[House Hearing, 109 Congress]
[From the U.S. Government Publishing Office]


 
SEAMLESS TRANSITION: WHERE ARE WE NOW?


WEDNESDAY, SEPTEMBER 28, 2005

U.S. HOUSE OF REPRESENTATIVES,     
COMMITTEE ON VETERANS' AFFAIRS,
Washington, D.C.

	The Committee met, pursuant to notice, at 10:39 a.m., in room 334, 
Cannon House Office Building, Hon. Steve Buyer [Chairman of the Committee] 
presiding.
	Present:  Representatives Buyer, Everett, Miller, Boozman, Evans, 
Snyder, and Michaud.

	THE CHAIRMAN. The hearing of the the House Veterans' Affairs Committee 
will come to order.  The hearing will address Seamless Transition.  The date 
is September 28, 2005.
	First of all, I would like for everyone to know that I also sit on 
Energy and Commerce, and we are in the middle of a markup right now on an 
energy bill relative to expanding our refinery, storage, pipeline, and 
investigation with regard to potential gas price gouging, and that is 
occurring right now, and we're in an amendment process.  So if I am called 
out, Mr. Boozman will take the chair.
	Today's hearing will provide the Committee with an update on the 
Department of Veterans Affairs and the Department of Defense in their efforts 
to implement Seamless Transition.
	Over the last year, myself and other distinguished members of this 
Committee, along with staff, have conducted numerous field and site visits at 
VA and military treatment facilities and military bases.
	I am concerned that there is a significant disconnect between what 
Congress envisions, what the VA envisions, and what DOD policy makers 
envision, and what the three of us are initiating and what is actually taking 
place not only in Congress but also at all levels of the two departments.
	Unfortunately, this disconnect that I will refer to, I believe, is 
coming at a significant cost to our taxpayers and, more importantly, to our 
soldiers, sailors, airmen, and Marines, Coast Guardsmen, and their families 
that have unselfishly served and sacrificed to our nation.
	It appears to me that the two departments continue to issue broad 
policy statements regarding Seamless Transition, VA-DOD sharing, and other 
initiatives, with little action on implementing congressionally mandated 
guidance from two different defense bills.
	Although the term "Seamless Transition" is a relatively new word that 
is thrown around in this town, the concept was codified into law in 1982, when 
Congress passed the Veterans Administration and the Department of Defense 
Health Resources Sharing and Emergency Operations Act, often referred to as 
the Sharing Act.  The Sharing Act created the VA-DOD Health Care Resources 
Sharing Committee to supervise and manage opportunities to share medical 
resources.
	In 1996, the departments renamed the Sharing Committee the VA-DOD 
Executive Council.
	In 2002, the departments administratively created the VA-DOD Joint 
Executive Council to provide oversight to the executive council on health care 
sharing.
	In 2002, Congress amended Title 38 to mandate that the departments' 
under secretaries head the Joint Executive Council, and in 2003, Congress 
codified the Joint Executive Council into law.  Congress directed the JEC to 
review all aspects of both departments to include plans for the acquisition of 
additional resources, especially new facilities and major equipment and 
technology, in order to assess potential opportunities for the coordination 
and sharing of resources.
	Congress also directed the Secretary of Veterans Affairs and the 
Secretary of Defense, in section 721 of Fiscal Year '03, National Defense 
Authorization Act, to develop a joint strategic vision and a strategic plan 
to shape, focus, and prioritize the coordination and sharing efforts among the 
appropriate elements of the two departments.  Section 721 also required them 
to incorporate the goals and requirements of the joint sharing plan into 
strategic and performance plans of each department under the Government 
Performance and Results Act, herein referred to as the GPRA.
	Despite 20 years of congressional mandates for VA-DOD resource 
sharing, various name changes, other administrative actions, a presidential 
task force, the two departments are still operating, I believe, in separate 
worlds.  Even though, yes, they are meeting, yes, they are talking, we are 
very anxious for some action.
	Equally troubling, the two departments have been working in this 
exchange of patient health information electronically for now over seven 
years.
	One of the largest and most far-reaching task force recommendation 
that VA and DOD developed and deployed this by 2005, the electronic medical 
records -- they asked that they be interoperable, bi-directional, and 
standards-based.
	Currently, service members transitioning to veteran status must still 
make hard copies of their military medical records and hand-deliver them to 
the VA, because each department is proceeding separately with the development 
of its own respective health information system, VA's HealtheVet VistA, and 
DOD's Composite Health Care System II.
	The estimated cost of these separate independent systems is 
approximately 1.2 billion and 3.8 billion respectfully.
	In addition, the two departments differ in their legal interpretations 
of HIPAA, the Health Insurance Portability and Accountability Act, Privacy 
Rule.
	Quite frankly, I believe that is unacceptable.
	For these reasons, I have asked representatives from GAO and Health 
and Human Services to testify about their observations regarding HIPAA.
	So, when I visited the polytrauma center in Minneapolis, I was disturbed 
when I heard that certain things couldn't be done because of HIPAA.
	In addition, the Committee will hear testimony from experts in the field of health information technology.
	Lastly, I want the Committee to hear firsthand from VA and DOD 
regarding their efforts to collaborate and coordinate policy, people, and 
resources to achieve the Seamless Transition.
	Our service personnel and their families have faithfully and 
diligently served this nation well, providing for their benefits reflect the 
gratitude of a grateful nation.
	It also serves to say thank you for your sacrifice and unselfish 
commitment in protecting America's cherished freedoms and liberties.  I fully 
expect both departments to work together to fulfill this moral and legal 
mandate.
	Unfortunately, I sincerely question the level of commitment by DOD on 
making Seamless Transition a priority. Simply put, this Committee invited 
Under Secretary Chu to appear here today.  He declined.
	According to his office, his schedule could not accommodate this 
important hearing.  Equally telling, Secretary Chu's Assistant Secretary for 
Health Affairs, Dr. Winkenwerder, was equally not available to testify.
	Given the importance of this issue, I am deeply troubled by both of 
them omitting their appearance here today, but I welcome the testimony of the 
Principal Deputy Assistant Secretary of Health Affairs and the Office of 
Personnel and Readiness.
	It is more appropriate for this Committee, though, to hear from the 
Under Secretary Chu himself.  After all, he serves as the legally appointed 
department head on the Joint Executive Council.  His counterpart thought 
enough of this issue to appear.
	I would like to now recognize the Ranking Member, the gentleman from 
Illinois, Mr. Evans.
	MR. EVANS. Thank you, Mr. Chairman.
	It is interesting that, after five recent hearings on this topic, why 
you must now ask DOD and VA to define what they mean by the term "Seamless 
Transition," as you did in their letters of invitation to this hearing.  We 
should be asking each agency to demonstrate achievement based on measured 
performance.  That said, VA and DOD have agreed on procedures to achieve a 
more seamless transition than what has been proposed.
	They also have generally assured, for example, that the most seriously 
injured do not slip through the cracks in the medical system.  We need to 
review performance to judge the real impact on veterans. Our efforts must 
appeal to a broad spectrum of our veterans needs.
	Mr. Chairman, clearly, there is progress, but some of these issues 
continue to impede further process and development.
	HIPAA, continues to impact information exchange between DOD and VA.  
We should strive to resolve this and other impediments, and I appreciate you 
holding the hearing.  Both the Democratic and Republican caucuses, I think, 
are in session.  Technically, we should not be, but we need to get moving on 
this issue and not wait for the problem with the attendance at our respective 
caucuses.
	I yield back, Mr. Chairman.
	THE CHAIRMAN. I associate myself with the comments of Mr. Evans and 
appreciate his cooperation so we may proceed.
	At this point, I recognize Mr. Boozman for an opening statement.
	MR. BOOZMAN. Thank you, Mr. Chairman, and I thank you and Mr. Evans 
for holding this hearing.  It is such an important topic.
	I would like to comment briefly about the subCommittee meeting that we 
had in New Hampshire a week or so ago.  We had a field hearing, and Mr. 
Bradley was there, and Mr. Michaud, and it really went very, very well.
	I was especially pleased with what we heard from our witnesses.
	In a nutshell, New Hampshire is doing it right, and I hope the 
witnesses from the National Guard Bureau and other Federal agencies will 
export those best practices nationwide.
	I think the first lesson that we took away from the hearing is 
involving the families of the soldier pre-, during, and post-deployment in a 
program of education and counseling that is very vital.
	The second most important issue is that the Army must make several days of 
active duty drill time available to the returning Guard units to conduct this 
early intervention-type program.
	Thirdly, the VA vet center system plays a key role in minimizing post-
deployment de-mobilization readjustment issues, and we heard that, I think, 
over and over again, and fourth, the National Guard Bureau needs to impose 
these best practices across the nation.
	The New Hampshire Guard has designed a program called Reunion and 
Entry for returning Guardsmen and their families.  The program makes use of 
resources from VA vets, small business development centers, and state agencies 
such as the employment service and highway patrol.
	Guard personnel involved included those from combat arms and support 
units.  The program truly is excellent.
	Col. Deb Carter deserves an awful lot of credit. She met with leaders from 
the 82nd Airborne, Marines, and Navy, determined best practices going into this.
	They lined up the agencies to train 300 full-time staff and 500 family 
members in suicide prevention, PTSD, and access to resources, and as a result, 
again, their efforts have been very, very good.
	The soldiers went through a five-day Army de-mobilization at Fort Dix, 
returned home.  Then they were given the day off to unite with their families 
and were called to participate in a three-day tap featuring educational and 
stress-related issues, and I want to submit the rest of this to the record so we 
can go ahead and move on and get the testimony, but again, I really do want to 
compliment the New Hampshire group.  I think they are doing an excellent job.
	One of the problems that we have with the Guard units versus the regular 
units is that it's unlike coming back with your unit and it's kind of business 
as usual.  These folks are going back to the civilian work place, and the 
transition is much more difficult, I think.
	So, again, thank you, Mr. Chairman and Mr. Evans, for having the hearing.
	Mr. Chairman, I would also like Col. Carter's statement from the field 
hearing to be made part of the record, so that others may learn from her 
experience.
	THE CHAIRMAN. Hearing no objection, so ordered.
	MR. BOOZMAN. Thank you.
	[The attachment appears on p. 166]
	
	THE CHAIRMAN. I would now like to yield to Dr. Snyder, and before I do 
that, let me thank you.  I want to thank you and Chairman McHugh for the work 
that you did in the 2003 and 2004 defense bill, along with Lane Evans and 
others. I mean when you go through, and I had an opportunity to go in greater 
detail, exactly what you laid out to DOD and VA with regard to this issue, and 
you did it twice, and you have really -- it is a very fine product, and so, 
we're going to get into this today about what they have picked and chosen to 
follow and not follow, and so, I am really pleased that you are here.
	Mr. Michaud?
	MR. MICHAUD. Thank you very much, Mr. Chairman. I, too, want to thank you, 
Mr. Chairman, and Ranking Member Evans, for having this hearing.
	It is extremely important that we do have that seamless transition.
	We did have a very good hearing in New Hampshire, and I took a lot away 
from that hearing, and I appreciate Chairman Boozman for having it in New 
Hampshire, and I agree with -- associate myself with his remarks as far as what 
we heard in New Hampshire, and I look forward to hearing from both panels today, 
as far as the seamless transition.
	I yield back the balance of my time.
	THE CHAIRMAN. For the record, Dr. Snyder is the Ranking Member on the 
personnel Subcommittee of the House Armed Services Committee, and helped co-
author the two provisions in the '03 and '04 defense bills referencing 
collaboration and DOD-VA sharing.
	Mr. Miller, do you have an opening statement?
	MR. MILLER. I will enter it in the record, Mr. Chairman.
	THE CHAIRMAN. Your statement will be submitted for the record.
	[The statement of Mr. Miller appears on p. 64]
 
	THE CHAIRMAN. All members' statements may be submitted for the record and 
have three days to do so.
	At this point, we will recognize our first panel, Ms. Cynthia Bascetta, 
the Director of Veterans Health and Benefits Issues, United States Government 
Accountability Office; Ms. Linda Koontz, the Director of Information Management 
Issues, United States Government Accountability Office; Dr. Jonathan Javitt, the 
former presidential appointee to the President's Information Technology Advisory 
Committee, Health Care Delivery and Information Technology SubCommittee; and Dr. 
Peter Dysert, the Chief Medical Information Office, Baylor University Medical 
Center.
	I would ask our witnesses to limit their oral testimony to five minutes.
	Do each of you have a written statement?
	They have all nodded their head in the affirmative, and I will ask that 
your written statement will be made part of the official hearing record, and I 
will ask all members to hold questions until the panel has completed, and I now 
recognize the first panel.
	We may proceed first with Ms. Bascetta.

STATEMENTS OF MS. CYNTHIA BASCETTA, DIRECTOR, VETERANS HEALTH AND BENEFITS 
ISSUES, U.S. GOVERNMENT ACCOUNTABILITY OFFICE; ACCOMPANIED BY MS. LINDA 
KOONTZ, DIRECTOR, INFORMATION MANAGEMENT ISSUES, U.S. GOVERNMENT 
ACCOUNTABILITY OFFICE; JONATHAN JAVITT, M.D., M.P.H., FORMER PRESIDENTIAL
APPOINTEE, PRESIDENT'S INFORMATION TECHNOLOGY ADVISORY COMMITTEE (PITAC), 
HEALTH CARE DELIVERY AND INFORMATION TECHNOLOGY SUBCOMMITTEE; AND PETER 
DYSERT, M.D., CHIEF MEDICAL INFORMATION OFFICER, BAYLOR UNIVERSITY MEDICAL 
CENTER

STATEMENT OF MS. CYNTHIA BASCETTA

	MS. BASCETTA. Thank you, Mr. Chairman, and members of the Committee.
	I am pleased to be here today to discuss our ongoing review of VA's 
efforts to collaborate with DOD to ensure a seamless transition to VA health 
care for service members. DOD recently reported that more than 15,000 OEF/OIF 
service members have been wounded in combat, and both the Congress and the 
President have urged the departments to ensure that service members experience a 
smooth transition to VA's health care system.
	I would like to make two points today.
	The first is that VA has instituted policies, procedures, and outreach 
efforts designed to provide OEF/OIF service members with timely access to health 
care.  We will be evaluating the effectiveness of VA's actions in our ongoing 
work.
	Since 2002, VA has taken important steps, some at the direction of this 
Committee, to improve service members' transition.
	The Secretary's April 2003 memorandum, for example, authorized VA to give 
service members who sustained combat injuries priority access to VA health care.
	Three subsequent directives put additional transition-related policies in 
place.
	One requires each VA medical facility to designate a clinically trained 
combat case manager to coordinate care.
	A second directive requires each medical facility to designate a point of 
contact to receive and expedite transfers from MTFs to VA medical facilities, 
and a third directive expanded the scope of care at certain facilities to create 
four polytrauma rehabilitation centers.
	Notably, these centers provide psychological treatment for family members 
and use high-technology prosthetics to maximize the recovery of service members 
with severe and disabling trauma.
	Besides these directives, VA and DOD jointly established a program to 
place VHA social workers at selected MTFs to coordinate the transfers from 
military to VA health care for service members.  VBA benefit counselors are also 
located in the MTFs to assist in filing claims for disability compensation, 
vocational rehabilitation, and other VA benefits.
	In addition, vet centers hired 50 peer counselors in 2004, and VA is 
planning to hire 50 more this year to provide outreach in home communities for 
those veterans in need of readjustment services, including counseling, 
employment assistance, and other social services.
	The second point I would like to make today concerns a vital transition 
issue involving the sharing of health care information between DOD and VA.
	While progress has been made since we last testified on this issue about 
four months ago, the absence of specific data sharing procedures continues to 
hinder VA's efforts to obtain needed health information from DOD.
	Specifically, we have been tracking the progress VA and DOD have made in 
sharing health information.  On the positive side, VA officials told us that DOD 
is expected to transmit deployment health assessment data to VA monthly 
beginning in October 2005.
	This routine data sharing will be useful to VA clinicians, who will be 
able to access the data in the course of treating OEF/OIF service members who 
arrive at the VA for care.
	The data includes, for example, service members' answers to questions 
about potential exposures to toxic substances and psychological injuries that 
could benefit from mental health services.  But, at this time, DOD does not have 
plans to transmit the same health assessment data for National Guard and reserve 
members, who, as you know, comprise about 35 percent of the OEF/OIF forces.
	VA officials told us that it would be helpful to receive individual health 
assessment data in aggregate form, in addition to the individual data, to plan 
for the needs of current service members who may seek VA health care.  Sharing 
this information would be consistent with the President's task force finding 
that comprehensive health data is essential for VA to forecast and prepare for 
changes in the demand for health care services.
	Another shortcoming is the lack of a data sharing agreement on the 
specific types of health information that will be exchanged and when the 
information will be shared for those who may transition to VA health care.
	VA and DOD signed an MOU in June this year, but it does not constitute an 
agreement for the routine sharing of health information.
	For example, VA officials still do not receive a list of service members 
undergoing a physical evaluation board for separation from the military.
	With this information, VA believes it would be better positioned to make 
appropriate transfers to VA health care prior to discharge and to reduce the 
chance of interruption in medical treatment plans.
	DOD officials told us they are working on a policy directive to do this, 
and I was informed this morning that it was signed yesterday.
	Mr. Chairman, this concludes my remarks, and I would be pleased to answer 
questions that you or the other members may have.
	[The statement of Ms. Cynthia Bascetta appears on p. 66]
 
	THE CHAIRMAN. Thank you very much.
	Ms. Koontz?

