[Senate Hearing 114-219]
[From the U.S. Government Publishing Office]
DEPARTMENT OF DEFENSE APPROPRIATIONS FOR FISCAL YEAR 2016
----------
WEDNESDAY, MARCH 25, 2015
U.S. Senate,
Subcommittee of the Committee on Appropriations,
Washington, DC.
The subcommittee met at 9 a.m. in room SD-192, Dirksen
Senate Office Building, Hon. Thad Cochran (chairman) presiding.
Present: Senators Cochran, Murkowski, Blunt, Daines,
Durbin, Mikulski, and Reed.
DEPARTMENT OF DEFENSE
Defense Health Programs
STATEMENT OF LIEUTENANT GENERAL PATRICIA HOROHO,
SURGEON GENERAL, UNITED STATES ARMY
opening statement of senator thad cochran
Senator Cochran. Good morning. The Subcommittee on Defense
Appropriations will please come to order. We want to welcome
our distinguished panel of witnesses for our hearing this
morning. We have the Surgeon General of the Army, Lieutenant
General Patricia Horoho; 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 of the Defense Health Management Systems.
We appreciate very much your submitting testimony for the
record, and we welcome you here to review the budget request
regarding the programs under your jurisdiction, as we try to be
helpful and responsible in the expenditure of funds. We
recognize these are very important national security assets,
and we want to be sure that we are supporting you in the
efforts you are making to continue to fulfill the missions
under your responsibility.
I am going to recognize the distinguished Senator from
Illinois, Mr. Durbin, for any comments he would like to make.
statement of senator richard j. durbin
Senator Durbin. Thanks, Mr. Chairman. I am glad that we are
having this hearing. I want to echo your words and thank
General Horoho as well as Admiral Nathan and General Travis not
only for appearing today but for their significant service to
our country.
I know they are in a period of transition in their
military, professional, and personal lives, and I thank you for
all that you have given to this Nation and given to the men and
women in uniform during the course of your service.
I am proud this subcommittee has really done some amazing
work, particularly over the last several years, to increase the
resources available to the Department of Defense (DOD) in the
area of medical research. It has made and is making a
tremendous difference for our war fighters, from advances to
battlefield medicine to extraordinary possibilities in
transplantation, orthotics, and prosthetics. Importantly, the
impact of these advances is felt across the country and around
the world.
We face another tough budget year. I am hoping that
research funding will continue to be increased. It is important
that we have a trajectory, a positive trajectory, to encourage
researchers and to really establish those breakthrough findings
that lead to better quality of life for people in the military
and around the world.
A lot of challenges--sexual assaults, suicide prevention,
the integrated electronic health record program, and the
overall Military Health System (MHS)--that a DOD-led review
last year found was good but had significant areas in need of
improvement. They are important for our ability to make sure we
serve the men and women in uniform.
Just a shout out to a home State effort; the James Lovell
Federal Health Care facility is unique. It is a joint venture
between the Department of Defense and the Veterans
Administration (VA). I did not know if this marriage was ever
going to take place, and I did not know if it would last once
it took place. We were blending together two different Federal
agencies, two different cultures, two different recordkeeping
systems, two different unions. It was quite a challenge, but we
now have 5 years of working together in finding new and more
effective ways to deliver healthcare service to the men and
women at Great Lakes Naval Training Station, as well as to
veterans from that region of my State of Illinois. I hope we
will learn some valuable lessons about that and talk about
them.
At the same time, we have some new issues, cost of compound
pharmaceuticals, which I would not have identified going into
this hearing as a problem, but it is a big challenge in terms
of resources, the future of TRICARE. We now have the report of
the Military Compensation Retirement Commission to take a look
at.
We have a lot to look at in light of this hearing and
questions today, and I thank the chairman for bringing this
together.
Senator Cochran. Thank you very much, Senator.
Senator Mikulski has submitted a statement that she would
like to have included in the record, without objection.
[The statement follows:]
Prepared Statement of Senator Barbara A. Mikulski
Thank you Chairman Cochran and Vice Chairman Durbin for convening
this hearing to examine the President's fiscal year 2016 budget request
for the Department of Defense's Defense Health Programs. I want to
thank our witnesses, the Surgeon Generals from the Army, Navy, and Air
Force, as well as Mr. Chris Miller, the Program Executive Officer of
Defense Health Management Systems.
These witnesses work day in and day out to improve the health of
all of our military families. They know that the core of our military
is not just weapons, but people. We have been at war for over a decade.
Some bear permanent wounds of war, and all bear the permanent impact of
war.
Today, we will talk about how to best get care for our military
members and their families. Access to great healthcare means ensuring
troops injured in battle are given immediate, effective, and great
care; ensuring wounded warriors are provided with the very best follow-
up care, treatment, and supports when they get home; ensuring that
those working on our military bases have access to reliable, undeniable
communities that keep them healthy and happy; ensuring returning
service men and women have the support services necessary to get--or
keep--them healthy as they cope with post-traumatic stress or other
conditions; and ensuring family members have the support services they
need to help their loved ones heal and to heal themselves and their
families. The very best healthcare involves cutting edge medical
treatments, but it also involves support systems and community health
efforts to help people get--or stay--healthy.
We are all well aware of the very serious medical challenges facing
the military today, like post-traumatic stress, brain injuries,
amputations and serious trauma from IEDs, and prescription drug abuse.
But the military faces other very serious health challenges that often
go unrecognized and unpublicized. Obesity costs the military $1.6
billion annually, only 25 percent of the population is eligible for
military service, and it is the leading cause of people being
discharged. Tobacco use also costs the military $1.6 billion annually.
In order to tackle all of these health challenges, from post-traumatic
stress to obesity to prescription drug abuse. We must do more to create
environments that support our military members and families in being
healthy.
That's why I am encouraged when the Department of Defense
undertakes initiatives like the Healthy Base Initiative. This
initiative recognizes that a person's physical health is directly
related to their mental wellness, their jobs, and their families. If we
want to reduce obesity in the military, we can't just tell people to
eat better and exercise more. We have to meet people where they are. We
need to have dining facilities on bases serving food that is nutritious
and delicious. We need to have commissaries and farmers' markets
providing fresh fruit and produce at reasonable prices. Instead, we
have too many bases where the only food options are fast-food or
vending machines or dining halls that serve liver and onions. We need
to do a better job of encouraging active living with options like bike
paths and parks. We must make sure that gyms are open at times most
convenient for those serving and their families.
If we want to reduce smoking in the military, we have to look
broader than just diagnosing a nicotine addiction and putting people on
the patch. While that may work for some people, it won't work for
everyone. We need to look at what may drive people to smoke, whether
its job or family stresses, unhappiness or dissatisfaction. We need to
look at the fact that cigarettes are often cheaper on military bases
than they are off bases. We, DOD and all Federal health programs, need
to think broader about how to really improve the overall health of our
Nation. That's where the Healthy Base Initiative comes into play. I am
so pleased that DOD launched this initiative and am very proud to have
Ft. Meade included.
DOD is working with 14 military installations to improve military
health and well-being through prevention-oriented approach. Each base
has designed a program that fits their individual needs. All 14
installations are looking to bring healthier food options to bases.
USDA is helping with farmers' markets, the Culinary Institute of
America and Sam Kass are helping with healthy and tasty foods, and
local school districts are getting involved to make sure kids start
good behaviors early. I am very encouraged by what I have seen so far
and I am really looking forward to hearing DOD's plan, vision, and
timeframe for Healthy Base as it enters its next phase.
Those who choose to serve their country deserve the very best
healthcare available. Those of us in charge of the Federal checkbook
must keep an eye on skyrocketing health costs and come up with
solutions that reduce costs and improve health.
Senator Cochran. I want to first recognize in this order
the witnesses we have in this first panel, Surgeon General of
the Army, Lieutenant General Patricia Horoho; Surgeon General
of the Navy, Vice Admiral Matthew Nathan; Surgeon General of
the Air Force, Lieutenant General Thomas Travis; and Executive
Officer of the Defense Health Management Systems, Mr. Chris
Miller.
Lieutenant General Patricia Horoho, welcome. You may
proceed with your comments or statement.
SUMMARY STATEMENT OF LIEUTENANT GENERAL PATRICIA HOROHO
General Horoho. Thank you, sir. Chairman Cochran, Ranking
Member Durbin, and distinguished members of the subcommittee,
thank you very much for this opportunity to tell Army
Medicine's story.
On behalf of the dedicated soldiers and civilians that make
up Army Medicine, I extend our appreciation to Congress for
your support. I want to acknowledge America's sons and
daughters who are in harm's way; over 141,000 soldiers are
deployed or forward stationed. Army Medicine has nearly 2,500
soldiers and civilians deployed around the globe.
This has been a year of unprecedented challenges and
accomplishments. Army Medicine trained every soldier deploying
to West Africa to ensure their safety. Medical research teams
from MRMC (Medical Research and Materiel Command) serving with
our interagency partners spearheaded Ebola efforts on the
ground in Liberia and in the lab by developing a groundbreaking
vaccine.
Our U.S. treatment facilities were certified as Ebola
treatment facilities by the CDC (Centers for Disease Control
and Prevention). We made tremendous strides in our
transformation to a system for health, and our journey of
becoming a high reliability organization for safety and
healthcare delivery.
Our soldiers' readiness remains our number one priority. We
added combat power back to the force by reducing the number of
soldiers who were non-deployable due to health reasons. We also
significantly increased medical and dental readiness, and we
are enhancing health readiness by weaving the Performance Triad
in the ``DNA'' of our Army. The MHS review validated our
pathway to improve safety and quality of care for our soldiers,
our family members, and retirees, and the review showed that we
are either above or comparable to the best healthcare systems
in the Nation.
Our programs and initiatives that contribute to our success
are further outlined in my written testimony, and what I would
like to do is use the balance of my time to discuss the two
major threats that are facing Army Medicine today.
An ever changing security environment demands that Army
Medicine diligently maintain a medically ready force and a
ready medical force. The first threat is viewing Army Medicine
through the lens of a civilian healthcare system.
Army Medicine is so much more. We are national leaders in
medicine, dentistry, research, education, training, and public
health. These are all intimately linked to soldiers' and our
providers' deployment readiness.
Our hospitals are our health readiness platforms, and this
crucial link to readiness sets us apart from the civilian
healthcare system. Army Medicine provided the majority of
operational medicine and combat casualty care in Iraq and
Afghanistan that led to a 91 percent survivability rate for
wounded servicemembers.
The NATO Medical Center of Excellence adopted key focus
areas from our 2011 health service support assessment as best
practices and lessons learned.
These invaluable battlefield experiences permeate our
education training platforms at Uniformed Services University,
AMEDD (U.S. Army Medical Department) Center & School, the
Medical Education and Training Center, and our medical centers.
Any radical departure from our combat tested system would
degrade readiness in an environment where the next deployment
could be tomorrow.
The second threat to Army Medicine is the return of
sequestration. Sequestration would have a significant
detrimental impact on our patients, their families, and our
medical team. Devastating reductions to both civilian personnel
and military would impact every Army Medicine program.
Sequestration would cause MEDCOM to close inpatient and
ambulatory surgical centers at a number of our military
treatment facilities, jeopardizing our ready and deployable
medical force.
Reductions driven by sequestration would be devastating and
very different from our current right sizing to currently align
our medical capabilities. Our valued civilian employees were
extremely sensitive to the furloughs and hiring freeze in 2013.
Two years later, we still have not been able to replace all of
these highly skilled employees.
PREPARED STATEMENT
Servicemembers go into battle confident because Army
Medicine in concert with our sister services goes with them.
For the past 13 years, when wounded servicemembers on the
battlefield heard the rotors of a Medivac helicopter, they
believed they were going to survive. We must protect the system
that gave them that confidence.
I would like to thank my partners in the Department of
Defense, the VA, my colleagues here on the panel, and Congress
for your continued support. The Army Medicine team is proudly
serving to heal and very honored to serve.
Thank you.
[The statement follows:]
Prepared Statement of Lieutenant General Patricia D. Horoho
Chairman Cochran, Ranking Member Durbin, 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 with whom I am truly honored to serve.
I would like to start by acknowledging America's sons and daughters
who are still in harm's way--today nine of ten Active Army and two Army
National Guard division headquarters are committed in support of
Combatant Commanders across the globe. More than 141,000 Soldiers are
deployed or forward stationed and 18,000 Reserve Soldiers are
mobilized, sacrificing for our freedom. And to the thousands of 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. In the past we spoke
of interwar periods, a time to recover, to take a knee. I do not see
this recovery period on the horizon...as reflected in our current
deployment levels, the op-tempo around the world is accelerating with
an ever changing security environment.
Since 1775, America's medical personnel have stood shoulder-to-
shoulder with our fighting troops in harm's way, received them at home
when they returned, and worked tirelessly to restore their health, both
mental and physical. Our world-class combat casualty care, which
extends from the medic on the front lines to our CONUS-based medical
centers, has resulted in the highest survivability rates in the history
of modern warfare. Throughout the most challenging times our Nation has
faced, our Soldiers remained confident and mission-focused, knowing
when they looked over their shoulder, an Army Medic would be following
in their footsteps. While the wounds of war have been ours to mend and
heal, our extraordinarily talented medical force also has cared for the
non-combat injuries and illnesses of our Soldiers and their Families,
in theater as well as at home.
Army Medicine is comprised of a committed team of over 150,000
Active Duty, Reserve Component, Civilian and Contract professionals who
serve in over five continents, across 18 time zones, providing cutting
edge medical readiness and healthcare throughout the world. Army
medicine is so much more than a civilian healthcare system; we are
national leaders in medicine, dentistry, medical research, education,
and training, and public health. It is an honor to lead this
outstanding enterprise, earning the trust and caring honorably and
compassionately for our 3.9 million Soldiers, Family Members, and
Retirees across the globe.
Today, Army Medicine provides high quality, safe healthcare, while
working tirelessly to optimize the readiness, resilience, and
performance of our Forces. We continue to focus our efforts across our
enduring four priorities: deployment medicine and 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 engrained in our DNA and drive all that we do; they span the entire
spectrum of health readiness delivery from medics saving lives on the
battlefield to researchers discovering new vaccinations in our labs
across the globe.
Over the last few years, we have made great strides in improving
the health readiness of the force, leading the Army's cultural change
towards a more ready and resilient Soldier. This success was achieved
by promoting the Performance Triad, comprised of healthy sleep,
activity, and nutrition, and increasing the impact on our readiness
touch points to include embedded providers, Soldier Centered Medical
Homes, dental clinics, and garrison medical facilities. Our medical
force has remained ready and deployable, leveraging lessons learned in
theater to improve care in garrison, and using evidenced-based practice
and cutting edge research to improve care delivered far forward.
Clearly, now is not the time to waver in the support we provide to
our Nation's heroes. We not only have to keep the faith and provide for
those who are still recovering from the visible and invisible wounds of
war, but we also need to remain trained and ready to respond to
emerging crises around the world, from Ebola to the Ukraine. The
increasing instability across the globe demands that we ensure the
health readiness of our Soldiers while sustaining our ready medical
force. Our Military Treatment Facilities (MTFs) are vital to this as
they are our Health Readiness and Training platforms where our medical
teams work together to hone their critical wartime skills and remain
ever ready.
These complex and uncertain times require that we continue our
unwavering dedication to our enduring missions, transform from a
healthcare system to a System for Health, persist in our efforts to
demonstrate the characteristics and behaviors of a high reliability
organization, and lead the way with innovative research, diplomacy, and
collaboration. However, all the lessons learned and progress we have
made as a result of the last 13 plus years of persistent conflict and
our focused efforts at continuous improvement along our four priorities
are at risk of being slowed, halted, and reversed, given an unstable
funding environment and the detrimental second-and third-order effects
of sequestration.
consequences of sequestration
There is no doubt sequestration has had and will continue to have a
significant negative impact on the Army Medical Command (MEDCOM). This
impact is felt particularly hard with our dedicated and absolutely
essential civilian staff. While many think of MEDCOM as green suit
healthcare providers, the reality is civilian employees comprise 60
percent of the MEDCOM workforce. They are the backbone, stability, and
glue of our system.
Sequestration in fiscal year 2013, combined with the furlough and
hiring freeze, had a profound impact on MEDCOM. Our valued civilian
employees were extremely sensitive to the tumult and uncertainty caused
by sequestration. Many high performing and valued civilian employees
experienced burn out, lost faith, and left the MEDCOM for employment
with organizations that were not affected by sequestration, such as the
VA. The remaining workforce was challenged to absorb the work of
departed personnel. In some cases, reduced staffing led to a negative
cycle of decreased access for some beneficiaries resulting in a
corresponding reduction in patient loyalty. In addition, the hiring
freeze instituted from January through December 2013 inhibited our
ability to replace the employees who departed the MEDCOM. Despite
aggressive hiring actions since 2014, MEDCOM has not yet regained the
lost civilian personnel. As of January 2015, we continue to have a
shortfall of over 1,800 civilians.
Sequestration would force us to suspend all discretionary spending,
including capital equipment, facility restoration & modernization,
sustainment and procurement. Additionally, this would place significant
constraints on all non-healthcare delivery spending, such as training,
education and public health. Every effort would be made to protect
primary care, behavioral health (BH), specialty care, surgical
capabilities, inpatient services, and healthcare delivery at our
largest MTFs, in addition to world-wide public health/veterinary
services (food and water source inspections) to protect required go-to-
war clinical capabilities. Based on our experience from the 2013
Sequester, we expect to lose an additional 3,000 civilians across the
command.
With a reduced civilian workforce, sequestration will also lead to
reductions in military end-strength in the MEDCOM. The Army is
preparing to drawdown to an Active Duty end strength of 450,000
Soldiers that will result in a reduction of more than 800 active duty
MEDCOM personnel. If sequestration returns, the Army may be compelled
to reduce active duty end-strength to 420,000, leading to an
anticipated reduction of greater than 3,000 active duty MEDCOM
personnel.
We will not compromise the safety of our patients as a result of
sequestration; however, the combination of military and civilian
reductions will cause the MEDCOM to close inpatient and ambulatory
surgical centers at a number of MTFs. This would severely impact our
ability to support the health readiness of our Soldiers, impact the
readiness of our providers, and break trust with our Soldiers,
Families, and Retirees, by forcing them to the TRICARE network.
I have grave concerns essential programs for rebuilding our
Soldiers after over a decade of conflict will take the brunt of these
cuts. The impacts will be visible in decreased resources to sustain
initiatives in BH and Traumatic Brain Injury (TBI); a decrease in
access to care; and extended appointment wait times for our Soldiers,
Families, and Retirees at our health readiness platforms. MEDCOM would
reduce research and training programs throughout the Command to ``must-
fund'' levels. This will significantly reduce progress that has been
made in medical programs over the last few years both in the areas of
research and training of the force.
With this said, we have every intention to work diligently to
maintain our progress, and act as faithful stewards of all that we are
provided.
unwavering dedication to enduring missions
Even as the Army shifts from years of continuous war, ongoing
operations demand that Army Medicine sustains the enduring missions
essential to the health and wellness of our Soldiers. These enduring
missions include Warrior Care, BH, Tele-health, TBI, the role of women
in the Army, and Sexual Harassment/Assault Response and Prevention
(SHARP).These programs are the backbone for restoring and then
optimizing the health readiness of our Soldiers and preparing them for
future global engagements or transition to their post-Army careers.
Warrior Care
Caring for our wounded, ill, and injured is our highest calling. We
must continue to ensure they are provided the best healthcare possible
to remain on active duty or to successfully transition out of military
service back to Hometown, USA. Warrior Care is an enduring mission for
the Army and Army Medicine. It remains fully funded despite budget
turmoil.
Over the past 7 years, there has been significant investment in the
development of the Warrior Care and Transition Program (WCTP). WCTP
personnel are committed to providing the best care and treatment for
every wounded, ill, or injured Soldier. As of February, 2015, a total
of 66,113 Soldiers have completed the WCTP with 29,492 of these
Soldiers returning back to the force. This unprecedented 45 percent
return-to-duty rate is a direct result of the dedication of our Wounded
Warrior cadre, clinical providers, and support staff.
From February 2014 through February 2015, the overall Wounded
Warrior population decreased by more than 40 percent, from 7,008 to
3,996. This is largely attributed to the drawdown of forces in
Afghanistan. The Warrior Transition Command (WTC) conducts an analysis
twice yearly to ensure that Warrior Transition Units (WTU) are properly
structured to provide optimal care for our wounded, ill, and injured
Soldiers. As the wounded, ill and injured population continues to
decline, we will make recommendations to the Army to right size the
WCTP footprint to meet the population needs while still sustaining the
high quality care we provide today, regardless of the population.
As a result of the analysis completed during fiscal year 2013, The
WTC successfully inactivated five WTUs and all nine Community Based
WTUs (CBWTU) in fiscal year 2014. Additionally, 11 Community Care Units
(CCUs) were activated. CCUs improve care for assigned Soldiers, provide
better access to resources on installations, and reduce delays in care.
Soldiers reassigned to a CCU from an inactivating CBWTU maintained
continuity of care with their same primary care team within their local
community. In addition, no Soldiers receiving care within the WCTP had
to move or PCS due to an inactivating or activating CCU. As of February
1, 2015, a total of 677 Soldiers (17 percent of the total population)
were assigned to a CCU receiving care in their home communities.
The WCTP remains committed to returning Soldiers to duty. However,
when Soldiers are unable to return to duty, we are dedicated to
supporting a seamless transition to ensure their continued success.
Approximately 60 percent of Soldiers in the WTUs are enrolled in the
Integrated Disability Evaluation System (IDES). MEDCOM, in
collaboration with the VA, continues to improve guidance to increase
standardization and reduce variation within the Medical Evaluation
Board (MEB) phase of the IDES process. In 2014, Army Medicine launched
the Medical Evaluation Board Remote Operating Centers (MEBROCs) to
increase IDES enterprise capacity. As a result of this monumental
effort, the total Army average for the MEB Phase has remained below the
100-day active duty and a 140 day Reserve Component standard across all
components for 16 consecutive months. Additionally, the efficiencies
created by the IDES Service Line led to an overall savings of $12.8M in
2014. These improvements not only benefit our wounded, injured, or ill
Soldiers and their Families, but also maintain the overall medical
readiness of our total force enabling the Army to fully support future
global engagements.
As the WCTP shifts to aiding a population more likely to be ill or
injured rather than wounded, our Cadre training is continuously refined
to meet the needs of the Soldier. The WTC recently finalized a draft
Army Regulation as a single source document which consolidated all
existing WCTP policies. The draft Army Regulation is being staffed and
will be released in the coming months. A newly created WCTP Soldier and
Leader Guide offers practical guidance to facilitate the recovery and
transition of Soldiers and their Families. The Army Medical Department
Center & School (AMEDDC&S), in coordination with the WTC, provides a
comprehensive, blended-learning training program to better prepare
Soldiers from all Military Occupational Specialties (MOSs) to serve as
cadre in the WTUs. The training program orients new cadre and nurse
case managers to this very unique environment where physical injuries,
PTSD and other BH issues, and Family concerns are commonplace.
Career and Education Readiness activities are the centerpiece of an
effective transition from the Army for Wounded, Ill and Injured
Soldiers. WTC's coordination of enhanced WTU vocational, career
opportunities and programs in coordination with Army G-1's Soldier for
Life (SFL) Transition Assistance Program (TAP) and other external
resources, is successfully preparing Soldiers for post-Army employment,
education, and independent living services. SFL TAP provides robust
transition assistance as part of the new Veterans Opportunity to Work
initiative which is available to all eligible Soldiers. Soldiers
complete a 12 month post-transition budget, identify any skill gaps
during a Military Occupational Specialty crosswalk with civilian
occupations, and complete career assessments in order to effectively
make future career decisions.
The Soldier will always be the center of gravity for our Army and
Army Medicine. The optimized WCTP will remain an enduring program that
helps fulfill the Army's commitment to never leave a fallen comrade.
Behavioral Health (BH)
The longest period of conflict in our Nation's history has
undeniably inflicted physical, mental and emotional wounds to the men
and women serving in the Army--and to their Families. The majority of
our Soldiers have been extremely resilient during this period and are
thriving. However, Army Medicine 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, and is unquestionably an enduring mission.
Army Medicine anticipates sustained growth in BH care requirements.
In fiscal year 2015, the Army will resource an estimated $350 million
to support BH and sustained implementation of BH initiatives. These
funds specifically support the 11 recognized enterprise BH Service Line
(BHSL) clinical programs under each MTF's standardized Department of
Behavioral Health.
The Army's continued emphasis to extend BH care to Soldiers and
Families and decrease stigma is likely to increase the use of BH care.
The readiness of the force is contingent upon providing access to high-
quality BH care to Soldiers and Family Members. The Army's BH System of
Care (BHSOC) standardizes and integrates the best clinical practices
into a single, interconnected system. It supports the readiness of the
force by promoting health, identifying BH issues early, delivering
evidence-based treatment, and leveraging all resources in the Army
community to decrease risk for suicide and other adverse events.
The Army screens Soldiers for BH conditions, including PTSD, at
several points in the Force Generation cycle. The Army's screening
program includes assessments before and after every deployment and
annually, exceeding the DOD requirements. The Army also screens for BH
conditions at primary care visits and has placed BH professionals in
Patient Centered Medical Homes (PCMHs) to expedite consultation and
treatment. As MEDCOM expanded access to the BHSOC, utilization of
outpatient BH increased from approximately 900,000 encounters in fiscal
year 2007 to over 2.1 million in fiscal year 2014. Soldiers with BH
conditions used outpatient BHcare more frequently to address BH issues
and fewer acute crises have occurred. Soldiers required 173,000
inpatient BH bed-days in 2012, but only 112,000 in 2014. We are also
confident the BHSOC, along with the Army's Suicide Prevention Programs,
contributed to the decrease in suicides from 2012 to 2014.
The Army is removing the stigma associated with seeking BH care
with programs such as Embedded BH (EBH) that provides targeted care in
close proximity to Soldiers' unit areas and in close coordination with
unit leaders. As of January 2015, Army Medicine has 49 EBH teams,
including 10 that were established in 2014. Of these, 36 directly
support Brigade Combat Teams (BCTs), while the remaining 13 support
non-BCT operational units including military police and combat
engineers. By fiscal year 2016, we expect to have 65 EBH teams
operational.
In 2014, Army Medicine implemented the BH Data Portal (BHDP) at
every MTF. BHDP is a web-based application that gathers standardized,
automated clinical data from Soldiers receiving care for BH conditions.
It tracks patient outcomes, satisfaction, and risk factors to improve
program assessment and treatment efficacy. This innovative program was
identified by the DOD as a best practice and selected to be implemented
across the other Services. Additionally, it was cited in the August
2014 President's executive actions on improving BH services throughout
the DOD.
We continue to use complementary and alternative therapies to
decrease the use of psychotropic drugs. The use of psychotropic drugs
in Soldiers is trending down. From 2012 to 2014, the rate of prescribed
psychotropic drug use decreased from 23.15 percent to 20.7 percent.
This is a direct result of our BH support programs and management of
these conditions through evidence based non-medication regimens.
Due to the significant national shortage of child and adolescent BH
providers, traditional models of care have been unsuccessful in
delivering services to Family Members. In response, Army Medicine
implemented the Child and Family Behavioral Health System (CAFBHS) in
March 2014, a new and innovative method to deliver BH care to Army
Families. The CAFBHS more efficiently delivers care by consulting and
collaborating with primary care teams in the PCMH, placing BH providers
in on-post schools, and using regional tele-consultation to increase
access to BH care. In addition, primary care managers are trained in
the screening and treatment of common BH disorders within the PCMH.
There are currently 150 BH providers working in the CAFBHS, including
50 providers in 46 schools at 8 installations. Over the next 2 years,
CAFBHS will increase to 381 BH providers supporting 107 schools across
32 installations delivering comprehensive BH support to Army Families.
Tele-health
The expansion of Tele-health (TH) capability is a vehicle for Army
Medicine to expand our influence into the Lifespace of our Soldiers,
Families, Retirees, and Civilians. TH is the future of medicine and a
core clinical capability of Army Medicine that can increase access to
care, reduce cost, and alleviate quality and readiness challenges. Army
TH currently provides clinical services across the largest geographic
area of any TH system in the world including 18 time zones in over 30
countries and territories across all five Regional Medical Commands
(RMCs) and in active theaters of operation. Army TH accounts for over
95 percent of all clinical TH encounters in the DOD.
During fiscal years 2008-2014, Army TH provided over 150,000
provider-patient encounters and provider-to-provider consultations in
garrison and operational environments across 30 specialties. Tele-BH
(TBH) currently accounts for 88 percent of total TH volume in garrison
and 58 percent in the operational environment. Army Medicine currently
executes approximately $21 million per year on clinical uses of TH such
as TBH. Additionally, the Army developed and uses mobile health
applications for beneficiaries with TBI and is expanding its use of
educational systems as a force multiplier for Pain Management.
In fiscal year 2015, Army Medicine is introducing a 3-year
expansion plan for TH to create a Connected, Consistent Patient
Experience (CCPE). The CCPE will create a 360: care continuum around
patients using advanced TH modalities. The core elements of the CCPE
include establishing a Virtual PCMH, optimizing provider-to-provider
tele-consultations systems, expanding clinical video-teleconferencing
systems to new specialties, piloting remote health monitoring, and
continuing to mature Army TH in operational environments.
Traumatic Brain Injury
Another enduring mission is our focus on providing our Soldiers and
other beneficiaries the very best TBI care in the Nation. From January
1, 2000, through June 2014, approximately 307,283 Service Members have
been diagnosed with TBI, with 253,350 (82 percent) of these injuries
being classified as mild TBI (mTBI), or concussions. Since 2000, Army
Soldiers comprise approximately 58 percent of all DOD TBI cases, making
this issue a clear priority for Army Medicine. The number of Soldiers
diagnosed with concussions has steadily increased among all Army
components, with the sharp increases beginning in 2006 attributable, in
part, to screening efforts and other early detection initiatives.
The Army TBI Program continues to build on innovations,
partnerships, and research to better prevent, diagnose, treat and track
mTBI and concussion as we transition from a conflict-focused to
garrison-focused program. This program focuses on five essential
elements: A mandatory education component for all Army personnel; one
worldwide standard of care for assessing and treating Soldiers who may
have been exposed to a potentially concussive event; an expansive
garrison clinical care program to meet the medical and rehabilitation
needs of patients with all severities of TBI; baseline neurocognitive
testing of all deploying Soldiers; and an aggressive research program
to advance mTBI and concussion diagnosis and treatment. Through
collaborations with the National Football League and the National
Collegiate Athletic Association, the Army is increasing awareness,
reducing stigma associated with seeking care, and changing the culture
regarding brain injuries on the battlefield and at home.
The Army accepted a proffer from the Intrepid Fallen Heroes Fund to
build six centers devoted to advanced treatment of complex mTBI. These
Intrepid Spirit clinics will provide advanced integrative care and
intensive outpatient programs for patients with multiple diagnoses (to
include TBI, chronic pain, and BH conditions). Intrepid Spirit Fort
Campbell opened on September 8, 2014, and facilities at Fort Hood and
Fort Bragg are expected to be completed by November 2015. Army Intrepid
Spirit Clinics are programmed for Joint Base Lewis-McChord and Forts
Carson and Bliss.
The Army manages the largest portfolio of TBI-related research in
the world, with an investment of over $800 million since 2007. For
fiscal year 2015, the total expenditures are estimated at $96 million,
with the bulk of TBI funding from DHP Congressional Special Interest
(CSI) funding. As of June 2014, over 590 research projects have been
awarded or are pending award. Research is ongoing across the continuum
of care from prevention, early screening and identification, to better
diagnostic tools, imaging, and treatment options, to rehabilitation and
return to duty determinations. From a treatment perspective, the
Medical Research and Materiel Command is dedicated to developing FDA-
approved therapies designed to assess and treat the injured brain.
These innovations will ensure those without injury can stay in the
fight, while those who are diagnosed are effectively treated to
preserve their future health.
Additionally, we are leveraging the strength of multiple agencies,
including the Defense Centers of Excellence for Psychological Health
and TBI (DCoE), the Defense and Veterans Brain Injury Center (DVBIC),
our sister Services and the VA to translate research findings into the
latest guidelines, products, and technologies.
