now been up to 100% of these privacy deficiencies, but we don't know the relationship between the issue about sensitive and safe environment and women's satisfaction with their treatment and their perceptions of their care.

Some of the other transformation initiatives we're working on with a group of women's health experts, we have rolled up an asessment tool and survey of our emergency rooms.  We are launching a very large project of staff education for both nursing staff and providing staff in emergency rooms.  There's a particularly good opportunity in this area to look at changes in emergency room use by women.  The efficacy of the training, the kinds of needs that women have for emergency room care and how we can look at patterns of use of [fee]-basis care by the emergency rooms.  We know that about 20% of our women Veterans use the emergency room every year and so we have a lot to learn about why and how they used the emergency rooms?  

We're very, very interested in someone being hooked in in terms of the true outcome of staff education.  We certainly measure things like their learning and some measures of proficiency, but we don't have measures of true changes in behavior or of eventual development of proficiency and competency and outcome measures of increased staff education and this is an area that is kind of circumscribed.  There are only 120 emergency rooms in the VA and they are in various complexity levels.  We know a lot about them from baseline, so this is a true opportunity for lots of different kinds of research in health services.

I mentioned breast cancer before, one of the things that we are developing is an IT Fix, to be able to track abnormal tests and what is obviously really critical, which is timeliness to treatment and advocacy of treatment.  How women come in and out of treatment for breast cancer.  We are just underway on this Breast Cancer Clinical Case Registry and it will be launched in September.  So, again, an opportunity and something that's being implemented to look at some of the elements of implementation science and the efficacy of our efforts.

The Teratogenic Identification of Drugs—this is a measure that is actually an IT measure, but it's also an education measure.  We're looking at how to train many providers, female health providers, in the use of drugs that can cause birth defects in women and while we're working on the CPR aspects to alert providers, we also know that there's a lot of educational needs particularly in the area of mental health, which has a high number of teratogenic drugs.  So we're looking at the possibilities for rolling out an educational program and that's under development.

Culture change—I've often spoken about the fact that we need to change the VA.  My overarching goal has been to enhance the language, the practice and the culture of VA to be more inclusive of women Veterans.  It's kind of a funny thing that I mentioned to some other people and have often been talking with them you basically have to speak to the goal, you have to put it right out there.  You have to tell people anecdotes, you have to tell people women Veterans' experience and you have to encourage them to be different in their cultural competence and in their approach to women Veterans.  

We've done many, many things in our communications campaign and I'll be pointing out a few of them here on these slides.  If anyone's interested in organizational change I think this is a good area to take a look at some of the things that have occurred because of the cross-VA work we've done and some of the gaps that we are continuing to address.

We do have a cross-VA workgroup because we decided it wasn't effective to just talk to ourselves about this.  We are reaching Veterans and employees in terms of the cultural change.  It's a very interesting activity.  Some of the things that we're doing—these are our most recent posters—you'll begin to see these around and women Veterans have told us that being invisible—this is part of the sensitivity and safe environment—being invisible is something that is really hard for them.  Not treating them the same  way as male Veterans is part of our campaign.

The other part that you'll see on this poster—and I'll show you a couple of others—is the message that says, "It's our job to give her the best care anywhere."  One of the cultural changes that we've been working on has to do with the fact that in most VAs it's been seen as the job of the women Veteran program manager or the women Veterans program to take care of women.  We don't do that with any other minority group, any other population minority in the VA.  We don't say, if there's a radiology problem, or an ortho problem that, for example, that the minority coordinator at the VA should only take care of people of certain races and ethnicities, but when we think about women Veterans, we've relegated the job of taking care of women to a very small part of the infrastructure, that's no longer working, as we turn around in the next couple years and 10% of our population is female, we have to change the culture so that VA employees realize that it's everyone's job.I'd be fascinated if somebody wanted to look at some of the outcomes of this cultural campaign and tell us what's working and what's not working.

