[Senate Hearing 115-]
[From the U.S. Government Publishing Office]



 
       DEPARTMENT OF DEFENSE APPROPRIATIONS FOR FISCAL YEAR 2018

                              ----------                              


                       WEDNESDAY, MARCH 29, 2017

                                       U.S. Senate,
           Subcommittee of the Committee on Appropriations,
                                                    Washington, DC.
    The subcommittee met at 10:30 a.m., in room SD-192, Dirksen 
Senate Office Building, Hon. Thad Cochran (chairman) presiding.
    Present: Senators Cochran, Shelby, Murkowski, Blunt, 
Daines, Moran, Durbin, Murray, Tester, and Schatz.

                         DEPARTMENT OF DEFENSE

              Defense Health Program and Military Medicine

STATEMENT OF LIEUTENANT GENERAL NADJA Y. WEST, SURGEON 
            GENERAL AND COMMANDING GENERAL, UNITED 
             STATES ARMY MEDICAL COMMAND


               opening statement of senator thad cochran


    Senator Cochran. Good morning. The subcommittee will come 
to order. Today, we are receiving testimony on the Military 
Health System and the medical readiness of our servicemembers.
    We are pleased to welcome to the hearing Lieutenant General 
Nadja West, Surgeon General of the Army, Vice Admiral Forrest 
Faison, Surgeon General of the Navy, Lieutenant General Mark 
Ediger, Surgeon General of the Air Force, and Ms. Stacy 
Cummings, Program Executive Officer of the Defense Healthcare 
Management Systems.
    Our military has made great strides in areas ranging from 
medical research breakthroughs to expedited treatment and 
medical evacuations off the battlefield. We are particularly 
proud of the work performed by the 81st Medical Group flying 
out of Keesler Air Force Base. Guess where that is? Biloxi, 
Mississippi.
    This morning, the committee would like to learn more about 
the Department's progress on implementing the new electronic 
health record system and its integration with the Department of 
Veterans Affairs and private healthcare providers. That is a 
big challenge right there in one sentence.
    We are aware the Department began deployment of its new 
electronic health record system in February at Fairchild Air 
Force Base in Washington. The committee looks forward to 
hearing about the success of this program thus far, and 
understanding its future challenges.
    We appreciate you being here with our committee, and your 
preparation of prepared statements, which will be included in 
the record.
    We applaud your efforts to increase medical readiness and 
provide quality healthcare to our servicemembers, their 
families, and military retirees.
    [The statement follows:]
               Prepared Statement of Senator Thad Cochran
    Good morning, the subcommittee will come to order. Today, we are 
receiving testimony on the military health system and the medical 
readiness of our servicemembers. We are pleased to welcome Lieutenant 
General Nadja West, Surgeon General of the Army; Vice Admiral Forrest 
Faison, Surgeon General of the Navy; Lieutenant General Mark Ediger, 
Surgeon General of the Air Force; and Ms. Stacy Cummings, Program 
Executive Officer of the Defense Healthcare Management Systems.
    Our military has made great strides in areas ranging from medical 
research breakthroughs to expedited treatment and medical evacuations 
off the battlefield. We are particularly proud of the work performed by 
the 81st Medical Group flying out of Keesler Air Force Base.
    This morning, the Committee would like to learn more about the 
Department's progress on implementing its new electronic health record 
system, and its integration with the Department of Veterans Affairs and 
private healthcare providers.
    We are aware the Department began deployment of its new electronic 
health record system in February at Fairchild Air Force Base in 
Washington. The Committee looks forward to hearing about the success of 
this program thus far, and to understanding its future challenges.
    We appreciate your testimony today and applaud your efforts to 
increase medical readiness and provide quality healthcare to our 
service members, their families, and military retirees.
    Now I turn to the Vice Chairman, Senator Durbin, for his opening 
remarks.

    Senator Cochran. I now turn to the distinguished Vice 
Chairman, Senator Durbin, for his opening remarks.

                 STATEMENT OF SENATOR RICHARD J. DURBIN

    Senator Durbin. Thanks, Mr. Chairman. I am pleased to join 
you in welcoming our witnesses to our hearing on the Department 
of Defense Health Programs.
    DOD (Department of Defense) health readiness is a critical 
part of our overall readiness. There can be no doubt that the 
most valuable resource in our military is the men and women who 
serve. They make a tremendous sacrifice. Our job is to ensure 
that DOD and the Services are resourced to meet the medical 
needs of our Service men and women, at home and while they are 
deployed.
    This includes facilities, technology, agility to respond 
quickly to a wide array of contingencies, but the goal is 
always the same. Before the men and women of the Armed Forces 
can fight for this country, they must be fit to deploy.
    From the outlines of its fiscal year 2018 budget, the new 
Administration is very concerned about augmenting the hard 
power of our military. Let us not lose sight of the soft power 
resources that are also critically important.
    In recent years, we have seen the use of defense health 
care around the world to great effect. It is reflected in many 
ways, from rushing doctors, nurses, and medics to far away 
countries suffering from natural disasters, to smaller 
engagements with friendly countries to increase their medical 
capacity. We need to remember this as we receive and consider 
the fiscal year 2018 budget.
    While we often hear about the challenges in the Military 
Health System, I believe we also need to celebrate today its 
successes. Chief among these is the fact that our combat 
survival rate for American forces has never been higher. That 
speaks to the innovation in each of the Services to meet the 
evolving challenges of the battlefield.
    It also means we must continue research in fields such as 
combat casualty care and infectious disease. As you know, DOD 
medical research is one of my top priorities.
    With Chairman Cochran's great support, and my Senate 
colleagues as well, we have increased research funding over 32 
percent over the last 4 years. This is important because as 
more of our soldiers, sailors, marines, and airmen survive 
their injuries, their needs from the Military Health System 
have been evolving.
    The funding Congress adds each year to the defense bill 
includes support for a range of medical research, from modern 
prosthetics to more effective treatments for traumatic brain 
injury.
    My colleague, Tammy Duckworth, a new Senator from Illinois, 
who served this country so well, brought home the scars of war, 
and she has been a frequent beneficiary of the good research 
that has been done on prosthetic devices. It is nothing short 
of amazing what she has been able to do to recover and become a 
full member of the United States Senate.
    Breakthroughs in these fields are improving the quality of 
life of our servicemembers after the fight, which is part of 
our responsibility as well.
    Let me bring up an issue where I think we can do better. 
Overall individual health is a key component of military 
readiness. This includes encouraging healthy lifestyles that 
reduce missed time due to illness and injury while promoting 
faster recuperation.
    Further curbing the use of tobacco in the military is a 
prime way to accomplish these goals, and one of my top 
priorities. We have realized that across the healthcare systems 
of America. I do not see that reflected in the Department of 
Defense policy, and I will ask specific questions.
    It saves money. Ensures a healthy force, but it is 
frustrating to hear that bureaucratic red tape is holding back 
progress on this tobacco issue. I would like to hear from the 
Surgeon Generals about their ongoing efforts to reduce tobacco 
use.
    We have a lot to discuss, including proposed significant 
changes to the Military Health System, TRICARE, and the roll 
out of new electronic healthcare records.
    I want to thank each and every one of you for your service 
to our country and your efforts to better the lives of the 
personnel we have entrusted to your care. It is an essential 
part of maintaining a ready force.
    Thank you, Mr. Chairman.
    [The statement follows:]
            Prepared Statement of Senator Richard J. Durbin
    Mr. Chairman, I am pleased to join you in welcoming our witnesses 
to our hearing on the Department of Defense health programs.
                            health readiness
    DoD health readiness is a critical part of our overall readiness 
posture. There can be no doubt that are most valuable resource is our 
military personnel--the men and women that make tremendous sacrifices 
to keep us safe.
    Our job is to ensure that the DoD and the Services are resourced to 
meet the medical needs of our servicemen and women at home and while 
deployed.
    This includes the facilities, technology and agility to respond 
quickly to a wide-array of contingencies, but the goal remains the 
same: before the women and men of the Armed Forces can fight for this 
country, they must be fit to deploy.
                          hard and soft power
    From the outlines of its fiscal year 2018 budget, the new 
administration is very concerned about augmenting the ``hard power'' of 
our military.
    We must not lose sight of the fact that the DoD has its own 
``soft'' power resources that are also very effective. In recent years 
we have seen the use of defense healthcare around the world to great 
effect. This is reflected in many ways: from rushing doctors, nurses, 
and medics to faraway countries that have suffered from natural 
disasters, to smaller engagements with friendly countries to increase 
their own medical capabilities and build goodwill.
    We need to remember this as we receive and consider the fiscal year 
2018 budget.
                            medical research
    While we often hear about challenges in the Military Health System, 
I believe we also need to celebrate its successes. Chief among these is 
the fact that our combat survival rate has never been higher. That 
speaks to the innovation in each of the Services to meet the evolving 
challenges of battlefield medicine. It also means that we must continue 
research in fields such as combat casualty care and infectious 
diseases.
    As you know, DoD medical research is a top priority of mine. With 
Chairman Cochran's great support and that of our Senate colleagues, we 
have increased research funding over 32 percent over the last 4 years. 
This is important because as more of our soldiers, sailors, marines and 
airmen survive their injuries, many times their needs from the Military 
Health System will evolve.
    The funding Congress adds each year to the defense bill includes 
support for a range of medical research, from modern prosthetics to 
more effective treatments for traumatic brain injury. Breakthroughs in 
these fields are improving the quality of life of our service members 
after the fight, which is part of our Nation's responsibility to our 
servicemen and women.
                                tobacco
    Of course, overall individual health is a key component of military 
readiness. This includes encouraging healthy lifestyles that reduce 
missed time due to illness and injury while promoting faster 
recuperation times.
    Further curbing the use of tobacco in the military is a prime way 
to accomplish these goals and a top priority of mine. It saves money 
and ensures a healthier force, but it is frustrating to hear that 
bureaucratic red tape is holding back progress on this critical issue.
    I would like to hear from the Surgeons General about ongoing 
efforts to reduce tobacco use, and what steps are needed to make more 
progress now.
                               conclusion
    We have a lot to discuss, including proposed significant changes to 
the Military Health System and TRICARE, and the roll out of the new 
electronic health record that seems to show great promise.
    Thank you for your service and for your work to better the lives of 
the personnel entrusted to your care. It is an essential part of 
maintaining a ready force.

    Senator Cochran. Thank you. We are pleased to welcome our 
distinguished witnesses who are here at our hearing, Lieutenant 
General Nadja West, Surgeon General of the Army, Vice Admiral 
Forrest Faison, Surgeon General of the Navy, Lieutenant General 
Mark Ediger, Surgeon General of the Air Force, and Ms. Stacy 
Cummings, Program Executive Officer of the Defense Healthcare 
Management Systems.
    I am going to defer my opening statement and go right to 
recognition of this panel for any statements they wish to make. 
We will proceed with questions after that.
    First, Lieutenant General Nadja West, Surgeon General of 
the Army.