STATEMENT OF MS. LINDA KOONTZ

	MS. KOONTZ. Mr. Chairman and members of the Committee, I am pleased to 
participate in today's discussion of the efforts of the Departments of Veterans 
Affairs and Defense to make transition of active duty personnel to veteran 
status as seamless as possible.
	One goal of these efforts is for the two departments to be able to 
exchange patient health information electronically, and ultimately, to have 
interoperable electronic medical records.
	Sharing of medical information can help ensure that active duty military 
personnel and veterans receive high-quality health care and assistance with 
disability claims, goals that, in the face of current military responses to 
national and foreign crises, are more essential than ever.
	As you know, for the past seven years, VA and DOD have been working to 
achieve these capabilities, beginning with a joint project in 1998 to develop a 
government computer-based patient record.
	As we have noted in previous testimony, the departments achieved a measure 
of success in sharing data through the one-way transfer of health information 
from DOD to VA.  However, the longer-term objective of virtual medical record is 
more complex and challenging, and potentially much more rewarding.  For example, 
the data in the virtual medical record are to be computable.  That is, they are 
not just displayed as in a paper record.  Computable data are powerful. They can 
trigger actions alerting clinicians of a drug allergy, for instance, or of a 
significant change in the vital signs, such as blood pressure.
	To achieve this longer-term objective, the departments have much work 
still to do.
	In the past year, VA and DOD have built on their previous efforts and 
begun to implement applications that exchange limited electronic medical 
information between the departments' existing health information systems.  These 
applications were developed through two information technology demonstration 
projects.
	The first application, bi-directional health information exchange, enables 
the two-way exchange of health information on shared patients.
	The departments have implemented this application at five sites, where it 
is being used for rapid exchange of information on shared patients, specifically 
pharmacy data, drug and food allergy information, patient demographics, and 
laboratory results.
	The second application, laboratory data sharing interface, allows the 
departments to use each other's laboratory resources.
	It enables them to rapidly send and receive lab orders and results, all 
electronically.  This application has been implemented at six sites.
	The two applications have significant benefits, according to the 
departments, because they enable lower costs and better service to patients by 
saving time and avoiding errors.
	Since our last report on the department's efforts to achieve a virtual 
medical record, VA and DOD have taken several actions, but the departments have 
not yet achieved the two-way electronic data exchange capability originally 
envisioned.
	They have implemented three recommendations that we made in June 2004.
	They have developed an architecture for the electronic interface between 
DOD's clinical data repository and VA's health data repository, which are to 
contain the medical record information that will be accessed by the department's 
next-generation systems.
	They established the VA-DOD Health Executive Council as the lead entity 
for the interface project, and they established a joint project management 
structure to provide day-to-day guidance for the initiative.
	However, the department's project management plan for the interface 
development is not yet sufficiently detailed.
	Moreover, the departments have experienced delays in their efforts to 
begin exchanging computable patient health data, and they have not yet fully 
populated their data repositories with the information that they intend to 
exchange.
	In summary, Mr. Chairman, developing an electronic interface that will 
enable VA and DOD to exchange computable patient medical records is a highly 
complex undertaking that could lead to substantial benefits.
	VA and DOD have made progress in the electronic sharing of patient health 
data in their limited near-term demonstration projects.
	They have also taken an important step toward their long-term goals by 
improving the management of the program to develop the all important interface 
between the two data repositories.
	However, the departments still face considerable work and significant 
challenged before they can achieve their long-term goals.
	This concludes my statement.  I would be happy to answer questions at the 
appropriate time.
	[The statement of Ms. Linda Koontz appears on p. 82]
	THE CHAIRMAN. Thank you, Ms. Koontz.
	Dr. Javitt?

STATEMENT OF JONATHAN JAVITT, M.D., M.P.H.C

	DR. JAVITT. Thank you, Mr. Chairman.  Thank you for inviting me back to 
this Committee.
	You have asked me to bring your Committee up to date on mature, scaleable 
private sector technologies for two-way health data interchange.
	Now, I have founded and directed publicly-traded companies that deliver 
electronic health solutions.  I have served as the senior executive of Fortune 
100 companies that deliver such solutions, and my family's financial security is 
tied to the premise that the private sector can ultimately construct and deliver 
e-health solutions that save money while they are saving lives and suffering.
	Despite my private sector credentials and experience, it is my duty to 
tell you that the current comprehensive electronic health environment of the 
Veterans Health Administration surpasses any capability available today on the 
planet, whether in the private sector, other departments of the U.S. Government, 
or the highly profiled activities of other countries.
	Let me be clear that I am speaking only about VistA CPRS and not about 
VA's personnel or financial management software initiatives.
	I offer that opinion as one who strongly supports President Bush's 
policies, including those expressed in OMB Circular A76, and who is proud to 
have been commissioned by the President to lead the PITAC's Committee on health 
care and the report on revolutionizing health care through information 
technology.
	The Committee I chaired was composed entirely of individuals from the 
private sector, including former senior Microsoft and Oracle executives, the 
chairmen of computer science and electrical engineering at two prestigious 
universities, and we received extensive input from the entire IT community.
	I will admit that our initial working assumption was that the VA approach 
to e-health, using MUMPS and other less-than-mainstream technologies, must be an 
example of government waste and inefficiency.
	Instead, after examining the VA's achievement on paper, in testimony, and 
in numerous sites of care, we concluded that the VA had built something unique, 
something that should be considered a national treasure and a resource to be 
leveraged into the private sector.
	I had the honor of accompanying President Bush and senior members of his 
administration to examine the electronic health records system of the VA and 
their capabilities for health data interchange.  On that occasion, the president 
noted information technology hasn't really shown up in health care yet, but it 
has in one place, in one department, and that's the Department of Veterans 
Affairs.
	Notably, Medicare administrator Mark McClellan, himself a physician and a 
conservative economist, who served on President Bush's Council of Economic 
Advisors, came to the same conclusion in urging that the VA system be adopted by 
medical care givers across the country as a low-cost means of entering the e-
health world.
	As I understand the issue before this Committee, there should be no 
question about whether the Veterans Health Administration has used homegrown 
information technology to create a miraculous transformation in our ability to 
move health care information where it needs to go.  A pile of scholarly articles 
several feet high attests to the fact that medical errors occur in fewer than 
one in 10,000 prescriptions in veterans hospitals, compared to one in five 
prescriptions in paper-driven private sector hospitals.  The article from the 
New England Journal that I have submitted to you documents that our nation's 
veterans receive higher-quality care than is received under Medicare for 
conditions such as diabetes and heart disease, to name two of 12 conditions.
	Other studies point to the demonstrated improvements in diabetes 
management, care for patients with congestive heart failure, smoking cessation, 
cholesterol reduction, pneumonia, and influenza vaccination, and other health 
outcomes among Americans' veterans that far surpass comparable measures in the 
private sector.
	The VA system is remarkably stable and secure.  Most recently, the 
Department of Health and Human Services in the civilian sector has been forced 
to allocate hundreds of millions of dollars to reconstructing health records 
destroyed in the wake of Hurricane Katrina.  In contrast, it took the Veterans 
Health Administration less than 100 hours of staff time to safely transfer all 
records from the disaster zone to Texas.  They would have done it electronically 
instead of by magnetic media had the regional private sector-run 
telecommunications infrastructure remained viable.
	Your Committee has heard testimony on this subject from former Secretary 
Principi and a host of others, and yet a parade of contractors from private 
sector interests come before you regularly and ask that you fix what is not 
broken in favor of the principle that small government is better than big 
government and that the private sector, given sufficient resources, will provide 
better quality, more efficient, lower-cost solutions than government employees.  
Despite the fact that these contractors have not yet built a viable distributed 
electronic health record that spans institutions, either in the private sector 
or for the Department of Defense, they will certainly promise to deliver on 
spec, on time, and on budget for the VA.
	As the article from the IEEE that I have brought you documents, such 
massive contractor-led Federal software projects are likely to fail.
	In fact, an honest look at the origins of the current CPRS program of the 
VA will readily discern that CPRS was born out of the ashes of a failed 
contractor-driven attempt to build a VA medical records system.
	In general, I believe in small government and out-sourcing, just as I 
believe in basic principles of aerodynamics.
	However, when I watch an aerodynamically implausible bumblebee fly across 
my back yard, my first impulse is not to legislate it out of existence.
	There are exceptions to every rule, and the electronic medical records 
system of the VA is a notable exception to the principles of OMB Circular A76.
	The irony of this all is that card-carrying IT professionals would call 
the dedicated professionals within the VA dangerous amateurs, in the same way 
that the executives of major computer companies that no longer exist spoke with 
derision about Jobs, Wozniak, and Gates.  To an IT professional, there is 
nothing fundamentally different about computerizing the traffic control system 
of London, England, and computerizing the English national health system, except 
that the Brits, after spending $10 billion, are finding out that there are 
substantial differences.
	In short, the answer to locating the best technology for two-way health 
data interchange is to look no further than the information technology apparatus 
of the Veterans Administration, and to continue to encourage and to demand two-
way data interchange with the Department of Defense, and to lower whatever 
barriers can be lowered by congressional mandate that exist in HIPAA.
	I would advise this Committee to continue careful, thoughtful, and 
aggressive oversight to make private sector resources available to help the VA 
implement mainstream solutions that may be more scaleable than some of the 
current solutions built of necessity, and to allocate funds to leverage the 
pioneering concepts and solutions of the Veterans Health Care Administration 
into the private sector.  To do anything else would be a disservice to our 
veterans and ultimately to our nation.
	Thank you.
	[The statement of Jonathan Javitt, M.D., M.P.H., appears on p. 104]
	THE CHAIRMAN. Thank you, Dr. Javitt.
	Dr. Dysert?




STATEMENT OF PETER DYSERT, M.D.

	DR. DYSERT. Yes.
	Chairman Buyer, Ranking Member Evans, and members of the Committee, thank 
you for the time to be here today to share my perspective and relay to you some 
of the experiences I have had in the private sector trying to successfully 
computerize clinical care.
	My written remarks are a matter of record, so I am not going to bore you 
with repeating those, and I am also not going to sit up here and read to you 
kind of my position. What I would like to do is take the five minutes you have 
granted me to have a conversation with you from my perspective as somebody who 
is really in the middle of a $140 million project of trying to convert our 
hospital from being paper-based to electronic-based.
	Let me start my remarks by telling you I am not going to use very 
technical terms, because in my opinion, a lot of these projects have kind of 
sunk to the level of pure technology, and words like transmission and interfaces 
and things like that have shifted the focus of these projects to a technical 
level in taking them away from the very human dimension of both the people who 
use the systems and the people who receive the care delivered by care providers.
	First of all, just some general observations about computer application 
designs.
	From my perspective, the rationale for making investments in technology is 
not at a feature and function level.
	It is the ability of the application to support work flow, and the focus, 
in return for investment in technology, should be primarily focused to achieving 
efficiencies and improvements in productivity.
	When you look at a project, those should be the words you should be 
hearing played back to you.  What's this going to do to provider efficiency and 
productivity?  Because then it gives you the context to ask a very non-technical 
and simple question:  How effective can a computer system be when it takes an 
inherently mobile professional like a physician or a nurse, forces them to sit 
down at a computer terminal after the fact, and document work they've already 
done?  In my opinion, there is a very important link in this goal for safety and 
quality that's related to efficiency in productivity.
	The reason quality pays and the reason technology is a wise investment in 
supporting quality -- it will only deliver if it improves the efficiency and the 
productivity of the people trying to deliver care.
	The second point I will make is most existing technology solutions in 
health care are architected around computable or structured data, when, in 
reality, the practicalities of care involves all four information types of free 
text, data, speech, and image, and any successful solution needs to incorporate 
to the same level of value all of the information types.
	The human interface design, again around productivity and efficiency, is a 
very important consideration.  Most physicians in my world tell me that any time 
a computer application relegates the interchange from their perspective to one 
of a clerk-type activity, that's the -- they didn't go to medical school to be a 
clerk.  They went to medical school to be a physician.
	So, any time you transform the human interaction for care providers to one 
of being a clerk and documenting work they have already done, it is the best and 
most legitimate reason for providers of care to push back from using that 
technology.
	I would like to close my remarks -- and again, I have given you in my 
written testimony kind of the blueprint that we followed on a technology level, 
and there are probably terms you do not understand, but I will just tell you, if 
you are not hearing these terms played back to you as you look at investing in 
future solutions, then I think you are not buying the right product.
	The points I want to make are central.
	Number one, efficiency and productivity, the value for the investment in 
technology needs to return in that space, and it will deliver quality.
	The whole concept of seamless and integration does not need to be bi-
directional, does not need to be transmitted or any of those types of things, it 
needs to put the center of that, the human facet, and concepts like access need 
to become important.
	Can I, through a browser link, simply get access to information in another 
system, and do not leave it to the technologist to integrate the data, but 
remember, I have got a brain, and cognitively, the whole idea of seamlessness 
needs to put the human user in the center of the discussion and relegate the 
technology terms to something technology people talk about.
	It needs to be focused on terms like access.  Can I access this 
information?
	For example, if you have invested in creating a system to support all the 
VA hospitals, are all the records basically accessible, do not need to be moved 
or transmitted? Can we use internet families of technology to answer and access 
that kind of information?
	I would close my technology comment by saying that why in the world would 
anybody building a health care platform today ignore the success and the 
capabilities, the scaleability of the internet family of technologies?  I think 
if the internet and the browser has done one thing, they have taken the role of 
the computer and moved it from something purely technical people saw value in so 
that us non-technical types see value in the computer using browser and internet 
technology, and I would just encourage this Committee to look forward and look 
at its investments and thing of things like inter-operability and communication 
in terms of things like access.
	Can the user access this information?
	The last principle I would leave you with is one I try to operate against 
every day.
	Perfect is the enemy of good.
	Thank you very much for your valuable time and the opportunity to testify, 
and I would be glad to take your questions.
	[The statement of Peter Dysert, M.D. appears on p. 107]

