[House Hearing, 111 Congress]
[From the U.S. Government Publishing Office]




                         [H.A.S.C. No. 111-149]
 
          DEPARTMENT OF DEFENSE MEDICAL CENTERS OF EXCELLENCE


                               __________


                                HEARING

                               BEFORE THE

                    MILITARY PERSONNEL SUBCOMMITTEE

                                 OF THE

                      COMMITTEE ON ARMED SERVICES

                        HOUSE OF REPRESENTATIVES

                     ONE HUNDRED ELEVENTH CONGRESS

                             SECOND SESSION

                               __________

                              HEARING HELD

                             APRIL 13, 2010

                                     
[GRAPHIC] [TIFF OMITTED] TONGRESS.#13




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                    MILITARY PERSONNEL SUBCOMMITTEE

                 SUSAN A. DAVIS, California, Chairwoman
VIC SNYDER, Arkansas                 JOE WILSON, South Carolina
LORETTA SANCHEZ, California          WALTER B. JONES, North Carolina
MADELEINE Z. BORDALLO, Guam          JOHN KLINE, Minnesota
PATRICK J. MURPHY, Pennsylvania      THOMAS J. ROONEY, Florida
HANK JOHNSON, Georgia                MARY FALLIN, Oklahoma
CAROL SHEA-PORTER, New Hampshire     JOHN C. FLEMING, Louisiana
DAVID LOEBSACK, Iowa
NIKI TSONGAS, Massachusetts
                David Kildee, Professional Staff Member
               Jeanette James, Professional Staff Member
                      James Weiss, Staff Assistant



                            C O N T E N T S

                              ----------                              

                     CHRONOLOGICAL LIST OF HEARINGS
                                  2010

                                                                   Page

Hearing:

Tuesday, April 13, 2010, Department of Defense Medical Centers of 
  Excellence.....................................................     1

Appendix:

Tuesday, April 13, 2010..........................................    19
                              ----------                              

                        TUESDAY, APRIL 13, 2010
          DEPARTMENT OF DEFENSE MEDICAL CENTERS OF EXCELLENCE
              STATEMENTS PRESENTED BY MEMBERS OF CONGRESS

Davis, Hon. Susan A., a Representative from California, 
  Chairwoman, Military Personnel Subcommittee....................     1
Wilson, Hon. Joe, a Representative from South Carolina, Ranking 
  Member, Military Personnel Subcommittee........................     3

                               WITNESSES

Green, Lt. Gen. Charles Bruce, USAF, Surgeon General, U.S. Air 
  Force..........................................................     6
Rice, Dr. Charles L., President, Uniformed Services University of 
  Health Sciences, Performing the Duties of the Assistant 
  Secretary of Defense for Health Affairs, U.S. Department of 
  Defense........................................................     4
Robinson, Vice Adm. Adam M., USN, Surgeon General, U.S. Navy.....     5
Schoomaker, Lt. Gen. Eric B., USA, Surgeon General, U.S. Army....     4

                                APPENDIX

Prepared Statements:

    Davis, Hon. Susan A..........................................    23
    Green, Lt. Gen. Charles Bruce................................    56
    Rice, Dr. Charles L..........................................    29
    Robinson, Vice Adm. Adam M...................................    49
    Schoomaker, Lt. Gen. Eric B..................................    41
    Wilson, Hon. Joe.............................................    26

Documents Submitted for the Record:

    [There were no Documents submitted.]

Witness Responses to Questions Asked During the Hearing:

    [There were no Questions submitted during the hearing.]

Questions Submitted by Members Post Hearing:

    [There were no Questions submitted post hearing.]
          DEPARTMENT OF DEFENSE MEDICAL CENTERS OF EXCELLENCE

                              ----------                              

                  House of Representatives,
                       Committee on Armed Services,
                           Military Personnel Subcommittee,
                           Washington, DC, Tuesday, April 13, 2010.
    The subcommittee met, pursuant to call, at 5:30 p.m., in 
room 2118, Rayburn House Office Building, Hon. Susan A. Davis 
(chairwoman of the subcommittee) presiding.

OPENING STATEMENT OF HON. SUSAN A. DAVIS, A REPRESENTATIVE FROM 
    CALIFORNIA, CHAIRWOMAN, MILITARY PERSONNEL SUBCOMMITTEE

