[Senate Hearing 113-762]
[From the U.S. Government Publishing Office]



 
       DEPARTMENT OF DEFENSE APPROPRIATIONS FOR FISCAL YEAR 2015

                              ----------                              


                        WEDNESDAY, APRIL 9, 2014

                                       U.S. Senate,
           Subcommittee of the Committee on Appropriations,
                                                    Washington, DC.
    The subcommittee met at 9:58 a.m., in room SD-106, Dirksen 
Senate Office Building, Hon. Richard J. Durbin (chairman) 
presiding.
    Present: Senators Durbin, Mikulski, Cochran, Murkowski, and 
Blunt.

                         DEPARTMENT OF DEFENSE

                        Medical Health Programs

STATEMENT OF LIEUTENANT GENERAL PATRICIA D. HOROHO, 
            SURGEON GENERAL, DEPARTMENT OF THE ARMY


             opening statement of senator richard j. durbin


    Senator Durbin. Good morning and welcome to the 
subcommittee. We are going to start a minute or two early, 
because Senator Mikulski has to get down to the floor on an 
important issue that is pending before us, and we will be 
called for a vote at 11 o'clock, so we want to have her 
participation and as much time as possible.
    Before we begin this hearing this morning, I am going to 
ask all who are gathered here today to join me in standing for 
a moment of silence for those who died at last week's tragic 
shooting at Fort Hood, including Sergeant First Class Daniel M. 
Ferguson, Staff Sergeant Carlos Lazaney Rodriguez, and Illinois 
native Sergeant Tim Owens.
    Would you all please rise?
    Thank you very much.
    I would like to welcome our witnesses, Lieutenant General 
Patricia Horoho, Surgeon General of the Army; Vice Admiral 
Matthew Nathan, Surgeon General of the Navy; Lieutenant General 
Thomas Travis, Surgeon General of the Air Force; and Mr. 
Christopher Miller, program executive officer for Defense 
Healthcare Management Systems.
    Our hearing today focuses on the well-being of our 
servicemembers, and it is paramount on our minds. One of the 
responses to the tragic shooting at Fort Hood on April 2 has 
been to ask questions about how we support our troops as they 
deal with stressors from long overseas deployment, personal 
relationships, financial stress, and so many other things.
    I am not going to speculate about what happened that caused 
this tragedy at Fort Hood. The investigation will have to 
answer those questions. But in an interview with the Washington 
Post this weekend, General Peter Chiarelli, the former Vice 
Chief of Staff of the Army, stated that efforts to hire more 
mental health clinicians are hamstrung by the same shortages 
that affect the entire country.
    This is an alarming statement from a retired general who 
has put so much work into how the Armed Forces deals with post-
traumatic stress.
    This subcommittee is keenly interested in the witnesses' 
assessment of the Defense Department network of care for 
servicemembers and families. And we may never know the cause, 
the real cause, of this tragedy at Fort Hood. But last week's 
tragedy shows us that even at one of the best military bases in 
the world, with a reputation for mental health excellence, 
there are problems that still exist. This subcommittee is 
committed to identifying strategies to confront those problems.
    While caring for the psychological health of our 
servicemembers remains a serious challenge, achievements in 
medical research for battlefield medicine have been enormous. 
Improved tourniquets and compounds, like QuikClot, treat 
hemorrhages and have given our servicemembers extra minutes and 
hours that literally make the difference between life and 
death.
    Thanks to these research efforts, military personnel in 
Iraq and Afghanistan survived and are surviving at a rate 2 to 
3 times that of the Vietnam War. It is nothing short of a 
miraculous revolution.
    These advances don't stop at the battlefield or at level 
one trauma hospitals. Amazing research affecting the quality of 
life of this new generation of wounded warriors has been 
emerging. There is a picture I am going to show you of Army 
Specialist Luis Puertas, who I met last month when he was in 
Washington.
    September 2006, he was on patrol in Baghdad; a bomb ripped 
his Humvee. He lost both of his legs instantly. The 
department's advances in medical research saved his life and 
gave him an opportunity to inspire a Nation.
    When he arrived at Walter Reed, he said he just wanted to 
learn how to walk again. Then he said a strange thing happened. 
He decided that instead, he wanted to run. He played soccer in 
high school in Florida. He had never run competitively, so he 
started training.
    Three hundred and sixty days after his amputation, he had 
his first Army 10K. Last May, he competed in the fourth annual 
Wounded Warrior games in Colorado Springs, finishing first in 
100-meter, first in the 200-meter, and first in the 1,500-meter 
races.
    He represented the United States at the 2013 International 
Paralympic Committee World Championships in Lyon, France, last 
July. And he wants to represent the U.S. in Rio in 2016. Lives 
saved, lives improved. This is what medical research is all 
about.
    Researchers at Johns Hopkins University, and I know the 
pride that Senator Mikulski takes in that great institution, 
performed the first-ever double hand transplant procedure on a 
combat-wounded quadruple amputee in December 2012.
    Last year, and I am equally proud, the Rehab Institution in 
Chicago has joined in research contributing to the world's 
first thought-controlled bionic leg. Astounding.
    It is a result of American researchers across the country 
rising to the challenge and pushing the boundaries. None of it 
would have been possible without the investments made by the 
Department of Defense (DOD) and Congress and the American 
people working to ensure that we maintain our lead role in 
research and innovation.
    Today's budget, of course, faces a constrained environment, 
but we also have to continue to think of new ways to provide 
healthcare and research.
    Captain James A. Lovell Federal Health Care Center in North 
Chicago is the first of its kind partnership between the Active 
military, in this case, the Department of the Navy, and the 
Department of Veterans Affairs (VA). This was a rough marriage, 
to bring together in a matter of just blocks that Great Lakes 
Hospital and the North Chicago VA Hospital that was destined to 
be closed. It is open, and they merged together.
    The battles we fought between different cultures, Active 
military versus VA, different unions, different computer 
systems. I want to know if we have learned anything from it. I 
will ask that during the course of the hearing.
    In a similar vein, the Integrated Electronic Health Record 
program is long overdue and long over budget. It is time for 
some hard questions to be asked about whether progress is being 
made.
    Finally, and most recently, the fiscal year 2015 budget 
proposes consolidating TRICARE, as well as additional fees and 
pharmacy co-pays, in order to rein in escalating and 
unsustainable health care costs. I can't think of a more 
controversial issue that can come before any committee that 
relates to our military than to talk about benefits, starting 
with TRICARE. So we are going to ask a few questions today 
about it.
    I look forward to your testimony.
    Since Senator Cochran is not here at the moment, I will 
turn it over to the chairman of the full committee, Senator 
Barbara Mikulski.


                statement of senator barbara a. mikulski


    Senator Mikulski. Mr. Chairman, thank you very much, and 
thank you for your prompt rescheduling of this hearing. I know 
there had to be some arrangements earlier.
    And to you, sir, I really want to note your longstanding 
commitment to the health and well-being of our military, both 
as they fight the war and when they come.
    It was you who introduced me to Tammy Duckworth, then a 
young military officer who had done some of her tour in 
Maryland in Cecil County up near Aberdeen, and then, of course, 
in the tragic helicopter shooting where she lost both of her 
legs.
    And now thanks to military medicine, and her own grit, 
verve, courage, and bravery, she is now Congresswoman 
Duckworth. Aren't we proud of her and the healthcare system 
that helped bring her to us and bring her back home?
    So today, I know that, as we look at our budget, we have to 
focus on several things. Thanks so much for the moment of 
silence for Fort Hood, but it shows that we need to have a 
renewed commitment also to mental health.
    So much of military medicine focuses on acute care, and I 
believe that we need to support that, the physical injury in 
battlefield, the mental health toll that it has taken, and the 
work that we need to do on acute care.
    But acute care is really based on research. I really 
believe that we thank you again for what we put in the budget, 
and the President. But let's take a look at our research budget 
to make sure we are putting the right resources in the right 
way for what the soldier and his or her family is facing.
    You noted that double-amputee transplant that Dr. Lee 
performed at Johns Hopkins. It was stunning.
    I recall another case when I visited Walter Reed where 
there was this young man bending over a table, and as he turned 
to face me, and I wanted to shake his hand, there had been an 
amputation right above the elbow on both arms because of an IED 
(improvised explosive device) in Iraq. I thought about that guy 
for a number of years as we have worked on this issue.
    So when I went to Hopkins to hear about this, it was 
stunning, the fact that they could do a transplant on both 
arms, muscle and nerve. It was phenomenal.
    Mr. Chairman, what was so phenomenal, too, was not only the 
brilliance of the surgeon, but the new techniques being 
developed so that there wouldn't be the rejection of the 
surgical efforts that ordinarily happen.
    So we are onto something. But it takes a lot of work of 
gifted scientists, and it takes a lot of money to be able to do 
that. So we need to focus on all of that.
    But the other things I am going to focus on are sometimes 
called soft medicine, but there is nothing soft about it. And 
this goes to the areas of public health, infectious disease, 
and adopting best practices from the civilian domain.
    Right now, we are worried about Russian troops mounting on 
the Ukrainian border. I worry about that too. And we should. 
But I also worry about Ebola sweeping across Africa, that could 
sweep across the Atlantic and sweep right into our own country.
    And I know that as we stand sentry in a global network of 
public health and biosurveillance on a disease like Ebola, 
where are they doing that? They are doing it at CDC (Centers 
for Disease Control and Prevention), but they are doing it 
right up at Fort Dietrich in Maryland, where they have seen it. 
They know what to do. There has even been a movie about it. So 
nobody thinks about that. Yet the consequences to our society 
could be something. Infectious disease, public health.
    And last but not at all least, best practices from the 
civilian domain. I was appalled to read the latest data of the 
number of military personnel who are now on food stamps.
    Mr. Chairman, I know you and my good friend--our good 
friend--Roy Blunt on the Agriculture Committee are shocked by 
the fact that there has been a tremendous increase in the 
number of our military on food stamps. Right now, there are 
several thousands. Can you believe that?
    So not only is there the stress of battlefield. There is 
the stress of even being a soldier.
    So then we wonder why do they smoke? Why do they overeat 
the wrong foods? Why aren't they doing broccoli and quinoa and 
kale? And why aren't they watching Dr. Oz and Mark Hyman? Why 
aren't they at Whole Foods? They are trying to get food, let 
alone Whole Foods.
    So I think we need to look at this. The fact that now we 
are actually going to cut the commissaries, can you believe 
that? We will spend millions and millions and billions on many 
of the things that we do that are important. I don't minimize 
that. But we need to be looking at what we do to support the 
military family.
    I know you have embarked on something called the Healthy 
Base Initiative, which, quite frankly, I am very excited about, 
because it is the best practices coming from the civilian 
domain to support the family with everything on a base, from 
what goes on at the daycare center to what is being sold in the 
commissary.
    I really don't think we ought to cut the commissary budget. 
I also don't think we ought to have military on food stamps. 
And I think if we want to be really looking at the stress the 
families are facing in our military, the everyday stress, we 
have to look at their activities of daily living, support them, 
and have a more holistic approach and a more integrative 
health.
    So we have a lot to go over, and it ranges from acute 
healthcare to mental health to research to infectious disease 
that could sweep the Nation, to really looking at our family 
across the stovepipes, because I know the commissary budget 
doesn't even come under you all, and yet it is one of the most 
important tools that you have on the health and well-being of 
the military families located on garrisons throughout our 
country.
    So thank you for your service. Let's look forward to how we 
can work together.
    Mr. Chairman, you now know why I wanted to get a doctorate 
in public health.
    Senator Durbin. Your efforts are going to help progress in 
that area as much as a doctorate. Thank you, Madam Chairwoman.
    Senator Blunt, do you want to say a word or two in opening?
    Senator Blunt. I will wait for questions.
    Senator Durbin. Thanks a lot.
    Let me just say that we are going to recognize first 
Lieutenant General Patricia Horoho, Surgeon General of the 
Army.
    Each of you has a written statement, which we have reviewed 
and put in the record, so take 5 minutes and give us the 
highlights and summary.


       summary statement of lieutenant general patricia d. horoho


    General Horoho. Thank you, sir. Chairman Durbin, Chairwoman 
Mikulski, and Senator Blunt, thank you for this opportunity to 
tell the Army Medicine story.
    On behalf of the nearly 156,000 dedicated soldiers and 
civilians who comprise Army Medicine, I extend our appreciation 
to Congress for your support.
    Recently, our Nation felt the weight of another tragedy at 
one of our military posts. My heart goes out to their families 
for their loss. The survivors, their families, and the entire 
Fort Hood community are demonstrating courage and resilience 
through these difficult times.
    We are supporting and tracking the progress of the 
survivors, providing longitudinal care and support throughout 
recovery, just as we continue to do for those who were impacted 
by the 2009 Fort Hood tragedy.
    I am extremely proud of the teamwork, the support, and the 
compassion displayed, and it truly is a total Army and 
community effort. I want to thank the members of the committee 
who have reached out to our soldiers, families, and the 
communities at Fort Hood.
    I want to also recognize the Army's 32,000 soldiers 
deployed to Afghanistan, the additional 120,000 soldiers 
deployed in support of the national defense strategy and their 
families for the strength and foundation. We continue to 
optimize health and expand our reach, truly focusing of the 
total Army Force, Active, Guard, and Reserve.
    Today, I am happy to report that this hard work is showing 
results in moving us toward a system for health. Our medical 
and dental readiness levels are the highest since 2001. 
Behavioral healthcare has increased from 900,000 encounters in 
2007 to almost 2 million encounters in 2013.
    Since embedding behavioral health into our brigades, 
soldier access outpatient behavioral healthcare more 
frequently, had fewer acute crises, and required approximately 
25,000 fewer inpatient psychiatric beds days in 2013 compared 
to 2012.
    Through expanded use of complementary therapies, integrated 
pain management, and clinical pharmacists in our medical homes, 
we saw a decrease in polypharmacy by almost 50 percent.
    Our performance triad of healthy sleep, activity, and 
nutrition is spreading across our total Army Force. And at our 
Army wellness centers, 62 percent of individuals saw a 4-
percent decrease in their body mass index and a 15-percent 
increase in cardiovascular fitness.
    These successes are due to a comprehensive system of care 
that extends from a deployed environment across our medical 
commands and into the lifespace. This translates to better 
health, improved readiness, lower healthcare costs, and a 
stronger Army. But there is more that we must do.
    As a leader, I get asked what keeps me up at night. I worry 
about the long-term repercussions of these wars on our 
veterans. I worry about sexual assault and sexual harassment 
occurring across our Nation and Department of Defense. I fear 
that in these times of dynamic uncertainty, our military 
hospitals are viewed through the lens of a civilian healthcare 
system. I worry that our Nation does not fully understand the 
model of combat care and the vital connection between the 
battlefield and our military hospitals as readiness platforms 
for skilled sustainment.
    I worry about losing the science and technology that has 
accelerated medical advances, giving the American public the 
confidence to allow their sons and daughters to serve. I am 
concerned that Army Medicine is viewed through an optic that is 
not wide enough to appreciate that we train more than 35,000 
students annually at our AMEDD (U.S. Army Medical Department) 
Center and School and have almost 1,500 physicians in graduate 
medical education where our board pass rates are higher than 
the national average.
    I am concerned that our nurse anesthetist program, which 
ranks No. 1 in the Nation, and our physical therapy doctoral 
program, which ranks fifth nationally, remain connected to our 
readiness platforms.
    Our wartime lessons learned led to more than 30 evidence-
based military clinical practice guidelines, saving lives and 
improving outcomes.
    During the last 10 years, there have been over 450 patent 
applications for inventions that involved our medical research 
and materiel command, our labs, and our hospitals. We are more 
than healthcare providers in a hospital; we are a robust 
interconnected system that has accelerated research, academics, 
and medical innovation for our Nation.
    As we go through times of dynamic uncertainty, we must 
preserve these medical capabilities to meet our Nation's 
mission. What is at stake is not the day-to-day care, but our 
ability to respond to future missions at the level we have over 
the past 13 years. We must aggressively sustain our readiness 
platforms and maintain trust with the American people.