	THE CHAIRMAN. Perfect is the enemy of good.
	Well, it is an inquisitive statement.  I guess it is why I am so bothered 
that the torte lawyers have sort of moved America away from negligence to 
comparative negligence to now strict liability standards in almost every 
jurisdiction, you know.
	I am sorry.  That is what I was thinking by your statement.
	Let me thank both of you, actually the entire panel, in particular -- I 
have heard from the ladies quite a bit, so let me just be complimentary to my 
other two witnesses, okay, for a second.
	It is refreshing.
	It is what we hope to expect when we ask people to testify before a 
congressional panel, not that I agree with everything that you said, but you 
stated your opinions, and you stated them professionally, and that is refreshing 
to me, and I am sure to my colleagues that were listening to you, because what 
you are sharing with us is helpful, and I appreciate that.
	We get that from the General Accounting Office.  We do not always get that 
from witnesses, and I just want you to know, personally, for me, it is very 
refreshing.
	Since you went last, Dr. Dysert, you had mentioned that IT must deliver on 
efficiency and productivity.  If I may, I would add a preposition to it.
	IT must deliver on efficiency and productivity to improve safety and 
quality patient care.
	You concur, right?
	DR. DYSERT. I agree, but I think -- 
	THE CHAIRMAN. So that the -- well, let me just say this.  So that the 
development of that system -- the computer is just a tool.  It is an enabler to 
achieve greater standards and quality of care, right?  Isn't that what we are 
trying to do here -- 
	DR. DYSERT. Yes, sir.
	THE CHAIRMAN. -- and trying to achieve?
	I do not think anyone has an -- I agree, doctors go to medical school, and 
you do your job, and to deliver on that quality patient care, part of this is 
when you are able to put down on the record your diagnosis and the prognosis in 
a manner that everybody understands, it sure helps the care givers, the follow-
on or collaborative care givers, pretty important in seamlessness.
	DR. DYSERT. It is called communication and collaboration.
	THE CHAIRMAN. Yeah.
	DR. DYSERT. It is not a technical term of interfacing.
	THE CHAIRMAN. Well, all right, all right, all right.  I am not going to 
quibble about words, even though I am a lawyer and love to do that, but all 
right.
	Dr. Javitt, in your written statement, you indicated that the VA should 
not be allowed to continue ad hoc development and selective adoption of the VA 
health record at the regional or division level, and that IT budget authority 
should be centralized.  You kind of get my attention.
	Could you please explain and expand on your recommendations?
	DR. JAVITT. I think we have reached a point of maturity within the 
Veterans Health Administration that we know what works in VistA CPRS.  The whole 
country knows that we need to get to standardized medical terminology, and you 
have got a solution that demonstrably works, where the President of the United 
States looks at this, looks at what he can see at our universities, and says 
this is extraordinary, and yet, we still have some culture within the VA that 
allows people who direct regional-level operations to say I will implement this 
part but not that part, we will use this terminology but not that terminology.
	So, I think Congress could save a good bit of taxpayer money and further 
improve the care within the VA by giving the Under Secretary of Health and at 
central headquarters within the Veterans Health Administration, not outside the 
health administration, but within the top-level doctors at the VA, the authority 
to have one seamless electronic health record that is implemented the same way 
in every VISN.
	I would like to just take a moment to echo some of what Dr. Dysert said, 
because his points about the need for economic efficiency and the need for much 
more creative human computer interfaces are actually points one and point seven 
of the PITAC report to the President.
	Clearly, it is a waste of time to have a nurse read a patient's 
temperature on a thermometer and put it into the computer.  We really need the 
R&D allocations to have thermometers that talk to computers, to have blood 
pressure cuffs that talk to computers, to free physicians and nurses and other 
medical personnel from clerical tasks, so they can spend their time actually 
working with, talking to, and taking care of their patients, but that is sort of 
the next frontier once we have stabilized an e-health environment where the most 
basic level can move seamlessly across the country, and it is a critical 
frontier, because at the end of the day, putting a computer and a screen between 
the doctor and a patient does nothing to contribute to the quality of that 
doctor-patient relationship.
	THE CHAIRMAN. All right.
	I turn to the two doctors here for a moment.
	You, Dr. Dysert, are developing a system -- and I would submit that you 
are in a luxury.  The reason I use the word "luxury" is that, with the DOD and 
VA, we have a patient that is moving rapidly through a system of care, and how 
do we move that patient through that system of care rapidly and touching a new 
doctor so many times, from the combat aid station to the combat support 
hospital, MEDEVAC to Landstuhl, brought to the United States, from the United 
States sent to a polytrauma center, in a matter of weeks.
	This is not the luxury of you receiving your patient and you getting to 
know everything about your patient.  So, this issue about seamlessness is 
extraordinarily important in our health system.
	So, I wanted you to know that I am taking your words and your counsel, and 
I do not know if I can -- I am trying to figure out how I do that overlay onto 
our challenge.
	If you have any comments based on what I said, I invite them.
	DR. DYSERT. Yes, Mr. Chairman, if you would allow me.
	The whole idea of referral of patients -- we represent a quaternary, 
tertiary care hospital that gets many patients sent to us from rural communities 
for care.
	One of the central themes that led us to deciding that we would build our 
platform on internet families of technology was simply the personal experience 
that we all have today of being able to seamlessly access information anywhere 
in the world if it is known and in a computer system with relative ease.
	I will not discount the importance of systems being able to exchange data 
at machine levels through interfaces and other technologies.
	The good news is there is a great growing family of tools kits built the 
internet family uses every day to exchange information.
	I guess our point was -- and back to my "perfect is the enemy of good 
content" -- is that while we develop at a system level the interfaces -- and 
these things take time -- we felt it was better to provide the human direct 
access through the browser-based technology to getting at the answer, and let me 
give you a very specific example.
	We have a number of different types of digital radiology systems in our 
health care environment.
	Our approach, while we looked at the technical possibilities of making 
them all a single system, was to provide through a browser a link and a secure 
sign-on that would allow a physician to access all those radiology systems while 
the technology types figured out a way to get them to talk together at a 
technology level.
	We thought it was better not to wait on the technology at an interface 
level to deliver access, because it's one of the biggest challenges physicians 
face in clinical decision-making, is simply having access to information that's 
already known about the patient, and my point about contrasting technology-based 
interfaces with the human version of that -- and that's access -- is we think 
you do it every day in your private life; we do not think health care should be 
any different.
	So, while we develop at a technology level the ability to data exchange, 
we have tried to use internet families of technology to provide access for the 
human to that information, because it already exists.
	Does that address your question?
	THE CHAIRMAN. My compliments to the VA, Secretary Mansfield, Dr. Pearl, 
and what you have done in your collaboration with the military health delivery 
system. Great.  But what good is it when I take the patient -- the patient is 
taken from Landstuhl to Minneapolis and he does not have his records?
	What good is it if we are going to develop that type of system and hand-
off, and if we could get to this enabling system; see what I mean?
	Every person along the way -- if you are the receiver at the polytrauma 
center, and five other doctors at five other sites have already touched your 
patient, you sure need to know what they have done, and you do not even have a 
record.  Little frustrating for you, isn't it, a little challenging?  
Unnecessarily challenging, right?  That is why we are here today, and it is not 
just that particular reason. I just want to let you know that, as we develop 
these systems, your counsel is important, but I just want you to know our 
challenges here are great.  Let me yield now to Mr. Evans, and I am anxious to 
hear from Dr. Snyder soon.
	MR. EVANS. Mr. Chairman, thank you.
	Are the five sites sharing bi-directional information and six sites 
sharing laboratory data doing so under local agreements or in comprehensive 
national agreements?
	DR. JAVITT. Could I hear the question again, please?
	MR. EVANS. Are the five sites sharing bi-directional information and six 
sites sharing laboratory data doing so under local agreements or in 
comprehensive national agreements?
	DR. JAVITT. I think that one is outside of my specific competence, but if 
it could be re-focused -- 
	THE CHAIRMAN. Counsel, will you read this?
	MR. SISTEK. Yes.
	The question is directed towards GAO and regards the five sites that are 
now sharing bi-directional health information and the six sites sharing 
laboratory data.  Are these sites doing this sharing agreement under local 
agreements, between the local VA and DOD facilities, or is there some sort of 
over-arching and national agreement?
	THE CHAIRMAN. Thank you, Mr. Evans.
	MS. KOONTZ. Thank you.
	My understanding, that these are at multiple sites, and the agreements 
extend beyond just a single location.
	MR. EVANS. I yield back the balance of my time.
	THE CHAIRMAN. Mr. Boozman?
	MR. BOOZMAN. [Presiding] Yes.
	Again, I appreciate you all being here.  We had the opportunity to have 
you in earlier in a very informal session. I think we really learned a lot.
	You mentioned that one of the problems we have got is that the records are 
not -- they are kind of -- some physicians are doing -- are recording in one 
way, and others are recording in any other way, so it is incomplete.
	In the private sector now, because of Medicare and insurance plans and 
things, you really do not have that problem like you used to, because their 
attitude is, if it is not written, you do not get paid for it, and so, 
physicians are careful to document, you know, the things that they need to do 
for the level of exam and what they are doing.
	We do not really have the hammer like that in the VA system.  Again, that 
is a pretty big hammer.  You know, if they review your case and they say, well, 
you did not do that, and all the ones like this, you are not getting paid for.
	I guess, you know, kind of the challenge is how do we -- I mean, you know, 
what hammer do we have to get that done?
	DR. JAVITT. With all due respect, Mr. Boozman, from what I have seen, the 
consistency in the documentation of computerized medical records within the VA 
is far more consistent and comprehensive than it is within the civilian sector.
	I am currently an expert witness in a major health care fraud case in the 
State of Vermont brought by the U.S. Attorney there that involves consistency of 
medical records in the civilian sector, and the variability there, and the 
standards -- is extraordinary, and the standards there are practically non-
existent, and it is true that, certainly, Medicare audits can be used as a club 
to encourage better documentation, but as long as documentation is done on 
paper, there will be as many ways of documenting as there are doctors and nurses 
out there practicing, whereas when I talk about differences in nomenclature from 
one VISN to another, I am talking about very technical differences that only 
matter not because you can't understand what the doctors in one VISN meant 
versus what the doctors in another VISN meant, but because in order for the data 
to become computable, in order for us to be able to apply the kind of medical 
decision rules that save lives every day -- for instance, identifying the 
patients who have had a heart attack but are not getting better blockers, the 
patients who are on blood thinners but may not have gotten the appropriate test 
to make sure those blood thinners are safe -- in order to be able to go the next 
generation of medical decision making and patient safety, you need nomenclature 
that is computable from one place to another, and that is the next challenge 
within the VA.  The private sector, to the extent that it is still based on 
paper, cannot even begin to talk about that challenge.
	MR. BOOZMAN. Okay.  Very good.
	The other thing is the -- as we try and work -- and again, I am not a -- I 
have trouble with e-mail, but as we try and communicate, you know, as you said 
earlier, that it is communicating and things back and forth with our computer 
systems, what system do we use?
	Do we dump all the information into a warehouse-type thing and then get it 
from that?  I mean is that the system that we are trying to get up and running, 
or how are we approaching that?
	MS. KOONTZ. Well, ultimately, in terms of VA's and DOD's long-term goals, 
what they hope to have is standardized data in each of their two data 
repositories which hold the data, and they will make -- and I now hesitate to 
use this word, but there will be an interface between these two repositories 
that will allow the information to be exchanged. So, yes, there is basically 
pools of data which will be standard to avoid the problems in, you know, 
interpretation, so we record it the same way, and also, as Dr. Javitt said, to 
make it computable.
	MR. BOOZMAN. I know some of the -- like immigration, the border guards and 
things, you know, they have problems in having to collect a lot of data from a 
lot of agencies.  They have been able to do that recently, or have a pilot 
project going on where they are able to interface that data, and the people 
still have ownership of their data without the central pooling.
	So, is the technology -- is it leap-frogging ahead where -- I mean do we 
need to look at that?  That makes more sense than giving up your data.
	Do you understand what I am saying?
	MS. KOONTZ. I do understand what you are saying. Not being familiar, 
though, with the specifics of that particular instance, it is difficult for me 
to comment about, you know, a particular situation like that, but -- 
	MR. BOOZMAN. But are you familiar with that type of technology that is 
available?
	MS. KOONTZ. No, I am not familiar with that kind of technology, no.
	MR. BOOZMAN. Okay.
	DR. JAVITT. I think, in the U.S., we have the tools.  Secretary Thompson 
was prescient in licensing the vocabulary for the whole country, and Secretary 
Principi endorsed that.  It is a very simple problem.
	If two doctors are talking and one says crushing sub-sternal chest pain 
and the other one says angina, each of those doctors knows that they are 
describing the same entity, or likely to be, but two computers talking to one 
another do not know that those are the same entities.  So, it is just a matter 
of standardizing nomenclature and standardizing vocabulary in ways that we 
already know how to do but having the discipline to implement.
	MR. BOOZMAN. Okay.  Thank you.
	DR. DYSERT. Can I make one comment, Mr. Boozman?
	MR. BOOZMAN. Yes, sir.
	DR. DYSERT. On the whole issue of computability of information, and I 
think you are a physician, as well.  You know, the transition for physicians 
from what I would represent to be an analog thought process to a binary decision 
tree of documentation is no small challenge, and the problem that I hear played 
back from physicians is things like computability and converting to structured 
data is something that is seen to largely create value downstream from the point 
of care.
	The terms that resonate with providers of care when they are looking for a 
role of technology to serve in a meaningful way -- you have the terms I used 
before -- communication for the purpose of collaboration in the management of 
their patients.
	What I hope the government will do and what we are trying to do now -- and 
it is a mighty challenge -- is to not lose sight of where the value is, and have 
a balance between downstream aggregated data for the purpose of looking at 
outcomes versus enabling the care providers up front to do what they do in 
medical practice, and that is communicate and collaborate.
	DR. JAVITT. May I just take a moment to endorse what Dr. Dysert said but 
go one step further and point out that the world of natural language processing, 
the world of neuro-networks outside of medicine has progressed to where, with 
concerted R&D, we can have computers listen to one doctor say crushing sub-
sternal chest pain, listen to another doctor say angina, and automatically code 
that to be the same thing. We do not have to force doctors to do things that are 
different from what they would like to do every day if we do this right.
	MR. BOOZMAN. Mr. Snyder, you are up.
	MR. SNYDER. I do not know who to direct this question to.
	My understanding is that in the sequelae from Katrina in which VA patients 
were -- had to be evacuated from several of the VA facilities, that whatever 
facility they ended up at -- and I think many of them ended up at another VA 
hospital -- that the electronic transfer of their medical records worked, and it 
worked well.  Do any of you have any knowledge of that or any comment on that?
	DR. JAVITT. I did not see it happen firsthand. What I understand is that, 
had the local internet infrastructure not gone down, there would not have been a 
need for data transfer; the data would have actually been visible in whatever 
hospital these vets were evacuated to, but because of the failure of the 
internet infrastructure, VA was able to burn magnetic tapes and transport the 
magnetic tapes, so the records were preserved.
	MR. SNYDER. Is it your understanding, also, that then that worked well at 
the receiving facility?  I mean it was essentially the same format, I would 
assume, at the receiving VA hospital?
	DR. JAVITT. To the best of my knowledge, there is no veteran whose 
electronic medical records were lost in the process.
	MR. SNYDER. That was my understanding.
	We also have an occasion going on now where -- several members have done 
on a similar thing, but on one of my visits to Iraq where I visited a treatment 
facility at Camp Taji, and then we went to a hospital where we saw some -- that 
day -- some wounded soldiers from Arkansas, went to Landstuhl, and I visited 
with folks there, including another wounded Arkansan, who was unconscious at the 
time, and then he was subsequently moved to Walter Reed, where I visited with 
him there a week or so later, and then visited with him while he was still 
undergoing outpatient treatment when he was back in Arkansas at his home, and I 
may be wrong, but I don't think the system is quite as smooth as the VA, as we 
were talking about, but I have not had major complaints about the transfer of 
medical records in a system that very rapidly moves people in the war situation.
	They feel very confident about moving people at quite severe levels of 
injury with all kinds of machinery and medication support and putting them on a 
plane and moving them.
	I have not heard complaints about medical records transfers not working.  
Have you all heard anything about that, anything to the contrary within the 
military?
	DR. JAVITT. The challenge you have is that CHCS1, which is the current 
level of implementation for military inpatient records, is not yet at a point 
where a lot of what doctors need, the images, the cardiograms, all of the, you 
know, thousands of tests that are critical for caring for a patient, can be 
transmitted through that system.  It is not there yet.
	So, you know, at some level, information -- 
	MR. SNYDER. It has got to be a hard record of some kind, somebody carries 
an envelope.
	DR. JAVITT. At another level, a lot of it has to be moved manually.
	DR. DYSERT. Can I add to the comment?  Would you mind?
	MR. SNYDER. Sure.
	DR. DYSERT. I think this is a very important consideration as the future 
gets looked at from a system perspective.
	I applaud and I am certainly not here to criticize the efforts of the VA.
	As has been said already, they are a leader in many respects.
	I think, having not started a project over 20 years ago but started a 
project in the last couple of years, our approach is different, because we had a 
different set of tools to use to build our system.
	I think a question and something I would look for in the future is why 
would we have records in one location at risk that needed to be moved or 
accessed because they were physically associated with the application that 
supported patient care?  I think the modern of families of technology gives you, 
at a national level, the ability to probably virtually store your records in 
more than one location without the need to physically transport and have a 
physical barrier to access.
	MR. SNYDER. I think that is right.
	The frustration, I think, for this Committee and the Armed Services 
Committee and other folks that follow this is we seem to have independent 
systems that work pretty well, but there just has been this frustration with why 
they can't do such a good job of communicating with each other, which I think is 
what GAO has been following and you all are referring to.
	I trained at a couple of different VAs, both as a medical student and as a 
family practice resident, and I can remember when essentially the VA chart was 
pages and pages of illegibility, and 25 years ago, when I was a resident, I got 
in the habit of typing -- I would borrow the secretary's typewriter and type my 
admission notes, and it created a stir, because it was the only typed note in a 
medical record, in, you know, literally, for some of the patients, decades of 
illegibility, and then there would be this typed note, and so, we have moved 
from that, but we still have this issue of the two government entities.
	What comments do you all have with regard to the fact that we talk about 
the military system and the VA system, as such, that are straightforward 
government -- I am sorry, I did not see my light -- government entities.  The 
fact that Tricare -- so many of them are private providers -- where does that 
fit into this issue of sharing of medical information?
	DR. JAVITT. I think, before getting into Tricare, you were asking about 
where is that gap between VA and DOD, and although I had no mandate to do so, I 
can honestly state that I led the first inspection of the VA's electronic 
medical records system by an Army surgeon general since that system has existed.
	Gen. Peak came to look at the VA system for the first time approximately a 
year-and-a-half ago, and he found that that system was vastly different in its 
capability and vastly richer in its capability than his career staff had been 
telling him.
	Now, fortunately, some of that career staff has now departed from the 
Department of Defense, and I have heard that there is a potential for more 
openness and more listening, but perhaps the most useful thing this Committee 
could do would be to bring the senior leadership of the Department of Defense's 
medical establishment together with the VA and make them look at each other's 
tools and see where there is room for sharing, and there is room for bilateral 
sharing.  Some of the work that the Department of Defense has done in a 
structured outpatient note might have some value to the VA, but until somebody 
with, you know, three stars on his shoulders is willing to ignore what he is 
hearing from professional staff and go look and go see, there is probably not 
much hope for the kind of sharing you are talking about.
	The Tricare folks, unfortunately, are largely in an environment where they 
are going to get whatever care is available to them in the community.
	It could be that Tricare could help facilitate the use of electronic 
medical records in places where Tricare comprises a large part of individual 
doctors' and hospitals' business, but in places where Tricare is just a small 
part of a doctor's business, Tricare has no more ability to help that doctor 
move to electronic medical records than any other insurance company does.
	MR. SNYDER. I am not sure where my time is, Mr. Chairman.  Thank you.
	MR. BOOZMAN. Mr. Michaud?
	MR. MICHAUD. Thank you very much, Mr. Chairman. This question is for the 
GAO.
	In your written testimony, you stated that DOD is providing post-
deployment health assessment information of individuals who have been discharged 
from the military to the VA.  The assessment has self-reported responses that 
can help identify individuals at risk of PTSD.
	To your knowledge, how is the VA planning to use this information, and 
will they use it to conduct targeted outreach to the veterans?
	MS. BASCETTA. They plan to use the information in two ways.
	First of all, for the information that is available now -- some of it was 
made available in July -- when a veteran or a service member comes to the VA for 
care, they have access to their post-deployment survey in their medical record, 
and they are supposed to be getting that monthly in October.
	What they would like, in addition, is that information in the aggregate, 
so that they can look at what the potential demand for mental health services 
might be coming down the road and where those services might be needed 
especially if service members are going to be returning disproportionately to 
certain areas.
	They do not have that aggregate information at this point.
	MR. MICHAUD. Also in your testimony you state that DOD is not providing VA 
with the health assessment information for -- from reserve and National Guard 
members.  These veterans actually represent roughly one in three of the OIF and 
OEF forces.  Why is DOD not providing VA with this information, and how will 
this impact seamless transition for these veterans?
	MS. BASCETTA. It obviously has a negative impact on the transition for 
Guard and reserve members.  Honestly, we are not clear on what the reason is.  
It has something to do with the legal status of Guard and reserve members, as 
opposed to active duty members, and I think if that were resolved, there is a 
solution to getting that information to VA, and I would encourage you to ask DOD 
that question.
	MR. MICHAUD. I definitely will.
	In your opinion, when one in three are reserve and National Guard members 
that are putting their lives on the line, and a lot of them have lost their 
lives in this war, why would we want to treat them less than we would for an 
active member because of a legal status?
	Has GAO taken a position and has encouraged DOD to provide this 
information?
	MS. BASCETTA. Yes, we would.
	We would certainly not want to treat anyone differently who has, you know, 
put their life on the line in either of these conflicts.
	In the transition assistance program, where we also noted in a report that 
we issued in May differences between the way the Guard and reserve and the 
active duty members were transitioned, received transition assistance, DOD, to 
its credit, has been working to assure that there is equal treatment of Guard 
and reserve members, and there are logistical difficulties, but they are 
certainly not insurmountable.
	MR. MICHAUD. Thank you very much.
	I yield back the balance of my time, Mr. Chairman.
	MR. BOOZMAN. One thing that came up in the testimony with Dr. Snyder -- I 
know we did a good job of, you know, saving things and stuff, but were the 
digital x-rays -- were they lost?
	DR. JAVITT. I do not have specific knowledge.  I saw Dr. Kolodner in the 
room, and he probably knows the answer.
	MR. SNYDER. Okay.  Very good.
	Dr. Dysert, the transfer of the digital x-rays really is not a problem.  I 
know that people do that all the time.
	DR. DYSERT. Well, again, I hate to get down at a word and semantic level, 
but the notion of transfer feels like it is a technology movement -- using 
technology movement of a file from one system to another, and I think it is the 
framework for my comment earlier:  Perfect is the enemy of good.  Sometimes 
there is an equally effective way and it is an access thought.
	We are simply providing access to the information, creates value, without 
having to physically move at a system level, and the unfortunate thing with 
computer technology and interfaces -- sometimes they do require technical 
perfection to function in the exchange of information between systems versus you 
or I simply hitting a link that takes us to that PAX web viewer and you are able 
to see that image, even though it is resident on the original system.  Nothing 
has been transferred at a system level.  I am simply accessing where that image 
is.  Does that make sense?
	MR. BOOZMAN. Yes, sir, very much.
	Ms. Bascetta, according to Dr. Jones' testimony, VA and DOD signed a 
memorandum of agreement in June regarding the resolution of the HIPPA privacy 
rule.  Are you familiar with the agreement, and in your opinion, to what extent 
does it resolve the untimely sharing of medical records between the two 
departments?
	MS. BASCETTA. It does not resolve it at all, unfortunately.  We testified 
about this in May, when we had a copy of the draft MOU, which is identical to 
the one that was signed in June.
	The MOU essentially restates the circumstances under which DOD and VA can 
exchange individually identifiable health information, and it includes 
references to provisions of the HIPAA privacy rule, but it doesn't constitute a 
data sharing agreement, and that is what they really need to move to a seamless 
system.
	They need to know exactly which individually identifiable information they 
are going to share, and they need to know the point in the process that they 
will share that information for service members.
	It is interesting that they have apparently signed this directive to 
address the second part of the question, that at the point of the PEB, when, 
essentially, the military is pretty likely to medically discharge a service 
member, they are going to transfer information to VA, and that is important for 
the Veterans Benefits Administration, in particular, and probably is soon enough 
for them to get that information for processing disability compensation claims.
	We still have questions about how the two departments could work together, 
could collaborate to determine even earlier points in the process for other 
service members who, for example, might need medical rehabilitation. You know, 
is there a way for VHA to access information more broadly about service members 
who may be in that need of VA medical care?
	MR. BOOZMAN. I guess the next question would be, then, you know, since we 
are at this impasse again, how do we resolve that?
	MS. BASCETTA. Well, there are a couple of options.
	The presidential task force essentially recommended a few years ago that 
DOD and VA ask HHS to declare them a single health care system, and they said 
that if they were to do this, they could avoid what would otherwise be these 
cumbersome agreements that need to be put in place to be HIPAA compliant.  In 
the JEC's annual report last December, they have a response to the task force's 
recommendation, and they essentially indicate that they do not need to do that, 
that they can handle their data sharing needs under HIPAA without going to HHS, 
but they have not done that, at least not to our satisfaction.
	MR. BOOZMAN. I guess since we have got the inability to obtain the health 
information on the reserve and national guard members from DOD, what is the 
byproduct of that?  How does that affect timely access for care to the service 
members involved?
	MS. BASCETTA. Well, until some of the unique difficulties with information 
-- health information on Guard and reserve members are resolved, they will be at 
a disadvantage.
	MR. BOOZMAN. Dr. Snyder?
	MR. SNYDER. Help me with my ignorance on this, on the MOU.  I do not 
understand how it is supposed to work.  I guess in my naivete when we first 
started hearing about it, I was like you, Doctor, where I thought that you are 
talking about information being in a location someplace and the person shows up 
at a VA facility and that treating facility accesses that information.
	If they are then transferred from Walter Reed and are getting some follow-
up care at the VA, that facility accesses that information.
	I do not understand the MOU.  I mean it specifically talks about -- well, 
I do not understand how it is supposed to work according to this MOU.
	If I am a patient, are we assuming that, for legal purposes, these are 
separate entities and that a person in the military can refuse to have 
information transferred to the VA?
	MS. BASCETTA. Well, I suppose they could, but the way it works is that, 
right now, they are not considered a single entity, but that should not pose a 
barrier, and in the situation you just described, where someone is transferred 
from an MTF to a VA, there is no HIPAA problem, because under the continuity of 
care scenario, those records transfer. Under other situations, a service member 
could sign an authorization to have the records transferred.  What we are 
talking about are -- and what DOD and VA are trying to negotiate are those 
situations in which a service member has not transferred to a VA facility but 
there is the potential for them to do that, and the issues that need to be 
worked out in those cases are what information VA needs to prepare for that 
patient and how soon they can get access to that information.
	MR. SNYDER. So, a line in the MOU talks -- am I taking too much time, Mr. 
Chairman?  Where it says -- the Department of Veterans Affairs' responsibilities 
-- and they both have responsibilities, which are about the same -- shall 
provide DOD Tricare with information necessary to provide medical treatment to 
veterans.
	Okay.  Information necessary, but then, down below, it says that -- shall 
provide a veteran or service member's information to DOD pursuant to prior 
written authorization by the service member.
	Are those two in conflict, or am I missing something, where it says shall 
provide information necessary to provide medical treatment, and then, down 
below, it says the disclosure of information pursuant to prior written 
authorization.
	What I am getting at is if you have a difficult patient -- I mean we are 
all difficult patients at some point -- somebody who is -- I will make up 
something -- abusing oxycodone or something, and wants to -- did that in 
military service, and now -- and that is in the medical record, and now it is 
going to transfer to the VA. Can that person say no, I do not want my medical 
records to be accessed, I am not going to give you written authorization, or are 
we one entity in terms of providing treatment?
	MS. BASCETTA. No, they are definitely not one entity at this point.  That 
is what the task force recommended that they ask HHS, to declare them one 
entity, but certainly somebody could -- under the scenario you describe, they 
could refuse to have their medical record transferred, but the more -- that is 
not, you know, the kind of situation that has come up.
	MR. SNYDER. No, I would think -- 
	MS. BASCETTA. What has come up is that, in fact, if someone is being 
transferred under continuity of care, the VA can get the information that they 
need, and they do not necessarily need the entire medical record.  They probably 
only need, at least in the immediate term, the record that is pertinent to that 
episode of care, and HIPAA does not pose a barrier in that situation.
	MR. SNYDER. Which, if you believe in the concept of the total patient, 
would make some providers very apprehensive that I only want the information 
about the gun shot wound to his hand.
	MS. BASCETTA. Right.
	MR. SNYDER. I do not need the stuff about his antidepressants.  I do not 
need the stuff about his suicidal gestures.
	MS. BASCETTA. Right.
	MR. SNYDER. That is, I would think, problematic.
	Thank you for your indulgence, Mr. Chairman.
	MR. BOOZMAN. Mr. Michaud?
	[No response.]
 