    Mrs. Davis. Good afternoon. I was going to say good 
evening. Good late afternoon.
    Today the Military Personnel Subcommittee meets to receive 
testimony on the progress of Medical Defense Centers of 
Excellence. Three years ago, as different types of casualties 
than had been initially anticipated mounted, Congress realized 
that the Department of Defense [DOD] had to do a better job 
preventing, diagnosing, mitigating, treating, and 
rehabilitating these injuries.
    One of these injuries, traumatic brain injury, or TBI, was 
somewhat new for the military and, in truth, for medicine in 
general. Advances in both protective armor and battlefield 
medicine were saving lives that would have been lost in 
previous wars. The knowledge and expertise to deal with TBI was 
not resident anywhere. So, as has been the case in previous 
wars, the Department of Defense will need to be at the leading 
edge of medical research.
    Another injury, post-traumatic stress disorder, or PTSD, 
was better known, but the clinical expertise to deal with it 
was more resident in the Department of Veterans Affairs [VA].
    After many years of relative peace followed by an intense 
period of conflict, the medical research and development 
functions of the Department of Defense found themselves 
inundated with requirements. The military medical establishment 
has been made great, heroic even, improvements to trauma care 
during this conflict, but more remains to be done both for 
initial battlefield treatment and long-term rehabilitation.
    This is why these Medical Centers of Excellence that we are 
going to be talking about today are so important, and why our 
frustration is so pronounced with the excessive amount of time 
it has taken to get these centers up and running.
    The first appropriation for this purpose was made almost 
three years ago. Several months after that the House and Senate 
Armed Services Committees included a requirement to establish 
centers of excellence in TBI, PTSD, and vision in the National 
Defense Authorization Act of 2008. Today, only two of these are 
in actual operation, combined by the Department as the Defense 
Center of Excellence.
    Little apparent progress has been made in establishing the 
Vision Center of Excellence nor, as far as we can tell, with 
either the Hearing Center of Excellence or the Traumatic 
Extremity Injuries and Amputation Center of Excellence required 
by the National Defense Authorization Act for 2009. So clearly 
we are concerned about the Department's slow pace in developing 
such an important function.
    Excessive delays are not our only issue, however. The 
center that has been established, the Defense Center of 
Excellence, while having achieved some notable small-scale 
successes, has not inspired great confidence or enthusiasm thus 
far. The great hope that it would serve as an information 
clearinghouse has not yet materialized. The desire that the 
center become the preeminent catalogue of what research has 
been done, what is being done, and what needs to be done has 
not been realized. Part of this is no doubt due to the fact 
that the Department's Center of Excellence, what we know as 
DCoE, has had to create or, more accurately, recreate all of 
the administrative infrastructure and processes required to 
oversee medical research on such a monumental scale. However, 
the center has also made some serious management missteps that 
call into question its ability to properly administer such a 
large and important function.
    We look forward to hearing how the Department plans to 
improve this organization going forward so it can realize the 
goals set for it by Congress.
    Today we will hear from the senior medical leadership from 
the Department of Defense. Dr. Charles Rice is the President of 
the Uniformed Services University of Health Sciences and is 
currently performing the duties of the Assistant Secretary of 
Defense for Health Affairs. In this role, Dr. Rice directly 
oversees the Defense Center of Excellence, as well as the 
establishment of the other centers of excellence.
    We are also fortunate to have with us Surgeons General, 
Lieutenant General Eric Schoomaker from the Army, Vice Admiral 
Adam Robinson from the Navy, and Lieutenant General Bruce Green 
from the Air Force. They will all describe how well the current 
centers support the requirements of their services.
    Welcome, gentlemen.
    General Green, I know this is not the first time you have 
appeared before our panel, but it is the first time since your 
promotion to Surgeon General of the Air Force, so we welcome 
you. And thank you to all of you for being here.
    Throughout our conversation today, it should go without 
saying that all of us, members of the legislative and executive 
branches, are committed to providing the very best care 
possible to our wounded warriors. It is not hyperbole to say 
that our military health system has made previously impossible 
feats routine. This is a testament to the commitment displayed 
on a daily basis by everyone who is associated with the 
military health system. We must do our part to make this trend 
continue.
    Once again, thank you for being here. We look forward to an 
active discussion, and I will turn now to Mr. Wilson for any 
remarks he would like to make.
    [The prepared statement of Mrs. Davis can be found in the 
Appendix on page 23.]

   STATEMENT OF HON. JOE WILSON, A REPRESENTATIVE FROM SOUTH 
   CAROLINA, RANKING MEMBER, MILITARY PERSONNEL SUBCOMMITTEE

    Mr. Wilson. Thank you, Chairwoman Davis, and thank you for 
holding this hearing. I cannot overemphasize the importance of 
the four Department of Defense medical centers of excellence 
established by Congress to meet the needs of our returning 
wounded and injured service members. The medical centers of 
excellence were intended to be the overarching body for each of 
the focus areas that coordinates, inspects, and oversees the 
tremendous amount of good work being done across the nation to 
help our troops returning with brain injuries, mental health 
problems, vision and hearing injuries, and extremity injuries 
and amputations.
    As a veteran myself and father of four sons currently 
serving in the military, I particularly have an understanding 
of what you are doing and I am so grateful that my second son 
is a graduate of the Uniformed Services University. I am very 
grateful that he has served as a Navy doctor with the SEALs and 
the Rangers in Iraq. General Green, I also have to point out I 
have a nephew who just concluded six months service in the Air 
Force in Iraq. So our family is joint service.
    I continue to be amazed by the dedication and remarkable 
accomplishments of the health care and scientific community 
both in the public and private sectors that have led to the 
innovation and advancement of battlefield medicine in post 
trauma care and rehabilitation.
    Because of the volume of work being done, it is important 
to make sure that the efforts are focused and coordinated to 
avoid duplication and ensure the best use of our resources. In 
my mind, that is the role of the centers of excellence.
    With that, I recognize some of the centers of excellence 
have been in existence longer than others and thereby there 
will be a difference in the level of achievement among the 
centers. I am concerned it takes such an inordinate amount of 
time to establish a center and to get it up and running once it 
has been legislated.
    I am anxious to hear from our witnesses today how well the 
centers of excellence are operating and how effective they are 
in getting the best care and treatment available to our wounded 
and injured service members. They deserve no less.
    Finally, I would like to welcome our witnesses. All of you 
are so well thought of in the military and by the citizens of 
our country. Thank you for participating in the hearing today. 
I echo Chairwoman Davis' welcome in particular to General 
Green, and I look forward to your testimony.
    [The prepared statement of Mr. Wilson can be found in the 
Appendix on page 26.]
    Mrs. Davis. Thank you, Mr. Wilson.
    We will start with you, Dr. Rice.

STATEMENT OF DR. CHARLES L. RICE, PRESIDENT, UNIFORMED SERVICES 
  UNIVERSITY OF HEALTH SCIENCES, PERFORMING THE DUTIES OF THE 
    ASSISTANT SECRETARY OF DEFENSE FOR HEALTH AFFAIRS, U.S. 
                     DEPARTMENT OF DEFENSE

    Dr. Rice. Madam Chair, distinguished members of the 
subcommittee, good afternoon and thank you for the opportunity 
to discuss with you today the Department's Centers of 
Excellence. I have submitted a much more comprehensive summary 
of the accomplishments of the centers as well as an outline of 
the major milestones for the coming year. So I will confine my 
remarks to what needs to be accomplished during this year.
    Of our four Centers of Excellence in the military health 
care system, the Center for Psychological Health and Traumatic 
Brain Injury has been established for the longest period of 
time and is the furthest along in an operational sense. The 
Hearing, Vision, and Traumatic Extremity Injuries and 
Amputation Centers were designated more recently and they are 
catching up in their organizational development.
    Since stepping into my current role six weeks ago, I have 
communicated to my staff and to the services that we must 
execute our responsibilities expeditiously in order to meet our 
obligations. Specifically, the most critical item is the 
approval of a concept of operations that will be coming to me 
for final approval very shortly.
    Governance issues are equally critical, and we will seek to 
exercise a consistent governance model across all of the 
centers. I plan to have our governance structure developed and 
approved by the end of May.
    This summer we will open the National Intrepid Center of 
Excellence at Bethesda, a major milestone.
    We are working closely with our colleagues at the 
Department of Veterans Affairs to ensure that our approach is 
integrated and represents the clinical best practices and is 
informed by the most current research to serve our wounded 
warriors and our veterans.
    We have embarked on a course that will result in more 
patient centers and higher quality care and service to our 
patients and to their families. The Department is appreciative 
of the support and the guidance that the committee has made in 
the establishment of our Centers of Excellence.
    Thank you again, Madam Chair and members of the committee, 
for the opportunity to be with you today. I look forward to 
your questions.
    [The prepared statement of Dr. Rice can be found in the 
Appendix on page 29.]
    Mrs. Davis. Thank you very much. I appreciate your being 
brief. We are trying to do these special hearings in an hour 
and to be able to pinpoint the most essential issues that we 
need to address.
    General Schoomaker.

