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



                       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


               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 
    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 
    We have a lot to look at in light of this hearing and 
questions today, and I thank the chairman for bringing this 
    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 
    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 
    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 
    Lieutenant General Patricia Horoho, welcome. You may 
proceed with your comments or statement.


    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 
    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 
    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 
    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 
               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 
    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 
    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.
    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 
    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 
    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 
    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 
    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.
    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 
    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 
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 
    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.
    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.
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
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 
    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 
    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 
    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 
    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 
    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 
    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.
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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.
    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 
    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 
    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 
    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 
    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 
    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 
    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.
    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 
    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.
    \1\ ONC, Physician Adoption of Electronic Health Records (http://
    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 
                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 
    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 
    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 
    NIH. Senator Murkowski just joined us and feels 
passionately about the same subject, and certainly in the 
Department of Defense.


    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 
    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 
    Senator Durbin. Thank you, General. Thank you, Mr. 
    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 
    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 
    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 
    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 
    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 
    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.


    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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. 
    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 
    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 
    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 
    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 
    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 

                       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 
    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 
    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 
    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 
    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 
    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 
    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 
    Mr. Miller. No comment, sir.


    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 
    [The following questions were not asked at the hearing, but 
were submitted to the Department for response subsequent to the 
       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 
    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 
    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/
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
              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 
    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 
    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 
    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.]