[Senate Hearing 111-217]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 111-217
 
 HEARING TO EXAMINE THE IMPLEMENTATION OF WOUNDED WARRIOR POLICIES AND 
                                PROGRAMS

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



                                HEARING

                               before the

                       SUBCOMMITTEE ON PERSONNEL

                                 of the

                      COMMITTEE ON ARMED SERVICES
                          UNITED STATES SENATE

                     ONE HUNDRED ELEVENTH CONGRESS

                             FIRST SESSION

                               __________

                             APRIL 29, 2009

                               __________

         Printed for the use of the Committee on Armed Services




                  U.S. GOVERNMENT PRINTING OFFICE
54-356                    WASHINGTON : 2009
-----------------------------------------------------------------------
For sale by the Superintendent of Documents, U.S. Government Printing 
Office Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800; DC 
area (202) 512-1800 Fax: (202) 512-2104  Mail: Stop IDCC, Washington, DC 
20402-0001




                      COMMITTEE ON ARMED SERVICES

                     CARL LEVIN, Michigan, Chairman

EDWARD M. KENNEDY, Massachusetts     JOHN McCAIN, Arizona
ROBERT C. BYRD, West Virginia        JAMES M. INHOFE, Oklahoma
JOSEPH I. LIEBERMAN, Connecticut     JEFF SESSIONS, Alabama
JACK REED, Rhode Island              SAXBY CHAMBLISS, Georgia
DANIEL K. AKAKA, Hawaii              LINDSEY GRAHAM, South Carolina
BILL NELSON, Florida                 JOHN THUNE, South Dakota
E. BENJAMIN NELSON, Nebraska         MEL MARTINEZ, Florida
EVAN BAYH, Indiana                   ROGER F. WICKER, Mississippi
JIM WEBB, Virginia                   RICHARD BURR, North Carolina
CLAIRE McCASKILL, Missouri           DAVID VITTER, Louisiana
MARK UDALL, Colorado                 SUSAN M. COLLINS, Maine
KAY R. HAGAN, North Carolina
MARK BEGICH, Alaska
ROLAND W. BURRIS, Illinois

                   Richard D. DeBobes, Staff Director

               Joseph W. Bowab, Republican Staff Director

                                 ______

                       Subcommittee on Personnel

                 E. BENJAMIN NELSON, Nebraska, Chairman

EDWARD M. KENNEDY, Massachusetts     LINDSEY GRAHAM, South Carolina
JOSEPH I. LIEBERMAN, Connecticut     SAXBY CHAMBLISS, Georgia
DANIEL K. AKAKA, Hawaii              JOHN THUNE, South Dakota
JIM WEBB, Virginia                   MEL MARTINEZ, Florida
CLAIRE McCASKILL, Missouri           ROGER F. WICKER, Mississippi
KAY R. HAGAN, North Carolina         DAVID VITTER, Louisiana
MARK BEGICH, Alaska                  SUSAN M. COLLINS, Maine
ROLAND W. BURRIS, Illinois

                                  (ii)


                            C O N T E N T S

                               __________

                    CHRONOLOGICAL LIST OF WITNESSES

 Hearing to Examine the Implementation of Wounded Warrior Policies and 
                                Programs

                             april 29, 2009

                                                                   Page

Gadson, LTC Gregory D., USA......................................     5
Noss, Kimberly R., Ph.D..........................................     6
Kinard, 1st Lt. Andrew K., USMC (Ret.)...........................     7
Williamson, Randall B., Director, Health Care, Government 
  Accountability Office; Accompanied by Daniel Bertoni, Director, 
  Education, Workforce, and Income Security Issues; and Valerie 
  C. Melvin, Director, Human Capital and Management Information 
  Systems Issues.................................................    26
McGinn, Gail H., Deputy Under Secretary of Defense for Plans, 
  Department of Defense..........................................    54
Embrey, Ellen P., Acting Principal Deputy Assistant Secretary of 
  Defense for Health Affairs.....................................    60
Dimsdale, Roger, Executive Director, Department of Veterans 
  Affairs/Department of Defense Collaboration, Office of Policy 
  and Planning, Department of Veterans Affairs...................    65
Meurlin, Maj. Gen. Keith W., USAF, Director, Office of Transition 
  Policy and Care Coordination, Department of Defense............    70
Timberlake, RADM Gregory A., USN, Director, Interagency Program 
  Office, Department Of Defense/Department Of Veterans Affairs...    75
Guice, Karen S., M.D., M.P.P., Executive Director for the Federal 
  Recovery Coordination Program, Department of Veterans Affairs..    80

                                 (iii)


 HEARING TO EXAMINE THE IMPLEMENTATION OF WOUNDED WARRIOR POLICIES AND 
                                PROGRAMS

                              ----------                              


                       WEDNESDAY, APRIL 29, 2009

                               U.S. Senate,
                         Subcommittee on Personnel,
                               Committee on Armed Services,
                                                    Washington, DC.
    The subcommittee met, pursuant to notice, at 2:33 p.m. in 
room SH-216, Hart Senate Office Building, Senator E. Benjamin 
Nelson (chairman of the subcommittee) presiding.
    Committee members present: Senators E. Benjamin Nelson, 
Hagan, Begich, Graham, Chambliss, Thune, and Wicker.
    Committee staff member present: Leah C. Brewer, nominations 
and hearings clerk.
    Majority staff members present: Jonathan D. Clark, counsel; 
Gabriella Eisen, counsel; and Gerald J. Leeling, counsel.
    Minority staff members present: Paul C. Hutton IV, 
professional staff member; Daniel A. Lerner, professional staff 
member; Lucian L. Niemeyer, professional staff member; Diana G. 
Tabler, professional staff member; and Richard F. Walsh, 
minority counsel.
    Staff assistants present: Mary C. Holloway, Jessica L. 
Kingston, Brian F. Sebold, and Breon N. Wells.
    Committee members' assistants present: Ann Premer, 
assistant to Senator Ben Nelson; Gordon I. Peterson, assistant 
to Senator Webb; Roger Pena, assistant to Senator Hagan; Clyde 
A. Taylor IV, assistant to Senator Chambliss; Adam G. Brake, 
assistant to Senator Graham; Erskine W. Wells III, assistant to 
Senator Wicker; and Rob Epplin, assistant to Senator Collins.

   OPENING STATEMENT OF SENATOR E. BENJAMIN NELSON, CHAIRMAN

    Senator Ben Nelson. Good afternoon. The subcommittee meets 
today to discuss the implementation of wounded warrior 
programs, policies, and plans by the Department of Defense 
(DOD) and the Department of Veterans Affairs (VA).
    This hearing was originally scheduled for April 1, 2009, 
but unfortunately, had to be postponed due to a series of 
stacked votes. I want to thank the members of our second and 
third panels, who were all present and accounted for, ready to 
testify, when the hearing was called off at the last minute. We 
thank you for your patience and understanding.
    The delay produced a very positive result. On that same 
day, April 1, Senator Graham and I were fortunate enough to 
meet with a group of wounded warriors and some of their family 
members who candidly shared with us the positive and negative 
experiences they'd gone through, and are still going through, 
on their journeys through treatment, the disability evaluation 
process, and transition to the next chapters of their lives.
    During that meeting, Senator Graham and I mentioned the 
possibility of the group testifying at a hearing on a future 
date, to which they all graciously agreed. Now, little did they 
know the day would come so soon. Because of the hearing's 
postponement, we were able to create a new first panel and we 
have invited them all to speak about their experiences as 
seriously wounded servicemembers, veterans, and as spouses of 
wounded warriors.
    We all remember February 18, 2007, the day the first in a 
series of articles appeared describing problems faced by our 
wounded warriors receiving care in an outpatient status. Many 
of these servicemembers, who were wounded or injured in service 
to our Nation, were living in substandard facilities, were 
unaccounted for, and were fighting their way through a bungled, 
adversarial administrative process to rate their disabilities. 
After they left DOD care, they had to start all over with the 
VA, and many fell through the cracks in the transition. As a 
result of these articles and various reports on wounded warrior 
transition policies and programs, Congress passed the Wounded 
Warrior Act, which was incorporated into the National Defense 
Authorization Act (NDAA) for Fiscal Year 2008.
    The Wounded Warrior Act, among many other things, required 
DOD and VA to work jointly to develop and implement a 
comprehensive set of policies to improve the care, management, 
and transition of recovering wounded, ill, and injured 
servicemembers. The Act also required the Comptroller General 
to assess and report on the progress made by the two 
departments in this endeavor. This report is near completion, 
so on our second panel we have personnel from the Government 
Accountability Office (GAO) to share their findings.
    On our third panel, we'll have several representatives from 
DOD and VA. They will discuss DOD and VA efforts to organize 
and resource wounded warrior program and policy improvements, 
as well as the accomplishments to date of the DOD/VA Wounded, 
Ill, and Injured Senior Oversight Committee (SOC) which has 
been in place for nearly 2 years and is comprised of several 
high-level DOD and VA officials. In fact, in a hearing earlier 
this year, Secretary Gates himself pledged to chair this 
oversight committee's meetings during this period of 
administration transition, along with Secretary Shinseki of the 
VA. This is evidence of the priority placed on helping wounded 
warriors and their families within the highest echelons of 
these departments. I'll introduce our DOD and VA witnesses when 
the third panel convenes.
    I'm very pleased to welcome our first panel. These men and 
women, who represent wounded, Active Duty servicemembers, 
veterans, and their families, are the reason we're all here 
today. We have with us Lieutenant Colonel Gregory D. Gadson, 
United States Army; Lieutenant Colonel Raymond T. Rivas, United 
States Army; his wife, Mrs. Colleen O. Rivas; Ms. Kimberly R. 
Noss, Ph.D., the spouse of a seriously wounded servicemember; 
and First Lieutenant Andrew K. Kinard, United States Marine 
Corps.
    The wounded warrior legislation passed by Congress required 
DOD and VA to collaborate on many levels. The departments have 
been tasked with great challenges, such as jointly developing a 
fully interoperable electronic health record, improving the 
disability evaluation system (DES), establishing centers of 
excellence for psychological health, traumatic brain injury 
(TBI), and eye and auditory trauma coordinating care, and much 
more. Collaboration on such a large scale was new ground for 
these two huge government agencies. The fact that DOD and VA 
have been able to work so closely on so many different levels 
is a sign of great commitment on their part to ensuring that 
our wounded, ill, and injured servicemembers and their families 
are given the best care management and support possible while 
navigating through these bureaucratic processes. With any 
undertaking of this magnitude, there are bound to be 
outstanding issues and problems to work out along the way.
    I visited with many of our wounded warriors, including 
soldiers from Nebraska, at Walter Reed Army Medical Center 
(WRAMC). The servicemembers that I've spoken with lauded the 
treatment they were receiving at WRAMC, and so, I commend the 
efforts of those who have worked to improve the outpatient care 
and treatment of our wounded warriors. I also learned, however, 
of many issues that indicate there's still work to be done.
    We've heard of the shortage of healthcare professionals. We 
owe it to our troops and our country to adequately assess the 
medical condition of our servicemembers prior to their 
deployment. I recently learned of incomplete medical 
assessments, due to a shortage of time or manpower, which, in 
one case, resulted in the unnecessary exacerbation of a 
servicemember's medical condition. In another case, the 
incomplete medical assessment resulted in the deployment of a 
medically unfit servicemember whose condition quickly 
deteriorated in Afghanistan, causing him to collapse in the 
field. This servicemember consequently had to be medically 
evacuated from the forward deployment for a known medical 
condition.
    When our servicemembers return home with war wounds, it's 
imperative that we have the medical personnel and resources 
available to care for them. It's also essential that we make 
efforts to treat our servicemembers as close to home as 
possible. The ability to receive care near their home base 
provides a better network of support for the servicemember, and 
will likely speed recovery time.
    Ensuring we have the means and resources in place for 
medical assessments and adequate treatment facilities is why 
oversight hearings such as this are so very important. As we 
reflect on the work done to date in improving these policies 
and programs for our servicemembers and their families, we must 
also identify any existing gaps or problems in the care, 
coordination, and transition process. Only after we identify 
problems can we work to find answers and provide the highest 
quality of care for our wounded, ill, and injured 
servicemembers and their families.
    This is far more than just a procedural issue. The purpose 
of these massive policy and program reforms is to care for our 
wounded warriors.
    Now it's my pleasure to welcome Senator Graham. We're 
delighted to have you here with us today to discuss these 
critical issues, and I ask if you would like to make an opening 
statement.
    Senator Graham, would you like to make an opening 
statement?
    Senator Graham. Very briefly, Mr. Chairman.

              STATEMENT OF SENATOR LINDSEY GRAHAM

    Senator Graham. I want to thank you for conducting this 
hearing. You've been a terrific supporter of the Wounded 
Warrior Program, and men and women in the military, in general. 
We met with this group. We were going to have a hearing a 
couple of weeks ago, and we had a bunch of votes scheduled, but 
the Chairman was kind enough to come to my office, and I think 
we got a lot out of that meeting with our wounded warriors who 
are here today, and Andrew Kinard who worked in my office 
(gesturing), and we learned a lot. One thing I learned is that 
I don't want these hearings to be taken by anybody as there's a 
lack of caring--there's not a lack. People care a lot. There's 
a lot of bureaucracy out there that cares a lot. We've just got 
to get it focused on doing the best job it can.
    Secretary Gates has put $300 million in the budget, which 
will help us. It's a budgetary item now for the Wounded Warrior 
Program, and the purpose of these hearings is to learn how to 
do it better, and not to question anybody's motives. If the 
services are not being delivered well, it's not because people 
don't care, it's because it's just not working right.
    For these Warrior Transition Units (WTUs), we hear some 
disturbing reports that people feel like the odd guy out. 
Family members feel like the command climate wasn't as 
responsive as it could be. That disturbs me. I'd just say this, 
if you're in charge of a WTU, we're going to judge you by how 
you take care of those who have paid a real heavy price. I hope 
that problem can be fixed and is not as bad as some people have 
said it was.
    We're here today to learn, and the best way to learn is 
from people who live it. That's panel one, and the next panel 
are the people in charge of making sure it works. We're going 
to be a team. Every American wants us to get this right. This 
has nothing to do with party politics. This is the one thing 
that will bring this country together above all else, taking 
care of the men and women who have been hurt.
    Thank you, Mr. Chairman, for having the right tone and 
attitude about how to do this.
    Senator Ben Nelson. Thank you, Senator Graham. You have 
been steadfast in your support for this program, whether the 
roles were reversed and you were chairman and I was ranking 
member, or the current situation, we will continue to make it 
bipartisan, nonpartisan, because there's nothing partisan about 
the need for care for our men and women and their families who 
serve our country in so many different ways.
    Now to our first panel. We welcome four frank assessments 
of the strengths and weaknesses of the systems supporting 
wounded warriors and their families, as well as any 
recommendations that they may have for improvements in the 
future.
    We'll begin by hearing opening statements, followed by some 
questions. First, Lieutenant Colonel Gadson, if you would 
please start us off, and then we'll work our way down the 
table.

            STATEMENT OF LTC GREGORY D. GADSON, USA

    Colonel Gadson. Chairman Nelson and Senator Graham, 
distinguished members of this subcommittee, thank you for this 
opportunity to testify today to share my experiences as a 
wounded warrior in the Army medical system.
    First and foremost, I cannot overstate how impressed I am 
with the treatment and care I have received since I was 
wounded, nearly 2 years ago. WRAMC and other Service medical 
centers have treated unprecedented injuries and trauma, and not 
only successfully treated those injuries, but enabled those who 
have been injured to rejoin society and live productive lives. 
For that, I am truly grateful and humbled by those in the 
medical community who have dedicated their lives to making us 
well.
    Dealing with severe injury and trauma is not easy. When you 
consider the myriad of injuries, as well as the unfamiliarity a 
typical family has in dealing with an injured servicemember, 
it's easy to understand how difficult a task it is to recover. 
I can say, from my vantage point, that our medical system is up 
to the task.
    Over the past 23 months, I have seen tremendous 
improvements in the quality of care for injured servicemen and 
their families. However, that does not mean that there isn't 
room for improvement or gaps don't exist in the system.
    One such gap that I personally experienced involves support 
from a nonmedical attendant. Current policy allows nonmedical 
attendants to be reimbursed for meals and lodging. Nonmedical 
attendants' roles are to provide assistance to injured 
servicemembers in activities they cannot do for themselves--
i.e., bathing and driving, et cetera. In my case, my wife was 
reimbursed as a nonmedical attendant while our household was at 
Fort Riley, KS. However, when we decided to relocate to the 
local area in proximity to WRAMC, her nonmedical attendant 
reimbursement was discontinued.
    What I want to illustrate to you is that we don't want to 
put families in a hardship situation when deciding how and who 
will assist the servicemember who needs assistance. The fact 
that per diem and lodging are paid to nonmedical attendants 
shows an inconsistency in rate, essentially paying nonmedical 
attendants based on location. I believe there should be a set 
rate for nonmedical attendants, as well as the per diem and 
lodging. The situation that family members often find 
themselves in is how to deal with the loss of income while the 
servicemember recovers. I have personally seen families remain 
apart while the serviceman recovers, because they cannot afford 
to remain together. This is a choice families should not be 
forced to make.
    I would like to emphasize the Army's dedication to our 
wounded warriors. Our purpose here is to see continued 
improvement.
    Thank you for holding this hearing, and thank you for your 
continued support for warriors. I look forward to your 
questions.
    Senator Ben Nelson. Dr. Noss?

              STATEMENT OF KIMBERLY R. NOSS, PH.D.

    Dr. Noss. First of all, I'd like to thank the committee for 
allowing me to speak today on behalf of my husband, Sergeant 
First Class Scot Noss, U.S. Army.
    Scot was severely injured in Afghanistan in 2007. He 
suffered a severe brain injury, with damage to his frontal 
lobes and brain stem. He had two broken ribs, a pelvic 
fracture, three fractured vertebras, and broken feet. So, he 
sustained a very polytraumatic injury. However, the brain 
injury was the worst, where, 2 years later, he is currently 
minimally conscious and is 100 percent dependent for daily 
living activities.
    The past 2 years have been very challenging, considering 
that we, as a country, were not prepared to take care of these 
severely injured soldiers. Men and women of the Armed Forces 
are surviving injuries that would not have survived other wars 
because of the medical technology available in theater and 
because of our excellent training from the medic, corpsmen, and 
from the para-rescuemen. However, there is a huge gap between 
that technology and training available in theater and what is 
available stateside for continued long-term healthcare and 
services for our severely wounded warriors.
    I come here today representing the minority of injured, the 
minimally conscious realm of injury, but represent the ones who 
need the majority of the long-term healthcare for the rest of 
their life. One issue that needs to be addressed is TRICARE's 
lack of coverage of cognitive rehabilitative therapies. Those 
on Active Duty are able to access this care, but are 
prohibited, once retired, which is why many families fight to 
stay in Active Duty service. Unfortunately, just recently at 
the DOD Cognitive Rehabilitation Consensus Conference, DOD 
commissioned a formal Emergency Care Research Institute, 
Institute of Technology Assessment on the benefits of cognitive 
rehabilitation for combat-injured veterans. This report stated 
that the assessment, in question, found that the available 
evidence was of insufficient quantity nor quality to reach 
meaningful evidenced-based conclusion on the efficacy of 
cognitive rehabilitation for TBI. However, the Defense Center 
of Excellence (DCoE) of Psychological Health and Traumatic 
Brain Injury, a center created by this committee, recently 
issued a white paper supporting cognitive rehabilitation as a 
well-accepted and usual-customary component of comprehensive 
rehabilitation for persons with moderate to severe TBI. 
Unfortunately, for no other reasons, the conclusion of the 
report stated that, even though cognitive rehabilitation 
research shows promising results, they are now, at this time, 
not covering for veteran-status injured soldiers.
    If DOD will cover cognitive rehabilitation for Active Duty 
soldiers, why will they not cover it once he is a veteran? Why 
is it sound therapy for an Active Duty servicemember, but not a 
retiree?
    While I understand that this committee does not have 
jurisdiction over disability compensation, it is still 
important that you understand that compensation for men and 
women with mild to moderate functional TBI needs to be 
addressed. These men and women will not have the opportunity to 
have a career or retirement because of their limitations from 
their combat injuries. What will their future entail? These 
individuals fall short for benefit coverages that will ensure a 
healthy lifestyle, but they are not employable, because of 
their injuries.
    What about the caregivers of the severely injured soldiers? 
The mean age of injured soldiers is 22 years old. If this 
individual requires 24-hours/7-days-a-week care or constant 
supervision for safety, how can their family, which most likely 
are in the prime of their career, afford to quit their jobs and 
forego retirement benefits to take care of their loved one? 
What about the 18-year-old wife who did not have the 
opportunity for education and chose to take care of her 
severely injured husband instead of putting him in a nursing 
home? This wife will not have means to income, and should be 
compensated for her caregiving capabilities and services. 
Nursing homes are not an option for these young men and women 
coming back from overseas injured.
    The collaborative efforts of DOD and VA have been evident; 
however, there is still much work to be done. For example, it 
would be very helpful if a Veteran Benefit Administration (VBA) 
employee was housed in all of the wounded warrior advocacy 
offices. For example, the United States Special Operations 
Command (SOCOM) Care Coalition has been my main source of 
information and advocacy. Due to the classified nature of SOCOM 
warriors, if the VBA employee was located in their office, the 
transfer of veteran status would be smoother because of the 
initial and continual presence from the transition to veteran 
status.
    Finally, I'd like to say that we should not reinvent the 
wheel. If TBI rehabilitation and care is better in the private 
sector, that's where our men and women should go. This country 
alone has 1.5 million brain injuries a year, where the Armed 
Forces have only sustained 8,000 since 2001. The VA should have 
an open mind and a higher fee-based budget to provide the 
necessary care for these individuals, as well as TRICARE 
stepping up to the plate to provide such services as cognitive 
rehabilitation. These men and women of the Armed Forces have 
earned options and deserve the best in continued healthcare 
services for their entire life.
    I would like to say that, even though these have been the 
negative aspects of our journey, I do thank DOD and the SOCOM 
Care Coalition. Scot was a proud Army Ranger, and he fought 
gallantly for his country. I'd also like to thank the VA. They 
kept my husband alive and have done superb. Thank you.
    Senator Ben Nelson. Lieutenant Kinard?

       STATEMENT OF 1ST LT. ANDREW K. KINARD, USMC (RET.)

    Lieutenant Kinard. Yes, sir. Good afternoon, Chairman 
Nelson, Senator Graham, and members of the subcommittee.
    I'm pleased to appear before you today to discuss my 
experiences as a warrior in transition. I hope that, by sharing 
some of these challenges that I've faced, and some of the 
successes that I've had, that you can gain a collective 
understanding of the path forward from here. What I'd like to 
focus on are some common themes that unite a lot of the wounded 
warriors that are returning home.
    I've faced many challenges in the 2\1/2\ years of my 
recovery since being injured in Iraq, first of all let me say 
that I would not be here today were it not for the dedication 
and professionalism of our medical service personnel. Every 
breath that I take is a testimony to their service. I mean 
that.
    I was injured, like I said, 2\1/2\ years ago, and my 
subsequent medical evaluation and recovery consisted of over 60 
surgeries and countless hours of physical therapy, occupational 
therapy--you name it, I went to just about every service except 
for gynecology. [Laughter.]
    I was an inpatient at WRAMC when the Washington Post broke 
the stories, and remained there through all the changes that 
ensued during the fallout. Some of them have been pretty 
effective, and some of them we have some way to go forward.
    If I might just make a quick comment on the GAO study that 
you will hear about in the next panel, I've had a chance to 
read that study, and their overall assessment shows that 60 out 
of 76 of the criteria have been met. My comment to that is, 
although mathematically that sounds like a pretty good progress 
report, even the GAO itself admits that they did not actually 
study the effectiveness of each of those policies that had been 
met. All they did was check the box that there is a policy that 
was created; they didn't actually look at ``is this working or 
not?''
    What I'd like to talk to you about today is how we can look 
at some of these policies that have been out there and say: 
``are they working or are they not? How can we reduce 
redundancies within the system? How can we streamline things so 
that the net effect is a decrease in the amount of confusion 
amongst the wounded veterans and their families?''
    The biggest item is case management and care coordination. 
The need for competent case management at all phases of 
transition cannot be overstated, but it's especially critical 
during the rehabilitation and reintegration phases of a 
person's transition. If you can get the proper care identified, 
I think you're going to have a very successful chance of a good 
recovery. When my doctors knew what was going on and when we 
identified which specialty service I needed to go see, there's 
no question, I thought the care that I received at WRAMC in 
Bethesda was excellent. However, the problem arises in an 
outpatient status, keeping track of the number of case managers 
alone can be overwhelming. I can count eight different case 
managers that I had to keep track of at any one time. The 
burden of responsibility fell on me to make sure that I knew 
which of my case managers to go to for which problem. In 
effect, I was left with a handful of business cards. They all 
said, ``Hey, call me if you have any problems.'' I said, ``I 
don't really know what to ask or not to ask.''
    I think one of the things that has been a great success has 
been the creation of the overall care coordination program 
within DOD and VA. The DOD has a coordination program called 
the Recovery Care Coordination Program. The VA, on the other 
hand, has the Federal Recovery Coordination Program (FRCP). 
What they simply do is bring together all the resources that we 
have available within the DOD and the VA, and, at a 30,000-
level view, say, ``How can we coordinate some of these 
things?'' It's a one-stop shop.
    My concern is that, while the Recovery Care Coordinators 
(RCCs) and the Federal Recovery Care Coordinators (FRCCs) are 
really doing the same thing, and the only difference is what 
category of wounded person they're treating, FRCCs typically 
manage the care of the more seriously injured and more 
critically injured servicemembers, while RCCs treat the less 
severely injured. The two systems are administered by two 
different departments. One's by VA, one's by DOD, and yet, 
they're supposed to be doing the same thing and bringing the 
same resources to bear.
    At what level are we going to be coordinating these two 
programs to make sure that we're getting the most effective 
treatment delivered to the servicemember and that we're 
reducing redundant programs so we can also make sure we're 
spending dollars on beans and bullets where we need to, as well 
as maximizing our dollars spent on wounded warriors?
    I'd also like to comment briefly on the DOD DES Pilot 
Program that was created directly as a response to some of the 
criticisms raised in the WRAMC coverage by the Washington Post.
    In an effort to simplify and streamline the process, before 
the DES pilot was created, a recovering servicemember would 
have to be rated, their whole body rated by the DOD, found 
unfit to continue service, then transferred into the VA, rated 
again, and then receive disability compensation. The VA would 
take quite a while, and there would be a many-month gap between 
receiving that critical compensation. What DOD and VA did was, 
they streamlined that process by eliminating one of those two 
medical examinations. At the same time, I think we still need 
to make sure and follow up that DOD and VA are doing the 
handoff correctly and effectively. For myself--and I don't want 
to get into specifics of my case; but, as an example, it took 
me roughly 9 months for DOD and VA to figure out that my legs 
were not growing back. There's some efficiencies that I think 
we can still continue to enjoy and benefit from if we take hard 
looks and ask the second and third panel of witnesses how we 
can really make it work for us up here on the first panel.
    Thank you, gentlemen and ma'am, for your time, and I 
appreciate the opportunity to answer your questions.
    [The prepared statement of Lieutenant Kinard follows:]
      Prepared Statement by 1st Lt. Andrew K. Kinard, USMC (Ret.)
    Good afternoon, Chairman Nelson, Senator Graham, and members of the 
committee. I am pleased to appear before you today to discuss my 
experiences as a warrior in transition. I hope that by sharing with you 
some of the challenges that I have faced and the successful experiences 
that I've had, this committee will gain a better understanding of the 
issues that are common to all recovering servicemembers.
    Although I have faced many challenges since I was wounded in Iraq 
2\1/2\ years ago, let me first say that I wouldn't be here today were 
it not for the dedication and professionalism of the medical personnel 
who treated me from the battlefield through surgical centers in Al 
Asad, Balad, Landstuhl, Bethesda, and Walter Reed. Every breath that I 
take is a testimony to their service.
    I was injured in the Al Anbar Province, Iraq on October 29, 2006. 
My subsequent medical evacuation and recovery consisted of over 60 
surgeries and countless hours of occupational and physical therapy. I 
was an inpatient at Walter Reed when the Washington Post stories broke 
and remained there through all of the changes that followed. Some of 
the changes to the transition system have been very effective and 
others remain ineffective due to lack of oversight or interagency 
coordination.
    As you have heard from the other witnesses, recovering 
servicemembers are facing a myriad number of issues at each phase of 
transition--recovery, rehabilitation, and reintegration. These three 
phases were formalized by the Department of Defense (DOD) in the 
Directive-Type Memorandum of January 19, 2009 which establishes policy 
for the Recovery Coordination Program. One caveat is that the three 
phases cannot be viewed exclusively as a linear progression; it is not 
uncommon for reintegration to begin prior to the completion of 
rehabilitation or for a recovering servicemember to require services 
typically associated with the recovery or rehabilitation phases after 
reintegration is considered complete. For example, this is the case for 
many servicemembers who have a Traumatic Brain Injury (TBI). Oftentimes 
they will have returned to their home communities but require ongoing 
cognitive therapy. I have tried to capture thematic issues faced by 
recovering servicemembers at the second two phases of transition: 
rehabilitation and reintegration.
                             rehabilitation
    The need for competent care management at all phases of transition 
cannot be overstated, but it is especially critical during the 
rehabilitation phase as the recovering servicemember navigates the 
various outpatient services available. Two programs are now available 
to assist recovering servicemembers in coordinating their care: the 
Recovery Care Coordination (RCC) Program and the Federal Recovery 
Coordinator (FRC) Program. While each of these two programs essentially 
provide the same service--with very seriously injured servicemembers 
managed by a FRC and less severely servicemembers managed by a RCC--the 
RCC program is managed by the DOD and the FRC program is managed by the 
Department of Veterans Affairs (VA). It is essential that Congress not 
view these two programs as completely unrelated, but rather Congress 
should ensure interagency coordination as DOD and VA implement these 
relatively new programs.
    Prior to the FRC and RCC programs becoming available, the onus was 
on the recovering servicemember to keep up with all of the different 
case managers and their individual responsibilities. When I was at 
Walter Reed Army Medical Center, I had a medical case manager, a non-
medical case manager, a social worker, a medical board case manager, a 
Physical Evaluation Board Liaison Officer, a Navy-Marine Corps Liaison 
Officer, a Wounded Warrior Regiment case manager, and a Marine Corps 
patient administration team. This list of medical support personnel is 
roughly the same for all recovering servicemembers in its composition 
and in the confusion it creates among wounded warriors. What became 
especially problematic before the advent of recovery coordinators was 
the transfer of a recovering servicemember to a different medical 
facility. At each transfer, recovering servicemembers commonly started 
fresh with case managers who had no previous knowledge of medical 
history for that patient.
    The long list of case managers and other support staff that I 
previously mentioned all fall within the DOD health care system. As 
servicemembers transition from active to veteran status, most, if not 
all, of those case managers will be exchanged for new ones in the VA 
system. Rather than veterans navigate a new health system with no 
institutional memory of their medical history, a FRC or RCC can ensure 
a continuity of medical care.
    Additionally, the net result of the number of support staff is that 
there is a broad diffusion of responsibility among case workers, and 
the recovering servicemember loses confidence in the government's 
ability to maintain accountability of his care. Each case worker has a 
specific role in that servicemember's recovery, and the burden of 
responsibility falls on the servicemember to keep track of which case 
manager provides each service. The assignment of a FRC or RCC provides 
the recovering servicemember with a single point of contact for 
decisions regarding his or her care. The effectiveness of these two 
programs, however, should not be measured exclusively by the mere 
presence of a policy statement outlining the program, but rather by 
continuous assessments by stakeholders in the process and by recovering 
servicemembers themselves.
                             reintegration
Disability Evaluation System Pilot Program
    In an effort to simplify and streamline the process by which 
servicemembers are medically evaluated, retired, and enrolled into the 
VA, the National Defense Authorization Act for Fiscal Year 2008 
authorized the Secretary of Defense to develop a Disability Evaluation 
System pilot program. For those who are evaluated through the pilot, 
the advantages are that there is only one medical evaluation instead of 
two and that the veteran is immediately enrolled in the VA upon 
retirement. Those who are not a part of the pilot program must be 
medically evaluated by their Service--with each Service having 
different medical standards--then retire. Upon retirement, the veteran 
must then be medically evaluated by the VA and oftentimes wait many 
months before receiving disability compensation.
    Despite the efficiencies gained by a single medical evaluation 
using a common standard, the process is often delayed because the 
disability claim jumps back and forth between the DOD and VA. Health 
records may be shared electronically, but disability claims are still 
printed out and physically sent through each office responsible for the 
paperwork.
    Additionally, there has been no change in streamlining the case 
managers responsible for each claim. Each servicemember must keep track 
of up to five different case managers who each have some part in the 
claim process. DOD and VA have both retained a case manager for each 
segment of the pre-pilot process; the pilot should make an effort to 
reduce the number of case managers to a single case manager responsible 
for the entire claim process.
                               employment
    Many have recognized the need for purposeful activity for those 
assigned to the various wounded programs to promote recovery and 
prevent disciplinary problems. Fortunately, many local companies and 
organizations would like to hire wounded/ill/injured servicemembers for 
internships while they are healing. These internships can provide a 
sense of purpose and provide work experience that can be helpful if and 
when the servicemember leaves the military. The DOD operates a program 
called Operation Warfighter which places injured servicemembers within 
the National Capitol Region into internships at locally based Federal 
agencies. This is a successful program but is very limited.
    Allowing this program to expand across the country as well as 
allowing individuals to intern or have temporary assignment at a local, 
State, or Federal agency or even a private company would provide a 
significant benefit to those assigned to one of the military Services' 
wounded warrior units. From my personal experience, I didn't start 
feeling like my ``old self'' until I started an internship at the 
Pentagon working 20-25 hours a week in the time between physical 
therapy appointments.
                                summary
    As the next panels of witnesses come up to testify, you know that 
they are well intentioned and have our best interests at heart. I 
respectfully request that you keep in mind two questions as you listen 
to their testimony:

          1. How is effectiveness measured in each of the different 
        programs?
          2. How do you ensure that programs within each of the 
        military departments and among different Federal agencies are 
        compatible with each other?

    The senior leadership in the DOD and the Veterans Administration 
have done a remarkable job in breaking down institutional barriers in 
the last 2 years to provide the best access to services and address 
difficulties with case management. Unfortunately, this level of 
cooperation has not yet been institutionalized at the end-user level--
that of the recovering servicemember--and many issues remain at that 
level with respect to access to services and case management. Effective 
oversight of interagency coordination is essential as we move forward 
so that the men and women who have sacrificed so much are best equipped 
to recover, rehabilitate, and reintegrate as productive members of our 
society.
    Thank you, Senator Nelson and Senator Graham for the invitation to 
appear before you today. I appreciate the opportunity to be a part of 
our American process . . . to come before you and present my 
perspective to an elected body that has the opportunity to make a 
difference for so many. I look forward to answering any questions you 
may have.

