[Senate Hearing 112-114]
[From the U.S. Government Publishing Office]


 
          SEAMLESS TRANSITION: IMPROVING VA/DOD COLLABORATION 

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

                                HEARING

                               before the

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                      ONE HUNDRED TWELFTH CONGRESS

                             FIRST SESSION


                              MAY 18, 2011

                               ----------                              

       Printed for the use of the Committee on Veterans' Affairs















          SEAMLESS TRANSITION: IMPROVING VA/DOD COLLABORATION




















                                                        S. Hrg. 112-114

          SEAMLESS TRANSITION: IMPROVING VA/DOD COLLABORATION

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

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                      ONE HUNDRED TWELFTH CONGRESS

                             FIRST SESSION

                               __________

                              MAY 18, 2011

                               __________

       Printed for the use of the Committee on Veterans' Affairs


        Available via the World Wide Web: http://www.fdsys.gov/

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                     COMMITTEE ON VETERANS' AFFAIRS

                   Patty Murray, Washington, Chairman
John D. Rockefeller IV, West         Richard Burr, North Carolina, 
    Virginia                             Ranking Member
Daniel K. Akaka, Hawaii              Johnny Isakson, Georgia
Bernard Sanders, (I) Vermont         Roger F. Wicker, Mississippi
Sherrod Brown, Ohio                  Mike Johanns, Nebraska
Jim Webb, Virginia                   Scott P. Brown, Massachusetts
Jon Tester, Montana                  Jerry Moran, Kansas
Mark Begich, Alaska                  John Boozman, Arkansas
                       Kim Lipsky, Staff Director
                 Lupe Wissel, Republican Staff Director













                            C O N T E N T S

                              ----------                              

                              May 18, 2011
                                SENATORS

                                                                   Page
Murray, Hon. Patty, Chairman, U.S. Senator from Washington.......     1
Burr, Hon. Richard, Ranking Member, U.S. Senator from North 
  Carolina.......................................................     4
Tester, Hon. Jon, U.S. Senator from Montana......................     5
Isakson, Hon. Johnny, U.S. Senator from Georgia..................     6
Johanns, Hon. Mike, U.S. Senator from Nebraska...................     6
Boozman, Hon. John, U.S. Senator from Arkansas...................     7
Brown, Hon. Scott P., U.S. Senator from Massachusetts............   377
Begich, Hon. Mark, U.S. Senator from Alaska......................   379

                               WITNESSES

Gould, Hon. W. Scott, Deputy Secretary of U.S. Department of 
  Veterans Affairs...............................................     8
    Prepared statement...........................................    10
    Response to prehearing questions submitted by Hon. Patty 
      Murray.....................................................    22
    Response to posthearing questions submitted by Hon. Patty 
      Murray.....................................................    23
Lynn, Hon. William J., III, Deputy Secretary, U.S. Department of 
  Defense........................................................    29
    Prepared statement...........................................    30
    Response to prehearing questions submitted by Hon. Patty 
      Murray.....................................................    34
    Response to posthearing questions submitted by Hon. Patty 
      Murray.....................................................   366


          SEAMLESS TRANSITION: IMPROVING VA/DOD COLLABORATION

                              ----------                              


                        WEDNESDAY, MAY 18, 2011

                                       U.S. Senate,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 10:03 a.m., in 
room 418, Russell Senate Office Building, Hon. Patty Murray, 
Chairman of the Committee, presiding.
    Present: Senators Murray, Tester, Begich, Burr, Isakson, 
Johanns, Brown of Massachusetts, and Boozman.

       OPENING STATEMENT OF HON. PATTY MURRAY, CHAIRMAN, 
                  U.S. SENATOR FROM WASHINGTON

    Chairman Murray. This hearing will come to order. Welcome 
to everyone who is here today. We are here today to examine the 
ongoing efforts of the Department of Defense and the Department 
of Veterans Affairs to provide a truly seamless transition for 
our servicemembers and our veterans.
    It has been more than 4 years since the world learned about 
the shameful conditions and bureaucratic red tape confronting 
our wounded, ill, and injured servicemembers that were 
recovering at the Walter Reed Army Medical Center.
    We have learned and done a lot in that time, and over the 
past decade that we have been at war. We have also learned much 
from what our new veterans have told us. Next week, we will 
hear from some of them about their experiences when we hold a 
followup to this hearing.
    Yet, despite all that has been learned and all that has 
been done to address these shortfalls over the last several 
years and despite the significant improvements in cooperation 
between Department of Defense and VA, substantial challenges 
remain.
    One of the primary areas that requires further improvements 
is the coordination of medical care for the injured. As you 
both know, prescribing narcotics is on the rise in the 
military. A military doctor stationed at Madigan Army Medical 
Center, in my homestate of Washington, recently cited an Army 
Surgeon General number that almost 14 percent of soldiers have 
been prescribed some form of opiate drug, with a full third of 
them being prescribed more than one opiate.
    It is imperative that those individuals receive a truly 
seamless handoff to VA medical care so a provider there can 
manage those medications after the individual has left the 
service. If that link is not made, those new veterans become 
far more likely to abuse drugs, become homeless, or commit 
suicide.
    A key tool in this effort should be the post-deployment 
health assessment. However, I hear frequently from veterans 
that no one has followed up on the results of their screenings, 
they did not get referred to VA care nor did VA reach out to 
them, and there was no followup to ensure they received the 
care they needed. This process must be improved.
    Care for those who have been traumatically injured is 
another key priority. While the Department of Defense has 
outstanding prosthetic care, VA needs to do a lot better. I was 
shocked to hear of a veteran who, after receiving advanced 
prosthetics from the military, went to VA to have them adjusted 
and maintained. However, when the veteran got to the prosthetic 
clinic the VA employees were fascinated by his device, having 
never seen that model before, and were more interested, he 
said, in examining it than him.
    With the rates of injuries requiring amputation rising, we 
need to have the best possible care. As of early March 2011, 
409 Operation Enduring Freedom servicemembers have needed limbs 
amputated.
    Not long ago, the idea that battlefield medicine could save 
the life of a quadruple amputee was unthinkable, but now it is 
the reality. VA is responsible for these veterans for the rest 
of their lives, and VA must be up to the task.
    After a decade of continuous conflict, I am concerned that 
the Nation is becoming desensitized to the physical and 
psychological wounds of war. While those watching on the 
nightly news may feel as though they have seen many such 
injuries, we can never forget how truly devastating some of 
these injuries are, and what an overwhelming impact they have 
on the servicemember or veteran's life, as well as on their 
family.
    One tool to raise the quality of care in this area is the 
Center of Excellence on Amputations and Extremity Injuries, and 
establishing all of the centers of excellence that were 
required by law.
    Unfortunately, there has been very little progress in 
making these centers operational, with delays caused by what 
can only be characterized as bureaucratic infighting. I know 
that I speak for several Senators in saying we want these 
centers brought online, as the law requires, immediately.
    Mental health care is another area where we can improve 
collaboration. I note that the Departments have agreed on an 
integrated mental health strategy, and I look forward to the 
results of your continuing efforts to meet the guidelines of 
that strategy. This will be an important step toward making 
care more standardized and evidence-based, and will reduce 
duplication.
    Health care is not the only area that needs better 
collaboration. This Committee has previously looked at the 
Departments' Joint Disability Evaluation System. While 
streamlining efforts where we can is important, the 
implementation of this joint program has not been without 
problems. Unfortunately, the numbers for this new process are 
trending in the wrong direction, and I would like to know what 
improvements DOD and VA hope to make in this regard.
    This is particularly concerning because all too often this 
time spent waiting results in our men and women in uniform 
falling through the cracks of the system. You shared 
particularly troubling information about the number of wounded 
warriors who have taken their own lives or turned to drug abuse 
while waiting to complete the disability evaluation process. I 
look forward to actually asking you about this in the question 
and answer and comment period following your statement.
    Just last month this Committee held a hearing on employment 
and transition of new veterans. As a result of that hearing and 
numerous discussions with employers and veterans, I have 
introduced the Hiring Heroes Act, which will help streamline 
the hiring process for new veterans and equip them with the 
skills to successfully navigate the civilian employment market.
    That legislation will also require participation of all 
servicemembers in the Transition Assistance Program (TAP). I 
believe this will dramatically improve the experience of 
servicemembers who are transitioning out of the military and 
equip them with the skills needed to succeed in the civilian 
workforce.
    This will be especially true as VA, Labor, and the military 
services update and revise their portions of TAP. The revised 
program should be more relevant, user-friendly, and tailored to 
the needs of the individual servicemember.
    Underlying many of these issues are significant questions 
about IT solutions and how they affect health care and 
benefits. I am pleased to hear that Secretary Gates and 
Secretary Shinseki recently agreed to a plan that will deliver 
a common, integrated electronic health system. This level of 
communication and integration has the potential to 
revolutionize the way we deliver health care to servicemembers 
and veterans, and dramatically improve our current efforts.
    Deputy Secretary Lynn, I think you would call it a ``force 
multiplier.''
    We all want to see this project accomplished correctly and 
on schedule, and we expect to see the same level of commitment 
to the development of a joint electronic health record under 
the leadership of the next Secretary of Defense as we have 
witnessed recently by Secretary Gates.
    As we assess the current state of DOD/VA collaboration, we 
must remember that the issues we confront today will not go 
away when the last troops leave Iraq and Afghanistan. Rather, 
they will be with us as a Nation for many years to come. When 
we send servicemembers into harm's way, it is our non-
negotiable duty to take care of them when they return home. 
Providing the best possible care and benefits to veterans is a 
cost of war. It is a cost that must be paid in full.
    So I want to thank both Deputy Secretaries for being here 
today. In your capacities as the co-chairmen of the Senior 
Oversight Committee, you are the individuals who can make these 
things happen, and we are counting on your leadership of your 
respective Departments. So, we look forward to hearing from 
both of you.
    I will now turn to Ranking Member Burr for his opening 
statement.

        STATEMENT OF HON. RICHARD BURR, RANKING MEMBER, 
                U.S. SENATOR FROM NORTH CAROLINA

    Senator Burr. Thank you, Madam Chairman, and to both Deputy 
Secretaries, welcome. I am pleased with the progress that is 
being made improving the lives of our Nation's wounded 
warriors, their families, and as they transition from active 
duty to veterans' status. I look forward to discussing how 
effectively the two Departments are working together and what 
more can be done.
    I want to apologize to both witnesses and to my colleagues. 
I just had an Honor Flight land about 40 minutes ago and 
shortly they are going to be at the World War II Memorial. 
Sometimes you do things out of a sense of urgency, so I will 
leave you and run down there to enjoy what may be their only 
viewing of the memorial built for their sacrifices.
    There has been a long history, going back to 1982, of DOD 
and VA sharing medical resources. However, only recently have 
the Departments attempted to collaborate on specific care 
programs for the Nation's most severely wounded.
    Many of these programs began in response to recommendations 
from various commissions to address the 2007 media reports of 
poor conditions at Walter Reed. The idea for developing these 
``joint'' programs was to cut through the bureaucracy and 
create a better transition for both veterans and their 
families.
    It has been 4 years since the issues at Walter Reed came to 
light, and I cannot help but wonder if what we have done is to 
just create more bureaucracy.
    One area that was implemented at the suggestion of the 
Dole-Shalala Commission is the Federal Recovery Coordination 
Program. As this program was visualized, the government would 
hire Federal recovery coordinators to help veterans and their 
families navigate all of the benefits the servicemembers were 
entitled to throughout the entire Federal Government.
    Unfortunately, this is a perfect example of an idea that 
looked great on paper, but has yet to live up to expectations. 
A recent GAO report on the program shows that there are still 
problems with the two agencies working together. According to 
the report, there are problems coordinating the seven different 
services available through VA and DOD that support wounded 
servicemembers.
    For example, because both VA and DOD have care 
coordinators, there is a possibility for overlap in case 
management resulting in a duplication of efforts.
    Another problem is that one case file is not shared by both 
VA and DOD care coordinators. Because of this, GAO found a 
situation where a veteran with multiple amputations had one 
goal set by his FRC and the complete opposite goal set by his 
DOD recovery care coordinator. The FRC was instructing the 
veteran to transition out of the service and the RCC set a goal 
for that same veteran to remain on active duty. Surely, this is 
not the kind of service that Dole-Shalala envisioned.
    Another area that has been slow to move forward is 
integrating electronic health records. In April 2009, the 
President announced the development of an integrated electronic 
health record that will follow a veteran ``from the day they 
first enlist until the day they are laid to rest.'' However, 2 
years later, the Departments only recently identified a path 
forward which includes VA adopting DOD's electronic health 
records system. While I am happy that this important venture is 
moving forward, I am disturbed it took 2 years to get to this 
point and wonder when, or if, this project will be completed.
    While the Departments have worked slowly on IT issues, they 
may have jumped the gun on the benefits side. Last year, DOD 
and VA started to roll out worldwide an integrated disability 
evaluation system or IDES. This was supposed to smooth the 
transition to civilian life by allowing injured servicemembers 
to find out what benefits they would get from each category 
before leaving the military.
    But there have been a range of challenges, including 
logistical issues, staffing shortages, inadequate IT solutions, 
and concerns about the quality-of-life for servicemembers going 
through the process. Also, goals set by VA and DOD for customer 
satisfaction are not being met and some facilities are 
struggling to meet timeliness goals.
    Nationwide, it is taking on average 394 days to complete 
the process, almost 100 days longer than the target; and at 
Camp Lejeune, it is taking on average 512 days. That is almost 
1\1/2\ years. These delays and the impact they are having on 
our wounded servicemembers are a serious concern.
    Overall, several years after instituting a coordinated 
effort to ensure we are taking care of our most severely 
wounded, ill, and injured servicemembers, issues still remain. 
All of this suggests that we need to take a serious look at 
whether these programs, as currently structured, are the best 
way to meet the needs of wounded servicemembers and their 
families.
    Madam Chairman, as we move forward, I certainly look 
forward to working with you to ensure that the two Departments 
work as a team to see that wounded our servicemembers get the 
care, the services, the benefits they earn and need without 
hassles and without delays.
    To our witnesses today, I commend you for the effort that 
both of you have made and encourage both the VA and the DOD to 
figure out what we need to move forward at a pace consistent 
with what I think we all share is in the best interest of these 
servicemen and women who we are here to serve. I thank the 
chair.
    Chairman Murray. Thank you very much, Senator Burr.
    I will turn it over to our Members for any opening 
statements if they wish to give them. We will begin with 
Senator Tester.

                 STATEMENT OF HON. JON TESTER, 
                   U.S. SENATOR FROM MONTANA

    Senator Tester. I will be very quick, Madam Chair. I 
appreciate your remarks and I appreciate your holding this 
hearing with the Ranking Member.
    I will just say thank you both for being here. This is 
critically important stuff.
    Whether you are talking about employment or medical records 
or mental health counseling--the list goes on and on--we have 
an obligation. And quite frankly, I have been on this Committee 
now starting my fifth year; and you have a Committee here that 
is willing to work with both the Department of Defense and VA 
to make things better for our veterans.
    And, we have got a backlog, the VA has a huge backlog. I 
think the medical record issue is very, very important; and I 
think it falls on both the Department of Defense and VA to have 
a sense of urgency. Let us just put it that way.
    Then we are seeing the employment numbers or should I say 
unemployment numbers, coming out on our veterans which are 
catastrophic in my opinion. The people who serve this country 
come home, and they cannot get a job.
    So, the transition between DOD and VA needs some work, and 
I will just tell you both are quality individuals. I have 
worked with you before. You have some people around you who are 
very, very good. We have just got to get this fixed. I mean, we 
really do. Whatever we can do, and hopefully you have some 
suggestions on what maybe we can do as a Committee, what you 
need as individual agencies to move forward with the seamless 
transition in a way that makes sense in all areas because our 
veterans deserve no less. Thank you, Madam Chair.
    Chairman Murray. Thank you.
    Senator Isakson.

               STATEMENT OF HON. JOHNNY ISAKSON, 
                   U.S. SENATOR FROM GEORGIA

    Senator Isakson. Thank you, Madam Chairman. I will be brief 
too. In fact, I will apologize, first. I have to walk out for 
about a 10-minute interview and I will be right back, because 
this is my number 1 issue on the Committee, as the Chairman 
knows. General Schumacher in Augustine, Georgia at Fort Gordon 
and the Charlie Norwood VA established the first seamless 
transition program for veterans leaving DOD and going into 
veterans health care. We have a lot of examples of the lives 
that were saved and the mental health improvement that soldiers 
have had from that, and I think we are going to hear some good 
news today on coordination and collaboration between DOD and 
Veterans Affairs. I appreciate both our Under Secretaries being 
willing to come and testify. If you all will pardon me, I will 
be back in 10 minutes to engage in questions and answers.
    Thank you, Madam Chairman.
    Chairman Murray. Thank you.
    Senator Johanns.

                STATEMENT OF HON. MIKE JOHANNS, 
                   U.S. SENATOR FROM NEBRASKA

    Senator Johanns. Madam Chair, thank you very much.
    Gentlemen, thank you so much for being here.
    The previous opening statements have really covered the 
bailiwick, if you will, so I do not have to say much. But there 
would be a couple of things that I would like to offer.
    One is, we all acknowledge that processing time is just 
dismal. You look at the number of days, and it is discouraging. 
It is for us; I know it must be for you. So, I look at that and 
I ask myself a couple of things.
    One is as benchmarks are established to see if we are 
actually improving the system; how are we doing in meeting 
those benchmarks in a couple of areas? One area is just the 
mechanics of getting things done. Do we have the right IT 
system in place? How far along are we in deploying it? Is it 
working? Are people getting the training they need to deal with 
it? So, it is the platform sorts of issues.
    The second piece of it, though, is the human component. Are 
there offices that are just simply doing better and why are 
they doing better? If they have the same tools, the same 
resources, is it better leadership? Is it people that have 
received the training they need? Is it the fact that the 
positions that open up can be filled and so you do not have a 
problem there?
    For example, in the mental health area, I think part of the 
problem we are running into is we just do not have the 
evaluators to move the cases to get them done. I would like to 
hear your reaction to that statement as to whether you think 
that is an issue too.
    Again it just seems to me that if we could find some places 
where things are working--where cases are being processed, 
where the work is moving--and try to figure out what they are 
doing right there. It may unlock the door, if you will, to 
other areas of the country or other parts of the system that 
are not working as well.
    I agree with Senator Tester. You know, you are quality 
people with unbelievable backgrounds. You are here for a 
reason, and my attitude is as a Member of this Committee is I 
want to try to do everything I can to support your efforts to 
deal with this issue because at the end of the day if we can 
reduce the number of days for processing, we benefit people who 
have served. And that is huge. I mean, that is why all of us 
want to be on this Committee, to try to improve the lives of 
people who have served.
    With that I am anxious to hear your testimony and anxious 
to ask a few questions. Thank you.
    Chairman Murray. Thank you.
    Senator Boozman.

                STATEMENT OF HON. JOHN BOOZMAN, 
                   U.S. SENATOR FROM ARKANSAS

    Senator Boozman. Thank you, Madam Chair. I appreciate your 
leadership and the Ranking Member's in having the hearing. This 
is really very important. I too apologize. I am a Ranking 
Member on another Committee, and I am going to have to sneak 
out in a bit.
    But I do appreciate both of you. I know that you are 
working really hard to resolve this. Not only are you working 
hard, but I know that this is also important to Secretary 
Gates, and Secretary Shinseki, you know, who are working hard 
to get this resolved.
    We have got the problem not only of the problem with our 
wounded but also it makes it difficult for those in filling 
those slots when people are in limbo, and so that makes it 
difficult because we are running so lean and mean right now, 
you know, there are just lots of reasons that we need to get 
this done.
    So, we do appreciate your hard work. I know that I and the 
rest of the Committee are committed in a very bipartisan way to 
help you in any way that we can, whether we need additional 
legislation or additional prodding or whatever in order to get 
this done. So, thank you very much.
    With that I yield back.
    Chairman Murray. Thank you.
    Today this Committee will hear from Deputy Secretary of 
Defense William Lynn, and from Deputy Secretary of Veterans 
Affairs, Scott Gould. Both deputy secretaries are co-chairman 
of the Senior Oversight Committee which is charged with 
supervising joint VA DOD initiatives.
    So, we appreciate both of you being here this morning and 
look forward to your testimony, and I will turn it over to you 
two to decide who will begin.