Women in the Army
Women have played a key role in America's military efforts since
the Revolutionary War. Time and time again they have proved their value
in all operational and garrison environments. From the medic on the
battlefield, 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 improving the readiness of our Total
Army Family.
The Army continues to open previously closed positions and
occupational specialties to women. Over the past 27 months, the Army
opened six previously closed MOSs and over 55,000 positions across all
Army components. Army Medicine is providing direct support to the
Soldier 2020 initiative led by the U.S. Army Training and Doctrine
Command (TRADOC) and Army G-1 to identify, select, and train the best-
qualified Soldiers for each MOS.
The U.S. Army Research Institute of Environmental Medicine
(USARIEM) supports TRADOC in conducting the ``Physical Demands Study''
to establish occupational-specific accession standards for the combat
arms specialties currently closed to women. The goal is to develop
valid, safe, legally defensible physical performance tests that predict
a Soldier's ability to perform the critical, physically demanding
occupational tasks of currently closed MOSs. The Army's scientific
approach for evaluating and validating MOS-specific performance
standards aids leadership in selecting and training Soldiers,
regardless of gender, to safely perform the physically demanding tasks
of their Army occupation. This approach will ensure that standards are
maintained and will give every Soldier the opportunity to serve in
positions where he or she is capable of performing to standard.
In July of 2011, I had the distinct honor to deploy in support of
the International Security Assistance Force in Afghanistan to examine
healthcare in the Central Command Area of Responsibility. Specifically,
the team focused on readiness, resilience, MEDEVAC enhancements,
medical information technology, education and training, and
enhancements to Body Armor. Recently, the lessons learned were adopted
by 15 NATO partners at the Military Medicine World Conference in
Budapest, Hungary.
Our work on the ground served as the foundation for the Women's
Health recommendations in the Health Services Support Assessment in May
2012, the establishment of the Women's Health Task Force, and the
creation of 26 tasks focused on supporting female Soldiers in austere
deployed environments. We established standardized education for
healthcare providers and treatment algorithms throughout theater to
avoid unwarranted movement of women inside a combat zone for care
allowing Soldiers to focus on the primary mission. These and other
efforts across the Army served as the preamble for integrating women
into expanded roles and opportunities while protecting them from
illness and disease.
The Women's Health Task Force is now issuing its final report after
making significant progress on a number of fronts and transitioning
their work to our institutional organizations. Key accomplishments
include: helping develop female specific body armor, introducing
devices and exploring the feasibility and utility of self-diagnosis
kits, updates to training curriculum, establishing a women's health
Internet portal, and addressing mental health and SHARP issues in a
deployed environment. I am very proud of the team and the tremendous
contributions they have made to our Army.
The Women's Health Service Line (WHSL) is dedicated to ensuring
safe, quality patient care and a consistent patient experience across
the enterprise. Their efforts focus on wellness and readiness,
perinatal, and operational medicine in areas such as group prenatal
care, cancer prevention, and postpartum readiness have been
instrumental in improving healthcare outcomes and patient satisfaction.
Human Papillomavirus (HPV) is the primary causative agent for cervical
cancer and, according to the National Cancer Institute, is responsible
for nearly of all vaginal cancers. Partnered with an education
component, WHSL has taken the lead in the effort to vaccinate both boys
and girls beginning at age 11 and as late as 26 years old to stamp out
this preventable disease.
Sexual Assault/Sexual Harassment Prevention
The Army and Army Medicine continue to attack the complex
challenges of sexual assault. While we have made much progress, much
work remains. Sexual assault and harassment directly contradict 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, Army Medicine continues to be
at the forefront of the management, regulatory guidance, and oversight
of care for all sexual assault victims. Regardless of evidence of
physical injury, all patients presenting to our health readiness
platforms with an allegation of sexual assault receive comprehensive
and compassionate treatment. They are offered a Sexual Assault Forensic
Examination (SAFE) by a trained and competent Sexual Assault Medical
Forensic Examiner (SAMFE) within our military health system or at a
local facility through a memorandum of agreement. Seamless follow-on
care is coordinated and managed through the sexual assault medical
management team who are a designated multidisciplinary group of
healthcare providers who coordinate with the Sexual Assault Response
Coordinators (SARCs) and Victim Advocates (VAs) to develop a care plan
based upon the patients input and needs. Army Medicine has 217 SARCs
and VAs. Furthermore, there are 118 qualified SAMFEs supporting 32
MTFs, meeting the 2014 NDAA requirement to have a Sexual Assault Nurse
Examiners at each of our 20 MTFs with a 24-hour emergency room
capability.
The AMEDD SAMFE training meets CENTCOM pre-deployment requirements
for healthcare providers assigned to Role II and Role III healthcare
facilities. To support pre-deployment and local SAMFE requirements, the
MEDCOM SHARP Program Office hosted and trained 141 SAMFEs in fiscal
year 2014. Army Medicine is in the process of aligning our SAMFE
training in the AMEDDC&S and developing a certification process for all
SAMFEs. The 2015 NDAA directs that our SAMFEs are trained and
certified; with these changes to our curriculum, not only do we meet
the requirements of the NDAA 2015, but we establish ourselves as a lead
and benchmark for the DOD.
transitioning from a healthcare system to a system for health
Army Medicine has made great progress over the last 3 years in our
transition from a Healthcare System to a System for Health (SFH).
Health is a critical enabler of readiness, and Army Medicine is a
valuable partner in making our Force ``Army Strong.'' In 2012, we began
our journey to aggressively transition 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 critical enabler for readiness. 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. Our efforts to transform to a System for
Health are aligned along three lines of effort focusing on the
Performance Triad, Delivery of Health, and Healthy Environments.
The Performance Triad
The strength of the Army and the cornerstone of landpower's
historical and future success hinges on the human dimension-- the
Soldier. Yet, daily, over 43,000 Soldiers, or the equivalent of 12
Brigade Combat Teams, are non-deployable; annually, 10 million duty-
days are limited or lost related to injuries, 80 percent of which are
preventable. As the Army faces a draw down, it remains obligated to
provide a Total Force that is ready for any mission in a complex world
with an ever changing geopolitical landscape.
The impacts of restful sleep, regular physical activity, and good
nutrition are visible in both the short- and long-term. The Performance
Triad is a solution and key enabler to augment individual and unit
readiness. It optimizes Soldier performance, and tackles the non-
deployable and injury challenges by teaching, coaching, and mentoring
Soldiers and Families to improve health related behaviors. The
Performance Triad empowers them to take personal responsibility for the
betterment of their health readiness, resilience and performance. The
Performance Triad is a lifestyle, a way of being, and represents how to
impact the Lifespace of the Total Force--where people live, work, and
play.
The Performance Triad is aligned with the Army Warfighting
Challenges, the Human Dimension, and the Chief of Staff of the Army's
Soldier optimization efforts. The Performance Triad enhances readiness
by promoting sleep, physical activity, and nutrition through health
literacy campaigns delivered through a variety of channels including
traditional print, digital and social media. These efforts are targeted
to meet the needs of our Soldiers, Families, DA Civilians, and Retirees
where they live and work. When individuals and units adopt the tenets
of the Triad, they optimize the physical fitness, cognitive dominance,
and emotional resilience of the Total Army Family.
Over the past year, the Army completed a 6-month pilot program that
tested the Performance Triad curriculum across three active duty
battalions, including one deployed to Afghanistan. The results of the
pilot project revealed that the majority of Soldiers are not meeting
the basic Performance Triad targets essential for readiness, health,
and performance. More detailed fiscal year 2014 Performance Triad pilot
results revealed that few Soldiers understand how to properly train to
be tactical athletes, only 4-5 percent of Soldiers met the sleep
targets, only 2-4 percent met all of the nutrition targets, and despite
unit physical training, only 29-42 percent met the activity targets.
After completion of the program, positive changes included: Soldiers
who slept eight hours during the weekends improved from 33 percent to
46 percent, refueling after exercise and fish consumption improved, and
overall, 26 to 40 percent of Soldiers improved on the Performance Triad
targets. Over 50 percent of Soldiers reported they liked the program,
felt the program influenced readiness, would use the information in the
future, felt the program was successful, and would recommend Army-wide
implementation. From a small unit leadership perspective, Soldiers
believed their squad leaders became better coaches over the course of
the program.
The feedback and lessons learned from the fiscal year 2014 pilot
informed the fiscal year 2015 Performance Triad curriculum revision.
Utilizing the revised content, a second pilot will provide training to
up to 30,000 active duty Soldiers across Forces Command, the U.S. Army
Reserve and National Guard. As part of this pilot, Army Medicine
initiated a pilot at the AMEDDC&S in January 2015 within the Basic
Officer Leader Course, the Captain's Career Course, and the Non-
Commissioned Officer School to teach leaders the importance of
practicing the tenets of the Triad in all environments and to be able
to impart knowledge within their spheres influence. For military units,
the Performance Triad is a squad-leader-led program that provides
first-line supervisors easy-to-use tools required to coach, teach, and
mentor the tenets of human performance optimization. In support of
mission command, the Performance Triad curriculum influences health
readiness and serves as a forcing function to synchronize efforts
across installations and operationalize policies and programs offering
a whole-of-Army approach.
The Army continues to invest in the Performance Triad to achieve
the collective vision set forth in the Army Warfighting Challenges, the
Human Dimension, and the Ready and Resilient Campaign. The successful
Army-wide implementation of Performance Triad tenets will optimize the
health readiness, resilience and performance of the Total Force.
Delivery of Health
The Delivery of Health domain focuses on restoring health through
providing early access to evidence-based, safe, high quality, person-
centered, predictive, proactive and collaborative healthcare while
focusing on restoring health and wellness after an injury or illness.
Integration of PCMH, SMCH and our health service lines, such as the
Physical Performance Service Line, with tools, resources, and pathways
to facilitate health, wellness, and readiness is imperative, as are
critical programs such as the Army Wellness Centers, Dental ``GO First
Class,'' and our focus on optimizing Brain Health.
Musculoskeletal injuries (e.g., low back pain) are the leading
reason for Soldiers seeking medical care. Outpatient medical encounter
rates for active duty members across all Services nearly doubled
between 2002 and 2012. These types of injuries negatively impact
military readiness. At any time, 10 percent of active duty Soldiers are
non-deployable due to physical profiling for musculoskeletal issues.
More than 75 percent of non-battle medical evacuations from Iraq and
Afghanistan were for musculoskeletal conditions.
Given the magnitude of this problem, MEDCOM established the
Physical Performance Service Line (PPSL) to implement a standardized
system of care to address such musculoskeletal health. This service
line is focusing on four lines of effort to track the Soldier across
the spectrum of musculoskeletal health, from human performance
optimization (HPO) and injury prevention (IP) through early
identification and expert management of musculoskeletal injuries, and
subsequently through rehabilitation and reintegration processes.
PPSL's initial areas of effort included development of an
operational training course for embedded physical therapists in the
BCTs, development and oversight of musculoskeletal action teams (MATs),
standardized Physical Readiness Training-based e-profile templates for
upper and lower body injuries, acute and traumatic musculoskeletal
injury screening, referral tools for primary care providers, and a
standardized aquatic rehabilitation pilot program. They are leading the
way in ensuring we are delivering the very best standardized and far
forward musculoskeletal care to our Soldiers, Families and Retirees
across our System for Health.
Army Wellness Centers (AWC) are also instrumental in assessing and
improving the health of the force, especially those who are at
increased risk for obesity or other chronic conditions. In fiscal year
2014, the AWC served 27,964 clients of all beneficiary type in 22
locations. An analysis of clients who visited AWCs between October 1,
2010, and September 30, 2014, revealed that of the 7,464 clients who
had at least one follow-up BMI assessment (with at least 30 days
between assessments), 59 percent saw a statistically significant
decrease in BMI. These clients averaged a 4 percent decrease in BMI
during this same timeframe.
Another health delivery domain initiative is the dental ``GO First
Class'' readiness program. This has spearheaded dental readiness
compliance by combining dental exams with cleanings resulting in a 50
percent reduction in oral disease related to caries (cavities) among
active duty Soldiers. The cost savings associated with this initiative
has recovered the equivalent of 61 man-years and $13.5 million in
treatment costs across the Army Dental Command.
We also placed a special emphasis on brain health to improve
Soldiers' cognition, emotional, and physical strength. Brain health
rehabilitation and reconditioning programs assist Soldiers as they
return to highest possible level of fitness and readiness. Our goal is
to also optimize cognitive and emotional fitness enriched by training,
learning, and improving performance in all human domains through
attention, reasoning, decisionmaking, problem solving, learning,
communicating, and adapting. These programs are an integral step in
helping Soldiers and beneficiaries return to a full state of health
readiness and performance.
Healthy Environments
Healthy Environments diffuses the SFH into the Lifespace of our
beneficiaries through environmental, occupational, and public health
programs that promote healthy lifestyles to reduce the likelihood of
illness or injury. This requires a ``whole Army'' approach where
everything from physical layouts, installation services, and command
policies at installations support this focus on readiness and
transition to health. SFH maintains health in safe, sustainable
communities which support informed choices and healthy lifestyles
through the promotion of Healthy Environments.
Recently on a visit to Fort Campbell, I saw this in action. The
hospital has done an outstanding job in focusing on the nutritional
aspects of the Performance Triad in addition to sleep and activity.
They have a garden where young children come to help tend and are
educated on the nutritional aspects of different vegetables. They also
took out soda machines and replaced them with healthy drink options. In
six weeks they eliminated 600 pounds of sugar being consumed by our
Service Members, employees and Family Members. They also moved the
dessert bar which was the first thing you saw when you walked into the
dining facility to the rear and replaced it with a salad bar. The
results were nearly a 50 percent reduction in sales of desserts and a
40 percent increase in sales of salads.
These are only a few examples of the impactful changes our SFH is
having across our Army. This momentum absolutely must continue, and
will surely pay readiness dividends in the future.
continuous journey to a high reliability organization
While our transition to a SFH is relatively new, we have been on a
longstanding, continuous journey to fully demonstrate the
characteristics and behaviors of a high reliability organization (HRO),
and serve as the Nation's leader in creating a culture of safety in
healthcare.
HROs exceed the standards for their industry by having well-
established policies and systems in place that ensure consistency of
practice and enable them to reach their goals of zero preventable harm,
a paramount of patient safety. A HRO is committed to achieving zero
preventable harm by successfully limiting the number of errors in an
environment where normal accidents can occur due to the risk factors
and complexity of the practice. The success of a HRO relies on
leadership, an established culture of safety, and robust process
improvement initiatives leading to enhanced efficiencies and
effectiveness of healthcare delivery culminating in positive patient
outcomes.
Recently, Army Medicine completed four of five HRO Regional Command
Summits across the United States and Europe. The theme was educating
and developing a collective mindfulness on ``what we can do today to
become an HRO tomorrow.'' Command teams were charged with determining
actions that can be executed immediately to empower their teams in
prioritizing safety in a deliberate approach to patient-centered care
and positive outcomes. This effort is a cornerstone to the future of
not just Army Medicine, but to healthcare across the globe.
SECDEF MHS Review
In May 2014, the Secretary of Defense ordered the Military Health
System (MHS) Review to assess the state of healthcare, patient safety,
and quality of care within the MHS. We electively chose to compare
ourselves to the best facilities by utilizing quality and safety
benchmarks employed by other high performing civilian hospitals. The
review concluded that the Army provides high quality care that is safe
and timely, and is comparable to the healthcare found across the
civilian sector. However, we are not satisfied and will continue to
strive to lead American healthcare specifically in the area of patient
safety.
This extensive report clearly validated that our transformation to
a HRO is the correct course in providing safe and quality care to our
Soldiers, Families and all entrusted to our care. Over the next year,
transparency will be increased regarding patient safety metrics so our
patients and external stakeholders can measure our system against the
best in the Nation. The journey to become a HRO will not be complete in
the next few years, but will take a generation to achieve our pursuit
of zero preventable harm.
Operating Company Model
Army Medicine accelerated our transformation into a HRO with the
implementation of the Operating Company Model (OCM) methodology as a
means of decreasing variance and improving consistency, clarity, and
accountability. Within the OCM framework, we established seven service
lines, as previously described in this testimony, that are aligning
capabilities to improve patient safety, quality, efficiency,
productivity, and financial optimization across multiple clinical
domains. The utilization of these service lines and the OCM was a
necessary step to further the principles and imperatives of a HRO
across the enterprise.
Integrated Resourcing and Incentive System
During these challenging fiscal times, Army Medicine must continue
to enhance value across the enterprise and drive the adoption of OCM
practices. We have achieved this through the use of a financial
incentive model called the Integrated Resourcing and Incentive System
(IRIS). IRIS is the vehicle for Army Medicine to ensure that our MTFs
are resourced for value production at an adequate level to improve
access to care, recapture care, improve satisfaction, improve quality
of care and incentivize for improved health outcomes. IRIS is MEDCOM's
tool to adequately fund MTFs based on their performance plan to produce
quality outcomes and safe delivery of healthcare.
Patient-Centered Medical Home
As part of our ongoing movement to become a HRO, we have focused on
not just delivering care, but ensuring superior health outcomes. A
major proponent of successful health outcomes for our Soldiers,
Families, and beneficiaries is our PCMH model. Army Medicine is a clear
leader in transforming primary care within the Military Health System.
The PCMH model encompasses all primary care delivery sites in the
direct care system, under the umbrella of the Army Medical Home (AMH),
including our MTF-based Medical Homes, Community-Based Medical Homes
and SCMHs.
Primary Care is delivered through an integrated healthcare team of
professionals that proactively engages patients as partners in health.
It relies upon building enduring relationships between patients and
their provider--doctor, nurse practitioner, physician assistant and the
extended team--and a comprehensive and coordinated approach between
providers and community services. The AMH is the foundation of
Readiness and Health and represents a fundamental change in how we
provide comprehensive care to our beneficiaries including primary care,
BH, clinical pharmacy, dietetics, physical therapy, and case
management. Currently, 137 AMHs across the United States, Europe, and
the Pacific are caring for 1.3 million beneficiaries supported by a
budget of $74.3M. All of the AMHs have been recognized by the National
Committee for Quality Assurance (NCQA) representing the gold standard
of patient-centered medical care.
Army Medical Homes consistently perform better than the historical
Army clinic model. They distinctly focus on quality and safety
outcomes, medical readiness categories, polypharmacy and BH admission
rates, as well as cost containment by decreasing emergency room
utilization, medical board timelines, and per capita cost while
increasing patient continuity with a focus on wellness. Their overall
patient and staff satisfaction is exponentially higher than the
historical Army clinic model.
A major initiative introduced in the PCMH to improve readiness of
the force and Family health is the integration of clinical pharmacists.
Army Medicine recognizes the expanded role of clinical pharmacists to
address polypharmacy risk, the use of multiple medications to treat
chronic conditions, and adverse drug events that lead to a higher rate
of hospital admissions. Integrating clinical pharmacists into PCMHs
improves patient quality, safety, and efficiency by decreasing overall
healthcare costs, minimizing adverse drug events, reducing hospital
admissions and improving patient outcomes. In 2014 Army Medicine
programmed $16 million for fiscal year 2016 to support this critical
initiative. This funding is significant because it provides a clinical
pharmacist for every 6,500 enrolled beneficiaries, fully integrating
clinical pharmacists into medical homes.
Additionally, the MEDCOM Primary Care Service Line initiated a 6-
month pilot program at two medical homes to compare the effectiveness
of digital versus traditional paper BH screening for depression, PTSD,
anxiety, and alcohol misuse. The pilot revealed that digital screening
was more than twice as sensitive as paper screening (30 percent versus
12 percent positive response rate). In the digital group, twice as many
positive screens were addressed by their primary care manager (PCM)
when compared to the paper group. The digital record also provides
seamless access by the PCM to review historical response trends
resulting in a comprehensive plan of care to more effectively address
the condition. On average, there are 25,000 primary care visits per day
across Army medicine; this tool could potentially increase access to
thousands of patients with unaddressed BH concerns each day. Based on
these results the primary care service line is developing a strategy to
deploy digital BH screening to all medical homes.
Recognizing a need for increased, confidential interaction between
patients and medical providers, the Army Medicine secure messaging
system (AMSMS) was developed to provide both patients and providers
with additional convenient means of communication through online
messaging. Messages from patients are triaged and answered by staff
without the challenges of navigating telephonic processes. AMSMS has
been deployed throughout all Army Medical Homes. As of September 30,
2014, Army Medicine had nearly 305,000 uniquely connected patients
(some could be multiple members in a single Family) with approximately
3,400 registered providers and 6,500 registered support staff,
supporting approximately one million messages since its inception.
Secure messaging has a 97 percent satisfaction rating. The MHS Review
specifically highlighted secure messaging as a powerful tool to help
the MHS improve in access, safety, and quality. We are actively
conducting a marketing campaign to promote this critical initiative
aimed at increasing the number of beneficiaries enrolled in secure
messaging.
Surgical Services Line
The Surgical Services Service Line (3SL) is focused on a surgical
services model that optimizes the productive, efficient and financially
sustainable delivery of surgical care, increasing access to value-
based, quality care for beneficiaries across all MTFs. 3SL's success is
measured not only by increased access to care for our beneficiaries,
cost savings to MEDCOM and higher quality outcomes, but in a ready and
deployable medical force, enhanced Soldier readiness and improved
combat casualty care. In 2014, 3SL implemented the National Surgical
Quality Improvement Program (NSQIP) at all 25 surgical MTFs. Less than
10 percent of all U.S. hospitals that provide surgical care utilize
NSQIP. The initiatives spearheaded by 3SL realized an estimated cost
savings of $38 million for in fiscal year 2014. These and many other
advances have been the catalyst to move Army Medicine forward and serve
as a blueprint to become a HRO.
Clinical Performance Assurance Division
As part of our transition to a HRO, the Clinical Performance
Assurance Division (CPAD), containing the Patient Safety Program, was
established in 2012 and aligned under the MEDCOM Deputy Commanding
General for Operations. The MEDCOM Patient Safety Program, in
coordination with regional and MTF Patient Safety Leaders, works to
engage leadership at all levels to cultivate a culture of safety
environment of trust, transparency, teamwork and communication to
improve safety and prevent adverse events. They frequently conduct
scheduled and unscheduled visits at the MTF level to address system
issues potentially affecting patient safety through training and
clinical process review. Since the establishment of CPAD, Army Medicine
has made significant progress in the reporting, investigation and
mitigation of issues that could cause patients harm.
Partnership for Patients
In 2014, the continued implementation of Partnership for Patients,
a national program sponsored by the Centers for Medicare and Medicaid,
resulted in a 26 percent decrease in preventable harm events over the
last two quarters and a 37 percent decrease overall since Army Medicine
implemented the program in 2012. The CPAD medication safety team
provided an analysis of workload, resulting in the hiring of 21
clinical pharmacists and 17 pharmacy technicians to increase the
oversight of medication safety across Army Medicine. They also
petitioned the Drug Enforcement Agency to provide DOD an exemption to
allow our pharmacies to take back unused medications including
scheduled medications in an effort to provide an increased level of
safety for our Army Families.
Team Approach
MEDCOM continues to build a culture of safety through the further
incorporation of Team Strategies and Tools to Enhance Performance and
Patient Safety (Team STEPPS) to enhance team communication and
collaboration so that every team member has a voice in providing
health. TeamSTEPPS is an evidence based teamwork system that employs
group huddles to encourage open dialogue and synchronization of efforts
to optimize the use of information, people, and resources to achieve
the best clinical outcomes for patients. TeamSTEPPS was initially
deployed across the MEDCOM in 2011 and has led to significant
improvements in teamwork and collaboration in critical areas such as
our surgical suites and inpatient care areas. The TeamSTEPPS program
facilitated the training of over 400 trainers through virtual training
programs leading to over 60K medical and dental personnel trained.
Additionally, TeamSTEPPS simulation based Operating Room Team training
program was facilitated at 12 MTFs since 2012, resulting in the
identification and avoidance of potential patient safety incidents
while safely increasing operating room efficiency.
Patient CaringTouch System
To reduce variance and improve patient outcomes, the Army Nurse
Corps developed and implemented the Patient CaringTouch System (PCTS).
The PCTS is a strategic, patient-centered framework for nursing,
founded on evidence-based practice and collaboration with America's top
performing hospitals. It provides a framework which focuses on patient
advocacy, enhanced communication, evidenced based practice, capability
building, and healthy work environments.
The PCTS methodology is the foundation for the delivery of high
quality, evidence-based care that includes the Family and is driven by
patient-centric outcomes. When the five elements are combined
synergistically, PCTS improves patient outcomes and nursing staff
effectiveness, as well as decreases clinical practice variance. The
focus on the patient experience through the implementation of PCTS
resulted in a decrease in wait times, increase in attentiveness to
patient and Family needs, and increase in patient engagement to discuss
symptoms and medications.
leading the way
Army Medicine is leading the way in the areas of innovative medical
research, diplomacy, and collaboration. 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. The U.S. Army Medical Research and Materiel Command (MRMC) is
the Army's medical materiel developer responsible for medical research,
development, and acquisition and medical logistics management. MRMC's
role is to research and develop technologies and tools to ensure our
Soldiers remain in optimal health and are equipped to protect
themselves from disease and injury, particularly on the battlefield.
Research conducted at MRMC thru joint efforts leads to medical
solutions--therapeutics, vaccines, diagnostics, and actionable
information--that benefit both military personnel and civilians.
More than a decade of war has led to tremendous advances in
knowledge and care of combat-related wounds, both physical and mental.
Our decisions today must preserve the Army's core medical research
competencies and, through continued medical research investments,
ensure strategic flexibility to respond to future operational threats.
The DOD stands alone as the world's leading organization for trauma
research and development.
The Joint Trauma System (JTS) was established in 2006 and is
located at the U.S. Army Institute of Surgical Research (ISR), Joint
Base San Antonio. Its mission is to improve trauma care delivery and
patient outcomes utilizing continuous performance improvement and
evidence-based medicine driven by analysis of data maintained in the
DOD Trauma Registry. The JTS has collected data from more than 130,000
combat casualty care records from Iraq and Afghanistan. The data have
resulted in 39 Clinical Practice Guidelines (CPGs) to provide enduring
evidence-based, best-practice recommendations for trauma care. The
continuous monitoring and evaluation of outcomes after implementation
of the CPGs provides evidence necessary to turn results into improved
outcomes for combat casualties. The success of the JTS is clearly
reflected through sustainment of the lowest lethality rate ever
recorded during our current conflicts.
In conjunction with delivering rapid and effective combat casualty
care, the Army continues to refine surgical and hospital capabilities
based on lessons learned from the past 13 years of conflict. These
initiatives complement our advances in combat casualty care at the
point-of-injury to sustain and to increase battlefield survival rates.
Lessons learned from the Iraq and Afghanistan theaters of operations
led to the clear requirement to make fundamental changes to the design
of the Forward Resuscitative Surgical Team (FRST) and the Field
Hospital (FH). The key changes to the FRST and FH designs include
modularity, scalability, and the ability to conduct split-based
operations. The new structure, approved in August 2014 by the Vice
Chief of Staff of the Army, will meet the needs of both conventional
and non-conventional forces. These enhanced capabilities will be
critical to rapidly supporting future operations in various conflict
environments across the globe.
MRMC will expertly manage and execute congressional special
interest (CSI) funds to meet the intent of Congress, to seek and fund
the best science with a keen focus on military relevance, where
applicable. The CSI funds are executed through established, highly
effective, efficient, and low cost processes using only approximately
15 percent in research management support costs for the MRMC and the
remaining 85 percent of all the CSI funds being placed on awards to
maximize the science and the taxpayers' investment.
Historically, infectious diseases are responsible for more U.S.
casualties than enemy fire. Continued progress to address these
emerging threats requires ongoing commitment to funding, developing
personnel with expertise in infectious diseases, and maintaining
stateside and overseas laboratory infrastructure and overseas field
sites for clinical studies and response to contingencies. The
coordinated and swift response to the Ebola virus outbreak demonstrated
the value of continued funding in this area.
Army Medicine closely partnered with interagency partners including
the Centers for Disease Control and Prevention (CDC) in the domestic
and global Ebola virus response. The U.S. Army Medical Research
Institute of Infectious Diseases (USAMRIID) Diagnostic Systems Division
provided Ebola testing capability for the National Laboratory Response
Network (LRN), qualification testing for other LRN laboratory use of
the FDA Emergency Use Authorization (EUA) Ebola diagnostic assay, and
pre-deployment training for laboratory personnel staffing mobile
laboratories in Liberia. USAMRIID laboratory personnel, in
collaboration with National Institute of Allergy and Infectious
Diseases personnel have continuously staffed the Liberian National
Reference Laboratory at the Liberian Institute of Biomedical Research,
in a host nation capability and capacity development initiative to
provide lasting enhancements to laboratory capability that will endure
beyond the current outbreak.
MRMC overseas laboratories, the U.S. Army Medical Research Unit-
Kenya and Armed Forces Research Institute of Medical Sciences in
Thailand, are providing technical support to their host nations'
laboratory preparedness and Ebola virus disease (EVD) response planning
efforts. Additional EVD research and development efforts executed at
MRMC including the Walter Reed Army Institute of Research (WRAIR) and
USAMRIID, funded by the Chemical and Biological Defense Program (CBDP),
have contributed to the development of investigational EVD
therapeutics, vaccines and diagnostics. Vaccine development efforts are
being accelerated in response to the current West African outbreak to
include several CBDP-funded candidates projected to enter Phase 2-3
clinical testing in early 2015. The MRMC Ebola Response Management Team
has developed a proposed organizational framework for DOD and HHS
elements to partner and collaborate with other U.S. Government agencies
involved in the EVD outbreak, the World Health Organization, non-
governmental agencies, and foreign governments (i.e. Liberia, Sierra
Leone, and Guinea) to collaboratively engage West Africa in the conduct
of clinical trials at the strategic, operational, and tactical levels.
The WRAIR HIV program is currently conducting an early Ebola Vaccine
Trial in collaboration with National Institutes of Health (NIH)-
National Institute of Allergies and Infectious Diseases (NIAID) to test
the safety and immunogenicity of an experimental vaccine candidate.
As we globally rebalance to the Pacific, our Soldiers will deploy
to areas plagued with endemic infectious diseases such as malaria and
dengue, as well as emerging disease threats across 105 million square
miles. Experts predict that infectious diseases will be the primary
cause of hospitalization of U.S. military in the Asia-Pacific region.
In an effort to combat this distinct threat to the force, USAMRMC
laboratories continue to build on partnerships with Navy Medicine,
Federal agencies, academia, non-governmental organizations, other
private entities, and foreign Governments. These relationships leverage
resources for continued development of endemic infectious disease
treatments, preventive drugs, vaccines, vector control, and diagnostic
tools essential to preserving the readiness of the force.
Examples of recent successes include a rapid diagnostic test for
cutaneous leishmaniasis, developed by MRMC and industry partners under
the U.S. Army Small Business Innovation Research program. This device
received FDA clearance in November 2014 and is now commercially
available. Additionally, two malaria treatment drugs are expected to be
licensed in 2018 and two malaria vaccine candidates are scheduled to be
transitioned to advanced development in fiscal year 2017-2018. Early
clinical trials have begun on the effectiveness of vaccines targeting
hemorrhagic fever and organisms causing bacterial diarrhea.
It is imperative we sustain funding to finalize these revolutionary
advances that will not only ensure the safety of our global force, but
ultimately save millions of lives across the world.
Education and Training
Army Medicine continues to lead the Nation in attracting and
educating the best medical minds. Our Graduate Medical Education (GME)
programs and education programs receive high praise from accredited
bodies, and our trainees routinely win military-wide and national level
awards for research and academics. Currently, we have 1596 Health
Professionals Scholarship Program students in medical, dental,
veterinary, optometry, nurse anesthetist, clinical psychiatry and
psychiatric nurse schools. Additionally, the Uniformed Services
University of the Health Sciences is a critical institution dedicated
to developing and training clinicians in leadership, clinical, and
combat casualty care as well as operational medicine. Our GME training
programs have 1,476 trainees in 148 programs located across 10 of our
MTFs. 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
with 95 percent first-time board pass rate last year.