We also have goals around implementing VA health policy, so here we get again to implementation science and this started with the undersecretary's report in 2008 in which we rolled out recommendations specific to policy and, in fact, then implemented them as Handbook 1330.01 which is the directive on health services to women Veterans.  

It outlined specific services that must be provided and it's been a very interesting process in terms of implementation because unlike policies that are now coming out, we did not put a timeline in this policy.  It defines models of care, three clinic models, general primary care, clinics where the care is integrated, separate, but shared space, free-standing women's health centers.

We've seen different implementation because we wanted very much to have individual facilities decide what were the best ways to deliver care to women at those sites.  So we have different models at different sites and obviously creates the questions of what is effective?  What leads to satisfaction and what leads to best outcomes?

We do have some systematic data collection processes now available, which, as many of you know, from the practice-based research network that we've begun to put these into systems that you can access in terms of—and maybe I'll back up just a minute.  When you think about three different clinic models, if you want to do research on certain things, you could select facilities that have specific models of delivery of care to women Veterans and we can now know—or very soon, we'll actually know exactly who the designated women's health providers are, who is seeing women, where the women are seen and what kind of model—how long they've been seen in those types of clinics.  We're going to have a lot of granularity to the data about the delivery of health care.  That certainly is going to be a very powerful variable when we look at other clinical issues for women Veterans.

We are also improving our Reproductive Health Services as I've beefed up here and hired a director of Women's Reproductive Health, Dr. [Zeffman] and deputy of Reproductive Health, Dr. [Fibitz], program manager, project managers in reproductive health.  

We are seeing new and upcoming policies, maternity care coordination, where we designate that there must be a designated maternity care coordinator in each facility.  Infertility policy, as we expand and define an area that is constantly being re-defined for us, which is the area of reproductive health technologies, trying to fit VA policy within the guides of Congress and what Veterans most want from us and what they most need from us.  

We've had an interesting implementation of emergency contraceptive rights in terms of Plan B and how that has gone over in the VA world, just some of the challenges that we face.  The Caregiver Law gave us newborn care and childcare pilots will be needing evaluation of the childcare pilots, particularly in about 12 months.  

We also have put tremendous effort into influencing VA education initiatives.  The Women's Health Education had to figure out how to get new providers or retrained providers or interested providers in women's health and help make them proficient.  Most of you are probably aware of our National Women's Health Mini-Residency Program.  You may not be as aware of the standardized curriculum, but we've now trained 1,200 primary care providers, most of those trainings have been covered by IRV of consent and we can also go back and identify cohorts.  Many of the providers have been very interested in working with us on some of the outcome possiblities.  We haven't had research support to look at this tremendous amount of data that is available about what is the outcome of training people in Mini-Residencies?  

Another partnership that we've been very active in is similar and we are the kind of flagship topic area for SimLEARN, so SimLEARN has involved the Mini-Residencies, our ED curriculum.  We have pevic and breast [inaudible].  We have a computerized training called Mammocare, which is about learning to detect breast nodules.  In our overall strategic initiatives, we have a number of areas where SimLearn is our partner.  It's another area, of course, where it begs for more advanced research collaboration.  SimLEARN is really kind of the training of the future for a lot of medical practitioners and we were just at a meeting this morning with a number of people talking about we're on the cusp of this everywhere.  There's some research being done, but it's just a tremendously exciting area for research to be done.

We also have long supported the advanced fellowships in women Veterans health and we've been doing work to offer an additional fellowship site to support the current Women's Health fellowship sites and to expand fellowships beyond medical fellowships to the allied health groups.  Of course, advanced fellowships also have a tremendous focus on research, so we're trying to support the fellows in any part of the research that they would like to be involved in.

We also have monthly provider audio conferences and we've expanded this now to nurse audio conferences and my office co-sponsors a second VA Women's Health Research Conference, which was another agenda-setting conference for women health.  I think it's important for you to know—I didn't mention it earlier—that on the HSR&D Web site there is the information from the Women's Health Research Conferences and there is an evident synthesis for all the research that has been done recently and published in women's health.