STATEMENT OF THE HONORABLE W. SCOTT GOULD, DEPUTY SECRETARY OF 
              U.S. DEPARTMENT OF VETERANS AFFAIRS

    Mr. Gould. Chairman Murray, thank you, and good morning, 
Ranking Member Burr when he steps back in, and Members of this 
Senate Veterans' Affairs Committee.
    I am honored to be here today with my partner Deputy 
Secretary Bill Lynn to discuss the issues that you mentioned, 
and frankly, the progress being made by VA and DOD to meet the 
needs of our returning and injured servicemembers, and to 
report on the wide range of collaborative efforts that are 
ongoing between our two Departments.
    I asked that my written statement be included in the 
record.
    Chairman Murray. Both of your statements will be included.
    Mr. Gould. Thank you, ma'am.
    VA and DOD are committed to providing a comprehensive 
continuum of care and benefits that optimizes the health and 
well being of servicemembers, veterans, and their eligible 
beneficiaries.
    We have worked together closely for the past 2 years to 
ensure the smooth transition of servicemembers to veteran 
status. However, our Departments recognize that there is much 
more to do.
    I would like to thank Deputy Secretary Lynn and all the 
dedicated staff at the Department of Defense for their hard 
work and commitment to our team.
    The result of their work is a wide array of programs and 
initiatives aimed at improving this transition. The programs 
and initiatives address basically five areas of opportunity.
    Outreach efforts focused on informing and attracting more 
servicemembers to our benefits and services programs. Clients 
customer service initiatives designed to improve their 
experience in all facets of our health and benefits programs. 
Health care services designed to improve physical and mental 
health. Benefit services that assist with education, employment 
and/or compensation. Finally, the management infrastructure 
that supports the exchange of health and benefit information 
between the servicemember, the veteran, DOD, the VA, and 
frankly, the private sector.
    Collectively these initiatives are designed to make a 
complex array of benefits and services easier to access for the 
over 200,000 servicemembers and demobilizing Guard and 
Reservists that transition from active duty each year.
    Today I would like to highlight three VA/DOD collaborative 
initiatives that we are currently using to assist transitioning 
servicemembers.
    The first initiative is the DOD Yellow Ribbon program for 
mobilized members of the National Guard and Reserve. VA staff 
provides support at Yellow Ribbon events hosted by each of the 
services during the entire deployment cycle: beginning, middle, 
and end.
    In fiscal year 2010, there were over 2,000 of these events 
attended by over 600,000 servicemembers and their families.
    The second initiative changes the process through which 
wounded, ill, and injured servicemembers determine whether they 
will return to duty, medically retire, or leave the service 
with a VA disability. This new system is called the Integrated 
Disability Evaluation System or IDES.
    IDES is a better system for the servicemember and veteran 
than the legacy DES system. Medically separating servicemembers 
no longer experience a pay gap and now have only one medical 
exam with one proposed disability rating.
    IDES has also virtually eliminated the inconsistencies that 
often previously existed in disability ratings among the 
services and between the services and VA. A goal of IDES is to 
reduce the average processing time from 540 days, which it is 
today in the old system to 295 days while still respecting 
servicemember needs through the healing process.
    Unfortunately, IDES currently runs alongside the old DES 
system. There are approximately 14,000 servicemembers in the 
old system and only 13,000 in the new system. This means that 
two servicemembers with identical injuries may go through 
different processes with different levels of convenience and 
responsiveness. We are committed to eliminating this inequity 
by implementing IDES nationwide by the end of this fiscal year.
    Although the Departments have worked through many 
challenges to improve the IDES process, we are not fully 
satisfied, and we are working aggressively to address 
improvements. Secretary Gates and Secretary Shinseki are also 
personally involved in making additional process improvements 
to IDES.
    Third, I would like to address the major strides we have 
made in sharing health and benefits data between our two 
Departments. Our objective is to ensure that appropriate 
health, administrative, and benefits information is visible, 
accessible, and understandable to all appropriate users through 
secure and interoperable information technology.
    For the past several years, we have shared increasing 
amounts of health information. Our clinicians can now 
electronically access health information for almost 4,000,000 
servicemembers and veterans at a rate of 96,000 views per week.
    Chairman Murray, I would like to invite you and all of the 
Committee Members to Washington's VA medical center for a 
demonstration of our VA's electronic health record to see how 
it interfaces with DOD health data, and I think you all will be 
impressed.
    Even though we already exchange data between DOD and VA, 
and 100 percent of servicemembers and veterans already have an 
electronic medical record, the systems are in need of 
modernization. Recently the Secretaries formally agreed that 
our two Departments would work cooperatively toward a single 
joint common electronic health record. We call this effort the 
Integrated Electronic Health Record or IEHR.
    We are currently developing detailed plans to achieve this 
complex goal. But once completed, the IEHR will be a national 
model for capturing, storing, and the sharing of electronic 
health information.
    Last, as a measure of our collaborative efforts and the 
concerted outreach efforts we have taken to inform and to 
attract servicemembers and veterans to use the services and 
benefits they have earned, I would like to share with you the 
following statistics.
    As of January 2011 over 50 percent of separated OIF, OEF, 
OND veterans have sought VA health care. And, as of May 1 of 
this year, 504,000 students were enrolled in college under the 
new G.I. Bill.
    We believe these new statistics are a validation of our 
outreach efforts. I can assure you VA will not rest until all 
veterans receive the benefits and services for which they are 
eligible. We look forward to working with Congress and with 
this Committee to achieve that goal.
    Chairman Murray, Ranking Member Burr, this concludes my 
statement. Deputy Secretary Lynn and I look forward to your 
questions.
    [The prepared statement of Mr. Gould follows:]
     Prepared Statement of Hon. W. Scott Gould, Deputy Secretary, 
                  U.S. Department of Veterans Affairs
    Chairman Murray, Ranking Member Burr, Members of the Senate 
Veterans' Affairs Committee, I am pleased to be here today to discuss 
the progress being made by the Department of Veterans Affairs (VA) and 
the Department of Defense (DOD) toward meeting the needs of returning 
and injured Servicemembers and to report on the wide range of VA and 
DOD collaboration that is ongoing between our two Departments. 
Secretary Lynn and I have worked together for the past 2 years to 
confront the major challenges before us. Our goal is to ensure the 
Servicemembers' transition between VA and DOD is as smooth as possible 
and honors the enormous commitment they have made to the country and we 
have made to them as Veterans. Our Departments understand that we are 
responsible for the same men and women at different times of their 
lives and that together our Departments can help improve their 
transition experience as they move from one stage to the next. Since VA 
last testified before this Committee on VA/DOD collaboration efforts in 
2008 we have made significant progress improving the transition process 
from military to civilian life, as well as enhancing the collaboration 
that exists between VA and DOD.
                   major initiatives and improvements
    The two Departments continue to drive toward providing a 
comprehensive continuum of care to optimize the health and well being 
of Servicemembers, Veterans, and their eligible beneficiaries. Our 
joint efforts to provide a ``single system'' experience of life-time 
services are supported by three common goals: 1) efficiencies of 
operations; 2) health care; and 3) benefits. The goal of efficiencies 
of operations describes the Department's efforts to reduce duplication 
and increase cost savings through joint planning and resource sharing. 
Our health care goal is a patient-centered health care system that 
consistently delivers excellent quality, access, and value across the 
Departments. We also strive to anticipate and address Servicemember, 
Veteran, and family needs through an integrated approach to delivering 
comprehensive benefits and services. I will describe the significant 
VA/DOD collaborative initiatives and programs to achieve these goals. 
In addition, I will also highlight outreach activities that complement 
these efforts.
    VA and DOD collaboration is governed by two oversight bodies co-
chaired at our level called: the Senior Oversight Committee (SOC) and 
the Joint Executive Council (JEC). As you know, the SOC was created in 
May 2007 in response to issues raised at the Walter Reed Army Medical 
Center. Since its inception, the SOC has served as the single point of 
contact for oversight, strategy, and integration of wounded, ill, and 
injured (WII) policies by DOD and VA. These efforts are coordinated to 
improve Servicemember and Veteran support throughout their recovery, 
rehabilitation, and reintegration to the Armed Forces and/or civilian 
life. As the co-chairs of the SOC, Deputy Secretary Lynn and I work 
together to keep the momentum going on this important work. While the 
SOC primarily focuses on WII issues, some objectives and initiatives 
overlap with broader DOD personnel and readiness issues and are, 
therefore, monitored by the VA/DOD JEC that I co-chair with Under 
Secretary of Defense for Personnel and Readiness, Dr. Clifford Stanley.
    The JEC provides senior leadership for the more expansive issues of 
collaboration and resource sharing between VA and DOD. The JEC directs 
appropriate resources and expertise to specific operational areas 
through its sub-councils, the Health Executive Council (HEC) and the 
Benefits Executive Council (BEC), and the Interagency Program Office 
(IPO) and several Independent Working Groups (IWGs). The JEC is also 
responsible for the preparation of the VA/DOD Annual Report and the VA/
DOD Joint Strategic Plan (JSP) that is submitted to this Committee.
    The JSP is the primary document through which the Secretaries of 
the Departments convey the coordination and sharing efforts between the 
two Departments. The JSP allows VA and DOD to guide and track the 
progress of interagency collaborative efforts to improve on the 
delivery of comprehensive benefits, provide patient-centered health 
care, and deliver effective and efficient delivery of benefits and 
services. While the JSP is managed by the JEC, it is a multifaceted 
document that encompasses a wide range of VA/DOD initiatives, some of 
which are also monitored and tracked in the SOC. Specific SOC 
initiatives documented in the JSP include the Federal Recovery 
Coordination Program (FRCP), Integrated Disability Evaluation System 
(IDES), Integrated Mental Health Strategy (IMHS), Centers of 
Excellence, and eBenefits. Whereas the SOC focuses on the WII 
population, the JEC serves as the permanent oversight body for the 
broad VA/DOD issues affecting all Servicemembers and Veterans.
    Many initiatives originating in the SOC are now institutionalized 
and tracked in the JEC. For example, the SOC aggressively pursued the 
development of the IMHS to immediately address the growing mental 
health needs of the WII and their families. After the strategy was 
approved by the SOC in October, 2010 we transferred it to the HEC under 
the JEC for permanent oversight and implementation. Similarly, the 
issue of credentialing and privileging of providers was initially 
examined in the SOC and transferred to the HEC for permanent oversight 
and management.
                       efficiencies of operations
    VA and DOD continue to leverage opportunities to create 
efficiencies by improving resource and information sharing and 
enhancing the coordination of business practices through joint 
planning. Some of these joint initiatives include: data sharing; the 
Integrated Disability Evaluation System (IDES); the VA/DOD Federal 
Recovery Care Program (FRCP); and the James A. Lovell Federal Health 
Care Center (JALFHCC).
Data Sharing Between the Departments of Defense and Veterans Affairs
    In the last 2 years, we have made major strides in sharing health 
and benefits data between our two Departments, and made significant 
progress toward our long-term goal of seamless data sharing systems. 
Our objective is to ensure that appropriate health, administrative, and 
benefits information is visible, accessible, and understandable through 
secure and interoperable information technology to all appropriate 
users. For the past several years, we have shared increasing amounts of 
health information to support clinicians involved in providing day-to-
day health care for Veterans and Servicemembers. Our clinicians can now 
access health information for almost four million Veterans and 
Servicemembers between our health information systems. Veterans and 
Servicemembers are able to access increasing amounts of personal health 
information from home or work sites through our ``Blue Button'' 
technology, using VA and DOD secure Web sites.
    For the last 2 years, we have worked together on a Virtual Lifetime 
Electronic Record (VLER). This project takes a phased approach to 
sharing health and benefits data to a broader audience, including 
private health clinicians involved in Veteran/Servicemember care, 
benefits adjudicators, family members, care coordinators, and other 
caregivers. We are in the first phase of this project, with five 
operational ``pilot'' sites where we are sharing health information 
between VA, DOD, and private sector health providers.
    More recently, Secretary Gates and Secretary Shinseki formally 
agreed that our two Departments would work cooperatively toward a 
common electronic health record. We call this effort the ``integrated 
Electronic Health Record,'' or iEHR. As I speak to you today, our 
functional and technical experts are meeting to develop and draft 
detailed plans on executing an overall concept of operations that the 
two Secretaries will utilize to determine the best approach to 
achieving this complex goal. Once completed, the iEHR will be a 
national model for capturing, storing, and sharing electronic health 
information.
James A. Lovell Federal Health Care Center
    The James A. Lovell Federal Health Care Center (JALFHCC) 
demonstration project is the culmination of over 5 years of 
collaboration between VA and DOD. The JALFHCC combines the missions of 
the Naval Health Clinic (NHC) Great Lakes and the North Chicago VA 
Medical Center. The JALFHCC is the first clinically and 
administratively integrated facility of its kind in the Nation, 
highlighted by a single governance structure covering personnel, IM/IT 
and financial integration. The facility serves both VA and DOD 
beneficiaries as an integrated entity. The JALFHCC demonstration 
project held a dedication ceremony on October 1, 2010.
Integrated Disability Evaluation System
    In early 2007, VA partnered with DOD to make changes to the DOD's 
existing Disability Evaluation System (DES). A modified process called 
the VA/DOD DES Pilot Model was launched in November 2007, and was 
intended to simplify and increase the transparency of the DES process 
for the Servicemember while reducing the processing time and improving 
the consistency of ratings for those who are ultimately medically 
separated. VA/DOD implemented the pilot in response to the issues 
raised at the Walter Reed Army Medical Center concerning the DOD 
Disability process in February, 2007, and the subsequent findings of 
many commissions, studies and reports. The pilot addressed 
recommendations that could be implemented without legislative change. 
Authorization for the pilot was included in the National Defense 
Authorization Act 2008 and further energized our efforts for improving 
DOD's DES.
    From the outset, the Departments recognized that the VA/DOD DES 
Pilot Model was preceded by an outdated DOD legacy process that was, in 
some cases, cumbersome and redundant. The DES Pilot Model was launched 
originally as a joint VA/DOD process at three operational sites in the 
National Capital Region (NCR) and was recognized as a significant 
improvement over the legacy process. As a result, and to extend the 
benefits of the Pilot Model to more Servicemembers, VA and DOD expanded 
the Pilot. The DES Pilot Model started in the fall of 2007 with the 
original three pilot sites in the NCR and ended in March 2010, covering 
27 sites and 47 percent of the DES population. In July 2010, the co-
chairs of the SOC agreed to adopt the pilot process as the standard 
business practice, expand the pilot, and rename it the Integrated 
Disability Evaluation System (IDES). Senior leadership of VA, the 
Services, and the Joint Chiefs of Staff strongly supported this plan 
and the need to expand the benefits of this improved DES Pilot Model to 
all Servicemembers. VA and DOD are now working together to complete the 
final 50 percent of the system. As a result, in October, 2010 we 
started the transition from the existing legacy DES to IDES using the 
DES Pilot Model process. Currently there are 78 IDES sites operational 
nationwide (which includes the original 27 Pilot Model sites) 
representing 74 percent of the population. When fully implemented in 
October 2011, there will be a total of 139 IDES sites.
    Through the implementation of IDES, the Departments have created a 
more transparent, consistent, and expeditious disability evaluation 
process for Servicemembers being medically retired or separated from 
military service and provide a more effective transition as they move 
from DOD to VA. We believe that through the implementation of the DES 
Pilot Model we have largely achieved that goal. In contrast to the DES 
legacy process, IDES provides a single disability examination and a 
single-source disability rating that both Departments use in executing 
their respective responsibilities. This results in more consistent 
evaluations, faster decisions, and timely benefits delivery for those 
medically retired or separated. IDES has enhanced all non-clinical 
care, administrative activities, case management, and counseling 
requirements associated with disability case processing. As a result, 
VA can deliver benefits in the shortest period allowed by law following 
discharge, thus eliminating the ``pay gap'' that previously existed 
under the legacy process, i.e., the lag time between a Servicemember 
separating from DOD due to disability and receiving his or her first VA 
disability payment.
    IDES has also eliminated much of the sequential and duplicative 
processes found in the legacy system. Since the beginning of the pilot, 
over 5,800 Servicemembers have completely transitioned from referral 
into IDES to Veteran status. As of April 30, 2011 there were 13,762 
active cases in the IDES process. Prior to the roll out of IDES, it 
took an average of 540 days for the VA and DOD processes to be 
completed. Now under IDES the goal is to complete the process within 
295 days, while simultaneously shortening the period until the delivery 
of VA disability benefits after separation from an average of 166 days 
to approximately 30 days (the shortest period allowed by law).
    Despite the overall reduction in combined processing time achieved 
to date, there remains room for significant improvement in IDES 
execution. VA and DOD recognized that as we expanded outside of the 
NCR, we did not have robust business processes in place to certify each 
site's preparedness before it became operational. Through our analysis 
of lessons learned, we have developed Initial Operating Capability 
(IOC) readiness criteria that ensure that future sites are 
operationally ready for IDES. For a site to be deemed ready it must: 1) 
provide adequate exam coverage through either the Veterans Health 
Administration (VHA), Veterans Benefits Administration (VBA) contracted 
services, or DOD; 2) have sufficient space and equipment for VA and DOD 
personnel; 3) meet VA information technology requirements; and 4) have 
local staff who have completed IDES training. If any of these criteria 
are not met, then the site is not considered certified to implement 
IDES.
    VA and DOD have hosted three joint training/planning conferences to 
set the stage for the roll-out of IDES sites. The conferences have 
resulted in improved communications between VA and DOD at each site, 
individual site assessment analyses and evaluations, and development of 
joint local plans to meet IOC requirements.
    As the Departments continue to move forward, we are aware of the 
concerns and recommendations of the Government Accountability Office 
(GAO) in its December 2010 report entitled ``Military and Veterans 
Disability System: Pilot has Achieved Some Goals but Further Planning 
and Monitoring Needed.'' VA and DOD agreed with the GAO recommendations 
and we are currently acting on those recommendations.
    VA and DOD are committed to supporting our Nation's wounded, ill, 
and injured warriors and Veterans through an improved IDES. We 
recognize the requirement to continually evaluate and improve the 
process, and are constantly working toward that end.
Federal Recovery Coordination Program (FRCP)
    In October 2007, the SOC established FRCP as a VA-administered 
program with joint oversight by VA and DOD. It is designed to 
coordinate access to Federal, state, and local programs, benefits, and 
services for severely wounded, ill, and injured Servicemembers, 
Veterans, and their families. The SOC maintains oversight of the FRCP. 
The program was specifically charged with providing seamless support 
from the time a Servicemember arrived at the initial Medical Treatment 
Facility in the United States through the duration of care and 
rehabilitation. Services are now provided through recovery, 
rehabilitation, and reintegration into the community. Federal Recovery 
Coordinators (FRC) are Masters-prepared nurses and clinical social 
workers who provide for all aspects of care coordination, both clinical 
and non-clinical. FRCs are located at both VA and DOD facilities.
    FRCs work together with other programs designed to serve the 
wounded, ill, and injured population including clinical case managers 
and non-clinical care coordinators. FRCs are unique in that they 
provide their clients a single point of contact regardless of where 
they are located, where they receive their care, and regardless of 
whether they remain on Active Duty or transition to Veteran status.
    FRCs assist clients in the development of a Federal Individual 
Recovery Plan and ensure that resources are available, as appropriate, 
to assist clients in achieving stated goals. More than 1,300 clients 
have participated in the FRC program since its inception in 2008. 
Currently, FRCP has more than 700 active clients in various stages of 
recovery. There are currently 22 FRCs with an average caseload of 33 
clients. A satisfaction survey conducted in 2010 reported that 80 
percent of FRCP clients were satisfied or very satisfied with the 
program.
National Resource Directory
    Also established by the SOC, the National Resource Directory (NRD) 
is a comprehensive, Web-based portal that provides Wounded Warriors, 
Servicemembers, Veterans, and their families with access to thousands 
of resources to support recovery, rehabilitation, and reintegration. 
NRD is a collaborative effort between the U.S. Departments of Defense, 
Labor, and Veterans Affairs and has more than 13,000 Federal, state and 
local resources which are searchable by topic or location. NRD's 
success has resulted in more than 3,000 visitors per day to the Web 
site. NRD is continuously improving and implementing enhancements to 
the Web site that were identified by recent usability testing. In 
April 2011, the NRD launched a mobile version of the Web site.
                              health care
    VA and DOD are committed to working together to improve the access, 
quality, effectiveness, and efficiency of health care for 
Servicemembers, Veterans and their beneficiaries. Some of our 
cooperative efforts include the Integrated Mental Health Strategy 
(IMHS), suicide prevention programs, Polytrauma and Traumatic Brain 
Injury (TBI) care, Centers of Excellence, Operation Enduring Freedom 
(OEF)/Operation Iraqi Freedom (OIF)/Operation New Dawn (OND) Care 
Management/Coordinators, VA's liaisons for health care, and joint 
efforts to address toxic exposures/environmental hazards.
Integrated Mental Health Strategy
    The development of the IMHS was a major focus of the SOC in FY 2010 
and was finally approved in October 2010. Oversight of the program was 
then transferred to the Health Executive Council (HEC) under the JEC 
and the implementation of the strategy was approved at the November 8, 
2010 HEC. The IMHS was developed in order to address the growing 
population of Servicemembers and Veterans with mental health needs. 
Mental health care provides unique challenges for the two organizations 
with separate missions in that they serve the same population, but at 
different times in their lives and careers. As such, the IMHS centers 
on a coordinated public health model to improve the access, quality, 
effectiveness, and efficiency of mental health services. Recipients of 
these services include Active Duty Servicemembers, National Guard and 
Reserve Component members, Veterans, and their families.
    The IMHS derives from joint efforts in 2009 and 2010 between VA and 
DOD subject matter experts, which included the DOD/VA Mental Health 
Summit. The Strategy is defined by 28 Strategic Actions which fall 
under the following four strategic goals: 1) Expand access to 
behavioral health care in DOD and VA; 2) Ensure quality and continuity 
of care across the Departments for Servicemembers, Veterans, and their 
families; 3) Advance care through community partnership and education 
and reduce stigma through successful public communication and use of 
innovative technological approaches; and 4) Promote resilience and 
build better behavioral health care systems for tomorrow.
    This collaboration is providing unique opportunities to coordinate 
our mental health efforts across the two Departments, for the benefit 
of all of our Servicemembers and Veterans.
Suicide Prevention/ Veterans Crisis Line
    The VA Suicide Prevention Program is based on the concept of ready 
access to high quality Mental Health Care and other services. The 
Suicide Prevention network of Suicide Prevention Coordinators and Care 
Managers is based at every Medical Center and at very large Community 
Based Clinics across the country and provides a wide array of services, 
tracking, monitoring, and outreach activities. All Suicide Prevention 
Program elements are shared with the DOD and a conference is held 
annually to encourage use of all strategies across both Departments 
including products and educational materials. One of the main 
mechanisms to access this enhanced level of care provided to our high 
risk patients is through the Veterans Crisis Line. The Crisis Line is 
located in Canandaigua, New York, and partners with the Substance Abuse 
and Mental Health Services Administration's (SAMHSA) National Suicide 
Prevention Lifeline. All calls from Veterans, Servicemembers, families, 
and friends calling about Veterans or Servicemembers are routed to the 
Veterans Crisis Line. The call center started in July 2007 and the 
Veterans Chat Service was started in July 2009. To date the call center 
has:

     Received over 400,000 calls;
     Initiated over 14,000 rescues;
     Referred over 53,000 Veterans to local Suicide Prevention 
Coordinators for same day or next day services;
     Answered calls from over 5,000 Active Duty Servicemembers;
     Responded to over 15,000 chats;
    The call center is responsible for an average of 300 admissions a 
month to VA health care facilities and150 new enrollments a month for 
VA health care.
VA/DOD Collaborations for Polytrauma/Traumatic Brain Injury (TBI)
    VA and DOD share a longstanding integrated collaboration in the 
area of TBI. Providing world-class medical and rehabilitation services 
for Veterans and Servicemembers with TBI and polytrauma is one of VA's 
highest priorities. Since 1992, VA and the Defense and Veterans Brain 
Injury Center (DVBIC) have been integrated at VA Polytrauma 
Rehabilitation Centers (PRC), formerly known as Lead TBI Centers, to 
collect and coordinate surveillance of long-term treatment outcomes for 
patients with TBI. From this collaboration, VA expanded services to 
establish the VA Polytrauma/TBI System of Care to provide specialty 
rehabilitation care for complex injuries and TBI.
    Today, this system of care spans more than 100 VA medical centers 
to create points of access along a continuum, and integrates 
comprehensive clinical rehabilitative services, including: treatment by 
interdisciplinary teams of rehabilitation specialists; specialty care 
management; patient and family education and training; psychosocial 
support; and advanced rehabilitation and prosthetic technologies. In 
addition to specialty services, Veterans and Servicemembers recovering 
from TBI receive comprehensive treatment from clinical programs 
involved in post-combat care including: Primary Care, Mental Health, 
Social Work and Care Coordination, Extended Care, Prosthetics, 
Telehealth, and others.
    VA's provision of evidence-based medical and rehabilitation care is 
supported through a system-wide collaboration with the Commission on 
Accreditation of Rehabilitation Facilities to achieve and maintain 
national accreditation for VA rehabilitation programs. Collaboration 
with the National Institute on Disability and Rehabilitation Research 
TBI Model Systems Project enables VA to collect and benchmark VA 
rehabilitation and longitudinal outcomes with those from other national 
TBI Model Systems rehabilitation centers. With clinical and research 
outcomes that rival those of academic, private sector, and DOD 
facilities, VA leads the medical and scientific communities in the area 
of TBI and polytrauma rehabilitation.
    Since April 2007, VA has screened more than 500,000 Veterans from 
Operation Enduring Freedom (OEF)/Operation Iraqi Freedom/(OIF)/
Operation New Dawn (OND) entering the VA health care system for 
possible TBI. Patients who screen positive are referred for 
comprehensive evaluation by a specialty team, and are referred for 
appropriate care and services. An individualized rehabilitation and 
community reintegration plan of care is developed for patients 
receiving ongoing rehabilitation treatment for TBI. Veterans who are 
screened and report current symptoms are evaluated, referred, and 
treated as appropriate.
    Additionally, 1,969 Veterans and Servicemembers with more severe 
TBI and extensive, multiple injuries were inpatients in one of the 
specialized VA Polytrauma Rehabilitation Centers between March 2003 and 
December 2010. VA and DOD collaborations in the area of TBI include: 
developing collaborative clinical research protocols; developing and 
implementing best clinical practices for TBI; developing materials for 
families and caregivers of Veterans with TBI; developing integrated 
education and training curriculum on TBI for joint training of VA and 
DOD heath care providers; and coordinating the development of the best 
strategies and policies regarding TBI for implementation by VA and DOD.
    Recent initiatives that have resulted from the ongoing 
collaboration between VA and DOD include:

     Development and deployment of joint DOD/VA clinical 
practice guidelines for care of mild TBI;
     A uniform training curriculum for family members in 
providing care and assistance to Servicemembers and Veterans with TBI 
(``Traumatic Brain Injury: A Guide for Caregivers of Servicemembers and 
Veterans'');
     Implementing the Congressionally-mandated 5-year pilot 
program to assess the effectiveness of providing assisted living 
services to Veterans with TBI;
     Integrated TBI education and training curriculum for VA 
and DOD health care providers (DVBIC);
     Revisions to the International Classification of Diseases, 
Clinical Modification (ICD-9-CM) diagnostic codes for TBI, resulting in 
improvements in identification, classification, tracking, and reporting 
of TBI;
     Collaborative clinical research protocols investigating 
the efficacy of various TBI treatments; and
     Development of the protocol used by the Emerging 
Consciousness care path at the four PRCs to serve those Veterans with 
severe TBI who are slow to recover consciousness.
VA Liaisons for Health Care
    VA has a system in place to transition severely ill and injured 
Servicemembers from DOD to VA's system of care. Typically, a severely 
injured Servicemember returns from theater and is sent to a military 
treatment facility (MTF) where he/she is medically stabilized. A key 
component of transitioning these injured and ill Servicemembers and 
Veterans are the VA Liaisons for Health Care, who are either social 
workers or nurses strategically placed in MTFs with concentrations of 
recovering Servicemembers returning from Iraq and Afghanistan. After 
initially having started with 1 VA Liaison at 2 MTFs, VA now has 33 VA 
Liaisons for Health Care stationed at 18 MTFs to transition ill and 
injured Servicemembers from DOD to the VA system of care. VA Liaisons 
facilitate the transfer of Servicemembers and Veterans from the MTF to 
the VA healthcare facility closest to their home or the most 
appropriate facility that specializes in services that their medical 
condition requires.
    VA Liaisons are co-located with DOD Case Managers at MTFs and 
provide onsite consultation and collaboration regarding VA resources 
and treatment options. VA Liaisons educate Servicemembers and their 
families about VA's system of care, coordinate the Servicemember's 
initial registration with VA, and secure outpatient appointments or 
inpatient transfer to a VA health care facility as appropriate. VA 
Liaisons make early connections with Servicemembers and families to 
begin building a positive relationship with VA. VA Liaisons coordinated 
7,150 referrals for health care and provided over 26,825 professional 
consultations in fiscal year 2010.
VHA OEF/OIF/OND Care Management
    As Servicemembers recover from their injuries and reintegrate into 
the community, VHA works closely with FRCs and DOD case managers and 
treatment teams to ensure the continuity of care. Each VA Medical 
Center has an OEF/OIF/OND Care Management team in place to coordinate 
patient care activities and ensure that Servicemembers and Veterans are 
receiving patient-centered, integrated care and benefits. Members of 
the OEF/OIF/OND Care Management team include: a Program Manager, 
Clinical Case Managers, and a Transition Patient Advocate (TPA). The 
Program Manager, who is either a nurse or social worker, has overall 
administrative and clinical responsibility for the team and ensures 
that all OEF/OIF/OND Veterans are screened for case management. 
Clinical Case Managers, who are either nurses or social workers, 
coordinate patient care activities and ensure that all clinicians 
providing care to the patient are doing so in a cohesive and integrated 
manner. The severely injured OEF/OIF/OND Veterans are automatically 
provided with a Clinical Case Manager while others may be assigned a 
Clinical Case Manager if determined necessary by a positive screening 
or upon request. The TPA helps the Veteran and family navigate the VA 
system by acting as a communicator, facilitator, and problem solver. VA 
Clinical Case Managers maintain regular contact with Veterans and their 
families to provide support and assistance to address any health care 
and psychosocial needs that arise.
    The OEF/OIF/OND Care Management program now serves over 54,000 
Servicemembers and Veterans including over 6,300 who have been severely 
injured. The current caseload each OEF/OIF/OND case manager is managing 
on a regular basis is 54. In addition, they provide lifetime case 
management for another 70 Veterans by maintaining contact once or twice 
per year to assess their condition and needs. This is a practical 
caseload ratio based on the acuity and population at each VA health 
care facility.
    VA developed and implemented the Care Management Tracking and 
Reporting Application (CMTRA), a Web-based application designed to 
track all OEF/OIF/OND Servicemembers and Veterans receiving care 
management. This robust tracking system allows clinical case managers 
to specify a case management plan for each Veteran and to coordinate 
with specialty case managers such as Polytrauma Case Managers, Spinal 
Cord Injury Case Managers, and others. CMTRA management reports are 
critical in monitoring the quality of care management activities 
throughout VHA.
    OEF/OIF/OND Care Management team members actively support outreach 
events in the community, and also make presentations to community 
partners, Veterans Service Organizations, colleges, employment 
agencies, and others to collaborate in providing services and 
connecting with returning Servicemembers and Veterans.
Caregiver Support
    Caregivers are a valuable resource providing physical, emotional, 
and other support to seriously injured Veterans and Servicemembers, 
making it possible for them to remain in their homes. Recognizing the 
importance of providing support and services to the caregivers of 
certain Veterans and Servicemembers who incurred or aggravated a 
serious injury in the line of duty on or after September 11, 2001, the 
new Caregivers and Veterans Omnibus Health Services Act of 2010, signed 
into law by President Obama on May 5, 2010, enhances existing services 
for caregivers of Veterans who are currently enrolled in VA care. It 
also provides unprecedented new benefits and services to family 
caregivers who care for certain eligible Veterans and Servicemembers 
undergoing medical discharge who have a serious injury that was 
incurred or aggravated in the line of duty on or after September 11, 
2001 and who are in need of personal care services. These new benefits, 
which are being implemented through an Interim Final Rule published 
earlier this month, include, for designated primary family caregivers 
of eligible Veterans and Servicemembers, a stipend, mental health 
services, and health care coverage if the primary family caregiver is 
not otherwise entitled to care or services under a health-plan 
contract.
    Starting in May 2011, we will begin to roll out these services and 
process applications to ensure delivery of benefits within the next few 
months. VA already offers a range of benefits and services that support 
Veterans and their family caregivers. These include such things as in-
home care, specialized education and training, respite care, equipment 
and home and automobile modification, and financial assistance for 
eligible Veterans. VA is enhancing its current services and developing 
a comprehensive National Caregiver Support Program with a prevention 
and wellness focus that includes the use of evidence-based training and 
support services for caregivers. VA has designated Caregiver Support 
Coordinators at each VA Medical Center to serve as the clinical experts 
on caregiver issues; these Coordinators are most familiar with the VA 
and non-VA support resources that are available. VA has a Caregiver 
Support Web site (www.caregiver.va.gov) and Caregiver Support Line (1-
855-260-3274) which provides a wealth of information and resources for 
Veterans, families, and the general public.
Toxic Exposures
    VA and DOD are also working very closely together on toxic exposure 
issues. The DOD/VA Deployment Health Working Group (DHWG) under the JEC 
coordinates VA and DOD responses to toxic environmental exposures, such 
as exposures to burn pit smoke in Iraq and Afghanistan and to 
contaminated drinking water at Camp Lejeune. The DHWG facilitates 
interagency collaboration on surveillance of the potential health 
effects of environmental exposures, and coordinates communications to 
ensure consistency between DOD and VA.
    VA recognizes that the past methods of assessing specific hazardous 
exposures for links to adverse health outcomes has its limitations in 
that other important associations between deployment and adverse health 
outcomes may not be identified. As a result, VA is planning to expand 
upon current deployment-specific longitudinal cohort studies of 
Veterans who were deployed using non-deployed and non-Veteran 
comparison groups. The intent is to track, observe, compare, and 
analyze health outcomes in each group over time. This approach allows 
for examination of differences in health outcomes between those who 
were deployed to a combat theater of operations with those who were not 
deployed. An advantage of these studies is that they allow for a 
determination of the contribution of deployment to adverse health 
effects, as well as the examination of possible associations between 
potential environmental exposures and adverse health effects.
    In addition, VA recognizes the need to collaborate with DOD, to 
plan for future studies of deployed personnel from the time of 
deployment through the life span of all deployed Veterans. These 
studies would involve a cohort of deployed personnel, and non-deployed 
personnel and non-Veterans for purposes of comparison. This approach 
would allow for the examination of differences in all health outcomes 
and allow for the attribution of possible adverse health effects that 
may have resulted from a specific assignment or deployment. VA is 
currently evaluating opportunities for such studies.
Camp Lejeune
    From the 1950s through the mid-1980s, persons residing or working 
at the U.S. Marine Corps Base Camp Lejeune, North Carolina, were 
potentially exposed to drinking water contaminated with volatile 
organic compounds (including industrial solvents and benzene from 
underground storage tanks). VA takes the health concerns of Veterans 
and their family members who were stationed at Camp Lejeune during this 
period very seriously. To provide fair and consistent decisions based 
on service during the period of potential exposure, VA has centralized 
Camp Lejeune-related claims processing at its Louisville, Kentucky, 
Regional Office.
    The Agency for Toxic Substances and Disease Registry (ATSDR) is 
conducting ongoing research related to the potential exposures. Current 
ATSDR research is concentrating on refining hydrological modeling to 
determine the extent of benzene contamination. This information will 
then be used along with results from ongoing population studies to 
determine if the potentially exposed population at Camp Lejeune has 
experienced an increase in adverse health effects such as birth 
defects, cancers, and mortality. VA will closely monitor this research 
and will quickly consider the findings and take appropriate action. In 
addition, VA will support these studies by acting on ATSDR requests to 
confirm specific Veteran's health issues. VA representatives regularly 
attend the quarterly Community Action Panel meetings hosted by ATSDR. 
This fosters a close working relationship between ATSDR and VA and 
allows the Department to stay current with current research efforts.
Burn Pits
    VA is very concerned about any potential adverse health effects 
among Veterans as a result of exposure to toxins possibly produced by 
burn pits. VA has asked the Institute of Medicine (IOM) to review the 
literature on the health effects of such exposures. While it is 
possible some Veterans could experience health problems related to 
exposures to toxins possibly produced by burn pits, the extent of the 
impact on health is unknown at this time. IOM's examination of the 
scientific literature related to the burn pits in Iraq and Afghanistan 
also will determine what substances were burned in the pits and what 
byproducts were produced. We expect this study to be completed by early 
2012. Other VA actions to address this issue include education of 
clinical providers and researchers. Experts from VA have provided 
several environmental exposure workshops to Compensation and Pension 
examiners, Environmental Health Coordinators, and primary care 
providers. These workshops address exposures to burn pits, oil fires, 
and sand and dust. VA researchers are collaborating with DOD and non-
governmental experts in designing pulmonary research that will help 
answer questions in this important area.
                         centers of excellence
The Departments have established several collaborative Centers of 
        Excellence.
    DOD Center of Excellence for Psychological Health and Traumatic 
Brain Injury (DCoE)
    In addition to the longstanding affiliation with DVBIC, VA 
collaborated to help DOD develop and establish the Defense Centers of 
Excellence (DCoE) for Psychological Health and Traumatic Brain Injury. 
While DOD has lead Agency responsibility for this Center, with 
operational oversight assigned to the Assistant Secretary of Defense 
for Health Affairs ASD(HA), VA provides three staff members to DCoE: 
the Deputy Director for the DCoE, and two VA Senior Consultant/Liaison 
subject matter experts--one for TBI (from Office of Rehabilitation 
Services), and one for psychological health (from Office of Mental 
Health Services). VA staff members work closely within the DCoE, and 
their input is highly regarded for all policy recommendations related 
to TBI and Psychological Health, both within VA and DOD.
DOD Vision Center of Excellence (VCE)
    DOD has lead Agency responsibility for this Center, and has 
assigned operational oversight to the Navy. In September 2010, a 
contract was awarded for the DOD/VA Vision Registry Pilot. The 
development of the registry pilot is currently in the test phase with 
linkages to the VA Data Store expected in the fourth quarter of FY 
2011. Once proof of concept of the registry development is validated, 
the next phase will be to establish the registry as a program and 
system of record for full implementation. The Registry is being 
designed to interface with the electronic health records of VA and DOD, 
including iEHR, and other registries containing information about 
patient outcomes related to injuries that impact vision care and 
rehabilitation. The Vision Registry will be the first capability to 
combine VA and DOD clinical information into a single data repository 
for tracking patients and assessing longitudinal outcomes.
    Located in the National Capital Region, the VCE receives 
operational support from the Navy, and from the Office of Patient Care 
Services within VA. Currently, the VCE has a total of 13 permanent 
government employees (2 military, 6 DOD civilian, and 5 VA civilian 
employees).
DOD Hearing Center of Excellence (HCE)
    The HCE continues to work toward achieving initial operating 
capability. DOD has lead Agency responsibility for this Center, and has 
assigned operational oversight to the Air Force. The primary focus of 
this Center is to implement a comprehensive plan and strategy for a 
registry for hearing loss and auditory injuries. VA will have access to 
the registry and the ability to add pertinent information regarding 
outcomes for Veterans who subsequently receive treatment through VA. 
The draft functional requirements for a Hearing Loss and Auditory 
System Injury Registry have been established to identify, capture, and 
longitudinally manage auditory injury data. Establishing and resourcing 
the Registry and clinical electronic network will help to prioritize 
joint collaborations for prevention and health care to improve outcomes 
for Servicemembers and Veterans with hearing loss and auditory 
disorders.
    An interim director for the HCE has been appointed and a working 
group of subject matter experts (SME) representing each Military 
Department and VA was established. The HCE operational plan, facility 
planning and staffing documents, Registry implementation plan, and 
proposed budget are pending approval by DOD.
DOD/VA Extremity and Amputation Center of Excellence (EACE)
    This DOD Center of Excellence was legislatively mandated to be 
``jointly'' established by DOD and VA. The Deputy Secretary of Defense 
signed a Memorandum that established the Traumatic Extremity Injuries 
and Amputations Center of Excellence, and assigned operational 
oversight to the Army Surgeon General. A joint Memorandum of 
Understanding (MOU) for establishment of the Center was signed by the 
Assistant Secretary of Defense for Health Affairs (ASD (HA)) and Under 
Secretary of Health (VA) on August 18, 2010. A primary focus of this 
CoE will be to conduct research; there is no requirement for an 
associated Registry. VA and DOD have continued joint collaboration to 
meet the responsibility to perform basic, translational, and clinical 
research to develop scientific information. Continued focus will be on 
research efforts aimed at saving injured extremities, avoiding 
amputations, and preserving and restoring function of injured 
extremities.
    A working group comprised of representatives from the Services, VA, 
and Health Affairs has developed the concept of operations for the 
structure, mission and goals for the Center. Pending final approval by 
DOD, this plan will be sent to VHA for review and concurrence. Location 
of this CoE is yet to be determined. A small administrative staff and 
team of researchers are planned for this CoE; less than 25 total staff, 
of which four to six are being requested from VA.
    Funding for the EACE in FY 2011 has been identified, and is being 
provided through the US Army Office of the Surgeon General. An interim 
director for the CoE has been appointed, and a working group of SMEs 
representing each Military Department and VA has been established.
                         benefits and services
Benefits Delivery at Discharge (BDD) and Quick Start
    The BDD and Quick Start programs are elements of the Veterans 
Benefits Administration's (VBA) strategy to provide transitional 
assistance to separating or retiring Servicemembers and engage 
Servicemembers in the claims process prior to discharge. A pre-
discharge claim is any claim received from a Servicemember prior to 
release from active duty. VBA's goal is to ensure that each and every 
Servicemember separating or retiring from active duty who wishes to 
file a claim with VA for service-connected disability benefits will 
receive assistance in doing so.
    Participation in the BDD program is open to Servicemembers who are 
within 60 to 180 days of being released from active duty and who are 
able to report for a VA examination prior to discharge. BDD's single 
cooperative examination process meets the requirements of a military 
separation examination and a VA disability rating examination. There 
are currently 96 BDD memoranda of understanding (MOU) covering the 131 
military installations throughout the Continental United States, 
Germany, Italy, Portugal, the Azores, and Korea. The MOUs facilitate 
the collaboration between local VA Regional Offices (VARO) and local 
military installations by streamlining processing of pre-discharge 
claims. The BDD program goal is to provide disability compensation 
benefits within 60 days of discharge or retirement from active duty. 
The national average for processing is 92.3 days.
    VA introduced the ``Quick Start'' pre-discharge claims process in 
July 2008. This provides Servicemembers within 59 days of separation, 
or Servicemembers within 60-180 days of separation who are unable to 
complete all required examinations prior to leaving the point of 
separation, to be assisted in filing their disability claim. Since 
2010, the VAROs in San Diego and Winston-Salem process all Quick Start 
claims. In FY 2010, there were 54,733 claims received at MOU sites. VA 
and DOD are collaborating to improve the marketing and awareness 
strategies to increase participation in both programs.
Military Service Coordinators (MSC)
    MSCs are located at key MTFs and VA medical facilities to meet with 
every injured OEF/OIF/OND Servicemember when medically appropriate. 
MSCs educate Servicemembers regarding VA benefits and services as well 
as additional benefits such as Social Security. MSCs assist 
Servicemembers and Veterans in completing benefits claims and gathering 
supporting evidence to facilitate expedited processing. VBA has 
approximately 120 MSCs providing benefits information and assistance in 
support of approximately 250 military installations.
VBA OEF/OIF/OND Case Managers
    VBA places a high priority on ensuring the timely delivery of 
benefits to Servicemembers and Veterans seriously injured in OEF/OIF/
OND. Each VARO has a dedicated OEF/OIF/OND case manager who is 
responsible for overseeing the OEF/OIF/OND workload and outreach 
initiatives. The case manager's responsibilities include working 
closely with National Guard and Reserve units to obtain medical records 
and coordinating with VHA case managers for expedited medical 
examinations.
    VBA OEF/OIF/OND case managers work with MTFs to ensure timely VA 
notification of new OEF/OIF/OND casualty arrivals and schedule 
inpatient visits by VA representatives. VARO and MTF staffs coordinate 
procedures at the local level.
    VARO employees contact Servicemembers as quickly as possible to 
provide claims assistance and complete information on all VA benefits. 
Some benefits, such as home and automobile adaptation grants and 
vocational rehabilitation benefits, may be used prior to a 
Servicemembers' release from active duty.
                              va outreach
Social Media (OPIA)
    VA has worked with DOD on a number of social media efforts 
including Facebook, Twitter, and a VA blog to post information relevant 
to newly separated Veterans. VA launched a Facebook page and Twitter 
feed aimed at returning Servicemembers that now has 110,000 subscribers 
and 16,000 followers, respectively. Since early 2010, VA has made a 
deliberate and concerted effort to reach new Veterans in their own 
communities through dozens of active VA medical centers on Facebook and 
Twitter. Currently, 84 of 152 VA medical centers operate Facebook pages 
and 45 operate Twitter feeds which keep Veterans informed and aware of 
events, changes, and tips for obtaining VA benefits. For example, VA 
uses both online resources to continually remind Veterans about the 
extension of retroactive stop-loss special pay. Additionally, VA 
recently shared information about the new Post Traumatic Stress 
Disorder (PTSD) application on its blog. The medical centers reach a 
combined audience of over 37,000 Veterans and their family members 
annually. eBenefits
    The eBenefits online Web-portal is a joint VA and DOD service that 
provides resources and self-service capabilities to Servicemembers and 
Veterans with a single sign-on. eBenefits is evolving as a ``one-stop 
shop'' for benefit applications, benefits information, and access to 
personal information. VA and DOD collaborate in quarterly releases to 
provide users with new self-service features. Servicemembers and 
Veterans can access official military personnel documents and generate 
civil service preference letters using the portal. Additional features 
allow users to apply for benefits, view the status of their disability 
compensation claims, update direct deposit information for certain 
benefits, and obtain a VA-guaranteed home loan Certificate of 
Eligibility.
    In June 2011, VA will enhance eBenefits to allow Servicemembers to 
participate in the Transition Assistance Program (TAP) online and 
integrate the VetSuccess portal, thus expanding the services Veterans 
can receive through a single sign-on. As of March 31, 2011, there were 
over 278,000 registered eBenefits users. Between July 1, 2010, and 
March 31, 2011, there were over 2 million unique visits to the 
eBenefits portal.
Vet Centers
    Vet Centers are community-based counseling centers that provide 
outreach counseling and case management referrals for Veterans. Vet 
Centers also provide bereavement counseling for families of 
Servicemembers who died while on Active Duty. Through December 2010, 
Vet Centers have cumulatively provided face-to-face readjustment 
services to approximately 500,000 OEF/OIF/OND Veterans and their 
families. As outlined in Section 401 of Public Law 111-163, VA is 
currently drafting regulations to expand Vet Center eligibility to 
include members of the Active Duty Armed Forces who served in OEF/OIF/
OND (includes Members of the National Guard and Reserve who are on 
Active Duty).
    In addition to the 300 Vet Centers that will be operational by the 
end of 2011, the Readjustment Counseling Service program also has 50 
Mobile Vet Centers providing outreach to separating Servicemembers and 
Veterans in rural areas. The Mobile Vet Centers provide outreach and 
direct readjustment counseling at active military, Reserve, and 
National Guard demobilization activities. In response to the Ft. Hood 
shooting, VA deployed four Mobile Vet Centers that provided services to 
over 8,200 Active Duty Services members, Veterans, and families in the 
Ft. Hood community. In addition, VA's Secretary is adding licensed 
family counselors to over 200 Vet Center sites to better assist with 
military related family problems.
Transition Assistance Program
    The Transition Assistance Program (TAP) is conducted under the 
auspices of a Memorandum of Understanding between the Departments of 
Labor, Defense, Homeland Security, and VA. The Departments work in 
conjunction with DOD in scheduling briefings and classes on 
installations to best serve Servicemembers. There is also a quarterly 
meeting between the Departments to discuss marketing and improvement of 
TAP. VA's MSCs lead regularly scheduled TAP briefings at military 
installations throughout the country and at overseas locations. VA has 
streamlined and updated the VA portion of TAP, and in July 2011, an 
updated online version of the presentation will be available via 
eBenefits. In addition, VBA provides benefits transition briefings to 
Servicemembers retiring, separating, and residing overseas, as well as 
demobilizing Reserve and National Guard members (most demobilization 
briefings are conducted by VHA). In FY 2010, approximately 207,000 
Active Duty, Reserve, and National Guard Servicemembers participated in 
over 5,000 transition briefings. For the period October 1, 2010, 
through March 2011, over 83,000 Active Duty, Reserve, and National 
Guard Servicemembers participated in over 2,000 transition briefings.
Disabled Transition Assistance Program
    The Disabled Transition Assistance Program (DTAP) provides 
Servicemembers with information about VA's Vocational Rehabilitation 
and Employment (VR&E) program. DTAP is the first step to ensuring 
professional and personal success after the military for eligible 
Veterans with disabilities. DTAP briefings are typically conducted in 
addition to the TAP briefings for Servicemembers with disabilities. 
During FY 2010, over 37,000 Servicemembers participated in 1,748 DTAP 
briefings around the world. Over 19,000 Servicemembers participated in 
874 DTAP briefings during the period of October 1, 2010, through 
April 22, 2011.
Yellow Ribbon Reintegration Program
    Through the DOD Yellow Ribbon Reintegration Program (YRRP), 
National Guard and Reserve units are partnering with VA to increase 
awareness and utilization of VA benefits, programs, and services. VHA 
has actively supported the DOD YRRP since the creation of the program 
in 2008. VHA personnel participate at Yellow Ribbon events across the 
country by providing: information; live briefings on VA benefits, 
programs, and services; personal assistance with VA form completion; 
and referrals to VA facilities for assistance. Representatives from VBA 
also participate in many Yellow Ribbon events providing information on 
VA disability compensation, education, loan guaranty, vocational 
rehabilitation and employment, and insurance.
    A growing number of military units are working closely with VA 
personnel to conduct 90-day post-deployment Yellow Ribbon events in VA 
medical centers (VAMC) in various states, resulting in cost savings and 
the strengthening of VA/DOD partnership at the local level. Conducting 
these events in VAMCs facilitates a smooth transition between DOD and 
VA by getting Servicemembers in the door of the VAMC and establishing a 
level of comfort with VA care. Servicemembers attending Yellow Ribbon 
events at a VAMC have opportunities for on-the-spot referrals for VA 
care, and, in some cases, same day care.
    In 2008, VHA's Office of Interagency Health Affairs placed a full-
time VA employee in the DOD YRRP at the Pentagon to assist in 
coordinating activities and policies. The role of the liaison is to 
serve as the full-time, on-site source of VA information for Yellow 
Ribbon specific issues and expedite the exchange of information between 
VA and the DOD YRRP Office. The liaison assists the YRRP Office with 
policy and procedure development by providing expertise and information 
on VA's structure, benefits, and services. In addition, the liaison 
works collaboratively with VA staff members to assist with coordination 
of personnel and resources to support Yellow Ribbon events.
Demobilization Initiative for Returning Veterans
    In coordination with National Guard and Reserve units, VAMC and 
Veterans Integrated Service Network (VISN) staff, along with Vet Center 
and VBA staff, provide briefings on VA services and benefits. These are 
conducted at 63 National Guard and Reserve demobilization sites 
nationwide. VHA staff also facilitate enrollment in VA health care by 
assisting National Guard and Reserve members with completing VA health 
care enrollment forms when they choose to enroll on site. The forms are 
then processed through VHA's centralized Health Eligibility Center. The 
National Guard and Reserve members also receive outreach materials and 
a watermarked letter which serves as a type of temporary ID confirming 
enrollment in VA Health Care.
    The watermarked letter includes the name and phone number of the 
National Guard and Reserve member's local OEF/OIF/OND Program Manager 
and lets VAMC staff know that he or she has enrolled in VA care, thus 
opening doors to immediate access within VA Health care services at 
their local VA Medical Center. During FY 2010, VHA supported 1,339 
demobilization events, providing VHA staff with face-to-face 
interactions for nearly 74,000 Servicemembers. As a result, 70,000 have 
registered or enrolled in VHA Health care.
Post-Deployment Health Reassessment (PDHRA)
    Since 2006, VHA has been focused on managing referrals from Reserve 
components for Servicemembers and Veterans who have completed the 
PDHRA. The PDHRA program requires these assessments to be completed at 
90-180 days post-deployment. DOD uses a contractor to provide these 
screenings, either at a face-to-face event or the member may elect to 
use the on-line assessment, which is followed up by a call with the 
contractor's health care provider. When the PDHRA takes place at a 
face-to-face event, the local VAMC and Vet Center staff, when notified, 
will provide VA Outreach, education, enrollment, and as needed, 
referral for clinical services. Referred Veterans have a choice to 
receive their care at a local VAMC, Vet Center, or if they are a dual 
beneficiary may receive care for a non-service-connected condition via 
the TRICARE network.
    For Servicemembers who request a VHA appointment, the onsite VA 
staffs are able to schedule appointments for them at their local VAMC. 
During FY 2010, VHA supported 339 DOD PDHRA events with 44,443 Veterans 
and 1,319 family members attending. Of these Veterans, 38,059 were OEF/
OIF/OND Veterans.
                               conclusion
    VA and DOD continue to work together diligently to resolve 
transition issues while aggressively implementing improvements and 
expanding existing programs. These efforts continue to enhance the 
effectiveness of support for Servicemembers, Veterans, and their 
families. While we are pleased with the quality of effort and progress 
made to date, we fully understand our two Departments have a 
responsibility to continue these efforts. Through IDES, our goal is to 
create a less complex process which is more transparent to the 
Servicemember. We designed our case management programs to provide 
seamless support through the duration of care and rehabilitation and we 
are constantly improving those systems. We continue to explore ways to 
expand the availability of comprehensive benefits, online resources, 
and transition education programs to provide Servicemembers and 
Veterans direct access to the information and benefits they need. In 
addition, the two Departments are working toward a goal of a fully 
developed Virtual Lifetime Electronic Record that will provide health 
and benefits data to all authorized users in a safe, private, secure 
manner, regardless of the user's location. Recently, Secretary Gates 
and Secretary Shinseki formally agreed that our two Departments would 
work cooperatively toward a common electronic health record. We are 
looking forward to delivering on this commitment.