Our education programs 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. Furthermore, it ranked the
Army-Baylor University Graduate Program in Health Administration
program as the 11th out of 75 national programs. Overall, we not only
have the largest training program in the military, we are one of the
largest medical education systems in the country.
Global Health Diplomacy
Demand for Army capabilities and presence continues to increase
across all Combatant Commands in response to growing and emerging
threats. We continue to develop key relationships with our interagency
partners and our allies to enhance security cooperation, provide
foreign humanitarian assistance, build partner capacity, and
participate in multi-lateral exercises. Army Medicine is a key combat
multiplier that increases access and collaboration with military
medical activities in partnerships across the globe. Increasing health
diplomacy offers a collegial and non-threatening means of engaging with
partner countries, states and foreign groups. Health in many instances
offers access and opens gateways not otherwise available through
conventional means.
Establishing and maintaining medical partnerships is crucial to
supporting the Army's Regionally Aligned Forces (RAF) construct. Many
RAF engagements during 2014 were focused primarily on medical support
and humanitarian assistance, especially in Africa, South America and
across the Asia Pacific regions. Furthermore, health diplomacy
facilitated by Army Medicine personnel has opened dialogues and shaped
early working relationships with China, Vietnam and other foreign
militaries and groups. These engagements have strengthened our
relationship with many of our allied partners throughout the world. For
example, just one unit, the 30th Medical Brigade, will complete
engagements with 19 partner nations this year alone.
Sustaining the Force through Collaboration
Just as Army Medicine increases engagement with our global
partners, we are increasing collaboration with the Department of
Veterans Affairs, as well as supporting the establishment of the
Defense Health Agency (DHA) to ensure our Soldiers and Veterans have
improved access to the care and support they have earned through their
distinguished service.
Over the past decade, the Army has increased partnerships with the
VA through sharing agreements that provide care to VA beneficiaries in
various healthcare facilities that have excess capacity. This enables
VA beneficiaries to receive high quality, cost effective, and timely
care in locations where the VA may have limited capability or
resources. In fiscal year 2014, Army Medicine provided $49 million in
healthcare services to VA beneficiaries at 19 locations across the
country. The range of services varies by location and is the result of
matching VA's needs with the Army's excess capacity. In some locations,
such as Honolulu and El Paso, we provide a broad spectrum of inpatient
and outpatient specialty services.
Although Army Medicine does not have any joint facilities with the
VA, there are locations where the Army and VA facilities are located in
close proximity or connected, but remain distinct organizations with
close collaboration. In a new collaborative effort, the Army will
occupy a portion of the Major General William H. Gourley VA-DOD
Outpatient Clinic in Marina, California. At this location Army staff
will provide care to DOD beneficiaries in a DOD clinic imbedded within
the larger VA facility. The clinic is expected to open in fiscal year
2017.
Operating as a joint team allows us to share best practices and
lessons learned across the services. 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. The
establishment of a DHA in October 2013 represented a major milestone
towards modernization and integration of military medical care.
Army Medicine has been a key contributor to the transition and
integration of the ten shared services by providing 643 personnel to
the DHA thus far. In the last year, all ten shared services have
reached initial operating capability and are expected to reach full
operating capability by October 1, 2015, with some possibility of
establishing full operating capability ahead of schedule. The AMEDD
will continue to drive fundamental changes within the MHS and support
these transformation efforts that improve readiness and quality of
healthcare while containing costs.
As part of Governance reform, six enhanced Multi-Service Markets
(eMSM) were also established covering San Antonio, the Puget Sound,
Hawaii, Colorado Springs, Tidewater, and the National Capital Region.
The MHS expects substantial savings from these markets because they
enable the market manager to cross Service boundaries and shift
healthcare from the private sector to military treatment facilities,
which are our readiness platforms. This workload recapture directly
impacts the readiness of the Army by ensuring providers, nurses, and
other clinicians are able to sustain their clinical combat trauma care
skills and capabilities. The Army currently is the Service Lead in
three markets: Hawaii, Puget Sound, and San Antonio.
conclusion
Army Medicine provides certainty in an uncertain world. We have
always been a force enabler, assuring and caring for Soldiers on the
battlefield and at home. We have also always been a leader in
healthcare and health, contributing enormously to solving military,
national, and global health concerns. To adapt from a World War I song
lyric: ``When we are needed--we are there!''
During these uncertain times, Army Medicine must continue to
provide certainty to our Soldiers, Families, and our Retirees. We must
deliver on our Nation's obligation to care for our Soldier's needs,
restore full function, promote readiness, and optimize their
performance. These efforts will provide the foundation for the
effectiveness of our entire Army, and play an important role in
contributing to global stability.
It is during this time, as we draw down from over 13 years of
conflict, that we must ensure that Soldiers and their Families are
strengthened with resiliency built to carry them through future global
conflicts and hardships. It is during this vital period that Army
Medicine will play an essential role as the Army's health readiness
platform. I am committed to ensuring that during these drawdown years,
our ability to carry out the readiness mission does not diminish.
Together, we must keep the momentum going and remain proactive,
ensuring our enduring missions, transition to a System for Health and
progress toward a high reliability organization with our innovative
research, diplomacy, and collaboration continuing full speed ahead.
The fiscal challenges that loom ahead are daunting. However, we
will continue to support the Army in any austere environment at home or
abroad. These are times of great uncertainty and opportunity, and while
there will be many challenges, anything less than our top performance
will cost lives. As partners with Congress, I am confident that none of
us will allow that to happen on our watch.
Senator Cochran. Thank you very much. We are going to
recognize each member of the panel for an opening statement,
and our next witness is the Surgeon General of the Navy, Vice
Admiral Matthew Nathan.
STATEMENT OF VICE ADMIRAL MATTHEW NATHAN, SURGEON
GENERAL, UNITED STATES NAVY
Admiral Nathan. Thank you, sir. Chairman Cochran, Vice
Chairman Durbin, distinguished members of the subcommittee, I
am grateful for the opportunity to appear before you today on
behalf of the dedicated men and women of Navy Medicine. I 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 any time, anywhere. Navy
Medicine protects, promotes, and restores the health of sailors
and marines around the world, ashore and afloat, in all warfare
domains.
We exist to support the operational missions of both the
Navy and the 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, we are staying the course with our
strategic priorities of readiness, value, and jointness.
Individually and collectively, these mutually supported focus
areas are instrumental in shaping our decisionmaking, internal
processes, and organizational capacity.
Our strategy is aligned, balanced, and unified, and I
believe strengthened because everyone in Navy Medicine has a
distinct and important role in contributing to the success of
these efforts.
By leveraging the capabilities of our patient-centered
medical home, what we call ``medical home port,'' and
completing our CONUS hospital optimization plan, we are moving
more and more workload into our military hospitals, growing our
enrollment, rebalancing staff, and reducing overall purchase
care expenditures.
We recognize the health of our beneficiaries is the most
important outcome and our systems must be aligned to support
that priority. Healthcare should not be supply driven or volume
based. It is about patient-centered care and focused on all
dimensions of wellness with body, mind, and spirit.
We must never waiver in our commitment to provide care and
support to our wounded warriors and their families. This is
particularly true for the treatment of mental health issues and
traumatic brain injury (TBI).
While our present conflicts may be coming to an end, the
need for quality mental health and TBI care will continue, and
we are posed to provide these services now and in the future.
We continue to embed mental health capabilities in
operational units and primary care. We do this in order to
identify and manage issues before they manifest to
psychological problems or crises. This priority extends to
suicide prevention efforts, where we train sailors, marines,
and their families to recognize the 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 predictive factor and protective factor in preventing
suicide, and we must remain ready and accessible to those who
need our help.
Strategically, I am convinced that we are stronger as a
result of our work with the other services, our interagency
partners, including the VA, leading academics, and private
research institutions, and other civilian experts. These
collaborations are vital as we leverage efficiencies and best
practices in clinical care, as well as research and
development, medical education, and global health security.
The enterprise strength of Navy Medicine has been and
always will be our people. I can assure you that the men and
women serving around the world are truly exceptional and guided
by the Navy's core values of honor, courage, and commitment.
Of note, I am continually inspired by the skill and
dedication of our young hospital corpsmen, many of whom may be
just out of high school or just out of college, and whose
parents, like myself as the father of a teenager, marvel at
their ethics and capabilities, but still wince occasionally
when turning over the keys to the family vehicle. Yet, they
have stepped up. We ask a lot of these young people and they
have performed.
As I travel and see our corpsmen operating forward aboard
ships or deployed throughout the world, I can assure you, Mr.
Chairman, that you and the American people can be very proud of
their performance. In fact, of the 15 Silver Stars awarded to
sailors during OIF (Operation Iraqi Freedom) and OEF (Operation
Enduring Freedom), 14 went to Navy corpsmen.
We need to recognize what sets us apart from civilian
medicine. We are truly a rapidly deployable, vertically and
fully integrated medical system. This capability allows us to
support combat casualty care with unprecedented battlefield
survival rates over the last 13 years, to meet the global
health threats, as we did in deploying labs and personnel to
Liberia that slashed the Ebola diagnosis time from days to
hours, and to have our hospital ships, the USNS Comfort and the
USNS Mercy, ready to get underway quickly to support
humanitarian assistance and disaster reliefs around the world.
We must also understand that our readiness mission is
intricately linked to our work and our personnel day to day in
our hospitals and clinics, in our labs, and in our classrooms.
Our patients expect a lot of us, and they should. I am
privileged to work so closely with my fellow Surgeon Generals
who are equally passionate about continuous improvement and
moving the military health system forward as a truly high
reliability organization.
PREPARED STATEMENT
These are the transformational times for military medicine,
the likes of which I have not seen in my career. 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 our joint
opportunities.
I am encouraged with the progress we are making, but I am
not yet satisfied. We will continue to look for ways to improve
and remain on the forefront of delivering world class care, any
time, anywhere.
Thank you, sir, for your steadfast support, and I look
forward to your questions.
[The statement follows:]
Prepared Statement of Vice Admiral Matthew L. Nathan
Chairman Cochran, Vice Chairman Durbin, distinguished Members of
the Subcommittee, on behalf of the Navy Medicine team--over 63,000
dedicated men and women serving around the world--I want to thank the
Committee for your tremendous support. I am grateful for the
opportunity to appear before you today and I can report to you that
Navy Medicine is capable, mission-ready and steadfast in our commitment
to deliver world-class care, anytime, anywhere.
Strategy: Aligned, Balanced and United
The core mission of Navy Medicine is inextricably linked to that of
the United States Navy and the United States Marine Corps. We protect
the health of combat-ready Sailors and Marines in support of global
expeditionary missions. Navy Medicine operates underway in all warfare
domains and in all environments. This mission requires us to be agile
to support the full range of operations and be ready to respond where
and when called upon. The Chief of Naval Operations has maintained this
imperative through his Sailing Directions: (1) Warfighting First; (2)
Operate Forward; and (3) Be ready. These tenets are impactful as we
sustain our readiness posture to meet these demanding missions.
Within Navy Medicine, we are staying the course with our 2015
strategic priorities of readiness, value and jointness. Specifically:
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 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.
Individually and collectively, these mutually-supportive focus
areas are instrumental in shaping our decisionmaking, internal
processes and organizational capacity. We are continuing to drive
progress in several key objectives including delivering ready
capabilities to the operational commanders and ensuring clinical
currency of our medical force. Within the context of providing best
value for our beneficiaries, we are sustaining efforts to decrease
enrollee cost and increase recapture of private sector purchased care,
as well as standardize our clinical, non-clinical and business
processes. Navy Medicine continues to leverage joint capabilities to
improve interoperability and efficiencies. Our priorities are
strengthened because everyone in Navy Medicine has a distinct and
important role in contributing to the success of these efforts.
We are advancing joint efforts through the Defense Health Agency
(DHA) and its supporting role to the Services' medical departments. Our
collective goal is to facilitate greater integration of clinical and
business processes across the Military Health System (MHS) through the
implementation of shared services. This portfolio of services, all on
track to reach full operating capability by October 2015, includes:
facilities; medical logistics; health information technology; health
plan; pharmacy; contracting; budget and resource management; medical
research and development; medical education and training; and, public
health. They will be important in building a sustainable business model
for the DHA, creating system-wide efficiencies and reducing process
variation.
Our collaborative work is evident in response to the comprehensive
review of the MHS directed by the Secretary of Defense in May 2014. The
90-day review was directed to assess whether (1) access to medical care
in the MHS meets defined access standards; (2) the quality of
healthcare in the MHS meets or exceeds defined benchmarks; and (3) the
MHS has created a culture of safety with effective processes for
ensuring safe and reliable care of beneficiaries. This review applied
evidence to what we had previously only been able to presume with
regard to quality, safety, and access. We can now assertively conclude
Navy Medicine performs comparably to civilian healthcare systems. This
rigorous self-assessment demonstrated that we have areas of excellence
and areas that could benefit from further improvement. The review
afforded us the opportunity to drill down on these opportunities for
improvement. In response, we are systemically and aggressively
addressing all lagging outliers within Navy Medicine, with demonstrable
results already achieved. We are also working with the other Services
and the Assistant Secretary of Defense for Health Affairs (ASD(HA)) to
transform the MHS into a high reliability organization (HRO) and build
a robust performance management system. The review served as an
important catalyst to support performance improvement through better
analytics, greater clarity in policy, improved transparency, and
alignment across training and education programs. I am committed to
these transformation efforts and confident that we have a sound and
actionable strategy to support our way forward.
Within Navy Medicine, our continuous process improvement (CPI)
efforts are leveraging both our Lean Six Sigma (LSS) program and our
industrial engineering (IE) capabilities to ensure that efforts are
aligned with Navy Medicine strategic priorities. This approach enables
us to track the progress of projects, validate results, communicate
lessons learned and best practices, as well as improve communication at
all levels. In fiscal year 2014, over 100 performance improvement
projects were completed throughout Navy Medicine, with approximately
the same number currently in progress. Focus areas include
standardizing clinical and business practices, improving quality and
access, recapturing private sector care, as well as specific
initiatives in logistics, pharmacy, laboratory processes and surgical
services.
Sound fiscal stewardship of our resources is critical to ensuring
we have the capability to provide outstanding care to our
beneficiaries. The President's Budget for fiscal year 2016 adequately
funds Navy Medicine to meet its medical mission for the Navy and Marine
Corps; however, we remain concerned about the uncertainties and
associated challenges with any sequestration impacts. The President's
Budget also contains important proposals to modernize and simplify
TRICARE, along with adjusting cost sharing requirements for some
beneficiaries and incentivizing the use of the mail order pharmacy. We
support these important proposed changes as necessary to help sustain
an equitable healthcare benefit. Navy Medicine appreciates the
Committee's strong continuing commitment to our resource requirements
and recognizes the significant investments made in support of military
medicine.
We are committed to achieving the Department of Defense (DOD)
objective of preparing auditable financial statements and reports,
including providing substantiating supporting documentation. As a
result, audit readiness is a priority for Navy Medicine and we continue
to make progress in this important area. We have deployed standard
operating procedures supporting key financial business processes and
provided thousands of training hours to financial, materiel management
and administrative personnel across the enterprise. These efforts
strengthen internal controls, improve documentation and help foster
continuous business process improvement. In addition, this work helps
our decisionmaking capabilities and demonstrates to our stakeholders
that Navy Medicine is an accountable steward of the resources we
receive.
Mission: Force Health Protection
The foundation of Navy Medicine is force health protection. We
protect, promote and restore the health of our Sailors and Marines in
all environments, ashore and afloat. This responsibility requires us to
be agile, flexible and capable in all aspects of expeditionary medical
operations from preventive medicine to combat casualty care to
humanitarian assistance and disaster response (HA/DR). As a ready
medical force, we must be prepared for any contingency and be capable
of operating where it matters and when it matters.
Navy Medicine continues to sustain unparalleled levels of mission
success, competency and professionalism while providing world-class
trauma care and expeditionary force health protection in support of
U.S. and coalition forces in the southern Afghanistan Train Advise and
Assist Command-South (TAAC-S) Combined Joint Area of Operations (CJOA).
As troop levels decreased more than 75 percent during 2014, the forward
deployed NATO Role 3 Multinational Medical Unit (MMU) continued to
provide the high-level evaluation, resuscitation, surgical
intervention, post-operative care, behavioral health and patient
movement services our combatant commanders expect from us. Despite
manning reductions from 133 to 87 personnel, the MMU maintains 12
trauma bays, four operating rooms, eight intensive care beds and 12
intermediate care beds.
In 2014, trauma teams at the Role 3 MMU cared for over 1,600 trauma
patients and 130 point-of-injury patients that led to 220 admissions
and 75 successful operative procedures. The Role 3's patient movement
element safely evacuated over 145 patients to higher echelons of care.
Navy Medicine's dedication to the warfighter and successful mission
accomplishment led to the sustainment of the highest combat injury
survival rate in the history of modern warfare, 98 percent. A
significant force-multiplier, the Role 3 MMU enabled execution of
decisive war-fighting strategies by meeting and exceeding operational
and force protection requirements across a highly kinetic battle space.
Navy Medicine has been supporting DOD's interagency efforts in
response to the Ebola Virus Disease (EVD) outbreak in West Africa. In
September 2014, the Naval Medical Research Command deployed two mobile
labs to Liberia in support of U.S. Africa Command (AFRICOM)
participation in Operation UNITED ASSISTANCE (OUA). The mobile labs,
each manned by Navy Medical Service Corps microbiologists and hospital
corpsmen (advanced laboratory technicians), are rapidly deployable
detection laboratories that incorporate immunological and molecular
analysis techniques. The mobile labs optimize these technologies to
rapidly detect infectious pathogens. The labs' detection capabilities
effectively reduced the amount of time it takes to determine whether a
patient has EVD from several days to a few hours, which greatly reduced
the amount of contact that suspect, non-infectious EVD cases have with
confirmed infectious cases. We also deployed 23 Navy Medicine personnel
in support of the in-theatre Joint Medical Training Teams which are
providing important training to host nation healthcare personnel. In
addition, 28 Navy Medical Corps and Nurse Corps officers completed
specialized Ebola-specific training at Fort Sam Houston as part of the
Joint Expeditionary Medical Support Team. The team maintained a
continuous response posture in support of the Department of Health and
Human Services' (DHHS) mission to provide specialized services for
domestic Ebola-related prevention and response. Navy Medicine hospitals
and clinics assiduously prepared for potential EVD patients by
implementing Centers for Disease Control (CDC) protocols, performing
exercises and training in personal protective equipment.
Navy Medicine's investments in Global Health Engagement (GHE),
including participation in humanitarian civic action (HCA) missions and
multi-lateral exercises, are critical to improving and sustaining
medical response capacity and stability, preventing and combating
global health risks, and providing force health protection for our
personnel. These efforts directly support our capability to respond to
world-wide crises and offer unmatched training opportunities to build
joint, interagency and international relationships. Naval forces are
uniquely positioned to readily meet the challenges of HA/DR missions
across the globe. In this regard, we are maturing our strategic
partnerships in support of global health security, health threat
mitigation, and health stability operations. Building relationships
through health promotes our U.S. security interests and supports
important theatre security cooperation activities. These efforts also
leverage interoperable capabilities with our allies, as well as
interagency and non-governmental organizations (NGOs).
Navy Medicine's participation in enduring HCA missions and
military-to-military exercises is also important to sustaining the
readiness skills of our personnel. In 2014, the hospital ship USNS
MERCY (T-AH 19) participated in the 24th Rim of the Pacific (RIMPAC)--a
biennial exercise that included 22 nations, 49 ships and submarines,
more than 200 aircraft and 25,000 personnel. RIMPAC featured robust
military medical engagement, with MERCY participating in exchanges and
drills with partner nations, including the People's Republic of China.
Plans for Navy's HCA missions in 2015 include Pacific Partnership (PP)
and Continuing Promise (CP) which foster relationships with partner and
host nations in the Pacific Rim/East Asia and South America/Caribbean,
respectively. These missions include both hospital ships with MERCY
participating in PP and USNS COMFORT (T-AH-20) supporting CP. These
missions will also include medical personnel from the Army and Air
Force as well as NGO partners and regional host nations.
In support of the geographic combatant commanders and Navy
component commands, Navy Medicine personnel are assigned world-wide
supporting GHE activities and global health security, including
research and development at our overseas laboratories, public health
through Navy Environmental Preventive Medicine Units (NEPMUs). We also
have cadre of interagency liaison officers and two health affairs
advisors in the Pacific area of responsibility assigned to the
embassies in Port Moresby, Papua New Guinea and Hanoi, Vietnam.
Readiness is also directly supported by important health services
such as the provision of eyewear. The Naval Ophthalmic Support and
Training Activity (NOSTRA), located in Yorktown, Virginia, is DOD's
lead agent for all ophthalmic needs. The command coordinates the
fabrication of eyewear amongst 26 Navy and Army optical laboratories to
produce nearly 1.5 million pairs of spectacles, gas mask inserts, and
ballistic eye protection eyewear annually for active duty, reserve
component, and qualified beneficiaries. NOSTRA also fabricates eyewear
in support of Pacific Partnership, Continuing Promise and other civic
action missions. Committed to continuous improvement, this past year
NOSTRA reduced its ophthalmic production rework to a 1.2 percent yearly
average, which is well below the national average of 6 percent, through
implementation of process changes and staff training.
Health: Delivering Patient and Family-Centered Care
We recognize the health of our beneficiaries is the most important
outcome and our systems must be aligned to support this priority. It is
not supply-driven or volume-based; it is patient-centered, focused on
health outcomes and includes all dimensions of health ? body, mind and
spirit.
Our Medical Home Port (MHP) program is the foundation to providing
integrated and comprehensive primary care. It is a team-based approach
offering same day access, preventive services, standardized clinical
processes, interactive secure messaging and access to a 24-hour Nurse
Advise Line. All Navy MHP practices have undergone rigorous evaluation
of clinical and business process standards and achieved recognition by
the National Committee for Quality Assurance (NCQA) and the Tri-service
Patient-centered Medical Home Advisory Board.
Nearly all of Navy Medicine's 750,000 MTF enrollees are receiving
care in a MHP and our metrics show continued improvement. In fiscal
year 2014, access to acute and routine appointments improved ten and
five percent, respectively, while emergency department utilization
decreased by 6 percent from the prior year. We have also seen an
increase in the number of beneficiaries utilizing secure electronic
messaging to communicate with their providers, with over 290,000
patients sending more than 30,000 messages per month. These tools
enhance provider-patient communication, improve access and help reduce
unnecessary clinic visits and expensive use of the emergency
department.
We are also expanding important population health management
capabilities at several of our MHP sites. The adaptable and scalable
framework is derived from a MHS Innovation Award-winning pilot program
at Naval Medical Center, San Diego and Naval Hospital Camp Pendleton.
This initiative allows for the development of a cohesive and targeted
population health strategy that utilizes stratified analyses to
determine the type and amount of resources necessary to manage health
needs at the local facility. Efforts will focus on all levels of
disease prevention in order to improve the health outcomes of our
patients. We are also leveraging the unique data analysis capabilities
and the health promotion and wellness expertise of the Navy and Marine
Corps Public Health Center (NMCPHC) to support each site.
We are ensuring that our Sailors and Marines have access to the
benefits of MHP by tailoring programs for the operational forces,
including access to integrated behavioral and psychological healthcare
providers. We implemented six Marine-Centered Medical Home (MCMH) and
three Fleet-Centered Medical Home (FCMH) demonstration sites and
planning is underway for an additional 19 sites by the end of 2015. The
trends are encouraging with initial data showing Marines not enrolled
in MCMH are twice as likely to seek care via the emergency department
as compared to those enrolled in a MCMH. Most importantly, we are
getting positive feedback from our line and USMC commanders about
improved access and readiness for their personnel.
The Navy Comprehensive Pain Management Program (NCPMP) is now
integrated within MHP furthering the interdisciplinary approach. This
alignment allows us to better focus on prevention, compliance with
clinical practice guidelines and improved provider and patient
education. In partnership with the University of New Mexico and Army
Medicine, we implemented Project ECHOTM--a tele-mentoring
program connecting pain management specialists with our primary care
providers to help manage patients with chronic or acute pain.
Complementary and Alternative Medicine (CAM) modalities are also
provided at various Navy MTFs such as acupuncture to treat chronic
pain, migraine headaches, back and neck pain and a variety of other
conditions. In fiscal year 2014, we expanded acupuncture and pain
management training opportunities for our clinicians to help broaden
the availability within Navy Medicine.
The maturation of our MHP efforts has been complemented by the
implementation of the Navy CONUS Hospital Optimization Plan, a
comprehensive initiative at nine of our U.S. hospital MTFs. Inpatient
bed capacity, workload, staffing and beneficiary population were
carefully assessed at each MTF to determine ability to recapture
inpatient workload, optimize primary care enrollment and determine
specialty services. The plan resulted in the realignment of personnel
and services at several of our MTFs which will help sustain the
operational readiness skills of our provider teams, improve MHP
enrollment capabilities and enhance our private sector care recapture
efforts. The plan also focused on the realignment of our family
medicine graduate medical education (GME) programs in order to
strengthen our training pipeline by maximizing our residents' exposure
to required case numbers and complexity of care.
We are grateful for your support of our military construction
requirements as we work to provide outstanding facilities for our
patients and staff. The new Naval Hospital Guam opened its doors in
April 2014 in a location Navy Medicine has served proudly since 1899.
The new hospital incorporates advances in healthcare delivery,
providing a facility that will improve patient life safety and increase
efficiencies in hospital operations, while meeting the full spectrum of
medical and surgical care for all eligible beneficiaries. The completed
hospital provides 281,000 square feet of modern healthcare spaces,
including 42 beds, four operating rooms, two cesarean-section rooms,
and improved diagnostic and ancillary capabilities to include magnetic
resonance imaging and computed tomography scanning suites. As a vital
readiness and quality of life platform for Joint Region Marianas (JRM)
and the pivotal Pacific AOR, this military construction project also
established a successful model for building regional partnerships.
Collaborating with JRM and through the defense reutilization program,
medical equipment from the old hospital that was not selected for reuse
by DOD generated opportunity and goodwill to benefit other healthcare
facilities and partners in that medically underserved region. Our
service members, their families, retirees, and veterans are better
served by the opening of this state-of-the-art facility.
Navy Medicine is committed to providing quality medical care to our
wounded warriors and their families. This is particularly true for the
treatment of mental health issues and traumatic brain injury (TBI).
While our present conflicts are coming to an end, the need for quality
mental health and TBI care will continue and we are poised to provide
these services now and in the future. We work closely with Navy Safe
Harbor and the USMC Wounded Warrior Regiment to ensure quality care,
coordinated care, and smooth transitions of care.
Navy Medicine provides timely, evidence-based mental healthcare for
Sailors, Marines and their families across the continuum of care,
including resiliency training, outpatient care, and inpatient
treatment. Evaluation and treatment services are available ashore and
underway, in the United States, and in a variety of locations overseas.
The primary objective of all mental healthcare is to help individuals
achieve their highest level of functioning while supporting the
military mission. We are increasingly focused on ensuring that our care
is evidenced-based and supported by quantifiable treatment outcomes.
Regular audits conducted by our Psychological Health Advisory Board
reflect both the benefits of our mental healthcare and compliance with
clinical practice guidelines that exceed the civilian sector
particularly for the treatment of post-traumatic stress disorder (PTSD)
and depression, which are common issues within the wounded warrior
population. We are also encouraged by the promising research conducted
by the Naval Health Research Center (NHRC) in alternative therapies
such as mindfulness as a stress reduction and resilience building
technique.
We continue to embed mental health providers directly within
operational units. Embedded mental health providers reduce stigma,
increase access to care, and help detect stress injuries early before
they lead to decreased mission capability and mental health problems.
We are also embedding mental health providers in primary care settings.
The Behavioral Health Integration Program (BHIP) in the Medical Home
Port will establish over 80 BHIP sites throughout the Navy, Marine
Corps, and the fleet. BHIP sites are established at two Marine-Centered
Medical Homes, one Fleet-Centered Medical Home and 38 Navy Medical Home
Ports.
We must also ensure that our families have access to the support
services they need. Since its inception in 2008, the Families Over
Coming Under Stress (FOCUS) program has enhanced resilience and
decreased stress levels for thousands of active duty service members
and their families. FOCUS supports family psychological health and
resiliency-building and addresses family functioning in the context of
combat deployments, multiple deployments, and high-operational tempo.
Through the application of a three tiered approach to care (community
education, psycho-education for families and brief-treatment
intervention for families), FOCUS has shown statistically significant
outcomes in increasing family functioning and reducing negative
emotions in both parents and children. To date over 500,000 service
members, families, providers and community members have participated in
this service at one of our 23 locations worldwide. As part of the
transition to a government operated program, we are working to continue
these important support services and planning is ongoing to ensure they
are appropriately realigned within Navy and Marine Corps family
programs.
Navy Medicine remains committed to supporting the psychological
health needs of Navy and Marine Corps reservists and their families.
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
12,000 reservists in fiscal year 2014. They also made over 600 visits
to reserve units and provided presentations to approximately 63,000
reservists, family members and commands. Over 1,500 service members and
their loved ones participated in one of 14 Returning Warrior Workshops
(RWWs) conducted last year. RWWs assist demobilized service members and
their families in identifying issues that often arise during post-
deployment reintegration.
Navy Medicine continues to work with the National Intrepid Center
of Excellence (NICoE) to enhance our treatment regimens and increase
our understanding of TBI. We currently have one NICoE satellite clinic
located at Naval Hospital Camp Lejeune with another planned for Marine
Corps Base Camp Pendleton in proximity to the new hospital. The NICoE
satellites are designed to provide advanced evaluation and care for
service members with acute and persistent clinical symptoms following a
TBI. These facilities adhere to a core concept of care (including a
standardized staffing and treatment model) that was jointly developed
by 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). Through our NICoE satellites,
Naval Hospital Camp Lejeune and Naval Hospital Camp Pendleton will
serve as the East and West Coast hubs for the referral and treatment of
patients with acute and persistent post-concussive symptoms.
The OASIS program (Overcoming Adversity and Stress Injury Support)
provides assessment and treatment for severe combat stress reactions
and combat-related PTSD ? with the goal of returning as many troops as
possible to full duty, while also improving the quality of their lives
and relationships. OASIS is a residential program located at Naval Base
Point Loma in San Diego that offers a variety of evidence-based
therapies, individual case management, recreation therapy, mind body
medicine, family involvement, and peer support in a safe, secure, and
therapeutic environment. To date, over 300 service members with
recalcitrant PTSD have benefited from a broad variety of therapeutic
experiences, such as ``moral injury'' group therapy (an existential
group therapy program), meditation, yoga, anger management, sleep
retraining, recreation therapy, acupuncture and therapeutic art.
The Navy Case Management team is comprised of over 220 specially
trained licensed registered nurses (RNs) and social workers (LCSWs)
committed to helping service members and their families understand
their medical status and obtain required services throughout the entire
care process. In 2014, Navy clinical case managers were assigned to 23
MTFs and provided services to over 23,000 patients, an 11 percent
increase from 2013. Clinical case managers work as part of the recovery
team along with recovery care coordinators (RCCs), nonmedical case
managers (NMCMs), and/or Federal recovery coordinators (FRCs). Together
these specialists help service members successfully navigate through
the military medical system, which can be very complex.
Each and every suicide is a tragedy that has significant impact on
families, shipmates and mission readiness. As part of the Department of
the Navy's commitment to suicide prevention, Navy Medicine works
closely with our line counterparts to reduce suicide risk by equipping
Sailors with training, tools and practices to be psychologically
healthy and resilient. Education and prevention initiatives train
personnel to recognize stress in themselves and others and apply tools
to manage and reduce its negative effects. Suicide prevention requires
all of us to be vigilant and strengthen the connections with those
around us. We recognize that personnel in the midst of professional or
personal transitions may be particularly vulnerable to suicide so we
continue to reinforce importance of reaching out to every Sailor, every
day.
The Department of the Navy does not tolerate sexual assault and has
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 directly supports the
Sexual Assault Prevention and Response (SAPR) program by ensuring the
availability of sexual assault forensic exams (SAFE) at shore and
afloat settings. We are focused on having proficient, confident and
caring SAFE providers ready to perform 24/7 in meeting the short and
long-term medical needs our victims of sexual assault. SAFE providers--
including sexual assault nurse examiners, physicians, physician
assistants, advanced practice nurse practitioners and independent duty
corpsmen--are trained and available to ensure timely and appropriate
medical care for sexual assault victims in all military platforms
served by Navy Medicine. We currently have over 875 SAFE-trained
providers in our MTFs and serving on operational platforms (surface,
air, submarine and expeditionary).