    Senator Ben Nelson. We thank you very much, Lieutenant 
Kinard.
    We've had join us, since we began, Senator Hagan from North 
Carolina, Senator Begich from Alaska, Senator Chambliss from 
Georgia, Senator Thune from South Dakota, and Senator Wicker 
from Mississippi. Why don't we ask if there are any comments 
that you'd like to make before we turn to questions. [No 
response.]
    I guess we're ready to turn to some questions. We will do 
6-minute rounds.
    Some of these questions will, in one way or another, be 
comparable to some of the testimony you've already made. But, 
perhaps it'll be a little bit different. For example, this one. 
Where you had care managers, and they were working with you, do 
you think they were effective in getting you better care?
    We'll start with you first, Lieutenant.
    Lieutenant Kinard. The question, sir, is were the case 
managers effective in delivering? Yes and no. I feel that the 
sheer volume alone of case managers, the number of case 
managers there are available, creates a diffusion of 
responsibility within the overall system. Having the RCC 
program and the FRCP, which are relatively new--what they do 
is, they bring all those together to one person that I can call 
and say, ``Let's figure this out together.'' I think that is 
certainly a great improvement that DOD and VA have made. I 
can't say, in every single case, that the case managers dropped 
the ball, but it certainly will make it easier having these 
programs in place with effective oversight and coordination 
between the two departments to allow us to achieve the maximum 
medical benefit.
    Senator Ben Nelson. What we did see, though, is, in 
bringing a case manager in, at least it appears that we got 
over the hurdle that we had, where people were unaccounted for. 
Wounded warriors were unaccounted for. At least was it 
effective in having you accounted for? Did we make any progress 
there?
    Lieutenant Kinard. I think the individual Services have 
made tremendous efforts in accountability. At the end of the 
day, just looking at this issue through the lens of your 
average patient, the 18- to 24-year-old male, he's going to 
trust that guy in uniform. He's going to go to the sergeant, 
he's going to go to his noncommissioned officer. I think we've 
done a tremendous job, and the Services ought to be commended 
for how they've really stepped up to the plate with case 
management and with accountability.
    Senator Ben Nelson. Thank you. Dr. Noss?
    Dr. Noss. I was very fortunate to have the SOCOM Care 
Coalition manage--and continue to manage--Scot's care and his 
Active Duty status, and know that he will be a part of the 
SOCOM Care Coalition for life. If we're trying to have a system 
to be modeled by, I really do think it's the Care Coalition. 
They have done a fabulous job ever since General Brown started 
the organization.
    I have not had any bad experiences when it comes to case 
management, because of the Care Coalition.
    Senator Ben Nelson. Mrs. Rivas?
    Mrs. Rivas. We haven't had any bad experiences, either. The 
case manager, in fact, saved us. When he first arrived at 
Brooke Army Medical Center (BAMC), he just sat there in a room, 
and, at that point, he didn't have a case manager. When they 
assigned him a case manager, that's when things started moving 
along. With the TBI, he couldn't remember anything. She 
coordinated everything and made sure that he got to where he 
needed to be and that all of his care was taken care of. We had 
a wonderful experience.
    Later on, SOCOM came in, the Care Coalition. At first, they 
didn't realize he was there; he was kind of in limbo. When they 
found him, that's when the ball started rolling. They have 
stayed with us afterwards and made sure that we are up on any 
new care issues that arise. They've both been wonderful.
    I need to add this, too. The case manager, she was the one 
that was able to get his outpatient farmed out to the 
Rehabilitation Institute of San Antonio. It's an institute that 
helps with mild to severe brain injuries. If it wasn't for 
that, he wouldn't be where he is today. The outpatient care has 
been wonderful.
    Senator Ben Nelson. Such a simple concept, but an essential 
part of the tracking and keeping care appropriate and constant 
so that something doesn't lose its momentum.
    Mrs. Rivas. It's made all the difference in the world to 
us, to where he is today and to where he was. He couldn't do 
simple things like get dressed and feed himself, and he 
stuttered terribly, he couldn't carry on a conversation. They 
worked with him on every aspect, and he is so much better 
today. I have to say, we have a wonderful VA vocational 
counselor that we've been put in touch with, and she got him 
involved in the Easter Seals program. It's just having that 
contact.
    Senator Ben Nelson. Thank you.
    Colonel Gadson?
    Colonel Gadson. Yes, sir. I would echo what Lieutent Andrew 
Kinard said. The multiple case managers can be a bit confusing, 
and I personally have raised a question as to why--in fact, in 
Andrew's case and my case, because we're amputees, we have a 
specific amputee case manager, and then we have another case 
manager, and he may even have some additional ones.
    I guess the frustration is, where is the accountability? 
Even to this point, I would say that I don't understand what 
the clear delineation between responsibility is, and so, 
there's a potential gap, not that I've had any personal issues 
with it. You have to be on your game and understand what's 
going on, and make sure that doesn't happen. I feel like I've 
been able to, for the most part, advocate for myself. I think 
there's room to streamline that, and I think they recognize 
that, but we haven't gotten there yet.
    Senator Ben Nelson. Senator Graham.
    Senator Graham. Thank you, Mr. Chairman. I thank the panel 
for sharing your experiences with us.
    Make sure I get this right. You get wounded, you get back 
home, your Active Duty pay continues until you're medically 
discharged. Is that right?
    Colonel Gadson. Correct.
    Senator Graham. Now, in terms of support for the spouse 
who's life has changed as much as yours has, there is a 
compensation stream, is that right, Colonel Gadson?
    Colonel Gadson. Sir, first I'd like to say that they have 
the Traumatic Servicemembers' Group Life Insurance, which is 
the traumatic insurance that you get.
    Senator Graham. How much is that?
    Colonel Gadson. It really depends on your injury. There's 
no set amount.
    Senator Graham. Okay. But, you get a payment.
    Colonel Gadson. You get a payment. That can, in some cases, 
be used to offset that, but I can tell you certain 
circumstances where people have had to move and they haven't 
been able to sell their house, and it starts eating into money 
that wasn't necessarily designed for that.
    Senator Graham. But, my question is, a family member is 
going to, maybe, have to quit their job----
    Colonel Gadson. Yes, sir.
    Senator Graham.--or certainly, their life is affected 
dramatically. What income stream is available to them? Dr. 
Noss?
    Dr. Noss. Right now, through VA benefits, they have a small 
portion--it's called aid and attendance--which is to pay for 
caregiving hours or to be utilized by the family member who's 
doing the caregiving.
    Senator Graham. How much money did that mean for you?
    Dr. Noss. $580 a month.
    Senator Graham. Okay. Andrew, you're not married, I know. 
Your dad's a doctor, and your mom--are fairly well off, but 
there are a lot of guys your age that don't have that--what do 
single guys get?
    Lieutenant Kinard. Single guys, with the family members 
coming to take care of them? I am not familiar with the 
compensation, sir.
    Colonel Gadson. Senator Graham, I believe, right in the 
Washington, DC, area, the per diem for a caregiver--or 
nonmedical attendant would have been about $30 a day.
    Senator Graham. Okay. Your concern is, it shouldn't be 
based on where you're located, it should be a flat rate, where 
they bump up based on location, right?
    Colonel Gadson. Plus per diem, yes, sir.
    Senator Graham. Mrs. Rivas, did you get any income support?
    Mrs. Rivas. I'm not aware of any of this. We lived off his 
retirement pay and savings so this is new information to me.
    Senator Graham. All right. That's why we have these 
hearings.
    The point that I'm trying to make is that the country needs 
to come to grips with the fact that the moment the person is 
catastrophically, devastatively injured, the family changes, 
and I think most Americans would like an income stream 
available to family members who provide that support that 
otherwise would be given by the Government. But, the one thing 
highly unlikely, the Government caretaker's not going to live 
with you 24-hours-a-day, maybe, like a family, so that's 
something, Mr. Chairman, I think we can look at, is finding a 
revenue stream.
    Now, Dr. Noss, how old are you?
    Dr. Noss. I'm 28 years old.
    Senator Graham. What's your educational background?
    Dr. Noss. I have a doctorate in chemical engineering. I 
actually just graduated, this past semester.
    Senator Graham. How old is your husband?
    Dr. Noss. He's 31. He's an E-7.
    Senator Graham. As Andrew said, most of these wounded are 
young people right?
    Dr. Noss. Yes.
    Senator Graham. What have you found, in terms of their 
spouses' capability or family members' capability to survive 
these injuries, financially?
    Dr. Noss. Actually, the 2 years that I have been inpatient 
with my husband, because Scot is still inpatient at the VA in 
Tampa, a majority of the families are very young. Most of the 
wives who come with their injured husbands don't have jobs. 
They were stay-at-home mothers, they are 17-, 18-, 19-year-old 
high school-educated, young women.
    Senator Graham. Andrew, what would you have done if you 
didn't have the family you have?
    Lieutenant Kinard. Sir, I would have been by myself. My dad 
left his practice for 2 months, came up to Washington, DC, 
moved up here. My mom lived with me for over 7 months until I 
was discharged from the hospital and able to take care of 
myself.
    Senator Graham. Colonel Gadson?
    Colonel Gadson. Senator, the tough task, as you're saying 
and alluding to, is that these are young families. I was a 
senior officer, and I had the revenue to be able to withstand 
my wife not being at work as a professional schoolteacher. But, 
even that, that took about a third of our income away from us.
    Senator Graham. I think this is something the committee can 
work on.
    You're still on Active Duty is that right, Colonel?
    Colonel Gadson. Yes, sir.
    Senator Graham. They're going to let you stay on Active 
Duty, it looks like?
    Colonel Gadson. They are.
    Senator Graham. I want to congratulate the Service for 
doing that.
    Andrew, I know you're going to Harvard Law School. To those 
that helped Andrew, look what you've done. He's going to 
Harvard and has a great life ahead of him.
    It took you 9 months to get from one medical evaluation to 
the other? Tell me about that again. What's the 9 months?
    Lieutenant Kinard. Sir, I actually did most of that when I 
was a congressional fellow in your office.
    Senator Graham. Yes, I know. [Laughter.]
    You've gone Hollywood on me, now, I see you on TV all the 
time. [Laughter.]
    Lieutenant Kinard. No comment. [Laughter.]
    Sir, that was one of the big issues that was highlighted. 
The inadequacies with the flexibility and the speed.
    Senator Graham. You were medically discharged from the 
Marine Corps about a month ago, is that right?
    Lieutenant Kinard. That's right.
    Senator Graham. Now, you're 100 percent disabled by VA?
    Lieutenant Kinard. Yes, sir.
    Senator Graham. What took 9 months to figure out that your 
legs weren't going to grow back? Tell me what you mean by that.
    Lieutenant Kinard. There were actually two different boards 
that I went through. There's the Medical Evaluation Board 
(MEB), which is the DOD evaluation of your fitness to continue 
service in the military in the job in which you were assigned, 
or they can find you another job. Then, once they determine 
that you are no longer fit to continue serving, they refer you 
over to VA to a Physical Evaluation Board (PEB) that rates the 
amount of compensation you are owed for your injuries. It's 
going from that one board, where they have to prepare all the 
materials, hand it to the next board; if there's anything 
wrong, it gets sent back. Then, that other board sits on it and 
they----
    Senator Graham. Is that still the case today?
    Lieutenant Kinard. It is. I hate to say that every case is 
9 months, but I think I fell within about an average period of 
time for the DES.
    Senator Graham. Thank you.
    Colonel Rivas. Senator, if I can make a comment?
    Senator Ben Nelson. Yes.
    Colonel Rivas. My situation is a little different from the 
other individuals here. I was retired at 100 percent from the 
military, 100 percent from VA. I was a civilian engineer with 
DOD, with the Army. I was medically retired from that, at a 
significantly reduced income. I was a licensed law enforcement 
police officer in the State of Texas, was retired from that, 
with no retirement income. So, we've seen significantly reduced 
income from my retirement. The issue I have is with the 
concurrent receipt law, the way it's currently written. Even 
though I had 35 years of military service, both Active and 
Reserve, I lose all my VA to get my military retirement. I 
think that's a real injustice, because if I had 20 years, the 
way the law is written, I would receive both of those. I didn't 
choose to get blown up before I made sure I had 20 years of 
Active Duty, so I could get both of those. We have to wait 
until I'm age 60.
    Senator Graham. You were injured when you were a Guard 
member or a Reserve----
    Colonel Rivas. Reserve. Since then, I've come down with 
some secondary issues with kidney failure and some other 
issues. My family's concern is I may not live long enough to 
see my concurrent receipt.
    Senator Graham. Thank you.
    Senator Ben Nelson. We've been working on that program, 
making some improvements, but we still have a long way to go to 
get that fair and equitable. Thank you.
    Senator Hagan.
    Senator Hagan. Thank you, Mr. Chairman.
    First, I want to thank each and every one of you for all of 
your service, and the wives, you, too, are to be complimented 
for all of your extended care that you've been giving.
    Dr. Noss, I have question for you. Your husband is 
currently--I think you said, is in Tampa; he's still in care.
    Dr. Noss. Yes. He is still an inpatient at the Tampa VA, 
the Polytrauma Unit.
    Senator Hagan. Will he leave? Will he be sent someplace 
else? What's his long-term prognosis, as far as where he might 
go?
    Dr. Noss. He's going home with me.
    Senator Hagan. He'll be able to come home?
    Dr. Noss. We're going to make it where he can come home. I 
don't believe in putting him in a nursing facility for long 
term.
    Senator Hagan. Then, from the standpoint of any sort of 
financial help to you at that point in time, what has VA 
established for that?
    Dr. Noss. They do have a benefit package that Scot will 
receive every month, and it is a substantial amount of money. 
However, the net income will be small because you have to take 
into consideration our bills that we will incur each month. For 
example, I know of a family who has a quadriplegic and he's on 
a ventilator. Because of needing a 24-hour power source, their 
power bill is over $1,000 a month. This is due to the 
ventilator, and his bed--he has to have a special type of bed 
that's hooked up to power. Because of the special care that 
Scot is going to receive because of his injuries, we're going 
to have to pay for large bills. Despite the substantial amount 
of benefit money that will come in per month, the net is going 
to be small.
    Senator Hagan. You mentioned one other comment. I believe 
it was the cognitive rehabilitative therapy, that if--as long 
as he was considered active military, he would receive that, 
but then, once he became veteran status, it was not funded.
    Dr. Noss. Yes, ma'am, that's correct.
    Senator Hagan. Is he currently getting that?
    Dr. Noss. Yes, he is receiving cognitive therapy at the VA, 
at the Polytrauma Unit, which I have to say is absolutely 
fabulous. I just love them down there. However, my concern is 
if we need to take him to a private-sector rehabilitation 
center. TRICARE, as it is stated right now, will not pull from 
the supplemental fund that they have set aside for Active Duty 
soldiers to pay for cognitive rehab for veteran status.
    Senator Hagan. I see.
    Dr. Noss. So, right now they are not covered for cognitive 
rehab.
    Senator Hagan. It feels like we ought to be doing something 
about that, too.
    Dr. Noss. Right. I really hope you can.
    Senator Hagan. Lieutenant Colonel Rivas, I hear, all the 
time, your concern on the concurrent receipt issues. That's 
something I'm glad to hear Senator Nelson say we've been 
working on for a long time, but it seems like we certainly need 
to be moving forward, because it doesn't make a lot of sense to 
me at all.
    Thank you, Mr. Chairman.
    Senator Ben Nelson. Thank you, Senator.
    Senator Thune.
    Senator Thune. Thank you, Mr. Chairman.
    Let me also add my deep appreciation to all of you for your 
great service to our country and the sacrifices that you and 
your families have made. We are, as a Nation, enormously 
grateful. Please know how much we appreciate that.
    In his prepared testimony, Major General Meurlin outlined 
several improvements that DOD and VA have made to DES through 
the pilot program. He also says that more should be done and we 
need to ``shift away from a focus on pay entitlements to one of 
recovery, rehabilitation, transition, and making the 
servicemember a viable member of society.''
    I guess what I would ask any member of the panel to answer 
is, in your opinion, what steps can DOD or VA and this 
committee take to improve the system and focus more on 
recovery, rehab, and transition?
    Colonel?
    Colonel Gadson. Yes, sir. I have a few suggestions.
    The first is--and I know we're working toward that--is 
getting VA and DOD together at the highest levels. The Army--I 
was fortunate enough to have the Army to send me to graduate 
school, and I'm finishing up my graduate degree at Georgetown 
now, while I am recovering. But to illustrate this, in terms of 
VA benefits, there are some VA benefits that I don't have 
access to unless I retire. By staying on Active Duty, I'm only 
authorized a one-time $11,000 vehicle grant, because I lost my 
legs, and that's to get a new vehicle and modify that vehicle. 
Then there is a $60,000 housing grant--again, for the 
modification of an existing home or to apply toward a home. 
Other than those two benefits, I cannot access my education 
benefits for vocational rehabilitation. For instance, my 
daughter is a junior in high school, and I will not be able to 
use any of my veteran's benefits toward her college, which I 
would be able to do if I were to retire.
    I think we need to take a comprehensive look at those 
benefits, and merge that. Those benefits were built under the 
assumption that, when a servicemember was severely injured, he 
was going to be out. As we look at our force, as an All-
Volunteer Force, many people still opt to continue to serve, or 
would like to continue to serve, and they should be allowed to 
have access to a benefit. This is not a benefit to double any 
kind of compensation or get something that you're not 
authorized, but just giving you access to it when you need to. 
I think that's a discussion or a dialogue that needs to take 
place as we look at these two things holistically.
    Senator Thune. Good.
    Dr. Noss?
    Dr. Noss. About the rehabilitation for minimally conscious 
patients, I really do think that integration into a civilian-
sector rehab would benefit these men and women greatly. There 
are four polytrauma centers in the country right now, a fifth 
one being built in San Antonio. There's one located in Tampa, 
where I'm located now, which I'm so grateful that the Fisher 
House was built on its campus. I have been staying at the 
Fisher House for a year and a half now. There's one in 
Richmond, Minnesota, and Palo Alto.
    Now you're having an issue of families relocating from 
their strong support systems and from their family in order to 
be close to the polytrauma center. That shouldn't be an issue. 
The family should be able to relocate to their desired location 
and have some sort of rehabilitation in the private sector.
    My husband is still Active Duty, and I'm fighting to keep 
him Active Duty. It's not about the money. I've been hearing 
for 2 years now, ``Now, Mrs. Noss, if you retire him, you'll be 
getting more money every month.'' I don't care about the money. 
What I'm caring about is the fact that when he retires, he will 
lose some of his coverage for his therapies. I am really 
fighting to keep him in. I'm so appreciative of DOD for 
actually understanding my reasons for wanting to keep him 
Active Duty, and they've been very helpful.
    For the cases, as my husband, the minimally conscious 
patients that are still Active Duty and have retired since, 
really need to work on how we can better improve the health 
care after veteran status is achieved.
    Senator Thune. Anybody else?
    Lieutenant Kinard. Senator Thune, very briefly, if we're 
shifting away from a focus on pay and entitlements, where are 
we shifting to? I think the word is reintegration. Becoming 
productive members of our society is essential. Picking back 
up, getting back up on our feet, moving forward. We got 
injured, but, hey, we still have value and we can be 
productive. I think we need to take a look at some of the 
employment opportunities available while servicemembers are 
recovering in the WTUs.
    There's a program here in the National Capital region 
called Operational Warfighter. I think it's a fantastic 
program. It allows guys at WRAMC and Bethesda to go intern in 
any of the Federal agencies in the Washington, DC, area. The 
downside is, it's only in the Washington, DC, area, that I know 
of. If you're at Fort Bragg, if you're at BAMC, if you're at 
any of the other medical military treatment facilities, I don't 
know what programs are available to get guys into some sort of 
internship, especially for the ones that know that they're 
going to be transitioning out of the Service.
    In a way, as the old saying goes, ``Idle hands make for the 
devil's work.'' Having gainful employment, in whatever 
capacity, even looking at perhaps doing something within the 
private sector for those that are in more remote locations and 
don't have Federal or State agencies right there, I think that 
could be a great step forward towards reintegration.
    Dr. Noss. May I add one more thing, as well? With the 
integration to society for the mild to moderate brain-injured 
who fall beneath the realm of the benefits to compensate a 
healthy lifestyle, the employment rate is drastically lower 
because of their combat injury. For example, I have befriended 
a family whose son was in an improvised explosive device blast 
in 2003. Because of his injuries, he is not able to have a very 
high-stress job. He is able to work produce at a grocery store, 
and that's a very healthy transition into society for him. He 
feels a part of the society again, he doesn't feel like he's 
lost any type of integrity, and he's really proud of that job.
    Helping these mild to moderate brain-injured men and women 
be able to find something to help them become productive 
citizens is very important for them for long-term recovery.
    Mrs. Rivas. I'd like to add something to that, too. Our VA 
counselor got us involved with the Easter Seals program, and 
they've been working with Ray on a daily basis on cognitive 
skills and job skills and job training. Outsourcing to the 
Easter Seals and other programs like that have been a big help.
    Senator Thune. Mr. Chairman, I appreciate very much the 
perspective offered here, and I hope that we can use the 
insights as we shape policies to deal with these very important 
issues. Thank you.
    Thank you all very much for being here today and for your 
testimony.
    Senator Ben Nelson. Thank you.
    Senator Begich.
    Senator Begich. Thank you very much, Mr. Chairman. Thank 
you for holding this hearing.
    Thank you all for your testimony, I have learned a great 
deal listening. It sounds like you have also learned something 
about a program that exists, which I think is part of the 
process of this hearing.
    I just want to make sure I understand how that works and 
how the nonmedical attendants receive pay or don't receive pay. 
I want to make sure I understand that clearly. Who can walk 
through that with me?
    Lieutenant Colonel Gadson?
    Colonel Gadson. Yes, sir.
    Senator Begich. If you can walk me from the point of when 
the injury occurs. What next?
    Colonel Gadson. Okay. A soldier is injured, and typically 
they will remain in a hospital, in an inpatient status, until 
their medical condition gets to a point where they can transfer 
or transition to an outpatient status. In the case of these----
    Senator Begich. I'm sorry to interrupt you--both of these 
facilities, so far, are all military-operated facilities.
    Colonel Gadson. I can't speak for anything outside of 
WRAMC, but typically WRAMC and BAMC and Palo Alto, out in 
California, have them--and Bethesda--have the most severely 
injured.
    Senator Begich. Okay.
    Colonel Gadson. The nonmedical attendant is typically tied 
to that. We have TBI, and there are some other situations 
wherein--when a soldier is in an outpatient status, but they 
cannot perform all the things that they need to do. I couldn't 
drive, I couldn't get in and out of a vehicle, I couldn't wash 
without assistance. My wife became that attendant for me, she 
became that person that did those things for me, and she had to 
quit her job. We had to relocate our family to this area, and 
she was no longer working.
    Senator Begich. Can I interrupt you for a second? So, 
during that process, she did receive, or did not receive----
    Colonel Gadson. When my house was at Fort Riley, KS, which 
is where I was stationed when I got hurt, she received 
nonmedical attendant----
    Senator Begich. Because she was at the location----
    Colonel Gadson. She was there with me.
    Senator Begich. Understood.
    Colonel Gadson. Then, when we moved here to consolidate our 
family, it stopped, because she was in the local area. It 
really doesn't make any sense. Another way of describing the 
situation would be, if I were stationed in this local area, and 
I was stationed at Fort Belvoir and gotten hurt, and the exact 
same thing happened to me, she would have never received 
nonmedical attendant.
    Senator Begich. Oh, really?
    Colonel Gadson. Right. Because she's in the local area. The 
rule or regulation or policy doesn't--it doesn't----
    Senator Begich. Doesn't make sense.
    Colonel Gadson.--doesn't make sense. Then, my point is it 
pays lodging and per diem for the local area, so someone in San 
Antonio probably gets paid less than Washington, DC, because of 
the difference in the----
    Senator Begich. Sure, the housing costs.
    Colonel Gadson.--the cost of living. That was why my 
recommendation was there should be a flat rate, regardless of 
wherever it's taking place. Then, of course, you cover the per 
diem and lodging also.
    Senator Begich. Anyone else want to add to that?
    Dr. Noss?
    Dr. Noss. The transition from your acute military facility, 
post-injury, to your acute rehabilitation facility--I'm going 
to have to use myself as the experience. When Scot was injured, 
he was taken to Bethesda, and we were there for 8 weeks, and 
then we transitioned to the VA in Tampa. The nonmedical 
attendee status remained with me, and still is, in Tampa. I'll 
tell you what, we earn that money whenever we are receiving 
that nonmedical attendee, because it is very hard. Being a 
caregiver to a 100 percent dependent loved one is the hardest 
thing I ever had thought or imagined doing. But, I love him 
very much, and that's why I do it. But, that nonmedical 
attendee pay will be drastically reduced whenever he is veteran 
status. It actually goes away. What everyone continues to tell 
me is that, ``Well, his benefits will counteract the nonmedical 
attendee's pay, and you will receive more.'' I think people 
forget that, because of Scot's status, I had to file for 
guardianship for him. Now I have to account for every cent that 
I pay for his benefit from his benefit money. When I have no 
income coming in, because I'm his 100 percent caregiver, I also 
have to have accountability for every cent that's spent out of 
his benefit money. It's going to be very stressful. I know I'm 
not the only family out there that this is happening to, and it 
especially is worse when a soldier's parents receive 
guardianship of him. They are watched like a hawk with his--
their money. It is very unfair, in some circumstances.
    Senator Begich. Thank you.
    Colonel Gadson. Senator, I failed to mention--and the 
Doctor reminded me--and my wife would say this if she were 
here--that is now a person that is no longer productive in 
society. My wife was a full-time teacher. She was working, 
being productive, and she's no longer working and being 
productive, working toward a retirement, and all those other 
things. It's really kind of a double whammy, in terms of, your 
ability to produce. I'm not advocating that the Government 
should cover all of that. But, you have to understand the scope 
is not just someone quitting their job and being compensated, 
but they're no longer producing money towards the household and 
retirement and all those other kinds of things.
    Senator Begich. Thank you very much.
    My time has expired, but I want to say, again, thank you 
very much. I'm actually very familiar with this from the 
Medicaid end. I have a nephew that has spina bifida, and he's 
now in his late 20s, and I clearly understand the nonmedical 
attendant and what that means, and the stress that does to the 
family, and the cost, and the economic costs. Again, I thank 
you for being here. The information is very helpful, and it's 
helped me think of some ways that maybe we, as a committee--
subcommittee, can move forward. Thank you very much.
    Senator Ben Nelson. Thank you, Senator.
    Senator Chambliss.
    Senator Chambliss. Thank you very much, Mr. Chairman.
    Let me thank our witnesses for really excellent testimony. 
Thank you for your frankness, too.
    I want to particularly say to you spouses how much we 
appreciate you. Commitment to the military is a family 
commitment, we understand that. We just thank you for your 
service, in addition to the service of your spouses.
    Andrew, I know, as a marine lieutenant, you have to feel 
like you're still in combat every day you work for Graham. I'm 
sorry you have to put up with him like you do Senator----
[Laughter.]
    I just have one question, and it goes to exactly what you 
were talking about, Andrew, with respect to the coordination of 
all of these services that you receive. We have a unique 
situation down in Augusta that I hope I can stick around and 
talk to the next couple of panels on with respect to the 
Eisenhower Medical Hospital and the VA and the Medical College 
of Georgia, all of which are participating in care for our 
wounded warriors. Case management is a key aspect of what 
they're doing there. I noted with interest what you talked 
about. You have all these business cards, and you didn't know 
who to call, although you knew they were all going to help you, 
but trying to figure out who you need for the particular 
service.
    I want you to talk a little bit more about that, as to how 
that is working today, versus how it was 2 years ago, a year 
ago, or whatever, when you had somewhat of a state of confusion 
as to who you should call. If anybody else has any experience 
in that same regard, I wish you'd comment on that.
    Andrew?
    Lieutenant Kinard. Yes, sir. Interestingly enough, the one 
single point of contact that I have is based out of Eisenhower 
in Augusta. Because I'm from South Carolina, she's the closest 
point of contact to me.
    She is what's known as a Federal Recovery Coordinator 
(FRC), and this program was created in response to some 
legislation that was passed in title 16 of the National Defense 
Authorization Act for Fiscal Year 2008, 2 years ago. I'd say 
that my experience with her has been very positive. I was 
referred into this program, just in January of this year, after 
struggling through--and, Senator Nelson, part of what I was 
talking with Senator Graham about, the 9 months that it took 
them to evaluate me--I had reached some walls there. I called 
her on the phone. I was referred to the program. Literally the 
next day, she had options e-mailed to me, that said, ``If you 
want to do it this way, we can do this; if you want to do it 
this way, we do that.'' I said, ``I'll take option B.'' She 
took care of it, it was done. I said, ``Wow, this, for the 
first time, feels great,'' knowing that there's somebody I can 
call that I can hold their feet to the fire, saying, ``Why 
isn't this done?'' or ``Let's get some answers here.''
    A couple concerns of mine are how the FRC program is 
coordinated with the RCC program. I don't have any suggestions 
for that. I just merely want to highlight that perhaps that 
merits some taking a looking at.
    Also, the FRC program, which was designed to take care of 
the very seriously injured servicemembers, do they have the 
right authorities that they need? Do they have enough authority 
to take care of the problems? Senator Nelson, I appreciate what 
you said in your opening statement, sir, and, as Senator Graham 
echoed, as well--that nobody is arguing here about what 
servicemembers deserve: the best of the best that our Nation 
can provide. I applaud you for that recognition. The question 
is, how do we provide that best of the best? I think the FRC 
program is a great start.
    Dr. Guice, from whom you will hear on the second or third 
panel, is the program director of this FRC program. She'll be 
testifying here today. I recommend you ask her some questions 
about how she feels about the authorities that have been 
provided to her, if they can meet the needs of the 
servicemembers.
    Senator Chambliss. Yes.
    Dr. Noss. I'd like to also make another comment. I know 
throughout this whole hearing you've heard Care Coalition, Care 
Coalition the whole entire time, coming from me and the 
Rivases, as well. The Care Coalition is the advocacy group from 
SOCOM. As Andrew was talking about the many business cards that 
he received, he did not know who to call first. From day one, 
the SOCOM Care Coalition was my one point of contact. They have 
been able to organize my life when I was not able to organize 
my life. They were able to itemize the pros and cons of staying 
Active Duty versus retirement. They have been there the whole 
entire way and have made my life easier. I can honestly say 
that I have never been told ``no'' by the SOCOM Care Coalition. 
I've been told ``maybe'' a couple of times on some little 
sticky issues, but I really do feel like they have been able to 
take me from the most traumatic day of my life and carry me 
through to where I was able to graduate with my dissertation 
and my Ph.D. I do credit them for doing that for me.
    That one point of contact has always been there for me from 
day one, and that was from the SOCOM Care Coalition.
    Senator Chambliss. Okay.
    Mrs. Rivas. It's the same for us with the SOCOM Care 
Coalition. Then we have VA, too. But, it's the SOCOM Care 
Coalition that has helped us the most.
    Lieutenant Kinard. Senator Chambliss, if I might jump in 
here and bring one point.
    Senator Chambliss. Sure.
    Lieutenant Kinard. The SOCOM Care Coalition is a separate 
entity in the same scheme as each of the Services have their 
own service-oriented and service-specific WTU. Army has the 
Army Wounded Warrior Program. Marine Corps has the Wounded 
Warrior Regiment. SOCOM has their own. When they show up to 
WRAMC, the Special Forces guys, they just disappear, and 
they're taken care of. From these two witnesses here, they've 
received the highest marks, I think, out of the any service-
specific transition units.
    However, what a concern of mine is, is the net effect when 
we have DOD-mandated programs and then we have each of the 
Service-specific programs. If you're in the Navy, you have a 
different one than the Army or your Marine Corps associates. 
Where are these being coordinated? Who's taking care of making 
sure that we're eliminating redundancies so that the net effect 
is felt by the families who get lost.
    Dr. Noss. I also would like to make a comment. Even though 
Scot is being taken care of by the SOCOM Care Coalition, his 
Wounded Warrior project manager from the Army is involved in 
his care as an Active Duty and as a veteran status. They 
actually work hand in hand at the SOCOM Care Coalition office. 
So, I do credit the Army as well for taking really good care of 
my husband.
    Senator Chambliss. Thank you.
    Colonel Gadson. Senator, just one last comment. It has 
improved greatly over the last 2 years. I think DOD is working 
toward making it more efficient. There is definitely room for 
improvement. I think all of us would echo this sentiment, that 
there are a whole lot of folks that are out there trying to do 
the right thing and trying to do some good. Sometimes they're 
just stepping on each other. When you put that in light of 
dealing with these traumatic and difficult times, a lot of 
times it gets drowned out, and it's too much for folks to 
manage. I would say that probably SOCOM Care Coalition again, 
does it the best; and that's generically, regardless of the 
Service. They're smaller, in a much tighter community, and so I 
think that's why they're more efficient.
    Senator Chambliss. Thank you very much, all of you, for 
your excellent testimony today. Thanks, Mr. Chairman.
    Senator Ben Nelson. Thank you, Senator.
    I, too, want to add my thanks for your willingness to come 
and tell us, as you've seen it and experienced it, and are 
continuing to experience it. We want you to know that we're 
very interested, not only in what you have to say, but in 
finding solutions to the areas that need further work. You can 
be sure that we're going to do everything we can to try to plug 
those holes and make it work the way Americans want it to work 
for our men and women and their families who serve our country 
in so many important ways.
    Thank you, and may God bless you all. Thank you.
    Let's give them a round of applause, shall we? [Applause.]
    [The prepared statements of Colonel and Mrs. Rivas follow:]
         Prepared Statement by LTC Raymond T. Rivas, USA (Ret.)
    I was medically retired from the U.S. Army in September 2008 after 
being injured in Iraq in October 2006. When I retired, I had completed 
14 years of Active Duty and 20 years of Reserve Duty and served on 
multiple Operation Enduring Freedom and Operation Iraqi Freedom 
deployments since September 11.
    When I was originally injured in October 2006 in Iraq, I was 
Medivac'd out of theater and sent to the Landstuhl Regional Medical 
Center in Germany for evaluation. My memory is extremely vague about 
this. I was told that I spent 7 days there and convinced the 
neurological staff that I was fit to return to duty. I returned to 
Iraq, of which I do not remember any of this, and spent approximately 
10 days there. I was allowed to go out on missions to forward operating 
bases, and on mission convoys. It was then reported to my chain of 
command that my behavior was extremely ``bizarre'' and I was referred 
to the Air Force Expeditionary Hospital neurologist. After being 
examined by him, the orthopedic staff, eye specialist and hearing 
specialist it was determined that I had a traumatic brain injury, eye 
injury, moderate to severe hearing loss, and a fractured right patella 
(knee). I was put on priority Medivac to Landstuhl Regional Medical 
Center enroute to Brooke Army Medical Center (BAMC). I do not remember 
any of this, and have referred to my records for this information. 
Based on my records, the Chief of Neurology at the Balad Field 
Expeditionary Hospital informed my Command that I did a ``very good 
sales job'' of talking myself back to Iraq to rejoin my unit and should 
have been sent stateside immediately.
    In route from Iraq to Germany I had several ``unresponsive'' 
episodes during flight. What I do remember about my first few months at 
BAMC was that the system was ``overwhelmed'' with the influx of new 
patients. I was pretty much on my own for 2-3 months. I had a couple of 
``battle-buddies'' who helped me with dressing, bathing, and eating, as 
I was not able to do any of these unassisted.
    I believe it was approximately 3 months after being there that I 
began to work with my case manager, Ella Stiles. She immediately began 
to make things happen in a positve way for my health care. About this 
same time, I was contacted by the U.S. Army Special Operations BAMC 
Liason, Sergeant First Class Craig Coker, who informed me that he had 
just found out I was one of his Special Operations Officers that the 
``ball'' really began to ``roll''.
    Once he got involved, I began to get the care I needed for my 
aforementioned injuries. As mentioned I was medically retired from the 
Army at 100 percent in September 2008 and am now enrolled full time at 
the Easter Seals Hospital Brain Injury program in San Antonio, TX, 
where I continue to participate in their Cognitive Rehabilitation 
Therapy program.
    There are some things that I think must be changed: The Traumatic 
Servicemember Group Life Insurance Program (TSGLI) expanded this past 
year to include traumatic brain injury (TBI). While implementing these 
new changes, the Government Accountability Office contacted my wife and 
asked to use my medical records in developing the criteria for 
moderate/severe TBI.
    When the changes were implemented, the CARE Coalition which is part 
of the Special Operations Command submitted my TSGLI Insurance Claim 
packet. I met the requirements for the maximum insurance reimbursement 
amount of $100,000; however, I was only awarded partial payment with no 
explanation of why. I am currenly awaiting word on my appeal that has 
been submitted by the CARE Coalition. This program is not user 
friendly, if the injured servicemember meets the requirements for a 
particular payment amount, he should get it. I feel this is looked at 
as a game of ``lets''-only give minimal amounts and make the 
servicemember file an appeal, and then we will give a little more, and 
if a final appeal is filed we will give some more.
    Second, I have great ``heart-burn'' over the concurrent receipt law 
as now written. As the law now stands, only a servicemember with 20 
active duty years is allowed to get both his/her military and VA 
pension simultaneously.
    A Chapter 61 (Medical) Retiree with less than 20 active duty years 
is not eligible for concurrent receipt; a Chapter 61 National Guard or 
reservist with a ``20 year'' letter is eligible, once they turn age 60. 
This is a clear case of bias and injustice. The servicemember, and 
Guardsman or reservist who is injured in combat in a theater of 
operations who was wounded by no fault of his own should not be 
penalized for ``getting blown-up'' or ``shot'' prior to serving 20 
active duty years. I had served my country for over 34 years and did 
not choose to be seriously injured in Iraq in 2006.
    This injury has not only ended my military career, but also my 
civilian career as an engineer with the Department of Defense for whom 
I worked for 18 years and as a licensed peace officer in the State of 
Texas where I served as a Reserve Sheriff's Deputy for 8 years with the 
Comal County Sheriff's Department. I hope this committee is 
instrumental in doing the right thing in helping make the appropriate 
changes to the concurrent receipt law to include those such as myself 
who received combat injuries and forced to retire prior to serving 20 
years of active duty.
    I would also like to give accolades to the Disabled Sports USA 
program who has been sponsoring me to participate in Adaptive Sports 
these past few months throughout the United States the past few months, 
and the Department of Veterans Affairs, Frank Tejeda Outpatient Clinic, 
Vocational Rehabilitation Counselor who got me enrolled in the Easter 
Seals Program.
                                 ______
                                 
              Prepared Statement by Mrs. Colleen O. Rivas
    I am Colleen Rivas, the wife of LTC Raymond T. Rivas (Retired). I 
would like to share my views and experiences of the past few years as 
well as discuss the challenges that lie ahead for my family as we deal 
with the traumatic brain injury (TBI) that my husband received 2\1/2\ 
years ago in Iraq.
    One of the issues that I feel very strongly about is the comparison 
being made between TBI and post-traumatic stress disorder (PTSD). In my 
opinion there are profound differences between these two injuries. TBI 
is a physical trauma that can range from mild to severe. PTSD is an 
emotional trauma which can have debilitating effects. I have dealt 
firsthand with both of these traumas where Raymond is concerned; PTSD 
more so after Afghanistan which was in the form of nightmares and some 
depression. What we could not deal with on our own he was able to 
obtain help with through the VA in the form of counseling. The TBI has 
been an entirely different matter. When Raymond first returned to the 
U.S. he was sent to Brooke Army Medical Center. He suffered from severe 
headaches that painkillers and brain blocks had no affect on. In 
addition to the headaches, he had trouble with his balance, his depth 
perception, his speech, his eye to hand coordination, his memory, which 
included both his long-term and short-term and any task that involved 
sequencing. He was unable to go anywhere by himself because he was 
constantly getting lost. It took a year for him to regain his balance 
and depth perception. Now, 2\1/2\ years later, he still suffers from 
daily headaches, however their severity has lessened. He has regained 
most of his long-term memory; however he still has trouble with his 
short-term memory which includes misplacing items on a daily basis and 
constant repetition of subjects previously discussed. In addition, he 
cannot follow a detailed set of instructions nor can he multi-task. His 
condition is frustrating for both him and our family.
    Another issue that I feel very strongly about is the transition of 
the soldier from the battlefield back to civilian life. One thing that 
I have noticed over the years with Raymond's numerous deployments is 
the difficulty of transitioning back to everyday life and the stresses 
that go along with family and work. In my opinion, some sort of 
decompression time needs to be built in to ``time served'' so that 
soldiers can get readjusted to civilian life. I feel like reservists 
especially have it hard because their deployments are longer and when 
they are released from active duty, they go right back into their 
civilian jobs. Some injuries such as mild TBI as well as PTSD may not 
be apparent until months later. In addition to an assessment as soon as 
the soldier returns home, some type of reassessment should be done 
several months later. It is after the soldier returns home and the 
honeymoon period is over that a lot of the problems begin. Furthermore, 
if any type of combat action was seen then counseling should be 
mandatory for the soldier and the family. Soldiers need to understand 
that their families will never fully understand what they have been 
through because the family member will never have that experience, and 
families need to understand that the soldier they sent off to war may 
not be the same soldier that they get back. For our family, the worst 
adjustment period was after Afghanistan. Raymond saw a lot of action 
due to the fact that he was stationed at a Special Forces Fire Base and 
when he returned from active duty he went straight back into a 
stressful job and a house full of teenagers. The stress of trying to 
readjust to civilian life almost destroyed our entire family. I 
strongly feel that mandatory counseling for him and our family would 
have made the transition much easier.
    It has been a long 2\1/2\ years with a lot of ups and downs. Based 
on reports from military and VA nuerologists some type of long-term 
care will be needed in the next 5 years. Fortunately, we are working 
with many good private as well as government organizations that can 
help us with what lies ahead.

    Senator Ben Nelson. The second panel is comprised of GAO 
subject-matter experts: Randall B. Williamson, who is the 
Director for Health Care, we welcome you; Valerie C. Melvin, 
Director for Human Capital and Management Information Systems 
Issues, we welcome you; and Daniel Bertoni, Director of 
Education, Workforce, and Income Security, we welcome you.
    We look forward to hearing your assessment of the progress 
made by the departments, thus far, as well as identification of 
areas where work remains to be done. You've had the benefit of 
hearing some of our servicemembers and family members express 
their concerns, as well as their experiences.
    With that in mind, Mr. Williamson, we'll ask you if you 
have an opening statement.

  STATEMENT OF RANDALL B. WILLIAMSON, DIRECTOR, HEALTH CARE, 
    GOVERNMENT ACCOUNTABILITY OFFICE; ACCOMPANIED BY DANIEL 
 BERTONI, DIRECTOR, EDUCATION, WORKFORCE, AND INCOME SECURITY 
  ISSUES; AND VALERIE C. MELVIN, DIRECTOR, HUMAN CAPITAL AND 
             MANAGEMENT INFORMATION SYSTEMS ISSUES

    Mr. Williamson. Thank you, Mr. Chairman, and members of the 
subcommittee. We are pleased to be here today to discuss 
actions that VA and DOD are taking to transition our Nation's 
recovering servicemembers back to Active Duty or to a veteran 
status.
    Beyond adjusting to their injuries, recovering 
servicemembers may face additional challenges, including 
difficulties managing their outpatient recovery process, 
navigating the military's DES, and transitioning between care 
provided by DOD and VA.
    Our testimony today will discuss the progress made by DOD 
and VA to jointly develop policies on improvement to the care, 
management, and transition of recovering servicemembers, as 
mandated by the NDAA for Fiscal Year 2008. We'll also address 
challenges both agencies face as they develop and implement 
policies on these issues.
    With me today are Dan Bertoni, a director overseeing our 
work on DOD and VA DESs, and Valerie Melvin, a director who 
heads up our work on issues related to information sharing and 
DOD and VA health records. NDAA for Fiscal Year 2008 required 
DOD and VA to jointly develop and implement comprehensive 
policies in four areas: care and management, medical and 
disability evaluation, return of servicemembers to Active Duty, 
and the transition of the recovering servicemembers from DOD to 
VA.
    Within these 4 areas, we identified 76 individual 
requirements contained in the NDAA for Fiscal Year 2008. DOD 
and VA are addressing these areas and requirements through its 
Wounded, Ill, and Injured SOC, which was established in May 
2007 as a vehicle for jointly addressing issues for recovering 
servicemembers. It is staffed with both DOD and VA employees.
    Overall, DOD and VA have made good progress in developing 
policies spelled out in NDAA for Fiscal Year 2008. They have 
completed joint policy development for 60 of the 76 
requirements. The remaining 16 requirements are in progress, 
and VA and DOD officials expect to complete policy development 
for these requirements by midyear.
    In developing policies to address NDAA for Fiscal Year 2008 
requirements, DOD and VA have faced numerous challenges, and 
will continue to do so as they further develop policies and 
oversee policy implementation.
    For example, improving the DES for recovering 
servicemembers poses a major challenge. Numerous studies have 
highlighted long delays and confusion that ill or injured 
servicemembers face as they navigate the military DES.
    To help remedy these problems, VA and DOD initiated a DES 
Pilot Program as a test for consolidating the two departments' 
DESs. Both agencies have indicated that decisions on the 
feasibility of consolidating their disability systems will be 
made after the pilot project is completed.
    Possible expansion of this pilot is currently being 
considered. However, from our perspective, it is unclear what 
specific criteria DOD and VA will use to evaluate the pilot and 
whether they will have complete information needed for this 
evaluation.
    Another daunting challenge involved DOD and VA efforts to 
share electronic health records, an effort that has been 
underway for over a decade. While the departments are making 
progress towards increased information sharing, they face 
further challenges in managing initiatives required to achieve 
this goal.
    GAO has recently reported that the two departments' plans 
to further increase their electronic sharing capabilities do 
not consistently identify results-oriented performance measures 
to accurately assess progress toward the delivery of that 
capability, nor have the departments completed all necessary 
activities to fully set up their Interagency Program Office 
(IPO), including hiring a permanent director and deputy 
director. Until these challenges are fully addressed, the 
departments and their stakeholders may lack the comprehensive 
understanding they need to effectively manage their progress 
toward achieving increased sharing of information between the 
departments.
    Finally, recent staff changes and working relationships 
within the SOC could also pose a future challenge. Since 
January, the SOC has experienced turnover in leadership and 
changes in policy development responsibilities. Also, DOD 
established two new organizations as a means to establish a 
permanent structure to support the SOC.
    Some DOD officials consider the changes to be positive 
developments that will enhance the SOC's effectiveness. In 
contrast, others are concerned with issues related to 
communication and interaction among SOC members. Given the 
recent organizational changes that have occurred in support of 
the SOC, how this plays out in the future is unknown.
    Mr. Chairman, this concludes my remarks. We'll be happy to 
answer any questions you have.
    [The prepared statement of Mr. Williamson follows:]
              Prepared Statement by Randall B. Williamson
    Mr. Chairman and members of the subcommittee: We are pleased to be 
here today as you examine issues related to meeting the critical needs 
of recovering servicemembers by reviewing the progress made by the 
Department of Defense (DOD) and the Department of Veterans Affairs (VA) 
in jointly developing policies mandated by the National Defense 
Authorization Act for Fiscal Year 2008 (NDAA 2008).\1\
---------------------------------------------------------------------------
    \1\ Pub. L. No. 110-181, 122 Stat. 3.
---------------------------------------------------------------------------
    Over 1.6 million U.S. troops have deployed in Operation Enduring 
Freedom (OEF) and Operation Iraqi Freedom (OIF) since October 
2001.2,3 In February 2009, DOD reported that over 33,000 
servicemembers have been wounded in action since the onset of these 
conflicts.\4\ Because of improved battlefield medicine, those who might 
have died in past conflicts are now surviving, many with multiple 
serious injuries such as amputations, traumatic brain injury (TBI), and 
post-traumatic stress disorder (PTSD). Beyond adjusting to their 
injuries, recovering servicemembers may face additional challenges, 
including difficulties managing their outpatient recovery process, 
difficulties navigating the military's disability evaluation system, 
and problems transitioning between care provided by DOD and care 
provided by VA.
---------------------------------------------------------------------------
    \2\ Terri Tanielian and Lisa H. Jaycox, Invisible Wounds of War, 
Psychological and Cognitive Injuries, Their Consequences, and Services 
to Assist Recovery (Santa Monica, CA: RAND Corporation, 2008).
    \3\ OEF, which began in October 2001, supports combat operations in 
Afghanistan and other locations, and OIF, which began in March 2003, 
supports combat operations in Iraq and other locations.
    \4\ Department of Defense, Operation Iraqi Freedom (OIF) U.S. 
Casualty Status, Operation Enduring Freedom (OEF) U.S. Casualty Status. 
www.defenselink.mil/news/casualty.pdf. (accessed Feb. 19, 2009).
---------------------------------------------------------------------------
    Questions were raised in the media and by Congress about whether 
DOD and VA are prepared to meet the needs of the increasing number of 
recovering servicemembers and veterans. In February 2007, a series of 
Washington Post articles disclosed deficiencies in the provision of 
outpatient services at Walter Reed Army Medical Center, including poor 
living conditions at Walter Reed, a confusing disability evaluation 
system, and servicemembers remaining in outpatient status for months 
and sometimes years without a clear understanding about their plan of 
care or the future of their military service. Various review groups 
investigated the challenges that DOD and VA faced in providing care to 
recovering servicemembers and made a number of recommendations to 
address the problems they identified. Shortly after the media 
disclosures, we testified about the challenges facing recovering 
servicemembers during their recovery process.\5\
---------------------------------------------------------------------------
    \5\ GAO, DOD, and VA Health Care: Challenges Encountered by Injured 
Servicemembers during Their Recovery Process, GAO-07-589T (Washington, 
DC: Mar. 5, 2007) and DOD and VA Health Care: Challenges Encountered by 
Injured Servicemembers during Their Recovery Process, GAO-07-606T 
(Washington, DC: Mar. 8, 2007).
---------------------------------------------------------------------------
    In May 2007, DOD and VA established the Wounded, Ill, and Injured 
Senior Oversight Committee (SOC) to address the problems that had been 
identified with the care of recovering servicemembers. The committee is 
co-chaired by the Deputy Secretaries of DOD and VA and includes 
military Service Secretaries and other high-ranking officials within 
both departments. One of the SOC's primary responsibilities is to 
oversee the development of policies in response to the recommendations 
of the review groups that studied the issues associated with recovering 
servicemembers' health care and benefits. Generally, senior officials 
from the SOC sign and issue interim policy guidance, which is then 
vetted through DOD's and VA's internal processes to be finalized as 
department policies.
    The NDAA 2008, which was enacted in January 2008, requires DOD and 
VA, to the extent feasible, to jointly develop and implement a 
comprehensive policy on improvements to the care, management, and 
transition of recovering servicemembers. Specifically, section 1611(a) 
of the NDAA 2008 directs DOD and VA to cover four key areas: (1) care 
and management, (2) medical evaluation and disability evaluation, (3) 
the return of servicemembers to active duty, and (4) the transition of 
recovering servicemembers from DOD to VA. Because of the related 
ongoing work of the SOC, it assumed responsibility for addressing these 
requirements. The NDAA 2008 also requires GAO to report on the progress 
DOD and VA make in developing and implementing the comprehensive 
policy.\6\ Our work is focused on the status of the development of the 
comprehensive policy, which includes the development of multiple 
policies that are further enumerated in sections 1611 through 1614 of 
the law.
---------------------------------------------------------------------------
    \6\ Pub. L. No. 110-181, Sec. 1615(d), 122 Stat. 3, 447.
---------------------------------------------------------------------------
    In my testimony today, I will discuss our preliminary findings on: 
(1) the progress DOD and VA have made in jointly developing 
comprehensive policies for recovering servicemembers in the areas of 
care and management, medical and disability evaluation, return to 
active duty, and transition from care and services received from DOD to 
VA as required by sections 1611 through 1614 of the NDAA 2008; and (2) 
the challenges DOD and VA are encountering in the joint development and 
initial implementation of these policies.
    To assess the extent to which DOD and VA have made progress in 
developing the required policies, we asked SOC representatives to 
report on the status of policy development for the 76 individual 
requirements that we identified in sections 1611 through 1614 of the 
NDAA 2008, which we grouped into 14 categories.\7\ (See app. I for a 
summary of these requirements and categories.) We also asked the SOC 
representatives to provide documentation to substantiate the status of 
each requirement, and we verified the reported status of each 
requirement by reviewing this documentation. We determined whether each 
of the requirements (1) had been completed, (2) was in progress, or (3) 
had not been acted upon. We considered a requirement to have been 
``completed'' if a document had been signed and approved by DOD, VA, or 
both, at the SOC level, that contained standards, guidelines, or 
procedures that addressed the requirement, even if DOD, VA, or both 
plan to issue additional policies on the subject.\8\ We considered a 
requirement to be ``in progress'' if documentation demonstrated that 
work had been initiated to develop standards, guidelines, or procedures 
that addressed the requirement. We considered a requirement not to have 
been acted upon if no action had been taken to develop standards, 
guidelines, or procedures that address the requirement. We based our 
review in part on the interim policy documents signed by DOD and VA 
officials working through the SOC. In some cases, interim policy 
documents were signed by officials of both departments, and in other 
cases, the documents were signed by officials of one department, 
depending upon the requirement. Interim policy documents could be in 
the form of memoranda of agreement, memoranda of understanding, 
directives, decision- or directive-type memoranda, instructions or 
policy memoranda, or other guidelines or forms of guidance. In 
addition, we conducted follow-up interviews with DOD and VA officials 
when we needed clarification on the reported progress or additional 
documentation. We did not, however, evaluate the quality of the policy 
documents we reviewed. To identify the challenges DOD and VA 
encountered in jointly developing and initially implementing the 
required policies, we interviewed officials from both departments to 
obtain an account of their experiences in the policy development 
process. In conducting our work, we interviewed the acting Under 
Secretary of Defense for Personnel and Readiness, the Executive 
Director and Chief of Staff of the SOC, the departmental co-leads for 
most of the SOC work groups, the acting Director of DOD's Office of 
Transition Policy and Care Coordination, and other relevant DOD and VA 
officials. We shared the information contained in this statement with 
DOD and VA officials, and they agreed with the information we 
presented.
---------------------------------------------------------------------------
    \7\ We defined an individual requirement as a provision within 
sections 1611 through 1614 related to the policy required by 1611(a) 
that directs DOD, VA, or both to take a specific action or to include a 
specific criterion in their policy. The SOC's legal counsel reviewed 
these requirements and our groupings, and agreed with our approach.
    \8\ Completed policy guidance also included interim policy guidance 
signed by the SOC.
---------------------------------------------------------------------------
    We conducted our work from May 2008 through April 2009 in 
accordance with all sections of GAO's Quality Assurance Framework that 
are relevant to our objectives. The framework requires that we plan and 
perform the engagement to obtain sufficient and appropriate evidence to 
meet our stated objectives and to discuss any limitations in our work. 
We believe that the information and data obtained, and the analysis 
conducted, provide a reasonable basis for any findings and conclusions.
                               background
    Over the past 8 years, DOD has designated over 33,000 
servicemembers involved in OEF and OIF as wounded in action. The 
severity of injuries can result in a lengthy process for a patient to 
either return to duty or to transition to veteran status. The most 
seriously injured servicemembers from these conflicts usually receive 
care at Walter Reed Army Medical Center or the National Naval Medical 
Center.\9\ According to DOD officials, once they are stabilized and 
discharged from the hospital, servicemembers may relocate closer to 
their homes or military bases and be treated as outpatients by the 
closest military or VA facility.
---------------------------------------------------------------------------
    \9\ These servicemembers may also receive care at Balboa Naval 
Hospital in San Diego, CA, or at Brooke Army Medical Center in San 
Antonio, TX.
---------------------------------------------------------------------------
    Recovering servicemembers potentially navigate two different 
disability evaluation systems that serve different purposes. DOD's 
system serves a personnel management purpose by identifying 
servicemembers who are no longer medically fit for duty. If a 
servicemember is found unfit because of medical conditions incurred in 
the line of duty, the servicemember is assigned a disability rating and 
can be discharged from duty. This disability rating, along with years 
of service and other factors, determines subsequent disability and 
health care benefits from DOD. Under VA's system, disability ratings 
help determine the level of disability compensation a veteran receives 
and priority status for enrollment for health care benefits. To 
determine eligibility for disability compensation, VA evaluates all 
claimed medical conditions, whether they were evaluated previously by 
the military service's evaluation process or not. If VA finds that a 
veteran has one or more service-connected disabilities that together 
result in a final rating of at least 10 percent,\10\ VA will pay 
monthly compensation and the veteran will be eligible to receive 
medical care from VA.
---------------------------------------------------------------------------
    \10\ VA determines the degree to which veterans are disabled in 10 
percent increments on a scale of 0 to 100 percent.
---------------------------------------------------------------------------
Efforts to Address the Care and Benefits for Recovering Servicemembers
    Efforts have been taken to address the deficiencies reported at 
Walter Reed related to the care provided and transitioning of 
recovering servicemembers. After the press reports about Walter Reed, 
several high level review groups were established to study the care and 
benefits provided to recovering servicemembers by DOD and VA. The 
studies produced from all of these groups, released from April 2007 
through June 2008, contained over 400 recommendations covering a broad 
range of topics, including case management, disability evaluation 
systems, data sharing between the departments, and the need to better 
understand and diagnose TBI and PTSD.\11\
---------------------------------------------------------------------------
    \11\ The reports are as follows: Independent Review Group, 
Rebuilding the Trust: Report on Rehabilitative Care and Administrative 
Processes at Walter Reed Army Medical Center and National Naval Medical 
Center (April 2007); Task Force on Returning Global War on Terror 
Heroes, Report to the President (April 2007); Department of Defense 
Task Force on Mental Health, An Achievable Vision: Report of the 
Department of Defense Task Force on Mental Health (June 2007); 
President's Commission on Care for America's Returning Wounded 
Warriors, Serve, Support, Simplify (July 2007); Veterans' Disability 
Benefits Commission, Honoring the Call to Duty: Veterans' Disability 
Benefits in the 21st Century (October 2007); and Inspectors General, 
Department of Defense, Department of Veterans Affairs, DOD/VA Care 
Transition Process for Servicemembers Injured in OIF/OEF (June 2008).
---------------------------------------------------------------------------
    In May 2007, DOD and VA established the SOC as a temporary, 1-year 
committee with the responsibility for addressing recommendations from 
these reports. To conduct its work, the SOC established eight work 
groups called lines of action (LOA). Each LOA is co-chaired by 
representatives from DOD and VA and has representation from each 
military Service. LOAs are responsible for specific issues, such as 
disability evaluation systems and case management. (See table 1 for an 
overview of the LOAs.) The committee was originally intended to expire 
May 2008 but it was extended to January 2009. Then, the NDAA 2009 
extended the SOC through December 2009.\12\
---------------------------------------------------------------------------
    \12\ Duncan Hunter National Defense Authorization Act for Fiscal 
Year 2009, Pub. L. No. 110-417, Sec. 726, 122 Stat. 4356, 4509 (2008).
---------------------------------------------------------------------------
      
    
    
      
    In addition to addressing the published recommendations, the SOC 
assumed responsibility for addressing the policy development and 
reporting requirements contained in the NDAA 2008. Section 1611(a) of 
the NDAA 2008 directs DOD and VA, to the extent feasible, to develop 
and implement a comprehensive policy covering four areas: (1) care and 
management, (2) medical evaluation and disability evaluation, (3) the 
return of servicemembers to active duty, and (4) the transition of 
recovering servicemembers from DOD to VA. The specific requirements for 
each of these four areas are further enumerated in sections 1611 
through 1614 of the law and would include the development of multiple 
policies. Table 2 summarizes the requirements for the jointly developed 
policies.
      