    Thank you again for your support to our wounded, ill, and injured 
Servicemembers, Veterans, and their families and your interest in the 
ongoing collaboration and cooperation between our Departments. Chairman 
Murray, Ranking Member Burr, this concludes my testimony. I will be 
happy to respond to any questions that you or other Members of the 
Committee may have.
                                 ______
                                 
Response to Prehearing Questions Submitted by Hon. Patty Murray to Hon. 
 W. Scott Gould, Deputy Secretary, U.S. Department of Veterans Affairs
    Question 1. In advance of the hearing, please provide the Committee 
with the following information for each location using the integrated 
Disability Evaluation System (IDES):

          e) The current staffing level for Military Services 
        Coordinators.
          Response. Early in FY 2011, for the first 55 IDES sites, 68 
        Military Service Coordinators (MSCs) provide Servicemember 
        counseling and support. As of April 30, 104 Military Service 
        Coordinators (MSCs) were providing Servicemember counseling and 
        support at 77 IDES sites. We expect to end FY 2011 with a 
        presence of 261 FTE, a mix of MSCs and Rating Veterans Service 
        Representatives (RVSRs), across approximately 139 sites. RVSRs 
        do the disability rating determinations and are located at the 
        three Disability Rating Activity Sites (DRAS) where they 
        complete the rating decisions used by both VA and DOD. The MSCs 
        are located at the MTFs or other IDES locations and they assist 
        the Servicemembers with gathering the medical evidence needed 
        for the RVSRs to rate the case.

          f) The average time to complete all medical examinations.
          Response. As of March 31, 2011, the average number of days to 
        complete all required exams, cumulative since the Initial 
        Operating Capability, is 62 days.

          t) The funding level for the IDES process, including funds 
        that will be provided from any source.
          Response. VA's IDES associated resources available for FY 
        2011 are estimated at $58 million. A detailed breakout by 
        source and function is provided below.

        [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
        
                                 ______
                                 
  Response to Posthearing Questions Submitted by Hon. Patty Murray to 
  Hon. W. Scott Gould, Deputy Secretary, U.S. Department of Veterans 
                                Affairs
    Question 1. IDES is to be fully implemented in October of this 
year. Have the remaining sites been certified to meet Initial Operating 
Capability readiness criteria in order to meet this target date?
    Response. The remaining IDES sites will be certified by 
September 30, 2011 prior to reaching their Initial Operating Capability 
(IOC). As sites are being brought on in stages, certification occurs in 
the final stage when the site has completed all program requirements 
and is determined to be operational.

    Question 2. The Virtual Lifetime Electronic Record (VLER) is in its 
first phase with five operational pilot sites where DOD and VA, as well 
as private sector health care providers, are sharing health 
information. Please comment on the progress being made at each of these 
sites, as well as any delays or collaboration issues that have occurred 
with respect to execution of those pilots.
    Response. VA is conducting an 11-region pilot of VLER Nation Wide 
Health Information Network Exchange. This pilot is currently active at 
five of the 11 planned locations, with the remaining six sites 
scheduled for activation in fall 2011. Information about the five 
locations currently sharing information is provided below as requested. 
To date, no major delays or collaboration issues have been identified.

    San Diego, CA Veterans Affairs Medical Center (VAMC)--private 
partners Kaiser Permanente (KP)/San Diego Beacon (UC San Diego)
     Currently operational and sharing information with Kaiser 
Permanente and DOD
         - Shared patients with Kaiser Permanente: 491
         - Shared patients with DOD: 10,539
     San Diego Beacon exchange planned for FY12

    Hampton, VA VAMC--private partner MedVirginia
     Currently operational and sharing information with 
MedVirginia and DOD
         - Shared patients with MedVirginia: 7,278
         - Shared patients with DOD: 5,283

    Spokane, WA VAMC--private partner Inland Northwest Health Services 
(INHS)
     Currently operational and sharing information with INHS 
and DOD
         - Shared patients with INHS: 3,000
         - Shared patients with DOD: 479

    Richmond, VA VAMC--private partner MedVirginia
     Currently operational and sharing information with 
MedVirginia
         - Shared patients with MedVirginia: 10,690

    Asheville, NC VAMC--private partner Western North Carolina Health 
Network (WNCHN)
     Currently operational and sharing information WNCHN
         - Shared patients with WNCHN: 491

    Question 3. A strategic goal of the Integrated Mental Health 
Strategy is to reduce stigma through successful public communication 
and use of innovative technological approaches. How are both approaches 
directly addressing servicemembers' concerns about avoiding detrimental 
effects on their career when seeking mental health care?
    Response. VA has established two national messaging campaigns, one 
for suicide prevention and one promoting the message that Veterans 
should seek mental health assistance when needed. We have employed the 
use of an experienced public relations firm to help us with these 
efforts. The firm understands the need to project these messages in a 
way that emphasizes the strengths of Veterans and does not stigmatize 
the situation more. Veteran groups have been consulted and messages 
crafted to demonstrate that seeking mental health care leads to 
improved functioning. Great care is taken to portray Veterans as being 
stable or fit.
    The VA National Suicide Hotline has re-branded itself as the 
Veterans Crisis Line and provides anonymous services to those who do 
not want to be identified. Veterans Chat (www.veteranscrisisline.net) 
is completely anonymous and provides a way to seek help without stigma 
attached.
    With regard to the use of innovative technological approaches, one 
example is the PTSD Coach smartphone application (app), which was 
jointly developed by VA and the Department of Defense (DOD) and 
launched in April 2011. Since its launch, the PTSD Coach has been 
downloaded by over 10,000 individuals in 37 countries. The app lets 
users track their PTSD symptoms, links them with public and 
personalized sources of support, provides accurate information about 
PTSD, and teaches helpful, evidence-based strategies for managing PTSD 
symptoms. The app is one of the first in a series of jointly designed 
resources by VA's National Center for PTSD and DOD's National Center 
for Telehealth and Technology to help Servicemembers and Veterans 
manage their readjustment challenges and receive anonymous assistance.
    A series of Web-based self-help programs is also being developed as 
part of the Integrated Mental Health Strategy. These programs are 
designed to be accessed anonymously, so that an individual can work on 
his or her own mental health or readjustment issues without 
experiencing detrimental career consequences. These programs will 
provide Veterans and Servicemembers with direct access to highly 
interactive, evidence-based self-help programs that may help them 
manage their symptoms and solve their problems without ever interacting 
with a mental health provider. Veterans and Servicemembers who so 
choose will also have the option of calling a toll free number to speak 
confidentially and anonymously with a coach who can help him/her 
through the program content.
    Furthermore, VA has disseminated and implemented telemental health 
services throughout Veterans Health Administration (VHA) to further 
promote access to mental health care. In fiscal year 2010, VHA provided 
telemental health services to approximately 50,000 Veterans. 
Significantly, many patients have expressed preference for telemental 
health services. VA is currently working to promote the delivery of 
evidence-based psychotherapies (EBPs) through telemental health 
modalities, which has been shown in initial research and clinical 
experiences to yield outcomes for many Veterans that are equivalent to 
traditional face-to-face EBP services.

    Question 4. VA researchers are collaborating with DOD and non-
governmental experts in designing pulmonary research that will help 
answer questions about burn pit exposure. What protocols have been 
developed as a result of this effort?
    Response. There have been no clinical protocols developed to date 
as this issue is still being researched. Individual chemicals produced 
by burn pits can affect the skin, respiratory system, internal organs, 
the nervous system, and the gastrointestinal tract. However, most toxic 
materials from burn pits are eliminated from the body in a matter of 
weeks. Several active VA efforts are under way to study the possible 
health effects of burn pits and to provide a scientific basis for the 
development of clinical protocols. For example:

     VA asked the Institute of Medicine for an in-depth review 
of existing literature on burn pits and on the long-term health effects 
of exposure to burn pits in Iraq and Afghanistan. Their report is due 
in late 2011.
     VA is leading the National Health Study for a New 
Generation of U.S. Veterans, which will reach out to 30,000 deployed 
and 30,000 non-deployed Veterans over 10 years. It covers a wide 
spectrum of health topics, including those that may be associated with 
burn pits.
     VA is participating in the Millennium Cohort Study, a DOD 
project begun in 2001 that has almost 150,000 participants. Data is 
being collected on respiratory health.
     VA researchers are participants in a DOD sponsored 
Pulmonary Health WorkingGroup focused on potential lung diseases 
associated with deployment. This group has met several times and has 
formulated key research questions which include the following:

    1) What are the causes of the limited number of chronic lung 
disease cases identified to date?
    2) Are these cases an exacerbation of pre-existing lung disease?
    3) What are the short-term & long-term pulmonary effects in the 
deployed population?
    4) Can responsible agent(s) be identified?
    5) Do preventive measures during deployment need to be initiated?

     VA is sponsoring additional studies by individual VA 
researchers and tracking other studies by non-VA researchers; and
     Veterans can find out more about their health concerns 
related to potential exposures to burn pits by getting an exposure 
assessment offered by VA's War Related Illness and Injury Study Center 
(WRIISC) program. The WRIISC provides clinical expertise for Veterans 
with deployment health concerns or difficult-to-diagnose illnesses. 
WRIISCs are in three locations: Washington, DC; East Orange, NJ; and 
Palo Alto, CA. For an appointment at a WRIISC, a VA primary care doctor 
must make a referral.

    Question 5. To what extent is the Department utilizing hyperbaric 
oxygen therapy to treat veterans? Additionally, what research protocols 
are currently active that deal with hyperbaric oxygen therapy?
    Response. Attached please find The VA Report to Congress on 
Hyperbaric Oxygen Treatment. This was submitted to Congress on April 2, 
2010.
    VA has a long history of supporting research to improve wound 
healing. There are VA investigators exploring the use of Hyperbaric 
Oxygen Treatment (HBOT). For example, DOD is currently funding three 
coordinated research trials on the use of HBOT for persistent symptoms 
after mild TBI. A VA researcher at the Richmond VA Medical Center 
(VAMC) is participating in two of these trials. Two other VA 
investigators are also participating in other capacities with DOD on 
HBOT studies. HBOT is provided for Food and Drug Administration 
approved conditions at several VAMCs. VA will continue to support 
promising research in Complementary and Alternative Medicine and HBOT 
to ensure that Veterans have access to the best evidence-based health 
care.

    Question 6. VA has said, ``We are committed to working with the 
Department of Defense, veteran service organizations and veterans to 
ensure that all those who may have been exposed at McMurdo Station 
receive the maximum amount of care and benefits they are entitled to 
under the law.'' What is being done for those who are still suffering 
from cancers that the VA has yet to connect to McMurdo Station?
    Response. VA has not promulgated any presumptions of service 
connection based on exposure to radiation at McMurdo Station. Any 
Veteran exposed at McMurdo Station who has health concerns that they 
feel may be related to their exposure at McMurdo Station may file a 
claim for VA compensation and may be referred for a compensation and 
pension examination, if necessary, to decide the claim.

    Question 7. There are serious challenges in combatting the stigma 
associated with seeking mental health care. The Departments are still 
struggling to make it acceptable to ask for help. Additionally, 
commanders have an obligation to know how fit and ready those in their 
units are. In the meantime, providing confidentiality for 
servicemembers to seek treatment is very important. What is an 
acceptable balance of these concerns?
    Response. It is widely recognized that patients' personal 
information about mental health treatment has been the basis for 
stigmatization and that stigmatization discourages patients from 
seeking needed mental health treatment. Research indicates that privacy 
of health care information is one of Servicemembers' major concerns in 
their decision not to seek mental health care.
    Under its mission, the DOD must ensure the medical readiness of its 
force. Thus DOD has an obligation to assess Servicemembers' fitness for 
duty, and a right to require Servicemembers to provide the information 
DOD needs to conduct this assessment. In this respect, active duty 
Servicemembers have no right to confidentiality, vis a vis, their 
employer, the DOD. In contrast, Veterans, non-active reservists, and 
National Guard members all have a legitimate expectation of 
confidentiality in VA because VA, as a civilian health care provider, 
has a professional obligation to protect the confidentiality of its 
patients. Just as lawyers and chaplains have a fiduciary obligation to 
protect the information of clients in order to maintain the trust 
relationship that is essential to their roles, VA providers must 
protect their patients' information in order to maintain the trust 
required to fulfill their mission of service to Veterans.
    In VA, as in private-sector health care, breaching patient 
confidentiality by disclosing protected health information against the 
patient's wishes requires special justification that meets clear and 
rigorous standards. Disclosures of protected health information by VA 
must comply with all applicable privacy statutes and regulations, such 
as the Privacy Act, the HIPAA Privacy Rule, 38 U.S.C. 7332, and 38 
U.S.C. 5701. Once VHA determines there is authority to release, a 
disclosure is ethically justifiable if all of the following conditions 
are met:

    1) There is a high probability of harm to the patient or others;
    2) The probable harm is very serious;
    3) The probable harm is imminent;
    4) There is a high probability that information disclosure will 
mitigate the harm; and
    5) No other reasonable means are available to mitigate the harm.

    For example, when a VHA provider determines that a soldier who 
carries a weapon poses a high risk of immediate harm to his unit, the 
provider has a duty to take action, which would include warning the 
patient's DOD provider or command. When the conditions for a duty to 
warn are met, the duty is absolute.
    Meeting our obligation of confidentiality and ensuring patient 
choice regarding the sharing of that information are important for all 
patients, but especially important for Reservists and National Guard 
members who are subject to being recalled to active military service. 
Individuals in this cohort are often highly motivated to remain 
eligible to return to active military service in the future, and may 
fear that their eligibility could be adversely affected should their 
health information be disclosed to DOD. At a time when VA is actively 
reaching out to this cohort to encourage them to seek evaluation for 
Post Traumatic Stress Disorder, Traumatic Brain Injury, suicide risk, 
military sexual trauma, and other conditions potentially associated 
with military service, VA's routine release of these patients' health 
information to DOD could seriously undermine these patients' 
willingness to provide VHA health care providers with thorough and 
accurate health information, their likelihood of seeking care in VHA, 
and their trust in the VHA health care system overall.
    As VA and DOD prepare to make significant investments to modernize 
their electronic health record systems, a variety of decisions must be 
made about how best to protect and promote the interests of patients. 
Such decisions must drive the design of IT systems. In particular, 
there is a need to ensure that the electronic health record ``Way 
Ahead'' is based on patient choice standards regarding access to health 
information. In this regard, a task force on VA/DOD Health Information 
Sharing is being convened to develop and recommend Consensus Standards 
on Health Information Sharing between VA and DOD to help guide policy 
and practice with regard to sharing of health information, including 
the design of future electronic health record systems, such as VLER. 
The intent is that these Consensus Standards will define an ethically 
appropriate balance of these concerns.