	MR. BOOZMAN. Thanks very much to the panel.  We certainly appreciate your 
being here, and now we are going to move on to our second panel.
	[Pause.]
 
	MR. BOOZMAN. Thank you all very much for being here.
	On the second panel, we have the Hon. Gordon H. Mansfield, Deputy 
Secretary, Department of Veterans Affairs; Dr. Stephen L. Jones, Principal 
Deputy Assistant, Office of Health Affairs, Office of Personnel and Readiness, 
U.S. Department of Defense; Maj. Gen Ronald G. Young, Acting Director, National 
Guard Bureau Joint Staff, National Guard Bureau; Col. Sheila Hobbs, Senior 
Patient Administrator, Office of the Surgeon General, United States Army; Ms. 
Susan McAndrew, Senior Health Information Privacy Policy Specialist, Office of 
Civil Rights, U.S. Department of Health and Human Services.
	I would like for our witnesses to limit their oral testimony to five 
minutes, as your complete written statement will be made part of the official 
record of the hearing.  I ask that the members hold all questions until the 
panelist has finished.
	Mr. Mansfield.

STATEMENT OF HON. GORDON H. MANSFIELD, DEPUTY SECRETARY, DEPARTMENT OF 
VETERANS AFFAIRS; ACCOMPANIED BY ADM. DANIEL L. COOPER, UNDER SECRETARY FOR 
BENEFITS; DR. MICHAEL KUSSMAN, DEPUTY UNDER SECRETARY FOR HEALTH; MR. JOHN
BROWN, DIRECTOR, SEAMLESS TRANSITION OFFICE; DR. BARBARA SIGFORD, CHIEF, 
PHYSICAL MEDICINE AND REHABILITATION PROGRAM MANAGER, VETERANS HEALTH 
ADMINISTRATION; MS. KAREN OTT, VA/DOD LIAISON OFFICE; DR. STEPHEN L. JONES, 
PRINCIPAL DEPUTY ASSISTANT IN THE OFFICE OF HEALTH AFFAIRS, OFFICE OF 
PERSONNEL AND READINESS, U.S. DEPARTMENT OF DEFENSE; MAJ. GEN. RONALD G. 
YOUNG, DIRECTOR, NATIONAL GUARD BUREAU JOINT STAFF, NATIONAL GUARD BUREAU; 
COL. SHEILA HOBBS, SENIOR PATIENT ADMINISTRATOR, OFFICE OF THE SURGEON 
GENERAL, UNITED STATES ARMY; AND MS. SUSAN McANDREW, SENIOR HEALTH 
INFORMATION PRIVACY POLICY SPECIALIST, OFFICE OF CIVIL RIGHTS, U.S. 
DEPARTMENT OF HEALTH AND HUMAN SERVICES STATEMENT OF HON. GORDON H. MANSFIELD

	SECRETARY MANSFIELD. Thank you, Mr. Chairman, and members of the 
Committee, for this opportunity to appear before you.
	I am here as one individual representing a agency that has 230,000 people.  
I am sitting here with representatives of an agency that has additional numbers.
	So, you have the two largest agencies in the government sitting at this 
table.  The VA is lucky, very lucky.
	We have a single mission, and that is to take care of veterans, to take 
care of veterans' health care, to take care of veterans' benefits, and to give 
them repose in a national cemetery if they so wish, a national shrine that would 
honor their service.
	These two big bureaucracies are charged with working together to take that 
individual, that young man or young woman who steps forward to become a member 
of the armed services, and we should recognize that, when that person steps 
forward, as they progress through a career in DOD, at some point in time they 
are going to become the responsibility of the Department of Veterans Affairs.
	For these two agencies to work together, as the Chairman mentioned 
earlier, we have a bureaucratic entity, the Joint Executive Council, and I would 
mention here that the goals for that council, as evidenced in their latest 
strategic plan and report that came here to this Congress, include leadership, 
commitment, and accountability, high-quality health care, seamless coordination 
of benefits, integrated information sharing, efficiency of operations, and then 
goes on to joint contingency readiness capabilities and other issues.
	I think, rather than read the statement -- I request that my official 
statement be included in the record and Iwill talk about some issues, as I 
mentioned, two big bureaucracies.
	So, how do we make this work?
	Again, I would tell you that, from the VA's perspective, our one unique 
mission is that veteran and recognizing who and what they are, and we are 
required to take care of them.
	The Executive Council, in providing leadership, looks at things at a high 
level, and let me talk about some of the issues that we are dealing with right 
now, some of which have been covered here.
	For example, we know that there is concern here on the Hill, as there is 
in our agency and at DOD, about the issue of PTSD.
	So, that issue has been a subject of discussions both off the record and 
on the record with the senior leadership, but I can tell you right now that we 
are tracking -- keeping track of the OIF/OEF veterans, 393,407 that have been 
separated, how many of those come from National Guard or how many come from 
active duty, how many of those have asked for or are seen for readjustment 
counseling service, how many have been evaluated or treated for PTSD, and how 
many have ongoing treatment, and that is a subject matter that this council, at 
its senior level, has been able to look at, deal with, and try and get the 
message out all the way to the field that this is an important issue.
	Benefits:  The fact that these individuals coming into service at some 
point in time are going to be veterans is important.  We have an effort underway 
to make sure that not just OEF and OIF but all members leaving the service are 
seen, are given an opportunity to be briefed on what those benefits are, how 
they can be accessed, and how VA can assist them.
	Medical facilities:  We're doing an awful lot of work.  As has been 
mentioned here in the area of seamless transition, as the Chairman mentioned and 
other members mentioned, the road from Iraq or Afghanistan to Landstuhl to 
Walter Reed to a VA hospital is one that we have spent a lot of work, energy, 
and effort on in the last few years to make sure that this works.
	Then in the areas, for example, as mentioned, in the records area, HIPPA 
has come up and some questions have been asked.
	It has been up and down the line a number of times, questions asked about 
what are the ability to withhold information or what are the ability to exchange 
information, what are the points where information stops, what is the 
information that can be asked for and required.
	We have moved forward to the point where we have had general counsels from 
HHS and general counsels from DOD and general counsels from the VA sitting down 
at a table and talking about how do we handle this, and we have got an agreement 
now at that high level, but we still need to move it down to the bottom line.
	There is a piece of legislation, S. 1182, I believe it is, on the other 
side, that deals with this issue, and it would resolve it once and for all by 
saying that health care information can be moved back and forth between DOD and 
VA.  I would make the point, seeing the red light, Mr. Chairman, that I do 
believe that Dr. Chu and myself and the members of the Joint Executive Council, 
the subCommittees on health care and the subCommittees on benefits, have done a 
lot of work.  We have tried to get the message out that we have to make this 
work, have tried to get the message out that that person coming on duty from day 
one is going to be a veteran, and we need to consider that, and we need to make 
sure that the effort is there to ensure that the benefits, as you mentioned, 
sir, that have been earned by that service member are delivered in a timely and 
accurate manner.  We are making sure that we take care of these young men and 
women, and I think that I can say that we have done, over the course of the last 
year, the last two years, the last three years, a better job than had been done 
in the past, but I would also say that we still have a long run to go.  There 
is, I see, a commitment by VA and DOD to travel together down that road, and we 
are working on that.
	Thank you very much.
	[The statement of Secretary Gordon H. Mansfield appears on p.      120]
 
	THE CHAIRMAN. [Presiding] Thank you, Secretary Mansfield.
	Secretary Jones?