           SUMMARY STATEMENT OF LIEUTENANT GENERAL NADJA WEST

    General West. Good morning, Chairman Cochran, Vice Chairman 
Durbin, and distinguished members of the subcommittee. Thank 
you so much for the opportunity to highlight the important work 
Army Medicine does in support of our Nation.
    I am extremely proud to lead the dedicated professionals of 
the Army Medicine team. On behalf of these professionals, I 
would like to thank Congress for the continued support in all 
that we do.
    I would also like to recognize America's sons and daughters 
that are currently forward stationed or deployed around the 
world. As you mentioned, Mr. Durbin, they are the reason why 
Army Medicine and the entire Joint Health Services Enterprise 
exist.
    As we continue to be the Nation's premier expeditionary and 
globally integrated medical force, readiness without question 
remains my number one priority. Predictable and consistent 
funding is essential to ensure we maintain our readiness to 
support and answer our Nation's call.
    It is important to emphasize that Army Medicine is 
comprised of a mix of integrated health services, research, 
training, and education unlike any other healthcare 
organization in the world. From our garrisons to the farthest 
sites around the globe, Army Medicine provides quality health 
care when needed.
    When assessed against nationally accepted quality 
benchmarks for healthcare, our performance, along with that of 
our Navy and Air Force colleagues, meets or exceeds our 
Nation's top performing civilian systems. We also maintain 
these standards while sustaining readiness and engaging in and 
supporting operational missions, a mission set our civilian 
counterparts do not have.
    Still, we are consistently working to improve, to increase 
access, to decrease unnecessary variability, and to enhance 
patient experience. I assure you that Army Medicine has been 
listening and responding.
    Over the last year, we have launched aggressive efforts to 
expand access to improved quality for all who rely on us. Last 
year when I testified before this committee, I promised that I 
would create 379,000 additional primary and specialty care 
appointments, and I am very proud to share with you that we 
have exceeded that goal by more than 200 percent, adding 
836,000 additional appointments in 2016.
    By far, our most promising initiative to bring care closer 
to our patients is Virtual Health. Army Medicine is recognized 
as a leader in Virtual Health with services spanning 30 
countries and territories, over 30 clinical specialties, and 
the potential uses are far reaching, from remotely monitoring 
patient vitals to providing virtual consultations, to a medic 
actually providing combat casualty care or treating a combat 
casualty.
    We see Virtual Health as a means to evolutionize access, 
whether in garrison facilities, at our patient's home, or at 
the point of injury.
    Remarkable advances have also been made in preventing and 
treating infectious diseases, such as the Zika virus, as well 
as treating physical and mental combat related wounds.
    The importance of sustained and predictable funding is 
paramount to continuing our medical research that saves lives, 
decreases morbidity, and improves quality of life.
    In anticipation of future challenges, Army Medicine today 
is preparing for our tomorrow. Capabilities required to support 
the future operating environment are going to look much 
different than they do today. The emergence of peer and near 
peer adversaries combined with rapid technological expansion 
threatens the current construct of battlefield medical support.
    In a multi-domain battle environment, we may not have 
uninterrupted air superiority, which will impact our ability to 
conduct on demand patient evacuation, and our medics and other 
early responders may find themselves providing complex 
prolonged field care.
    The best support of our Joint Force--to be able to support 
our Joint Force, we need to be able to rapidly scale and 
reconfigure our capabilities. For example, last year Army 
Medicine rapidly assembled a damage control surgical capability 
to support forces operating in a widely-dispersed environment 
within the U.S. Africa Command area of responsibility.
    Retaining this agility is key as we continue to work with 
our colleagues to implement the 2017 NDAA (National Defense 
Authorization Act). Readiness is foremost, and we must maintain 
the ability to flex with our service to provide the right 
capability while continuing to meet or exceed national quality 
care standards in our garrison environments. This is our sacred 
trust with our Nation.
    In closing, lessons learned over the past 15 years have 
changed how care is delivered on the battlefield and at home. 
These outcomes, lives saved, and advancements do not happen by 
chance. They are a product of a thoughtfully organized, tested 
and proven assemblance of medical treatment facilities, 
research labs, and training and education campuses, similar to 
those that exist in the Navy and Air Force components of our 
health enterprise.
    They are also the result of an integrated, well 
synchronized plan, but we cannot be satisfied with the past 
successes. We must remain vigilant, for if we do not, as my 
Chief, General Milley, says, we will pay the price in the blood 
of our injured.
    So, our readiness to support our Nation and our Army can 
never and will never be in doubt. So, thank you for your 
continued support to our soldiers, to our Army, and to Army 
Medicine.
    [The statement follows:]
              Prepared Statement of General Nadja Y. West
    Chairman Cochran, Ranking Member Durbin, distinguished members of 
the subcommittee, thank you for the opportunity to testify on the 
current state of Army Medicine and future challenges. Your continued 
support enables Army Medicine to remain ready and responsive to global 
threats and other uncertainties. It has been a privilege to serve as 
The Army Surgeon General and Commanding General of US Army Medical 
Command, and I am incredibly proud to lead a team of talented and 
dedicated professionals. Every individual that makes up our Army 
Medicine team remains our most valuable asset and we have a sacred 
obligation to care for those who serve our Nation and their families.
    Army Medicine is part of an integrated Joint Health Services 
Enterprise (JHSE), which is globally engaged, supporting Combatant 
Commanders in 140 locations across five continents. We continue to 
provide medical support to our Forces engaged in conflict across the 
globe while concurrently responding to natural disasters, infectious 
disease outbreaks, and other complex contingency operations. Given the 
lethality and complexity of the battlefield, in conjunction with our 
sister services, we have achieved stunning survivability rates and the 
lowest rate of disease and non-battle injuries.
    Our medical knowledge in trauma care, traumatic brain injury, 
aeromedical evacuation, amputee care, and other combat medicine-related 
disciplines have changed how trauma care is delivered on the 
battlefield, home front, and across the globe. These outcomes, lives 
saved, and advancements do not happen by chance, as they are the result 
of an integrated and well-synchronized plan and a healthcare delivery 
capability that extends from the battlefield to the garrison 
environment.
    To remain the Nation's premier expeditionary and globally 
integrated medical force, readiness is my number one priority, which is 
in 100 percent alignment with the Army Chief of Staff priorities. We 
must be ready to support our Army and the Joint Force in any 
environment; ready to adapt and apply our full spectrum of AMEDD 
capabilities from injury to recovery; ready to identify and apply 
innovative technologies; and ready to strengthen the physical and 
psychological wellbeing of our Soldiers, Soldiers for Life, and their 
Families. Predictable and consistent funding is essential for the Army 
and Army Medicine to improve readiness and progress toward a more 
modern, capable, and responsive future medical force. If we return to 
sequestration-level funding in fiscal year 2018, Army Medicine will be 
unable to sustain the levels of responsiveness and readiness that our 
Army and our Nation requires to face emerging challenges and 
contingencies.
    We are preparing for future operating environment challenges, as 
the global security environment remains volatile, uncertain, and highly 
complex. The emergence of peer and near-peer adversaries combined with 
rapid technological expansion presents great risk to the traditional 
construct of battlefield medical support. Electronic warfare, unmanned 
aerial vehicles, extended-range weaponry, and non-traditional kinetics 
present real possibilities for increased lethality and decreased 
patient evacuation opportunities. Nonetheless, we must innovate and be 
prepared to deliver world-class Health Services Support in any dynamic 
or contested environment.
    As we look to the future, the Multi-Domain Battle concept 
consisting of land, air, maritime, space and cyberspace domains will 
require us to be increasingly responsive and able to rapidly scale and 
reconfigure our medical support capabilities. Army Medicine has been 
proactive in balancing land-component modularity while promoting inter-
Service interoperability; ensuring the right medical capabilities will 
be available at the right place and right time. Combatant Commands rely 
on the Services, particularly the Army, for medical capabilities to 
support a vast range of military operations. Last year Army Medicine 
rapidly assembled a damage control surgical capability to support 
special and conventional forces operating in a widely dispersed 
environment within the U.S. Army Africa Command region. Deemed an 
overwhelming success, these small resuscitative teams continue to 
rotate every 4 months and demonstrate Army Medicine's commitment to 
provide rapid and adaptive solutions to support Combatant Commands and 
the Joint Force.
    Army Medicine is about to undergo significant organizational change 
associated with the fiscal year 2017 National Defense Authorization Act 
(NDAA) which may have far-reaching second and third order effects. We 
are working closely with the Defense Health Agency (DHA) and the JHSE 
to implement these legislative changes, which requires deliberate 
planning and analysis. We wholeheartedly support the intent of Congress 
and will work diligently to also meet the operational requirements of 
our Combatant Commanders and provide quality healthcare to our 
beneficiaries.
    In support of my number one priority of readiness, we have 
established four Lines of Effort as part of the 2017 Army Medicine 
Campaign Plan: (1) Readiness and Health; (2) Force Development; (3) 
Healthcare Delivery; and (4) Taking Care of Ourselves, our Soldiers for 
Life, Department of the Army (DA) Civilians, and Families. These 
priorities endure, our resolve has strengthened, and we continue to 
move forward with implementation. In the face of global security and 
industry reform challenges, we will continue to innovate and evolve to 
become an integrated system for health and the Nation's first choice 
for expeditionary health services. Since 1775, Army Medicine has 
responded to the call--whenever and wherever needed--supporting the 
Soldier and all those entrusted to our care.
                          readiness and health
    Readiness remains the most critical focus of the Total Army and 
supporting the Soldier's readiness is Army Medicine's primary mission. 
No other health system operates at the scale and magnitude of Army 
Medicine, which serves over 11,000 new accessions monthly across the 
total force. Army Medicine serves over 180,000 patients on a daily 
basis, but our readiness mission extends well beyond the walls of our 
military treatment facilities to include expeditionary medicine, 
medical evacuation, an array of public health services, and medical 
research efforts to protect our Soldiers before, during, and after 
deployment. Readiness permeates everything we do from prevention and 
resilience to rehabilitation and transition. As the Nation's premier 
and globally integrated medical force, we have enhanced individual and 
unit readiness by embedding assets within the maneuver Brigade Combat 
Teams to prevent and treat musculoskeletal injuries, address behavioral 
health issues within our formations, and enhance our responsive medical 
capabilities.
    Medical readiness consists of two essential components, a force 
that is medically ready and a medical force that is prepared to provide 
capability in any environment our Force needs us: (1) individual 
Soldiers must be physically and mentally fit, ready to deploy anywhere, 
anytime and (2) Army Medicine must be a responsive medical capability 
with clinically proficient individuals who are also facile in their 
warrior tasks and drills. Our ability to sustain readiness and deploy 
healthy individuals and organizations in support of the world's premier 
combat force must be absolute.
Soldier Medical Readiness
    A fit and healthy fighting force is the foundation of a strong 
national defense and the strength of our Army is inextricably linked to 
our Soldiers' individual health and wellness. Because the Army is a 
demanding profession with a host of injury risks, Soldiers must have 
the requisite level of endurance to perform the physical and mental 
tasks of their occupation. Although medical readiness is a shared 
responsibility between the individual Soldier, Command Teams and 
enabling organizations, Army Medicine plays a decisive role in 
monitoring, assessing and identifying key health-related indicators and 
outcomes as well as providing recommendations to mitigate these risks.
    Within the behavioral health sphere, Army medicine has leaned far 
forward with our Embedded Behavioral Health (EBH) program, which has 
been consistently recognized as a DoD-wide best practice. EBH provides 
early Behavioral Health (BH) intervention and treatment to Soldiers in 
close proximity to their unit area. Soldiers receive expedited 
evaluations and treatment from a single provider, which greatly 
improves continuity of care and facilitates close coordination with 
unit leaders. The enduring working relationship between the BH provider 
and key battalion personnel also addresses stigma commonly associated 
with seeking BH care.
    EBH has been associated with improved access, quality, and safety 
in Soldier care and improved readiness to deploy. Since the 
implementation of EBH in 2012, 45 percent fewer Soldiers with Post-
Traumatic Stress Disorder (PTSD) have received prescriptions for 
benzodiazepines, a potentially addictive group of medications. Further, 
we have increased the use of evidenced-based psychotherapy and 
intensive outpatient program options. With more Soldiers receiving care 