Navy Medicine recognizes the importance of leveraging collaborative
relationships with the Army and Air Force, as well as the Department of
Veterans Affairs (VA), and other Federal and civilian partners. Our
partnerships foster a culture in which the sharing of best practices is
fundamental to how we do business. These synergies will help all of us
provide better care and seamless services to our beneficiaries and be
better positioned to address future healthcare challenges.
We work closely with the VA in assessing opportunities to
collaborate cost effectively share services to meet the needs of
service members and veterans. There are a full range of unique
collaborations, sharing agreements and partnerships that benefit both
Departments' beneficiaries. Our shared goal remains to seek
opportunities to partner in local markets in order to measurably and
mutually improve the access to healthcare services. We continue to see
progress at the Captain James A. Lovell Federal Health Care Center
(FHCC), the first demonstration of an integrated DOD/VA facility
established in 2010. To ensure our personnel sustain their readiness
and combat casualty skills, the FHCC and Stroger Hospital in Chicago
initiated a new training partnership that embeds our Navy Medicine
personnel in Stroger's busy trauma and burn units for one to 2-month
rotations. The Cook County Trauma Experience (CCTE) allows Navy
physicians, nurses and corpsmen to work alongside Cook County trauma
surgeons and gain valuable trauma care experience. An important focus
area remains ensuring efficient health information technology to
support providers' ability to deliver healthcare to both VA and DOD
beneficiaries in the FHCC integrated environment. As statutorily
required, a thorough evaluation of the FHCC, led by DOD and the VA, is
currently underway to objectively assess the demonstration and consider
options for both Departments moving forward.
We, along with the Army, Air Force and DHA, are working with DOD in
support of the Defense Healthcare Management Systems Modernization
(DHMSM) efforts to acquire and configure a new electronic health record
(EHR). This EHR will be used in our MTFs, onboard naval vessels and in
the field with the Marines forces. It is also fundamental to supporting
our interoperability with the VA and private sector providers. Two Navy
MTFs, Naval Hospital Bremerton and Naval Hospital Oak Harbor, are
expected to be part of initial operating capability (IOC) deployment.
Mission-Ready: The Navy Medicine Team
The Navy Medicine team, officers, enlisted personnel, government
civilians and contractors, serves around the world delivering
outstanding care and support services to Sailors, Marines, their
families and all those entrusted to our care. This diverse and
inclusive workforce is guided by the Navy Core Values of honor, courage
and commitment. I am inspired by their contributions to ensuring that
Navy Medicine, and those we serve, are mission-ready.
Active component (AC) and reserve component (RC) health professions
recruiting and retention remains a priority and we are grateful for the
Committee's support of important special pay and incentive programs. In
fiscal year 2014, Navy Recruiting was successful in attaining 100
percent of the AC Medical Department officer goal and, due to high
retention rates, overall officer manning reached 100 percent, a 10-year
high. Some specialty shortages exist mainly due to billet growth and
primarily in mental health specialties; however, we continue to see
progress in psychiatry, clinical psychology and social work, with
manning levels at 92 percent, 90 percent and 93 percent, respectively.
We recognized the increasing demand for mental health services and have
worked to recruit, train and retain personnel in these specialties.
Overall RC Medical Department officer manning is 95 percent;
however, there are significant shortages in Medical Corps manning at 75
percent and shortfalls continue in orthopedic surgery, general surgery
and anesthesiology. In fiscal year 2014, RC Medical Corps recruiting
attained 67 percent of the accession goal relying heavily on the direct
commission officer market. RC shortages are being addressed by
continuing to offer targeted special pay and initiating retention
bonuses, loan repayment plans and monthly stipends for healthcare
professionals pursuing a critical subspecialty.
Both AC and RC Hospital Corps enlisted recruiting was successful in
fiscal year 2014 with both attaining 100 percent of goals. While
overall manning is healthy in both components, challenges exist within
the Fleet Marine Force Reconnaissance Corpsman specialty due to billet
growth and a complex production pipeline.
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 January 2015, our
civilian end strength was 11,510, which is in line with our overall
requirements, and we continue to emphasize the importance of attracting
and retaining talented civilian personnel within Navy Medicine.
Navy Medicine's Reintegrate, Educate and Advance Combatants in
Healthcare (REACH) Program is an important initiative that provides
recovering service members mentors in our MTFs who provide them with
hands-on training and learning experiences in healthcare. Additionally,
recovering service members are connected with career coaches who offer
career and educational guidance for a number of medical disciplines.
The program also strengthens our personnel's continued care and support
when they see the patients they have cared for and mentored become one
of their colleagues. This positive feedback allows the REACH Program to
continue to expand. This year, Naval Hospital Jacksonville joined 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 as
MTFs that participate in the REACH program. Last year, over 200 hundred
wounded warriors have accessed services at our REACH sites. Since the
inception of the program in March 2011, 58 students have transitioned
to healthcare careers in Navy Medicine, other Federal agencies or in
the private sector.
Education and Training: Sustaining Excellence
Investments in education and training are critical for meeting our
current requirements and preparing for future challenges. We support
the continuum of medical education, training and qualifications that
enable health services and force health protection. Our Naval Medical
Education and Training Command (NMETC) is continuing to apply
innovative, cost-effective learning solutions to fully leverage
technology, partnerships and joint initiatives. These collaborative
efforts were important as the DHA reached initial operating capability
for medical education and training shared services. During calendar
year 2014, 3,609 Sailors completed METC Basic Medical Technician
Corpsmen Program at the joint Medical Education and Training Campus
(METC) and earned the rating of hospital corpsman. They trained
alongside Soldiers and Airmen in an outstanding academic environment.
In addition, 2,249 hospital corpsmen trained in advanced technician
programs at METC.
Navy's Medical Modeling and Simulation Training Program Management
Office is co-located with the Air Force Medical Modeling and Simulation
Training Office at Randolph Air Force Base, Texas. They are
collaborating to address common approaches to simulation utilization to
support training for care of combat injuries as well as training for
high-risk populations such as the complicated obstetric and neonatal
cohort. Shared projects included identification of best airway trainer
and identifying standardized training adjuncts to support trauma combat
care courses for all three Services.
Our Surface Warfare Medicine Institute (SWMI) expanded its training
for the Surface Force and Dive Independent Duty Corpsman (IDC) with two
new state-of-the-art virtual reality medical simulation rooms and
expanded access to training at the Bio-Skills Center at the Naval
Medical Center, San Diego. This training is critical as we prepare
high-performing hospital corpsmen for challenging assignments in the
fleet and with the Marine Corps.
Graduate medical education (GME) is critical to the Navy's ability
to train board-certified physicians and meet the ongoing requirement to
maintain a tactically proficient, combat-credible medical force. Robust
GME programs continue to be the hallmark of Navy Medicine. Despite the
challenges presented by fiscal constraints, pressures due shifting
priorities and new accreditation requirements, GME remains resilient
and focused on the mission, with particular emphasis on readiness,
value and jointness.
Our institutions and training programs continue to demonstrate
outstanding performance under the Next Accreditation System of the
Accreditation Council for Graduate Medical Education (ACGME). All Navy
GME programs have now transitioned to the Next Accreditation System
(NAS) and the three major teaching hospitals all successfully underwent
Clinical Learning Environment Review (CLER) visits this year.
Strategic efforts to improve recruiting into undermanned specialty
training programs over the past several years have been successful. We
have had enough qualified applicants for previously challenging
specialties such as neurology, neurosurgery, urology and radiation
oncology to restore and maintain the required pipeline. Specialties
that are still working to attract sufficient qualified applicants are
at the top of our priority list and include general surgery, family
medicine and aerospace medicine.
In addition, this year family medicine training sites and billets
were realigned consistent with our CONUS Hospital Optimization Plan.
Navy GME restructured from six sites four and redistributed the
inservice training billets among the remaining sites, reserving five
outservice training billets per year for both PGY-1 and PGY-2 training
as needed to maintain the pipeline during the transition.
Board certification is a universally recognized hallmark of strong
GME. The 5 year average first time board certification pass rate for
Navy trainees is 93 percent. Our board pass rates meet or exceed the
national average in virtually all primary specialties and fellowships.
Our Navy-trained physicians continue to demonstrate they are
exceptionally well-prepared to provide care to all members of the
military family and in all operational settings ranging from the field
hospitals of the battlefield to the platforms that support disaster and
humanitarian relief missions.
Research and Development: Driving Innovation
For over 75 years, Navy Medicine has conducted a global research
and development (R&D) program that is currently executed through the
Naval Medical Research Center (NMRC), its subordinate labs, numerous
joint service initiatives and a well-established cooperative
infrastructure of universities, industry, and other government
agencies. The mission is focused on biomedical research supporting our
operational forces and service members. These priorities 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.
NMRC and the seven subordinate laboratories (Naval Health Research
Center, San Diego; Naval Medical Research Unit-SA, San Antonio; Naval
Medical Research Unit-D, Dayton; Naval Submarine Medical Research
Laboratory, Groton; Naval Medical Research Unit Two, Singapore; Naval
Medical Research Unit Three, Cairo, and Naval Medical Research Unit
Six, Lima) collectively form the NMR&D Enterprise that is the Navy's
and Marine Corps' premier biomedical research, surveillance/response,
and public health capacity building organization. Over 1,600 dedicated
professional, technical, and support personnel are focused on force
health protection and enhancing deployment readiness of DOD personnel
world-wide. Earlier this year, I visited our Naval Medical Research
Unit Three in Cairo, the oldest overseas military medical research
facility and one of the largest research laboratories in the North
Africa-Middle East region. I had an opportunity to see firsthand the
outstanding research being conducted and the importance of our enduring
partnerships in this important region.
Ongoing research and development ensures service members' health is
better protected, operational tempo is more effectively performed, and
the rehabilitation of the ill and injured is continuously improved. In
addition, NMR&D is an active participant in global health security
efforts and focuses on mitigating the spread of antimicrobial
resistance, emerging and reemerging infectious diseases, including EVD,
malaria, and Middle East Respiratory Syndrome caused by a Coronavirus
(MERS CoV). NMR&D Enterprise labs work with partners around the world
to enhance detection and bio-surveillance capabilities, to improve
reporting systems and to build host-country response capacity. In
collaboration with the Walter Reed Army Institute of Research (WRAIR),
our experts are engaged in military malaria research, including the
development of candidate malaria vaccines.
Active collaboration with industry is important given the dual-use
nature inherent in military medicine research. In 2014, Navy Medicine
executed almost 100 new public-private Cooperative Research and
Development Agreements (CRADA) partnerships leveraging internal and
external capabilities and resources toward accelerating the development
of new biotechnologies
Navy Medicine professional training activities continue to satisfy
all requirements that exist for accreditation of post-graduate
healthcare training programs in which new medical, dental, nursing and
allied health professionals gain advanced skills. An important
component that supports the accreditation of our post-graduate
healthcare training programs is through trainee participation in the
Clinical Investigation Programs (CIPs) based at our teaching MTFs. The
conduct and findings from these investigations, in addition to
satisfying training requirements, also support the need to develop new
knowledge and advanced interventions to better treat service members
with combat injuries, to prevent training injuries, and to provide
better medical care to our healthcare beneficiaries. With $3.6 million
funded by Navy Medicine in fiscal year 2014 and an additional $4
million in external grants received for clinical research, our teaching
MTFs conducted a total of 612 clinical research projects which resulted
in 296 scientific publications and 701 scientific presentations. These
clinical research projects directly improve the delivery of quality
medical care at the MTF sites. The findings of the clinical research
projects were published in high-impact, peer-reviewed medical and
scientific journals and were presented at both national and
international scientific meetings.
Way Forward
Our center of gravity is readiness. We continue to ensure that our
Sailors and Marines are medically ready to successfully execute their
demanding missions, whether deployed or ashore. Our operating forces
are supported by a highly trained, innovative and cohesive Navy
Medicine team whose primary focus is taking care of them, their
families and others entrusted to our care. This mission--our
obligation--is what makes us unique. We continue to make steady
progress; however, all of us recognize the formidable work ahead during
this unprecedented period of transformation in healthcare. I am
confident Navy Medicine will meet these challenges with commitment,
skill and professionalism.
Senator Cochran. Thank you very much, Admiral. We now will
hear from Lieutenant General Thomas Travis.
STATEMENT OF LIEUTENANT GENERAL THOMAS TRAVIS, SURGEON
GENERAL, UNITED STATES AIR FORCE
General Travis. Good morning, sir. Thank you, Chairman
Cochran, Ranking Member Durbin, distinguished members of the
subcommittee. Thanks for inviting us to appear before you
today.
Since 9/11, the Air Force has accomplished over 200,000
patient movements in our AIRVAC system, including 12,000
critical care patients.
The historical survival rate for U.S. casualties in the
past 13 years once they entered the Theater Medical System is a
reflection not just of Air Force but our combined commitment to
the highest quality of care for our patients.
Critical care transport teams were developed by the Air
Force in the late 1990s, and have now become the international
benchmark for safe ICU (intensive care unit) level patient
movement, and we are sharing this knowledge with other nations
so they can partner with us.
It has changed the way we operate in the deployed
environment and in fact, really has changed for medicine. We
have adapted that capability now to meet the Joint Staff
requirements for intra-theater and route tactical critical care
of fresh or postoperative ICU level casualties with our Army
partners via rotary and tactical aircraft, many from point of
injury in the past few years.
Our medical response teams include rapidly deployable
modular, scalable field hospitals that provide immediate care
within minutes of arrival, the expeditious medical support
health response teams, which are an evolution of our combat
proven EMEDS (expeditionary medical support systems) teams, are
now being deployed across our Air Force. They provide immediate
emergency care within minutes of arrival, surgery and intensive
care within 6 hours, and full ICU capability within 12 hours.
Because of our experience with EMEDS and our rapid ability
to respond, once approved, in support of Operation United
Assistance in Liberia, an Air Force medical team quickly
deployed and set up the first healthcare worker Ebola disease
treatment center utilized by the U.S. Public Health Service.
Our medical forces must stay ready through their roles in
patient-centered full tempo healthcare services that ensure
competence, currency, satisfaction of practice, while fostering
innovation.
We cannot separate care at home from readiness because what
we do and how we practice at home every day translates into the
care that we provide when we deploy.
In addition, for well over a decade, we have had a cadre of
our best physicians, nurses, and technicians embedded in world
class Centers for Sustainment of Trauma and Readiness Skills or
C-STAR facilities, such as the University of Maryland's
Baltimore Shock Trauma, University of Cincinnati, and St. Louis
University, in order to train trauma and critical care
transport teams before they deploy, and it has worked.
We are now committed to expanding training opportunities
for non-surgical and non-trauma related skills to ensure all of
our personnel remain ready and current, providing hands-on
patient care of greater volume and complexity than we normally
see in our facilities. The VA assists us with this as well.
We recently held a course at Nellis Air Force Base in
Nevada in cooperation with the University Medical Center, Las
Vegas, to help us expand these training opportunities, and we
have a dozen more courses this year.
This will further expand the system we have in place to
identify training requirements and track completion of training
events down to the individual and team level.
In the Air Force I grew up in, the operators were primarily
pilots and navigators. There are now many more types of
operators as air power is projected through the various
domains, aerospace and cyberspace, and in very new ways.
Air Force Medicine is also adapting and innovating to
better support the airmen who safeguard this country 24/7, 365
days a year. In that regard, Air Force Medicine is now focusing
more on human performance. Our AFMS (Air Force Medical System)
strategy embraces this, and to focus on this as a priority, we
recently revised our vision to state that our supported
population is the healthiest and highest performing segment of
the U.S. by 2025.
This vision is focused on health rather than healthcare,
and is connected to the imperative to assure optimum
performance of airmen. We have begun now either embedding or
dedicating medics to direct support missions such as special
operations, remotely piloted aircraft, intel, or other high
stress career fields, and these embedded medics have clearly
had a positive impact on those airmen, their mission
effectiveness, and their families.
Patient safety and quality care are foundations supporting
our beneficiaries in their quest for better health and improved
performance, and in order to improve both safety and quality,
we are committed, as my partners have stated, to become a
highly reliable healthcare system adopting safety culture and
practices similar to other highly reliable sectors, such as
aviation.
This is a journey being undertaken by healthcare systems
across the country. The AFMS joins with our Army and Navy
partners as we transform into a fully integrated system that
consistently delivers quality healthcare wherever we are, while
improving the health and readiness of our forces.
PREPARED STATEMENT
With our vision of health and performance in mind, we are
committed to providing the most effective prevention and best
possible care to a rapidly changing Air Force, both at home and
deployed.
I am confident that we are on course to ensure medically
fit forces, provide the best expeditious medics on the planet,
and improve the health of all we serve to meet our nation's
needs.
Thanks to the committee for your continued strong support
of Air Force Medicine and the military health system, and the
opportunity to provide further information to you this morning.
[The statement follows:]
Prepared Statement of Lieutenant General Thomas Travis
Chairman Cochran, Ranking Member Durbin, and distinguished members
of the Subcommittee, thank you for inviting me to appear before you
today. After more than 13 years of war, in which the Military Health
System (MHS) attained the lowest died-of-wounds rate and the lowest
disease/non-battle injury rate in history, the Air Force Medical
Service (AFMS) is envisioning future conflicts and adjusting our
concepts of operations to prepare to provide medical support in
situations that could be very different than what we have faced in the
current long war. Among many efforts, we are focusing on enroute care
to include aeromedical and critical care evacuation, expeditionary
medical operations, and support to personnel during combat operations.
Future contingencies may require longer transport times of more acute
casualties without the benefit of stabilization in fixed facilities, as
we have had in Iraq and Afghanistan. We have to consider worst case
scenarios, which will prepare us well for less challenging
circumstances. By enhancing clinical skills through partnerships with
busy, high acuity civilian medical centers (such as our training
programs in Baltimore, Cincinnati, St. Louis, and, most recently, Las
Vegas), regular sustainment training for all team personnel, and
developing new medical capabilities, we are committed to being just as
ready or more ready at the beginning of the next war as we are in the
current war. Our Nation expects no less--and our warriors deserve no
less.
Since 9/11, we have logged over 200,500 patient movements,
including 12,000 critical care patients. The 96 percent survival rate
for U.S. casualties once they enter the Theater Medical System is a
reflection of our commitment to the highest quality of care for our
patients. As part of a remarkable Joint expeditionary healthcare
system, deployed care has dramatically evolved during the wars and
produced advances in scientific knowledge now in use across the U.S. to
improve trauma outcomes.
Critical Care Air Transport Teams (CCATT) were developed in the
late 1990s and have become the international benchmark for safe ICU-
level patient movement. The AFMS adapted that capability to create the
Tactical Critical Care Evacuation Team (TCCET), which consists of teams
of medical personnel and equipment with specialized skills and training
to meet Joint Staff requirements for intra-theater enroute tactical
critical care transport of fresh and post-operative ICU-level
casualties via rotary-wing or other tactical aircraft. Additionally, we
recently developed a capability called Enhanced TCCET (TCCET-E), which
is capable of short notice deployments performing surgical
stabilization using interior of aircraft if required and supporting
long-range patient movement. We have teams poised and ready to launch
on C-130s or C-17s in the USEUCOM/USAFRICOM AOR today.
Our health response teams now 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), an evolution of our combat-proven and scalable
Expeditionary Medical Support (EMEDS) teams, are now being deployed
across our Air Force. They provide immediate emergency care within
minutes of arrival, surgery and intensive critical care units within
six hours, and full ICU capability within 12 hours of arrival. The HRT
also helps tailor clinical care to the mission, adding specialty care
such as OB-GYN and pediatrics for humanitarian assistance or disaster
relief missions. This evolved expeditionary HRT capability has been
successfully deployed and is on track to replace our previous
generation of EMEDS by 2016.
In support of OPERATION UNITED ASSISTANCE in Liberia, an Air Force
medical team quickly deployed and set up the first healthcare worker
Ebola Virus Disease (EVD) treatment center utilized by the U.S. Public
Health Service. The Air Force also provided 24 medical personnel to the
Healthcare Worker Training Program, training over 1,500 healthcare
workers in the proper procedures in dealing with Ebola infected
patients. In support of Health and Human Services within the
continental United States, the AFMS provided 12 personnel for
USNORTHCOM's rapid response team that could respond to any city within
the U.S. Additionally, the Air Force and USTRANSCOM developed the first
Transportable Isolation System (TIS) to provide a capability to
transport multiple contagious patients while mitigating/minimizing the
risk of exposure to the aircraft and aircrew. While thankfully not
needed in the recent EVD response, this is a capability which could
prove useful in future infectious disease contingencies around the
globe or here at home.
Our medical forces must stay ready through their roles in patient-
centered, full-tempo healthcare services that ensure competence,
currency, and satisfaction of practice and foster innovation. In
support of the MHS Quadruple Aim of Readiness, Better Health, Better
Care, and Best Value; the AFMS is incorporating best practices such as
Patient-Centered Medical Home (PCMH) and advanced surgical technology
and techniques to ensure our staffs have the needed tools to care for
patients at home or deployed. We can't separate care at home from
readiness, as what we do and how we practice at home translates into
the care we provide when we deploy. We have to augment our experience
and training to be truly ready, as there is undoubtedly a difference
between being prepared for downrange combat casualties and the type of
every day medical care provided at in-garrison medical treatment
facilities (MTF). We have a mature, combat-proven system for augmenting
the clinical experience of our teams.
For well over a decade we have had a cadre of our best physicians,
nurses, and technicians embedded in world-class Center for Sustainment
of Trauma and Readiness Skills (C-STARS) facilities such as the
University of Maryland's Baltimore Shock Trauma, University of
Cincinnati, and St. Louis University. Hundreds of our medics have had
elite trauma and critical care training through these facilities and
remain prepared to deploy anywhere needed; whether to the AF-led
theater hospitals in the USCENTCOM AOR, as CCATT team members, or to
whatever location U.S. forces are deployed. We remain committed to the
relationship we have with these civilian facilities, and rather than
reducing training platforms as we come home from the current war, we
intend to expand training opportunities to keep skills current and our
team ready.
We are committed to expanding training opportunities for non-
surgical and trauma related skills to ensure all our personnel remain
ready and current. The AFMS continues its transition to a tiered,
centrally managed training platform called Sustained Medical and
Readiness Training, or SMART, which provides hands-on patient care of
greater volume and complexity. Our first SMART course began recently at
Nellis AFB, Nevada, in cooperation with the University Medical Center
in Las Vegas, with plans for more than a dozen additional classes with
students from all over the Air Force in the next year.
As SMART requirements expand and the program matures, other local
and regional partnerships will be developed to meet AFMS training
needs, and we will establish a training ``battle-rhythm'' to provide
deployable Airmen hands-on, high acuity care opportunities on a regular
basis. This will further expand the system we have in place to identify
training requirements and track completion of training events down to
the individual.
Collaboration with the Department of Veterans Affairs (VA) through
sharing agreements and joint initiatives enhances our providers'
clinical currency, saves Federal dollars, and maintains readiness. As a
result of our efforts to encourage participation in the DOD-VA Resource
Sharing Program, we now have 49 Air Force-VA sharing agreements with 10
Master Sharing Agreements covering all available clinical services at
nine MTFs. Our relationship with the VA extends to clinical currency
opportunities for both entities. Our relationship with the VA extends
to clinical currency opportunities for both entities.
One recently developed venture of this nature is with the Buckeye
Federal Healthcare Consortium in Ohio. This consortium promotes
healthcare resource sharing between Wright-Patterson AFB Medical Center
and VA medical facilities in Dayton, Columbus, and Cincinnati, serving
158,137enrolled veterans. A sharing agreement with Veterans Integrated
Service Network 10, which supports veterans in three States, is
currently being reviewed. Air Force-VA sharing agreements enhance
access to specialty care for VA patients, allow VA physicians to use
the MTF's operating suites, and provide a great venue for our Air Force
medics to hone their readiness skills in a high-acuity environment.
The United States Air Force's core missions are Air and Space
Superiority, ISR (Intelligence, Surveillance, and Reconnaissance),
Rapid Global Mobility, Global Strike, and Command and Control. These
are almost identical (but in different terms) to the missions the USAF
had in 1947. But we now do these missions in three domains: air, space,
and cyberspace. In the Air Force I grew up in, the ``operators'' were
primarily pilots and navigators. There are many more types of
``operators'' these days, as Air Power is projected through the various
domains in very new ways. Air Force Medicine is adapting and innovating
to better support the Airmen who safeguard this country 24/7, 365 days
a year. In that regard, Air Force Medicine is now focusing on human
performance. This is not a huge shift for us. Since the AFMS began in
1949, Air Force medics have focused on occupational and population
health and prevention. We are simply taking it to the next level. Our
AFMS strategy embraces this, and to focus on this as a priority, we
recently changed the AFMS vision to state: ``Our Supported Population
is the Healthiest and Highest Performing Segment of the U.S. by 2025.''
This goal is focused on health rather than healthcare, and is clearly
connected to the imperative to assure optimum performance of Airmen.
Every Airman (or other-Service member) has human performance demands
placed on them by virtue of their operational and mission tasks--and
these demands have changed, rather than decreased, due to the
technologies employed in current mission environments. This strategy
will help to change culture, ultimately enabling our Airmen to not only
strive to prevent or ameliorate disease, but to promote performance.
In view of our evolving Air Force, the AFMS is evolving to ensure
that as many of our supported Service members are available to their
commander as possible, able to perform the exquisite set of skills that
are now required of them. Health in the context of mission equates to
performance, and every medic or healthcare team must know how the
mission might affect the health of the individual or unit, and how
medical support affects the mission. I think this is just as relevant
for other beneficiaries, to include family members and retirees, who
also have performance goals in their day-to-day activities. Toward that
goal, we have begun either embedding or dedicating medics to directly
support missions such as special operations, remotely piloted aircraft,
intel, and explosive ordnance disposal (EOD), which have had a clearly
positive impact on those Airmen, their mission effectiveness, and their
families. We are moving rapidly to make this ``mission specific''
support a more wide-spread practice.
At the clinic level, our intent is to provide customized
prevention, access, and care for patients, recognizing specific
stresses associated with career specialties. Our goal is to prevent
physical or mental injuries where possible, and if unable to prevent,
provide rapid access to the right team for care and recovery to full
performance. As a result, mission effectiveness and quality of life
should improve, and long-term injuries or illnesses should be mitigated
to provide for a healthier, more active life, long after separation or
retirement. Concordantly, long-term healthcare costs and disability
compensation should also decrease.
Patient safety and quality care are foundational to supporting our
beneficiaries in their quest for better health and improved
performance. In order to improve both safety and quality we are
committed, as part of the MHS, to become a high reliability healthcare
system. This is a journey being undertaken by healthcare systems across
the country. To achieve this goal we need a focused commitment by our
leadership and staff, instilling a culture of safety and quality,
constant measurement of the care we provide combined with robust
process improvement at all levels. These key tenets will enable the
AFMS to achieve the principles of high reliability seen in aviation and
nuclear communities, and are aimed at eliminating medical errors. To
that end, we are committed to strengthening our performance improvement
programs and training all medics as ``process improvers.'' This will
require advanced training for key leaders and staff, driving process
improvement activities from the executive suite down to the front lines
of our clinics and wards. A culture of safety requires that all AFMS
members are empowered and understand their responsibility to report any
unsafe condition or error, with the intent to make improvements and
raise awareness across the enterprise.
In support of Human Performance and Enroute Care initiatives, our
C-STARS faculty and civilian partners are comparing aeromedical
evacuation timing and combat casualty outcomes to help medical teams
determine ideal timing of evacuation to optimize treatment successes.
While we have been very proud of our accomplishments in quickly
transporting patients to higher levels of care, the decision of when to
move a patient must be data-driven, and our experience in the current
long war should help guide such future decisions, and may have great
relevance in anti-access/area denial scenarios in future wars.
We also focus research on better care and health for Air Force
families. Over the last few years we have teamed up the Wright-
Patterson AFB Medical Center with the Nationwide Children's Hospital
and Dayton Children's Hospital in Ohio to identify autism spectrum
disorder susceptibility genes, rare variants, and interventions to
enable early intervention and treatment. This endeavor continues to
support development of the Central Ohio Registry for Autism, which will
enroll 150 families in the next phase of patient studies through
September 2015, 50 percent of which are military families. Early
intensive behavioral intervention with Applied Behavior Analysis (ABA)
therapy offers promise. According to research, up to 20 percent of
children diagnosed with autism before age 5 who receive ABA therapy
``recover'' from the condition. There are many Air Force families who
could potentially benefit from this type of treatment, and we will
continue this important collaborative effort.
With more than one million patients enrolled, Patient-Centered Home
(PCMH) has made significant progress toward greater continuity of care
and improved patient and provider satisfaction. Over the last year,
patients have seen their assigned provider team 92 percent of the time,
our highest continuity rating thus far. PCMH has increased primary care
manager same day access, reduced local emergency room utilization,
decreased the need for specialty care referrals, and improved patient
experiences resulting in a remarkable healthcare satisfaction rating
over 95 percent.
In concert with PCMH is our ongoing secure messaging capability
called MiCare. The Air Force has now implemented MiCare at all 75 of
its MTFs worldwide and averages over 220,000 messages per month. As of
December 2014, there are over 412,000 Air Force registered users,
allowing patients and providers to communicate on a secure network
regarding non-urgent healthcare concerns. The network also allows our
patients to view their healthcare record, make appointments, renew
prescriptions, and receive important preventive care messages from
their PCMH team. A recent secure messaging satisfaction survey
demonstrated that 97 percent of over 13,000 survey respondents were
satisfied with their secure messaging transaction and more than 86
percent agreed it helped them avoid a trip to an emergency room or an
MTF for a medical problem.
Another important initiative concerning in-garrison care is our
continued support of a robust Tele-Health program. Project ECHO
(Extension for Community Health Outcomes) has evolved to cover eight
long-term healthcare concerns and services to include complicated
diabetic management, chronic pain management, traumatic brain injury,
behavioral health, acupuncture, addiction, neurology, and dental
disease. This Tri-Service effort builds specialty care capacity into a
primary care clinic and participating ECHO providers comment on their
increased clinical knowledge and confidence in patient management of
these complicated diseases. Providers report an overall 95 percent
approval rating in the ECHO's value to their practice. ECHO fits
seamlessly into the PCMH model of healthcare delivery. During 2014,
ECHO saw technological improvement by moving from the traditional VTC
suite to the providers' desktop web-based video platform. In effect, we
are using ``new'' technology to bring back the ``old fashioned''
curbside consult. Based on the University of New Mexico model, when
fully matured, ECHO is projected to reduce referrals to the TRICARE
network across 21 specialties over a 7-year expansion plan. This has
the potential to enhance team-based care for chronic disease by
incorporating the specialist into the team via digital connections.
The AFMS currently has two major health promotions initiatives.
First, we're rolling out our ``Healthcare to Health'' program at six
installations to better address adult and childhood obesity through
proven patient and parent-focused interventions. Secondly, we're
implementing a nutrition therapy Tele-Wellness at 15 smaller MTFs. This
will allow those stationed at smaller locations access to one of our 31
dieticians stationed around the globe. We're also developing our Group
Lifestyle Balance (GLB) and 5210 Healthy Military Children programs.
GLB addresses the fastest growing problem facing our population today,
pre-diabetes. It is geared towards helping participants lose five to 7
percent of their body weight and increasing their physical activity
level. The 5210 Healthy Military Children program is a primary
prevention approach to childhood obesity with consistent messaging
about healthy habits.
The wellness and resilience of our deploying Airmen remains a top
AFMS priority. We have a new and improved Pre-Deployment Mental Health
Training module designed to enhance an Airman's understanding of combat
related stresses and how to mitigate the risk factors. The training has
four platforms tailored to different target audiences--leaders, medical
and mental health providers, chaplains, and all other Airmen. Our
redeploying Service members whose deployed role poses an increased risk
for posttraumatic stress have been attending a 2-day program at our
Deployment Transition Center at Ramstein Air Base, Germany. Research
demonstrates this initiative has reduced reported Post-Traumatic Stress
(PTS), interpersonal conflict, and problematic alcohol use in our
returning Service members. Each Airman is screened for PTS several
times per deployment. When signs of PTS are detected, evidence-based
treatments are provided in our MTFs. PTS rates continue to be low
across the Air Force due in part to these combined efforts.