STATEMENT OF LT. GEN. ERIC B. SCHOOMAKER, USA, SURGEON GENERAL, 
                           U.S. ARMY

    General Schoomaker. Chairwoman Davis, Representative 
Wilson, and distinguished members of the Personnel 
Subcommittee, thank you for inviting us to discuss the five 
Centers of Excellence directed by Congress in the 2008 and 2009 
National Defense Authorization Acts. Like my colleagues, I have 
submitted a much lengthier statement, but anticipating that 
your questions will be more illuminating, I will keep my 
comments very brief.
    These Centers of Excellence offer great promise to our 
warriors and patients, to the Department of Defense and to the 
nation. I foresee a day when these centers are acknowledged as 
worldwide leaders in their respective disciplines. However, we 
are not there yet; and we are moving slowly in some areas, as 
should be expected of any undertaking of this magnitude.
    Despite the growing pains we experienced standing up these 
centers, I am confident the Department is now moving in the 
right direction to provide the centers with the governance and 
the support to allow them to flourish.
    Like the Congress, I remain concerned about unnecessary 
duplication of programs and unnecessary competition among the 
services and federal agencies that are conducting research and 
providing care.
    Perhaps the greatest contribution offered by these centers 
will be their role as the conduit for a two-way dialogue 
receiving external expertise from federal agencies and private 
industry and academia, and communicating the Department's 
internal perspective to those same leaders in government, 
science, education and industry.
    These centers serve as what I call the catcher's mitt, a 
single point of contact for vetting new ideas, for 
synchronizing competing interests, and for standardizing 
evidence-based practices and clinical guidelines. Alignment of 
these programs under a single overarching construct would be 
ideal to reduce the number of oversight groups and 
administrative overhead, while ensuring agile and responsive 
translational research and medical programs.
    The Department and the services are working together to 
establish favorable conditions for these five centers to be 
models of health care excellence. Ultimately, the centers will 
achieve their original vision and be critical enablers to 
improving readiness, health and quality of life for our service 
members, our veterans, and our family members.
    Thank you for holding this hearing and for your steadfast 
support of Army medicine and the entire military health system. 
Thank you, ma'am.
    [The prepared statement of General Schoomaker can be found 
in the Appendix on page 41.]
    Mrs. Davis. Thank you.
    Admiral Robinson.

STATEMENT OF VICE ADM. ADAM M. ROBINSON, USN, SURGEON GENERAL, 
                           U.S. NAVY

    Admiral Robinson. Chairwoman Davis, Mr. Wilson, and 
distinguished members of the subcommittee, thank you for the 
opportunity to provide my perspective on the Defense Centers of 
Excellence. More importantly, thank you for your leadership on 
this issue. Your vision and direction provided us a solid 
foundation on which to build the Centers of Excellence and 
further support our responsibility and privilege for the care 
of our wounded warriors and their families.
    As our wounded warriors return from combat and begin the 
healing process, they deserve a seamless and comprehensive 
approach to their recovery. We want them to mend in body, mind, 
and spirit. The Defense Centers of Excellence for Psychological 
Health and Traumatic Brain Injury were established to leverage 
the collective efforts of the services by bringing together 
treatment, research and education and support of this 
psychological health and traumatic brain injury.
    In addition, the DOD has been working to establish three 
additional Centers of Excellence which Congress directed. These 
include the Traumatic Extremity Injuries and Amputation, the 
Center of Excellence for Vision and the Center of Excellence 
for Hearing.
    I have often referred to our obligation to our wounded 
warriors and their families as a commitment measured in 
decades, not years. To meet our obligations, we much build 
supporting organizations for the long haul and continuously 
adapt our practices to meet the emerging needs of our patients. 
Military medicine leadership must determine how to best to 
maximize the operational efficacy of the DCoE and help 
facilitate their important synchronization efforts. The DCoE 
must be organized and aligned to provide for the efficient 
delivery of services to our clinicians, to our patients, and to 
our families. Our goal must be to enable the DCoE to focus on 
its core competencies and operate efficiently with the 
necessary supporting command and control elements in place.
    Associated with review of options for the DCoE realignment, 
there is consensus among the ASD-HA [Office of the Assistant 
Secretary of Defense for Health Affairs] leadership and the 
Surgeons General, that the National Intrepid Center of 
Excellence, the NICoE, currently a DCoE component center, 
should be organized under the Commander National Naval Medical 
Center [NNMC] and subsequently the Commander Walter Reed 
National Military Center Bethesda. As a clinical entity, the 
model of NICoE being organizationally aligned in NNMC is 
consistent with the construct of the Center for the Intrepid 
currently in place at Brooke Army Medical Center, BAMC, in San 
Antonio.
    I, along with my fellow Surgeons General, and the ASDHA 
leadership are committed to ensuring that we will build on the 
vision advanced by the Members of Congress and the hard work of 
the dedicated professionals at all the Centers of Excellence, 
medical treatment facilities, research centers, and our 
partners in both the public and private sector.
    I want to thank the committee for your support, for your 
confidence and your leadership. It has been my pleasure to 
testify before you today. I look forward to your questions.
    [The prepared statement of Admiral Robinson can be found in 
the Appendix on page 49.]
    Mrs. Davis. Thank you.
    General Green.