So I mentioned briefly we've moved a little bit beyond providers and this picture actually is a picture of Dr. [inaudible] being trained on the computerized Mammocare breast training, but we have audio conferences in nursing, where we're expanding a year-long Mini-Residency series for nurses and as I said, we have developed ten modules now for training emergency room providers.  We also give out grants to the field for innovative educational projects, Telehealth pilots and any and all of these areas are areas for research collaboration.

Now I want to get to research, I've talked about research all the way along because my office partners very closely with researchers, people call me up, we talk about ideas, we get people hooked together, we do a lot of research networking.  We actually have a strategic goal that is focused on increasing our understanding of the effects of military service on women's lives.  So what are some of the things that the office has actually done.  We launched the Women's Health Evaluation Initiative, which is our partnership with Susan Frain and a great number of folks at Palo Alto to do deep dives into the [inaudible] database and [inaudible] files, so that we have a more complete understanding of the women Veterans who receive services in VA.  Out of that have been generated any number of research protocols, posters, some publications.  We always welcome people's interest in the work of the Women's Health Evaluation initiative.

I can't take any credit for it, but the Practice-Based Research Network which now have—I always forget this—37 sites, something like that, which is really a [bridgeful] network of folks in VA who want to study women Veterans and who want to be able to access significant numbers of women or their research protocols.  So the entire Practice Based Research Network is based on the idea of collaborative research and us helping you get enough women to study in the appropriate cells for your research work and there's much interest in that.  You can Google that and we could probably talk just about that for an hour, but the Practice Based Research Network is an exciting effort.  One of the things that's exciting about it is we had a sociologist looking at the work of research and women Veterans health care as a policy office and what he kept commenting about was how women will collaborate on research to get ahead.  Women who do research particularly seem to know that while there's competition to get publication, there's tremendous benefit of collaborating.  So the work in research in women's health has really grown exponentially in large part due to these kind of virtual networks that we've been working through.

We also have underway in VA a couple of cohorts, post- deployment health.  There are research efforts going on on combat and trauma exposure, many different kinds of mental health conditions and reproductive and gender specific health. 

The other thing that part of this research network has helped to do is it's another arm of the data—many people don't realize that prior to my coming to central office almost none of our databases were clean with regard to gender data.  One of my strongest efforts, I think, has been to push our data sources to clearly identify the sex and gender variable and then to be able to put it forth in a way that people could report on gender data.  So we've really grown from that era, we now have been able to look not just on gender specific disparities, but a lot of gender specific work.

I think one of the things that we have learned is we could go on looking at men versus women, gender disparity kind of work, or gender differences work, but many times the much more interesting work is the subjects of women that we can look at.  So looking at things by race, looking at things by ethnicity, by looking at geography and age, there's some very, very interesting examination of our population of women Veterans.  As I had mentioned and I actually honestly forgot they were on this slide, here is the systematic review, more research published on women Veterans over the past five years than in the preceding 25 years altogether.  I'm thankful to the evidence since this group—[inaudible] [Mayberry] for her work on the literature and it is an active literature.  Since this is a review, you can get the articles.

I mentioned Dr. Frain's work with us on the sociodemographics and use of VHA care.  We did the overall demographic for up to 2009 and we're going to add on the 2010 data and we're continuing to look at fee basis data.  We're actually looking at a lot of things about cost data and use of care and we're continuing to look at diagnoses and trying to tackle that very difficult area of race and ethnicity.

We've always been challenged by data quality issues.  For those of you who are not aware, you have to really pay attention to the employees that are in the [inaudible] database and then we're also challenged by looking at things over time and here is the link for electronic version of the Sourcebook and we still have paper versions I'd be happy to send to anyone who would like to have the hard copy on your desk.

A couple of things we learned from the Sourcebook, I just want to go over a couple of quick slides.  I touched on the frequency of women using VHA care in this slide—I'm not going to go into a lot of details.  Susan does a great job of talking about this, but just looking at women use VHA care intensely.  When you look at men versus women, you can see that in the more than 6 visits, the average visits, women are using VHA outpatient care more intensely than men do. 