Airmen account for 14 percent of Service member traumatic brain
injuries (TBI), only 2 percent of these cases are deployment related
and 86 percent of those are mild concussion injuries. Though the
incidence of TBI is low in the Air Force, we remain committed to
providing quality care for our Airmen who have sustained these
injuries. Our Air Force TBI clinic at Joint Base Elmendorf-Richardson
maintains cross-Service support to optimize care within the DOD. For
our more difficult cases we partner with the National Intrepid Center
of Excellence for Psychological Health and TBI and Intrepid Spirit
Satellites.
Air Force suicide rates remain lower than the U.S. and DOD average,
but suicide awareness and prevention is a major concern for all Air
Force leaders. Identified suicide risk factors continue to be
relationship issues, financial problems, and legal problems. Our most
``at risk'' career fields continue to be security forces, aircraft
maintenance, and intelligence. This year's suicide prevention efforts
will transition from computer-based training to a more personalized,
face-to-face delivery method. Supervisors and other mentor-leaders will
facilitate small group discussions allowing more direct participation
by Airmen. This will leverage our ``Wingman culture'' which is key to
identifying and assisting Airmen. We are also adding an annual
Frontline Supervisor Training refresher for our at-risk career field
leaders to ensure their mentoring and awareness skills remain honed.
Timely intervention utilizing counseling techniques learned during
these training just may prevent future tragedies. Counseling services
are available to our Airman and their families from chaplains, Military
Family Life Consultants at the Airman and Family Readiness Centers,
mental health providers working in primary care settings, and of
course, evaluation and therapy delivered in our mental health clinics.
Suicide prevention in the Air Force relies on leaders and communities
working together to bolster Airmen resilience and create a supportive
environment where seeking help early is seen as a strength. We know
what we do prevents some suicides, but we are not satisfied and will
continue to focus hard on this issue.
We remain vigilant in our efforts to prevent hearing loss among
Service members exposed to high intensity occupational noise. Often
these exposures result in auditory and balance injuries, to include
tinnitus (ringing in the ears) and hearing loss, currently the clear
number one and two VA reimbursable health concerns. The DOD Hearing
Center of Excellence (HCE) is a Tri-Service/VA collaboration with the
Air Force serving as the lead agent. The HCE aim is to improve the
auditory health of beneficiaries.
This year the HCE will implement the DOD Comprehensive Hearing
Health Program designed to prevent and ultimately eliminate noise-
induced hearing loss. A lofty but possible goal with outreach and
awareness is essential to making this work. Identification of hazardous
noise sources, effective and consistent hearing conservation methods,
as well as monitoring hearing and proper hearing protection use are all
education topics important to the HCE. This year also marks the
beginning of the Baseline Audiogram (hearing test) at Accession Program
for all Air Force members. This initiative ensures Airmen have a
documented hearing screening prior to initial noise exposure, allows
comparison of hearing ability over the course of a military career,
provides better tracking ability of hearing loss trends throughout our
Air Force, and when necessary, provides the capability to remove Airmen
from hazardous noise exposure.
In 2015, the HCE will continue to develop the Joint Hearing Loss
and Auditory System Injury Registry, a comprehensive effort to identify
and track the incidence and care of auditory and balance system injury,
facilitate research, develop best practices, and better educate Service
members and veterans. The registry will improve the quality,
reliability, and continuity of healthcare for Service members while
they're on active duty and once they've transitioned to the VA. In
addition to registry efforts, the HCE is focused on allowing Active
Duty hearing conservation documentation to be shared with the VA to
allow a smooth transition and continuity of care across the two
departments.
Looking ahead, the AFMS is committed to working with our sister
Services in continuing to shape the Defense Health Agency (DHA). We are
optimistic that our efforts will result in efficiencies and cost
savings across the MHS, as well as provide common solution sets to
enhance interoperability at home and in a deployed setting. The ten
shared services, such as IT and logistics, will standardize processes
and reduce duplication across the MHS. Another example of our
integration across the medical Services is our focus on enhanced multi-
Service markets, or eMSMs, where we have large beneficiary populations
and can target operational and business efficiencies, such as in the
National Capital Region, Tidewater Virginia, San Antonio, Colorado
Springs, Puget Sound, and Hawaii markets.
The AFMS joins with our sister Services as we transform, as part of
the MHS, into a fully integrated system that consistently delivers
quality healthcare while improving the health and readiness of our
forces. With our vision of health and performance in mind, we are
committed to providing the most effective prevention and best possible
care to a rapidly changing Air Force, both at home and deployed. I am
confident that we are on course to ensure medically fit forces, provide
the best expeditionary medics on the planet, and improve the health of
all we serve to meet our Nation's needs. I thank the Subcommittee for
its continued strong support of Air Force medicine and the opportunity
to testify at this hearing.
Senator Cochran. Thank you. Our other witness this morning
in this panel is the Program Executive Officer of the Defense
Health Management Systems, Mr. Chris Miller. Welcome, Mr.
Miller. You may proceed with your statement.
STATEMENT OF CHRISTOPHER MILLER, PROGRAM EXECUTIVE
OFFICER, DEFENSE HEALTH MANAGEMENT SYSTEMS
Mr. Miller. Thank you, sir. Chairman Cochran, Ranking
Member Durbin, distinguished members of the subcommittee, thank
you for the opportunity to address the Subcommittee on Defense
Appropriations.
I am honored to represent the Department of Defense as the
Secretary's Program Executive Officer responsible for the
Department's efforts to modernize our electronic health records
(EHRs) and to make them interoperable with those of the
Department of Veterans Affairs and our private sector
providers.
I also have the privilege of representing the DOD/VA
Interagency Program Office as the current Acting Director. Our
servicemembers, veterans, retirees, and their families deserve
nothing less than the best possible care and service that DOD
and VA can provide, with a seamless transition for
servicemembers as they move from Active Duty to veteran status.
To this end, DOD is committed to two equally important
objectives, improving the data interoperability with both VA
and our private sector care partners, and modernizing our
electronic health record to provide our clinicians and
beneficiaries the best possible tool available.
Over the past 18 months, we have made significant progress
in achieving these objectives. Today, the DOD and VA share a
significant amount of health data, more than any other two
major health systems in the United States.
DOD and VA clinicians are currently able to view records of
more than 5.9 million shared patients who have received care
from either department, and we have recently extended this
capability to the VA's benefits adjudicators.
This data is available in real time, and the number of
records viewable by both Departments continues to increase. VA
and DOD have successfully accessed this data through our
current systems nearly a quarter million times a week.
Interoperability requires a steadfast commitment and
continuous improvement. Just last week, we deployed software
updates and delivered updated national standard data maps. This
upgrade allows us to be more comprehensive, reliable, and
responsive than ever in sharing data with VA and our private
sector partners, and enables data exchange with the Social
Security Administration and our DOD beneficiaries through
TRICARE online.
On a parallel path, DOD's modernization effort is well
underway. An independent analysis of our requirements and the
robust health IT (information technology) marketplace concluded
that the acquisition of an off-the-shelf product would allow
DOD to leverage the latest commercial technologies, improve
usability and interoperability, and ultimately provide savings
to the American taxpayer.
We are currently in source selection, and the Department
remains on track to award the contract later this year. This
competitive acquisition process will capitalize on the robust
commercial EHR marketplace and leverage industry's real life
experiences with deploying and managing a large health system
modernization.
Although we will not know the final figure until the
contract is awarded, we estimate the new competitive contract
will save DOD at least $5 billion compared with the previous
joint iEHR (integrated electronic health record) acquisition
plan.
Most importantly, interoperability with the VA and the
private sector remains paramount and will not be compromised.
Our goal is a system for the future which is open and flexible
and can easily adapt to changing requirements.
The system must support our military readiness by
addressing the increasing demands across a spectrum of military
operations, including forces deployed and those afloat, and
must also contribute to our ability to perform our health
mission and enable all mission elements of the military health
system.
This includes casualty care, humanitarian assistance,
disaster response, a fit, healthy, and protected force, healthy
and resilient individuals, families and communities, education
and research, and performance improvement.
DOD and VA remain in mutual agreement that interoperability
with each other and our private care partners is a top
priority. We also agree that we should be leaders in health
data sharing and continue to support each other's modernization
efforts.
This strategy makes sense for both Departments and provides
the most effective approach moving forward to care for our
servicemembers, veterans, and their families.
In the past 18 months during my tenure, DOD and VA have
done more to improve our interoperability and modernize our
systems than in the previous 5 years of effort. This is a
result of getting back to acquisition basics, getting the
requirement right, thinking like a taxpayer, and delivering on
our promises.
Chairman Cochran, Vice Chairman Durbin, and members of this
subcommittee: Thank you for the opportunity to testify today.
The Department of Defense has taken very seriously its
responsibility to provide first-class healthcare and enable the
seamless sharing of health records with the Department of
Veterans Affairs and our private sector care partners.
PREPARED STATEMENT
The Department greatly appreciates Congress's continued
interest and efforts to help us deliver the healthcare that our
Nation's veterans, servicemembers, and their dependents
deserve, whether it is on the battlefield, at home with their
families, or after they have faithfully concluded their
military service.
The Department of Defense and our colleagues at the
Department of Veterans Affairs will continue to work closely
together in partnership with Congress to deliver benefits and
service to those who sacrifice so willingly for our Nation.
Again, thank you for this opportunity, and I look forward
to your questions.
[The statement follows:]
Prepared Statement of Christopher A. Miller
Chairman Cochran and Ranking Member Durbin, 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 Secretary's program executive responsible for the
Department's efforts to modernize our electronic health records (EHRs)
and to make them 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.
Our Service members, Veterans, retirees, and their families deserve
nothing less than the best possible care and service the DOD and VA can
provide. Our mission is to fundamentally and positively impact the
health outcomes of active duty military, Veterans, and eligible
beneficiaries. To this end, DOD is committed to two equally important
objectives: improving data interoperability with both VA and our
private sector care partners, and awarding a contract to modernize our
electronic health record by the end of fiscal year 2015.
Over the past 18 months, we have made significant progress in
achieving these objectives. Today DOD and VA share a significant amount
of health data--more than any other two major health systems. DOD and
VA clinicians are currently able to use their existing software
applications to view records of more than 5.9 million shared patients
who have received care from both Departments. This data is available
today in real time and the number of records viewable by both
Departments continues to increase. VA and DOD healthcare providers and
VA claims adjudicators successfully access data through our current
systems nearly a quarter of a million times per week.
On a parallel path, DOD's modernization effort is well underway. An
independent analysis of our own requirements and the robust health IT
marketplace concluded that the acquisition of an off-the-shelf product
would allow DOD to leverage the latest commercial technologies, improve
usability and interoperability with the private sector as well as with
VA, and ultimately provide savings to the American taxpayer. We are
currently in source selection and the Department remains on track to
award the contract later this year. Although we won't know the final
figure until the contract is awarded, we estimate the new competitive
contract will save at least $5 billion when compared with the previous
joint iEHR acquisition plan. Most importantly, interoperability with VA
and the private sector remains paramount and will be achieved as
mandated by Congress.
Our goal is a system for the future which is open and flexible and
can easily adapt to changing requirements. The system must support our
military's operational readiness by addressing the increasing demands
across the spectrum of military operations, including forces deployed
and afloat. It must also contribute to the overall ability of DOD to
perform its health mission and enable all mission elements of the
Military Health System including casualty care, humanitarian
assistance, disaster response; a fit, healthy, and protected force;
healthy and resilient individuals, families, and communities; and
education, research, and performance improvement.
DOD and VA remain in mutual agreement that interoperability with
each other and our private care partners is a top priority. We agree
that this broader interoperability can best be achieved with our
current strategy to pursue separate, interoperable systems. This
strategy makes sense for both Departments and provides the most
effective approach moving forward to care for our Service members,
Veterans and their families. We have had direct senior-level oversight
from both Departments as well as rigorous oversight from both Congress
and the Executive Branch. In the past 18 months during my tenure, DOD
and VA have done more to improve our interoperability and modernize our
systems than in the previous 5 years of effort.
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 constantly collaborating as we
pursue complementary paths to achieve interoperability for the EHRs of
Service members, Veterans, retirees, and beneficiaries. Specifically,
DOD's goals are:
--Provide seamless, integrated sharing of standardized health data
among DOD, VA, and private sector providers; and
--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
Over the last 30 years, information technology has revolutionized
industry after industry, dramatically improving the customer experience
and driving down costs. Today, in almost every sector besides health,
electronic information exchange is a common way to do business. A
cashier scans a bar code to add up our grocery bill. We check our bank
balance and take out cash with a debit card that works in any ATM
machine across the globe.
Achieving this type of seamless data integration is dependent on
achieving a common set of data standards across all healthcare venues,
not on sharing the same software system. Since 2008, DOD and VA have
been exchanging a significant amount of electronic information.
Unfortunately, the information was in multiple disparate tools and most
of the information had not been standardized so that it could be used
for automated reminders or in electronic clinical decision support. As
an example, DOD and VA had different names for ``blood glucose'' in
their software systems, making it difficult for clinicians to integrate
and track blood sugar levels of diabetics across the two systems. For
data sharing and interoperability to be meaningful and useful to
clinicians, healthcare data must be mapped to standard codes and
displayed in a user-friendly way. This is equally important for sharing
data with our private sector partners who use a variety of different
health IT systems.
DOD and VA, with the assistance of the IPO, have completed the
initial mapping of all structured data and clinical domains to national
standards, thereby establishing the foundation of the two Departments'
seamless data integration. Because we mapped much of our data to
national standards, we will also be able to increasingly share this
information with our private care partners who use many different
health IT systems. In the example I just mentioned, today, and moving
forward, both VA and DOD clinicians will see a common, standardized
name for a patient's blood glucose results that can also be matched up
with data from the private sector. We now have this standardized data
for almost a million medical terms, and we are working to further
improve and maintain these data maps moving forward.
Building upon the achievement of a common set of data standards
between the two Departments, DOD has continued to develop and deploy
follow-on interoperability initiatives, including development and
expansion of the Joint Legacy Viewer (JLV), an integrated display of
DOD, VA, and private sector data for clinicians. The Department has
expanded the capacity, functionality, and number of users of JLV.
Originally developed as a pilot program with 275 users at 9 sites,
there are currently more than 3,700 JLV users at more than 270 sites
across DOD and VA with access to 5.9 million patient records. This
includes the successful deployment of JLV to 325 users at 56 of the 57
Veterans Benefit Administration Regional offices and other key sites.
Over the next year, the Department plans to fully incorporate private
sector care data into the JLV and data sharing infrastructure and
continue its rolling deployments. By the end of April, the Departments
plan to begin the next phase expansion of JLV to more than 10,000 users
to meet the Health Executive Committee's (HEC's) approved requirements.
As JLV capacity and use increase, the Department will begin to phase
out existing legacy viewers, with full consolidation planned in 2016.
In April, the Department plans to conduct an Operational Assessment
(OA) to independently evaluate our interoperability efforts. The OA
will be a scenario-based test conducted by the Operational Test
Agencies in an operational environmental with typical users at an Army,
Air Force, Navy, and a VA clinic. The OA will determine the
effectiveness (business process support and accuracy), suitability
(usability and reliability), and survivability (cybersecurity) of the
system.
For DOD, achieving data interoperability with VA is also the path
forward to exchanging health information with private healthcare
providers. Today, more than 60 percent of all Service member,
dependent, and beneficiary healthcare is provided outside a military
treatment facility through TRICARE network providers. DOD exchanges its
electronic patient health data with the public and private sector by
means of the DOD Virtual Lifetime Electronic Record-Health Exchange
(VLER-H/E) that is connected to the national e-Health Exchange. DOD is
focused on deploying private sector interoperability to our military
treatment facilities around the country that have an associated private
sector Health Information Exchange (HIE) that is connected to the
eHealth Exchange. Currently, DOD is one of 81 participants in the
eHealth Exchange. DOD plans to connect to an additional 15 HIE partners
by the end of the year, based on functional and business factors.
The Departments have made substantial progress toward
interoperability, and by June 2015 DOD will have met the fiscal year
2014 National Defense Authorization Act (NDAA) requirement that our EHR
system be interoperable with VA with an integrated display of data that
complies with IPO-identified national standards. In addition, DOD's
upcoming acquisition of a modernized EHR system will reflect our
steadfast commitment to continued interoperability. The Request for
Proposals (RFP) contains requirements for interoperability and criteria
that were coordinated with VA and the HHS Office of the National
Coordinator for Health IT (ONC). Looking forward, we will continue to
improve data sharing efforts with VA and the private sector in order to
create an environment in which clinicians and patients from both
Departments are able to share current and future healthcare information
for continuity of care and improved treatment.
Goal 2: Modernize the Electronic Health Record (EHR) Software and
Systems Supporting DOD and VA Clinicians
From 2010 to 2013, DOD and VA executed a joint program called the
integrated Electronic Health Record (iEHR) in an attempt to create a
single next-generation EHR system, led by the DOD/VA Interagency
Program Office (IPO). In February 2013, VA independently determined
that their best course of action was to evolve their current legacy
system, the Veterans Health Information Systems and Technology
Architecture (VistA), rather than pursue a new joint system. The
underlying factors that made evolving VistA a logical and sound
decision for VA--a workforce trained to use the system, in-house
development and support capacity, and an already-installed EHR baseline
in all of their hospitals--do not apply to DOD.
In response to VA's decision, DOD performed an extensive analysis
that determined many viable off-the-shelf EHR products could
potentially meet our requirements in a cost-effective manner that would
allow us to benefit from industry's robust competitive EHR software
marketplace. The Government used to be the leader in medical
information technology, but industry advances in recent years have far
eclipsed our capabilities. This competitive strategy will leverage
commercial industry adoption which has increased from approximately 40
percent of private-sector clinicians using some type of EHR in 2007 to
78 percent at the end of 2013 \1\. It will also save us more than $5
billion compared to the prior joint iEHR strategy.
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\1\ ONC, Physician Adoption of Electronic Health Records (http://
www.healthit.gov/newsroom/physician-adoption-ehrs).
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As part of this new strategy, the Undersecretary of Defense for
Acquisition, Technology & Logistics (AT&L) assumed responsibility for
healthcare records interoperability and related modernization programs.
DOD established the Defense Healthcare Management Systems Modernization
(DHMSM) Program Office and dedicated a Program Manager to lead a
competitive acquisition process that is evaluating off-the-shelf
solutions which will offer reduced costs, schedule, and technical risk,
and will provide access to increased current and future capability by
leveraging advances in the commercial marketplace.
Currently, we are employing a comprehensive open standards approach
for our EHR and interoperability programs, which is accelerating the
achievement of the President's open standards agenda. EHR software is
not a defense-unique product, and developing clinical software is not a
core competency for DOD. The EHR marketplace in the U.S. is expected to
reach $9.3 billion this year; VA and DOD combined make up less than 5
percent of the total U.S. market for healthcare management software. We
want to engage and leverage this vibrant marketplace to help us
identify the solution approach that provides best value and meets our
operational requirements.
Over the last year, I have engaged extensively with industry and
government agencies to learn from prior business acquisition programs.
As part of our market research efforts, we met with healthcare
organizations including Intermountain Healthcare, Northwestern Memorial
Hospital, the Children's Hospital of Wisconsin, Kaiser Permanente,
Hospital Corporation of America, Inova, 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 provided valuable insight and lessons learned that
informed our acquisition strategy.
One of the main lessons we learned from industry was the importance
of early engagement with the functional community. As a result, the
Program Office formalized the DOD clinical community's relationship to
the acquisition by establishing the role of Military Health System
(MHS) Functional Champion within the program. The Functional Champion
is charged with leading the functional requirements process,
representing the clinical community's interests throughout the
acquisition, and leading workflow standardization. The MHS and each
Service has a designated Functional Champion.
Since October 2013, the DHMSM program has conducted four Industry
Days and released seven Requests for Information and three draft RFPs;
garnering more than 2,000 questions and comments. The final RFP was
released on August 25, 2014 and proposals were submitted on October 31,
2014. Source selection is currently underway and competition has been
robust. A competitive range determination was made on February 23, 2015
and DOD is on track to award a contract by the end of fiscal year 2015.
After contract award, the modernized EHR system will be independently
tested to ensure it meets operational and interoperability requirements
for effectiveness, suitability and interoperability with VA and private
sector healthcare providers.
Our early engagement with industry also reinforced the value of
establishing a realistic deployment timeline. Our aggressive timeline
is consistent with similar EHR modernization efforts in the commercial
industry. The program has tailored its acquisition strategy to
streamline documentation and gain schedule efficiencies. We are
committed to collaborating with industry and pursuing this
modernization in a transparent and fair way that maximizes competition.
In alignment with the deadline set out in the fiscal year 2014 NDAA,
Initial Operational Capability is planned for the end of 2016 at eight
sites, representing all three Services, in the Puget Sound area of
Washington State. Full Operational Capability, currently estimated for
Fiscal year 2022, will include deployment to medical and dental
services of fixed facilities worldwide, including 55 hospitals, 352
clinics, and 282 dental clinics. Deployment will occur by region (three
in the continental U.S. and two overseas) through a total of 24 waves.
Each wave will include an average of three hospitals and 15 physical
locations, and last approximately 1 year. The full deployment schedule
is being evaluated as part of source selection and will be baselined at
contract award; the objective is to maximize the speed of deployment
without increasing risk or compromising performance or suitability.
To support the release of the final RFP release milestone, the
DHMSM Program Office developed a formal life cycle cost estimate (LCCE)
and schedule estimate for the EHR modernization program. The current
DHMSM (LCCE) is roughly $10.5 billion. This estimate covers 18 years
from fiscal year 2014 through fiscal year 2032 and includes all
deployment and sustainment costs over the life of the program. A review
of the current DHMSM LCCE against the August 2012 IPO LCCE for the
joint iEHR program indicates the current approach will save the DOD
more than $5 billion. As part of DOD's ongoing acquisition program
rigor, these cost and schedule estimates are being refined and will be
further updated prior to contract award. Additionally, an Independent
Cost Estimate will be developed to support contract award. We expect
that estimate to reflect additional cost savings as a result of the
competitive acquisition process.
A new operational medicine joint Program Office has been
established under PEO DHMS to lead the EHR deployment to operational
medicine environments worldwide, including theater hospitals, battalion
aid stations, hospital ships, forward resuscitative sites, naval
surface ships, aero medical platforms, and submarines. This Program
Office will deliver the DHMSM EHR system plus additional theater
medical capabilities to support operational, peacetime, and
humanitarian care to provide better care for all military healthcare
beneficiaries, and is developing a fielding strategy to synchronize EHR
deployment between garrison and operational forces. Our objective is to
field to these environments concurrently with fixed facility
deployment, but the schedule will be subject to the availability of
operational units for modernization. We are in the process of
finalizing the acquisition strategy for operational medicine
deployment.
dod/va interagency program office update
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. In this role, the IPO has collaborated closely with the
Office of the National Coordinator for Health IT (ONC) to ensure the
national standards identified meet the interoperability needs of the
Departments. The IPO has also worked with DOD and VA to oversee the
mapping of the Departments' health data to these standards.
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 greater use of
national standards 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.
Over the past year the DOD, VA and the IPO have been integrated
into ONC's planning for national health IT advancements. The
Departments and the IPO have been key contributors in the development
of ONC's recently-released Interoperability Roadmap. Looking forward,
DOD, VA and the IPO plan to: support development of a coordinated
governance and a framework for nationwide health IT interoperability;
collaborate with the standards community and industry to improve
technical standards and implementation guidance for sharing and using a
common clinical data set; and participate in ONC efforts to incentivize
the healthcare community to share data using common technical
standards, including a common clinical data set.
During the past year, the IPO has completed three important
technical guidance documents for interoperability. The Information
Interoperability Technical Package (I2TP) is an implementation document
that outlines IPO-required and -recognized national health data
interoperability standards. The Health Data Interoperability Management
Plan (HDIMP) documents the IPO and Departments' strategy and role in
supporting the Departments' management and governance efforts. The
Joint Interoperability Plan documents the IPO and Departments'
technical vision for interoperability and their plans for achieving
seamless data integration. Together, these documents provide a
foundation for the Departments' efforts toward seamless
interoperability.
conclusion
Chairman Cochran, Vice Chairman Durbin, and members of this
Committee, thank you for the opportunity to testify today. The
Department of Defense has taken very seriously its responsibility to
provide first-class healthcare to our Service members and their
beneficiaries, and to enable the seamless sharing of integrated health
records with the Department of Veterans Affairs and our private sector
care partners.
The Department greatly appreciates the Congress' continued interest
and efforts to help us deliver the healthcare that our Nation's
Veterans, Service members, and their dependents deserve. Whether it is
on the battlefield, at home with their families, or after they have
faithfully concluded their military service, the Department of Defense
and our colleagues at the Department of Veterans Affairs will continue
to work closely together, in partnership with Congress, to deliver
benefits and services to those who sacrifice so willingly for our
Nation. Again, thank you for this opportunity, and I look forward to
your questions.
Senator Cochran. Thank you very much, Mr. Miller. I am
pleased now to call on my distinguished friend from Illinois,
Senator Durbin.
Senator Durbin. Thanks, Senator Cochran. If you look at the
overall budget, there are very few areas where you can see an
increase. In this fiscal year, there was an 11-percent increase
in medical research at the Department of Defense. That was not
an accident. It was a conscious decision made by the
subcommittee to provide resources to the Department of Defense
for their valuable medical research.
I was hoping that it would complement the efforts underway
at the National Institutes of Health, the Department of
Veterans Affairs, and the Centers for Disease Control, and we
have asked the question repeatedly to make certain that
coordination was taking place so the efforts could be
complementary, not duplicative, taxpayers' dollars well spent
on medical research that first serves our men and women in the
military but then serves America and the world at large.
Which of you can comment on that coordination?
General Horoho. Thank you, Senator. We now have formal
agreements in place with the National Institutes of Health,
with other interagency partners, along with our joint sister
services, to ensure that we have the right processes in place
to avoid duplication and ensure we are focusing on military
relevancy.
Senator Durbin. That is what I want to hear. I am going to
ask that question every time I get the chance because I am
going to continue to fight for more medical research across the
board.
NIH. Senator Murkowski just joined us and feels
passionately about the same subject, and certainly in the
Department of Defense.
MILITARY HEALTH SYSTEM REVIEW
Secondly, Secretary Hagel ordered a review, medical
military health system review, which was reported recently. It
really was designed to assess the performance of our military
health systems when it came to safety, quality, and access,
particularly in relation to top performing healthcare systems.
The results were mixed. One assessment team member, Janet
Corrigan, said and I quote, ``Overall, MHS performance mirrors
what we see in the private sector, a good deal of mediocre,
pockets of excellence, and some serious gaps.''
How are you and other leaders of the military health system
responding to this report?
Admiral Nathan. Thank you for the question, sir. The review
confirmed that we have a system of accountability. We see at
headquarters what is happening at the deckplate and in the
fields. That is the good news. What is reported out in the
field by our various hospitals as far as quality, access, and
safety is faithful to what we see at headquarters. We believe
we have a good picture of what is happening out there.
This review also allowed us to look at how we can
collaborate better as an enterprise, we share many things, but
we may have somewhat different approaches to these three
aspects of care. This has allowed us to be more congruent and
to create a formalized pathway to what is called ``a high
reliability organization,'' similar to an aviation or the
nuclear Navy. When you look at the number of occurrences in the
nuclear Navy, they are essentially mistake free. The focus is
how do we replicate that performance? The review has been good
for this assessment.
Senator Durbin. I concede a point made earlier in your
testimony that the military health system has proven themselves
over and over again when it comes to dealing with combat
situations, trauma situations, maybe teaching the rest of our
health systems a lot of lessons that are valuable.
I would like to get into this question of safety and
quality performance. General Travis, I note in your biography
that you are one of the few pilot physicians. This question is
really up your alley.
General Travis. Yes, sir.
Senator Durbin. There is a doctor in Boston named Atul
Gawande who has written a book about lists. He starts the book
by telling the story of flying complex bombers before World War
II, where the missions failed. The decision was made by our Air
Force to come up with a checklist for pilots, which I think is
being used virtually across the board, at least across our
Nation, everywhere. He suggests the same kind of meticulous
checklist needs to be established for medical care to achieve
goals when it comes to safety and quality performance.
I would like to hear your thoughts on that.
General Travis. Yes, sir. It is a great question. I tell my
folks and anyone else who will listen that I started flying
fighters, and back in the day when I was flying Red Flag
missions and leading Red Flag missions, almost every year we
would lose an airplane and a couple of people in those
exercises.
At the time, and this was--I hate to tell you how long ago
it was--almost 39 years ago, we kind of expected that you might
lose some airplanes and people every year in training out of my
squadron, as kind of the cost of readiness.
The way I translate this out of the MHS review--frankly,
the three of us all welcomed the opportunity for the deep dive
and the look, as my partners have said. The way I translate
that from what you referenced is why would we expect or why we
would accept that we would harm any patients as the cost of
doing healthcare. It is not a military problem. It is a
healthcare problem.
We have all strapped this on. I think the MHS review,
frankly, energized us on something we have all cared deeply
about for years. We do not get into this business to hurt
anybody or harm anybody, and why would we expect or accept any
errors or patient harm is just kind of the way healthcare goes.
You are exactly right, there is congruence. The difference
is, I would tell you, you just cannot do it with a checklist.
The culture of safety has to be there. The transparency, much
like a flight lead in a flight who could be a Lieutenant--and I
have done it--could tell a Colonel you screwed up, sir, and
here is what I would do different in the future. We ought to
have our technicians, our youngest airmen, no matter what their
rank, being able to tell the team we screwed up or let's not
screw up, time out, we are about to do something wrong.
That is the culture we are all very willing to embrace. I
think it is a natural for DOD, to be honest with you, highly
reliable.
Senator Durbin. Thank you, General. Thank you, Mr.
Chairman.
General Travis. Yes, sir.
Senator Cochran. Thank you, Senator. The Senator from
Alaska, Ms. Murkowski.
Senator Murkowski. Thank you, Mr. Chairman. Welcome to the
committee and thank you all for all that you do for our
military and their families.
MEDICAL RESEARCH FUNDING
I have had on occasion before this committee to bring up
the issue of ALS (amyotrophic lateral sclerosis), Lou Gehrig's
disease, and the association--the not-well-understood
association--between the incidence of that disease and those
who have served in our military. Those who have served are
twice as likely to be afflicted with ALS, which you know is a
very horrible and debilitating disease.
I appreciate the question that Senator Durbin has presented
this morning in terms of the efforts that we focus. We have the
peer-reviewed medical research program, and again I have a
particular interest in what is going on with the ALS research
program.
Last year, this committee appropriated funds directly to
the ALS research program, and in previous years it had been
included on a list of eligible conditions when the House took
the lead there in appropriating the funds.
The program is currently funded at $7.5 million. The
question to you, General, is whether in your view this research
program towards ALS has proven effective, if it is a good
investment. If the subcommittee were to look to perhaps
increase that allocation upwards, would you view that as a good
investment given the presumptive nature of this disease to our
military?
General Horoho. Thank you, ma'am. First, thank you very
much for the support in the past in this important area. There
has been almost $47 million since fiscal year 2007 that has
funded about 34 different projects that are ongoing, and then
the $7.5 million you talked about in fiscal year 2013, fiscal
year 2014 and 2015.
I do believe it is important. I think we are still learning
much from exposure to Gulf War illness. We are continually
looking at all of our soldiers, sailors, airmen, and marines'
environmental exposures and different diseases that have an
outbreak.
Any time we have research dollars that are dedicated to
allow us to look at preventive measures and protective
measures, I think it is very important.
Senator Murkowski. That will continue to be a priority and
I will be working with my colleagues here on the committee as
we try to gain a better understanding as to how that connection
may actually work.