                           prepared statement


    Though we live in uncertain times, one thing is certain: A 
healthy, resilient, and ready Army will be, as it always has 
been, the strength of our Nation.
    I want to thank my partners within the Department of 
Defense, the VA, my colleagues on the panel today, and the 
Congress for your continued support. Army Medicine is truly 
proudly serving to heal and honored to serve.
    Thank you.
    [The statement follows:]
      Prepared Statement of Lieutenant General Patricia D. Horoho
    Chairman Durbin, Ranking Member Cochran, and distinguished members 
of the subcommittee, thank you for the opportunity to tell the Army 
Medicine story and highlight the incredible work of the dedicated men 
and women I am honored to serve with. On behalf of the dedicated 
Soldiers and civilians that make up Army Medicine, I extend our 
appreciation to Congress for the faithful support to military medicine, 
which provides the resources we need to deliver leading edge health 
services to our Warriors, Families and Retirees.
    I would like to start by acknowledging America's sons and daughters 
who are still in harm's way--today the U.S. Army has 32,000 Soldiers 
committed to operations in Afghanistan and an additional 120,000 
Soldiers forward-stationed or deployed in nearly 150 countries, doing 
the hard work of freedom. And to the Army Medicine personnel currently 
deployed in support of global engagements--they and their families are 
in my thoughts, making me proud to serve as the Surgeon General of the 
Army.
    Since 1775, America's medical personnel have stood shoulder to 
shoulder with our fighting troops, received them at home when they 
returned, and been ready when called upon to put their lives on the 
line. While the wounds of war have been ours to mend and heal during a 
period of persistent conflict, our extraordinarily talented medical 
force also cared for the noncombat injuries and illnesses of our 
Soldiers and their Families. It is an honor to serve as the commander 
of this outstanding healthcare organization, caring honorably and 
compassionately for our 3.9 million beneficiaries.
    Never before has our Total Army had such a combination of years of 
combat medical experience, innovation and technology, communications 
systems to link us together, and a training platform to build a diverse 
array of skill sets. The strengths of the Army Medicine Team have been 
built on the lessons learned, codified and continually tested and 
improved upon, because our Nation's heroes deserve nothing less.
    Today Army Medicine provides responsive and reliable healthcare, 
while improving the readiness, resilience, and performance of our 
Force. We focus our efforts across the four top priorities: Combat 
casualty care; readiness and health of the Force; a ready and 
deployable medical force; and the health of families and retirees. 
These four priorities are strategically nested with those of the U.S. 
Army and Military Health System, and span the entire spectrum of health 
from medics providing combat casualty care on the battlefield to 
primary care teams back in garrison caring for Soldiers, Families and 
Retirees.
                          combat casualty care
    Combat Casualty Care extends from lifesaving treatment by the medic 
at the point of injury, to the combat support hospital, through theater 
evacuation, to definitive care, healing and rehabilitation at our U.S.-
based Medical Centers, and includes the transition of our Wounded 
Warriors back to service or returning home as Veterans through the 
disability evaluation system. And Combat Casualty Care is not limited 
to the battlefield of today, but extends to the research and 
development, development of leaders and doctrine that will save lives 
and maintains health in all future operational environments. The 
Soldiers serving in combat zones now and in the future deserve the same 
quality care as those who we served during the peak years of two 
simultaneous theaters of conflict.
    Our medical teams have achieved the highest combat survival rates 
in history. Multiple improvements in battlefield medical care, 
including the effective use of Tactical Combat Casualty Care protocols 
at the point of injury, tourniquet use, rapid evacuation, and early 
pain management strategies have contributed to the all-time high 
survivability rate of 91 percent during Operations Enduring Freedom and 
Operations Iraqi Freedom despite more severe and complex wounds. 
Moreover, our unwavering support of wounded, ill, or injured Soldiers 
has allowed necessary healing and recovery, and enabled a 47 percent 
return-to-duty rate for the Force. This translates to a cost-avoidance 
to recruiting and training of $2.2 billion.
    We also have considered the long-term impacts of war, recognizing 
that not all combat injuries are visible. The rapid coordination of 
traumatic brain injury screening and clinical practice guidelines 
allowed for our in-theater concussive care centers to provide a 98 
percent return-to-duty rate. In addition, by embedding capabilities 
such as behavioral health and physical therapy with deployed units, we 
provide early intervention and treatment, keeping the Soldier with the 
unit and decreasing the requirements to evacuate Soldiers from theater. 
Through a combination of efforts, suicides in Active Duty Soldier ranks 
fell from 165 to 126 in 2013.
                   readiness and health of the force
    Army Medicine directly influences combat power by ensuring the 
medical readiness and the health of the Force, both Active and Reserve 
Components. To maintain a ready and deployable Force, our Nation's 
Total Army requires a comprehensive System for Health designed to 
maximize the fighting strength, prevent disease and injury, build 
resiliency and promote healthy behaviors. Our personnel and services 
must maintain, restore, and improve the deployability, agility, and 
performance of our Service Members. Our readiness platforms include aid 
stations, Soldier Centered Medical Homes, dental clinics, garrison 
medical facilities. Programs and initiatives designed to improve 
healthy behaviors, such as the Performance Triad of healthy sleep, 
activity, and nutrition, increase the health and resilience of our 
Soldiers to better prepare them for challenges unseen.
                  a ready and deployable medical force
    A ready and deployable medical force is key to the support of the 
Army and the Nation. We must also ensure our own medical personnel are 
prepared for future challenges. The skills, knowledge, and abilities 
that have provided our Nation's military the highest quality care must 
be preserved, and continue to evolve to meet the needs of future 
conflicts. Our Nation has never had a more combat skilled medical 
force, able to rapidly introduce lessons learned from the battlefield 
into mainstream clinical practice. It is the healthcare of our 
Soldiers, Families, and Retirees in the garrison environment that 
provides the clinical platform for our providers to treat, train, 
educate, and maintain the critical wartime clinical skills needed to 
save lives along the continuum of battlefield care. Whether it is the 
clinical currency of deployed healthcare providers, or the training and 
leader development to command a medical treatment facility, Army 
Medicine ensures the Army maintains a medically ready Force and a ready 
medical force to support them.
                  the health of families and retirees
    Our Families have demonstrated unprecedented strength and 
resilience, quietly shouldering the burdens of our Nation's wars. Our 
System for Health provides care that recognizes the unique 
circumstances and stressors placed on our military families. By 
decreasing variance across our enterprise through service lines, we are 
employing a system that improves efficiency, quality, and the patient 
care experience.
    A comprehensive and coordinated team working to move the dial 
further towards health has demonstrated that this model can and does 
work. The successes seen in our Patient Centered Medical Homes and Army 
Wellness Centers, with decreased Body Mass Index, improved health 
outcomes, improved medical readiness, and decreased over-utilization of 
emergency room (ER) services, are several examples of how our model or 
care can improve the health of our population.
    As the size of our Army draws down, we must continue to support a 
high-quality, leading-edge healthcare system. This is both a time of 
challenge--and a time of great opportunity. We remain steadfast in our 
commitment to four top priorities: combat casualty care; readiness and 
health of the Force; a ready and deployable medical force; and the 
health of families and retirees.
          military medicine at a crossroad--the interwar years
    Since September 11, 2001, more than 1.5 million Soldiers have 
deployed, and many have deployed multiple times. Our Nation has never 
endured two simultaneous conflicts for this length of time. We must 
make certain we use our inter-war years, working aggressively to ensure 
we maintain robust combat casualty care skills and maintain trust with 
the American people. Our Nation's sons and daughters in uniform deserve 
nothing less than the level of support and capability we provided 
during our years in Iraq and Afghanistan.
    Army Medicine encompasses care, education, training, and research 
that extend through the full life-cycle of a Soldier. Our commitment to 
Wounded Warriors and their Families must never waiver, and our programs 
of support and hope must be built and sustained for the long road ahead 
as the young Soldiers of today mature into our aging heroes in the 
years to come. For those who have borne the greatest burden through 
injury or disease suffered in our Nation's conflicts, we have an even 
higher obligation to the wounded and to their families. They will need 
our care and support, as will their families, for a lifetime.
                     not until i have your wounded
    We are at our best when we operate as a part of a Joint Team. 
Between 2005 and 2013, the case fatality rate for US personnel in 
Afghanistan decreased significantly from 17 percent down to 9 percent, 
despite increases in battlefield injury severity. Our collective 
effort--Army, Navy, and Air Force--transcends individual services, 
seamlessly synchronizes care, and saves lives on the battlefield. The 
Army Medical Department (AMEDD) is focused on building upon these 
successes. As we continue our readiness mission at home, we are 
steadfast in our commitment to working as a combined team, anywhere, 
anytime.
    The AMEDD contributes 40 percent of the MHS personnel hours, and 
provides 49 percent of the care to all Service Members. We are not only 
the Army's readiness platform, but also a significant contributor to 
the readiness of our total military.
    Our medical combat readiness, from how we train to how we treat, 
has inherently unique characteristics compared to trauma training 
received in the civilian sphere. Performing complex combat trauma care 
in a chaotic and hostile environment, whether at the point of injury or 
en route to a combat support hospital, requires a mastery of complex 
clinical skill sets, performing simultaneous triage and emergency care. 
It is only through the continued use of validated and matured training 
platforms that we sustain the capability and maintain a highly 
proficient medical force ready for the next theater of conflict.
    The Borden Institute is an agency under the AMEDD Center and School 
(AMEDD C&S) that was established in 1987 to foster and promote 
excellence in military academic medicine through publications. In 2013, 
the 4th edition of the Emergency War Surgery (EWS) handbook was 
published, capturing the most current lessons learned from battlefield 
medicine, and highlighting advancements in both techniques and 
processes that are shown to improve survival rates. The newly 
formulated paradigm of Damage Control Resuscitation provided balanced 
resuscitation techniques that have reduced the mortality rate of 
massive transfusion casualties from 40 percent to less than 20 percent. 
In addition, the EWS handbook outlines the Tactical Combat Casualty 
Care (TCCC) system, which divides forward care into stages depending on 
the tactical situation, including guidelines for when and how to employ 
hemorrhage control, airway management, and tourniquet use.
    Our Army is charged with being prepared to face tomorrow's 
challenges. Wartime medical lessons learned have led to over 36 
evidence-based, battlefield-relevant Clinical Practice Guidelines that 
have decreased combat morbidity and mortality. As we continue to care 
for the needs of the current Force, we must also anticipate how our 
National Defense strategic pivot to the Asia-Pacific could influence 
medical threats. History demonstrated during the Vietnam War, Korean 
War, and World War II's Asia-Pacific conflicts, that the cumulative 
effect of disease represented the greatest drain on U.S. combat power.
                         traumatic brain injury
    Between 1 January 2000 and 30 June 2013, almost 300,000 DOD Service 
Members worldwide have been diagnosed with Traumatic Brain Injury 
(TBI), with approximately 82 percent of these injuries being classified 
as mild TBI or concussions. Since 2000, Army Soldiers comprise almost 
60 percent of all DOD TBI cases, making this issue a clear priority in 
Army Medicine. Since almost 80 percent of the Army's TBI cases occurred 
in garrison, our need for continued research to improve care is not 
limited to wartime medicine.
    Army Medicine leads the Nation in TBI efforts; we have mandated TBI 
education across the entire Army, published a comprehensive TBI 
screening policy in both deployed and garrison environments, 
implemented a TBI tracking mechanism for Soldiers, and employed sensor 
technology to learn more about concussions. We also ensure that every 
Army MTF has the capability to care for Soldiers with TBI. For fiscal 
year 2015 we have invested over $77 million in our infrastructure to 
provide care for Soldiers who have TBI.
    Through case experiences such as those at the National Intrepid 
Center of Excellence (NICoE), we better understand the broad range of 
complexity that can be seen in TBI. The Army is engaged in multiple 
efforts to ensure Soldiers exposed to potentially concussive events and 
those diagnosed with mild TBI/concussions are tracked to provide 
situational awareness to healthcare providers and leaders, and improve 
medical care delivery. For those with more complex diagnoses, satellite 
facilities are being built across the Army through the generosity of 
the Intrepid Fallen Heroes Fund. Construction of the Intrepid Spirit 
Satellite facility at Fort Campbell is nearing completion, and Army 
Medicine will provide operational sustainment that equates to $11.7 
million. This is the first of six Army satellites to be built, with 
others planned at Fort Bragg, Joint Base Lewis-McChord, Fort Hood, Fort 
Carson and Fort Bliss. These centers will provide advanced integrated 
care for patients who have multiple diagnoses (to include TBI, chronic 
pain, and behavioral health disorders) and require intensive outpatient 
treatment.
    The Army Medical Research and Materiel Command (MRMC) manages the 
largest TBI research portfolio in the world. The DOD has invested over 
$730 million since 2007 on TBI research designed to advance detection 
and treatment, including studies to identify TBI biomarkers, improve 
neuroimaging techniques, understand the chronic effects of neurotrauma, 
and evaluate new treatments.
    To better address the long-term consequences of blast, we must 
first be able to objectively identify blast exposures in the individual 
Warfighter. U.S. Army Training and Doctrine Command (TRADOC) has teamed 
with MRMC to investigate currently deployed military sensors and 
additionally any commercial off the shelf (COTS) sensors currently in 
use by the athletic community. The helmet mounted sensor is providing 
complementary early identification data on Soldiers that are exposed to 
potentially concussive events. The Joint Trauma Analysis and Prevention 
of Injury in Combat (JTAPIC) Program is the repository for the sensor 
and exposure data, and shares the data across the DOD.
    Addressing known gaps throughout the continuum of care, and through 
collaborations with numerous academic and industry partners, the Army's 
TBI research portfolio addresses basic science, prevention, detection, 
screening, assessment, treatment, recovery/rehabilitation, and chronic 
effects. These scientific advancements will lead our Nation to 
breakthroughs in detection and care benefitting both military and 
civilian TBI/concussion patients.
    While research in civilian medicine can take 16 years to integrate 
findings into clinical practice, through collaboration with 
organizations such as the Defense Centers of Excellence and the Defense 
and Veterans Brain Injury Center, we are able to more rapidly translate 
research findings into the latest guidelines, products, and 
technologies. Improved data sharing between agency, academic and 
industry researchers accelerate progress and reduce redundant efforts 
without compromising privacy. This rapid coordination is what led to a 
98-percent RTD rate in theater for those Service Members treated at our 
Concussion Care Centers in Afghanistan.
    In August 2013, the White House released the National Research 
Action Plan (NRAP) mandating interagency collaboration to better 
coordinate and accelerate TBI and psychological health (including 
suicide) research. MRMC is working closely with other Federal agencies 
such as National Institutes of Health (NIH), National Institute of 
Neurological Disorders and Stroke (NINDS), National Institute on 
Disabilities and Rehabilitation Research (NIDRR) and the Department of 
Veterans Affairs (VA) to execute the President's National Research 
Action Plan. In addition, the Federal Interagency Traumatic Brain 
Injury Research (FITBIR) Informatics System is a central repository for 
new data, using common data elements, and linking existing databases to 
facilitate data sharing among military, Federal and civilian 
researchers and clinicians.
                        the transitioning force
    There is no greater honor than serving to help wounded, ill or 
injured (WII) Soldiers heal and transition successfully back to the 
Force or into private sector jobs and careers. Warrior Care is an 
enduring commitment for our Army. I want to thank the Congress for your 
unwavering support of these efforts and for the warm embrace of our 
communities as we transition our Veterans back to hometown USA. Army 
Medicine supports programs such as Soldier for Life, aimed at best 
serving our transitioning Warriors. The Soldier for Life program 
enables Soldiers, Veterans, and Families to leave military service with 
the resources regarding employment, education, and health.
    Since the inception of Warrior Transition Units (WTU) in June 2007, 
nearly 67,000 Soldiers and their Families have either progressed 
through or are being cared for by dedicated caregivers and support 
personnel. Over 30,000 of these Soldiers have returned to the Force, 
and nearly 15,000 are still serving. This translates to an overall 
cost-avoidance to the Army of $2.2 billion to recruiting and training 
new accessions.
    The Army created Warrior Transition Units (WTUs) to provide command 
and control as well as medical management for Active Component, ARNG, 
and USAR Soldiers. The WTU population continues to decline as fewer 
Soldiers whose injuries and illnesses require this focus are entering 
these units, more Soldiers departing, fewer deployments, fewer medical 
evacuations, and fewer Reserve Component mobilizations.
    Recent Force structure changes within the Warrior Care and 
Transition Program (WCTP) are a direct reflection of the decreasing WTU 
population, and retain scalability in order to meet the Army's future 
needs. Over the past 14 months, the Army-wide WCTP population has 
declined by approximately 3,000 Soldiers as a result of reduced 
contingency operations, thus allowing the Army to tailor the WCTP 
structure to best meet the needs of the declining population. As of 
March 10, 2014, 6,826 Soldiers were assigned or attached to WTUs and 
CBWTUs--the lowest level since the fall of 2007. This is the result of 
a well-synchronized effort across the DOD to decrease variance in how 
we manage our WII.
    Despite a declining WTU population, our commitment to provide the 
best care and support for our WII Soldiers is unwavering. Therefore 
Secretary of the Army approved the implementation of several changes to 
the WCTP during fiscal year 2014 to include inactivation of five WTUs 
and establishment of 13 Community Care Units (CCUs) on 11 selected 
installations to replace the nine Community Based Warrior Transition 
Units (CBWTUs).
    In fiscal year 2014, the Overseas Contingency Operations (OCO) 
contribution to the WCTP has decreased while the Defense Health Program 
contribution remains constant. We anticipate that the overall impact of 
deactivating 5WTUs and activating 13 CCUs will net a financial savings 
of approximately $7 million for the Army by fiscal year 2015.
    These WTU Force structure changes are not related to budget cuts, 
sequestration, or furlough, but will improve the care and transition of 
Soldiers through standardization, increased span of control, better 
access to resources on installations, and reduction of unnecessary 
delays in care. As they did in CBWTUs, CCU Soldiers heal in their home 
communities via the TRICARE network, and case management interactions 
are telephonic and via email. Community Care realigns the management of 
these Soldiers to Warrior Transition Brigades/Battalions (WTBs) with 
CCUs at select Army installations under dedicated Cadre that will 
provide enhanced medical management and mission command for these 
Soldiers by being attached directly to a WTB on an installation with 
direct triad of leadership and senior commander involvement.
    Our commitment to care extends through the transition of Soldiers 
and Families, who are best served when this process is as efficient and 
seamless as possible. Interoperability of agencies is important to 
aiding in the warm hand-off of care between the DOD and the VA, which 
led to the creation of the Community of Practice (CoP) as a part of the 
Interagency Care Coordination Committee. The CoP is designed as a 
borderless, virtual, interagency network of programs and individuals 
with the common purpose to improve complex care coordination. It gives 
a formalized operating structure to the facilitation of cross-program 
collaboration, knowledge, and informal engagement.
    never shall i leave a fallen comrade--the integrated disability 
                           evaluation system
    A key element of our Warrior Ethos is that we never leave a Soldier 
behind on the battlefield. This commitment extends beyond the 
battlefield to the unwavering commitment of Army Medicine. The 
Integrated Disability Evaluation System (IDES) is a close partnership 
with the VA, we continue to improve our processes, honoring that 
commitment to ensure Soldiers are not left behind or lost in a 
bureaucracy. We continue to strive for improvements with the physical 
disability evaluation system and seek ways to make it less 
antagonistic, more understandable for patients and Families, more 
equitable for Soldiers, and more user-friendly. IDES is a joint DOD/VA 
process designed to provide a seamless transition from military service 
to civilian life for our WII. Key goals of IDES are to reduce overall 
processing time, reduce duplicative exams from DOD and VA, and increase 
transparency for Soldiers and their Families. Currently, 2.5 percent of 
the Total Force is enrolled in IDES.
    In 2013, the Army launched the IDES Dashboard, which enables 
Soldiers and Commanders to view a Soldiers' current status in the IDES 
process, increasing transparency while transitioning to Veteran status. 
The IDES Dashboard is hosted on the AMEDD's Command Management System.
    To improve efficiency, MEDCOM established the IDES Service Line 
(IDES SL) to deploy strategy, maintain accountability, and centrally 
optimize a sustainable, standardized process. The IDES SL has 
streamlined case processing by increasing collaboration at the MTF-
level, and establishing Medical Evaluation Board (MEB) remote operating 
centers to increase capacity and address the Reserve Component (RC) 
case backlog, all while creating scalable solutions for surges in IDES 
referrals. Over the past year, the IDES SL has decreased overall MEB 
Phase processing time, with 80 percent of cases now meeting the DOD 
timeliness standard; a significant improvement from 40 percent of cases 
meeting the standard in November 2012. In addition, 100 percent of the 
Active Component is meeting the MEB timeline standard.
    In order to better serve our RC Soldiers requiring a medical board, 
the Army continues the deliberate approach developed at the RC Soldier 
Medical Support Center (RC SMSC). The reduced backlog and increased 
productivity allows for the dissolution of the RC SMSC and transfer of 
packet development to each component, which reduces personnel costs and 
the time the Soldier spends in the disability process, and increases 
the number of Soldiers that can be evaluated in any given year.
    To improve transparency of the process for Soldiers and commanders, 
MEDCOM and Army G-1 partnered to deliver the Soldier and Commander IDES 
Dashboard in September 2013. The dashboard enables Soldiers to view 
their current case status within the IDES process along with real and 
projected timelines for completion. In February 2014, the Total Army 
average number of days for the MEB Phase remained below the 100-day AC/
140-day RC standard for all components, with an average number of days 
for the Total Force being 82 days (77 days for Active Component, 107 
for COMPO 2, and 115 for COMPO 3). This 50-day reduction since February 
2013 reflects the largest improvement in efficiency since the inception 
of the IDES program and the investment of $203 million in fiscal year 
2014. The implementation of the IDES SL and process improving 
initiatives have resulted in positive changes that have allowed MEDCOM 
to shape its workforce into a lean organization, resulting in a 
decrease in the necessary level of investments to $152.5 million for 
fiscal year 2015.
                 a globally ready and deployable force
    Our Nation's Army is regionally engaged and globally responsive, 
providing a full range of capabilities to combatant commanders in a 
joint, multi-national environment. Army Medicine is both a valuable 
part and key enabler of the ready and deployable Force. As our military 
strategy rebalances towards the Asia-Pacific, the readiness of our 
military requires preparation to meet the medical challenges on a 
global level. The strategic focus on the Asia-Pacific includes an 
individual Soldier's readiness to face infectious disease threats, the 
preparation of our medical assets to conduct disease surveillance, and 
the innovation of medical research to advance care in a corner of the 
globe covered by large bodies of water and increased distances for 
medical movements.
    As an Army, as a military, and as a Nation, we have a global 
influence on medicine and health. During a recent visit to the Asia-
Pacific, I met with some of our dedicated Soldiers, leaders, and global 
partners. I also had the pleasure of visiting our Armed Forces Research 
Institute of Medical Sciences (AFRIMS) facility in Thailand. We take 
great pride in our 53-year relationship between the U.S. Army and the 
Royal Thai Army at AFRIMS. Like our other overseas medical research 
laboratories, it serves as a model for medical partnership, as 
scientists from around the world come together to tackle common yet 
challenging medical threats such as malaria, Dengue Fever, and HIV. 
AFRIMS provides a strategic platform to interact with other countries 
in Southeast Asia, and the research conducted is unique and 
complementary to other international research efforts, serving as an 
example of how medical diplomacy opens doors of opportunity that can 
further relationships with other countries in this region of the globe.
    The DOD supports global health engagement efforts that align with 
the DOD mission to help ensure geopolitical stability and security. The 
Army's Global Health Engagements (GHE) and global presence support 
those DOD efforts. Military medicine has shown that we are a force 
multiplier and an enabler of readiness and global diplomacy.
    We proudly export our military medical expertise. In support of 
Geographic Combatant Command (GEOCOCOM) requests in fiscal year 2013, 
the AMEDD Center and School (AMEDD C&S) provided training for 266 
students from 64 countries in 47 different courses. The U.S. Army 
Medical Command (MEDCOM) also supported numerous GEOCOCOM GHE's, 
including 15 different exercises to include a Veterinary Team in 
Africa, 26 Subject Matter Expert (SME) exchanges in areas such as 
critical care nursing, and 41 Augmentation Support Packages across the 
globe. Collaborating with the international military medical community 
builds a broader understanding of the global health threats that can 
not only impact our fighting strength, but can also impact the 
stability of our allies.
    The foresight to invest in the challenges of tomorrow is key to 
having an adaptable Force. Our medical accomplishments over the last 13 
years of combat are rooted in investments starting 20 years prior and 
continuing through today. Our ability to medically prepare the Force is 
based on risk, not the size of the mission. As we right-size our 
capabilities to align with a smaller Total Army, I want to reinforce 
the value in continuing to invest in our medical research, medical 
collaboration and diplomacy, and medical education. From the foxhole to 
the medical treatment facility, we must continue to identify innovative 
and cost-effective ways to optimize the clinical currency of our 
providers in support of medical readiness, performance, and the health 
of our Force.
                           women in the army
    Women have been a part of America's military efforts since the 
Revolutionary War. As their roles continue to evolve, Army Medicine 
recognizes the unique health concerns of women in the military. Females 
make up 15.8 percent of the Force today--including Active Duty and RC--
and the percentage of women continues to grow, up about 4 percent from 
20 years ago. The global impact our military has made during the last 
13 years of war could not have been achieved without strong and 
confident women. From the female medic on the Female Engagement Team, 
to the civil affairs officer, women in uniform have been an 
irreplaceable asset to our Nation. Advances in medical care and 
research that enhance the health, performance and readiness of female 
Soldiers and Family members, are advances that improve the readiness of 
our Total Army Family.
    In January 2013, the Secretary of Defense rescinded the 1994 Direct 
Ground Combat Definition and Assignment Rule (DGCAR). This decision 
expands career opportunities for women and provides a greater pool of 
qualified members from which our combatant commanders may draw. Soldier 
2020 is the Army's task force led by the U.S. Army Training and 
Doctrine Command (TRADOC) and Army G1 to identify, select, and train 
the best-qualified Soldiers for each job, which ultimately strengthens 
the Army's Future Force. An ongoing collaborative effort between U.S. 
Army Research Institute of Environmental Medicine (USARIEM) and TRADOC 
is measuring physical demands beginning with Military Occupational 
Specialties (MOSs) in the high physical demand combat occupations 
currently closed to females. The goal is to develop valid, safe, and 
legally defensible physical performance tests to predict a Soldier's 
ability to perform the critical, physically demanding occupational 
tasks. The Army's scientific approach for evaluating and validating 
MOS-specific performance standards aids leadership in selecting and 
training Soldiers--regardless of gender--who can safely perform the 
physically demanding tasks of their occupation, ensuring Force 
capability and readiness, and providing every Soldier the opportunity 
to serve in any position where he or she is capable of performing to 
the standard.
    The AMEDD welcomes the increased opportunity for women in combat 
roles and has a long history of working to provide high-quality 
deployment readiness and healthcare for female Service Members. Army 
Medicine continues the ongoing work to support women in remote, austere 
and Outside the Continental U.S. (OCONUS) locations, where routine well 
woman care may not be readily available. The Government Accountability 
Office (GAO) report, released in January 2013, concluded that the DOD 
is addressing the healthcare needs of deployed Service Women.
    The Army is the first military service to focus specifically on 
women's health issues, particularly related to deployed environments. 
As a part of the Health Service Support (HSS) assessment team that 
deployed to Afghanistan in 2011, I evaluated the issues and concerns 
that female Soldiers experience both in the theater of operation and in 
the garrison environment. Following the HSS white paper on the concerns 
of female Soldiers in the combat theater, the Women's Health Task Force 
was established in 2012, with a full publication of the assessment team 
findings to be released in 2014.
    Army Medicine established the Women's Health Task Force (WHTF), 
composed of a team of SMEs in a variety of disciplines from the Army, 
Sister Services, and outside agencies to address the unique health 
concerns of women serving in the military. The WHTF is shaping 
education, equipment and care for the next generation of women in the 
military. Some of the WHTF initiatives include education and training 
of female Service Members and their leaders to prevent gynecological 
problems from occurring in austere settings, and early recognition and 
treatment if they occur. The U.S. Army Public Health Command (USAPHC) 
has also created marketing and instructional items, such as those to 
educate female Soldiers on the use of the Female Urinary Diversion 
Device when in a field environment.
    The WHTF team coordinated with the Program Executive Office (PEO) 
Soldier for updates to the new female body armor with improved 
maneuverability and fit for the female body shape. The Female Improved 
Outer Tactical Vest (FIOTV) has been fielded out of Fort Campbell, 
Kentucky, Fort Bragg, North Carolina, Joint Base Lewis-McChord, 
Washington, and Fort Carson, Colorado, with positive reviews on comfort 
and maneuverability by those who have been issued the FIOTV. We 
currently have just over 24,000 FIOTVs on contract, but that number is 
going to increase to approximately 75,000 in 2014, which should see 
final delivery before the end of the fiscal year.
    As part of the Army Medicine 2020 Campaign Plan, we established a 
Women's Health Service Line (WHSL) to manage the unique health needs of 
women. The development and structure of care delivery is tailored to 
ensure responsive and reliable health services for female Soldiers, 
Families and Retirees that improves readiness, saves lives, and 
advances wellness with evidence-based practices standardized across 
clinical processes in our organization. The WHSL focuses on three major 
priority areas of operational medicine, wellness, and perinatal care, 
and has identified items such as appropriate screening tools for 
Intimate Partner Violence to incorporate into all primary care visits. 
The Army continues to emphasize the importance of women's health by 
resourcing the WHSL at $170 million in fiscal year 2015.
                         the reserve component
    As an integral part of our military, the Reserve Components (RC) 
are continually called upon to support operations around the globe. The 
Total Force relies on critical enabler capabilities provided by a 
trained and ready Reserve Component. Since September 2001, more than 
800,000 RC Service Members have been involuntarily and voluntarily 
called to Active Duty in a Federal status. The RCs for each Service are 
responsible for ensuring that their Service Members are not only 
properly equipped and trained, but also medically ready to serve.
    The Army National Guard (ARNG) and United States Army Reserve 
(USAR) provide strategic and operational depth and flexibility to the 
capabilities of our Force and are a valuable connection to the broader 
U.S. population. Significant Army capabilities are in the RC, 
therefore, when it pertains to readiness of the Force, building a 
System for Health is just as important for the RC Soldiers as it is for 
those who serve on Active Duty full-time.
    Units are more effective when they can train and deploy with all of 
their members, and early medical screenings enable deployability. 
Medically ready Soldiers require less medical and dental support in 
theater and fewer medical evacuations from theater, both of which 
ensure commanders are able to operate at full capability and conserve 
resources. Since the implementation and funding of the RC annual 
medical screening program in 2007, the RC Soldiers have shown marked 
improvement in achieving readiness goals. As of January 2014, 83 
percent of ARNG Soldiers and 79 percent of USAR Soldiers met DOD 
Medical Readiness classification standards. Further, 90 percent of ARNG 
and 87 percent of USAR Soldiers met DOD dental class 1 and 2 readiness 
standards. This is the highest state of medical readiness since the 
start of the conflicts in 2001.
    MEDCOM has been actively partnering with the line leaders to reduce 
suicide in Soldiers serving the ARNG and USAR by improving access to BH 
care. The ARNG currently has a Director of Psychological Health in each 
of the 54 States and territories to assess and provide BH support. The 
USAR is doing the same at each of its Regional Support Commands with a 
coordinator at the Office of the Chief Army Reserve (OCAR) Surgeon's 
Office. At this time, these positions are fully funded and over 90 
percent filled.
    In accordance with the current Reserve Soldier Readiness 
Procedures, the Army screens RC Soldiers prior to departing a theater 
of operations and at the demobilization stations for potential issues 
related to BH. Leaders can also refer Soldiers for treatment if they 
feel it is indicated. Each of the RCs conducts mental health 
assessments at 6 months, and again at 1-2 years post-deployment. If 
treatment is required, the Army refers Soldiers to the servicing VA 
Medical Center or MTF as appropriate. These screening events are 
important portals through which Soldiers with BH conditions, such as 
depression and PTSD, are referred for care.
    Finding innovative ways to extend our influence in the ARNG and 
USAR populations is important to set the stage for Army Medicine to 
truly strengthen the health of our Nation by impacting those in uniform 
who work within our civilian communities.
 strengthening the health of our nation by improving the health of our 
                       army: a system for health
    Health is a critical enabler of readiness, and Army Medicine is a 
valuable partner in making our Force ``Army Strong.'' Our strategy--the 
Army Medicine 2020 Campaign Plan--supports the Army's vision for 2020 
and beyond, the Army's Ready and Resilient Campaign Plan (R2C), and the 
MHS Quadruple Aim. The Army Medicine 2020 Campaign Plan ensures we 
remain a vibrant and relevant organization contributing to our Nation's 
security. The health of the Total Army Family (Soldiers, Retirees, 
Family Members and civilians) is essential for Force readiness, and 
prevention is the best way to optimize health. Protecting our Army 
Family from conditions that threaten health is operationally sound, 
better for individual well-being and ultimately cost effective.
    We are aggressively moving from a healthcare system--a system that 
primarily focused on injuries and illness--to a System for Health that 
now incorporates and balances health, prevention and wellness as a part 
of the primary focus for readiness. Through early identification of 
injury and illness, surveillance, education, and standardization of 
best practices, we are building and sustaining health and resiliency. 
This also moves our health activities outside of the brick and mortar 
facility, brings it outside of the doctor's office visit, and into the 
Lifespace where more than 99 percent of time is spent and decisions are 
made each day that truly impact health.
    We are investing in research focused on prevention. As an example, 
U.S. Army Research Institute of Environmental Medicine (USARIEM) 
investigators, along with extramural collaborators, have an ongoing 
research program to better understand the physiological mechanisms 
underlying musculoskeletal injury risk potential and ways to mitigate 
that risk. They are identifying the mediators of muscle and bone 
repair, tissue adaptation, and biomechanical factors of injury and 
fatigue. USARIEM researchers are exploring the rehabilitation science 
applications for Wounded Warriors, the pathways involved in muscle 
recovery, as well as possible nutritional interventions.
                         the performance triad
    The impacts of restful sleep, regular physical activity, and good 
nutrition are visible in both the short- and long-term. The Performance 
Triad is an initiative under the R2C Plan and central to the Army 
Medicine 2020 Campaign Plan which focuses on sleep, activity, and 
nutrition to improve readiness and health.
    The Performance Triad is also a key element within the System for 
Health and one of the fundamental mechanisms to optimize performance, 
resilience, and health. The program is being piloted in three diverse 
Army units at: Joint Base Lewis-McChord, Washington; Fort Bliss, Texas; 
and Fort Bragg, North Carolina. At these sites, we are equipping 
approximately 1,500 Soldiers with activity monitors, performing 
periodic assessments, and providing leaders with weekly activities to 
incorporate into training time. The primary objectives of the pilot, 
which concludes in May 2014, are to assess the reach, effectiveness, 
implementation, adoption, and programmatic achievements and gaps to 
inform and improve a broader implementation. The total cost to 
implement this pilot program, to include equipment, training materials, 
and data analysis is $970,000.
    The health and readiness of our Reserve Component Soldiers, where 
approximately 70 percent of our deployable medical assets are nested, 
is also a critical component of overall mission readiness. We have 
initiated a Performance Triad Pilot Program to begin in the RC in 2014.
    The Performance Triad is not just for Soldiers. The U.S. Army 
Public Health Command (USAPHC) will launch a parallel Total Army Family 
program to improve the performance and health of all Army Medicine 
beneficiaries. The Performance Triad not only supports improved 
strength, endurance, power and physical performance, it also seeks to 
support emotional and mental health and well-being.
    Only 1-2 percent of Americans including Active Duty Soldiers 
achieve ideal cardiovascular health due to barriers associated with 
lifestyle behavior. As an invited participant in the Army Surgeon 
General Performance Triad Campaign, the Integrative Cardiac Health 
Project (ICHP) Cardiac Center of Excellence at Walter Reed National 
Military Medical Center (WRNMMC) develops, evaluates and implements new 
models of personalized cardiovascular health for the military 
population primarily via lifestyle behavior change. Cardiovascular 
disease remains the leading cause of death for military beneficiaries, 
accounting for 1 of every 3 deaths. It also serves as is the leading 
healthcare-related cost to the MHS. Data also shows that Wounded 
Warriors with amputations are at significantly increased risk for 
cardiovascular compared to non-injured Service Members. ICHP is the 
only Center of Excellence that specifically addresses these obstacles 
related to healthy living in the military.
    Since the initial launch at the former Walter Reed Army Medical 
Center in 1999, the ICHP continues to provide expertise and experience 
in healthy behavior modification in the military population. In 
collaboration with Johns Hopkins University, ICHP recently created a 
new, no-cost clinical-decision support tool to better identify 
cardiovascular disease risk in an individual patient. This tool not 
only allows for providers to detect disease at an earlier stage but 
also has proven to help increase awareness in patients with family 
history of premature heart disease. This research has been recognized 
nationally and cited as evidence for the new 2013 American Heart 
Association Clinical Guidelines for Prevention. Supporting the MHS 
strategic focus on health rather than on disease, ICHP continues to 
translate evidence-based research findings into clinical practice and 
is synchronized with Army Medicine's movement to improved health.
                  a call to action, a case for change
    The health of the military and the health of the Nation are not 
separate discussions. Both the National healthcare conversation and the 
direction of the MHS directly impact Army Medicine. The Nation's 
current disease-centric healthcare system focused on treating illness 
adversely impacts health and is a driver for the rising cost of care.
    Our Nation's Soldiers come from our citizens. Only 25 percent of 
young adults in the prime recruitment age of 17-24 years-old are 
eligible for military service, while the remaining 75 percent 
disqualify due to weight, other medical conditions, fitness levels, 
criminal history, or failure to graduate from high school. Based on 
current trends, the health problems in American youth are projected to 
increase. The youth of today are less prepared for entry-level military 
physical training than their predecessors, and poor physical 
conditioning is associated with higher injury risk in those qualifying 
for military service. If large numbers of possible recruits are 
ineligible to serve, and poor activity and nutrition impact the 
readiness of those that do enter military service, then the issue is 
not only a matter of national health but also a matter of national 
security.
                           behavioral health
    The longest period of war in our Nation's history has undeniably 
led to physical, mental and emotional wounds to the men and women 
serving in the Total Army--and to their Families. The majority of our 
Soldiers have maintained resilience during this period; however, the 
Army is keenly aware of the unique stressors facing Soldiers and 
Families today, and continues to address these issues on several 
fronts. Taking care of our own--mentally, emotionally, and physically--
is the foundation of the Army's culture and ethos.
    The AMEDD anticipates sustained growth in behavioral health (BH) 
needs, even as overseas contingency operations decrease. The Army's 
continued emphasis to reduce the stigma for Soldiers and Families 
seeking help will result in increased BH workload. The growth in demand 
drives an increased investment in BH services from fiscal year 2014 to 
fiscal year 2015, for a final total of $375 million.
    More Soldiers with Post Traumatic Stress Disorder (PTSD) have 
accessed BH each year since 2003, and we have over 104,844 diagnosed 
cases of PTSD from 2003 through February 2014. Of those Soldiers who 
have been diagnosed, approximately 84 percent of cases have deployed. 
The lessons learned from military medicine's experience over the last 
decade have informed the broader medical community, not just the BH 
community, about the processes and characterization of trauma-related 
events.
    The Army has aggressively extended access to BH care through 
screening programs, and has optimized the system of BH care to 
efficiently deliver evidence-based treatment. Over the last few years, 
we have established a BH Service Line (BHSL) to coordinate standardized 
BH delivery across the enterprise, and integrate BH staff under one 
department head at over 90 percent of our MTFs. Critical to this effort 
has been the standardization of clinical BH programs, from around 200 
locally managed to 11 enterprise programs that best form a cohesive 
system. This integration reflects the best-practices at leading 
civilian institutions and enhances multidisciplinary teamwork and 
efficient care delivery.
    While stigma and reluctance to seek BH care still exists among 
Soldiers, far more are using outpatient BH services to receive care 
earlier and more frequently. Greater demand increases BH requirements, 
requiring higher provider inventory and resourcing support. MEDCOM has 
taken several steps to increase the number of touch-points, 
specifically through enhanced screening throughout the Army Force 
Generation (ARFORGEN) cycle and by increasing the availability of BH 
care as part of routine practices at the Soldier level.
    Subsequently, the Army implemented Embedded Behavioral Health (EBH) 
across the Force in October 2012 and MEDCOM will complete the process 
in October 2016. As of January 2014, 37 Brigade Combat Teams (BCT) and 
14 other brigade-sized units are supported by EBH Teams. As a direct 
result, utilization of BH care increased from approximately 900,000 
encounters in 2007 to almost 2 million in 2013.
    As Soldiers have used outpatient BH care more frequently to address 
their issues, fewer acute crises have occurred. In 2013, suicides in 
Active Duty Soldier ranks fell from 165 to 126, and the rate of Active 
Duty Army suicides decreased from 27.9 per 100,000 person-years of 
Active Duty in 2012 down to 23.7 per 100,000 in 2013. In addition, 
Soldiers required approximately 25,000 fewer inpatient psychiatric bed 
over the same time period, a cost avoidance of approximately $28 
million. Moreover, these better outcomes drive increased acceptability 
of the value of BH care, driving down stigma, resulting in more 
Soldiers willing to engage in an episode of care, while driving up 
demand and resource requirements.
    Approximately half of all Army suicides have a history of a 
documented BH diagnosis, and nearly one-third were seen for BH care 
within the 30 days prior to death. This does not indicate a failure of 
BH care, but rather the fact that the highest risk individuals are 
often the ones who engage in BH treatment. The MEDCOM strategy of 
prevention focuses both on the general population of all Soldiers and 
Soldiers accessing clinical services, including BH care, and is 
consistent with the new Department of Veterans Affairs (VA)/DOD 
Clinical Practice Guideline for the Management of Patients at Risk for 
Suicide. We target three domains: screening and risk assessment, 
education and public awareness, and treatment. Army Medicine has 
demonstrated success by looking at ways to bring healthcare and 
education to the foxhole, allowing us to increase accessibility, 
visibility, and ultimately trust, while decreasing the stigma and time 
spent away from the unit.
    MEDCOM is actively partnering with leaders to reduce suicides in 
Soldiers serving in ARNG and USAR by improving access to critical BH 
care. The Reserve Components (RCs) are increasing uniformed BH 
personnel and structure to ARNG and USAR units from 152 to 492 fully 
drilling reservists over the next 3 years, and these BH personnel 
remain with the units throughout the deployment cycle allowing for 
continuity and fostering trust with the unit members. The Transitional 
Assistance Management program (TAMP) provides 180 days of transitional 
health benefits after regular TRICARE benefits end. RC members 
separating from a period of active duty greater than 30 consecutive 
days in support of contingency operation are eligible for TAMP, and BH 
services are available to Soldiers and Families under TAMP.
    The Medical Retention Processing Program (MRP2) is designed to 
voluntarily return RC Soldiers back to temporary Active Duty to 
evaluate and/or treat RC Soldiers with unresolved mobilization 
connected medical conditions or injuries that either were not 
identified, or did not reach optimal benefit prior to release from 
Active Duty. In addition, the Active Duty Medical Extension (ADME) 
Program is designed to voluntarily place RC Soldiers on temporary 
Active Duty in order to evaluate or treat their service-connected 
medical conditions or injuries so that they may be returned to duty 
within the respective RC as soon as possible.
    It is also important to improve how we monitor progress, 
particularly during points of transition. The scientific literature 
indicates that creating a common understanding of the clinical progress 
between both the provider and patient improves adherence to care and 
increases the chances that Soldiers will complete a full course of 
treatment. The Army developed the Behavioral Health Data Portal (BHDP), 
which is a web-based application that tracks and reports in real-time 
on the Soldier's treatment progress at each session. The BHDP tracks 
clinical outcomes and satisfaction in BH clinics, thus enabling 
improved analysis of treatment and BHSL program efficacy. BHDP is now 
in use at all MTF BH clinics (including EBH clinics) serving Active 
Duty Soldiers with over 30,000 data collections per month. This 
innovative program was the 2013 Government awardee of the Excellence in 
Enterprise Information Award from The Association for Enterprise 
Information, and it has been identified by the DOD as a best practice. 
In September 2013, the DOD required all Services to adopt BHDP to 
standardize outcome collection across the Armed Forces.
    The Office of the Army Surgeon General established the Mental 
Health Advisory Teams (MHAT) in 2003 at the request of the Multi-
National Corps-Iraq Commander. Since that time, 12 MHAT missions 
provided a broad scope assessment on a recurring basis in deployed 
environments (combat, peacekeeping, humanitarian). The reports proved 
to be an effective tool for assessing point-in-time BH care needs and 
trends in mental health and morale in our troops. Results from MHATs, 
and the ongoing examination of in-theater BH issues, have led to 
numerous evidence-based recommendations that have impacted policy 
regarding dwell time and deployment length, improved distribution of BH 
resources to improve access to care, and modified the doctrine of the 
Combat and Operational Stress Control.
    As a Nation, we have learned that BH issues such as PTSD can be 
well-managed with proper care. Approximately 80 percent of Service 
Members with PTSD return to productive and engaging lives. The Army 
seeks to further understand and improve the prevention, diagnosis and 
treatment of BH conditions through clinical and scientific research. 
The BHSL is fully funded, having obligated $323 million in fiscal year 
2013; distributed $358 million in support of BHSL efforts in fiscal 
year 2014 and estimated a requirement of $375 million in fiscal year 
2015.
                               telehealth
    The Army is providing tomorrow's medicine today through the use of 
Telehealth (TH). Army clinicians currently offer care via TH in 
multiple medical disciplines across 18 time zones and in over 30 
countries and territories. Army TH provides clinical services across 
the largest geographic area of any TH system in the world. This enables 
the Army to cross-level clinical care capacity across the globe in 
support of our Soldiers and their Families. Using TH, the Army provided 
over 34,000 real-time patient encounters and consultations between 
providers in garrison in fiscal year 2013, and over 2,300 additional 
encounters in operational environments. While Army provides care via TH 
in 28 specialties, Tele-Behavioral Health accounts for 85 percent of 
total TH volume in garrison and 57 percent in operational environments, 
and over 2,000 portable clinical video-teleconferencing systems have 
been deployed to support Behavioral Health providers across the globe.
    Funding for our TH investments is $21.4 million in fiscal year 
2015, and we look forward to continued and accelerated growth of TH in 
support of our beneficiaries.
                            dental readiness
    No military unit can afford the loss of manpower and readiness due 
to medical circumstance that can be mitigated or treated. During the 
recent war years, the value of our dental capability to improve dental 
health and wellness in order to prevent issues that could negatively 
impact the fighting strength cannot be overlooked. As a system that has 
always demonstrated that the majority of influence, both positive and 
negative, occurs in the dental care an individual maintains at home, 
dentistry has long been a model of a System for Health.
    Dental wellness continues to increase primarily due to 
standardization of clinical processes with the Go First Class combined 
appointments. Since 2011, dental readiness has increased to 93 percent, 
and almost half of all Active Duty Soldiers have no dental needs beyond 
routine daily care and cleaning. The Army dentistry rationale is to 
aggressively improve Dental Wellness today to prevent a Dental 
Readiness issue tomorrow. In fiscal year 2015, we invested $1.4 million 
for community oral health and disease prevention.
                         a ready medical force
    Our direct care delivery system, the ``bricks and mortar,'' is 
America's medical readiness system for the Services. It is the daily 
delivery of care that allows us to maintain our healthcare providers' 
critical skills that guarantee a ready and deployable medical force 
capable of providing the critical life-saving care to our deployed 
Service Members. The front lines of healthcare in a garrison setting 
are in the patient centered medical home and the military treatment 
facility. It is in these facilities that we sustain these critical 
skills during the inter-war years.
    Theater-prepared healthcare providers require professional and 
operational development, which begins in our garrison medical 
facilities. In the last two wars, AMEDD Operating Forces provided 70 
percent of combat casualty care within the theater of operation, and 20 
of the 35 AMEDD healthcare provider specialties have deployment rates 
of greater than 75 percent.
    Within our Graduate Medical Education (GME) programs, we continue 
to attract and educate some of the best medical minds. We currently 
have 1,621 Health Professionals Scholarship Program students in 
medical, dental, veterinary, optometry, nurse anesthetist, clinical 
psychiatry and psychiatric nurse schools; in our GME training programs 
we have 1,465 trainees invested in 148 programs located across 10 of 
our MTFs. Our training programs receive high praise from accredited 
bodies, and our trainees routinely win military-wide and national level 
awards for research and academics. Our GME graduates have continued to 
exceed the national average pass-rate of 87 percent for specialty board 
certification exams, with a consistent pass rate of approximately 92 
percent for the last 10 years. Overall, we not only have the largest 
training program in the military; we have the largest number of 
programs under one system in the U.S., and although they are not 
accredited under one institution, the administration of the residents 
occurs under a single sponsoring system of the AMEDD.
    At the AMEDD Center and School, the flight paramedic training 
program that was initiated in 2012 has trained a total 124 flight 
paramedics, with a significant first time pass-rate of over 93 percent, 
well above the 74 percent pass-rate in the civilian sector.
    Our educational investments have been recognized nationally. The 
Army Medicine's Physical Therapy Program at Baylor University is 
currently the 5th ranked program in the country out of over 210 
national programs; our graduates have a 100-percent licensure pass rate 
in the past 3 years and have advanced the science through numerous 
peer-reviewed journal article publications. U.S. News and World Report 
most recent survey of graduate schools ranked the U.S. Army Graduate 
Program in Anesthesia Nursing (USAGPAN) as the number one program in 
the Nation out of 113 nursing anesthesia programs.
          developing leaders--building capacity and character
    The Total Army calls upon each of us to be a leader, and Army 
Medicine requires no less. The Army defines leadership as a process, 
not as a position. Leadership is about influencing people by providing 
purpose, direction, and motivation, all while accomplishing a mission. 
Like the Army line branches, AMEDD leader development requires 
approximately 16 years of specialized military and medical training.
    Army Medicine has capitalized on our leadership experiences in full 
spectrum operations while continuing to invest in relevant training and 
education to build agile, confident, and competent leaders. We have 
examined our leader development strategy to ensure that we have clearly 
identified the knowledge, skills, and attributes required for 
successful AMEDD leadership. In alignment with the Army Campaign Plan, 
the AMEDD has included a fourth line of effort (LOE) in the Army 
Medicine 2020 Campaign Plan--Develop Leaders and Organizations to 
address the full spectrums of leadership from leader development, 
talent management and organizational development.
    The AMEDD Officer Leader Development (OLD) Implementation Team 
convened in June 2013 to work 5 strategic initiatives and 29 
recommendations identified from the AMEDD OLD Evaluation. The team 
examined leader development within the AMEDD holistically, focusing on 
the institutional, operational and self-developmental domains. 
Presently, 19 of the 29 recommendations are complete or transitioning 
to appropriate organizational proponents for final completion. The 
remaining 10 long-term recommendations are continuing to move forward.
    Army Medicine must grow our Soldiers by leveraging the AMEDD OLD 
Evaluation, re-emphasizing and redesigning Leader Development programs 
to include Professional Military Education, and taking an active role 
in ensuring success throughout the ranks of tomorrow's future leaders. 
Our Total Army requires agile and adaptive leaders, both military and 
civilian, who thoroughly understand their role in mission command. Army 
Medicine represents a powerful workforce of competent, adaptive and 
confident Leaders capable of decisive action. The MEDCOM will adapt to 
the unfolding strategic environment by ensuring all leaders receive 
quality training, education, and broadening experiences.
    Within the AMEDD, our recruitment, development and retention of 
outstanding medical professionals--physicians, dentists, nurses, 
ancillary professionals and administrators--remain high priorities. 
With the support of Congress, through the use of flexible bonuses and 
competitive salary rates, we have been able to meet most of our 
recruiting goals. Yet we recognize that competition for medical 
professionals will grow in the coming years, amidst a growing shortage 
of primary care providers and nurses. I am proud to command some of the 
brightest medical minds--both military and civilian--our country has to 
offer. The young men and women who choose to enter military service or 
serve our Nation's military as civilians during a time of war exemplify 
what it means to provide selfless service to our country.
              sexual assault/sexual harassment prevention
    Our Force is becoming increasingly diverse, and as opportunities to 
be leaders and influencers continue to expand, it is important that 
Army Medicine continues to develop and shape our team members to serve 
honorably, to be good stewards of the Army Profession, to be respectful 
leaders, and to provide respectful and compassionate medical care. We 
must hold each other accountable, consistent with the Army Ethic and 
Army Values, in a manner worthy of serving our Nation's Service 
Members.
    Sexual assault and harassment go against Army Values; these acts 
degrade our readiness by negatively impacting the male and female 
survivors who serve within our units; it also negatively impacts other 
Soldiers exposed to this behavior. As an integral participant in the 
Army's Sexual Harassment/Assault Response and Prevention (SHARP) 
program, the AMEDD's goals are to increase the medical readiness of the 
Army and ensure the deployment of healthy, resilient and fit Soldiers, 
through compassionate and respectful care that treats every patient 
with dignity and respect, Army Medicine is establishing the benchmark 
to comprehensively support victims and survivors following a sexual 
assault.
    Across our Army, 40 percent of our MTFs perform the Sexual Assault 
Forensic Exam (SAFE), and the remaining MTFs augment care through 
memorandums of agreement (MOA) or understanding (MOU) and contract 
services with local civilian hospitals to ensure all victims are 
offered a uniform standard of care in compliance with the standards and 
protocols established by the Department of Justice (DOJ). We are 
actively engaged with the office of the Assistant Secretary of Defense 
for Health Affairs to ensure our program meets the requirements of the 
National Defense Authorization Act for fiscal year 2014 in this area.
    The MEDCOM Sexual Assault Task Force is assisting the Army SHARP 
Program Office to revise the MEDCOM Regulation regarding management of 
sexual assault. The revised regulation includes guidance to Command 
Teams and healthcare providers that expand and enhance how they respond 
to patients following a sexual assault. Engaging the patient in an 
individualized healthcare plan is a key component. Additionally, the 
regulation emphasizes the provision of timely, accessible and 
comprehensive medical management to victims who present at Army MTFs 
and all of the necessary follow up care. In addition to immediate 
medical needs, care includes assessment of risk for pregnancy, options 
for emergency contraception, risk of sexually transmitted infections, 
behavioral health services or counseling, and necessary follow-up care 
and services for the long-term.
    Army Medicine is leaning forward to expand the knowledge and skills 
of our sexual assault examiners working in our MTFs, ensuring our 
ability to provide compassionate and holistic support to these 
patients. The Army significantly increased and expanded the number of 
providers certified in sexual assault treatment to address the full 
spectrum of victim needs. Providers who serve the Army SAFE program as 
Sexual Assault Medical Forensic Examiners (SAMFE) include physicians, 
physician's assistants, advanced practice registered nurses, and 
registered nurses. MEDCOM has over 300 healthcare providers trained as 
SAMFEs, Sexual Assault Care Coordinators (SACCs) and Sexual Assault 
Clinical Providers (SACPs) and 398 Sexual Assault Response Coordinator 
(SARC)/Victim Advocate SHARP-trained personnel.
    Although there is no nationally mandated standard for SAMFE 
providers, the Army Medicine training and examinations meet DOJ 
guidelines. We have developed a leading standard for SAMFE providers 
with assistance of national SME's and offices. Army Medicine is leading 
a national conversation on a SAMFE Leading Standard with the DOJ, US 
Army Criminal Investigation Command (CID), U.S. Army Criminal 
Investigation Laboratory (USACIL), and the International Association of 
Forensic Nurses (IAFN). All Army SAMFE providers must complete MEDCOM's 
standardized SAMFE Training, based on the DOJ Training Standards. The 
Army is also working on a certification process, working through the 
challenges associated with supporting sexual assault victims in remote, 
austere, and OCONUS locations.
 the health of our families and retirees: patient centered medical home
    The Patient Centered Medical Home (PCMH) model for primary care is 
a key enabler of the transition to a System for Health and the MHS 
Quadruple Aim: readiness, population health, experience of care, and 
per capita cost. A medical home relies upon building enduring 
relationships between patient and provider, and a comprehensive and 
coordinated approach to care between providers and community services. 
By redesigning healthcare delivery around the patient, primary care 
truly becomes the foundation of health and readiness, and drives the 
desired strategic outcomes.
    PCMH represents a fundamental change in how we provide 
comprehensive care for our beneficiaries--involving primary care, 
behavioral health, clinical pharmacy, dietetics, physical therapy, and 
case management. Since PCMH implementation began in January 2011, 120 
PCMH practices caring for 1.2 million Soldiers and Families have 
completed standardized initial implementation. Of these practices, 23 
are the Soldier version of PCMH or the Soldier Centered Medical Home 
(SCMH), caring for 200,000 Soldiers. In 2013, 64 new PCMH and SCMH 
practices were added. The remaining 25 practices will complete initial 
implementation by end of fiscal year 2014.
    The fiscal year 2015 core budget for PCMH is $73.6 million, which 
is inclusive of efforts to build a premier patient-centered, team-
based, comprehensive System for Health. Additionally, a fiscal year 
2015 investment of $21.4 million to PCMH for TBI/Psychological Health 
adds BH providers to PCMH, enhancing access to care and making BH care 
a part of the larger medical home.
    The medical home actively integrates the patient into the 
healthcare team, offering evidence-based prevention and a personalized 
comprehensive care plan. PCMH/SCMH health and quality indicators 
outperform traditional primary care providing significantly better 
access to the beneficiaries' primary care manager (PCM) and PCM team, 
better patient and staff satisfaction, and improved health and 
readiness outcomes. In addition, PCMH showed significant reductions in 
ER over-utilization by more than 47,000 visits, translating to an 
estimated $16.4 million in variable cost savings. These improvements 
relative to traditional primary care were maintained despite the 
relative challenges created by sequestration.
    SCMH practices achieved remarkable impact on Soldier medical 
readiness during 2013. Of the Soldiers in the SCMH, 92 percent are 
medically ready (a 3-percent increase), compared to 85 percent across 
the rest of the Army. Polypharmacy rate decreased to 2.6/100 enrollees 
from the benchmark of 4.8/100. The behavioral health admission rate was 
21/1000, remaining lower than the benchmark of 30/1000.
    The focus for Army PCMH in 2014 will be to complete initial 
implementation in the remaining PCMH/SCMH practices, integrating pain 
management capability and traumatic brain injury care more fully into 
PCMH/SCMH practices, continuing refinement and maturation among 
existing practices especially in their health promotions role.
    Integrated with the PCMH as part of the comprehensive care team are 
the 19 USAPHC Army Wellness Centers (AWC), costing $12.1 million 
annually. The AWCs are demonstrating how a standardized holistic 
primary prevention strategy can greatly contribute to our ability to 
get ahead of disease. In fiscal year 2013, AWCs evaluated 15,200 
individuals, including Active Duty (61 percent), Family Members (21 
percent), Civilians (10 percent), Reservists (2 percent), and Retirees 
(3 percent). In fiscal year 2014, four additional AWCs will be 
implemented. The AWCs have achieved an annual cost-avoidance in fiscal 
year 2013 of $1.2 million.
    Analysis of 3 years of data collected by the AWCs show that for the 
2,400 individuals who had at least one follow-up visit for their Body 
Mass Index (BMI), 62 percent saw a statistically significant decrease 
in BMI (average 4-percent decrease). Of the 437 clients who had a 
baseline and follow-up test for maximal oxygen consumption 
(VO2 max), 60 percent saw a significant increase in 
VO2 max, with an average improvement of 15 percent. Current 
research indicates that a 2 percent to 3 percent reduction in weight is 
associated with clinically significant improvement in risk factors for 
chronic disease and a cost-avoidance of $202/year per 1 point BMI 
decrease, and that an increase in VO2 max of the magnitude 
observed in the AWC data is associated with a decrease in the risk of 
all-cause mortality and cardiovascular disease.
            strategies to enhance efficiency of direct care
    Increasing healthcare costs, the increasing burden of preventable 
diseases, and mounting fiscal pressures are driving the Nation to 
examine how we are delivering care, and how we incentivize and enable 
health. We need a stable fiscal platform in the MHS focused on 
prevention, while at the same time reducing costs and improving 
efficiencies.
    We are implementing strategies to incentivize improved health 
outcomes. The AMEDD has had great success with the Performance Based 
Adjustment Model (PBAM) in improving both capacity and quality. The 
Army has reduced the Active Duty no-show rate for medical appointments 
from 11.6 percent to 5.2 percent in the past 36 months, increasing the 
efficiency of our medical system in supporting Soldier readiness.
    Currently, the AMEDD is implementing the Integrated Resourcing and 
Incentive System (IRIS). IRIS focuses on 3 areas to further 
improvements regarding MTF performance: Primary care enrollment, 
accountability tied to performance plans through a Statement of 
Operations, and strategic incentives that encourage prevention 
strategies. For fiscal year 2014, Army MTFs are being funded for 
primary care based on a capitated rate for their planned enrollment. 
IRIS also incentivizes recapture of primary care from the purchased 
care network. IRIS also pays the MTF fee-for-service for primary care 
delivered to TRICARE Plus and other beneficiaries that are not enrolled 
to the MTF, providing additional motivation for our MTFs to recapture 
primary care.
    There are 48 total incentive metrics within IRIS, with the goal 
being to align funding and incentives to enhance MTF value production. 
Army Medicine is moving the needle in the right direction--recapturing 
care, improving access to care, improving satisfaction, and improving 
quality of care.
 ``we recruit soldiers, but re-enlist families.''--army family programs
    We must never lose sight of the fact that the most important 
formation in the Army is the Family unit. Army Medicine is setting the 
conditions to better understand the Army Family. Improving the health 
of our Army Families will improve the strength, performance, and 
readiness of the Soldier, and also establish an example for our Nation 
on a way forward to improve the health of communities.
    The Community Health Promotion Council (CHPC) at each Army 
installation synchronizes programs between service providers (medical 
and garrison) and unit leaders. Health Promotion Officers (HPO), who 
are aligned with Senior Commanders, facilitate the CHPC process and 
coordinate R2C activities for command teams, unit leaders and SMEs 
across the installation in support of the health of the entire 
population.
    Army Medicine is also establishing the Child and Family Behavioral 
Health System (CAFBHS) model that aligns with and supports the PCMH 
model and other primary care Family Member--oriented clinics, such as 
pediatrics and obstetrics. CAFBHS also leverages tele-behavioral health 
capabilities to enhance outreach to remote areas, create partnerships 
with on-post and civilian communities, standardize patient screening 
and assessment, and monitor through the BHDP. The CAFBHS blends best 
practices in consultation, collaboration and integration of BH care to 
meet the needs of the Army Family, improve access, and decrease stigma.
    Just as we have placed BH providers closer to our Soldiers through 
the EBH program, a component of CAFBHS is the School Behavioral Health 
(SBH) program, where comprehensive BH services are available at DOD/
installation-based schools to support military children and their 
Families. The SBH provides a continuum of care from prevention through 
early intervention to BH treatment focused on improving academic 
achievement, maximizing wellness and resilience, and promoting optimal 
military/Family readiness. Currently SBH programs operate in 46 schools 
on 8 installations.
    I want the story of the military Family to resonate throughout our 
Nation's history as an example of resilience--demonstrating the 
powerful impact that can be felt when we invest not only in the 
Soldier, but in the Family members, old and young, who support our 
heroes.
     ``medicine is the only victor in war''--army medical research
    History is replete with examples of war serving as a catalyst for 
medical innovation and of battlefield medicine producing advances in 
civilian healthcare. For more than 200 years, the Army's efforts to 
protect soldiers from emerging health threats have resulted in 
significant advances in medicine. Our medical research has played a key 
role in our national defense throughout history, continually responding 
to emerging battle and non-battle threats, capturing lessons learned, 
and sharing those advances with the world. Military medicine continues 
to work to reduce morbidity and mortality resulting from devastating 
injuries on the battlefield, achieving the historically high 
survivability rate of 91.3 percent in the current conflict.
    MRMC is leading Army Medicine in scientific research, with ongoing 
efforts focused on establishing more effective methods for diagnosis, 
treatment, and long-term management of the health-related consequences 
of war, including TBI, behavioral healthcare, PTSD, burn and other 
disfiguring injuries, chronic pain, and limb loss.
    The DOD and the Services plan, program, budget and execute funding 
to address DOD and Service military medical Research, Development, Test 
and Evaluation (RDTE) needs and requirements for supplies, equipment, 
and medical knowledge unique to the battlefield. To accomplish this 
mission, the Army and DOD coordinate with the other Services and 
Federal agencies to target and align research efforts. The military 
also partners with academia and industry to develop medical solutions 
for warfighters and military healthcare providers. As a business model, 
MRMC and the U.S. Army Medical Research Acquisition Activity (USAMRAA) 
provide multiple avenues to foster relationships and to award grants 
and contracts to institutions focused on performing medical research 
and development. For example:
  --In 2008 MRMC established the Armed Forces Institute of Regenerative 
        Medicine (AFIRM), a multi-institutional, interdisciplinary 
        network with two academic consortia, one led by Wake Forest 
        University, the other by Rutgers University, working to develop 
        advanced treatment options for our severely wounded Service 
        Members. The AFIRM II 5-year, $75 million award in September 
        2013 to the Warrior Restoration Consortium under Wake Forest 
        University is focused on extremity injury, cranio-maxillofacial 
        injury, burns/scar-less wound healing, composite tissue 
        transplantation, and genitourinary/lower abdominal 
        reconstruction.
  --Army Medicine is also conducting critical research to improve 
        treatment of battlefield injuries. Investments for treating 
        battlefield eye trauma include research to develop novel and 
        improved ocular wound dressings that can be deployed into 
        theater and applied or administered immediately following 
        blast, burn or chemical trauma to the eye, designed to deliver 
        therapies to control infection and promote wound repair, 
        mitigating the deleterious effects of eye injuries.
  --The U.S. Army Institute of Surgical Research (USAISR) received 
        clearance from the U.S. Food and Drug Administration (FDA) for 
        the Burn Resuscitation Decision Support System-Mobile (BRDSS), 
        also called Burn Navigator, the first of its kind algorithm-
        based decision assist system for use in managing fluid 
        resuscitation of severely burned patients. Designed with the 
        medical providers in mind who may be forward deployed who do 
        not routinely care for burn patients, the technology has been 
        shown to improve patient outcomes with more accurate early 
        fluid resuscitation.
  --In September 2013, researchers unveiled the world's first thought-
        controlled bionic leg. Funded through the MRMC's Telemedicine 
        and Advanced Technology Research Center (TATRC) and developed 
        by researchers at the Rehabilitation Institute of Chicago 
        Center for Bionic Medicine, this prosthetic advancement was 
        highlighted by the New England Journal of Medicine because the 
        type of technology was previously only available for arms.
  --The diversity of operational medical challenges and environmental 
        health threats that will increase with a change in focus to the 
        Asia-Pacific must continue to fuel our research efforts. The 
        DOD has a history of coordinating the capabilities of our Army 
        and Navy overseas medical research laboratories and our major 
        stateside laboratories, such as the Walter Reed Army Institute 
        of Research (WRAIR) and the U.S. Army Medical Research 
        Institute of Infectious Diseases (USAMRIID), as platforms for 
        infectious disease research with the National Institute of 
        Allergy and Infectious Diseases (NIAID) of the National 
        Institutes of Health (NIH).
  --In October 2013, reports of the successful trials that could 
        produce the world's first malaria vaccine led the headlines of 
        international news. Malaria has been a significant medical 
        threat in every major U.S. military conflict during the 20th 
        century. Results of the phase III malaria vaccine trial being 
        conducted in Africa were presented at the 6th Multilateral 
        Initiative on Malaria Pan-African Conference by the principal 
        investigator at U.S. Army Medical Research Unit-Kenya (USAMRU-
        K). This success gives hope that a vaccine will be available by 
        2015.
  --For the first time in more than 25 years, the FDA has approved an 
        additional red blood cell storage solution. Hemerus Medical 
        LLC, in partnership with the U.S. Army Medical Materiel 
        Development Activity, received FDA approval for a whole blood 
        collection system that has been approved for 6-week red blood 
        cell storage. Research not only yields materiel products such 
        as equipment and pharmaceuticals, but it also provides 
        ``knowledge'' products, such as new clinical practice 
        guidelines (CPGs) and protocols. The Joint Trauma System (JTS), 
        located at the U.S. Army Institute of Surgical Research 
        (USAISR), has collected data from more than 130,000 combat 
        casualty care records from Iraq and Afghanistan and will 
        continue to provide guidance in the form of CPGs. The Joint 
        Theater Trauma System, which was developed in Iraq by the U.S. 
        Central Command (CENTCOM) surgeon's office, is being considered 
        for applications in the Asia-Pacific and possible adaptation 
        for future missions anywhere in the world.
    We need to continue making deliberate, resource-informed decisions 
to ensure we meet the needs and challenges of today while preparing for 
tomorrow. While we owe it to this generation of Soldiers and Families 
to help them deal with the consequence of war, long after the last 
Soldier departs Afghanistan, we also owe the next generation of 
Soldiers the best that our research and development can offer.
                     the future of military health
    We are at our best when we operate as a joint team. Together with 
Dr. Woodson, the Service Surgeons General are working to organize and 
lead the MHS into the future by building a stronger, even more 
integrated team. Our integrated approach to battlefield medicine has 
had great successes, and this enhanced integration of our capabilities, 
collaborating to provide care, is leading to a stronger, more relevant 
military health system for the future. Our commitment is to achieve 
greater unity of effort, improve service to our members and 
beneficiaries, and achieve greater efficiency through rapid 
implementation of common services and joint purchasing, as well as 
other opportunities for more streamlined service delivery. The 
President's budget for fiscal year 2015 adequately funds Army Medicine 
to meet the medical mission. We will continue the collective work of 
optimizing policies and processes across the MHS to advance our 
transformation to a System for Health.
    Military medical care is one of the most valued benefits our great 
Nation provides to its Service Members. We understand that we cannot 
ask our beneficiaries to share more of the cost of healthcare without 
also looking within to streamline. The rising cost of healthcare 
coupled with the increasingly constrained defense budget presents a 
challenge to the MHS. In doing our part, Army Medicine is developing 
innovative and effective ways to deliver care in a resource constrained 
environment while integrating health and readiness into everything we 
do.
    The establishment of a Defense Health Agency (DHA) in October 2013 
represented a major milestone towards modernization and integration of 
military medical care. Army beneficiaries constitute 49 percent of the 
inpatient and outpatient workload in the MHS, and Army Medicine fully 
supports the ongoing structural and governance reforms within the MHS 
to better serve our population. The DHA implementation is key to 
reducing the growth of healthcare costs, reducing variance, recapturing 
workload, and improving standardization of clinical and business 
processes. Implementation has included successful transition of 6 
shared services to the DHA, and the AMEDD will continue to drive the 
fundamental changes within the MHS.
    The fiscal year 2015 President's budget includes proposals for a 
TRICARE Consolidated Health Plan along with modest increases in 
beneficiary out-of-pocket costs for Active Duty families, Retirees and 
their families, and RC members and their families. These proposals 
reflect the DOD efforts to modernize and simplify the TRICARE program 
that will place the program on a stable, long-term footing. Army 
Medicine joins our Army Chief of Staff in supporting the 2015 budget 
the President has put forward. These cost savings are essential to 
ensuring that our beneficiaries continue to receive the high quality 
care they deserve. It represents a responsible path forward to 
sustaining the Military Health benefit in a changing world and 
recognizes that the fiscal health of the country is a vital element in 
our National security. This change will be successful if it is combined 
with health initiatives and fully capitalizing on the readiness 
platform in our direct care system.
    The budget being put forward reflects our commitment to the broad 
range of responsibilities of the MHS; the medical readiness 
requirements needed for success on the battlefield of today and 
tomorrow; the patient-centered approach to care that is woven through 
the fabric of MHS; the transformative focus of the System for Health 
for our population; the public health role we play in our military 
community and in the broader American community; the reliance we have 
on our private sector health-care partners who provide indispensable 
service to our Service Members and their Families; and our 
responsibility to deliver all of those services with extraordinary 
quality and care.
                             the road ahead
    We have an enduring obligation to the men and women in uniform, to 
their families who serve with them, and to the retired personnel and 
families who have served us in the past. For those who have borne the 
greatest burden through injury or disease suffered in our Nation's 
conflicts, we have an even higher obligation to the wounded and to 
their families. Some will need our care and support, as will their 
families, for a lifetime.
    We will not lose sight of this obligation in our inter-war years, 
and will work aggressively to ensure we maintain robust combat casualty 
care skills and maintain trust with the American people. Our Nation's 
sons and daughters in uniform deserve nothing less than the level of 
support and capability we provided during our years in Iraq and 
Afghanistan.
    In closing, though we live in uncertain times, one thing is 
certain--a strong, decisive Army will be--as it always has been--the 
strength of our Nation. I am proud of Army Medicine's proficient, 
professional and courageous performance of mission over the last 238 
years to help our Soldiers, Families and Veterans. In partnership with 
the DOD, my colleagues here at the panel today, the VA, and the 
Congress, we will be prepared for tomorrow's challenges. Thank you for 
the opportunity to tell the Army Medicine story. Thank you for your 
continued support of our Total Army Family.
    The Army Medicine Team is proudly Serving to Heal, and Honored to 
Serve.