in the outpatient setting, BH conditions are being managed earlier, 
before crises occur. Soldiers required 67,000 fewer inpatient bed days 
for all types of BH conditions in 2016, as compared to 2012 (approx. 41 
percent decrease), due to improvements in outpatient services, EBH, 
Intensive Outpatient Programs and case management. EBH's effectiveness 
has been further supported in a program evaluation conducted by the 
Massachusetts Institute of Technology (MIT) between 2010 and 2015. As 
of December 2016, we have fully implemented EBH in all operational 
units, to include 62 EBH teams staffing 450 EBH providers in direct 
support of 31 brigade combat teams and 156 other battalion and brigade 
sized units.
    While some level of illness, training-related or operationally-
induced injury is unavoidable; there are many opportunities to 
intervene before a health-limiting event occurs. Army Medicine is 
leveraging our System for Health programs and Health Information 
Technology (HIT) to better detect such opportunities to improve 
readiness, such as the Medical Readiness Assessment Tool (MRAT). The 
MRAT is a HIT decision support tool that predicts if a Soldier is at 
risk for becoming non-deployable in the next 4-6 months. The tool uses 
diagnoses and medication data from the electronic health record (EHR) 
and fitness performance data from unit tracking systems to identify 
Soldiers with recurring medical limitations and high-risk behaviors 
that predispose them to illness and injury. The MRAT facilitates early 
intervention. When a high-risk condition is identified, including the 
management of multiple complex prescriptions, the Soldier's health team 
can intervene to prevent addiction or a permanent medical limitation.
    Army Medicine is positively influencing a culture of health by 
providing Soldiers and Commands comprehensive health services, 
education, tracking and monitoring tools. The Army is currently in the 
final phase of a medical readiness transformation. We have modified our 
readiness systems to improve Commanders' understanding and engagement. 
In June 2016 we launched a readiness dashboard, the Commander's Portal, 
and a reengineered physical profiling system (eProfile), which includes 
over 250 standardizing templates for the most commonly profiled 
injuries and illnesses. Using only one web-based tool, which our line 
leaders affirm is much easier to use, Commanders can view all medical 
readiness data, to include eProfile and MRAT, and communicate directly 
with medical providers before making deployability determinations for 
their Soldiers.
    The Commander's Portal and other transformation initiatives have 
resulted in more timely identification of deficiencies, improved 
communication between healthcare teams and unit commanders, and 
increased oversight of unit and individual medical readiness. Between 
February 2016 and February 2017, deployable rates increased across all 
three Army Components. Additionally, dental programs such as Go First 
Class, Direct Care Dental Services, and the Deployed Dental Care 
Program have reduced dental treatment needs by over 50 percent and 
improved dental wellness. Go First Class combines dental exams with 
hygiene and restorative appointments, and has saved nearly one million 
man hours spent traveling to and from appointments.
    As our readiness tools and programs mature, Army Medicine will 
continue to incorporate lessons learned to reduce the burden on 
commanders, clinicians, and Soldiers to manage health and readiness. In 
2014 we launched the Performance Triad program to empower our Soldiers 
and families with knowledge and tools to improve their personal health 
readiness through changes in sleep, activity, and nutritional habits. 
With the Performance Triad we have developed a sustainable program to 
meet the health needs of Soldiers and leaders. Strong leadership 
support for the Army Performance Triad has increased healthy food 
options in our installations' dining facilities and has positively 
impacted work-rest cycles in training and garrison settings. After 
unit-wide application of the Performance Triad tenets, an armored 
battalion reported a 21 percent increase in gunnery scores, and another 
infantry battalion achieved an all-time lowest adverse safety incident 
rate at the Joint Readiness Training Center (JRTC). Engaged leadership 
is the most important factor in influencing the healthy behaviors 
within our formations, and I am confident we are continuing to move in 
the right direction. Army Medicine will continue to provide tools and 
knowledge to steer a cultural change toward health, optimal performance 
and sustained readiness.
Ready and Responsive Medical Capability
    In order for the Army to prevail on the battlefield, in the 
unforgiving crucible of ground combat, our Soldiers must be in top 
physical and mental health. Our medical branch of our Army must not 
only ensure medical readiness of our Force but must also be ready, 
agile, and responsive to deploy on a moment's notice, save lives, and 
evacuate casualties to definitive care. While we are the experts on 
battlefield medicine and applaud achieving remarkable combat 
survivability rates over the past 15 years, we must continue to improve 
and innovate to achieve our goal of zero preventable battlefield 
deaths.
    To be postured to respond to the next set of challenges we must 
focus our clinical training efforts and mitigate critical capability 
gaps. We anticipate the future threat environment may require casualty 
care holding that exceeds current evacuation planning factors (i.e. the 
Golden Hour). Due to tactical or operational circumstances, any member 
of the ground force healthcare team (combat medic, nurse, or physician) 
may be faced with providing prolonged casualty care in an environment 
lacking robust medical infrastructure. Army Medicine is exploring 
multiple methods to reduce risk caused by evacuation limitations, such 
as bringing surgical capabilities further forward to the point of 
injury. Virtual Health (VH) capabilities may also augment treatment 
when a patient's condition is deteriorating and threatens to outpace 
the skill level of a first responder. Ultimately, prolonged care 
requires core clinical and battlefield medicine competencies at every 
skill level; and competency requires repetition.
    We view our Medical Treatment Facilities (MTFs) as health readiness 
platforms that provide training in support of responsive medical 
capabilities and to maximize medical readiness of the total Army. MTFs 
provide our medics, doctors, nurses and other health professionals the 
opportunity to perform skill repetitions every day, both individually 
and more importantly, collectively as a team. We leverage our larger 
facilities to develop and sustain the trauma, critical care, and 
complex surgical care skills required to save lives on and off the 
battlefield. The Army also maintains sophisticated simulation training 
centers to further maintain the proficiency of our medical personnel, 
particularly those deploying or assigned in operating force formations. 
For example, the Anderson Simulation Center, located at Madigan Army 
Medical Center, is the first DoD facility to be accredited both by the 
American College of Surgeons (ACS) and the Society for Simulation in 
Healthcare (SSH). We are proud that the Anderson Simulation Center 
remains one of seven sites across the United States to hold Level 1 SSH 
accreditation.
    Training is the foundation of a ready and responsive medical force. 
Army Medicine conducts training and operations across every platform, 
from expeditionary and prehospital to primary and tertiary care. 
Sustainable medical readiness stems from daily MTF operations and 
multiple echelons of medical training and education programs across 
Army Medicine. Each year we train more than 35,000 students at the Army 
Medical Department Center and School Health Readiness Center of 
Excellence, and nearly 1,500 physicians in Graduate Medical Education 
(GME). Most notably, our GME programs are vital in force generation and 
retention. The reach of Army GME extends across all Army components. 
Those leaving active duty service are a primary source of GME-trained 
physicians for the Nation's civilian healthcare system, as well as the 
Army Reserves and National Guard, which helps offset civilian physician 
training shortages.
    Army Medicine hosts the largest GME platform in the DoD with the 
largest number of training institutions, programs, and officers in 
training. Approximately 93 percent of all Army GME training is 
conducted within a DoD program or institution. There is a national 
shortage of residency training positions in the civilian sector; 
therefore, training in DoD facilities ensures sufficient quantity for 
each specialty needed to meet the requirements of the Joint Force, 
global health engagement and medical force readiness requirements. Our 
reputation for superior clinical training and leadership development 
boosts recruiting and retention efforts and our first time medical 
board certification pass rate of 95 percent well exceeds the 87 percent 
national average. However, we still suffer shortages in several key 
surgical specialties. Orthopedic, thoracic, and general surgery are 
critical shortfalls for Army Medicine across all components. We are 
actively working to adapt and align residency and fellowship training 
allocations to better emphasize trauma care capability, which will 
include expanding partnerships with civilian institutions to establish 
enduring training platform agreements for GME. We have also begun 
collaborating across the Services to leverage tri-service training 
platforms to optimize individual and team training opportunities.
    Army Medicine collaborates with the civilian healthcare industry to 
expand readiness capabilities; we have learned from industry, just as 
industry has learned from us. Industry frequently looks to Army 
Medicine for cutting edge prehospital, trauma, and rehabilitation 
advances, and we actively collaborate with them, particularly in the 
research realm. Combat casualty care research and revolutionizing 
clinical practices led to one of the highest survival and recovery 
rates among injured Service Members over the past 15 years. Many of the 
skills applied on the battlefield have been incorporated into military 
and civilian prehospital and trauma protocols. Public-private 
partnerships facilitate resource sharing and expedite research, 
development, and acquisition in many mission-relevant healthcare areas. 
Past decisions have led to remarkable advances in the knowledge and 
care of infectious diseases such as Zika, Ebola, HIV, and Malaria. 
Further advances have also been made in physical and mental combat-
related wounds, such as Traumatic Brain Injury (TBI) and Post Traumatic 
Stress Disorder. Our decisions today must preserve the Army's core 
medical research competencies; and through continued investment, build 
a capability that ensures strategic advantage in future and more 
complex operational scenarios.
                           force development
    Army Medicine includes 138,000 Soldiers and civilians serving in 
diverse clinical, support, and research specialty areas and the 
majority of our uniformed medical force is in the Army Reserve and Army 
National Guard. Integration of this total Force helps us provide 
responsive medical capabilities whether on a battlefield, in an austere 
environment, addressing a humanitarian crisis, or answering any other 
call to our Nation. We have not only invested in educating and training 
our Force but also are committed to building high-performing medical 
teams that will thrive in a highly complex future operating 
environment. Army Medicine has taken proactive measures in our Force 
development to ensure that we are able to support rapid deployments 
with mission-ready personnel and equipment. We invest heavily in our 
most valued asset, our people, to ensure the Army Medicine team 
continues to demonstrate individual and collective excellence.
    The acquisition, development, employment, and retention of a broad 
and diverse spectrum of healthcare talent are critical to conduct 
missions across multiple domains, and to meet the challenges of 
enduring requirements and unanticipated contingencies. Army Medicine is 
continuing to deliberately manage talent at all levels and in all 
components. We are improving efforts to match specific job requirements 
with the individual's skills and experience, while developing them to 
their fullest potential. Last year, our Talent Management Directorate 
collaborated with stakeholders to fully codify the knowledge, skills, 
and behaviors required for senior leader billets and reviewed all 
positions to match talent with strategic organizational demands. We are 
also transforming our Professional Filler System (PROFIS), in which 
medical personnel are on-notice to deploy in support of an operational 
unit.
    Future-focused human capital management is further complemented by 
medical force modernization efforts to better align Army Medicine in 
support of the Army and Joint Force. In fiscal year 2017 the Army began 
fielding a redesign to increase capabilities of the Combat Support 
Hospital. The newly configured Field Hospital (FH) includes more 
specialized physician and nursing staff; and is able to accommodate 
split operations while preserving full medical, communication, and 
command capabilities. Furthermore, modular augmentation detachment 
options enable scalable surgical treatment and hospitalization 
requirements. Another redesign initiative, the Forward Resuscitative 
Surgical Team (FRST), will launch in fiscal year 2018. This rapidly 
deployable team is self-mobile, networked, modular and scalable. In 
addition to providing damage control surgery, FRSTs provide emergency 
treatment and postoperative care. The conversion timelines for both the 
FH and FRST span fiscal year 2017 to fiscal year 2022; and all 
projected modernization requirements are synchronized between Active 
and Reserve Components.
    Other examples of increased versatility and agility include en-
route critical care teams and the enhanced combat medic initiatives. 
Our en-route critical care nurses continue to deploy and fly missions; 
this capability, in combination with paramedic flight training, adds 
immediate life-saving measures in the pre-hospital environment. Army 
Medicine is actively increasing enlisted en-route care providers to 
meet the objective of having a Paramedic with Critical Care Training in 
the back of every Army Air Ambulance. Enlisted skill capability 
requires expansion because the tactical environment involves combat 
medics working without a provider on site, particularly when evacuation 
is delayed or unavailable. In previous wars, up to 90 percent of combat 
deaths occurred before a casualty reached a medical treatment facility; 