Let me ask a question to both you and General Travis here
this morning. As you know, the Army has been involved in a
series of community meetings, these listening sessions, to
discuss the force structure reductions. In my State, we have
had a couple different hearings, one up in the Interior where
the Army is considering the possible deactivation of the first
Stryker brigade combat team (BCT). It is the only BCT there at
Fort Wainwright. Fort Wainwright, as you know well, hosts
Bassett Army Community Hospital, which also serves the airmen
there at Eielson.
At the same time Army is considering a possible reduction,
Air Force is looking at plussing up with the addition of the
two squadrons of F-35s, and then down at JBER (Joint Base
Elmendorf-Richardson), we have another situation where the Army
is considering the possible deactivation of the 4th Airborne
BCT, the only BCT there at JBER. The 673rd Medical Group serves
the members of this brigade as well as the airmen of JBER.
If the Army were to eliminate its brigade at JBER, would we
see a downsizing of the 673rd Medical Group to the detriment of
the airmen at JBER?
The question to you this morning is as we are looking to
these possible reductions in forces, either up in the Interior
or down at JBER, the impact then to the delivery of medical
services for our Air Force given the very joint nature of our
facilities at JBER and Wainwright/Eielson, if you could speak
to that.
General Travis. Ma'am, thanks for that. We have a very good
system of looking at not just population at risk but missions
that need to be supported in these Bases, and certainly as
there are shifts on the Air Force side, and we always
acknowledge what is going on with the populations we support,
or in the case of Wainwright, the folks that support us.
Because of all the changes in Air Force force structure,
similar to the other services, we have a pretty agile system
for manning and supporting these facilities to make sure our
Airmen, their families, and if our joint partners need us to
support them as well, as we do at JBER.
I would tell you we will certainly respond and support to
make sure we do not lose the capability. Alaska is challenging.
We certainly do not want to leave them unsupported there.
Senator Murkowski. General Horoho----
Senator Cochran. Senator, your time has expired.
Senator Murkowski. May I just ask General Horoho----
Senator Cochran. If the Senator from Rhode Island would
yield to you for that question.
Senator Reed. I will yield.
Senator Murkowski. I just wanted to know if General Horoho
had a comment on Bassett.
General Horoho. I will do it very quickly. We are actually
committed to maintaining capabilities because of the remoteness
of that area.
Senator Murkowski. Excellent. Thank you.
Senator Cochran. Thank you, Senator. The Senator from Rhode
Island.
Senator Reed. Thank you. Now I would like to interpret what
I said in Rhode Islandese, which is I was going to yield to
Senator Mikulski but she gracefully said no, and then of
course, I yielded to Senator Murkowski. That is the English
translation of what we do constantly in Rhode Island. Forgive
me; okay?
Mr. Miller, thank you for your great work. One of the great
efforts we have had underway is to make uniform the DOD and VA
healthcare records. When are we going to start seeing DOD
personnel who retired several years ago start coming back into
this electronic system? Is that on your horizon?
Mr. Miller. Sir, I would argue that is happening as people
come back into the system, we are bringing those records back
into electronic. I do not think personally, sir, it is cost
effective to go pull those records back in, but I will tell you
every time we have an encounter/interaction, we are working to
bring those people into electronic so that data can flow, sir.
Senator Reed. It is not a conscious effort to get 100
percent, it is case by case?
Mr. Miller. Yes, sir.
Senator Reed. If someone leaves Active service today and
becomes a patron of the VA, how fast will their records show up
in the VA system?
Mr. Miller. Sir, it is already there. The way the system
works today, sir, is we have data exchange that works in real
time, so today if I could take you to a VA Clinic, they could
pull up and see a DOD record, and then as part of the
transition, prior to separation, we do send data to have it
available on the VA side.
I view success here really in the eyes of our clinicians
and our users, and that is what I am listening to right now,
and they do seem happier than they have been. I do not think we
are ever completely done here, I think we have work to do, but
they are able to see and access more information than they had
previously.
What I mentioned in my comments, the extension into the
benefits side, I think, will have a significant impact as we
also think about who else also has to have access to that
information to really make sure we are taking care of our
veterans, sir.
Senator Reed. Can you just quickly list, what are the great
challenges? We hear constantly of difficulty with electronic
records and financial records, et cetera. What are the
challenges you are facing and how are you facing them, and do
you need more resources to do it?
Mr. Miller. Sir, what I usually tell people is my problem
right now is not a technical problem; that our challenges today
are really about people and process. We can pick any number of
tools in this area, the commercial market is very robust, there
are lots of solutions out there, I think the more important
factor is how are we training our people, how are we getting
the culture right, and how we are really making sure we get
them ready for this.
I think one of the things you will look at when you go
through any of these kinds of transformations is the
fundamental rethinking of our business processes, so we are
being efficient and we are really thinking about how we want to
do business in a consistent manner to help us in terms of
quality and safety.
I would offer that today, where my focus really is is
making sure in partnership with the services and with the
Defense Health Agency that we are really thinking through the
training piece, the deployment piece, and making sure that we
have sufficient resources to make sure we handle that.
I have visited a number of facilities that have gone
through this, and their message routinely is it is all about
the changed management and the training, it is not about the
tool, it is about how you use that tool, and that is what we
are focused on, sir.
Senator Reed. That is where the resources are going?
Mr. Miller. Sir, if you look at my cost estimate, you will
see there are parts of it that deal with buying the tool, but I
think you will also see a significant investment that is going
towards training and the changed management, and the things
necessary to make this thing really operationally work, sir.
Senator Reed. Thank you, sir. To the Surgeon Generals
first, thank you for your service, and your compassion and care
of our personnel, both uniformed and their families.
MEDICAL FACILITIES
One of the issues that came up in the report of the Uniform
Commission on Compensation was the need to make medical
facilities more accessible, not just for convenience of the
patients but also so you have the skill levels necessary to be
a deployable force if we go into the fight.
Just a quick comment, General Horoho, and then all the way
down the line.
General Horoho. Yes, sir. We have actively been engaged in
that over the last several years, putting our green suiters
where military relevancy and competency is needed, so in our
medical centers, the focus of combat casualty care, also
graduate medical education programs, and partnering with
civilian communities and having trauma care consortiums to
bring in the right level of care. It is an active engagement
across the board.
Senator Reed. Will the access of additional retirees into
the system as proposed by the Commission help you with that
training expertise and experience?
General Horoho. We have been actively, over the last couple
of years, brought in as many patients as possible that we can
make sure that it is the right type of patients, so the skill
sets are related to military relevancy.
Senator Reed. Admiral and General.
Admiral Nathan. Yes, sir. Although it is important and key
to focus on the combat casualty and trauma capabilities, the
majority of the issues that plague commanders in the combat
arena are diseases and non-battle injury.
MEDICAL FACILITY ACCESSIBILITY
As General Horoho said, it is important that we have a wide
range of patients from the young pediatric patients, and since
we are all involved in non-combatant evacuations and
humanitarian missions, to the elderly. We must be capable of
caring for all disease states.
We have a robust collaboration with academic centers, and
in addition, all of us have robust partnerships with shock
trauma areas so we can continue to cycle our trauma teams
through very busy trauma centers in the civilian sector to keep
their skills sharp between conflicts.
Senator Reed. General Travis, please.
Senator Cochran. The time of the Senator has expired.
Senator Reed. Thank you. General, will you take that one
for the record?
General Travis. Yes, sir.
Senator Reed. Thanks.
[The information follows:]
Yes, increasing access of additional retirees into the
system will help us with maintaining the medical readiness
skills necessary to meet the mission. While combat trauma
capabilities are extremely important and have allowed us to
achieve a 97 percent survival rate, diseases and non-battle
injuries has been the majority (77 percent) of the care
provided in the deployed environment. Allowing patient access
with the right volume, right acuity, and right diversity of
care, from trauma to rehabilitation ensures our medics keep
their skills sharp to respond to any situation from combat to
humanitarian missions. In addition, we also have a robust
civilian partnership collaboration with academic centers where
our medics are able to get valuable patient care experience
when we can't provide it within our own facilities.
Senator Cochran. The distinguished Senator from Maryland,
Ms. Mikulski.
Senator Mikulski. Well, we know we got the Maryland part, I
do not know about ``distinguished.'' Good morning, everybody.
Mr. Chairman, thank you for holding, I think, one of the most
important components of our service to the military. This is
really the commitment to making sure that we are committed to
the well-being of the war fighter and to the war fighter's
family.
I want to first of all thank General Travis for his
service. I understand he is retiring. We just want to thank you
for the great job that you have done. We hope we see you more,
and thank you for the kind words about Maryland Shock Trauma.
To you, General Horoho, I understand you will be leaving
this post at the end of 2015.
General Horoho. Yes, ma'am.
Senator Mikulski. I wish you could have made it to 2016, we
could have had a going away party together. I know we are both
committed.
First of all, before I get to my question, on behalf of
Maryland and the people I represent, we want to really thank
you. We want to thank you and we want to thank every man and
woman under your command who really serves the needs of our
military. You have saved lives for them on the battlefield, you
have saved families and the intact marriages because of what
you do back home.
We just really want to say thank you to every doctor,
nurse, social worker, support service, we could go through an
honor roll of clinical care in this team approach you have had.
We want to say thanks.
The second thing is we in Maryland are very grateful for
military, the presence of military medicine. We are so proud of
the fact that we have Walter Reed Naval, Bethesda in our State.
Mr. Chairman, the fact that they are not climbing the walls
at this hearing is a tribute to the fact that there are no
scandals. There is no latest fad in the Washington--not fad,
surprise in the Washington Post that everybody is here raising
questions or raising hell about.
First of all, what a great transition that has been, and
the wonderful research that is done, Fort Detrick, who made
invaluable contributions during the Ebola crisis, I could go on
and on. Your presence in Maryland is just so fantastic.
Let me get to my question. Your work in acute care is
stunning, trauma medicine. It is really ground breaking and
pioneer work, and I think even Nobel Prize quality. Post-acute
care, rehab. My question goes to the war fighter and the war
fighter's family, and to the larger, we are almost primary
care, because we think of the stunning achievements, which I
absolutely just cherish when we think about what you have done.
My question is have we changed the culture, and is there a
cultural impact upon your work, I know what the President
wants, in terms of looking at the family, looking at primary
care, looking at the Healthy Base Initiative, and so on. Are
they just like waiting you out, General, for you to leave? Are
we only going to focus on acute care and the research and
military relevance? Military relevance to me is also are our
children of our war fighters having their own post-traumatic
stress.
My question to you is where are we on that culture that
goes to not only the dramatic things that are done and stunning
things that are done, but this day-to-day kind of medicine that
keeps families intact and war fighters?
I will just close with this question. They closed
commissaries. Well, Healthy Base, buying food. In Maryland, at
Fort Meade, it has become almost like the settlement house for
teaching nutrition to the young enlisteds and their families.
They were closing fitness centers at 6 o'clock at night when
many of our war fighters do not go to work out until 11
o'clock.
I see my time is up, but I feel very passionately about
this, so that when I am here, it is not only buying the latest
robot to do the latest surgery, which I support, but where are
we in terms of this?
General Travis, do you want to comment?
General Travis. Yes, ma'am. Amen, because frankly, healthy
resilient families make healthy resilient airmen, soldiers,
sailors, marines. Those warriors have to know their families
are healthy and well taken care of, number one.
Prevention of childhood obesity, lowering smoking and other
tobacco use, addressing adult obesity and retiree obesity are
all things, and the Healthy Base Initiative is one of the more
personnel leaning kind, because it is a community issue, not
just a medical issue.
As you say, commissaries, commanders, everybody has to pay
attention to this. Frankly----
Senator Mikulski. Is the military committed to this
approach?
General Travis. I believe we are.
Senator Mikulski. I am not questioning you, please, do not
misunderstand. Are they just waiting you out?
General Travis. No, ma'am. I think frankly--I will speak
for the Air Force and I will let my partner speak, and I will
keep it very brief--I think certainly in our Air Force we are
starting to hear much more about human performance,
availability of warriors to do the job because as a downsizing
force that still has tremendous stress on those warriors. That
stress translates to the families, by the way. If folks are
healthier, happier, more resilient, able to do their job--I
think commanders get that now, not just medics--we see that in
high stress communities where they have actually asked us--they
used to kind of keep us at arm's length, you know, ``Doc, we
will come see you when we need you''--not anymore. They come to
us and say how can you help us do this better, and we are doing
that across the Air Force.
Senator Mikulski. General.
General Horoho. Ma'am, the Army is committed to this
transition of readiness, resiliency, not just of our soldiers
but their family members. We are looking at the Performance
Triad being embedded in the DNA of our Army. We are now going
to have a pilot of 30,000 soldiers and their families.
We learned from the first pilots that we did, and we have
enhanced our training, and we have incorporated this into our
comprehensive soldier family fitness. We are also embedding the
tenets of the Performance Triad into the Army's strategy of
having our soldiers being human weapon systems and looking at
cognitive, physical, mental, spiritual, and emotional
dominance.
I believe this is a culture change that is taking root.
Senator Mikulski. Why did they want to close commissaries
and zero out the Healthy Base Initiative?
General Horoho. Ma'am, I am not sure----
Senator Mikulski. I do not mean closed every commissary,
but there was an actual downsizing. I envisioned, as did the
Fort Meade Garrison Commander, that the commissary became a
tool that they used for the family, and just what they did--he
was stunned by the farmers market turnout, the young enlisted
spouses, the comradery that came out of it, as well as
nutrition and so on.
You are telling me big Army embraces this, but big budget
does not.
General Horoho. I do not want to answer for Installation
Command.
Senator Mikulski. It is not about an Installation Command.
I get this. What you need to know, as I wrap up this year and
next year, that this thinking is going to go by the wayside,
when exactly that is what we need to bend the healthcare curve.
We would welcome additionally through other conversations,
I know our time is limited this conversation.
Admiral Nathan, I want to go to Mr. Miller, Mr. Chairman,
with your indulgence, on the medical records or health records.
Are they only about the war fighter or are they records also of
the military family?
Mr. Miller. Ma'am, when I talk, I talk about the entire
family. I think one of the things you are going to see us from
a technical perspective try to do is to embrace the family more
and to provide more access.
I think one of the things we are clearly hearing from
industry is you have to increase the patient engagement, and
obviously taking care of our family members is a part of that
equation. I do not think just about the medical record in terms
of the theater piece or taking care of our Active Duty, I also
think every day about making sure that our beneficiaries and
our veterans are also being taken care of, ma'am.
Senator Mikulski. One, we really need this link to VA. I
know the chairman is so committed also to veterans' healthcare.
What we find again is the war fighter might be in good shape,
but the family is undergoing other things, not only a traumatic
thing like breast cancer with the spouse, but also the mental
health of the children, with a major family provider away, it
has created--I am not saying our kids are nervous or anxious or
whatever, but we have to look at this.
Mr. Miller. Yes, ma'am. I think one of our objectives is to
be able to provide a platform where the commanders have access
to information and can make those decisions to really
understand the overall readiness of the force.
I also think we have to remember that many of our
dependents actually go on Active Duty, and think about the
enlistment process and the accessions process, if we could just
pull that information forward and not have to ask them to go
through another physical or ask them to fill out another form.
We are thinking holistically, ma'am, about how do we really
have a longitudinal record for both our Active and those
dependents so we really can understand the total force.
Senator Mikulski. This is my last question. The chairman
has been generous. In Maryland, we have everyone from Walter
Reed Naval, Bethesda to Johns Hopkins and University of
Maryland and their hospitals. We hear also from the private
practice of medicine as well as academics, they are fed up with
these medical records. I hear doctors wanting to retire because
they feel they are doing more time with clicks and modems than
with patients and Motrin. Are you facing that?
Mr. Miller. Yes, ma'am. One of the things we are looking
at, too, is visibility. Let me give you another example. My
niece's husband is a flight surgeon in the Air Force down in
Biloxi. He grew up going through his medical training using
electronic health records. When he reported to his first duty
station and had to use our current system, he called me and
basically yelled at me.
He said you are taking away my productivity, this system is
not user friendly, I know how to use the commercial systems,
you have put me back a decade.
I think it is important to realize in our military health
system, we have multiple generations of people using the
systems, and I think we are going to find some people embrace
it and other people, we are going to have to work with them to
get them comfortable.
I think the most important thing that I would tell
everybody is this is a tool. What we have to focus on is what
are outcomes and how we want to use that tool, because if we
have that focus on making it user friendly and we think about
really what our people need, we can make it work.
I think where you hear these bad examples are when people
do not take time to really work through the changed management
and get people comfortable. That is when you hear these bad
examples, ma'am. I do hear that, and I think we understand it,
and I think we are trying to do everything we can to mitigate
it, ma'am.
Senator Cochran. The time of the Senator has expired, a
couple of times. The distinguished Senator from Montana, Mr.
Daines.
Senator Daines. Thank you, Mr. Chairman. In February, I had
the true privilege of presenting the Defense of Freedom Medal
to a great Montana resident named Richard Zelinsky. Richard was
one of the more than 200,000 patient movements since 9/11, and
he spoke highly of the outstanding treatment received in the
Center, received in the theater, during his transport, and at
Landstuhl Regional Medical Center.
Lieutenant General Travis, on behalf of Richard, a resident
of Stevensville, Montana, I want to thank you and your team for
the professionalism and the dedication they give day in and day
out, be it here at home or in the most dangerous parts of the
world, to keep our men and women ready to serve our country at
a moment's notice.
I would also like to extend those thanks to all the fine
folks sitting here. Oftentimes when you come to the Hill, you
do not get much of a thank you, but when you put it on the face
of those men and women that you serve, you know it is worth it.
Thank you, along with those who are serving out in the field
that may not always get the thanks they truly deserve.
Mr. Miller, a question. As the DOD Health Care Management
System has worked to improve information between the VA and the
DOD, have these efforts led to a measurable improvement in the
healthcare our service men and women receive?
Mr. Miller. Sir, I think one of the things we are working
through right now is really understanding what our outcomes
are. We have agreed to specific use cases that the DOD and the
VA are looking at, and are actually starting to look at our
measurements and how we are doing.
I would offer, sir, I view success really from the people
that are using the system. I go around a lot and I talk to a
lot of people, and I would tell you today that I can put VA
clinicians and DOD clinicians in the room, and we are actually
now talking about looking at the same information, we are
actually able to access that information, and we are able to
improve the timeliness that it takes to do things, whether on
the clinical side or on the BVA (Board of Veterans Appeals)
side, by the tools that we have provided over the past 18
months.
We are talking about metrics. We are looking at how we
share information. I think ultimately success here is really
whether or not our clinicians and the BVA claims adjudicators
can get their job done, and that is who I am listening to right
now, sir.
Senator Daines. What do you think--I spent 28 years in
business. There is an old saying, ``If you aim at nothing, you
will probably hit it.'' It is a complex system, but I know the
role of leadership is to distill it down to the most important
elements to measure those things that have the greatest
leverage and ensure they connect to how you define quality of
care and outcomes.
What are two or three of those metrics as you are looking
at that process that you think we ought to be focused on in
measuring success?
Mr. Miller. Yes, sir. A couple of things we are looking at
right now. One is what percentage of our records are
correlated, which basically means whether or not I can
electronically send the information from the DOD and VA and we
can access it in real time. We are doing things there to make
sure that number continues to rise.
We are also looking at how much the people are actually
using the system. I think one of the challenges of these
complex systems is whether or not the people actually
understand that some of this information is available, how do
you get access to it. We are looking at that kind of
information.
The other piece that I would remind everybody is we talk a
lot about DOD/VA. The reality is 60 percent of our care on the
DOD side comes from the private sector. If we really want to
understand the integrated health and what is really going on,
you have to tackle that problem, and this is a much bigger
national issue, but we are involved and we are looking at how
much we are able to start pulling that information in so that
when we are looking at it, we really truly have the complete
picture and our clinicians can make the best decision no matter
where that care is being provided.
Senator Daines. How much of the voice of the veteran in
that process is part of that metric in terms of a survey going
directly to the customer, if you will?
Mr. Miller. Right now, sir, actually both the VA and the
DOD is going through an assessment process to really understand
how well our systems are working. One of the things I brought
into this process is a real structured discipline, and one of
the things you do in this manner is you really go through a
test and evaluation phase.
The VA under their Veterans Health Administration is doing
a formal survey of their users to include the different areas.
They are going to be getting those results back and share that
with us.
On the DOD side, the Director of Operational Test and
Evaluation in the Army Test and Evaluation Command, they are
also going through a test process for us that will start here
in April, and we are going to take those results and we are
going to basically put them on the table and talk about what we
have to do to further implement them.
Senator Daines. Mr. Miller, thank you. One last question,
we are running out of time. We have seen the very disturbing
news this last week about personal information being
compromised here of the men and women who wear the uniform.
What steps have you taken to ensure the privacy of our
service men and women as this information gets shared between
agencies?
Mr. Miller. I would offer that the protection of
information is obviously a challenging and I think growing
threat. I think on our side what we are doing as we look to the
future is if you look at our request from industry, you are
going to see some very rigid and challenging security things
that we are asking for.
Obviously, there are rules like HIPAA (Health Insurance
Portability and Accountability Act) and our home security, but
we are actually going a step further and really asking to see
things like the source code, and really trying to understand
how secure the systems are, so that we can do everything
possible to protect that information because it is valuable
information and sensitive. We are bringing in some real
information assurance experts as part of our team to make sure
we do this right.
Senator Daines. As a closing comment, we have heard a lot
of concerns from our veterans on this and our men and women who
are serving, and they are worried, now my family's information
will be accessible to other folks who would be a significant
threat to our country, and we must do everything possible to
ensure we protect the privacy of information of our men and
women in uniform.
Thank you.
Mr. Miller. Yes, sir.
Senator Cochran. The Senator from Missouri.
CONSTRUCTION PRIORITY
Senator Blunt. Thank you, Chairman. Thank you for holding
this hearing. General Horoho, last year, I asked you at this
same hearing about the hospital at Fort Leonard Wood, which you
said was still the number one construction priority on the Army
side for healthcare.
I asked General Denaro the other day that same question. He
said still number one, but no money. Do you have any thoughts
about how we move forward with either upgrading that hospital
or what we need to be doing as it relates to that important
facility at Fort Leonard Wood?
General Horoho. Yes, sir. Actually, it still is our number
one priority within hospitals. We now have it in the POM, 17-21
POM, which last year when I said it was a priority, we had some
funding shortfalls, had to make some decisions, and now we were
able to get it back into the POM. It is still my number one
priority of the hospitals.
Senator Blunt. It is in the 17-21 POM?
General Horoho. Yes, sir.
Senator Blunt. Mr. Miller, do you work with both the VA and
the other military facilities? Is that part of your job?
Mr. Miller. Sir, I do work with them from an IT
perspective, sir. I do not directly deal with them in a
clinical perspective, but I do in terms of IT support both
departments.
Senator Blunt. I thought it was interesting, the number you
mentioned earlier of how much private sector healthcare is
delivered to people in the military. Obviously, in the VA,
Congress expressed a great desire last year to give veterans
more options. I do not know that you can answer this question
based on what you are doing with the VA.
I would say I think the VA has been really short in taking
advantage of that opportunity. I think yesterday they finally
said well, in terms of facilities, maybe we can measure 40
miles by how long it takes to get there rather than the
shortest distance on any map. I think the term that may have
been used was ``as the crow flies.''
The other thing that I am concerned about, Chairman and
others here, is that the 40-mile facility radius, certainly the
intent of the Congress was 40 miles from a facility that
provided the treatment you needed rather than a facility that
provides any treatment.
We may have to go back and clarify that. It is clear to me
the VA, if they wanted to, could clarify that just as easily as
they could decide what the 40 miles was intended to meet.
For veterans to have a choice and for the VA to compete to
provide services to veterans is an important thing.
The other thing I want to talk about, maybe with all three
of our panelists here, is what is happening in terms of--what
changes do you see in terms of mental healthcare in your part
of the Service.
BEHAVIORAL HEALTH
Again, last year we talked about this. General, I asked you
if you thought the NIH estimate, which at the time was one out
of four Americans, had a diagnosable and almost always
treatable mental health issue, and you said yes.
Your answer was we recruit from the general population. I
asked did you think that extended to the military, and you said
we recruit from the general population, we have no reason to
believe our number would vary from that.
I think in all our branches of service, we are moving
toward trying to be sure we look at that as another health
issue and look at ways we can take people with that particular
health problem and make them just as integral a part of what
happens in defending the country, if it is treatable.
Let's just go down the line of what you see happening and
what you hope to happen in the mental health area as you look
at the service men and women you are responsible for from their
healthcare perspective.
General Horoho. Thank you, Senator. We have been making
great strides in the area of psychological health and
behavioral health. With embedded behavioral health, we have
seen a reduction, a 50-percent reduction, of inpatient
admissions. We have more than doubled to about two million
outpatient visits, so I think that shows we are decreasing the
stigma.
MENTAL HEALTH INTEGRATION
We have trained our primary care providers in behavioral
health, and we have them in our soldier-centered medical homes
where soldiers get their care as well as our patient-centered
medical homes, where family members get their care, so it is
much more accessible.
In looking at readiness and resiliency, we have the
Performance Triad focusing on sleep and nutrition, what we
found is 75 percent of depression is related to challenges
within sleep, so I think if we can focus on healthy minds,
healthy bodies, we can help to reduce the impact of behavioral
health issues. We are looking at this from just not a clinical
perspective, from actually readiness, resiliency, and really
improving the lives of our soldier members through a system
perspective.
Senator Blunt. Chairman, if I could have an extra minute, I
would like for Admiral Nathan and General Travis to answer that
question as well. Admiral.
Admiral Nathan. Thank you, sir. One of the changes you will
note when you come into our military facilities today as
opposed to a year ago, on the intake, no matter who you are
visiting or why you are there, you will be asked by the intake
person how are you doing mentally, do you have any concerns of
self harm, do you have any concerns of harm to others.
Also, as General Horoho said, we now embed mental health in
our primary care environments, so in the good old days, if your
primary care doctor felt that maybe you need to get some help,
they suggested you make an appointment. You would have to make
an appointment. Now, we can in many cases walk you down the
hall to see someone, with open access, to give you at least a
few minutes of a preliminary intake in mental health. There is
eye-to-eye contact and a warm handoff with patient and
provider.
Finally, I would say as General Horoho mentioned, if we are
going to make great inroads in this country, inside or outside
the military, we have to reduce the stigma. I think we have
been working very hard at that now to get people comfortable
with raising their hands and saying I need help.
Senator Blunt. Thank you. General.
General Travis. Yes, sir. I will not repeat anything that
has been said, but it all applies to the Air Force as well.
Just to put a short kind of operational spin on this, we now
have commanders that understand that their operators,
intelligence folks, RPA operators, distributed common ground
stations, explosive ordinance disposal, and many more of our
career fields, the commanders now get the fact that these
folks--it is just part of the human condition--can have mental
health issues or problems brought on by stress, that range all
the way from drug and alcohol use to domestic violence, all the
way to suicide.
We have committed ourselves in the Air Force medical home
to now embedding the right forces where they are needed in
these high stress career fields, some with Top Secret
clearances, that have access to these individuals while they
are at work doing things they cannot talk about at home.
In fact, one of the intel wings last year told me those
embedded folks prevented two suicides. They know it. I would
tell you there are a whole lot more airmen and families that
could have been impacted by mental health sequelae, short of
suicide. Suicide is on the far end.
All those other things that make airmen unwell or their
family is dysfunctional, I know we have had an impact there,
too. Stigma, in my opinion, is coming down. I really do believe
that.
Great question, sir. Thank you.
Senator Blunt. Thank you. Thank you, Chairman.
Senator Cochran. Thank you, Senator, for your contribution
to the hearing.
Let me ask General Horoho, we are looking at the
possibility that we are going to have to recommend cut backs in
funding under the state of the law. As it exists right now, we
are restrained in the total amount under the Budget Act that we
are going to be able to make available to all appropriated
accounts.
There is competition on what is needed and what is not
needed. Can we do without one thing or less than we have been
used to seeing for certain programs?
The Senate's approach has been to include the majority of
the medical research additions in competitively research grant
programs. This allows medical experts to come in and actually
advise and recommend which programs would be the most, I guess,
cost effective, or what seems to be the emergency of the day
that needs attention.
How are you recommending that we consider these choices in
order to have the least pain and difficulties as we go through
the next fiscal year?
General Horoho. I will take that one, Senator, and then we
will just pass it all the way down.
Senator Cochran. Thank you.
General Horoho. Right now, across our medical centers and
our healthcare system, we are at the PB16 sequestration level.
When we look at the provision of care and the ability to
maintain all of our missions, that includes also our research
funding. Right now, we are good where we are at.
MEDICAL RESEARCH FUNDING
If we go into the sequestration in the Budget Control Act,
that will have almost like a double effect when we look at it
through the lens of military healthcare, and research is
included in that. We have already taken our reductions that are
there.
My concern when we look through the lens of research, that
is what has allowed us to remain relevant in the challenges
that we have seen over the last 13 years, because we had funded
research that answered questions that were asked 20 to 15 years
ago.
I think we have to be very, very careful in the right
amount of research funding to ensure that we keep the right
scientists on the team, that we keep relevancy for our war
fighters and the ability to be honest, to be cutting edge in
our technology, and our provision of care for the future.
Admiral Nathan. Sir, I would just add that research
generally is funded by two mechanisms, one is the advocacy of
yourself and Congress in apportioning money from a base for
research, and the other is in reimbursable monies that come
from grants, academic grants.
As the economy swings up and down, those grants can go up
and down, so we rely on a fairly consistent funding base that
we receive from Congress to maintain the continuity of that
research as grants fluctuate.
Senator Cochran. Do the others on the panel have a comment
or suggestion?
General Travis. No, sir. I agree with everything that was
said.
Mr. Miller. No comment, sir.
ADDITIONAL COMMITTEE QUESTIONS
Senator Cochran. Thank you very much. I appreciate the
cooperation and assistance of the distinguished panel. I think
you have done an excellent job of putting in perspective a lot
of the day to day challenges that we face providing military
benefits in the way of hospitals and healthcare, making sure
our forces are healthy and ready to protect our national
security interests.
For that, we are all very grateful to the medical community
who are represented today by this distinguished panel. We
appreciate your cooperation with our committee.
Senators may submit written questions to follow up on
issues we discussed today. We hope you will be able to respond
to those inquiries or follow up questions within a reasonable
time, so we can include your responses in full in our committee
report.
[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 Thad Cochran
Question. The Committee has consistently recommended in past bills
significant funds for medical research. Can you describe some of the
positive outcomes that resulted from this funding and provide an update
on any recent breakthroughs that are attributable to the medical
research done by the Department?
Answer. The Department of Defense (DOD) and the Services manage and
execute the President's Budget (PB) core medical research and
development programs to address threats to which our military personnel
are exposed from accession, through training, deployment, evacuation,
treatment and rehabilitation. Building on the backbone of the service's
military laboratory medical research and development subject matter
expertise, the additional funds added by Congress enhance the core
capabilities and accelerate and broaden the military medical research
base.
Recent successes of the military core research and development
efforts include but are not limited to the following:
Adenovirus Vaccine.--The Adenovirus Vaccine is a Defense Health
Program (DHP)-funded development program that resulted in the delivery
of a Food and Drug Administration (FDA) approved vaccine to prevent
Febrile Respiratory Illness (FRI) in military basic training
populations. Recent data shows that the vaccine is 99 percent effective
in preventing FRI caused by adenovirus types 4 and 7, and annual net
savings associated with the vaccine's use are estimated at $20 million.
Burn Resuscitation Decision Support System-Mobile (BRDSS-M).--The
BRDSS-M is an Army-funded development program that resulted in the
delivery of an FDA cleared medical device to both the battlefield and
civilian medical treatment facilities. The BRDSS-M is a first of its
kind algorithm-based decision assist system that tracks hourly fluids
administered and urine output to generate a recommendation of
appropriate fluid needs. This helps to avoid over- or under-
resuscitating burn patients, directly reducing morbidity and mortality.
Joint DOD VA Suicide Data Repository (SDR).--The SDR was developed
in conjunction with a DHP study that compiled data to answer questions
about suicide and deployment. The SDR allows researchers and policy
makers to use population level data to evaluate trends and answer
questions about suicide. The collaborative effort involves the Defense
Suicide Prevention Office, Veterans Health Affairs, and Centers for
Disease Control's National death Index and has been functional since
February 2014.