    Senator Durbin. Thanks, General.
    Admiral Nathan.
STATEMENT OF VICE ADMIRAL MATTHEW L. NATHAN, SURGEON 
            GENERAL, DEPARTMENT OF THE NAVY
    Admiral Nathan. Chairman Durbin, Vice Chairman Cochran, 
Senator Blunt, I am grateful for the opportunity to appear 
before you today on behalf of the dedicated men and women of 
Navy Medicine. We would like to thank the committee for the 
outstanding support and confidence that you maintain.
    I can report the Navy Medicine team is mission ready and 
delivering world-class care anywhere at any time.
    Our Navy Medicine optempo remains quite high, protecting, 
promoting, and restoring the health of sailors and marines 
deployed around the world, ashore and afloat, in all warfare 
domains, especially still in the area of conflict in the Middle 
East.
    We exist to support the operational missions of both the 
Navy and the Marine Corps. These responsibilities require us to 
be agile and an expeditionary medical force capable of meeting 
the demands of crisis response and the global maritime 
security.
    Within Navy Medicine, our planning efforts must always be 
synchronized with the Navy and Marine Corps. Our way forward 
reflects purpose and commitment to build on the work and the 
investments that we made last year.
    Our strategic goals remain simple but complete: Readiness, 
value, and jointness. The goals are critical to sustaining our 
readiness mission, remaining flexible in the face of changing 
operational requirements and fiscal challenges, as well as 
effectively managing our resources.
    They also leverage the use of technology and telehealth, 
help standardize clinical and business processes, and improve 
alignment.
    Throughout Navy Medicine, our leaders are achieving 
measurable progress on these goals, and I am encouraged by the 
fact that these priorities are taking hold throughout our 
enterprise.
    By leveraging the capabilities of our patient-centered 
medical home, known as Medical Home Port, and initiating our 
own CONUS (continental United States) hospital optimization 
plan, we are moving more workload into our military treatment 
facilities (MTFs), we are growing our enrollment, rebalancing 
our staff, and we are reducing overall purchase care 
expenditures.
    Just as importantly, we are ensuring that our graduate 
medical education programs remain second to none, and our 
provider teams sustain the clinical currency to always be 
battlefield ready.
    Strategically, I am convinced that we are stronger as a 
result of our work with other services, interagency partners, 
leading academic and private research institutions, and other 
civilian experts. These collaborations are vital as we leverage 
efficiencies and best practices in clinical care, research, 
education, global health engagement, and support for our 
wounded servicemembers in their recovery and transition.
    To echo my partner here and colleague in the Army, 
Lieutenant General Horoho, when something happens to any of our 
members in our sister services, when they are in pain, we are 
in pain.
    Psychological health is an important component of overall 
force health protection. We recognize that prolonged 
operational stress can have significant and potentially 
debilitating consequences. We continue to embed our mental 
health capabilities in operational units and primary care 
settings in order to identify and manage issues before they 
manifest as psychological problems.
    This priority extends to suicide prevention where we train 
sailors, marines, and their families to recognize operational 
stress and use tools to manage and reduce its effects.
    As leaders, we have renewed our emphasis on ensuring that 
we focus on every sailor, every day, particularly those in 
transition or facing personal or professional adversity.
    We know that an increasing sense of community and purpose 
is an important protective factor in preventing suicide, and we 
must remain ready and accessible to those who need our help.
    These are transformational times for military medicine. 
There is much work ahead as we navigate important challenges 
and seize opportunities to keep our sailors and marines 
healthy, maximize the value for all our patients, and leverage 
the joint opportunities.

                           PREPARED STATEMENT

    I am encouraged with the progress we are making, but I am 
not satisfied. We continue to look for ways to improve and 
remain on the forefront of delivering world-class care anytime, 
anywhere.
    Again, thank you, and I look forward to your questions.
    [The statement follows:]
          Prepared Statement of Vice Admiral Matthew L. Nathan
    Chairman Durbin, Vice Chairman Cochran, distinguished members of 
the subcommittee, I am grateful for the opportunity to appear before 
you today and update you on Navy Medicine, including our priorities, 
opportunities and challenges. On behalf of the 63,000 dedicated men and 
women of Navy Medicine, we want to thank the committee for your 
outstanding support and confidence. I can report to you that the Navy 
Medicine team is mission-ready and delivering world-class care, 
anytime, anywhere.
           strategic priorities, alignment, and optimization
    Navy Medicine is an integral part of the Navy-Marine Corps team, 
protecting, promoting and restoring the health of Sailors and Marines 
around the world--ashore and afloat--in all warfare domains. We exist 
to support the operational missions and core capabilities of both the 
United States Navy and the United States Marine Corps. These 
responsibilities require us to be an agile, expeditionary medical force 
capable of meeting the demands of crisis response and global maritime 
security. In this regard, the Chief of Navy Operations has articulated, 
directly and succinctly, his ``Sailing Directions'' tenets--Warfighting 
First, Operate Forward and Be Ready. These tenets are particularly 
relevant as we navigate current and emerging challenges. Navy Medicine 
stands ready as we move forward at this pivotal time in our history.
    Within Navy Medicine, our strategic planning efforts are 
synchronized with the Navy and Marine Corps. The Navy Medicine 2014 
Charted Course reflects purpose and commitment to build on the work and 
investments we made last year. Our overarching strategic goals are:
    Readiness.--We provide agile, adaptable, and scalable capabilities 
prepared to engage globally across the range of military operations 
with maritime and other domains in support of the national defense 
strategy.
    Value.--We will provide exceptional value to those we serve by 
ensuring highest quality through best healthcare practices, full and 
efficient utilization of our services, and lower care costs.
    Jointness.--We lead Navy Medicine to jointness and improved 
interoperability by pursuing the most efficient ways of mission 
accomplishment.
    The goals are critical to sustaining our readiness mission, 
remaining flexible in the face of changing operational requirements and 
soundly managing our resources. They also leverage the use of 
technology and telehealth, help standardize clinical and business 
processes and improve alignment. We are ensuring that our investments 
and objectives are targeted to support these strategic goals and serve 
as a foundation for our initiatives. Throughout Navy Medicine, our 
leaders are achieving measureable progress and I am encouraged that 
these priorities are taking hold throughout our system.
    In this fiscal environment, we understand the demands facing all of 
us and we remain committed to deriving best value from the resources 
provided to us. We are working diligently to optimize our system, 
implement efficiencies and reduce purchased care expenditures for our 
enrolled patients. I continue to make recapturing private sector 
healthcare a priority for our military treatment facility (MTF) 
commanders and commanding officers. We are carefully tracking metrics 
that give us insight into our purchased care expenditures to help us 
manage and optimize our system. Navy Medicine is moving more workload 
into our MTFs, growing our enrollment and reducing the overall 
purchased care expenditures. I am encouraged by the progress we are 
making in this important area and will continue to address this issue 
as a key strategic initiative throughout 2014.
    We are grateful to the Committee for continued support of our 
resource requirements especially given the overarching fiscal 
uncertainties. The passage of the Consolidated Appropriations Act of 
2014 provides us with stability for planning and execution of our 
requirements for this fiscal year. The President's budget for fiscal 
year 2015 continues to adequately fund Navy Medicine to meet its 
medical mission for the Navy and Marine Corps. We also support the 
changes to TRICARE contained in the President's Budget, including 
initiatives to simplify and modernize the program through the 
Consolidated Health Plan, and update beneficiary out-of-pocket costs 
with modest increases. These changes to the program are important to 
ensuring the delivery of sustainable and equitable healthcare benefits.
    Nonetheless, we did face the uncertainties and associated 
challenges with sequestration during the past year. We remained 
committed to delivering the healthcare services to our beneficiaries. 
We worked to channel the required sequester cuts in fiscal year 2013 to 
facilities sustainment and modernization, equipment purchases, 
contracts and travel. However, the cumulative effects of these 
reductions must be carefully assessed as we look to recapture workload 
and make needed investments in our facilities. In addition, we are 
carefully watching the impact on recruiting, retention and morale of 
our civilian personnel following the furlough and government shutdown 
in 2013.
    Navy Medicine is committed to achieving the Department of Defense 
(DOD) objective of preparing auditable financial statements and 
reports. Becoming audit ready will demonstrate to our stakeholders that 
Navy Medicine is an accountable steward of the resources we receive and 
help support our decisionmakers with ready, accurate and timely 
information. We developed, refined and deployed our standard operating 
procedures for multiple business processes and initiated corrective 
actions when indicated. This strategy of process documentation and 
remediation has strengthened internal controls and improved resource 
management. Although we have made substantial progress, much work still 
remains to achieve audit readiness and to sustain improvements.
    The establishment of the Defense Health Agency (DHA) on October 1, 
2013 is an important milestone for military medicine and our collective 
efforts to realize potential efficiencies and savings throughout the 
Military Health System (MHS). All of us recognize the opportunity this 
represents to standardize our practices and drive out complex 
variation, while maintaining clear lines of authority necessary to 
support each Service's operational requirements. Efforts to improve 
integration of MTFs and purchased care networks (TRICARE) continue with 
implementation of six enhanced multi-service markets (eMSMs). Navy 
Medicine is working with the DHA, in conjunction with the Army and Air 
Force, to ensure that rigorous business case analyses are conducted and 
validated for the shared services while we continue to focus on 
refining 5-year business plans and improved integration of healthcare 
benefits and services in the six eMSMs. Our collective efforts should 
culminate on generating efficiencies and savings within the MHS through 
continued health plan integration and the development of the next 
TRICARE contract.
    Looking to fiscal year 2015, the standup of the DHA included 
assumptions about workload and cost savings. While the dollar 
reductions were largely in the private sector account, the assumption 
of increased workload was placed on MTFs with the expectation of no 
increased resource demands. As described above, we are hard at work to 
do everything possible to ensure that the Navy MTFs improve production 
and reduce cost.
    Integrated and comprehensive primary care delivery is foundational 
to a quality health system. It is also critical to our efforts in 
improving the health and wellness of our beneficiaries, and achieving 
best health outcomes at the lowest cost. Medical Home Port (MHP) 
transforms the delivery of primary care to an integrated, team-based 
approach offering same day access, proactive prevention services and 
standardized clinical processes. It also includes expanded healthcare 
teams including behavioral health providers and access to pain 
management specialists. Nearly all of Navy Medicine's 780,000 total MTF 
enrollees are now receiving care in a MHP. In addition to primary care, 
Navy Medicine is expanding patient-centered, integrated care to the 
specialty and inpatient areas through Medical Neighborhoods. All of our 
MHP practices have applied for National Commission for Quality 
Assurance (NCQA) recognition. To date, 80 percent have been reviewed by 
NCQA and obtained recognition, while the remaining practices are 
currently awaiting results. Of those to receive recognition, 93 percent 
have received NCQA's highest level of recognition. These results are a 
full 10 percent higher than the average scores for civilian practices.
    We tailored the MHP model for the operational community so that all 
Sailors and Marines receive the same patient-centered benefits. There 
are nine demonstration project sites--six for Marine-Centered Medical 
Home (MCMH) and three for Fleet-Centered Medical Home (FCMH)--all of 
which will enhance access between patients and their healthcare team. 
The teams also integrate behavioral and psychological healthcare 
providers to improve medical readiness. In 2014, we plan on expanding 
MCMH to 16 additional sites and FCMH to 15 additional sites.
    We are employing key information technology tools to improve the 
efficiency of healthcare delivery. Every MHP team can communicate with 
their patients through interactive and secure electronic messaging. 
This capability improves communication, access to care, continuity and 
patient satisfaction while reducing in-office visits. In addition, we 
collaborated with the other Services to create and deploy standardized 
Tri-Service work flow templates to enhance clinical operations and care 
documentation aligned with evidence-based guidelines.
    As our MHP practices continued to mature over the past year, we 
have seen favorable trends in key metrics including:
  --Navy Medical Readiness Indeterminate status decreased 14 percent;
  --Access to acute appointments improved 19 percent as Primary Care 
        Manager (PCM) continuity increased 12 percent, to an all-time 
        high of 65 percent;
  --Emergency Department utilization decreased by 12 percent;
  --The number of beneficiaries utilizing secure messaging increased 50 
        percent and now exceeds 200,000 patients sending over 20,000 
        messages per month.
    In order to leverage our MHP capabilities and support our strategic 
priorities, we implemented the Navy CONUS Hospital Optimization Plan 
that will impact nine of our hospitals in the United States. These 
proactive efforts are directly focused on improving readiness and 
value, as well as enhancing our graduate medical education (GME) 
programs. Changes in medical practice, including the migration to more 
outpatient care and shifts in populations, required us to carefully 
examine how healthcare was delivered and resourced. We used a 
population-based approach to establish targeted MTF enrollment and 
realignment of inpatient capabilities consistent with higher 
concentrations of our beneficiaries and greater patient acuity. After 
the realignment is completed, it will allow us to expand MHP 
enrollment, optimize inpatient capacity, recapture workload and ensure 
that our training programs remain second to none and our provider teams 
sustain the clinical currency to always be battlefield ready.
    Telehealth capabilities will continue to be important in employing 
the power of health information technology in delivering outstanding 
care, without the barriers of time and distance. To ensure that we are 
taking advantage of telehealth opportunities throughout Navy Medicine 
and within the Military Health System, I established a program 
management office within the Bureau of Medicine and Surgery, along with 
two regional project offices at Navy Medicine East (Portsmouth, 
Virginia) and Navy Medicine West (San Diego, California). Naval 
Hospital Camp Lejeune initiated programs to support a broad spectrum of 
clinical services including pediatric subspecialty consultation, tele-
ICU, tele-behavioral health, tele-insomnia, tele-neurology, orthopedic 
consult service, tele-pain, and Battalion Aid Station consultative 
service. Navy Medicine East is also initiating a large tele-radiology 
program to provide after-hours and subspecialty coverage throughout the 
region focused on improving the quality of care and saving resources. 
In addition, a Memorandum of Agreement was signed between Navy Medicine 
West and the Army's Pacific Regional Medical Command (PRMC) regarding 
collaboration on telehealth initiatives in the Pacific. WESTPAC Medical 
Alliance MTFs on Guam, Okinawa, and Yokosuka receive tele-critical 
care, tele-behavioral health, and provider-to-provider tele-
consultations from PRMC. Moving forward, we will continue to identify 
telehealth opportunities for improving the health and readiness of our 
Sailors, Marines and families.
    In addition to utilizing the most current technology, we know how 
important our facilities are to both patients and staff and we are 
grateful to you for your funding of our military medical construction 
requirements. In December 2013, a state-of-the-art replacement hospital 
was opened onboard Marine Corps Base Camp Pendleton. Naval Hospital 
Camp Pendleton is responsible for providing healthcare to Marines, 
Sailors, their families and all our beneficiaries in their catchment 
area as well as patients from six large branch medical clinics and 
seven active-duty Regimental Aid Stations. Our newest Navy MTF has 42 
staffed inpatient beds and an efficient ambulatory outpatient treatment 
capacity to serve our patients. Our Naval Medical Logistics Command 
(NMLC) played an integral role in outfitting this new facility with a 
state-of-the-art automated supply replenishment system using a 2-bin 
radio frequency-identification (RFID)-enabled supply system designed to 
minimize clinical involvement in supply chain activities, reduce waste 
and streamline replenishment actions. Due to the hard work of a 
dedicated team, I am proud that Naval Hospital Camp Pendleton was 
delivered under budget and ahead of schedule.
                            focus on health
    Force health protection is the core mission of Navy Medicine. We 
execute these responsibilities from the battlefield to the bedside, and 
in all domains in which Sailors and Marines operate. Despite the 
drawdown of forces in Afghanistan, our operational tempo remains high 
as Navy and Marine Corps forces operate forward throughout the world.
    We continue to lead the NATO Multinational Medical Unit (MMU), 
operating at Kandahar Airfield in Afghanistan. During its mission, this 
unit provided world-class combat casualty care to our warfighters. 
While the number of active and reserve personnel serving at the MMU has 
been reduced to approximately 133 from 250 last year, they are 
continuing to execute their demanding responsibilities with skill and 
dedication. It serves as the primary trauma receiving and referral 
center for all combat casualties in Southern Afghanistan and has 12 
trauma bays, 4 operating rooms, 8 intensive care beds and 10 
intermediate care beds. The MMU's partnership with the Joint Combat 
Casualty Research Team provides the platform for the advancement of 
military medical research in the areas of pre-hospital enroute care, 
traumatic brain injury, hemorrhage acute care, as well as prevention, 
recovery and resiliency.
    Our operational commanders rely on Navy Medicine for rapid 
assessment and identification of hazards presenting potential health 
threats to our deployed personnel and recommendations for protective or 
control measures. The four Navy Environmental and Preventive Medicine 
Units (NEPMUs), often the first responders, are important to these 
efforts as they provide Navy and Marine Corps forces with specialized 
public health services including disease surveillance, environmental 
health, entomology, industrial hygiene, and audiology. The NEPMUs 
maximize the readiness of operational forces worldwide by identifying 
and assessing health stressors to our personnel created by their work 
and their deployment settings. Additionally, the physicians, 
scientists, and corpsmen at the NEPMUs can advise commanders on proper 
controls that should be implemented to maintain the health and well-
being of service members.
    Psychological health is an important component of force health 
protection. We recognize that prolonged operational stress can have 
significant and potentially debilitating consequences. The Navy's 
Combat and Operational Stress Control programs promote psychological 
health and advance the quality and delivery of mental healthcare. Our 
emphasis is on fostering resilience, providing aggressive prevention 
programs, reducing stigma and targeting early recognition of stress 
problems. We are also working with our Navy and Marine Corps line 
counterparts in ensuring that combat and operational stress control 
concepts are being taught throughout the leadership training continuum.
    We continue to embed mental health capabilities in primary care 
settings and operational units in order to identify and manage issues 
before they manifest as psychological problems. We have mental health 
providers assigned to a variety of operational units including aircraft 
carriers, Marine Corps infantry regiments, special operations commands 
and in a variety of other settings including deployed Amphibious 
Readiness Groups. The Behavioral Health Integration Program (BHIP) in 
our Medical Home Port continues its implementation. Currently, 43 BHIP 
sites are established with the remaining 36 scheduled to be implemented 
by the end of fiscal year 2014. This initiative integrates behavioral 
health into primary care and can help improve access and reduce the 
stigma of seeking help.
    As we approach the conclusion of America's longest conflict, we 
must remain vigilant to the psychological health issues that will 
continue to emerge. Navy Medicine is at the forefront in identifying 
and implementing best practices and is actively engaged in research 
efforts to better understand, diagnose and treat injuries related to 
combat and operational stress. Our Psychological Health Pathways (PHP) 
pilot program, an initiative to standardize clinical care and 
assessment practices in tandem with a web-based registry, is collecting 
outcome measures at 21 clinics across the Navy and Marine Corps. Over 
two million data points have been collected in this registry and are 
being used to provide critical patient information to providers, as 
well as aggregated data for leaders. In the coming months, the lessons 
learned from PHP will be employed to roll-out a similar system for 
tracking behavioral health treatment outcomes. The Navy will join the 
other Services in implementing the Behavioral Health Data Portal 
(BHDP), which will provide standardization in our attempts to supply 
behavioral health providers with real-time outcome data to better 
inform treatment and tailor interventions to the individual patient.
    We also recognize the challenges that our service members face as 
they transition from the military. Our Navy Medicine case management 
team is comprised of 235 nurses, social workers, and support staff who 
work diligently to assist our beneficiaries to achieve wellness and 
autonomy through advocacy, communication, education, and identification 
of service resources.
    Family support programs are important to our efforts in building 
resiliency, developing sound coping skills and managing stress. One of 
our most successful continuing efforts is the Families Over Coming 
Under Stress (FOCUS) program which has reached over 435,325 service 
members, family members, and providers since its inception in 2008. 
Through program briefings and outreach presentations, consultation, 
skill-building groups, and family resiliency training, FOCUS has 
enhanced resilience and decreased stress levels for active duty members 
and their families. Outcomes have shown improvements in parent and 
child psychological health (including reductions in depressive and 
anxiety symptoms over time), improved family adjustment, and improved 
quality of marriage.
    The Navy and Marine Corps Reserve Psychological Health Outreach 
Program (P-HOP) provided over 13,000 outreach contacts to returning 
service members and provided behavioral health screenings for 
approximately 3,300 reservists in fiscal year 2013. They also made over 
700 visits to reserve units and provided presentations to approximately 
72,000 reservists, family members and commands. Similarly, over 1,800 
service members and their loved ones participated in Returning Warrior 
Workshops (RWWs). RWWs assist demobilized service members and their 
families in identifying immediate and potential issues that often arise 
during post-deployment reintegration.
    Navy behavioral health providers are trained in evidence-based 
treatment for trauma-related disorders, including PTSD. This trauma may 
result from combat, sexual assault, or other events. Our mental health 
providers must be trained and ready to support whenever they are called 
upon. In the wake of the tragic mass shootings at the Washington Navy 
Yard on September 16, 2013, Navy Medicine activated our Special 
Psychiatric Rapid Intervention Team (SPRINT). The team was on site the 
day of the shooting and provided behavioral and emotional support 
services to the victims over the next 12 days.
    In 2013, Navy Medicine initiated a standardized process to assess 
traumatic brain injury (TBI) programs and care at all Navy MTFs. The 
overarching goal of this initiative is to ensure that the care provided 
to all patients is standardized, consistent and appropriate. This 
initiative will also ensure that those involved in the provision of 
care adhere to identified best practice standards. We also developed 
four clinical algorithms for use in non-deployed settings which mirror 
the in-theatre TBI care system.
    The TBI program at Naval Hospital Camp Lejeune (NHCL) became 
operational in August 2013 as one of nine proposed National Intrepid 
Center of Excellence (NICoE) satellites (two Navy sites and seven Army 
sites). Naval Hospital Camp Pendleton's TBI program also has an 
identified building site for their NICoE satellite in close proximity 
to the newly opened hospital. The NICoE satellites are designed to 
provide advanced evaluation and care for service members with acute and 
persistent clinical symptoms following a TBI. The satellites use a core 
Concept of Care--including a standardized staffing and treatment 
model--that was drafted jointly by all the Services, as well as the 
NICoE, the Defense Centers of Excellence for Psychological Health and 
TBI (DCoE), and the Defense and Veterans Brain Injury Center (DVBIC).
    In theatre, the Navy continues to provide concussion care at the 
Concussion Restoration Care Center (CRCC) at Camp Leatherneck, 
Afghanistan. Since August of 2010, the CRCC has treated nearly 1,300 
service members with concussion. CRCC patients have a 98-percent return 
to duty rate in an average of 9 days. All Sailors and Marines deployed 
``boots on the ground'' are also required to complete post-deployment 
health assessments. Those who endorse any TBI-related symptoms are 
flagged to receive follow-up evaluation and, if necessary, treatment. 
Navy Medicine supplements the Post-deployment Health Assessment (PDHA) 
with an event-driven process, utilizing the TBI exposure tracking list 
generated from the DODI 6490.11 (DOD Policy Guidance for Management of 
Mild Traumatic Brain Injury/Concussion in the Deployed Setting) to 
identify Sailors and Marines for additional follow-up.
    Every suicide is a tragedy. It is a loss of a valued shipmate that 
impacts command cohesiveness--a loss the Navy and Marine Corps are 
determined not to accept. Preventing suicide is a command-led effort 
that leverages a comprehensive array of outreach and educational 
services. The number of active duty suicides in the Navy fell from 59 
in calendar year 2012 to 44 in 2013; while USMC suicides declined from 
48 to 45 for the same period. We remain cautiously optimistic as we 
combat this difficult problem. Preventing suicide requires each of us 
to actively participate and be in engaged in the lives of our shipmates 
and colleagues. Education and prevention initiatives train Sailors to 
recognize operational stress and use tools to manage and reduce its 
effects. Mobile Training Teams teach Sailors resiliency and provide 
them with tools to navigate stress and interrupt the path to suicidal 
behaviors. A-C-T (Ask--Care--Treat)--a bystander intervention tool--
remains an important framework of response.
    During fiscal year 2013, we completed an in depth review of Navy 
Medicine suicides that occurred during the previous two calendar years. 
This review was precipitated by a significant increase in the 
proportion of Navy suicides that were occurring within the medical 
community. Data from this review suggested that individuals who were in 
the midst of personal or professional transitions were particularly 
vulnerable to suicide. This finding prompted a renewed emphasis by Navy 
Medicine leadership on ensuring that we focus on every Sailor, every 
day, particularly those in transition or facing adversity. An 
increasing sense of community and purpose is an important protective 
factor in preventing suicide and we must remain ready and accessible to 
those who need help.
    The Department of the Navy (DON) does not tolerate sexual assault 
and implemented comprehensive programs that reinforce a culture of 
prevention, response, and accountability for the safety, dignity, and 
well-being of Sailors and Marines. Navy Medicine provides 
compassionate, competent, medical care that is victim-centered, gender-
sensitive and takes into account the reporting preferences of the 
individual. In support, Navy Medicine is committed to the success of 
the Sexual Assault Prevention and Response Program and to ensuring the 
availability of sexual assault forensic exams (SAFE) at shore and in 
afloat settings. SAFE providers are trained and available to ensure 
timely and appropriate medical care for sexual assault victims in all 
military platforms served by Navy Medicine. We established a 
comprehensive program to provide victims of sexual assault access to 
SAFE at both 24/7 MTFs and non-24/7 MTFs. The scope of this program 
extended to the operating forces at U.S. Fleet Forces and U.S. Pacific 
Fleet to provide the same level of training and care in maritime and 
expeditionary environments for victims of sexual assault. As of 
February of this year, 917 providers at our MTFs and operational 
platforms (surface, air, expeditionary and submarine) have been SAFE 
trained.
    The 21st Century Sailor and Marine initiative is an important 
effort designed to maximize readiness, maintain resiliency and hone the 
most combat effective force possible. Included in this program are the 
following areas: Readiness; safety; physical fitness; inclusion; and, 
continuum of service. This program provides alignment and unity of 
effort in several critical areas including suicide prevention, 
intolerance for sexual assault and harassment, and promotion of healthy 
lifestyles and work-life balance. Navy Medicine's programs on health 
promotion and education, tobacco-free living, excessive alcohol use 
prevention and nutrition directly support these important priorities.
                mission-focused: the navy medicine team
    The fabric of Navy Medicine is our people--a team of over 63,000 
men and women serving around the world in support of our mission. We 
are officers, enlisted personnel, government civilian employees, 
contract workers and volunteers working together in a vibrant 
healthcare community. We value the skill, experience and contributions 
of our personnel--all are vital to Navy Medicine's success in 
delivering world-class care around the globe.
    We continue to focus on ensuring we have the proper workforce, 
aligned with the appropriate mix of recruiting, retention, as well as 
education and training incentives. We are grateful for your support of 
our special pays and bonus programs. I believe these incentives, along 
with a robust student pipeline, are important in sustaining our 
recruiting successes, ensuring healthy manning and retention levels and 
mitigating the risk associated with an improving civilian labor market 
for healthcare professionals.
    In fiscal year 2013 Navy Recruiting attained 100 percent of the 
active component (AC) Medical Department officer goal and our overall 
active component officer manning is 99 percent, a 10-year high. Some 
shortfalls do exist, mainly due to billet growth and primarily in the 
mental health specialties. However, mental health provider manning 
continues to improve with psychiatry, clinical psychology and social 
work manned at 90 percent, 88 percent, and 58 percent, respectively. We 
project our social work manning to be over 80 percent by the end of 
fiscal year 2014.
    Within the Navy Medicine reserve component (RC), we attained 75 
percent of our officer goal. Recruiting RC Medical Corps officers 
remains a challenge. Given the higher retention rates in the AC, we 
rely more heavily on the challenging Direct Commission Officer market 
for our reserve physicians. While overall RC Medical Department manning 
stands at 91 percent, manning within the Medical Corps is 67 percent, 
with specialty shortfalls persisting in orthopedic surgery, general 
surgery and anesthesiology. Within the RC Nurse Corps, our stipend 
program as well as recruiting and retention bonuses have had a 
significant impact in improving manning for certified registered nurse 
anesthetists and mental health nurse practitioners.
    Our AC and RC Hospital Corps enlisted recruiting attained 100 
percent of goal for fiscal year 2013. Our AC enlisted manning is 100 
percent, despite some shortages in key Navy Enlisted Classification 
Codes (NECs). Surface and submarine independent duty corpsmen (IDCs) 
are both manned at 90 percent, with our dive IDC manning currently at 
86 percent. Fleet Marine Force reconnaissance corpsmen manning is 58 
percent. Manning levels in this community are a direct result of 
special operations growth. We are utilizing special and incentive pays, 
along with increased recruiting efforts, to improve manning in this 
critical skill set. At the end of fiscal year 2013, our RC enlisted 
manning was 101 percent.
    Navy Medicine's Federal civilian workforce provides stability and 
continuity within our system, particularly as their uniformed 
colleagues deploy, change duty stations or transition from the 
military. Throughout our system, they provide patient care and deliver 
important services in our MTFs, research commands, and support 
activities as well as serve as experienced educators and mentors--
particularly for our junior military personnel. As of the end of fiscal 
year 2013 our civilian end strength was 12,246, which is in line with 
our overall requirements.
    Navy Medicine's Reintegrate, Educate and Advance Combatants in 
Healthcare (REACH) Program is an important initiative that provides 
wounded warriors with career and educational guidance from career 
coaches, mentoring from medical providers and hands-on training and 
experiences in our MTFs. We are committed to helping our service 
members with their recovery and transition and I am particularly 
encouraged by the opportunities that REACH provides for careers in 
healthcare. REACH is now available at Naval Medical Center Portsmouth, 
Naval Medical Center San Diego, Naval Hospital Camp Lejeune, Naval 
Hospital Camp Pendleton, Walter Reed National Military Medical Center 
and Naval Health Clinic Annapolis. We have successfully transitioned 
eight wounded warriors into part-time positions at our MTFs and 70 
recovering service members have enrolled in healthcare-focused college 
degree programs.
    Navy Medicine is stronger as a result of our diversity and 
inclusion. We are a diverse, robust and dedicated healthcare workforce, 
and this diversity also reflects the people for whom we provide care. 
We take great pride in promoting our message that we are the employer 
of choice for individuals committed to a culturally competent work-life 
environment; one where our shipmates proudly see themselves represented 
at all levels of leadership. We will continue to expand our outreach to 
attract and retain diverse talent, ideas and experiences in order 
sustain our mission success.
                  innovative research and development
    Navy Medicine Research, Development, Testing, and Evaluation 
(RDT&E) is inextricably linked to our force health protection mission. 
Navy Medicine RDT&E priorities are operationally focused and include: 
Traumatic brain injury and psychological health; medical systems 
support for maritime and expeditionary operations; wound management 
throughout the continuum of care; hearing restoration and protection; 
and, undersea medicine. In addition, these priorities fully support 
Navy Medicine's strategic goals of readiness, value, and jointness by 
developing products that preserve, protect, treat, or enhance the 
health and performance of Sailors and Marines. RDT&E efforts represent 
cost-effective, value-based solutions, and align with efforts from the 
others Services to avoid unnecessary duplication.
    The Naval Medical Research Center (NMRC) and its seven subordinate 
laboratories (Naval Health Research Center, San Diego, California; 
Naval Medical Research Unit-SA, San Antonio, Texas; Naval Medical 
Research Unit-D, Dayton, Ohio; Naval Submarine Medical Research 
Laboratory, Groton, Connecticut; Naval Medical Research Unit Two, 
Singapore; Naval Medical Research Unit Three, Cairo, and Naval Medical 
Research Unit Six, Lima) collectively form an RDT&E enterprise that is 
the Navy's and Marine Corps' premier biomedical research, surveillance/
response, and public health capacity building organization.
    Our researchers continue to make progress with some of our most 
challenging health issues including malaria. Experts from NMRC and 
other Federal and industry partners published the results of a 
successful clinical trial of a new malaria vaccine. This is the first 
time 100 percent protective efficacy has been achieved in any clinical 
test of a candidate malaria vaccine. Malaria continues to present a 
major challenge to force health protection during operations in any 
environment where malaria is endemic. The results of these clinical 
trials offer significant promise for protecting the health our deployed 
service members and the world's population.
    On September 20, 2013, Naval Medical Research Unit Two (NAMRU-2), 
Singapore, also designated Naval Medical Research Center--Asia (NMRC-
A), officially opened its doors during a ribbon cutting ceremony at its 
new location at Navy Region Center, Singapore, inside the Port of 
Singapore Authority (PSA) Sembawang. This opening ended a lengthy 
transition that started in June 2010 when the political situation in 
Indonesia forced NAMRU-2 out of Jakarta, Indonesia to become NAMRU-2 
Pacific, at Joint Base Pearl Harbor-Hickam, Hawaii. In addition to the 
command, support and science operations now in Singapore, NAMRU-2 has a 
field activity in Phnom Penh, Cambodia that has grown from a small 
infectious disease surveillance operation in the mid-1990s to a full 
state-of-the-art infectious diseases laboratory. NAMRU-2 supports its 
infectious disease surveillance, response, and capacity building 
efforts throughout Southeast Asia in cooperation with the Army's Armed 
Forces Research Institute for Infectious Diseases (AFRIMS) in Bangkok, 
Thailand. Last month, I had an opportunity to visit the NAMRU-2 and 
meet the outstanding staff as well as our military medical counterparts 
in Vietnam and Cambodia. I saw firsthand the outstanding international 
collaboration between our scientists and the high value infectious 
disease research being conducted. These efforts are important as we 
continue to develop partnerships and foster cooperation in the Asia-
Pacific area.
    Our Clinical Investigations Program (CIP) is an important component 
of the Navy Medicine research portfolio. Navy Medicine satisfies the 
requirements that exist for accreditation of postgraduate healthcare 
training programs through trainee participation in CIPs at our teaching 
MTFs. The clinical research is developed by our medical, dental, 
nursing and allied health sciences trainees. In fiscal year 2013, our 
MTFs conducted a total of 527 clinical research projects that resulted 
in 436 scientific publications. Our CIPs improve the quality of patient 
care and add to the global compendium of knowledge, as the findings 
were published in peer reviewed medical and scientific journals and 
presented at both national and international meetings.
              excellence in health education and training
    Education and training is critical to the future of Navy Medicine. 
We train our personnel to meet the current challenges of providing 
state-of-the-art healthcare and provide them with the skills sets to 
adapt and respond to ever-changing operational demands moving forward. 
In this regard, we advance the continuum of medical education, training 
and qualifications that enable health services and force health 
protection through innovative and cost-effective learning solutions.
    Onboard the tri-service Medical Education and Training Campus 
(METC), the largest integrated medical training facility in DOD, 
Sailors are training side-by-side with Soldiers and Airmen. METC is 
impressive in scope and curricula as it now encompasies 51 programs of 
instruction, approximately 6,000 average daily student load, and over 
21,000 graduates a year. With outstanding facilities, advanced 
educational technologies and a great faculty, METC is providing our 
corpsmen, and their Army and Air Force counterparts, with unmatched 
training opportunities. Last year, 4,392 corpsmen graduated from the 
METC Basic Medical Technician Corpsmen Program and 1,107 completed 
advanced training programs. Currently, approximately one-third of our 
hospital corpsmen are METC graduates.
    Graduate Medical Education (GME) is critical to the Navy's ability 
to train board-certified physicians and meet the requirement to 
maintain a tactically proficient, combat-credible medical force. 
Robust, innovative GME programs continue to be the hallmark of Navy 
Medicine and I am pleased to report that despite the challenges 
presented by fiscal constraints and new accreditation requirements, our 
programs remain in excellent shape.
    Our institutions and training programs continue to demonstrate 
outstanding performance under the Accreditation Council for Graduate 
Medical Education (ACGME). Board certification is a key metric of 
strong GME and the 5-year average first time board certification pass 
rate for our trainees is 93 percent. These results meet or exceed the 
national average in virtually all primary specialties and fellowships. 
We are watchful of developing trends over the next several years to 
include a highly visible institutional role in the accreditation 
process and oversight, increased emphasis on the ability to demonstrate 
a culture of safety and supervision in the accreditation of training 
programs and improved alignment between training and operational 
requirements.
    Our education and training capabilities will continue to adapt and 
evolve to ensure we meet the demands of providing Navy Medicine 
personnel who are well-prepared and mission-ready.
                        global health engagement
    Navy Medicine is uniquely postured by our global health engagement 
(GHE) capabilities in security cooperation, health threat mitigation 
and force health protection to support the warfighter across the full 
range of military operations. These efforts are important in building 
relationships and increasing interoperability with our allies, 
international organizations, as well as inter-agency and non-
governmental organization partners. They also improve readiness by 
providing unmatched training and experiential opportunities that will 
help assure our success in peace and at war.
    We currently have Navy Medicine personnel dedicated to GHE 
activities across 90 countries in support of our Geographic Combatant 
Commanders and Naval Component Commands. In general, these personnel 
are engaged daily with host nation personnel and their counterparts 
throughout the country. This includes three primary overseas labs, two 
Health Affairs Attachee Offices in U.S. Embassies, a comprehensive 
Defense HIV-AIDS prevention program working with 80 foreign militaries, 
and a network of ten liaison activities collaborating with 
international and inter-agency global health partners at home and 
abroad.
    In addition, we are committed to providing humanitarian assistance 
and disaster relief (HA/DR) whenever and wherever needed. HA/DR is a 
core capability of Naval forces and enhances readiness across the full 
range of military operations. The Navy is well-suited for these 
missions because our expeditionary forces are on station and can 
quickly respond when crises arise.
    Our hospital ships, USNS Mercy (T-AH 19) and USNS Comfort (T-AH 
20), are executing our Global Maritime Strategy by building the trust 
and cooperation we need to strengthen our regional alliances and 
empower partners around the world. Mercy and Comfort are configured to 
deploy in support of missions globally including in Latin America and 
the Pacific. With each successful deployment, we increase our 
interoperability with host and partner nations, non-governmental 
organizations (NGOs) and our interagency partners.
    As a result of sequestration, the Navy deferred Continuing Promise 
2013, and the humanitarian deployment of Comfort to Central and South 
America. However, since September 2013, Navy Medicine, in coordination 
with U.S. Pacific Fleet, has been supporting the development of Pacific 
Partnership 2014. This year's mission is unique as the United States 
will be partnering with Australia and New Zealand aboard a Japanese 
ship to provide health assistance, subject matter expertise exchanges 
and other related activities.
    It is important to recognize that Navy Medicine personnel who 
participate in enduring humanitarian civic action (HCA) missions such 
as Pacific Partnership and Continuing Promise often describe them as 
life changing and I agree. Continued deployment of our hospital ships 
provide medical capacity building and care to thousands of people 
throughout the world. These experiences cannot be replicated and the 
benefits to our readiness and response capabilities are significant.
                             collaborations
    We are stronger as a result of our work with the other Services, 
interagency partners, leading academic and research institutions and 
other civilian experts. These collaborations are important as we 
leverage efficiencies in patient care, research, education and 
technology.
    Navy Medicine has a long history of collaborating with the 
Department of Veterans Affairs (VA). We have unique collaborations and 
over 55 sharing agreements that benefit both Departments' 
beneficiaries, including the Captain James A. Lovell Federal Health 
Care Center (FHCC) in North Chicago. The fiscal year 2010 National 
Defense Authorization Act established a 5-year demonstration project 
located at the FHCC which will be carefully assessed over the next year 
to support a report to Congress to help inform the future of this 
facility and the potential for similar ventures between DOD and VA. Our 
respective leadership teams are engaged at all levels and addressing 
important issues including health information technology 
interoperability, business and administrative processes, leadership 
opportunities and staff assignments. There is also an active FHCC 
Stakeholders Advisory Council comprised of local stakeholders from 
Veterans Service Organizations, community and university 
representatives, the managed care support contractor, and other key 
groups. Our priorities remain ensuring that our recruits, service 
members and beneficiaries have unimpeded access to high quality 
healthcare and in our staff maintaining their clinical skills in 
support of the readiness mission.
    Another important collaboration with the VA is the Integrated 
Disability Evaluation System (IDES). IDES is in its fifth year as a 
service member-centric, DOD/VA program designed to transition wounded, 
ill, and injured service members to civilian life with no gaps in 
benefits or medical care between the DOD and VA. Navy Medicine has 
primary responsibility to oversee and implement the first 100 days of 
the IDES process, which includes both the Referral Phase and the 
Medical Evaluation Board (MEB) Phase. In collaboration with our VA 
counterparts, we met the 100-day MEB phase goal for 24 consecutive 
months for Navy service members, and 21 consecutive months for Marine 
Corps service members.
    We established the Navy Medicine Records Activity (NMRA) on January 
1, 2014, to collect and review all Service Treatment Records (STRs) of 
separating or retiring active and reserve component service members in 
the Navy and Marine Corps. Throughout our MTFs and operational 
commands, we are working together to ensure complete medical and dental 
documentation is included in the STR. NMRA ensures all STRs are 
complete by performing a quality assurance check prior to being scanned 
into the Health Artifact and Image Management Solution (HAIMS) database 
for timely retrieval by the VA.
    The Vision Center of Excellence (VCE) is a congressionally directed 
DOD/VA Centers of Excellence. Navy Medicine is the Lead Component for 
the VCE and provides support operational support and oversight. The VCE 
continues to engage across the continuum of care in support of advances 
in vision rehabilitation through the development of recommendations for 
clinical assessment, management, rehabilitation, and referral of visual 
and oculomotor dysfunction, as well as visual field loss associated 
with TBI. The team is working to address the clinical challenges of 
visual dysfunction associated with TBI through various educational 
workshops and work groups. VCE experts have developed and implemented 
the Defense and Veterans Eye Injury and Vision Registry (DVEIVR) to 
combine DOD and VA clinical ocular information into a single 
centralized repository of data. DVEIVR will allow the VCE to provide 
longitudinal outcomes to enhance clinical best practices, guide 
research and inform policy.
                             our way ahead
    Navy Medicine remains fully engaged--at home and underway with the 
Fleet and Marine Forces. We are providing world-class care globally and 
operating across the entire dynamic--in the air, on and below the sea 
and on land. For us, this is a remarkable privilege and honor.
    These are transformational times for military medicine. There is 
much work ahead as we navigate important challenges and seize 
opportunities to keep our Sailors and Marines healthy, maximize the 
value for all our patients and leverage joint opportunities. I am 
encouraged with the progress we are making but not satisfied so we 
continue to look for ways Navy Medicine can improve and remain on the 
forefront of delivering world-class care, anytime, anywhere.