   STATEMENT OF LT. GEN. CHARLES BRUCE GREEN, USAF, SURGEON 
                    GENERAL, U.S. AIR FORCE

    General Green. Chairwoman Davis, Congressman Wilson, and 
distinguished members of the committee, thank you for the 
opportunity to discuss the DOD Centers of Excellence, and 
specifically the plans for the Air Force Medical Service to 
establish the Hearing Center of Excellence. We believe these 
centers support the military health service strategic goals and 
our mandate for trusted care to those who serve.
    The creation of a Hearing Center of Excellence is relevant 
and necessary for military members and veterans. Hearing loss 
is a major cost incurring disability for both DOD and VA. In 
fact, tinnitus and hearing loss were the most prevalent 
service-connected disabilities for veterans who began receiving 
compensation in 2009. The Hearing Center of Excellence will be 
a collaborative DOD and VA team focused on prevention, 
diagnosis, mitigation, treatment, and rehabilitation of hearing 
loss and auditory problems. It will bring new technology and 
research to current hearing conservation programs, but will not 
replace existing efforts.
    The Hearing Center of Excellence executive hub will be in 
San Antonio at Wilford Hall Medical Center, leveraging the 
robust Air Force and Army staffing of ENT [ear, nose, throat] 
and audiology experts, as well as established partnerships with 
VA hospitals and the University of Texas San Antonio Medical 
School. San Antonio is a rich research environment with many 
military and civilian research entities to help with the 
outreach.
    A central aspect of our Hearing Center of Excellence will 
be a hearing loss and auditory system injury registry that will 
record injury, diagnose surgical and other inventions for 
hearing loss and auditory system injuries. An electronic 
bidirectional exchange of information with the VA will ensure 
tracking of hearing outcomes for veterans entered into the 
registry who receive treatment, whether at DOD facilities or 
the VA.
    The Air Force is committed and well prepared to fulfill 
this important mission. Our long experience with hearing 
programs will serve as a strong foundation for this center, and 
we will build upon the many outstanding DOD and VA efforts 
already in progress. Plans are well underway, and we look 
forward to exploring new opportunities with our colleagues in 
DOD, our sister services, the VA, and civilian academic 
institutions.
    We truly appreciate the committee's support, and thank you 
for this opportunity to testify. We stand ready for your 
questions.
    [The prepared statement of General Green can be found in 
the Appendix on page 56.]
    Mrs. Davis. Thank you very much.
    To all of you, I appreciate your being here and the work 
you are doing in the centers.
    Dr. Rice, if I can just turn to you first, in your 
testimony you say that the centers will lead our efforts to 
identify gaps in our scientific knowledge about wounds, 
injuries, and diseases, as well as prioritizing and 
coordinating research efforts to fill those gaps. I think that 
is really what Congress was intending because we know that 
there is great interest, and I certainly appreciate my 
colleagues in wanting to do all that we can for the service 
members and also for their families who serve as chief 
caregivers in many of these areas.
    And yet that is really what the goal was three years ago, 
and I know you have only been in this position and it is a 
temporary one, and we want to acknowledge that. I want to know 
how you see our ability to actually realize those goals. What 
have you done since you have had a chance to just begin this, 
and I know it has been very, very short, how much longer will 
it take before the Department actually starts achieving some of 
those goals and really have the kind of strategic plan to 
prioritize and do exactly what I think the Surgeons General are 
saying, we don't want to duplicate a lot of efforts. What do 
you see more specifically?
    Some of this was in your address but you had very brief 
remarks, so we want to give you an opportunity to talk about 
that more.
    Dr. Rice. Thank you.
    I bring to this my perspective from having spent much of my 
career in the civilian academic world and understanding how 
efforts like this come together. They are not easy to do when 
you reach across disciplines, and as I am sure Dr. Snyder will 
attest, the bringing together different specialties inside the 
house of medicine and then reaching across into other 
disciplines, psychology, engineering, pharmacology, what have 
you, becomes an increasing challenge.
    In fact, if you take probably the prototype in academic 
centers, the canary in the mine, is cancer centers. And the 
National Institutes of Health recognized the complexity of this 
problem by actually awarding planning grants for universities 
that want to establish Cancer Centers of Excellence. These 
grants go up to five years in length. So the understanding is 
that bringing a group of disparate professionals together is a 
complex undertaking.
    That said, we all recognize a sense of urgency and feel 
that sense of urgency.
    I think another level of complexity for this particular 
constellation of injuries is that there is no gold standard 
diagnostic test for traumatic brain injury or post-traumatic 
stress, unlike say a myocardial infarction where we have an 
array of screening tests and then more confirmatory tests, 
including an angiogram or a technician scan to define precisely 
the anatomy and the physiology of the injury. In the case of 
traumatic brain injury or post-traumatic stress, we don't have 
anything quite like that.
    So bringing all of these aspects together has been a 
complex undertaking. I think we have had some growing pains, 
and I think we are beginning to get our arms around it. I am 
very encouraged by what I have seen.
    Mrs. Davis. Dr. Rice, as you look at organizationally what 
we have tried to do, and there is discussion about whether the 
program should basically nest or rest in any one of the 
services and how that is organized, are there some things, even 
in this relatively short time you have looked at and you have 
said, I wonder why did they set that up that way? What were 
they thinking? Where are those areas?
    Dr. Rice. I think General Schoomaker very accurately 
pointed out that we have an infrastructure for the management 
of research that all the services share. Much of it is based up 
at the Medical Research and Materiel Command at Fort Detrick. 
It is a very well developed and organized operation, and one of 
the options under consideration for us is to put much of the 
infrastructure there. The three Surgeons General are discussing 
that. That is what I alluded to in my testimony. We expect a 
recommendation to come from them very shortly that will help us 
get this organizational infrastructure in the right place so 
that we can execute swiftly.
    Mrs. Davis. Is there a sense that perhaps that discussion 
needed to be much earlier? Is this a little delayed in terms of 
where we are, and I will certainly give all of the Surgeons 
General a chance to address that, but has it taken the 
knowledge of trying to do this time for everyone to catch up in 
terms of trying to figure out where the best is 
organizationally?
    Dr. Rice. Certainly in retrospect you can make that 
argument. Prospectively, alluding back to my experience in the 
civilian academic world, when you are bringing together 
professionals from, say, the college of nursing, the college of 
medicine, the college of pharmacy and the school of social 
work, the only place that this winds up is in the office of 
provost, which is not really well set up to manage an 
operational organization.
    I think that is analogous to what we saw with the 
development of the Defense Centers of Excellence. And as time 