    
    
      
Selected Initiatives of the SOC
    Since its inception, the SOC has completed many initiatives, such 
as establishing the Defense Centers of Excellence for Psychological 
Health and Traumatic Brain Injury and creating a National Resource 
Directory, which is an online resource for recovering servicemembers, 
veterans, and their families. In addition, the SOC has undertaken 
initiatives specifically related to the requirements contained in 
sections 1611 through 1614 of the NDAA 2008. Specifically, the SOC 
supported the development of several programs to improve the care and 
management of benefits to recovering servicemembers, including the 
disability evaluation system pilot and the Federal Recovery 
Coordination Program. These programs are currently in pilot or 
beginning phases:

         Disability evaluation system pilot: DOD and VA are 
        piloting a joint disability evaluation system to improve the 
        timeliness and resource use of their separate disability 
        evaluation systems. Key features of the pilot include a single 
        physical examination conducted to VA standards by the medical 
        evaluation board that documents medical conditions that may 
        limit a servicemember's ability to serve in the military, 
        disability ratings prepared by VA for use by both DOD and VA in 
        determining disability benefits, and additional outreach and 
        nonclinical case management provided by VA staff at the DOD 
        pilot locations to explain VA results and processes to 
        servicemembers. DOD and VA anticipate a final report on the 
        pilot in August 2009.
         Federal Recovery Coordination Program: In 2007, DOD 
        and VA established the Federal Recovery Coordination Program in 
        response to the report by the President's Commission on Care 
        for America's Returning Wounded Warriors, commonly referred to 
        as the Dole-Shalala Commission. The commission's report 
        highlighted the need for better coordination of care and 
        additional support for families. The Federal Recovery 
        Coordination Program serves the most severely injured or ill 
        servicemembers, or those who are catastrophically injured. 
        These servicemembers are highly unlikely to be able to return 
        to duty and will have to adjust to permanent disabling 
        conditions. The program was created to provide uniform and 
        seamless care, management, and transition of recovering 
        servicemembers and their families by assigning recovering 
        servicemembers to coordinators who manage the development and 
        implementation of a recovery plan. Each servicemember enrolled 
        in the Federal Recovery Coordination Program has a Federal 
        Individual Recovery Plan, which tracks care, management, and 
        transition through recovery, rehabilitation, and reintegration. 
        Although the Federal Recovery Coordination Program is operated 
        as a joint DOD and VA program, VA is responsible for the 
        administrative duties and program personnel are employees of 
        the agency.
          Beyond these specific initiatives, the SOC took 
        responsibility for issues related to electronic health records 
        through the work of LOA 4, the SOC's work group focused on DOD 
        and VA data sharing. This LOA also addressed issues more 
        generally focused on joint DOD and VA data needs, including 
        developing components for the disability evaluation system 
        pilot and the individual recovery plans for the Federal 
        Recovery Coordination Program. LOA 4's progress on these issues 
        was monitored and overseen by the SOC. The NDAA 2008 
        established an interagency program office (IPO) to serve as a 
        single point of accountability for both departments in the 
        development and implementation of interoperable electronic 
        health records.13,14 Subsequently, management oversight of many 
        of LOA 4's responsibilities were transferred to the IPO. Also, 
        the IPO's scope of responsibility was broadened to include 
        personnel and benefits data sharing between DOD and VA.
---------------------------------------------------------------------------
    \13\ Pub. L. No. 110-181, Sec. 1635, 122 Stat. 3, 460-63.
    \14\ Interoperability is the ability of two or more systems or 
components to exchange information and to use the information that has 
been exchanged.
---------------------------------------------------------------------------
 dod and va have completed the majority of the requirements to jointly 
    develop policies on care and management, medical and disability 
  evaluation, return to active duty, and the transition from dod to va
    As of April 2009, DOD and VA have completed 60 of the 76 
requirements we identified for jointly developing policies for 
recovering servicemembers on: (1) care and management, (2) medical and 
disability evaluation, (3) return to active duty, and (4) servicemember 
transition from DOD to VA. The two departments have completed all 
requirements for developing policy for two of the policy areas--medical 
and disability evaluation and return to active duty. Of the 16 
requirements that are in progress, 10 are related to care and 
management and 6 are related to servicemembers transitioning from DOD 
to VA. (See table 3.)
      
    
    
      
DOD and VA Have Completed More Than Two-Thirds of the Requirements 
        Regarding the Care and Management of Recovering Servicemembers
    We found that more than two-thirds of the requirements for DOD's 
and VA's joint policy development to improve the care and management of 
recovering servicemembers have been completed while the remaining 
requirements are in progress. (See table 4.) We identified 38 
requirements for this policy area and grouped them into 5 categories. 
Although 28 of the 38 requirements had been completed, one category--
improving access to medical and other health care services--had most of 
its requirements in progress.
      
    
    
      
    Most of the completed requirements were addressed in DOD's January 
2009 Directive-Type Memorandum (DTM), which was developed in 
consultation with VA.\15\ This DTM, entitled Recovery Coordination 
Program: Improvements to the Care, Management, and Transition of 
Recovering Servicemembers, establishes interim policy for the 
improvements to the care, management, and transition of recovering 
servicemembers in response to sections 1611 and 1614 of the NDAA 2008. 
In consultation with VA, DOD created the Recovery Coordination Program 
in response to the NDAA 2008 requirements. This program, which was 
launched in November 2008, extended the same comprehensive coordination 
and transition support provided under the Federal Recovery Coordination 
Program to servicemembers who were less severely injured or ill, yet 
who still were unlikely to return to duty and continue their careers in 
the military. This program follows the same structured process as the 
Federal Recovery Coordination Program. However, DOD oversees this 
program and the coordinators are DOD employees.
---------------------------------------------------------------------------
    \15\ DOD and VA will also be issuing a joint directive regarding 
the policies.
---------------------------------------------------------------------------
    DOD's January 2009 DTM includes information on the scope and 
program elements of the Recovery Coordination Program as well as on the 
roles and responsibilities of the recovery care coordinators, Federal 
recovery coordinators, and medical care case managers and non-medical 
care managers. According to DOD officials, DOD took the lead in 
developing policy to address the requirements for care and management 
because it interpreted most of the requirements to refer to active duty 
servicemembers.
    According to DOD and VA officials, the January 2009 DTM serves as 
the interim policy for care, management, and transition until the 
completion of DOD's comprehensive policy instruction, which is 
estimated to be completed by June 2009.\16\ This policy instruction 
will contain more detailed information on the policies outlined in the 
DTM. A VA official told us that VA also plans to issue related policy 
guidance as part of a VA handbook in June 2009. The VA official noted 
that the final form of the policy document would correspond with DOD's 
instruction.
---------------------------------------------------------------------------
    \16\ DOD issues directive-type memoranda to address time-sensitive 
actions that affect current policies or that will be developed into new 
DOD policies. A directive-type memoranda establishes temporary policy 
and provides DOD the direction to implement the policy when time 
constraints prevent publishing a new policy or a change to an existing 
DOD policy.
---------------------------------------------------------------------------
DOD and VA Have Completed All of the Requirements for Developing Policy 
        on the Medical Evaluation and Disability Evaluation of 
        Recovering Servicemembers
    DOD and VA have completed all of the requirements for developing 
policy to improve the medical and physical disability evaluation of 
recovering servicemembers. (See table 5.) We identified 18 requirements 
for this policy area and grouped them into three categories: (1) policy 
for improved medical evaluations, (2) policy for improved physical 
disability evaluations, and (3) reporting on the feasibility and 
advisability of consolidating DOD and VA disability evaluation systems.
      
    
    
      
    DOD issued a series of memoranda that addressed the first two 
categories starting in May 2007. These memoranda, some of which were 
developed in collaboration with VA, contained policies and implementing 
guidance to improve DOD's existing disability evaluation system. To 
address the third category in this policy area, DOD and VA have issued 
a report to Congress that describes the organizing framework for 
consolidating the two departments' disability evaluation systems and 
states that the departments are hopeful that consolidation would be 
feasible and advisable even though the evaluation of this approach 
through the disability evaluation system pilot is still ongoing. 
According to an agency official, further assessment of the feasibility 
and advisability of consolidation will be conducted. DOD and VA 
anticipate issuing a final report on the pilot in August 2009. However, 
as we reported in September 2008, it was unclear what specific criteria 
DOD and VA will use to evaluate the success of the pilot, and when 
sufficient data will be available to complete such an evaluation.\17\
---------------------------------------------------------------------------
    \17\ GAO, Military Disability System: Increased Supports for 
Servicemembers and Better Pilot Planning Could Improve the Disability 
Evaluation Process, GAO-08-1137 (Washington, DC: Sept. 24, 2008).
---------------------------------------------------------------------------
DOD Has Completed Establishing Standards for Determining the Return of 
        Recovering Servicemembers to Active Duty
    DOD has completed the requirement for establishing standards for 
determining the return of recovering servicemembers to active duty. 
(See table 6.) \18\
---------------------------------------------------------------------------
    \18\ The NDAA 2008 directed the Secretary of Defense to respond to 
this policy requirement. VA does not participate in return-to-duty 
decisions.
---------------------------------------------------------------------------
      
    
    
      
    On March 13, 2008, DOD issued a DTM amending its existing policy on 
retirement or separation due to a physical disability. The revised 
policy states that the disability evaluation system will be the 
mechanism for determining both retirement or separation and return to 
active duty because of a physical disability. An additional revision to 
the existing DOD policy allows DOD to consider requests for permanent 
limited active duty or Reserve status for servicemembers who have been 
determined to be unfit because of a physical disability. Previously, 
DOD could consider such cases only as exceptions to the general policy.
    According to a DOD official, it is too early to tell whether the 
revisions will have an effect on retirement rates or return-to-duty 
rates. DOD annually assesses the disability evaluation system and 
tracks retirement and return to duty rates. However, because of the 
length of time a servicemember takes to move through the disability 
evaluation system--sometimes over a year--it will take a while before 
changes due to the policy revisions register in the annual assessment 
of the disability evaluation system.
Over Two-Thirds of the Requirements for Improving the Transition of 
        Recovering Servicemembers from DOD to VA Have Been Completed
    DOD and VA have completed more than two-thirds of the requirements 
for developing procedures, processes, or standards for improving the 
transition of recovering servicemembers. (See table 7.) We identified 
19 requirements for this policy area, and we grouped them into 5 
categories. We found that 13 of the 19 policy requirements have been 
completed, including all of the requirements for two of the 
categories--the development of a process for a joint separation and 
evaluation physical examination and development of procedures for 
surveys and other mechanisms to measure patient and family satisfaction 
with services for recovering servicemembers. The remaining three 
categories contain requirements that are still in progress.
      
    
    
      
    Most of the requirements for improving the transition from DOD to 
VA were addressed in DOD's January 2009 DTM--Recovery Coordination 
Program: Improvements to the Care, Management, and Transition of 
Recovering Servicemembers--that establishes interim policy for the 
care, management, and transition of recovering servicemembers through 
the Recovery Coordination Program. However, we found that DOD's DTM 
includes limited detail related to the procedures, processes, and 
standards for transition of recovering servicemembers. As a result, we 
could not always directly link the interim policy in the DTM to the 
specific requirements contained in section 1614 of the NDAA 2008. DOD 
and VA officials noted that they will be further developing the 
procedures, processes, and standards for the transition of recovering 
servicemembers in a subsequent comprehensive policy instruction, which 
is estimated to be completed by June 2009. A VA official reported that 
VA plans to separately issue policy guidance addressing the 
requirements for transitioning servicemembers from DOD to VA in June 
2009.
 dod and va officials experienced challenges during joint development 
            and initial implementation of required policies
    DOD and VA officials told us that they experienced numerous 
challenges as they worked to jointly develop policies to improve the 
care, management, and transition of recovering servicemembers. 
According to officials, these challenges contributed to the length of 
time required to issue policy guidance, and in some cases the 
challenges have not yet been completely resolved. In addition, 
challenges have arisen during the initial implementation of some of the 
NDAA 2008 policies. Finally, recent changes to the SOC staff, including 
DOD's organizational changes for staff supporting the SOC, could pose 
challenges to the development of policy affecting recovering 
servicemembers.
Various Challenges Arose during Policy Development
    DOD and VA officials encountered numerous challenges during the 
course of jointly developing policies to improve the care, management, 
and transition of recovering servicemembers, as required by sections 
1611 through 1614 of the NDAA 2008, in addition to responding to other 
requirements of the law. Many of these challenges have been addressed, 
but some have yet to be completely resolved. DOD and VA officials cited 
the following examples of issues for which policy development was 
particularly challenging.

         Increased support for family caregivers. The NDAA 2008 
        includes a number of provisions to strengthen support for 
        families of recovering servicemembers, including those who 
        become caregivers. However, DOD and VA officials on a SOC work 
        group stated that before they could develop policy to increase 
        support for such families, they had to obtain concrete evidence 
        of their needs. Officials explained that while they did have 
        anecdotal information about the impact on families who provide 
        care to recovering servicemembers, they lacked the systematic 
        data needed for sound policy decisions--such as frequency of 
        job loss and the economic value of family-provided medical 
        services. A work group official told us that their proposals 
        for increasing support to family caregivers were rejected twice 
        by the SOC, due in part to the lack of systematic data on what 
        would be needed. The work group then contracted with 
        researchers to obtain substantiating evidence, a study that 
        required 18 months to complete. In January 2009, the SOC 
        approved the work group's third proposal and family caregiver 
        legislation is being prepared, with anticipated implementation 
        of new benefits for caregivers in fiscal year 2010.
         Establishing standard definitions for operational 
        terms. One of the important tasks facing the SOC was the need 
        to standardize key terminology relevant to policy issues 
        affecting recovering servicemembers. DOD took the lead in 
        working with its military services and VA officials to identify 
        and define key terms. DOD and VA officials told us that many of 
        the key terms found in existing DOD and VA policy, the reports 
        from the review groups, and the NDAA 2008, as well as those 
        used by the different military services are not uniformly 
        defined. Consequently, standardized definitions are needed to 
        promote agreement on issues such as

                 identifying the recovering servicemembers who 
                are subject to NDAA 2008 requirements,
                 identifying categories of servicemembers who 
                would receive services from the different classes of 
                case managers or be eligible for certain benefits,
                 managing aspects of the disability evaluation 
                process, and
                 establishing criteria to guide research.

          In some cases, standardized definitions were critical to 
        policy development. The importance of agreement on key terms is 
        illustrated by an issue encountered by the SOC's work group 
        responsible for family support policy. In this case, before 
        policy could be developed for furnishing additional support to 
        family members that provide medical care to recovering 
        servicemembers, the definition of ``family'' had to be agreed 
        upon. DOD and VA officials said that they considered two 
        options: to define the term narrowly to include a 
        servicemember's spouse, parents, and children, or to use 
        broader definitions that included distant relatives and 
        unrelated individuals with a connection to the servicemember. 
        These two definitions would result in significantly different 
        numbers of family members eligible to receive additional 
        support services. DOD and VA officials decided to use a broader 
        definition to determine who would be eligible for support.
          Of the 41 key definitions identified for reconciliation, DOD 
        and VA had concurred on 33 as of March 2009 and these 33 
        standardized definitions are now being used. Disagreement 
        remains over the remaining definitions, including the 
        definition of ``mental health.'' A DOD official stated that 
        given the uncertainty associated with the organizational and 
        procedural changes recently introduced to the SOC (which are 
        discussed below), obtaining concurrence on the remaining 
        definitions has been given lower priority.
         Improving TBI and PTSD screening and treatment. 
        Requirements related to screening and treatment for TBI and 
        PTSD were embedded in several sections of the NDAA 2008, 
        including section 1611, and were also discussed extensively in 
        a task force report on mental health.\19\ DOD and VA officials 
        told us that policy development for these issues was difficult. 
        For example, during development of improved TBI and PTSD 
        treatment policy, policymakers often lacked sufficient 
        scientific information needed to help achieve consensus on 
        policy decisions. Also, members of the SOC work group told us 
        that they disagreed on appropriate models for screening and 
        treatment and struggled to reorient the military services to 
        patient-focused treatment. A senior DOD official stated that 
        the adoption of patient-focused models is particularly 
        difficult for the military services because, historically, the 
        needs of the military have been given precedence over the needs 
        of individual servicemembers. To address these challenges, the 
        SOC oversaw the creation of the Defense Centers of Excellence 
        for Psychological Health and Traumatic Brain Injury--a 
        partnership between DOD and VA. While policies continue to be 
        developed on these issues, TBI and PTSD policy remains a 
        challenge for DOD and VA. However, DOD officials told us that 
        the centers of excellence have made progress with reducing 
        knowledge gaps in psychological health and TBI treatment, 
        identifying best practices, and establishing clinical standards 
        of care.
---------------------------------------------------------------------------
    \19\ Department of Defense Task Force on Mental Health (2007).
---------------------------------------------------------------------------
         Release of psychological health treatment records to 
        DOD by VA health care providers who treat members of the 
        National Guard and Reserves. Section 1614 of the NDAA 2008 
        requires the departments to improve medical and support 
        services provided to members of the National Guard and 
        Reserves. In pursuing these objectives, VA faced challenges 
        related to the release of medical information to DOD on 
        reservists and National Guard servicemembers who have received 
        treatment for PTSD or other mental health conditions from VA. 
        DOD requests medical information from VA to help make command 
        decisions about the reactivation of servicemembers, but VA 
        practitioners face an ethical dilemma if the disclosure of 
        medical treatment could compromise servicemembers' medical 
        conditions, particularly for those at risk of suicide. The 
        challenge of sharing and protecting sensitive medical 
        information on servicemembers who obtain treatment at VA was 
        reviewed by the Blue Ribbon Work Group on Suicide Prevention 
        convened in 2008 at the behest of the Secretary of Veterans 
        Affairs. DOD and VA are continuing the efforts to develop 
        policy to clarify the privacy rights of patients who receive 
        medical services from VA while serving in the military, and a 
        protecting the confidential records of VA patients who may also 
        be treat by the military's health care system. The need to 
        resolve this challenge assumes even greater importance in light 
        of DOD's and VA's increasing capability to exchange medical 
        records electronically, which will expand DOD's ability to 
        access records of servicemembers who have received medical 
        treatment from VA.
Future Challenges Could Impede the Joint Implementation of Policy 
        Initiatives
    In addition to challenges encountered during the joint development 
of policy for recovering servicemembers, additional challenges have 
arisen as DOD and VA have begun implementing NDAA 2008 policy 
initiatives.

         Medical examinations conducted as part of the DOD/VA 
        disability evaluation system pilot. In 2007, DOD and VA jointly 
        began to develop policy to improve the disability evaluation 
        process for recovering servicemembers and began pilot testing 
        these new procedures in the disability system. One significant 
        innovation of the disability evaluation system pilot is the use 
        of a single physical examination for multiple purposes, such as 
        for both disability determinations and disability benefits from 
        both departments. In our review of the disability evaluation 
        system pilot, we reported that DOD and VA had tracked 
        challenges that arose during implementation of the pilot but 
        had not yet resolved all of them.\20\ For example, one 
        unresolved issue was uncertainty about who will conduct the 
        single physical examination when a VA medical center is not 
        located nearby. Another challenge that could emerge in the 
        future is linked to VA's announcement in November 2008 that it 
        would cease providing physical reexaminations for recovering 
        servicemembers placed on the Temporary Disability Retired List 
        (TDRL).\21\ However, VA made an exception to its decision and 
        will continue to provide reexaminations for TDRL servicemembers 
        participating in the disability evaluation system pilot. In 
        March 2009, VA officials told us that they were developing a 
        policy to clarify this issue.
---------------------------------------------------------------------------
    \20\ See GAO-08-1137.
    \21\ Recovering servicemembers may be placed on the TDRL if they 
are found to be medically unfit for duty and have service-related 
illnesses or injuries that are not stable enough for assignment of a 
permanent disability rating. Assignment to the TDRL temporarily retires 
and provides servicemembers with disability benefits for up to 5 years 
while they wait for their disabling medical conditions to stabilize. A 
TDRL retiree must undergo periodic medical reexaminations and 
evaluations every 18 months. See 10 U.S.C. Sec. Sec. 1202, 1210.
---------------------------------------------------------------------------
         Electronic health information sharing between DOD and 
        VA. The two departments have been working for over a decade to 
        share electronic health information and have continued to make 
        progress toward increased information sharing through ongoing 
        initiatives and activities. However, the departments continue 
        to face challenges in managing the activities required to 
        achieve this goal. As we previously reported,\22\ the 
        departments' plans to further increase their electronic sharing 
        capabilities do not consistently identify results-oriented 
        performance measures, which are essential for assessing 
        progress toward the delivery of that capability.\23\ Further 
        challenging the departments is the need to complete all 
        necessary activities to fully set up their IPO, including 
        hiring a permanent Director and Deputy Director. Defining 
        results-oriented performance goals in its plans and ensuring 
        that they are met is an important responsibility of this 
        office. Until these challenges are fully addressed, the 
        departments and their stakeholders may lack the comprehensive 
        understanding that they need to effectively manage their 
        progress toward achieving increased sharing of information 
        between the departments. Moreover, not fully addressing these 
        challenges increases the risk that DOD and VA may not develop 
        and implement comprehensive policies to improve the care, 
        management, and transition of recovering servicemembers and 
        veterans.
---------------------------------------------------------------------------
    \22\ GAO, Electronic Health Records: DOD's and VA's Sharing of 
Information Could Benefit from Improved Management, GAO-09-268 
(Washington, DC: Jan. 28, 2009).
    \23\ These plans are the November 2007 VA/DOD Joint Executive 
Council Strategic Plan for Fiscal Years 2008-2010 (known as the VA/DOD 
Joint Strategic Plan) and the September 2008 DOD/VA Information 
Interoperability Plan (Version 1.0).
---------------------------------------------------------------------------
Changes to the SOC's Staff and Scope of Policy Development 
        Responsibilities Could Pose Future Challenges
    Recent changes to staff and working relationships within the SOC 
could pose future challenges to DOD's and VA's efforts to develop joint 
policy. Since December 2008, the SOC has experienced turnover in 
leadership and changes in policy development responsibilities. The SOC 
is undergoing leadership changes caused by the turnover in presidential 
administrations as well as turnover in some of its key staff. For 
example, the DOD and VA deputy secretaries who previously co-chaired 
the SOC departed in January 2009. As a short-term measure, the 
Secretaries of VA and DOD have cochaired a SOC meeting.
    DOD also introduced other staffing changes to replace personnel who 
had been temporarily detailed to the SOC and needed to return to their 
primary duties. DOD had relied on temporarily-assigned staff to meet 
SOC staffing needs because the SOC was originally envisioned as a 
short-term effort. In a December 2008 memo, DOD outlined the 
realignment of its SOC staff. This included the transition of 
responsibilities from detailed, temporary SOC staff and executives to 
permanent staff in existing DOD offices that managed similar issues. 
For example, the functions of LOA 7 (Legislation and Public Affairs) 
will now be overseen by the Assistant Secretary of Defense for 
Legislative Affairs, the Assistant Secretary of Defense for Public 
Affairs, and the DOD General Counsel. DOD also established two new 
organizational structures--the Office of Transition Policy and Care 
Coordination and an Executive Secretariat office. The Office of 
Transition Policy and Care Coordination oversees transition support for 
all servicemembers and serves as the permanent entity for issues being 
addressed by LOA 1 (Disability Evaluation System), LOA 3 (Case 
Management), and LOA 8 (Personnel, Pay, and Financial Support). The 
Executive Secretariat office is responsible for performance planning, 
performance management, and SOC support functions. According to DOD 
officials, the new offices were created to establish permanent 
organizations that address a specific set of issues and to enhance 
accountability for policy development and implementation as these 
offices report directly to the Office of the Under Secretary of Defense 
for Personnel and Readiness. Currently, many of the positions in these 
new offices, including the director positions, are staffed by officials 
in an acting capacity or are unfilled.
    DOD's changes to the SOC are important because of the potential 
effects these changes could have on the development of policy for 
recovering servicemembers. However, officials in both DOD and VA have 
mixed reactions about the consequences of these changes. Some DOD 
officials consider the organizational changes to the SOC to be positive 
developments that will enhance the SOC's effectiveness. They point out 
that the SOC's temporary staffing situation needed to be addressed, and 
also that the two new offices were created to support the SOC and 
provide focus on the implementation of key policy initiatives developed 
by the SOC--primarily the disability evaluation system pilot and the 
new case management programs. In contrast, others are concerned by 
DOD's changes, stating that the new organizations disrupt the unity of 
command that once characterized the SOC's management because personnel 
within the SOC organization now report to three different officials 
within DOD and VA. However, it is too soon to determine how well DOD's 
new structure will work in conjunction with the SOC. DOD and VA 
officials we spoke with told us that the SOC's work groups continue to 
carry out their roles and responsibilities.
    Finally, according to DOD and VA officials, the roles and scope of 
responsibilities of both the SOC and the DOD and VA Joint Executive 
Council appear to be in flux and may evolve further still.\24\ 
According to DOD and VA officials, changes to the oversight 
responsibilities of the SOC and the Joint Executive Council are causing 
confusion. While the SOC will remain responsible for policy matters 
directly related to recovering servicemembers, a number of policy 
issues may now be directed to the Joint Executive Council, including 
issues that the SOC had previously addressed. For example, management 
oversight of many of LOA 4's responsibilities (DOD and VA Data Sharing) 
has transitioned from the SOC to the IPO, which reports primarily to 
the Joint Executive Council. LOA 4 continues to be responsible for 
developing a component for the disability evaluation system pilot \25\ 
and the individual recovery plans for the Federal Recovery Coordination 
Program. It is not clear how the IPO will ensure effective coordination 
with the SOC's LOAs for the development of IT applications for these 
initiatives. Given that IT support for two key SOC initiatives is 
identified in the joint DOD/VA Information Interoperability Plan, if 
the IPO and the SOC do not effectively coordinate with one another, the 
result may impact negatively on the development of improved policies 
for recovering servicemembers.
---------------------------------------------------------------------------
    \24\ The Joint Executive Council is responsible for addressing 
strategic issues affecting both departments and developing a joint DOD/
VA strategic plan.
    \25\ LOA 4 is developing a tracking system for the disability 
evaluation system pilot that tracks information about servicemembers 
such as the assignment of a physical evaluation board liaison officer 
and timeframes for completing the disability evaluation processes.
---------------------------------------------------------------------------
    Mr. Chairman, this completes our prepared remarks. We would be 
happy to respond to any questions you or other members of the 
subcommittee may have at this time.
                      contacts and acknowledgments
    For further information about this testimony, please contact 
Randall B. Williamson at (202) 512-7114 or [email protected], Daniel 
Bertoni at (202) 512-7215 or [email protected], or Valerie C. Melvin at 
(202) 512-6304 or [email protected]. Contact points for our Offices of 
Congressional Relations and Public Affairs may be found on the last 
page of this testimony. GAO staff who made key contributions to this 
testimony are listed in appendix II.
      
    
    
      
    
    
      
    
    
      
    
    
      
    
    
      
    
    
      
    
    

    Senator Ben Nelson. Ms. Melvin?
    Mr. Williamson. We just have one statement.
    Senator Ben Nelson. Thank you very much, Mr. Williamson.
    As you look at trying to develop an intercooperative 
arrangement between two distinct agencies, did you get a sense 
that maybe there is a tendency for an agency to create a silo 
for protection or stovepiping, as it's sometimes called? Did 
you see an indication that that might be broken down to where 
there truly could be a bridge built between the two agencies to 
smooth the transition? Obviously, there is a transition in 
place today, it's just not smooth. Is it possible to smooth it 
to the level we need and want it to be?
    Mr. Williamson. Mr. Chairman, the SOC was created to deal 
with a crisis situation, and it was created to overcome the 
silos that might have existed in both agencies. I think it has 
enjoyed some relative success. I think the question now is, 
with the new organizations on the DOD side that have been 
created to support the SOC, and with certain other changes, 
whether that smoothness will continue. Indications that we have 
so far is that the changes--and granted, the changes have only 
been in place for 4 months--are being accomplished. Again, I 
think a large part of the success of the SOC has occurred due 
to personality-driven kinds of considerations. The people who 
have been there in the past have gotten along, and they've 
communicated well up to this point. I think, now, with future 
changes looming, in terms of top-level people who are going to 
be leaving and others taking their place, it remains to be seen 
just how smoothly things will work out.
    Senator Ben Nelson. Any comments from either of the other 
panelists?
    Mr. Bertoni. Sure, I could add something from a disability 
determination perspective.
    I have followed this pilot from the initial tabletop 
exercise through the initial pilot phase with just 3 locations, 
to now it's up to 14 locations. I can say for both DOD and VA--
it's a partnership. They're sharing information, they're trying 
to flatten the process and the handoff.
    I do see an effort to do that, to make it a seamless 
process, to view this as a continuum of care from the 
battlefield injury to the stabilization of the person. Then 
ultimately making a decision on what we will do with this 
person's future, whether they go back into the Service and have 
the appropriate supports in play, or to transfer that person 
into the civilian world and perhaps VA. There's coordination 
there between the board liaisons and the military Service 
representatives. There is an effort to do that, certainly. 
There's always room for improvement, and we can talk about 
that.
    Senator Ben Nelson. Ms. Melvin, I know that a lot of people 
think that information technology is just something that's 
essentially mechanical, and if you come up with the same 
system, everything will transfer. Is that a misnomer here, as 
well?
    Ms. Melvin. Yes, it is, sir. There's a big issue, relative 
to interoperability, and that's the critical aspect that has to 
be into play for VA and DOD to share their electronic health 
information. Getting to interoperability requires a lot of 
agreement, relative to standards, and those standards relate to 
medical terminology, data transfer, just a complex host of 
issues that have to be considered. It's not a matter of just 
having systems developed. It is a matter of being able to 
understand the requirements that each of those departments has. 
What are the priorities, relative to their needs, and how do 
you build those systems, and build the interoperable 
capabilities that will allow the necessary data to be 
exchanged?
    Senator Ben Nelson. Mr. Williamson, is it possible to get 
the two agencies to determine the same level and interest and 
need for the same criteria for determination of status of 
health and whether you're partially incapacitated or grossly 
incapacitated? Are their interests so different that you can't 
bring this together with a single set of criteria, or are you 
hopeful that it's possible to establish a single set of 
criteria, which would mean coming up with the same language, 
the same approach, which would make the transfer of records 
clearly more doable?
    Mr. Williamson. Clearly, Mr. Chairman, the two agencies are 
distinctly different, even though they share many of the same 
issues. I think, through the SOC and through the Joint 
Executive Council (JEC)--which is another DOD/VA coordination 
body--they have taken steps to come together. As you saw in our 
written statement, there are issues over definitions.
    Senator Ben Nelson. Right.
    Mr. Williamson. Definitions--one that's still being decided 
is, what is ``mental health''? What does it encompass? 
Certainly, the scope and eligibility and other issues regarding 
servicemembers depends on having a common understanding of 
terms.
    So, the SOC has worked its way through about three-quarters 
of the definitions. They're working on the others, but it's not 
easy.
    I think the SOC provides a good vehicle for doing that.
    Senator Ben Nelson. I was taken by what Mr. Bertoni said 
about their willingness to cooperate, and people of goodwill 
who desire to cooperate typically find a way to make things 
happen. Those who don't, don't. I might ask, do you think that, 
in the process, there is a senior partner and a junior partner, 
or do we have coequal senior partners between the two agencies?
    Mr. Williamson. I think the two agencies would like to view 
themselves as equal. There are probably situations where one 
takes precedence when you're talking about certain issues. Some 
issues relate more to DOD than they do VA, in terms of Wounded 
Warrior Units and so on. Naturally, DOD would take the lead in 
those situations. On other issues, VA might take a lead. But, I 
think when you're talking about transition issues, they both 
try to be full partners.
    Senator Ben Nelson. I'm encouraged to hear your assurances 
that it appears that there's a cooperative spirit and a sincere 
and significant effort to make happen what everybody wants to 
have happen; a smooth transition for our members and their 
families.
    Mr. Williamson. One notable thing is that the Secretaries 
of both DOD and VA have come together and have been real 
participants in this debate, have participated in SOC meetings, 
and have participated in JEC meetings. I think that says a lot 
for what the agencies are trying to do.
    Senator Ben Nelson. It certainly sends the right message 
and lends the credibility that's necessary for this to happen. 
Thank you.
    Senator Graham.
    Senator Graham. Thank you, Mr. Chairman.
    Mr. Williamson, did you hear the testimony of Lieutenant 
Kinard, when he was talking about the GAO report that said a 
program existed, but that you really didn't evaluate the 
quality of the program. Is that a fair criticism?
    Mr. Williamson. We looked at policy. The first step in this 
process is, do they have policies in place? I think we said 
they're doing a pretty good job. I was listening to that 
testimony, and I thought I would get a question on this.
    I think that the proof's in the pudding, in terms of 
implementation. I think that has to play out for many of these 
76 requirements.
    There are a couple of things we're going to be embarking on 
in the near future. We're going to be looking at the FRC/RCC 
process. We're going to be undertaking a review of that, which 
is very much akin to implementation. We're going to be looking 
at how that's been implemented. Also, we're going to be looking 
at the DCoE for Psychological Health and TBI, which, again, the 
SOC has been involved in with respect to the TBI/post-traumatic 
stress disorder (PTSD) issue. We're going to be looking at 
those from the standpoint of implementation.
    To look at all 76 requirements, in terms of implementation, 
is a big task. We're going to try to zero in on those that we 
think are very important and that need to be addressed soon.
    Senator Graham. Fair enough. One thing I'd like to just 
bring to the committee's attention, and to the public and our 
panel members, is that Colonel Gadson's a good example of how 
this war is different. He is going to remain on Active Duty it 
looks like. That just shows you how far we've come, in terms of 
medical technology and the desire of our soldiers to stay 
connected to their units and to the military.
    There will always be two decisions to be made. The one 
thing I don't want to do is rush a decision, because I think if 
it's up to Andrew, in many ways, he'd still be on Active Duty, 
but he's made the decision to move forward. We have some young 
men and women serving on Active Duty. I think there's a blind 
captain who's an instructor at West Point. There are some 
amputees that are serving. I think that's good.
    Just to let my colleagues up here know that there's always 
going to be some delay in making decisions, because the first 
decision, as to whether or not you can stay on Active Duty, is 
an important decision. More times than not, for most of the 
people hurt, their goal is not to be discharged. I want to make 
sure that we have a system that looks closely at the ability to 
continue to serve, and think outside the box, and make places 
for people like Colonel Gadson and others.
    Now, once the decision has been made that you're not going 
to be able to stay on Active Duty, I do believe that we can do 
a lot better. The two agencies involved have two different 
missions. DOD's mission is to take care of soldiers, their 
families, and fight and win this war. VA is to take care of 
those who have served. The interim period of time between 
medical discharge and evaluation and rehabilitation is always 
going to be complex. This idea of having standard definitions, 
that mental health services and rehabilitative services, for an 
Active Duty member, should not be materially different than 
somebody that goes into the VA. That's what Dr. Noss was 
telling us, and that's what Colonel Gadson was telling us, 
that, ``When I was an Active Duty person, or I lived in this 
region, I had certain services available. When I went into this 
new system--the VA--all of a sudden, my access to outpatient 
services was limited.''
    Did you look at that?
    Mr. Bertoni. I can talk a bit about that. I've done a lot 
of work across a lot of different programs, and I can say in 
many respects, the policies and procedures that pertain to the 
Guard and Reserve often do put them potentially at a 
disadvantage. At least there's a belief in many respects. In 
some cases, we've identified that.
    The issue here is when you look at DES, one in four folks 
coming into that system are either a Guard or Reserve Force 
member. A larger portion of our standing military is Guard or 
Reserve.
    I've brought this up in other testimonies, and it might be 
time to start looking at our policies.
    Senator Graham. Colonel Rivas was telling us about 
compensation. He's a reservist. Not 20 years retirement 
eligible. He has to wait until he's 60.
    Mr. Bertoni. There are many issues relating to preexisting 
conditions and how many guardsmen can get caught in that 
situation and be aced out of benefits. I think we have policies 
that were set up when we had this traditional army from many 
years ago, and we're moving to a new force.
    Senator Graham. Do you think both organizations are 
sensitive to the Guard and Reserve dilemma?
    Mr. Bertoni. Yes, I think they are, and in the case of the 
DES, which we have been able to get behind, versus just saying 
there's a policy.
    Senator Graham. One final area, and I'll yield here. Dr. 
Noss was talking about when her husband was Active Duty, that 
when he got out of the Active Duty system, there was a 
limitation on access to therapy. Did you find that when you 
were looking at it, that going from one system to the other all 
of a sudden changed the menu you had to choose from, in terms 
of therapies?
    Mr. Bertoni. No, we didn't look at that specifically. 
Again, we were following the pilot.
    Senator Graham. I think that's what she said. When her 
husband got discharged, some of the therapies that were 
available on Active Duty were not available through the VA 
system. Thank you very much.
    Senator Ben Nelson. Thank you, Senator.
    Senator Begich.
    Senator Begich. Thank you very much, Mr. Chairman. I want 
to follow up on the comment from the lieutenant regarding the 
76 policies. That's the magic number, and they've done 60, 70 
of these, and that you just confirmed that they have the 
policies in place.
    Are you planning, or will you be doing any kind of a 
measurement of the success of these policies, or is there a 
baseline to measure against? In other words, I'm going to speak 
for a moment as a former mayor. When we got audited at times by 
our internal auditor, we'd write a policy. Satisfied, you check 
the box and move on. It's when they came back and said, ``What 
did you do?'' that was more important. So what's the plan? Or 
is there a plan? If there's no plan, do we need to help you get 
a plan on that?
    Mr. Williamson. I mentioned two of the things we're going 
to be doing.
    Senator Begich. I heard those, but on these specific--and 
here's why. I'm walking through the steps, 76 new policies. Of 
those 76 new policies, what Senator Graham was getting at, and 
that is now, there should be some measurable method to 
determine if those polices are working or not. In order to 
determine that, you have to have a baseline to where they are 
on every one of those policies and where they hope to go and if 
they achieve that.
    I understand the other 2 you mentioned, but specifically 
about these 76, who wants to answer? I see Mr. Bertoni.
    Mr. Bertoni. I could talk again about this in terms of the 
disability program. Right now, we have a disability system, the 
current system that nearly all folks are going through. We have 
a pilot that we're looking at right now, 14 locations, on its 
way up to 21 by June. Potential to roll that out worldwide, so 
that is potentially what will be.
    We have been able to look at that pilot. We've been 
tracking that for over a year, looking at many aspects of what 
DOD and VA are trying to do there. In many respects, the 
baseline is, is what is now? What is the current system? What 
is broken? What are they trying to do? How is the pilot 
comparing against that existing system?
    That at least in this example, that's a baseline in many of 
the policies that Randy referred to. Modifications of the 
existing system, and many of the policies that are being folded 
into the pilot. In some ways, we had looked at, got behind the 
implementation and effectiveness of some of these policies, at 
least from the disability standpoint.
    Senator Begich. What I would like to see is graphically, 
what happens? In other words, if the person used to take this 
much time going through the process, how much time does it take 
him now? He used to receive this much service. Now they're 
receiving this much service. That's something that you could 
share at some point, even though it's at a pilot status, of how 
that is?
    Mr. Bertoni. Certainly. The pilot's ongoing, but we issued 
two testimonies and one report on this. Certainly DOD and VA 
are tracking timeliness, transparency, customer satisfaction, 
and measuring it against the existing system. With 14 sites, 
there is some data coming in, and I could say if you looked at 
that data, it tends to be trending pretty well.
    Our concern is that it is fairly early on. Some of the more 
high-risk, more difficult sites won't be rolled out until 
around the time they have to cut off data analysis to begin 
writing the final report. I don't know if you all will have the 
data you're looking for, in terms of the effectiveness of this 
pilot relative to the other system as of August 2009.
    Senator Begich. Let me follow up on the definition issue. 
You mentioned--I don't know who mentioned it--about three-
quarters of the definitions were agreed to, or there's an 
understanding. I'm guessing the last quarter is the tougher 
group. What's the timetable that you think you'll see 
unification of these definitions?
    Mr. Williamson. In terms of when they'll be----
    Senator Begich. When they have agreed on it?
    Mr. Williamson. I don't know. I think that's a good 
question for the next panel. They're the ones doing it.
    Senator Begich. Next panel, be ready. That's the question. 
You might just include it in your opening comments so we 
dispense with it. One other idea I'll just put on the table. 
Again, I don't know all the technical terms, so I apologize, 
and you could clarify them for me. As described by the 
lieutenant, as you're being discharged, there's a process of 
termination, and then there's a process with the VA. Why not 
have one board meeting? Why not just combine them together and 
have one review at the same time, even though there may be 
differences in some of the questioning, allow that to occur, 
and then you're done?
    Mr. Bertoni. Again, it is the DES. That's exactly what the 
pilot is trying to do. Right now, we have a MEB, an informal 
PEB, then the formal PEB, the DOD rating, the decision on 
fitness and unfitness.
    Senator Begich. All at the same time?
    Mr. Bertoni. This is the DOD system. Once that occurs, and 
if the person is found unfit, they'll transition into the 
civilian world. They'll go through another set of reviews for 
VA.
    What the pilot is trying to do is to move the person 
through concurrently in these two systems, have the MEB, the 
PEB, have the VA in there early at the same time doing a 
comprehensive physical exam, issuing a rating the DOD can use 
to make the fit/unfit decision and VA will use to ultimately 
assign a disability rating to the servicemember.
    In this situation, the servicemember is going to know 
pretty much what he or she will receive as soon as he leaves 
the Service. That's the idea, it is to try to compress this and 
make separate situations, processes concurrent.
    Senator Begich. Last question on that. Based on the pilot--
and, again, because I'm new here, I don't know what the 
timetable was. Using just my thinking, it sounds like it's much 
better than the existing system, no matter how you cut it. 
There are jurisdictional issues, but if the goal is to deal 
with the service person as the priority, then the 
jurisdictional issues should go by the wayside.
    Putting that aside for a second, have you or has someone--
and maybe it's the next panel--laid out a strategy or 
timetable, assuming--and that's what I would assume here for a 
moment--pilots are working, when do we see them all up and 
operational, so the old system is gone? Is that the next panel?
    Mr. Bertoni. We have some information on that. I don't know 
that we would say it's much better. I think that the jury's 
out. We have 14 sites. There's limited data that is coming in. 
They haven't stressed the pilot under a range of scenarios that 
they could stress it under. There are a number of different 
bases with different characteristics, and I think they're 
working toward those farther down the line. I do know they'll 
be up to 21, I believe, sites by June 2009. They have to issue 
a final report in August.
    I don't know if they're going to say that at that time, 
that this is ready for further expansion. I think there are 
another seven sites they might roll out in the fall. But a 
timeline for worldwide implementation, I haven't seen anything 
to that effect.
    My concern is that they have all the data, and that this be 
a data-driven decision that they can crank back into any system 
that is proposed.
    Senator Begich. Thank you very much. My time is up. Thank 
you all for your testimony.
    Senator Ben Nelson. Thank you, Senator.
    Senator Hagan.
    Senator Hagan. Mr. Chairman, I'm going to wait for the next 
panel, thank you.
    Senator Ben Nelson. Thank you. We thank the panel for your 
appearance here today, for providing us an update and analysis 
of progress, and we hope that this partnership that you're a 
part of, as well, will continue into the future. Time is 
important, but getting it right is also important. So we thank 
you. Thank you very much.
    On our third panel, we welcome Gail H. McGinn, Deputy Under 
Secretary of Defense for Plans; Ellen P. Embrey, Acting 
Principal Deputy Assistant Secretary of Defense for Health 
Affairs; Roger Dimsdale, Executive Director, VA/DOD 
Collaboration, Office of Policy and Planning for the VA; Major 
General Keith W. Meurlin, United States Air Force, Acting 
Director of the Office of Transition Policy and Care 
Coordination; Rear Admiral Gregory A. Timberlake, United States 
Navy, Acting Director of the Joint DOD/VA IPO; and Dr. Karen 
Guice, Executive Director of the Federal Recovery Coordination 
Program for the VA.
    We have many actings here today because of the change in 
administrations. We're very fortunate to have your testimony, 
because each of you has played an integral role in developing 
and implementing these wounded warrior policies. We're 
obviously counting on you to give us your honest assessment of 
the work that the departments have completed, as well as areas 
where problems remain, and work also remains.
    We look forward to your statements. Ms. McGinn, if you 
would like to begin.