Junctional Hemorrhage Control Devices.--Prior to 2010 there were no
available technologies to control junctional (inguinal/axillary)
hemorrhage in the field. Extensive development, testing and funding
provided by the Army, Navy, Air Force Labs and U.S. Special Operations
Command have led or contributed to the FDA approval and
commercialization of four devices for controlling blood loss.
Vascularized Composite Allotransplantation (VCA).--Face and
extremity (hand/arm) transplants--which are known collectively as
VCAs--are still relatively rare occurrences. VCA improves functional
and aesthetic deficits remaining after reconstructive surgery has
reached the limits of its capability and it is one of the regeneration
and repair research focus areas of the Armed Forces Institute of
Regenerative Medicine II (AFIRM II). The Army, DOD, NIH, VA, have
provided $75 million in funds over 5 years, which have been leveraged
to add a much larger civilian investment.
ZMappTM.--The Chemical and Biological Defense Program,
Science and Technology is responsible for the development of
ZMappTM a cocktail of three monoclonal antibodies developed
by Mapp Bio in collaboration with the U.S. Army Medical Research
Institute of Infectious Disease and the Public Health Agency of Canada
for the treatment of Ebola. ZMappTM is included in ongoing
phase II efficacy clinical studies in West African Ebola patients and
was used to treat patients in the United States in 2014.
The additional committee recommended funds above the President's
Budget have allowed the Department to fund many breakthroughs in
medical research which benefit the population as a whole. The
additional funds also allow funding of research that benefits military
family members and other beneficiaries. Below are a few examples of the
many Congressional Special Interest (CSI) funded successes, through the
Congressionally Directed Medical Research Programs (CDMRP):
The Joint Warfighter Medical Research Program (JWMRP) is currently
funding the advanced development of a vaccine for the prevention of
Norovirus for prevention of viral gastroenteritis disease, common in
closed or semi-closed facilities (ships, schools, hospitals, etc.).
Also, the program is funding the development of the Transportable
Pathogen Reduction and Blood Safety System; a portable device that
reduces the risk of transmission of pathogens in whole blood collected
and transfused in combat. In addition, the JWMRP is funding the final
validation and performance testing and conduct of clinical trial
evaluations of the Non-Electric Disposable Intra Venous Infusion Pump;
an en-route pain management and anesthesia/sedation pump that does not
require to be connected to an electrical outlet.
The approximately $850 million DOD investment in Traumatic Brain
Injury (TBI) research since 2007 has resulted in two FDA-cleared
cleared devices to screen for signs related to TBI (The Defense
Automated Neurobehavioral Assessment tool and the Ahead-100
TM device) and a blood test for biomarkers released by a
brain injury that is in the final stages prior to FDA submission. In
addition, a number of DOD-funded strategic initiatives are in progress,
including the TBI Endpoint Development consortium in which the FDA is
an active participant to validate meaningful comparison measures for
TBI diagnostic and therapeutic trials. This initiative is widely viewed
by academic and industry as the critical path to the future approval of
diagnostics and treatments for Traumatic Brain Injury.
The Spinal Cord Injury Research Program supported the design, test
and evaluation of an implantable stimulator to activate and/or block
nerves involved in bladder functions to normalize them after spinal
cord injury. The investigator was further selected for fiscal year 2014
funding to modify and optimize the device for human use and to submit
an Investigational Device Exception application to FDA.
The Amyotrophic Lateral Sclerosis (ALS) Research Program
successfully identified a number or neuroleptic compounds that restored
mobility in model systems, such as the antipsychotic drug pimozide.
Armed with the data, the investigator initiated a trial to look at the
effect of pimozide in ALS patients
The Multiple Sclerosis (MS) Research Program funded the development
of an advanced MRI technology, known as diffusion basis spectrum
imaging to reveal underlying complexities of MS, including
inflammation, demyelination, and axonal loss. This is important, as
edema and inflammatory cells obscure the ability of current imaging
techniques to detect actual damage to the nerve and makes it harder to
assess the effectiveness of treatment approaches.
CDMRP also manages and executes Breast, Prostate, Ovarian and other
cancer research programs which have resulted in several breakthroughs
that are-or will be- game-changers in the way these cancers are
diagnosed, managed and/or treated. For instance:
The Peer-reviewed Cancer Research Program funded investigators that
confirmed the idea that Ultra Violet DNA damage occurs long after
exposure due to the creation of lesions at the molecular level,
resulting from exposure to the sun and damage of melanin in the skin
layers.
The Prostate Cancer (PC) Research Program established the PC
Clinical Trials Consortium (PCCTC) to support the collaborations and
resources necessary to rapidly execute Phase II or Phase I/II clinical
trials of therapeutic agents or approaches for the management or
treatment of prostate cancer. As of 2013, the PCCTC accrued over 3,500
PC patients to more than 80 phase I/II clinical trials studying more
than 50 drugs. The PCCTC rapidly advanced 9 therapeutic candidates to
phase- III clinical testing, including 2 FDA approved drugs, Zytiga
and Xtandi, which have become standard of care for the treatment of
advanced PC.
The Breast Cancer Research Program (BCRP) funded a project that
created a test that can detect metastatic breast cancer (BC) with
efficiency better than any test currently used. This test will allow
for the monitoring of patients response to treatments and for
appropriate change of course by physicians to avoid ineffective,
unnecessary therapies.
BCRP also funded a project that demonstrated estrogen receptor
positive (ER+) BC is sensitive to a cyclin-dependent kinase inhibitor,
in combination with hormonal therapy. This combination therapy provides
improvement in progression-free survival. FDA granted accelerated
approval in February 2015 under the trade name Ibrance. If ongoing
phase-III trials confirms it benefits, Ibrance can become a new
standard of care therapeutic for ER + BC in post-menopausal women.
For more CDMRP information, please visit http://cdmrp.army.mil/
search.aspx.
Question. The coordination between the University of Mississippi
and Walter Reed's Army Institute of Research is an example of a strong
partnership between the Department of Defense and academic research
labs for addressing tough problems like malaria prevention and
treatment. Do you believe the side effects of drugs used for malaria
are limiting their safe and effective use in some troop populations? If
so, what efforts are being made by the Department of Defense to develop
new, safer drugs to reduce side effects?
Answer. Yes, the undesirable side effects of malaria and leishmania
drugs directly impact their use for both disease prevention and
treatment by Service Members. FDA-approved drugs currently available
for prevention include mefloquine, doxycycline, and atovaquone/
proguanil and they each have different side effect profiles. Mefloquine
was once widely used to prevent malaria infection in troops. It now has
a black box label warning of potentially debilitating neurologic and
psychiatric side effects. Doxycycline can cause increased sensitivity
to sunburn and gastrointestinal upset. It also interacts with common
medications such as oral contraceptives. Atovaquone/proguanil, while
the least toxic, must be taken daily to be effective. Military
personnel returning from Afghanistan are treated for two weeks with the
drug primaquine to clear Plasmodium vivax malaria, a relapsing form of
the disease, from the liver. One percent of the military, 10 percent of
African American males, carry a genetic defect and cannot take
primaquine because they experience hemolysis during its use.
Miltefosine is an approved oral drug with 70 percent efficacy against
leishmaniasis, however its use is limited by gastrointestinal and
reproductive toxicity.
To develop new drugs, the DOD program has established unique assays
and screens to evaluate the safety and efficacy of all new drugs for
malaria and leishmaniasis. These capabilities do not exist in the
commercial market, thus DOD researchers are uniquely positioned to
target safety concerns borne out from years of experience developing
anti-parasitic drugs. DOD researchers at the Walter Reed Army Institute
of Research (WRAIR) and the Navy Medical Research Center, funded by the
Military Infectious Diseases Research Program (MIDRP), are currently
conducting studies specifically targeted toward the development of
newer and safer drugs for the prevention of malaria.
The University of Mississippi has a long history working with the
WRAIR. One example was formed in 2008 where the WRAIR, the University
of Mississippi and the State University of New York Upstate Medical
University, Syracuse formed the Non-Hemolytic 8-AQ Consortium, focused
on improving the safety and efficacy of drugs like primaquine, the only
FDA approved drug effective against relapsing malarias found in
Afghanistan, Southeast Asia, and Korea. The consortium has also
determined that up to 10 percent of humans are unable to properly
convert primaquine into a form active against relapsing malarias.
Studies are underway to develop new drugs which overcome this
particular metabolic deficit and which will be broadly active and safe
in all populations. The consortium has also reformulated primaquine
into a form demonstrating reduced hemolysis in animal models. Clinical
trials with this new primaquine formulation will soon be undertaken to
assess its safety profile in genetically deficient human populations.
These advances by WRAIR and their multiple academic partners can
now inform both new drug development campaigns to overcome these
liabilities and clinical practice to ensure that the right drugs are
selected for the right populations to treat and ultimately eradicate
malaria.
Question. Traumatic Brain Injury is a major concern for this
subcommittee, and I believe that we should continue to pay 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 pneumatic 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?
Answer. The Army is committed to protecting the force from
traumatic brain injury through improved training, equipment, and
understanding of the mechanism of injury. The cost of treating
Traumatic Brain Injury (TBI) varies greatly depending on the severity
of the injury as well as other factors. With prompt identification,
medical evaluation, education and prescribed rest, most concussions,
also known as mild TBI (mTBI), will resolve without significant lasting
symptoms. However, a small percentage may have ongoing symptoms
including but not limited to headache, balance issues, fatigue, poor
concentration, depression and other psychological symptoms that benefit
from targeted medical, behavioral health and rehabilitation
intervention. Army Medicine spent approximately $52 million in fiscal
year 2014 on specialty care for all severities of TBI, from mild to
severe; education and training efforts; and improved tracking and
surveillance of TBI. The long term Army TBI care costs for those with
ongoing symptoms, those who require intensive outpatient programs,
those who leave the military, or those who transition to the VA are yet
undefined as a whole.
We do not know the total cost over time of researching, developing,
fielding and sustaining personal protective equipment (PPE) for either
the reduction of risk of events that can cause TBI, or the severity of
injuries that occur. The cost of developing, researching and procuring
(PPE) is spread across equipment development mission space, where
medical research informs the process. As TBI is caused by a blow or
jolt to the head, and is associated with not only impact but also
linear and rotational acceleration forces on the head, PPE is unlikely
to eliminate completely the risk of internal shaking and shearing of
brain tissue. However, the Army will continue to research and develop
equipment and technologies towards the goals of improved effectiveness
of PPE and reduced risk for our Soldiers.
______
Question Submitted by Senator Roy Blunt
Question. LTG Horoho, you stated in the Defense Health Hearing that
the General Leonard Wood Army Community Hospital (GLWACH) is back on
the Army's Program Objective Memorandum (POM) for fiscal year 2017-
2021. With recent Army hospitals costing anywhere from $404 million at
Ft. Riley to $1.03 billion at Ft. Belvoir, it seems the $210.9 million
currently on the Future Years Defense Program (FYDP) for Army medical
facility replacements makes a hospital replacement nearly
inconceivable. Considering other services' medical MILCON priorities
and the looming threat of sequestration, how likely is it the GLWACH
will actually make it onto the fiscal year 2017 FYDP? What is the
timeframe when GLWACH will no longer be suitable as a facility?
Answer. The Defense Health Agency received senior Military Health
System (MHS) leadership concurrence to place the first $100 million
increment (of an estimated $540 million project cost) of the GLWACH
Hospital Replacement project in fiscal year 2021. The Army is
reasonably certain that the first increment of the GLWACH Hospital
Replacement project will remain in the fiscal year 2017-2021 FYDP. The
project will compete in the next round of the Defense Health Program
(DHP) Medical MILCON Capital Investment Decision Model (CIDM) process
to determine MHS priority and incremental funding profile. Future
fiscal impacts (e.g. sequestration or other funding constraints) could
affect the outcome of CIDM. The estimated project cost of $540 million
must be incremented over 2-3 fiscal years in order for the DHP medical
MILCON program to stay within its projected total obligation authority.
MEDCOM and the GLWACH staff are committed to ensuring the safety
and providing the best care to our patients and staff, regardless of
the age of our facilities. Until a facility replacement project is
completed, the MEDCOM will incur higher facility life-cycle costs
associated with maintaining and sustaining this 50-year old facility.
MEDCOM has completed and continues to enact numerous alteration and
addition projects to address some of the changes in healthcare delivery
and population increases over the lifespan of the facility. However,
the integrity of the original facility and many of its systems are
failing. Recent repair projects focused on the Mechanical, Electrical,
Plumbing (MEP) systems and Air Handling Units (AHUs).
______
Questions Submitted by Senator Richard J. Durbin
Question. A 2011 Department of Defense (DOD) study found that the
prevalence of smoking is higher in the military (24 percent) than the
general adult population (20 percent), and that the availability of
cigarettes on military installations made it easier to smoke. A 2008
Department of Defense (DOD) study found that almost one in three
military smokers began doing so after enlisting. Service members who
use tobacco are more likely to drop out of basic training, and sustain
injuries. In 2008, smoking among active-duty members cost the
Department more than $1.6 billion annually in smoking-related medical
care, increased hospitalization, and lost days of work. In addition,
the Navy is actively looking at banning tobacco sales on ships and
bases, and the other services are considering it. Last year, this
committee ended the taxpayer subsidy on tobacco sold at military
commissaries.
Do each of you agree that smoking has an adverse impact on service
members' health and on individual military readiness?
Answer. Yes, smoking has an adverse impact on Service-members'
health and readiness. Past and present science demonstrates the
irrefutable negative impact of smoking on every organ in the human
body. Quitting smoking is the single most important action that a
current smoker will take to improve their health and the length and
quality of their life. Tobacco use and its negative impact are found to
be more strongly related to combat readiness than other health issues.
Tobacco use among Service members has several negative impacts.
Injured Soldiers who use tobacco are predisposed to a prolonged return
to duty time, degrading the unit's combat readiness. A strong
association exists between tobacco addiction and mental health
diagnoses, mood disorders, and substance abuse. Also, tobacco use
compromises dental health and contributes to medically non-ready
Soldiers due to non-deployable dental classifications. Finally,
Soldiers who smoke have significantly lower levels of physical fitness
and are at increased risk for training injuries.
Question. Reducing tobacco use in the military would seem to be a
win-win. Not only would it save lives, but it would also improve short-
term readiness and save each service annual tobacco-related healthcare
costs. Are the Surgeons General pursuing specific actions to curb
tobacco use?
Answer. Ten Army military treatment facilities (MTFs) established
Tobacco-free campus policies in support of TSG's vision. These policies
address support for improving tobacco cessation access to care through
increasing utilization of the TRICARE Quitline, Chantix, and
availability of nicotine replacement therapy. Moreover, the Army offers
tobacco cessation/counseling in Army Medical Homes, as well as
leveraging technology in the Army Wellness Centers to educate clients
on the availability of live chat quit tobacco access, and tobacco
cessation text support programs, which reaches into the life space
where people live, work, and play.
U.S. Army Public Health Command (USAPHC), Army Institute of Public
Health (AIPH), Health Promotion and Wellness Portfolio, completed a 12
month evaluation of the Fort Stewart/Hunter Army Airfield Tobacco-free
medical campus policy. This policy primarily focused on extending the
tobacco free campus and did not establish a tobacco free workforce. The
evaluation of the first Army tobacco free medical campus showed that
employees experienced significant reductions in secondhand smoke
exposure after the implementation of the policy. AIPH incorporated the
lessons learned and evaluation results to inform the U.S. Army MEDCOM's
Tobacco Free Living policy, tool kit, and Tobacco Free Living
implementation document.
In an effort to protect our workforce from tobacco-related risks,
we are expanding this policy across medical campuses Army-wide and
adding the stipulation that employees cannot use tobacco while on duty.
In addition, the Army is preparing to release a revised Army Regulation
600-63 (Army Health Promotion) which details several tobacco reduction
initiatives. This revised regulation is expected to be published in the
next 60 days.
Question. There are indications that the real cost of tobacco may
be higher than the $1.6 billion estimated in the 2008 study. Does the
panel believe it would be useful for Congress to direct an updated
study, which can also assess the impact of policy changes such as
eliminating the subsidy for tobacco and the ban on smoking on
submarines?
Answer. There is reason to believe the costs of tobacco-related
healthcare and other costs may certainly be higher than previous
estimates, particularly if we include issues related to third-hand
smoke exposure. We believe that current policies (e.g., the lower
tobacco pricing on military bases) are likely associated with (1)
impaired troop readiness, (2) increased tobacco product usage, (3)
increased preventable tobacco-related health problems, (4) increased
burden on the DOD healthcare system for treatment and care of Active
Duty Soldiers, Military Families and Veterans affected by smoking (1st,
2nd or 3rd hand smoking), (5) increased costs to the DOD with less
productive Soldiers (due to chronic illnesses caused by tobacco usage),
and (6) decreased workforce productivity. Should Congress direct
another study into the costs of tobacco use in the military, we would
like to see an examination of tobacco-related costs associated with
each of these areas. We'd also like to determine if any differences in
these areas exist based on military tobacco policy changes.
______
Questions Submitted by Senator Brian Schatz
Question. DOD's medical mission is critical to our national defense
and ensuring the health of the all-volunteer force. We have an
important responsibility to protect the health and well-being of all of
those in the DOD's care--servicemen, women, civilians, and their
families. Our responsibility to provide that care extends to those who
are deployed and to those at home. One of the challenges that DOD is
continuing to grapple with is promoting access to mental health. I know
the Department is working hard to reduce and eventually eliminate the
stigma associated with mental health treatment so that more servicemen
and women will avail themselves of the programs that have been setup to
help them confront the trauma and stresses of war. In my view,
eliminating this stigma is critical to giving servicemembers and
deployed civilians the resolve they need to take advantage of the care
they need to become whole again, and there is still work that needs to
be done.
Can you give me your views on what you see are the major hurdles to
eliminating the stigma associated with mental health treatment, and how
this budget request programs funds to help overcome those hurdles?
Answer. Army Medicine has made significant strides in overcoming
the hurdles of stigma associated with seeking behavioral healthcare
through a number of efforts. Embedded Behavioral Health (EBH) and BH
providers within primary care clinics were specifically designed to
improve access to care by increasing the number of potential touch
points through which Soldiers can initiate care. From fiscal year 2007
to fiscal year 2014, outpatient BH encounters increased from 900
thousand to 2.1 million. This has allowed the Army to provide care to
Soldiers earlier in the course of their BH condition, before crisis
occurs.
EBH, which embeds behavioral health providers within Army units,
has significantly increased behavioral health visits and enhanced the
communication between Commanders and behavioral health providers. In
addition, having behavioral health providers available during sick call
and routine medical appointments has also improved access to care.
PB16 allows Army medicine to successfully meet the ongoing high
demand for acute BH appointments. This funding supports the plan of
Army-wide implementation of EBH by September 2016. By reducing the
distance between the Soldier, leaders, and the behavioral health
provider, we have made progress in reducing the stigma barrier.
Question. The Department of Defense possesses one of the Nation's
treasured institutions, the Uniformed Services University of the Health
Sciences, which educates the next generation of Army, Air Force, Navy,
and Public Health Service healthcare leaders and providers. I am
interested in hearing the perspective of the Surgeons General regarding
the value of the University and its graduates to the medical, nursing,
and dental corps of the DOD and the Nation as a whole.
Can you offer some thoughts on the value that USUHS provides to the
Military Health System and the Nation?
Answer. Thank you for the opportunity to highlight the exceptional
value of the Uniformed Services University of Health Sciences (USU) to
the Army. USU trains physician, nursing, and dental students through a
rigorous healthcare education combined with equally rigorous training
in leadership, military medicine and public health. Within the F.
Edward Hebert School of Medicine, Daniel K. Inouye Graduate School of
Nursing, and the Postgraduate Dental College, students learn in a
variety of settings, including modern classrooms and laboratories, a
world-renowned simulation center, major military hospitals and clinics
stretching from Bethesda to Honolulu, summer operational experiences
with military units, and highly demanding field exercises in order to
prepare them to be outstanding clinicians and superb Army officers.
Graduates leave USU as prepared, career-committed Army medical officers
who are ready to perform in any setting, from a modern tertiary care
hospital or primary care clinic to an operating room in a combat
support hospital or a treatment tent in a refugee camp.
USU has graduated nearly 2,000 Army physicians, nurses, and
dentists whose leadership and military unique training from the
University have served the AMEDD extraordinarily well. Presently, 26
percent of the Army Medical Corps are graduates of USU. These officers
are more likely to assume major leadership positions, and in fact,
comprise 40 percent of the current cadre of Army Medical Corps
Colonels, with significantly higher levels of retention until
retirement and forming the backbone of experience and leadership at
senior levels. The Deputy Surgeon General is a USU graduate, and there
are a number of current and former flag officers who are USU graduates.
USUHS provides the Army Nurse Corps (ANC) with opportunities for
its officers to obtain degrees at all levels from a Masters in Nursing
(MSN) to a clinical (DNP) or research nursing doctorate (PhD), allowing
our personnel to pursue excellence in academics, scholarship and
research. Since the ANC began enrolling personnel into the USUHS
program in 1993, there have been nearly 1300 degrees conferred in these
specialties: Master of Science in Nursing (636), Certified Registered
Nurse Anesthesia (298), Family Nurse Practitioner (261), Perioperative
Clinical Nurse Specialist (55), Psychiatric Mental Health Nurse
Practitioner (22), and Doctor of Philosophy in Nursing Science (20).
Each program's curriculum is designed with the military student in
mind, ensuring they train in an environment that fully develops them in
their role as an Army Nurse. The USUHS Anesthesia Nursing program is
ranked 5th according to U.S. News and World Report 2015 ranking of best
anesthesia nursing programs and 41st amongst all Graduate Nursing
programs in the United States.
Question. Can you please speak specifically to what the Army is
doing to align medical personnel training and certification to align
with civilian standards to make it easier for these soldiers to
eventually transition to civilian careers?
Answer. The Academy of Health Sciences (AHS), as part of the U.S.
Army Medical Department Center and School (AMEDDC&S), aligns medical
military training/medical certification with civilian standards,
allowing for Soldiers to eventually transition to civilian careers.
All Army officers are required to enter the Army with a civilian
degree. The additional officer clinical/medical training conducted
builds on the initial entry degree and meets or exceeds civilian
standards. This is accomplished through affiliations with various
universities for the respective Areas of Concentration (AOC) for
officers. For example, the AHS, AMEDDC&S, prepares Army officers in the
70A (Health Care Administrator) AOC to graduate with a Master's Degree
in Healthcare Administration from Baylor University and subsequently
certify with one of several civilian healthcare administration
professional affiliations/societies.
There are only two enlisted medical Military Occupational
Specialties (MOS) that require Soldiers to hold a credential in order
to graduate from Advanced Individual Training (AIT) and become MOS
Qualified (MOSQ). These are 68C, Practical Nursing Specialist (Licensed
Practical Nurse), and the 68W, Healthcare Specialist (Combat Medic).
Licensed Practical Nurses receive the National Council of State Boards
of Nursing Licensure, and Combat Medics receive the National Registry
of Emergency Medical Technician (NREMT) while in military training.
Additionally, the following military medical MOSs and Additional
Skill Identifiers (ASI) require Soldiers to sit for their certification
prior to graduating from AIT or advanced schooling: 68KM2: Cytology
(Cytotechnologist); 68V: Respiratory Specialist; 68WF2: Flight
Paramedic.
The following military medical MOSs and ASIs allow for Soldiers to
sit for their certification prior to graduating, or at their follow on
duty station, once all credentialing requirements are met: 68A:
Biomedical Maintenance Specialists; 68B: Orthopedic Specialist; 68D:
Operating Room Specialist; 68E: Dental Specialist; 68F: Physical
Therapy Specialist; 68G: Patient Administration Specialist; 68H:
Optical Laboratory Specialist; 68J: Medical Logistics Specialist; 68K:
Medical Laboratory Specialist; 68L: Occupational Therapy Specialist;
68M: Nutrition Care Specialist; 68N: Cardiovascular Specialist; 68P:
Radiology Specialist; 68Q: Pharmacy Specialist; 68R: Veterinary Food
Inspection Specialist; 68S: Preventive Medicine Specialist; 68T: Animal
Care Specialist; 68U: Ear, Nose and Throat Specialist; 68Y: Eye
Specialist.
All of the Army medical MOSs have a degree plan through an approved
Service Members Opportunity Colleges (SOC). In addition, many MOSs have
a direct Memorandum of Understanding established with an individual
college/university which have validated their programs. Recently, the
National American University was added to the SOC for the 68W MOS
(Combat Medic), awarding on average 45-60 credit hours towards an
Associate of Applied Science in Emergency Medical Services, Bachelor of
Applied Science in Management.
______
Questions Submitted to Vice Admiral Matthew Nathan
Question Submitted by Senator Thad Cochran
Question. Do you believe the side effects of the drugs for malaria
and leishmaniasis are limiting their safe and effective use in some
troop populations? What efforts are being made by the Department of
Defense toward the development of newer, safer drugs or toward reducing
the side effects of existing drugs? Has the University of Mississippi/
Walter Reed Army Institute of Research program produced a strong
partnership between DOD and academic research labs for addressing these
problems? Is this partnership effectively identifying alternative
therapies and developing solutions to reduce the severe side effects of
the existing malaria and leishmaniasis drugs?
Answer. The undesirable side effects of malaria drugs directly
impact use of both malaria chemoprophylaxis (drugs used to prevent
disease) and treatment. FDA-approved drugs currently available for
chemoprophylaxis include mefloquine, doxycycline, and atovaquone/
proguanil. Mefloquine was once widely used to prevent malaria infection
in troops. It now has a black box label warning of potentially
debilitating neurologic and psychiatric side effects. Doxycycline can
cause increased sensitivity to sunburn and gastrointestinal upset. It
additionally interacts with common medications such as oral
contraceptives. Atovaquone/proguanil, while the least toxic, must be
taken daily to be effective.
Military personnel returning from Afghanistan are treated with 2
weeks of the drug primaquine to clear Plasmodium vivax malaria, a
relapsing form of the disease, from the liver. Individuals (1 percent
of the military, 10 percent of African American males) are genetically
deficient in G6PD (Glucose-6-Phosphate Dehydrogenase) and cannot take
primaquine because they experience hemolysis during its use. Another
approved oral drug, miltefosine, has 70 percent efficacy against
leishmaniasis; however, its use is limited by gastrointestinal and
reproductive toxicity.
DOD researchers, funded by the Military Infectious Diseases
Research Program (MIDRP) at WRAIR/Naval Medicine Research Center (NMRC)
in Silver Spring, MD, are currently conducting studies specifically
targeted toward the development of newer and safer drugs for the
prevention of malaria. The DOD program has established unique assays
and screens to evaluate the safety and efficacy of all new drugs for
malaria and leishmaniasis. These capabilities do not exist in the
commercial market, thus DOD researchers are uniquely positioned to
target safety concerns borne out from years of experience developing
anti-parasitic drugs.
WRAIR has maintained a long and productive relationship with the
University of Mississippi and other academic institutions to discover,
design, and develop newer and safer anti-parasitic drugs required for
military use but with little commercial value. The collaboration
described here among scientists from WRAIR, University of Mississippi
and SUNY Upstate Medical Center, Syracuse was formed in 2008 as the The
Non-Hemolytic 8-AQ Consortium. It is focused on improving the safety
and efficacy of 8-aminoquinoline drugs like primaquine, the only FDA
approved drug effective against relapsing malarias found in
Afghanistan, Southeast Asia, and Korea.
The consortium has reformulated primaquine into a form
demonstrating reduced hemolysis in animal models of G6PD. Clinical
trials with this new primaquine formulation will soon be undertaken to
assess its safety profile in G6PD deficient human populations. The
consortium has also determined that potentially 10 percent of humans
are unable to properly convert primaquine into a form active against
relapsing malarias. Studies are underway to develop new 8-
aminoquinolines which overcome this particular metabolic deficit and
which will be broadly active and safe in all populations.
These advances by WRAIR and their academic partners can now inform
both new drug development campaigns to overcome these liabilities and
clinical practice to ensure that the right drugs are selected for the
right populations to treat and ultimately eradicate malaria.
______
Questions Submitted by Senator Richard J. Durbin
Question. A 2011 Department of Defense (DOD) study found that the
prevalence of smoking is higher in the military (24 percent) than the
general adult population (20 percent), and that the availability of
cigarettes on military installations made it easier to smoke. A 2008
Department of Defense (DOD) study found that almost one in three
military smokers began doing so after enlisting. Service members who
use tobacco are more likely to drop out of basic training, and sustain
injuries. In 2008, smoking among active-duty members cost the
Department more than $1.6 billion annually in smoking-related medical
care, increased hospitalization, and lost days of work. In addition,
the Navy is actively looking at banning tobacco sales on ships and
bases, and the other services are considering it. Last year, this
committee ended the taxpayer subsidy on tobacco sold at military
commissaries.
Do each of you agree that smoking has an adverse impact on service
members' health and on individual military readiness?
Answer. I concur that smoking can adversely impact the health and
readiness of our force.
Question. Reducing tobacco use in the military would seem to be a
win-win. Not only would it save lives, but it would also improve short-
term readiness and save each service annual tobacco-related healthcare
costs. Are the Surgeons General pursuing specific actions to curb
tobacco use?
Answer. Navy Medicine encourages tobacco free living, promotes
tobacco free medical campuses and deglamorizes tobacco use as part of
its overarching health promotion programs. Our Medical Inspector
General inspects comprehensive tobacco control programming provided by
Navy Medicine. Inspection items include tobacco cessation programs,
policy and enforcement of tobacco use areas, and clinical practices
such as screening, diagnosing and treating tobacco use.
Nicotine Replacement Therapies approved by the Food and Drug
Administration have been made available to assigned service members
aboard all ships, in all base clinics and pharmacies, and Battalion Aid
Stations at no cost to the member since September 2012 and to family
members via TRICARE in April 2013. Navy Medicine uses the evidence
based Veterans Administration/Department of Defense Management of
Tobacco Use Clinical Practice Guidelines for addressing and treating
tobacco in Primary Care, Medical Home Port and Specialty Clinics. This
clinical process is assessed through the use of metrics with the
Population Health Navigator Dashboard.
Question. There are indications that the real cost of tobacco may
be higher than the $1.6 billion estimated in the 2008 study. Does the
panel believe it would be useful for Congress to direct an updated
study, which can also assess the impact of policy changes such as
eliminating the subsidy for tobacco and the ban on smoking on
submarines?
Answer. Our Nation has over 50 years of overwhelming evidence of
the impact of tobacco use and disease, disability and death.
Additionally, there is scientific evidence and research-tested
interventions to reduce tobacco use and secondhand smoke exposure. I
believe we should direct our efforts to on-going general health and
readiness surveillance which includes self-reported tobacco use in the
electronic health record and health risk assessments. An updated study
is not recommended that this time.
______
Questions Submitted by Senator Brian Schatz
Question. DOD's medical mission is critical to our national defense
and ensuring the health of the all-volunteer force. We have an
important responsibility to protect the health and well-being of all of
those in the DOD's care--servicemen, women, civilians, and their
families. Our responsibility to provide that care extends to those who
are deployed and to those at home. One of the challenges that DOD is
continuing to grapple with is promoting access to mental health. I know
the Department is working hard to reduce and eventually eliminate the
stigma associated with mental health treatment so that more servicemen
and women will avail themselves of the programs that have been setup to
help them confront the trauma and stresses of war. In my view,
eliminating this stigma is critical to giving service members and
deployed civilians the resolve they need to take advantage of the care
they need to become whole again, and there is still work that needs to
be done.
Can you give me your views on what you see are the major hurdles to
eliminating the stigma associated with mental health treatment, and how
this budget request programs funds to help overcome those hurdles?
Answer. One of the major factors in the perpetuation of stigma is
the misperception among service members that seeking mental health
treatment or receiving such treatment will cause harm to their careers
or invite disapproval from the chain of command. While certain mental
health conditions do pose a bar to deployment or continued service,
most do not. A more accurate message is that untreated mental illness
is much more of a threat to career progression and mission
accomplishment than receiving effective mental health treatment, and
that the act of seeking treatment is a sign of strength, not weakness.
This approach, which emphasizes that treatment can help, rather than
hurt, a career, can diminish the stigma associated with seeking mental
healthcare.