has gone by, I think the realization has come that keeping an 
operational responsibility inside of what is primarily intended 
to be a policy development office was not the best choice.
    Mrs. Davis. Thank you. I want to follow up with one more 
question. I guess my colleague had to leave already. I am sorry 
he didn't have a chance to ask a question.
    I know you are aware that the House Appropriations 
Subcommittee on Defense was concerned about the fact that all 
of the DCoE folks went from Washington to San Diego, and we are 
always happy to have people in San Diego, for a conference, and 
there was some concern that perhaps the entire department, 
everybody involved, did not need to go to build the 
relationships I happen to believe that are required when people 
are working together, but there was a way to do this without 
having it be so costly. Would you like to add to that in any 
way because I know that they were concerned and they even asked 
us to help answer that question better.
    Dr. Rice. Well, I think we are certainly looking into 
issues like that and putting management controls, better 
management controls into place so we make sure that we don't 
spend money unnecessarily. I can't speak to the decision making 
that went into that particular conference at the time, but I 
can assure you that we will make sure that the controls are in 
place in the future.
    Mrs. Davis. Thank you.
    Mr. Rooney.
    Mr. Rooney. Thank you, Madam Chair. Thank you to the panel. 
I don't necessarily have any questions. I just want to thank 
you personally for the work that we are trying to accomplish 
here, I think together. Having worked on a few pieces of 
legislation that specifically deal with post-traumatic stress 
disorder and terminal brain injury, it is enlightening, and I 
understand it can be as frustrating for you as it is for us. 
But it is good news that we are able to sit here today and talk 
about how we are going to get this done, and I know that is the 
objective of everybody on the panel, as it is for this 
committee.
    With that being said, I just want to thank you for all of 
the work you have put in and look forward to having a 
continuous working relationship with all of you.
    I yield back.
    Mrs. Davis. Thank you. Dr. Snyder.
    Dr. Snyder. Thank you, Madam Chair. I want to be sure I 
understand the very basics. We have five Centers of Excellence 
at least on paper, correct? Traumatic Brain Injury, Traumatic 
Injury to Extremities; is that correct?
    General Schoomaker. The Defense Center of Excellence for 
Traumatic Brain Injury and Psychological Health are combined 
into one center. So two of the centers are combined into one.
    Dr. Snyder. They were authorized by separate 
appropriations.
    General Schoomaker. But the Department chose to put them as 
a single center.
    Dr. Snyder. Which makes sense. And then we have Extremities 
Center?
    General Schoomaker. Yes. Extremities and Amputation.
    Dr. Snyder. So it was referred to as five, but two were 
combined into one.
    General Schoomaker. Yes.
    Dr. Snyder. Regarding Dr. Rice's comments earlier, I think 
these have all been set up or established or mandated to do 
them by legislation and my question is: Did we make a mistake? 
We are House Members. We are prepared to acknowledge that we 
make mistakes sometimes. We didn't set up Centers of Excellence 
for neurological problems or for orthopedic neck injuries or 
Centers of Excellence for cancer or heart disease or lung 
disease or toxicological injuries or from fires. We set up 
these because we hear from constituents and we thought there 
was a gap.
    My question is a general one. Are we barking up the wrong 
tree here? Perhaps we should not have mandated Centers of 
Excellence, perhaps there should be other ways, maybe greater 
funding of research, maybe oversight and coordination amongst 
different health care institutions? I am almost asking your 
personal opinion, did we make a mistake by requiring these 
Centers of Excellence? Dr. Rice, do you want to start?
    Dr. Rice. No, sir, I don't think so. I think what you did 
was galvanize the Department's attention around a complex set 
of injuries that we had not really dealt with very much in the 
past, in part because this is a different kind of war with a 
different kind of enemy and in part because our success rate 
for resuscitation in the field is so much greater than it was 
in previous engagements.
    I do think that you bring up a very good point, and if I 
may draw on my civilian academic experience, one of the things 
that has served most institutions well is to require somewhere 
around the five to seven-year mark a review to ask is this 
structure really still the right one? Is it necessary for this 
to continue as is? And if I might suggest, I would propose that 
perhaps we have a discussion about whether undertaking 
something like that might serve our patients well.
    Dr. Snyder. At the five-year mark should this be continued 
or completely discontinued, and recognize that there may be a 
different way of getting at it or adjust it?
    Dr. Rice. Or evolve into a different structure, yes.
    General Schoomaker. Well, sir, I would have to agree with 
Dr. Rice. I think that the Congress did not fundamentally make 
an error in directing that these centers be established. But I 
will concede that I don't think that we executed it flawlessly.
    I think having said that, I believe there has been more 
done than may be readily apparent to many folks. These are not 
brick and mortar centers. We avoided deliberately the attempt 
to put structure, physical structure, where it was not needed. 
And I would point out that Congress preceded this in the NDAA 
[National Defense Authorization Act] 2006 by mandating that the 
Department look very proactively and exhaustively at all, 
especially research dollars, that were directed to the same 
language, prevention, mitigation, management, and treatment of 
blast injury. That was without money attached to it, but it 
forced us and the Department chose to take that legislative 
mandate and to delegate that to the Army and then to Army 
Medicine and then to the Medical Research and Materiel Command 
[MRMC] where we did a gap and redundancy analysis and 
identified what areas both in research and treatment we were 
most lacking in.
    I always saw that as an effort on the part of Congress and 
the Department to create the highway for when moneys began to 
flow to direct those efforts. When you all then created the 
five centers, I saw that as highlighting areas within the blast 
injury program we had identified as particularly vulnerable 
areas and where we were getting most of our concerns for 
patient care.
    And it is at that point I think we began the internal 
dialogue that you are hearing us talk about here in how do we 
execute those centers. I do believe and I hope we have an 
opportunity to talk about what the centers have achieved 
because again, for example in the case of extremity injury and 
amputation, I think we have done some terrific things, and that 
your mandating in legislation that we have this center has 
allowed us to align and cobble together efforts across all of 
the three services and the Veterans Administration and the 
private sector in I think a very positive and proactive way.
    Admiral Robinson. First of all, I am not going to be the 
only SG [Surgeon General] that says you made a mistake; you did 
fine. And I mean that sincerely. I think what we have found is 
in executing this we haven't been very facile in our attempts 
to get the organizational structure to execute the plan. I 
think that the MRMC, which is long established and has the 
infrastructure, as already has been stated, was the right 
thing. And once we got the DCoE, the psychological health, once 
we got some of the DCoE studies there, we have made tremendous 