    Question 8. Do Federal Recovery Coordinators have sufficient access 
to patients and facilities and authority within both Departments to 
effectively case-manage their patients?
    Response. Federal Recovery Coordinators (FRC) provide care 
coordination for clients regardless of where they are located and 
without regard to active duty or Veteran status. FRCs work with care 
and case management officials within the Departments of Veterans 
Affairs and Defense to ensure that clients receive appropriate benefits 
and services in a timely manner. While there are often isolated issues 
of access and authority, FRCs have not experienced systematic problems 
with respect to the clients who are referred to them.
    The Federal Recovery Coordination Program (FRCP) is a referral 
program and participation is voluntary. Consequently, it is unclear 
whether all of the eligible ``severely wounded, ill, and injured'' 
Servicemembers and Veterans who could benefit from the FRCP are being 
enrolled in the program. The FRCP cannot readily identify these 
individuals because the ``severely wounded, ill, and injured'' 
classification is not captured in existing data sources. Additionally, 
the program's broad eligibility criteria cannot be used systematically 
to identify potentially eligible Servicemembers and Veterans. Instead, 
the FRCP must rely on referrals from others to identify these 
individuals, although the program has also taken steps to identify 
potential enrollees through the FRCs' efforts at medical facilities and 
through a ``look back'' initiative to identify eligible Veterans who 
were wounded prior to program implementation.

    Question 9. The joint electronic health record is the largest 
program ever developed between VA and DOD. The continuum of quality 
health care for millions of servicemembers and veterans is depending on 
the success of this project. What specifics can you provide on the 
time-line for delivery, project costs, and expectations?
    Response. The VA and DOD are working together to jointly develop an 
electronic health record that will provide information to both agencies 
about our Servicemembers and Veterans. Both agencies have agreed to 
consolidate data where applicable, use common services and develop a 
joint platform in order to realize economies of scale. We call this 
effort the ``integrated Electronic Health Record,'' or iEHR. Our 
functional and technical experts are currently developing a joint 
governance process, an overall concept of operations, and detailed 
plans to achieve this complex goal. The iEHR will be a national model 
for capturing, storing, and sharing electronic health information.

    Question 10. How would a joint electronic health record help the 
Department deal with exposure cases?
    Response. The integrated Electronic Health Record (iEHR) is a key 
strategic resource in improving the care of Servicemembers before, 
during, and after the transition from active duty to Veteran status. 
The implementation of common medical terminology will greatly enhance 
the ability to exchange computable, interoperable patient-centered 
data. A single record for each Servicemember and Veteran will add new 
capabilities for clinicians at both DOD and VA to quickly find needed 
information, improve operational efficiency, and reduce the need for 
redundant evaluations and testing. Jointly developed decision support 
resources and evaluation measures will help maintain a similar high 
standard of care and patient safety across both Departments, while 
improving the ability to both benchmark and identify patterns and 
trends over time. A common record for each Servicemember and Veteran 
will provide a foundation for improved communication across Departments 
in the form of electronic referrals, consultation requests, orders 
portability, and provider-provider messaging, thereby enhancing the 
continuity and timeliness of patient care. Transition for 
Servicemembers includes not only medical care, but evaluation for 
disability and benefits, which will also be enhanced as both 
Departments adopt matching terms and a common language to describe the 
care received by our beneficiaries. Our future electronic health record 
will contain not only resources for providers and clinical teams, but 
provide rich access to information for both Servicemembers and 
Veterans. Patient facing resources in the form of web portals, personal 
health records, eHealth and mobile applications which will remain 
consistent and familiar across the continuum from active duty to 
Veteran status, will highly increase the engagement of the 
Servicemember and Veteran in his or her care, and as a result, improve 
the patient care experience and improve health.

    Question 11. The Department recognizes the need to collaborate with 
DOD to plan for future studies on deployed personnel from the time of 
deployment through the life span of all deployed veterans. Today, where 
is the Department with this assessment?
    Response. Working together, VA's Health Services Research and 
Development (HSR&D) and the DOD have recently released (February 2011) 
the VA/DOD Collaboration Guidebook for Healthcare Research to 
facilitate collaborative human subject healthcare research between VA 
and the DOD. The Guidebook provides suggestions and guidance for:

     Identifying collaborators with common research interests/
goals;
     Summaries of administrative and funding mechanisms; and
     Procedures and protocols needed for collaborative 
endeavors.

    In addition, the Guidebook offers:

     Suggestions for developing and submitting a proposal;
     Examples of successful and unsuccessful research 
collaborations;
     List of commonly used acronyms; and
     Links to additional resources.

    This is now available at http://www.research.va.gov/va-dod/ and 
will assist researchers in both VA and DOD who are planning future 
studies on deployed personnel from time of deployment throughout the 
lifespan. This question is also related to questions #2, #9, and #10, 
with respect to data sharing between VA and DOD, that will be essential 
to such future research.

    Question 12. As members of the Guard and reserves transition in and 
out of active duty, they repeatedly switch between TRICARE, private 
insurance, and VA medical care. This creates a number of concerns 
regarding coordination of care, quality oversight, and the simple 
ability of the servicemember and family to manage those changes. How 
are these transitions being tracked by the Department and effectively 
managed?
    Response. VA's Operation Enduring Freedom/Operation Iraqi Freedom/
Operation New Dawn (OEF/OIF/OND) Care Management teams actively provide 
outreach to returning Guard and Reserve including annual Welcome Home 
events to welcome Servicemembers returning from deployment, and 
extended family members, to increase awareness of VA benefits and 
services. VA is partnering with National Guard and Reserve units to 
conduct 90-day post-deployment Yellow Ribbon events to increase 
awareness and utilization of VA benefits, programs and services. 
Military services demobilization events provide a setting for post-
deployment National Guard and Reservist members to receive in-person 
briefings about VA services and benefits from locally-based VA Medical 
Center (VAMC), Veterans Benefits Administration and Vet Center staff. 
VHA staff facilitate enrollment on site for VA health care by assisting 
National Guard and Reserve members with completing VA health care 
enrollment forms, which are then processed by the VAMC where they live. 
The National Guard and Reserve members who register for VA Health Care 
receive a letter with the contact information of their local VAMC OEF/
OIF/OND Program Manager. This letter serves as a temporary 
identification card for VA Health Care. VA coordinates referrals from 
Reserve components for National Guard and Reserve members and Veterans 
who have completed the Post Deployment Health Reassessment (PDHRA), a 
DOD program, which assesses returning Servicemembers for the need for 
health care services at 90-180 days post-deployment. When the PDHRA 
occurs at a face-to-face event, the local VAMC and Vet Center staff 
provide VA Outreach, education, enrollment, and as needed, referral for 
clinical services. Referred Veterans have a choice to receive their 
care at a local VAMC, Vet Center, or through the TRICARE system, which 
may be at a VAMC. For Servicemembers who request a VHA appointment, the 
onsite VA staff already has enrollment information in the Computerized 
Patient Record System and is able to schedule appointments immediately 
at their local VAMC.
    VA staff also works closely with the Transition Assistance Advisors 
(TAAs) who work in each state/territory and serve as the statewide 
point-of-contact to assist Servicemembers in accessing VA benefits and 
healthcare services. They coordinate with VA to assist the 
Servicemember/Veteran in the navigation processes from DOD, TRICARE, 
and VA.
    OEF/OIF/OND Care Management teams screen all returning combat 
Servicemembers and Veterans for the need for case management services 
at their initial VA appointment. Those who present with needs requiring 
case management support or who request a case manager, receive ongoing 
case management services according to their individualized care plan. 
All Veterans and Servicemembers receiving case management services, 
including Guard and Reserve, are tracked using a Web-based tracking 
system. VA case managers maintain regular contact with Servicemembers/
Veterans and their families/caregivers to provide support and 
assistance in addressing any health care and psychosocial needs and 
coordinate services among providers within VA, DOD, and the community.
    VA has specialized resources to support clinical teams coordinating 
care. These resources include VA's Liaisons to the TRICARE Regional 
Office, who serve as intermediaries between VA facilities and the 
TRICARE regional contractors. They actively assist with authorizations 
and claims. Monthly calls with TRICARE contractors and VA's Medical 
Sharing Office are held to review active duty Servicemembers who are 
receiving joint VA/DOD care. Education classes are held with the VA 
Medical Sharing Office to educate VA staff including OEF/OIF/OND care 
management teams and VA Liaisons for Healthcare as well as DOD and 
TRICARE staff, to ensure transition processes and procedures are 
consistent. The Health Eligibility Center serves as an overall resource 
for VA enrollment and eligibility questions.

    Chairman Murray. Thank you very much.
    Secretary Lynn.

 STATEMENT OF HON. WILLIAM J. LYNN III, DEPUTY SECRETARY, U.S. 
                     DEPARTMENT OF DEFENSE

    Mr. Lynn. Thank you very much, Chairman Murray. I look 
forward to conversing with you, Ranking Member Burr, and the 
other Members of the Committee.
    Let me say at the outset I want to recognize and appreciate 
the partnership that DOD and VA has established under the 
leadership at VA of Scott Gould and General Shinseki. I think 
we have taken it to a new level. Both Departments I think are 
truly committed to making this a seamless transition for our 
servicemembers from the DOD system to the VA system, and I 
think the professionalism and the commitment of the staff in 
both Departments is helping making that a reality.
    We have reached a historic level of cooperation between the 
two Departments, but there are still, as Scott said, tasks to 
accomplish. But let me just orallu stress a couple of the items 
where I think we have started to make progress.
    I think the greater cooperation at a basic level means that 
the soldiers who separate from the services are greeted by more 
comprehensive mental and physical care, by greater opportunity 
for education and jobs, and by a deeper societal commitment to 
ensuring their welfare.
    Especially when you compare the experience of our troops 
today to the generation of heroes who returned from Vietnam, I 
think the progress we have made toward a single system of 
lifetime care is significant.
    As you noted, Deputy Secretary Gould and I oversee the 
support system that is in place to treat our wounded, ill, and 
injured. What I would like to do is just highlight a couple of 
efforts that we have made to improve the transfer and care of 
our wounded warriors and our progress toward establishing an 
electronic health record.
    One of the central goals that Secretary Gould and I have 
had has been to modernize the disability evaluation system 
which had really remained in place unchanged for decades.
    Today the revised and improved integrated disability 
evaluation system serves about half of the 26,000 person 
population with a wider adoption a top priority. We are hoping 
to achieve that by the end of the year.
    Servicemembers using IDES receive a single set of physical 
disability examinations conducted according to VA examination 
protocols with simultaneous processing by both Departments. 
This has created a more consistent set of evaluations, a more 
orderly experience for servicemembers and their families, and 
during the transition those processed through IDES continue to 
receive full pay, allowances, compensation, medical-based 
support, care, and benefits. This largely eliminates the 
benefits gap that occurred under the legacy system.
    In short, IDES is fair, faster, and a significant 
improvement over the legacy system. By years' end we hope to 
have completely fielded IDES at the 139 sites nationwide.
    The average IDES processing time, as Scott mentioned, is 
currently about 400 days. That is down from the 540 days of the 
legacy system but it has not reached the goal that we have set 
up--under 300 days--and so we have a further distance to go but 
we do not plan actually to stop there. We have a Tiger team 
working on ideas of how we would set a goal beyond 300 days.
    Electronic health records is also a promising area of 
collaboration. Among the many current systems that exchange 
data to varying degrees, DOD and VA have created a service 
called the blue button: that will allow beneficiaries to safely 
and securely access personal health data at TRICARE online; to 
support our most severely wounded and injured at Walter Reed, 
Bethesda, and Brooke Army Medical Center; and to provide 
scanned records and radiology images for patients transferring 
to some of VA's polytrauma rehabilitation centers.
    To create a truly integrated electronic health record, DOD 
and VA have agreed to implement a joint common platform that 
has compatible data and services, joint data centers, common 
interface standards, and a common presentation format.
    We are going to utilize commercially available components 
whenever possible. This is an ambitious program and it has 
great potential benefits. But we also need to recognize that 
developing a large-scale IT system is difficult business, 
especially an interoperable system across two major Federal 
departments. So, we are closely absorbing lessons from other 
successful large joint IT systems. We plan to use those lessons 
to lead us to the best possible outcome.
    I cannot overstate how far DOD has come with our VA 
partners in the 4 years since our leaderships have made working 
jointly a standard operating procedure.
    Despite the significant achievements, however, we should 
not underestimate what remains to be done. Taking care of our 
wounded, ill, and injured servicemembers is one of the highest 
priorities for the Department, the service secretaries, and the 
service chiefs. Indeed, as Secretary Gates often remarks, other 
than the wars themselves we have no higher priority.
    So Madam Chairman, thank you again for your support of our 
wounded, ill, and injured servicemembers, veterans, and their 
families. I look forward to your questions.
    [The prepared statement of Mr. Lynn follows:]
   Prepared Statement of William J. Lynn III, Deputy Secretary, U.S. 
                         Department of Defense
    Chairman Murray, Ranking Member Burr, and Members of this 
Committee, thank you for inviting us to testify before you today. We 
meet at a time of historic cooperation between the Department of 
Defense (DOD) and Department of Veterans Affairs (VA). Thanks to 
President Obama's commitment to Veterans, and to delivering the care 
they have earned, we have established a programmatic cohesion between 
our Departments that is better than ever before. More so than at any 
time in our Nation's history, soldiers who separate from the service 
are greeted by more comprehensive mental and physical care; by greater 
opportunity for education and jobs, and by a deeper societal commitment 
to ensuring their welfare. Especially when you compare the experience 
of our troops today to the generation of heroes who returned from 
Vietnam, the progress we have made toward a single system of lifetime 
care is significant.
    The accomplishments to date are the result of budget increases for 
the VA; the personal involvement of Secretary Gates and Secretary 
Shinseki, and of bureaucratic spadework at every level in both 
Departments.
    Deputy Secretary Gould and I have the distinct honor of overseeing 
the support systems in place to treat our wounded, ill, and injured. We 
accomplish this work through the Senior Oversight Committee, which the 
Secretaries of Defense and Veterans Affairs established in May 2007. 
The Senior Oversight Committee is focused on the care of our wounded 
warriors as they transition from the Department of Defense to the 
Department of Veterans Affairs. Today I would like to update you on our 
efforts to improve the transfer and care of our wounded warriors, 
including significant advances in diagnosing and addressing Traumatic 
Brain Injury and mental health issues. I would also like to brief you 
on our progress toward establishing an electronic health record.
    The 2007 revelations regarding Walter Reed were a wakeup call for 
us all. In the four years since, our Departments have worked in tandem 
to improve policies, procedures, and legislation that impacts the care 
of our wounded warriors. As a result of efforts in both Departments and 
in Congress, we have reached important milestones in improving care for 
our wounded veterans. These milestones include a new disability 
evaluation system, improved case management, the sharing of electronic 
health care data, and the treatment of the signature wounds of our wars 
today, Traumatic Brain Injury and Post Traumatic Stress Disorder.
                      disability evaluation system
    One of our main goals has been to modernize the Disability 
Evaluation System, which had remained relatively unchanged for decades. 
The revised and improved system developed by DOD and VA, known as the 
Integrated Disability Evaluation System (IDES), today serves over half 
of the approximately 26,000 people in the system. Its wide adoption is 
a priority of the VA and DOD leadership.
    Servicemembers using IDES receive a single set of physical 
disability examinations, conducted according to VA examination 
protocols, with simultaneous processing by both Departments. Designing 
the process in this way ensures the relationship between servicemembers 
and VA is established before they separate from the service, and 
delivers disability benefits at the earliest possible time. It also 
leads to more consistent evaluations and a more orderly experience for 
servicemembers and their families. Under IDES, duplicative requirements 
and misaligned timetables are reduced or eliminated. Servicemembers who 
are processed through IDES also continue to receive full pay, 
allowances, compensation, medical and base support care and benefits as 
they prepare to transition to civilian life and VA care. This is an 
improvement over the legacy system, which sometimes left outgoing 
servicemembers with a gap before their VA benefits began.
    In short, IDES is fairer, faster, and has eliminated the ``benefits 
gap'' between DOD and VA that plagued the legacy system. By the end of 
this year, IDES will be completely fielded and serving people at 139 
sites nationwide. As a result, DOD and VA will be able to deliver 
benefits more expeditiously. Today's average IDES processing time is 
approximately 400 days from referral to post-separation, down from 540 
days. The goal of IDES is to bring processing time down under 300 days, 
and a tiger team is currently devising means to reduce this further.
                      traumatic brain injury (tbi)
    In the Afghanistan and Iraq campaigns, we can be thankful that 
advances in protective equipment and battlefield medicine allow more of 
our warfighters to come home to their families and a grateful Nation. 
This also means more troops are surviving who would not have done so in 
past conflicts--brave men and women who will need care long after the 
conflicts are over. Because of the prevalence of IEDs on the 
battlefield, more of these warriors return not only with visible 
wounds, but with invisible wounds that cannot be seen and are hard to 
treat.
    We as a department have come a long way in recognizing this 
reality. In 2010, the Department established the National Intrepid 
Center of Excellence, which is dedicated to advancing our understanding 
of combat related psychological health and Traumatic Brain Injury 
conditions. Already, we have made significant advancements in 
diagnosing Traumatic Brain Injury during the past several years, 
including early detection and state-of-the-art treatment for those who 
sustain TBI.
    Today, we better understand blast dynamics, have improved the 
detection of biomarkers used in the diagnosis of concussion, and can 
make quicker and more accurate diagnoses. This in turn drives the 
development of new treatments. We are also helping increase awareness 
of the signs and symptoms of TBI and when and how to undergo an 
evaluation. Materials aimed at line commanders, providers, and 
servicemembers themselves as well as our Online Family Caregiver 
Curriculum are now widely available.
    One of the emerging findings from the body of research on TBI is 
the importance of beginning treatment early. So we are aggressively 
working to improve the diagnosis and treatment of TBI in-theater. Steps 
we have taken include deploying a rapid field assessment of mild TBI 
and requiring, since 2010, the comprehensive evaluation of 
servicemembers who are exposed to potential concussive events.
    Overall, we have made great strides in finding TBI, tracking TBI, 
and treating TBI. We are now working to prevent TBI through developing 
better protective equipment and operational procedures. And in a sign 
of our recognition of TBI as the signature combat injury of our times, 
we accord those who suffer from it and mild TBI with the oldest 
commendation given by our military, the Purple Heart.
                             mental health
    Despite our efforts to date, a tragic number of our servicemembers 
and veterans commit suicide. DOD and VA have developed a mental health 
strategy that ensures our suicide prevention efforts fully complement 
one another. We have consolidated reporting of suicide events and 
standardized the measure of risk and protective factors. A web-based 
clearinghouse now serves as a tool for research and analysis. We have 
also developed new clinical guidance for depression, substance abuse, 
mild TBI, and co-occurring psychological disorders. Clinical tools such 
as the VA/DOD Major Depressive Disorder Toolkit and the Co-occurring 
Conditions Toolkit help providers used evidence-based approaches to 
treating mental and physical illness.
    Because not every veteran or servicemember lives near a facility 
that can provide the needed level of care, we are exploring the use of 
telehealth services and establishing a network of practitioners to 
serve rural locations. We have developed Mobile Telehealth Units, a 
web- based assistance program, smart phone applications to aid in the 
management and treatment of PTSD, and the Virtual PTSD Experience, an 
immersive, interactive activity that educates users about combat-
related stress.
    We have long known at the Defense Department that when you enlist a 
serviceperson, you effectively enlist a family. And when it comes to 
mental health, families are a crucial link. Our efforts to support 
families include a 24/7 phone line, online chat, and email; online 
self-help tools; and in Transition, a coaching and assistance program 
to bridge gaps in behavioral health support during transitional 
periods. Many of you have seen the Sesame Workshop programs that help 
children cope with deployments and injured parents or read one of the 
190,000 copies of ``A Handbook for Family and Friends of 
Servicemembers.'' The mental and emotional health needs of military 
children are among the least attended to, but most important, aspects 
of our current tempo of operations.
    We are also seeking to break the cycle of silence around mental 
health issues. Public education initiatives, including the Real 
Warriors Campaign, encourages servicemembers and veterans grappling 
with psychological health concerns to seek treatment. The campaign's 
public service announcements, which reach over 1.5 million 
servicemembers each week, feature servicemembers who have reached out, 
obtained care, and continue to lead productive military and civilian 
careers.
                      advances in case management
    We have also made significant progress in how the cases of 
individual veterans are managed. Thanks to legislative changes in FY 
2008 National Defense Authorization Act and the December 2009 
Department Instruction 1300.24, non-medical care provided to wounded, 
ill, and injured servicemembers has been standardized across military 
departments.
    Today, Recovery Care Coordinators develop a comprehensive recovery 
plan for each servicemember's non-medical needs. This plan includes 
tracking actions and points of contact to meet the goals of the 
servicemember and his or her family. Recovery Care Coordinators then 
work with commanding officers and medical care providers to implement 
the plan. Servicemembers with injuries of a catastrophic nature are 
further assisted by a Federal Recovery Coordinator. These coordinators 
are also assigned to severely injured and ill servicemembers who are 
highly unlikely to return to duty and who will most likely be medically 
separated from the military.
    Within DOD there are currently 146 Recovery Care Coordinators in 67 
locations placed within the Army, Navy, Marines, Air Force, United 
States Special Operations Command and Army Reserves. The Care 
Coordinators who work out of these centers are hired and jointly 
trained by the Department and the Services' Wounded Warrior Programs. 
To ensure cases are managed so as to avoid duplication, we are striving 
to better coordinate their efforts. There also currently are 22 Federal 
Recovery Coordinators at 12 medical treatment facilities and VA medical 
centers around the country.
                 sharing healthcare data electronically
    One of the most promising areas of collaboration between our 
Departments is electronic health records. To ensure the continuity of 
care, health care data must be shared. At present, a number of 
information systems share data. The Federal Health Information Exchange 
provides for the one-way electronic exchange of historic healthcare 
information from DOD to VA for separated servicemembers. The 
Bidirectional Health Information Exchange (BHIE) allows clinicians in 
both Departments to view health data on shared patients. The Clinical 
Data Repository/Health Data Repository (CHDR) enables bidirectional 
sharing of outpatient pharmacy and medication allergy data. The DOD and 
VA have created a service called the ``Blue Button'' that, once 
complete, will allow beneficiaries to safely and securely access 
personal health data at TRICARE Online, the Military Health System's 
Internet point of entry. And to support our most severely wounded and 
injured servicemembers, Walter Reed Army Medical Center, National Naval 
Medical Center Bethesda, and Brooke Army Medical Center are providing 
scanned records and radiology images for patients transferring to VA 
Polytrauma Rehabilitation Centers in Tampa, Richmond, Palo Alto, and 
Minneapolis.
    To work toward a true integrated electronic health record (iEHR), 
DOD and VA have agreed to implement a joint common platform with 
compatible data and services, data centers, interface standards, and 
presentation formats. Our joint approach will utilize commercially 
available components whenever possible. It will be led by a Program 
Executive and Deputy Director selected by the Secretary of Defense and 
Secretary of Veterans Affairs and overseen by an advisory board co-
chaired by the DOD Deputy Chief Management Officer and the VA Assistant 
Secretary for Information and Technology.
    We are also working with the private sector on the Nationwide 
Health Information Network and the Virtual Lifetime Electronic Record. 
These efforts will enable the Departments to view a beneficiary's 
healthcare information not only from DOD and VA, but also from other 
participants in the network. To create a virtual healthcare record, 
data will be pulled from existing electronic healthcare records and 
exchanged using data sharing standards and standard document formats. A 
standard approach will not only improve the long-term viability of how 
information is shared between VA and DOD. It will also enable the 
meaningful exchange of information with other government and private 
sector providers. Both DOD and VA are currently executing pilots to 
demonstrate the value of this approach.
    These various systems, while incredibly important to patient care, 
do not yet constitute a fully electronic health record. Such a record 
will contain all relevant health information from accession through end 
of life for all servicemembers and veterans, improving patient outcomes 
while reducing cost.
    As we go about this ambitious program that has such potential 
benefit for our servicemembers, it is important to keep in mind the 
difficulty of what we are trying to accomplish. Developing large-scale 
IT systems is difficult for any organization, public or private. 
Jointly developing an interoperable system across two major Federal 
departments is more difficult still. Secretaries Gates and Shinseki 
appreciate this. They remain personally involved, and have directed us 
to approach this project bearing several lessons in mind. To the extent 
that other large joint IT systems have succeeded, they have based on a 
common data foundation, common service bus, and common service broker. 
We are closely observing these lessons and are confident they will lead 
to the best possible outcome.
    Finally, the James A. Lovell Federal Health Care Center in North 
Chicago, Illinois has combined the missions of the Naval Health Clinic 
Great Lakes and the North Chicago VA Medical Center into a single 
organizational structure. This unique DOD/VA effort operates under a 
single line of authority, integrating management of the full spectrum 
of health care services. Through this effort, we are demonstrating just 
how compatible our two Departments' clinical processes and business 
rules are, which will help to enable the implementation of a joint, 
common electronic health record platform. In standing up this effort, 
the Departments developed reusable capabilities such as joint patient 
registration, medical single sign on with context management, and 
orders portability. These capabilities are in demand throughout our 
respective enterprises, and will be fully leveraged as we develop 
electronic health records.
                               conclusion
    These measures, taken together, substantially and materially affect 
the experience of our men and women in uniform, and the families who 
support them. Our work to improve the care of wounded warriors, 
especially as they transition from DOD to VA, is the core of our 
efforts to provide those who have sacrificed so much the care and 
benefits they are owed. I cannot overstate how far DOD has come with 
our VA partners in the four years since our leaderships have made 
working jointly a standard operating procedure.
    Despite the significant achievements I have highlighted in this 
testimony, we should not underestimate what remains to be done as we 
care for a new generation of veterans who have served under such 
difficult circumstances, for such sustained periods. We will continue 
to work with our colleagues at VA and throughout the government to do 
everything we can to provide our servicemembers with the absolute best 
care and treatment. Taking care of our wounded, ill and injured 
servicemembers is one of the highest priorities for the Department, the 
Service Secretaries, and the Service Chiefs. As the Secretary Gates 
often remarks, other than the wars themselves, we have no higher 
priority.