    Senator Durbin. Thank you, Admiral.
    General Travis.
STATEMENT OF LIEUTENANT GENERAL THOMAS W. TRAVIS, 
            SURGEON GENERAL, DEPARTMENT OF THE AIR 
            FORCE
    General Travis. Chairman Durbin, Vice Chairman Cochran, 
Senator Blunt, thank you for inviting me to appear before you 
today with my partners.
    Our military forces have benefited from the vast 
achievements Army, Navy, and Air Force medics have jointly made 
in deployed and en route care since the beginning of the 
current war.
    With this war winding down, even with fiscal challenges, we 
now have a clear responsibility to make sure military medics 
are well-trained, well-prepared for whatever contingency the 
future brings, to include combat operations, stability 
operations, humanitarian assistance, or disaster relief.
    To enhance our core competency in providing far-forward and 
en route care, both on the ground and in the air, we must 
ensure that our providers and staff continue to have robust 
opportunities to practice their skills, and that we continue to 
pursue critical research and modernization initiatives in the 
future.
    We very successfully leverage civilian partnerships to 
maintain trauma skills in our C-STARS (Center for the 
Sustainment of Trauma and Readiness Skills) platforms, one of 
which is in Baltimore's Shock Trauma.
    And as this war subsides, I am convinced we will rely even 
more strongly on these relationships to help us train and to 
conduct critical research.
    As the way we fight war evolves, the way we provide medical 
support for operators is also evolving.
    Airmen who are manning systems such as distributed common 
ground stations, space and cyber-operations, or remotely 
piloted aircraft, and those who operate outside the wire, such 
as security forces, special operation forces, and explosive 
ordnance disposal specialists, all face distinct challenges.
    These types of injuries or stressors, both visible and 
invisible, to members and their families are also changing. We 
must provide medical support in different ways than we have in 
the past to address what we describe as an expanding definition 
of operators and step up to our role as human performance 
practitioners.
    Not only will access and care be more customized for the 
mission, but so will prevention. For example, we have embedded 
mental health providers with the right level of security 
clearance in several remote warfare units to be readily 
available at the duty location to provide early intervention 
and care for those experiencing occupational stress that could 
affect their performance. These important operators may not 
have otherwise sought care.
    I would add that 2 days ago, I visited the 480th 
intelligence wing at Langley Air Force Base Virginia, where you 
have hundreds of very young airmen who are watching screens 24/
7, 365 days a year. And their leadership is convinced that what 
we have done there, we have prevented suicides in the last 2 
years. I am, too.
    The Air Force is committed to the department's plan for the 
reorganization of the military health system to include the 
establishment of the Defense Health Agency. There are many 
changes in the works for how we will operate, and we are 
excited to be fully engaged with our partners in this tough 
work.
    And it is tough work, as we continually focus on providing 
trusted care and maintaining a fit, healthy, ready fighting 
force.
    Personally, I have been in the Air Force for over 37 years, 
first as a pilot and for many years now as a physician. And in 
my career, I have never seen a time when it was more evident 
how important military medicine is to the operational 
capability of this Nation.
    We have learned much and our medics have performed 
magnificently. Even in the face of budget challenges we have to 
be as ready at the beginning of the next war as we are now at 
the end of the current war.

                           PREPARED STATEMENT

    I think our Nation expects that. Our members and their 
families deserve nothing less. Your continued support of Air 
Force Medicine and military medicine and our missions are 
greatly appreciated.
    Thank you for that support and for your invitation to be 
with you today.
    [The statement follows:]
         Prepared Statement of Lt. Gen. (Dr.) Thomas W. Travis
    Chairman Durbin, Vice Chairman Cochran, and distinguished members 
of the subcommittee, thank you for inviting me to appear before you 
today. The Military Health System (MHS) is a world-class healthcare 
organization, and the Air Force Medical Service is proud to be a full 
partner. We have successfully overcome many significant challenges 
since we last met with the subcommittee, and greatly appreciate your 
strong support.
    As the war draws down and the focus shifts to in-garrison care, it 
is tempting to compare the MHS to civilian healthcare organizations. 
But there is a cost associated with being prepared to execute our 
readiness missions, and no civilian healthcare system in the world can 
do what we do--and have done--when called upon to provide deployed and 
en-route care. That is the one key message I hope to leave with you 
today. The AFMS remains closely linked with our Army and Navy 
colleagues in our efforts to achieve the MHS Quadruple Aim of 
Readiness, Better Health, Better Care, and Best Value--but Readiness is 
first!
    The AFMS is committed to supporting the Line of the Air Force 
mission--our ``True North''--maintaining a medical force that is 
trained and ready to deploy at a moment's notice, but also aligned with 
our wings in support of their operational missions. We have logged an 
astounding 194,300 patient movements since 9/11, including transporting 
7,900 critical care patients. We provided ``care in the air'' to more 
than 5,000 patients in 2013 alone, including almost 300 Critical Care 
Air Transport Team (CCATT) missions for the most seriously ill and 
injured. Recently, the Lung Team and one of our CCATTs transported the 
wife of a service member in need of a lung transplant on an 
Extracorporeal Life Support (ECLS) machine from Landstuhl, Germany to 
Joint Base Andrews, Maryland--the longest trip ever for transporting a 
critically ill patient on ECLS who survived. Further research into use 
of the ECLS for the comprehensive treatment of combat casualties with 
single and multi-organ failure is underway at the Joint Battlefield 
Health and Trauma Institute by Air Force investigators. Our CCATT 
capability has allowed us to advance our practice of transporting only 
stable patients to a paradigm of en-route patient treatment that has 
become integral to health service support in joint doctrine.
    As we strive for even greater survival rates, we've evolved our 
CCATT capability point-of-injury response. This provides more capable 
care further forward and more sophisticated in-transit support. Our 
Tactical Critical Care Evacuation Teams (TCCETs) provide damage control 
resuscitation on rotary-wing, forward-deployed fixed-wing, and tilt-
wing aircraft, and have accomplished more than 1,600 critical care 
patient movements since we began the program in June 2011, many from 
point of injury. In an effort to ensure these teams are fully trained 
to provide continuous en-route critical care, we have partnered with 
the University of Cincinnati (UC) Medical Center to develop a TCCET 
course at the same location as our CCATT training. We have dedicated 
Air Force Medics on staff at UC to provide this training. We have 
similar trauma training partnerships with Baltimore Shock Trauma and 
St. Louis University for our ground-based expeditionary medical teams. 
These partner universities are each a Center for the Sustainment of 
Trauma and Readiness Skills, or C-STARS.
    Our health response teams include rapidly deployable, modular, and 
scalable field hospitals that provide immediate care within minutes of 
arrival. The Expeditionary Medical Support Health Response Teams (EMEDS 
HRT) are successfully deployed as a part of our continuous evolution in 
medical response capabilities anywhere in the world. They provide 
immediate emergency care within minutes to hours of arrival--surgery 
and intensive critical care units in place within 6 hours, and full 
capability established within 12 hours of deployment arrival.
    The training course at Camp Bullis, near San Antonio, was updated 
to provide more realistic training scenarios to prepare for disaster 
and humanitarian missions that may require pediatric, women's health, 
and geriatric care while maintaining the ability to use this capability 
in a wartime setting. This evolved expeditionary HRT capability was 
successfully demonstrated in Peru in 2012, and is on track to be fully 
deployed as a replacement of our previous generation of EMEDS by 2016.
    The success of TCCET, CCAT, and EMEDS-HRT in expanding our 
capabilities relies on collaboration with our civilian partners in the 
areas of research, education and training, and provider currency. We 
are involved in some amazing state-of-the-art research in our major 
thrust areas of En Route Care, Force Health Protection, Expeditionary 
Medicine, Human Performance and Operational Medicine.
    One fascinating example is the Airborne Laser Sensor project, a 
collaborative effort with U.S. Customs and Border Protection that uses 
an AF-developed airborne sensor flown on Air Force aircraft to sense 
and detect laser illumination of aircrew to determine the occupational 
health hazard from laser exposure. Another example is our partnership 
with the Battlefield Health and Trauma Research Institute and the San 
Antonio University Health System to conduct research on spinal 
fractures, blood transfusions, sepsis, burns, hemorrhagic shock, and 
compartment syndrome. In support of Human Performance and Enroute Care, 
our C-STARS faculty and civilian partners are studying the timing of 
aeromedical evacuation on the clinical status of combat casualties to 
help medical teams determine the best timing of evacuation to optimize 
health outcomes. While we have been very proud of our success in 
quickly returning patients to higher levels of care when required, the 
decision of when to move a patient must be data-driven, and our 
experience in the current long war should help guide such decisions in 
the future.
    We also focus research on better care and health for Air Force 
families. For the past several years, Wright-Patterson AFB Medical 
Center, Nationwide Children's Hospital, and Dayton Children's Hospital 
in Ohio have teamed to develop protocols to identify autism spectrum 
disorder susceptibility genes and rare variants to allow early 
intervention, and have created the Central Ohio Registry for Autism. 
Many families have already benefitted from this ongoing research, and 
many more will.
    Our C-STARS partnerships in Baltimore, Cincinnati and St. Louis 
provided critical trauma and CCATT training to our deploying medics 
during the war and will remain significant platforms. However, with the 
end of the war and drawdown of theater hospitals where readiness 
currency is at its highest, we need to expand our training 
opportunities in the pause between hostilities to ensure all of our 
personnel remain ready and current to care for our wounded warriors 
from point of injury to rehabilitation. We are transitioning to a 
layered, centrally managed platform emphasizing hands-on patient care, 
called Sustained Medical Airmen, Readiness Trained (SMART). SMART 
establishes a three-tiered approach where personnel at facilities of 
all sizes will train with a standardized curriculum using organic 
training opportunities, local training affiliation agreements with 
partnering hospitals, and, when necessary, regional currency sites to 
ensure required skills are preserved and staff is sustained in a 
trained and ready status. We anticipate our first class at a Regional 
SMART site to begin in September at Nellis AFB, Nevada, which is our 
alpha test site.
    In another exciting new program, we have joined with the Uniformed 
Services' University of the Health Sciences (USUHS) to create an 
Enlisted to Medical Degree Preparatory Program (EMDP2). The program is 
designed to help highly motivated active duty enlisted to complete the 
coursework necessary to apply for medical school while on active duty. 
This 2-year program serves as one component in a comprehensive plan to 
recruit a student body that mirrors the diversity of our Nation and 
expands the pool for future top-notch military clinicians, leaders, and 
scholars. The Air Force and the Uniformed Services University have 
selected the first five candidates, who will begin their studies later 
this summer.
    In addition to education and training, human performance 
initiatives are critical to optimizing performance of our personnel, 
especially as the definition of the ``warfighter'' has evolved. For 
example, Remotely Piloted Aircraft (RPA) and Distributed Common Ground 
System (DCGS) operators execute their core missions in garrison, 
requiring a shift in how we view and provide medical support. We have 
customized our medical support to meet the needs of Airmen performing 
these very stressful missions. Our medics are becoming Human 
Performance Practitioners--actively seeking opportunities to sustain, 
enhance, and optimize performance of Air Force personnel.
    Lessons learned in support of Special Operations Forces through the 
Preservation of Force and Families initiative have improved our support 
of other ``Battlefield Airmen'' (for example, Combat Search and Rescue, 
Tactical Air Control Party, and Explosive Ordnance Disposal 
Specialists). Tailored physical therapy support, psychological support, 
and by-unit Primary Care Manager empanelment for these Airmen have 
allowed prompt identification of physical and mental disease, rapid 
treatment and aggressive case management/care coordination to return 
these Airmen to their elite, high-performing state. We are teaming the 
right specialties and support agencies to keep our Airmen at the top of 
their game. To do this effectively, some of our medics possess the 
level of security clearance required for them to be fully read-in on 
missions and challenges and, in some cases, to have office space where 
the missions are executed, which greatly improves access and trust.
    Additionally, we are studying the operational and occupational 
health effects impacting personnel in Air Force-specific aircraft to 
determine risk of short-term and potentially long-term neurocognitive 
deficits secondary to high altitude exposure and to develop methods to 
reduce prevalence of these injuries. Results of this work to date have 
directly impacted operational activities associated with the U-2 
aircraft to mitigate health effects, and we will continue to monitor 
this population through ongoing research.
    The success of our operational health initiatives relies on a 
strong foundation of in-garrison care. We continue to embrace the 
principles of Patient-Centered Medical Home (PCMH) to improve patient 
care, access and outcomes. We have attained all-time-high levels of 
provider and team continuity throughout 2013, while reducing emergency 
room utilization rates. We developed standardized support staff 
protocols to promote evidence-based practice, reduce variation, and 
enhance reliability by utilizing PCMH teams to their fullest 
capabilities. The protocols have also helped improve currency of our 
medics while creating access opportunities for our patients.
    Likewise, we have achieved enhanced access through the continued 
deployment of secure messaging. This technology has now been launched 
throughout the AFMS and includes more than 305,000 enrolled users 
sending over 41,000 messages per month. This leading-edge communication 
tool provides an additional venue to meet patient needs without face-
to-face appointments, and helps our patients partner with providers in 
the management of their care.
    Last year we reported that we launched our telehealth initiative 
called Project ECHO (Extension for Community Health Outcomes) with one 
specialty (complicated diabetes management) serving three military 
treatment facility (MTF) pilot sites. Now in our second year, we have 
added chronic pain management, traumatic brain injury, behavioral 
health, dermatology, ENT and acupuncture for a total of seven live ECHO 
specialty series and are on track to add four more specialties areas 
(Addictions, Infectious Disease, Neurology and Dental) this coming 
year. We have expanded participation to include all Services and the 
Department of Veterans Affairs (VA). In addition, continuing medical 
education accreditation was granted for six of the seven ECHOs. 
Participating provider response has been overwhelmingly positive with a 
17-percent increase in provider knowledge and confidence level in their 
management of these complicated patients, and an overall 95-percent 
approval rating in the ECHOs' value to their practice. Project ECHO is 
postured for MHS-wide adoption under the new Defense Health Agency.
    Our patient safety program continues to be the bedrock of our 
healthcare operations. Patient safety managers collaborate with subject 
matter experts in risk management, clinical quality, customer service, 
professional staff management, compliance and accreditation to ensure 
we provide the highest quality care in the safest environment possible 
for our beneficiaries. The ``Partnership for Patients'' initiative was 
implemented by the MHS in 2013 ensuring that each MTF develop processes 
and programs to reduce risk to our patients related to 10 Healthcare 
Related Conditions. We successfully rolled out all of the 
implementation guidelines last year and are pleased to report that the 
AFMS has fully implemented all 119 elements.
    The high quality of our care in our inpatient facilities is 
monitored and validated by, the Joint Commission (TJC), the leading 
accreditor of healthcare organizations in America. This past year three 
of our hospitals earned top accreditation honors by TJC for exemplary 
performance and were named among the Nation's Top Performers on Key 
Quality Measures. The Joint Commission recognized these hospitals for 
their outstanding performance using evidence-based clinical processes 
that are shown to improve care for certain conditions, including heart 
attack, heart failure, pneumonia, surgical care, children's asthma, 
stroke and venous thromboembolism, as well as inpatient psychiatric 
services. Our facilities achieving top honors include the 96th Medical 
Group, Eglin Air Force Base, Florida; 48th Medical Group, RAF 
Lakenheath Air Base, England; and the 81st Medical Group, Keesler AFB, 
Mississippi.
    World-class healthcare begins with disease prevention: We promote 
healthy behaviors and lifestyle choices to reduce illness and ensure a 
high quality of life for our Airmen and their families, resulting in a 
healthy, fit, resilient and productive force. We are targeting 
nutritional fitness, physical activity, healthy weight and tobacco-free 
living. Ten percent of active duty Airmen are obese. While this rate is 
much lower than the civilian average, we will continue to execute 
initiatives such as ``Go For Green''--a food labeling system in 
military dining facilities that promotes healthy food choices. The Air 
Force has vigorously supported the National Prevention Council 
commitment to expand tobacco-free environments, and we are very 
encouraged by the results. Smoking in the Air Force has seen a steady 
decline; our current smoking prevalence of 14 percent is lower than the 
national average of 18 percent. But we will work to drive it even 
lower.
    To increase resilience of deploying Airmen and reduce the 
likelihood of post traumatic symptoms, our Airman Resilience Training 
provides standardized pre- and post-exposure training and reintegration 
education, which we are now redesigning to be better tailored to 
specific groups of deployers. Even though Air Force rates of Post-
Traumatic Stress Disorder (PTSD) remain relatively low compared to the 
other Services, we continue looking for ways to prevent or minimize 
symptoms.
    We have formally trained the majority of our mental health 
providers and all new social work and psychology trainees on evidence-
based treatments for PTSD, and the Center for Deployment Psychology at 
the Uniformed Services' University offers ongoing provider training 
support. The Air Force continues to actively participate in joint and 
collaborative research projects with the U.S. Army Medical Research and 
Materiel Command, STRONG STAR and Penn State, looking at the 
effectiveness of treatments, biomarkers and the future of PTSD 
treatment. We believe these efforts will continue to pay huge dividends 
in the future.
    The mental health of our Airmen and their families' remains an 
important focus area for us. We are continually striving to improve 
access to mental healthcare through initiatives such as Patient-
Centered Medical Home-Behavioral Health (PCMH-BH), which embeds mental 
health providers within the primary care clinics of each MTF to offer a 
lower-stigma mental healthcare option for beneficiaries. Another 
initiative is Mental Health Integration, a demonstration project at two 
of our MTFs to evaluate placing full-service mental health capability 
in Primary Care, promoting early intervention, improved access, and 
continuity of care within the MTF. The deployment of video 
teleconferencing capabilities in our mental health clinics has also 
helped to address the needs of our patients. We stood up six hubs for 
tele-psychiatry services throughout the AFMS, providing important 
psychiatric consultation to MTFs without on-site psychiatry. Each of 
these resources support increased access while reducing the stigma of 
seeking mental health assistance.
    Fortunately, the incidence of deployment-associated traumatic brain 
injury (TBI) has remained low for the Air Force. However, we remain 
committed to ensuring appropriate care for our Airmen who have 
sustained TBI through referrals to the National Intrepid Center of 
Excellence for Psychological Health and Traumatic Brain Injury, and to 
the many TBI programs throughout the Department of Defense (DOD). Our 
TBI Clinic at Joint Base Elmendorf-Richardson is engaged in cross-
Service efforts to standardize and optimize TBI care within the DOD.
    We remain concerned about suicides in the Air Force. In December 
2013 we released an updated and refined version of ``The Air Force 
Guide for Suicide Risk,'' based on research and published best 
practices over the last 10 years. This document provides a resource of 
state-of-the-art knowledge for the clinical management of suicide-
related ideation and behaviors, allowing better standardization of 
clinical assessment and treatment of at-risk patients. The new version 
adds references for cognitive behavioral treatments for suicidal 
patients. This valuable resource will assist the ongoing training of 
our mental health personnel; improve the quality of care provided to 
those at risk of suicide, and support effective consultation to Air 
Force supervisors of Airmen at risk.
    Airmen and their families are our most important resource and in an 
effort to improve the care provided to Air Force Families, we have 
recently completed a comprehensive examination of the relationship 
between deployments and subsequent rates of family violence. We found 
that among deployers, the rate of spouse abuse and child maltreatment 
is about the same before and after deployment. We have also identified 
a few specific situations that place military families at higher risk 
for family violence and are targeting family violence prevention 
efforts to those families at risk.
    We are also committed to ensuring quality, compassionate care for 
victims of sexual assault, through the Air Force's Sexual Assault 
Prevention and Response Program. The Air Force has processes in place 
to perform Sexual Assault Forensic Exams (SAFE) either within the Air 
Force MTF, another nearby military medical facility, or through 
partnerships with civilian experts in the local community. We utilize 
sexual assault forensic examination training programs that comply with 
the standards established in the Department of Justice ``National 
Protocol for Sexual Assault Medical Forensic Examinations.'' In 
addition, we have designated executive level oversight at our MTFs, 
incorporated First Responder training requirements in the Major Command 
(MAJCOM) compliance inspection, and initiated a bi-directional 
information and communication link specific to sexual assault 
prevention and response, facilitating updates and answers to and from 
our MTFs. We stand ready to support every sexual assault victim with 
respect, compassion, urgency and professionalism.
    Another area of concern is the impact of hearing loss on 
operational readiness and longterm quality of life. Hearing loss 
remains an easily overlooked occupational injury in service members and 
Veterans. As lead agent for the DOD Hearing Center of Excellence (HCE), 
the Air Force supports the efforts of the HCE to create better 
awareness of this pervasive injury through comprehensive hearing health 
programs. The HCE is finalizing the development of the Joint Hearing 
Loss and Auditory System Injury Registry and has established necessary 
agreements to access relevant DOD and VA data sources, standardize data 
collection, and manage data requirements. Initiatives are underway 
across the MHS and VA to improve hearing protection, standardize 
baseline and periodic hearing assessments across the Services, and 
establish engineering and acquisition best business practices that 
reduce hazardous noise at the source. Hearing loss is a mostly 
preventable disease, and both the operational and medical communities 
have a huge stake in preventing this injury.
    The DOD Centers of Excellence are one of many areas where DOD and 
the Services work closely with the VA. As most of our military patients 
at some time pass through each other's doors, it makes sense to plan 
together and share resources where feasible. Our relationship with the 
VA also expands clinical currency opportunities for both entities. We 
have had great success through the DOD/VA Joint Incentive Fund; 46 
percent of all joint incentive fund projects include Air Force MTFs.
    One of the most successful projects is the Joint Vascular and 
Endovascular Surgical Services project at David Grant Medical Center 
(DGMC), Travis AFB, California. Working with the Northern California VA 
Health Care System, millions of dollars have been saved in only 2 years 
and more than 350 VA and DOD patients have stayed in in the Federal 
care system. The vascular team at DGMC has embraced this initiative and 
enhanced their clinical skills with the increased patient load. In 
addition to efforts at DGMC, the Air Force has seen similar success at 
the Michael O'Callaghan Federal Medical Center (MOFMC), Nellis AFB, 
Nevada with their cardiac catheterization laboratory seeing both VA and 
DOD beneficiaries exceeding all early projections by approximately 20 
percent. This project is only one of the sharing initiatives at this 
Joint Venture site.
    Other successful sites include the 81st Medical Group at Keesler 
AFB, where their long list of Joint Incentive Projects include a Joint 
Cardiovascular Care Center that to date has seen a cumulative benefit 
of $9.4 million and sustains the clinical currency of the Air Force 
providers with the continued influx of VA patients. This is only one of 
the successes at the 81st Medical Group; others include a joint 
business office function that has the common goal is to reduce 
duplication of services, capitalize on respective core competencies, 
and optimize volume to deliver services safer and more economically.
    Throughout the Air Force Medical Service, DOD/VA sharing has been 
implemented and is continually emphasized as a way to enhance the 
clinical currency of our providers as well as provide economic, high 
quality healthcare for both DOD and VA beneficiaries. Recent efforts at 
the 88th Medical Group, Wright-Patterson AFB, Ohio have resulted in a 
significant increase in the number of VA patients being seen at that 
location with anticipation that it will continue to grow in the future. 
Efforts at Eglin AFB, Florida are generating large increases in VA 
visits and surgeries and have made them the fifth largest sharing site 
in the AFMS. We will continue to push for more sharing at sites in 
close proximity to VA facilities and where there is an opportunity to 
care for VA patients in our MTFs.
    The fiscal year 2015 President's budget includes a proposal for a 
TRICARE Consolidated Health Plan along with modest increases in 
beneficiary out-of-pocket costs for active duty families, retirees and 
their families, and reserve component members and their families. These 
proposals reflect the Department of Defense's efforts to modernize and 
simplify the TRICARE program that will place the program on a stable, 
long-term footing.
    Finally and importantly, the AFMS is united with our Army, Navy and 
DOD colleagues in support of the MHS governance reform efforts. The 
Defense Health Agency stood up in October 2013, and as of this date the 
first seven of 10 planned shared services have reached IOC. These 
include Facility Planning, Medical Logistics, Health Information 
Technology, TRICARE Health Plan, Pharmacy, Budget & Resource 
Management, and Contracting. The DHA is on target for the next group of 
shared services to reach IOC this year and full operating capability in 
October 2015. We remain fully committed to achieving reforms for best 
value and interoperability by seeking common solutions as we provide 
better care and better health to our beneficiaries.
    In conclusion, despite the challenges we all experienced in the 
past year, the Air Force Medical Service continued to focus hard on 
providing operational support and high quality care around the globe, 
in-garrison and deployed, on the ground or in the air--that's what we 
mean by ``Trusted Care Anywhere!'' I am honored to lead and serve with 
Air Force medics during this very important time. But I am just as 
honored to partner with my Army and Navy colleagues as we move forward 
together to build an even better Military Health System. Thank you for 
your continued support of our critical mission.

    Senator Durbin. Thank you, General.
    Mr. Miller.
STATEMENT OF CHRISTOPHER MILLER, PROGRAM EXECUTIVE 
            OFFICER, DEFENSE HEALTHCARE MANAGEMENT 
            SYSTEM
    Mr. Miller. Chairman Durbin, Vice Chairman Cochran, Senator 
Blunt, thank you for the invitation and for welcoming me today 
to discuss the progress we have been making with respect to 
electronic health records (EHR) interoperability.
    I was appointed to my position last September by Under 
Secretary Frank Kendall. I am the department's senior official 
responsible for electronic health records interoperability with 
the Department of Veterans Affairs and with our civilian 
partners. I also have the privilege of representing the DOD-VA 
Interagency Program Office, or the IPO, as the acting director.
    My job and singular focus is to provide real healthcare IT 
(information technology) solutions to America's finest that 
support and defend this great Nation.
    As you are aware, in 2009, DOD and VA were called upon to 
work together and build a seamless system of integration. To 
that end, the departments are pursuing complementary efforts. 
Specifically, the departments are, one, working to provide 
seamless, integrated sharing of standardized health data among 
DOD, VA, and private sector providers; and two, modernize our 
electronic health records software and systems supporting our 
DOD and VA clinicians.
    DOD's efforts with respect to these two goals can be seen 
in three distinct programs.
    First, in January 2013, the Secretaries committed to 
executing several near-term interoperability missions. We knew 
that we could not wait to modernize our electronic health 
record systems to see near-term improvement. These were 
completed last December, and we are currently working follow-on 
initiatives in partnership with the VA.
    Among these efforts are the joint legacy viewer and 
improved data federation, which, combined, provide access to an 
integrated view today of DOD and VA's health records.
    We also worked to establish a medical community of interest 
network that is designed to improve the transport and how we 
exchange information between departments. The progress made 
will continue, and we will continue to work to expand the level 
of interoperability among DOD and VA over the next years.
    The departments exchange more than 1.5 million elements of 
data today. And as of January, there are more than 5.2 million 
correlated health records between the two departments.
    The departments have also achieved greater levels of 
integration and interoperability at the Captain James A. Lovell 
Federal Health Care Center in North Chicago.
    In February, we completed capability upgrades that will 
further improve the level of interoperability. One such 
capability called orders portability creates an efficient 
methodology between the DOD and VA healthcare systems to share 
laboratory, radiology, and consult orders between the two 
systems.
    North Chicago continues to be a pioneer in achieving new 
found levels of interoperability and operations between both 
departments.
    Second, in May 2013, Secretary Hagel announced the decision 
to pursue a full and open modernization of our DOD's electronic 
healthcare systems. This was based on a comprehensive analysis 
of alternatives.
    This announcement also directed the Under Secretary of 
Defense for Acquisition, Technology and Logistics, who is my 
boss, to assume responsibility for the program. Since October, 
the DOD has stood up a program office, established a 
comprehensive plan, developed our initial cost position, and 
hosted three industry days to open dialogue about the program.
    We have also worked to develop a series of draft RFPs 
(request for proposals), which we released our first one on 
January 29, and the second RFP was released on March 28. There 
was one remaining draft RFP planned later this year, which 
ultimately all will culminate in a final request for proposals 
from industry in the fourth quarter of 2014.
    We have also finalized our acquisition strategy, which 
documents our approach to ensure we are developing a program 
that is operationally effective at the right cost for the 
American taxpayer.
    A critical component of the DHMSM (Defense Healthcare 
Management Systems Modernization) acquisition is the need for 
open standard platform flexibility. We are employing a modular 
and open systems approach to ensure that we have the 
capabilities needed to prevent vendor lock-in, and rapid 
insertion of technologies.
    Lastly, the IPO will chart the way forward for DOD and VA 
health data interoperability as a clinical and data 
standardization leader. On December 20, 2013, the IPO delivered 
its annual report to Congress outlining this new strategy.
    A new IPO charter was also jointly signed by both 
departments in January 2013, making it responsible for 
establishing, monitoring, and improving the clinical and 
technical standards, profile, and process to create seamless 
integration of health data.
    It will support both departments' and the Office of 
National Coordinators' endeavor to adopt national standards, 
specifications, and certification criteria to improve health IT 
and its applications.
    These standards are key for achieving full interoperability 
and require our long-term support and commitment.
    We are on track to publish our initial technical standards 
package later this month.
    Senators of the committee, DOD's collective efforts with 
Congress over the past 6 months have been met with the utmost 
dedication. Since October, I have engaged the committees 26 
times. Further, we have met the first of the three required 
NDAA (National Defense Authorization Act) requirements and are 
on track to meet the remainder throughout this year.
    We recently briefed this committee on our EHR monetization 
program and have submitted our signed acquisition strategy. The 
IPO also delivered its annual report to Congress ahead of 
schedule and has maintained its statutory and courtesy 
quarterly briefings to Congress.

                           PREPARED STATEMENT

    Providing high-quality healthcare for current 
servicemembers, their dependents, and veterans is among our 
Nation's highest priorities. Continuity of care is a key 
component, and interoperability is essential. It is important 
that we get this right, and we never lose sight of our mission 
and who we are serving.
    I am committed to being open and transparent, and I look 
forward to your discussion and your dialogue today as we 
exchange ideas regarding DOD's effort with electronic health 
records interoperability.
    [The statement follows:]
              Prepared Statement of Christopher A. Miller
    Chairman Durbin and Vice Chairman Cochran, thank you for the 
opportunity to address the Subcommittee on Defense of the Senate 
Appropriations Committee. I am honored to represent the Department of 
Defense (DOD) as the senior official responsible for the Department's 
efforts to modernize our electronic health records (EHRs) and to make 
them more interoperable with those of the Department of Veterans 
Affairs (VA) and private sector providers. I also have the privilege of 
representing the DOD/VA Interagency Program Office (IPO) as the current 
Acting Director.
    The Department's modernization efforts, known as DOD Healthcare 
Management Systems Modernization (or DHMSM), will replace the current 
DOD legacy military health systems with industry leading capabilities. 
We are committed to acquiring an EHR system that will appropriately 
serve the men and women who serve us in the most efficient and 
effective manner. To this end, DOD has a dedicated Program Executive 
Officer (PEO) in myself, as well as a dedicated DHMSM Program Manager 
(PM), and we have also brought onboard acquisition professionals with 
recent business IT acquisition experience. In addition, DOD has 
dedicated a PM to oversee the Department's interoperability efforts and 
ensure the continued maturation of data exchange with VA and private 
sector providers. These organizational changes for this critical 
undertaking are representative of its steadfast commitment to the 
modernization and interoperability of our EHRs and is one of the many 
reasons for our recent progress.
                               background
    As you are aware, in 2009, the Departments were called upon by the 
President to, ``work together to define and build a seamless system of 
integration so that when a member of the Armed Forces separates from 
the military, he or she will no longer have to walk paperwork from a 
DOD duty station to a local VA health center. Their electronic records 
will transition along with them and remain with them forever.''
    To that end, the Departments are pursuing complementary paths to 
modernize their respective EHRs. Specifically, the Departments' goals 
are:
      1. Provide seamless, integrated sharing of standardized health 
        data among DOD, VA, and private sector providers; and
      2. Modernize the Electronic Health Record (EHR) software and 
        systems supporting DOD and VA clinicians.
goal 1: provide seamless integrated sharing of standardized health data 
              among dod, va, and private sector providers
    In January 2013, the Secretaries committed both Departments to 
executing several data interoperability initiatives on an accelerated 
timeline to be completed no later than December 31, 2013. The 
Departments finished all of these key Accelerator projects scheduled 
for completion in fiscal year 2013 and will develop and deploy follow-
on Accelerator initiatives during fiscal year 2014. The accelerators 
included improving and deploying the Janus Joint Legacy Viewer (JLV) to 
seven locations; expanding JLV use in two additional locations; 
upgrading DOD Blue Button; expanding Captain James A. Lovell Federal 
Health Care Center (JAL FHCC) capabilities; improving data federation 
between the Departments; improving the process of patient identity 
management within both Departments; and establishing the Medical 
Community of Interest as the network infrastructure and architecture 
for the DOD and VA medical community to have secure, real-time access 
to patient data. These efforts will continue to expand the level of 
interoperability among DOD, VA, and private sector providers.
    The Department is furthering its interoperability efforts as it 
nears completion of a Health Data Sharing and Interoperability Roadmap 
that includes an acquisition and technical strategy based on functional 
requirements. Consistent with the fiscal year 2014 NDAA and in 
consultation with VA, is a comprehensive document that addresses health 
data sharing and interoperability across the life cycle, including data 
sharing/interoperability with VA, private healthcare providers, and 
patients. The efforts outlined in the Roadmap continue and improve upon 
the progress made by the previously completed Accelerator efforts to 
share standards-based, computable data among the Departments and 
private sector providers.
   goal 2: modernize the electronic health record (ehr) software and 
               systems supporting dod and va clinicians.
    In February 2013, VA assessed its EHR needs and determined that its 
best course of action would be to evolve its legacy EHR system, VistA 
to serve VA's modernization goal. The decision to proceed with this 
system update (known as VistA Evolution) included such factors as 
VistA's large installed base, trained workforce, and in-house 
development and support capacity. In May 2013, Secretary Hagel 
announced the decision to pursue a full and open competition to 
modernize DOD's EHR systems based on an Analysis of Alternatives which 
carefully considered options that would provide state-of-the-art 
capabilities to our clinicians and the best services to our soldiers, 
sailors, airmen, and Marines. This announcement directed the 
Undersecretary of Defense for Acquisition, Technology & Logistics 
(USD(AT&L)) to assume responsibility for ``DOD healthcare records 
interoperability and related modernization programs.'' In September 
2013, I was designated by the Undersecretary as PEO for the DOD 
Healthcare Management Systems (DHMS). DOD also established the DHMSM 
program to lead a competitive acquisition process that considers 
commercial solutions which will offer reduced costs, schedule, and 
technical risk, as well as providing access to increased current and 
future capability by leveraging advances in the commercial marketplace. 
Based on current market research, a VistA-based solution will likely be 
part of one or more potential solutions proposed in response to the DOD 
solicitation.
    A critical component to the requirements of the DHMSM acquisition 
is the need for open standards. Currently, DOD is employing a 
comprehensive open standards approach for its EHR and interoperability 
programs, which is accelerating the achievement of the President's open 
standards agenda. DOD efforts are capitalizing on the significant 
investment made under the Health IT for Economic and Clinical Health 
Act that accelerated EHR adoption through the Centers for Medicare and 
Medicaid Services' (CMS) EHR Adoption Incentive Program. The CMS 
program has successfully accelerated the availability of robust 
government certified interoperable commercial EHR products.
    The use of all of these mechanisms creates a transparent, open 
standards approach that will ensure that the competitive EHR market 
place is better able to respond to the interoperability needs of the 
Departments. Additionally, this approach will enable private sector 
health information obtained by DOD and VA to be more easily federated 
with VA and DOD health information. Since more than 50 percent of 
healthcare in both VA and DOD is provided in the private sector, this 
open approach is critical to providing a comprehensive seamless patient 
health record. As part of the DHMSM strategy, the DOD intends to have a 
robust testing strategy that ensures the system meets operational 
requirements for effectiveness, suitability and interoperability with 
VA and other private sector providers.
    These many requirements for the DHMSM acquisition will ensure an 
efficient and effective EHR system. Subsequently, these demands for the 
acquisition have led to the DHMSM program establishing an aggressive, 
yet feasible schedule through which we are seeing early results. Since 
October 2013, the DHMSM program has conducted three well-attended and 
highly anticipated Industry Days and released its first of three 
planned draft Requests for Proposal (RFPs) on January 29, 2014. The 
final RFP release is expected no later than the fourth quarter of 
fiscal year 2014. Additionally, DHMSM representatives have met with 
Intermountain Healthcare, the Children's Hospital of Wisconsin, Kaiser 
Permanente, and Presence Health to open dialogue regarding acquisition, 
development, and sustainment of their EHR systems. These conversations 
with Healthcare and other health IT industry leaders provides valuable 
insight and lessons learned that will improve our acquisition strategy.
    To maintain success on our timetable and to reach Initial Operating 
Capability in 2016, as this committee has requested, DOD needs the 
release of withheld fiscal year 2013-2014 funds. Any disruption of 
program planned events and milestones due to withheld funds causes a 
domino effect which will negatively impact DHMSM and all 
interoperability efforts with VA and private sector providers. The DOD 
has held regular discussions with this committee to address this 
request and alleviate these funding constraints, but the window for 
maintaining our current successes is fast closing.
    DOD is currently developing formal life cycle cost estimates (LCCE) 
and schedule estimates for the health data sharing and interoperability 
effort as well as the DHMSM EHR modernization program. DOD has 
developed initial rough order of magnitude (ROM) cost estimates to 
inform future budget submissions. A review of the ROM cost estimates 
against the August 2012 IPO LCCE indicates that the current approach 
will be more cost effective for DOD. As part of DOD's ongoing 
acquisition program rigor, these cost and schedule estimates are being 
refined for RFP release and will be further updated prior to contract 
award. Additionally, a Cost Assessment and Program Evaluation 
Independent Cost Estimate will be developed to support contract award.
     ipo way forward as a clinical and data standardization leader
    On December 20, 2013, the DOD/VA Interagency Program Office (IPO) 
delivered its fiscal year 2013 Annual Report to the appropriate 
congressional committees and outlined this new strategy. The timeliness 
of the report demonstrates the Departments' commitment to Congress to 
maximize transparency in achieving their stated goals: seamless 
integration of data and modernization of EHR systems.
    The Departments also signed a new charter for IPO in order to align 
with the Departments' parallel strategies. IPO is responsible for 
establishing, monitoring, and approving the clinical and technical 
standards profile and processes to create seamless, integration of 
health data. Under its new structure, IPO will support the Departments' 
and Office of the National Coordinator (ONC) endeavors to adopt 
national standards, specifications, and certification criteria to 
improve health IT and its application.
    National standards make it possible to increase the level of data 
exchange and computability. These standards serve as a common language 
for DOD, VA, and private sector data which will comport and format the 
information shared. IPO's partnership with ONC to pursue national 
standard provides the vital link which makes DOD and VA data 
interoperable with that of the private sector, and which provides the 
Departments EHR systems the flexibility to respond to the evolving 
healthcare marketplace.
                               conclusion
    Senators of the committee, DOD's collective efforts with Congress 
over the past 6 months have been met with the utmost dedication. Since 
October 2013, I have engaged this committee and its House counterpart 
three times, the House Armed Services Committee six times, the Senate 
Armed Services Committee four times, the House Veterans Affairs 
Committee twice, and the Senate Veterans Affairs Committee three times. 
Further, we have met the first three of the NDAA's requirements and are 
on track to meet the remainder throughout the year. We recently briefed 
this committee on our expectations for completing a DHMSM plan for 
expenditure. IPO delivered its fiscal year 2013 Annual Report ahead of 
schedule and has maintained its statutory and courtesy quarterly 
briefings to Congress. IPO, DOD, and VA have remained thoroughly 
involved with Congress's GAO inquiries to track the modernization of 
our EHRs.
    I look forward to today's discussion, as well as the continued 
exchange of ideas with you regarding EHR systems throughout our 
acquisition and interoperability efforts. Again, thank you for this 
opportunity, and I look forward to your questions.