progress. For example, hyperbaric oxygen therapy, does it work? 
Is it helpful in traumatic brain injuries? We don't have the 
answers to that, but we have a really good prospective 
randomized trial set up and ready to go and it is being 
executed now. It took us a long time to get there but the 
reason is we didn't have the proper infrastructure, which MRMC 
had and we were looking at the wrong places.
    We thought, General Schoomaker and I thought of that a 
couple of months back, but it took a while to get there.
    Also, and it has been alluded to, the Centers of Excellence 
have to leverage the Department of Veterans Affairs as well as 
the academic community, and I underline the Department of 
Veterans Affairs because, as I have said repeatedly through the 
year, the systematic rehabilitative care issues, which are now 
becoming all of our responsibilities, need to be funded through 
the traditional organization that had the responsibility for 
systematic rehabilitative care. So I am not suggesting that it 
is now only residing with DVA [Department of Veterans Affairs], 
it resides with us also. But we need to leverage that 
information and a lot of the resources, both intellectual, 
academic, and research and practical that DVA has.
    So I think to add onto this, I think it is a focused area 
that we now have and we need to be very careful as to how we 
proceed. I would also say in a five-year period or some period 
of time, looking back and being honest with do we need this 
center now, may be the thing to do or how should we change this 
center as opposed to just letting it go in perpetuity.
    General Green. Dr. Snyder, I would say on first blush I 
agree with you, that we have looked at certain centers and 
didn't take on a lot of other disease processes and perhaps 
things that would be equally valuable to gain research and put 
dollars towards. But I have to admit as I looked into this, and 
I will talk more to the hearing, but even with all of the other 
centers, it was an extremely wise thing to identify gaps and 
get us thinking. And so with the five centers that have been 
stood up, looking at what has happened over in the AOR [area of 
responsibility] and the type of injuries that have been coming 
back and the rehabilitative needs of those folks and our 
wounded warriors, in essence what Congress was able to do for 
us was to get us to improve our communication. The influx of 
dollars gave the ability for us to not only talk better with 
our civilian counterparts, but also amongst ourselves to 
leverage the different assets that we had.
    I think it was wise for us not to set up brick and mortar 
structures to do this. I think this is really about 
establishing research networks. So the tricky part is kind of 
establishing what are those governance and the controls, if you 
will, on how we are going to do that. Should it all be 
conferences or research, or should it all be telemedicine in 
terms of how we communicate? And the answer is it is taking a 
little bit of all of them.
    So what you are seeing evolve over the last two years is 
the understanding that we don't necessarily need to build new 
infrastructure to do this, that we need to take advantage of 
the structures that are in place. We all recognize the large 
dollars that are up at MRMC in terms of how they manage the 
research agenda for us in large part. The Navy labs are also 
quite large, and the Air Force is a fairly small player in 
terms of how this works, and yet we have good programs just 
like the other services and the civilian sector does. And so 
when you get us all talking together, and similar to how the 
NIH [National Institutes of Health] doles out dollars for 
research based on the most promising technologies and ways we 
can move forward, you now start seeing the progress that we are 
hoping for.
    So what we have learned is that we don't want to set up 
duplicative infrastructure, that we do want these registries to 
be attached, and we do want to be able to share information 
even between the centers, and the way to do that is to kind of 
look at front shop, back shop where not everybody needs to have 
public affairs guidance and ways to interface with Congress but 
there needs to be that back shop activity that knows the 
questions that are being asked and knows how to formulate 
solution sets to move forward and to get things out into the 
public domain so that we can let contracts and seek researchers 
who have promising technologies. So I think that is where we 
are right now. We are realizing that we need to leverage the 
services' existing capabilities, place back shop functions in 
places where they have those skills, and take the research 
agenda and perhaps the executive oversight for a particular 
research area, one of these COEs [Centers of Excellence], and 
now leverage that expertise to bring a whole different group of 
people together rather than just putting money into some of the 
older projects that have been ongoing because there may be new 
things that haven't been considered simply because of how they 
were funded.
    So I think that is the advantage of doing the COEs. Whether 
we pick the right gaps or not, I can't answer for you, sir, but 
it is creating communication and it is moving us forward.
    Dr. Snyder. Thank you.
    Mrs. Davis. Thank you. I think that your responses get 
largely into the interchange that I would love to see amongst 
the three of you as thinking about perhaps ways in which the 
Congress set this up or the way some of the organization moves 
forward, it has created some inhibitions in terms of what you 
have actually wanted to see accomplished or where you felt some 
of the frustrations in not being able to move forward in the 
way that you thought. Are there some things that we could even 
at this point, because not all of this is so developed that you 
cannot go back and say okay, there is another way to do this, 
are there some areas in which you would really like to have it 
move in somewhat of a different direction perhaps?
    You mentioned the NIH, the way the NIH doles out grants. I 
don't have a clear picture. If there is a really great idea out 
there, how does that get heard and how are those grants 
realized at this point, either within, among the services and 
through the DCoE as a whole?
    General Schoomaker. I think this is really one of the real 
benefits of the approach that we now are taking. I talked about 
that in my opening statement, we have a single catcher's mitt 
now.
    One of the things that we need to acknowledge, ma'am, I 
think all of us do, is that none of this has been static. Even 
battlefield injury hasn't been static. The definition of what 
constitutes concussive injury, the fact that sequential 
concussive injury, undiagnosed, unmanaged, untreated, as it is 
on the sports field or in the civilian sector, has contributed 
to some of our problems. And the overlap between concussive 
injury and post-traumatic stress and post-traumatic stress 
disorder, those are only being defined as the war has been 
fought and as we have tried to grapple with these.
    What I think the centers do offer us is an opportunity to 
in a sense funnel in all of those interests and emerging ideas, 
practices, research avenues and, as I said before, to focus the 
dialogue internally from the standpoint of the provider and the 
communities of our services in such a way that we vet and 
prioritize rack and stack and how we go forward and, once those 
have been established, to clearly establish practice 
guidelines, standard policies as they apply to how we manage 
them. And I think we are starting to get some experience with 
that.
    The Defense Center of Excellence for Traumatic Brain Injury 
and Psychological Health, for example, has helped us with 
battlefield protocols, with how we identify and manage at the 