STATEMENT OF GAIL H. McGINN, DEPUTY UNDER SECRETARY OF DEFENSE 
                FOR PLANS, DEPARTMENT OF DEFENSE

    Ms. McGinn. Thank you, Mr. Chairman, Senator Graham, 
members of the subcommittee. I'm pleased to be with you today 
to discuss DOD's ongoing effort in collaboration with VA to 
support America's wounded warriors and their families. I will 
be addressing the organization DOD has put in place to continue 
building on the partnership between our two agencies.
    DOD has made, in my estimation, an extraordinary 
organizational commitment to sustaining and enhancing our 
structures for continued progress on this front. Two years ago, 
when events brought to light the need for focus on wounded 
warrior support, the departments moved quickly to put an 
organizational structure in place to staff the SOC in its 
decisionmaking and oversight role.
    Because we needed to move quickly, the structure was of 
necessity ad hoc, comprised of borrowed executives, civilian 
detailees, borrowed military manpower, and contractors. DOD is 
now replacing this ad hoc staff with permanent employees, 
including the dedication of three senior executive resources, 
and over 50 permanent traditional positions.
    These are in addition to the resources dedicated to the 
IPO. Our new structure creates a Director of Transition Policy 
and Care Coordination and an Office of Strategic Planning and 
Performance Management, encompassing an executive secretariat 
for managing SOC and JEC matters. This structure continues the 
work of the prior organization.
    The lines of action continue. Transferred to permanent 
executives and the functions of a previous senior oversight 
staff office transferred to the executive secretariat. This 
organization has several important features.
    First, it solves an organizational issue. There was 
previously no senior executive charged exclusively with working 
with VA to achieve a seamless transition for our 
servicemembers, and now there will be.
    It enhances our role with the JEC and the development of 
the Joint Strategic Plan to drive the improvement and benefits 
and healthcare for all veterans, in addition to continuing the 
extraordinary efforts in support of the wounded warrior.
    These offices of DOD are co-located with the VA office, a 
VA/DOD co-location to ensure day-to-day collaboration. In fact, 
they recently moved to new permanent office space.
    I've worked for DOD for decades, and I've never seen faster 
and more committed progress than that embodied in the 
accomplishments of the SOC as it addressed the various 
recommendations of numerous studies and commissions and the 
challenges given to us by your congressional action.
    The DES pilot, the revolution in care coordination and 
customer care, advances in responding to TBI and PTSD, and 
progress and sharing of electronic information. This is not all 
of it, but it is impressive. My colleagues will speak to these 
and other accomplishments in more detail.
    But as you've heard in the first panel, our work on behalf 
of the wounded warrior is not done. As the GAO representative 
noted, we are creating new organizations. We are completing our 
hires and we will ensure that our processes, their 
collaboration with VA, and for integration into the priority 
work of DOD are accomplished.
    We will establish metrics and evaluation processes to make 
sure our focus is steady and to make sure that we can see where 
our policies and practices may break down now that we've 
started to implement them so that we can find the gaps and fix 
them.
    We will continuously review program implementation to find 
those policy and program gaps. We will integrate the strategic 
planning for support of the wounded warrior into the overall 
plans of the Under Secretary of Defense for Personnel and 
Readiness so that all of these plans are embedded in the 
essence of what we do every day in Personnel and Readiness.
    We will continue to review the support systems for the 
wounded and also for their families and loved ones, and 
continue our focus on customer care. We will continue our 
emphasis on mental health and the need for psychological 
fitness.
    The commitment of our leadership is unwavering. As noted, 
Secretary Gates and Secretary Shinseki chaired the SOC during 
the transition so that we could continue the momentum. 
Yesterday, Deputy Secretary Lynn and Deputy Secretary Gould 
from VA co-chaired their first SOC and made a commitment to go 
forward on behalf of wounded warriors.
    Mr. Chairman and members of this subcommittee, we thank you 
for your continuing support as we strive to work with you to 
provide the best possible care and opportunities for our heroic 
wounded warriors and their families. Thank you.
    [The prepared statement of Ms. McGinn follows:]
                  Prepared Statement by Gail H. McGinn
    Mr. Chairman, and members of the subcommittee, it is my pleasure to 
be here today to discuss with you the Department's ongoing aggressive 
support of programs for our wounded, ill, and injured servicemembers, 
veterans and their families. Secretary Gates has affirmed that next to 
the war itself, support for our wounded, ill, and injured is the 
Department's highest priority. We have made a lot of progress in the 
last 2 years, but our work is not done. We very much appreciate your 
support of our ongoing efforts.
    I'm here today to relate the Department's recent establishment of a 
capability to permanently sustain enhanced joint oversight and 
management of wounded warrior matters and to continue supporting 
operations of the Department of Defense (DOD)/Department of Veterans 
Affairs (VA) Senior Oversight Committee (SOC). Let me first provide 
some background to talk about how we organized initially, and then I 
will turn to our new alignment, designed to institutionalize and enrich 
our oversight and management of wounded warrior matters.
                               background
Senior Oversight Committee:
    In the spring 2007, Secretary Gates requested an oversight 
committee of senior military and civilian officials be created to make 
certain that recommendations and mandates from a number of sources, 
including a Presidential Commission, and legislation were addressed. As 
a result, the SOC for the Wounded, Ill, and Injured (WII) was 
established. The SOC is co-chaired by the Deputy Secretary of Defense 
and Deputy Secretary of Veterans Affairs, and brings together on a 
regular basis the most senior decisionmakers from both Departments to 
ensure timely decisions and actions. The SOC is the main decision body 
for oversight, strategy, and integration of proposed measures for DOD 
and VA efforts to improve seamlessness across an injured 
servicemember's recovery, rehabilitation, and reintegration continuum.
    The two Departments and the SOC have been in the process of 
implementing more than 600 recommendations from 6 major studies and the 
National Defense Authorization Acts for Fiscal Year 2008 and Fiscal 
Year 2009. My colleagues will discuss specific accomplishments, but the 
initiatives to accomplish these requirements fit within a context of 
the following fundamental changes:

         Increasing collaboration between DOD and VA on issues 
        to deliver a world class continuum of care for our WII.
         Revamping the approach to care and case management, 
        and fully embracing a customer-centered process that includes 
        involvement of the family and caregivers through the use of the 
        Recovery Care Program and the Federal Recovery Coordination 
        Program.
         Increasing the sharing of medical and beneficiary 
        information between DOD and VA.
         Recognizing psychological fitness is as important as 
        physical fitness.
Overarching Integrated Product Team:
    The SOC established an Overarching Integrated Product Team (OIPT) 
to closely track and coordinate recommendations from studies and 
reports for successful implementation of appropriate support and care 
for WII servicemembers. The OIPT reports directly to the SOC and is 
responsible for coordinating, integrating, and synchronizing actions. 
The OIPT's mission is to:

         Act as the primary DOD and VA coordinating and 
        functioning agent for all recommendations from reports by 
        commissions, task forces, congressional studies, and NDAA 
        mandates.
         Coordinate analysis and review of recommendations and 
        mandates, and present consolidated decision packages to the 
        SOC.
         Refine strategic program guidance and joint planning 
        objectives in conjunction with the Joint Strategic Plan of the 
        Joint Executive Council (JEC).
         Approve plans, timelines, and proposed actions, and 
        report these to the SOC.
         Maintain close coordination, and integration where 
        possible, with the military Services, Joint Staff, and all 
        pertinent Federal departments/agencies with respect to their 
        efforts to improve care and benefits for WII servicemembers and 
        their families.
         Coordinate public relations and communications efforts 
        internal to DOD and VA and external with outside departments/
        agencies, Congress, veterans support organizations, the media, 
        and the public.
         Review legislation for actionable and/or reportable 
        items.
         Maintain an electronic database for the complete 
        tracking of actionable items.
         Recommend resourcing solutions.
Lines of Actions:
    To organize for responsibility and accountability, the SOC 
established eight lines of action (LoAs) and assigned the 
recommendations and mandates consistent with the LoAs missions, which 
are as follows:

          Line of Action 1: Disability Evaluation System. Develop and 
        establish one solution for a DOD and VA Disability Evaluation 
        System using one integrated disability rating system that is 
        seamless, transparent, and administered jointly by both 
        Departments. That system must remain flexible to evolve and 
        update as trends in injuries and supporting medical 
        documentation and treatment necessitates. Streamline the 
        transition process for the servicemember separating from DOD 
        and entering the VA system of benefits.
          Line of Action 2: Traumatic Brain Injury (TBI) and Post 
        Traumatic Stress Disorder (PTSD). Address improvements in 
        consistency and capability surrounding TBI and psychological 
        health (PH) across the full continuum of care within DOD and 
        VA. The effort has been on the collaborative development and 
        continuous improvement of servicemember/veteran-focused 
        programs dedicated to TBI and PH prevention, protection, 
        identification, diagnosis, treatment, recovery, research, and 
        rehabilitation.
          Line of Action 3: Case and Care Management. Coordinate 
        medical and nonmedical care, rehabilitation, benefits, and 
        delivery of services and support that will effectively guide 
        and facilitate servicemembers, veterans, their families, and 
        caregivers throughout the entire continuum of care.
          Line of Action 4: DOD/VA Data Sharing. Ensure appropriate 
        demographic, personnel, and medical information on 
        servicemembers, veterans, and their family members is visible, 
        accessible, and understandable through secure and interoperable 
        DOD and VA information management systems.
          Line of Action 5: Facilities. Ensure facilities are provided 
        that deliver the care servicemembers and veterans have earned 
        and deserve. In accordance with existing laws and regulations, 
        establish standards for the inspection of quarters used by WII 
        servicemembers; conduct an assessment of the existing DOD 
        medical support infrastructure; and summarize inspection 
        results to Congress. Finally, examine the process of 
        establishing and maintaining medical facility design criteria 
        and make recommendations for improvement.
          Line of Action 6: Clean Sheet Review. Provide WII 
        servicemembers and their families the best quality care with a 
        compassionate, fair, timely, and non-adversarial disability 
        adjudication process. An ideal process will be developed for 
        providing care and benefits to WII servicemembers, veterans, 
        and their families. The ideal process will not be constrained 
        by current laws, policies, regulations, organizations, 
        infrastructure, or resources.
          Line of Action 7: Comprehensive Legislation and Public 
        Affairs. Coordinate the development of comprehensive 
        legislation that will provide the best possible care and 
        treatment for WII servicemembers and their families. 
        Additionally, keep the public informed of significant 
        accomplishments and events.
          Line of Action 8: Personnel, Pay, and Financial Support. 
        Ensure each seriously wounded, ill, or injured servicemember 
        has a level of compensation, benefits, and financial support to 
        maintain their dignity and support their recovery, 
        rehabilitation, and reintegration.
Wounded, Ill, and Injured Senior Oversight Committee (WII SOC Staff 
        Office)
    Given the scope and magnitude of the issues addressed and the 
complexity of integrating recommendations within DOD and VA, the SOC 
directed the creation of a full time joint-departmental support staff. 
In the interest of time, the WII SOC Staff Office was staffed with 
civilian detailees from both DOD and VA, borrowed military manpower, 
and contractor personnel. It was led by a senior executive detailed 
from the Department of the Army and a VA detailed senior executive as 
the Chief of Staff. The WII SOC Staff Office provided assistance, 
advice, and expertise to facilitate changes to policies, procedures, or 
legislation so that all recommendations relative to the recovery, 
rehabilitation, and reintegration of WII servicemembers and their 
families were effectively and efficiently resolved or addressed. The 
Staff Office served as the integration focal point to both the SOC and 
OIPT and tracked the actions overseen by the SOC. The Staff Office was 
charged with providing senior level review and advising the SOC on the 
progress of the WII program. The SOC delegated authority to the Staff 
Office to task deliverables directly to the LoA representatives to 
ensure SOC requirements were met. Within the Staff Office, a group of 
DOD and VA personnel jointly served as points-of-contact within the 
eight LoAs. In this role, LoA liaisons were responsible for 
facilitating communication between their LoA and the Staff Office. 
While the Staff Office served as the administrative body facilitating 
the efforts of the LOAs and ensuring milestones were met, the 
substantive work assigned by the SOC was accomplished by the LOAs.
LOA Assignments/Staffing:
    When we initially categorized the recommendations to be addressed 
within the LoAs, we assigned LOA lead responsibilities to senior 
Department officials who, along with VA co-leads, energized their 
staffs to meet the requirements of SOC-assignments. In some cases, 
lines of action responsibilities were not clearly in any particular 
senior official's portfolio, but implementing the recommendations 
became a Department priority so we made the best functional fit 
possible. For instance, LoAs 1, 3 and 8 were assigned to senior 
officials in the Office of the Secretary of Defense, Navy, and Air 
Force, respectively, none of whom had complete Department 
responsibilities beforehand for oversight and management of WII SOC 
recommendations assigned in these LoAs.
    As with the WII SOC Staff Office, in many cases, staffing this 
newly created organization to support the SOC required detailing 
military and civilian help to LOA leads. Of course, the offices from 
which these detailees came have had to adjust work and resources 
accordingly.
The Joint Executive Council
    The SOC and its supporting structure were designed to focus on the 
elimination of deficiencies in the wounded warrior continuum of care. 
The JEC drives the entire panoply of DOD/VA interagency strategy and 
policy interactions. It has been co-chaired by the Deputy Secretary of 
the Department of Veterans Affairs and the Under Secretary of Defense 
for Personnel and Readiness. It oversees the efforts of a Health 
Executive Council, Benefits Executive Council and Interagency Program 
Office and all other councils or work groups designated by the co-
chairs. The JEC works to remove barriers and challenges which impede 
DOD and VA collaborative efforts, asserts and supports mutually 
beneficial opportunities to improve all business practices, ensures 
high quality cost effective services for both DOD and VA beneficiaries, 
and facilitates opportunities to improve resource utilization. All this 
is spear-headed and monitored through a joint strategic planning 
process that results in recommendations to the Secretaries on the 
strategic direction for the joint coordination and sharing efforts 
between and within the two Departments for all overlapping matters. 
This year, we ensured that the SOC actions and milestones were laid 
into the JEC Strategic Plan.
                  establishing permanent organizations
    After almost 2 years of SOC operations and achieving what we 
believe are significant positive outcomes, it became evident that to 
further enrich oversight and management of this priority mission and to 
posture the Department for sustaining this level of support to our WII 
servicemembers and their families, a permanent structure was needed. 
The Department did not have full-time executive leaders dedicated to 
DOD/VA collaboration and transition. In order to improve on the 
integration of DOD and VA into a single team to address wounded warrior 
needs as well as the integration of these issues into the management 
framework of the Under Secretary for Personnel and Readiness, the 
Department has created two new permanent offices in DOD. We believe 
that establishing these two offices will keep support of the wounded 
warrior at the forefront in our daily efforts and priorities and give 
us greater ability to improve the continuum of care with VA for all 
servicemembers. Additionally, further teaming with our colleagues, 
we've co-located our two new offices with their VA counterpart 
liaisons, thereby enhancing our synergistic efforts.
Transition Policy and Care Coordination Office
    The Under Secretary of Defense for Personnel and Readiness 
established late last year the Office of Transition Policy and Care 
Coordination (TPCC). Maj. Gen. Keith Meurlin, USAF, was appointed 
Acting Director. The TPCC assumed responsibility for policy and 
programs related to disability systems, servicemember transition to 
veteran status, separations from the Armed Forces, case and care 
coordination, and pay and benefits entitlements for wounded, ill, and 
injured servicemembers, veterans and their families. These assigned 
responsibilities include the totality of functions assigned to SOC LoAs 
1, 3 and 8, which were originally assigned to Deputy Under Secretary of 
Defense for Military Personnel Policy, the Deputy Assistant Secretary 
of the Navy for Military Personnel Policy, and the Deputy Assistant 
Secretary of the Air Force for Force Management and Integration, 
respectively. Additionally, subsets of other responsibilities formerly 
assigned to Deputy Under Secretaries for Military Personnel Policy and 
Military Community and Family Policy are now included in the TPCC's 
portfolio. TPCC assumed responsibility for management and monitoring of 
performance against DOD/VA Benefits Executive Council (BEC) goals and 
for coordinating with VA in support of BEC activities. Additionally, 
TPCC has the authority to enter into agreements, within the scope of 
assigned responsibilities, with VA and represent OUSD (P&R) as a member 
on councils and interagency forums established under the authority of 
the DOD/VA JEC, the BEC and the SOC. The TPCC is up and running and 
keeping pace with meeting SOC, JEC and BEC requirements. Staffing 
military and government civilian positions is ongoing, expecting full 
staff to be in place by the end of this calendar year. Thirty-eight 
personnel will be reassigned or hired to accomplish these duties.
Office of Strategic Planning and Performance Management/Executive 
        Secretariat to the SOC/JEC
    At the same time the TPCC was formed, the Office of Strategic 
Planning and Performance Management/Executive Secretariat to the SOC/
JEC was established. Mr. Clarence Johnson, a Senior Executive 
Servicemember, was appointed Acting Director. The Executive 
Secretariat, which aligned some DOD staff--mostly temporary contractor 
or military--from the WII SOC Staff Office, is up and running as well. 
We expect to hire a permanent Senior Executive Service Director and the 
office should be fully staffed by the end of this year. We are adding 
14 full time permanent personnel to support this function. This office 
has many of the responsibilities formerly accomplished by the WII SOC 
Staff Office, including tracking progress of SOC-directed actions (LOA 
liaison responsibility as before remains); tracking the status and 
accomplishment of the more than 600 actions embraced by the two 
Departments; and in collaboration with VA counterparts, establishing 
SOC and JEC agendas, scheduling SOC, OIPT and JEC meetings and 
supporting the oversight functions of the SOC, OIPT and JEC. 
Additionally, this Office has broadened responsibility to provide the 
planning and management function for DOD's involvement in the Joint 
Executive Council, including the Department's role in the development 
of the JEC Joint Strategic Plan and ensuring the accomplishment of 
actions identified in that plan. Finally, this Office has 
responsibility for ensuring the integration of these plans and actions 
into the structure of the Under Secretary of Defense for Personnel and 
Readiness strategic planning and performance management processes. The 
Executive Secretariat reports to the Deputy Under Secretary of Defense 
for Plans.
                  other realignment notes and closing
    I earlier spoke about the alignment of LoAs from the initial SOC 
support structure to the permanent structure. I indicated that LoAs 1, 
3, and 8 were aligned from disparate owners to the TPCC. With the 
exception of LOA 6 whose work has been completed, the other LOAs 
remained in place with their missions held constant and their 
responsibilities captured in SOC LOA assignments.
    From the SOC perspective, LOA 4 issues continue to be administered 
with representatives from DOD and VA. From the JEC standpoint, 
electronic media was highlighted as outlined in Public Law 110-181--
fiscal year 2008, National Defense Authorization Act, Section 1635, 
with the establishment of the Interagency Program Office (IPO) to focus 
the integration of electronic health information for the DOD and VA. 
Rear Admiral Gregory Timberlake has been assigned as the acting 
Director with a permanent Senior Executive Service solution being 
pursued and the Deputy position is planned to be filled by a VA Senior 
Executive Service employee.
    As we sustain and enrich our support to the wounded warrior, we aim 
to continue to build upon the partnership with VA to jointly tackle 
major issues that emerge in the transition of our servicemembers from 
active duty to veteran status. Our new structure actually streamlines 
our processes for DOD/VA collaboration, and progress continues.
    Under this new alignment, the SOC has met twice and dealt with very 
substantive issues. Our two cabinet secretaries chaired a SOC in 
February. The OIPT continues to meet frequently, bringing key issues to 
discuss and prepare for the SOC forum and reporting on SOC milestones 
and achievements. In the future our collaboration should be enhanced 
through the increased focus on the JEC, made possible by our new 
organizational structure, and by implementation of a new concept--a 
Principals' JEC, which would be chaired by our two Secretaries when the 
business of the JEC requires their personal involvement.
    While we are pleased with the quality of effort and progress made, 
we fully understand that there is much more to be done. We believe we 
have, thus, postured ourselves to continue providing world-class 
support to our warriors and veterans while allowing us to focus on our 
respective core missions. Our dedicated, selfless servicemembers, 
veterans and their families deserve the very best, and we pledge to 
give our very best during their recovery, rehabilitation and return to 
duty or to the society they chose to defend.
    Thank you for your generous support of our wounded, ill, and 
injured servicemembers, veterans, and their families. I look forward to 
your questions.

    Senator Ben Nelson. Thank you.
    Ms. Embrey?

STATEMENT OF ELLEN P. EMBREY, ACTING PRINCIPAL DEPUTY ASSISTANT 
            SECRETARY OF DEFENSE FOR HEALTH AFFAIRS

    Ms. Embrey. Mr. Chairman, Senator Graham, members of the 
subcommittee, thank you again for the opportunity to discuss 
what DOD is doing to improve the quality of care for our 
wounded warriors with respect to psychological health needs and 
TBI.
    I'm very pleased to be here. It has been my great honor and 
responsibility over the last 2 years to be the DOD lead in 
partnership with my counterparts in the VA, Dr. Lou Beck and 
Dr. Ira Katz, to address the work of line of action 2, which 
focuses on achieving improvements and help outcomes associated 
with psychological health, PTSD, and TBI.
    Today I also briefly discussed the role of my office in 
overseeing the health-related aspects of line of action 4, 
which focused over the last 2 years on DOD/VA sharing of 
information technology and information.
    Regarding line of action 2, the Department is committed to 
ensuring that all servicemembers, especially those with mental 
health and TBIs, receive consistently excellent care across the 
entire care continuum. For both psychological health and TBI, 
our focus has been on building and sustaining physical and 
mental resilience and improving the quality and consistency of 
prevention, protection, diagnosis, treatment, recovery, and 
transition programs for both DOD and VA.
    For TBI, this also includes a significant emphasis on 
research to clarify and improve clinical diagnostic treatment 
and rehabilitation technologies and therapies, especially for 
mild TBI, known as concussion, but also moderate, severe, and 
penetrating TBIs.
    While DOD has been actively expanding and implementing 
programs on psychological health and TBI, we also have been 
working to evolve and expand the sharing of medical and 
beneficiary data as directed by line of action 4. This 
collaboration has ensured that information is viewable, 
accessible, and understandable through secure and interoperable 
information systems and greatly advanced the electronic sharing 
of benefit, personnel, and health information between the two 
agencies over the last several years.
    Details of these efforts have been included in my submitted 
testimony for the record. I would also like to add that 
recently, we have refocused our efforts to commit to build a 
virtual lifetime electronic record to ensure health and benefit 
information is available in either system to support the 
servicemember, veteran, and their families at any time, from 
the point of accession to burial.
    Mr. Chairman, DOD greatly appreciates the committee's 
strong support and the concern that you have shown for their 
health and well-being. I stand ready to answer your questions.
    [The prepared statement of Ms. Embrey follows:]
                 Prepared Statement by Ellen P. Embrey
    Chairman Nelson and distinguished members of the committee, thank 
you for the opportunity to bring you up to date on what the Department 
of Defense (DOD) is doing to improve the quality of care for our 
wounded warriors with psychological health needs and traumatic brain 
injuries (TBIs). I am pleased to be here.
    From other witnesses today, you have heard how DOD has organized to 
address the many recommendations offered to improve care for our 
wounded warriors. I have had the great honor and responsibility to 
lead, in partnership with my counterparts in the Department of Veterans 
Affairs (VA), the work of Line of Action 2, which focused on the 
recommendations related to psychological health, including post-
traumatic stress disorder (PTSD), and TBI. In addition, because I have 
assumed responsibilities as the acting Principal Deputy Assistant for 
Health Affairs, I have added oversight of health-related actions of 
Line of Action 4, DOD/VA Data Sharing Information Technology. Ms. Norma 
St. Claire, the Director of the Joint Requirements and Integration 
Office, is the DOD co-lead for DOD's personnel and benefits related 
LOA4 actions.
    The DOD is committed to ensuring that all servicemembers, but 
especially those with psychological health needs or TBIs, consistently 
receive excellent care across the entire medical continuum. For TBI, 
this continuum includes diagnostic categories from mild TBI (also known 
as concussion) to moderate, severe, and penetrating TBI, including 
those with the most severe head injuries. For both psychological health 
issues and TBI, the continuum of care includes prevention, protection, 
diagnosis, treatment, recovery, and transition from DOD to VA.
    In 2007, the Department embarked upon a comprehensive plan to 
transform our system of care for psychological health and TBI. The plan 
was based on seven strategic goals:

         Building a strong culture of health leadership and 
        advocacy;
         Improving the quality and consistency of care, across 
        the country and around the world;
         Creating easy and timely access to care, regardless of 
        patient location;
         Strengthening individual and family health, wellness, 
        and resilience;
         Ensuring early identification and intervention for 
        individual conditions and concerns;
         Eliminating gaps in care for patients in transition; 
        and
         Building a network to leverage and/or direct medical 
        and cross-functional research, including new and innovative 
        treatments, technologies, and alternative medicine techniques.

    Throughout 2008, we made significant progress toward achieving 
those goals, and I would like to tell you, briefly, where we are on 
each of them.
                        leadership and advocacy
    In November 2007, we established the Defense Centers of Excellence 
for Psychological Health and Traumatic Brain Injury (DCoE). In 
partnership with VA, academia, and others, the DCoE will lead the 
effort to develop excellence in prevention, diagnosis, practice 
standards, training, outreach, and direct care for those with TBI and 
psychological heath conditions, and provide the nexus for research 
planning and monitoring.
    Since its inception, the DCoE has focused its efforts on the 
development and continuous improvement of a patient-centered network 
dedicated to all issues related to psychological health and TBI.
                     improving the quality of care
    To improve the quality and consistency of mental health care, DOD 
and VA continue our longstanding effort to develop and update clinical 
standards and guidelines, which incorporate lessons learned and best 
practices, and establish evidence-based care as the enterprise standard 
for acute stress disorder, PTSD, depression, and substance use 
disorders.
    Over the past year, the Clinical Practice Guideline for depression 
has been updated and entered into the final stages of revision, and 
revisions to the Guideline on PTSD have been initiated based on 
emerging best practices. DOD purchased clinical tools and equipment to 
fully enable our clinicians to provide state-of-the-art care. For 
example, we have accelerated the purchase of imaging equipment at 
medical centers with high concentrations of patients with TBI.
    The DOD introduced an evaluation tool, the Military Acute 
Concussion Evaluation tool, to assess the likelihood of mild TBI, and 
we published clinical guidelines for its management in operational 
settings. We initiated a certification process for multi-disciplinary 
teams delivery TBI care in medical treatment facilities, and worked 
with the United States Central Command to standardize the decision 
process for determining when to return a servicemember to full duty or 
to the United States for further treatment.
    The Department joined with VA to implement a standardized training 
curriculum on evidence-based psychotherapy for PTSD. To date, the 
DCoE's Center for Deployment Psychology alone, or in partnership with 
other organizations (e.g., Services, MTFs, VA), has trained 1,634 
providers from DOD, Federal agencies, and the civilian sector in the 
use of evidence-based treatments for PTSD (specifically Prolonged 
Exposure and Cognitive Processing Therapy). Similarly, the DCoE's 
operational arm for TBI (the Defense and Veterans Brain Injury Center), 
supported by VA, has trained more than 1,600 medical providers on 
evidence- and consensus-based treatments.
    To recognize the challenging diagnoses, and unique requirements, 
that can accompany psychological health and TBI wounds, the DCoE worked 
with the Intrepid Fallen Heroes Foundation to design and begin 
construction of a new facility, the National Intrepid Center of 
Excellence.
    The new center will provide an interdisciplinary team of clinicians 
and scientists dedicated to a holistic evaluation and treatment 
approach for servicemembers with mental health and TBI conditions, and 
it will provide advanced diagnostics and comprehensive treatment 
planning for those whose mental health conditions or TBIs are not 
responding to traditional methods. When the new center is complete, we 
expect that there will be no finer care available in the country, or 
perhaps the world, for wounded warriors with these conditions.
    In a similar manner, the DCoE, the National Institutes of Health 
Office of Research on Women's Health, and VA cosponsored a meeting, in 
October 2008, to identify and explore the existing science on trauma 
spectrum disorders (such as PTSD and TBI) related to military 
deployment and, for the first time, addressed the question of how 
personal differences may impact an individual's response to treatment. 
We are continuing to work together to further examine outcomes 
associated with these different treatment modalities.
    In January 2009, also for the first time, DOD and VA co-sponsored a 
conference on suicide prevention entitled, ``Building Community 
Connections: Suicide Prevention for the 21st Century,'' to foster 
partnerships between suicide prevention experts in government, 
medicine, and communities. The conference, which featured a wide range 
of speakers including psychological health experts, not-for-profit 
organizations, community leaders, survivors, mental health specialists, 
and chaplains, focused on four tracks: Clinical Intervention, A Multi-
Disciplinary Approach, Practical Applications and Tools, and Research 
and Academics.
                        improving access to care
    To improve access to mental health care, regardless of location, we 
funded the hiring of additional mental health and other specialty 
providers by the Services, and implemented a policy that requires first 
appointment access within 7 days for mental health concerns.
    DCoE is leading efforts to standardize DOD telehealth services for 
psychological health and TBI including the establishment of a Federal 
Partners Exploratory Committee on telemental health. The Center is 
working with the MHS' Office of the Chief Medical Officer to define 
telemental health as a standard of care. Leveraging the capabilities of 
the Services, TRICARE, and civilian providers, DCoE had recently begun 
serving as a coordinating and resource center for an emerging 
telehealth network of systems across DOD. Efforts are focused on 
establishing a collaborative network to rural and underserved locations 
by connecting various rural patients with treatment facilities via 
telehealth technologies, including web-based applications.
              strengthening resilience and reducing stigma
    To strengthen resilience to psychological stress and traumatic 
events, the Department is implementing solid prevention and health 
protection policies, including removing or mitigating organizational 
risk factors, bolstering resilience characteristics in our Service 
personnel, and strengthening family wellness.
    To reduce the stigma associated with mental health issues, the 
Department is mounting a pro-resilience and anti-stigma campaign, and 
has established a number of effective outreach and educational 
initiatives. For example, we gained line leadership support for the 
effort to increase psychological fitness through resilience-building 
programs. We also eliminated the requirement to divulge combat-related 
mental health history on security clearance forms.
    In November, 2008, with the assistance of the Service Vice Chiefs, 
DCoE began development of the ``Real Warriors, Real Battles, Real 
Strength'' campaign, which stresses the impact of war on servicemembers 
and emphasizes that seeking help for psychological concerns is a sign 
of strength. Supporting initiatives already have been implemented 
across the Services to target their individual cultures. The DOD-wide 
campaign is scheduled to begin in April 2009.
    The DCoE also helped develop educational tools, including a project 
with the nonprofit organization behind ``Sesame Street,'' to produce 
more than 700,000 DVDs to help families, and especially children, cope 
with deployed parents or loved ones. To date, more than 350,000 of 
these DVDs have been distributed.
    One exciting initiative in this area is ``SimCoach,'' a program 
currently under development that will allow warriors and families to 
electronically query top experts in psychological health and TBI, and 
discuss their injuries with their peers.
    Specifically targeted to the Armed Forces younger population, 
SimCoach will combine the best of simulation, advanced gaming 
technology, artificial intelligence, and avatar-based computer 
interaction to encourage warriors and their families to initiate 
treatment or access educational resources. It will also reduce the 
stigma associated with seeking psychological health care.
                   caring for patients in transition
    The DOD is working with its Federal and private sector partners to 
eliminate gaps in care as patients transition through the various 
health systems, or to different duty locations. For example, we 
recently established an assisted living pilot program in Johnstown, PA, 
to improve functionality and independent living after TBI. This program 
will provide valuable insight for replication in other areas where 
appropriate. We also provided significant support to DOD/VA efforts to 
establish the Federal Care Coordination program and stood up a TBI care 
coordination system to integrate Federal, State, and local resources.
                       screening and surveillance
    To ensure early identification and intervention of mental health 
and TBI issues, the Department enhanced post-deployment assessments and 
reassessments. Additionally, in July 2008, the Department began 
conducting baseline neuro-cognitive assessments on Active and Reserve 
personnel prior to deployment. To facilitate the continuity of care for 
veterans and servicemembers, we implemented a common DOD/VA post-
deployment TBI assessment protocol, which will allow clinicians, across 
the enterprise, to collect and access the same information.
    We designed and implemented the Mental Health Self Assessment 
Program, which offers Service personnel and their families the 
opportunity to identify their own symptoms and access assistance before 
a problem becomes serious. The self-assessments address PTSD, 
depression, generalized anxiety disorder, alcohol use, and bipolar 
disorder, and may be taken anonymously online, over the phone, or at 
special events held at installations. After completing a self-
assessment, individuals receive referral information that includes 
services provided by TRICARE, Military OneSource, and VA Vet Centers.
                 medical and cross-functional research
    The Department is building a network in which to leverage and 
direct medical and cross-functional research that will enhance 
prevention, detection, diagnosis, and treatment of combat-related 
psychological health and TBI issues. For example, with the support of 
the Service Vice Chiefs of Staff and the Surgeons General, DCoE is 
sponsoring an expedited, intramural (DOD facilities), multi-center 
randomized clinical trial of hyperbaric oxygen (HBO2) therapy for 
chronic and mild-to-moderate TBI patients.
    The study, which is in the advanced development phase, will answer 
important questions regarding efficacy in this population, including 
whether HBO2 therapy should be provided to servicemembers when 
indicated. Currently, the study is awaiting Investigational New Drug 
registration by the Food and Drug Administration (FDA). Once FDA 
approval is obtained, we expect the study to be completed in about 18 
months.
    The DCoE also participated in blast mitigation studies through and 
with the United States Army Medical Research and Materiel Command, and 
is working with external groups, such research universities as the 
Massachusetts Institute of Technology and Virginia Tech and the 
National Football League, to explore new ways to mitigate the effect of 
blast and blunt trauma on our populations.
    Together with ongoing research activities supported by the Joint 
Improvised Explosive Device Defeat Organization, and the Institute of 
Soldier Nanotechnology, we have learned a great deal about how to keep 
our servicemembers safe before, during, and after physically traumatic 
events.
    In addition, we initiated numerous research projects to enhance the 
diagnosis and treatment of TBI and mental health conditions. Indeed, 
thanks to the tremendous support of Congress, DOD is now one of the 
world's leading sponsors of such research. The Department has initiated 
research projects across the continuum of care to further science in 
the areas of TBI and psychological health, including:

         Basic research directed toward gaining greater 
        understanding of the brain and how it works;
         Applied research to provide more in-depth knowledge of 
        TBI and psychological health prevention, treatment, diagnosis, 
        and recovery techniques;
         Advanced technology development to create new tools, 
        technologies, pharmaceuticals and devices, and treatment 
        protocols to improve prevention, diagnosis, treatment, and 
        recovery;
         Clinical trials to demonstrate the safety, toxicity, 
        and efficacy of candidate pharmaceuticals, prototype medical 
        devices, or protocols benefiting patients diagnosed with TBI or 
        mental health conditions; and
         Complementary and alternative medicine approaches to 
        the treatment of PTSD and TBI, such as yoga or acupuncture.
                          dod/va data sharing
     While Line of Action 2 was actively expanding and implementing 
programs on psychological health and TBI, Line of Action 4 was working 
closely with our VA partners to evolve and expand the appropriate 
sharing of medical and beneficiary data between DOD and VA. We have 
worked closely with multiple program offices in both Departments, as 
well as the DOD/VA Interagency Program Office, to ensure that 
information is viewable, accessible, and understandable through secure 
and interoperable information management systems
    We have made great strides forward in the electronic sharing of 
benefits, personnel, and health information between DOD and VA during 
the past few years. Intensive planning and collaboration regarding 
health, personnel, and administrative DOD/VA electronic data exchange 
continue to enhance the support we provide for our wounded, ill, or 
injured servicemembers and veterans. Key LOA4 health data sharing 
accomplishments since February 2007 include the following:

         Initiated electronic transmissions of DOD digital 
        radiographs and scanned medical records from three major DOD 
        Medical Centers to four VA Polytrauma Centers;
         Increased data sharing between DOD and VA from a few 
        DOD sites before July 2007 to all DOD sites today;
         Added procedures, inpatient discharge summaries, 
        Theater clinical data, vital signs, family history, social 
        history, other history, and questionnaires to the data already 
        available between DOD and VA for shared patients;
         Established the DOD-VA Interagency Clinical 
        Informatics Board to give clinicians a direct voice in the 
        prioritization of enhanced health information sharing 
        capabilities that will enhance care delivery for common 
        beneficiaries treated by DOD and VA;
         Increased the availability of inpatient discharge 
        summaries shared with VA from 7 percent of DOD inpatient beds 
        to over 50 percent;
         Enabled the exchange of computable outpatient pharmacy 
        and medication allergy data at all DOD sites; and
         Began implementation activities to support National 
        Guard and Reserve component remote access to AHLTA, DOD's 
        electronic medical record.

    We are committed to continue to evolve and expand the appropriate 
electronic sharing of health, personnel, and benefits information to 
enhance care delivery and continuity of care for shared patients. In 
fact, current health information exchange capabilities between the 
Departments are well ahead of those in the private sector both in scope 
and scale. The current level of sharing has built a strong foundation 
for information interoperability needed to achieve our shared vision. 
Today, this shared information supports the delivery of high-quality 
healthcare and the administration of benefits to our servicemembers and 
veterans. With joint leadership, DOD and VA continue to develop and 
implement numerous interoperability initiatives. We are delivering 
information technology solutions that significantly improve the secure 
sharing of appropriate electronic health, personnel, and benefits 
information for our shared beneficiaries and support continuity of care 
for servicemembers transitioning to veteran status.
    Another witness, RADM Gregory Timberlake, will provide more 
information on the Interagency Program Office, which oversees the 
development and implementation of electronic health record systems or 
capabilities that allow for full interoperability of personal health 
care information between DOD and VA.
                               conclusion
    Mr. Chairman, the inspirational author Ralph Marston, tells us that 
``Excellence is not a skill. It is an attitude.'' Throughout DOD, we 
have adopted an ``excellence attitude'' about psychological health and 
TBI and, as a result, we have made remarkable progress in advancing 
critical solutions to the problems they present for individuals and 
families.
    Mr. Marston also reminds us that, ``It takes a long time to bring 
excellence to maturity.'' In that regard, he is also right--which means 
that, despite the progress, much work remains.
    We will continue to work with our private sector care partners to 
ensure the quality and consistency of care. We will continue to work to 
meet the needs of our Reserve Forces, especially those in rural or 
underserved areas. We will continue to do more at the policy level to 
adapt lessons learned and eliminate gaps in care for those in 
transition. We will continue to improve our efforts to recruit and 
retain high quality mental health providers while working with our VA 
partners to improve utilization strategies. We will continue to pursue 
every avenue to affect the suicide rates. We will continue to improve 
our abilities to share and exchange data with VA. We will continue to 
seek new ways to expand our knowledge and improve our ability to care 
for our servicemembers, veterans, and their families.
    DOD greatly appreciates the committee's strong support of America's 
Armed Forces and the concern you have shown for their health and well 
being. We have made great progress in meeting the challenges on many 
fronts and with the committee's continued help and support, we will do 
even more.
    Thank you for the opportunity to bring you up to date. We look 
forward to your questions.

STATEMENT OF ROGER DIMSDALE, EXECUTIVE DIRECTOR, DEPARTMENT OF 
VETERANS AFFAIRS/DEPARTMENT OF DEFENSE COLLABORATION, OFFICE OF 
      POLICY AND PLANNING, DEPARTMENT OF VETERANS AFFAIRS

    Mr. Dimsdale. Good afternoon, Chairman Nelson, Ranking 
Member Graham, Senator Hagan. I want to thank you for inviting 
the VA to participate in this hearing. My name is Roger 
Dimsdale and I'm pinch-hitting for Karen Pane, who's the acting 
Assistant Secretary for Policy and Planning. She had a family 
emergency and was not able to attend.
    Before I start with my oral statement, I would like to 
thank the members of the first panel. I learned a lot by 
listening to what they had to say. It's obvious that we have a 
ways to go. We're heading in the right direction, but we 
obviously have placed more emphasis on care and case 
management. I would also appreciate that my written statement 
be entered into the record.
    Senator Ben Nelson. It will be.
    Mr. Dimsdale. Mr. Chairman, I want to assure you and the 
committee that Secretary Shinseki is fully committed to 
supporting America's wounded warriors and veterans. As a sign 
of that commitment, Secretary Shinseki has already met with 
Secretary Gates four times to discuss wounded warrior issues. 
As Ms. McGinn brought up today, they co-chaired a SOC meeting 
during the transition.
    They have recently agreed to establish a joint Virtual 
Lifetime Electronic Record (VLER). The latest acronym is VLER, 
so I'll use the term VLER as we continue through the testimony 
here. On April 9, the President added support to the VLER. He 
and the two Secretaries announced the establishment of a joint 
virtual electronic record. The VLER will be for all current and 
future servicemembers, veterans, and eligible family members, 
and will contain all data to uniquely identify them and ensure 
the delivery of care and benefits for which they're eligible.
    The VLER will begin when an individual enters the Service 
and will continue throughout the period of time he or she is in 
the Service, into the veteran status, and throughout their 
life. It will contain health and administrative data, so the 
idea is this will be one single record, one single virtual 
electronic record which will track men and women throughout the 
life span of their service.
    VA and DOD, of course, have been working for years on this 
issue and recently have started to see some progress. 
Electronic records are a priority of the administration.
    Secretary Shinseki intends to do more than talk about it, 
and he holds our department accountable to accomplish this 
task. Another important example of an area in which DOD and VA 
have accomplished joint activity, is the DES pilot. The DES 
pilot was a demonstration project initially, then in the 
national capital region, to resolve the confusing aspects of 
the existing system, and to shorten the overall time required 
to complete the process.
    The pilot is intended for those servicemembers who are 
being medically separated or retired. The processing time for 
those currently enrolled in the pilot has been reduced by 
greater than 50 percent. Our business rule is that 
servicemembers departing Active Duty will receive their VA 
disability benefit check the month after they leave Active 
Duty.
    The pilot is currently conducted at 14 sites, with plans to 
expand and enhance the DES process to another 6 by August 31, 
2009. DOD and VA will submit a report to Congress on the 
lessons learned from the pilot, along with the recommendations 
as to the way ahead.
    As a result of what we've seen so far, VA and DOD would 
like to extend the policies and lessons learned from the pilot 
program to additional installations, taking this phased 
approach to wider implementation of the enhanced process. We'll 
help ensure success by making sure that we have the right 
processes in place.
    The VA's also very proud of the success of the joint DOD/VA 
FRCP. Dr. Karen Guice, the Executive Director of the FRCP for 
VA, is here with me to share with you details about the 
successes of the FRCP.
    We also believe that the successes we have seen in these 
joint efforts, as well as others I've listed in my written 
testimony, are the direct result of a structure that allowed us 
an open dialogue, encouraged collaboration, and focused on 
results.
    We have not changed our level of support for the SOC since 
it was started in May 2007 and will continue to do so. As 
you're aware, the NDAA for Fiscal Year 2009, section 726, 
requires that both departments write Congress on the way ahead 
for the SOC and the JEC, and we fully intend to work with DOD 
to submit a joint report.
    While we were pleased with the joint efforts and progress 
made, there's a good deal more to do. The VA is committed to 
providing support for our Nation's wounded warriors and 
veterans. As such, we believe that continued partnership with 
DOD is critical.
    The comment was made earlier in the GAO testimony that 
working harmoniously is the way ahead, and we are working 
harmoniously. DOD and VA are hand in hand. Certainly there are 
issues that take one department's track versus another. But 
overall, the cooperation has been great and will continue to be 
so.
    Thank you, Mr. Chairman and subcommittee members, for the 
opportunity. I look forward to answering any questions.
    [The joint prepared statement of Mr. Dimsdale and Dr. Guice 
follows:]
  Joint Prepared Statement by Roger Dimsdale and Karen Guice, MD, MPP
    Good afternoon Chairman Nelson, Ranking Member Graham, and members 
of the committee. My name is Roger Dimsdale, and I am the Executive 
Director of the VA/DOD Collaboration Office for the Office of Policy 
and Planning at the Department of Veterans Affairs (VA). I am pleased 
to provide the Subcommittee with the accomplishments and challenges 
related to implementing the various elements of the Wounded Warrior 
Act. I will also discuss the cooperative efforts between VA and the 
Department of Defense (DOD) responsible for the progress made to date, 
as well as our strategy for continued action. First, however, I would 
like to emphasize the administration's level of support for these 
activities.
    Secretary Gates and Secretary Shinseki have publically articulated 
their commitment to continued inter-Departmental cooperation. They are 
particularly supportive of joint activities that resolve issues 
concerning Wounded Warriors and have met numerous times to affirm their 
commitment and provide general guidance to staff.
    Successful implementation of the various provisions of the Wounded 
Warrior Act is a direct result of the structured interaction between 
the two Departments through the Senior Oversight Committee (SOC). The 
Overarching Integrated Product Team (OIPT), consisting of eight Lines 
of Action (LOA), supports the SOC. Each LOA is co-led by 
representatives from VA and DOD. This unique structure coordinates, 
monitors, and implements the over 600 recommendations from a variety of 
commissions, task forces, and studies. Currently, the two Departments 
maintain a collocated staff to support SOC and Joint Executive 
Committee (JEC) issues. Section 726 of the Duncan Hunter National 
Defense Authorization Act for Fiscal Year 2009 extended SOC operations 
until December 31, 2009. VA strictly interprets this mandate and has 
not changed its approach or organizational support to the LOAs.
    I would like to highlight some of the jointly developed and 
implemented accomplishments resulting from the Wounded Warrior Act. I 
will focus on the significant improvements to the disability evaluation 
system (DES), the collaborative efforts addressing psychological health 
and traumatic brain injury (TBI) through the Defense Centers of 
Excellence, innovative approaches to care management and coordination, 
the shared information technology (IT) efforts directed by the 
Interagency Program Office (IPO), and the various co-developed outreach 
materials and communication strategies.
                      disability evaluation system
    Improvements to the DES and VA compensation and pension program 
include: (1) the pilot program; (2) revisions to the VA Schedule for 
Ratings Disabilities (VASRD); and (3) expedited claims processing for 
Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF) veterans 
by VA.
    DOD and VA are currently conducting a pilot program to improve the 
current disability processes. The project, initially started at the 
medical treatment facilities in the National Capital Region, is 
expanding to include other facilities around the Nation. Key features 
include a single medical examination and disability rating for use by 
both Departments, as well as a reduction in the time required to 
transition to veteran status and receive VA benefits and compensation.
    Updating the VASRD to reflect the best medical information, and the 
signature conditions associated with new conflicts, is a priority. New 
rating criteria for the assessment of residuals of TBI became effective 
on October 23, 2008. The Veterans Benefits Administration (VBA) is 
processing claims from very seriously injured and seriously injured 
OEF/OIF Veterans on a first priority basis. VBA also conducts priority 
claims processing for initial and reopened claims from all in-theater 
war veterans received within 6 months after separation from service and 
appeals from such veterans of the initial claims decisions following 
such service. Subsequent PTSD claims submitted by returning theater 
veterans receive priority processing as well.
            psychological health and traumatic brain injury
    The Defense Centers of Excellence (DCoE) for Psychological Health 
and Traumatic Brain Injury is comprised of an active headquarters 
element, along with six component centers, including:

         Defense and Veterans Brain Injury Center;
         Center for Deployment Psychology;
         Deployment Health Clinical Center;
         Center for the Study of Traumatic Stress;
         National Intrepid Center of Excellence; and
         National Center for Telehealth and Technology.

    Over the past year and a half, the DCoE and its component centers 
have participated actively in several joint VA/DOD activities, 
including:

         Developing training programs for DOD and VA personnel 
        for the evaluation and follow-up of patients with TBI--1,500 
        participants have been trained thus far
         Developing a coding proposal that addresses 
        International Classification of Diseases (ICD-9) coding for 
        TBI, recently reviewed by the National Center for Health 
        Statistics
         Developing Clinical Practice Guidelines for mild TBI, 
        as well as updating the Clinical Practice Guidelines for 
        Substance Abuse and PTSD
         Cosponsoring the Annual Suicide Prevention conference 
        in January 2009, bringing together experts from the Federal and 
        civilian sectors to increase collaboration and communication on 
        the key topic of suicide prevention
         Participating in the Federal Partners Priority Work 
        Group on Reintegration
         Co-sponsoring a scientific conference on gender and 
        racial issues in Psychological Health and TBI on October 1 and 
        2, 2008 with NIH.