    Senator Durbin. Thank you very much, Mr. Miller.

                           BEHAVIORAL HEALTH

    General Horoho, let me ask you this first. I am concerned 
as to whether or not we have adequate behavioral medicine 
resources for our Active military. And I note that we have 
increased the number of behavioral health providers, most of 
them civilians, 43 percent between 2009 and 2013.
    However, the numbers that you gave us about the increased 
visits show an increase beyond 43 percent. The first question, 
are we bringing in enough behavioral health providers to meet 
the need?
    Secondly, a specific: The Army's goal has been to recruit 
10 psychiatrists annually. Over the last 5 years, they have 
only been able to recruit a total of six psychiatrists. What is 
the problem? Is there something we should be thinking about in 
order to entice the very best psychiatric professionals to help 
our men and women in uniform?
    I don't want to speculate about what happened at Fort Hood, 
but I do want to look, as you have, at the big picture and 
realize that we are facing challenges the military, I don't 
think, has ever faced in our history as a Nation.
    I mean, I can recall that scene in Patton where he leaned 
over the bed and slapped the soldier and said, I don't care if 
your nerves are shot, get back with your unit. And how we have 
come so far now to understand posttraumatic stress and what it 
can do physically and mentally to a person.

                      BEHAVIORAL HEALTH PROVIDERS

    So tell me, are we recruiting and enlisting adequate 
behavioral health providers? And why are we falling short, year 
by year, when it comes to recruiting psychiatrists?
    General Horoho. Thank you, Senator.
    When you brought up the story about Patton, my dad fought 
World War II, Korea, and Vietnam. He is 89 years old and still 
living today. And so I am reminded daily what we didn't do in 
the past and what different we are doing today.
    But we are also in an era where, I think, we don't know the 
impact of what 12 years of war has on an individual and on 
their family. And so there has been an aggressive movement to 
actually increase behavioral health capabilities, and not just 
psychiatrists, but really breaking down the barriers between 
psychiatrists, psychologists, psychiatric nurse practitioners, 
as well as our behavioral health technicians.
    And so we have looked at what are the behavioral health 
capabilities that we need and have increased those teams. We 
had a 150-percent increase in the number of behavioral health 
team members, so we are up to about 5,500 right now.
    Will we ever have enough? I don't think we will, because I 
think what we have seen is, as we have increased the number of 
behavioral health providers and we decrease the stigma by 
embedding behavioral health, where our soldiers are actually 
working so it breaks down that barrier, we are seeing an 
increase in demand. To do 2 million visits a year has really 
shown us that, I think, the stigma is starting to decrease.
    Senator Durbin. So we are going to write the GAO 
(Government Accountability Office) and ask them for their 
observations, particularly on the issue of psychiatrists. It 
seems to me that considering student loan forgiveness or 
something, that might be an enticement for the best psychiatric 
and psychological professionals to come join us, because we 
need them. So we will get back to you on that particular issue.
    I have a couple more questions that I want to ask in the 
brief time here.
    Mr. Miller, the Federal Government is not that good when it 
comes to computers. I just have to tell you that. There are 
some agencies that are spectacular, and a lot of them are 
disappointing. I need not tell you the frustration many of us 
felt with the rollout of the Affordable Care Act.
    I can tell you that since 9/11, hundreds of millions of 
dollars have been spent at the Federal Bureau of Investigation 
to give them the very best computer system. I think we are 
almost there, but there was a lot of angst and failure on that 
road.
    In 2009, the President challenged the Departments of 
Defense and Veterans Affairs to integrate their health records. 
And the estimate was it was going to cost us $4.2 billion and 
take 8 years. That was 2009.
    They said by 2017, at the cost of $4.2 billion, we should 
be able to get it done. Well, estimates are we spent not $4 
billion, but $28 million and basically abandoned that approach. 
Now we started all over again.
    And what is the goal now? The goal is in 7 or 8 years from 
now to have an integrated health record, not at the cost of 
$4.2 billion, but at the cost of $13.4 billion.
    Why is it that two major airlines can merge to put their 
computer systems together in a matter of weeks or months, and 
when it comes to merging systems in Government, it takes so 
long? We stumble so often, and it costs so much.
    Mr. Miller. Sir, I would comment in a couple ways. I would 
say, first off, sir, I think where we are today from a 
Department of Defense perspective is that we are bringing in a 
team of people that have the expertise and knowledge of how to 
get this job done.
    Myself as well as other people who have been brought in are 
acquisition professionals who know how to run large, complex 
business IT systems.
    I think you are correct, sir. We have a mixed track record 
at best in terms of how we addressed some of these business IT 
systems.
    Secondly, sir, I would offer that we are spending a lot of 
time with industry. I think one of the big things from the 
department's perspective right now, as you highlighted, we want 
to learn from industry and we want to figure out what their 
lessons learned are, how we should be approaching this problem, 
and how to make it go as quickly as it possibly can.
    I would say that in my interactions, and I spent a lot of 
time talking to industry, they don't go as fast as you may 
think, sir. I think that we do have a hard problem and we are 
aggressively attacking that problem, but I think we are going 
to get there, and I think we are going to do it in the most 
cost-effective way.
    I spent a lot of time talking to industry and their big 
lesson, and I think the big lesson learned that we have now on 
the Department of Defense side, is that this is not an IT 
problem. I think if we approach this simply as an IT problem, 
we don't focus on this as a business transformation. And I have 
a lot of support coming from, obviously, the people on this 
panel and other people to get this right.
    IT by itself will not fix this problem. This has to be 
where IT and our functional leadership and our medical 
leadership come together, and we collectively work to provide a 
solution in the most rapid way that we possibly can, leveraging 
industry.
    Senator Durbin. I only have a few seconds left, but I am a 
liberal arts lawyer. I didn't go to business school. I am, 
certainly, not a computer expert.
    What do you mean, this isn't an IT problem? We are talking 
about integrated medical records. You say it is a business 
transformation problem. Translate that for a liberal arts 
major.
    Mr. Miller. Well, sir, I am a liberal arts major, too. So 
what I mean, sir, is that I can go out and buy commercial 
software, right? I can go buy the software, and I can go try to 
implement it. But the reality, sir, is that software is 
designed to help our clinical community do jobs, right? So how 
those jobs get done in terms of what steps they must take and 
what screens they need to see is what has to be figured out, so 
that when we go deploy that software, that it is being done in 
a way that meets the requirement from the community.
    I think oftentimes where the Department of Defense has 
failed, and you can go back and look through many of our 
systems, we have not had the right partnership and the right 
efforts between our leadership there to understand exactly what 
they want that system to do.
    So I would give you an example, sir, of Microsoft Office. 
There are probably five or six ways in Microsoft Office that 
you can do certain things. But what we need to understand is 
how our community wants to do those, so that when we go buy it, 
we make sure it meets your requirement and we are delivering on 
schedule and making sure it works.
    I think sometimes people think it is just as simple as 
going out and buying some of these large, complex systems. And 
it is not, because we are really trying to change how we 
deliver health care, in the case of the department. And this is 
our opportunity to standardize and improve the care as part of 
this acquisition.
    Senator Durbin. All well and good. And I am not a business 
expert. I can tell you, when United Airlines and Continental 
Airlines merged, there were two miserable weeks for everybody, 
their passengers as well as their workers and staff when they 
decided to go to one common computer system. And then at the 
end of 2 weeks, it was done. Planes flew throughout.
    And I am just curious as to why it is taking 7 or 8 years 
at a crack to reach the point where we are still not sure we 
can get this done.
    Mr. Miller. Yes, sir. So let me give you another example, 
sir. Kaiser Permanente is the largest healthcare provider in 
the U.S. today. It took them over 7 years to deploy their 
electronic health records from start to finish.
    We are learning from them and other industry providers to 
figure out how to go faster.
    One of the challenges in the Department of Defense, we just 
don't have a few locations that we have to change software 
today. We have a number of different systems.
    And our challenge, sir, is we have over 1,000 locations 
that all have to be trained. They all have to be taught how to 
use this system. And so, whereas in your example there are 
probably a handful of people, we have a lot of people in a lot 
of locations around the world that all have to go into this 
effort.
    So I think from the initial baseline, I think you are going 
to see by the end of 2016, we will have initial capability. It 
will be up and running. Our challenge is going to be now 
working to get this onto ships and submarines and forward-
deployed areas that in your model, those kind of people don't 
really think about that.
    But we have to operate forward. We have to operate 24/7. So 
our biggest challenge is going to be how we deploy and go 
through the change management on a global scale with this 
system, sir.
    Senator Durbin. Thank you.
    Senator Cochran.

                   STATEMENT OF SENATOR THAD COCHRAN

    Senator Cochran. Mr. Chairman, I am pleased to join you in 
welcoming our distinguished panel of witnesses today to the 
Defense Subcommittee. We are reviewing and considering the 
fiscal year 2015 budget requests.
    We appreciate the important work that all of you are doing 
to provide services and information and contributions to the 
military medical corps. This includes others who are eligible, 
servicemembers as well as their families at home and while 
deployed around the world.
    We have seen a lot of positive impacts that have come from 
specialized information from those who have had experiences in 
combat.
    The medical group at Keesler Air Force Base, in particular, 
has accomplished a great deal in helping us understand in a 
better way the disease research and treatment opportunities 
that are available, and to expedite treatment with medical 
flights off the battlefield and into the hospital communities. 
We appreciate the education opportunities that Keesler has 
provided over the years.
    Like many sectors at the Department of Defense, the medical 
corps is not without its funding challenges. Your 
identification of those that you think are the higher 
priorities will be helpful as we make our decisions about the 
levels of funding for the different activities that come under 
your jurisdiction.
    But thanks for your good work, and thank you for helping 
our committee do our job.
    Senator Durbin. Senator Blunt.
    Senator Blunt. Thank you, Chairman.

                    MILITARY MENTAL HEALTH TRACKING

    General Horoho, yesterday in the Defense Committee and last 
week in the Armed Services Committee, Secretary McHugh and 
General Odierno both said that when a soldier, when a service 
person--this may have just been Army, which may be the next 
question I would ask, is this service-wide--when they transfer 
from one base to another, their health records are generally 
available, but their mental health records are not available to 
anyone in the command structure.
    So if you are having mental health treatment and you 
transfer to another base, and choose not to have mental health 
treatment, no one really understands in the command structure, 
at least, that disruption.
    Is that your impression as well?
    General Horoho. Senator, if I can expand upon that, there 
are several things.
    Right now, if a soldier is screened as high risk and is 
receiving behavioral health treatment and gets put on 
medication, there is a code that is put into the system, e-
Profile, that keeps them from being able to PCS (permanent 
change of station) to another station until they are at a 
stable point.
    When that individual is then able to move to another place, 
there is a behavioral-health-to-behavioral-health-provider warm 
handoff, for continuity of care to continue. So the losing 
behavioral physician calls the behavioral physician at the 
gaining location.
    If it is a high-risk soldier on stable medications, then 
there is a notification to the command surgeon, and also from 
commander to commander. So we have different acuity levels 
where we do that.
    If it is someone that is a low risk, their medical records 
transfer the information, but the commander is not called for 
those at low risk. So we have it almost stratified, depending 
on the types of behavioral health and the status of where they 
are at.
    Senator Blunt. Is that the same service-wide? Is that the 
same, Admiral, in the Navy? And the Air Force, General?
    Admiral Nathan. Yes, sir, it is very similar. I think the 
challenge is that, again, anybody who has fairly debilitating 
or remarkable mental health issues are identified and that warm 
handoff is made, if they are allowed to transfer.
    The challenge comes with those who are deemed to be mission 
ready or who are not deemed to be unfit for service. And when 
they transfer from one base to another, and they have been 
followed for a fairly routine mental health disorder, the 
current commander--and I think this is what the Army Chief of 
Staff was referring to--the current commander will not 
necessarily know their mental history, because it is not 
considered to impact their ability to perform the mission.
    The commander can only have insight into a soldier or 
sailor or airman's condition if they are deemed unfit to 
perform the mission or if other specific criteria are met, such 
as risk to harm others or self. Then they are entitled to know 
what is going on with that servicemember. Otherwise, it has to 
be voluntarily given to them.
    Senator Blunt. And, General Travis, is that the same?
    General Travis. It is the same, sir.
    Senator Blunt. So in this case, with the exception of 
someone who is deemed to be, I believe the term you used was 
at-risk, is the health record treated the same way as the 
mental health record? So the commander also wouldn't see the 
other health record under any circumstances unless there was 
something in that health record that indicated that individual 
was not ready for certain kinds of duty?
    General Horoho. The time when a commander gets to know is 
if there is someone that they believe is at-risk, and will 
impact the mission. If there is a concern, then the provider, 
whether it is a behavioral health or general physician, will 
get that information to the commander for them to know.
    Senator Blunt. And the behavioral health is treated the 
same way? Physical health concern would have the same 
treatment?
    General Horoho. Yes, sir.
    Senator Blunt. Well, treating these in the same way--and 
does anybody think that current system creates a gap that is 
problematic? No?

                    MILITARY MENTAL HEALTH TRACKING

    Admiral Nathan. Sir, the only comment I would make is we 
wrestle with how much to share with commands because the 
individual servicemember may not come forward for routine or 
for otherwise troublesome symptoms or issues if they believe 
everything they are going to tell somebody is going to be given 
to their commander or given to other people.
    So we have commanders who sometimes say, please tell me 
every individual who is in my command who is being followed for 
mental health issues, simple or severe. And the answer is that 
may help in some cases, but we worry about the individuals who 
won't step forward then and say I have a problem if I know my 
commander is going to know about it right away.
    Senator Blunt. The National Institutes of Health (NIH) says 
that 1 out of 4 adult Americans has a diagnosable mental health 
challenge, and treatable. Any reason to believe that that 
number is significantly different than that in the military, 
General?
    General Horoho. I don't believe it is different, because we 
recruit from the United States.
    And if I could just add one thing on the security 
clearance? It is a good example. Back in 2007, there was 
tremendous concern in the security clearance when you had to 
notify and state that you are getting behavioral health 
treatment. And so many, many soldiers would not get treatment 
based on that because they didn't want their career to be 
ruined.
    When that was taken out as a question, if it was behavioral 
health related to some type of trauma or deployment, they did 
not have to answer yes to that question. That helped to 
actually increase soldiers feeling comfortable seeking 
behavioral health care.
    Senator Blunt. I think that is probably right. I also read, 
it may have been an in-depth news article recently on veteran 
suicides, many of those veterans had been in a combat 
situation, and many had not.
    And we don't want to just assume that somebody who had 
multiple deployments or post-traumatic stress syndrome from 
having been in a different combat environment than soldiers and 
airmen and Marines and sailors used to be in, we don't want to 
assume that they are the only ones who are likely to have a 
problem on separation from the military.
    I mean, there are so many ways to deal with these problems. 
And back to the chairman's view of what we need to do to be 
sure that we are helping you get the professionals you need in 
the health service that can be there to deal with a problem 
that as a society, we need to deal with in a better way. And in 
the military, I think we need to deal with in a better way as 
well.
    Chairman, I have another question, but I will ask it after 
you all have had a chance for a second round.

                            MEDICAL RESEARCH

    Senator Durbin. Thank you, Senator Blunt.
    General Horoho, let me ask you this question. I believe in 
medical research. I am committed to medical research, relative 
to the NIH and Defense research, which would make a national 
commitment to it. And I believe in that. It is built into me.
    But my experience in the House and Senate is that we are 
inundated with people who have special pleas. They come to us 
with a child with diabetes, or a parent with Alzheimer's, and 
they ask for more medical research. Obviously. Every one of us 
would do the same.
    And it used to be, you would say, I would love to do that, 
but that is not the way it works. We send the money to the NIH, 
and they make the decision. It is not a political decision.
    Now let's talk about the Department of Defense medical 
research created by Congress and sustained by Congress and 
enhanced by this committee.
    There are two different approaches here, basic different 
approaches. The House is specific. The House talks about 
specific areas for specific diseases and how much money for 
each.
    In the Senate, we do some of that, but we also try to put 
it into what we call this peer-reviewed medical research 
program, so that we give priorities, but we don't put dollar 
amounts next to them. We want to let the peer-review process 
develop and let them determine which are the most promising 
areas.

                        MEDICAL RESEARCH FUNDING

    I think the bottom line here, and you tell me if I am 
missing this, is that the NIH is basically committed to basic 
research. And what we are talking about in the Department of 
Defense is translational research, taking that basic research 
and applying it.
    All of the research that went into that Johns Hopkins 
surgery, the man had a double hand replacement, had to be done 
to reach the point where it could be translated into a surgical 
procedure and post-operative treatment that worked.
    So that is how I kind of see a line being drawn between NIH 
basic research and Department of Defense translational.
    Long question, but here is where I am headed. When we take 
a look at where--we send you this list each year, on medical 
research. Is there a way through peer review or other source 
for you to evaluate where--it might be a situation where you 
say, if they just give us $10 million more in burn research, we 
are so close to something that really could be historic and 
important.
    We are trying to make these decisions as elected officials. 
Tell us from the medical research point-of-view what you think 
is the best practice.
    General Horoho. Senator, first, thank you for the support 
in the areas of research, because there has been tremendous 
changes over the last 13 years because of funding given 20 
years ago. It is a long tail, to be able to get us to where we 
can actually translate it into practice and changing how we 
provide care.
    In the question that you just asked, I think there are a 
couple things. As generous as the research budget is, there is 
still never enough that is there.
    And so what we have found, in different areas, we use 
tremendous amounts of partnerships with the civilian community, 
because we will get research to a certain point and then we 
will do these partnerships to allow it to continue. So that is 
one area, and I think it is important that we continue that.
    I think there are probably opportunities to have better 
feedback, in which you all could ask questions, and then we 
could give a status update of exactly where those research 
projects are or maybe where some vulnerabilities are. I think 
that is something that we could absolutely explore in doing 
that.
    But the growth that we have had over these last several 
years is really looking and saying, what is the military 
relevancy of the research that we are doing? How do we make 
sure that all three services are much more integrated in where 
we are spending our dollars as the dollars get tighter? And 
then where can we partner with the civilian healthcare system 
and researchers to apply basic research and translational 
research to really actually tackle some of those tough 
questions?
    Senator Durbin. I guess what I am looking for, either 
formally or informally, are some recommendations. Perhaps it 
can be done in private, because I don't want to reflect on 
anybody's priority here. There was a reason for it. We believed 
it was a good reason, and that is why it is on the list.
    But if you said to me, and I just used burn research as one 
example, if you said to me, ``We hope next year that we will be 
able to put more resources into burn research because we are 
close to something that could make a big difference in the 
lives of those who have been burn victims in combat,'' for 
example, that would help. It really would help, if that input 
could be given to us.
    I hope you will consider doing something like that along 
the way.
    General Travis. Senator, can I add a comment?
    Senator Durbin. Of course, General.
    General Travis. I love the question. Patty is exactly 
right.
    When you get handed research dollars that are directed very 
specifically, sometimes it is not operationally relevant. And 
we have done that for years, and we are happy to help the 
United States figure out these things. And it is good for our 
GME (Graduate Medical Education) programs to do research, no 
doubt about it.
    On the other hand, coming on the heels of this war and what 
we have learned in the years that have supported our efforts in 
this war, to get exactly to your comments about survivability, 
we actually really do appreciate the fact that we may be able 
to steer those dollars in a better way.
    I will give an example. We have a very direct relationship 
with the University of Maryland, Baltimore Shock Trauma, the 
University of Cincinnati, the University of St. Louis, where we 
are doing trauma care and teaching our airmen how to do trauma 
care. At the same time, one of the things we can bring to the 
table to get access to those trauma patients are DOD research 
dollars.
    That allows us to then use that university expertise as 
well as our own to direct research efforts to support future 
trauma care. It benefits us in what we are trying to do for the 
next war, and it has benefited us a lot in the past and this 
current war.
    The other thing it does, though, is it shares expertise 
with those universities and those communities. That then 
benefits the trauma systems around the Nation.
    So I love the question. I would be happy to talk more to 
you about it, or to your staff.

                   BETHESDA-WALTER REED CONSOLIDATION

    Senator Durbin. My last question. It is just kind of a 
general question. How is that marriage between Ms. Bethesda and 
Mr. Walter Reed working out?
    Admiral Nathan. Sir, the Secretary of Defense----
    Senator Durbin. It is taking a long time to answer.
    Admiral Nathan. I was the commander at Bethesda as we 
integrated Walter Reed and Bethesda together. It occurred on my 
watch. And it really is a synergistic relationship.
    And I think if I could just very quickly, the Secretary of 
Defense at the time, Secretary Panetta, asked me, how is it 
going? I said, it is sort of like a Little League game where 
the kids are like the people on the wards taking care of the 
patients. And the kids on the field are throwing people out and 
hitting pop flies and catching balls; however, the parents are 
in the stands strangling each other.
    That has gotten much better. I think it took a while for 
the leadership to come along, to follow the lead of the 
doctors, the nurses, the corpsmen, the medics who were taking 
care of the patients and putting that as their number 1 
priority.
    We are now seeing what we thought we would see, which is we 
learned a great deal from the wonderful things the Army was 
doing over on Georgia Avenue at Walter Reed. The Army has come 
over and seen some amazing things the Navy was doing. We have 
Air Force providers who were also seasoned and contributing.
    So I am very encouraged by the cultural integration that 
has occurred, while each service still preserves its tradition 
and its ethos. There is still a fair amount of rivalry in 
December, during the Army-Navy football game.
    So I think that its biggest challenge, to close, its 
biggest challenge right now is it is going to be recruiting a 
population of patients as it competes with the managed care, 
the private managed care in the area, and undergoes a heavy 
amount of construction and parking challenges, as it continues 
to build its infrastructure.
    The Walter Reed National Military Medical Center (WRNMMC) 
is going to have to recruit patients. The fact that we built it 
doesn't necessarily mean everybody will come.
    So the challenge is now to recruit the primary care base to 
feed that magnificent tertiary care facility, and continue to 
maintain it as the flagship military medical facility of the 
country.
    Senator Durbin. Thanks.
    Senator Cochran.
    Senator Cochran. Mr. Chairman, I think these witnesses may 
be aware of the fact that the University of Mississippi Medical 
Center and Walter Reed's Institute of Research are working on 
finding new treatments for malaria prevention.
    And I wonder whether or not you have anything that you can 
report to the committee, since I think we have provided some 
funding to help with these programs, whether or not there has 
been progress made by the Department of Defense to develop 
safer drugs and to treat or prevent malaria.
    Can you tell us anything to bring us up-to-date on that?
    Admiral Nathan. In short, sir, yes, there has been 
significant progress made. Just in this last year, a 
combination of both the academic sector that you alluded to, as 
well as the joint military research facilities, are preparing a 
vaccine, which is being readied for human factors trials. Our 
researchers have indicated that it could be ready for release 
in 3 to 5 years.
    The answer to malaria is going to be vaccination. It is 
going to be the only thing that really eradicates it, 
comparable to diseases like smallpox and polio.
    And so I think we are not going to see something in the 
next 12 months that is going to make a huge impact, but in the 
next 3 to 5 years, absolutely.
    Senator Cochran. Is this a legitimate and worthwhile 
investment of taxpayer dollars? Do you think it is that 
important for the future of military?
    Admiral Nathan. Absolutely, sir, for two reasons. One is, 
if you go back to previous world wars in the areas that are 
endemic with malaria, we lost more soldiers to malaria than we 
did to combat wounds. We still see troops occasionally crippled 
by malaria that are deployed in far-off regions.
    And what most people don't recognize is it is the No. 1 
infectious killer in the world. One million people a year die 
of malaria. So I believe that this military research and 
partnership with the private and academic sector is not only 
going to make a significant impact to the military, but it is 
going to be a tremendous diplomatic, ambassadorial capability 
that America generates for the rest of the world.
    Senator Cochran. Well, thank you very much. And thank you 
for your leadership in helping us deal more effectively with a 
serious problem.
    Thank you.
    Senator Durbin. Thank you, Senator.
    Senator Blunt.

                     MILITARY HOSPITAL CAPABILITIES

    Senator Blunt. General Horoho, I want to talk about 
military hospitals a little bit. I understand that the command, 
at least the Army command, is in the process of completing a 
study that will assess all its Army hospitals across the 
country. When will that study be available?
    General Horoho. Senator, there are a couple things. Over 
the last 2 years, we have been looking across all of our 
military treatment facilities to see where we can recapture 
care within the civilian network to bring more care back into 
our facilities, where do we need to maybe reshape some of the 
capabilities, and then how do we standardize the care at our 
clinics, our community hospitals, and our medical centers.
    So that has been ongoing over the last 2 years, and we are 
making some changes there.
    We have also been part of the OSD (Office of the Secretary 
of Defense) study, the modernization study, where the Army, 
Navy, and Air Force have been evaluated on efficiencies across 
all of our platforms.
    And then part of what we have to do is marry up our 
decisions with the final end-state for our Army, so as the Army 
reduces down to 450,000 right now, then that is driving some 
decisions of how much capability we can have at a certain 
installation based on the reduction of the population.
    And so there is not a certain line in the sand with the 
time. It has been ongoing and we know some of our areas where 
we are already starting to look and say we maybe need to move 
some of our capabilities because we have to recapture.
    And then there are some areas where we are saying we need 
to move some of our personnel because it would be better if we 
bought the capabilities within the civilian sector.

            FORT LEONARD WOOD HOSPITAL MILITARY CONSTRUCTION

    Senator Blunt. So at the General Leonard Wood Army Hospital 
in Fort Leonard Wood, Missouri, at least, that was ranked the 
Army's number two overall MilCon construction project in 2010. 
The only thing that has really changed at that 1941 facility 
since 2010 is the maintenance goes up every year.
    I think it has moved outside the 4-year window now. What 
would be the reason for that?
    General Horoho. Sir, one, Leonard Wood remains our No. 1, 
actually, for a new facility. But right now, as we stood up the 
Defense Health Agency, military construction and health 
facility planning is no longer an individual service. It 
actually is now within the Defense Health Agency.
    So each of the services puts in their request, their 
priority list, and then that decision is actually made by OSD.
    Senator Blunt. So the hospital at Fort Leonard Wood is 
still the Army's number 1 priority for hospital construction.
    General Horoho. Yes, sir.
    Senator Blunt. And that all goes to whom now?
    General Horoho. So that goes up to the Department of 
Defense for the decision to be made on military construction 
and funding.
    Part of what we have asked Fort Leonard Wood to do is to 
really--they have developed a get-well plan to actually look at 
how do they bring more patients into the current facility that 
they have, so that they build up their patient population. And 
we have worked very aggressively with the command on the ground 
in that area.
    Senator Blunt. Do any of these Army facilities, are they 
available to the community? Or only to retirees, veterans in 
the community? How does that work?
    General Horoho. Right now, the rules of engagement, it is 
for Active Duty military and their families, retirees and their 
families.
    Senator Blunt. And there are some communities where you 
would decide the better way to do that might be to take care of 
that in the community hospital and pay for that rather than 
have a hospital, is that what you said?
    General Horoho. So what we have looked at is to say, in 
certain areas, based on the funding, can we recapture care 
based on the rules of engagement? Can we recapture care within 
the area? If so, then we are doing that.
    If we find that no matter how many providers and clinicians 
we put in that area, we are not going to be able to recapture, 
because of the number of retirees that live in that area or the 
Active Duty, then that is when we make a decision to only have 
X number of providers and support staff, so we right size it, 
basically.
    We move those clinicians to another place where we would be 
able to bring in more care, because that is tied to readiness 
and skill sustainment.
    Senator Blunt. Okay, let me be sure I understand. The Army 
still has this hospital as number 1 on their list, but the Army 
wouldn't have made the final decision as to where the hospital 
should be, because it is now placed outside the fiscal year 
2015-19 program objective memorandum. But that would not have 
been a decision any longer made by the Army itself. It would 
have been made by the Defense Department.
    General Horoho. Yes, sir.
    Senator Blunt. Okay, thank you.
    Thank you, Mr. Chairman.
    Senator Durbin. Senator Murkowski.
    Senator Murkowski. Thank you, Mr. Chairman. And I thank 
each of you. Sorry that I missed the earlier testimony.
    I wanted to speak about an issue that I have raised before 
this panel I think every year since I have been on the 
Appropriations Committee and part of this subcommittee. And 
that is where we are with research on ALS (amyotrophic lateral 
sclerosis), also known as Lou Gehrig's disease.
    We all know that we haven't made any progress in finding a 
cure, and the treatments that are available out there are very, 
very limited. Yet, one thing that we do know for sure is that 
in our military and veteran population, they are more than 
twice as likely to come down with the horrid disease than any 
other populations out there. And given the cost of care as 
individuals live and ultimately die with ALS, the cost to our 
system is just going to see further increase.
    Given that we have currently $7.5 million in the ALS 
research program through the Department of Defense, the 
question I would have of you, General Horoho, is whether or not 
we should be doing more in this area in terms of research or 
perhaps if there were an ability to prioritize in certain 
areas.
    It has been suggested to me that one thing that we could do 
is to direct further focus or closer focus on therapy 
development within ALS itself.
    Can you speak to the issue, whether you feel we are making 
any headway, whether the resources are adequate, or whether we 
need to be doing more?

                   NEURODEGENERATIVE DISEASE RESEARCH

    General Horoho. Thank you, Senator.
    As you stated, 60 percent of our servicemembers are at risk 
for some type of neurodegenerative disease. And so we have had 
26 projects that have been funded since 2007 in the area of ALS 
research, and $7.5 million this year.
    We also are just venturing into an unprecedented consortium 
where we have $62 million that is going to the Department of 
Defense with the V.A. to actually look at neurodegenerative 
research.
    So I think we are starting to move in the right direction 
of really honing in and studying this particular area. I don't 
think I can say whether or not that amount of funding is the 
right amount of funding to actually tackle the research 
projects.
    But I do think there is a concerted effort moving in that 
area.
    Senator Murkowski. Well, I would suggest, and I would offer 
this up to the chairman and to the vice chairman, that there is 
more that we can be doing. That $7.5 million appropriated for 
peer-reviewed medical research on ALS, it is not that we are 
ignoring it, but in terms of, I think, the impact that we 
clearly see as it relates to those who again are just so 
susceptible, apparently, to this horrible disease, that we need 
to be doing more in this area.
    And if it is something that I can work with the chairman 
and the ranking member on, count me in, in doing just that.
    I would like to speak for a moment about the TRICARE 
changes. I understand that you have expressed support for the 
TRICARE changes in the fiscal year 2015 budget as a means of 
modernizing TRICARE. I guess I am looking at it and I am 
thinking that it actually takes us back in time.
    All I can see is that you are making servicemembers and our 
retirees pay TRICARE Prime enrollment fees, but we are only 
giving them TRICARE Standard services.
    It seems that you are getting more efficient from a budget 
perspective by charging more and streamlining services, but how 
can we really make the claim here that this is a more effective 
healthcare operation for our military members, for our retirees 
and their families?
    And when we kind of step back and look at the average 
annual loss of purchasing power from all of the pay and the 
benefit cuts that we see in this budget proposal, when you were 
formulating this, was there any thought given to the cumulative 
effect of all the proposed cuts on the paychecks of our 
servicemembers, of our retirees?
    Was this more of a budget-driven exercise in the context of 
defense healthcare?
    I am looking at it and I can tell you the folks that that I 
work for in Alaska are not excited about this. So I am trying 
to understand whether or not a proposal like this is a better 
way to go.
    Obviously, you have entitlement reform efforts like we have 
seen with the Military Compensation Reform and Modernization 
Commission that looks at it very methodically and more 
holistically. This is this year's budget going forward, and the 
question that I have of you, is this the right way to approach 
how we deal with our military retirees and military members and 
their families?
    General Travis. Well, let me start, ma'am. I appreciate the 
question. We do support the President's budget request, 
speaking only to the TRICARE part of this, because we obviously 
were not in the room for the discussion about all the other 
changes that you are talking about.
    I am acutely aware of the fact that as you add all these 
things together, it is nickels and dimes, and nickels and dimes 
add up.
    Senator Murkowski. They add up.
    General Travis. I don't disagree.
    The intent, of course, is to make this benefit sustainable. 
From an Air Force perspective, we have lived pretty much with a 
flat O&M budget for 10 years, Air Force Medicine. We are doing 
a lot of great things up at Joint Base Elmendorf, Alaska as you 
are well aware.
    Where I guess there may be concerns is even though, again, 
in isolation, looking at the cost, the TRICARE fees themselves 
are not exorbitant. On the other hand, when you are a young 
airman or young soldier or young sailor, and you are in a 
remote location where perhaps--and we have a lot of bases that 
are remote--where perhaps there may not be, and in fact, in 
many cases, there are not, any specialty care in the local MTF 
(Military Treatment Facility), the issue is, okay, then that 
becomes a have-not assignment.
    In other words, in that assignment, those young airmen are 
going to bear more of a financial burden. I understand it is a 
captain, and I know that we work through the averages of what 
that might be, but it is still a burden. And especially if you 
add it on to the other things that you mention. So that is the 
worry.
    Senator Durbin. Sorry, General.
    Senator Murkowski, we are out of time.
    Senator Murkowski. I know.
    Senator Durbin. We have a vote on the floor. We have a vote 
that has just about ended.
    Senator Murkowski. Thank you, to each of you.