STATEMENT OF DR. STEPHEN L. JONES

	DR. JONES. Thank you, Mr. Chairman.
	Mr. Chairman and distinguished members of the Committee, thank you for 
inviting us to meet with you today. It is my honor to represent the Military 
Health System.  I am especially pleased with the opportunity to discuss how we 
work together with the Department of Veterans Affairs to streamline the 
transition from military to veterans health care for our service members and 
their families.  With your approval, I will summarize for you my written 
statement, touching on some of the noteworthy defense programs and assuring you 
of our commitment to work with the VA to meet the needs of our service members 
and their families as they  move back to their civilian lives.
	We have endeavored to encompass and integrate the many steps involved with 
transitioning from the battlefield to military hospitals to hometown 
communities.  We have accomplished much, but we know that we can do more.
	Many of our transition initiatives with the VA support recommendations 
found in the President's task force to improve health care delivery for our 
nation's veterans.  These recommendations align into three broad categories:  
medical care and disability benefits, transitioning to home and the community, 
and sharing of service member personnel and health information.
	Each of these areas, military medicine plays a role. Let me offer just a 
few examples.
	Under medical care, by any measure, our war fighters who need medical 
treatment are receiving exceptional treatment and care by a dedicated health 
professional.  One such example is the Army's collaborative program with the 
VA's polytrauma rehabilitation center, which you are familiar with, Mr. 
Chairman, which is a boots-on-the-ground program to aid in our severely injured 
service members who need assistance during the long recovery and rehabilitation 
program.
	This program, an Army liaison officer at each of the polytrauma centers 
works with VA personnel to support service members and their families in 
addressing a broad array of issues such as travel, housing, and military pay, 
and Col. Hobbs is here from the Office of the Army Surgeon General, who can 
address specific questions that you may have, sir.
	In the transition process, the DOD-VA Seamless Transition program features 
VA social workers and benefits counselors assigned to eight military medical 
facilities around the country to guide service members through the transition 
process.
	The VA staff briefs service members while still on active duty about their 
VA benefits, including health care and disability compensation claims.
	They also enable the smooth transfer of care to VA medical centers located 
near the service member's home and then maintain contact with patients to ensure 
success of the discharge plan.
	Another example is the free counseling provided under the transition 
assistance program and the disabled transition assistance program.
	Both DOD and VA counselors offer extensive information on numerous issues, 
to include health coverage and insurance programs, as well as a full range of 
benefits available to them.
	To ensure we meet the particular needs of our reserve component members 
who transition and who are disabled and transition back to civilian life, we 
established an interagency demobilization working group which works to improve 
the process.
	One of the policy changes that they are considering recommending is 
mandating attendance at the VA benefits briefings, and I might mention, Mr. 
Chairman, I was up at Fort Drum yesterday and was pleased to see, with the VA 
counselors, are in the same building, that the medical clinical there, with the 
Fort Drum soldiers, as they seek health care.
	Another transition initiative created within DOD is military severely 
injured center established in February 2005 to operate on a 24/7 toll-free hot 
line for service members and families.
	The mission of the center is, quote, "to prepare severely injured service 
members to return to duty or to reintegrate successfully into their home towns." 
To meet this mission, this center assists injured service members to achieve the 
highest level of functioning and quality of life by offering advice and help and 
a full spectrum of benefits, connecting the service members and their families 
with helpful resources in solving problems.
	Currently, the center's health care managers, case managers, are working 
on more than 1,200 active cases.  Issues of top concern are financial resources, 
education, employment, and family services.
	This center, in concert with those operated by the individual services, 
provides a greater resource to cut through administrative obstacles and help 
ease the transition to civilian life.
	Mr. Chairman, we have materials outside on the table and have additional 
materials on this military severely injured center that is available for you, 
and I see I am getting a red light, too.  If I could have two more pages here, I 
would appreciate it.
	Under information sharing, which has been discussed here considerably this 
morning, is the third category of interest.
	We in the defense believe that sharing of necessary information is 
absolutely critical to an effective and transparent transition process.
	Again, together with the VA, we have made significant strides.
	Today, we have a memorandum of agreement that governs the sharing of 
protected health information and other individually identifiable information, 
and as I understand some of the discussions this morning, we were unaware of 
some of these difficulties, and we would like to work with the GAO and others to 
try to address some of these issues and attempt to solve the problems as quickly 
as we can.
	The Bi-directional Health Information Exchange operations in Seattle, and 
being tested in El Paso, enables near real-time sharing of outpatient 
prescription and demographic data between DOD and VA for patients treated in 
both health care systems.
	Inter-operability between our clinical data repository and VA's health 
data repository is getting much closer.
	We routinely share with the VA service member contact information when 
they separate from military service. It may not be as timely as needed 
sometimes, but we are sharing that data.
	While there are some discrepancies in this process, I understand that 
technical changes made last year resolve many of those problems.  The next step 
in this effort will result in sharing the member's name, Social Security number, 
unit ID, current location, contact information, and a brief explanation of 
medical condition.  Sharing this information with the VA at an earlier point in 
the transition process will allow expedited delivery of benefits to 
transitioning service members and reduce the chance of overlooking a particular 
individual.
	With the VA, we will continue to enhance our electronic information 
sharing structure in order to further enhance seamless transition for all who 
move from military service to civilian communities.
	Mr. Chairman, I would just like to emphasize what Secretary Mansfield 
stated.
	We are committed at DOD to working with the VA in meeting the goals which 
you have expressed in your statement this morning, and we have many people 
throughout the agency working.  We have people assigned with authority to try to 
-- and points of contact to work on the various issues, and I think, with good 
will and open communications, we are trying to do that.
	We appreciate your Committee holding this hearing. We appreciate your 
outstanding support for our American heroes, and we will be happy to answer any 
questions at your convenience.
	[The statement of Dr. Stephen L. Jones appears on p. 140]
 
	THE CHAIRMAN. All right.
	For the witnesses and my colleagues, we are going to have to recess for 
about 15 minutes.
	We have a vote on the motion to instruct on the Department of Homeland 
Security appropriations act, thereby followed by adoption of the rule on the 
Department of Justice appropriations authorization act.
	So, the Committee will be in recess for 15 minutes. I apologize to my 
colleagues for not giving a witness from the low country of South Carolina 10 
minutes because of his dialect.
	DR. JONES. I apologize.
	[Recess.]
 
	THE CHAIRMAN. The Committee will come back to order.
	I would ask unanimous consent to strike the word "speech" that was used 
right before the break and insert the word "dialect."
	Hearing no objection, so ordered.
	I had no objection with regard to your speech that you gave.
	It is just the dialect of the low country is a little slower than what 
perhaps I was used to and calculated. The word "tea" in Indiana has one 
syllable, not three.
	Let me now turn to Maj. Gen. Young for testimony.

STATEMENT OF MAJ. GEN. RONALD G. YOUNG

	MAJ. GEN. YOUNG. Mr. Chairman, distinguished members of the Committee, 
thank you for the opportunity to speak with you today about these vitally 
important programs.
	Today the National Guard has over 78,000 soldiers and airmen mobilized 
around the world for the global war on terrorism, over 325,000 since 9/11.
	That is why the transition assistance program is so critically important 
to our efforts to take care of service members and their families.
	The information received during TAP briefings and the opportunity to 
enroll in these vital benefits programs has long-lasting effects on our men and 
women in uniform, their families, and their communities.
	The effectiveness of transition assistance holds implications for the 
long-term health of our entire organization.  Transition assistance must be 
comprehensive, a continuum of care that begins before the service member 
deploys, continues while he or she is away, and follows through after their 
return.  TAP must provide a seamless transition from active duty back to the 
citizen soldier environment and thereafter.
	That is why the National Guard Bureau fully supports the recommendations 
contained in the recent GAO report and why we support programs such as the New 
Hampshire reunion and reentry program.
	The National Guard plans to continue to build on pilot programs like the 
one in New Hampshire.  Many of the decisions made during the transition 
assistance program process are family-based, as opposed to individual choices. 
This necessitates that the service member be united with his or her family 
during the process.
	In addition to the pressing need for the delivery of TAP information at or 
near the home station, there exists a need for more effective follow-through 
support in the period immediately following demobilization.
	To be truly effective, this follow-on support requires close coordination 
by TAP representatives at the state and local levels.  The New Hampshire model 
accomplishes this and much more.
	While the efforts at the demobilization station are essential, New 
Hampshire experienced great success with local management and coordination with 
veteran centers and the VA hospital counselors in providing counseling and 
education to returning members and their families.
	Returning soldiers testified that the one-on-one counseling which occurred 
during the additional transition days was very effective in helping them 
identify and/or cope with their reintegration back into the local community.
	This effort also educates the family on signs to look for when dealing 
with the stress and emotions of their service member's experiences.  This 
coordinated effort makes it easy for the service member to seek and receive the 
help that they may need.
	While New Hampshire should be applauded for their efforts, I would like to 
point out that there are other states, particularly Washington and New York, 
that are making great strides in their efforts, as well.
	Now more than ever, taking care of soldiers and airmen must be our highest 
priority.  Leveraging the benefits available to National Guard soldiers and 
their families through the transition assistance program is a key part of this 
commitment.
	As I stated earlier this year, TAP is a readiness issue.  The way we take 
care of service members and their families today will have a direct impact on 
how well we recruit and retain them in the future.
	Working with the members of this Committee, I believe that the Guard, 
along with DOD, Department of Labor, and the Department of Veterans Affairs, as 
well as state and local agencies, can dramatically enhance the effectiveness of 
the transition assistance program and thereby improve the quality of life of our 
service members and their families.
	I want to thank you again for the opportunity to be here today, and I look 
forward to your questions.
	[The statement of Maj. Gen. Ronald G. Young appears on p. 151]
 
	THE CHAIRMAN. Thank you very much.
	Col. Hobbs?

STATEMENT OF COL. SHEILA HOBBS

	COL. HOBBS. Mr. Chairman, distinguished members of the Committee, thank 
you for the opportunity to come before you to discuss invitational travel orders 
and support of family members of wounded and ill soldiers sent from VA medical 
centers and military treatment facilities.
	This is an area we have recognized is in need of work, and we appreciate 
the opportunity to share with you our systemic improvements.
	An invitational travel order is a mechanism used by the Army to cover 
transportation and sustainment costs.  A non-medical attendant order is a 
particular type of invitational travel order that allows family members of 
injured soldiers to travel from home or military treatment facilities or another 
medical treatment facility, including civilian and VA facilities.
	Non-medical attendant orders are issued when the medical authorities 
determine that a non-medical attendant is in the best interest of the patient.  
They are normally issued when patients are unable to travel alone due to 
physical or mental disability.
	The orders are issued and funded by the military treatment facility 
responsible for providing care. Non-medical attendant orders authorize 
reimbursement for travel, lodging, and meals, but the extensions are possible if 
required.
	Since the beginning of the global war on terrorism, the Army's Human 
Resources Command Casualty Branch has issued invitation travel orders to bring 
family members to the bedside of the injured soldiers while they are 
hospitalized.
	Invitational travel orders differ from the non-medical attendant orders 
that are issued by the military treatment facilities.
	In the past, there has been some overlap between the invitational travel 
orders used by Human Resources Command and the non-medical attendant orders used 
by the military treatment facilities.
	Once the soldiers are transferred to the VA medical centers, human 
resources command no longer has visibility over the soldiers and the family 
members.  When invitational travel orders expired, Human Resources Command was 
unaware of the situation.
	Once this was identified, a systemic flaw, action was taken immediately to 
correct the process.  Instead of extending the existing invitational travel 
orders by Human Resources Command to cover the soldiers and the family members 
at the VA medical facilities, the Army, MTFs, or military treatment facilities, 
are issued non-medical attendant orders to authorize family members' travel at 
the facility.  This allows the military treatment facilities to transfer the 
soldier and the family members.
	The military treatment facilities have the authority required to issue 
these orders upon request by the attending physician.
	Although this is a new process, it has only been in place for about two 
months, we already are seeing improvements.
	In addition, we have placed Army Medical Department representatives at 
four polytrauma centers to provide continuous support to our soldiers and family 
members.
	The seamless transition of soldiers and their family members that are 
treated at the VA medical centers is an integral part of providing care to our 
soldiers.  Non-medical attendant invitational travel orders are issued and 
tracked by the military treatment facilities will improve the transition.
	Whether the soldiers are receiving care at the military treatment 
facilities or at the VA medical center, the Army is committed to providing 
world-class compassionate care to our wounded warriors.
	Thank you for the opportunity to appear.
	[The statement of Col. Sheila Hobbs appears on p. 156]
 
	THE CHAIRMAN. Thank you very much.
	Mrs. McAndrew?

STATEMENT OF MS. SUSAN McANDREW

	MS. MCANDREW. Thank you, Mr. Chairman and members of the Committee.
	I am pleased to be here today to help clarify the application of the HIPPA 
privacy rule to the transfer of medical information between the Departments of 
Defense and the Veterans Affairs.
	Briefly, by way of background, the HIPPA privacy rule establishes for the 
first time a set of national standards for the protection of health information.  
These standards were issued in final form in December of 2000, and have been in 
operation widely since April of 2003.
	They are relevant to today's hearings, because the health care programs of 
both DOD and Veterans Affairs are subject to the suite of HIPPA requirements, 
including the privacy rule.
	I want to emphasize that the privacy rule has been carefully balanced to 
ensure that, while there are strong privacy protections for the health 
information of individuals, that those protections are not so strict as to 
interfere with the needed flow of information to provide individuals with 
quality access to care.
	One of the ways in which this balance is most effectively evidenced is in 
the provisions in the rule that make clear information is able to flow freely 
from provider to provider for the treatment of the individual.
	There has been discussions here in terms of the service member that is 
being transported and sees many doctors in the course of coming from overseas 
back to the United States and is in this -- is passed from facility to facility. 
The privacy rule, in fact, anticipates that and does allow that patient's 
treatment information to follow with him as he moves from one care setting to 
another, and I believe the GAO also made clear that, for that kind of treatment, 
the provision of treatment, there is really no HIPPA issue with regard to the 
VA's access to information in order to accomplish that.
	I would also emphasize that our definition of treatment is quite broad, 
and it does also cover the provision of related services, as well as the direct 
provision of care, the coordination of that care, consultation with other 
providers, and referrals to other treatment settings, so that an individual, if 
there is a transfer of the treatment of a soldier from a DOD medical facility 
into the VA's system, that treatment information can flow, and that is 
permitted, clearly, by the HIPPA rules.
	I wanted also to emphasize that there is one other provision of the HIPPA 
privacy rules that was intended to expressly recognize the need for the transfer 
of medical information as an active duty service member makes the transition to 
veteran status, and there is an express provision in the HIPPA privacy rule that 
does allow this information to be shared by DOD to VA upon the separation or 
discharge of the active duty service member, and the VA can use that information 
to determine the individual's eligibility for entitlement to veterans' benefits.
	When the privacy rule was being drafted, we were aware of the transfer 
programs in effect at that time as between the two departments.
	Through the comment period, we heard that there were no real objections to 
the transfer of this information and that it was being protected both within DOD 
and within VA, and so, there was an express provision to allow that program to 
continue unimpeded.
	As part of my statement for the record, I have included the actual 
regulatory provisions that are most relevant to this, and some of the regulatory 
discussion of this particular transfer provision, and so, I -- that is there in 
the record for reference, and I just want to say that we do appreciate the 
opportunity and the careful attention that both departments have been paying 
both to the achievement of the seamless transition of this information, as well 
as attention to the privacy interests at stake in the individual's information 
and that they have found solutions consistent with the privacy rule in order to 
have the seamless transition go forward, and I would be glad to answer any 
questions that you or the Committee members may have.
	[The statement of Ms. Susan McAndrew appears on p. 159]
 