however, throughout the most recent conflict, continuous process 
improvement in Tactical Combat Casualty Care drastically reduced the 
number of military personnel dying of potentially survivable combat 
wounds to a historic low of 3 percent. The many training improvements 
developed from the lessons of war are now saving lives, and the efforts 
to sustain these skills will offer the best chance of survival and 
recovery to those we care for in the future. Critical care is not just 
for the back of an air ambulance as it is also required on the ground 
to support expeditionary medical requirements.
    Military medical readiness is highly dependent on learning lessons 
from past conflicts and ensuring that we are prepared at the start of 
any conflict. Although military medicine has advanced throughout every 
successive conflict, we have experienced challenges when responding to 
the next war. For example, 5 years after the US successfully ended 
World War II, we entered the Korean War with a significantly reduced 
force and critical physician shortages. Although Task Force (TF) Smith, 
part of the 21st Infantry Regiment, was deemed to be at a high state of 
readiness and medical training; medical supplies were exhausted within 
hours of combat operations and simple medical procedures became overly 
complicated in an austere environment. While there was no shortage of 
medical ingenuity and heroism in saving as many as possible, there was 
no reliable resupply plan or evacuation route. We must use lessons 
learned from past and current conflicts to preserve and advance 
institutional knowledge and remain postured to save as many lives as 
possible on future battlefields.
Medical Innovation
    Army Medicine continues to lead with respect to medical innovation. 
The U.S. Army Medical Research and Materiel Command (USAMRMC) readily 
partners with our sister Services, the Defense Health Agency and other 
Federal agencies to coordinate and maximize DoD's efforts in research, 
development, testing and evaluation (RDT&E). Successfully advancing a 
new medical technology through all phases of RDT&E may require as much 
as $1 billion investment. Within the pharmaceutical industry, only one 
in twelve products will successfully make it to the market. To avoid 
exorbitant costs and timelines, Army Medicine purposefully seeks and 
fosters partnerships with academia and commercial industry to gain 
initial investments, industry expertise, and to leverage existing 
resources when possible. This shared model often results in faster 
development, fewer expended resources from a sole source, and dual-use 
products that immediately benefit the Service Members as well as 
civilians.
    The recent Zika vaccine trial at the Walter Reed Army Institute of 
Research (WRAIR) is an example of leveraged Federal and industry 
partnerships to fund and conduct clinical trials in the interest of 
military readiness and civilian health. This early-stage Zika vaccine 
effort is one of several federally-funded vaccine development 
initiatives under the auspices of the Department of Health and Human 
Services. After recognizing the epidemic potential of Zika, WRAIR 
scientists began work to manufacture vaccine doses for a clinical 
trial. The effort took just 8 months, which was unprecedented in the 
vaccine-developer community. The Army was able to rapidly move through 
developing, manufacturing, and testing a Zika vaccine because of its 
extensive experience and long-standing investments in other vaccine 
research platforms. Similarly, the Army's firmly established infectious 
disease experience and international relationships allowed our 
researchers and scientists to swiftly respond to the 2013 Ebola crisis 
in West Africa.
    DoD's efforts in research and development not only builds force 
readiness, but also increases national security and bolsters homeland 
security preparedness. Hemorrhage is the leading cause of death in both 
civilian and military trauma. In 2016, military surgical teams in 
Operation Inherent Resolve successfully used the innovative 
Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) 
catheter to save the lives of four combat casualties. The flexible 
catheter allows medical teams to control bleeding, restore blood 
pressure, and reduces the need for blood transfusion in an austere 
surgical scenario. The REBOA is now being used in civilian medical 
centers across the country in the care of US civilians injured in 
accidents, acts of violence and natural disasters.
    The Defense Health Program and Military Medical Research Programs 
are our Nation's primary funders of trauma and injury research and 
development. No other private or Federal entity provides significant 
funding to advance the science involved in acute casualty care. Army 
medicine works collaboratively to find and fill research gaps by 
funding high impact, high risk and high gain projects that other 
agencies often do not venture to fund. For example, military research 
supported an effort to develop a process to improve reconstructive 
transplantation procedures using personalized surgical devices designed 
and rapidly prototyped from virtual surgical simulations. This novel 
surgical technology is expected to benefit civilians and Service 
Members with devastating craniofacial injuries.
    Traumatic Brain Injury is another example of DoD's efforts in 
research and development. Since 2000, there have been over 357,000 TBIs 
diagnosed in the military. When TBI came into the forefront of the 
Nation's attention in 2006 the medical community had very few answers 
on how to prevent, treat, or limit morbidity related to TBI. Since then 
the Army has been at the forefront of TBI research, education, clinical 
care and policy. Collaboration between all three Services, the 
Department of Veterans Affairs (VA), and academia has contributed to 
improved TBI screening and treatment, as well as concussion management 
in deployed settings. The Army, along with the TBI Advisory Committee, 
has generated standardized clinical tools and clinical recommendations 
such as the Military Acute Concussion Evaluation. It has been an 
impressive journey as we progressed from limited treatment knowledge to 
clinical practice guidelines and full medical and leader engagement.
                          healthcare delivery
    From the battlefield to the garrison environment, Army Medicine 
provides access to safe, high quality healthcare. We cannot limit our 
focus to combat trauma, surgery, and burns--Army Medicine must preserve 
a broad range of medical capabilities. From 2001-2015 less than 21 
percent of those evacuated from theater were injured in battle; the 
vast majority of care addressed non-battle illnesses and injuries. To 
prepare for a myriad of settings and conditions, and sustain training 
and education programs, our medical centers, hospitals and clinics need 
access to a diverse case and patient mix to include our family members, 
DoD Civilians, and Soldiers for Life.
    Health services are an important benefit in the recruiting and 
retention of an all-volunteer force, as part of their unwavering 
commitment to serve and protect. To honor our commitment and 
beneficiaries' trust, we must continue to provide a health benefit 
commensurate or exceeding national standards. The primary performance 
domains of our healthcare system--access to care, quality and patient 
safety, and patient satisfaction--must be continually measured, 
assessed, and improved.
Access to Care (ATC)
    We are facing a rapidly shifting healthcare delivery landscape. 
Nationally, health costs are outpacing inflation and technology is 
impacting how health information and services are provided. There are 
increasing demands to improve efficiency, access, and the patient 
experience; and expectations to decrease cost, performance variability, 
and redundancy. Army Medicine has been listening and responding. Over 
the past year Army Medicine has implemented aggressive efforts to 
expand access to care to ensure all beneficiaries are seen by the right 
provider, at the right time, in the right venue. We thoroughly 
overhauled appointment-scheduling systems, modified operating hours, 
expanded secure messaging and telehealth initiatives, and expanded 
community based medical homes. In 2016 Army Medicine received two ATC 
awards, to include `Most Improved Service in ATC' from Military Health 
Service, and `High Reliability Organization: Improved Primary Care ATC' 
from the Association of Military Surgeons of the United States.
    As part of our effort to maximize ATC, we have added an additional 
836,000 appointments in 2016 compared to 2015. The Nurse Advice Line 
(NAL) combined with secure messaging improved utilization of self-care 
and primary care appointments and lessened inappropriate emergency 
care, avoiding $12 million in network costs in 2016. Concurrently, both 
inpatient and outpatient satisfaction has increased. Army Medicine has 
improved satisfaction rates by 10 percent over the past 2 years and is 
currently above the civilian benchmark for our medical and surgical 
services. Outpatient satisfaction in Army MTFs continues to be very 
high. Over 93 percent of beneficiaries indicate being satisfied with 
their overall healthcare and over 92 percent report being satisfied 
with their provider.
    To decrease access to care barriers, Army Medicine is bringing 
integrated care closer to the patient through a patient-centered 
primary care model. The Army Medical Home (AMH) staffs an integrated, 
multi-disciplinary healthcare team focused on proactive and 
comprehensive care. Each patient partners with a team of healthcare 
providers, which includes physicians, nurses, behavioral health 
professionals, pharmacists, dietitians, and others to develop a 
comprehensive, personal healthcare plan. The AMH model also extends to 
our Community Based Medical Homes (CBMHs) and Soldier Centered Medical 
Homes (SCMHs). CBMHs are located in off-post communities to more 
conveniently serve Army Families where they live and work. We have 
opened 20 CBMHs (serving 150K beneficiaries), and an additional seven 
CBMHs will open over the next 2 years. While all Army beneficiaries 
have access to primary care services with routine physical exams and 
accessible specialty care, the AMH offers enhanced care coordination, 
access, quality and safety. Our patient-centered access and care 
coordination initiatives have produced excellent results. Our hospital 
readmission rates have reduced from 34 per 1000 enrolled beneficiaries 
to 30 per 1000 enrolled beneficiaries from September 2015 to November 
2016. During this same timeframe, our preventable admission rate has 
improved from 20 per 100,000 to 17 per 100,000 enrolled beneficiaries.
    The Army SCMH is the Soldier's version of the AMH model. In 
addition to offering enhanced care coordination, access, quality and 
safety, the SCMH mission improves medical readiness. The SCMH delivers 
90 percent of Soldier care in a single location, eliminating the need 
for multiple referrals and the unnecessary loss of duty time. The SCMH 
model also integrates the medical staff from the Soldier's unit of 
assignment with the medical staff from the MTF. The physicians, medics, 
and physical therapists from the Soldier's Unit have a unique 
relationship, because they work and train alongside their patient 
population. This facilitates better rapport, accountability, and a 
direct line of communication with the Unit Commanders to advise them of 
high-risk Soldier activity or other concerning trends, such as 
musculoskeletal injuries.
    Virtual Health represents our largest initiative to improve access 
and bring care closer to the patient. Army Medicine is a recognized 
leader in VH, with services spanning 18 time zones, 30 countries and 
territories, and over 30 clinical specialties. Using VH, the best of 
Army Medicine can be brought to the patient wherever they are, whether 
deployed or in garrison. In 2016, our Regional Health Command-Europe 
exhibited exemplary utilization of VH by saving Soldiers, beneficiaries 
and Commanders an estimated 2,050 work and school days, $1.34 million 
in travel-related expenses, and 825,000 kilometers of travel. For many 
years Army Medicine has excelled with VH in the deployed environment. 
We have ongoing programs supporting Special Forces with real-time 
provider-provider and medic-Intensivist consults; and teleconsultation 
for all deployed providers (aka Ask-a-Doc).
    As we build capability on the battlefield, we also will continue to 
expand VH capabilities for our Soldiers and their Families in garrison. 
To augment current global VH offerings in over 30 specialties, we are 
collaborating with counterparts in the Joint Health Service Enterprise 
to establish an enterprise platform for Virtual Video Visits and a 
Global Teleconsultations Portal. These platforms will help meet the 
requirements for Section 718 of the 2017 NDAA, along with collaborative 
pilots beginning in Home Health Monitoring. Army Medicine is currently 
conducting over 40 pilots and programs to be used in the enterprise 
program and expand the use of VH for our beneficiaries.
    All VH programs are part of a comprehensive business plan for 
bringing tomorrow's healthcare today to our Nation's heroes. Current 
programs include emergency, primary and specialty care, and pre- and 
post-surgical consultations. Army Medicine is also rolling out VH cart 
technologies, which will enable providers to diagnose and treat 
patients remotely by electronically transmitting real-time vital signs 
and images. In culmination, we are establishing a Virtual Medical 
Center with clinicians and staff that specialize in remote care 
delivery. We envision a globally integrated garrison and deployed VH 
system under a centralized program structure.
Quality and Safety
    Whether delivered remotely, inpatient, or outpatient, all care 
provided must be safe and of a quality that meets or exceeds national 
benchmarks. By constantly asking ``What could possibly go wrong?'' 
using tools such as checklists and preparing for the unexpected, much 
in the way that a squad assesses the risks of a combat mission, 
medical, surgical and dental teams can reduce preventable errors to 
zero. To promote a culture of safety, we have incorporated patient 
safety tools and strategies and adopted aggressive high reliability and 
learning organization principles.
    Throughout the Army direct care system, all MTF staff are trained 
in Team Strategies and Tools to Enhance Performance and Patient Safety 
(TeamSTEPPS), which is an evidence-based set of teamwork tools, 
created by an enduring collaboration between the DoD and the Agency for 
Healthcare Research and Quality, to improve health team communication 
skills and optimize patient outcomes. Our care teams brief, huddle, and 
debrief during their shifts; and, if any staff member observes 
potential for patient harm they are required to speak up. Notably, as 