    Separately, DOD has provided $45 million to the DCoE for research 
to advance the assessment, treatment, and prevention of TBI and 
psychological health conditions. Five million dollars of these funds is 
targeted specifically for complementary and alternative medicine 
approaches to the treatment of psychological health problems and TBI.
                    care coordination and management
    DOD and VA have made significant improvement to the care and 
transition of recovering servicemembers. VA and DOD collaborate on 
issues related to mental and psychological health through a number of 
interactions, involving the DCoE as well as other mechanisms. Military 
liaisons at the four major VA Polytrauma Rehabilitation Centers provide 
a direct connection to the various military services. VA provides 
liaison officers at selected Military Treatment Facilities (MTF) to 
assist in delivery of VA care and benefits. Each VA medical center has 
an OEF/OIF team that facilitates transfers and coordinates VA care at 
that facility. The military Services have also created service-specific 
Wounded Warrior Programs to assist recovering servicemembers at each 
MTF. Finally, the Federal Recovery Coordination Program (FRCP), a joint 
program of DOD and VA, assists recovering servicemembers, veterans, and 
their families with access to care, services, and benefits provided 
through the various programs in DOD, VA, other Federal agencies, 
states, and private sector.
    Recovering servicemembers and veterans are referred to the FRCP 
from a variety of sources, including from the servicemember's command, 
members of the multidisciplinary treatment team, case managers, 
families already in the program, Veterans Service Organizations and 
nongovernmental organizations. Generally, those individuals whose 
recovery is likely to require a complex array of specialists, transfers 
to multiple facilities, and long periods of rehabilitation are 
referred.
    FRCP clients work with their Federal Recovery Coordinator (FRC) to 
create a goal-based Federal Individualized Recovery Plan (FIRP) with 
input from their family or caregiver, as well as from members of the 
client's multidisciplinary health care team. The FRC implements the 
plan by working with existing governmental and nongovernmental 
personnel and resources.
    Within the overall framework of care coordination and each client's 
particular needs and goals, the FRCs work with military liaisons, 
members of the Services Wounded Warrior Programs, service recovery care 
coordinators, TRICARE beneficiary counseling and assistance 
coordinators, VA vocational and rehabilitation counselors, military and 
VA facility case managers, VA Liaisons, VA specialty case managers, 
Veterans Health Administration and VBA OEF/OIF case managers, VBA 
military services coordinators, and others. FRCs do not directly 
deliver services; they coordinate the delivery of services and serve as 
a resource for enrolled servicemembers, veterans, and their families.
    Currently, 14 FRCs are working at 6 military treatment facilities 
and 2 VA medical centers. They are supported by a VA Central Office 
staff that includes an Executive Director, two Deputies (one for 
Benefits and one for Health), an Executive Assistant, and a Staff 
Assistant. In addition, the program receives personnel support at VA 
Central Office from the U.S. Public Health Service and DOD, with each 
sending two individuals on detail.
                  information technology collaboration
    DOD and VA have taken crucial steps toward creating a Joint Virtual 
Lifetime Electronic Record (VLER), as announced by President Obama on 
April 9, 2009. Both Secretaries are dedicated to ensuring strong 
executive oversight with specific attention to the Interagency Program 
Office, mandated by the Wounded Warrior Act (title XVI of the National 
Defense Authorization Act for Fiscal Year 2008), on behalf of VA and 
DOD, to provide oversight for VA-DOD data sharing initiatives. The 
emerging vision for the VLER initiative is for all current and future 
servicemembers, veterans, and eligible Family Members to have a VLER 
that will encapsulate all data necessary to uniquely identify them and 
ensure the delivery of care and benefits for which they are eligible. 
This proactive delivery begins upon oath of military service and 
continues beyond death to survivor benefits. To the user, the 
perception will be that one Federal entity delivers all benefits, care, 
and support.
    DOD and VA will develop workgroups to define the common services 
used by information processes in both Departments as well as the common 
functional processes within services unique to each Department. Joint 
DOD-VA efforts have already begun to define the data and business 
processes for this effort. The result will be an unprecedented unified 
data sharing between the two Departments.
                   outreach and communication efforts
    The Wounded Warrior Act called for joint outreach efforts to 
recovering servicemembers, veterans, and their families. As a result, 
web-based applications, assistance centers, and direct outreach 
activities were developed.
    The web-based National Resource Directory (the Directory) provides 
information on services and resources available through Federal, State, 
and local governmental agencies, veterans' benefit/service/advocacy-
organizations, professional provider associations, community and faith-
based/nonprofit organizations, academic institutions, employers, and 
philanthropic activities of business and industry. The Directory was 
developed jointly, and is currently co-managed by DOD, VA, and the 
Department of Labor.
    Other efforts include the Wounded Warrior Resource Center. This 
consists of a DOD website as well as a call center, and serves as a 
single point of contact for wounded, ill, and injured servicemembers, 
their families, caregivers, and those who support them. A MyeBenefits 
portal, currently under development, will provide individualized 
information upon login for all servicemembers and veterans.
    The National Guard Family Assistance Centers conduct in-person 
outreach for National Guard members throughout the 50 States, the 
District of Columbia, and U.S. territories. The Centers augment the 
support system for geographically dispersed families by providing 
information, referrals, and assistance to families during a 
servicemember's deployment. They support any military family member 
from any military branch or component.
    The Yellow Ribbon Reintegration Program provides National Guard and 
Reserve members and their families with information about services 
throughout the entire deployment cycle. VA participates in this effort 
with representation on the Advisory Board and assignment of a VA 
liaison within the program office.
    A handbook was developed by DOD and VA to help injured 
servicemembers and their families navigate the DOD and VA systems. The 
handbook is available electronically or in book format.
                               challenges
    Despite our collective success, we recognize that we have more work 
to do to implement the Wounded Warrior Act fully. Specifically, we 
must:

         Maintain a shared structure that continues to provide 
        guidance and oversight for these efforts;
         Continue to work toward one system that supports our 
        wounded warriors;
         Continue to address the unique needs of the National 
        Guard and Reserve components;
         Continue to work toward sharing information between 
        the two Departments; and
         Continue to address the mental health needs, including 
        addressing the stigma that continues to be associated with 
        seeking treatment for mental health disorders.
                               conclusion
    Successful collaboration between the Departments is a direct result 
of the coordination and oversight of the SOC. Secretary Shinseki and 
Secretary Gates continue to promote, support and direct these efforts 
through their actions, including their co-chairing of the SOC and the 
JEC.
    While we are pleased with the joint efforts and progress made, 
there is a good deal more to do. VA is committed to providing support 
for our Nation's wounded warriors and veterans. As such, we believe 
that continued partnership with DOD is critical, and no less than our 
servicemembers and veterans deserve.
    Thank you again for your support to our wounded, ill, and injured 
servicemembers, veterans, and their families.
    We look forward to your questions.

    Senator Ben Nelson. Thank you.
    General Meurlin.

STATEMENT OF MAJ. GEN. KEITH W. MEURLIN, USAF, DIRECTOR, OFFICE 
   OF TRANSITION POLICY AND CARE COORDINATION, DEPARTMENT OF 
                            DEFENSE

    General Meurlin. Chairman Nelson, Senator Graham, thank you 
for the opportunity to represent DOD and the Office of 
Transition Policy and Care Coordination this afternoon. I would 
like to briefly mention a few major areas where my office is 
currently engaged.
    The Physical Disability Board of Review has been 
established and is up and running. Although we encountered some 
challenges getting the program started, we're currently making 
very good progress. We're in the process of reevaluating our 
approach in two areas and expect significant modifications to 
be announced in the near future.
    The first area pertains to the scope of the review. It is 
our current intention to review all findings of the PEB, those 
fitting and unfitting conditions, along with the ratings 
assigned to those conditions. The second is the service 
specific DOD guidance that conflicts with the VA's Schedule for 
Rating Disabilities (VASRD) will be disregarded, and the 
conditions and rating will be evaluated only with VASRD in 
effect at the time the initial findings and determinations were 
made.
    We believe both of these changes are consistent with 
congressional intent, and understand making these changes as 
soon as possible is a matter of great concern to the committee.
    The Recovery Care Coordination program is up and running, 
with the initial cadre of 31 RCCs deployed to 13 military 
sites.
    My staff is training an additional 100-plus Army AW2 
advocates as RCCs using the standard DOD curriculum, which 
includes standard assessment tools and a comprehensive recovery 
plan for recovering servicemembers assigned an RCC. The Navy, 
Marine Corps, and Air Force are assessing how many more RCCs 
will be needed to ensure our recovering servicemembers are 
supported.
    We have issued interim recovery coordination program policy 
and the DOD instruction to establish uniform policy--uniform 
policy for the program implementation and deployment of RCCs 
and the development of a comprehensive recovery plan.
    Ongoing site visits, analysis of the standard assessment 
tools, and customer satisfaction surveys will allow us to 
evaluate the program, to assess the population served, and 
placement of additional RCCs. Recent discussions with the 
Services indicate that they are on board with these 
requirements.
    The third thing I'd like to mention is the progress we've 
made in regards to the DES pilot program. There will be a total 
of 21 sites participating in the program by June and anticipate 
starting an evaluation in the near future.
    The pilot is due to report to the SOC this coming August, 
and it's imperative to note, however, that the DES pilot is not 
an end-all solution, but rather a bridge, with the ultimate 
goal being in integrating DOD and VA systems at logical nodes.
    Ultimately, it is time for a national dialogue on how 
America supports its wounded, ill, and injured. We need to 
break down more barriers to trust and transparency, and shift 
away from a focus on paying entitlements to one of recovery, 
rehabilitation, transition, and making the servicemember a 
viable member of society.
    The Secretary of Defense put in place a voluntary program 
that provides the ability to expedite a servicemember through 
the DES. The expedited DES process is a special benefit for 
those servicemembers who sustain catastrophic injuries or 
illnesses from combat or combat-related operations, as defined 
in the policy. The establishment of the policy supports the 
Department's belief that there must be a special process for 
those members who sustain catastrophic disabilities while 
participating in combat or combat-related operations, in 
contrast with those disabled otherwise.
    We are excited about this program because it allows the 
early identification of a full range of benefits, compensation, 
and specialty care offered by VA.
    Finally, in the area of personnel pay and financial 
support, I'd like to bring your attention to the concept of 
caregiver compensation. The Center for Naval Analyses (CNA) is 
completing a study of wounded warrior caregivers, identifying 
that mothers and spouses spend on average up to a year, and in 
severe cases, much longer, providing physical and emotional 
support to their recovering servicemembers.
    The final report from CNA will be published shortly. Based 
on CNA's preliminary findings which were released in December, 
the Department proposed legislation for fiscal year 2010 to 
provide catastrophically wounded servicemembers with a special 
monthly compensation for their caregivers. The amount of the 
compensation would be based on the monthly income of a home 
health care aide and would continue until the catastrophically 
wounded servicemember transitions to VA.
    My bottom line is that America's families turned over their 
loved ones to us. We're returning some of them wounded, ill, 
and injured. The servicemembers and their families earned and 
deserve to have the best that we have to offer. We pledge to 
continue the work with your staff, VA, the Department of Labor, 
and others, to make that happen.
    Thank you for this opportunity. I look forward to your 
questions.
    [The prepared statement of General Meurlin follows:]
          Prepared Statement by Maj. Gen. Keith Meurlin, USAF
    Mr. Chairman, subcommittee members, I am pleased to be here today 
to discuss with you the Department's continued support of our wounded, 
ill, and injured servicemembers, veterans, and their families, and in 
particular, the continued work of the Office of Transition Policy and 
Care Coordination.
                               background
    On 14 November 2008, the Under Secretary of Defense for Personnel 
and Readiness established the Office of Transition Policy and Care 
Coordination (TPCC). It's mission is to ensure equitable, consistent, 
high-quality care coordination and transition support for members of 
the Armed Forces, including wounded warriors and their families through 
appropriate interagency collaboration, responsive policy and effective 
program oversight. The TPCC assumed responsibility for policy and 
programs related to the Disability Evaluation System, servicemembers' 
separation from the Armed Forces and transition to veteran status, 
wounded warrior case and care coordination, and related pay and 
benefits. These assigned responsibilities include the totality of the 
Department of Defense (DOD) functions formerly assigned to the DOD and 
Department of Veterans Affairs (VA) Wounded, Ill, and Injured Senior 
Oversight Committee (SOC) Lines of Actions (LOAs) 1, 3, and 8. The TPCC 
also assumed responsibility for management and monitoring of 
performance against DOD/VA Benefits Executive Council (BEC) goals and 
for coordinating with VA in support of BEC activities. The TPCC has the 
authority to enter into agreements with VA and represent the Under 
Secretary of Defense for Personnel and Readiness as a member on 
councils and interagency forums established under the authority of the 
DOD/VA Joint Executive Council (JEC), the BEC and the SOC. A TPCC 
Strategic Plan has been created incorporating objectives from the Under 
Secretary of Defense for Personnel and Readiness and the JEC.
                  disability evaluation system (loa-1)
    The mission of LOA-1, Disability Evaluation System (DES), is to 
develop and establish one solution for a DOD and VA DES that is 
seamless, transparent, and administered jointly by both Departments and 
uses one integrated disability rating system, streamlining the process 
for the servicemember transitioning from DOD to VA. That system must 
remain flexible to evolve as trends in injuries and supporting medical 
documentation and treatment necessitates. LOA-1 has continued to make 
significant steps forward in regards to the DES Pilot to include the 
pilot's expansion, the Expedited DES, and the Physical Disability Board 
of Review.
Disability Evaluation System Overview
    Now, as in the past, the DOD remains committed to providing a 
comprehensive, fair, and timely medical and administrative processing 
system to evaluate our injured or ill servicemembers' fitness for 
continued service using the DES. One way we have honored these men and 
women, was to develop and establish a DES pilot that provides one 
solution for a DOD and VA DES using one integrated disability rating 
system. This system has several key features: simplicity; non-
adversarial processes; single-source medical exam and disability 
ratings (eliminating duplication); seamless transition to veteran 
status; and strong case management advocacy. The system must remain 
flexible to evolve as trends in injuries and supporting medical 
documentation and treatment necessitates. LOA-1 has continued to make 
significant progress in regards to the DES Pilot to include the Pilot's 
expansion, the Expedited DES, and the Physical Disability Board of 
Review. However, it is time for a national dialogue on how America 
supports it wounded, ill, and injured. We need to break down more 
barriers to trust and transparency, and shift away from a focus on pay 
and entitlements to one of recovery, rehabilitation, transition, and 
making the veteran a viable member of society.
Disability Evaluation System Pilot
    During the reporting week ending April 19, 2009, 80 servicemembers 
entered the DES Pilot from 14 Military Treatment Facilities (MTFs) for 
a cumulative enrollment of 1,929 servicemembers since 26 November 2007. 
Of those, 344 servicemembers have completed the DES pilot by returning 
to duty, separating from service, or retiring. Seventy servicemembers 
were removed from the DES pilot for other reasons such as transferring 
to a location outside the DES pilot or case termination for pending 
administrative discharge processing. Currently, 1,515 servicemembers 
remain enrolled in the DES pilot.
    Active component servicemembers who completed the DES pilot 
averaged 271 days from Pilot entry to VA benefits decision, excluding 
pre-separation leave. Including pre-separation leave, Active component 
servicemembers completed the DES pilot in an average of 286 days. This 
represents a process which is 47 percent faster than the current DES 
and VA Claim process, and 3 percent faster than the 295 days originally 
projected for the pilot. Reserve component and National Guard 
servicemembers, who completed the DES pilot, averaged 249 days from 
pilot entry to issuance of the VA benefits letter, which is 18 percent 
faster than the projected 305 day timeline.
DES Pilot Expansion
    Based on guidance from the SOC, the DES pilot will expand to a 
total of 21 sites by June, 2009. In addition to the locations in the 
National Capital Region, which include Fort Belvoir and Fort Meade, the 
following expansion sites are now operating or are prepared to commence 
DES pilot operations:

         Naval Medical Center San Diego, CA and Fort Stewart, 
        GA, as of November 2008
         Camp Pendleton, CA, as of January 2009
         Naval Medical Clinic Bremerton, WA, Vance Air Force 
        Base, OK, and Fort Polk, LA, as of February 2009
         Nellis Air Force Base, NV, MacDill Air Force Base, FL, 
        and Marine Corps Base Camp Lejeune, NC, as of March 2009
         Fort Drum, NY, and Fort Richardson, Fort Wainwright, 
        and Elmendorf Air Force Base, AK, will commence operations on 
        April 30, 2009
Studies, Reports, and Policy Updates
    Data gathering and analysis are ongoing to support an August 2009, 
expansion decision by the SOC and delivery of a final report to 
Congress as required by National Defense Authorization Act (NDAA) 2008, 
section 1644(g)(3). Reports DOD previously delivered to Congress 
include:

         Feasibility of combining DOD and VA DESs (NDAA 2008, 
        Sec. 1612)
         Report on rating reductions after Physical Evaluation 
        Board appeals (NDAA 2008, Sec. 1615(e))
         Initial and Interim Status reports on the DES Pilot 
        (NDAA 2008, Sec. 1644)
         Initial Report on Army Medical Action Plan action to 
        improve Army DES (NDAA 2008 Sec. 1645)
         Report on the continuing utility of the Temporary 
        Disability Retirement List (NDAA 2008, Sec. 1647)

    Additionally, DOD continues to learn lessons from the pilot and 
capitalize on a continuous improvement process. Since August 2007, the 
Department, with VA coordination, has published seven policy updates. 
We will continue to refine the DES until national reform is complete.
Expedited DES
    The Secretary of Defense established a voluntary program that will 
expedite a servicemember through the DES. The Expedited DES process is 
a special benefit to those servicemembers who sustain catastrophic 
injuries or illnesses from combat or combat-related operations as 
defined in the policy. The establishment of the policy supports the 
Department's belief that there must be a special process for those 
members who sustain catastrophic disabilities while participating in 
combat or combat-related operations, in contrast with those disabled 
otherwise.
    To qualify, a servicemember's condition must be designated as 
``catastrophic'' and the injuries or illnesses must have been incurred 
in the line of duty and received as a result of the causes prescribed 
under the statutory definition of ``Combat-Related'' as used in the 
combat-related special compensation program. Under the Expedited DES, 
servicemembers receive a presumed 100 percent disability retirement 
from DOD. The Expedited DES process will allow the early identification 
of the full range of benefits, compensation and specialty care offered 
by the Department of Veterans Affairs.
Physical Disability Board of Review (PDBR)
    On January 12, 2009, the PDBR began accepting applications. As of 
April 22, 2009, the board received 306 applications. The board 
forwarded 148 cases to the military Services and 117 to the VA for 
records retrieval. The board has 19 complete records assembled and 
ready for adjudication and has closed 22 cases for administrative 
reasons. The board members have been assigned, trained on the PDBR 
process, and have received rating training from VA as well as cross 
training in other Service disability processes. The Central 
Adjudication Unit is 100 percent operational and has been permanently 
occupied since February 16, 2009. The Air Force, acting as the lead 
component of the PDBR, has negotiated privileges for direct computer 
access to VA claims records.
                       care coordination (loa-3)
    The mission of LOA-3, Care Coordination, is to simplify the care 
coordination process by providing uniform standards for wounded, ill, 
and injured servicemembers and their families throughout their 
continuum of care from recovery, rehabilitation, and return to duty or 
reintegration into the community.
Comprehensive Policy for Care, Management, and Transition of Recovering 
        Servicemembers
    A DOD Directive Type Memorandum, ``Recovery Coordination Program: 
Improvements to Care, Management, and Transition of Recovering 
Servicemembers'', was published and implemented by the Services' 
Wounded Warrior Programs in January 2009. A working group chaired by 
the Care Coordination Office in the Office of Transition Policy and 
Care Coordination is now writing the DOD Instruction to fully address 
the NDAA fiscal year 2008 requirements to establish Recovery Care 
Coordinators (RCCs) and a Comprehensive Recovery Plan for all 
recovering servicemembers. Members of the working group include 
representatives from the Service Wounded Warrior Programs, Surgeons 
General, Assistant Secretaries for Manpower and Reserve Affairs, Health 
Affairs and, Family Support Programs, the Joint Chiefs of Staff, Joint 
Task Force National Capital Region Medical, OSD Reserve Affairs, 
Services' Reserve Components, and the Department of Veterans Affairs.
Recovery Care Coordinators
    Currently there are 31 RCCs deployed across the United States at 13 
MTFs and installations. The RCCs have been trained using uniform, 
standard DOD curriculum, as required by Congress. This week my staff is 
training an additional 100 plus Army AW2 advocates as RCCs using this 
uniform standard curriculum.
Recovery Coordination Program Evaluation
    Preparation for the initial baseline evaluation of the DOD Recovery 
Coordination Program (RCP) is well underway. Metrics are currently 
being established to evaluate the program, and assess the current RCC 
workload. Customer satisfaction surveys will be administered to 
recovering servicemembers and families enrolled in the RCP and assigned 
an RCC.
Data Collection/Sharing
    `The TPCC has instituted a ``strategic pause'' to review all 
existing DOD/VA data sharing systems that pertain to the DOD and VA 
RCPs. The study is reviewing and cross-walking the Services' Wounded 
Warrior Program existing data collection systems.
    We are also conducting a review in mid-May of the standardized 
screening and assessment tools used to refer recovering servicemembers 
into the RCP. The results of this review and the IT Study will be 
incorporated into a solution for a data collection/sharing system for 
the RCPs. The data collected will be used to help determine workload 
and future deployment of RCCs. I've asked for the study results and 
recommendations by the end of May.
National Resource Directory
    The DOD, VA, and DoL Web site continues to provide services and 
resources for wounded, ill, and injured servicemembers, veterans, their 
families, and those who support them. It is an online tool for 
accessing more than 10,000 services and resources at the national and 
State level to support recovery, rehabilitation, and reintegration into 
the community. A recent informal survey reported 90 percent of our RCCs 
are using the National Resource Directory to assist them in the 
establishment of Comprehensive Recovery Plans and providing services 
and resources for our recovering servicemembers and their families.
             personnel, pay, and financial support (loa-8)
    The mission of LOA-8, Personnel, Pay, and Financial Support, is to 
ensure each wounded, ill, or injured servicemember has a level of 
compensation, benefits, and financial support to maintain their dignity 
and support their recovery, rehabilitation, and reintegration.
    LOA-8's accomplishments have continued with the launch of the Navy 
Wounded Warrior Database on 29 January 2009 and the release of the 
updated Electronic Compensation and Benefits Handbook in February 2009. 
LOA-8 has orchestrated advancements in data sharing between the VA and 
the Defense Finance and Accounting Service for Active Duty 
servicemembers who are being treated as inpatients at VA Medical 
Centers. Additionally, LOA-8 has continued to work closely in 
cooperation with VA in development of the eBenefits portal with the 
next two updated releases expected to be delivered in June and 
September 2009 respectively.
                                closing
    We are extremely proud of the progress made to date. Our obligation 
to our servicemembers, veterans, and their families is a lifetime 
pledge which requires our unwavering commitment to complete the work 
which has been started. There remains more work to do. Our valiant 
heroes and their families deserve our support and dedication to ensure 
their successful transition through recovery, rehabilitation, and 
return to duty or reintegration into their communities.
    Thank you for your generous support of our wounded, ill, and 
injured servicemembers, veterans, and their families. I look forward to 
your questions.

    Senator Ben Nelson. Thank you, General.
    Admiral Timberlake?

    STATEMENT OF RADM GREGORY A. TIMBERLAKE, USN, DIRECTOR, 
INTERAGENCY PROGRAM OFFICE, DEPARTMENT OF DEFENSE/DEPARTMENT OF 
                        VETERANS AFFAIRS

    Admiral Timberlake. Senator Nelson, Senator Graham, thank 
you for this opportunity to address you on the status of our, 
by which I mean DOD and VA, efforts to achieve full 
interoperability between the electronic health care records and 
those departments by September of this year.
    Let me begin with some background on the DOD/VA IPO, which 
had its genesis in the language of section 1635 of the NDAA for 
Fiscal Year 2008, which mandated that DOD and VA achieve fully 
interoperable electronic health record capabilities by 
September 2009, and established the IPO to oversee and help 
coordinate this effort.
    On April 17, 2008, VA and DOD officially formed the IPO. 
Within VA, the IPO was set up to report to the Deputy 
Secretary. Within DOD, IPO coordinates most of its activities 
through the Defense Human Resource Activity and the Office of 
the Under Secretary of Defense for Personnel and Readiness.
    The IPO receives strategic guidance from the Secretaries of 
DOD and VA, as well as from the JEC, which you've heard 
described earlier, the Health Executive Council for health-
related data sharing, and the Benefits Executive Council for 
personnel and benefits data sharing.
    In the early months, IPO was focused on the basics of 
acquiring office space, equipment, determining appropriate 
staffing levels, and beginning the process in advertising for 
personnel. Today, just under half of the permanent staff have 
been hired, standard operating procedures are in place, and a 
formal charter has been signed by the Deputy Secretary of VA 
and the Under Secretary of Defense for Personnel and Readiness, 
which specifies the scope of IPO's oversight responsibilities, 
and further clarifies the relationship of the IPO to the two 
departments.
    The current mission of our office is to provide management 
oversight of joint activities to accelerate that exchange of 
the electronic health care information between the departments. 
In this capacity, IPO is responsible for working with the 
departments on issues like supporting the definition of DOD and 
VA data-sharing requirements and showing that DOD and VA 
schedules are coordinated for the technical execution of the 
initiatives; assisting in the coordination of funding 
considerations; and assisting on obtaining input and 
concurrence of the multiple stakeholders.
    Originally, we expected to focus our efforts on the 
electronic health care record systems and other health care 
data-sharing initiatives between DOD and VA. However, the scope 
was later expanded at the suggestion of the Wounded, Ill, and 
Injured SOC to include personnel and benefits electronic data-
sharing as well.
    Responsibility for development of their requirements and 
the execution of information technology solutions still 
remained with the respective DOD and VA organizations. 
Technical execution also remains in the appropriate 
departmental offices, using the departments' established 
statutory and regulatory processes for acquisition, funding, 
management control, information sharing, and other execution 
actions, which are significantly different in each department.
    For the immediate term, IPO has centered its energies on 
ensuring that by September of this year, the systems are in 
place to allow for full interoperability of the electronic 
personal health information required for clinical care between 
DOD and VA. A key to that has been the adoption of a shared DOD 
and VA understanding of the meaning of the phrase ``full 
interoperability.''
    In our view, that phrase is best defined by the people who 
are using the systems daily to deliver care. With this in mind, 
we turn to the DOD/VA Interagency Clinical Informatics Board 
(ICIB), which is composed of clinicians from both DOD and VA. 
It is headed by the Deputy Assistant Secretary of Defense for 
Clinical and Program Policy and the Chief Patient Care Services 
Officer of the Veterans Health Administration (VHA).
    This group was given the responsibility for identifying and 
prioritizing the types and format of electronic medical 
information which clinicians need in order to provide the 
highest levels of care. In July 2008, the ICIB delivered these 
recommendations to the IPO and the Health Executive Committee 
(HEC), Information Management/Information Technology, Working 
Group.
    The recommendations were subsequently approved at the HEC, 
and then passed down to our DOD and VA information technology 
teams as they developed the tools and applications to put these 
requirements into operation. By leveraging many prior 
accomplishments to the departments toward the development of 
interoperable bidirectional electronic health records, the IPO 
and the departments were able to formulate a plan to achieve 
full interoperability for clinical care by the September 2009 
target date.
    As a part of this plan, VA's and DOD's ability to utilize 
well known interoperability systems, like the Federal Health 
Information Exchange and the Bidirectional Health Information 
Exchange, has been greatly expanded. At the same time, new 
systems have been added to the Clinical Data Repository/Health 
Data Repository to allow even more medical data to be 
transferred between the two departments.
    New pilot programs such as the SHIE imaging project, were 
developed. This pilot is now deployed and operational at a 
number of major military and VA medical centers across the 
country.
    Today, I'm pleased to report that I feel we are on target 
to achieve full interoperability of electronic health records 
for the delivery of clinical care by September 2009 as defined 
by the ICIB.
    But information technology is not static. As new systems 
for capturing, storing, archiving, and retrieving patient data 
are developed, we need to make sure that those systems are 
built in such a way that they allow the data to be fully shared 
between DOD, VA, and authorized private sector providers, such 
as our TRICARE network and the VA contract care network.
    As I've previously mentioned, on April 9, 2009, the 
President announced a new vision for how this would be 
achieved, centering on the development of a ``virtual lifetime 
electronic record,'' which Mr. Dimsdale has already alluded to. 
This virtual lifetime record will leverage investments already 
made in the existing DOD and VA electronic record systems, as 
well as industry best practices, to provide a system that will 
network with new and legacy applications.
    Right now, we believe it will be based on a ``common 
services'' approach that focuses on the development of 
standardized software applications to provide links between 
health care and benefits databases across the two departments. 
Timing is still in the early stages, but the way ahead looks 
promising, and I personally would look forward to briefing you 
on the progress, our progress on meeting the President's new 
initiative in the future.
    Thank you, sir. That concludes my statement, and I look 
forward to your questions.
    [The prepared statement of Admiral Timberlake follows:]
           Prepared Statement bt RADM Gregory Timberlake, USN
                              introduction
    Chairman Nelson and distinguished members of the committee, thank 
you for the opportunity to discuss the role of the DOD/VA Interagency 
Program Office (IPO) in the ongoing effort to achieve fully-
interoperable electronic healthcare information sharing between the 
Department of Defense (DOD) and the Department of Veterans Affairs 
(VA). We continue to make great strides in sharing electronic 
healthcare information, and have plans to do even more in the near 
future.
    The sharing of electronic health data has made significant progress 
in recent years. I will provide a brief historical overview of these 
efforts, outline some of the initiatives that form the foundation for 
future sharing efforts, and discuss how the IPO has successfully 
managed to grow into the institution that is envisioned by Section 1635 
of the National Defense Authorization Act (NDAA) for Fiscal Year 2008.
                          historical overview
    The Departments began laying the foundation for interoperability in 
2001, when they first shared healthcare information electronically. 
Since that time, both Departments have continued to enhance and expand 
the types of information that is shared, as well as the ways in which 
it is shared. The following examples illustrate some of the successes 
of the Departments' ongoing datasharing initiatives:

         The Federal Health Information Exchange (FHIE) data 
        repository allows electronic health information to be shared on 
        over 4.7 million separated servicemembers.
         The FHIE allows DOD and VA providers to access and 
        view 71 million laboratory results, 11.6 million radiology 
        reports, 73.1 million pharmacy records, 75.8 million standard 
        ambulatory records, and 3.1 million consultation reports, and 
        2.5 million deployment health assessments for shared patients.
         The Bidirectional Health Information Exchange (BHIE) 
        enables bidirectional real-time sharing of readable electronic 
        health information between DOD and VA for shared patients.
         Since July 2007, BHIE data from all DOD and VA medical 
        facilities are available to VA and DOD providers.
         As of February 2009, health data is available through 
        BHIE for more than 3.3 million shared patients, including over 
        117,900 Theater patients.
         BHIE also provides bidirectional access to inpatient 
        discharge summaries from DOD's inpatient documentation system. 
        This capability is operational at some of DOD's largest 
        inpatient facilities representing approximately 51 percent of 
        total DOD inpatient beds. DOD will increase the number of sites 
        with electronic inpatient documentation system in fiscal year 
        2009.
         In addition to sharing viewable test data, DOD and VA 
        have expanded the BHIE capability to support the sharing of 
        digital radiology images. The Departments have expanded the 
        BHIE Image Pilot to support the bidirectional exchange of 
        digital images at key locations. The technical accomplishments 
        and lessons learned from the bidirectional image pilot will be 
        used in broader image sharing planning activities.
         Since 2006, DOD and VA have been sharing computable 
        outpatient pharmacy and allergy data through the interface 
        between the Clinical Data Repository of AHLTA, DOD's electronic 
        health record (EHR), and VA's Health Data Repository (HDR) of 
        HealteVet VistA. This initiative is called ``CHDR''.
         CHDR integrates outpatient pharmacy and medication 
        allergy data for shared patients that is viewable by providers 
        in both Departments. Exchanging standardized pharmacy and 
        allergy data on patients supports better patient care and 
        safety through the ability to conduct drug-drug and drug-
        allergy interaction checks using data from both systems.
         In December 2007, all DOD facilities received the 
        capability to initiate the exchange of this data on shared 
        patients.

    By working together with the senior leadership of DOD and VA, 
policies have been established that enable each Department to address 
its unique requirements while also addressing shared requirements. This 
coordination has been furthered through the formation of oversight and 
governing bodies that ensure that information sharing efforts move in 
the right direction and at a pace that meets or exceeds the 
expectations of our stakeholders. Today, these efforts support the 
delivery of high-quality healthcare, continuity of care, and the 
administration of benefits to our servicemembers and veterans.
                  the foundation for interoperability
National Defense Authorization Act for Fiscal Year 2008:
    Section 1635 of the NDAA of 2008 requires DOD and VA to jointly 
develop and implement electronic health record capabilities that allow 
for full interoperability of personal health care information by 
September 2009. Section 1635 also requires the development of a DOD/VA 
IPO to act as a single point of accountability in the rapid development 
and implementation of EHR systems or capabilities that allow for full 
interoperability of personal healthcare information between DOD and VA.
    On April 17, 2008, a major milestone was met when the two 
Departments formed the IPO. In December, the DOD Delegation of 
Authority Memorandum, Establishment of the DOD/VA IPO within the Under 
Secretary of Defense for Personnel and Readiness was signed.
    The IPO's original focus was on EHR systems and other healthcare 
datasharing initiatives between DOD and VA. The scope of the IPO was 
later expanded by the Senior Oversight Committee (SOC) at the 
recommendation of the Overarching Integrated Product Team (OIPT) to 
include personnel and benefits electronic data sharing. The 
responsibility for developing requirements and technical execution of 
information technology solutions remains with the respective DOD and VA 
organizations. Technical execution will also remain in the appropriate 
DOD and VA offices, using the Departments' respective established 
statutory and regulatory processes for acquisition, funding, management 
control, information assurance, and other execution actions.
    The IPO oversees actions to accelerate the exchange of healthcare 
information between the Departments. In this capacity, the IPO is 
responsible for working with the Departments on joint functional 
activities such as supporting the definition of DOD/VA datasharing 
requirements, ensuring DOD/VA schedules are coordinated for the 
technical execution of the DOD/VA datasharing initiatives, assisting in 
the coordination of funding considerations, and assisting in obtaining 
the input and concurrence of stakeholders. Additionally, the IPO 
monitors and provides input on personnel and benefits electronic 
datasharing initiatives between DOD and VA.
    In order to provide initial staff for the IPO, an Acting Director 
from the DOD and an Acting Deputy Director from the VA were detailed to 
the IPO, along with four military personnel. In August 2009, all four 
of these military personnel will be retired from active duty service. 
In January 2009, I was appointed as the acting Director of the IPO. Mr. 
Cliff Freeman is the acting Deputy Director. The IPO's initial full 
staffing structure consists of two Senior Executive Service positions, 
14 DOD and VA civilian Government Service positions, and a small 
contingent of contracted employees (up to 16). Of the government 
positions, three VA employees and one DOD employee are now hired and 
working. Candidates for four of the remaining position have been 
selected, and another six are in the final approval process. Additional 
staffing includes the possible hiring of another six contract support 
personnel. Ten contracted support staff are currently working on a 
full-time basis at the IPO.
Governance:
    The mission of the IPO will evolve over time. Currently, it 
provides a forum for high level coordination and guidance to ensure 
that full interoperability is achieved. In this role, the IPO will work 
in parallel with, and build upon the successes already achieved by the 
DOD/VA Joint Executive Council (JEC) and the SOC.
    The IPO receives guidance from the Secretaries of DOD and VA, and 
the JEC. The IPO works collaboratively with the Health Executive 
Council (HEC) for health related data sharing and the Benefits 
Executive Council (BEC) for personnel and benefits data sharing. The 
JEC provides leadership oversight of the HEC and BEC, as well as other 
councils or work groups designated by the co-chairs. If the IPO has 
issues that cannot be resolved at the HEC and BEC levels, we raise 
those issues up to the JEC.
DOD/VA Interagency Clinical Informatics Board:
    Early on, the IPO and the Departments agreed to turn to the 
Interagency Clinical Informatics Board (ICIB) to assist in the 
prioritization of DOD/VA health data interoperability initiatives. The 
ICIB is a professional organization comprised of clinicians from both 
DOD and VA. The Deputy Assistant Secretary of Defense for Clinical and 
Program Policy and the Chief Patient Care Services Officer, Veterans 
Health Administration, serve as its lead functional proponents. Through 
the ICIB, we enable the clinical community to define the items that 
must be shared by September 2009 in order to achieve full 
interoperability. Once the ICIB's needs for electronic data sharing are 
identified and prioritized, their recommendations are forwarded to the 
HEC for review and approval. Upon approval by the HEC, the list of 
priorities is handed off to requirements and definition teams, and then 
to our information technology teams to develop applications and tools 
to put them into operation.
      strategy and planning to meet the interoperability deadline
    The Departments and the IPO developed two key documents to serve as 
guides in our ongoing interoperability efforts. The DOD/VA Information 
Interoperability Plan (IIP) was signed September 15, 2008, delivered to 
Congress, and released to the Government Accountability Office. The IIP 
is updated and resubmitted annually. This document describes the 
current state of electronic data sharing between the Departments and 
provides the broad, strategic organizational framework for current and 
future work. It also establishes the scope and general milestones 
necessary to measure progress toward intermediate and long term goals. 
As capabilities become approved and funded, definitive milestones are 
incorporated into the DOD/VA Joint Strategic Plan (JSP). The JSP 
represents an effort to provide a more detailed roadmap for the 
Departments' interoperability goals.
    Together, the IIP and the JSP provide the Departments with a clear 
strategy to achieve our short-term, medium-term, and long-term 
electronic data sharing goals. By leveraging the prior accomplishments 
of the Departments toward the development of interoperable 
bidirectional electronic health records, efforts to achieve full 
interoperability of patient healthcare data are currently on track to 
meet the September 2009 deadline, in accordance with the plans laid out 
in the IIP and the JSP.
                               conclusion
    Beyond the 2009 Target for Interoperability:
    Efforts are underway to deliver full interoperability for the 
provision of clinical care by September 2009, and expanded 
interoperability capabilities beyond September 2009. However, both 
Departments and the IPO recognize that ``interoperability'' does not 
have a discrete end point, as technologies and standards continue to 
evolve. The Departments and the IPO will continue to take a leading 
role in the continued development of electronic health records data 
sharing.
    Looking ahead, the Departments believe that they are close to 
settling on a dramatic new approach to information sharing that takes 
advantage of cutting-edge developments in the information technology 
industry to create a single virtual lifetime electronic record that 
captures a servicemember's relevant health and benefits information 
from the time of accession to the time of burial. Through the 
Departments' joint adoption of a strictly-defined set of uniform 
software standards, an architectural framework can be created that is 
capable of integrating the best software health information technology 
systems from both the private sector and the government. This method of 
information-sharing has the potential to revolutionize the way that 
health and benefits data is shared between the Departments. Preliminary 
strategic-level planning for this effort is now underway.
    Thank you for the opportunity to address the committee, and to 
provide you with an update on the important work that we are doing to 
improve and advance electronic health information sharing between the 
DOD and the VA. I look forward to keeping you apprised of our progress 
as we move forward in support of our wounded, ill, and injured 
servicemembers, veterans, and their families.

    Senator Ben Nelson. Thank you, Admiral.
    Dr. Guice?

 STATEMENT OF KAREN S. GUICE, M.D., M.P.P., EXECUTIVE DIRECTOR 
 FOR THE FEDERAL RECOVERY COORDINATION PROGRAM, DEPARTMENT OF 
                        VETERANS AFFAIRS

    Dr. Guice. Good afternoon, Chairman Nelson, Ranking Member 
Graham, and Senator Hagen, Lieutenant Colonel Gadson, 
Lieutenant Colonel Rivas, Mrs. Rivas, Dr. Noss, and Lieutenant 
Kinard. Your strength and perseverance is a standard for all of 
us. Sixteen months ago, the FRCP was created to address 
services and benefits coordination problems across two large, 
complex systems of care and benefits.
    The FRCP is a joint program of DOD and VA, with VA serving 
as its administrative home. It is designed to provide oversight 
and coordination for very seriously or catastrophically 
wounded, ill, or injured servicemembers, veterans, and their 
families.
    To do so, the FRC develops a customized individual recovery 
plan that is used to monitor and track the services, benefits, 
and resources needed to accomplish the identified goals. The 
goals were those of the servicemember or veteran with input 
from their family or a caregiver and members of the 
multidisciplinary team. The number and types of goals are 
related to the medical problems, the stage of recovery, and the 
holistic needs of the family and client.
    Developing goals is a methodical process that begins with 
evaluation. FRCs review the relevant records and discusses 
specific challenges with the various healthcare providers and 
case managers. This appropriation allows for a structured 
dialogue with the client in developing the plan. The FRC and 
the relevant case manager determine responsibility and the 
timeline for implementing the steps necessary to reach a goal.
    The FRC then monitors progress with the case manager and 
the client, providing support and additional resources to both 
until the goal is reached. FRCs frequently organize meetings 
with providers, case managers, and clients to make sure 
objectives and expectations are clear. The plan and the goals 
change as the client progresses through the stages of recovery, 
rehabilitation, and reintegration.
    The FRC provides a single consistent point of coordination 
throughout this progression. Accountability for the plan rests 
with the FRC. Today, 14 FRCs are located at 6 military 
treatment facilities and 2 VA medical centers. All have a 
clinical background, with most being nurses or social workers. 
One is a vision rehabilitation specialist. All have prior 
experience in either the military or VA health care system.
    Collectively, they have over 200 years of professional 
experience, all at a Master's level, and many have advanced 
practice degrees. All have specialized knowledge in either one 
or more clinical areas. They frequently consult each other, 
bringing their collective knowledge and experience to bear for 
their clients.
    Currently, 257 clients are enrolled in the program. 
Seventy-five percent of these are still Active Duty. Generally, 
these clients are very seriously or catastrophically ill or 
injured and require a complex array of specialists, multiple 
interfacility transfers, and lengthy rehabilitation. 
Individuals are either referred to the program or identified by 
FRCs from daily census lists and during attendance at specialty 
team care meetings or downrange video conferences.
    On the back of our newly designed brochures is the new 
toll-free number to make it easier to refer potential clients 
or get additional information about the program. A description 
of the program is on the National Resource Directory's Web site 
and the VA's Operation Iraqi Freedom Web site. The program has 
a strategy to reach out to those who went through the system 
prior to its inception and who might still benefit from a 
recovery plan and care coordination.
    Care coordination improves service integration among 
different delivery systems and eases transition from one system 
of care to another. It's not a bandaid or an indication of 
failing systems. Instead, it is another step in the evolution 
toward a fully integrated system where care and benefits are 
organized around the multiple needs of individuals across the 
care continuum.
    FRCs, in keeping with this concept, coordinate the delivery 
of services and resources for servicemembers, veterans, and 
their families, in accordance with the goals identified in the 
plan. They work with military Services, RCCs, Tricare, VHA, 
VBA, other governmental resources, including State and local 
agencies, as well as the private sector. For those 
servicemembers and veterans not enrolled in the program, there 
are a variety of other programs, services, and resources 
designed to meet their needs through the DOD and VA. I 
appreciate your input and collaboration as the program matures, 
and I particularly appreciate your support, and I look forward 
to your questions. Thank you.
    Senator Ben Nelson. Thank you. You were all here and heard 
my comments about stove piping and the silo effect of agencies. 
Based on everything that you've heard thus far, and the GAO 
report, are you all of the opinion that we're breaking that 
down here so we can have a fully integrated system to smooth 
the transition and have it for every step along the way, 
including every aspect of the servicemember's life, as well as 
his or her family's? Is that fair to say, that what might have 
been there in the past is not there today?
    Ms. McGinn. Senator Nelson, I think we have to be 
constantly vigilant because of the nature of our organizations. 
I do think in the last 2 years, watching the collaboration 
between DOD and VA, at the highest level, not at the patient 
care level, has been extraordinary. I think one of the 
indications of that is the development of this FRC, where the 
SOC decided they wanted there to be one definitive person, and 
that person was decided that they would be administratively 
done by VA.
    I think that at our organizational high level, the co-
location of the offices, the people that we have put in place 
in an acting capacity, continue to build relationships with VA.
    Going forward, we not only have SOC issues that we work 
together on, but also JEC issues, which are the issues that 
cover all of the matters between DOD and VA, and we need to 
strengthen those relationships.
    DOD is leaning forward to do that and avoid having the 
kinds of silos that we've had in the past. As I said in opening 
remarks, we never really had a senior executive dedicated to 
breaking down those silos before, in terms of collaboration 
with VA, and now we will, so I'm hopeful for that.
    Senator Ben Nelson. Is that generally shared?
    Mr. Dimsdale. Sir, I would like to add my comments. It's 
not Kumbaya. Nothing is Kumbaya, but we talk daily. We sit 
side-by-side and work daily, and so the silos are breaking 
down. But there's a lot of work to continue. I want to assure 
you that it's an ongoing effort, and we're doing everything we 
can to move the ball in the right direction.
    Senator Ben Nelson. Are you in a position where if you run 
into a question of legal authorities, that you could bring back 
to us any kind of statutory change that might be necessary to 
further break it down or to establish this integrated system?
    Mr. Dimsdale. I believe so, sir.
    General Meurlin. Mr. Chairman.
    Senator Ben Nelson. Sure.
    General Meurlin. To bring it down to a lower level from 
what Ms. McGinn was talking about, we recently invited the 
Medical Director of the Richmond VA Polytrauma Unit to go over 
on a C-17--go over to Landstuhl and look at the operation 
there, collaborate with DOD physicians at the receiving point 
from the area of responsibility, and then come back in that 
operation.
    We're going to expand that program to the other VA 
Polytrauma Units. We're planning those forces together, which I 
think will help out in easing the transition and acceptance of 
patients as they come back.
    Yesterday, at the SOC that was mentioned earlier, in 
reviewing a way ahead for the DES system, the larger look at 
it, we saw both Deputy Secretaries, really, I think, in quite 
agreement and accord, which set a tone for the rest of the 
organization. So as Roger said, we have offices together in the 
palatial Hoffman Building down in the south end of Alexandria, 
and we're working together with staffs and mixing them. I think 
we're making great progress on that.
    Senator Ben Nelson. You mentioned on the FRCP that a 
decision was made as to which agency would probably be in the 
best position to administer this. Are you finding other areas 
where assigning one of the agencies the responsibility makes 
more sense than both agencies trying to coordinate work 
together on it?
    General Meurlin. Sir, since Dr. Guice and I have been 
working quite closely and commiserating on the two different 
bits of law, one that established the FRCs and then, later on, 
the NDAA that established the RCCs. Really pretty parallel 
programs. The question is, as we work through this, since they 
are so parallel, why not bring them both together? I think 
probably the initial intent was to have one program cover all 
niches, the FRCs for the ones that are most seriously injured 
and destined to depart from DOD and move into VA. But also, the 
Category 2, the middle level, that really are up in the air 
whether they will progress medically to return to duty or then 
depart.
    So I think there's a lot of questions there. I know that 
was the number-one priority or the number-one recommendation of 
the Dole-Shalala Commission. It's one that I think we're making 
progress in that area. I think it's going to be absolutely 
significant to the success of the recovery and reintegration of 
our soldiers, sailors, airmen, and marines.
    Senator Ben Nelson. Dr. Guice?
    Dr. Guice. I'd just agree with him.

    [After reviewing the transcript, Dr. Guice submitted the following 
change to the previous statement: ``I'd strongly agree with him.'']