	THE CHAIRMAN. Thank you very much for your appearance before the 
Committee, Ms. McAndrew.
	This is going to be a very good discussion, and I am going to yield as 
much time as Dr. Snyder would like to have, because there is a good overlay here 
between the two of us, in his work on the personnel Committee of Armed Services.  
I realize that we are dancing within your jurisdiction on armed services, but 
this is all about our seamlessness, and I also have oversight on the health 
subCommittee on Energy and Commerce with regard to Health and Human Services, 
and it just makes me stand on end when I go out into the field and I hear 
someone at the local level saying, well, I can't because of HIPPA, and I just go 
crazy, and so, your appearance here -- I was paying very close attention to the 
two principals at the table while you were testifying.
	The purpose of your testimony was not just for me. It is for both of you, 
both of the two secretaries here, and that is the reason I wanted Secretary Chu 
here.  So, please convey that to him, and also Secretary Winkenwarder, because 
they are in very responsible positions, and they can send it down line.
	We should not be hearing I can't because of HIPPA. We have just heard -- 
okay?  I have not heard that, Secretary Mansfield, from the -- well, strike 
that.
	I did hear at the VA facility with regard to -- in Minneapolis -- with 
regard to these records, but I just want to make sure that the two principals 
are comfortable with what you have just heard.
	Do both of you acknowledge and are comfortable with what you just heard?
	SECRETARY MANSFIELD. Yes, sir.
	THE CHAIRMAN. All right.
	Secretary Jones?
	DR. JONES. Yes, sir.
	THE CHAIRMAN. All right.
	Maj. Gen. Young, it is my understanding that the National Guard Bureau has 
entered into a memorandum of agreement with the Department of Veterans Affairs 
regarding transition assistance.  Could you please provide the Committee with 
more details on the nature of the agreement, in greater detail?
	MAJ. GEN. YOUNG. Yes, sir, Mr. Chairman.  We started working with the 
Department of Veterans Affairs at the National Guard Bureau back in 2004, when 
Secretary Principi was still there, and after Secretary Principi left, we formed 
a joint working group, or during that time-line, we formed a joint working 
group, and it has continued and still continues today to work on the seamless 
transition between the two departments.
	We signed a memorandum of agreement, the two under secretaries for health 
administration and benefits administration, Dr. Perlan and Mr. Cooper, signed 
that memorandum, and then Gen. Blaum signed it on May the 19th out in Omaha, 
Nebraska, in front of all the adjutants general from around the country.
	THE CHAIRMAN. So, he did this on his own initiative?
	MAJ. GEN. YOUNG. Yes, sir.  Well, Gen. Blaum and Secretary Principi 
started the discussions, and then it followed through in the new administration 
over at Department of Veterans Affairs, and it came to conclusion with the 
signing ceremony out at Omaha, Nebraska, on May the 19th.
	Now, what that memorandum of agreement does -- it commits both of the 
departments to various things, one of them being establishing two offices, a 
seamless transition office, and at National Guard Bureau, we have appointed a 
program manager, and hired him even before the signature on the two documents.
	It establishes that the two departments will establish mutually beneficial 
opportunities to exchange and educate and train our families and our service 
members about the benefits with VA, because it is a complex system, and 
guardsmen, as you know, until after 9/11, now that we have got over 300,000 
veterans, did not play into that system too much. So, now, with this many 
veterans, it is absolutely critical that they understand all their entitlements, 
all their benefits, and how to get that seamlessly without much difficulty.
	Part of the agreement -- on National Guard Bureau's behalf, we took out of 
hide about $5 million from our other programs to establish state benefits 
advisors at every state, at the joint force headquarters level.
	So, we are in the process of hiring the remaining -- to have 54 state 
benefits advisors at the joint force headquarters level, sir, not only to take 
care of Guard families but all families and all service members that are back in 
a state and need some assistance in getting their VA benefits.
	That program, I believe, because of some of the initial states that, early 
on, took it out of hide and hired that person, they are getting lots of 
business, and I believe that in the future we are going to have to add to that 
one-or-two-person office to help take care of all the work load.
	In addition, sir, as part of our effort at National Guard Bureau, we have 
across the country over 400 family assistance centers.
	We have 92 wings and wing family program coordinators.  We have 54 state 
family program directors.
	Each of those entities, when you add them all together with our state 
benefits advisors, accounts to about 600 different service areas out there, 
service centers, that we can assist families and service members.  So, we are in 
the process of bringing their level of expertise up to a higher level as it 
relates to veterans affairs, their benefits, and their entitlements.
	So, this has been a mutually very beneficial relationship and agreement, 
and we think it is paying great dividends.
	THE CHAIRMAN. Now, I realize you do not have operational control over 
various state adjutant generals.  So, do we have a patchwork going on out there, 
a quilt, or how is this on the implementation?
	MAJ. GEN. YOUNG. Sir, when we were out at Omaha, of course, all the 
adjutant generals -- I spoke to all the chiefs of staff, who were there at the 
same time, about the New Hampshire model.
	I had seen it earlier and been briefed on it, and the experience in New 
Hampshire with 900 returning soldiers has been just absolutely phenomenal, and 
the continuation of care and counseling that they have received is going to pay 
great dividends in the future for those families and stuff.
	So, we are sharing that model at Guard Bureau, and I am also the J1, the 
personnel officer, at National Guard Bureau.  I believe that model is the best 
we have in the country, but I do not want to say that the other adjutant 
generals are not doing the same types of things.
	In Ohio, where I am from, the adjutant general there has worked very 
closely with the Department of Health and Human Services.
	He has worked with several other state agencies, the governor's office, 
and they have a program very similar, but the uniqueness of what happened in New 
Hampshire was that they went to the First Army commander, and they were able to 
get five additional days of Title 10 active duty service once they returned from 
the demobilization station, which was up at Fort Dix, and they were able to keep 
them on active duty, bring them home, have a very short welcome home ceremony 
with the leadership, give them a day off with their families immediately when 
they got home, and then bring them in for three days' worth of activities.
	The first day, they broke their groups down into three different groups.  
The first day was a group of more of administrative details, checking over all 
the records, the pay records, all those types of things.
	Day two was a day at the VA hospital that the VA conducted, actually 
giving them VA physicals, enrolling them and getting them enrolled in the 
program at that very setting, going through one-on-one counseling, and sir, you 
know that soldiers are macho-type people, male or female.  They do not like to 
admit a weakness, especially to military superiors. The one-on-one counseling 
provided at the VA hospitals and the opportunity to meet with -- at the vet 
centers with a veteran and talk issues brought many things out that our service 
members, their commanders, their senior NCOs did not even know was going on with 
those individuals, and in some cases do not even know it today because it is 
protected-type communication.
	THE CHAIRMAN. You said this was funded out of hide.  What was the money 
taken from?
	MAJ. GEN. YOUNG. It was funded out of hide, sir.
	THE CHAIRMAN. The money was taken from what?
	MAJ. GEN. YOUNG. Well, sir, what they did in -- sir, I can't talk all the 
particulars about exactly where they took the money from.
	They had -- with the global war on terrorism, our states have some 
additional money for active duty special work-type days.
	THE CHAIRMAN. What type of an account was the money taken from?
	MAJ. GEN. YOUNG. Well -- 
	THE CHAIRMAN. If you don't know the answer today, you can submit it for 
the record.
	MAJ. GEN. YOUNG. Yes, sir, I will
	THE CHAIRMAN. All right.
	MAJ. GEN. YOUNG. I will do that.
	THE CHAIRMAN. To you and to your team -- and please extend to the chief of 
the Guard Bureau that this is leadership, when you take an initiative and you do 
something like this, and I want to compliment the VA for signing this agreement.
	My question is where is the rest of DOD?
	Secretary Jones, we know what the Guard Bureau is doing, and they have 
entered this agreement, they have taken initiative.
	So, where is the Department of Defense?
	DR. JONES. Well, Mr. Chairman, as Secretary Mansfield stated, our 
agreements are all centered around the joint planning process that we have 
underway, and as alluded to, we have six major goals, 21 objectives, and I think 
it is, 125 specific action items.
	As part of the presidential management agenda, 10 of those objectives are 
green; 11 of those objectives are yellow, which means we need additional work.  
I am pleased to say none of them are red.
	So, I mean 123 action items, sir -- I mean I think a lot of activity is 
going on.
	Now, whether we are being as successful as we would all like to be in, as 
you say, bringing those to fruition, the answer would be no, but a lot of good 
hard work is going on between the two agencies to try to reach the ultimate 
goal.
	THE CHAIRMAN. Well, the gentleman to your left, in his opening statement, 
referred to the Executive Council as bureaucratic.  Would you agree with that?
	DR. JONES. I would like to think not, sir, but I mean we are two large 
organizations.
	THE CHAIRMAN. Well, if that is happening, you are the principals 
responsible, right?
	DR. JONES. Yes, sir.
	THE CHAIRMAN. If you recognize that, you have got to somehow cut through 
it to perfect change, right?
	DR. JONES. Yes, sir, and we are trying to do that. I have been here less 
than a year, and I enjoy going to work every day, because as you know, we are 
working on important things.
	THE CHAIRMAN. I don't mean to put you in an awkward position, Dr. Jones.
	My question really dealt more on the personnel side, and that is not your 
level of expertise, and again, that is why we wanted Secretary Chu here.
	DR. JONES. Yes, sir.
	THE CHAIRMAN. My last question dealing with the Guard -- and then, Dr. 
Snyder, I am going to yield to you -- is a key to the successful transition 
during the demobilization the ability to use the drill time.
	I think that is what we have learned on the reserve component side, 
especially in your ramp-up, and then as you also return home.
	The New Hampshire guard was authorized several drill days immediately 
after their return home, and I would like to know, though, whether or not this 
is a Guard policy -- is this a Guard Bureau policy, or is this one that each 
state is using based on their own resources?
	COL. HOBBS. Sir, it is more a each-state initiative using their own 
resources.
	The five days, sir, immediately after demobilization for the New Hampshire 
model was all Federally funded Title 10 man days, and as you know, our soldiers 
are on a transition leave period anyway, and depending on one year boots on the 
ground and 18-month mobilization orders, that can extend out to about 45 days, 
but First Army allowed them to stay and not be on leave for five extra days when 
they got back to home station.  So, that was all Federally funded.
	Now, they come back to drill at about the 60-day mark.  So, they come back 
to their IDT status about 60 days after they return from a deployment.
	So, other states have the same opportunity to go to the Army commanders 
and ask for that same type of program, and I have no reason to believe that it 
would not be allowed.
	THE CHAIRMAN. Mr. Snyder?
	MR. SNYDER. Thank you, Mr. Chairman.
	Ms. McAndrew, I wanted to have you explain the memorandum of understanding 
for me, please, with regard to data sharing.
	Is this the first memorandum of understanding, or does this replace 
something that was there before?
	MS. MCANDREW. Actually, we are not a party to the memorandum of 
understanding, and I just saw it for the first time today at the hearing.
	MR. SNYDER. So, when you testified just a while ago that information can 
be freely provided provider to provider, I thought you were stating that based 
on your understanding of what is in the memorandum of understanding.
	MS. MCANDREW. No.  That was one of the provisions in the rule itself, the 
standards itself.
	MR. SNYDER. The HIPPA standards.
	MS. MCANDREW. Right.
	MR. SNYDER. So, you have not read the -- so I have got a fresh mind there 
to explain this language, then, since you have not looked at it before.  It says 
here the Department of Veterans Affairs shall provide DOD with information 
necessary for DOD to provide medical treatment to veterans. That is consistent 
with what you said, correct, that information can flow freely from provider to 
provider.
	MS. MCANDREW. Right.  I would interpret that as referencing the ability to 
use and disclose protected health information in order to provide treatment to 
the patient.
	MR. SNYDER. What I don't understand, then, is where this provision comes 
into effect, where it says that Veterans Affairs shall provide a veteran or 
service member's information to DOD pursuant to prior written authorization by 
the service member.
	MS. MCANDREW. That is another means by which information nay be used and 
disclosed.  They are not mutually exclusive.
	The way the privacy rule is structured, it identifies uses and disclosures 
of identifiable health information, where the entity, the covered entity may 
make those uses and disclosures without the individual's agreement.
	Where they want to make a use or disclosure that is not within one of 
those express permissions in the rule, they can do it provided they obtain the 
individual's written authorization to make that use or disclosure with the 
information.
	MR. SNYDER. You said earlier that it is a very broad -- 
	MS. MCANDREW. Treatment is a very broad -- 
	MR. SNYDER. It is very broad.
	MS. MCANDREW. -- definition, because I mean the purpose the individual is 
coming to a covered entity, a health care provider, is to be treated, and we did 
not want the privacy protections, which really are to keep that information 
confidential within the health care system, to interfere with the doctor's 
ability to be able to use the information to treat the patient or to consult 
with others as necessary to make sure that the patient gets the best quality of 
care.
	MR. SNYDER. Secretary Mansfield, I was not here when you -- I had to step 
out for a few minutes.  I was not here when you gave your opening statement, but 
in your written statement, you state that the whole concept of seamless 
transition came about to help the OIF/OEF returning servicemen and veterans and 
women transition seamlessly, but aren't we really like the end of about a -- or 
in the middle of a 20-plus-year process of trying to have DOD and VA work better 
together for providing the services?
	SECRETARY MANSFIELD. Yes, sir, you are correct. As the Chairman stated in 
his opening statement, that goes back to the '80s.
	MR. SNYDER. Yes.
	SECRETARY MANSFIELD. I think what I was trying to say in the statement -- 
and excuse me if it didn't come across -- was that the current focus on the 
seriously injured that are in military treatment facilities has been treated by 
us in the concept of a seamless transfer in that system, although the big 
picture--seamless transition--has been there, and we have attempted to work on 
it for a longer period of time, and that involves whether you have been in Iraq 
or Afghanistan or anywhere and are departing the service.
	MR. SNYDER. In your opening statement -- I assume your opening statement, 
like every other opening statement from the administration, went to OMB first 
before it came here?
	SECRETARY MANSFIELD. Yes, that is the process, procedure -- 
	MR. SNYDER. Yes.
	SECRETARY MANSFIELD. -- and requirement.
	MR. SNYDER. I understand.
	I have difficulty finding, you know, the future challenges and where the 
problems are.  I am always suspicious those kind of get buffed away when they go 
through the OMB process, but could you give me a list of what you see as the 
obstacles ahead of you in the area of medical records, you know, all those kinds 
of issues where -- that you see as being a challenge for both -- you can join 
in, too, Dr. Jones, if you like -- where you see the challenges ahead of us, 
particularly ones where you think there may need to be congressional help?
	SECRETARY MANSFIELD. If you go back to the document I did refer to in my 
comments, sir -- it is the Joint Executive Council annual report.
	MR. SNYDER. Right.
	SECRETARY MANSFIELD. I talked about the goals, leadership, commitment, and 
accountability.  That is a requirement to start with, and as I indicated, we 
need that at the top to be able to force these issues down through these two 
massive bureaucracies to make sure that people everywhere, at every level and 
position in these organizations, understand that the importance of the 
organizations rests on those individuals that come into DOD, raise their right 
hand, go on active duty, and then at some point in time are going to become 
veterans.  We need to recognize that as the starting point, and then we need to 
work together to move the information on those folks across that spectrum of 
care, maybe sometimes even back and forth, to make sure that we have the 
information available to ensure health care in one sense and benefits in the 
other sense, and that's the first requirement.
	MR. SNYDER. So, you are saying that is still a problem.
	SECRETARY MANSFIELD. Well, I am saying it's still something that we have 
to focus on and make sure that we make it work.
	The Chairman, at a previous hearing -- and I wasn't here, although I read 
it -- made a comment about an issue, IT. I think he said what we have to deal 
with here is the commitment of leadership to get the job done, and that is the 
first starting point that has to be done for all of this stuff, and we are 
making the point that it is bureaucratic, but it is the nature of how these 
organizations work, that we put this organization together, and we have to make 
the bureaucracy work, but sometimes, at the top, we have to know when to reach 
out and go around the bureaucracy and find out what is going on down at the 
bottom and then make a corrective action, bring it back up to the top.
	A good example of that is the dental care issue that we had, mostly 
involving National Guard and reserve troops that came through our reporting 
process at VA, where all of a sudden it started spiking, and I was looking at it 
for a couple of months, then I had them go and do a review, and found out folks 
were getting treated before they went overseas with -- I don't know what you 
call it.  They were extracting teeth and then sending them over for a year's 
duty, no care over there, coming back, requiring extensive treatment, but at 
double the numbers that we had projected we would have to deal with.
	So, we had to reach around that, find out what was going on, get our 
dental -- our medical professionals involved in that.  They came up with a 
report.  We brought it back to this council, and we had the problem solved.
	We now have a better understanding of what the requirements that DOD has 
to do with the money that they are being given to do it and what we have to do 
in that process.
	So, it requires the leadership to be involved, to be focused, and to keep 
looking always, not at these reports and these papers, down at those individuals 
that are standing there, those men and women that are serving, and recognizing, 
from my point, as I said, that they are going to become veterans, and we need to 
start as soon as we can to line it up, so that when they do become veterans, as 
soon as we can do it, we present them with the benefits that they have earned 
for the health care that they need.
	THE CHAIRMAN. Will the gentleman yield to me for a second?
	MR. SNYDER. Yes.
	THE CHAIRMAN. On the dental, I think this Committee has to accept some 
responsibility, and let me extend an apology to the Veterans Affairs.
	There are some unintended consequences by some action that we took on this 
Committee, and that we recognized after the first Gulf war that we were also 
going to have veterans coming back, we didn't know how they were going to be 
doing, and we wanted to make sure that the VA was open and accessible to them.  
An unintended consequence is that we did not anticipate that DOD would not take 
care of the dental services with regard to these individuals that were brought 
on active duty, Dr. Jones, and so, what happened is that DOD, who gets their 
payments through the supplemental -- we don't do supplemental on VA.
	So, we are thinking, when we passed on the supplemental, that these call-
ups and things are going to be taken care of out of DOD.
	DOD does a cost shift and takes that -- these guardsmen and reservists and 
then -- dumping is a hard word, but you cost shift these individuals into the 
VA, and it was a struggle and was also a deficit for which we then had to make 
up, Dr. Jones.
	I yield back to the gentleman.
	MR. SNYDER. I think we were all surprised, too, by the number of Guard and 
reservists who were not medically fit for deployment at the time of their 
activation.  This was like a couple of years ago, and it was a little over 20 
percent were not medically fit for deployment, and I think the overwhelming 
majority of that was dental, and so, they did get fixed up so they could go, but 
my guess is that there was work to be done when they got back, and you all had 
to bear the burden.
	I am not going to belabor it.  My time is up, but I want to be sure I 
understood what you are saying.
	Are you saying that we still are having a problem at the highest levels of 
leadership in terms of commitment to this process?
	SECRETARY MANSFIELD. No, sir.  I made the point early on, I believe, right 
now, we do have the commitment.
	MR. SNYDER. All right.
	SECRETARY MANSFIELD. It is just we have to make sure that we reach out and 
follow through and get it done. HIPPA is a good example.
	I mean we are talking about patients in a bed that have come back from a 
war with serious wounds, and we have got general counsels at the departmental 
level sitting there talking about who can get the information to treat them.  
That is not the way we should be doing business.
	MR. SNYDER. Well, I mean I think your point is a good one.
	I mean I am coming in the middle of this, but the memorandum of 
understanding is not that old.
	SECRETARY MANSFIELD. Well, sir, part of that, too, though, if you look at 
it, as a, you know, fellow brother at the bar, you have got a law that went on 
the books in April of 2003, and lawyers look at it, and they want to look at 
case histories and see how many decisions have been made and what it means, and 
they are looking at that while the doctor is looking at the patient in the bed, 
and we have to work our way through this, but you know, if it requires the 
highest level to deal with it, we need to deal with it, but it needs to, again, 
be forced back down through the system so everybody understands what they have 
to do, and it is not what they have to do, it is what they ought to be doing 
that we are talking about.
	MR. SNYDER. Thank you, Mr. Chairman.
	DR. JONES. Congressman, can I add on?  I think the issue you brought up 
with the dental care is an issue of how the system does work, though.  Dr. 
Mansfield called Dr. Chu, said he thought there was a concern.  We brought that 
to the HEC, pulled together a joint Committee between the two agencies.
	It was then briefed to the Health Executive Council, and we are continuing 
to work that issue now to make sure that we aren't dumping.
	So, I mean that's an example of how the process, while it might not be 
perfect, is working.
	We are able to surface problems and try to deal with those problems.
	THE CHAIRMAN. Col. Hobbs, you are representing the Army Surgeon General's 
office here.  Is that correct?
	COL. HOBBS. That is correct, sir.
	THE CHAIRMAN. What is your background?
	COL. HOBBS. I am a patient administrator, sir, patient administration, 
medical records, sir.
	THE CHAIRMAN. Are you Medical Service Corps?
	COL. HOBBS. Yes, sir.
	THE CHAIRMAN. Your prior assignment was what?
	COL. HOBBS. Prior assignment -- I have worked at Walter Reed, the Office 
of the Army Surgeon General previously, and I am there now, sir.
	THE CHAIRMAN. Is the Dental Corps a combat multiplier?
	COL. HOBBS. Indeed, it is, sir.
	THE CHAIRMAN. Indeed it is.
	COL. HOBBS. It is, sir.
	THE CHAIRMAN. I like that answer.  Indeed it is.
	That is a great answer, isn't it, Dr. Snyder? Indeed.  Indeed it is.
	COL. HOBBS. Yes, sir.
	THE CHAIRMAN. No, I liked your answer.  I loved the answer.  So does Maj. 
Gen. Webb, he would probably like that answer, too.
	We recognize that when soldiers go to war, they are focused on a lot of 
things, and it is doing the job and the mission, essential tasks at hand, saving 
a buddy, fighting, grabbing a meal when they can, and they are not brushing 
their teeth, and they come back with gum disease and dental problems.
	Most of the guys pulled off the battlefield, dental. Is that right, Col. 
Hobbs?
	COL. HOBBS. Yes, sir.
	THE CHAIRMAN. Dental.
	So, if we know that going in, Dr. Jones, we have got to know that going 
out.
	So, if you said that you are working on it, if I were to, in the second 
week of October -- we are not going to be in session, and I go to one of the 
demobilization sites, what am I going to see?
	Am I going to see guardsmen and reservists having gotten their dental 
taken care of on active duty prior to discharge, or am I going to see that these 
individuals were eager to get out of service, ended up with a physical 
assessment, and were informed that they can just get their dental at the VA?  
What am I going to find out?
	DR. JONES. Well, for one, I hope that you would find out that we are being 
responsive and that we are making changes and that the system is working the way 
it is intended to work, and as you know, in the demobilization process, where 
you do have an individual, all of the boxes has to be checked, you go through 
the computer screen, and you sit with an individual who is then saying are you 
sure this is going, are you sure that all the information is in there that we 
need, are there any other concerns that you may have, and if there is dental 
concerns, hopefully we are going to be addressing them then, but I will be 
pleased to follow through with you, sir, and see where we are on October 2, if 
that is appropriate.
	THE CHAIRMAN. You know, when it comes to medical ailments that that 
soldier may have, we don't discharge them and say just go to the VA, all right?  
We try to hold them -- we take care of our own.  It is the philosophy, it is the 
values, correct?
	DR. JONES. Correct.
	THE CHAIRMAN. Of all services.
	DR. JONES. Correct.
	THE CHAIRMAN. My only point is -- I will stop beating on this one -- 
dental needs to be included in that whole person holistic approach to medical 
care.  Would you agree?
	DR. JONES. Yes, sir.
	THE CHAIRMAN. All right.
	MR. SNYDER. If I might put on my family doctor hat, that is a problem that 
we have throughout health care in America, that years ago, decades ago, probably 
a century or two ago, we just separated this part of the -- the teeth from the 
body, and it plagues all kinds of people.  It makes it difficult to control all 
kinds of diseases, that our insurance system handles teeth differently than it 
handles other things, and it is a problem, and I appreciate you pointing it out.