                     ADDITIONAL COMMITTEE QUESTIONS

    Senator Durbin. Thank you very much, Senator.
    Thank you to the witnesses today. We will have some written 
questions sent your way. If you can respond in a timely 
fashion, we would appreciate it.
    [The following questions were not asked at the hearing, but 
were submitted to the Department for response subsequent to the 
hearing:]
       Questions Submitted to Lieutenant General Patricia Horoho
            Questions Submitted by Senator Richard J. Durbin
    Question. How does the Department of Defense work with the National 
Institutes of Health and other government agencies to coordinate their 
research and ensure it is complementary and not duplicative?
    Answer. The Department of Defense (DOD) and the Services coordinate 
with other Federal agencies to target and align research and 
development (R&D) efforts within their areas of expertise. The DOD does 
not invest in any research that is unnecessarily duplicative of 
National Institutes of Health (NIH)-funded efforts. The DOD focuses on 
research and development of military medical products that are unique 
to battlefield healthcare and that may have dual use within the 
civilian community. The DOD partners with the NIH, the Department of 
Veterans Affairs (VA) and other Federal Agencies, academia and private 
industry to accelerate military medical advancements. The NIH funds 
science and technology efforts that support intellectual endeavors and 
provide new data for further research related to overall health 
conditions of the general population.
    One of the largest areas of coordination and collaborative effort 
is in Traumatic Brain Injury (TBI) and Psychological Health R&D. In 
2012, President Obama directed the National Research Action Plan (NRAP) 
to increase coordination between the DOD, VA, Health and Human 
Services, and Department of Education. The NRAP builds on substantial 
work already underway across Federal agencies and provides a 
comprehensive approach to accelerate research; and to standardize, 
integrate and share data across all agencies. Under the NRAP the DOD, 
through the U.S. Army Medical Research and Materiel Command, is the 
lead Federal agency for conducting joint review and analysis of the 
portfolios of research across these participating Federal departments.
    In addition, certain Congressionally Directed Medical Research 
Programs (CDMRP) are appropriated by Congress for execution by the 
Defense Health Program to address more general research areas of 
concern to the Nation, such as breast cancer and prostate cancer. The 
DOD runs these programs in a complementary and synergistic fashion to 
the NIH-funded research efforts by identifying areas and gaps that may 
benefit from targeted research. The DOD executes these missions through 
efficient and effective practices and incorporates many steps in the 
planning and coordination efforts to avoid duplicative research that 
may be funded by other Federal agencies. In both peer and programmatic 
review of research proposals, the CDMRP incorporate representatives 
from other Federal agencies, such as the NIH, the Centers for Disease 
Control and Prevention, and the VA who provide information regarding 
the research being funded in related areas by their own organizations. 
Feedback is provided to and investigated by the CDMRP regarding whether 
proposed research has already been published or is the subject of an 
application to another funding agency, and if the level of effort of 
the principal investigator and all key personnel is appropriate. The 
CDMRP and NIH have developed a common classification system for 
comparing and presenting their cancer research portfolios. This system 
created the International Cancer Research Partners, which currently 
consists of 55 world-wide cancer organizations. Additionally, the CDMRP 
participates on numerous interagency committees pertaining to diseases 
such as breast cancer, autism, muscular dystrophy, tuberous sclerosis 
complex, Gulf War injury, and others. These interactions provide 
opportunities for each organization to increase awareness of their 
research portfolios, and thereby avoid unnecessary duplication.
    Furthermore, the DOD has a long history of coordination and 
collaboration with the National Institute of Allergy and Infectious 
Diseases (NIAID) of the NIH to utilize the capabilities of our DOD 
domestic and overseas medical research laboratories, as platforms for 
infectious disease research. The Military HIV Research Program (MHRP) 
collaborates with the Division of AIDS (DAIDS) of NIAID. Through this 
partnership, NIAID has access to an effective HIV/AIDS vaccine 
development program executed by the MHRP and a high quality network of 
overseas DOD laboratories and field stations in resource-restricted 
nations with high HIV/AIDS burdens. In return, the MHRP benefits from 
NIAID's stewardship and coordination of national/international efforts 
on HIV/AIDS vaccine research and product development, a large portfolio 
of industrial and academic AIDS vaccine research partners and advisors, 
and a large portfolio of vaccine candidates in different stages of 
development. The highly successful MHRP/DAIDS collaboration is managed 
through steering committees and a joint scientific advisory board 
involving all government partners to avoid duplication of R&D efforts.
    As a final point, the National Interagency Confederation for 
Biological Research (NICBR), associated with Fort Detrick, Maryland, is 
comprised of nine Federal agencies engaged in biotechnology and 
biodefense research who work in synergy to achieve a healthier and more 
secure Nation. The NICBR currently includes the National Interagency 
Biodefense Campus and the Frederick National Laboratory for Cancer 
Research. The NICBR's mission is to develop unique knowledge, tools, 
and products by leveraging advanced technologies and innovative 
discoveries to secure and defend the health of the American people. In 
support of these efforts, subcommittees and working groups foster 
interagency collaboration; maximize safety and productivity of 
biological research and technology development; and minimize 
duplication of effort, technology, and facilities among the 
signatories. Additionally, the U.S. Army's Medical Research Institute 
of Chemical Defense and the Medical Research Institute of Infectious 
Diseases coordinate their research efforts with the NIH as part of the 
HHS Public Health Emergency Medical Countermeasure Enterprise strategic 
reviews.
    Question. In particular, as a result of congressional interest, a 
significant portion of DOD medical research is focused on issues like 
breast cancer, Alzheimer's disease, prostate cancer, and autism. These 
conditions affect servicemembers and their families along with the 
general U.S. population. In light of that, how does DOD ensure that 
those efforts are fully in line with the leading Federal experts for 
those portfolios at NIH?
    Answer. The Department of Defense (DOD), through the 
Congressionally Directed Medical Research Programs (CDMRP), 
collaborates with expert representatives from the National Institutes 
of Health (NIH), Department of Veterans Affairs (VA), and other non-DOD 
Federal agencies by requesting them to serve on peer review panels, as 
well as the Integration Panels which identify research gaps, define 
investment strategies, and make funding recommendations. Fourteen of 
the sixteen Integration Panels (or other equivalent advisory boards) 
for the fiscal year 2014 programs currently managed by the CDMRP 
include representatives from non-DOD Federal agencies, including NIH, 
VA, Centers for Disease Control and Prevention (CDC), and the Food and 
Drug Administration.
    The CDMRP established a Memorandum of Agreement with NIH to test 
and evaluate sharing of CDMRP research proposal information in the NIH 
data center, allowing for greater transparency across the agencies. The 
CDMRP networks with multiple Federal and non-Federal committees to 
compare research portfolios, identify gaps in research funding, and 
improve existing research efforts. Additionally, the CDMRP engages 
individuals from Federal and non-Federal committees to participate in 
the peer and programmatic review of applications, and serve on review 
boards to monitor and oversee the progress of awards. These 
collaborations strive toward synergy with other agencies and 
diversification of research portfolios, and underscore the importance 
of interagency research coordination efforts.
    The CDMRP participates in several Federal interagency committees or 
working groups to include, but not limited to: the Advisory Committee 
on Breast Cancer in Young Women, a CDC-led committee; the Federal 
Interagency Traumatic Brain Injury Research Working Group, a NIH-
sponsored group; the Interagency Autism Coordinating Committee, a 
Federal advisory committee that coordinates efforts within the 
Department of Health and Human Services (DHHS) where Federal and non-
Federal members are included; the Interagency Breast Cancer and 
Environmental Research Coordinating Committee, a congressionally 
mandated committee co-chaired by the National Institute of 
Environmental Health Sciences and the National Cancer Institute (NCI); 
the Interagency Urology Coordinating Committee, a Federal advisory 
committee, facilitated by the National Institute of Diabetes and 
Digestive and Kidney Disorders of the DHHS; the International Cancer 
Research Partners, a group of 56 cancer funding organizations, 
including the CDMRP and NCI; the Muscular Dystrophy Coordinating 
Committee, a NIH-established committee; the National Alzheimer's 
Project Act Advisory Council on Alzheimer's Research Care and Services, 
composed of members of the VA, Centers for Medicare and Medicaid 
Services, not-for-profit, and State-level; the Trans-Agency Early Life 
Exposures and Cancer Working Group, a working group composed of 
representatives from NIH, CDC, and the CDMRP; the Trans-NIH Tuberous 
Sclerosis Complex Working Group, a NIH-sponsored group; and also 
participates in the Federal Research Subgroup, along with members from 
the National Institute of Neurodegenerative Disease and Stroke and the 
National Institute of Aging, to align Federal research with the NAPA, 
while reducing overlaps and identifying synergies.
    Question. What type of collaborative research does DOD conduct with 
the private sector?
    Answer. The U.S. Army Medical Research and Materiel Command 
(USAMRMC) manages and executes research portfolios across a broad range 
of military medicine, to include research on combat casualty care, 
infectious diseases, operational medicine, rehabilitative medicine and 
prosthetics, as well as Congressional special interest topics in cancer 
and other diseases. To accomplish its mission to create and deliver 
medical solutions for the warfighter, USAMRMC partners with innovative 
companies and renowned academic and research institutions to support 
research across the product lifecycle, from basic research to advanced 
product development, using a variety of vehicles, including grants, 
cooperative agreements, and contracts. The USAMRMC provides multiple 
ways for the private sector to engage with the Command, such as Program 
Announcements, Requests for Proposals, a continuously open Broad Agency 
Announcement, New Products and Ideas Submission website, Small Business 
Innovation Research and Small Business Technology Transfer Research 
programs. The Command also maintains a Strategic Partnership Office and 
an Office of Small Business Programs for outreach.
    USAMRMC continuously fosters collaboration and fund sharing with 
industry to bring products to the warfighter and the market place. 
Since the market share of military medical products is relatively 
small, the extraordinary cost of developing and delivering safe and 
effective medical products for use by the Department of Defense (DOD) 
and civilian medical practitioners means that DOD is dependent upon 
investment by industry. USAMRMC invests taxpayer funds in the earliest 
stages of science and technology development, and then works diligently 
to find commercial partners willing and able to fund the final 
development of products incorporating these new technologies in forms 
useful to both DOD and industry. This approach maximizes use of scarce 
DOD resources, while producing affordable products that benefit both 
the Warfighter and the civilian community.
    The scientists and engineers in our laboratories are often co-
authors of publications with private sector scientists and engineers. 
USAMRMC has six major laboratories and it often partners with private 
institutions through Cooperative Research and Development Agreements 
for data, labor, and cost sharing on projects of mutual interest. These 
partnerships have generated, or are in the process of generating, 
cutting edge technologies or treatments for warfighters and the 
civilian community, of which we have many examples. First, the U.S. 
Army Aeromedical Research Laboratory's collaboration with small 
business companies and academic institutions developed safer helmet 
designs and standards for the sporting and civilian air medical 
transport industries; and improved data collection systems for use by 
the automotive and aviation industries to assess vehicle occupant crash 
safety. Second, the U.S. Army Institute of Surgical Research, working 
with two civilian research consortia, created the Armed Forces 
Institute of Regenerative Medicine; a multi-institutional, 
interdisciplinary network focused on developing advanced treatment 
options, such as skin and organ regrowth, as well as face and arm 
transplants, for severely wounded Servicemen and women. Third, the U.S. 
Army Medical Research Institute of Chemical Defense partners with 
numerous civilian laboratories in pursuit of medical chemical defense 
research, including academic partners such as Ohio State University, 
the Universities of Utah, California and Colorado; or private sector 
firms such as Battelle and South Research Institute. Fourth, the U.S. 
Army Institute of Environmental Medicine, among other efforts, 
collaborates with the Boston Athletic Association to research ways to 
prevent heat injuries in marathon runners but also to use the data to 
update the guidance that the DOD provides to Service Members for heat 
injury management. Fifth, the U.S. Army Medical Research Institute of 
Infectious Disease partners with domestic and international academic 
institutions and companies for research and development of cutting-edge 
medical countermeasure against lethal viral diseases, such as Ebola, 
Hantavirus and Marburg virus, and these efforts have shown promising 
results in protecting non-human primates. Finally, the Walter Reed Army 
Institute of Research (WRAIR) prides itself on the numerous 
partnerships and collaborations with other governmental institutions, 
pharmaceutical companies, and not-for-profits. In collaboration with 
Glaxo-Smith-Kline and Sanofi-Pasteur, the WRAIR is researching and 
developing vaccines for Malaria and Dengue, respectively.
    One technique for collaborating with the private sector that has 
proven extremely effective is the establishment of consortia. The 
Consortium to Alleviate Posttraumatic Stress Disorder (PTSD) is a new 
research effort focused on discovery and development of biomarkers for 
PTSD that can be used for therapeutics and outcome assessment. This 
effort represents a major investment to advance knowledge related to 
biomarkers and clinical utility. The Chronic Effects of Neurotrauma 
Consortium will, among other goals, develop and advance methods to 
treat and rehabilitate chronic neurodegenerative disease and other 
comorbid effects of mild traumatic brain injury (TBI) and concussion. 
While these consortia have just recently been established, they have 
already established leadership roles in the fields of TBI and PTSD 
research.
    Question. NIH and VA upload all research abstracts into a program 
called RePorter, but DOD does not provide information to that database. 
Does DOD plan to provide this information to RePorter?
    Answer. Yes, The Department of Defense (DOD) is evaluating 
information transfer to the Research Portfolio Online Reporting Tools-
Expenditures and Results (RePORTer). The RePORTer website provides a 
central point of access to reports, data, and analyses of NIH research. 
It was initially developed in response to the requirement to closely 
track research projects funded by the American Recovery and 
Reinvestment Act but it soon became evident that this is a powerful 
tool for enabling visibility of all NIH funded research. The DOD, 
through the U.S. Army Medical Research and Materiel Command (USAMRMC), 
is currently testing the transfer and management of project 
information. The use of RePORTer is an aim within the National Research 
Action Plan. USAMRMC is also investigating other components of NIH's 
research proposal and project management tools as well, because we 
believe that economies of scale and improved inter-agency strategic 
planning of research efforts can be realized through the use of such 
centralized systems, where data types and classification are 
appropriate for public release. This level of common research portfolio 
management, within the biomedical sphere, will become increasingly 
important as we adjust to fiscal realities and improve business 
practices in the years ahead. Shared research data that is coded in 
common data elements will make it possible to conduct additional and 
larger analyses on existing data and therefore will increase the return 
on investment for every dollar of federally funded research.
    Question. How is DOD ensuring that its research is shared widely?
    Answer. The Department of Defense's (DOD's) intramural and 
extramural biomedical research is shared through many avenues to 
include the peer-reviewed scientific literature, media releases, 
scientific and medical specialty conference presentations. In addition, 
extramural research is shared via the Congressionally Directed Medical 
Research Programs website where anyone can look up specific programs or 
specific projects within programs in a manner similar to the search 
page of the National Institutes of Health (NIH) Research Portfolio 
Online Reporting Tools-Expenditures and Results (RePORTer) system. DOD 
and the Services also sponsor symposia to facilitate dialogue and 
exchange of scientific knowledge. One such symposium is the annual 
Military Health System Research Symposium held each August where many 
of the intramural and extramural biomedical researchers present their 
latest findings.
    Question. Please explain the importance of battlefield research 
within the DOD medical budget.
    Answer. Department of Defense (DOD) senior leader emphasis and 
Congressional support to military medical research have been critical 
to medical research successes and lifesaving advances over the past 
decade.
    The medical challenges confronted by military caregivers in 
Afghanistan and Iraq established the imperative for trauma and 
battlefield research. Military research is aimed at providing readily-
deployable materiel and knowledge solutions to reduce morbidity and 
mortality on the battlefield. Throughout history, military medical 
research has been a leader in trauma care, infectious disease, military 
operational medicine, and recently in rehabilitative and regenerative 
medicine.
    From 2005 to 2013, the fatality rate for U.S. service personnel in 
Afghanistan decreased by 50 percent to the lowest recorded in the 
history of warfare. The reason for this is multifactorial, however, two 
factors stand out: (1) investments in requirements-driven, battlefield 
research and (2) establishment of a trauma system which identifies 
needs for research and translates results into best clinical practices. 
The research is programmed and performed by the Services (Army, Navy, & 
Air Force) and the Defense Health Program. The Joint Trauma System 
(JTS) has enabled the U.S. military, for the first time in history, to 
translate battlefield lessons into evidence-based practices 
disseminated across the force. The collection and analysis of 
battlefield data has changed not only the way we approach medical care 
but also how we develop and field equipment, enhance force protection, 
and implement warfighting tactics, techniques, and procedures.
    Military medicine has always been a fertile breeding ground for the 
advancement of medicine. Many of the results from battlefield research 
have improved the survival of victims injured in civilian settings.
    Examples of military medical advances that have informed civilian 
practice of medicine include: use of life-saving tourniquets and 
hemostatic dressings to control bleeding; medical evacuation or patient 
transport improvements; advances in the use of blood components to 
prevent bleeding and restore circulation; discovery of tranexamic acid 
(TXA) as a life-saving medication for combat injured; the use of less 
invasive endovascular technologies to treat vascular trauma and shock; 
and temporary vascular shunts to save mangled extremities.
    Question. Since 2011, DOD and NIH have been collaborating on a 
centralized database for traumatic brain injury (TBI) called FITBIR 
(``fit-burr''). Has this project fostered transparency and 
collaboration on TBI?
    Answer. Yes, however Federal agencies are only in the beginning 
stages of data submission. The Federal Interagency Traumatic Brain 
Injury Research (FITBIR) informatics system is a central repository of 
raw research data from clinical Traumatic Brain Injury (TBI) projects. 
It is not a patient data or outcomes registry. It is intended to enable 
comparisons of research data and to stimulate the analysis of the data 
by researchers who were not necessarily involved with the original 
project but may have unique hypotheses that can be tested without the 
expense of running a separate clinical study. This could lead to 
unanticipated findings as well as further validation of existing 
findings. The Department of Defense (DOD) has mandated the use of 
FITBIR for all Defense Health Program and Army-funded TBI research. DOD 
researchers began to populate FITBIR in the past year.
    The TBI research community has reacted in a uniformly positive 
manner regarding the potential this system offers for sharing data and 
stimulating further study and collaboration. The system provides a 
period of embargo of the data so it can be quality assured and to allow 
the providing research team to present and publish their findings 
before the data is made available for scrutiny and use by other 
researchers. Only after there has been sufficient time for project data 
to be made available for use by other scientists will we be able to 
definitively assess the impact, though the expectation is that the 
impact will be significant. Additionally, the system will enhance 
transparency between research teams, which is one of the objectives of 
its development.
    Question. The agreement governing this collaboration (FITBIR) is 
set to expire in March 2015. Is DOD on track to renew this agreement at 
the appropriate time?
    Answer. Yes. The current Memorandum of Agreement between the U.S. 
Army Medical Research and Materiel Command and the National Institutes 
of Health does end in March 2015. However, a path for renewal is 
included in the wording of the current agreement. In addition, on 
August 31, 2012, President Obama issued an Executive Order directing 
the Departments of Defense, Veterans Affairs, Health and Human 
Services, and Education, to develop a National Research Action Plan 
(NRAP) on posttraumatic stress disorder, other mental health 
conditions, and Traumatic Brain Injury ``to improve the coordination of 
agency research into these conditions and reduce the number of affected 
men and women through better prevention, diagnosis, and treatment.'' 
The NRAP was published and released in August 2013 and includes the 
Federal Interagency Traumatic Brain Injury Research informatics system 
as a component of inter-agency efforts.
    Question. What results have we seen from the Department's research 
efforts into TBI and psychological health?
    Answer. Since 2007 Congress has given the Department of Defense 
(DOD) almost $1.5 billion to address the daunting challenges of 
Traumatic Brain Injury (TBI) and Psychological Health (PH). The DOD, 
through the Defense Health Program and the U.S. Army Medical Research 
and Materiel Command (USAMRMC), is collaborating with the best and 
brightest minds from government, academia, and industry to identify and 
investigate more effective diagnostics and treatments with a focus on 
delivering solutions. Service members deserve cutting-edge, world-class 
care, but evidence-based medicine is expensive, complicated, and takes 
time to develop. Rigorous research ensures that treatments and services 
provided to military and Family members are effective and do not have 
unintended negative effects. Although we are just beginning to realize 
findings from studies initiated with the infusion of research funding 
begun in 2007, some research has already resulted in impactful changes. 
Below are examples of results and accomplishments from the investment 
in TBI and PH research.
    USAMRMC is managing the largest TBI research investment in the 
world with over $750 million invested since 2007 in over 530 studies. 
TBI diagnostics and treatments are of the highest priority to DOD and 
Army leadership. While there is no single objective test that can 
accurately diagnose TBI, we are making important advances on blood-
based biomarkers to help detect injuries quickly and accurately, 
developing portable objective neurophysiological tests that use 
existing tools such as eye tracking and quantitative 
electroencephalography, refining neurocognitive tests embedded in the 
Military Acute Concussion Assessment, improving neuroimaging 
technologies such as High Definition Fiber Tracking and other 
structural and functional imaging tools so physicians and patients can 
detect brain abnormalities, and are aggressively researching treatments 
to facilitate recovery and return to duty. Above all, when researching 
new diagnostics and therapies we need to make sure that they are safe 
and effective for our Soldiers and their Families. Therefore, we work 
closely with the Food and Drug Administration (FDA) to make sure all of 
our advancements comply with regulatory standards. Brain injuries vary 
from patient to patient and we are exploring treatment options to allow 
physicians to customize therapies to the individual patient's specific 
needs. Often, multiple treatment and rehabilitation strategies are 
required for our Soldiers with TBI; therefore, our research spans the 
array of detection and treatment options.
    The Army has been working closely with the National Football League 
(NFL) and is participating in a $60 million TBI research effort funded 
by the NFL, General Electric, and Under Armour to accelerate TBI 
research. We are currently developing a collaboration with the National 
Collegiate Athletic Association (NCAA) called the NCAA-DOD Grand 
Alliance that will involve research into the natural history of TBIs, 
research involving the testing and application of diagnostic tools 
under development, and efforts geared towards education and prevention 
of TBI.
    In addition to the materiel solutions under development, our 
research program continues to yield knowledge at a rate that is 
straining the abilities of the peer-reviewed literature to keep pace. 
In many cases this knowledge is used to inform our materiel 
development, but it also has informed the development of diagnostic and 
management recommendations developed by the Defense and Veteran's Brain 
Injury Center and distributed by the Defense Centers of Excellence for 
Psychological Health and Traumatic Brain Injury. These span guidelines 
for rapid assessment and management in field and garrison environments; 
recommendations for imaging the TBI casualty; recommendations for 
screening for endocrine dysfunction after TBI; and managing co-
morbidities such as depression and Posttraumatic Stress Disorder 
(PTSD).
    As we make further progress, we are faced with the challenge of 
funding successful efforts through translation into clinical use. As 
each device or therapy reaches the stage of clinical trials, the costs 
increase significantly. A single phase III (definitive) clinical trial 
of a therapy would easily consume a significant portion of our annual 
funding. Clinical translation of therapies for central nervous system 
diseases has historically cost 50 percent more than testing a blood 
pressure or diabetes medication. These costs, combined with the low 
success rate of such trials (which is essentially zero for TBI at 
present) have driven the large pharmaceutical companies out of the 
arena over the past 5 years. We have identified foundational challenges 
in how TBI is clinically characterized, how clinical trials have been 
performed, and in how animal models are used that are leading us to new 
ways of classifying TBI, new ways of assessing whether or not a given 
therapy is doing what we expect, and new methods and models of TBI in 
animal research. These new methods are based upon a ``bench to bedside 
and back'' that together, once completed, will dramatically improve the 
processes of developing and translating diagnostics and therapies. 
Because of our focus on identifying these foundational issues, several 
major pharmaceutical firms have begun to express interest in re-
entering the field in collaboration with the DOD and FDA. While this is 
not a ``cure'' for TBI, it will go a long way towards enhancing our 
ability to move promising diagnostic tools and therapies to clinical 
use and that, in turn, will improve our ability to care for those who 
have suffered brain injury.
    USAMRMC also manages a comprehensive portfolio of more than $740 
million in PH research that includes more than 347 studies focused on 
delivering solutions. The portfolio addresses the topics of PTSD, 
suicide, substance abuse, Family issues, and violence within the 
military. Resilience building is also a focus because it is a critical 
piece in the prevention of PH problems.
    Since WWII, incident rates for combat-related PTSD have typically 
been estimated to be somewhere in the range of 15-20 percent of those 
exposed. Historical trends and number of troops deployed (1,344,668) 
during this period would suggest that an estimated 161,000 or more 
cases could be diagnosed over the next 20-40 years. Suicidal behavior 
is an urgent national problem that affects all Americans across all 
dimensions of society, including those who have chosen to serve the 
Nation in uniform. With all things considered, and with what we know 
about the U.S. national suicide rate, we must continue to take a 
coordinated and multi-faceted approach to the challenge of suicide.
    Army-led Mental Health Advisory Teams have deployed to theater and 
generated numerous evidence-based recommendations that have impacted 
policy (e.g. dwell-time and deployment length), improved distribution 
of mental health resources and services throughout theater, impacted 
the number of mental health personnel in theater, and modified the 
doctrine of the Combat and Operational Stress Control.
    The DOD has made contributions to the field of PTSD screening, 
prevention, and treatment and we eagerly await findings from studies 
that if successful, will improve the standard of care of PTSD. For 
instance, Army and Defense Health Program (DHP) funded research has 
informed the development of Clinical Practice Guidelines (CPGs), to 
include the Department of Veterans Affairs (VA)/DOD PTSD CPGs and the 
recently released CPGs for assessing and managing patients at risk for 
suicide. Also, DHP supported research contributed to the new PTSD 
definition in the recently released 5th edition of the American 
Psychiatric Association's Diagnostic and Statistical Manual of Mental 
Disorders (DSM-V).
    DHP supported research also found that among Operation Enduring 
Freedom (OEF)/Operation Iraqi Freedom (OIF) Veterans with PTSD, the 
integration of mental health into primary healthcare clinics resulted 
in increased use of mental health services, a reduction in time between 
referral and initial psychiatric evaluation and facilitated improved 
follow-up specialty care. This supports the integration of behavioral 
health services and primary care.
    Additionally, DHP funding supported a pilot trial of inpatient 
cognitive therapy for the prevention of suicide in military personnel 
with acute stress disorder or PTSD. This study developed and evaluated 
a new manual of Post-Admission Cognitive Therapy. Initial results are 
promising and suggest that inpatient admissions following suicidal 
ideation/attempt benefit from immediate individualized psychotherapy, 
which is not usually done. A larger randomized clinical trial is 
underway.
    DHP funding also supported a study to evaluate the effectiveness of 
an early intervention, brief cognitive-behavioral therapy for 
suicidality (BCBT-S) to prevent suicide among active duty Soldiers. The 
study's initial results are promising at 6-months post-intervention and 
suggest symptom reduction and day-to-day functioning are more stable 
following treatment relative to the control group. Suicide attempt rate 
in experimental treatment was 1/3 that of the control group (treatment 
as usual). Re-hospitalization rates had a similar finding, i.e. 1/3 
fewer than in the control group.
    In addition, a recently completed trial of the generic medication 
Prazosin for nightmares associated with combat-related PTSD in active 
duty Soldiers who returned from Iraq and Afghanistan supports the 
recently revised DOD/VA CPGs that recommend adjunctive treatment with 
Prazosin for nightmares. Also, initial findings suggest that treatment 
delivered daily over 3 weeks is as effective as treatment delivered 
weekly over 8-10 weeks. If findings are confirmed upon the completion 
of a larger clinical trial, this exciting effort will be a game-changer 
resulting in faster PTSD recovery.
    The Military Suicide Research Consortium (MSRC) is dedicated to 
developing validated suicide prevention intervention efforts. The DHP 
funded MSRC represents innovation in research program management and 
structure that allows rapid responding and execution of research 
efforts, with research beginning within months as opposed to years. The 
MSRC has 21 projects underway that are examining strategies to reduce 
suicide risk, prevent re-attempts, and understand bereavement among 
military Families after a Veteran or active duty member of the military 
has died by suicide. Two intervention studies have already demonstrated 
promise from pilot studies and larger trials are underway.
    The Army Study to Assess Risk and Resilience in Servicemembers is 
the largest study of mental health risk ever conducted among military 
personnel. The Army and National Institute of Mental Health partnership 
is aimed at identifying risk and protective factors for suicide and PH, 
informing the development of evidence-based interventions, and rapidly 
identifying high risk groups. It has also provided empirical data to 
support and/or refute assumptions that had previously been made without 
any data.
    Army funded research conducted at the Walter Reed Army Institute of 
Research demonstrated that resilience training can reduce mental health 
symptoms associated with combat. Data from the Army funded Millennium 
Cohort Study has revealed emerging trends and informed policies related 
to mental health, physical health, health-related behaviors (e.g., 
prospective assessment of health outcomes and potential open-air burn 
pit smoke exposure in Iraq did not show any clear population-level 
increases in chronic multi-symptom illness, respiratory symptoms or 
rheumatologic conditions in personnel deployed near documented open-air 
burn pits).
    Finally, the Army adapted military resilience training into a 
telephone/webinar-based intervention to provide education, training in 
coping skills and support to the spouses of Soldiers. A study funded by 
the DHP demonstrated improved resilience and coping behaviors and 
decreased depression, anxiety, and role strain. Contributions stemming 
from this pilot research program resulted in a roll-out of the program 
within the VA system. Educating Spouses on what to expect has the 
additional benefit of increasing recognition of early adjustment 
problems and promoting help-seeking behaviors.
    Question. How is this research affecting the way we care for the 
mental health needs of Service members?
    Answer. Our Nation's investment in military behavioral health (BH) 
and traumatic brain injury (TBI) research has improved clinical 
practice. Before implementing clinical interventions, research helps 
determine if there is a need, if there is a mechanistic rationale, the 
efficacy of the intervention under controlled conditions in a 
randomized clinical trial, and its effectiveness under real-world 
conditions. In the past several years, there have been numerous 
examples of successful outcomes stemming from research investment.
    Research investigating the integration of BH providers into primary 
care settings has found that patients identified as needing BH care are 
more likely to follow through on BH referrals if those providers are 
co-located with the referral source. Furthermore, studies have shown 
that integrating BH services into primary care can improve patient and 
medical provider satisfaction, decrease patient symptoms, increase 
functioning, and reduce healthcare costs. Integrating BH care into the 
Army Patient-Centered Medical Home has resulted in substantial changes 
in the way Army Medicine delivers BH care.
    In addition, Army and VA researchers determined that Prazosin, a 
drug that was previously used to treat high blood pressure, when 
administered in conjunction with psychotherapy, reduces nightmares and 
improves sleep among veterans with Posttraumatic Stress Disorder 
(PTSD). This finding is a breakthrough discovery that is improving PTSD 
therapy outcomes. Additionally, findings suggest that improvements in 
sleep reduce the use of alcohol by PTSD sufferers, in part because they 
have a reduced need for self-medication in the search for higher 
quality sleep.
    Also, preliminary findings suggest that compressing treatment 
schedules for PTSD-directed psychotherapy from weekly to daily sessions 
and reducing the duration of treatment from 12--15 weeks to 2--3 weeks 
yields positive clinical results. Compressing the treatment schedule 
also reduces dropout rates, a key indicator of the overall treatment 
effect. Two additional key studies exploring compressed treatment 
regimens are ongoing.
    Furthermore, research indicates that some Soldiers may be more 
likely to engage in telemedicine-based interventions over conventional 
treatment for reasons of privacy and perceived anonymity. Technology-
based interventions can expedite effective treatments; offer a provider 
multiplier effect; and increase treatment access and adherence for 
those who need help. Research projects comparing in-person treatment 
with telemedicine approaches are ongoing and preliminary findings 
suggest they are equally effective. Telemedicine and ``net-based'' 
interventions can be tailored to individual, group, or self-
administered treatment modalities.
    In the area of biomarkers research, considerable neurobiological 
PTSD and TBI research has been funded in the past 7 years, seeking to 
better understand the underlying processes associated with risk, 
mechanisms of development, key brain structures involved, and 
identification of diagnostic biomarkers. Validation research is 
ongoing, with the potential to objectively confirm a PTSD or a TBI 
diagnosis through a simple blood test.
    Lastly, the 2013 Mental Health Advisory Team (MHAT 9) mission to 
Afghanistan was directed by the Chief of Staff of the Army and 
supported by the leadership of U.S. Forces--Afghanistan. The Chief of 
Staff of the Army directed that MHAT 9 target the role of small unit 
leadership as a factor in influencing the mental health and well-being 
of Soldiers. MHAT 9 key findings indicated a generally positive message 
with (a) the lowest levels of behavioral health problem (e.g., anxiety, 
depression, acute stress, etc.) and suicidal ideation reported across 
the last 4 MHATs, (b) Soldier perceptions of their small unit 
leadership rated significantly higher than in 2012, and (c) a 
significant rise in individual and unit morale relative to 2012.
    Question. What is the Army doing to fill the gap in behavioral 
health specialists and ensure the mental health needs of our Service 
Members are met?
    Answer. Army Medical Command initiated the Behavioral Health 
Service Line (BHSL) to implement a standardized system of care to 
identify, prevent, treat and track behavioral health (BH) issues 
affecting Soldiers and beneficiaries. The BHSL enhances existing BH 
efforts by ensuring an enterprise wide approach to the delivery of 
existing and emerging BH programs. The Army is filling the gap in BH 
providers and meeting the needs of Service Members through innovative 
programs such as Embedded Behavioral Health (EBH), aggressive 
recruiting and hiring of quality providers, expansion of Tele-
Behavioral Health (TBH), and through partnership with the U.S. Public 
Health Service.
    The EBH model is an early intervention and treatment model that 
promotes Soldier readiness (before, during, and after deployment). It 
provides multidisciplinary BH care to Soldiers in close proximity to 
their unit area and in close coordination with unit leaders. 
Utilization of this model has shown statistically significant changes 
in key areas, such as; improved mission readiness, increased outpatient 
utilization and decreased need for acute inpatient psychiatric care.
    Since 2003, the Army has increased the government service 
professional BH staff by 150 percent from 1,342 in 2003 to 3,213 in 
September 2013. As of March 2014, the Army had 5,275 behavioral health 
providers. The Army's current requirement is 5,665 personnel, including 
professional providers and BH technicians. We expect that the 
requirements for providers will evolve as the needs of Army 
beneficiaries change.
    An effective way to address increased demands in patient care, 
especially in remote areas, is through TBH. From fiscal year 2009--
fiscal year 2013, Army tele-health clinical volume grew 619 percent, 
driven largely by TBH. In fiscal year 2013, the Army provided over 
34,000 real-time patient encounters and asynchronous tele-consultations 
in garrison, and over 2,300 additional encounters in operational 
environments in 28 specialties. Tele-behavioral accounted for 85 
percent of total tele-health volume in garrison and 57 percent in 
operational environments. Over 2,000 portable clinical video-
teleconferencing systems have been deployed to support BH providers 
across the globe.
    Since 2008, the U.S. Public Health Service has continuously 
provided Public Health Service Mental Health providers to augment the 
Army by providing direct clinical care to Soldiers and their Families. 
Eighty-one of 95 billets are currently filled and 43 new billets were 
created at locations not previously supported by the U.S. Public Health 
Service.
    Question. The structure of the proposed TRICARE pharmacy co-pays 
strongly incentivizes members to fill their prescriptions at pharmacies 
within military treatment facilities. Yet we continue to hear concerns 
about the current wait times at numerous pharmacies. What steps are 
being taken to alleviate wait times, and will current facilities be 
able to process an increase in prescriptions?
    Answer. The Defense Health Agency Pharmacy Board of Advisors 
included plans to address increased workload and subsequent wait times 
as a result of the proposed change in the TRICARE pharmacy benefit. 
Analysis of a previous benefit change indicated that military 
pharmacies might recapture up to 20 percent of the retail workload from 
the TRICARE for Life (> 65) population. Estimated growth in 
prescription volume was projected and provisions were made to hire 
additional staff to prevent increases in wait times. Efforts to 
encourage the use of mail order delivery have been put in place to 
support improved wait times and offer additional customer service 
opportunities. The Pharmacy Board of Advisors is closely tracking 
prescription growth at military pharmacies monthly and point of service 
transition weekly as beneficiaries switch their chronic medications 
from retail to mail/Military Treatment Facility (MTF) pharmacies.
    Question. Can you please give us an update on the operations of the 
Defense Health Agency over the past 6 months? What advantages and 
challenges have you seen in implementing this new system?
    Answer. The Defense Health Agency (DHA) reached Initial Operating 
Capability (IOC) on October 01, 2013. Currently, seven of the ten 
shared services have reached IOC and are providing integrated support 
to the Services. Pharmacy operations, health information technology, 
and medical logistics have been particularly successful and aggressive 
in their implementation of initiatives.
    A new Health Care Operations (HCO) Directorate is working with the 
Services to develop standard clinical practices and deliver integrated 
care to beneficiaries. The HCO Director is also leading the look at the 
future of TRICARE contracts and how to shape them to ensure our managed 
care partners align with the future goals of the Military Health 
System.
    The DHA provides an opportunity to create a more collaborative and 
integrated healthcare system. An integrated system reduces the growth 
of healthcare costs, reduces unwarranted variation, and improves 
standardization of clinical and business processes, thus resulting in 
improved patient safety, clinical outcomes, and efficiencies.
    These efficiencies allow Army Medicine to focus on its priorities 
such as Combat Casualty Care, ensuring the Army maintains medically 
ready forces, and that our personnel provide the highest quality of 
medical care delivery at any time and at any location, no matter how 
remote or austere.
    Similar to any new type of relationship, partners need to get to 
know each other, understand each other's nuances, and develop trust 
through open dialogue, collaboration, and full transparency.
    Question. As the customer for the end product, what input are you 
giving as DOD prepares its RFP for DHMSM? What progress have you seen 
to date, and what challenges do you see?
    Answer. The Services established a council of colonels, called the 
Functional Advisory Council (FAC), comprised of voting representatives 
of each Services and a representative from the Operational Medicine 
community. The FAC provides coordination between the functional 
community, Military Health System (MHS) governance structure, facility 
level clinical and business subject matter experts, the functional 
sponsor/community and the Defense Healthcare Management Systems 
Modernization (DHMSM) program for key decisions such as requirements 
and implementation planning. The Services have been briefing the 
functional community on the DHMSM program and the importance of their 
critical review of the Request for Proposal (RFP). This has allowed the 
end-users to ask questions and provide direct input to the RFP. All 
recommendations have been sent to the program office to add to the next 
version of the RFP.
    Through the collaborative activities of the functional community, 
support of the Defense Health Agency (DHA) and Service leadership, the 
program office has delivered all milestones on time. The functional 
community is driving the requirements and working collaboratively with 
the program office. Challenges include: (a) continued, timely release 
of funds to prevent schedule slippage; (b) having a secure and stable 
network and bandwidth to support the system; (c) business process re-
engineering; and (d) timely training of National Guard and Reserve 
units. Premature training will result in additional training since the 
users will have forgotten what they learned from the initial training 
to time of use. To address these challenges the FAC has sponsored many 
off-sites to clearly define the requirements.
    Question. The Committee has been very pleased with the retention 
rate for USUHS graduates (medicine, nursing, psychology), which far 
exceeds that of those trained in civilian health science programs. 
However, the Committee understands that non-physician USUHS students 
also need clinical training experience, which can be achieved at 
military treatment facilities. Please provide a report on the number of 
non-physician USUHS students who have received placements at military 
treatment facilities and the feasibility of increasing these 
opportunities, including cross-Service placements (e.g. Navy student 
placed in an Army MTF).
    Answer. The University has two major populations of non-physician 
clinical students. They are in the Daniel K. Inouye Graduate School of 
Nursing (GSN) and the F. Edward Hebert School of Medicine Medical and 
Clinical Psychology department (MPS).
    The Graduate School of Nursing at the Uniformed Services University 
for the Health Sciences (USUHS) had 694 non-physician, advanced 
practice nursing students receive clinical training experiences in 
military treatment facilities over its 20-year history. USUHS graduate 
nursing education is in a joint environment. All student clinical 
training experiences are cross-Service placements for nurse 
practitioners, nurse anesthetists and clinical nurse specialists. Of 
the 56 clinical sites used for nurse training, 36 are military 
treatment facilities or clinics. The others are in Department of 
Veterans Administration (VA), U.S. Public Health Service (USPHS) or 
civilian sites. Over the past 5 years, there has been an average of 70 
GSN students admitted per year. Additional opportunities for access to 
specific types of patients are explored as the need arises.
    The Medical and Clinical Psychology program at USUHS had 108 non-
physician, clinical psychology students (80 military, 28 civilian) 
receive training over its 22-year history of having a clinical training 
program. The Medical and Clinical Psychology program is also a joint 
training environment. During their 4 to 6 years of training at USUHS, 
psychology students participate in one of 47 year-long practicum 
placements for clinical training. Military students participated in 29 
practicum placement sites, 9 of these sites are military treatment 
facilities (MTFs). The 20 civilian sites include the VA and other 
civilian treatment facilities. Civilian students participated in 30 
practicum placements; two of those were in MTFs.
    After their time at USUHS, psychology students participate in a 1 
to 2 year internship/residency clinical training experience. Of the 44 
military students who have attended internship/residency, all have gone 
to one of 10 MTFs. These placements involve same-Service placements 
(i.e., an Army student attends an Army internship/residency), but the 
sites may offer cross-Service experiences. Civilian students attended 
one of 9 internship/residency placements, none of which were MTFs (all 
were VAs or other civilian hospitals). Over the last 5 years in Medical 
and Clinical Psychology, there has been an average of 8-9 students 
admitted per year, 6 military students and 2-3 civilian students, on 
average.
                                 ______
                                 
                Question Submitted by Senator Tom Harkin
    Question. Since 1992, the Department of Defense has put nearly $3 
billion into the Breast Cancer Research Program (BCRP), which is 
conducted through the U.S. Army Medical Research and Materiel Command. 
This research was integral in the development the breakthrough drug 
Herceptin, the OncoVue breast cancer risk assessment test, and the 
discovery of a frequently mutated gene that contributes to the 
development of several cancers. These are just three examples of real 
results that have positively impacted millions of lives inside and 
outside of our Armed Forces.
    Given the ongoing challenges that breast cancer poses in our 
society, what are the critical areas of research that the Department of 
Defense will be targeting with the $120 million in funding BCRP 
received in fiscal year 2014? Are there any other government agencies 
that are looking into these specific areas of research?
    Answer. The Department of Defense (DOD) Breast Cancer Research 
Program (BCRP) has played a major role in the significant progress that 
has been made in the breast cancer field since 1992. Despite the 
program's contributions that have made an impact on millions of lives, 
the DOD BCRP recognizes that many overarching questions still remain 
unanswered in breast cancer, and that funding must be invested in 
critical areas of research in order to make breakthroughs that will 
save lives and lead to eradication of this disease. To meet this urgent 
need, the fiscal year 2014 BCRP has taken two new approaches.
    First, the BCRP prepared a brief overview of the breast cancer 
landscape that describes what is currently known about incidence, 
death, recurrence, metastatic disease, risk factors, and treatments. 
The document is posted on the Congressionally Directed Medical Research 
Programs (CDMRP) website (http://cdmrp.army.mil/bcrp/pdfs/
bc_landscape.pdf). The intent of the landscape document is to provide 
applicants with a concise overview covering the topics that are most 
pertinent to the BCRP's vision of ending breast cancer. In the fiscal 
year 2014 BCRP Program Announcements, applicants are strongly urged to 
read and consider the landscape before preparing their applications, to 
ensure that their proposed research is aimed at the critical areas in 
breast cancer that must be addressed.
    Second, considering the breast cancer landscape, each fiscal year 
2014 BCRP application is required to address at least one of the 
following ten overarching challenges: prevent breast cancer (primary 
prevention); identify what makes the breast susceptible to cancer 
development; determine why some, but not all, women get breast cancer; 
distinguish aggressive breast cancer from indolent cancer; conquer the 
problems of over diagnosis and overtreatment; identify what drives 
breast cancer growth and determine how to stop it; identify why some 
breast cancers become life-threatening metastasis; determine why/how 
breast cancer cells lay dormant for years and then re-emerge 
(recurrence) and determine how to prevent recurrence; revolutionize 
treatment regimens by replacing interventions that have life-
threatening toxicities with ones that are safe and effective; eliminate 
the mortality associated with metastatic breast cancer.
    While these critical areas of research have been specified by the 
BCRP, the program recognizes that there are many other important issues 
within the breast cancer landscape which may not be covered by this 
list of overarching challenges. As such, applicants may identify and 
provide justification for addressing another overarching challenge that 
is related to the breast cancer landscape. It is important to note that 
the BCRP does not restrict the types of research that can be proposed 
to address these overarching challenges. The program enables 
researchers to address these challenges from any discipline.
    No other Federal agencies are looking into these specific areas of 
research because the CDMRP participates in several Federal interagency 
committees or working groups to include, but not limited to: the 
Advisory Committee on Breast Cancer in Young Women, a Centers for 
Disease Control and Prevention (CDC)-led committee; the Interagency 
Breast Cancer and Environmental Research Coordinating Committee, a 
congressionally mandated committee co-chaired by the National Institute 
of Environmental Health Sciences and the National Cancer Institute 
(NCI); the International Cancer Research Partners, a group of 56 cancer 
funding organizations, including the CDMRP and NCI; the Trans-Agency 
Early Life Exposures and Cancer Working Group, a working group composed 
of representatives from National Institutes of Health, the CDC, and the 
CDMRP.
                                 ______
                                 