part of a High Reliability Organization (HRO), team members are 
strongly encouraged to voluntarily report errors and near-misses. Non-
punitive reporting practices in a climate of psychological safety 
contribute to institutional learning and increase safety and 
performance. Army Medicine strives to strike the balance between 
psychological safety and accountability.
    Negligence and lack of competence are in the minority of root 
causes for patient harm; most errors are caused by disconnected or 
antiquated workflow systems or processes. Once the conditions that led 
to an error are identified, mitigation and improvement strategies can 
be implemented throughout the organization. Since 2011, Army Medicine 
improved 4 percent on communication openness measures, and 5 percent on 
non-punitive response to errors, which exceeds national benchmarks.
    In the Military Health System (MHS) Review of 2014 nearly 200 
metrics were evaluated and indicated significant variation in MTF 
performance. Since then, Army Medicine has taken corrective action to 
meet action plan requirements and has improved outlier MTF performance 
to the standard or better. Army Medicine is also complying with 
specific MHS Review recommendations to expand the American College of 
Surgeon's National Surgical Quality Improvement Program (NSQIP), 
designed to improve the quality of surgical care and skill (readiness) 
experience, to all MTFs where surgery is performed. Only 681 hospitals 
worldwide, and 603 of the 5,564 registered acute care hospitals 
nationwide participate in NSQIP. We are proud to include all of our 
hospitals in this nationally validated, risk-adjusted, outcomes-based 
program. Because we collect, analyze, and take action on this 
benchmarked data, we are among the top 25 percent of hospitals in the 
United States. Dwight D. Eisenhower Army Medical Center in Fort Gordon, 
Georgia, has been recognized by the American College of Surgeons for 
its exemplary surgical outcomes that place them in the top 1 percent of 
hospitals nationwide in overall surgical morbidity. In collaboration 
with our tri-service and civilian partners, we are identifying and 
acting on data trends, developing and sharing best practices, 
standardizing processes and workflows, and putting systems in place to 
prevent surgical ``Never Events,'' such as wrong site surgeries and 
unintended retained foreign objects.
  taking care of ourselves, our soldiers for life, da civilians, and 
                                families
    Army Medicine is constantly progressing to preserve a healthy force 
with the physical, mental, emotional, and behavioral capabilities to 
adapt to and cope with adversity. Our supporting family members and DA 
Civilians also face chronic stress, adversity, insufficient sleep, 
inadequate activity and poor dietary habits. Our family members are 
especially vulnerable to increased stress when Service Members are away 
from home either while deployed or during training exercises. Soldiers, 
Families, and Civilians serving and supporting deserve our undivided 
attention. As such, it is our duty to promote, improve, conserve, and 
restore the physical and psychological well-being of all our 
beneficiaries.
Behavioral Health
    Family readiness supports Soldier readiness. Army Families 
experience significant stressors, such as frequent moves that 
necessitate changing of jobs and schools, establishing new friend and 
support networks, and deployments of spouses and parent(s). Research 
has demonstrated that combat deployments have had negative effects on 
up to 30 percent of family members. National shortages in behavioral 
health services further hinder the resiliency of our families. To 
address behavioral health (BH) access challenges, Army Medicine 
launched the Child and Family Behavioral Health System (CAFBHS). The 
CAFBHS boosts access and decreases stigma by positioning care near to 
where family members live, work and go to school. In fiscal year 2016, 
CAFBHS encounters numbered 252,867, an increase of 10.4 percent from 
the previous year. Significantly, we saw a 16.5 percent increase of 
child and adolescent encounters. Recognizing this specific increased 
demand, we have established partnerships with on-post and community 
organizations, such as the Military Child Education Coalition. 
Additionally, BH services will further expand in fiscal year 2017 to 
100 on-post schools across 18 installations. Ongoing integration of BH 
into Primary Care, leveraging provider-to-provider teleconsultation and 
expanding community partnerships will be necessary to meet increasing 
BH demands.
    To further reduce the stigma associated with seeking help for BH 
care, we have also positioned BH professionals in the Army Medical 
Homes. BH screening is part of every primary care visit, and affords an 
additional opportunity to a patient who is undecided about seeking BH 
services, or perhaps does not yet recognize the need. We are making 
every effort to recognize BH ``vital signs,'' and address them early in 
a safe and comfortable environment. The Tri-Services are collecting 
data to track clinical outcomes in BH patients. The Behavioral Health 
Data Portal (BHDP) has made it possible to gather BH vital signs at 
every visit and track associated symptoms over time. At each visit, the 
patient is given self-reporting questionnaires to complete on a tablet 
or kiosk. The results are immediately available to the provider 
facilitating an efficient method to monitor symptoms; make adjustments 
to the treatment plan; measure the effectiveness of treatment; and 
inform decisions regarding BH readiness. Aggregated data are used to 
create system-wide treatment outcome measures which inform future 
policy to maximize the quality and effectiveness of care. The BHDP is 
available in 100 percent of Army BH clinics, 14 CAFBHS clinics, 11 
primary care clinics, and four Army National Guard (ARNG) States; we 
are continuing to implement at additional clinics, including ARNG 
clinics.
    Often referred to as the invisible wound of war, PTSD is the most 
common BH diagnosis after exposure to traumatic events; 5-20 percent of 
Soldiers who have deployed to Iraq or Afghanistan meet the clinical 
criteria for PTSD. Routine screening for PTSD is conducted in primary 
care settings, pre- and post-deployment, and annually throughout a 
Soldier's career. Of Soldiers who received a new diagnosis of PTSD in 
Army BH clinics, approximately 70 percent received at least four 
treatment encounters within 90 days, a rate far exceeding those 
reported in other studies of VA or civilian populations. Though not 
limited to combat, PTSD is common after other traumatic events, 
including sexual assault, accidents, and natural disasters. There is 
also a strong association with other mental and physical health 
problems, such as chronic pain, fatigue, concentration or memory 
problems, and persistent health concerns following blast related 
concussions.
    An alarming disorder associated with PTSD and other BH conditions 
is substance abuse. Currently, 30 percent of Soldiers with a behavioral 
health condition screen positive for substance use disorder, and 50 
percent with suicidal ideation screen positive for excessive alcohol 
use. In fiscal year 2016, the Army enrolled over 11,600 Soldiers, the 
equivalent of over two brigade combat teams, in mandatory Substance Use 
Disorder Clinical Care, which significantly restricts their readiness 
to deploy. Following a 2015 study, the Secretary of the Army ordered 
the transfer of substance use disorder clinical care assets from 
Installation Management Command to Army Medicine. Since assumption in 
October 2016, we have made significant progress in key safety and 
quality areas.
    Addiction trained providers are available to support embedded BH 
providers in the Soldiers' unit area. This increased proximity reduces 
missed duty time, streamlines appointments and improves communication 
between medical providers. Army Medicine is working to improve outcomes 
for all beneficiaries with substance use disorders through earlier 
detection and intervention. The realignment of substance abuse 
rehabilitation and treatment under Army Medicine facilitates full 
integration into BH clinics and the entire medical system of care. This 
allows us to treat and manage substance use disorders at multiple 
points of entry, and as a multi-disciplinary treatment team engaging 
primary care providers, who often prescribe these medications, 
behavioral health providers, and addictions specialists.
                         soldiers in transition
    Whether suffering from a physical or mental illness, Army Medicine 
makes extraordinary efforts to rehabilitate our Soldiers. 
Unfortunately, certain conditions are not conducive to continued 
service. Soldiers who are not medically ready to deploy are referred to 
a Medical Evaluation Board (MEB), and if deemed unfit, enter the 
Integrated Disability Evaluation System (IDES). The Army, in 
conjunction with Department of Veterans Affairs, has made tremendous 
progress in decreasing Disability Evaluation System (DES) processing 
time. Three years ago, the average time for a Soldier in the DES was 
well over 400 days. Over the past year, the average time to complete 
all components of this very complex process has improved to less than 
250 days, which is well below the DoD standard of 295 days. Compared to 
2012, a Soldier now spends one third less time (143 days less) in the 
IDES process, which improves unit readiness by allowing replacement of 
non-deployable Soldiers in a timely manner. Workflow standardization 
and closer collaboration between DoD and VA partners has provided 
greater predictability for Soldiers and their Families as they 
transition to the next stages of their lives. Army Medicine will 
continue to provide a consistent and predictable process that enables 
Soldiers with serious medical conditions to be able to plan for the 
next phase of their life as a proud Veteran or Army Retiree.
    Soldiers who cannot recover while serving in their assigned unit, 
due to a more complex illness or injury, may be placed in our Warrior 
Care and Transition (WCT) Program. Army Warrior Care's whole-Soldier 
approach is a crucial part of the pact by which the Army fulfills its 
duty to those citizens who heed the call to serve. The WCT program 
occupies a special place on the healthcare continuum where bedside 
medical treatment ends and the full emotional and physical recovery 
journey begins. A multi-disciplinary team advocates for and serves the 
Soldier, their family, and caregivers. WCT care includes coordination 
of complex treatment requirements; mind and body rehabilitative 
programs; reconditioning activities like sports and art; education and 
career resources; and a path to return to the force fully healed.
    Since inception, more than 72,000 wounded, ill, or injured Soldiers 
and their families have completed the WCT program, with over 30,000 
returning to the force. Soldiers who return to the force result in a 
substantial cost savings in terms of recruitment, education and 
training. The Army also benefits in terms of readiness by retaining 
experienced, highly educated and trained Soldiers. As of December 2016, 
our WCT population was 2,250 (decreased from 2,861 1 year ago), of 
which 48 Soldiers were battle injured. This represents a great shift 
from our highest population of 12,279 in July 2008, of which 1,996 
Soldiers were battle injured, corresponding with a drawdown in 
contingency operations. In June 2016 the WCT program consolidated from 
25 to 14 units and aligned to U.S. Forces Command Force Projection 
Platforms, Divisions, and Corps, but this program will remain an 
enduring capability that can be rapidly expanded when needed. Our 
wounded, ill and injured Soldiers will continue to receive the highest 
level of care in order to successfully recover and return to the force 
or transition to Veteran status. I will also continue to improve upon 
our current relationships with the VA and our Veteran and Military 
Support Organizations to ensure our transitioning Soldiers have the 
resources required for a successful transition to Veteran status.
    Some of our Warriors cannot return to duty, but have gone on to 
make remarkable contributions to society in sports, the arts, skilled 
trades, and public or government positions. WCT hosted the 2016 Warrior 
Games, delivering not only unparalleled recognition for wounded 
athletes, but also inspiration for countless other wounded who could 
see a road to recovery through sports. Drawing upon their experiences, 
education, insights, and the emotional and physical rehabilitation 
delivered by WCT, our Warriors serve as role models--inspiring both 
Soldiers and civilians spiritually and physically.
                               conclusion
    The sun never sets on Army Medicine. We are globally engaged, 
supporting our Army whenever and wherever needed; we have done so since 
1775 and will continue as long as there is an Army. Congressional 
support has enabled Army Medicine and advanced military medical care in 
support of our Nation, our Army, and the Joint Force. What we do is 
truly important but is not the complete story of Army Medicine.
    Just as the Army protects our freedoms and national interests, Army 
Medicine protects our Soldiers, Retirees, and their families by 
enabling readiness and promoting health. To take care of our Soldiers, 
our medical professionals ensure they receive the care they need and 
the care they deserve from the forward edge of battle all the way back 
to their homes. That is what we do but, in closing, I would like to 
describe what we are for. Army Medicine is for saving lives and 
conserving the fighting strength. Our Nation sends their sons and 
daughters to answer our Nation's call knowing we will take care of them 
whenever and wherever needed.
    The Strength of our Army is derived from our Soldiers, and in turn, 
their Families. Our strength is not derived from a weapon or a weapons 
system; it is derived from our people. Army Medicine is a driving force 
behind the innovations and technologies that allow us to adapt to 
future challenges that may arise at home or abroad. We will continue to 
provide the full spectrum of care from point of injury or illness on a 
battlefield through rehabilitative care while continuing to meet or 
exceed national quality of care standards in garrison environments. 
This is our sacred trust with our Nation and our readiness to support 
our Nation's Army can never and will never be in doubt.
    I remain committed to improving readiness, enhancing the healthcare 
delivered to our beneficiaries, evolving to support the Army and Joint 
Force in future conflicts, and continuing to take care of our Soldiers, 
Civilians, and their Families. I appreciate the subcommittee's work and 
continued support to our Army, our Soldiers and to Army Medicine.