    Mrs. Chairman, thank you again for your support of our Wounded, 
Ill, and Injured Servicemembers, Veterans and their families. I look 
forward to your questions.
                                 ______
                                 
  Response to Prehearing Questions Submitted by Hon. Patty Murray to 
 Hon. William J. Lynn III, Deputy Secretary, U.S. Department of Defense
    Question 1. Please provide the Committee with the following 
information for each location which is using the Integrated Disability 
Evaluation System (IDES):
    Response. DOD answers, extracted from the Veterans Tracking 
Application, are provided in the attached spreadsheet, which lists each 
of the current 78 IDES locations and the requested data for items a-d 
and g-s. VA is responding to 1e, f, and t. Additional responses by the 
services to individual questions are included below. The responses to 
question 2 are also attached.

          a) The Initial Operating Capability (IOC) date.
          b) The number of servicemembers expected to enter the IDES 
        process each year.
          c) The number of servicemembers currently enrolled in the 
        IDES
          d) The current staffing level for Physical Evaluation Board 
        Liaison Officers.
          e) The current staffing level for Military Services 
        Coordinators. [See VA responses.]
          f) The average time to complete all medical examinations. 
        [See VA responses.]
          g) The length of time, on average, servicemembers have been 
        pending in the IDES process.
          h) The number of individuals who have been pending in the 
        IDES process for longer than 295 days.
          i) The number of individuals who have been pending in the 
        IDES process for longer than 540 days.
          j) The average time it takes to complete the IDES process.
          k) The total number of individuals who have completed the 
        IDES process.
          l) The number of individuals who have completed the IDES 
        process and were placed on the permanent disability retirement 
        list.
          m) The number of individuals who have completed the process 
        and were placed on the temporary disability retirement list.
          n) The number of individuals who have completed the process 
        and were separated with severance pay.
          o) The total number of individuals who have been removed from 
        the IDES process.
          p) The number of individuals removed from the IDES process 
        who received an Administrative Discharge after court martial.
          q) The number of individuals removed from the IDES process 
        who received an Administrative Discharge excluding court 
        martials.
          r) The number of individuals who have died during the IDES 
        process and the causes of their deaths.
          s) The number of individuals in the IDES who were returned to 
        duty.

        [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
                
          More on Item r. The number of individuals who have died 
        during the IDES process and the causes of their deaths.
          Response. The VTA database indicates that 40 Service Members 
        have died while enrolled in IDES. A spreadsheet is attached 
        (only Army has responded as of 11:48 Monday, May 16, 2011).

        [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
        

          t) The funding level for the IDES process, including funds 
        that will be provided from any source. [Additional responses 
        from VA found in VA statements.]

              Military Departments and VA--Air Force Answer
------------------------------------------------------------------------

------------------------------------------------------------------------
Physical Evaluation Board:
  Manpower Costs for IDES* (FY12 and out years) (Off,            $4.875M
   Enl, Civ)............................................
  Operations and Maintenance Costs (FY12 and out years).           $159K
  Equipment.............................................           $187K
  Space.................................................          $1.41M
  Training (Annual Conference)..........................          $1.50M
Military Treatment Facilities:
  PEBLO (funded and identified unfunded requirements)...           $6.0M
  Equipment (High Speed Copies, Scanners)...............           $517K
  Operations and Maintenance............................           $217K
    Patient Travel for Compensation & Pension exams.....            $14K
  Psychiatrist (Hickam).................................           $225K
------------------------------------------------------------------------
* Manpower costs include extensive use of Reserve Component since FY07
  and projected need to maintain that back-up for surge in workload. In
  FY11, Reserve Component man days used were 372 days for Enlisted and
  993 man days were used for Officers.

    2. In advance of the hearing, please provide the Committee with 
copies of the following:

          a. All weekly or monthly IDES Reports for 2011 that have not 
        previously been provided to the Committee

        [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
                
          b. Any IDES Customer Satisfaction Quarterly Reports that have 
        not previously been provided to the Committee
    Response. Office of Wounded Warrior Care and Transition Policy: The 
most recent published report for the period Oct-Dec 2010, is attached.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    3. For each branch of the military, please provide a detailed plan 
for how the IDES process will be implemented at overseas locations.
    Response. This data was previously provided to SVAC on March 29, 
2011, regarding the November 18, 2010, hearing.

    Navy: The Navy and Marine Corps have agreed in concept that the 
overseas (OCONUS) assigned personnel, requiring a referral into IDES, 
will receive permanent change of station orders to a continental United 
States (CONUS) location where sufficient resources exist to support the 
needs of the servicemember and family. The CONUS location will depend 
on the medical condition, the potential separation site, and the 
personal desires of the Sailor or Marine. However, the location must be 
near a Navy or Marine Corps activity for detailing and separation 
purposes and a Veterans Affairs (VA) medical facility to accomplish the 
compensation and pension evaluation. The VA has been active in the Navy 
OCONUS implementation meetings to date and has been informed that we 
project approximately 170 cases annually. The VA has not expressed any 
objections or concerns to the plan since caseload will be dispersed 
across the country.
    Air Force: Proposed Plan for Overseas IDES is to return Airmen 
either to TRAVIS AFB or ANDREWS AFB; those in PACAF would be sent on 
medical TDY Orders to Travis; those in USAFE would be sent on medical 
TDY orders to Andrews. Compensation and Pension exams will be scheduled 
in advance with the Military Services Coordinator and the PEBLO will 
coordinate timely TDY orders. The Airmen will return to their OCONUS 
duty station pending the decision of the Physical Evaluation Board. Air 
Force has finalized the overseas proposal and forwarded a copy of the 
memo to VA. Our intent is to meet with representatives from Veterans 
Affairs to identify requirements for Military Services Coordinators and 
Compensation and Pension Exams.
    Army: Based upon guidance received from The Surgeon General on 
March 25, 2011, the Army intends to bring Soldiers that are assigned 
overseas and are referred into the disability evaluation system to a 
continental United States (CONUS) location for processing through IDES. 
The Soldier will receive permanent change of station (PCS) orders to an 
installation that has an active IDES program and that is near the 
Soldier's home of record. When it is in the best interest of the 
Soldier and his or her family to remain at their overseas location, the 
Soldier, as an exception to policy and in lieu of PCS orders, will be 
provided medical temporary duty orders to travel to a CONUS location to 
complete those aspects of the disability process that are not available 
in the OCONUS location (e.g. the compensation and pension examination) 
and then return to their duty station. Given that the anticipated 
workload will be spread among all IDES sites, no significant increase 
in cases at any one location is expected. The Army will continue to 
develop this plan and thoroughly discuss it with the VA.
                                 ______
                                 
Response to Posthearing Questions Submitted by Senator Patty Murray to 
 Hon. William J. Lynn III, Deputy Secretary, U.S. Department of Defense
    Question 1. A strategic goal of the Integrated Mental Health 
Strategy is to reduce stigma through successful public communication 
and use of innovative technological approaches. How are both approaches 
directly addressing servicemembers' concerns about avoiding detrimental 
effects on their career when seeking mental health care?
    Response. The Departments are coordinating public communications 
regarding mental health care availability and effectiveness to ensure 
that there are adequate and consistent sources of information that 
directly address Servicemembers' concerns about seeking care. These 
concerns most often involve effect on career, effect on peer 
acceptance, effect on family acceptance and interference with presence 
on the job. Messaging from DOD leaders emphasize that seeking care is a 
sign of strength, and that seeking mental health care will not 
adversely affect one's career.
    An example of the technological approach being utilized is the 
Department's National Center for Telehealth and Technology (T2), which 
is engaged in multiple projects to help servicemembers access 
information and care while avoiding concern that accepting care in 
innovative ways. One such project is afterdeployment.org, a web-based 
application spanning18 topics: post-traumatic stress, depression, 
anger, drugs and alcohol, tobacco, physical injury, resilience, 
military sexual trauma, health and wellness, sleep, families and 
friendships, anxiety, Traumatic Brain Injury, life stress, stigma, 
families with kids, spirituality and work adjustment. Designed to 
provide an online and anonymous self-care solution, the Web site offers 
multiple access points to learn, immerse, and engage in behavior-change 
strategies. Features include topical libraries, self-assessments, 
video-based personal stories, interactive workshops, community forums, 
expert blogs and a provider training portal. To date, evaluation of the 
Web site indicates it is effective and well-received and the site has 
approximately 5,000 monthly visitors.
    T2 has also developed the ``T2 Virtual PTSD Experience'' a Web-
based 3D virtual world resource providing an interactive, immersive 
tool that informs users about PTSD causes, symptoms and resources for 
care. This tool, accessible 24/7 from a personal computer, allows 
servicemembers, veterans, and their families to access PTSD-related 
resources in a convenient, personal, and anonymous way.

    Question 2. The Department's Extremity and Amputation Center of 
Excellence is a joint program established to conduct clinical research 
as well as develop scientific information aimed at saving injured 
extremities, avoiding amputation, and preserving and restoring function 
of injured extremities. The Department has already developed the 
concept of operations for the structure, mission and goals for the 
Center, so what is delaying final approval?
    Response. The Department is examining the implementation status of 
this and other Centers for Excellence. We would welcome the opportunity 
to brief you or your staff on their current status, and the targets and 
goals for meeting the objectives of each Center.

    Question 3. Today, the Vision Center of Excellence, the Hearing 
Center of Excellence, and the Limb Extremity Center of Excellence all 
face major challenges in meeting their mandated objectives due to 
insufficient resources, limited staffing, lack of organizational 
governance oversight, and inadequate funding. Please provide the 
Committee with a detailed time line, complete with targets and goals, 
for each Center.
    Response. The Department is examining the implementation status of 
these and other Centers for Excellence. We would welcome the 
opportunity to brief you or your staff on their current status, and the 
targets and goals for meeting the objectives of each Center.

    Question 4. There are serious challenges in combating the stigma 
associated with seeking mental health care. The Department is still 
struggling to make it acceptable to ask for help. In the meantime, 
providing confidentiality for servicemembers to seek treatment is very 
important. Additionally, commanders have an obligation to know how fit 
and ready those in their units are. What is an acceptable balance of 
these concerns?
    Response. There are no easy solutions to this problem. As you 
indicate, an acceptable balance includes measures to ensure 
confidentiality for routine matters and notification to commanders in 
more serious cases.
    Confidentiality for routine mental health evaluations must be 
present so that each individual servicemember can overcome the common 
reluctance to seek help early. In July 2009, the Department issued a 
directive type memorandum in order to help achieve this aim. In more 
serious cases, such as those involving threat of harm to self or 
others, or risk of endangering the military mission, commanders must be 
notified.

    Question 5. What is the Department doing to improve conditions in 
the Warrior Transition Units? Is there a way that VA can assist?
    Response. The Army and Marine Corps have taken significant steps to 
improve conditions in the Warrior Transition Units (WTUs) and Wounded 
Warrior Regiment (WWR). The Army created a systematic framework called 
the Comprehensive Transition Plan (CTP), a structured multidisciplinary 
process accomplished for every Warrior in Transition that includes an 
individual plan that the Warrior in Transition builds for him/herself 
with the support of the WTU cadre. This process allows Warriors in 
Transition to customize their recovery process, enabling them to set 
and reach their personal goals.
    There are also currently 56 Ombudsmen at 31 sites, usually co-
located with a military treatment facility (MTF). These Ombudsmen 
advocate for Warriors in Transition and Families as they deal with 
various issues related to health care and transition, such as physical 
disability processing, reserve component medical retention, transition 
to the VA, and pay issues. In addition, Veterans Benefit Advisors and 
Veterans Health Advisors are available to help Warriors in Transition 
and their Families apply for VA benefits and to coordinate health care 
to ensure a smooth transition for those Soldiers who will be 
transitioning to Veteran status.
    The Department leadership and the Army continues to work with 
Congress to fund military construction projects, including the 
development of Warrior Transition complexes that will serve both 
Warriors in Transition and their Families. To date, more than $1.2 
billion dollars has been spent or obligated to improve the 
accessibility and quality of Wounded Warrior barracks. Construction of 
complexes continues through FY 2012 at which time 20 state-of-the-art 
complexes will be in operation.
    The Marine Corps WWR continues to enhance its capabilities to 
provide added care and support to wounded, ill, and injured (WII) 
Marines and their families in accordance with the Commandant's Planning 
Guidance. The WWR has evolved from its initial focus, standing up 
programs and services to address the immediate needs of Marines and 
families as well as building capabilities and structure based on 
confirmed requirements and findings in warrior care.
    The WWR currently has 49 Recovery Care Coordinators (RCCs) located 
in the WWR headquarters and battalions, military treatment facilities, 
and VA Polytrauma Centers. The RCC program continually adopts 
improvements to help WII Marines and families through heightened 
coordination with all WII Marines' advocates, which include Federal 
Recovery Coordinators.
    Marine Section Leaders have the ability to provide motivation and 
daily accountability to help Marines meet their established goals, and 
there is mandatory participation in the Warrior Athlete Reconditioning 
Program (WAR-P) for Marines in the WWR. As part of the Integrated 
Disability Evaluation System (IDES), Marines receive support from 
Regional Limited Duty Coordinators who assist Marines processing 
through the system, and Wounded Warrior Attorneys who provide advice.
    The Marine Corps has also evolved a practice of staying in contact 
with Marines post-transition via the Call Center or District Injured 
Support Coordinators, who are located throughout the country, to ensure 
identified transition needs have been satisfied. The Call Center also 
receives calls for assistance and serves as the WWR's hub for social 
media outreach to include Facebook and Twitter, which helps ensure 
Marines and families stay up-to-date on warrior care.
    The Department has also focused considerable effort to improve and 
streamline the Medical Evaluation Board (MEB) and Physical Evaluation 
Board (PEB) processes and reduce paperwork requirements to more 
efficiently move a servicemember's disability package through the 
adjudication process. The collaboration between the Department of 
Defense (DOD) and the Department of Veterans Affairs (VA) ensures that 
Warriors in Transition have priority processing by the Veterans Health 
Administration (VHA) and Veterans Benefits Administration (VBA) 90 days 
prior to separating so they can receive their VA benefits and health 
care immediately upon discharge.

    Question 6. What is the Department doing at Joint Base Lewis-
McChord to address the average wait time for a servicemember in the 
Integrated Disability Evaluation System (IDES) pilot program to get a 
medical examination, especially given that this program is being 
implemented worldwide?
    Response. At the time of the hearing, the VA completed disability 
examinations at Joint Base Lewis-McChord in an average of 46 days for 
Active Component (AC) soldiers and 49 days for Reserve Component (RC) 
soldiers. DOD is working with VA to improve IDES timeliness at all 
locations, including Joint Base Lewis-McChord. To address timeliness 
for our Servicemembers at Joint Base Lewis-McChord, DOD and VA monitor 
IDES performance, examine timelines, and identify VA staffing and 
resource requirements so that solutions can be effectively implemented 
to achieve timeliness goals. As a result, DOD has 14 IDES-related 
hiring actions pending at Joint Base Lewis-McChord and anticipates the 
additional staff will dramatically improve IDES timeliness for 
Servicemembers there.

    Question 7. In the Joint Base Lewis-McChord Integrated Disability 
Evaluation System (IDES) pilot program the ratio of servicemembers to 
DOD case managers is 130 soldiers to 1 case manager. This is well over 
the goal of 20 servicemembers for every 1 case manager. What is the 
Department doing to address this troubling ratio?
    Response. To address this ratio, the Department and the Services 
are working aggressively to hire additional Physical Evaluation Board 
Liaison Officers (PEBLOs) to reach the desired case manager ratio of 
1:20. Providing better, expedited IDES processing is a priority for the 
Department and we are actively engaged at the individual installation 
level to accomplish this.

    Question 8. The joint electronic health record (EHR) is the largest 
program ever developed between VA and DOD. The continuum of quality 
health care for millions of servicemembers and veterans is depending on 
the success of this project. Please provide a time-line for delivery, 
project costs, and expectations.
    Response. The work continues on implementation plans and the 
refinement of initial cost and schedule estimates. Despite this ongoing 
work, the Department does not have a completed timeline for delivery or 
project costs at this time. The Secretaries of Defense and Veterans 
Affairs chair recurring meetings on the integrated EHR (iEHR) and 
agreed to the joint development/acquisition of a number of functional 
capabilities/applications for iEHR, using the following business rules:

     Purchase commercially available solutions for joint use 
whenever possible and cost effective;
     Adopt applications developed by DOD, VA, or Federal 
agencies if a modular commercial solution is not available and 
currently exists inside government; and
     Approve joint application development on a case by case 
basis, and only if a modular commercial or federally-developed solution 
is not available.

    Moving forward, the Departments will continue efforts to develop a 
joint EHR by taking the following steps:

     Implement the EHR Governance Model
     Name EHR Program Executive
     Complete development of common data model, translation 
service and other building blocks of the ``To Be'' architecture
     Finish negotiations for Data Center consolidation
     Implement pilots of the EHR Graphic User Interface (GUI)
     Finalize VA use of the DOD data model and acquisition of 
services
     Purchase Enterprise Service Bus for both Departments
     Establish Open Source Custodial Agent

    Question 9. How will the Department, along with VA, improve the 
reporting and tracking of potential cases of hazardous exposures?
    Response. DOD will improve reporting and tracking by creating 
individual longitudinal exposure records (ILERs), where multiple 
information management systems are mined for exposure related 
information and the results made available to the VA for diagnoses, 
treatment, and claims adjudication. The ILERs will, among other things, 
serve to take the burden of proof off our Veterans to prove Service-
connected exposures.

    Question 10. As members of the Guard and reserves transition in and 
out of active duty, they repeatedly switch between TRICARE, private 
insurance, and VA medical care. This creates a number of concerns 
regarding coordination of care, quality oversight, and the ability of 
the servicemember and family to manage those changes. How are these 
transitions being tracked by the Department, and effectively managed?
    Response. Tracking the care of Guard and Reserve members 
transitioning in and out of active duty is far more difficult, in part 
because private insurance partners generally do not share enrollment 
data or health care documents with DOD. That said, there are provisions 
in Federal law that assist with these transitions, and the Department 
has undertaken a number of efforts to further assist Guard and 
Reservists.
    For example, the Uniformed Services Employment and Reemployment 
Rights Act (USERRA) provides that a person returning to a civilian job 
after military service is entitled to reinstatement of employer-
provided health insurance coverage. Members of the Guard and Reserve 
may choose to enroll in TRICARE Reserve Select, which allows them to 
select TRICARE as their insurance provider while they are in a civilian 
status. Additionally, Guard/Reserve servicemembers and their families 
are eligible for TRICARE coverage up to 180 days pre-deployment, and 
180 days post-deployment. If they are already a TRICARE Reserve Select 
member their premiums will be waived during this time period.
    Furthermore, the Virtual Lifetime Electronic Record (VLER), once 
completed, will aid servicemembers, both Active Duty and Guard and 
Reserve, as they transition to and from the Military Health System by 
ensuring their information can be exchanged between DOD, VA, other 
agencies, and the private sector.