	THE CHAIRMAN. Thank you.
	Let me move to the issue on physical separation or separation physicals, 
assessments.
	I have no interest in revisiting the quibble that Dr. Winkenwarder and I 
had, and we had to bring in, then, Ed Wyatt, who was with me when we wrote the 
law, to figure out exactly what all this is.
	It is kind of interesting.
	This comes down to, when I chaired Personnel, what I intended; Ed Wyatt, 
when he wrote it, what did he mean by what he wrote, and then he is having to 
implement -- I mean it was one of these kind of things we went through, and then 
there was a population at large, too, including military organizations and 
veterans service organizations, who also interpreted one way, and I just want to 
ask this.  Do you think it is a good idea that we should make these mandatory, 
these separation physicals, or should we just keep them as assessments?
	What is your counsel to the Committee?  I am going to ask the two 
principals.
	SECRETARY MANSFIELD. I will go back to my original comments, sir, which 
said that I think we need to start keeping track of these folks as soon as they 
raise their right hand, and go forward, and in the process of doing that, 
probably when they leave the military, I would definitely go for making it 
mandatory and then giving it to us directly, immediately.
	THE CHAIRMAN. Dr. Jones?
	DR. JONES. Sir, as you know, it is controversial within the medical 
community as to the cost involved and whether hands-on physicals are necessary, 
and at this point in time, of course, the decision is the assessment is 
satisfactory unless additional -- unless items come up that need additional 
follow-through.
	I guess I would stand by the position that we have now, sir.
	SECRETARY MANSFIELD. Sir, I might have to add an amendment at the end that 
that was my personal opinion and probably not an administration opinion.
	THE CHAIRMAN. Well, all right, I am going to get into this, because I 
authored some of this stuff, and you know, it goes back to a living history of 
first Gulf war, guys coming back, and ladies, gee, it was in their head, it 
really wasn't physical; oh, gosh, perhaps they really do have some concerns 
here.
	We do compensation on undiagnosed illnesses, a lot of money put into 
research.  Then my concerns about establishing a baseline, pretty important.
	So, then, on the Armed Services Committee, we say, okay, we are going to 
do these physical exams; oh, I meant physical assessments.  We don't want to 
delay mobilizations, okay, but it is really important that a baseline be 
achieved at some point, because part of this whole transition is into a benefits 
side.
	So, if an individual, then, is discharged and all you have is a physical 
assessment, or you don't even have that, maybe that record is gone, then, years 
later, they come back, and now they file a claim on the VA, and we have no 
baseline.
	So, when you say, oh, my gosh, I don't think we should do mandatory 
physical exams, because it is going to cost too much, really?  Cost too much.  
To whom?
	We here in Congress have a perspective in that the Federal dollar here is 
fungible, because we see it going into many different agencies and departments.
	So, when you don't put that cost on us, but if we don't do it, then what 
cost are we putting on the VA later on, not only by processing multiple claims 
later on, without a baseline, and that is why I asked the question about 
mandatory.  Right now, it is just voluntary.
	So, let me ask Secretary Mansfield if I may turn to Adm. Cooper.  May I?
	SECRETARY MANSFIELD. Yes, sir.
	THE CHAIRMAN. What is VBA's position on the utilization of the BDD 
physical exam process?
	ADM. COOPER. I am not sure I understand.  We are very strong -- and for 
the same reason you say -- by having people come into our benefits delivery at 
discharge, because we do get that baseline.
	As you know, we signed an MOU to conduct the physical, primarily for the 
service persons themselves, either at a VA facility or at the military facility, 
whichever might be closer or more convenient, but the primary point is, even if 
they have a discharge physical, our requirements for a VA physical are a little 
more extensive, and quite specific.
	THE CHAIRMAN. I apologize.  My question really wasn't asked right.  I kind 
of put two things together.  You are very kind.
	Let me take a step back.  Let me ask it this way. If Congress were to 
mandate these physicals, separation physical, whether the individual may have a 
particular ailment, we are just saying if you are being discharged from the -- 
if you are going to be discharged from the United States military, you are going 
to get a physical, is that a good idea or not a good idea?
	ADM. COOPER. I personally think it is a good idea.
	I certainly got one when I left.  I mean I was an officer and got the 
physical when I left.
	I, frankly, honestly, was not aware that we were not doing it these days.
	THE CHAIRMAN. Well, it is voluntary right now.
	Isn't that correct, Dr. Jones?
	DR. JONES. Yes, sir.
	THE CHAIRMAN. It is voluntary.  So, we are not setting a baseline for you.
	ADM. COOPER. No, and that is the reason I am very strong for our BDD 
process, because that way, anybody who even thinks they might have a physical 
problem will come to us and we can get a good solid baseline physical, and 
thereby, 10, 15, 20 years later, if they come back in and say not only am I 
worse on that particular problem but I have this other thing, then we can go 
back and use that as a base.
	THE CHAIRMAN. This BDD discharge is done at the military medical treatment 
facility?
	ADM. COOPER. We have 140 sites around the country where we have people who 
take in the claims when the people come in and register, and then we will try to 
get them the physical at the closest place.  We do on the military base or if a 
VA medical hospital is nearby, we will do it there.  We have this MOU that I 
mentioned that allows, if discharge physicals were being done, for either one of 
those places to do it, and they would adhere to our more rigid physical 
requirements for the physical exam.
	THE CHAIRMAN. I don't want to get too far out in front of the Disability 
Commission, but I think our quest here is to the soldier that has been injured 
or wounded in some capacity, and now he's facing his physical discharge, 
seamless -- I want to make sure we are all on the same sheet of music -- 
seamless transition would be that he gets a physical discharge and his rating is 
then immediate.  Is that not the goal?
	ADM. COOPER. That is the goal, absolutely.
	Now, let me interject something here.  So that the service person can get 
paid as soon as legally possible, it is important that we have that medical 
information on their disabilities before they get out, because it takes us a 
certain discrete amount of time to complete the compensation process.
	THE CHAIRMAN. Let me for a moment entertain a discussion with Dr. Snyder 
from the personnel Committee standpoint.  I have not spoken with John McHugh 
about this. Have you touched on this issue at all?  Maybe this is something we 
should have some further conversations about it.
	MR. SNYDER. I have not had recent discussions with him either.
	THE CHAIRMAN. With Chairman McHugh?
	MR. SNYDER. Chairman McHugh.  Maybe it might be one of those topics we 
would want to consider having a joint hearing.
	THE CHAIRMAN. All right.
	MAJ. GEN. YOUNG. Mr. Chairman?
	THE CHAIRMAN. Yes.
	MAJ. GEN. YOUNG. Could I share just a few observations from the 900 
soldiers that went to the VA hospital -- 
	THE CHAIRMAN. Absolutely.
	MAJ. GEN. YOUNG. -- in New Hampshire that I think are kind of pertinent 
here?
	Five points, sir.
	Almost 50 percent of the 900 soldiers requested follow-up support after 
their initial counseling back in New Hampshire at the VA hospital one-on-one 
counseling session, 50 percent of them.
	Now, they had just came from the demobilization station and the transition 
assistance program there and had checked all the blocks and came back to New 
Hampshire.
	Second point:  Almost half of the soldiers filed VA claims during the 
three-day process conducted back in New Hampshire.
	One of every 10 returning soldiers received acute care through the VA 
emergency room while processing.
	All soldiers were provided a safe environment to disclose medical issues, 
and 2 percent were actually retained on active duty in a medical hold status.  
So, they were not allowed to go off of active duty but were kept on active duty 
and sent back in a medical hold.
	The last point is all soldiers completed a dental assessment through the 
VA, securing their dental benefits for the next two years.  Just a couple of 
points there.
	THE CHAIRMAN. Secretary Mansfield and Secretary Jones, after 20 years of 
working DOD-VA sharing issues to include seamless transition, seamless care, and 
all the resources allocated towards this effort, staff, time, and money, you 
know, I almost have to ask what do we show for our efforts?
	Now, you gave your testimony, so I don't want to be too openly critical, 
and I know that we have military liaisons at the VA trauma centers, we have VA 
reps at Walter Reed in Bethesda, but I mean look at what remains, the 
recommendations out of the presidential task force, even, the medical records, 
the physicals, the sharing of information between the two departments that, as 
we just discussed, that could benefit the soldier now or later on in life.
	I guess let me just boil it down to where are we going from here?  Tell me 
what is in front of you right now, between now and the next six months.
	What is in front of the joint Committee?
	SECRETARY MANSFIELD. Sir, I think that you have focused in again on the IT 
issue, and we had a hearing here not too long ago about that that I recollect, 
and we are moving forward on that.
	That obviously is a big issue, one that we have not produced what we 
should have produced, one that we are -- we at the VA are moving forward to deal 
with, and I know one that DOD is also moving forward to deal with.  It is again 
one of those issues that is going to continue to require high-level attention 
and management concern to make sure that it happens as required.
	So, that is a key area, and the other issues here, where we are dealing 
with health care, as I mentioned, I think we can say that we are doing a good 
job in that area and we are moving towards doing an even better job.
	The benefits area is also one where I think we have cooperated a lot more 
than we had in the past.  We have got VA benefits counselors on Navy ships that 
are steaming home from battle areas.  We have got them at, you know, hundreds of 
posts around the country and the world, preparing these soldiers for the 
transition, and we are continuing to work on those efforts, and I think, again, 
it comes down to focused leadership, dealing with the specific issues, making 
sure, again, as I said, that we do recognize that seamless transfer means from 
the start to the end, and that we just keep working on it, recognizing that we 
are here, you know, not for this report or not for the reams of paper that gets 
submitted -- we are here for that individual, as I said, that started out by he 
or she raising their right hand and moved forward, and they became a veteran, 
and we are required to take over and give them the medical care and the benefits 
that they have earned and needed, and we need to do it the best way we possibly 
can.
	THE CHAIRMAN. Secretary Jones?
	DR. JONES. Yes, sir, Mr. Chairman.  I would echo Secretary Mansfield's 
remarks, and one issue that -- you asked what have we done.
	The joint incentive fund, where, as you realize, we -- DOD puts in 15 
million and VA puts in 15 million, and I know you have visited a lot of the VAs 
and a lot of the MTFs, and I haven't had a chance to visit as many as you, but I 
have had an opportunity to go to about five or six of them, and what impresses 
me is the creativity and the willingness and the people wanting to work together 
at the local level.  So, I mean I think that fund allows us to capture some of 
the creativity and to remove some of the obstacles at the local level, where 
they want to try to work together and make things happen in the local health 
care market.
	So, you know, that is one specific issue.
	Another issue I think we have made progress is in the joint purchasing, 
and as you are aware, just on the joint purchase in the pharmaceuticals, I think 
the estimate is that, together, we have saved over 420 million last year by 
combining the VA and the DOD, but I would echo -- 
	THE CHAIRMAN. On what?
	DR. JONES. Joint pharmaceutical purchases, sir.
	THE CHAIRMAN. You don't even want to come close to that issue with me.  
You understand that, right?
	DR. JONES. Yes, sir, but I would echo Secretary Mansfield's remark, and 
Mr. Duffy and myself are trying to go back, with others, on the strategic plan 
and to make sure that we are able to focus on those issues, on those elements 
that aren't moving forward, that, as you say, the bureaucracy is getting in the 
way, and to give that leadership focus so that we can move those forward and 
make sure that we reach resolution.
	THE CHAIRMAN. It is just really unfortunate that you have created 
something out there, then sucked yourself in a lawsuit unnecessarily and going 
against things that I have actually written, which I wrote, and I intended to 
do.  It just blows my mind that DOD would go out and do such things. I just 
can't even fathom nor even begin to comprehend.
	DR. JONES. I understand, sir.
	THE CHAIRMAN. I know.  It is why we are in litigation.
	In the GEC annual report, one of the objectives of strategic goal five, 
efficiency of operations, was identifying of collaborative opportunities for 
joint construction activity in 2007 to 2010 time-frame.  According to the 
objective, the list of opportunities for joint construction was to be identified 
after the release of the  BRAC list.  Can you testify as to what is the status 
of the list?
	SECRETARY MANSFIELD. The status of the BRAC list is that it is submitted 
to Congress by the President, waiting the 45-day time-line.
	I would make the point, sir, that -- 
	THE CHAIRMAN. No, the list of your opportunities of joint construction.
	SECRETARY MANSFIELD. I am sorry.  We are still waiting the BRAC decision.
	We also have moved forward in the BRAC arena with the VA forming a senior-
level task force, and that issue, with the BRAC being on the agenda at the last 
two meetings and scheduled to be on for a meeting when the final decision, 
whatever that is, is made, which is -- 
	THE CHAIRMAN. All right.  You are waiting until after the Congress acts 
and the President signs, then you go. Is that what you are -- 
	SECRETARY MANSFIELD. Yes, sir.
	THE CHAIRMAN. Okay.  That is fine.  I just wanted to know where it is 
proceeding.
	Dr. Kussman, may I ask you a question, if we can do musical chairs here?
	How valuable is it to you to receive, if you could get them, the pre- and 
post-deployment physical assessments? Is that of any value to you?
	DR. KUSSMAN. Yes, sir, it is of obvious value to us, as was mentioned, 
both from an aggregate point of view, looking at demographic issues, as well as 
the specific issue, because as the individual transitions from DOD to the VA, 
they may come to us at certain points, and having the information that is on the 
post -- particularly the post-deployment screen, would help the provider who is 
assessing that individual who comes to know what things that they mentioned that 
they -- symptoms they may have had or experiences they may have had during that 
deployment.
	THE CHAIRMAN. Compare that value to the value of receiving a post-
deployment and/or discharge examination. Compare the physical assessment to an 
examination.
	DR. KUSSMAN. Are you asking me whether I think that the actual physical 
examination is needed for people both in the post-deployment or prior to 
discharge?
	THE CHAIRMAN. I want to know if you think it is valuable to the VA if we 
were to mandate -- this Committee -- 
	DR. KUSSMAN. I understand.
	THE CHAIRMAN. -- mandate, in conjunction with the Armed Services 
Committee, mandates the discharge physical exam, I want you to be able to tell 
me your opinion.  Is that valuable to us, or do you say no, we just -- the 
physical assessments are fine?
	DR. KUSSMAN. Without trying to equivocate, I think, if you asked me about 
-- as a clinician, as a physician -- of whether I think that this is needed or 
not, I think that the literature shows very clearly that routine physicals, 
without symptom-directed indications, are not very valuable, particularly in 
young people.
	Having said that, a thorough assessment that could result in the actual 
hands-on or physical exam is appropriate in those settings.  Because if a 
certain person says they have back pain, then that should be evaluated, and if 
they say they can't hear, it should be.
	But if they say they don't have anything and they are young, then the 
actual putting a stethoscope on the chest or poking the abdomen or doing a 
neurologic exam has been shown not to be very productive.
	It is not matter of saving money.  It is a matter of efficiency of 
evaluating people, that you do not find anything from it.
	THE CHAIRMAN. Okay.  That is fair enough.  I asked you from a clinician 
standpoint, but now, when you couple that with the fact that, when somebody goes 
into the military, we, the government, accept responsibility over that person's 
body and mind, all right, so when we accept that responsibility and then when 
they discharge, we say unto them that our responsibility is to make you whole, 
if it is not, and we do that in some measurements.
	Now, I mean there are some related measurements that I think would be 
pretty important -- hearing test, eye test, some basics out there that we don't 
even get from physical assessments -- and suppose, because we link this to what 
I have just described, outside of the clinician's point of view, establishing 
this baseline would be pretty important given our liability exposure.
	DR. KUSSMAN. Yes, sir, and I think that, generally speaking -- and I would 
have to defer to Dr. Jones because I can't remember now, because I am getting 
old and retired five years ago, but there is a physical evaluation that is done 
on active duty people on a regular basis.  I think it is every three to five 
years, or is it every five years?  I can't remember exactly when it is.  Five 
years.  Okay.
	So, there are repeated baselines for someone who stays in for an extended 
period of time -- hearing, blood pressure, eye exam, dental exam, and all those 
other things.
	So, there is a track record of that repeatedly during a 20-year -- if you 
are only in for four or five years or three years, that probably wouldn't be 
repeated, but having said that, I would agree with you that there probably is a 
set of data that would be very nice to have, like a hearing test, because that 
is a very common thing that somebody complains about, and it would be nice to 
know that their hearing was fine when they transitioned.
	Blood pressure might be a good thing to check, and so, I think that the 
thing that we probably ought to look at, or I would suggest to look at, -- from 
Mike Kussman's individual opinion is -- is to determine what data sets would be 
of great value longitudinally to track people but not necessarily doing 
everything to everybody.
	THE CHAIRMAN. That is fair.  Thanks.
	Col. Hobbs, to what extent is the issue of ITOs and NMAs an issue of 
manpower or resources?
	COL. HOBBS. Yes, sir.  It is not an issue of manpower or resources.  It is 
a process that we are working to continue to -- 
	THE CHAIRMAN. So, it is an issue of leadership?
	COL. HOBBS. It is the process that -- it is a process.
	THE CHAIRMAN. Who commands the process?
	COL. HOBBS. The leadership does command the process, sir.
	THE CHAIRMAN. So, it is neither an issue of manpower or resources.
	This is an issue of leadership.
	Well, I am going to extend some compliments, because you identified a 
problem, and then took actions to correct the problem, right?
	COL. HOBBS. Yes, sir.
	THE CHAIRMAN. In the Army's evaluation of determining where some of the 
problems lie in regards to the ITOs and NMAs, was this -- I know you said a 
systemic problem. When you use that word "systemic," you are saying to me that, 
you know, Steve, this was not just isolated, this was not just regional, this 
was CONUS-wide or even worldwide.  Is that what I am to interpret from the word 
"systemic" that you used in your opening testimony?
	COL. HOBBS. Sir, I would say inconsistency throughout our system.
	We would find that we would see the most problems where we have our larger 
volumes.
	THE CHAIRMAN. Dr. Sigford, could you come forward? Would you state your 
background and credentials, please?
	DR. SIGFORD. Yes, sir.
	THE CHAIRMAN. Your full name.
	DR. SIGFORD. Barbara Jean Sigford.  I am a physician, physical medicine 
and rehabilitation, a physiatrist.  I am chief of physical medicine and 
rehabilitation at the Minneapolis VA and also national program director for 
physical medicine and rehabilitation.
	THE CHAIRMAN. Are you affiliated with the polytrauma center in 
Minneapolis?
	DR. SIGFORD. Yes, I am.
	THE CHAIRMAN. On my trip to the Minneapolis VA -- in particular, the 
polytrauma center -- I asked you what some of the problems you were having with 
some of the patients, and I appreciated your candor.  You expressed some concern 
with regard to the medical records on patients from Landstuhl, Germany.
	So, before you answer this question on this premise, will you, for the 
record, explain what the polytrauma center is, how many we have, what is the 
purpose of the polytrauma center?
	DR. SIGFORD. Yes, sir.  We have four polytrauma rehabilitation centers 
which were designated in February, our first meeting in -- 
	THE CHAIRMAN. Where are they located?
	DR. SIGFORD. I am sorry?
	THE CHAIRMAN. Where are they located?
	DR. SIGFORD. They are located in Richmond, Virginia; Tampa, Florida; 
Minneapolis, Minnesota; and Palo Alto, California.
	Their purpose is to provide rehabilitation care for severely injured 
service members or National Guard, reservists.
	THE CHAIRMAN. Now the purpose of the polytrauma center is what?
	DR. SIGFORD. To provide rehabilitation care and associated medical care 
that is a continuing need after their transfer from a military treatment 
facility.
	THE CHAIRMAN. So, these are active duty soldiers.
	DR. SIGFORD. The majority are, yes.
	THE CHAIRMAN. So, they are with you for a point in time, and then they 
transfer back to a military medical treatment facility or they could be 
potentially discharged on-site
	DR. SIGFORD. That is correct.
	THE CHAIRMAN. The issue on medical records -- can you tell me about it?
	DR. SIGFORD. Our current access to medical records is through a paper copy 
of medical records.  We do not have access to an -- through an electronic system 
for medical records.  So, we rely on paper copies, hard copies of the medical 
records to provide the care for the individuals that are transferred to our 
facilities.
	We receive that information either via fax or physically accompanying the 
service member when they arrive.
	THE CHAIRMAN. These patients -- now we are getting in on the issue of 
seamless.  We are going to go right down to it on patient care.
	What kind of problems are some of the doctors running into when, all of a 
sudden, you receive that active duty patient and you do not have all the medical 
records? What is happening?
	DR. SIGFORD. Well, I believe probably the example I gave you when you 
visited Minneapolis about the soldier who was transferred to us from Landstuhl 
was perhaps the most complex problem we have faced, and that was an individual 
who had had emergency surgery, abdominal surgery, in Landstuhl. Those records 
did not follow him to the military treatment facility and, thusly, did not 
follow him to the VA.  We then had to use teleconferencing to receive the 
information we needed to provide the continued required care for his abdominal 
injuries, and I think that is probably the most complex situation, but we do 
follow up with phone calls and direct one-to-one conversations.
	THE CHAIRMAN. These active duty liaisons that are at the four polytrauma 
centers -- pretty important?
	DR. SIGFORD. Yes.
	THE CHAIRMAN. Why?
	DR. SIGFORD. They provide us with a military presence for individuals, our 
active duty individuals, which is greatly appreciated by the men and women who 
have served in the armed forces, as well as their families.  They really 
appreciate having this military presence.  They also are able to make 
connections back to the military treatment facility, often assisting us with 
accessing the information in medical records which may not have followed the 
individual directly, and then they are also able to help with benefits, the 
boarding process, the travel orders, invitational travel orders, and other 
processes like that in the seamless transition process.
	THE CHAIRMAN. Having the opportunity to speak to some of the families, you 
know, they expressed some real concern.  They were in an I don't know land, and 
VA extending support, Fisher House support -- you have heard the testimony of 
Col. Hobbs, representing the Office of the Surgeon General, United States Army, 
and corrective action taken.  What is happening on the ground, though?  Are you 
able to testify with regard to that?
	DR. SIGFORD. In terms of support to families?
	THE CHAIRMAN. Support to the families.
	DR. SIGFORD. I can speak mostly from my experience at Minneapolis, and 
that is we do have a Fisher House.  We have a very active voluntary services 
program, many people who want to donate and support these families, and I 
believe, while I don't know the specifics at each of the polytrauma centers, 
each has developed their own programs individually and specific to their areas.
	We have case managers who are assigned to the service members and their 
families to be at their disposal, to help problem solve and provide support.
	We provide them with lodging, and often additional activities and 
amenities as needed.
	THE CHAIRMAN. All right.
	Seamless Transition is this large umbrella term.  It is, isn't it?  So 
many things are covered underneath it, and the structure is very large.
	I know, Secretary Mansfield, you have an office dedicated, but it is for a 
limited scope, is it not?  It is regarding the active being treated in your 
facilities and those with whom you may have contractual relationships with at 
large.
	SECRETARY MANSFIELD. The office that Mr. Brown heads up is concentrated on 
the seriously injured active duty member that is coming from a military 
treatment facility.
	THE CHAIRMAN. Okay.
	Well, this is going to be -- the seamless transition issue, I just want 
all of you to know, is going to be a continuous dialogue.
	I mean there are -- Secretary Mansfield, you have been around the block a 
few times, and so, you know that there are certain issues out there that are 
called maintenance issues, right, and you are aware of the interest of the full 
Committee on a bipartisan basis on the issue, not only of this Committee but 
also of the Armed Services Committee, and Dr. Jones, if you can please express 
up the chain to Secretary Chu with regard to our concerns about the two defense 
bills and implementation, we think it is important.  I know there is a lot on 
your plate, and there is a lot of contingencies and a lot of things that you are 
doing, a lot of things that the nation calls upon you to do, and you are 
stretched pretty thin.
	So, I am not here to beat up on you.  I am just concerned, as you are, 
about the soldier and the sailor, the airman, Marine, the Coast Guardsman, and 
the reserve components, and they should never be caught in bureaucracies, right, 
and it is how we move them from one system to the other.
	So, we have got these systems that try to have their separate identities, 
yet there needs to be that cohesion, a system that is synergistically 
intertwined, pretty important, and figuring out how to do all that is not easy.
	Let me shift gears.
	Does anybody have anything they would like to comment with regard to the 
issues on seamless transition before I move into a separate, completely 
different area?
	[No response.]
	