Mental health use—we know that women more frequently than men have a mental health diagnosis and they also have a fairly high frequency of intense mental health use.  Here's the mental health use for—Slide 30 for men and women, comparing the two groups.  What is this about?  When we look at slides like this, we look to the issues of strategic planning, of training mental health providers.  We look at the issues of this pipeline of women that we need to be able to plan for.

As I mentioned early on, the increase in women with service-connected disabilities—this Slide 31 compares the year 2000 to the year 2009 and the actually quite significant increase in each category of service-connectedness in terms of our women Veterans how many have, for example, the greater than service-connected 100% and we don't know if this has to do with more claims, whether claims are being decided in women's favor or things like more combat experience, more trauma experience in general may lead to more claims.  We have no idea what it's about, but we are continuing to trend this information.

As I said, of the folks who use VA, of the Veteran patients proportionally more women with service-connected—and maybe a burden of illness connected with their service-connected rating.

So there's other ways that we look at understanding women Veterans.  Donna Washington performed the National Survey of Women  Veterans, the Executive Summary was released in 2010 and she'a published other articles since then.  It was a stratified sample, with 3,500 participants in one-hour telephone interviews.  We learned a lot about barriers to access, the fact that women who don't use VA have very low perception of the quality, but women who do use VA have fairly good perception—you know, report strong quality perceptions.  Congress has ordered us to do a scientific survey of women Veterans.  We are having meetings about the survey instrument and that will be rolled out late this year to OMB and then after that to the field.  That study will involve about 8,500 women Veterans.

The Women Vietnam Veterans long-term study is underway and they have been collecting data on women serving in country and a look back kind of study.  The OEF/OIF cohort study has a significant over sampling of women.  So the original target was 60,000 Veterans with 12,000 women in that environmental epidemiological study.

Just to summarize, the key kinds of research questions that I've been reviewing have to do with outcomes across the board about implementation of science, about education and having you all who are interested in this call today, be thinking with us, to tell us what we need more research on.  We have a very active partnership with a number of research centers in order that we can together truly explore the issues for women Veterans and for the subgroups of women who need our care.

We also are beginning to get a significant access to women who've never used VA and that for the future may be a way that we can help researchers compare women Veterans who did serve and deployed and non-deployed groups to women Veterans who used VHA care.  Only 17% of women Veterans used VA care and one of the mantras that I have often when I see published research is for people to continue to specify that the research is either about women who are in our VHA system or who are not, because my sense when we look at the burden of illness, the burden of service-connectedness, that we may have a different population who use VA from the population of women Veterans who do not use VA.

This is just a summary, we want to be able to disseminate the interventions that work, these are our areas of concern: quality across systems, access and awareness to care.  The things that women better need to learn about the care.  So I think we're ready now, Mollie, for questions and I'll let to take back to moderate.

Moderator:  Thank you very much, Dr. Hayes.  We have had some questions come in and for those of you that joined us after the top of the hour, I would like you to know that you do need to submit all questions and comments in writing.  Patty, the first issue that I would like to address is that we have had a couple requests for the hard copy of the Sourcebook.  Can you please remind people again who they can contact to receive a hard copy of that book?

Patricia Hayes:  Yes.  Then we can put it up on the site.  If they send an e-mail to Arethea Johnson, A-R-E-T-H-E-A  Johnson at va.gov, we will mail one.

Moderator:  Thank you very much and I can follow up by responding to each of these questions with her e-mail.  So the first question that came in—oh, go ahead.

Patricia Hayes:  People can contact me if you have any difficulty with that, that would be fine.

Moderator:  Thank you.  The first question that came in: "Is mental health engagement and improving access to these services a research priority?"

Patricia Hayes:  Certainly mental health engagement—part of why we didn't list that on my strategic priorities per se is because of our engagement with the Office of Mental Health, who now—and has had a branch on women Veterans mental health—their strategic priority is in many ways the engagement for women Veterans and mental health issues.  So absolutely, it's definitely a strategic engagement.  The other reason why I don't sort of put it forth as a huge issue is because about 60 or 70% of the research already underway is on mental health issues and it continues to be a high priority, but it's not as significant as a gap as we have in some of these other areas.