    Chairman Murray. Thank you. Secretary Lynn, you said that 
you want to go beyond the 300 days. We are not there yet. When 
do we expect to reach the goal of 300 days?
    Mr. Lynn. The hope is to have the system which is now 
implemented in about half or for half the servicemembers, half 
of 26,000. We hope to have that system fully implemented by the 
end of this year, so that is this fiscal year, this fall.
    Chairman Murray. So the 15,000 that Secretary Gould talked 
about that are in the new system?
    Mr. Lynn. There is another 14 or so thousand that are in 
the old system. We want to transition those over the next six 
or so months into the new system.
    What we found, though, as we transition them in, what 
happens is that initially we actually get quite a lowering of 
the number of days as we work through the more routine cases on 
the faster system.
    But then what we find is that the time tends to come back 
up as we hit the harder backlog of cases. We need to work our 
way through that backlog which is what we are doing now with 
the existing cases, and so the data has actually gone up from 
where it was last fall.
    But we are working our way through that backlog. When we 
get our way through that backlog, we will then have a system 
where we are taking members who start in the new system and 
finished in the new system. At that point we should hit that 
295 days. I cannot give you a date but I would say----
    Chairman Murray. Are we talking months or years?
    Mr. Lynn. I would say 1 to 2 years.
    Chairman Murray. It still will take that long just to get 
people----
    Mr. Lynn. I would hope to do it in a shorter period of 
time, but I do not want to overpromise.
    Chairman Murray. Is there anything this Committee can do to 
help expedite that, because these are individuals who are 
living in limbo.
    Mr. Lynn. Well, I think both Departments are committed to 
putting their resources toward working through the backlogs; 
and also when you go to a new system, you create transition 
difficulties. You need to surge resources to bases and 
facilities that are having problems.
    So, we have committed with our VA partners to do that. It 
is going to take over $700 million over several years. So, we 
are certainly looking. We will present that in our budget. We 
would certainly look for congressional support to spend those 
resources.
    Chairman Murray. This Committee needs to know honestly what 
the budget needs are because this is an obligation. We throw 
around 13,000, 300 days. These are individuals who are living 
through this, and I am very conscious of that. So we want to 
work with you, but we need honest budgets from both of you 
about what that will take.
    Mr. Lynn. Absolutely.
    Chairman Murray. I referenced something in my opening 
remarks that I want to ask about. The Department of Defense 
provided this Committee with information on those 
servicemembers who have died while they were enrolled in the 
joint disability program. Of the 34 deaths, 13 were suicides or 
drug overdoses. That is very troubling information.
    That means that the rate of suicide for those that are 
going through this program is more than double the rate of the 
Army and the Marine Corps. So, I wanted to ask both of you what 
your respective Departments are doing to address this troubling 
trend of suicides within the joint disability program?
    Mr. Lynn. Madam Chairman, the level of suicides is too 
high. Frankly, it is too high Department-wide. It is, as you 
know, higher with the people facing the challenges with 
disabilities. Certainly, they have a more challenging life, and 
we need to do everything we can to ease those challenges.
    Part of it is what we just discussed. We need to make the 
disability evaluation system, that transition from DOD to VA, 
as expeditious and as congenial as possible. That is what we 
are about.
    We also need to support families and servicemembers with 
disabilities strongly in terms of the care coordinators, in 
terms of wounded warrior transition units. We need to inform 
families of the warning signs for suicides.
    Chairman Murray. You are saying we need to do that. Are we 
doing that?
    Mr. Lynn. Yes, we are.
    Chairman Murray. How is that being done?
    Mr. Lynn. Well, the system that is in place right now is we 
work with care coordinators to alert them to the signs.
    Chairman Murray. Actively, so everybody is involved in 
this?
    Mr. Lynn. Actively. Everybody is involved in this. The 
warrior transition units are particularly trained to look for 
signs and they are trained in how to deal with those. We have a 
broader suicide prevention system. We pay particular attention 
to the families of servicemembers because they are the most 
likely to be in a position to observe the early warning signs.
    Chairman Murray. Something is not working when we have this 
high number. Can you give me ideas or even a commitment to go 
back and take a look at these numbers and really look at our 
outreach? What are we doing to help support our families? Is it 
over use of drugs? And, come back to us because this is just 
unacceptable.
    Mr. Lynn. The numbers are too high, and I am happy to come 
back to you, Madam Chair.
    Chairman Murray. OK. Secretary Gould how about in the VA?
    Mr. Gould. First of all, the numbers that you mentioned I 
just became aware of quite recently, and it is tragic to hear 
about the individual losses going down that list of individuals 
from DOD that have committed suicide. It is heart wrenching.
    As Secretary Lynn just said, we are very focused on making 
sure this transition goes well. The individuals who obviously 
are in that data are all on active duty and under the care of 
the DOD during that time.
    What we are trying to do is backstop in that process. VA is 
moving in parallel while those individuals are getting direct 
care. Bill has mentioned all of the various attributes of that.
    When transition time does come, VA is very focused on 
making sure that we are working to prevent suicides. We are 
conducting outreach and public education. We are amping up the 
resources that we bring to the fight on these issues. We are 
working to destigmatize it. We have a national crisis line that 
has served over 400,000 people. Approximately 14,000 have been 
saved since 2007. We are working very, very hard and in a very 
focused fashion.
    Chairman Murray. Now, as result of the Joshua Omvig bill 
that we all worked to pass and support, I know that.
    I just want to say, Secretary Gould, I am very concerned 
about the high number of suicides, as I just said; but knowing 
that, we need to double our efforts with the soldiers who are 
coming out of that program and leaving, because once they have 
left the program they are out there in the world, and we have 
to make sure that we are finding them.
    So, I am hoping that you take a look at those numbers and 
reflect on that given what we are doing with servicemembers who 
leave and go into the VA system.
    Mr. Gould. Chairman Murray, we will. I would add and I 
think we all agree that the IDES systems is absolutely better 
than the legacy system. It is shorter. It eliminates the pay 
gap. The whole purpose here is not to put a veteran family in a 
situation where they do not have a paycheck. We want to make 
sure we are moving to that world. We do not want them to have 
to confront multiple medical examinations. The new system has 
one.
    So we think that on the whole the IDES system, despite the 
fact that it can and will be better, is a much better system 
than the one we are leaving behind.
    Chairman Murray. I think we all agree on that; but in the 
meantime, as you both just said, it is a while before we 
transition into that.
    So, I would like for the record for the both of you to 
provide the number of servicemembers and veterans who committed 
suicide or overdosed, who were in the warrior transition units 
and in the VA for the first time.
    So, if you could get back to me with those numbers I would 
appreciate it.
    Senator Isakson.
    Senator Isakson. Thank you, Madam Chairman.
    Secretary Lynn, I am told by Jim Lorraine at the Charlie 
Norwood VA and Laurie Ott, one of the big community supporters 
of that, that the Federal recovery program is essential to 
getting the seamless transition working, FRCs I think they call 
them.
    They commended the Department and the VA on establishing 
those. But there are only 22 Federal recovery coordinators in 
the United States and only two in Georgia where every ground 
troop from the U.S. Army goes through Georgia, either at 
Benning or Stewart, before they are deployed.
    It seems like 22 is a very small number of people to 
coordinate the transition of those wounded veterans from active 
duty to veterans care.
    What are you all doing to expand the Federal recovery 
program, the coordinator program, and how are you working to 
better get coordination between those coordinators working 
better?
    Mr. Lynn. Coordination is the key word there, Senator. The 
Federal recovery coordination program referred to is a VA 
program and I will turn to Secretary Gould.
    We have a parallel program called recovery care coordinator 
that complements that. We have actually 146 recovery care 
coordinators. That is a DOD program that handles people as they 
are in the DOD system that coordinates with their families, 
helps them navigate through that system. That is at 67 
different installations. I do not know how many are in the 
installation you cited. We can get that for you.
    They then coordinate with the Federal recovery coordination 
system which is a VA system. The objective is to make those two 
systems work seamlessly and in a complementary fashion.
    Let me ask Scott to talk about the FRC program.
    Mr. Gould. Senator, just to get a sense of the numbers 
here, about the 1,300 clients in that system were served by 
individuals that you mentioned. About 80 percent customer 
satisfaction rating for that.
    I view this as a joint program. Our predecessor started 
this in 2007 and recognized the following reality, that we had 
two agencies absolutely dedicated to taking care of their 
troops but what we wanted to focus on is making sure that the 
transition works more effectively.
    I think there is a very strong role. Bill and I have 
committed to a review of the Federal recovery coordinator 
program. We are going to hear a report next month in the Senior 
Oversight Committee, and the whole goal is to provide that 
person who has a view that extends between agencies and make 
sure that any last barrier can be knocked down, and any margin 
of additional service that we can provide to those most 
seriously wounded, ill, and injured warriors is provided.
    Senator Isakson. Well, if, as Secretary Lynn says, he has 
163--is that right?
    Mr. Lynn. One hundred forty-six.
    Senator Isakson. If he has 146 coordinators at active duty 
and you have 22 in the FRC, that ratio itself begs the 
question: are we not understaffed, because the number is going 
to be about equal.
    Mr. Gould. And, Senator, if that were the extent of the 
people who are focused to provide care coordination in VA, then 
I would conclude, as you have, that there is imbalance, but it 
is not.
    We have hundreds of people dedicated to care coordination 
roles within VA, and Mr. Lynn has just cited those individuals 
within DOD who provide that function. The Federal recovery 
coordinators are the layer on top of that which make sure that 
all of the individuals who are focused on providing care 
ordination, case management, team leaders, nurses on the 
ground, physicians, et cetera, at these facilities are working 
together across the boundary, and so the Federal recovery 
coordinators are really that top layer that ensures that the 
final measure of coordination is occurring between the two 
entities.
    But we have literally hundreds of people dedicated to that 
in the same way that the service does in our individual 
domains. What we want to do is function better across agencies.
    Senator Isakson. Well, you used a word that I hear very 
often that is problematic for me and that is layer. Sometimes 
there are too many layers and that is when people fall through 
the cracks.
    So, I think working on the coordination between those 
layers in the handoff is critical. And, my time is almost up, 
but I do want to mention one other thing. I have always taken 
great joy in the great logistics of our military and the great 
utilization they do and how they get so much done with so 
little.
    But I am really worried with Walter Reed closing and 
Bethesda taking over all of the work in this area, and the 
number of wounded warriors and their types of injuries from the 
wars we have been in, and coming to Washington, I am wondering 
if Bethesda is going to be able to handle the weight of that.
    In Augusta, and I am not shilling for the home team here, 
but they are at 50 percent capacity at the VA hospital there. 
They could treat double the number of soldiers that they are 
treating right now.
    It would seem to me that with the numbers growing like you 
said in the testimony that I would like for you all to take a 
look at what facilities VA has around the country that are 
maybe underutilized in that rehabilitation so we can get better 
ratios for our soldiers. When we reach that level at Bethesda, 
we are sure we have the capacity to treat them.
    Mr. Gould. Senator, I would be pleased to do that. We are 
constantly looking for opportunities to joint venture. In fact, 
we have nine locations across the country now that are under 
active consideration.
    Senator Isakson. Thank you.
    Chairman Murray. Senator Tester.
    Senator Tester. Thank you, Madam Chair. It is not my home 
team so I can say this.
    I think it makes perfect sense to take a look at those 
facilities and figure out which ones. I mean, these are, well, 
I mean, it you do not want to overload one if the others are 
working. So, I appreciate Senator Isakson bringing that up.
    Deputy Secretary Lynn, you guys know the statistics for 
unemployment for our veterans as they come back in. It is 
atrocious. True, we are coming out of the worst recession since 
the 1930s. But the fact of the matter is where unemployment 
rates are for our veterans returning from combat are totally 
unacceptable.
    The chairman has a bill of which I am a co-sponsor of that 
she referenced in our opening remarks, and one of the things it 
does is it establishes a system for certifying the work and the 
skills gained the in the active military service.
    Can you clarify whether the DOD has the ability to 
establish such a system? And what it does is basically if you 
have a medic that is working in the medical field or if you 
have a truck driver, the list goes on and on. There are a lot 
of skills that are learned in the military. To be able to 
certify to the private sector once they get out of the DOD, be 
able to certify to the private sector that they have these 
skills.
    Does the DOD have the ability?
    Mr. Lynn. I will have to get back to you for the record. I 
am not aware of any program like that.
    Senator Tester. If we were to set a program up like that, 
would you have the ability? Do you know that? If you do not, 
that is fine. You can get back to me on it. If we were to set a 
program up where the military, the Department of Defense, 
certifies that the work that these folks have done in the field 
establishes them at a level of expertise for the private 
sector, would the DOD have that ability?
    Mr. Lynn. Let me get back to you.
    Senator Tester. I appreciate that.
    I think it is critically important. We heard from not 2 or 
3 weeks ago a young gentleman by the name of Eric Smith in here 
who could not get a job in the medical field because there was 
no recognition of the work he had done as a medic, which is 
pretty incredible.
    Deputy Secretary Gould, we have talked about electronic 
medical records for a long, long time. The GAO came out with a 
report or expressed concerns that the DOD and the VA lacked the 
mechanisms for identifying and implementing an efficient and 
effective IT solutions to create a joint system. I am sure you 
are aware of that. Can you speak to the measures you have taken 
to address that?
    Mr. Gould. Senator, I would be happy to. If I might, just 
to add for Bill Lynn's sake, at the VA we have been very 
focused on this issue. I think you are right. It is an 
opportunity for our veterans to translate the skills that they 
have, and so we actually have been working with DOD on this.
    VA has a system in place to help translate those skills 
that you are talking about. Someone who drives a truck in the 
military, who logs 100,000 miles under combat conditions, they 
ought to be safe for America's roads. Can we find a way to do 
that a little bit more easily and efficiently? My sense is we 
can.
    Senator Tester. Yes, and before I get--I will not ask this 
question again because you heard it but the fact is once they 
get to the VA end of things, once they get under your 
supervision, it is too late. This process has to be started 
when they are in the active military because it is important we 
certify what they have done.
    So, I appreciate that.
    Mr. Gould. Sure.
    Senator Tester. I appreciate, Deputy Secretary, I 
appreciate you being willing to get back to us and talk to us 
about how the Chairman's bill will work, in fact, in the 
military because if it does not work we are going to have to 
address that then.
    How about the GAO concerns about the IT between DOD and VA?
    Mr. Gould. Senator, I think the GAO concerns are 
legitimate, and as a result, the two secretaries got together 
and said we are going to fix it. That is the reason why we 
decided to implement a joint common electronic platform for our 
health records.
    But one thing if I could say quickly that should give this 
Committee confidence that we are heading down the right road 
despite Secretary Lynn's concerns about the challenge of doing 
that is we have already delivered a prototype of the new 
interface. We will have in place by July of this year the new 
graphical user interface that will be the front-end of the 
system.
    Senator Tester. Does that address the GAO concerns?
    Mr. Gould. It does directly so it provides that common 
interface that both the DOD doctors and VA doctors have said 
would optimize their ability to treat patients in the system. 
We will have a single sign on in the North Chicago VA by the 
end of this year, and last, we will have significant 
functionality shared between the two agencies by June 2012. We 
are moving down the road quickly on incremental delivery of 
this new system.
    Senator Tester. So, would it be fair to say the recent 
concerns that GAO put forth, you have addressed all the 
concerns?
    Mr. Gould. I think that is fair to say that GAO has laid 
out an objective analysis of where we were, and in the last 60 
to 90 days we have taken enormous strides forward. Those 
recommendations and the direction that the Secretary has set 
have got us going to address these. We will do that.
    Senator Tester. Are there any concerns that are not being 
addressed?
    Mr. Gould. No.
    Senator Tester. OK. I am out of time.
    Chairman Murray. Senator Johanns.
    Senator Johanns. Thank you, Madam Chair.
    Let me just offer for the record. I think, Senator Tester, 
you have a good idea here. When you think about our military 
today, it is vastly different than my generation, if you will, 
30 years ago or 40 years ago.
    These are true professionals. These are men and women who 
come and oftentimes make a career in the military. They are all 
volunteer. They are getting outstanding training. They are 
developing specialties in given areas that would translate to 
the private sector. I just wonder if we are not utilizing, 
fully utilizing that in terms of trying to employ them as they 
leave and return to the private sector.
    This is not well known but USDA actually has college where 
we grant degrees. Taxpayers do not pay for it so it is self-
sustaining. But it is almost like that kind of concept, and I 
did not come prepared today to testify on that but you have 
turned a light bulb on in my head. I think it is a good idea 
and would be happy to work with you, Senator Tester, on that.
    Let me, if I might, start my questioning with a thought or 
two about mental health services. One of the things I mentioned 
in my opening statement is--just raise the question--are there 
enough evaluators as part of the backlog in terms of getting 
services? The fact that we have our evaluators just as busy as 
they possibly can be, doing as much as we possibly can, but we 
have positions open or we do not have enough. I would like to 
hear your thoughts on that, either one of you. It is actually a 
question for both of you.
    Mr. Gould. So, Senator, let me start in. We have almost 
20,000 people in the VA focused on mental health care delivery, 
social service workers, clinicians, physicians, and the like.
    So, I believe that we have adequate resources in VA to be 
able to respond to any demand that DOD places on it. In fact, 
one of the things that Bill Lynn and I are working to do is to 
make sure that the process is as quick and efficient as it can 
be so that we do not create a logjam within the Armed Forces 
that would, as Senator Tester mentioned earlier, create a 
readiness issue for us.
    So, we are very focused on that. We believe we have the 
right capability. Deploying it at the moment in time where it 
is needed is a challenge. We need to get better advance data 
about where the demand will be and we have put in place 
contracting resources to be able to handle that surge capacity 
so that when we pick up the phone and call for additional 
services we can bring those into the challenge of processing 
individuals in IDES.
    Senator Johanns. Secretary Lynn, any thoughts?
    Mr. Lynn. Yes. The biggest challenge that we have in this 
area is bringing the resources to the right place at the right 
time. And, by that I mean, we need to particularly focus on 
units that are deploying and then just returned from 
deployment.
    That tends to be a surge. Several thousand come to one 
location in a single point in time, and it overwhelms any 
reasonable number of mental health professionals they might 
have. They are just never going to have enough to deal with 
that surge in the confined period of time that you really want 
to.
    And, what you want to do is do an evaluation of people when 
they come home. You actually want to do baseline before they 
go. You want to do an evaluation when they come home, and then 
you want to do one 90 or 120 days later because oftentimes 
issues pop up that are delayed.
    What we have been trying to do in working with VA to tackle 
that is to make much greater use of virtual resources, not try 
and have a full complement of people on-site necessarily. That 
would be very difficult logistically to do. But to use virtual 
tools, to use Skype, use online materials.
    What this does is gives you an opportunity to have a 
personal consultation with each member rather than just say 
fill out a form which is the old method. In doing that, we have 
been particularly dependent on the resources that Scott just 
mentioned.
    We need to be able to take mental health professionals from 
around the country, point them to Fort Bragg or Fort Hood or 
Camp Lejeune, whatever the unit is returning to, so that we can 
bring that level of attention to the unit when they need that.
    The Army in particular has stepped out and has pioneered in 
this. The Marine Corps and the other services are going right 
behind them in doing it, and I think we can make significant 
progress in that area.
    Senator Johanns. OK. I am out of time.
    Chairman Murray. Thank you very much.
    Senator Brown.

               STATEMENT OF HON. SCOTT P. BROWN, 
                U.S. SENATOR FROM MASSACHUSETTS

    Senator Brown of Massachusetts. Thank you, Madam Chair.
    Last December, GAO found that one of your pilot sites 
which, to be fair, was experiencing severe staffing shortages, 
spent an average of 140 days to complete just one exam. I know 
the desired timeline is 45 days. What is going on with that 
particular site? Are things getting better? Either one I guess.
    Mr. Lynn. Why do not I start. I mean, I think you have got 
the numbers right. I am not sure which site you are talking 
about. But there are challenges in making this transition. 
Overall, where we stand right now is that the old system, the 
average, the average not just for the evaluation but to get 
through the whole system is about 540 days.
    The average to get through the new system right now stands 
just under 400. We have a goal of getting it under 300. To get 
to that point what we have to do is deal exactly with the choke 
points that you are talking about, and our plan is to surge 
resources, in this case medical resources, to these choke 
points to get that backlog removed so that we hit the targeted 
number of days for each stage in the process, 45 as you said 
for the medical evaluation.
    Senator Brown of Massachusetts. So is streamlining still to 
be at 400 days, 300 days, is that considered streamlining 
still? I mean, is that a realistic number?
    Mr. Lynn. Certainly, relative to 540.
    Senator Brown of Massachusetts. Yes. But when you are the 
servicemember trying to get on with your life, I mean, it is an 
eternity.
    Mr. Lynn. Fair enough. Go ahead.
    Mr. Gould. Senator, I would just add that one of the 
challenges, I think one of the limitations of focusing on the 
time in the system is that there are actually two forces at 
work here.
    One is that we want to provide that servicemember with as 
much time as they and their families need to make that 
adjustment, and if that means a month or 2 months or 3 months 
and they are on military pay and they are getting military 
health care and their family is on TRICARE and we know where to 
find them and we know where to house them, that is a positive 
in my view.
    On the other hand, you do have individuals who say, look, I 
have come to terms with this. It has been life altering but my 
life is not over. I am ready for that transition. I think that 
is where you are pointing. That time needs to be shorter.
    What we are striving to create here is a system that allows 
the individual and the services the flexibility to get what 
each individual case requires. Our standard here is the 
veteran-centric approach which is what is good for them, what 
is right for them. We are also using other measures than length 
of time through the process. Customer satisfaction being one. 
Utilization being another.
    So, we are trying to find a balanced score card of how to 
measure people in this process and take care of them while we 
do.
    Senator Brown of Massachusetts. Are you concerned at all 
that, you know, when you are dealing with the contracting 
departments that they may be outpaced by innovative 
developments in IT and are you using things and are you 
adapting about using things like cloud data storage? Are you up 
on those things?
    Mr. Gould. Senator, yes, I think this is one of the key 
components of the integrated electronic health record that 
secretaries Gates and Shinseki recently directed our two 
organizations to do.
    And, if I could just pick up a couple of key components 
there. One is we are adopting an open standard, common standard 
for data. We are building a new interface on a common basis. We 
are turning to the private sector to build the applications 
that will be part of this joint common electronic health 
platform. So we are leveraging to the maximum extent possible 
even so far as to use open source techniques to increase our 
rate of innovation and improve the rates of change that we have 
in our electronic health record systems.
    Senator Brown of Massachusetts. Just to stick with you for 
a second, sir, I cannot tell you how many hearings--I was just 
at hearing previously when we were talking about FEMA giving 
monies out inappropriately though no fraud, just through a 
mistake.
    I have had hearings with Senator Carper, and just monies 
that are going out under Medicare and Medicaid just through 
mistakes, 76 billion a year, and, you know, it is just a 
mistake. OK great.
    How sure will you be in the VA knowing that if Lieutenant 
Colonel Brown comes before you and you have everything that I 
am the right guy and that I am getting the benefits that I 
deserve?
    Mr. Gould. That is a complex set of issues there. One is 
how effectively are we managing IT and making sure we do not 
have those high dollar mistakes.
    I think I am proud of our change in performance over the 
last 2 years at VA. When we came on board there were over 300 
separate IT projects. Today there are a little over 100. Only 
20 percent of those projects were meeting their milestone 
goals, cost, schedule, and technical performance. Today over 80 
percent are meeting those.
    Bill and I have committed to use that process called agile 
development in this joint development exercise that we are 
about to go through, and so we are bringing a sense of urgency 
and oversight and quality of management to this process that I 
think will avoid or lower substantially the risk that we might 
misspend money in this process.
    Senator Brown of Massachusetts. Thank you.
    Thank you, Madam Chair.
    Chairman Murray. Thank you.
    Senator Begich.