    Senator Cochran. Thank you very much, General. I will now 
recognize the distinguished Vice Admiral Forrest Faison, 
Surgeon General of the Navy, for any opening statement.
STATEMENT OF ADMIRAL FORREST C. FAISON, III, SURGEON 
            GENERAL, UNITED STATES NAVY
    Admiral Faison. Sir, thank you. Chairman Cochran, Vice 
Chairman Durbin, distinguished members of the subcommittee, 
thank you for the opportunity to update you on Navy Medicine. 
We value your important oversight role and remain grateful for 
your support.
    Navy Medicine is a versatile, ready, agile, and rapidly 
responsive medical force that directly supports the Navy and 
Marine Corps, America's premier maritime and expeditionary 
forces, anywhere and everywhere our Nation calls upon them.
    I can assure you the men and women of Navy Medicine, 63,000 
strong, are working hard to support that force and provide 
world class care anytime, anywhere.
    My full statement provides you with detailed updates, but 
in the interest of time, my opening remarks will focus on our 
most important priority, readiness. We have no greater 
responsibility than standing readiness now and in the future.
    On any given day, Navy Medicine personnel are forward 
deployed with the Fleet, Marine Forces, Special Warfare Units, 
the Joint Force, and at overseas commands, supporting a high 
operational tempo in meeting the demand for contingency 
operations around the world.
    Just as importantly, shipmates are supporting the Navy-
Marine Corps team in a variety of ways, including delivering 
care in our statewide and overseas hospitals and clinics, 
continuously honing their clinical and operational skills and 
training to provide lifesaving and health sustaining 
capabilities when deployed to their operational platforms 
around the world.
    Those responsibilities set us apart from the civilian 
healthcare sector. We remain one of the few nations that 
maintain a sizeable immediately ready to serve medical force at 
standing to support both operational contingencies and rapid 
disaster response, helping to preserve America's strategic 
influence in key regions around the world, and strengthening 
relationships with our partners and allies.
    In sustaining our readiness capabilities for the next 
conflict, new approaches to training, preparation, equipment, 
and support required by our operational and deployed medical 
personnel will be critical to realizing high combat 
survivability, as we witnessed during the most recent 
conflicts. These considerations are critically important as we 
move forward.
    Skills sustainment of our medical personnel is paramount. I 
have previously articulated the important role of our military 
treatment facilities in ensuring our personnel have the vital 
skills and clinical competencies needed to save lives on the 
battlefield.
    These military commands are our training and surge 
platforms where we prepare and then rapidly surge medical 
forces when needed. They provide peacetime healthcare as one of 
several ways to preserve their clinical skills, but that is not 
their primary purpose.
    Their readiness and force projection platforms combined and 
integrated within Navy Medicine's readiness commands and 
structure allow our personnel to gain both clinical 
competencies and develop required military skills in these 
commands, and are prepared to rapidly surge when required.
    One of our primary reasons for the high combat 
survivability rate we have realized is the heroic work by our 
Navy hospital corpsmen, the Navy's largest enlisted rating. You 
and the American public can be justifiably proud of their 
tremendous sacrifices and contributions.
    Corpsmen are responsible for delivering initial healthcare 
on the battlefield or in an isolated assignment, aboard a ship 
or submarine, far away from shore or any MTF (Military 
Treatment Facilities).
    To this end, we are changing and improving the training of 
our hospital corpsmen ``A'' school in San Antonio. Our 
curriculum changes are focused on providing ready and relevant 
training that will prepare them to manage the continuum of care 
in a high threat or complex environment most likely to be 
encountered by our sea-based expeditionary Navy and Marine 
Corps Forces.
    We are also continuing to leverage our private and academic 
partnerships in key areas, such as trauma training at LA 
County, where we have trained over 3,100 personnel, as well as 
the trauma and burn program at the Federal Health Center in 
Chicago, in partnership with Cook County Health and Hospital 
Systems.
    Our readiness focus is also evident in our commitment to 
global health engagement. As I speak to you this morning, Navy 
Medicine personnel are deployed in support of Continuing 
Promise 2017, a civic humanitarian mission in the Caribbean, 
Central and South America, where they are working with host 
nation counterparts to deliver medical service.
    Likewise, these shipmates concluded a similar mission in 
September, Pacific Partnership 2016, a major multilateral 
disaster relief preparedness mission in the Indo-Asia Pacific 
area of operations.
    These efforts are complemented by the innovative work in 
our research and development labs around the world where we are 
addressing critical military relevant research priorities, 
including malaria vaccine development, to protect our forces 
now and in the future.
    All Navy Medicine Commands, MTS, education and training, 
research and development, public health, and logistics, are 
focused on protecting the health of sailors, Marines, and their 
families, in preparing for the next deployment.
    In closing, America's sailors and marines are the most 
highly trained, educated, and specialized forces in our 
Nation's history. Each is essential to the mission. The demand 
to keep them healthy, ready, and on the job has never been 
greater. At the same time, they must be confident that their 
family members will be well cared for when they are deployed.
    We in Navy Medicine have no greater calling than to ensure 
we are doing all we can to provide the best care our Nation can 
offer, and do all in our power to one day return home alive, 
safe, and well, those who have volunteered to defend our 
freedom.
    Thank you, sir. I look forward to your questions.
    [The statement follows:]
        Prepared Statement of Vice Admiral C. Forrest Faison III
    Chairman Cochran, Vice Chairman Durbin, distinguished Members of 
the Subcommittee, thank you for the opportunity to update you on Navy 
Medicine. You have an important oversight role and we remain grateful 
for your support. Navy Medicine is a ready, agile and rapidly 
responsive medical force that directly supports the Navy and Marine 
Corps, America's premier expeditionary forces. I can assure you that 
the men and women of Navy Medicine--63,000 strong--are working hard to 
support that force and provide world-class care, anytime, anywhere. We 
never waiver from our commitment to those entrusted to our care, 
wherever they serve.
                          strategic framework
    In 2016, the Chief of Naval Operations (CNO) issued A Design for 
Maintaining Maritime Superiority which clearly articulates several key 
strategic imperatives and initiatives for the Navy. His message is 
clear: We must understand the character of the changing security 
environment and be ready to rapidly respond. Navy Medicine understands 
this mandate as we are the ready medical force that supports both the 
Navy and Marine Corps in all warfare domains.
    In alignment with the CNO and the Commandant of the Marine Corps, I 
issued my Commander's Guidance which focuses on the need to recognize 
that, in these transformational times, providing the best readiness, 
operational support, and health to the force protecting our interests 
around the world, requires unmatched commitment by all in Navy 
Medicine. I also reiterated our important guiding principles: honor the 
trust to provide the best care possible to those who defend our 
freedom; honor the uniform we wear; and, honor the privilege of 
leadership. Our strategic priorities include:

  --Readiness: We save lives wherever our forces operate--at and from 
        the sea.

  --Health: We will provide the best care our Nation can offer to 
        Sailors, Marines and their families to keep them healthy, ready 
        and on the job.

  --Partnerships: We will expand and strengthen our partnerships to 
        maximize readiness and health.

    These goals are directly relevant to the men and women of Navy 
Medicine. We never waiver from our core readiness responsibilities: 
ensuring the medical capabilities of our operational units and 
platforms are ready and the readiness, training, clinical experience, 
and preparation of the medical force supporting them is unmatched. Our 
Navy and Marine Corps is more highly trained, specialized, and deployed 
than ever before. Every Sailor and Marine is critical to the mission. 
We protect, maintain and restore the health of our service members and, 
in doing so,we treat them and their families as ``family'' by 
integrating healthcare in their lives through enhanced access and 
convenience. We are working hard to ensure that our Sailors and Marines 
have the healthcare support when and where they need it (and want it), 
making them partners in health and improving readiness. Navy Medicine 
is also stronger as a result of our partnerships and collaborations. We 
will continue to leverage these opportunities with the other Services, 
Defense Health Agency (DHA), interagency partners, academia and 
industry to fulfill our responsibilities and advance common interests.
    I recognize that sustained and measurable progress on these goals 
requires the contributions from the entire Navy Medicine team. I am 
encouraged as to how strongly these priorities are resonating 
throughout our commands and we will continue to build on the progress 
we have made. We will, however, be challenged as our operational tempo 
remains high, the healthcare landscape continues to evolve, and our 
beneficiary population demographics and expectations change. These are 
significant considerations that will continue to influence our planning 
as we move forward.
    Navy Medicine is grateful for your efforts in supporting our 
resource requirements. Inherent in our business practices is sound 
fiscal stewardship of the resources provided to us. The fiscal year 
2017 National Defense Authorization Act (NDAA) directs many significant 
changes to the Military Health System (MHS), including the 
administration of our military treatment facilities (MTFs). I want to 
assure you that we are working closely with the DHA, the Joint Staff, 
the Army and Air Force to develop implementation plans to realize the 
very real benefits intended. These provide a great opportunity to us, 
but given our high operational tempo and the transformational impact on 
the Services and Combatant Commands, it is important that we proceed to 
affect these reforms with the requisite due diligence, rigorous 
analyses and careful planning. This is necessary to meet congressional 
intent while continuing to support a highly deployed expeditionary 
force with global commitments in a rapidly evolving and challenging 
world.
              sustaining readiness: now and in the future
    Navy Medicine provides ready, agile, and rapidly responsive force 
medical projection to a highly mobile expeditionary Navy and Marine 
Corps team. On any given day, Navy Medicine personnel are forward 
deployed with the Fleet, Fleet Marine Forces, special warfare units and 
at overseas commands, all while continuing to support a high 
operational tempo and demand to support overseas contingency operations 
and numerous joint taskings in multiple areas. Just as importantly, our 
shipmates are supporting the Fleet and Fleet Marine Force in a variety 
of ways, including delivering care in our state-side and overseas MTFs, 
continuously honing their clinical and operational skills and training 
to provide life-saving and health sustaining capabilities when deployed 
to the operational platforms to which they are assigned. As the Navy 
and Marine Corps' ready medical force, Navy Medicine has full-spectrum 
responsibilities to man, train and equip--to ensure individual clinical 
and operational readiness, deployable unit/platform readiness and force 
readiness.
    These responsibilities set us apart from the civilian healthcare 
sector. We remain one of the few nations that maintain a sizable, 
ready-to-immediately-surge standing medical force to both support 
operational contingencies and rapid disaster response, helping to 
preserve America's strategic influence in key regions of the world and 
strengthening relationships with our partners and allies. We are ready 
to get out the door and save lives tonight and this is the foundation 
of our commitment to those who serve and their families: We will be 
with them whenever and wherever they go, from day one forward.
    The highest combat survival rate in recorded history during the 
last conflict was the direct result of three factors: (1) advanced 
training, preparation, and improved equipment of our corpsmen and 
medics to provide life-saving intervention at the point of injury; (2) 
forward deployment and rapid access to forward resuscitative surgery to 
provide timely damage control surgery; and (3) rapid and effective 
medical evacuation and enroute care to higher echelons of care within 
and outside of theater. We also had several advantages in a network of 
robust operating bases, rapid casualty recovery, a commitment by 
leadership to provide on-demand aeromedical evacuation, enabled by 
relatively unchallenged ground and air superiority. In sustaining our 
readiness capabilities for the next conflict, likely in a denied 
environment and a distributed force, we must recognize that the 
training, preparation, equipment and support required by our 
operational and deployed medical personnel will need to change in order 
to sustain high combat survival under those different circumstances. 
Survivability in the future warfighting environment requires medical 
capabilities which are immediately deployable, designed, sustained and 
integrated into the operating forces to meet Navy and Marine Corps 
unique requirements. These considerations are important as we move 
forward with our expeditionary health service systems modernization 
efforts.
    As a former commander/commanding officer of a medical center, 
hospital and deployed commander in theater of an expeditionary medical 
facility, I know the importance and operational effectiveness of having 
a fully trained and ready medical force capable of sustaining 
unprecedented battlefield survival.
    In my previous testimonies, I have articulated the important role 
that our MTFs have in ensuring that our personnel have the vital skills 
and clinical competencies to save lives on the battlefield. These 
military commands are our training and surge platforms where we prepare 
and then rapidly surge medical forces when needed. They provide 
peacetime healthcare as one of several ways to preserve clinical 
skills, but that is not their primary purpose. They are readiness and 
force projection platforms. Combined and integrated within Navy 
Medicine's readiness commands and structure, our personnel gain both 
clinical competencies and develop required military skills in these 
commands.
    Clinical experience sustained within these MTFs is important to 
operational readiness and I believe that our collective efforts within 
the MHS to better codify the knowledge, skills and abilities required 
will be important moving forward. This is critical as we implement 
required reforms to ensure we operate those training and surge 
platforms in ways that enhance readiness, rapid deployment of forces, 
and ultimately combat survival. As a subset of those platforms, we must 
also recognize that our overseas MTFs have an additional role--that of 
medical support to the forward deployed Naval and Marine force. They 
are the ``ship's sick bay'' for those overseas forces and are critical 
to our ability to keep that force on point, on station, and ready to 
respond. We must also recognize that our overseas MTFs directly support 
our forces operating forward in their area of responsibility and have 
unique requirements, including disaster response. All Navy Medicine 
commands--MTFs, education and training, research and development, 
public health, logistics--are focused on preparing for our next 
conflict.
    Within Navy Medicine, we recognize the value of private and 
academic partnerships in areas such as trauma training. Our Navy Trauma 
Training Center (NTTC) operates at Los Angeles County + University of 
Southern California (LAC+USC) and provides our personnel first-hand 
clinical experience at this Level 1 trauma center. To date, we have 
trained over 3,100 personnel through this partnership and have added a 
four-day short course for our interested international partners. We are 
also continuing to use our agreement with the Cook County Health and 
Hospital Systems (CCHHS) Trauma and Burn Experience for our Navy 
medical personnel assigned to the Federal Health Care Center (FHCC) in 
North Chicago to have one to 2 month rotations in their trauma and burn 
units. Our military providers work hand-in-hand with the attending 
surgeons, residents and nurses to gain a multi-faceted experience aimed 
at management of the acutely injured patient. We are working to expand 
these types of partnerships, both domestically as well as in creating 
innovative collaboration exchanges with foreign partners in countries 
where the trauma injury mix and acuity is much greater in order to 
sustain our combat casualty skills for our trauma teams and improve the 
MHS Joint Trauma System.
    I also want to reiterate the important role that graduate medical 
education (GME) has in maintaining an agile, ready, and proficient 
medical force. The training our trainees receive and the care they 
provide in our teaching facilities directly support readiness--
including combat casualty care, humanitarian assistance/disaster 
response (HA/DR) and global health engagement (GHE). Our Navy-sponsored 
full time in-service training (FTIS) GME is the most tailorable tool 
for generating physicians to meet operational readiness requirements. 
We can shape the operationally-relevant content of training, mentor 
junior physicians with deployment-seasoned senior physicians, and 
inculcate military culture and ethos. Our programs also allow for 
maximum agility and responsiveness in medical specialist force 
generation in support of Combatant Command requirements. These programs 
are also some of the best in the country, civilian or military: Our 
leadership can look with confidence into the eyes of American families 
and tell them the men and women caring for their loved ones are among 
the best trained in the nation. When available and appropriate, we 
actively partner with civilian training institutions to help maintain 
our specialty requirements. But we recognize civilian GME cannot absorb 
the number of Navy's traditional specialty training requirements due to 
a national shortfall in residency positions, especially in some of our 
critical wartime specialties.
    As required by the fiscal year 2017 NDAA, we, in conjunction with 
the DHA, Army and Air Force, are jointly working on the required 
oversight process to ensure that GME program investments fully support 
the readiness of our personnel, service members for whom we care, and 
our Services' unique and joint missions. In a dynamic environment, we 
continue to pay careful attention to our GME portfolio to ensure we can 
adjust and meet changing demands.
    One of the primary reasons for the high combat survivability rate 
we have realized is due to the heroic work by our hospital corpsmen, 
the Navy's largest enlisted rating. Corpsmen are responsible for 
delivering initial care on the battlefield or in an isolated assignment 
aboard a ship or submarine far from any MTF. This will continue to be 
true and relevant in future conflicts as well. Well trained and 
experienced corpsmen are critical to combat survival in all domains 
where the Navy and Marine Corps operate. Our ability to provide top 
quality training and a robust follow-on clinical experience for our 
hospital corpsmen will most certainly drive the survivability of combat 
casualties in any future conflicts. To this end, we are changing and 
improving the training of our corpsmen at HM ``A'' school at the 
Medical Education and Training Campus (METC) in San Antonio, Texas. Our 
curriculum changes are focused on providing ready and relevant training 
that will prepare these personnel to manage the continuum of care in 
high threat complex environments most likely to be encountered by our 
sea-based expeditionary Navy and Marine Corps forces. In parallel with 
improving our foundational and follow-on clinical training, we are 
working closely with the DHA to ensure our other advanced medical 
specialist training programs conducted at METC achieve or maintain 
civilian equivalent academic accreditation and credentialing 
opportunities. I am committed to helping ensure that our corpsmen get 
the industry equivalent certifications and licensure they have earned. 
These credentials will further elevate the quality of care provided as 
part of our commitment to American families and will help our corpsmen 
when they transition back to the civilian sector with industry-
recognized and valued skills.
    Another important component of readiness comes from our commitment 
to GHE. These efforts support the Navy's global reach and forward 
presence by fostering and sustaining cooperative relationships with 
allies and international partners. GHE activities have become valued 
and integral assets supporting Combatant Commanders' priorities, 
including participation in humanitarian civic action (HCA) missions. 
USNS MERCY (T-AH 19) deployed in support of Pacific Partnership 2016, 
the largest annual multilateral, multi-service disaster relief 
preparedness mission conducted in the Indo-Asia Pacific area of 
operation. Medical, dental, veterinary, and public health services, 
along with engineering and disaster response training and medical 
education were provided in Timor Leste, Philippines, Vietnam, Palau, 
Malaysia and Indonesia, all strong partners in the Pacific and critical 
to our efforts to ensure peace and economic stability in that part of 
the world. The medical team provided direct medical and dental care to 
over 9,500 patients and performed 343 surgeries aboard MERCY. I was 
aboard MERCY in Malaysia and had the opportunity to see firsthand the 
multilateral cooperation, training and subject matter expert exchanges.
    Continuing Promise 2017, a HCA mission currently underway in the 
Caribbean, Central and South America, is being conducted with USNS 
SPEARHEAD (T-EPF 1), an expeditionary fast transport vessel used to 
transport personnel and equipment. Embarked are medical personnel who 
are working with host nation counterparts and health professionals in 
Guatemala, Honduras and Colombia. This mission employs an expeditionary 
approach with our teams being transported ashore to provide care. An 
estimated 15,000 people will be provided a variety of medical services.
    GHE missions are often referred to as ``soft power'' and in many 
cases the exact impacts are hard to quantify. While it is difficult to 
measure good will, in almost every theater and country where we execute 
these missions, we see increased access, increased transparency and 
interoperability, along with increased opportunities for those partner 
nations to contribute to regional security and stability.
    Our personnel must also be prepared to support efforts associated 
with public health emergencies and augment whole of government efforts 
as the largest Federal medical force. Navy Medicine actively supported 
the Department of Defense interagency efforts to address the Zika virus 
outbreak to include adapting the Centers for Disease Control and 
Prevention's Zika Action Plan for use at Navy and Marine Corps 
installations. As part of this plan, the Navy Entomology Center of 
Excellence (NECE) conducted installation technical assistance visits to 
assess the comprehensive mosquito vector controls necessary to reduce 
the risk of disease transmission. The Navy and Marine Corps Public 
Health Center (NMCPHC) developed timely educational material for 
beneficiaries, with emphasis on pregnant women and women of 
childbearing age to help decrease the risk of microcephaly. Commanders 
quickly promulgated force health protection guidance to best protect 
operational Sailors and Marines as concerted efforts actively monitored 
for and tracked confirmed cases.
    Navy Medicine continues to collaborate and coordinate with the 
Services and interagency partners to mitigate the threat of Zika virus 
to beneficiaries through policy, prevention, and response. Our teams 
made significant contributions toward Zika virus and blood screening 
diagnostics. The Naval Medical Research Center (NMRC) developed a 
confirmatory Plaque Reduction Neutralization Test which is currently 
the only DoD diagnostic laboratory facility to utilize this advanced 
capability and that has helped decrease the burden of tests sent to 
other already burdened Federal and State reference laboratories. The 
test is necessary to confirm positive serology for the Zika virus and 
also provides rapid, in-house results to support our personnel engaged 
in sustained expeditionary operations in support of a high operational 
tempo. Furthermore, to diminish the risk of a tainted DoD blood supply, 
the Navy Blood Program established Zika testing at designated blood 
donor sites.
          improving health, optimizing care and driving change
    Our Sailors and Marines are the most highly trained, educated and 
specialized force in our Nation's history--and each is essential to the 
mission. The demand to keep them healthy and on the job has never been 
greater. At the same time, they must be confident that their family 
members will be well cared for when are they deployed. In addition, the 
healthcare industry and practice of medicine are rapidly changing and 