Moderator:  Thank you for that response.  The next question that came in is: "I understand VA is mandated to focus on VA research only, why does the VA refrain from partnering with outside researchers who research non-VA service providers like non-profits, et cetera?

Patricia Hayes:  I really can't totally address—I'm aware of the issue about PIs having to be VA employees and those kind of issues and the issues about research priorities from the [inaudible] research they'd have to address that.  I actually think that we are doing a good bit—much of women's health research in VA is actually funded by NIH or NIMH.  We, in my office, do a lot of cross-system work with non-profits and I certainly encourage people to look to other sources.  We're doing a lot of education through academic affiliations and through groups like the American Medical Association, [ANSIS], [SIGUM] and kind of name the kinds of partnerships that we've been developing—I don't know how that's being interpreted in terms of the rule of focusing on VA, but there are Veterans everywhere and I think that partnership—as long as the focus is in the best interest of Veterans, there certainly can be productive partnerships.

Moderator:  Thank you for that response.

Patricia Hayes:  I should mention and not to leave out DOD, because DOD is ramping up some great work on women in the military.

Moderator:  Thank you for that.  The next question that has come in: "What progress and needs are there for women health research involving health information technology, particularly with VA-EHR, VA Electronic Health Records?"

Patricia Hayes:  I am a little stumped on exactly how to answer that.  We have been involved and are continuing to be involved in work with the electronic health records and the development of the new [I-squared-HR], whatever it's currently called.  We need people to be beta sites or if they're beta sites for some of that, that they actually represent women [inaudible] in the development and health Informatics.  There's a lot of things in the electronic health records—I shouldn't say that.  There are gaps currently in the electronic health records that we are very aware of, things like last menstrual period, whether someone's on contraception or not   whether they have had a hysterectomy, some of those things being put together to be key issues for women, whether they've had children or not, all those things are things that are not currently in the record.  We've been working with the Informatics teams to find ways to get CPRS changed.

The other part is just really the issue of things like breast tracking, being part of the system in a way that takes into account a lot of non-VA information and so we're working with health Informatics teams on some of those issues.  I'm not sure if I answered the question, but I'll try again if you want to reframe it.

Moderator:  Thank you very much.  The next quetion: "What sorts of issues will the OEF/OIF cohort study be looking at?

Patricia Hayes:  There's more than one cohort study and I should refer to Dr. Haskell and her colleagues at Yale-West Haven who have a cohort of women, 1,500 women, that they have been looking at a lot of issues around mental health issues, depression, pregnancy, various things that they are looking at, stress responses and health and they compare men and women and women who are in the VA and not-VA and they also have other partners—I'm leaving the partners off right now because I can't remember their names right now, but that's one cohort.

The other is the Environmental [inaudible] Service is a survey and there are a lot of items in there that have to do with reproductive health.  So it asks about health occurences that are  gender specific, that occured while on active duty, also things like miscarriages and pregnancies and it started as a prospective study, so [there'll be] longitudinal data from that OEF/OIF epidemiological study.

Moderator:  Thank you for that response.  The next question that has come in: "Will the Vulnerability Screening Tool be completed by the WVPMs?

Patricia Hayes:  The Vulnerability Screening Tool is a homelessness screening tool and it's going to be rolled out.  It's actually right now in a very early pilot stage.  It's going to be the provider.  I should say that it's nested—there will be a screening tool that is rolled out by the Homelessness Group that every provider will be screening most patients, very simple couple of questions having to do with: "Are you at risk of being homeless right now today?"  We knew from Dr. Washington's research and others that there are some factors that are predictive of homelessness, even when someone isn't homeless today.  So the vulnerability tool is to look at—the provider and patient looking at together what are the things that might put her at higher risk of homelessness and so it would be a provider/patient tool.