    Senator Ben Nelson. Other comments that you might want to 
make about this progress?
    Ms. Embrey. Sir, I think VA has long been a source of 
expertise for PTSD and for severe TBIs within the Federal 
Government, and DOD has learned from its expertise and has been 
partnering with them on a variety of protocols, standards, and 
guidelines.
    We believe so strongly that when we set up our Center of 
Excellence within DOD, we made our deputy for that center a VA 
employee who retains employment with VA to ensure close 
integration of the programs of care for both DOD and VA through 
that Center of Excellence.
    Senator Ben Nelson. If the military can have joint 
commands, it would seem to me the agencies can find a way to do 
some of this jointly as well, recognizing how important it is, 
but also how common it can be to have both agencies have 
similar responsibilities because of the needs.
    Senator Graham.
    Senator Graham. Thank you, Mr. Chairman. This has been a 
very informative hearing, I think. To all who attended, thank 
you. This has helped the committee a lot, and we appreciate 
your time.
    I think we are making progress. I guess from the 30,000-
foot view of things, number one, you get injured, I want to 
make sure that you get a fair evaluation as to whether or not 
you're fit for duty. Right, General?
    First thing is, can this servicemember return back to 
service. Do you agree with that?
    General Meurlin. Absolutely.
    Senator Graham. Is that kind of a hope and dream of most 
people that are injured?
    General Meurlin. It is. Most people that are injured, the 
different hospitals and patients that I've visited with, that's 
their ultimate objective. Now, the question which was brought 
up in the first panel is, is that in their best interest?
    Even in the expedited process, we made sure that it was a 
provision that even though if they're catastrophically wounded, 
we expedite the DES process, and they leave the Service, that 
if they do retain a level that they can come back, that we 
allow for that provision to petition to come back.
    Senator Graham. The only reason I mentioned that is the 
Colonel Gadsons of the world. There's no other time in American 
history that someone like him would be able to serve. The one 
thing you want to do is to have a system that can capture 
people like him, but realize that a lot of these young men and 
women are going to have to move on to civilian life. All of 
them can't be integrated back into the military, so let's not 
lose sight of that.
    One of the goals is to make sure that the Colonel Gadsons 
of the world and others have a chance to continue to serve. 
Now, once the decision has been made that you're not going to 
be able to stay on Active Duty, I think that the goal here, 
between the two of you all, is the same. That when you leave 
DOD, I just want to make sure that when you go into the VA 
system, that whatever rehabilitative services you had as an 
Active Duty member, are not lost because your status changes. 
But here's the real problem. Most of these services are 
provided by centers that are exceptional. The Guard member, the 
reservist, or the person being discharged, may go back to a 
home area that's not nearly as robust as what WRAMC provides.
    That is what Dr. Noss is trying to tell us. Let's make sure 
that you could go back to Allendale, SC, for the medical 
requirement, where you're a guardsman or reservist. There's 
just going to be limitations as to the rehabilitation services 
available to you.
    What I want to do is make sure that whatever is available, 
that it's available as soon as possible, and we think outside 
the box. The goal is to reintegrate people in society. To come 
up with--I don't know if it's a voucher plan. I don't know 
exactly what it is. But the moment you hit medical retirement, 
the moment you go back into the civilian community, whether 
you're a guardsman or a reservist or medical retired Active 
Duty person, you go to a rural area, we want to do as much as 
far as you can, understanding there are limitations. 
Apparently, there are some areas of improvement there.
    The second problem is, General, you were talking about a 
report coming out in December, how the Nation can help care 
providers, family members who are going to provide care, 
income-wise. That is coming out in December. Is that right?
    General Meurlin. The preliminary study that CNA did, their 
preliminary results came out in December. The final results are 
going to be coming up very shortly.
    Senator Graham. The final results will suggest to Congress 
that we creative a revenue stream greater than we have today?
    General Meurlin. Yes, sir. There's proposed legislation 
coming forward for compensation for caregivers, that will 
provide for a benefit for caregivers equal and approximate to 
what a caregiver commercially would be earning.
    Senator Graham. That would last for how long?
    General Meurlin. As long as the individual requires.
    Senator Graham. Okay. I think that is a great idea, because 
we focus on the wounded warrior and their family member. They 
have to drop most of their hopes and dreams. That's just the 
way it is, and we want to help them where we can. Finally, Mr. 
Dimsdale, you were talking about standardized definitions. 
Mental health services available through DOD should be the same 
as VA when somebody falls into these programs. Whatever 
rehabilitative services, whatever definitions we have, are we 
moving down the road to getting standardization?
    Mr. Dimsdale. Yes, sir, but it is not easy.
    Senator Graham. I know it would be hard.
    Mr. Dimsdale. This is anecdotal, but there were like 45 
definitions we were working on, and I think we got agreement on 
about 35 out of the 45. There are policies, as far as benefits 
are concerned, based on the definitions. We are continuing to 
wicker this thing down, but we have a ways to go.
    Senator Graham. The category of somebody who's medically 
retired, not fit for duty, that, to me, is your first 
evaluation to make. Once that happens, what's the problem after 
that?
    Mr. Dimsdale. I'll give you an example. When you asked the 
question, I was writing notes and trying to get some answers. 
I'll give you an example. The definition of catastrophically 
injured entitles people to different things.
    Senator Graham. Based on what organization you're in, DOD 
versus VA?
    Mr. Dimsdale. As far as the determination of what is 
catastrophic? So Joe or Jane get injured, and we call them 
catastrophically injured. One agency may say one thing. Another 
may say another. What the individual gets is based on the 
definitional acceptance.
    Senator Graham. Are there differences within the Services, 
or just VA/DOD?
    Mr. Dimsdale. I cannot answer that, sir. I would have to 
get back----
    Senator Graham. But you know that is a definitional 
problem?
    Mr. Dimsdale. Yes, sir.
    Ms. Embrey. My sense is that it's a difference between DOD 
and VA. The authorization and the way the defense health 
program is set out and the benefits and whether we have prime 
and basic and different other kinds.
    Senator Graham. You're on to the problem. Just keep us 
informed. The more standardization, the easier it is for the 
case manager and the troops and their family to get through 
this thing. I know it's hard, but like Senator Nelson said, 
we're joining everybody else. It was hard. I never thought I'd 
be in an office.
    I went and did some Reserve duty in Iraq, and there was a 
coastguardsman there. That's the first guy I met, and he said, 
``What the hell are you doing here?'' We had people from 
everywhere, every branch of the Service guarding the Service. 
You couldn't tell the difference. This stuff does work.
    Thank you, Mr. Chairman.
    Mr. Dimsdale. Sir, let me do my homework, and we will get 
back to you for the record.
    Senator Graham. Sure, that's good.
    [The information referred to follows:]

    On 10 December 2008, the Overarching Integrated Product Team 
approved 33 wounded, ill, and injured related standard terms and 
definitions. Terms and definitions that have already been defined in 
the Code of Federal Regulations must not be used until after 
legislative changes have been made. Veterans Affairs and the Department 
of Defense continue to work on reaching consensus for additional terms 
and definitions that impact the wounded, ill, and injured servicemember 
and veteran.
    Proposed terms and definitions for major life activities, mental 
disorder, recovering servicemember, and serious illness or injury will 
require legislation.
    Attached is a copy of the signed agreement and the agreed upon 
definitions.
      
    
    
      
    
    
      
    
    
      
    
    
      
    
    
      
    
    
      
    
    
      

    Mr. Dimsdale. I don't want to send you a woof ticket. I 
want to get something straight.
    Senator Graham. I got you. Thank you for participating and 
serving our Nation.
    Mr. Dimsdale. Thank you.
    Senator Ben Nelson. Thank you, Senator. Senator Hagan?
    Senator Hagan. Thank you, Mr. Chairman. I can understand 
how confusing this would be for the men and women in the 
Service who obviously, once they're veterans, they've all been 
in DOD or the Reserves or the National Guard. Then it seems 
like they're in a different language and a different world 
going into VA. I think this committee is excellent, and I 
certainly think it is time that we try to mesh the two in a 
seamless fashion.
    Dr. Guice, I think you were talking a little bit, too, 
about some of the case manager aspects, and I know that 
Lieutenant Kinard said that he had eight different case 
managers. So these pilot programs you're doing now, is that 
actually going to solve those issues?
    Dr. Guice. The term ``case manager'' is a fairly ubiquitous 
and generic term. It is a term used to describe any 
organization service delivery system. You have case managers in 
the legal system. You have case managers in public assistance 
programs. You have case managers in healthcare. In healthcare, 
case managers are usually aligned with a service line or a 
specialty, but they exist within a single facility; for 
example, in a hospital or in an outpatient unit of a hospital. 
They are very key in actually organizing the individual's care 
in that facility.
    When the individual moves to another facility--for example, 
if you're at WRAMC and you go down to the polytrauma unit in 
Tampa, you would have another set of case managers similarly 
aligned because of your constellation of injuries.
    Having a care coordinator eases that transition. The care 
coordinator in the FRCP, for example, will stay with that 
servicemember and family when they transition over to the VA 
polytrauma unit, and then when they transition back, and 
however many transitions they need to make it through the 
medical system because specialized care occurs in a variety of 
different places.
    Care coordinators can help connect the dots for the 
individual, making sure that all the case managers are aware of 
any particular needs of that individual or family, and making 
sure it is as comfortable a transition as possible. Transitions 
are always difficult, but the coordination effort reduces the 
challenges veterans, servicemembers, and caregivers face.
    Senator Hagan. Do we have enough personnel to do the care 
coordinator model?
    Dr. Guice. I believe we do. I think it is under continuous 
evaluation, it may change tomorrow, depending upon what 
happens. It is always something that we are constantly looking 
at, recalibrating, and adjusting.
    Senator Hagan. Great. Then this is a follow-up to Senator 
Graham's question, but I really think that keeping our wounded 
warriors employed is critical, if they can be. Obviously, if 
it's a catastrophic injury, in many cases, they cannot.
    But I encourage the Services to devise road maps to enable 
our wounded warriors with additional skill sets, with the 
transition into civilian life, or perhaps the Services could 
utilize them in another capacity, keeping them on duty.
    These wounded warriors, if they could be trained to serve 
as administrative personnel, be assigned as case managers, be 
assigned as mentors to other wounded warriors. I was just 
curious as to what are your thoughts on this, and is this being 
done?
    General Meurlin. It is. On the first point that Senator 
Graham mentioned on Lieutenant Colonel Gadson being retained in 
the Service as a double amputee. In the Air Force, we had, a 
number of years ago, the first amputee above the knee who's 
flying. He's a pilot with the 89th and back on flying status. 
We've made a huge change in how we look at injuries.
    Part of the RCC program, this is a group that's 
administered by DOD that does the care management that Dr. 
Guice was talking about, and developing the comprehensive 
recovery plan for the individual, looks at where that 
individual wants to go, what his ultimate destination is, or 
hers, and then programs it along. We work with the Department 
of Labor. We work with VA. We work with the Services to see how 
they can be retained if they want to or how they want to 
transition.
    There are a number of programs out there. We've been 
working with one in the very infant stages now of training 
people to work within the Civil Service, actually leading them 
and training them while they're in that recuperative time to 
ultimately be employable. All of this, and this larger package 
gets taken care of or coordinated by the RCC or the FRCC to 
facilitate that smooth transition.
    Senator Hagan. Thank you. Thank you, Mr. Chairman.
    Senator Ben Nelson. Thank you, Senator. Thank you to all 
the panels for your candid and heartfelt testimony today. The 
journey has thus far been a long one, but we recognize that 
we're not at the conclusion of it yet. Even when we get to the 
conclusion, there will be a need to continue to work together 
to make certain that the integrated system continues to work 
forward. Thank you very much.
    The written testimony submitted by all witnesses today will 
be included in the record, without objection. Additionally, we 
received a statement from the Blind Veterans Association, and 
without objection, it too will be included in the record of 
this hearing.
    [The prepared statement of Dr. Zampieri follows:]
            Prepared Statement by Dr. Thomas Zampieri, Ph.D.
                              introduction
    Chairman Nelson, Ranking Member Graham, and members of the Senate 
Armed Services Subcommittee on Personnel, on behalf of the Blinded 
Veterans Association (BVA), thank you for this opportunity to submit 
our testimony for the record regarding the lack of progress on the 
implementation of the Wounded Warrior section 1623 of the National 
Defense Authorization Act (NDAA) for Fiscal Year 2008 to establish a 
program for the large numbers of military vision injured. BVA was 
established in 1945, and congressionally chartered in 1958, as the only 
Veterans Service Organization exclusively dedicated to serving the 
needs of our Nation's blinded veterans and their families, and BVA 
finds the bureaucratic problems associated with the slow implementation 
of the congressionally mandated NDAA Vision Center of Excellence 
section 1623, today demands more oversight by this committee and more 
direct questions today. The NDAA section 1623 required establishment of 
the joint Department of Defense (DOD) and Department of Veterans 
Affairs (VA) Vision Center of Excellence (VCE) and Eye Trauma Registry.
    On March 17, 2009, three Operation Iraqi Freedom (OIF) and 
Operation Enduring Freedom (OEF) seriously eye injured veterans 
recently testified and shared stories before the House VA subcommittee 
on Oversight and Investigations hearing on how there was and still is 
no Seamless Transition program for them between DOD medical treatment 
facilities and VA medical centers. Despite a dedicated working group of 
senior military and VA ophthalmologist and optometry professionals 
working since November 2007, with specific plans for how the joint 
Vision Center of Excellence should be established and operate, for 14 
months there has been a lack of administrative support, failure to 
approve organizational charter until February 2009, and according to 
several senior DOD sources a persistent funding challenge to establish 
this VCE. When asked how much has been spent on the Vision Center of 
Excellence since October 2008 at the House VA Oversight hearing the 
response was incredible low total of ``DOD has spent $7,000 for the 
Vision Center of Excellence'' and it was not until March 12,2009 that a 
letter was sent to Chairman Mitchell on the VA Oversight Subcommittee 
that $3 million had been identified for the VCE 13 months after 
congress required the establishment of the VCE.
                    obstacles to vce implementation
    OIF and OEF servicemembers with both penetrating eye trauma and 
Traumatic Brain Injury (TBI) visual impairment have had to wade through 
a DOD bureaucracy. DOD has given us the impression that, for them, an 
entire year's time to create an organizational charter is actually not 
that long. Persistent excuses for lack of action range from ``no plan 
was approved for VCE'' to, of course, ``no funding has been found to 
create VCE.''
    When NDAA was enacted in January 2008, an immediate reaction from 
some senior level Assistant Secretary of Defense for Health Affairs 
officials was that VCE was an ``unfunded mandate by Congress'' that 
would cost ``an estimated $5 million that we do not have built into 
this fiscal year 2008 year's budget.'' If this were the case, questions 
should be asked at Pentagon, ``Why were these funds not requested in 
either last year's May 2008 War Supplemental (H.R. 2462) when $162 
billion'' was provided for, among other things, ``wounded warrior 
care'' or, better yet, in the fiscal year 2009 Defense Appropriations 
request to cover this fiscal year 2009 year's start-up costs. Instead, 
on April 12, in early June, and again in early August at the Skyline 
Drive office of the Assistant Secretary of Defense for Health, then 
once again on September 24, senior officials repeated the claim that 
finding even the bare minimum of $3 million to fund start-up costs for 
the Vision Center of Excellence VCE presented a very significant 
funding challenge.
    For 4 years, BVA has attempted to bring to the attention of the 
Armed Services Committees, the Defense Appropriations Committees, both 
VA Committees, DOD Health Affairs, and the Veterans Health 
Administration (VHA) the ever-increasing prevalence of combat eye 
trauma and TBI visual dysfunction among servicemembers. We have become 
increasingly concerned about the growing numbers of both the battle 
wounded who have penetrating direct eye trauma (13 percent of all 
evacuated wounded have experienced eye trauma) and/or TBI-related 
visual complications (64 percent with TBI have tested positive for 
visual dysfunction).
    Responses to these pleas have included ``the need to wait until the 
next plan is approved,'' ``NDAA reports come late for review,'' 
``inability to find office space,'' and the aforementioned ``lack of 
funding.'' The cumulative result of these responses has been delayed 
action, scarce resources for establishment of the VCE, no dedicated 
space, no request for funding for staffing or construction even today 
while witnesses testify before your committee.
    The Pentagon did appoint the first Director of VCE in November 
2008. Colonel Donald Gagliano is a highly qualified and dedicated 29-
year Army career ophthalmologist who served in Iraq for 1 year. Also 
appointed was an equally well-qualified VA Deputy Director of VCE, Dr. 
Claude Cowan with distinguished career in ophthalmology research, 
education, and clinical practice here in Washington DC VA medical 
center. BVA fully supported both of these appointments. The two 
directors of the VCE have entered these challenging positions with 
virtually no office space, little staffing support, funding for 3 onths 
of $7,000, no organizational charter until February 2009, and thousands 
of combat eye-wounded servicemembers and veterans spread across various 
military medical facilities and VA medical centers. Thanks to MILCON/VA 
Appropriations Chairman Chet Edwards, VA received a $2 million 
appropriation for IT Registry support for fiscal year 2009. Although 
Senate MILCON/VA Appropriations Chairman Tim Johnson also helped 
provide an additional $6.9 million to VHA, questions persisted for 
months regarding a plan on how to use these funds because of lack of 
implementation of the VCE within DOD.
    The OIF and OEF eye wounded who have recently enrolled in the VA 
health care and benefits system never should have encountered this 
difficult process. Quick action by Secretary Gates, in cooperation with 
Secretary Shinseki and with the full attention of the Senior Oversight 
Committee, is now vital to correct this mess and these witnesses must 
explain why this process has been delayed.
    BVA emphasizes that the clinical skills of the DOD professional eye 
care providers, both ophthalmology and optometry, have been excellent. 
In many cases, they have been no less than outstanding. Ophthalmology 
surgery not possible during previous wars has saved the vision of many 
soldiers and marines. Nevertheless, the system that organizes and 
administers such treatment must become accountable for all battle eye 
wounded and TBI patients affected. It must answer for the lack of 
action inherent in its failure to begin staffing procedures that will 
eventually reach 12 positions, failure to locate office space, and 
failure to address the issue of construction renovation funding for the 
National Naval Medical Center.
             prevalence and incidence of visual impairments
    As of September 2008, VHA reported 8,747 diagnoses of TBI with 
approximately 7,500 in diagnostic testing for possible TBI. Improvised 
Explosive Device (IED) blasts contributed to more than 60 percent of 
these injuries. As of January 30, 2009, a total of 33,993 
servicemembers had been wounded or injured by accidents in Iraq. The 
number of those wounded in hostile operations and requiring air medical 
evacuation from Iraq between March 19, 2003, and January 30, 2009, from 
one early report was 9,375, of which an estimated 13 percent (1,219) 
had sustained combat penetrating eye trauma. Some 135 of this number 
blinded have enrolled in VA Blind Rehabilitation Service (BRS) 
programs. This past November, however, the Military Surveillance 
Monthly Report contained an article from DOD on eye injuries among 
members of Active components (U.S. Armed Forces, 1998-2008) that 
detailed, by ICD, diagnostic code searches turning up 4,970 perforating 
and penetrating eye trauma cases, 4,294 chemical or thermal burns, and 
686 damaged optic nerves, most of which were from among OIF and OEF 
injured.
    The number of direct battle eye injuries does not include estimates 
of all moderate-to-severe TBI servicemembers or veterans who have 
visual dysfunction, according to VA research of those tested by either 
neuro-ophthalmologists or low-vision optometrists at a few military and 
VA centers. We stress that while only a small percentage of the eye 
injured meet the legal blindness definition of 20/200 or less of visual 
acuity, those with neurological vision dysfunction from mild, moderate, 
or severe TBI will require long-term VA eye care follow-up in low-
vision clinics. Veterans with a history of ocular battle injuries are 
also at high risk of developing retinal detachments, traumatic 
cataracts, glaucoma, and other delayed TBI neuro-visual complications 
that can occur years after the initial injury.
    The top three contributors to combat eye injuries have been 
Improvised Explosive Devices (IEDs), Rocket-Propelled Grenades (RPGs), 
and Mortars, with IEDs causing 56.5 percent of all eye injuries in 
Iraq. Just how many servicemembers have actually sustained moderate-to-
severe TBI injuries to the extent that they are experiencing neuro-
sensory visual complications is anyone's guess. The estimates in 
professional journals and other publications indeed change from month 
to month. The 64 percent figure (those with TBI who have experienced 
visual dysfunction) represent those with associated neurological visual 
disorders of diplopia, convergence disorder, photophobia, ocular-motor 
dyshnction, color vision loss, and an inability to interpret print. 
Some TBIs result in visual field defects with enough field loss to meet 
legal blindness standards. We are also finding ever increasing numbers 
of TBI-caused ``functionally blinded'' OIF and OEF veterans who, while 
not legally blind, are unable to perform normal daily activities 
because of loss of vision. More TBI visual screening, diagnosis, 
treatment, and new outcome studies should be initiated without delay.
    One early VA research study (2005) of OIF and OEF servicemembers 
who had entered the VA system with an ICD-9 (diagnostic code) search 
found 7,842 individuals with a traumatic injury of some kind. 
Consistent with recent media articles and VA reports, the most common 
traumatic injury diagnoses were hearing loss and tinnitus (63.5 
percent). We now know that 94,191 of the more than 1.5 million troops 
who have served in OIF and OEF are now service-connected for tinnitus 
while 78,076 are service-connected for hearing loss. A major cause of 
this hearing loss (60 percent of the cases) is exposure to IEDs. The 
second most common VA diagnostic code was for visual impairment (27.9 
percent). We submit to this subcommittee that the cases of sensory loss 
of hearing and visual impairment as a result of TBI constitute has been 
a ``the sensory silent epidemic'' not widely reported by DOD or the 
media. They are, nevertheless, the #1 hearing loss, and #2 vision 
injuries from OIF and OEF combat injuries.
                 neurological impact of tbi dysfunction
    Perception plays a major role in an individual's ability to live 
life. Although all senses play a significant role in perception, the 
visual system is critical to perception, providing more than 70 percent 
of human sensory awareness. With hearing being another critical 
component, IED blast injuries can obviously impair markedly these two 
key sensory systems.
    Vision provides information about environmental properties. It 
allows individuals to act in relation to such properties. In other 
words, perceptions allow humans to experience their environment and 
live within it. Individuals perceive what is in their environment by a 
filtered process that occurs through a complex, neurological visual 
system. With various degrees of visual loss comes greater difficulty to 
clearly adjust and see the environment, resulting in increased risk of 
injuries, loss of functional ability, and unemployment. Impairments 
range from loss in the visual field, visual acuity changes, loss of 
color vision, light sensitivity (photophobia), and loss of the ability 
to read and recognize facial expressions.
    Although one can acquire visual deficits in numerous ways, one 
leading cause is injury to the brain. Damage to various parts of the 
brain can lead to specific visual deficits. Some cases have reported a 
spontaneous recovery but complete recovery is unlikely and early 
intervention is critical. Current complex neuro-visual research is 
being examined in an attempt to improve the likelihood of recovery. 
Nevertheless, the extent of the recovery is often limited and will 
usually require long-term follow-up with specialized adaptive devices 
and prescriptive equipment.
    The brain is the most intricate organ in the human body. The visual 
pathways within the brain are also complex, characterized by an 
estimated two million synaptic connections. About 30 percent of the 
neocortex is involved in processing vision. Due to the interconnections 
between the brain and the visual system, damage to the brain can bring 
about various cerebral visual disorders. The visual cortex has its own 
specialized organization, causing the likelihood of specific visual 
disorders if damaged. The back of head, the occipitotemporal area of 
the brain is connected with the ``what'' pathway. Thus, injury to this 
ventral pathway leading to the temporal area of the brain is expected 
to affect the processing of shape and color. This can make perceiving 
and identifying objects difficult. The occipitoparietal area (posterior 
portion of the head), is relative to the ``where,'' or ``action'' 
pathway. Injury to this dorsal pathway leading to the parietal lobe 
will increase the likelihood of difficulties in position (depth 
perception) and/or spatial relationships. In cases of injury, 
individuals find it hard to determine an object's location and may also 
discover impaired visual navigation.
    It is highly unlikely that a person with TBI will have only one 
visual deficit. A combination of such deficits usually exists due to 
the complexity of the organization between the visual pathway and the 
brain. The most common cerebral visual disorder after brain injury 
involves visual field loss. The loss of peripheral vision can be mild 
to severe and requires specific visual field testing to be correctly 
diagnosed. In turn, a number of prescribed devices are frequently 
necessary to adapt to this loss.
    Accompanying such complex neurological effects on the patient is 
the overwhelming emotional impact of brain injury on the patient and 
hislher family. BVA would ask the Senate Armed Services Committee 
members to seriously consider the ramifications of such visual 
injuries. Brain injuries are known for causing extreme distress on 
family members who must take on the role of caregivers. According to a 
New England Journal of Medicine report of January 30, 2008, TBI 
``tripled the risk of PTSD, with 43.9 percent of those diagnosed with 
TBI also afflicted with PTSD.''
    At present, the current system of screening, treatment, tracking, 
and follow-up care for TBI vision dysfunction is inadequate across the 
systems. Adding visual dysfunction to this complex mix of other 
physical and mental injuries, especially if undiagnosed, makes attempts 
at rehabilitation even more daunting and potentially disastrous unless 
there are significant improvements in the screening, treatment, 
tracking, and follow-up care through the proposed and legislated Vision 
Center of Excellence.
                     vce to address critical issues
    BVA believes that the VCE Eye Trauma Registry is where vital 
components for research, best practices, outcome measures, and 
education can be developed and refined for the eye trauma wounded and 
those with TBI vision dysfunction. Critical vision research coordinated 
with the Defense Veterans Brain Injury Centers and Defense Centers of 
Excellence for TBI can facilitate effective eye trauma research between 
DOD and VA. We predict that the number of TBI-injured will again 
increase beginning this spring as the troop surge into Afghanistan gets 
underway.
    BVA wishes to clear up false misinformation about VCE that has 
recently become commonplace: First, VCE is not to be one large clinical 
eye treatment center for all combat eye injured. It is better 
understood as ``a virtual center with connectivity'' to the four major 
military trauma centers identified last June in testimony before VA 
Committee as (Bethesda National Naval Medical Center, Brooke Army 
Medical Center, Madigan Army Medical Center, and San Diego Naval 
Medical Center), the soon-to-be five VA Polytrauma Centers. The VCE 
will connect there and the hundreds of other military or VA medical 
centers where the highest proportion of eye-injured and TBI-wounded are 
already receiving specialized eye surgery care and low-vision 
optometric services.
    Second, VCE is not a DOD blind center or rehabilitation facility. 
It will, however, coordinate its work with the already existing, 
skilled, multidisciplinary VA Blind Rehabilitation Centers (BRCs) and 
low-vision clinics with decades of experience treating blinded 
veterans. The VCE Eye Trauma Registry will track all eye injured and 
TBI visually impaired, coordinate joint vision research, promote best 
practices, and develop educational information on vision services for 
both providers and families.
                     va brs and low-vision services
    A positive note is that the challenges inherent in the growing 
number of returning OIF and OEF servicemembers needing screening, 
diagnosis, treatment, and a coordinated Seamless Transition of services 
can be met by the existence of world-class VA BRCs. The programs 
provided at such centers now have a 60-year history. In the larger 
picture of VA programs for blind and visually impaired veterans, BVA 
began working more than 4 years ago to ensure that VA expand its 
current capacity to serve blinded veterans. Such expansion became 
necessary as the aging population of veterans with degenerative eye 
diseases requiring specialized services has continued to increase.
    As a result of efforts to broaden and increase services, 54 new 
outpatient intermediate low-vision and advanced blind rehabilitation 
outpatient programs already have specialized staffing in place. Many of 
these new programs are opening with veteran-centered, low-vision 
specialized teams providing the full range of basic, intermediate, and 
advanced rehabilitation services. Accompanying these gains is special 
VA emphasis on outcome measurements and research projects within VHA. 
The VA approach of coordinated team methods for rehabilitation care has 
unlocked strategies for new treatments and provided the most updated 
adaptive technology for blinded veterans. The new, specialized low-
vision and blind programs already existing within the VA system must be 
utilized by DOD through VCE. The eye injured must receive high quality 
health care with proven outcomes that include constantly emerging 
vision research.
    The mission of each Visual Impairment Services Team (VIST) program 
is to provide blinded veterans with the highest quality of vision loss 
services and blind rehabilitation training that truly help them adjust 
to the major changes they have experienced in their lives. To 
accomplish this mission, VISTs have established mechanisms to 
facilitate more completely the identification of blinded veterans and 
to offer a review of benefits and services for which they are eligible. 
The VIST concept was created in order to coordinate the delivery of 
comprehensive medical and rehabilitation services for blinded veterans. 
VIST Coordinators can assist not only newly blinded veterans with 
timely and vital information leading to psychosocial adjustment, but 
can also provide similar assistance to their families.
    Seamless Transition from DOD to VA is best achieved through the 
dedicated work of VIST Coordinators and Blind Rehabilitation Outpatient 
Specialists (BROS) but many DOD case managers are unaware of these key 
contacts. They are in a unique position to provide comprehensive case 
management services to returning OIF/OEF service personnel for the 
remainder of their lives if consulted. VIST Coordinators are now 
following the progress of 135 recently OIF or OEF blinded veterans who 
are being served on an outpatient basis and 585 low vision veterans. 
The VIST system currently employs 112 full-time and 43 part-time 
Coordinators. There are 39 full-time BROS/VIST teams who also manage 
these cases and VA is process of recruiting another 28 BROS for these 
clinics for veterans.
    The VA BROS is a highly qualified professional. Many BROS hold 
Masters Degrees in both Orientation and Mobility and Rehabilitation 
Teaching. BROS also receive extensive cross-training at 1 of the 10 
BRCs nationwide. The training prepares such individuals to provide, in 
the veteran's home environment, the full range of mobility, living, 
adaptive, manual, and other skills essential to blind rehabilitation. 
VIST/BROS teams are also well equipped to provide excellent local 
services on a continuing basis when a veteran returns home from an 
inpatient stay at a BRC.
    Advanced Outpatient Rehabilitation Programs occur in ``Hoptel'' 
settings, as VA calls them. Hoptel sleeping arrangements function 
perhaps more like hotels than hospitals. Such programs offer Skills 
Training, Orientation and Mobility, and Low-Vision Therapy for veterans 
who need treatment with prescribed eye wear, magnification devices, and 
adaptive technology to enhance remaining vision.
    A VIST Coordinator manages the blind programs with other key staff 
consisting of certified BROS, Rehabilitation Teachers, Low-Vision 
Therapists, and a part-time Low-Vision Ophthalmologist or Optometrist. 
Medical, surgery, psychiatry, neurology, rehabilitative medicine, 
pharmacy, physical therapy, and prosthetics services can all be 
consulted as needed within the VA Medical Center, effectively providing 
the full continuum of care for the OIF and OEF veterans. DOD and VA are 
in the process of developing a bi-directional electronic eye trauma 
Registry that exchanges eye surgery records and clinical eye 
examinations case information. BVA warns that Private agencies that 
offer blind rehabilitation would rarely have full on site consultative 
medical services, surgical subspecialties, and psychiatry all co-
located within one facility, meaning veterans and their families would 
have to travel additional distances to obtain needed outpatient care 
for other conditions, adding to wait times for consultants, delays in 
obtaining prescribed medications, or waiting on new treatment plans and 
disrupting critical training time for orientation or mobility blind 
training. BVA strongly recommends that private agencies utilized for 
any services provide evidence of peer reviewed outcome studies, quality 
assurance standards, research experience, and information technology 
systems that can exchange records to VA system. We also recommend that 
they be accredited by the Commission on Accreditation of Rehabilitation 
Facilities CAW, that they are required to utilize VA electronic health 
care records for clinical standards of care, and that they meet 
specific outcome measures for contracts.
    Another important model of service delivery that does not fall 
under VA BRS is the VICTORS program, or the Visual Impairment Center to 
Optimize Remaining Sight. VICTORS is an innovative program that has 
been operated by VA Optometry Service for more than 18 years. The 
program consists of specialized services to low-vision veterans who, 
though not legally blind, suffer from visual impairments. Veterans must 
generally have a visual acuity of 20/70 through 20/200 to be considered 
for VICTORS. The program, entirely outpatient, typically lasts 3-5 
days. Veterans undergo a comprehensive, low-vision optometric 
evaluation. They receive prescribed low-vision devices and are trained 
in the use of adaptive technology to optimize functional independence.
    The Low-Vision Optometrists employed in the Intermediate Low-Vision 
programs are ideal for the highly specialized skills necessary for the 
assessment, diagnosis, treatment, and coordination of services for Iraq 
and Afghanistan returnees with TBI visual symptoms. This is because 
such veterans often require long-term follow-up services. The programs 
also assist the aging population of veterans with degenerative eye 
diseases. Such programs often enable working individuals to maintain 
their employment and retain full independence in their lives. They also 
provide testing for and research into the effectiveness of adaptive 
low-vision technology aids that have recently become available through 
training, review, and research. In conjunction with a wide network of 
VA eye care clinics existing in VA medical centers nationwide, combined 
VIST/BROS teams and Intermediate/Advanced Outpatient programs can 
provide a wide network of specialized services for these OIF and OEF 
veterans and their families once the VCE is fully operational.
    These new VA Advanced and Intermediate rehabilitative low vision or 
blind out-patient programs, are cost effective for high-need, low-
vision OIF/OEF veterans with residual vision from TBI. Combined VIST/
BROS teams and IntermediateIAdvanced Outpatient programs can provide a 
wide network of specialized services for servicemembers and their 
families in coordination with existing VA Eye Care clinics within VA 
medical centers. VCE is critical to the success of all of the 
aforementioned specialized VA services.
                              conclusions
    Serious combat eye trauma and visual dysfunction associated with 
TBI among OIF and OEF service personnel have become the second most 
common injury resulting from the two conflicts. More than 9,940 visual 
injuries have occurred and unknown thousands more have TBI visual 
dysfunction stemming from TBI if Rand Study projections are correct. We 
urge members ofthe full Senate Armed Services Committee to demand 
compliance with the existing NDAA requirements. DOD should have either 
requested from congress, or provided the $5 million funding for the 
remainder of fiscal year 2009 from the War Supplemental, for joint 
professional and administrative staffing, office space renovation 
funds, information technology funding, and the Senior Oversight 
Committee should have coordinated and complied with of all 
congressionally directed activities established in section 1623 Vision 
Center of Excellence and Eye Trauma Registry. The establishment of the 
Defense Intrepid Center of Excellence for Mental Health and the TBI 
Center of Excellence had $64 million for fiscal year 2009, but the VCE 
had no directed funding source causing delays and frustration between 
the two systems. Immediately establishing the VCE would substantially 
improve the multidisciplinary coordination, treatment, rehabilitation, 
and research into eye trauma and TBI-related visual impairment 
experienced by servicemembers and veterans throughout the DOD and VA 
systems.
    BVA again expresses sincere gratitude to this Subcommittee for the 
opportunity to present our testimony. We hope that you understand the 
deep sense of frustration we have felt over the course of the 14 months 
since NDAA established VCE. Simply put, the time for DOD and VA to 
implement the VCE fully as intended by Congress, is now. With the large 
numbers ofveterans suffering direct eye injury from battle and TBI 
visual dysfunction, further delay is unacceptable. Because the 
population of war wounded servicemembers and veterans is widely diverse 
geographically, it is not appropriate or reasonable that one military 
or VA medical treatment facility become the one eye clinical center for 
all eye-wounded servicemembers or for TBI patients with visual 
dysfunction. Depending on such an idea would be cost prohibitive and 
delay care for literally thousands ofmen and women veterans and having 
the VCE connect those various already existing sites ofeye surgery care 
is critical now.
    We request that the Armed Services Committee require that both 
Secretary Gates and Secretary Shinseki get VCEon track again and comply 
with all required reports on the implementation ofthis center within 30 
days of this hearing. The Defense Appropriations Committee should 
ensure in the next War Supplemental later this month that funding be 
included for the following necessary items as opportunity to add 
additional directed funding to fix this.
                            recommendations
         The Secretary of Defense and Secretary of Veterans 
        Affairs must immediately direct the Senior Oversight Committee 
        Executive Director to implement the organizational structure 
        and staffing for VCE and provide full DOD/VA clinical/
        administrative staffing. They must oversee the securing of 
        temporary office space for at least 12 staff members and see 
        that financial resources are in place to begin full 
        implementation of the operations of VCE. Assistant Secretary 
        Defense for Health Affairs should then report back to this 
        committee within 30 days. VHA was provided $6.9 million in 
        fiscal year 2009 for VCE these funds should be utilized now for 
        at least some of the expenses associated with VCE's 
        establishment.
         The military director of VCE, Colonel Gagliano, and VA 
        Deputy Director Dr. Cowan need immediate administrative staff 
        support, office equipment, travel funding, and educational 
        support resources from both DOD and VHA to implement the new 
        VCE joint program, with no less than $2,500,000 million to fund 
        the final quarters of fiscal year 2009 in the war supplemental.
         Congressional oversight should ensure that MILCON/VA 
        and Defense Appropriations Chairmen and Ranking Members review 
        budgets for fiscal year 2010 to ensure that they provide no 
        less than $6.8 million for VCE activities All Program 
        Operational Management initiatives should be funded for fiscal 
        year 2011, fiscal year 2012, and fiscal year 2013 as mandated 
        by the reporting clause in the National Defense Authorization 
        Act of 2009 and reported to this committee within 30 days of 
        this hearing date.
         The information technology Registry will require 
        $2,000,000 for fiscal year 2009.
         Some $2,000,000 million is urgently needed to fund 
        Navy Medical Center renovation construction project that will 
        renovate office space and other facilities at National Naval 
        Medical Center in Bethesda, MD, where VCE Headquarters is to be 
        located.
         VCE must be patient and family centered, 
        comprehensively coordinated, and compassionate. All DOD/VA case 
        managers need educational updates on the various VA specialized 
        vision programs for eye trauma and TBI visual dysfunction. 
        Veterans and family members need information on all VA 
        locations of blind services within VA. VIST/BROS teams must be 
        notified early in the treatment process of transfers to their 
        local area of any seriously eye-injured servicemember.
         It should be a virtual center providing real Seamless 
        Transition that ensures electronic bi-directional registry 
        exchange of both inpatient and outpatient eye care clinical 
        records that both DOD and VA eye care staff can update and 
        share with the Veterans Benefits Administration so that 
        benefits for service-connected injuries can be assessed.
         Private agency involvement in the treatment and 
        rehabilitation process should be narrowly limited to those 
        meeting strict accreditation, CARF accreditation, quality 
        educational, and university peer-reviewed medical research 
        criteria. Such agencies should be equipped with 
        multidisciplinary staff support and meet all Health Insurance 
        Portability and Accountability requirements required in 
        existing DOD policy.
         VCE should become involved in the DOD peer-reviewed 
        Congressionally Directed Medical Research Program (CDMRP) in 
        order to encourage additional TBI visual dysfunction research. 
        More eye trauma research in conjunction with DOD, VA, NIH, and 
        universities with VA academic affiliations is desperately 
        needed now. Potential long-term consequences of mild-to-
        moderate TBI in OIF/OEF veterans are still unknown. Discoveries 
        of such consequences will require new technology and diagnostic 
        research support. BVA, supported by the current Veterans 
        Service Organization Independent Budget, requests $10 million 
        for CDMRP in fiscal year 2010 as directed vision research.
               disclosure of federal grants or contracts
Blinded Veterans Association
    The BVA does not currently receive any money from a Federal 
contract or grant. During the past 2 years, BVA has not entered into 
Federal contracts or grants for any Federal services or governmental 
programs.
    BVA is a 501c(3) congressionally chartered, nonprofit membership 
organization.

    Senator Ben Nelson. This hearing is adjourned. Thank you.
    [Questions for the record with answers supplied follow:]
           Questions Submitted by Senator E. Benjamin Nelson
                       electronic health records
    1. Senator Ben Nelson. Ms. Melvin, one of the keys to seamless 
transition between the Department of Defense (DOD) and the Department 
of Veterans Affairs (VA) health care systems is the ability to share 
medical records of servicemembers who receive care through both medical 
systems. The Wounded Warrior Act required the Secretaries of DOD and VA 
to develop and implement electronic health record systems that would 
allow for full interoperability of personal health care information by 
September 30, 2009. What is your assessment of the progress of DOD and 
VA have made in development of fully interoperable electronic health 
care record systems?
    Ms. Melvin. DOD and VA have taken important steps toward the 
development of fully interoperable electronic health care record 
systems; however they have more to do--not all electronic health 
information is yet shared. As we have previously reported,\1\ the 
departments have achieved certain levels of interoperability (that is, 
the ability to share data among health care providers). This includes 
sharing pharmacy and drug allergy data at the highest level of 
interoperability--that is, in computable form, a standardized format 
that a computer application can act on, as well as structured and 
unstructured data in viewable form. As of January 31, 2009, the 
departments reported that they were exchanging computable outpatient 
pharmacy and drug allergy data on over 27,000 shared patients--an 
increase of about 9,000 patients since June 2008.\2\ Nonetheless, the 
departments were not sharing all electronic health data, such as 
immunization records and history, data on exposure to health hazards, 
and psychological health treatment and care records. In addition, while 
VA's health data are all captured electronically, information is still 
captured on paper at many DOD medical facilities.
---------------------------------------------------------------------------
    \1\ GAO, Electronic Health Records: DOD's and VA's Sharing of 
Information Could Benefit from Improved Management, GAO-09-268 
(Washington, DC: Jan. 28, 2009).
    \2\ GAO, Information Technology: Challenges Remain for VA's Sharing 
of Electronic Health Records with DOD, GAO-09-427T (Washington, DC: 
Mar. 12, 2009).
---------------------------------------------------------------------------
    DOD and VA have indicated that they have plans to further increase 
health information sharing. In this regard, they have identified the 
Joint Executive Council Strategic Plan and the DOD/VA Information 
Interoperability Plan as defining their planned efforts to provide 
interoperable health records. However, as we testified in March 
2009,\3\ neither plan identified results-oriented (i.e., objective, 
quantifiable, and measurable) performance goals and measures that are 
characteristic of effective planning and can be used as a basis to 
track and assess progress toward the delivery of new interoperable 
capabilities. Accordingly, we recommended that the departments develop 
such goals and measures to be used in reporting of interoperability 
progress.\4\ In the absence of results-oriented goals and performance 
measures, progress reporting is largely limited to describing 
activities completed and increases in interoperability over time.
---------------------------------------------------------------------------
    \3\ GAO-09-427T.
    \4\ GAO-09-268.

    2. Senator Ben Nelson. Ms. Melvin, what are the challenges DOD and 
VA are facing in the development of interoperable electronic health 
care records?
    Ms. Melvin. In their development of interoperable electronic health 
records, DOD and VA face challenges in the areas of performance 
measurement, standards setting and compliance, and program office 
operation. These areas are essential to effectively increasing 
electronic health information sharing. First, as mentioned previously, 
our March 2009 testimony \5\ noted that the departments' 
interoperability plans lacked the results-oriented (i.e., objective, 
quantifiable, and measurable) performance goals and measures that are 
characteristic of effective planning. Specifically, of 45 objectives 
and activities identified in the plans,\6\ only 4 were documented in 
results-oriented terms. Thus, the extent to which the departments' 
progress could be assessed and reported was limited to reporting on 
activities completed and increases in data exchanged (e.g., increases 
in the number of patients for which certain types of data are 
exchanged). Second, while DOD and VA have agreed on numerous common 
health information technology standards that allow them to share health 
data, the departments must also ensure that their health information 
systems are aligned with national health information technology 
standards. Any level of interoperability depends on the use of agreed 
upon standards to ensure that information can be shared and used. 
However, Federal standards are still evolving, which could complicate 
VA's and DOD's efforts to maintain compliance. The need to be 
consistent with emerging Federal standards adds complexity to the task 
faced by the two departments of extending their standards efforts to 
additional types of health information. Third, we noted that the 
departments had not completed all necessary activities required for the 
Interagency Program Office to be fully operational. Department 
officials stated that this office will be crucial in coordinating VA's 
and DOD's efforts to accelerate their interoperability initiatives. 
However, the departments have yet to complete key activities to set up 
the office. For example, they have not yet hired a permanent Director 
and Deputy Director. Until the departments complete key activities to 
set up the office, it will not be positioned to be fully functional, or 
accountable for fulfilling the departments' interoperability plans.
---------------------------------------------------------------------------
    \5\ GAO-09-427T.
    \6\ The plans are the November 2007 VA/DOD Joint Executive Council 
Strategic Plan for Fiscal Years 2008-2010 (known as the VA/DOD Joint 
Strategic Plan) and the September 2008 DOD/VA Information 
Interoperability Plan (Version 1.0).

    3. Senator Ben Nelson. Ms. Melvin, will DOD and VA be able to 
achieve the requirement for fully interoperable electronic health care 
records by September 2009, as required by the Wounded Warrior Act?
    Ms. Melvin. It is uncertain as to whether DOD and VA will achieve 
fully interoperable electronic health care records by September 30, 
2009. Specifically, in order to meet the September 2009 requirement, 
the departments have identified six objectives to increase their 
sharing of electronic health information.\7\ However, five of the six 
objectives are not documented in terms that allow the departments to 
measure and report their progress toward delivering new capabilities. 
For example, DOD identified an objective to increase sharing of 
inpatient discharge summaries with VA; however this objective does not 
reflect a need to report progress in quantitative terms (e.g., 
interoperability levels to be provided, locations and types of medical 
facilities to be included, and number and types of patients for whom 
data is to be shared). Without measurable objectives, the ability to 
ensure that the departments are taking the necessary steps to achieve 
their interoperability goals is limited.
---------------------------------------------------------------------------
    \7\ These six objectives are identified in the September 2008 DOD/
VA Information Interoperability Plan (Version 1.0).

                      vision center of excellence
    4. Senator Ben Nelson. Ms. McGinn, the Wounded Warrior Act required 
DOD to establish a Center of Excellence in prevention, diagnosis, 
mitigation, treatment, and rehabilitation of military eye injuries. How 
much money has been spent to date in support of this Center of 
Excellence and what progress has been made to establish the Center?
    Ms. McGinn. DOD is committed to improving the quality of vision 
care for our wounded warriors and veterans, who deserve the very best 
for the sacrifices they have made for our Nation. During the past year, 
Optometry and Ophthalmology Consultants from the DOD and the VA created 
the plan that laid the foundation for the Vision Center of Excellence 
(VCE). DOD analyzed and reviewed the necessary requirements and 
identified $3 million in funding that was available at the beginning of 
fiscal year 2009 to commence initial operating activities.
    Colonel Donald Gagliano, VCE Executive Director, and Dr. Claude 
Cowan, VCE Deputy Director, were appointed in November 2008 and have 
made significant progress in strategic planning to achieve the 
objectives of the VCE. The VCE leadership have identified primary 
resource requirements, including personnel, registry, facilities, TDY, 
equipment, and operational support to appropriately obligate the 
funding available. $20,000 has been obligated to date, however, the VCE 
is expediting the expenditure of the remaining funds as our resource 
requirements are now clearly defined and we expect to obligate most of 
the remaining funds by the third quarter of fiscal year 2009.
    The VCE has also made significant progress to fulfill its mission 
to improve the health and quality of life for members of the Armed 
Forces and veterans through advocacy and leadership in the development 
of initiatives focused on the prevention, diagnosis, mitigation, 
treatment, and rehabilitation of disorders of the visual system. The 
VCE is taking the steps outlined below to ensure members of the armed 
services and veterans who are visually impaired receive appropriate 
blind/vision rehabilitation quickly and effectively:
Operations
    DOD and VA officials have been meeting since last year to help 
shape initial operations. They have developed enabling documents, DOD 
Directive and VCE Charter, to establish the Center. The VCE acquired 
short-term space near TRICARE Management Activity headquarters in Falls 
Church, VA, to begin initial operations and is working to secure 
funding for a long-term facility at the Walter Reed Naval Medical 
Military Campus. This location allows for collaboration and synergies 
with the vision care providers and patients in the National Capital 
Region and will allow the VCE to best meet its congressional mandate by 
being in close proximity to the new National Intrepid Center of 
Excellence for TBI, the National Eye Institute of the National 
Institutes of Health (NIH), the Uniformed Services University, and the 
National Military Advanced Training Center, a facility for the 
reintegration and rehabilitation of injured servicemembers.
Registry
    The Defense and Veterans Eye Injury Registry (DVEIR) will provide 
data necessary to measure rates of injuries and longitudinal outcomes. 
This will support the VCE's efforts to ensure the ongoing improvement 
in care and care processes and to foster consistency of care across the 
entire continuum of care. Under an initiative led by the VA, an 
Ophthalmology, Optometry, and Information Technology workgroup from the 
VA and the DOD has been meeting since March 2008 and has developed a 
concept of operations for the DVEIR. The concept of operations, already 
approved by the VA, examines development options and details a 
recommended approach to implementing the DVEIR. A joint effort is now 
in place to identify the specific technical requirements for 
interoperability, develop a strategic plan and outline milestones for 
implementation of the registry. The VA initiated a Memorandum of 
Understanding (MOU) with the Joint Theater Trauma Registry for data 
exchange and they expect to have developed a mutually satisfactory 
strategy to populate the registry by the end of fiscal year 2009.
Research
    Research will also help the VCE accomplish its goals. VCE 
leadership established research priorities for the congressional 
Special Interest Vision Research Programs and the congressionally 
directed Medical Research Program through collaboration with health 
professionals from the DOD, VA, NIH, Food and Drug Administration, 
other Federal health entities, and the private sector. Grant funding 
will be awarded based on those priorities. The VCE will continue to 
work with DOD, VA, and other outside entities to move research forward 
and assist those in need.
Outreach
    Outreach is central to the VCE mission. VCE staff members will 
interact with visually impaired warriors and veterans to identify 
unaddressed needs and help close those gaps. Colonel Gagliano and Dr. 
Cowan have visited wounded warriors and veterans at Walter Reed Army 
Medical Center and other vision care centers and listened to their 
concerns and experiences. The VCE leadership has solicited input from 
other centers of excellence, related Federal health agencies, multiple 
vision/veterans advocacy organizations, and affected members of the 
armed services and veterans for the VCE way ahead. They have 
participated in numerous meetings and conferences on visual impairment 
for warriors, including the Defense Centers of Excellence Strategic 
Planning Summit. To expand the centers' outreach efforts, the VCE 
Executive Director was appointed as the DOD ex officio member of the 
NIH National Eye Advisory Council. Additionally, the VCE is 
coordinating with the VA Blind Rehabilitation Service to establish an 
MOU.