                STATEMENT OF HON. MARK BEGICH, 
                    U.S. SENATOR FROM ALASKA

    Senator Begich. Thank you, Madam Chair, and again thank 
both of you for being here again for the opportunity to have a 
few questions.
    We had a conversation, Secretary Gould, regarding Alaska 
and kind of how to deliver services and how to make sure they 
get the delivery. Can you give me some thoughts in regards 
especially around telemedicine? That is one of our biggest 
opportunities I think in rural health care not only for our 
State but I think for any State, Senator Tester's, or others.
    So, could you give me some thoughts of how and what you see 
as an avenue and what the potential improvements are down the 
road in regard to telehealth and how you see that working 
especially in rural communities and then how connect up with 
existing services that may exist already in rural Alaska?
    Mr. Gould. Senator, thank you for that question.
    This is an exciting area for VA and for the delivery of 
medical care. As you know, VA is one of the country's leaders 
and innovators in telemedicine and telehealth.
    What makes it so sensible for VA to go out and go out hard, 
we are about a $165 million a year in investment in 
telemedicine and telehealth now, is that it essentially lowers 
the amount of time that a physician is in transit and puts him 
right out there in rural communities like your own and Senator 
Tester's. There are communities where our biggest concern is 
delivering high quality care and creating and maximizing 
access.
    So, the use of telemedicine and telehealth allows someone 
in a remote, rural or very rural location to be able to tap 
into the expertise and specialty care that VA has throughout 
the system.
    So, I see us using more of it. I see a strong business case 
for that to happen, and we are committed and engaged to rolling 
out telemedicine and telehealth nationwide.
    Senator Begich. Have you done, and when I say you I mean 
the VA, have they done a kind of strategic plan and kind of 
here is where we want to be with telehealth 5 years from now, 
10 years from now? Is that something that has been developed 
because it will require resources, partnerships? Is that 
something that could be available to me or to the Committee if 
there is such a report done?
    Mr. Gould. Certainly. There is a study and review, 
essentially the development of a business case with a clear 
vision, a net present value analysis that goes with that and 
the first wave of funds have obviously already been committed 
since we are a leader in this field. But we are putting 
additional money onto that this very year. I would be happy to 
share that with you.
    Senator Begich. Very good. I know we have introduced 
legislation about co-pays with regard to telemedicine. I do not 
know if you have had a chance to look at it. If you have not, 
we would be happy to share it with you because we think one is 
a cost saver for the VA. More people accessing it in certain 
ways will prevent higher costs in travel, higher cost in doctor 
visits and time consumption.
    So, if you have not looked at the legislation, we will 
share it with your office. I forgot to mention it to you when 
you came to see me that day.
    Mr. Gould. Thank you, Senator. It sounds like an innovative 
approach to essentially finding more efficient ways for us to 
deliver care.
    Senator Begich. A little more incentive to get them on 
that.
    You may have answered this already during discussion 
earlier both of you but, Secretary Lynn, let me ask, and I know 
as a Member of the Armed Services Committee, DOD does their 
thing and then VA does their thing. Having you both here today 
is, I think, a great statement of kind of how these connections 
occur.
    Can you just from, and again you may have said it earlier. 
I want to just, I guess, hear it for myself. Do you think the 
Department of Defense, do you think they are stepping in the 
right direction aggressively enough in regards to recognizing 
that this transition that occurs to the VA, you do not just 
stop and say OK VA you deal with it? Do you think there is a 
culture change occurring enough that DOD recognizes their 
relationship with the soldier does not end when they are 
discharged?
    Mr. Lynn. Yes, I think there has been a culture change, 
Senator, and I think it is happening at multiple levels. At the 
top, Secretaries Shinseki and Gates have started from the very 
beginning meeting jointly to ensure that we have this seamless 
transition in the most recent set-up meetings. We talked about 
it today as really focused on implementing this integrated 
disability evaluation system and on gaining a joint electronic 
health record system.
    So, I think that top level focuses there but I think that 
has permeated the organizations. The Army and the Marine Corps, 
the other services tell me that the level of cooperation at the 
base level between base commanders and VA is unprecedented, 
that they deal with them now every day.
    Part of it is with this disability evaluation system. But I 
think it is a broader relationship that is being built to 
accomplish just what you are talking about to make sure this 
transition that occurs is completely seamless.
    And, then finally in terms of the processes, the Integrated 
Disability Evaluation System which replaces the legacy DES 
which not only was not a system at all, it was actually a 
series of overlapping and inconsistent systems. Hence the 
integrated.
    It had several problems. As we talked about with Senator 
Brown, processing time was too long. The processes themselves 
were contradictory. You got two medical evaluations. The 
doctors had different opinions as they do.
    But maybe the biggest problem from the individual member is 
that it led often to a gap in pay and benefits. You would exit 
the DOD system and then it would take 6 or 9 months before you 
got fully into the VA system and actually got a check which is 
of course what it is.
    I think the new system, I do not want to say completely 
because you are going to find exceptions but it is designed to 
eliminate that gap, that we now keep them on the DOD payroll 
until they transition into the VA system, and that frankly 
creates a bill, but it is a bill well worth paying. So I think 
at that process level as well we have a cultural change in 
terms of how we view this.
    Senator Begich. I know my time is up. I know that is 
usually the biggest challenge for both the VA but DOD is kind 
of understanding that, and it sounds like you are making those 
good strides, that the soldier does not end the day they are 
discharged. They continue on, and there is this new integrated 
ability to ensure that, as you just described it, they do not 
have that gap of pay or benefits that are critical for that. 
Thank you.
    Obviously, the Committee Chairman who has put this meeting 
together today is really looking at this on an ongoing basis 
because I think that is where we hear, at least I hear the 
biggest complaints is that kind of once you are done with the 
DOD, then you are kind of out there in no man's land, and VA is 
trying to look at the process.
    So I appreciate both of you being here today.
    Chairman Murray. Thank you very much.
    Secretary Gould, as you know, last week the Circuit Court 
of Appeals ruled that VA's mental health services are 
inadequate and ordered the Department to work with the district 
court to revamp its entire mental health care system.
    I absolutely agree that more needs to be done to meet the 
mental health needs of veterans, but that ruling really was 
based on a number of points that I did not think were true and 
disagreed with.
    As all of us know, in the past several years Congress has 
made improvements to the VA's mental health programs and made 
it a high priority. We passed the Joshua Omvig Suicide 
Prevention Act, the Justin Bailey Act, and we increased funding 
for mental health services that allowed us to hire more than 
6,000 new mental health caseworkers since 2005.
    Those new professionals are seeing patients throughout the 
system including at many of our VA's clinics. And, I know that 
VA is currently revising the clinical standards that have 
transformed mental health care systems throughout the VA.
    There are absolutely things that the VA can do better 
especially reaching out to our veterans in rural America, and 
we know that VA and DOD have to work better together to make 
sure that mental health care needs are dealt with 
appropriately.
    I wanted to ask you today if you can discuss what the 
Department is going to do with respect to that Ninth Circuit 
ruling.
    Mr. Gould. Chairman Murray, thank you, and I think you are 
quite right to summarize at a high level of both the active 
involvement of this Committee in oversight and the changes that 
have been driven by legislation, by vigorous oversight, and of 
course, the work that the VA has done as well to improve mental 
health care and adjudication of claims at VA.
    The decision was based on 2007 data, and we have traveled a 
long way in the 4 years since then. Our review will be to ask 
DOJ to honestly look at this. Meanwhile, we are working as hard 
as we can to comprehensively improve mental health care.
    Examples would be initiatives like our 24/7 crisis line, a 
99 percent performance standard for 24-hour contact for anybody 
who is in crisis; 14 days or less, a 98 percent performance 
standard there. If somebody has an issue they can see somebody 
in 2 weeks' time.
    We are vigorously pursuing outreach like suicide 
prevention. We have public service announcements, marketing 
campaigns, buses driving around cities with 800 numbers to call 
and coordinators in every local community dedicated to flushing 
this out and bringing people forward and destigmatizing the 
need to find help.
    And last, we are focused on research. We are figuring out 
how to prevent this, how to protect people from it, and we are 
even inquiring into brain changes that will occur when someone 
is in a situation like this. We are also modernizing our 
disability claims system.
    So we will ask DOJ to take a look at this very hard, and 
meanwhile we are focused on doing what we can do which is to 
improve the continuum of care between DOD and VA.
    Chairman Murray. OK. I appreciate that very much.
    I mentioned the in my opening remarks the issue of 
prosthetics, and I heard from a veteran recently who had 
received advanced prosthetics from the military, and I 
understand that when he went to the VA to get them adjusted, 
the VA employees had never seen the model that he was using 
before and, like I said, they were more interested in looking 
at that than they were in looking at him.
    Secretary Gould, I wanted to ask you what needs to happen 
to raise the quality of prosthetic care to the level that the 
military provides today?
    Mr. Gould. Chairman Murray, first of all, for that 
individual, our deepest concerns and to focus on providing them 
the care that they need.
    Working with DOD on this is a little bit like working with 
DARPA. I mean, there is no question DOD has the primary 
responsibility for the advanced prosthetics. They have world-
class facilities in three locations across the United States, 
the funding to do that, and they can focus those resources on 
the people who need them and who need state-of-the-art 
bleeding-edge technology to be able to provide in this 
prosthetics world.
    We have 40,000 folks who have prosthetic devices in the VA, 
and by definition, we are restricted to providing technology 
that is commercially available. So, the DOD has got the lead 
stuff. We are providing commercially available. No question 
over time----
    Chairman Murray. I thought the VA did research.
    Mr. Gould. We do research as well, but not at the level and 
the sophistication and with the focus on so few individuals 
that DOD is able to employ in this instance. We do not have the 
same level of prosthetic leading-edge technology. We think we 
do it second to none for a broad base of individuals who have 
lost or had amputations due to vascular problems, not from 
combat.
    Chairman Murray. There has been a lot of progress in 
setting up the DOD/VA extremity and amputations center of 
excellence. When can we expect that to be fully operational?
    Mr. Gould. Chairman Murray, as you pointed out earlier, I 
think that is a question of both DOD and VA collaboration and 
cooperation on that. I would turn to Secretary Lynn for that 
piece of the puzzle.
    This is the centers of excellence in DOD.
    Mr. Lynn. Yes. Congress has directed several centers of 
excellence, not just for prosthetics.
    Chairman Murray. Correct.
    Mr. Lynn. There is the vision center. What I think I owe 
you, Madam Chairman, is I think we need to take a close look at 
where we are because, frankly, in preparing for this hearing I 
did a comprehensive review of what was directed and where we 
stood, and I think we are not where we need to be. So, what I 
would rather do is come back to you after taking a quick, 
relatively quick look, come back to you with a plan for how we 
are going to implement this.
    Chairman Murray. I would very appreciate that because we 
have a lot of frustration with those centers, that is, in 
getting them up and established, and I am hearing a lot of 
complaints about how far behind it is. So, if you can get back 
to me directly with that, I would appreciate it.
    Senator Tester.
    Senator Tester. Thank you, Madam Chair.
    For you Deputy Secretary Lynn, we have an Air Force Base in 
Great Falls called Malmstrom Air Force Base which we are 
particularly proud of in Montana and I think throughout the 
country.
    The issue of a medical records repository, which I do not 
know if you know anything about this, but the Air Force is 
looking to put a medical records repository, several of them 
around this country. Malmstrom Air Force Base is in the 
running. We have got Montana State University right next to 
that Air Force Base. It has a phenomenal amount of health 
technology system medical billing coding, medical transcription 
courses. It would be a perfect fit. There was a site survey 
recently completed on Malmstrom.
    Can you provide me or is it within your purview to be able 
to provide me with any details on the nature of the facilities 
being reviewed for suitability and discuss the current 
timetable for implementation of that?
    Mr. Lynn. That particular one, no. But what I can tell you 
it is as part of the integrated electronic health record that 
Secretary Shinseki and Gates have directed at a foundational 
level what will make this successful is the use of common data 
is for the same record to go from DOD to VA with the 
servicemember.
    The initial piece and in many ways the most important is to 
go with common data. Part of that is we are going to rely on 
common data centers. We are going to utilize common data 
centers. Where we are in terms of actual site locations I 
cannot get into at this point.
    Senator Tester. Can you get into it, can you go back and 
check?
    Mr. Lynn. I will certainly go back and check.
    Senator Tester. And let me know who is being considered and 
where we are at in that process?
    Mr. Lynn. Yes.
    Senator Tester. You are a gentleman and a scholar. Thank 
you.
    Deputy Secretary Gould, you and Joan Evans were in the 
other day in my office. I appreciate that visit. We talked 
about a pilot project around Vet Centers in, shall I say, 
frontier/rural areas of this country to really determine what 
kind of impacts there are because we have so many veterans 
living in rural areas, whether it is in Alaska, Montana, or 
other rural areas around this country.
    A pilot project in a highly rural area, I think, would be a 
great benefit. And, I just bring it up for the record today to 
make sure that it is on your radar screen and that we could 
work together potentially, work for that kind of a pilot.
    Mr. Gould. Senator, thank you. It is, and we appreciate 
that suggestion.
    Senator Tester. I appreciate your comment.
    Last, and I appreciate the Chairman going for any second 
round. American Indians serve in our Armed Forces at very, very 
high percentages, high greater numbers than any other ethnic 
group from a proportional standpoint. Health care for veterans 
on our Indian reservations is an ongoing struggle. Unemployment 
rates are through the roof.
    Are there any collaborative efforts that either of you know 
to specifically target the population in Indian country as they 
transition from the DOD to the VA?
    Mr. Gould. We have recently appointed a senior executive to 
focus on native peoples, their veterans' issues. We are 
focusing across the country on their needs, developing policies 
directly suited for them. We focus in our Yellow Ribbon and 
outreach efforts on making sure that every veteran is aware and 
enrolled in the system as early as possible. We are achieving 
about a 95-percent rate of penetration on that, and so, we are 
very focused on making sure that we have the people resources 
in place and the programs to be able to serve Native Americans.
    Senator Tester. I appreciate that. In these programs and as 
you are gathering information, is there any opportunity or 
effort, either one, to talk to the folks on the ground in 
Indian country to find out how they feel they could be served 
in a way that makes sense both from an effective standpoint and 
a monetary standpoint?
    Mr. Gould. Absolutely, Senator. In fact, we treat that as 
an intergovernmental issue with the tribal governments and 
extensive travel and outreach, engagement both when the tribes' 
representatives come here to Washington, extensive travel for 
Assistant Secretary Tammy Duckworth and her team is part of how 
we are trying to improve our outreach.
    Senator Tester. I appreciate that very much.
    Thank you, Madam Chair, and I want to once again thank you 
both for being here today. I appreciate it.
    Chairman Murray. Thank you. Senator Begich.
    Senator Begich. Madam Chair, just a couple of quick 
questions. I want to follow up, Secretary Gould. You had said 
that, in response to the Chairman's question, you do some 
research but you can use only commercially available 
prosthetics. Was that right?
    Mr. Gould. Correct. We are restricted to use commercially 
available prosthetics. Among the reasons for that are the very 
large number of people that need to have prosthetics supported 
over time so they have to be maintained, and we also use that 
to create competitive pricing among all the possible vendors 
that are out there so that we can get, obviously, the best 
value and the highest quality product for the prosthetics 
devices that we do purchase from the private sector.
    Senator Begich. So it does not create a problem because if 
there is something that is not commercially available, how do 
you deal with that?
    Mr. Gould. That is probably the challenge that Chairman 
Murray's constituent had. They left the DOD care, had a state-
of-the-art system in place, but went for VA care, found that it 
was something so new that they were not able to make the 
repairs or make the adjustments.
    What we have done is embed our VHA personnel, prosthetics 
personnel, in the DOD system so we have folks who are there who 
can get a window into that.
    I imagine that, I hope that the conversation that unfolded 
was, look, we do not know how to figure that out but we will 
figure out how to get you care. And, I would be very interested 
to hear kind of what happened as the next step in that 
conversation.
    Senator Begich. If I can explore it just a second longer. 
If the mechanism was unable to be dealt with or repaired under 
VA, but DOD installed it, did they have the expertise?
    Mr. Gould. Yes.
    Senator Begich. So why does not VA just contract with DOD 
and have it done?
    Mr. Gould. I imagine that the next step was to have that 
person go and get the care and service that they needed. I 
would think the Chairman's question and your follow-up to be 
about, are we doing as much as we can for those veterans who 
wear prostheses in our system, all 40,000 of them, many of them 
with diabetes and so on over time, I believe the answer is a 
wholehearted yes. We have a plan to further improve our system. 
We are working with our DOD colleagues on that.
    My earlier comments were just to show that there is an 
agency who is designated under law to be the primary lead for 
prosthetics and that is DOD; and as a consequence, the money, 
the people, the focus has resulted in world-class capabilities 
that would not be sensible to duplicate in the VA. But we still 
are able to avail ourselves of their knowledge and we are 
learning from them. In fact, all industry then picks up the 
best inventions that they have and tries to make them 
commercially available.
    Senator Begich. I will leave it at that. I just want to 
echo, and we have talked about this also, what Senator Tester 
said about Indian country, especially in Alaska, how to deliver 
services in the very rural areas as we talked earlier about 
telemedicine but also just ensuring that they receive the 
benefits, the contact is there, and then how to use as we have 
talked to the VA for the last couple of years since I have been 
here on how we maximize, especially in Alaska because it is 
very different than the rest of the country, in how Indian 
health care is delivered.
    Indian health care is done by a consortium of tribes. It is 
managed throughout the whole State. It is not done by the 
Indian Health Services which is a different kind of model, 
actually we would argue the better model and actually is 
proving to be a much better delivery of services within the 
Indian Health Service.
    But because of that, and especially in rural areas, we have 
veterans who live in rural areas who are trying to get access 
but in order to do that it is very complicated to get to 
Anchorage or Fairbanks or some of the hubs.
    But yet we have clinics that are operated by the tribal 
consortium of Indian Health Services that are right next to 
their home, sitting right there. In one case, we are building 
one of two in the country in Nome, Alaska, $170 million state-
of-the-art facility of the Indian Health Services to manage 
that whole area there, and there is no reason to replicate that 
from a veterans' standpoint when the service is high quality 
there.
    So I know your office or the VA has been working with us 
aggressively trying to figure out how to do this and to deliver 
this. So again, I just want to put on the record that we are 
anxious to find what that magical opportunity is because we 
know when it is all done, it is just about hard cash and how to 
pay for the services, the Indian Health Services does, but the 
VA, veterans gone over there.
    But the reality is taxpayers are paying for both of these 
anyway. So it is to me more of an accounting issue. I just want 
to emphasize our point here that we want to continue to work 
with you to figure out what that right opportunity is even if 
it is a small demonstration project of areas of remoteness that 
are not connected by road and some very clear clarification so 
we are not privatizing the VA. We are not doing any of that. We 
are just trying to create access with another government agency 
that has great quality service equal to the VA. So I just want 
to put that forward.
    Mr. Gould. Senator, thank you. Alaska has clearly been a 
big innovator here. One of our roles in VA is that we have to 
be flexible enough to work in partnership to create that 
community of care; and if there is a more efficient way, a 
better way for us to do it, we should certainly look into it.
    Senator Begich. Thank you.
    Thank you, Madam Chair.
    Chairman Murray. Thank you very much.
    I just wanted to mention to both of you, we have had a lot 
of discussion today about the joint disability evaluation 
system. At joint base Lewis-McChord in my homestate of 
Washington, the average time that a soldier waits to get a 
medical examination today is 84 days. That is well over the 
target of 45 days, and the ratio of servicemembers to DOD case 
managers is 130 soldiers to one case manager, well over the 
goal of 20 to 1. And, we know that soldier satisfaction is only 
54 percent.
    So, we have heard from a lot of soldiers who put their 
lives on hold, their families on hold, that they are concerned 
about this process. I appreciate the comments you have made 
today, and I know the transition is difficult. But we have got 
to keep focusing on this because these are real families that 
are struggling.
    With that, I do want to thank Secretary Gould and Secretary 
Lynn for sharing with us their views today on what the VA and 
DOD can do together to better care for our servicemembers and 
veterans with both the visible and the invisible wounds of war.
    Next week, as I mentioned, this Committee is going to be 
hearing testimony from returning servicemembers and veterans 
who are going to speak about their experiences and talk about 
areas where the two Departments from their viewpoint can 
improve coordination to better meet their needs.
    I did want to say I was very encouraged this morning to 
hear that the VA has now assisted more than 625 severely 
wounded veterans in applying for the new services under the 
caregiver program.
    We have been following that very closely. It is very 
important to us, taking a long time to get to this point, but I 
am glad that those families can now begin to receive those very 
important benefits. It is going to make a big difference in 
their lives.
    With that, I look forward to working with both of you, the 
VA and the Department of Defense, in the months ahead as we 
continue to make sure that our transitioning servicemembers get 
the best care and services as quickly as possible. I appreciate 
both of you again being here today.
    This hearing is adjourned.
    [Whereupon, at 11:33 a.m., the Committee was adjourned.]
      

                                  
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