Moderator:  Thank you for that response.  The next question: "Are there any initiatives to address gender neutral issues, specifically in women, such as diabetes, cardiovascular disease, obesity, et cetera?"  

Patricia Hayes:  We have some significant initiatives that we're already working on at my office.  I mentioned the cardiovascular risk group, there's actually a workgroup that's working on it if someone is interested.  They're beginning to look at everything from just the incidence of prevalence to whether women with certain cardiovascular risks or signs have gotten the appropriate testing in VA, than what's happened.  Each of those areas are areas that we need to put more initiative work in, both from research and from program action.  So we're just kind on the cusp of entering into each of those areas, but clearly clinical areas that we need to tackle.  There is some other research that is out there already, Dr. [inaudible] Mayberry's work on things like gender disparity in prevention screening for diabetics and other high risk groups there's also an [outcome] study there which you can refer to.  

Moderator:  Thank you for that response.  The next question: "Providing comprehensive primary care for women Veterans basic to VHA Handbook 1330.01 continues to be a challenge.  What does the research tell us about this challenge?"

Patricia Hayes:  I wish I had some research on it, that's where you can see some of the work that Becky [Yano] is designing, but we're hoping to get funded.  Right now we're collecting data on the relative implementation and what we know is that 99% of the hospitals, the bigger VA-MC facilities, have one women's health provider and about 60% of the C-blocks have at least one designated women's health provider.  So we know that there's a challenge, I don't have any data right now to tell us either the how and the why or what's happening to patients as a result of how long it takes to implement this.

Moderator:  Thank you for that response.  The next question: "There are some VAs where it is difficult to get female Veterans to participate in programming, how can the VA be creative in attracting more female Veterans to receive services?"

Patricia Hayes:  That question beggars sort of our whole outreach strategy and we are trying very hard at every level to get more media involvement, positive media involvement.  We also have done things like released public service announcements.  We have public service announcements that have actually been picked up by a lot of local stations and recently have found out that there were on during NFL games, so that the message to the community is that women are Veterans and then the message is we provide good care to you.  So many, many of the communications—there is an outreach toolkit that's on our site that lists everything from how to approach school groups and volunteers and PTAs and libraries to how to do things in the academic world and how to work with non-VA providers, to talk to them about their care of women Veterans, who they're seeing, but they don't know they're seeing.  So it's a multifaceted approach.  We know that some of it is working because the participation by women, market penetration has grown from 11% to 17% in the last four years, but it's not good enough, so we still have that challenge to continue forward.

The one thing we do know is that 'if you build it, they'll come', but it's not just if you build it, if you build the right kind of health care for women it grows very quickly at those sites, because women do tend to tell other women about their health care and that's one of the ways they find out about it.  So one way that a site that doesn't have very many women can also get women in is to implement the care and make sure that it's good care and change the environment and women will come.

I just want to add one other thing, which is, we have some recent data that we're looking at that we're in hopes to roll out from the New England cohort study.  Recent folks who have come to the VA, many of them have insurance, and yet they still say that they will continue to use the VA, despite having insurance to go elsewhere that the care is very good.  When the care is good, they choose VA over the other options.

Moderator:  Thank you for that response.  The next question: "Is there a need for better data collection for women Veterans use of contraception?"

Patricia Hayes:  I'm sure we can always use better data collection.  I would refer you to the work of Dr. Eleanor [Schwartz] and Dr. [Sonia Varel] located academically at Pittsburgh.  They're both looking at use of contraception in the VA, they've published and we certainly can get a lot more granularity about it, so, yes, it's an area where there's lots of work yet to be done.

Moderator:  Thank you for that response.  The next question: "Without local leadership, women's health services' improvements are slow to come.  Is there a central office program to help make hospital directors, chiefs of service, et cetera, aware of the high priority VA now places on women's health?"