    5. Senator Ben Nelson. Ms. McGinn, is development of the VCE on par 
with the development of the Centers of Excellence for PH and Traumatic 
Brain Injury (TBI)? If not, why not?
    Ms. McGinn. The VCE and the Defense Centers of Excellence (DCoE) 
for PH and TBI have similar missions: to improve the health and quality 
of life for members of the Armed Forces and veterans. Pentagon 
surveillance data indicates there are approximately 40,000 veterans 
that have sustained a TBI from January 2003-March 2009. Due to the 
number of people affected and a gap in addressing TBI and PH, Congress 
established the DCoE and appropriated initial funding for the effort in 
the Fiscal Year 2007 Supplemental Appropriations bill. The DCoE has 
made significant advances in education, training, research, and 
treatment.
    Some of these TBI injuries result in visual disorders. Visual 
dysfunction caused by TBI may be difficult to recognize due to the non-
specific nature of many of these symptoms. In addition, visual symptoms 
may be overlooked during routine medical screenings and the onset of 
visual symptoms can be delayed. In addition to TBI-related visual 
disorders, the changing military environment and new mechanisms of 
ocular injury, such as blast exposure, pose new challenges to vision 
care specialists. These facts contributed to the impetus for creation 
of the VCE and the DVEIR. The DOD and VA established the 
congressionally-directed VCE in recognition of the increased rate of 
ocular injuries and visual impairment incurred during the Operation 
Iraqi Freedom and Operation Enduring Freedom conflicts. As a result of 
collaborative efforts between the VCE and DCoE, initial screening for 
TBI now includes screening for vision problems, and the DOD and VA are 
collaborating on the development of clinical guidelines, research 
priorities, and outreach initiatives. The DVEIR will also help 
researchers better understand these injuries by longitudinally tracking 
outcomes. Other information gained through the registry will ensure 
that affected warriors and veterans are properly diagnosed and treated.
    Colonel Donald A. Gagliano, the VCE Director, and Dr. Claude Cowan, 
the VCE Deputy Director, were selected in November 2008. The DOD 
allocated $3 million in fiscal year 2009 for initial operational 
capabilities of the VCE and the DOD and VA have made significant 
progress working together to ensure the VCE is fully operational in the 
shortest amount of time to assist our warriors and veterans. The 
advanced development of the DCoE, due to an earlier recognition of the 
urgent need to address PH and TBI, has been an immense help to the VCE. 
Efficiencies are being achieved through a robust partnership, and the 
DCoE collaborates with the VCE to provide strategic guidance and 
lessons learned. This approach has allowed the VCE leadership to be 
immediately active in outreach, research, and data collection and the 
VCE and DCoE will continue to work together and identify areas where 
collaboration will benefit their common mission of improving the health 
and quality of life for members of the Armed Forces and veterans.

      funding for the defense centers of excellence for ph and tbi
    6. Senator Ben Nelson. Ms. Embrey, over the past 2 years a great 
deal of money, to the tune of at least $600 million, has been put 
toward PH and TBI. Do you have an assessment of how much of these funds 
have been directed towards the Centers of Excellence for PH and TBI?
    Ms. Embrey. As part of the supplemental funding provided, the 
following amounts show the Operation and Maintenance funding allocated 
for the DCoE for PH and TBI:

          Fiscal Year 2007/2008: $123 million
          Fiscal Year 2009: $126 million

    The following amounts show the Procurement funding allocated for 
the DCoE for PH and TBI:

          Fiscal Year 2007/2009: $345,000

    The following amounts show the Research, Development, Test, and 
Evaluation funding for the DCoE for PH and TBI:

          Fiscal Year 2007/2008: $45 million
          Fiscal Year 2009/2010: $90 million

    7. Senator Ben Nelson. Ms. Embrey, what mechanisms are in place to 
vet and execute contracts to conduct research, and are there metrics in 
place to maintain timelines for actionable results?
    Ms. Embrey. The projects that were selected and funded were vetted 
by the U.S. Army Medical Research and Materiel Command's (USAMRMC) 
congressionally directed Medical Research Programs. In addition, 
USAMRMC manages the research projects, to include grant execution and 
project monitoring.
    The process includes a review of proposals conducted according to 
the two-tier review model recommended by the National Academy of 
Sciences Institute of Medicine. This model has received high praise 
from the scientific community, advocacy groups, and Congress. The first 
tier is a scientific peer review of proposals against established 
criteria for determining scientific merit. The second tier is a 
programmatic review that compares submissions to each other and 
recommends proposals for funding based on scientific merit and overall 
program goals. Programmatic reviews of proposals are conducted by the 
Joint Program Integration Panel.
    Fiscal Year 2009: For the obligation of future PH and TBI research 
funding, the DCoE for PH and TBI plans to include language developed by 
the U.S. Army Medical Research Acquisition Activity the fiscal year 
2009 request for proposals to increase its visibility and oversight of 
ongoing and future research TBI and PH projects. This language is in 
the process of being finalized.
    In support of ongoing research gap analyses and management of the 
DOD PH/TBI research portfolio, DCoE endorses the solicitation of 
periodic updates from funded research programs. The autonomous 
operation of independent research must be carefully weighed against 
both the needs of the Department to measure intermediate progress 
towards an end state of a particular research product and the 
expectation for transparent accountability that comes with public 
funding.

    8. Senator Ben Nelson. Ms. Embrey, do the DOD and VA maintain 
separate peer review processes for the evaluation of research 
proposals, or do they work together on proposals in the areas of PH and 
TBI?
    Ms. Embrey. The DOD and VA do maintain separate peer review 
processes for evaluating research proposals; however, the VA advises 
DOD research offices to develop program announcements and identify key 
research priorities, specifically in the areas of TBI and PH. VA and 
DOD personnel often serve as scientific peer reviewers on committees 
evaluating proposals, and the respective expertise is invaluable for 
determining feasibility and scientific merit. Additionally, VA staff 
serves as programmatic reviewers on integration panels to ensure 
understanding of each other's research portfolios, programmatic focus, 
and to help prevent funding overlap. These efforts help to reduce 
unnecessary redundant funding and help the agencies to leverage their 
existing resources.

    9. Senator Ben Nelson. Ms. Embrey, to avoid duplicative efforts, 
who is ultimately responsible to coalesce the projects being performed 
by agencies and entities, such as the VA and other Federal agencies, 
State and private universities, and nongovernmental organizations to 
identify gaps in research or treatment and to ensure we gain economies 
of scale in the efforts currently being undertaken to help improve the 
diagnosis and treatment of PH issues and TBI?
    Ms. Embrey. The DCoE for PH and TBI provides the nexus for research 
planning and monitoring across DOD and with other Federal and non-
Federal agencies. In addition, the DCoE engages in activities to 
identify gaps in research and to avoid duplication of effort by 
building a PH and TBI research community. These efforts include:

         Coordinating development of recommended PH and TBI research 
        strategies, requirements, and priorities jointly across 
        multiple agencies;
         Working with the VA, NIH, and the Department of Education to 
        define common data elements, definitions, metrics, outcomes, 
        and instrumentation standards for research in PH and TBI;
         Conducting a comprehensive scan for research activities 
        related to PH and TBI, and integrating research efforts of 
        component centers, including the Blast Injury Research Program, 
        VA, Federal agencies, and civilian organizations;
         Performing gap analysis using the Joint Process Integration 
        Panel to define requirements and priorities as inputs to the 
        overarching Health Affairs biomedical research, development 
        testing, and evaluation (RDT&E) portfolio, joint development of 
        requests for proposals, and both programmatic and peer reviews;
         Developing PH and TBI research and clinical practice 
        clearinghouse capabilities;
         Consolidating and disseminating best practices and monitoring 
        clinical investigations (non-RDT&E); and
         Translating research into practical tools, technologies, 
        protocols, and clinical practices.

    The DCoE is in the process of planning an interagency PH and TBI 
Research Portfolio Coordination Conference for the fall of 2009. This 
will help to provide the major Federal PH and TBI research funding 
agencies with an opportunity to develop a qualitative and quantitative 
understanding of each other's portfolios, and to coordinate them more 
strategically in the future.
    The DCoE actively collaborates with the following agencies and 
institutions:
DOD Agencies:
         Bureau of Medicine and Surgery
         Office of Naval Research
         U.S. Army Medical Research and Materiel Command
         Armed Forces Health Surveillance Center
         Armed Forces Institute of Regenerative Medicine
         Uniformed Services University of the Health Sciences
         Center for Neuroscience and Regenerative Medicine
         Joint Improvised Explosive Device Defeat Organization
         Defense Advanced Research Projects Agency
Federal Agencies:
         VA
         NIH
         National Institute on Disability and Rehabilitation Research
         Centers for Disease Control and Prevention
         Department of Health and Human Services
Non-Federal Institutions:
         Post Traumatic Stress Disorder (PTSD)/TBI Clinical Consortium 
        Coordinating Center
         TBI Multidisciplinary Research Consortium
         PTSD Multidisciplinary Research Consortium

                   virtual lifetime electronic record
    10. Senator Ben Nelson. Admiral Timberlake, on April 9, President 
Obama announced plans to create a Virtual Lifetime Electronic Record, 
which would expand on the idea of fully interoperable electronic health 
record capabilities to include personnel, benefit, and administrative 
information. Secretary Gates and Secretary Shinseki support this plan, 
and I believe they chose the Interagency Program Office to take the 
lead on coordinating this initiative. What effect has this decision had 
on the Departments' plans to execute a fully interoperable electronic 
health record system or capability?
    Admiral Timberlake. Regarding the policy guidance provided by the 
President and the Secretaries, the DOD/VA Interagency Program Office 
(IPO) is establishing a virtual lifetime electronic record working 
group to provide a focused requirements and management effort to 
accelerate the adoption and implementation of this new virtual lifetime 
electronic record approach. We are in the early planning stages for the 
virtual lifetime electronic record and will be developing the timelines 
as we progress, but it is important to note that this approach will 
leverage the Interagency Clinical Informatics Board (ICIB) in 
prioritizing common services for clinical care as the process moves 
forward. Currently the IPO is only tasked to facilitate the development 
of the various working groups and governance structure in determining 
the way ahead. Efforts related to the planning for, and implementation 
of, the virtual lifetime electronic record are not intended to be a 
replacement to our congressionally-mandated objective of achieving full 
interoperability for the provision of clinical care by September 2009. 
These two very important efforts are aligned and do not conflict with 
one another.

    11. Senator Ben Nelson. Admiral Timberlake, will this initiative 
require a new system platform? If so, how do the Departments plan to 
fund it?
    Admiral Timberlake. The foundation of the virtual lifetime 
electronic record effort is the implementation of a Services Oriented 
Architecture (SOA) approach using common services. This provides an 
environment in which functions can be standardized and used across 
systems and processes. This approach adopts industry best practices to 
provide an environment in which data may be accessed through links to 
legacy applications. The Departments are working together to identify 
what common services are needed, reconcile clinical and business 
practices where needed, and prioritize the common services to be built 
or acquired. As more common services are used by DOD and VA, the 
systems become more interoperable over time, leading to further 
interoperability and the effective and efficient sharing of data 
between the Departments.
    Certain platform changes will need to be implemented to carry out 
the virtual lifetime electronic record mission. Such upgrades include 
the use of SOA to ensure that both DOD and VA systems are able to 
evolve, allowing for the effective and efficient integration of data 
sharing capabilities and services that provide the greatest benefit to 
our beneficiaries. Utilizing a SOA approach will provide methods for 
the development and integration of services by grouping functionality 
among common business processes. As the common services to be developed 
or acquired are defined, the Departments will need to estimate the 
resources needed.

    12. Senator Ben Nelson. Admiral Timberlake, are DOD and VA still 
separately funding fixes and improvements to the DOD's electronic 
health record system, AHLTA, and the VA's health record system, VistA? 
How can electronic health record interoperability move forward with 
such a disjointed approach?
    Admiral Timberlake. The DOD and VA are currently funding fixes and 
improvements to their respective electronic health record systems. 
Electronic health record (EHR) interoperability at the present time is 
accomplished by ensuring the access to data using the Bidirectional 
Health Information Exchange (BHIE). The data are shared bi-
directionally, in real time, for patients who receive care from both VA 
and DOD facilities and are viewable at all DOD and VA medical 
facilities. BHIE permits DOD providers to view BHIE data from all VA 
medical facilities and VA to view BHIE data from all DOD facilities. 
The Departments will continue to use and upgrade their current EHRs to 
provide and document clinical care while the way forward using a common 
services approach is being implemented. The evolution to the virtual 
lifetime electronic record will be incremental and rely on legacy 
systems and new common services.

          employment training for transitioning servicemembers
    13. Senator Ben Nelson. General Meurlin and Mr. Dimsdale, many of 
our service men and women enter the military out of a desire to serve 
their country and receive the education, training, and job stability 
benefits the military affords. We train them to do their jobs serving 
our country, but if they are injured severely enough then we medically 
separate them. With growing economic concerns affecting job 
opportunities across the country, we owe it to the men and women who 
have served and sacrificed for our country to ensure they have the 
tools and skills to succeed in the civilian sector once they are 
separated from the military. What employment training do we provide for 
wounded, ill, and injured troops leaving the military?
    General Meurlin. DOD has a longstanding partnership with the 
Department of Labor Veterans Employment and Training Service and the VA 
Vocational Rehabilitation and Employment Service. DOD, DOL, and VA 
along with the Department of Homeland Security, formalized our 
partnership with a MOU. The MOU lays out each Department's areas of 
responsibility for the deliver of services and programs that fall under 
the Transition Assistance Program (TAP) and the Disabled Transition 
Assistance Program (DTAP). This includes programs, services, training, 
and new initiatives for the wounded, ill, and injured.
    DOD and the Military Services Pre-separation Counseling: The 
process to inform and educate servicemembers (including wounded, ill, 
and injured about employment assistance and job training) begins with 
the Military Services' Pre-separation Counseling sessions. During pre-
separation counseling, servicemembers are given an overview of the 
employment and training assistance available by DOL and VA, in addition 
to other resources and programs. The Military Service Transition 
Counselor, Army Career and Alumni Program Counselor, or the Navy 
Command Career Counselor schedule the servicemember to attend the next 
available 2\1/2\ day DOL TAP Employment Workshop, VA Benefits (4 hours) 
and DTAP (2 hour) Briefings as part of the preseparation counseling 
process.
    DOL TAP Employment Workshops: During the DOL 2\1/2\ day DOL TAP 
Employment Workshop, DOL's professional staff provides training and 
assistance on resume writing, developing cover letters, job search 
techniques, interview skills, and researching the job market (local, 
State, and national level), salary negotiation, dress for success and 
more. They also get information on translating their military skills 
into civilian language. DOL provides employment assistance, job 
training assistance and other DOL TAP services and programs which fall 
under the purview of the Secretary of Labor to all separating 
servicemembers, including our wounded, ill, and injured. DOL 
established the Recovery and Employment Assistance Lifelines 
(REALifelines) Program dedicated to providing individualized job 
training, counseling, and reemployment services to wounded, ill, and 
injured servicemembers. DOL has staff at 16 Military Treatment 
Facilities (MFTs).
    VA Benefits Briefing: During the VA Benefits Briefing sessions, 
wounded ill and injured servicemembers are informed and educated about 
all VA benefits. These include information on education and training, 
health care, home loans, life insurance, vocational rehabilitation and 
employment (VR&E), disability benefits, and others. In addition, those 
who are wounded, ill, and injured are also scheduled to attend a 
separate DTAP Briefing designed solely for servicemembers leaving the 
military because of a service-connected disability, injury, or illness 
that was aggravated by military service.
    Other Support and Employment Programs for Wounded, Ill, or Injured 
(WII): The Military Services along with other organizations provide 
many great support programs for wounded, ill, and injured. All of them 
play a pivotal role in helping our deserving servicemember with 
employment assistance and job training. The goal is to help WII 
servicemembers fulfill their aspirations and achieve their employment 
goals. Several programs and services are: Military OneSource; Army 
Wounded Warrior Program; Navy's Safe Harbor Program; Marine Corps 
Wounded Warrior Regiment; Air Force Wounded Warrior Program; Heroes to 
Hometown (a DOD partnership with the American Legion for WII 
servicemembers); DOL's most recent ``America's Heroes at Work'' project 
that focus on the employment challenges of returning servicemembers 
living with TBI and/or PTSD.
    Mr. Dimsdale. The VA Vocational Rehabilitation and Employment 
(VR&E) Coming Home to Work (CHTW) program provides career counseling, 
training and education, and employment assistance to wounded, ill, and 
injured servicemembers. VA has stationed full-time vocational 
rehabilitation counselors at major DOD MTFs. These counselors work with 
CHTW coordinators at VA regional offices. CHTW coordinators also 
provide outreach and counseling services at DOD warrior transition 
units, post deployment health reassessment events, and at DOD Yellow 
Ribbon events. The CHTW program eases servicemember transition into to 
civilian life by providing expedited and comprehensive training and 
employment services that lead to suitable employment.

    14. Senator Ben Nelson. General Meurlin and Mr. Dismdale, are there 
incentives for companies to hire veterans?
    General Meurlin. The Department of Labor has the Work Opportunity 
Tax Credit (WOTC). The WOTC provides employers with Federal income tax 
credits for hiring certain targeted groups. Veterans and disabled 
veterans are groups included in the WOTC. Employers can receive up to 
$4,800 in tax credits for hiring veterans. The Federal Government also 
has Executive Order 13360 which sets goals for Federal agencies to 
provide contract opportunities for Service-Disabled Veterans Owned 
Small Businesses. The Veterans Benefits Act (VBA) of 2003 established 
the set-aside programs for Service-Disabled Veteran-Owned Small 
Businesses (SDVOSBs). Under SDVOSB, ``a contracting officer may award 
contracts on the basis of competition restricted to'' SDVOSBs if he or 
she is reasonably expects that no less than two SDVSOBs will submit 
offers and the award can be made at a fair market price.
VA Programs that Offer Incentives:
    Special Employer Incentives (SEI) - offers private companies the 
opportunities to hire disable veterans who face extraordinary 
circumstances to obtaining suitable employment. The VA can pay the 
employer up to 50 percent of the veteran's salary for up to 6 months. 
This payment is to help the employer recoup losses in production for 
having a senior employee assist with training the veteran.
    On-the-Job Training (OJT) - OJT is for Federal, State, local 
government as well as private sector employers. Employers have the 
opportunity to hire veterans that may need additional training on the 
job. The employer pays less than the journeyman wage and the VA pays 
the veteran a subsistence allowance to bring the salary up to the 
journey wage. An OJT may be a maximum of 2 years. Over time the VA pays 
less as the employers' portion of the veterans' salary increases. At 
the conclusion of the OJT, the employer is paying 100 percent of the 
veteran's salary at the journeyman wage.
    Non-paid Work Experience (NPWE) - NPWE is for Federal, State, and 
local government employers. It allows a servicemember the opportunity 
for a smooth transition from military to civilian work by building 
confidence as they recover and rehab prior to being released from 
Active Duty. Although employment is not guaranteed, the employer is 
encouraged to consider hiring veterans when positions open. The 
employer may choose to use Federal special hiring authority to hire the 
veteran non-competitively: Disabled veterans enrolled in VA Training 
Programs or Schedule A. VR&E provides a subsistence allowance to 
veterans based on the number of hours worked per week.
    Mr. Dimsdale. There are several tangible incentives available for 
both Federal agencies and private sector firms to hire veterans. The 
VR&E VetSuccess program assists veterans with overcoming obstacles to 
employment such as lack of civilian work experience, gaps in 
employment, and serious employment handicaps. Federal, State, and local 
government employers may hire veterans through the non-paid work 
experience (NPWE) program or Federal on-the-job training (OJT) program. 
Private sector firms may hire veterans through the OJT program for 
nongovernment employers, or through the special employer incentive 
program.
    The NPWE program is for Federal, State, and local government 
employers. This program allows a servicemember or veteran the 
opportunity for a smooth transition from military to civilian work by 
gaining meaningful work experience. The number of hours worked per week 
may be full or part-time depending on the participant's and employer's 
needs. However, during the NPWE program, VR&E provides a subsistence 
allowance to veterans based on the number of hours worked per week. 
Although employment is not guaranteed, the employer is encouraged to 
hire veterans when positions are open. The NPWE program provides the 
opportunity for veterans to try a new job in a new setting, while 
allowing the employer to assess the veteran's work habits in the work 
setting. If the employer decides to hire the veteran, the employer may 
choose to use a Federal special hiring authority to hire the veteran 
noncompetitively: disabled veterans enrolled in VA training programs or 
schedule A.
    The OJT program may be used by Federal, State, local government, as 
well as private employers. Employers have the opportunity to hire 
veterans that may need additional training on the job. Through the OJT 
program, the employer pays the veteran less than the journeyman wage 
and the VA pays the veteran a subsistence allowance to bring the salary 
to the journeyman wage. Over time the VA pays less as the employer's 
portion of the veteran's salary increases. At the conclusion of the OJT 
program, the employer is paying 100 percent of the veteran's salary at 
the journeyman wage. An OJT program may be a maximum of 2 years.
    Another incentive program that private sector employers may use to 
hire veterans is the special employer incentive (SEI). This program 
offers private companies the opportunity to hire veterans with 
disabilities that face extraordinary circumstances to obtaining 
employment. Extraordinary circumstances may be the seriousness of the 
veteran's disabilities, training deficits, or significant gaps in 
employment. VA can pay the employer up to 50 percent of the veteran's 
salary for up to 6 months. This payment is to help the employer recoup 
losses in production for having a senior employee assist with training 
the veteran.
    Additionally, VR&E continues to partner with the Department of 
Labor (DOL) Veterans' Employment Training Service (VETS) program to 
advance, improve, and expand employment opportunities for veterans with 
disabilities. The VETS program is charged to provide training and job 
placement services to veterans, with a special emphasis on veterans 
with disabilities. The VETS program provides grant programs to States, 
which fund local workforce boards to provide services in local 
communities throughout the Nation. Services are provided by disabled 
veteran outreach and placement (DVOP) coordinators and local veterans 
employment representatives (LVER) at local ``one-stop'' workforce board 
organizations. The DVOPs and LVERs are also co-located at VR&E offices 
throughout the country. DVOPs and LVERs work with veterans in VR&E from 
initial orientation through successful job placement by providing labor 
market information, job readiness services (interviewing skills and 
resume preparation), and job placement assistance for veterans enrolled 
in the VR&E program.

    15. Senator Ben Nelson. General Meurlin and Mr. Dimsdale, we know 
there is a shortage of behavioral health care professionals nationwide. 
Would it make sense for the DOD to adopt a program where they retain, 
educate, and train behavioral health care professionals for the force? 
As in other education programs, the servicemembers would need to apply 
and be selected. Could this concept potentially work for those who are 
being medically separated?
    General Meurlin. All Service components provide career 
opportunities based upon level of injuries and aptitude. The Services 
have been tasked to give directives and assignment limitations for 
wounded warriors with an expected completion date of June.
    Additionally, the Department has, over the past 2 years, been 
expanding educational programs for non-physician behavioral health 
specialties and continues to look at other opportunities to improve 
front-line mental health care. We have been working with the University 
of Southern California, which has developed a new Military Masters in 
Social Work program, as a potential source of new clinical social 
workers. We are also considering the development of a scholarship 
program for training civilians in behavioral health fields. Advanced 
degree programs are also being created. The Uniformed Services 
University of the Health Sciences currently has a PhD in Clinical 
Psychology program for military students and a similar PhD in Medical 
Psychology program with a clinical track for research-oriented clinical 
psychologists in the academic tradition. The Army has a Masters program 
with Fayetteville State University, NC (taught in San Antonio, TX) that 
provides social workers in uniform with a special counseling skill on 
deployment issues.
    Mr. Dimsdale. This question is specific to DOD and cannot be 
addressed by VA.

          hiring authority for civilian health care employees
    16. Senator Ben Nelson. Ms. McGinn, the Wounded Warrior Act 
authorized enhanced appointment and compensation authority for civilian 
health care personnel by authorizing DOD to exercise any authority 
under chapter 74 of title 38, which covers pay and hiring authorities 
of the VA. This would enhance DOD's pay and hiring authorities for 
purposes of recruitment, employment, and retention of civilian health 
care professionals. Has DOD used these authorities? If not, does it 
plan to?
    Ms. McGinn. The Department uses recruitment and compensation 
authorities for health care practitioners under both the Office of 
Personnel Management (OPM) title 38 delegation agreement and the 
provisions of the Wounded Warrior Act.
    OPM delegated to the Department a number of the VA title 38 
authorities via an agreement that was originally issued in 1994, and 
which was subsequently updated in July 2002 and July 2006. Incident to 
this delegation agreement, the Department has instituted a number of 
compensation flexibilities, as described below, to facilitate 
recruitment and retention of health care practitioners. These 
authorities are working well and do not need any modifications to 
improve their effectiveness.

         Special Salary Rate Authority: This authority is currently 
        being used by DOD to set special salary rates. It is used 
        mainly for nurses and pharmacists.
         Baylor Plan: This authority was authorized for use in DOD in 
        1996, but has had limited application.
         Premium Pay: The authority to pay Call Back Premium Pay was 
        authorized in 1996.
         Head Nurse Pay and Nurse Executive Special Pay: Head nurse 
        pay was authorized in August 2005, and is currently in use in 
        the Department.
         Hours of Employment: There is no evidence that this authority 
        is being used. This authority may not be necessary given the 
        higher salary levels provided under the National Security 
        Personnel System (NSPS).

    Under the Wounded Warrior Act, the Department is pursuing two major 
initiatives: an expedited hiring authority for healthcare practitioners 
and a new compensation system for non-NSPS physicians and dentists. We 
expect the expedited hiring authority to be released to the components 
by July 1, 2009. The delay in its delegation stemmed from an assessment 
of a recent court case on adjudication of certain veterans preference 
cases and the impact that ruling would have on the procedures for this 
authority. We have received the necessary guidance and have written the 
procedures for using the authority. We also need information on what 
type of positions should be covered by this expedited hiring authority. 
That information has been requested and we expect to have it collected 
by mid-June.
    The Policy Instruction for the new physicians/dentists compensation 
pay system was issued in December 2008. We are currently finalizing the 
system procedures and applicable salary survey instruments, with a 
scheduled conversion date for late September 2009. This system will be 
applicable to non-NSPS physicians and dentists and will enable the DOD 
to pay these employees a salary comparable to that paid by VA and under 
NSPS.
    In addition to the title 38 authorities, DOD has been making very 
effective use of the title 5 recruitment, relocation, and retention 
incentives. In 2008, DOD spent approximately $46 million on these 
incentives for employees in the medical occupations. Over 4,500 
incentives were processed, with an average value of over $10,000.
    DOD continues to make effective use of the Physicians Comparability 
Allowance, and plans to do so until the allowance amount is included 
into the physicians' pay under the Physicians and Dentists Pay Plan or 
NSPS.

    17. Senator Ben Nelson. Ms. McGinn, does DOD need any additional 
legislation to implement these hiring authorities?
    Ms. McGinn. Not at the present time. The Wounded Warrior Act has 
authorized enhanced appointment and compensation authority for civilian 
health care personnel by authorizing the DOD to exercise any authority 
under chapter 74 of title 38. This enhances DOD's pay and hiring 
authorities for purposes of recruitment, employment, and retention of 
civilian health care professionals.

                 wounded warrior information resources
    18. Senator Ben Nelson. General Meurlin and Mr. Dimsdale, you both 
mentioned the National Resource Directory (NRD) in your written 
statements as a jointly developed source of national, State, and local 
information for servicemembers, veterans, and their families. How is 
the National Resource Center different from the Wounded Warrior 
Resource Center that was mandated by the Wounded Warrior Act as a 
single point of contact for wounded, ill, and injured servicemembers, 
veterans, families, and caregivers?
    General Meurlin. The NRD, www.nationalresourcedirectory.org), is an 
online tool for servicemembers, veterans, their families, and those who 
support them. It provides access to more than 11,000 services and 
resources from Federal, State, local government programs and agencies, 
as well as philanthropic, academic institutions and professional 
associations, nonprofit and community-based organizations, Veteran 
Service, and nongovernmental organizations. The NRD offers information 
on: Benefits and Compensation, Education, Employment and Training, 
Family and Caregiver Support, Health, Housing and Transportation, 
Services and Resources, and Key Contact Information.
    The NRD, maintained through a collaborative partnership among DOD 
Labor and VA, was created to answer the needs identified by wounded, 
ill, and injured servicemembers, veterans, and families to provide a 
comprehensive online tool available to assist in transitioning into the 
civilian community. It is also part of a larger effort to improve 
wounded warrior care coordination and access to information on services 
and resources, key goals identified by both the President's Commission 
on Care for America's Returning Wounded Warriors (Dole-Shalala 
Commission) and Title XVI, ``Wounded Warrior Matters,'' of the 2008 
National Defense Authorization Act (NDAA). The NRD will also assist 
with the MyeBenefits effort.
    In April 2009, there were more than 60,000 hits to pages within the 
NRD. The TAP received the most hits to a single page; over 20,000 users 
accessed some form of information contained with the VA's website.
    The Wounded Warrior Resource Center (WWRC) Web site, 
www.woundedwarriorresourcecenter.com, meets the requirements of NDAA 
for Fiscal Year 2008, section 1616, which states: ``(b) Access. The 
center shall provide multiple methods of access, including at a minimum 
an Internet website and a toll-free telephone number (commonly referred 
to as a hot line) at which personnel are accessible at all times to 
receive reports of deficiencies or provide information about covered 
military facilities, health care services, or military benefits.''
    In response to this mandate, The WWRC Web site, a DOD site, 
provides wounded servicemembers, their families, and caregivers with 
information they need on military facilities, health care services, and 
benefits. It provides access to 1,000 links and supports access to the 
WWRC Call Center (also mandated by the NDAA), run by Military OneSource 
(MOS) with trained specialists who are available 24 hours a day, 7 days 
a week by phone at 1-800-342-9647 or by e-mail at 
[email protected].
    The WWRC Web site also provides access to FAQs, handbooks, and 
checklists for servicemembers, their families, and caregivers.
    In April 2009, the WWRC had 1,362 hits.
    Mr. Dimsdale. The NRD is an online tool for servicemembers, 
veterans, their families, and those who support them. It provides 
access to more than 11,000 services and resources from Federal, State, 
local government programs and agencies as well as philanthropic, 
academic institutions and professional associations, nonprofit and 
community-based organizations, veteran service, and nongovernmental 
organizations. The NRD offers information on: benefits and 
compensation, education, employment and training, family and caregiver 
support, health, housing and transportation, services and resources, 
and key contact information.
    The NRD, maintained through a collaborative partnership among the 
DOD, DOL, and VA, was created to answer the needs identified by 
wounded, ill, and injured servicemembers, veterans, and families to 
provide a comprehensive online tool available to assist in 
transitioning into the civilian community. It is also part of a larger 
effort to improve wounded warrior care coordination and access to 
information on services and resources, key goals identified by both the 
President's Commission on Care for America's Returning Wounded Warriors 
(Dole-Shalala Commission) and Title XVI, Wounded Warrior Matters, of 
the 2008 NDAA.
    In April 2009, there were more than 60,000 hits to pages within the 
NRD. The TAP received the most hits to a single page; over 20,000 users 
accessed some form of information contained with the VA's Web site.
    The WWRC Web site meets the requirements of NDAA Section 1616 which 
states: ``(b) Access. The center shall provide multiple methods of 
access, including at a minimum an Internet website and a toll-free 
telephone number (commonly referred to as a hot line) at which 
personnel are accessible at all times to receive reports of 
deficiencies or provide information about covered military facilities, 
health care services, or military benefits.'' In response to this 
mandate, the WWRC Web site, a DOD site, provides wounded 
servicemembers, their families, and caregivers with information they 
need on military facilities, health care services, and benefits. It 
provides access to 1,000 links and supports access to the wounded 
warrior resource call center (also mandated by the NDAA), run by 
Military OneSource (MOS) with trained specialists who are available 24 
hours a day, 7 days a week by phone at 1-800-342-9647 or by e-mail at 
[email protected]. The WWRC Web site also provides access to 
frequently asked questions, handbooks, and checklists for 
servicemembers, their families, and caregivers. In April 2009, the WWRC 
had 1,362 hits.

    19. Senator Ben Nelson. General Meurlin and Mr. Dimsdale, does 
having two major similar resources duplicate efforts or risk causing 
confusion for wounded servicemembers and veterans and their families?
    General Meurlin. We believe that the WWRC Web site is duplicative 
of the information contained within the NRD. All of the links found on 
the WWRC Web site are also on the NRD. However the NRD, which is a tri-
agency effort between DOD, Labor, and VA, reaches a wider audience and 
offers more services and resources than the WWRC Web site.
    Mr. Dimsdale. VA believes that the WWRC Web site is duplicative of 
the information contained within the NRD. All of the links found on the 
WWRC Web site are also on the NRD. Additionally, the majority of the 
questions received on the WWRC Web site are similar if not the same as 
questions received on the MOS Web site, or received by the wounded 
warrior resource call center run by MOS. The NRD, as a tri-agency 
effort, reaches a wider audience and offers more services and resources 
than the WWRC Web site.

                           clean sheet review
    20. Senator Ben Nelson. Ms. McGinn and Mr. Dimsdale, the Senior 
Oversight Committee (SOC) initially established eight lines of action 
to address issues regarding warriors in transition. One of these lines 
of action, which is now completed, was called a Clean Sheet Design, to 
answer the question of what we would do, having reviewed all of the 
issues, if we could start over with a clean sheet of paper? Did this 
line of action recommend a system that would be different from what we 
have today? If so, what would it look like?
    Ms. McGinn. Yes. The Clean Sheet Design did recommend a system that 
would be different from what we have today.
    The major features of the Clean Sheet Design are:

         1. Ability Assessment. For both the decisions that determine 
        whether or not a person is fit to continue in military service 
        and that determine the level of compensation for those who are 
        leaving the military, these recommendations would provide for 
        an ability assessment rather than a disability evaluation. This 
        is perceived to encourage a focus on rehabilitation, education, 
        and training to reach full potential rather than a focus on 
        limitations. The assessment would include a psychological/
        physical medical evaluation, a mental acuity assessment, and an 
        aptitude assessment.
         2. Continuation of Military Service (COMS). These 
        recommendations would streamline and accelerate the process by 
        which servicemembers are identified as candidates for the 
        continuation of military service decision and help them move 
        more quickly to begin their assimilation into a new life (if 
        appropriate), while ensuring that there is no penalty (in terms 
        of benefits or compensation) from leaving the service and 
        providing return rights if full recovery is more extensive than 
        expected.
         3. Compensation. These recommendations provide for three 
        components of compensation: military service annuity (based on 
        years of service and base pay); income replacement (may be 
        permanent, but focused on providing income while recovering and 
        participating in vocational rehabilitation to transition to a 
        new career); and WII compensation that would recognize the 
        significant quality of life impact. (This could be adjusted up 
        or down throughout the servicemembers or veteran's life, 
        depending upon significant changes in conditions.)
         4. Care. These recommendations would establish open access to 
        all DOD and VA facilities for all wounded, injured, or ill 
        servicemembers or veterans to ensure that access to care is not 
        dependent on military status. (Enable joint facilities in 
        selected areas and promote the idea of `Federal health care 
        facilities' to ensure that servicemembers and veterans 
        understand that they are appreciated by their country and their 
        government, not just their military service.)
         5. Consolidated Access to Benefits. To ensure that 
        servicemembers and veterans do not have to navigate the myriad 
        of benefits (and associated paperwork) that may be available to 
        them, these recommendations would create an expedited, 
        centralized capability to support the process by which benefits 
        are identified, obtained, adjusted, and updated and ensure that 
        servicemembers, veterans, and their families have the correct 
        benefits available at the correct time.
         6. Information Access. These recommendations would promote and 
        develop capabilities for the seamless exchange of information 
        across organizations to provide consistent, timely support and 
        care. The recommendations would enable access to all relevant 
        records to those who need it to track, update, and retrieve 
        information about health care and personnel status, provide 
        health care practitioners with additional insight into the 
        incident that caused a would, injury, or illness. (The recent 
        project to develop a Virtual Lifetime Electronic Record 
        announced by the President and the Secretaries of DOD and VA 
        would achieve these goals.)
         7. Continuous Improvement and Oversight. These recommendations 
        would establish an oversight body and define metrics to monitor 
        success. They would also clarify roles, accountability and 
        reporting procedures.

    Mr. Dimsdale. The Clean Sheet Review sets aside all existing 
constraints; e.g., Public Law, departmental policy, existing 
organizational boundaries, human capital strategies, and budgets, to 
portray a holistic, end-to-end support structure. The design addresses 
the needs of wounded, injured, and ill servicemembers/veterans and, 
from their perspective, provides overlapping, coordinated care from the 
point-of-wound/injury or onset of illness through their reintegration 
into military or civilian community and beyond. The Clean Sheet Review 
recommended:

          (1) A continuation of military service decision by three 
        processes based on severity of injury, similar to the three 
        categories implemented by the Federal recovery coordinator/
        recovery care coordinator architecture;
          (2) A conversion from a disability assessment to an ability 
        assessment that drives the clinical care regimen, 
        identification of needed benefits, the ability of a 
        servicemember to continue their military career, and 
        compensation;
          (3) Compensation including a military service annuity based 
        on time in service and base pay, paid for life, income 
        replacement and quality of life compensation;
          (4) Access to military/VA or civilian medical treatment 
        facilities (MTFs) that best meet a servicemember or veteran's 
        relevant clinical needs and are most convenient to where they 
        work or live without regard to their status as servicemembers 
        or veterans and at no additional cost;
          (5) Consolidation of benefits delivery from a single care 
        management team that functions as single approval authority for 
        all Federal benefits;
          (6) A convergence of information that supports managed access 
        to all relevant systems through a centralized portal for all 
        approved stakeholders and agents of the process; and
          7) A continuous process improvement and oversight function to 
        ensure responsiveness to wounded warriors and their families, 
        and constant process improvement to changing conditions and 
        opportunities.

            electronic health records of private sector care
    21. Senator Ben Nelson. Admiral Timberlake, the Interagency Program 
Office has focused a great deal on getting DOD and VA medical records 
online and interoperable. However, it is estimated that up to 60 
percent of medical care given to all servicemembers and their eligible 
dependents is provided by private health care professionals, outside of 
military or veterans medical facilities. Is the Interagency Program 
Office taking steps to include records of medical care provided outside 
of MTFs or VA medical centers, in order to create a truly comprehensive 
electronic health record?
    Admiral Timberlake. The virtual lifetime electronic record will 
foster interoperability and interchangeability through the use of 
common services, and support both the health mission of providers and 
the health needs of our warfighters. The open standards/open 
architecture technologies employed in the structure will facilitate 
secure, appropriate, and cost-effective data sharing with DOD, VA, and 
DOD managed care support contractors.
    The Departments' approach to the virtual lifetime electronic record 
will adopt industry best practices to provide an environment with links 
to new and legacy applications through service-oriented architecture 
using common services. Creating a truly comprehensive EHR will be 
accomplished by referencing national standards for health-related data 
guided by the Department of Health and Human Services (HHS). The 
virtual lifetime electronic record effort will help facilitate the 
effort towards achieving President Obama's goal of allowing for data 
sharing with the private sector.
    Additionally, as the Nationwide Health Information Network (NHIN) 
is developed and matures, it will be the means to obtain information 
from civilian healthcare providers and for them to gain appropriate 
access to the virtual lifetime electronic record. Recognizing that many 
private sector care clinical providers are not currently using 
electronic health records, DOD is developing the ability to scan paper 
records, make them available through AHLTA, and share them with VA. For 
example, if a patient is referred to a private sector provider and 
returns to the MTF with a consult report, that report can be scanned 
with the appropriate identifying information so others will know what 
it is and be able to access it.

         access to additional behavioral health care providers
    22. Senator Ben Nelson. Ms. Embrey, you state in your written 
testimony that the Department ``funded the hiring of additional mental 
health and other specialty providers by the Services, and implemented a 
policy that requires first appointment access within 7 days for mental 
health concerns.'' How many additional positions were funded, and is it 
enough?
    Ms. Embrey. In the past 2 years, Office of the Assistant Secretary 
of Defense (Health Affairs) has funded an additional 1,700 positions 
for mental health providers, to include contractors, to work in MTFs. 
We are also partnering with the Public Health Service to increase our 
number of mental health providers. Around each MTF, we have established 
a network of private care providers to augment the MTF's capability and 
capacity. When an MTF cannot satisfy the demand for mental health 
services, it uses the established referral process to obtain timely 
care for TRICARE beneficiaries from private care sources. To ensure 
availability of providers for this referred care, TRICARE has added 
more than 10,000 mental health professionals to the network during the 
past 2 years. As a result of the combination of MTF and network mental 
health capability and capacity, TRICARE beneficiaries do not currently 
encounter any systemic problems in obtaining timely access to mental 
health care.

    23. Senator Ben Nelson. Ms. Embrey, if additional behavioral health 
care positions were authorized, would the Services be able to recruit 
and hire them, given the national shortage of these providers?
    Ms. Embrey. Yes, the Services would be able to recruit and hire 
additional behavioral healthcare providers. National needs for mental 
health providers are developed by agencies such as the National 
Institutes of Mental Health, the Health Resources and Services 
Administration, and the Substance Abuse and Mental Health Services 
Administration--they have responsibilities related to mental health 
services throughout America. The DOD and VA are working closely on all 
aspects of identifying and meeting mental health staffing requirements 
for our wounded warriors and veterans; we have established a working 
partnership. DOD's mental health provider requirements are based on the 
needs of our wounded warriors, their families, and our beneficiaries. 
We are constantly adjusting these requirements.
    Medical workforce planning efforts throughout the DOD have 
streamlined the hiring process of behavioral healthcare providers, 
utilizing the appointing flexibilities we have as well as compensation 
incentives. We are now much more competitive for scarce and shortage 
healthcare providers. As a result, DOD has been able to increase 
recruitment and hiring of many behavioral healthcare positions.

    24. Senator Ben Nelson. Ms. Embrey, does the Department's policy of 
access to mental health care within 7 days apply only to wounded, ill, 
and injured servicemembers? Does it apply to family member 
beneficiaries?
    Ms. Embrey. Access standards apply to all TRICARE Prime enrollees, 
including Active Duty servicemembers and their eligible family members, 
retirees and their eligible family members, survivors, and certain 
other beneficiaries who might be enrolled in Prime.

    25. Senator Ben Nelson. Ms. Embrey, are the Services meeting the 
Department's policy of access to mental health care within 7 days?
    Ms. Embrey. MTFs are meeting this access standard, although not all 
MTFs have mental health (MH) specialty services (small units) and some 
do not provide MH specialty services to civilian beneficiaries. Ninety-
six percent of those seen in military mental health clinics are seen 
initially as ``walk-ins'' at the time of their initial contact with the 
clinic. Approximately 80 percent of those seen by appointment are seen 
within 7 days. Across the enterprise, more than 99.5 percent of those 
seen initially (who have had a minimum of 6 months without previous 
contact) for MH specialty care in military clinics are seen within the 
access standard.
    TRICARE provides Behavioral Health Provider Locators to assist 
beneficiaries to receive routine initial access (7 days or less) to 
network MH specialty providers. Most beneficiaries report by survey 
little to no problems accessing MH providers. Coverage includes up to 
eight sessions without a referral or authorization. Families of both 
Active Duty and activated Reserve component personnel receive full 
health care coverage, including MH benefits. Coverage for Reserve 
members continues up to 6 months after deactivation and will continue 
beyond that if they enroll in TRICARE Reserve Select.
                                 ______
                                 
             Questions Submitted by Senator Lindsey Graham
                         congressional efforts
    26. Senator Graham. Mr. Williamson, Mr. Bertoni, and Ms. Melvin, 
you have heard the concerns of our first panel of witnesses, and 
analyzed the government's response. Where are the gaps in policy and 
law that Congress needs to fill?
    Mr. Williamson, Mr. Bertoni, and Ms. Melvin. During our review of 
the status of DOD and VA's efforts to jointly develop the policies 
required by the NDAA of 2008),\8\ agency officials described two 
instances in which gaps in policy and law may need to be addressed. In 
one case, an official from the Wounded, Ill, and Injured SOC told us 
that one of the SOC's work groups had been contributing to legislation 
for improving support to caregivers of recovering servicemembers. In 
January 2009, the SOC approved the workgroup's proposal. A provision 
for caregiver benefits based on the SOC's proposal was included in the 
NDAA 2010 bill that was introduced in May 2009.\9\ In a second case, 
SOC officials told us that legislation may be needed to reconcile some 
of the eight outstanding wounded warrior-related definitions between 
the departments.
---------------------------------------------------------------------------
    \8\ Pub. L. No. 110-181, 122 Stat. 3.
    \9\ S. 1033, 111th Cong. Sec. 701 (2009).
---------------------------------------------------------------------------
    Further, our review of the military's temporary disability retired 
list (TDRL) identified two gaps in policy or law. First, in April 2009, 
we reported that DOD's temporary retirement program did not appear to 
be fulfilling one of its original objectives, that is, to return 
temporary retirees to military duty.\10\ Currently, only about 1 
percent of temporary retirees return to the military, suggesting that 
the purpose of temporary disability retirement in today's military may 
need to be clarified. Moreover, on average, it took far fewer than 60 
months to arrive at permanent disability rating decisions in most cases 
we reviewed. As such, the 5-year maximum eligibility period for these 
benefits maybe too long, particularly in view of wounded 
servicemembers' need for efficient resolution of their disability 
cases. Second, according to TDRL administrative staff, delays in 
reexaminations for temporary retirees are common because of limited MTF 
resources. Yet, staff indicated that the military rarely exercises its 
option to use medical reexaminations performed by civilian and VA 
physicians. A clearer policy regarding use of nonmilitary medical 
resources in these cases could reduce the MTFs' workload and the burden 
re-examinations place on temporary retirees.
---------------------------------------------------------------------------
    \10\ GAO, Military Disability Retirement: Closer Monitoring Would 
Improve the Temporary Retirement Process, GAO-09-289 (Washington, DC: 
Apr. 13, 2009).
---------------------------------------------------------------------------
    With respect to DOD's and VA's pilot of a joint system for 
evaluating disabilities, we did not set out to and therefore did not 
identify gaps in policy or law. However, one of the pilot's objectives 
is to identify potential legal and policy revisions that could enhance 
disability evaluation efficiency and effectiveness. As pilot expansion 
continues, and additional experience is gained from implementing the 
pilot at different locations, DOD or VA may decide to submit 
legislative proposals to Congress to change law or policy related to 
disability evaluation.

    27. Senator Graham. Mr. Williamson, Mr. Bertoni, and Ms. Melvin, 
policies are only as good as the institutions and people whose job it 
is to carry them out. Do we have the most effective mechanisms in place 
today to monitor how effectively policies are executed?
    Mr. Williamson, Mr. Bertoni, and Ms. Melvin. DOD and VA could 
benefit from effective mechanisms to monitor and oversee policy and 
program execution. In prior work, we have identified various examples 
of limitations or shortcomings in the departments' efforts for 
monitoring to ensure that policies are effectively executed.