	THE CHAIRMAN. No?
	Hearing none, let me ask a question with regard to -- under this issue on 
seamless and collaboration, is there anything going on right now between DOD and 
VA with regard to Hurricane Katrina and Rita that I should know about with 
regard to collaboration between VA and DOD?
	SECRETARY MANSFIELD. Sir, I would make the point that I think, although I 
would have to go back to the operations office and double-check, that we were 
collaborating at the point in time over the weekend, as required both under the 
plan and, as we usually do, informally, and had the VA, I think, can say we had 
our needs met as far as DOD goes.
	DR. JONES. Mr. Chairman, one of the things that we were working on early, 
before the storm, was to move approximately 3,000 patients who were in hospitals 
or in nursing homes to other facilities who were not in harm's way, and of 
course, the VA military health treatment facilities, and of course, commercial 
hospitals, were used to move those patients very successfully, and so, that was 
one instance where the plan worked and we worked together, along with others in 
the community.
	THE CHAIRMAN. All right.
	I know this was not the subject area of this hearing.  Congress is also a 
large organization, and we all have different responsibilities.
	I also serve on the Katrina Committee, and I am going to ask that you also 
pass this word along that the time-lines of the response, pre-landfall and post-
landfall, with regard to Hurricane Katrina is going to be important, and 
Congressman Thornberry of the Armed Services Committee is also on the Katrina 
Committee.
	Our responsibility is to look at the facts, not about assessing blame.
	We want to figure out who did what, when, where, and then we can get into 
the issues of what changes, if any, need to be made.
	So, please recognize that I will be coming with regard to obtaining the 
facts from DOD, the Guard Bureau, equally, please extend this, and to the VA.
	I will also be into the Coast Guard and the medical side on this one.
	So, I know that, VA, you had standing up an operations center, and I am 
sure that you have got to have a paper trail here at the ops center, do you not, 
Secretary Mansfield?
	SECRETARY MANSFIELD. Yes, sir.  We have a chronological, you know, day-by-
day report that comes out of that center.  They are working right now on the 
lessons learned, which is a built-in part of our system, also.
	THE CHAIRMAN. I just want you gentlemen to know that that tasking is 
coming, all right?  So, this report has to be done by mid-February.
	So, when I show up with a team, I don't want you to say, okay, we will get 
you the answers.
	Please put together what is necessary, and we are going to have to do -- 
obviously, the logistical function on DOD is pretty important.
	We are focusing this to your role and mission with regard to the national 
response plan, okay?  That is where I am going with this, okay?
	All right.
	I want to thank you for coming.  I want to thank you for your testimony.
	Ms. McAndrew, thank you very much for coming here. The two principals have 
heard your testimony.  That is extremely important, and please extend my regards 
to Lt. Gen. Kiley and Maj. Gen. Webb, all right?
	Again, let me thank you for the leadership in the Guard Bureau and the VA 
for that memorandum; pretty important.
	Dr. Jones?
	DR. JONES. Thank you, sir.
	THE CHAIRMAN. Thank you very much for being here.
	This hearing is now concluded.
	[Whereupon, at 2:24 p.m., the Committee was adjourned.]
    
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