Patricia Hayes:  We certainly have a number of ways that we work—there's both the carrot and the stick.  We frequently visit in the field, I actually talk to the facility directors and [inaudible] directors as often as I can.  Also for the first time ever, this year there is the stick, which is that the [division] performance requirements include progress on gender disparities in preventive care.  So that has gotten a good bit of attention on the women's programs and we think that there's a radiating effect, that if you start looking at one or two measures of gender neutral prevention issues for women, you're going to swoop in and pick up a lot of care for women when you do that.  We're tracking that as we go forward, there are some areas that are improving and we are reporting out to the field.  We just yesterday released a national report on some of our watch data by site visit.  In a week or so the facilities will be getting their individualized health assessment on how well they're rolling it out.  You're actually right in pointing out that it is a leadership issue.  Leadership has to be behind these issues in order to have the care for women be effective and be successful, so it's a tough issue.  It is a grassroots issue and it's a top-down issue and we're as involved as we can be in communicating that.

Moderator:  Thank you.  Next question: "With regard to the Breast Cancer Registry, will data be collected on all women seen in Women's Health clinics, Veterans employees, [inaudible] VA, or Veterans only?"

Patricia Hayes:  I don't know the answer to that.  Somebody's going to have to give us their name or whatever and we'll get back or we'll put it on the Web site.  I'm not sure because there's a big issue about the employee data being split aside.  If someone is a patient in the clinic, I believe we're going to have all the data, but I'm not certain of that.

Moderator:  Thank you.  If that person would like to type back in their contact information, we'll be happy to followup with you.  Next question: "Is TDR part of the Homeless Vulnerability Tool?"

Patricia Hayes:  I think it's a separate TDR screening, we're not trying to duplicate other screenings.  I'd have defer to Donna as to how that loads on the findings for prediction.  I just don't know the answers.

Moderator:  Thank you very much.  "The research initiative being considered for care and management of transgender Veterans, male to female, female to male?

Patricia Hayes:  Certainly.  We may have seen a shift in VA, even within the last six months, to get on board with recognizing transgendered Veterans and giving them dignified and respectful and appropriate medical care.  VA has stood up an Office of Health Equity, primarily to address the pending needs for putting together a strategic plan on transgendered, bisexual, lesbian, gay—so there's an administrative policy overlay that is making it more important and more critical to make sure that we tend to the needs of transgendered patients, transgendered Veterans.  One of the things we've known in women is that because of the population, more males than females, we actually have a fairly significant population of transgendered male to female being served in our women's clinics.  So women in the VA, women providers, have always been aware of many of the intricate medical and psychosocial issues for transgendered care.

A similar priority—it just didn't come down as one of the top five in my office, but we certainly are supportive and working with anybody who wants to do additional work, especially as VA implements some of the changes in policy about transgender care.  Tremendous oportunity to do work.

Moderator:  Thank you for that response.  The next question we have: "Are there any current initiatives examining racial, ethnic disparities in utlization and treatment among female Veterans?"

Patricia Hayes:  As an initiative, not per se.  You know, there are a number of areas—if you look at the work of the [inaudible] Center for Health Equity Research and [inaudible] at Pittsburgh and Philadelphia, they've done a lot of work on race and ethnicity, disparities in women, working with them as they've been subdivided [inaudible] by gender.  Frankly, the challenges in the VA around the race/ethnicity variable have been so significant that many researchers have kind of thrown up their hands.  We either get studies by race and ethnicity or by gender, but we don't as often get the subpopulation divided in the way that would be most effective for us, which is looking at the race/ethnic populations within the population of women.  

You may or may not know that of the OEF/OIF Veterans about 44% are non-white and so we are extremely aware that we need to be able to develop our health care system in a way that will be seen as appropriate by various subgroups of Veterans that will meet their needs, that will be one in which they can engage, that will be effective in terms of treatment outcomes and we need a tremendous amount of data on the subpopulations by race and ethnicity among our women Veteran cohorts.  So it continues to be a strong issue and certainly one that is supported by research, an RFP on those kinds of things is certainly supported in the research setting agenda.

Moderator:  Thank you.  Dr. Hayes, we do only have two questions remaining, are you able to stay on the line and finishing answering them?