           Questions Submitted by Senator Barbara A. Mikulski
    Question. DOD TRICARE does not currently cover obesity drugs. Are 
any of the Surgeon Generals aware of a statutory prohibition on the 
coverage of such medicines? Assuming there is no statutory prohibition 
in TRICARE for the coverage of obesity drugs, then is it the Surgeon 
Generals understanding that such coverage is permissible?
    Answer. With regard to contracts for medical care for dependents, 
Title 10, Section 1079(a)(11) states that, ``Treatment of obesity may 
not be provided if obesity is the sole or major condition treated.''
    In accordance with 10 USC Sec. 1079, there are multiple regulations 
and policies currently in place that address coverage of obesity drugs. 
Drugs for obesity and weight loss are excluded from the TRICARE 
pharmacy benefit. 32 CFR Sec. 199.4 (e)(15) (iii) states, ``Civilian 
Health and Medical Program of the Uniformed Services (CHAMPUS) payment 
may not be extended for weight control services, weight control/loss 
programs, dietary regimens and supplements, Appetite suppressants and 
other medications; food or food supplements, exercise and exercise 
programs, or other programs and equipment that are primarily intended 
to control weight or for the purpose of weight reduction, regardless of 
the existence of co-morbid conditions.''
    Army Regulation 40-3, Medical, Dental, and Veterinary Care, 
effective May 23, 2013, states in paragraph 11-10 that, ``Amphetamines 
and methamphetamines will not be prescribed as anorexic agents. Also, 
any medication used solely for its anorexic activity is prohibited from 
use in Army Medical Treatment Facilities (MTFs).''
    The Pharmacy TRICARE benefit is one of the shared services under 
the coordination and guidance of the Defense Health Agency (DHA) 
Pharmacy Operations Division effective October, 1, 2013. Guidance to 
the Services from DHA indicates prescribing and dispensing of drugs for 
obesity is inconsistent with Federal Statute, Health Affairs Policy, 
and DHA guidance.
                           obesity/overweight
    Question. What are each of the Surgeon Generals doing to address 
the issue of obese and overweight DOD dependents in their Services? In 
addition, what is being done with regard to obese or overweight active 
duty personnel? Please include information about medical treatment 
plans and options.
    Answer. The Army is tackling the issue of obese and overweight 
through comprehensive and community approaches for Soldiers, Families, 
retirees, and Department of the Army civilians. Army Medicine is 
incorporating Registered Dieticians into the Patient Centered Medical 
Home (PCMH). These providers focus on helping patients understand the 
value of healthy nutrition, one of the pillars of the Performance 
Triad. This is a constructive one-on-one benefit to the patient with 
increased access to the Registered Dietician through the Patient 
Centered Medical Home.
    Army Wellness Centers (AWC), an extension of the PCMH, deliver 
comprehensive health testing and education. The centers utilize a 
``Health Risk Assessment with Feedback'' method that encourages 
positive behavior change and is endorsed by the U.S. Preventive 
Services Task Force. There are currently 20 AWCs across the Army. AWCs 
have shown success in addressing Body Mass Index and body fat.
    The Army Nutrition Program recently submitted nutrition 
recommendations and updates to Department of the Army Pamphlet 600-4, 
Soldier's Blue Book, the Training and Doctrine Command guide for new 
Soldiers. The Army Nutrition Program is also collaborating with 
Installation Management Command to instill, create, and sustain healthy 
living environments where soldiers and families can make healthy 
choices around nutrition and activity. Installation Management Command 
and the Defense Commissary Agency are working together to offer Farmers 
Markets as allowed by the Office of the Secretary of Defense Memo dated 
July 30, 2013 that promotes ``fresh food'' at all dining venues on 
installations by incentivizing better food options and adopting a 
standard of at least 50 percent of menu items that meet green or amber 
Go For GreenTM Department of Defense Menu Criteria.
    Army Medicine is exploring collaborative partnerships to teach 
healthy nutrition. The Culinary Institute of America, the Harvard 
School of Public Health, and the Samueli Institute established the 
``Teaching Kitchen'' program to improve nutrition and culinary 
literacy. The Army Nutrition Program is working to create a hands-on 
cooking class that adapts the ``Teaching Kitchen'' curriculum for a 
military audience. The pilot called ``A Delicious Prescription for a 
High Performance Diet'' will be implemented at Fort Sam Houston in the 
fall of 2014.
    Question. In order to have the best health system in world, we must 
look at most effective healthcare in world--which oftentimes is a 
combination of western & eastern medicine. How do your branches look 
to--or work with--the civilian community to create comprehensive 
approaches to healthcare management that combines best of all available 
treatment options?
    Answer. Army Medicine historically and continuously pursues 
opportunities within the civilian community to advance the highest 
quality medical care to our Soldiers and beneficiaries. Medicine is an 
ever changing environment. Partnering with the civilian community 
ensures that the most current and innovative concepts and techniques 
are explored. The 2010 Pain Management Task Force (PMTF) identified 
selected complementary integrative medicine (CIM) therapies that were 
noted as having significant evidence of their safety and effectiveness. 
The CIM therapies identified by the Task Force were acupuncture, 
movement therapy or yoga, biofeedback, and medical massage therapy. We 
are collaborating with numerous organizations to advance research, 
education, and clinical care to ensure our Soldiers and their Families 
have access to comprehensive care options. I'd like to take a few 
moments to describe a few examples of these collaborations.
    We are partnering with the University of New Mexico School of 
Medicine's Project ECHO (Extension for Community Healthcare Outcomes) 
which is developing the capacity to safely and effectively treat 
chronic, common, and complex diseases in rural and underserved areas, 
and to monitor outcomes of this treatment. The partnership includes 
established programs at Dwight D. Eisenhower Army Medical Center at 
Fort Gordon for the Southern Region, Womack Army Medical Center at Fort 
Bragg for the Northern Region, and Tripler Army Medical Center in 
Hawaii for the Pacific Region. Europe and Madigan Army Medical Center 
for Western Region will be joining this initiative. San Antonio 
Military Medical Center and William Beaumont Army Medical Center are 
undergoing an assessment to be included as the program grows.
    The Army collaborates with several organizations with a common 
interest in expanding the utilization of complementary integrative 
medicine modalities. The National Center for Complementary and 
Alternative Medicine at the National Institutes of Health (NIH), the 
Bravewell Collaborative, and the Samueli Institute have all been 
extremely helpful in this effort.
    The Army Trauma Training Center at the Ryder Trauma Center, Miami, 
Florida has been in operation for more than 10 years and serves as an 
Army Forward Surgical Team Training facility, preparing military 
healthcare personnel to care to those injured on the battlefield.
    The inaugural Brain Health Consortium held April 10-11, 2014, was 
attended by world-renowned medical leaders in the military, academia, 
and research communities in neurology, neuroscience, psychiatry, and 
psychology. The goal was to better understand the state of the science 
of brain health and to discuss ways to improve the brain health of 
Soldiers and the Army Family.
    Established in 2007, University of California, Los Angeles (UCLA) 
Operation Mend provides combat injured military personnel with severe 
facial and other medical injuries access to the Nation's top plastic 
and reconstructive surgeons, as well as comprehensive medical and 
mental-health support for the wounded and their families. This is 
partnered with San Antonio Military Medical Center, the Department of 
Veterans Affairs (VA), Greater Los Angeles Healthcare System, and UCLA 
Health System.
    Landstuhl Regional Medical Center and UCLA are collaborating on 
Continuous (24/7) Electroencephalography Monitoring for the immediate 
detection of otherwise non convulsive seizures in patients within the 
first 72 hours of a traumatic brain injury. This program has the 
potential of reducing brain damage following brain injury by 
identifying subtle seizure activity and delivering appropriate and 
rapid treatment.
    Question. Last year at Camp Pendleton (on one of the furlough 
days), President Obama said that commissaries are an important benefit 
of military life. He also said closing commissary stores, ``Is not how 
a great nation should be treating its military and military families.'' 
I agree with the President. Do you--the Surgeon Generals--support the 
DOD's proposal to cut the Commissary budget? What will the impact of 
these cuts have on a military family budget and on military family 
health?
    Answer. The Army supports a holistic and comprehensive approach 
that reforms military compensation in a fair, responsible, and 
sustainable way. Unfortunately during this difficult fiscal environment 
tough decisions have to be made to reduce costs and one such method is 
by reducing commissary subsidies. While such reductions in commissary 
savings could impact the amount of disposable income our Soldiers have, 
Army Medicine will continue to work with the Army and the Department of 
Defense to educate Soldiers and their families on making healthy food 
choices.
    Question. Would each Surgeon General please provide information on 
your Service's policy and practice for the availability of integrative 
medicine treatments to service member & retiree families?
    Answer. The military is not immune to the nationwide issues of 
polypharmacy and prescription medication abuse and diversion. Army 
Medicine has been pursuing strategies that offer additional options 
that complement conventional therapies and practice. One example of 
this effort is the Army's use of complementary integrative medicine 
(CIM) modalities. Army Medicine is committed to the systematic 
deployment, integration, and evaluation of CIM modalities as a part of 
the comprehensive strategy to improve the health, wellness, and 
readiness of the force.
    The 2010 Pain Management Task Force identified selected CIM 
therapies that were noted as having significant evidence of their 
safety and effectiveness. The CIM therapies identified by the Task 
Force were acupuncture, movement therapy or yoga, biofeedback, and 
medical massage therapy. Under the auspices of the Army's pain 
management program, the CIM modalities are being employed or evaluated 
not as ``alternatives'' but rather as part of a menu of options for 
pain management that includes both conventional treatment modalities 
such as medications and interventional procedures like injections, 
nerve blocks, and surgeries, with these selected CIM modalities. The 
goal is to develop larger scale experience and evidence of which 
therapy and treatment combinations provide the best results for 
Soldiers.
    The Army has been collaborating with several organizations with a 
common interest in expanding the utilization of complementary 
integrative medicine modalities. The National Center for Complementary 
and Alternative Medicine at the National Institutes of Health (NIH), 
the Bravewell Collaborative, and the Samueli Institute have all been 
extremely helpful in this effort.
    Army clinicians are participating with the Air Force, Navy, and 
Veterans Health Administration (VHA) in a $5.4 million Joint Incentive 
Fund Project to field a standardized basic acupuncture training and 
sustainment model across the Department of Defense (DOD) and VHA 
medical facilities. Training teams have started traveling to Army, 
Navy, Air Force, and VHA medical facilities to deliver this training. 
The response from providers and patients has been overwhelmingly 
positive.
    Finally, Army Medicine, along with the Navy and Air Force, is 
collaborating through the Defense and Veterans Center for Integrative 
Pain Management on research studies related to the use of acupuncture 
and yoga as non-medication complements/alternatives to standard pain 
management therapies. Initial evidence indicates these can be effective 
complements and sometimes as an alternative to medications.
    Question. Given that in calendar year 2012 only 27 percent of 
active duty integrative medicine visits were for therapies other than 
chiropractic care, what barriers or operational issues limit your 
Service's expansion of other integrative medicine offerings to service 
members, retirees, and their families?
    Answer. It is understandable why chiropractic care has a 
significant prevalence among the complementary integrative medicine 
(CIM) modalities currently in use in military medicine. Chiropractic 
care was originally offered in 1995 as a demonstration program and 
later expanded as directed under Section 702 of the National Defense 
Authorization Act (NDAA) for fiscal year 2001. Three subsequent NDAA's 
allowed for expansion of the program, resulting in chiropractic 
services now being offered at sixty-two military treatment facilities 
but still limited to Active Duty Service members.
    The Army Pain Program has been moving towards a more 
multidisciplinary, multi-modal pain management strategy that leverages 
selected CIM modalities alongside more conventional pain management 
treatments such as medications and interventional procedures like 
injections, nerve blocks, and surgeries. In additional to chiropractic 
care, the Army's Interdisciplinary Pain Management Centers are 
employing modalities such as acupuncture, massage therapy, movement 
therapies such as yoga, and biofeedback. These are all proving to be 
effective complements and sometimes alternatives to medications.
    While the process for integration and expansion of other 
integrative modalities is a key part of Army's Pain Management 
Strategy, the use of these modalities is limited to the direct care 
system where we can generate expertise and capacity to provide these 
modalities. Title 32 CFR, section 199.4 essentially excludes CIM 
therapies from reimbursement under TRICARE.
    Question. What are each of your Service healthcare systems doing to 
advance whole system health improvement, such as Total Force Fitness 
and the Healthy Base Initiative?
    Answer. Army Medicine established the Performance Triad Task Force 
to fundamentally improve the health, readiness and performance of 
Soldiers, Family members, Department of the Army civilians and Retirees 
through the tenets of the Performance Triad. The Performance Triad 
promotes healthy lifestyles and choices around sleep, activity, and 
nutrition. The Performance Triad is nested within the Army's Ready and 
Resilient Campaign and aims to improve the overall health, readiness 
and resilience of the Total Army.
    To develop the concept for Army-wide implementation, the 
Performance Triad Task Force conducted 26-week pilot studies with 
battalion-sized units at three continental United States installations 
and in Afghanistan from September 2013 through May 2014. Unit and 
individual performance was evaluated during sustained simulated combat 
operations at the Combat Training Centers. Programmatic evaluation and 
analyses will occur from May to August 2014.
    The Performance Triad Task Force is collaborating with the Office 
of the Chief, Army Reserve and the National Guard Bureau to implement 
the Performance Triad program in the Reserves and National Guard. A 
pilot for the Army Reserve will commence in June 2014. The Performance 
Triad Army Family Campaign extends the Performance Triad education and 
training literature to Families, Retirees, and Department of the Army 
civilians.
    The Army Medical Command will conduct a Performance Triad kick-off 
across all Army Medical Treatment Facilities from June 2-6, 2014, to 
promote the tenets of the Performance Triad to the total Army Family.
                        healthy base initiative
    Question. Are you aware of the Healthy Base Initiative?
    Answer. Yes, the Army has three of the 14 Healthy Base Initiative 
pilot sites. They are located at Fort Meade, Maryland, Fort Bragg, 
North Carolina, and Fort Sill, Oklahoma.
    Question. What is your understanding of the Initiative and its 
purpose?
    Answer. The Healthy Base Initiative is a demonstration project for 
Operation Live Well that features a standardized framework for healthy 
communities and allows for customized, local approaches at 14 military 
installations around the world. The objectives are to optimize health 
and performance, improve readiness, decrease healthcare costs, and 
provide the Department of Defense with a validated framework for 
healthy communities that establish best practices in support of 
improved population health. The Healthy Base Initiative focuses its 
efforts on weight management, tobacco cessation, making informed 
nutritional food choices, and increasing physical activity.
    Question. How do you think the Healthy Base Initiative can be 
successful?
    Answer. The Healthy Base Initiative (HBI) will be successful 
because Senior Army Leaders and installation leaders are committed to 
establishing and maintaining healthy communities. Key installation 
partners and stakeholders must have a shared focus to assess, plan, 
implement, and measure population health initiatives in order to 
improve nutritional choices, increase physical activity, promote 
healthy weight and decrease tobacco use. Assessments conducted at the 
HBI pilot installations will establish best practices for promulgation 
across the Department of Defense.
    Question. The fiscal year 2014 omnibus bill included $3 million for 
the Healthy Base Initiative. Do you know how money is being used?
    Answer. The Department of Defense is currently in the next phase of 
the Healthy Base Initiative (HBI) after having finalized analysis of 
the data gathered from the 14 HBI pilot site locations. The Department 
of Defense is in the process of implementing specific initiatives such 
as education related to increasing physical activity, weight 
management, and tobacco cessation that will promote resilience and 
wellness of Service members and their families as part of the 
continuing HBI pilot.
    Question. How does DOD envision future of Healthy Base?
    Answer. Operation Live Well (OLW) is the Department of Defense's 
(DOD's) long-term healthy living initiative that aims to increase the 
health and wellness of active duty and reserve component Service 
Members and their families, retirees, and DOD civilians. It is a multi-
year effort that involves three phases. The first phase is an education 
and outreach campaign that includes the Healthy Base Initiative (HBI) 
demonstration. At the end of HBI, the DOD plans to publish a report 
outlining the initiative, findings, lessons learned, and 
recommendations. The results of HBI will inform the second phase of OLW 
and will be used to develop a long-term strategy and future policy. My 
understanding is that the DOD also plans to share findings with other 
interested stakeholders, e.g. sister Federal agencies and State/local 
governments. Phase three of OLW involves strategy implementation across 
the DOD.
    Question. Do you know how top DOD leadership is being trained and 
made aware of the Healthy Base Initiative?
    Answer. While I cannot speak on behalf of the Department of Defense 
(DOD), my understanding is that DOD leadership is well aware of the 
Healthy Base Initiative (HBI). The HBI team has briefed leaders at all 
DOD levels as well as Congressional members/staff, administration 
officials, sister Federal agencies, academia, and the private sector. 
All continue to provide excellent support to HBI and have expressed 
great interest in the potential benefits. To further these efforts, the 
DOD is considering optimal ways to support knowledge sharing as we 
expect to proactively roll out best practices across the DOD at the 
conclusion of the HBI.
                                 ______
                                 
              Question Submitted by Senator Mark L. Pryor
    Question. According to a recent report in the Washington Post, of 
the 2.6 million service members dispatched to fight the wars in Iraq 
and Afghanistan since 2001, more than half say their physical or mental 
health is worse than before they deployed. Many of the veterans from 
the wars in Iraq and Afghanistan continue to serve on active duty or as 
a member of the Reserve component. How is the Army tracking the growth 
of non-combat related injuries within the total Army, both the Active 
Duty and Reserve components? What is the Army doing to address this 
issue?
    Answer. The Army employs a variety of programs and data sources to 
track injuries in all components, during deployment and in garrison. 
The Army Institute of Public Health's Injury Prevention Program 
conducts a full array of core injury epidemiology to monitor injury 
surveillance data; provide field investigation capabilities; develop 
injury prevention policies and programs; evaluate existing injury 
prevention policies and programs; and disseminate scientific injury 
prevention information. The Army Combat Readiness/Safety Center tracks 
events which cause accidents, the Army Medical Command's (MEDCOM) 
clinical systems monitor and track the care of injured Soldiers, and 
medical informatics agencies within the MEDCOM's Plans, Analysis and 
Evaluations office, develop and monitor utilization and outcome data 
for injured Soldiers.
    Data sources for tracking injured Soldiers, both combat- and 
noncombat-related, include the Defense Casualty Information Processing 
System for deaths and wounded in action, the Integrated Disability 
Evaluation System for physical disabilities, the Defense Medical 
Surveillance System maintained by the Armed Forces Health Surveillance 
System for hospitalizations and outpatient visits, and many others.
    Army actions to reduce non-combat injuries include: modifications 
of physical training programs in basic combat training which reduced 
injury rates by 30 percent; enforcing use of seatbelts in tactical 
vehicles (Soldiers involved in High Mobility Multipurpose Wheeled 
Vehicle (HMMWV) crashes who do not wear seat belts are 6 times more 
likely to die than those who use the restraints); transitioning to the 
new T-11 parachute, which reduces jump-related injury rates by over 40 
percent compared to the older T-10 parachute; and developing training 
and education to prevent falls, promote motorcycle safety, and improve 
physical training.
                                 ______
                                 
              Questions Submitted by Senator Thad Cochran
    Question. General Horoho, in your testimony you talk about the need 
to preserve critical capabilities over the years between the current 
and next war. Would you share with the committee what you believe to be 
the most critical capabilities and how the Army plans to invest 
resources to preserve or expand those capabilities?
    Answer. After more than a decade caring for Soldiers severely 
injured from battlefield wounds and investing in combat casualty care 
research, Army Medicine, in close collaboration with the other 
services, boasts the lowest case fatality rate in the history of war. 
We must ensure that our military treatment facilities remain our 
readiness platforms and continue to advance military research to 
prepare for future challenges during the interwar years.
    Our Nation has never had a more skilled, combat-proven military 
medical force. Maintaining a robust direct care delivery system is a 
cornerstone to maintaining our healthcare providers' medical skills to 
ensure they are ready to deploy to the next conflict to provide 
critical life-saving care to our deployed Service members.
    Our Graduate Medical Education (GME) programs are essential for 
attracting and educating the next generation of medical providers. 
Currently we have 148 programs located across 10 Military Treatment 
Facilities (MTFs) with 1,465 students. Our training programs receive 
high praise from accredited bodies, and our trainees routinely win 
military-wide and national level awards for research and academics. Our 
GME graduates continue to exceed the national average pass-rate of 87 
percent for specialty board certification exams, with a consistent pass 
rate of approximately 92 percent for the last 10 years.
    Maintaining those combat medical skill sets in the absence of 
combat deployments will require sustained investment in trauma systems 
and trauma research. To that end, we have created a Tactical Medical 
Training Strategy including establishing the Center for Pre-hospital 
Medicine and maintaining the Army Trauma Training Center in Miami. We 
will continue to incorporate the hard-won lessons of tactical combat 
casualty care into all our training programs.
    The Joint Trauma System (JTS) and Department of Defense Trauma 
Registry enabled the Army Medical Department and our sister services to 
analyze combat casualty care data and conduct real time continuous 
process improvement. This system is now an enduring capability housed 
at the Battlefield Health and Trauma Research Institute in San Antonio. 
Efforts are currently underway to make injury and trauma management 
data from the Department of Defense (DOD) Trauma Registry available to 
our Department of Veterans Affairs (VA) partners who are performing 
important long-term outcomes studies in the areas of severe extremity 
and traumatic brain injury. We will continue to support the JTS so that 
our combat casualty care systems are prepared to begin the next 
conflict at the same performance level we ended the last ones and we 
are ready to learn new lessons that will emerge from the next conflict.
    The research capabilities of the U.S. Army Medical Research and 
Materiel Command (USAMRMC) have produced remarkable improvements in the 
treatment and rehabilitation of combat-injured patients as well as in 
the fitness and resiliency of our Soldiers. Sustained medical and 
trauma research funding for USAMRMC, its subordinate laboratories, as 
well as military-directed research at civilian and university 
laboratories, will be paramount to translate the large amount of basic 
and pre-clinical research into clinical practice. This sustained 
commitment to research funding will ensure we advance the science of 
military medicine to care for our Soldiers and many others, including 
those in the civilian sector, who benefit from military research 
discoveries in trauma, infectious disease, operational medicine, human 
performance optimization, and health in general.
    Question. General Horoho, Historically the Military Treatment 
Facilities take risk in their facilities sustainment, renovation and 
modernization budgets when money is short. What has been the impact to 
the Military Treatment Facility budgets during sequestration, and how 
does this impact the quality and access to care today and for the 
future?
    Answer. Properly maintaining and modernizing our Military Treatment 
Facilities is a critical element of providing a safe, reliable and 
modern environment of care for our beneficiaries. To date, all 
sequestration driven cuts to Sustainment, Restoration and Modernization 
programs were restored before they resulted in enduring negative 
impacts to quality and access to care.
    Question. General Horoho, Traumatic Brain Injury is a major concern 
for this subcommittee, and I believe that we should continue to pay 
very close attention to prevention as well as treatment. I am aware of 
research efforts to advance protection systems for our men and women in 
uniform, including cushioning systems in helmets that are already being 
used by the National Football League to prevent head injuries. How do 
treatment costs associated with traumatic brain injury compare with 
prevention costs associated with the development and fielding of 
personal protective equipment? Can you please also describe how the 
Brain Health Consortium assists with these types of efforts, and if 
this falls within their core objectives?
    Answer. The Army does not have information on cost comparison 
analyses of current Traumatic Brain Injury (TBI) treatment costs 
compared to the costs of development and fielding of personal 
protection equipment (PPE). The Army is committed to investigating, 
developing, procuring, and deploying the most effective PPE. The U.S. 
Army Medical Research and Materiel Command provides the medical 
parameters that assist the developers of PPE in fielding improved PPE 
systems to prevent and mitigate brain injury.
    Science not only helps inform decisions about the level of 
protection needed during a potentially concussive event but it also 
guides the most efficacious concussion treatment given the severity of 
the injury. From a treatment standpoint, the highest level of 
scientific evidence supports education, rest, and the positive 
expectation of recovery as cornerstones of first line treatment for 
mild TBI, also known as concussion. In Afghanistan, the Army 
implemented a comprehensive concussion policy designed to medically 
evaluate Soldiers as quickly as possible after an injury and 
established Concussion Care Centers dedicated to providing the highest 
level of treatment for these injuries allowing 98 percent of concussed 
Soldiers to return to duty.
    The Brain Health Consortium, which occurred on 10--11 April 2014, 
brought together military, academia and researchers in Neurology, 
Neuroscience, Psychiatry, and Psychology for challenging discussions on 
how to improve Brain Health for Soldiers and the Army Family. The Brain 
Health Consortium focused on attaining and sustaining optimum health, 
performance and well-being. A specific question posed related to how 
sleep, activity and nutrition affect the brain and, by extension, 
cognition and complex decisionmaking. The focus of the consortium was 
primarily pre-injury and although optimizing brain health prior to an 
injury may improve TBI recovery and outcomes; currently there is no 
evidence to definitively support this correlation.
                                 ______
                                 
         Questions Submitted to Vice Admiral Matthew L. Nathan
            Questions Submitted by Senator Richard J. Durbin
    Question. What is the Navy doing to fill the gap in behavioral 
health specialists and ensure the mental health needs of our service 
members are met?
    Answer. We are continuously working to ensure that the mental 
health needs of our service members are met by facilitating access to 
these providers (by integrating them into operational units and primary 
care settings), and by reducing stigma.
    In addition, mental health specialist staffing continues to improve 
as Navy Medicine places particular emphasis on growing mental health 
specialists. Since 2009, funded positions for active duty and GS 
civilian (excluding contractors) have increased by 59 percent (497 to 
750), while inventory (excluding contractors) in mental health 
specialties has increased by 40 percent (415 to 580) to meet new 
demand. Navy medicine is rapidly closing the gap for mental health 
specialty inventory to requirements through aggressive increases in 
active duty student pipelines to meet requirements, and anticipates 
continued staffing improvement. Our current mental health manning is 
Clinical Psychologist: 87 percent, Social Worker: 83 percent, 
Psychiatrist: 88 percent, and Mental Health Nurse Practitioner: 125 
percent.
    Question. The structure of the proposed TRICARE pharmacy co-pays 
strongly incentivizes members to fill their prescriptions at pharmacies 
within military treatment facilities. Yet we continue to hear concerns 
about the current wait times at numerous pharmacies. What steps are 
being taken to alleviate wait times, and will current facilities be 
able to process an increase in prescriptions?
    Answer. Navy Medicine continues to seek a balance between cost 
effective and efficient use of resources, pharmacy access (of which 
wait time is a factor), and patient safety. To this end, Navy Medicine 
is nearly complete with a replacement of outpatient pharmacy automation 
at over 25 of the larger Military Treatment Facility (MTF) locations. 
This project was in the planning phase from 2010 to 2012, and the 
implementation phase started in 2013. Replacement of outpatient 
pharmacy automation, which is over 10 years old and at the end of its 
useful life, is expected to improve efficiency of pharmacy processes, 
and support improved patient access (i.e. reduced waiting time) while 
supporting increased prescription volume.
    Question. Can you please give us an update on the operations of the 
Defense Health Agency over the past 6 months? What advantages and 
challenges have you seen in implementing this new system?
    Answer. Since establishment of the Defense Health Agency (DHA) on 
October 1, 2013, Navy Medicine continues to fully support 
implementation of Military Health System (MHS) governance reform 
initiatives. The MHS continues to move towards full operating 
capability (FOC) with facilities planning, medical logistics, health 
information technology (HIT), health plan, pharmacy, contracting, 
budget and resource management, and research, development, and 
acquisition shared service initiatives. Also, we continue our 
collective effort towards initial operating capability (IOC) for public 
health and medical education and training shared service initiatives. 
We continue to provide proactive and responsive leadership, embrace 
reforms, and minimize to the furthest extent possible potential 
negative impact on our operational capabilities.
    In addition to establishment of the DHA and targeted shared service 
initiatives, Navy Medicine advocates improving business planning and 
execution at the six enhanced Multi-Service Markets (eMSMs). We are 
proactively addressing the potential risk to the Services and the DHA 
if recapture targets associated with the shift of healthcare from the 
private sector network to Military Treatment Facilities (MTFs) are not 
met.
    The most significant advantage of implementing the new system is 
the DHA has begun to assume responsibility for shared services and 
other common clinical and business processes. This represents a unique 
opportunity to achieve higher levels of quality improvement, address 
healthcare delivery across the continuum of care, minimize practice 
variation, and more efficiently use capital and technology resources 
while providing essential support to the Services in carrying out their 
missions. Several challenges exist; however, with the new system 
including alignment of effort of the MHS Components, implementation of 
sound business processes to support the new agency, and an 
implementation timeline that may be too aggressive to mitigate 
unforeseen second and third order effects on delivery of care to our 
war fighters and their families. The changes related the implementation 
of the DHA must be balanced against DoN operational medical support 
requirements and made in consideration of the dynamic national 
healthcare market, external fiscal reductions and DOD priorities.
    Question. As the customer for the end product, what input are you 
giving as DOD prepares its RFP for DHMSM? What progress have you seen 
to date, and what challenges do you see?
    Answer. As one of the customers for the modernized EHR, the Navy 
has indeed had representatives involved in writing the requirements for 
the DHMSM RFP. Additionally, medical personnel across the Navy have 
been afforded the opportunity to review and comment on the first draft 
RFPs that have been released to date.
    To date, the DHMSM RFP process is on schedule to meet 
Congressionally mandated timelines as outlined in the NDAA 2014. 
Capturing the Military unique requirements continues to be our 
priority.
    Question. The Committee has been very pleased with the retention 
rate for USUHS graduates (medicine, nursing, psychology), which far 
exceeds that of those trained in civilian health science programs. 
However, the Committee understands that non-physician USUHS students 
also need clinical training experience, which can be achieved at 
military treatment facilities. Please provide a report on the number of 
non-physician USUHS students who have received placements at military 
treatment facilities and the feasibility of increasing these 
opportunities, including cross-Service placements (e.g. Navy student 
placed in an Army MTF).
    Answer. Medical Service Corps: 100 percent of Navy graduates of the 
USUHS clinical psychology doctoral program receive follow-on training 
at Military Treatment Facilities (MTF). Medical Service Corps USUHS 
clinical psychology students are required to complete the pre-doctoral 
internship at Navy Medical Center Portsmouth. This internship has 
received the highest level of accreditation from the American 
Psychological Association and provides excellent training on the full 
spectrum of military psychology topics. Upon completion of this 
internship, 100 percent of these students receive orders to another MTF 
where they are guaranteed the postdoctoral supervision hours that are 
required for licensure.
    Nurse Corps: The Nurse Corps currently has 43 Certified Registered 
Nurse Anesthetist, Doctor of Nursing practice (DNP) and PhD students in 
the program, including the overlap of incoming students and graduating 
students in June 2014. The average number of students is 33 among the 
three curriculums. The average matriculation and graduation rate will 
be 12 for each curriculum per year. All students receive clinical and 
didactic training at MTFs.
    The Family Nurse Practitioner program, established in fiscal year 
2014, currently has 11 students. Navy Nurse Corps will access an 
average of 5 and graduate 5 each year. All receive clinical and 
didactic training at MTF's.
    The Psychiatric Nurse Practitioner Doctoral program, established in 
fiscal year 2014, has one student who will receive clinical training at 
an MTF.
    For all programs, students will receive supplementary training in 
civilian settings when the patient acuity is not present in the MTF 
setting i.e. anesthesia training for cardiac by-pass surgery.
                                 ______
                                 
                Question Submitted by Senator Tom Harkin
    Question. Currently Walter Reed National Military Medical Center is 
conducting a 2,000 soldier study of a tool to predict medication 
response. This tool--PEER--compares a large database of drug outcomes 
with a test we already have, EEG, to reduce trial and error 
prescribing. It also builds evidence in an area where we need more.
    The fiscal year 2014 Omnibus Appropriations bill said that we would 
be updated in early 2014 on the interim results of this trial. When can 
we expect this update?
    Answer. As this study is under the cognizance of the Walter Reed 
National Military Medical Center and not Navy Medicine, I will defer to 
the Director, Defense Health Agency (DHA) and the Director, National 
Capital Region Medical Directorate to provide you the current status of 
the requested update.
                                 ______
                                 
           Questions Submitted by Senator Barbara A. Mikulski
    Question. DOD TRICARE does not currently cover obesity drugs. Are 
any of the Surgeon Generals aware of a statutory prohibition on the 
coverage of such medicines? Assuming there is no statutory prohibition 
in TRICARE for the coverage of obesity drugs, then is it the Surgeon 
Generals understanding that such coverage is permissible?
    Answer. According to Defense Health Agency (DHA), drugs for obesity 
and weight loss are excluded from the TRICARE Basic Program benefit in 
32 CFR Sec. 199.4(e)(15)(iii). The regulations states, ``CHAMPUS 
payment may not be extended for weight control services, weight 
control/loss programs, dietary regimens and supplements, appetite 
suppressants and other medications; food or food supplements, exercise 
and exercise programs, or other programs and equipment that are 
primarily intended to control weight or for the purpose of weight 
reduction, regardless of the existence of co-morbid conditions.''
    The pharmacy benefit is one of the shared services and is under the 
coordination and guidance of the DHA Pharmacy Operations Division 
effective 01 Oct 2014. Guidance to the Services from DHA indicates 
prescribing and dispensing of drugs for obesity is disallowed.
    Question. What are each of the Surgeon Generals doing to address 
the issue of obese and overweight DOD dependents in their Services? In 
addition, what is being done with regard to obese or overweight active 
duty personnel? Please include information about medical treatment 
plans and options.
    Answer. For the active duty, per OPNAVINST 6110.1J, Navy Medicine 
provides management and oversight ShipShape Weight Management Program 
and Navy Medicine Commands support bi-annual weight and measurements to 
assess maintenance of the minimal requirements set forth for accession 
and retention standards of height-weight and/or body fat for Navy 
service members.
    Navy Installations Command (CNIC) is responsible for providing 
fitness staff and facilities for physical fitness training at each 
installation and ensuring Command Fitness Leader (CFL) instructors and 
morale, welfare, and recreation (MWR) fitness staff comply with current 
policies when assisting with command physical training (PT), Fitness 
Enhancement Program (FEP), and Physical Fitness Assessment (PFA). The 
FEP is the Navy's physical training remediation program.
    The Navy and Marine Corps Public Health Center (NMCPHC) is 
designated as the program manager for ShipShape, the official Bureau of 
Medicine and Surgery (BUMED) weight management program. ShipShape is 
based on current evidence for healthy weight management from reviews of 
the literature and recommendations from professional organizations and 
has resulted in excellent weight loss outcomes for many participants. 
ShipShape supports the 21st Century Sailor and Marine Initiative for 
readiness and continuum of service by promoting permanent lifestyle 
improvements for nutrition, physical fitness, and psychological 
fitness.
    For both active duty and other beneficiaries, at the Primary Care 
level, height and weight is a standard assessment. Population Health/
HEDIS monitors metrics and set goals for the standard of care. The 
provider may refer the patient to Nutrition and Weight Management 
Classes or the Nutrition Clinic for group or individual appointments 
with the Registered Dietitian. Active Duty Service members may also 
self-refer to the Nutrition Clinic for weight control.
    Question. In order to have the best health system in world, we must 
look at most effective healthcare in world--which oftentimes is a 
combination of western & eastern medicine. How do your branches look 
to--or work with--the civilian community to create comprehensive 
approaches to healthcare management that combines best of all available 
treatment options?
    Answer. Navy Medicine treatment modalities are driven by evidenced-
based guidelines which are often times created based on scientifically 
investigated best practices utilized in the civilian community. Such 
evidenced-based medicine is practiced at each Military Treatment 
Facility (MTF). Evidence-informed modalities are practiced at various 
MTFs throughout Navy Medicine in collaboration with civilian research 
organizations such as the Samueli Institute and numerous universities 
detailed in the April 2012 Complementary and Alternative Medicine 
within the Military Health System Report to Congress.
    The Navy's Comprehensive Pain Management Program sponsors the 
training of 30 providers per year to attend The Helms Institute Whole 
Body Acupuncture training and well over 50 Health Care professionals 
attended the Annual Pain Care Skills Training held in September, 2013, 
at Naval Medical Center Portsmouth, VA.
    The Navy also participates in the National Capital Region Pain 
Initiative and the Wounded Warrior Pain Care Initiative hosted training 
with the global objective of providing pain skills education for PCMs, 
Family Practice Physicians, Pain Specialists, PAs, Nurses, Corpsmen, 
Pharmacists, Case Managers and other clinicians. The emphasis is on a 
multimodal approach that covered a variety of techniques and treatments 
that military healthcare is dedicated to embedding into all MTFs in 
order to decrease the likelihood of opioid dependence for chronic pain 
issues and increase the overall functionality of patients. This year's 
training included over 250 attendees from the Tri-Services and Veterans 
Administration. The skills covered included: The advanced acute pain 
course, auricular/battlefield acupuncture, behavioral health skills for 
pain, chronic pain ultrasound course, orthopedic medicine 
therapeutics), massage therapy, mind body medicine, pain pharmacology 
and trigger point injections, and science and technology.
    Question. Last year at Camp Pendleton (on one of the furlough 
days), President Obama said that commissaries are an important benefit 
of military life. He also said closing commissary stores, ``Is not how 
a great nation should be treating its military and military families.'' 
I agree with the President. Do you--the Surgeon Generals--support the 
DOD's proposal to cut the Commissary budget? What will the impact of 
these cuts have on a military family budget and on military family 
health?
    Answer. I support the Department of Defense compensation reform 
proposals contained in the President's fiscal year 2015 budget; however 
we recognize that commissaries are important to our service members and 
their families, particularly overseas. The Joint Chiefs of Staff have 
indicated that failure to approve these proposals will impact 
readiness, modernization and force structure. According to DOD, the 
commissary proposal will phase out the subsidy for CONUS locations over 
time provided to the Defense Commissary Agency; there are no plans to 
close commissaries.
    Question. Would each Surgeon General please provide information on 
your Service's policy and practice for the availability of integrative 
medicine treatments to service member & retiree families?
    Answer. Integrative medicine is focused on a personal relationship 
with one's provider that emphasizes focus on mind, body and soul- not 
just treating illness. Within our Medical Home Port (MHP) program, Navy 
Medicine has focused on this personal relationship with one's provider 
to maximize the therapeutic relationship, and focus on person as a 
whole. Our primary care continuity, a measure of whether a patient sees 
their personal provider when they come into clinic, is at an all-time 
high as of March 2014.
    Integrative medicine therapies are recommended in our VA/DOD 
Clinical Practice Guidelines for PTSD, depression, low back pain, and 
chronic opioid therapy. These therapies, which include acupuncture, 
chiropractic care, massage therapy, yoga and mind-body medicine are not 
a covered by the TRICARE Health Plan and as such would not generally be 
received by our beneficiaries in the purchased care environment. In 
response, Navy Medicine does have programs which offer chiropractic 
care and acupuncture, among other therapies within our various Military 
Treatment Facilities. The programs however, are limited to Active Duty 
because of high demand and limited resources.
    Question. Given that in calendar year 2012 only 27 percent of 
active duty integrative medicine visits were for therapies other than 
chiropractic care, what barriers or operational issues limit your 
Service's expansion of other integrative medicine offerings to service 
members, retirees, and their families?
    Answer. Complementary and alternative medicine (CAM) modalities are 
offered at many of our Military Treatment Facilities such as 
chiropractic and acupuncture that are recognized as evidence based best 
practices. The availability of such therapies is further constrained by 
the fact that CAM is provider dependent in that it is based on 
individual provider interest, background and specialized training which 
is generally not provided in conventional western medical education.
    The full complement of wellness practices delivered to all Navy 
Medicine beneficiaries, such as yoga and massage, are often provided in 
collaboration with community partners such as our military installation 
gymnasiums and wellness centers.
    The Navy's highly deployed operational forces pose a unique 
challenge in regards to integrative medicine. One way we are addressing 
this challenge is by tailoring our Patient Centered Medical Home model, 
coined Medical Home Port (MHP) for the operational community so that 
all Sailors and Marines receive the same patient-centered benefits 
including enhanced access and continuity between the patient and their 
care team. These teams integrate behavioral and psychological health 
providers to improve medical readiness and the provision of patient-
centered and whole-person care. Six Marine-Centered Medical Home (MCMH) 
and three Fleet-Centered Medical Home (FCMH) demonstration sites are 
operational with an additional 16 MCMH sites and 15 FCMH sites being 
planned for future expansion.
    Question. What are each of your Service healthcare systems doing to 
advance whole system health improvement, such as Total Force Fitness 
and the Healthy Base Initiative?
    Answer. Healthy Base Initiative (HBI) is a 1 year DOD demonstration 
project under the Operation Live Well Campaign. The Office of Deputy 
Assistant Secretary of Defense (ODASD) Health Affairs and ODASD 
Military Community and Family Policy have the lead on HBI with support 
from the Office of the Assistant Secretary of the Navy Manpower and 
Reserve Affairs, Commander Navy Installations Command, and Headquarters 
Marine Corps. Four bases were selected to participate for the Navy and 
Marine Corps: Joint Base Pearl Harbor- Hickam, Marine Corps Air Ground 
Combat Center Twentynine Palms, Naval Submarine Base New London and 
Marine Corps Base Quantico.
    In addition to support of HBI, the Navy and Marine Corps Public 
Health Center's Health Promotion and Wellness Department supports seven 
different health promotion campaigns aimed at improving health and 
wellness, which include key elements of the 21st Century Sailor and 
Marine initiative and are aligned with the National Prevention 
Strategy. These wellness campaigns encompass the following critical 
health promotion topics: healthy eating, active living, tobacco free 
living, psychological and emotional well-being, reproductive and sexual 
health, preventing drug abuse and excessive alcohol use, and injury and 
violence free living. Understanding the fluid nature of health and 
wellness, the products and resources were tailored to support Sailors, 
Marines, and beneficiaries across the continuum of care.
    Further exemplifying the unique delivery of health promotion 
services is the Blue-H Navy Surgeon General's Health Promotion and 
Wellness Award. This award encourages and recognizes Navy and Marine 
Corps organizations that actively promote health and wellness. Command/
organization submissions have increased each year and in total 137 
percent since the Blue-H Award's formal establishment in 2008. Among 
the CY2011 applicants were 77 percent of all Navy Operational Support 
Centers (124), 8 of the Navy's 11 aircraft carriers and 12 of the 
USMC's 16 Semper Fit Centers. The level of participation and diversity 
of participating commands highlights the relevant nature of the 
program, facilitating readiness, resilience, and recovery.
    Additionally, the ``Crews Into Shape Challenge'', held each March 
to coincide with National Nutrition Month, is a highly popular program 
to guide workplace-focused, team-oriented, physical activity and 
improved fruit and vegetable intake for all DOD members. This program 
was based upon the Center for Disease Control's (CDC) workplace health 
model of assessment, planning, implementation and evaluation for large 
scale organizations.
    Question. The Army is the only Service offering meditation, yoga, 
massage, cognitive behavioral therapy, biofeedback, breath based 
practices, and naturopathic medicine. I'd like the Air Force & Navy 
Surgeons to provide information on why their Services do not offer 
those other therapies?
    Answer. Complementary and alternative medicine (CAM) modalities are 
provided throughout Navy Medicine Military Treatment Facilities (MTF). 
Specifically acupuncture is provided in many of our MTFs as an avenue 
to treat chronic pain, migraine headaches, back and neck pain, anxiety, 
depression, insomnia, auricular pain and a wide variety of other 
conditions. Similarly, cognitive behavioral therapy is provided within 
each of our over 100 Navy Medicine Behavioral Health Specialty Care 
Clinics.
    Other CAM therapies are provided at MTFs near large Fleet 
concentration areas. These include, but are not limited to, 
biofeedback, hypnosis, heart rate control, massage, yoga, tai chi, 
meditation and clinical nutrition. The CAM therapies offered throughout 
Navy Medicine vary as these therapies are provider dependent and based 
on the individual provider's interest, training and background.
    In addition, Integrated Behavioral Health Consultants are embedded 
in nearly all primary care clinics and provide, among other treatments, 
mindfulness and breath-based therapies as well as self-management tools 
to assist with a variety of conditions and as an adjunct for pain. 
These services are provided to all Navy Medicine beneficiaries.
                                 ______
                                 
               Question Submitted by Senator Thad Cochran
    Question. Vice Admiral Nathan, Historically the Military Treatment 
Facilities take risk in their facilities sustainment, renovation and 
modernization budgets when money is short. What has been the impact to 
the Military Treatment Facility budgets during sequestration, and how 
does this impact the quality and access to care today and for the 
future?
    Answer. Significant reductions have been directed to our facilities 
sustainment, restoration and modernization (FSRM) funding. In fiscal 
year 2013 FSRM was cut $16.3M. These funds were eventually restored, 
but the delay in funding causes our aging infrastructure to continue to 
deteriorate, and makes repair/replacement more expensive later. 
Furthermore, the restoration of funding of special projects late in the 
fiscal year does not does not allow for or severely delays project 
design and acquisition (contracting) planning, which is required 18-24 
months in advance of award.
    There are no fiscal year 2014 sequester decrements for FSRM.
    FSRM funds may be reduced by up to 50 percent because of fiscal 
year 2015 sequestration. This calculation does not take into effect the 
continued restoration and modernization needs of our aging 
infrastructure. While the fiscal year 2015 Restoration and 
Modernization (R&M) funding requirement is calculated at $166 million 
we expect to receive $84.4M. Any curtailment will limit BUMED's ability 
to meet maintenance requirements and could cause difficulty in 
maintaining the Joint Commission accreditation standards.
                                 ______
                                 