Several Navy Medicine programs also have an anti-stigma component.
The utilization of embedded mental health providers within operational
units allows for the early identification and management of mental
health issues, while reducing many of the barriers to seeking care. The
Behavioral Health Integration Program (BHIP) employs a similar strategy
by integrating behavioral health providers into primary care clinics.
The early identification of mental health needs in a primary care
environment serves to normalize mental health treatment as an essential
part of healthcare, while increasing access and reducing the barriers
to seeking care.
Question. The Department of Defense possesses one of the Nation's
treasured institutions, the Uniformed Services University of the Health
Sciences, which educates the next generation of Army, Air Force, Navy,
and Public Health Service healthcare leaders and providers. I am
interested in hearing the perspective of the Surgeons General regarding
the value of the University and its graduates to the medical, nursing,
and dental corps of the DOD and the Nation as a whole.
Can you offer some thoughts on the value that USUHS provides to the
Military Health System and the Nation?
Answer. Navy Medicine values graduates from USUHS as an important
pipeline for generating physicians and leaders. These graduates
comprise a segment of all military physicians who understand the
dynamic military environment and the diverse settings in which they
will be expected to lead people and practice medicine. Developing that
combination of valuable qualities cannot be accomplished with the same
consistency and efficiency in the civilian sector. Having a core group
of physicians with that training background provides an element of
stability to the Military Health System. Overall, graduates from USUHS
continue on active duty longer than graduates from other accession
sources. As a result of higher continuation rates, USUHS-trained Navy
physicians comprise a significant proportion of Navy Medicine
leadership.
The value of USUHS extends to the entire Navy Medicine enterprise
including Dental Corps (DC), Nurse Corps (NC), and the Medical Service
Corps (MSC). The Naval Postgraduate Dental School is aligned
academically with the Postgraduate Dental College (PDC) at USUHS. The
PDC consists of the Army, Air Force, and Naval Postgraduate Dental
Schools. In addition, USUHS has served as the platform for the three
Services' dental schools to collaborate on efforts related to residency
training and education. Specific areas of advancement include sharing
best practices in resident education, Faculty development, Research
support, Learning Resource Center services, and the elevation of
academic excellence.
The USUHS Graduate School of Nursing (GSN) advanced practice
graduates have a 99.9 percent certification pass rate and the GSN at
USUHS is ranked 41st of over 400 nursing graduate schools in 2015 by
U.S. News and World Reports. In addition, the Certified Registered
Nurse Anesthetist program is consistently ranked as a top 10 National
Program. The Navy MSC sends officers to USUHS for a comprehensive
Clinical and Medical Psychology program, which is relied on by Navy
Medicine to increase and sustain healthy mental health assets. MSC
officers also attend USUHS programs for advanced training in Industrial
Hygiene and Environmental Health, both of which greatly enhance
readiness and force protection for the Navy and Marine Corps.
Question. I had a chance to speak with Secretary Mabus about what
the Navy is doing to ensure we are focusing sufficient resources and
attention to help sailors prepare for when they eventually separate so
that they can put the strongest foot forward. I know the Navy has
started to implement the DOD Military Life Cycle Transition Model so
that we can be proactive with aligning civilian standards long before
sailors intend to separate.
Can you please speak specifically to what the Navy is doing to
align medical personnel training and certification to align with
civilian standards to make it easier for these soldiers to eventually
transition to civilian careers?
Answer. Our Hospital Corpsmen (both Active Duty and Reserve) can
obtain certifications in more than 156 areas based on training and job
skills at no cost to the Sailor and all funded by Navy Credentialing
Opportunities Online (COOL). Since 2007, 4,340 Hospital Corpsmen have
been funded for 6,486 certifications. In addition, I have issued Bureau
of Medicine and Surgery Instruction 1500.23B--Institutional and
Programmatic Accreditation of Medicine Department Enlisted Technical
Education and Training which directs that all training taught by the
Bureau of Medicine and Surgery will maintain program accreditation to
ensure we are teaching to the highest standards and enabling Sailors to
obtain certifications in those programs. There are also 20 programs of
instruction at the joint Medical Education and Training Campus (METC)
in San Antonio and all maintain program accreditation in their
respective fields. This includes the Basic Medic Technician Corpsman
Program (HM A school) which maintains program accreditation in National
Registry for Emergency Medical Technicians.
______
Questions Submitted to Lieutenant General Thomas Travis
Questions Submitted by Senator Thad Cochran
Question. Please describe for the Committee the current and planned
efforts to advance digital pathology practices in the Air Force Medical
Service, and discuss the importance of having a robust digital
pathology network.
Answer. Air Force Telepathology Systems are currently deployed at
six Installations with consultation capability throughout the
enterprise using whole slide imaging. These digital pathology systems
are an integral part of the pathology practice and directly assist with
the delivery of accurate diagnosis and treatment for our patient
population and provide images where pathology specialists are located,
saving shipping and consulting fees. Additionally we are able to
consult with the Joint Pathology Center and Walter Reed National
Military Medical Center providing access to more specialties. Once
primary diagnosis approval is given by the Food and Drug
Administration, the Air Force Medical Service will attain a robust
digital pathology system and experience an annual savings of
approximately $5 million.
Funding is now available to complete deployment for the remaining
five United States Air Force Medical Treatment Facilities with
Pathology capabilities that need to be equipped with Digital Pathology
Systems, which will complete the equipment rollout for the United
States Air Force Regional Telepathology Program. The program is
transitioning to Defense Health Agency Health Information Technology.
The Air Force is the lead in enabling the other services and the
Veterans Administration with the advancement of Telepathology.
Question. One of the recommendations of the Military Compensation
and Retirement Modernization Committee is greater collaboration between
the Department of Defense and Department of Veterans Affairs. How do
you think the Department of Defense and the Department of Veterans
Affairs can better work together to share patient workload among
proximate facilities in order to maximize government resources and
provide patients timely access to quality healthcare? Do you believe
allowing the directors of medical centers to negotiate patient transfer
agreements among themselves might be a good first step to increase
collaboration?
Answer. The Department of Defense and the Department of Veterans
Affairs are already working together to increase collaboration and
share patient workload through efforts at the Health Executive
Committee and many of its work groups. An example would be the efforts
of the Joint Venture/Resource Sharing Work Group where medical
facilities from both agencies in close proximity to each other are
analyzed annually for potential sharing opportunities. Continued
emphasis by the Service Surgeons General and the Department of Veterans
Affairs leadership helps drive additional sharing. Also, continued
Congressional interest in seeing that sharing is a priority along with
continuation of the Joint Incentive Fund program will also keep the
appropriate level of emphasis on the program and drive additional
interest at the local level.
Yes, we agree that allowing the directors and commanders of medical
facilities to negotiate agreements locally is a good first step in
increasing collaboration. The Air Force Surgeon General encourages
Medical Treatment Facility Commanders to share with the Department of
Veteran Affairs medical facilities in their market area and as a
result, more Air Force medical treatment facilities are entering into
agreements or expanding their sharing opportunities with their
Department of Veteran Affairs partners. The agreements are developed
locally and then sent forward to higher headquarters for review and
final approval. Limiting factors, however, will keep sharing to a
minimum at some locations. Limiting factions include the Department of
Veterans Affairs medical facilities lack of capacity to see additional
patients due to inadequate staff or space, and the many Department of
Defense ambulatory care centers that lack specialty care. Where
capacity and need exist sharing agreements are locally negotiated and
approved. The result was that in fiscal year 2014 Air Force medical
treatment facilities saw over 70,000 veteran visits and admissions and
that number is expected to increase in this fiscal year.
______
Questions Submitted by Senator Richard J. Durbin
Question. A 2011 Department of Defense (DOD) study found that the
prevalence of smoking is higher in the military (24 percent) than the
general adult population (20 percent), and that the availability of
cigarettes on military installations made it easier to smoke. A 2008
Department of Defense (DOD) study found that almost one in three
military smokers began doing so after enlisting.Service members who use
tobacco are more likely to drop out of basic training, and sustain
injuries. In 2008, smoking among active-duty members cost the
Department more than $1.6 billion annually in smoking-related medical
care, increased hospitalization, and lost days of work. In addition,
the Navy is actively looking at banning tobacco sales on ships and
bases, and the other services are considering it. Last year, this
committee ended the taxpayer subsidy on tobacco sold at military
commissaries.
Do each of you agree that smoking has an adverse impact on service
members' health and on individual military readiness?
Answer. Yes. The Air Force concurs with the Institute of Medicine's
2009 report Combating Tobacco Use in Military and Veteran Populations,
which detailed the numerous adverse effects of tobacco use on health
and military readiness. Adverse health effects include premature death,
cancer, cardiovascular disease, emphysema, asthma, reproductive health
problems, oral disease--among many well-documented effects. Lesser
appreciated is that tobacco use also causes military-relevant health
problems which impacts mission performance, such as impaired physical
endurance; decreased night vision; hearing loss; impaired cognitive
function from nicotine withdrawal; increased risk of motor vehicle
accidents; increased work absenteeism; increased risk of lower
respiratory infections; impaired wound healing; increased postoperative
complications; and higher risk of periodontal disease (Box 2-1, page
50, IOM Report).
Question. Reducing tobacco use in the military would seem to be a
win-win. Not only would it save lives, but it would also improve short-
term readiness and save each service annual tobacco-related healthcare
costs. Are the Surgeons General pursuing specific actions to curb
tobacco use?
Answer. The Air Force is committed to advancing Comprehensive
Airman Fitness, of which Tobacco Free Living is a critical component.
In March 2015, we updated Air Force Instruction (AFI) 40-102, Tobacco
Free Living, which reinforces Air Force commitment to Tobacco Free
Living: ``Tobacco use degrades Air Force readiness, health, and leads
to preventable healthcare costs. The Air Force discourages the use of
all tobacco products'' (Chapter 1). The updated AFI further advances
tobacco-free environments, which Centers for Disease Control and
Prevention considers a best practice in a comprehensive tobacco control
program, by prohibiting tobacco use in installation recreation
facilities including but not limited to athletic fields, running
tracks, basketball courts, beaches, marinas, and parks, except in
designated tobacco areas. The AFI reinforces that medical campuses are
100 percent tobacco-free. It prohibits special events in Services'
facilities that promote tobacco use, such as ``Cigar Night''. The Air
Force is committed to continuing to lead DOD in promoting Tobacco Free
Living. As evidence of our progress, smoking prevalence among Airmen
has declined 43 percent from 19.7 percent in 2008 to 11.3 percent in
2014.
Question. There are indications that the real cost of tobacco may
be higher than the $1.6 billion estimated in the 2008 study. Does the
panel believe it would be useful for Congress to direct an updated
study, which can also assess the impact of policy changes such as
eliminating the subsidy for tobacco and the ban on smoking on
submarines?
Answer. Yes. A study by Centers for Disease Control researchers
last year (Am J Prev Med 2015; 48:326-33) found that smoking is
responsible for 9 percent of healthcare costs and costs $170 billion
annually in the United States. More than 60 percent of the costs
associated with smoking are borne by Federal health programs. In
addition, smoking exceeds 30 percent of total health expenditures in
non-Medicare, non-Medicaid Federal programs, such as TRICARE and
Veterans Affairs. Extrapolating these updated figures to the Department
of Defense's $50 billion Unified Medical Program would suggest that
tobacco may cost $4.5 billion or higher in preventable healthcare
costs, not including economic losses from lost productivity. Updated
economic analyses of tobacco's impact on the military will help
communicate the imperative to take action on tobacco, and quantify the
healthcare savings that will accrue from more aggressive tobacco
control in the Department of Defense.
______
Questions Submitted by Senator Brian Schatz
Question. DOD's medical mission is critical to our national defense
and ensuring the health of the all-volunteer force. We have an
important responsibility to protect the health and well-being of all of
those in the DOD's care--servicemen, women, civilians, and their
families. Our responsibility to provide that care extends to those who
are deployed and to those at home. One of the challenges that DOD is
continuing to grapple with is promoting access to mental health. I know
the Department is working hard to reduce and eventually eliminate the
stigma associated with mental health treatment so that more servicemen
and women will avail themselves of the programs that have been setup to
help them confront the trauma and stresses of war. In my view,
eliminating this stigma is critical to giving servicemembers and
deployed civilians the resolve they need to take advantage of the care
they need to become whole again, and there is still work that needs to
be done.
Can you give me your views on what you see are the major hurdles to
eliminating the stigma associated with mental health treatment, and how
this budget request programs funds to help overcome those hurdles?
Answer. The Air Force is working diligently to reduce the
perception of stigma associated with mental healthcare. We are making
progress. Every year increasing numbers of Airmen seek care. However,
many Airmen still avoid mental healthcare because they are embarrassed,
or unsure it will be helpful, or because they fear it may hurt their
career. Thus, the primary hurdle is communication: convincing Airmen
that treatment is a sign of strength, that it is effective, and that
seeking care early can save careers. The requested budget allows the
Air Force to continue to fund programs aimed at educating Airmen about
these benefits of early help-seeking. This message is carried in
programs such as our newly revised Suicide Prevention training,
Frontline Supervisor Training, and in organizational activities like
Wingman Days. A second approach is to bring care closer to the
individual in settings that are easier to access. Our integration of
mental health providers into primary care clinics and the embedding of
mental health providers into operations units are two programs that are
examples of that approach.
Question. The Department of Defense possesses one of the Nation's
treasured institutions, the Uniformed Services University of the Health
Sciences, which educates the next generation of Army, Air Force, Navy,
and Public Health Service healthcare leaders and providers. I am
interested in hearing the perspective of the Surgeons General regarding
the value of the University and its graduates to the medical, nursing,
and dental corps of the DOD and the Nation as a whole. I understand
that you are a graduate of the university.
Can you offer some thoughts on the value that USUHS provides to the
Military Health System and the Nation?
Answer. The real strength of the Uniformed Services University of
the Health Sciences (USUHS) is in the creation of future medical
leaders, similar to what occurs at the service academies. The USUHS
educational experience, coupled with a 7 year active duty service
commitment, breeds a medical officer dedicated to the Military Health
System (MHS) and its continued improvement. The graduates of USUHS
perpetuate a culture of service that has lasting implications for the
Military Health System and our Nation. As a testament, graduating a
minority of new Air Force physicians, 16 percent, each year, greater
than 33 percent of physician program directors, medical directors,
commanders and Air Force Medical Service senior Medical Corps leaders
are USUHS graduates.
USUHS provides an opportunity for dental and medical students from
the Army, Navy, and Air Force to take classes together and create
lifelong relationships. These relationships provide a lasting network
for collaboration and are crucial to both in-garrison and deployed
joint environment mission success.
USUHS does more than produce medical doctors, dentists, advance
practice nurse clinicians, scholars and scientists. USUHS prepares its
alumni to function within military treatment facilities, but also to
immediately deploy under austere/combat conditions and provide disaster
and humanitarian assistance. These graduates are prepared to lead and
practice in the unique military and Federal environments, while
contributing to cutting edge research in support of force protection,
military readiness and humanitarian intervention in our Nation's
Federal health systems. The graduates of USUHS have a 99.9 percent
national board certification pass rate and are fully prepared to
perform in a joint environment in any military setting upon graduation;
compared to an additional 3-9 month post-graduation residency period
required for graduates from civilian institutions.
The Graduate School of Nursing (GSN), has the unique ability and
agility to stand-up new academic clinical programs within 12 months
(i.e., psychiatric mental health and women's health practitioner
programs) in response to Services' requests.
USUHS is hosting the Federal Services Dental Educators Workshop
this year with a focus on expanding distance learning opportunities,
residency program resource sharing, dental simulation training and
opportunities for inter-professional education in Health Care. The
faculty has also been invited to participate in working groups bringing
a dental perspective to healthcare initiatives in Global Health and
Inter-professional Education.
Preventive dentistry and force health protection are key facets of
all the affiliated programs. Dental residents are imbued with the
importance of the dental readiness mission. Military Dentistry helps to
ensure that the line force is ``medically'' prepared for deployment.
USUHS is considered the ``gold standard'' for providing world class
medical education. They prepare military medics to successfully execute
the mission of the Department of Defense by providing world class
medical education with a military unique curriculum. USUHS is
accredited by 22 professional/specialized civilian entities.
Question. Can you please speak specifically to what the Air Force
is doing to align medical personnel training and certification to align
with civilian standards to make it easier for these airmen and women to
eventually transition to civilian careers?
Answer. The Department of Defense (DOD) has partnered with the
National Council of State Boards of Nursing as a step toward promoting
the development of bridge programs for current and former military
Medics and Corpsman seeking civilian careers in Nursing.
Additionally, the DOD has also been engaged with the Department of
Labor and the National Governors' Association to design and implement a
licensing and certification demonstration to create accelerated career
pathways for Service members and Veterans in selected civilian
occupations.
Entry level DOD medics are trained at the Medical Education and
Training Campus (METC), in San Antonio, TX. METC maintains programmatic
accreditation for 17 of its training programs and offers academic
credit for all METC courses. In response to increasing civilian
healthcare standards METC is working a pilot to establish degree
requirements for 4 specific medical training courses.
The Enlisted to Medical Degree Preparatory Program (EMDP2) is a
partnership between the Uniformed Services University and Health
Sciences (USUHS) and the Armed Services. This program provides
academically promising enlisted Service members an opportunity to
complete the necessary coursework required to apply for medical school
while remaining on active duty.
The Health Resources and Services Administration (HRSA) partnered
with the American Hospital Association and developed a toolkit that
provides guidance for hospital leaders on hiring Veterans in Advanced
Medical Operations, specifically qualified as licensed practical
nurses, registered nurses, nurse practitioners and physician
assistants. The HRSA also encourages physician assistance programs to
propose strategies to recruit, mentor and retain veterans within the
funding opportunities. The HRSA's National Health Service Corps (NHSC)
offers virtual job fairs in an on-line version of traditional job
fairs; connecting qualified job seeking health professionals with NHSC-
approved sites with open job opportunities.
The Veterans' to Bachelor of Science Degree in Nursing Program
(VBSN) was designed to increase enrollment, progression and graduation
of Veterans from baccalaureate nursing programs. In 2014 HRSA funded 11
new Schools of Nursing in addition to the 9 continuing awarded Schools
of Nursing with VBSN grants for a total of 20 projects. These grant
projects helped by providing a means of awarding academic credit for
prior military healthcare training, a means to assess clinical
competencies, provide mentorship and other support systems which will
equip Veterans to graduate and pass National Council Licensure
Examination.
The Department of Veterans Affairs (VA) has concluded a pilot that
involved assigning Veterans with military experience as medics and
corpsmen as intermediate care technicians (ICTs) in VA hospitals and
clinics. The Indian Health Service (IHS) and the VA are now developing
a Memorandum of Understanding that calls for IHS to hire a specific
number of ICTs by 2016.
The Air Force provides funding through an established process
designed to increase accountability and better manage costs for its
personnel to attend civilian conferences ensuring mission critical
training. Air Force military training facilities also maintain and
pursue needed training affiliation agreements that allow for its
personnel to obtain initial/proficiency training in civilian
institutions that are accredited by State or nationally recognized
entities.
______
Questions Submitted to Christopher A. Miller
Question Submitted by Senator Thad Cochran
Question. Regardless of what new solution is ultimately chosen as
the DOD EHR, the current inpatient electronic health record, Essentris,
is going to be utilized by MHS clinicians until 2022. Is there an
adequate, formal program in place, with clear guidelines for current
technology providers that would allow the current system to have the
advantage of enhanced technologies? Are you aware of enhancements to
the existing system that could be deployed that would improve
interoperability between MTFs and provide a clinician the ability to
access any active or archived patient record around the world? Are
there currently any limitations in law, policy memorandums, or internal
policies that would limit the ability of the program manager to
initiate or work with current providers to allow enhancement of current
capabilities? Are there any funds available within the Department of
Defense for the enhancement and evolution of capabilities in the
interim period between now and the time when DHMSM achieves IOC of its
procured EHR?
Answer. Mr. Miller's area of expertise is the acquisition of a
commercial-off-the-shelf (COTS) Enterprise Electronic Health Record
system, and this question is out of his purview. However, to address
the Senator's question, we asked our colleagues in the Office of the
Under Secretary of Defense for Personnel & Readiness for assistance,
and their response follows:
DOD's acquisition guidelines allow for the evaluation of enhanced
technologies when a need is identified, prioritized through governance,
and then funded. DOD's maintenance of its current EHR system (to
include Essentris) is critical for continuity of healthcare delivery
and operations until DHMS reaches full operational capability with the
new EHR. However, Essentris is maintained as a legacy system under a
sustainment contract using sustainment funds; as such, DOD is limited
to making changes related to identified patient safety issues or
changes in support of prioritized (and funded) System Change Requests
that are processed through governance.
There are no planned enhancements to Essentris. Steps to improve
interoperability have been taken since DOD achieved implementation of
Essentris in April 2011. As of November 2014, DOD improved Essentris'
ability to interface at each site, allowing for cross-site access to
better support real-time inpatient record access and documentation.
There are no legal or policy limits on enhancing legacy health IT
systems. If Essentris were to be modernized and/or upgraded, DOD would
still need to fund the costs associated with training its users on
these upgrades or enhancements, provide for integration testing
(Essentris interfaces with several other DOD systems), ensure DOD
Information Assurance requirements are met, and fund the annual
maintenance costs associated with all new hardware.
Essentris sustainment funding covers license costs and software
maintenance; it does not include development funds for system
enhancements. Any proposed enhancements would need to be approved and
funded through the governance process. Such enhancements would be
outside the scope of the Essentris sustainment contract and would
involve procurement through a different contract.
______
Question Submitted by Senator Roy Blunt
Question. The Department of Defense (DOD) and the National
Institutes of Health (NIH) are successfully partnering to create the
world's first human brain tissue repository for military personnel.
However, it is my understanding that scientific researchers are having
issues accessing post-mortem tissues from service members affected by
blast injury and that there are significant hurdles to gaining access
to these invaluable resources. Therefore, could you provide the
Committee with specific strategies for overcoming roadblocks to post-
mortem brain donation in the military, including consent issues that
are preventing access? How many brains are currently in the brain
tissue repository for military personnel?
Answer. Mr. Miller's area of expertise is the acquisition of a
commercial-off-the-shelf (COTS) Enterprise Electronic Health Record
system, and this question is out of his purview. However, to address
the Senator's question, we asked our colleagues in the Office of the
Under Secretary of Defense for Personnel & Readiness for assistance,
and their response follows:
The Department of Defense (DOD) has initiated a comprehensive
review of the process of obtaining brain specimens from deceased
Service members to better understand the devastating condition of
Traumatic Brain Injury. The Department plans to send the report to
Congress, required by Senate Report 113-211 on the Brain Tissue
Repository, in June, 2015.
______
Questions Submitted by Senator Brian Schatz
Question. I would like to discuss DOD's engagement around global
health. In West Africa, we saw the effects that weak health systems
abroad have on our national security and the implications that it has
for DOD's mission. I think it is important that DOD is working in
support of the President's Global Health Security Agenda to promote
global health as an international security priority. For you--for the
Military Health System--that means meeting the Combatant Commanders'
requirements to work with partners and allies to build their capacity
to manage and respond to local health challenges, and promote regional
stability by increasing access to basic health services. I am
supportive of those efforts. In my view, an ounce of prevention is
worth a pound of cure. But I wonder if we can get more out of our
engagements by being more selective about where we put our resources.
Can you describe how DOD measures its return on investment for
every dollar spent on global health engagement?
Answer. Mr. Miller's area of expertise is the acquisition of a
commercial-off-the-shelf (COTS) Enterprise Electronic Health Record
system, and this question is out of his purview. However, to address
the Senator's question, we asked our colleagues in the Office of the
Under Secretary of Defense for Personnel & Readiness for assistance,
and their response follows:
This is a work in progress. The Assistant Secretary of Defense for
Health Affairs funded a 2-year effort at the Uniformed Services
University of the Health Sciences (USUHS), called the Measures Of
Effectiveness in Defense Engagement and Learning (MODEL), to determine
the value of Global Health Engagement (GHE) activities and to better
inform future investments. MODEL's econometric methodology facilitates
the ability to ask hypothesis-driven ``if then'' questions, using
existing DOD sources like the Overseas Humanitarian Shared Information
System and the Theater Security Management Information System to test
relationships between GHE and desired strategic end-states. We believe
that MODEL has demonstrated the potential to help inform future GHE
investments.
In addition to funding the MODEL program, the Assistant Secretary
of Defense for Health Affairs recently funded a research study to
validate and refine what we currently believe are ``best practices'' in
planning and executing GHE activities. A new interdisciplinary Center
for Global Health Engagement and Department of Global Health at USUHS
will oversee these efforts.
Question. Are there specific metrics that DOD uses to inform how it
develops its global health engagement strategy?
Answer. Mr. Miller's area of expertise is the acquisition of a
commercial-off-the-shelf (COTS) Enterprise Electronic Health Record
system, and this question is out of his purview. However, to address
the Senator's question, we asked our colleagues in the Office of the
Under Secretary of Defense for Personnel & Readiness for assistance,
and their response follows:
Global Health Engagement (GHE) is not a single line of effort but
rather a diverse set of activities derived from and conducted in
support of many distinct programs, each of which is funded by specific
appropriations, under the oversight of one of four Assistant
Secretaries of Defense. These activities fall into three broad areas:
force health protection and readiness, medical stability operations and
partnership engagement, and threat reduction. Collectively, the
activities are valuable ``tools'' within the geographic combatant
command theater campaign plans as a means to partner with host nations
to achieve security cooperation and improve partner nation health
system capabilities and capacities, while simultaneously promoting,
mutual interoperability, regional stability, and improved strategic
access for the United States Government into these nations.
With respect to specific metrics, the Measures Of Effectiveness in
Defense Engagement and Learning (MODEL) has begun to work with
geographic combatant commands to pilot the use of appropriate
strategic, health, and readiness metrics for major GHE activities.
Examples of metrics that have been tested include the State Fragility
Index (to test overall impact of GHE) and Disability Adjusted Life
Years (to test the impact of the Defense HIV AIDS Prevention Program).
The State Fragility Index includes weighted measures including
Security Effectiveness, Security Legitimacy, Political Effectiveness,
Political Legitimacy, Economic Effectiveness, Economic Legitimacy,
Social Effectiveness, and Social Legitimacy. The Effectiveness Measures
produce an Effective Score and Legitimacy Measures are summed into a
Legitimacy Score. Combining both scores yields the State Fragility
Index. MODEL uses the State Fragility Index as a measure of
effectiveness against which DOD GHE level of effort is measured. In
other words, as DOD does more GHE, partner nations become less fragile.
The Disability Adjusted Life Year (DALY) for HIV/AIDS is the sum of
years of life lost and the years lost due to disability for people
living with HIV/AIDS. MODEL uses HIV DALY as a measure of effectiveness
against which DOD GHE level of effort is measured. In other words, as
DOD does more GHE, partner nations will have fewer years of life lost
and fewer years lost due to disability associated with HIV/AIDS.
Question. I want to ask about the Pacific Joint Information
Technology Center on Maui. This is an important program that supports
DOD medical readiness through rapid prototyping and advanced concept
development that directly serves PACOM's requirements and the
warfighter. I understand it is also involved in supporting information
sharing between DOD and the VA. The President's fiscal year 2016 budget
request realigns some of the funding from the research and development
account to operations and maintenance to support the ongoing activities
at the Pacific JITC.
Can you please explain the importance of the Pacific JITC to our
mission in the Pacific?
Answer. Mr. Miller's area of expertise is the acquisition of a
commercial-off-the-shelf (COTS) Enterprise Electronic Health Record
system, and this question is out of his purview. However, to address
the Senator's question, we asked our colleagues in the Office of the
Under Secretary of Defense for Personnel & Readiness for assistance,
and their response follows:
The Pacific Joint Information Technology Center (Pacific JITC) is
the Military Health System's (MHS) research center for joint concept
technology development, prototyping, and piloting of information
management and information technology (IT) products and services to
support Department of Defense (DOD) medical readiness requirements and
IT modernization needs across the continuum of care. Based in Maui,
Hawaii, the mission of Pacific JITC is to rapidly research, test and
develop warfighter medical solutions and products through pilots or
prototypes that provide mission critical value and actionable
information to DOD, including the Services, Combatant Commanders, and
the Department of Veterans Affairs (VA). Pacific JITC provides services
for early-stage research and development. Early piloting allows MHS to
be agile and flexible in determining what IT solution is best, most
cost effective and acceptable to the functional community before a
major acquisition is launched.
Pacific JITC includes an Integrated Test and Evaluation Center
(ITEC) and BioTechnology Hui. Located in Kihei, Hawaii, ITEC is the
first DOD/VA integrated lab to virtualize critical legacy systems. ITEC
provides an agile computing environment that supports military health
and interagency research and development, testing, and evaluation
missions. ITEC offers a state-of-the-art development environment to
test interagency ideas and prototypes, and facilitates innovation
through grants and challenges. ITEC incorporates virtual sandboxes,
creating a tightly controlled environment to run guest programs, and
facilitate Federal, private and public participation. The Biotechnology
Hui, which moved to Pacific JITC in 2011, supports applied research,
development and deployment of telehealth and biotechnology to improve
access and the quality of care to active duty military families and
impacted communities. Research areas include sensor technologies,
regenerative medicine, DOD/VA health information systems
interoperability, and dual use technologies.
Question. Can you please explain how the funds that are being
realigned to the operations and maintenance account will be used to
support the program's mission?
Answer. The reprogramming of fiscal year 2015 funds from RDT&E and
PROC to O&M has been requested to correctly align appropriations and
funding levels based on an evaluation of aligning the VA and DOD's data
exchange efforts with each Department's current EHR program strategy.
Fiscal year 2015 funding appropriated for the Defense Medical
Information Exchange (DMIX) program was based on the initial plan for
the integrated Electronic Heath Record (iEHR) program developed in
2013. This plan included developing substantial IT capabilities for the
exchange of healthcare data between Department of Defense (DOD),
Department of Veterans Affairs (VA), and private sector care providers,
as mandated by the National Defense Authorization Act, 2014. Over the
past year as DOD worked with private industry to develop the new
Request for Proposals, DOD refined the DMIX needs and performed a
detailed technical and cost review of its existing data exchange
systems and determined that streamlining existing systems would
increase data exchange capacity, cost less and provide capabilities
sooner. Based on this detailed technical and cost review, the program
expects to return more than $16 million to higher Defense priorities.
The majority of the O&M funding will be used to pay for hosting
services, license maintenance and leases necessary for the data
exchanges. The current data exchange capabilities were inherited
initiatives from another DHA (Defense Health Agency) IT program which
had been patched and expanded to try and meet current requirements.
After evaluation of the multiple data exchange capabilities that the
DMIX program inherited, a strategy was developed to meet the
interoperability requirements mandated by the fiscal year 2014 NDAA.
One of the key activities is to streamline the number of data exchange
capabilities. The strategy also includes increasing the number of
partners exchanging health data by increasing the number of DOD and VA
users and onboarding additional private eHealth Exchange partners. Both
of these capabilities rely on the data exchange capability in order to
collect the appropriate patient health data to be displayed in a manner
that can be read by healthcare providers from both Departments and
private eHealth Exchange partners. With the increase of eHealth
Exchange partners and number of Department users, there is a need for
additional hosting services and licenses to support the increased user
capacity.
DMIX architecture will also enable the VA interface to exchange
health data from the DOD's Healthcare Management System Modernization
(DHMSM) initiative and enable integration testing with current legacy
healthcare data. The DMIX data exchange capability will bridge the gap
between the legacy EHR systems and the DHMSM system once it goes into
production, and it will continue to be used by DOD as it transitions
from the legacy EHR systems to a modernized EHR. The DMIX interface is
a crucial part of DHMSM's strategy to meet their initial operational
capability (IOC).
SUBCOMMITTEE RECESS
Senator Cochran. We will reconvene on Wednesday, April 15,
at 10:30 a.m. to receive testimony from the Director of
National Intelligence and Under Secretary of Defense for
Intelligence.
Until then, the subcommittee stands in recess.
[Whereupon, at 10:17 a.m., Wednesday, March 25, the
subcommittee was recessed, to reconvene at 10:30 a.m.,
Wednesday, April 15.]