Patricia Hayes:  Yes.

Moderator:  Thank you.  "Will there be a staff available to add a women's coach to the team to call and assist women Veterans to their clinic appointments?"

Patricia Hayes:  I'm not sure what the source of the question is, but the real issue is locally there needs to be implementation teams oe women's health councils or groups that are working on a strategic plan for serving women Veterans at that site.  That strategic plan has to include the right kind of clinics, including the PACT models, which have adjunct individuals, including nurse care managers, case managers, health coaches and others and clerks and technicians and chaperones.  The real issue is: is there significant buy-in locally with—is the team getting together and making sure that all the things that they need to do good health care are included in the team membership.  So I'm not sure how else to answer that question.

Moderator:  Thank you for that response.  The next question: "If someone is interested in participating in some of these research questions, how do they get involved?"

Patricia Hayes:  I would think that they want to go on the HSR&D Web site, read about the Practice-based Research Network.  If you have a specific issue, you can e-mail me.  You can also go to Linda Lipson and ask to be on the Women's Research List Serve.  You can do a number of things in terms of getting in touch with the Practice-based Research nNnetwork, but in the VA there is a List Serve for women's health researchers.  Linda Lipson, L-I-P-S-O-N at the Office of Research keeps that List Serve and can allow you to be on it and you can put your questions out there about gathering with other people that want to do the same research.

We can also guide you—if you send an e-mail to me and tell me the specific—give me some time to get back to you, but if you want to know—we can network you to other sites that might be doing what you're interested in doing.  So a number of different ways, look what's on the research site, make a little bit of clarity about what you want or who you want to explore it with and we'll see whether we can hook you in.

You can also look on the Office of Academic Affiliations and we can publish again the list where there's women's health fellowship sites because the fellowship folks are all doing research and may be a direct link to you for the kind of research you may want to do, if you have a fellowship at your site or nearby.  

Susan Frain:  I also wanted to say if you have not already joined the Women's Veterans Health Consortium, that would be something to do because then you're in the network and can list areas of research interest and Becky Yano takes the lead with that, with Ruth klap, as the program manager and can help point people to other people who are interested in research in their area, so contacting Ruth Klap, which is Ruth, R-U-T-H.K-L-A-P@vA.GOV, is a program manager for the consortium and she can connect you to the right directions as well.  There is a prior Cyberseminar in the archives, the VA HSR&D archives Cyberseminar,—is about the consortium and [inaudible] as well if you want to learn more about that.

Patricia Hayes:  Thank you, Susan.  I think that really is the best advice about it because you're getting linked in across the country to the like-minded researchers.

Moderator:  Thank you very much for providing us that information, Dr. Frain and I also do want to mention that Ruth Klap is also the person to contact to join the Women's Health List Serve as opposed to Linda Lipson just an FYI, so again that the e-mail address is ruth.klap@va.gov and she will happily add you to the List Serve.  Okay.  That is our final question, so Dr. Hayes I'd like to see if you have any concluding comments you'd like to make.

Patricia Hayes:  No.  I simply appreciate the number of folks who dialed in today and your interest in women's health and I hope you feel encouraged that there are many, many opportunities to have research that will really be very helpful to women Veterans.  So thank you for your interest.

Moderator:  I, too, would like to echo my thanks for our audience joining us today and especially to Dr. Hayes for joining us and providing her expertise and for Susan Frain for her help as well and I do want to let people know about our next women's health session and that will take place next month June 28th at 12:00 p.m. Eastern, that is presented by Dr. Hector Rodriguez at UCLA and the topic will be Primary Care [inaudible] Formation and Evolution—Implications for Women's Health.  So please do join us for that and as both Dr. Frain and Dr. Hayes mentioned, you can access all the upcoming Cyberseminars and archived ones by going to the HSR&D Web site and you can look at the left navigation bar and you can open up the Cyberseminar catalog.  So again I would like to thank you all for joining us and this does formally conclude today's HSR&D Cyberseminar.

**[End of Recording]**