               Question Submitted by Senator Daniel Coats
    Question. What plans do you have to develop a world class website 
for the Medical Historian's Office that showcases Navy Medicine's proud 
history & heritage? Do you feel that the present page for the office 
encourages people to visit the office to conduct research or submit 
inquiries?
    Answer. Navy Medicine's Medical Historian webpage currently offers 
users a showcase of weekly historical photographs, monthly oral history 
transcripts, historical publications, a link to BUMED's digital archive 
(hosted on the Medical Heritage Library), and a history of the Navy 
Medical Department from the ``days of sail to the present.''
    In the coming months the site will be host to an original monograph 
commemorating Navy Medicine's role in World War I, a ``This Month in 
Navy Medicine History'' feature, and our oral history transcript 
collection. Goals for the site include a ``Frequently Asked Historical 
Questions'' section, a finding aid to our collections, a Medal of Honor 
page, virtual and interactive exhibits, as well as a more robust photo 
gallery broken down by theme.
    Navy Medicine is committed to preserving its heritage and making 
information available on platforms used by future generations.
    Question. What partnership opportunities does the Office of the 
Medical Historian plan to pursue in fiscal year 2015 with the Naval 
History & Heritage Command?
    Answer. The Navy Medicine Historian has been actively interfacing 
with our colleagues at the Naval History & Heritage Command (NHHC) as 
well as other Federal agencies to explore collaborative efforts in 
fiscal year 2015 and beyond. Upcoming partnerships include a Continuing 
Promise Art Exhibit at Naval Medical Center Portsmouth, VA, developing 
standard operating procedures and a guidebook for Navy oral histories, 
exploring collaborative digitization efforts, and the continuing 
partnership on commemorative projects. These efforts will include the 
World War I Centennial, Vietnam War Semi-centennial, and U.S. Navy in 
Afghanistan. Examples of recent collaborations include the ``Team of 
Teams: Navy in the Iraq War'' exhibit at the Naval Academy Museum, the 
Korean War History Panel Project at the Pentagon, and the Navy Medicine 
in Vietnam monograph.
    Question. The field of U.S. Navy Medicine History is vast. 
Opportunities for work on unexamined or understudied aspects in U.S. 
Navy Medicine History are as unlimited as the historian's imagination 
and curiosity. What are the specific gaps you have identified in U.S. 
Navy Medicine History literature that you would like to see filled 
particularly as it relates to issues of concern to the U.S. Navy today 
or because they relate to things that historians think U.S. Navy 
Medicine should know about itself?
    Answer. Navy Medicine has a rich history of service to our Nation 
and we work hard to preserve this legacy of excellence in caring for 
Sailors, Marines and their families. Throughout our history, Navy 
Medicine has been on the forefront of many ground-breaking innovations 
in medicine. This focus continues today as our researchers and 
clinicians are working around the world on some of our most challenging 
health issues, including infectious diseases, traumatic brain injury 
and battlefield injuries. We know today's hard work is necessary to 
meet the demands of tomorrow's challenges. Correspondingly, through 
insightful and informative publications from our historian, we are 
ensuring that the current and future generations of Navy Medicine 
personnel have access to the history of our history and the inspiring 
contributions of their predecessors.
                                 ______
                                 
       Questions Submitted to Lieutenant General Thomas W. Travis
            Questions Submitted by Senator Richard J. Durbin
    Question. What is the Air Force doing to fill the gap in behavioral 
health specialists and ensure the mental health needs of our service 
members are met?
    Answer. While there are no systemic gaps in meeting the mental 
health needs of Air Force service members, we have been working to 
steadily increase the number of behavioral health providers as directed 
by the fiscal year 2010 National Defense Authorization Act, Section 
714. This effort resulted in a 25 percent increase in funded 
authorizations for active duty mental health specialists programmed 
into the Air Force bottom-line from fiscal year 2011-2016. Any current 
or anticipated manpower gaps are filled by contractor staff internally 
or patients are referred to private sector care under the TRICARE 
service contracts.
    Question. The structure of the proposed TRICARE pharmacy co-pays 
strongly incentivizes members to fill their prescriptions at pharmacies 
within military treatment facilities. Yet we continue to hear concerns 
about the current wait times at numerous pharmacies. What steps are 
being taken to alleviate wait times, and will current facilities be 
able to process an increase in prescriptions?
    Answer. While the vast majority of Air Force pharmacies currently 
have sufficient operational flexibility to handle an increase in 
prescriptions, we continue to monitor the workload closely and have 
undertaken several projects designed to help support our military 
treatment facilities (MTF) in both the short and longer term. First, we 
developed modern staffing models to more accurately allocate manpower 
to our pharmacies according to their workload. Additionally, we are in 
the process of replacing existing pharmacy automation with state-of-
the-art equipment system wide. The new systems will replace older 
technology. The upgrade will maximize patient safety and reduce wait 
times as a result of work-flow optimization and improved production 
efficiency. MTF pharmacies may also electronically transfer 
prescriptions to home delivery (mail order) to eliminate wait times if 
desired by our beneficiaries. Plans are in-place to provide timely 
staffing augmentation to MTF pharmacies that see a significant increase 
in workload.
    Question. Can you please give us an update on the operations of the 
Defense Health Agency over the past 6 months? What advantages and 
challenges have you seen in implementing this new system?
    Answer. Seven shared services have now reached initial operational 
capability within the Defense Health Agency including TRICARE health 
plans, pharmacy, budget and resource management, medical logistics, 
facility planning, contracting, and health information technology. 
Although minor challenges have understandably been encountered during 
the transition to greater standardization, the true advantage of our 
new system has been the reformation of Military Health Service 
governance, which provides a structure for the Services to work 
collaboratively with OUSD Health Affairs and the Defense Health Agency 
to address differences in approach as they arise. We continue to move 
forward as a team toward a more integrated healthcare delivery system.
    Question. As the customer for the end product, what input are you 
giving as DOD prepares its RFP for DHMSM? What progress have you seen 
to date, and what challenges do you see?
    Answer. The Services created a ``Council of Colonels'', called the 
Functional Advisory Council (FAC), made up of voting representatives of 
each Service's Chief Medical Information Officer and a representative 
from the operational medicine community. The FAC serves as a liaison 
between the Defense Healthcare Medical System Modernization (DHMSM) 
program office, the clinical functional, and technical communities. The 
FAC leads activities associated with planning, designing, requirement 
elicitation, and coordination of communication between DHMSM and the 
rest of the Military Health System. With the FAC leading the 
requirements process and with the Defense Health Agencies' support, we 
are exceptionally pleased by the progress of the acquisition and the 
collaborative environment. Because of this collaboration and leadership 
support I am confident that the Air Force needs are well represented. 
There are two primary challenges we still face; one technical in having 
a secure and stable network for DHMSM and the other in taking full 
advantage of the new system through initiating business process 
reengineering/change management.
    Question. The Committee has been very pleased with the retention 
rate for USUHS graduates (medicine, nursing, psychology), which far 
exceeds that of those trained in civilian health science programs. 
However, the Committee understands that non-physician USUHS students 
also need clinical training experience, which can be achieved at 
military treatment facilities. Please provide a report on the number of 
non-physician USUHS students who have received placements at military 
treatment facilities and the feasibility of increasing these 
opportunities, including cross-Service placements (e.g. Navy student 
placed in an Army MTF).
    Answer. Graduate nurses average 70 students per year with 56 
clinical sites; 36 of which are military treatment facilities (MTF). 
The remainder of the clinical sites are located at Department of 
Veterans Affairs and civilian locations. Non-physician clinical 
psychology students average 8-9 per year with 29 practicum placement 
sites; 9 of which are at MTFs. All of these clinical sites include 
cross-Service placements and, the Services continually pursue 
additional placements as needed.
                                 ______
                                 
           Questions Submitted by Senator Barbara A. Mikulski
    Question. DOD TRICARE does not currently cover obesity drugs. Are 
any of the Surgeon Generals aware of a statutory prohibition on the 
coverage of such medicines? Assuming there is no statutory prohibition 
in TRICARE for the coverage of obesity drugs, then is it the Surgeon 
Generals understanding that such coverage is permissible?
    Answer. Drugs for obesity and weight loss are excluded from the 
TRICARE pharmacy benefit. The statutory prohibition (32 CFR Sec. 199.4 
15 (iii)) states, ``CHAMPUS payment may not be extended for weight 
control services, weight control/loss programs, dietary regimens and 
supplements, appetite suppressants and other medications; food or food 
supplements, exercise and exercise programs, or other programs and 
equipment that are primarily intended to control weight or for the 
purpose of weight reduction, regardless of the existence of co-morbid 
conditions.''
    Question. What are each of the Surgeon Generals doing to address 
the issue of obese and overweight DOD dependents in their Services? In 
addition, what is being done with regard to obese or overweight active 
duty personnel? Please include information about medical treatment 
plans and options.
    Answer. The Air Force is implementing the 2014 Department of 
Veterans Affairs/Department of Defense Clinical Practice Guideline 
``Screening and Management of Overweight and Obesity'' in our Military 
Treatment Facilities (MTFs). In addition, we are implementing a pilot 
program called ``Healthcare to Health'' at six MTFs. Initiatives in 
this program include: Group Lifestyle Balance, an evidence based 
diabetes prevention and weight management intervention; and ``5-2-1-
0'', a childhood obesity intervention to encourage children to eat at 
least five servings of fruits and vegetables, watch less than two hours 
of screen time, get at least one hour of physical activity, and consume 
no sugar-sweetened beverages. For Airmen who fail body composition 
assessment standards and others interested in losing weight, we offer 
``Better Body, Better Life'', a standardized weight management program. 
We are also promoting policy and environmental changes throughout 
installations to facilitate healthy eating and physical activity, 
including nutritional environmental assessments and ``Go For Green''--a 
point-of-decision stoplight tool to inform Airmen of healthy food 
options in military dining facilities.
    Question. In order to have the best health system in world, we must 
look at most effective healthcare in world--which oftentimes is a 
combination of western & eastern medicine. How do your branches look 
to--or work with--the civilian community to create comprehensive 
approaches to healthcare management that combines best of all available 
treatment options?
    Answer. The Air Force Acupuncture Center at Joint Base Andrews, 
Maryland, has reached out to the civilian physician community 
practicing various forms of Western and Eastern alternative medicine 
through the Maryland Acupuncture Society and the Greater Washington, DC 
Area Society of Integrative Medicine (GWDCSIM). GWDCSIM has held 
lectures given by civilian clinicians from the University of Maryland's 
Department of Alternative Medicine and as far away as Sydney, Australia 
via live the Internet.
    Question. Last year at Camp Pendleton (on one of the furlough 
days), President Obama said that commissaries are an important benefit 
of military life. He also said closing commissary stores, ``Is not how 
a great nation should be treating its military and military families.'' 
I agree with the President. Do you--the Surgeon Generals--support the 
DOD's proposal to cut the Commissary budget? What will the impact of 
these cuts have on a military family budget and on military family 
health?
    Answer. The Surgeon General has no opinion on commissary usage as 
this is outside his area of functional expertise.
    Question. Would each Surgeon General please provide information on 
your Service's policy and practice for the availability of integrative 
medicine treatments to service member & retiree families?
    Answer. Currently, chiropractic medicine is the only integrative 
medicine therapy offered by the Air Force to our active duty 
population. At this time, services such as massage therapy, yoga, and 
naturopathic medicine are not covered by TRICARE to be purchased out of 
the network.
    Question. Given that in calendar year 2012 only 27 percent of 
active duty integrative medicine visits were for therapies other than 
chiropractic care, what barriers or operational issues limit your 
Service's expansion of other integrative medicine offerings to service 
members, retirees, and their families?
    Answer. The simple answer is funding. The Air Force does not have 
an integrative medicine product line. Currently, we are collaborating 
with the other Services and the Department of Veterans Affairs through 
a joint funded program to teach providers battlefield acupuncture, a 
specific form of medical acupuncture for chronic pain. This program 
trains providers and physician extenders to use battlefield acupuncture 
for chronic pain treatment in non-specialist settings such as primary 
care. This is a far cry from bridging the gap between integrative 
medicine versus traditional pain management, but it is a start. With 
additional funding, the Air Force may be able to bolster its pain 
management program to meet the same treatment levels as the U.S. Army's 
Interventional Pain Management Center. This is a goal of the Tri-
service Pain Management Workgroup.
    Question. What are each of your Service healthcare systems doing to 
advance whole system health improvement, such as Total Force Fitness 
and the Healthy Base Initiative?
    Answer. The Air Force has adopted Comprehensive Airman Fitness 
(CAF), a holistic model of fitness including physical, mental, social, 
and spiritual domains. CAF recognizes that health and fitness go beyond 
clinical care provided in military treatment facilities. 
Communications, programs, and services are aligned with CAF. Each Air 
Force installation has a community action information board (CAIB), 
which is a cross-functional senior-level committee that facilitates 
assessing community health, and enacting programs and services that 
improve health, fitness, and resilience. Healthcare staff has 
representation at both the CAIB and its working group, the integrated 
delivery system. The Air Force Medical Service, through its health 
promotion program, seeks to create a ``culture of health'' across the 
base community through influencing policies, environment, culture and 
social norms that influence health behaviors. Examples of recent 
activities have included expanding tobacco-free environments, promoting 
healthy food options on base, and promoting physical activity. The 
Healthy Base Initiative pilot program is testing innovative initiatives 
to make healthy living the default choice and social norm.
    Question. The Army is the only Service offering meditation, yoga, 
massage, cognitive behavioral therapy, biofeedback, breath based 
practices, and naturopathic medicine. I'd like the Air Force & Navy 
Surgeons to provide information on why their Services do not offer 
those other therapies?
    Answer. The three Services recently approved the military health 
system (MHS) pain management working group charter. Its purpose is to 
standardize pain management across the MHS including the interventional 
pain management centers (IPMCs). Currently, the three Air Force IPMCs 
at Joint Base Elmendorf-Fort Richardson, Alaska; Eglin Air Force Base, 
Florida; and RAF Lakenheath, UK have contract personnel utilizing the 
congressional funding appropriated to the Services for pain 
intervention. Additional Air Force funding may be used to start up the 
two additional Air Force IMPCs or add more services such as those 
available at the Army IPMCs. The Army has the lead on the IPMCs, and 
therefore, the largest budget. This has allowed them to set up some of 
the services we do not offer.
    The Air Force IPMCs serve a specific role in the treatment of pain. 
We collaborate with physical therapy, occupational therapy, 
chiropractic therapy, behavioral health, pharmacy, neurosurgery, etc. 
to provide an interdisciplinary approach. The MHS pain management 
working group will be the key to success as we strive to ensure the 
best pain management interventions are available to our patients.
                                 ______
                                 
              Questions Submitted by Senator Thad Cochran
    Question. General Travis, would you describe for the committee 
efforts to advance digital pathology practices in the Air Force Medical 
Service and discuss the importance of having a robust digital pathology 
network?
    Answer. The goal for the Air Force Medical Service (AFMS) is to 
eliminate the use of pathology slides, ultimately converting to virtual 
slides. Virtual slides and staining will allow pathologists to review 
specimens on high resolution monitors at their workstations. Universal 
access to digital slides will eliminate specimen re-shipments and 
enable recapture of pathology workload currently being referred out-of-
network. The AFMS estimates a $1.8 million return on investment per 
year.
    A robust digital pathology network would minimize turnaround times. 
Use of digital pathology in the civilian sector has reduced 68 percent 
of pathology consultations to 7 days or less. If implemented, 
turnaround times for emergency consultation could be less than 24 
hours. Eventually all 52 military treatment facilities without 
pathologists can be supported by digital pathology through the 
established pathology hubs, eliminating shipment times and minimizing 
turnaround.
    Question. General Travis, with the drawdown in operations in 
Afghanistan, what efforts are being made to ensure your medical 
personnel and units like the 172nd out of Jackson, Mississippi are able 
to maintain their proficiency and knowledge gained after more than a 
decade of war?
    Answer. Aeromedical evacuation (AE) forces require a mix of 
operational and clinical training to ensure AE crew members stay 
current and qualified to perform the AE mission. These training events 
can be accomplished through multiple methods such as Aeromedical 
Readiness Missions (flying training missions) or static training 
missions (training missions conducted on a static aircraft or fuselage 
trainer). Results from a recent survey demonstrate that the majority of 
Air National Guard and Air Force Reserve units are able to maintain 
their clinical skills proficiency as a by-product of positions with 
civilian employers. Active Duty AE units will need to shift their focus 
to clinical training at local military hospitals or use Training 
Affiliation Agreements for training at civilian hospitals to maintain 
clinical skills. AE crews use simulated patients both on the ground and 
in the air to maintain proficiency. To supplement hands-on care at 
local hospitals, the Air Force Medical Service has recently approved 
funding to expand its clinical simulation program by upgrading 
simulation equipment with plans to fund simulator operators and one 
curriculum specialist to oversee the simulation program across the four 
active duty AE squadrons. The Air Force continues to optimize currency 
platforms at our military treatment facilities while expanding training 
opportunities through civilian collaborations as well as through 
advancements in technology. We currently have over 500 training 
affiliation agreements to offer a variety of clinical and formal 
training opportunities. One of our new programs is called Sustained 
Medical and Readiness Training (SMART); a tiered, hands-on, 
standardized curriculum offered through organic training opportunities 
and civilian partnering hospitals. Significant advancements in modeling 
and simulation also now offer amazing virtual reality scenarios, 
mimicking real-life to hone and advance clinical skills.
    Question. General Travis, Historically the Military Treatment 
Facilities take risk in their facilities sustainment, renovation and 
modernization budgets when money is short. What has been the impact to 
the Military Treatment Facility budgets during sequestration, and how 
does this impact the quality and access to care today and for the 
future?
    Answer. The fiscal uncertainty and sharp reductions resulting from 
sequestration proved disruptive to our planning process and execution 
in fiscal year 2013. However, the relief provided by the Bipartisan 
Budget Agreement greatly benefited our facility sustainment, 
restoration and modernization portfolios. The Air Force Medical Service 
would greatly benefit from similar reinstatement actions in fiscal year 
2016 sustained across the future years defense program. Continued 
projected reductions to research and development programs could both 
delay critical advancements in military medicine that allow us to 
provide cutting-edge care on the battlefield and impede our ability to 
provide state-of-the-art care to our members and families.
                                 ______
                                 
              Questions Submitted by Senator Daniel Coats
    Question. What plans are in place to establish a mentor program for 
Air Force spouses to learn more about being caregiver for loved ones 
with PTSD? Is it funded across the FYDP? If not, how much would be 
needed to create a world class training program?
    Answer. The Air Force is building programs in concert with the 
Office of the Secretary of Defense and our sister services to provide 
mentorship and support for caregivers of our wounded, ill and injured 
including those with post traumatic stress disorder (PTSD). While 
military family life consultants and installation Airman and Family 
Readiness Centers provide information to caretakers, educational needs 
are largely provided through other resources. The most appropriate 
resource is the patient's mental health provider. Every client is 
engaged in their treatment planning and with the patient's permission; 
the caretaker can be included in therapy or educational sessions. The 
Air Force promotes conjoint cognitive processing therapy, an evidence 
based treatment, which directly involves the spouse in treatment 
sessions. Medical case managers also assist with educational resources. 
Online resources are available at sites such as http://
afterdeployment.t2.health.mil/.
    Given the low frequency of PTSD (0.8 percent) in the active duty 
Air Force, more time and research are required to determine funding 
requirements. Pursuit of a single Department of Defense-wide program 
may be more tenable.
                                 ______
                                 
               Questions Submitted to Christopher Miller
            Questions Submitted by Senator Richard J. Durbin
    Question. Why do you think the revised strategy is better than the 
original plan for both Departments to use a single, joint system?
    Answer. DOD and VA face different electronic health record (EHR) 
deployment landscapes, operating environments, and military health 
requirements. VA treats an older population while DOD primarily cares 
for a younger, active duty population and their families. The principal 
focus of VA is on the delivery of primary and mental healthcare for 
veterans, while DOD maintains primary care for active duty service 
members, and their families, to include services such as pediatric 
care, or obstetric and gynecological care (accounting for 25 percent of 
hospital costs).
    Moreover, DOD's specific patient population is highly mobile. To 
reach all beneficiaries, DOD's system must operate worldwide, including 
theater environments, aboard ships and aircraft. More than sixty 
percent of the healthcare provided to DOD eligible beneficiaries occurs 
in the private sector and outside of the DOD or VA EHR systems. For our 
clinicians to make the best possible decision, it is essential that we 
ensure interoperability between DOD, VA, and the private sector. DOD's 
goal is to provide access to the needed health data regardless of where 
the care is provided or system being used.
    The Defense Healthcare Management Systems Modernization (DHMSM) 
program will deliver a modernized electronic health record (EHR) system 
to unify and increase accessibility of integrated, evidenced-based 
healthcare delivery and decisionmaking. When implemented, it will 
fundamentally and positively impact the health outcomes of active duty 
military, veterans, and beneficiaries by modernizing the software 
supporting DOD clinicians and integration of health data with the VA 
and private healthcare providers.
    The original plan to acquire and build a single integrated 
electronic health record (iEHR) system for both DOD and VA called for a 
``Best of Breed'' approach, a fully-customized solution delivering all 
required capabilities through multiple contracts and applications. It 
became apparent that this approach involved substantial risks in 
implementation due to the amount of integration required across 
applications and facilities and the need for ongoing software 
development. These risks would inevitably impact both schedule and cost 
over the course of the program.
    In February 2013, VA determined that the best course of action with 
respect to its EHR system and VA patient data was to evolve its current 
legacy system, the Veterans Health Information Systems and Technology 
Architecture (VistA) system. As a result of VA's decision, DOD 
undertook a review of its requirements and chartered an independent 
review to assess its own requirements and examine previous analysis of 
alternatives, industry analysis of the commercial Health IT market, and 
DOD's current acquisition approach. The analysis identified a number of 
viable off-the-shelf options for DOD, to include VistA-based products. 
The team recommended that DOD competitively pursue a ``Best of Suite'' 
system solution for electronic healthcare records.
    The DHMSM program provides substantial advantages over the previous 
iEHR strategy. Under this program, DOD will procure a ``Best of Suite'' 
EHR system, with minimal customization for critical, DOD unique 
requirements. There will be a single, multi-year contract award, which 
will be greater in scope but will require a less complex management 
effort. Acquisition of an integrated suite will allow the bundling of 
required capabilities, and will not interfere with the Departments' 
ongoing interoperability efforts. This approach will also minimize the 
amount of integration required, and will maximize the replacement of 
current DOD legacy systems. By adopting a commercial product, DOD will 
be able to leverage the latest commercial technologies and improve 
usability. Feedback from industry during DOD's draft request for 
proposal process and supporting industry days has validated this 
decision.
    These and other factors will result in potential savings (BY2014) 
based on current rough order of magnitude (ROM) cost estimates. These 
estimates are being updated and refined for the release of the final 
RFP later this year, and will be further updated prior to the contract 
award in fiscal year 2015.
    Question. Have firm cost and schedule baselines been established 
for this new plan?
    Answer. Yes. DOD has finalized an initial cost position for the 
DHMSM EHR modernization program (reflected in the table below). These 
estimates are being updated and refined for the release of the final 
RFP later this year, and will be further updated prior to the contract 
award in fiscal year 2015.

 
 
----------------------------------------------------------------------------------------------------------------
                                                                                                         Fiscal
                                                  Fiscal     Fiscal     Fiscal     Fiscal     Fiscal   year 2015-
             DHMSM (Then Year $M)               year 2015  year 2016  year 2017  year 2018  year 2019     2019
                                                                                                         Total
----------------------------------------------------------------------------------------------------------------
Total.........................................      148.9      575.0      769.7      790.9      915.9    3,200.4
RDT&E.........................................       91.4      499.2      373.4          -          -      964.0
Procurement...................................          -          -      302.8      617.1      628.8    1,548.7
Operations and Maintenance....................       57.6       75.8       93.5      173.8      287.1      687.6
----------------------------------------------------------------------------------------------------------------

    The following chart outlines the scheduling baseline for the DHMSM 
program.


    Question. Can you describe the advantages to DOD and VA of having 
an interoperable electronic health record at the successful completion 
of this program?
    Answer. An interoperable electronic health record will provide an 
environment in which clinicians and patients from both DOD and VA are 
able to share current and future healthcare information, ensuring 
continuity of care and improved treatment for our Service members and 
Veterans.
    For clinicians, having access to a complete and evolving EHR will 
enable them to provide the highest quality of care, regardless of the 
location. DOD's specific patient population is highly mobile. To reach 
all beneficiaries, DOD's system must operate worldwide, including 
theater environments, aboard ships and aircraft. More than sixty 
percent of the healthcare provided to DOD eligible beneficiaries occurs 
in the private sector and outside of the DOD or VA EHR systems. For our 
clinicians to make the best possible decisions, it is essential that we 
ensure interoperability between DOD, VA, and the private sector.
    For patients, an interoperable EHR will allow their health 
information to travel with them. They will no longer have to carry a 
paper copy of their health records with them as they move from one 
location, provider and system to another, or when they leave active 
service. DOD and VA beneficiaries can currently access and share their 
own electronic medical record information through a mechanism known as 
Blue Button, which can be accessed via personal computer, web browser, 
or on mobile devices. By providing convenient, anytime, anywhere access 
to personal health data, Blue Button engages beneficiaries and 
encourages participation in their own healthcare.
    The Departments have already made substantial progress toward the 
goal of interoperability. Currently, DOD provides VA with access to 
electronic records of all separating service members through the 
Federal Health Information Exchange (FHIE). In addition, the 
Departments' clinical providers have access to the Bi-Directional 
Health Information Exchange (BHIE), which is a secure, ``read only'' 
display of electronic health information exchanged between DOD's 
Military Health Systems and VA's VistA. Using BHIE, DOD and VA are 
currently sharing essential electronically-stored health information. 
Each day, more than 1.5 million data elements are exchanged between DOD 
and VA based on 60,000 requests from our 10.5 million authorized users 
with more than 5.2 million correlated records.
    DOD's EHR strategy is built around interoperability, to provide 
seamless, integrated sharing of standardized health data among DOD, VA 
and private sector providers. By the end of this summer, the DOD/VA 
Interagency Program Office (IPO) will provide technical guidance to 
support further data sharing between the two Departments. By the end of 
fiscal year 2014, DOD and VA will expand integrated health record 
viewer access from 500 to 3,500 users. We continue to improve data 
sharing efforts, with the goal of full interoperability by December 
2016.
    Question. What lessons has DOD learned from its collaboration with 
VA at the Lovell Federal Health Care Center in North Chicago, and how 
are we capturing what we're learning?
    Answer. The most important lesson learned from the collaboration at 
the Lovell Federal Health Care Center (FHCC) North Chicago is that 
prior to establishment of any future FHCCs, several key areas to 
integration must be fully addressed to ensure success. Most 
importantly, fully interoperable electronic health record (EHR) systems 
between the VA and DOD must be in place and are critical to the success 
of any significant healthcare collaborations between the two 
departments. In addition to information systems, collaboration efforts 
must recognize differing missions, goals, policies, procedures, and 
reporting requirements between DOD and DVA. DOD and VA are committed to 
adopting additional common standards of operations and systems and 
several initiatives are underway in support of this goal. DOD and VA 
representatives at all levels are working very closely with an 
independent contractor to prepare the FHCC evaluation report to 
Congress due October 2015, to ensure all lessons learned are chronicled 
and cataloged.
    Question. Does DOD plan to continue this pilot, as it is scheduled 
to finish in 2015?
    Answer. In November 2013, an approved DOD/VA Joint Incentive Fund 
project was used to award a contract to perform an enterprise 
evaluation and final report to Congress of the James A. Lovell Federal 
Health Care Center (FHCC). The report to Congress is due October 26, 
2015. The results of the evaluation as reported in the report to 
Congress will drive discussions between DOD and VA whether to continue 
the demonstration project model at the FHCC.
    Question. What plans does the Department have to replicate and 
expand this model to other parts of DOD and VA?
    Answer. In November 2013, an approved DOD/VA Joint Incentive Fund 
project was used to award a contract to perform an enterprise 
evaluation and final report to Congress of the James A. Lovell Federal 
Health Care Center (FHCC). The report to Congress is due October 26, 
2015. The results of the evaluation as reported in the report to 
Congress will drive discussions between DOD and VA whether to continue 
the demonstration project model at the FHCC.
                                 ______
                                 
             Questions Submitted by Senator Lisa Murkowski
                  mental health counselors in tricare
    Question. I realize that Mr. Miller may not be the ideal person to 
address this issue, but am directing this question to him as the senior 
DOD official representing TRICARE equities at this hearing. I am 
concerned with TRICARE's interim final rule which will have the effect 
of de-credentialing all of the State-licensed mental health counselors 
from seeing TRICARE patients at the end of this year. There isn't a 
CACREP-accredited counseling program in Alaska and it seems inequitable 
to tell counselors who have been successfully performing in TRICARE 
that they are no longer qualified to practice. This problem is 
compounded by the fact that we have a shortage of mental health 
providers in Alaska as well. I have offered two NDAA amendments to 
address this problem. In the 2013 bill it was a grandfathering 
provision and in 2014 bill it was a 1 year delay in de-credentialing. 
TRICARE opposed both of these amendments stating that it intended to 
address the problems in regulations, but we haven't seen a fix yet and 
time is running out. Our providers don't expect to see any relief and 
as a result they are beginning to close their practices to new TRICARE 
patients.
    Why is it necessary to de-credential experienced mental health 
counselors who are willing to conduct to practice on a supervised 
basis? Can these individuals be grandfathered?
    Answer. By Congressional direction, the Department developed, and 
then published on December 27, 2011, the Interim Final Rule (IFR) which 
prescribed quality standards for the independent practice of mental 
health counselors (MHC) under TRICARE. The IFR criteria, based on 
Institute of Medicine recommendations, specify a master's degree in 
mental health counseling from a program accredited by the Council for 
Accreditation of Counseling and Related Education Programs. The IFR 
transition period allows graduates of regionally-accredited Mental 
Health Counseling programs to be authorized as Certified MHCs if they 
pass a required examination and meet all other standards.
    While grandfathering does not ensure a provider will meet the 
quality standards for independent practice, the IFR generated over 400 
public comments that underscore the importance of balancing provision 
of quality mental health services with the preservation of continued 
ready access to licensed mental health professionals for our 
beneficiaries. These comments have been taken into consideration in 
developing the Final Rule regarding certification of mental health 
counselors under TRICARE. The Department is committed to preserving 
patient access to experienced and well trained mental health 
professionals and believes the upcoming rulemaking action will 
satisfactorily resolve these issues. The Final Rule is currently 
undergoing regulatory review by the Office of Information and 
Regulatory Affairs at the Office of Management and Budget before being 
published in the Federal Register. We anticipate the Final Rule will be 
published later this summer.
                  mental health counselors in tricare
    Question. How does TRICARE plan to address this problem so TRICARE 
beneficiaries in Alaska (which does not host a CACREP-accredited 
training program) will continue to have access to mental health 
counselors? When will that relief come?
    Answer. The Final Rule regarding certification of mental health 
counselors under TRICARE is in the final stages of coordination prior 
to publication. The Department is committed to preserving patient 
access to experienced and well trained mental health professionals and 
believes the upcoming rulemaking action will satisfactorily resolve 
these issues. We anticipate publication of the Final Rule later this 
summer.
    Additionally, as communicated to Senator Begich's staff on April 
30, 2014 and May 6, 2014, we do not anticipate Alaska beneficiaries 
will be negatively impacted. The tables below summarize the 
availability of mental health counselors (MHCs) in Alaska from April 
2013 to March 2014. These include 77 TRICARE Certified MHCs (across 14 
zip code areas) and seven Supervised MHCs (across five zip code areas) 
who provided care to 1,363 TRICARE beneficiaries. TRICARE will continue 
to provide beneficiary access to MHCs in the zip code areas listed 
below (Table 1). While under the Interim Final Rule, the providers 
listed in Table 2 would no longer be eligible to practice under TRICARE 
after December 31, 2014, only two zip codes (99524 and 99501) would no 
longer have any MHCs within their area. However, these two zip codes 
are in close proximity to Anchorage and have other mental health 
professionals who will continue to be available to provide care.
    Further, we learned that as of 2015, the University of Alaska will 
have two Clinical Mental Health Counselor programs accredited by the 
Council for Accreditation of Counseling and Related Education Programs 
(CACREP). CACREP accreditation will be applied to all students enrolled 
at the time of accreditation and to all future students' graduate 
credentials.

      TABLE 1: CERTIFIED MENTAL HEALTH COUNSELORS (CMHCs) BY REGION
 
------------------------------------------------------------------------
                                                            Zip     # of
                          City                              code   CMHCs
------------------------------------------------------------------------
ANCHORAGE...............................................    99503    17
ANCHORAGE...............................................    99507     3
ANCHORAGE...............................................    99508    10
ANCHORAGE...............................................    99515     1
ANCHORAGE...............................................    99516     1
ANCHORAGE...............................................    99518     4
EAGLE RIVER.............................................    99577     7
FAIRBANKS...............................................    99701    14
FAIRBANKS...............................................    99709     6
FAIRBANKS...............................................    99712     1
JUNEAU..................................................    99801     2
KODIAK..................................................    99615     1
PALMER..................................................    99645     2
WASILLA.................................................    99654     8
                                                         ---------------
    TOTAL...............................................  .......    77
------------------------------------------------------------------------


     TABLE 2: SUPERVISED MENTAL HEALTH COUNSELORS (SMHCs) BY REGION
 
------------------------------------------------------------------------
                                                            Zip     # of
                          City                              code   SMHCs
------------------------------------------------------------------------
ANCHORAGE...............................................    99524     1
ANCHORAGE...............................................    99501     1
ANCHORAGE...............................................    99503    *1
EAGLE RIVER.............................................    99577     1
ESTER...................................................    99725     1
FAIRBANKS...............................................    99701     1
JUNEAU..................................................    99801     1
                                                         ---------------
    TOTAL...............................................  .......     7
------------------------------------------------------------------------
* Licensed Psychological Associate in this region.

                                 ______
                                 
                Questions Submitted by Senator Roy Blunt
    Question. How will the Defense Healthcare Management System 
modernization support population health and the industry's shift from 
solely automating health systems to managing a person's health?
    Answer. The DHMSM program involves the acquisition of a new off-
the-shelf electronic health record (EHR) system that will provide an 
environment in which providers and beneficiaries are able to share 
current and future healthcare information, ensuring continuity of care 
and improved treatment for our Service members and Veterans. The use of 
state-of-the art technology and data analytics will encourage patients' 
participation in their own care, and help enhance DOD's focus on both 
population health and the health of our patients.
    An interoperable electronic health record will allow DOD to 
capitalize on the vast amounts of health data collected to increase the 
focus on proactive and preventive care versus reactive treatment of 
disease and illness. The DHMSM solution will have the ability to use 
data to perform predictive analysis to foresee patient behaviors and 
predict disease management, which will help healthcare providers find 
better ways to coordinate care and prevent illness. The use of data 
analytics will help achieve better health outcomes by reducing costs 
(e.g. reducing duplicative tests) and improving quality (e.g. matching 
diagnoses with previous prescriptions to identify disease trends). The 
competitive acquisition process will allow DHMSM to leverage private 
sector advancements in EHR technology, to include data analytics.
    The DHMSM acquisition will also encourage Service members' active 
engagement in their own care through technology. Patients will have 
access to their own personal health record, which will travel with them 
as they move from one location, provider and system to another, or when 
they leave active service. DOD and VA beneficiaries can currently 
access and share electronic medical record information through a 
mechanism known as Blue Button, which can be accessed via personal 
computer, web browser, or on mobile devices. By providing convenient, 
anytime, anywhere access to personal health data, Blue Button engages 
beneficiaries and encourages participation in decisions with their own 
healthcare team.
    The goal of the DHMSM program is not merely the acquisition of new 
commercial EHR software, but a shift in the way healthcare is delivered 
to our Nation's Service members and their families. The end result of 
the program will be a system that fundamentally and positively impacts 
the health outcomes of our beneficiaries, enhances our military 
readiness, and helps advance healthcare interoperability nationwide.
    Question. Key capabilities, which are wide spread throughout the 
healthcare industry, include medical device integration, remote 
hosting, use of mobile devices, and data analytics. How will DOD 
incorporate each of these functions into their efforts to support 
military health requirements?
    Answer. These functions will be incorporated into our draft request 
for proposal and vendors will be evaluated based on these capabilities 
as part of our evaluation process.
    The goal of the DHMSM program is an electronic health record (EHR) 
system that fundamentally and positively impacts the health outcomes of 
active duty military, veterans, and beneficiaries, enhances our 
military readiness, and helps advance healthcare interoperability 
nationwide. DOD recently issued a third draft Request for Proposal 
(RFP), which outlines the requirements necessary to meet the unique 
needs of the Military Health System, including deployment worldwide 
across multiple platforms; integration with private-sector providers, 
who account for more than 60 percent of the volume of care provided; 
and continuity across the full range of care, including pediatric, 
obstetric and gynecological care which account for 25 percent of 
hospital costs. These requirements will be further refined based on 
industry feedback before the final RFP is released later this year.
    As part of the DHMSM acquisition process, DOD is focused on 
delivering capabilities required to support Point of Care operations 
and the interface points required to meet downstream enterprise data 
needs. Specifically, the program is focusing on tight integration with 
medical devices and systems, such as endoscopes, lab instruments and 
bedside monitors, to support clinicians and patients at the point of 
care.
    The use of mobile devices is increasingly prevalent throughout the 
industry, and acquiring a system that incorporates the use of these 
devices is essential to improving the delivery of healthcare across 
multiple platforms. The system acquired by DOD through the DHMSM 
program will maximize the use of industry and national standards based 
interfaces expected to be common to all viable vendors.
    DOD and VA are jointly developing a pilot mobile access application 
to health record information with a common development framework, 
shared tools, synergy in development, and shared costs. This pilot will 
make available, in a mobile device tailored framework, some of the same 
personal health data that beneficiaries in both Departments can 
currently access online through Blue Button, including Progress Note 
Mapping; Joint Summary of Care and Mobile Blue Button; Pharmacy Refill; 
and Consults. It will also conform to DOD policies on network security 
and privacy. Led by the Department of Navy as a recently awarded Joint 
Incentive Fund project, the Joint DOD/VA Summary of Care and Mobile 
Blue Button application is expected to be iteratively fielded over the 
next 2 years.
    An interoperable EHR will provide an environment in which 
clinicians and patients from both DOD and VA are able to share current 
and future healthcare information, ensuring continuity of care and 
improved treatment for our Service members and Veterans. The DHMSM 
solution will have the ability to use data to perform predictive 
analysis to foresee patient behaviors and predict disease management 
which will help physicians find better ways to coordinate care and 
prevent illness. The use of data analytics will help achieve better 
health outcomes by reducing costs (reducing duplicative tests) and 
improving quality (matching diagnoses with previous prescriptions, 
identifying disease trends). The competitive acquisition process will 
allow DHMSM to leverage private-sector advancements in data analytics.
    Question. During the Industry Day events, the DHMSM Program Manager 
stressed the need for industry feedback to shape the requirements 
included in the final RFP. Are you getting enough helpful feedback and 
questions from industry thus far through the draft RFP and RFI process 
to improve the acquisition process? Please share specific examples.
    Answer. Yes, the feedback received from industry during the draft 
Request for Proposal (RFP) and Request for Information (RFI) process 
has been extremely useful and has provided key insights and lessons 
learned as we work toward releasing a final RFP later this year.
    DOD established the DOD Healthcare Management Systems Modernization 
(DHMSM) program to lead a competitive acquisition process that 
considers commercial solutions which will offer reduced costs, 
schedule, and technical risk, as well as providing access to increased 
current and future capability by leveraging advances in the commercial 
marketplace. A critical component of the DHMSM program is an aggressive 
schedule of industry engagement. The program has conducted three well-
attended and highly anticipated Industry Days. The third Industry Day 
was held on February 19, 2014, and was attended by nearly 500 
participants from 200 companies. A fourth Industry Day is planned for 
June 2014.
    DOD has released two of three planned draft RFPs for the DHMSM 
acquisition, and has received more than 1,000 industry comments and 
questions. The final RFP release is expected in the fourth quarter of 
fiscal year 2014. The response to the draft RFPs demonstrates the level 
of interest in the acquisition process among potential contract 
bidders, and provides DOD with valuable information as the final RFP is 
developed.
    As a result of comments received from industry regarding the 
complexity of the Contract Line Item (CLIN) structure, for example, the 
Program Office re-examined the structure and removed unnecessary 
complexity.
    The Program Office received feedback stating that potential 
offerors require additional information with the RFPs in order to 
successfully propose and price a solution meeting the Government's non-
functional requirements (i.e. training, mandatory interfaces, data 
migration, etc.). As a result, the Program Office refined the documents 
to be delivered with the RFP to reduce ambiguity and delays during the 
Source Selection process.
    In response to a targeted RFI, industry respondents confirmed the 
ability of Commercial Off-the-Shelf EHR software providers to propose 
and price in accordance with the Program's enterprise licensing 
strategy. This feedback allowed the Program Office to further tailor 
its licensing strategy to pursue an innovative, performance-based 
approach to purchasing software, affording the Government maximum 
flexibility while reducing total lifecycle costs of software licenses.
    Question. The issue of interoperability regarding EHR efforts 
continues to be discussed at length among healthcare leaders and 
innovators in the industry. How is the department addressing 
interoperability between the DOD, VA, the many TRICARE providers that 
serve the beneficiary population? How will the Department prepare for 
and measure interoperability?
    Answer. The IPO, DOD and VA are currently working with the Office 
of the National Coordinator, and other data standards organization to 
drive cohesive national data standards with industry so that our future 
acquisition will be interoperable not only with the VA but also the 
private healthcare market. These interoperability requirements will be 
included in our RFP and evaluated in our evaluation process.
    Providing high quality healthcare for current Service members, 
their families, and our Veterans is among our Nation's highest 
priorities. The Departments of Defense and Veterans Affairs are also 
committed to ensuring continuity of care as Service members transition 
to Veteran status. Enabling health information exchange between 
electronic health record (EHR) systems in DOD, VA, and private sector 
will serve as the foundation for a patient-centric healthcare 
experience, seamless care transitions, and improved care delivery.
    Our two Departments already have a significant amount of data 
interoperability. DOD and VA clinicians can currently view records on 
the 5.3 million shared patients receiving care from both Departments 
through our existing software applications. This data is available on-
demand to front-line clinicians in both Departments. VA and DOD 
providers generate data queries through our current systems nearly a 
quarter of a million times per week. Both Departments are committed to 
further improvements.
    In 2013, DOD and VA implemented several new data sharing 
enhancements to transform substantial amounts of read-only data into 
computable bidirectional data. This included standardizing data for key 
clinical domains. This data was incorporated into a common, joint 
viewer, which provides an integrated view of VA and DOD clinical 
information, and was deployed to nine pilot sites.
    The DOD/VA Interagency Program Office (IPO) is responsible for 
establishing, monitoring, and approving the clinical and technical 
standards profile and processes to create seamless, integration of 
health data across the VA and DOD and with private sector providers. 
Pursuant to its new charter, signed in December 2013, the IPO will 
support efforts by the Departments and the Office of the National 
Coordinator (ONC) to adopt national standards, specifications, and 
certification criteria to improve health IT and its application. By 
adopting the same national standards, the DOD, VA, and private sector 
providers can fluidly exchange data easily understand and use 
information they receive for clinical decisionmaking.
    Interoperability with private-sector providers is an essential 
element of our modernization program, as more than 60 percent of the 
healthcare provided to DOD-eligible beneficiaries occurs in the private 
sector and outside of the DOD or VA health systems. DOD is focused on 
deploying private sector interoperability in various DOD multi-service 
markets around the country that have mature private sector Health 
Information Exchange (HIE) capabilities.

                          SUBCOMMITTEE RECESS

    Senator Durbin. Thank you.
    [Whereupon, at 11:15 a.m., Wednesday, April 9, the 
subcommittee was recessed, to reconvene subject to the call of 
the Chair.]