point of injury concussive injury and such mundane matters as 
what do you do with your soldiers, sailors, airmen and marines 
who have had a concussive injury when it comes time to drive a 
vehicle.
    Those kinds of standard protocols and standard practice 
guidelines are now being generated by the centers, and I 
anticipate that is going to be more and more the work while the 
services execute how the programs are done sort of in the 
field.
    Admiral Robinson. I would then say taking that broad view 
and taking a much less broad view and one that is going into 
the administration and the process, something that General 
Green talked about in terms of the infrastructure, don't create 
five registries, create one and make sure that we can overlap 
those. Don't create an IT [information technology] system for 
each new center, have one and make sure that we are 
interconnected. Don't create practice guidelines in one center 
and find out they are sort of contradictory with a center over 
here. Put them together and make sure that we have this 
integrated from an infrastructure and a process point of view 
from the beginning as we start this.
    I think part of the slowness in getting the centers up, I 
will just comment, we were trying to figure out in some 
respects how to execute this, and it became very clear to 
General Schoomaker and myself a while back that there were--
MRMC was in place and there were processes and there was 
infrastructure that was in place at the Navy Medical Command 
and the Air Force has similar things, we didn't have to 
recreate or create new things, but we needed to get these 
centers into the right places so we could actually execute what 
we had. That was making sure that we were in alignment and that 
was Health Affairs and others giving us that policy guidance to 
make sure that we were together, and then leveraging our 
interagency partners and the academic community in addition.
    So it has been slow, but it has been fruitful in that this 
has been an ongoing and a very robust discussion within the 
services.
    Dr. Rice. One of the issues, one of the opportunities that 
we have had the opportunity at the university in a parallel 
effort was given to us by the 2008 appropriation which 
established the Center for Neuro Regenerative Medicine, also 
focused on traumatic brain injury and post-traumatic stress. 
But from much more of a basic point of view, I alluded earlier 
that there is no gold standard for the diagnosis of these 
injuries, and this is an effort to help identify those.
    That language in the appropriation specifically authorized 
the Department of Defense to reach across Wisconsin Avenue to 
collaborate with the National Institutes of Health and that has 
proven to have a galvanic effect. The people at the National 
Institutes of Health were eager to assist us in dealing with 
these injuries, and that particular language made that easy to 
do without the constraints of using part of a defense 
appropriation at another agency. So that is one example of 
something that the Congress might consider.
    Mrs. Davis. General Green, did you want to add to that?
    General Green. Briefly, I think it is important to 
understand whenever you are trying to arrive at a common 
vision, you have to basically explore where you are coming 
from. And so the trick with the COEs are when you bring a lot 
of different efforts together, especially when you go outside 
of medicine, each person thinks that they have the answer. So 
then you have to design the studies to try and find out what 
the evidence truly says is correct.
    You folks, probably much more than us, are approached by 
lobbyists and special interest groups from all over who think 
that they have a solution set for what we need. And what this 
effort is about is trying to find out what is it we need and 
how do we prove that this will actually do what it is said it 
will do. That takes a lot of time actually to design some of 
these things. Although I would love for us to have this 
infrastructure set up a little more robustly so that we could 
move forward, I am not too surprised that it has taken us some 
time to reach a common vision and that vision I think is to use 
our existing resources and now start defining these problems 
more closely.
    General Schoomaker. Ma'am, two more comments, quickly 
because I think there are some features of how we are now 
operating these three services in health affairs at the DOD 
level that are very, very favorable. The first is the rapidity 
with which we are making clinical improvements in battlefield 
medicine, evacuation, and care back here in CONUS [continental 
United States] based upon what my colleague, Admiral Robinson, 
just talked about is the creation of a single database. The 
Joint Theater Trauma Registry and its application through the 
three services and the DOD to look comprehensively across all 
services in all venues at how we manage traumatic care is 
almost unprecedented. We have essentially established what a 
large metropolitan community in the United States would have 
but across three continents and 8,000 miles. In doing that, we 
have created the framework for rapid movement of new knowledge 
and standardization of practices that has resulted in some of 
the unprecedented survival that you see today. And that has 
penetrated all of the way into areas like amputee care, which 
really quite frankly begins at the battlefield. Amputation 
medicine and extremity injury medicine begins in Balad, it 
begins in Bagram, at the first--in the corpsmen and the medic 
forward. Penetrating head injury is another good example in 
which the services have collaborated in advancing very rapidly 
the science and the clinical practice of penetrating injury.
    The second area that I think you need to recognize as a 
Congress that we are doing very well within the services is 
translational medicine: taking bench insights and basic science 
insights that are historically the purview of the Academy and 
groups like the NIH, and rapidly moving them across into 
applications, either intellectual products as in the case of 
battlefield medicine, or in the creation of new material 
products. That really requires the focus that these centers can 
provide for us. That is that we are not going to stop simply at 
proliferating new ideas and new basic science insights, we are 
going to rapidly move them across the chasm into the kind of 
advanced development, clinical trials and material development 
of new products that we need.
    Mrs. Davis. Thank you. I appreciate that. I guess the one 
question and sort of the bottom line on this is whether or not 
the work that is being done and the data that is being 
collected is being translated in the field to the extent that 
unit commanders are respectful of that data. Is that a concern 
that maybe I shouldn't be worried about? When we hear about the 
number of traumas, or even the multiple deployments for that 
matter that people have sustained, and we know that that 
cumulative effect has obviously--is going to have an impact on 
the service member. I don't know whether that is in your 
purview, to have a sense of whether people are really listening 
to that information you are working so hard to obtain. It 
obviously can restrict the commander in the field in terms of 
their ability to mobilize units to do the work that needs to be 
done out there.
    Admiral Robinson. Well, I will speak for the Marine Corps 
in one example, and that is with blast injuries. With blast 
injuries, there are a couple of examinations that can be given, 
the ANAM [Automated Neurological Assessment Metric] and the 
MACE [Mild Acute Concussive Evaluation]. The key here is that 
with the Marine Corps in the field, the Marine Corps leadership 
has recognized that there are a number of men and women who are 
subjected to blast that aren't unconscious or don't have any 