         In September 2008, we reported on the joint DOD-VA disability 
        evaluation pilot, noting that the departments needed to 
        maintain leadership oversight of the pilot to ensure that 
        needed resources are identified, implementation challenges are 
        overcome, and intended results are achieved-facilitating 
        successful implementation of potential widespread changes to 
        the disability evaluation process.\11\ Subsequently, DOD 
        created anew organizational structure--the Office of Transition 
        Policy and Care Coordination--to oversee transition support for 
        all servicemembers, including the pilot initiative. However, in 
        recent testimony, we reported that while some staff believed 
        this change would provide focus to implementing key policy 
        initiatives, including the pilot, other staff were concerned 
        the change may have a negative impact on the unity of command 
        within the SOC.
---------------------------------------------------------------------------
    \11\ GAO, Military Disability System: Increased Supports for 
Servicemember and Better Pilot Planning Could Improve the Disability 
Evaluation Process, GAO-08-1137 (Washington, DC: Sept. 24, 2008).
---------------------------------------------------------------------------
         Beyond the oversight structure, the DOD and VA plan to 
        leverage other mechanisms to help execute the pilot process; 
        however, the effectiveness of these mechanisms may diminish 
        over time. DOD and VA are using local agreement to establish 
        the pilot in new locations, based on the Benefits Delivery at 
        Discharge (BDD) model. These agreements reflect local 
        collaboration on pilot implementation, notably to ensure that 
        participants receive timely examinations. Nonetheless, while 
        local agreements may be an effective tool for implementing 
        change involving many parties, we have found in our review of 
        the BDD program that their effectiveness may fade over time. In 
        September 2008, we reported that the departments have relied on 
        local MOU at 130 military bases to execute the BDD program--a 
        program intended to expedite the application process for and 
        receipt of VA disability benefits to eligible 
        servicemembers.\12\ However, some bases faced difficulties 
        executing the program as agreed to in local MOUs due to changes 
        in base command and lack of communication between the agencies 
        or resource constraints, which negatively affected the 
        efficiency of and access to the BDD program. As such, we 
        recommended that VA and DOD take additional steps to ensure 
        best practices related to the BDD program are disseminated 
        across locations.\13\ Both agencies agreed with this 
        recommendation.
---------------------------------------------------------------------------
    \12\ GAO, Veterans' Disability Benefits: Better Accountability and 
Access Would Improve the Benefits Delivery at Discharge Program, GAO-
08-901, (Washington, DC, Sept. 9, 2008).
    \13\ This recommendation was given to VA and DOD under the auspice 
of the Chairs of the Joint Executive Council.
---------------------------------------------------------------------------
         In addition, our work examining military temporary disability 
        retirement, found that currently, there are not effective 
        mechanisms in place to monitor and ensure appropriate placement 
        on the TDRL or efficient processing of TDRL cases.\14\ DOD does 
        not use available data on outcomes in past TDRL cases to avoid 
        unnecessarily placing servicemembers on temporary retirement 
        whose disabilities are unlikely to change in severity. 
        Moreover, current quality assurance procedures do not provide 
        for the systematic monitoring of TDRL placement decision 
        accuracy and consistency. In addition, DOD does not have an 
        effective system for monitoring the timeliness of 
        reexaminations or a clear policy for addressing noncompliance 
        with TDRL requirements--mechanisms that would help prevent 
        lengthy delays in final disability determinations in TDRL 
        cases.
---------------------------------------------------------------------------
    \14\ GAO-09-289.
---------------------------------------------------------------------------
         Further, our recent study of VA training for disability 
        compensation claims processors found that the Department does 
        not centrally evaluate or collect feedback on training provided 
        to disability claims processors agencywide.\15\ As a result, it 
        lacks information on the adequacy of this training-information 
        critical to its efforts to overcome claims backlogs. The 
        Department concurred with our recommendation that it collect 
        and review feedback from claims processors on their training 
        conducted at VA regional offices to determine if the 80-hour 
        annual training requirement is appropriate and the extent to 
        which this training is relevant given their duties and 
        experience.
---------------------------------------------------------------------------
    \15\ GAO, Veterans' Benefits: Increased Focus on Evaluation and 
Accountability Would Enhance Training and Performance Management for 
Claims Processors, GAO-08-561, (Washington, DC: May 27, 2008).

    Beyond these examples, our current work has focused on DOD's and 
VA's joint development of the comprehensive policies to improve the 
care, management, and transition of recovering servicemembers, as 
required by the NDAA 2008. While the previous examples address related 
topics, our assessments of the status of implementation and the 
effectiveness of specific policies required by the NDAA 2008 will be 
addressed in future reports. For example, as part of our follow-on 
work, we plan to examine VA's and DOD's implementation of the Federal 
Recovery Coordination and Recovery Care Coordination Programs, which 
would include an assessment of how the departments are monitoring the 
---------------------------------------------------------------------------
care provided to recovering servicemembers.

    28. Senator Graham. Mr. Williamson, Mr. Bertoni, and Ms. Melvin, 
how will we know if laws and policies have made a positive difference 
for wounded servicemembers and their families, or not?
    Mr. Williamson, Mr. Bertoni, and Ms. Melvin. Performance goals and 
measures, and other evaluation tools, are key instruments for 
determining whether a positive impact has resulted from a given law, 
policy, or program. In this regard, NDAA 2008 directed DOD and VA to 
enhance their efforts to obtain meaningful feedback from patients and 
their families in order to accurately assess the quality of services 
provided to recovering servicemembers and facilitate the oversight of 
care and services. Additionally, once the departments have implemented 
the policies outlined in the NDAA 2008, we and others will be better 
positioned to evaluate whether the policy improvements are making a 
positive difference for wounded servicemembers.
    Nonetheless, our prior work on topics examining the policies 
outlined in the NDAA 2008 have identified various instances where the 
departments could improve their performance measures and efforts to 
evaluate disability evaluations and related programs.

         In September 2008, we reported that while DOD and VA had 
        established measures for the Disability Evaluation System (DES) 
        pilot's performance, and a mechanism for tracking performance, 
        they had not established criteria for determining whether the 
        pilot was successful and should be expanded on a large scale. 
        For example, they did not establish how much improvement in 
        timeliness or other indicators would be needed before deciding 
        that the pilot was successful. The agencies plan to issue their 
        final report to Congress in August 2009; however, it is unclear 
        whether they will have identified success criteria or collected 
        sufficient performance data on key indicators in order to 
        determine that the pilot was a success and a candidate for 
        large-scale implementation.
         Our September 2008 report also noted that the Army faced 
        challenges in demonstrating that improvements made to its 
        disability evaluations process have had an overall positive 
        impact on servicemembers' satisfaction, because it had not 
        implemented a survey that adequately targets and queries 
        servicemembers who are undergoing disability evaluations. We 
        recommended that the Army administer existing surveys to a 
        representative sample of servicemembers undergoing the 
        disability evaluation process, and consider developing 
        additional questions to better assess outreach and support 
        provided by Army legal staff throughout the process. DOD 
        agreed.
         With respect to the Benefits Delivery at Discharge (BDD) 
        program, we reported that DOD lacked sufficient measures to 
        track outreach to servicemembers about the program.\16\ While 
        VA and DOD had coordinated to raise servicemembers' awareness 
        about the program through VA benefits briefings, DOD was using 
        a flawed measure for determining the extent to which VA 
        benefits briefings were reaching all transitioning 
        servicemembers who could benefit from the program. We 
        recommended that DOD take steps to ensure more accurate 
        measurement of servicemember participation in transition 
        briefings and establish a specific plan to meet its goal of 85 
        percent participation. DOD agreed with this recommendation.
---------------------------------------------------------------------------
    \16\ GAO-08-901.
---------------------------------------------------------------------------
         Also on the BDD review, we found that VA and DOD lacked the 
        ability to measure the extent to which members of the National 
        Guard and Reserves have comparable access to programs that 
        expedite their VA disability benefits relative to other 
        servicemembers. Due to their rapid demobilization, National 
        Guard and Reserve members often cannot access the BDD program. 
        In response, VA established an alternative pre-discharge 
        program, which allows National Guard and Reserve members to 
        begin aspects of the application process early to expedite 
        receipt of their benefits. However, VA does not collect 
        sufficient data to determine the extent to which National Guard 
        and Reserve members are participating in and receiving 
        expedited benefits under either program. We recommended that VA 
        collect data for all claims filed by component and analyze the 
        extent to which different components are filing claims and 
        receiving timely benefits under BDD, predischarge, and 
        traditional claims processes. VA agreed with this 
        recommendation.
         Beyond DOD and VA disability programs, we also found 
        opportunities for improvement related to program measures used 
        in VA's Vocational Rehabilitation and Employment (VR&E) 
        program. In our January 2009 report, we noted that VA was not 
        adequately reporting program outcomes, which could limit 
        understanding of the program's performance. Accordingly, we 
        recommended that VA separately report both the annual 
        percentage of those who obtain employment and the percentage of 
        those who achieve independent living to increase the 
        transparency of VR&E's program performance.\17\ VA agreed with 
        our recommendation and indicated it will implement new 
        performance measures in fiscal year 2010.
---------------------------------------------------------------------------
    \17\ GAO, VA Vocational Rehabilitation and Employment: Better 
Incentives, Workforce Planning, and Performance Reporting Could Improve 
Program, GAO-09-34 (Washington, DC: Jan. 26, 2009).

                       electronic health records
    29. Senator Graham. Mr. Williamson, Mr. Bertoni, and Ms. Melvin, 
DOD and VA have been working on interoperable health care records for 
nearly a decade. Congress imposed a deadline of September 2009 for a 
fully functional, interoperable health care record for military 
retirees and veterans. Are they going to make it?
    Mr. Williamson, Mr. Bertoni, and Ms. Melvin. It is unclear whether 
DOD and VA will meet the September 2009 deadline for a fully 
functional, interoperable health care record. As previously mentioned 
in our response to question 3, the departments have not developed 
results-oriented goals that can be used to measure and report progress 
toward delivering new capabilities. As such, there is no basis to 
effectively assess the extent to which the departments will achieve 
fully interoperable capabilities by September 2009.

    30. Senator Graham. Admiral Timberlake, you have until September 
2009 to develop and implement a fully interoperable health care 
capability for DOD and VA. Are you going to make it?
    Admiral Timberlake. The IPO does not currently anticipate any major 
impediments to achieving full interoperability for the provision of 
clinical care by September 30, 2009. The DOD/VA IPO will provide 
management and oversight of potential risks involving the 
identification, coordination, and approval of information sharing 
requirements and the impact these processes may have on DOD/VA 
information sharing milestones.
    The Interagency Clinical Informatics Board (ICIB) is a clinician-
led group whose proponents are the DOD Deputy Assistant Secretary for 
Clinical and Program Policy and the VA Chief Patient Care Services 
Officer, Veterans Health Administration. The ICIB is co-chaired by 
designees of the proponents and includes representation from DOD and VA 
clinicians, information technology community, interagency sharing 
offices, Veterans Benefits Administration, DOD and VA local Joint 
Venture sites, Chief Medical Informatics Officers, and others.
    The DOD/VA Interagency Clinical Informatics Board defined the 
``fully interoperable'' requirements needed by healthcare providers for 
the provision of clinical care. Efforts are underway to deliver full 
interoperability for the provision of clinical care by September 2009.

    31. Senator Graham. Admiral Timberlake, what do you say to skeptics 
who believe that you are just playing with semantics when you assert 
that the goal will be achieved--skeptics who also question the ability 
of DOD and VA to deliver joint electronic capabilities, whether it be 
in the battlefield, or back home, where and when they are needed?
    Admiral Timberlake. While great successes have been achieved to 
date, as we go forward to enhance the interoperability with the vision 
for the virtual lifetime electronic record agreed to by the Secretaries 
on March 24th, the key interoperability challenges will include:

         Developing, adopting, and maturing standards at the national 
        level to ensure efficient operational use
         Updating systems, infrastructure, and technology consistent 
        with emerging standards
         Identifying and prioritizing information requirements as 
        defined by the business process owners and the functional 
        community
         Identifying, prioritizing, and implementing common services

    The departments also face challenges created by: different 
acquisition and funding cycles; different contracting processes; and 
differences in IA certification processes for VA, DOD, DISA, the 
Services, and the local level.
    We are working to not only identify areas where potential process 
differences may exist, but the departments and the IPO are 
collaboratively engaging in efforts to ensure that any impediment that 
may arise is resolved in an efficient manner.

                   wounded warrior act's final vision
    32. Senator Graham. Mr. Williamson, Mr. Bertoni, and Ms. Melvin, 
what are the biggest pieces of unfinished business that we as a Nation 
need to address in order to achieve the vision of the Wounded Warrior 
Act?
    Mr. Williamson, Mr. Bertoni, and Ms. Melvin. Among the most 
significant matters that need to be addressed to achieve the vision of 
the Wounded Warrior Act are improving customer-centered care within DOD 
and VA, ensuring the continuation of high-level leadership and 
attention to wounded warrior matters, improving the management of 
disability programs, and sharing electronic health records. For 
example, DOD and VA officials told us that the most difficult challenge 
in their efforts to improve the care, management, and transition of 
recovering servicemembers is to introduce needed cultural changes 
within their organizations--for example, to center medical care on the 
patient and to make the welfare of recovering servicemembers a higher 
priority. These cultural shifts represent a change to the tradition 
that the needs of military predominate over those of individuals, 
especially individuals who may not be able to return to a combat role.
    It is important that DOD's and VA's leaders maintain their focus on 
wounded warrior issues so that the processes, services, and benefits 
for recovering servicemembers continue to improve. The SOC has provided 
high-level leadership and focused attention on the development of 
solutions to many of the obstacles confronting recovering 
servicemembers. Sustained attention by DOD and VA top leadership is 
needed to ensure that as circumstances change and new issues emerge, 
actions are taken to address the challenges that remain for recovering 
servicemembers and their families.
    Further, managing disability evaluation and employment workloads 
with finite resources while maintaining accuracy, consistency, and 
timeliness of decisions will likely require continued focus on the part 
of DOD and VA. For example, in September 2008, we reported that the 
Army was experiencing delays in processing disability evaluations due 
to a shortage of key personnel and caseload surges, and identified 
specific gaps in legal supports, outreach and other supports to help 
servicemembers navigate the disability evaluation process. We made 
several recommendations to improve the efficiency of the process and 
supports to servicemembers. DOD generally agreed with our 
recommendations. Also, in February 2008, we reported that VA continues 
to face challenges in reducing the number of claims pending, speeding 
up the process of deciding claims, and improving accuracy and 
consistency of decisions across regional offices.\18\ Despite steps 
pursued by VA to improve the process, we reported that more fundamental 
reform may be needed. We are currently reviewing VA's disability claims 
workload and progress toward addressing these challenges. Further, in 
our VR&E report, we noted that the program had not gathered data on the 
number of staff it needs and was not using relevant data to identify 
future staffing needs.\19\ We recommended that VR&E engage in a 
strategic workforce planning process. VA agreed with our recommendation 
and indicated that VR&E would complete a study by the end of fiscal 
year 2010 to help it determine an appropriate counselor caseload.
---------------------------------------------------------------------------
    \18\ GAO, Veterans' Disability Benefits: Claims Processing 
Challenges Persist, while VA Continues to Take Steps to Address Them, 
GAO-08-473T (Washington, DC: Feb. 14, 2008).
    \19\ GAO-09-34.
---------------------------------------------------------------------------
    DOD and VA also need to complete the DES pilot, and determine 
whether the pilot process will become the way disability evaluations 
are conducted by both agencies. Once that decision is made, sustained 
management focus will be critical to ensuring successful implementation 
of any joint DOD/VA disability evaluation process on a large scale. 
Implementation of a joint disability evaluation process would address 
one of the issues that we have highlighted in our Improving and 
Modernizing Federal Disability Programs High-Risk Area--in efficient 
processing of disability evaluations.\20\
---------------------------------------------------------------------------
    \20\ GAO, High-Risk Series: An Update, GAO-09-271 (Washington, DC: 
Jan. 22, 2009).
---------------------------------------------------------------------------
    Our work to date has also identified a number of persistent 
challenges particular to the National Guard and Reserves community. For 
example, in our September 2008 report, we reported that the Army faces 
particular challenges in meeting timeliness goals for completing 
disability evaluations for reservists--who comprised about 20 percent 
of those undergoing disability evaluations in 2007. We recommended that 
the Army explore approaches to improving reservists' case development. 
DOD agreed with this recommendation. Also, as noted previously, we 
recommended that VA needs to take steps to better determine the extent 
to which National Guard and Reserves and other components participate 
in and benefit from programs--such as BDD and the alternate 
predischarge program--intended to expedite receipt, of VA benefits. VA 
agreed with this recommendation.
    Lastly, we have reported on and identified a number of challenges 
related to efforts to achieve the long-term vision of a single 
``comprehensive, lifelong medical record'' that would enable each 
servicemember to transition seamlessly between the DOD and VA. Our 
January 2009 report \21\ noted that while important steps have been 
taken, questions remained concerning when and to what extent the 
intended electronic sharing capabilities of the two departments will be 
fully achieved. We made recommendations that the departments use 
results-oriented performance goals and measures as the basis for future 
assessments and reporting of interoperability progress. The departments 
concurred with our recommendations.
---------------------------------------------------------------------------
    \21\ GAO-09-268.

    33. Senator Graham. Ms. McGinn, General Meurlin, Ms. Embrey, 
Admiral Timberlake, Mr. Dimsdale, and Dr. Guice, would you agree that 
in spite of some progress, wounded warriors and their families still 
need our help?
    Ms. McGinn, General Meurlin, Ms. Embrey, and Admiral Timberlake. We 
absolutely agree. Since the incidents at Walter Reed, there has been a 
renewed focus on wounded warriors and their families. But there is 
still much more to do. One area of interest that you brought up was 
support to family caregivers, which as we heard today is a growing 
priority. There is a DOD proposal to provide special monthly 
compensation for family caregivers paid to servicemembers who elect to 
participate in the expedited DES, and we are aware of at least two 
legislative proposals that are being initiated by Senators. It would be 
in the best interest of all concerned if we could examine all the 
proposals and capitalize on the best ideas for formal legislative 
action.
    Mr. Dimsdale and Dr. Guice. The many efforts of DOD and VA are 
making a difference for wounded warriors and their families. From the 
testimony of those servicemembers and veterans on the first panel, 
those that had care coordination provided by the SOC coalition or the 
Federal recovery coordination program had an easier time navigating the 
systems of care provided by both departments. The many initiatives 
required by the NDAA 2008 legislation are in place and their 
effectiveness will need to be measured and tracked. Both departments 
are committed to identifying problems and creating durable solutions.

    34. Senator Graham. Ms. McGinn, General Meurlin, Ms. Embrey, 
Admiral Timberlake, Mr. Dimsdale, and Dr. Guice, do you agree that the 
pathway to obtaining needed care remains complex and difficult to 
navigate?
    Ms. McGinn, General Meurlin, Ms. Embrey, and Admiral Timberlake. In 
our opinion, the complexity of injuries these servicemembers experience 
as a result of combat make the system of care difficult to navigate, 
not the care itself. The particular patterns of injury require numerous 
specialists, frequent interfacility transfers, and lengthy periods of 
rehabilitation. The challenges are only increased when a family needs 
assistance as well. Both departments have worked hard to improve the 
coordination of care and benefits, rather than requiring the wounded 
warrior, veteran or family manage the transitions and integrate the 
different delivery systems alone. The development of a Clinical Case 
Management application via Line of Action 3, addresses the case 
management workflow process by coordinating collaboratively across 
service lines and care locations. These improvements will lead to the 
efficient development of collaborative relationships among 
servicemembers, case managers, physicians, and other medical 
disciplines.
    Mr. Dimsdale and Dr. Guice. The complexity of injuries these 
servicemembers experience as a result of combat make the system of care 
difficult to navigate, not the care itself. The particular patterns of 
injury require numerous specialists, frequent interfacility transfers, 
and lengthy periods of rehabilitation. The challenges are only 
increased when a family needs assistance as well. Both departments have 
worked hard to improve the coordination of care and benefits, rather 
than requiring the wounded warrior, veteran, or family manage the 
transitions and integrate the different delivery systems alone.

    35. Senator Graham. Ms. McGinn, General Meurlin, Ms. Embrey, 
Admiral Timberlake, Mr. Dimsdale, and Dr. Guice, please address the 
concerns that you heard and tell us what more we can expect--or we need 
to legislate--to achieve improvements and reform in the year ahead.
    Ms. McGinn, General Meurlin, Ms. Embrey, and Admiral Timberlake. A 
large part of what we heard today had to do with care coordination 
between DOD and VA--streamlining information flow and performing the 
hand-off from one department to the other as seamlessly as possible. 
The office of Transition Policy and Care Coordination in partnership 
with the VA is working to make these two goals a reality.
    The information flow is now being managed by DOD/VA Recovery 
Coordinators, who, in concert with the medical and non-medical recovery 
teams and Services' Wounded Warrior Programs, act as the go-between for 
an injured servicemember, veteran, and their family with all the 
various case managers who now work for them.
    The SOC has directed DOD and VA to identify how to implement the 
Virtual Electronic Lifetime Record and streamline the DES, but the work 
has not risen above the working group level. Once we have identified 
what needs to change, we will come to Congress with a more formal 
proposal. We want to make sure we get this right the first time.
    Mr. Dimsdale and Dr. Guice. The testimony provided by the first 
panel of witnesses reminds us how important it is to ``get it right.'' 
Many more programs and resources are available today to those returning 
wounded or injured. It will be important to evaluate these programs and 
to compare the experiences of those returning today compared to those 
who returned in earlier years. Effectiveness should not be measured in 
the number of new programs or resources, but whether or not the system 
is improved as a result.

                        traumatic brain injuries
    36. Senator Graham. Ms. Embrey, what is the Department's estimate 
of the number of veterans who have suffered brain injuries in this war?
    Ms. Embrey. As of March 31, 2009, there are 40,035 unique patients 
in the DOD TBI surveillance database.

    37. Senator Graham. Ms. Embrey, do we have sufficient resources to 
provide for their care?
    Ms. Embrey. Over the past 5 years, we have made tremendous headway 
in the care of TBI, especially for chronic symptomatic concussion, also 
known as mild-TBI (mTBI). There are numerous TBI clinics located at 
different MTFs all over the country. Additionally, ongoing education of 
all providers has remained a priority. Since 2007, over 800 providers 
per year learn how to diagnose and treat TBI through the Defense and 
Veterans Brain Injury (DVBIC) annual military training. DVBIC works 
closely with the DCoE for PH and TBI to ensure that providers treating 
patients with TBI have the most up-to-date scientific information 
available. We currently have no data to suggest insufficient resources 
to care for the servicemembers with TBI.

    38. Senator Graham. Ms. Embrey, LTC Rivas testified that his brain 
injury in 2006 was not diagnosed and he returned to battle. What is 
different for a servicemember who is injured on the battlefield today?
    Ms. Embrey. DOD has taken many steps to ensure that what happened 
to LTC Rivas does not happen to others. Since 2007, several task force 
and commission recommendations have been incorporated into the DOD TBI 
Action Plan. Specific advancements implemented by the DOD include, 
using the Military Acute Concussion Evaluation to help diagnose mTBI 
and clinical practice guidelines for detecting and diagnosing TBI in 
deployed settings. In October 2007 the DOD published additional 
clinical guidance for the care of mTBI in the nondeployed setting and 
updated it in May 2008. Also in May 2008, the DOD implemented TBI 
assessment questions into the post-deployment health assessment and 
post-deployment health reassessment to ensure there was an avenue of 
treatment for ongoing symptoms for all servicemembers returning from 
deployment. The VA implemented similar questions in April 2007.

    39. Senator Graham. Ms. Embrey and Mr. Dimsdale, Congress intended 
that wounded servicemembers have the broadest possible options for 
brain injury care and rehabilitation, yet we are informed that Federal 
rules still limit accessible treatment options. What are the legal or 
bureaucratic barriers we need to address?
    Ms. Embrey. Active Duty servicemembers do have the broadest 
possible options for brain injury care and rehabilitation. The 
statutory scope of health care benefits for Active Duty servicemember 
is much broader than for all other categories of beneficiaries and does 
not limit the care to TRICARE authorized providers. There is no 
requirement that the care is medically or psychologically necessary, 
and the statute does not specifically prohibit custodial or domiciliary 
care. Further, reimbursement is made by using Supplemental Health Care 
Program (SHCP) funds to pay for the services. With the exception of 
benefit limitations based on Federal statute, any restrictions or 
limitations of the TRICARE Basic Program may be waived for Active Duty 
servicemembers under the SHCP in order to make available adequate 
healthcare services to Active Duty servicemembers or to keep or make 
the Active Duty servicemember fit to remain on Active Duty. Moreover, 
under section 1631 of the NDAA for Fiscal Year 2008, DOD may authorize 
Active Duty servicemember benefits for former members with a serious 
injury or illness if the care is not available in the VA. This 
authority expires December 31, 2012.
    Mr. Dimsdale. This question is specific to DOD and cannot be 
addressed by VA.

               medical disability evaluations and ratings
    40. Senator Graham. General Meurlin, should DOD get out of the 
business of evaluating and rating medical disabilities of 
servicemembers? If so, what needs to happen to achieve that goal?
    General Meurlin. Since the Career Compensation Act of 1949, DOD and 
VA have operated independent systems to examine, rate, and compensate 
disabled servicemembers and veterans. DOD, VA, congressional, and 
presidential commissions all concur on the need to eliminate dual 
adjudication of disability ratings by DOD and VA. On April 28, 2009, 
the SOC made the decision to establish a senior working group that will 
deliver to the SOC the vision, guiding principles, charter, and high-
level options and recommendation for getting DOD to provide a ``fit/
unfit'' finding with VA determining the disability rating and resulting 
compensation.

    41. Senator Graham. General Meurlin, has the paperwork required for 
medical and physical evaluation boards been reduced in the last 2 
years?
    General Meurlin. The military departments have taken initiatives to 
reduce paperwork and evolve archaic systems. For example, the Army has 
an initiative for an automated physical profile system that will feed 
profile data to the Medical Operational Data System and the Electronic 
Health Record AHLTA. The Medical Evaluation Board (MEB) is also being 
automated, which will improve MEB case file tracking, decrease process 
inefficiencies, and improve data quality. The automated MEB is 
scheduled for testing in August 2009 at Brooke Army Medical Center, in 
San Antonio, TX. The system is intended to provide an automated MEB 
using an interface that will deliver all permanent profiles with a 
numerical designator of 3 or 4 directly to the MTF's MEB Physician so 
they may validate and initiate disability processing accordingly. 
Additionally, based on the SOC's guidance, we are looking at ``Evolving 
the Disability Evaluation System'', which will help facilitate 
additional improvements over time.

    42. Senator Graham. General Meurlin, have the processes been 
streamlined or automated?
    General Meurlin. With the introduction of the DES pilot, both DOD 
and VA have put in place a process that has cut the time from referral 
into the DES to receipt of VA benefits by approximately half. The DES 
pilot simplifies the process by eliminating duplicate practices of the 
two departments. Complementing timeliness is the integration of new 
case management features, such as placing VA counselors in MTFs to 
ensure a smooth transition for members who must move to the care of the 
VA. The features of the DES pilot are the result of the hard work and 
excellent recommendations by several commissions and task forces. These 
features include: servicemember-centricity; simplicity; reduction of 
the adversarial nature of the DES process; faster and more consistent 
evaluations and compensation; a single medical exam and single-source 
disability rating; seamless transition to veteran status; case 
management advocacy; and expectation management.

    43. Senator Graham. General Meurlin, if a servicemember is not in 
the disability demonstration project--that is, the vast majority of 
servicemembers--what has changed since the 1940s when this archaic 
system was put into place?
    General Meurlin. Since the Career Compensation Act of 1949, DOD and 
VA have operated independent systems to examine, rate, and compensate 
disabled servicemembers and veterans. Both departments recognized the 
need to improve the current DES and stood up LOA-1. The intent was to 
develop and establish an integrated DOD and VA DES, one that is 
seamless, transparent, and administered jointly by both departments 
using one medical examination and one disability rating. In this 
regard, the department has published several policy updates to current 
suite of DOD regulations. In addition to the significant steps forward 
resulting from the DES pilot, the department has also initiated an 
Expedited DES, and a Physical Disability Board of Review.
    In January 2009, the Department published guidance for an expedited 
DES process. Accelerating the process for eligible servicemembers 
presumed to be 100 percent disabled allows for early identification and 
delivery of the full range of benefits, compensation, and specialty 
care offered by the VA to which the servicemember may be entitled. The 
goal is to move the member, consistent with medical and recovery care, 
to permanent disability retirement so that the member may obtain 
benefits from the VA as soon as possible. Participation in the 
expedited DES process is strictly voluntary. Members who are eligible 
are not required to be brought to maximum medical benefit prior to 
receiving their disability rating and retirement disposition provided 
the DES process is waived.
    The Secretary of Defense established a Physical Disability Board of 
Review (PDBR) with the Air Force as the lead agency to review 
disability ratings of wounded warriors, honoring the great sacrifices 
required of the men and women of our Armed Forces and providing another 
avenue of administrative recourse for our wounded veterans. Variances 
in disability ratings among the military departments for same or 
similar disorders created a perception of unfairness in applying 
disability ratings across the Services. Therefore, under the PDBR any 
servicemember may have his or her case reviewed by the PDBR if he or 
she was separated from the Armed Forces between September 11, 2001, and 
December 31, 2009. The PDBR applies to any servicemember separated due 
to unfitness for continued military service resulting from a physical 
disability under Chapter 61, Title 10 U.S.C., with a combined 
disability rating of 20 percent or less.

                        mental health providers
    44. Senator Graham. Ms. Embrey and Mr. Dimsdale, according to your 
treatment protocols, how frequently should a soldier or veteran with 
PTSD have face-to-face contact with a mental health provider?
    Ms. Embrey. DOD strongly encourages the use of the DOD-VA Clinical 
Practice Guidelines for the treatment of PTSD by providers treating 
servicemembers and veterans. The guideline, which was carefully 
developed by a team of subject matter experts from both DOD and VA, 
describes in great detail evidence-based assessment and treatment 
methodologies for use both in the primary care setting and the mental 
health setting. A range of treatments described in the guideline have 
extensive bases of support in the scientific literature, ranging from 
pharmacological to cognitive therapeutic interventions. While the 
guideline does not specify any particular frequency of face-to-face 
contact between patient and provider, it does reference specific 
treatment regimens widely known and used in the provider community.
    Mr. Dimsdale. PTSD is a condition that can have a number of 
different clinical courses. It can occur as a single episode, it can 
occur with remissions and recurrences, or it can be chronic. At any 
given time it could be associated with symptoms, distress, and 
impairments, or it could be in full or partial remission. Treatment can 
include pharmacotherapy, psychotherapy, and rehabilitation. The 
frequency of contact and decisions about face-to-face versus telemental 
health contacts must be individualized on the basis of a given 
patient's goals and needs at a given point in time.

    45. Senator Graham. Ms. Embrey and Mr. Dimsdale, how many more 
mental health providers have DOD and VA hired since 2001?
    Ms. Embrey. Mental health provider staffing (military and civilian 
only):

          Fiscal Year 2001 - 2,010
          Fiscal Year 2002 - 1,647 (^363)
          Fiscal Year 2003 - 1,643 (^3)
          Fiscal Year 2004 - 1,967 (+324)
          Fiscal Year 2005 - 1,911 (^56)
          Fiscal Year 2006 - 1,912 (+1)
          Fiscal Year 2007 - 2,530 (+618)
          Fiscal Year 2008 - 2,811 (+281)
          Fiscal Year 2009 - 3,515 (+704)

    Mental health provider staffing has been on a continuous ramp-up 
since 2003 and we continue to increase these numbers to meet increased 
patient demand. Overall, since 2001, we have increased mental health 
providers by 1,505. Although we do not have historical information on 
contract mental health providers, we currently have 711 working in our 
MTFs.
    Mr. Dimsdale. From 2001 to 2005, VA mental health staffing was more 
or less stable. However, since then, staffing increased by about 5,000 
full time equivalent positions from 13,950 to about 18,844 by the end 
of the second quarter of fiscal year 2009.

    46. Senator Graham. Ms. Embrey and Mr. Dimsdale, we have been told 
that there is a national shortage of mental health providers, is that 
correct? If so, are you working together on this national shortage?
    Ms. Embrey. National needs for mental health providers are 
developed by agencies such as the National Institute of Mental Health, 
the Health Resources and Services Administration, and the Substance 
Abuse and Mental Health Services Administration--they have 
responsibilities related to mental health services throughout the 
United States of America.
    DOD and VA are working closely on all aspects of identifying and 
meeting mental health staffing requirements for our wounded warriors 
and veterans; we have established a working partnership. DOD's mental 
health provider requirements are based on the needs of our wounded 
warriors, their families, and our beneficiaries; we are constantly 
adjusting these requirements.
    Mr. Dimsdale. Neither VA nor DOD can comment definitively about 
whether or not there is a national shortage of mental health providers. 
Projecting the needs for the mental health care workforce for the 
Nation as a whole is within the responsibilities of agencies such as 
the National Institute of Mental Health, the Health Resources and 
Services Administration, and the Substance Abuse and Mental Health 
Services Administration.
    VA has made major contributions toward developing the Nation's 
workforce in mental health. VA has long been one of the Nation's 
leaders in professional training for health and mental health care. 
With its academic affiliates, VA has been involved in graduate training 
in psychology and undergraduate medical education in psychiatry, as 
well as programs in a number of allied health professions. As a major 
provider of graduate medical education, VA makes a major contribution 
to work force development in psychiatry. Additionally, through an 
expanding array of VA supported internship and clinical post-doctoral 
fellowship positions, VA is making substantial contributions to 
workforce development in psychology.
    Currently, the Veterans Health Administration (VHA) employs over 
19,000 mental health workers. With the aid of newly-established 
recruitment initiatives, VA mental health staffing levels have 
increased by over 5,800 positions since fiscal year 2005, when VA began 
implementing its Mental Health Strategic Plan. Putting these figures 
into perspective, VA employs about 5 percent of the national pool of 
psychiatrists and psychologists.
    With staffing as projected, VHA is able to meet the mental health 
care needs of the veterans it serves.
    It has been VHA's experience that in certain localities, 
particularly highly rural regions, there is a limited number of mental 
health professionals, particularly psychiatrists. Specific hiring and 
retention incentives have been developed and used in such situations. 
VHA also has the flexibility to hire providers of other appropriate 
disciplines or to use fee-basis or contract care, when indicated, so 
that veterans have continuous access to the full continuum of mental 
health services. In addition, telemental health options are continually 
being expanded so that mental health professionals in areas where 
hiring is easier can provide services through video-conferencing to 
veterans in more rural sites. Through its recent efforts, VHA has 
developed an array of strategies to recruit and retain mental health 
professionals. It is currently working with DOD to share lessons 
learned, and to collaborate, as much as possible.

    47. Senator Graham. Ms. Embrey and Mr. Dimsdale, who monitors the 
performance of your health care systems in meeting the necessary 
frequency of face-to-face encounters with a mental health provider?
    Ms. Embrey. DOD maintains a range of systems and processes for 
ensuring the quality of mental health care for our beneficiaries. While 
``necessary frequency'' is something that is individually developed 
between the patient and provider as part of the treatment planning 
process, the overall quality of health care provided is paramount in 
the ongoing evaluation process. Quality of patient care is reviewed 
regularly through the peer review process in each MTF, so that any 
issues can be detected and remedied early on. Additionally, we strongly 
encourage the use of the DOD-VA Clinical Practice Guidelines, including 
those for major depression and PTSD. Provider adherence to these 
evidence-based guidelines increases quality of care and enhance the 
likelihood of positive patient outcomes.
    The DOD is planning to rollout a Behavioral Health Module as part 
of the electronic medical record. This module will include instruments 
that will be administered to our patients to measure the outcomes of 
their care. Frequency of sessions is less important than establishing 
that treatment is resulting in a positive outcome over time, whether 
that time is brief or over an extended period. Providers will also use 
this process to enhance treatment planning, and thereby facilitate 
positive outcomes within shorter periods of time.
    The Department closely monitors access to mental health care. 
Having moved the 30-day standard for a first mental health appointment 
up to a 7-day standard, we are working to ensure that all MTFs comply 
with the standard. We have augmented the number of mental health 
professionals significantly in order to facilitate such compliance and 
to make mental health care more available.
    Our Tricare Operations Center is able to monitor on a daily basis 
the number of available appointments in each clinic across the system, 
helping clinic managers better control patient flow and ensure the 
timeliness of mental health appointments.
    Mr. Dimsdale. VA uses performance metrics to monitor both access to 
mental health care and the continuity of mental health services. The 
entities with responsibility for measurement include the Office of 
Quality and Performance and the Office of Mental Health Services. The 
frequency of face-to-face encounters is based on the clinical needs of 
the individual.

    48. Senator Graham. Ms. Embrey and Mr. Dimsdale, are the resources 
available to meet the demand for care sufficient?
    Ms. Embrey. We have sufficient financial resources to meet our 
currently identified requirements associated with the demand for mental 
health treatment.
    Two years ago, Congress authorized special pays to incentivize 
recruitment and retention of health care providers, including mental 
health care providers. We are publishing a directive-type memorandum 
that will provide implementation guidance to the Services for offering 
special pays to psychologists and social workers.
    Mr. Dimsdale. The proposed VA budget includes adequate resources to 
meet the mental health care needs of veterans of all eras.

                             case managers
    49. Senator Graham. Ms. McGinn, General Meurlin, Mr. Dimsdale, and 
Dr. Guice, have you ever had a conversation about the problems we have 
heard involving the proliferation of case managers in DOD and VA?
    Ms. McGinn and General Meurlin. We do have numerous case managers 
assisting our recovering servicemembers. Both the President's 
Commission on Care for America's Returning Wounded Warriors and the 
NDAA 2008 recognized this and required one point of contact to oversee 
the recovering servicemember and family through recovery, rehab, and 
return to duty or reintegration into the community. This one belly 
button is our Recovery Care Coordinators and Federal Recovery 
Coordinators (FRCs). They, working with the medical and nonmedical 
team, will create a recovery plan for each servicemember and family 
with personal and professional goals that will guide them through their 
continuum of care. These coordinators work with the existing case/care 
managers to ensure the needs of our recovering servicemembers and 
families are met.
    Mr. Dimsdale and Dr. Guice. There is much confusion about case 
management and the number of case managers. The number of clinical case 
managers a recovering servicemember will have is related to the types 
and number of their injuries and the number of facilities where care is 
received. Clinical case managers are critical components of a 
multidisciplinary team--they implement the patient's clinical treatment 
plan and often serve as the link between the patient and providers. 
Non-clinical case managers assist recovering servicemembers and 
veterans with access to programs and benefits (childcare, adaptive 
housing, disability determinations, et cetera). Many of these non-
clinical case managers are also facility based. A recovering 
servicemember who requires care from three different facilities may 
have many case managers. Case managers generally assist the 
servicemember only while they are at the facility; upon transfer to 
another facility, the servicemember will encounter a new set of case 
managers.
    Care coordination decreases the opportunities for confusion by 
providing a single point of contact and coordinator for these 
servicemembers and their families. Federal recovery coordinators 
actively coordinate the services and benefits, and work with case 
managers to meet recovery needs of the servicemember.

    50. Senator Graham. Ms. McGinn, General Meurlin, Mr. Dimsdale, and 
Dr. Guice, what do you plan to do about the problem expressed by our 
witnesses today?
    Ms. McGinn and General Meurlin. It is our belief that past issues 
with multiple case managers are being resolved as the DOD Recovery 
Coordination Program and the DOD/VA Federal Recovery Coordination 
Programs continue to take hold. There are currently 147 RCCs working in 
27 locations around the country through each military department's 
Wounded Warrior Program, and we will continue to bring more on-line 
during fiscal year 2009. The RCCs and FRCs are absolutely critical to 
identifying issues early and bringing them to resolution as soon as 
possible. The work that the RCCs and FRCs are doing permit the wounded, 
ill, or injured servicemember and their families to concentrate on 
their medical recovery.
    Mr. Dimsdale and Dr. Guice. The problems articulated by the 
servicemembers and veterans on the first panel require thoughtful 
evaluation. Because so many resources and programs are now in place, a 
thorough understanding of their effectiveness is needed in order to 
better determine what remains to be addressed.

                   care for returning servicemembers
    51. Senator Graham. Dr. Guice, you served on the staff of the Dole-
Shalala Commission on care for returning servicemembers, is that 
correct?
    Dr. Guice. I served as the Deputy Director of the President's 
Commission on Care for America's Wounded Warriors, March 28, 2007-July 
31, 2007. My responsibilities included providing direction for 25 
researchers, managing relationships with Capitol Hill and Veteran 
Service Organizations, assisting Commissioners in developing 
recommendations and writing the final report, working with public 
relations to develop statements and press advisories, and assisting the 
Executive Director with strategic planning. I had primary 
responsibility for the recommendations on care coordination and 
rehabilitation.

    52. Senator Graham. Ms. McGinn, General Meurlin, Ms. Embrey, 
Admiral Timberlake, Mr. Dimsdale, and Dr. Guice, from your current 
vantage points, and based on what you have heard from our first panel, 
what are the biggest pieces of reform and improvement that are still 
needed to support seriously injured and ill servicemembers and their 
families?
    Ms. McGinn, General Meurlin, Ms. Embrey, and Admiral Timberlake. 
From a transition and care coordination perspective, we believe there 
are two problems being expressed by the previous witnesses. First, the 
policy, process, and provisos for getting a servicemember and their 
family started on the road to rehabilitation are still not streamlined 
enough. Specifically, Senator Nelson stated in his opening remarks that 
improvements are still needed in the DES, and we could not agree more. 
The SOC has discussed this, and we are responding by expanding the DES 
pilot to seven additional sites this year and we have implemented the 
expedited DES for those who opt to take advantage of it. Potentially 
combining the RCC and FRC programs may provide a more uniform approach 
to the servicemember and eliminate some confusion as well as requiring 
both the VA and DOD to come even more closely together in coordinating 
their care.
    Second, we need to do a better job of supporting our family 
caregivers. This is the reason DOD has put forth the proposal for 
special compensation to servicemembers who participate in the expedited 
DES to compensate a family caregiver. Additional bills have been 
introduced to address this issue. The need to support caregivers is 
there. We need to look at all the ideas, collect the best ones, and 
develop the best legislative solution possible.
    Mr. Dimsdale and Dr. Guice. Based upon the testimony of the first 
panel, once effective care/case management is established, it seems 
that the departments are meeting most of the needs of the affected 
servicemembers and their families. The challenge that remains is for VA 
and DOD to gain a clear understanding of the effectiveness of the new 
programs and policies established to support seriously injured 
servicemembers and their families. The assessment of the new programs 
and policies is an ongoing activity and both departments are committed 
to making reforms or improvements as necessary.

    53. Senator Graham. Ms. McGinn, General Meurlin, Ms. Embrey, 
Admiral Timberlake, Mr. Dimsdale, and Dr. Guice, are the right 
mechanisms in place to achieve them?
    Ms. McGinn, General Meurlin, Ms. Embrey, and Admiral Timberlake. 
The DES pilot and expedited DES are in place and already helping our 
servicemembers and their families. We are looking to expand the pilot 
as quickly as possible.
    For family caregivers, we will need new authority to begin a 
program, and look to the committee for assistance with that.
    Mr. Dimsdale and Dr. Guice. It would appear that based upon the 
testimony from the first panel that the departments are clearly moving 
in the right direction by providing effective care and case management, 
while improving access to benefits and services. The establishment of 
new programs and policies alone does not guarantee success, but must be 
evaluated to ensure they are achieving their intended purpose. The 
Government Accountability Office (GAO) indicated in its testimony that 
this is something it is considering for the near future.

    54. Senator Graham. Ms. McGinn, General Meurlin, Ms. Embrey, 
Admiral Timberlake, Mr. Dimsdale, and Dr. Guice, what are the obstacles 
that we need to overcome?
    Ms. McGinn, General Meurlin, Ms. Embrey, and Admiral Timberlake. 
While great successes have been achieved to date, as we go forward to 
enhance the interoperability with the vision for the virtual lifetime 
electronic record agreed to by the Secretaries on March 24, the key 
interoperability challenges will include:

         Developing, adopting, and maturing standards at the national 
        level to ensure efficient operational use
         Updating systems, infrastructure, and technology consistent 
        with emerging standards
         Identifying and prioritizing information requirements as 
        defined by the business process owners and the functional 
        community
         Identifying, prioritizing, and implementing common services

    The departments also face challenges created by: different 
acquisition and funding cycles; different contracting processes; and 
differences in information assurance certification processes for VA, 
DOD, DISA, the Services, and the local level.
    We are working to not only identify areas where potential process 
differences may exist, but the departments and the IPO are 
collaboratively engaging in efforts to ensure that any impediment that 
may arise is resolved in an efficient manner.
    Mr. Dimsdale and Dr. Guice. Since the passage of the 2008 NDAA and 
its wounded warrior provisions, significant progress has been made in 
the support provided to seriously ill and injured servicemembers, 
veterans, and their families. The departments remain committed to 
eliminating any obstacles that might prevent a truly seamless 
transition for the seriously ill and injured.

    55. Senator Graham. Ms. McGinn, General Meurlin, Ms. Embrey, 
Admiral Timberlake, Mr. Dimsdale, and Dr. Guice, what can Congress do 
to help?
    Ms. McGinn, General Meurlin, Ms. Embrey, and Admiral Timberlake. 
Congress has demonstrated its support by providing appropriate 
legislative authority and the resources necessary to establish and 
maintain the programs needed to provide for more effective care, 
rehabilitation, and transition for seriously ill and injured 
servicemembers, veterans, and their families. We look forward to 
working with Congress to ensure that we continue to support those who 
have born the burden of battle and their families.
    Mr. Dimsdale and Dr. Guice. Congress has demonstrated its support 
by providing appropriate legislative authority and the resources 
necessary to establish and maintain the programs needed to provide for 
more effective care, rehabilitation, and transition for seriously ill 
and injured servicemembers, veterans, and their families. The 
departments look forward to working with Congress to ensure that we 
continue to support those who have born the burden of battle and their 
families.
                                 ______
                                 
               Questions Submitted by Senator John Thune
                     implementation of section 703
    56. Senator Thune. Ms. McGinn and Ms. Embrey, what steps has the 
Department taken to implement section 703 of the NDAA for Fiscal Year 
2009?
    Ms. McGinn and Ms. Embrey. A chiropractic workgroup was convened 
composed of senior service representatives to determine where to expand 
chiropractic care to best meet the needs of our Active Duty 
servicemembers. The results of their careful deliberations are:
Air Force
    1st Special Operations Medical Group, Hurlburt Field
Army
        Army Community Hospital Ft Riley
        Army Community Hospital Ft Rucker
        Army Community Hospital Ft Polk
        Army Community Hospital Ft Wainwright
        U.S. Army Medical Center Landstuhl
        U.S. Army Health Clinic Grafenwoehr
Navy
        Naval Medical Clinic Quantico
        Navy Branch Health Clinic Groton
        Naval Hospital LeMoore
        U.S. Naval Hospital Okinawa

    These 11 sites will bring the total number of MTFs providing 
chiropractic care to Active Duty servicemembers to 60. We anticipate 
these new sites will become operational by September 30, 2009.

    57. Senator Thune. Ms. McGinn and Ms. Embrey, has the Department 
found a need, due to a rise in demand for musculoskeletal services, to 
expand the availability of chiropractors or chiropractic services on 
military bases, either in the United States or overseas?
    Ms. McGinn and Ms. Embrey. This year, we are expanding the number 
of MTFs that provide chiropractic care to Active Duty servicemembers 
from 49 locations to 60 locations. Chiropractic care is a valued 
treatment modality and we think that offering it at 60 locations 
provides a good balance.

    58. Senator Thune. Ms. McGinn and Ms. Embrey, has the Department 
encountered any obstacles in trying to find licensed chiropractors to 
be stationed at bases in the United States or overseas?
    Ms. McGinn and Ms. Embrey. No, we have not encountered any 
obstacles in finding licensed chiropractors willing to work with us to 
care for our Active Duty servicemembers.

    [Whereupon, at 5:07 p.m., the subcommittee adjourned.]

                                 