outward effects and we don't necessarily know that they are not 
injured. So there is a database in theater in Afghanistan in 
which they are looking at the number of personnel and the 
number of people that have three blasts. And three blasts, it 
doesn't mean that you come all of the way back to the states, 
but you come out and get a complete neurological exam and 
actually get looked at professionally to decide and determine 
if you have been injured and that injury was just unseen.
    I will leave that.
    There is the attempt to have baseline studies for the ANAM 
and other neurologic exams so that as we put people in theater 
we will have a baseline so we know if it does change.
    My point is there are attempts to look exactly at some of 
the things that you are saying, real-time actually today based 
upon what we have learned over the last two, three, four, five, 
six years regarding how we are taking care of individuals.
    Dr. Schoomaker. In the Army, ma'am, there is a growing and 
profound recognition on the part of the field commanders of the 
value of the joint medical system for the well-being of their 
soldiers and by extension their families.
    I have had field commanders tell me that it goes down to 
the detail of support, say, of medical evacuation in theater in 
Iraq and Afghanistan today. That combat aviation brigades, in 
whom we now embed Army medical evacuation, have organized much 
of their battlefield processes around support of the medical 
evacuation.
    What has been more difficult, because this is a learning 
process for us, is the impact of psychological health and such 
injuries as concussion. You know, I have said before we are in 
unfamiliar terrain: an Army entering into its ninth year of war 
in a cycle of deployment and redeploying soldiers that has 
never been experienced in history, with a dwell time back at 
home that is well below where we would like to see it. So I 
think this is a very active process of learning.
    But to answer your question directly, the respect that I 
think our line commanders have for this all of the way up to 
the senior leadership of the Army is very profound.
    Mrs. Davis. Dr. Snyder.
    Dr. Snyder. Just a follow-up question that maybe can be 
answered just with a nod of the head or shaking of the head. 
Going back to how Congress should provide oversight of this, I 
came into the hearing today thinking we have got five different 
centers and two of them combined and established at different 
times. If I heard you correctly, would a more helpful way for 
Congress to look at this and follow this along in the next 
several years would be to see this as five different centers 
but they are all attacking the same problem which is the blast 
injury? There are clearly going to be things that each of these 
centers look at that are apart from blast injuries, but we 
should see each of these centers of attacking the same problem 
of blast injury and we ought to look at all them together, not 
as five separate entities. Is that a fair statement, Dr. Rice?
    Dr. Rice. Yes, sir, I think it is. The fact is that 
patients don't get just a single injury. They may very well 
have mild TBI as well as hearing loss and loss of an extremity. 
So I think it is very important that these centers work 
together in a cohesive manner.
    Dr. Snyder. Thank you.
    General Schoomaker. Sir, I have rejected the notion that we 
have a signature injury of this war. We have a signature weapon 
of this war, and it is blast. That blast burns, it blinds, it 
deafens, it takes off limbs, and it causes enormous extremity 
injury. And I fully agree with what you said.
    Mrs. Davis. Thank you. The bells are ringing, but just a 
quick question.
    General, you mentioned the Joint Center of Excellence for 
Battlefield Health and Trauma Research that is under 
construction in San Antonio. What is that supposed to do when 
it is finished?
    General Schoomaker. We didn't mention this, but it was 
alluded to by General Green that in addition to the alignment 
of clinical and research efforts through things like the blast 
injury program and now these centers, is the alignment 
physically and collocation through the base realignment and 
closure of many of our assets. So Navy medicine and trauma is 
being relocated with Army medicine and trauma along with the 
Air Force.
    That includes things like biodefense assets which are being 
collocated in some laboratories in Fort Detrick and other 
places. So we are going to see an alignment, as in the Joint 
Battlefield Trauma Center down in San Antonio of the Army's 
Institute of Surgical Research along with the Air Force and the 
Navy's efforts in dental research and in other aspects of 
trauma.
    Mrs. Davis. And that doesn't represent any kind of 
duplication then?
    General Schoomaker. No, ma'am. I think that is the physical 
brick and mortar of this.
    Mrs. Davis. The ability to focus it together. Okay. Thank 
you.
    And Admiral Robinson, could you just provide us a little 
bit more detail on the hyperbaric oxygen therapy clinical 
trials that are being conducted right now? Is there something 
particular that we should know about that?
    Admiral Robinson. Nothing except we have now with the help 
of Colonel Scott Miller, who is an infectious disease physician 
at MRMC, he is also an Army physician, we have been able to 
actually develop prospective randomized trials to look at 
patients who have had had traumatic brain injuries, mild 
traumatic brain injuries, and whether they would benefit from 
having hyperbaric oxygen therapy. We have several centers where 
this is now occurring--Pendleton, LeJeune, Fort Carson I think, 
and also San Antonio. It is a tri-service event. We have now 
included more patients in the studies that we have to date than 
we have had in any of the literature that has been describing 
it for the last many years. And I think we have--it is blinded 
and it actually has a cohort that is a sham which means we are 
going to see if this actually works or if this is just a 
placebo effect.
    So I think we have good science and a good study in place 
that over the course of the next 24 to 36 months is going to 
actually give us definitive information as to whether 
hyperbaric oxygen works, at what tour it works, and also if it 
is harmful because that is the other question that people have. 
And from this, I think we can develop practical and successful 
and reproducible clinical guidelines or not based upon science 
and not anecdotal evidence.
    Mrs. Davis. Thank you.
    General Schoomaker. And, ma'am, for the record, lest our 
critics point out that we are using an infectious disease 
expert to run hyperbaric oxygen research, his expertise in 
infectious disease gave him great skills in randomized 
prospective trials and in FDA [Food and Drug Administration] 
certification of trials. So we have leveraged that.
    Mrs. Davis. Great. Thank you. As we look at the next 
authorization, maybe for the record some things that you would 
particularly like us to focus on, if we were to even have a 
hearing even six or nine months from now, you know, just 
thinking a little bit more about shortcomings that you think we 
might be talking about at that time that are of concern to you 
but also where we might place some additional resources to help 
you further do your jobs and to make certain that this does all 
the things that we really would like it to do for our service 
members. If you could be thinking some about that and get us 
that information, that would be helpful.
    Anything you want to add right off the bat to that? Or we 
will come back. All right. Thank you very much for all of you 
for being here. Thank you for the work that you do.
    General Schoomaker. Thank you.
    [Whereupon, at 6:45 p.m., the subcommittee was adjourned.]



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