this evolution continues to impact military medicine. Our patients have 
more choice than ever, with very different expectations. Their 
healthcare choices are driven by convenience, experience of care, and 
technology. These realities are fundamentally changing the way 
healthcare is delivered. For us, to remain engaged, relevant, and 
maintain visibility of the health of the force, we continue to partner 
with our beneficiaries to meet their needs. We are making progress, but 
more work is needed and we are committed to making those improvements. 
I continue to assert that the direct care system is the epicenter of 
these efforts. We can best support our beneficiaries and maintain 
visibility of their health and readiness when they come to us for their 
care. The MHS leadership understands this imperative and we will be 
leveraging the economies associated with greater standardization 
consistent with provisions in the fiscal year 2017 NDAA.
    Transformation to a high reliability organization (HRO) remains a 
major priority. Reflective of the variability that is inherent in 
American healthcare, we also have variability in healthcare and that 
impacts readiness. Our journey toward high reliability is our response. 
As a HRO, we have centered our work on improving clinical outcomes and 
coordination of care, enhancing access, leveraging technology and 
achieving the highest level of patient safety. To support these 
enterprise-wide efforts, I have assigned a flag officer to serve as 
Navy Medicine's chief quality officer to directly oversee and 
streamline our patient safety, quality and high reliability efforts.
    In addition, we have also assigned chief medical officers (CMOs) at 
our regional commands and MTFs to help drive change needed for HRO 
transformation at the deckplate. Navy Medicine is organizing several 
clinical communities--multidisciplinary teams comprised of stakeholders 
from each level of our organization--each organized around a specific 
clinical community (i.e. women's health, surgical services, dental) to 
improve innovation, foster collaboration, eliminate unnecessary 
variability, and reduce redundancy. In addition, we are fully engaged 
with the MHS to measure and monitor performance using the Partnership 
for Improvement (P4I) dashboard and continue to work with leading 
civilian healthcare organizations in our HRO journey.
    Convenient, accessible care is fundamental to our system. We 
recognize that if our patients confront challenges in making an 
appointment, contacting their provider or refilling a medication, they 
will seek their care elsewhere. My goal is to provide ``frictionless 
care'' focusing on: (1) promoting additional options for accessing care 
without requiring a visit to the MTF; (2) when a visit is needed, 
standardizing appointing processes; and (3) measuring our performance 
in meeting the needs and expectations of our patients. Navy Medicine 
should be their provider of choice and, when needed, our MTFs should be 
the place where our beneficiaries want and choose to obtain their care.
    The reality is that a ``visit'' is no longer limited to a face-to-
face interaction with a primary care provider and many needs don't 
require a visit to the provider. Our beneficiaries, over 815,000 of 
whom are enrolled to our Medical Home Port (MHP) clinics, now have the 
option of receiving care through multiple means conveniently, on their 
schedule and at the appropriate place of care for their needs. Our 
patients have busy lives and we know they have options for receiving 
their care. We are increasing access and options for them through in-
person visits, telephone consults, securing messaging with their PCM or 
triage and self-care advice with the nurse advice line. We have 
expanded the capabilities of MHP to include appointments with a growing 
number of embedded specialists such as behavioral health providers, 
clinical pharmacists, pain management experts and health educators.
    All of the Services are utilizing a ``First Call Resolution'' 
policy which addresses warm hand- offs between appointing and clinic 
personnel any time an appointment is not available that meets the 
patient's preferences. When our enrollees call for primary care 
appointments, their requests will be addressed on the first call. We 
provide an appointment or offer prompt phone consultation with a nurse 
or other team member to assist in arranging needed care. Our patients 
will not be asked to call back at another time. Secondly, our 
``Simplified Appointing'' policy enhances appointment availability and 
makes obtaining and booking appointments easier. While the MHS goal for 
same-day/next-day access is within 24 hours, Navy sets an internal 
stretch goal of 0.5 days in order to provide same day care as much as 
possible throughout our enterprise. We monitor the success of these 
initiatives, like many high-performing civilian health systems, through 
beneficiary experience of care survey results, and adding specific 
questions to the new Joint Outpatient Experience Survey (JOES) which 
examine the ease of making appointments, satisfaction with wait times, 
and whether our patients were asked to call back for an appointment.
    At a time when our patients have more choice than ever for care 
alternatives, they are choosing us and that allows us to maintain 
visibility and relevance over the health of the force. Approximately 97 
percent of primary care and urgent care is done in the MTFs, and I am 
encouraged by the progress we are making as evidenced by some of our 
key performance metrics. In fiscal year 2016, Navy Medicine increased 
enrollment in our MTFs by 3 percent and concurrently cut the 
appointment wait times--both for 24 hour and future appointments--
realizing 17.4 percent and 23 percent improvements, respectively. We 
are seeing better utilization of emergency department (ED) care among 
our enrolled beneficiaries with the average number of ED visits for 
primary care reasons decreasing 8.2 percent in the purchased care 
system. Furthermore, over 425,000 of our enrolled beneficiaries are now 
connected to secure messaging and they are sending, on average, over 
30,000 messages monthly to their providers.
    Recognizing that we have no higher priority than keeping our 
service members medically ready, Navy Medicine has tailored our MHP 
model for the operational community so more Sailors and Marines receive 
the same convenient access to care including integrated behavioral and 
psychological health resources. We currently have 28 Marine-Centered 
Medical Homes and five Fleet-Centered Medical Homes, a combined 
increase of ten from last year.
    In October 2016, Navy Medicine launched a Value-Based Care pilot at 
Naval Hospital Jacksonville. In selecting Jacksonville, we conducted a 
population and system needs analysis of direct care and purchased care 
data. Diagnosis codes were used to target high volume conditions, with 
active duty impact, high cost (either per encounter or by volume), 
patient satisfaction, and readiness (both medically ready and ready 
medical force). Purchased sector care volume and cost were also 
factored into selecting the conditions for this phased pilot. Low back 
pain, osteoarthritis, diabetes, and pregnancy were selected as the four 
medical conditions.
    The command formed integrated practice units (IPUs) comprised of 
physicians, nurses, ancillary support staff, behavioral health 
providers and other specialties that established evidence-based, 
standardized care pathways for each of these conditions. In an IPU 
model, care is administered along a continuum that simultaneously 
mobilizes all providers and other healthcare professionals associated 
with a patient's care, resulting in an impactful level of coordination. 
In this model, the patient is a key part of the treatment team. The 
improved coordination between the patient and a multidisciplinary 
healthcare team has led to improved outcomes, patient satisfaction, and 
a quicker return to duty for our active duty. I am encouraged by the 
commitment from our staff and the enthusiastic response from our 
patients. As the pilot progresses through fiscal year 2017, we will be 
carefully assessing how the Value-Based Care model impacts the 
experience and convenience of care for our patients, the use of 
technology to support their needs, and our ability to control the cost 
of care. This approach to healthcare delivery is unique such that we 
have begun collaborating with Harvard Business School's Institute for 
Strategy and Competitiveness, at their request, to document our pilot a 
case study as a best practice in healthcare.
    The evolution in healthcare, coupled with the expectations of our 
tech savvy Sailors, Marines and their families, make it imperative that 
we leverage the most appropriate technology acceptable and useful to 
them. Virtual Health (VH) enhances readiness and health, and improves 
the patient experience by facilitating how and when care is provided. 
Importantly, VH helps to mitigate the tyranny of time, distance and 
location--improving access to care for those in isolated sites. For 
Navy Medicine, as an expeditionary medical force, these capabilities 
are particularly important as Navy and Marine forces deploy around the 
world. By leveraging VH, we are now providing enhanced care that would 
not have been available just 5 years ago to our Sailors and Marines 
operating forward.
    Our HELP (Health Experts On-line Portal) at the Naval Medical 
Center Portsmouth continues to provide specialty and subspecialty 
consultations to Navy's afloat commands as well as our MTFs in the U.S. 
and overseas. HELP is being expanded to the Navy Medicine West area of 
responsibility this year. We are also leveraging current capabilities 
including tele-radiology and tele-dermatology support to MTFs and 
operational platforms in Europe and Bahrain, as well as tele-radiology 
support to providers in Djibouti. Our tele-critical care (TCC) at Naval 
Medical Center San Diego supports Naval Hospitals Camp Lejeune and Camp 
Pendleton with plans underway to provide capability this year to Naval 
Hospital Guam and our Role 3 Multinational Medical Unit in Kandahar, 
Afghanistan. There are tremendous opportunities associated with 
bringing care to our patients as part of our pursuit to improve the 
convenience of care. Earlier this year, we launched our Navy Medicine 
mobile application to better support our beneficiaries. Moving forward, 
we will continue to build on this platform throughout Navy Medicine to 
ensure our patients have access to a convenient, patient-centered 
mobile capability.
    Military medicine deployed a new electronic health record (EHR), 
MHS GENESIS, at its first site early this year. A project of this scope 
and magnitude is ambitious; however, the opportunity to substantially 
enhance the delivery of care is significant. The Services, DHA and 
Defense Healthcare Management Systems Program Executive Office are 
working closely to finalize configuration for initial operating 
capability (IOC). Naval Hospitals Bremerton and Oak Harbor are 
scheduled for IOC deployment later this year. MHS GENESIS will be used 
in our MTFs, onboard our afloat commands, and in the field with Marine 
forces, to drive standardization while providing one platform to access 
accurate healthcare data worldwide. In addition, this new EHR will 
maintain and further enhance interoperability with Veterans 
Administration (VA) and private sector systems, ensuring compatibility 
with the standardized healthcare data framework and exchange standards 
so that service members' and beneficiaries' medical records are readily 
accessible by all of their providers.
    Navy Medicine delivers worldwide, evidence-based mental healthcare 
for Sailors, Marines, and their families across the continuum of care. 
Evaluation and treatment services are available in multiple platforms 
and locations, with ongoing efforts to further improve access to 
services for our beneficiaries. The Behavioral Health Integration 
Program (BHIP), embedded within our Medical Home Port clinics, provides 
a pathway to access mental health services and has continued to see an 
increase in demand enterprise-wide. Placement of psychological health 
providers in MTF ED settings has streamlined referrals to specialty 
mental healthcare and reduced wait times. In addition, we are 
completing our roll-out of the Tri-Service Behavioral Health Data 
Portal (BHDP) at all our MTFs. BHDP is a software-based clinical 
evaluation tool that provides improved patient tracking with and across 
mental health clinics, real-time information regarding Sailors and 
Marines' psychological health readiness and helps ensure optimal, 
coordinated mental healthcare.
    We are continuing direct mental health support to Navy and Marine 
Corps operational units through a redistribution of existing personnel 
to high demand units. We have expanded our Embedded Mental Health (EMH) 
program to additional Fleet units. EMH providers deliver support and 
subject matter expertise directly to the operational forces by reducing 
barriers in accessing timely mental health evaluation and treatment. We 
know that psychological health impacts can be mitigated by the presence 
of these providers offering early evaluation, resilience training, 
counseling, and treatment to limit personnel losses, and in many cases 
result in service members returning to full duty.
    There are multiple settings in which operational/embedded 
psychological health providers have been functioning for many years 
including Marine infantry, aircraft carriers, amphibious assault ships 
and special forces. This forward footing has been highly regarded by 
Navy and Marine Corps commanding officers who appreciate and have come 
to expect the embedded mental healthcare and ready access to counsel on 
psychological health matters. This directly supports our Fleet and 
Fleet Marine Force readiness and operational tempo. Building on our 
commitment to the operational forces, we have bolstered our 
capabilities by increasing the number of EMH personnel assigned within 
Fleet Forces Command, Pacific Fleet Command, Special Warfare Command, 
and Coastal Riverine Groups. Correspondingly, our Operational Stress 
Control and Readiness (OSCAR) providers assigned to Marine Corps forces 
continue to provide mental health support at the Regimental, Division, 
Squadron, Group, and Marine Expeditionary Unit levels.
    These efforts also complement important work within the Navy, 
Marine Corps and Defense Suicide Prevention Office (DSPO) to advance 
suicide prevention programs, including identifying those most at risk. 
We know the devastating impact that suicide has on our families and 
commands and our priority continues to be improving resilience and 
breaking down barriers in seeking mental healthcare. In an attempt to 
standardize clinical suicide risk assessments across all primary care 
and specialty mental health clinics, Navy Medicine is implementing and 
training providers in a single screening tool in 2017. In addition, 
Navy Medicine consults as a subject matter expert to the Sailor 
Assistance and Intercept for Life (SAIL) program which targets patients 
recently discharged from the hospital with suicidal ideations to ensure 
continuity and coordination of mental healthcare. The post-psychiatric 
hospital time period is particularly high risk for patients.
    Throughout Navy Medicine, our commitment to preventing, 
identifying, educating, training and treating traumatic brain injuries 
(TBI) remains strong. Over 80 percent of TBIs are mild TBI, or 
concussion, and of these, over 80 percent are not deployment-related. 
We are continuing to collaborate with the other Services, DHA, and the 
Defense and Veterans Brain Injury Center (DVBIC) on several important 
components including training resources, data collection platforms and 
treatment methodologies. These efforts are complemented by research 
efforts with academic institutions directly related to improving TBI 
diagnosis and treatment. Our Intrepid Spirit Center at Naval Hospital 
Camp Lejeune recently designed and implemented a 5-week ``Return To 
Forces'' intensive TBI treatment program, tailored to the needs of 
Special Forces groups. Participants enter as a cohort and undergo a 
week-long comprehensive assessment, followed by four weeks of 
intensive, holistic, interdisciplinary treatment. Success rates have 
been good and demand has steadily been increasing. In an effort to 
share best clinical practices, our TBI clinic at Naval Hospital Camp 
Pendleton is developing a similar program and this model of care is 
being shared with the other Services.
    The Navy Comprehensive Pain Management Program (NCPMP), as an 
integrated component of our Medical Home Port clinics, provides a 
patient-centered, interdisciplinary approach focusing on comprehensive 
and coordinated treatment of pain while also targeting opioid abuse and 
addiction. Our strategy, in the treatment of acute and chronic pain, 
continues to emphasize compliance with clinical practice guidelines, as 
well as prevention and education, for both providers and patients. We 
are also continuing to utilize tele-mentoring programs to include, 
Project ECHOTM (Extension of Community Healthcare Outcomes) 
which expands the access to pain management specialists for our primary 
care providers. An analysis of ECHO clinics' effect on opioid 
prescribing habits indicates substantial reductions in opioid 
prescription prevalence for patients presented in the clinics. 
Analyzing patients' opioid prescriptions received 6 months before and 6 
months after presentation of their case at ECHO reveals the average 
day-supply of prescriptions fell by 10 percent after being presented 
and total prescriptions written to patients following their ECHO fell 
by 30 percent. Taken together, these observations indicate a more 
judicial use of opioid pharmacotherapy and more engaged management of 
patients receiving opioid prescriptions.
    We have also expanded our focus on long-term opioid therapy safety 
(LOTS) by: (1) increasing the education of our providers using the 
Joint Pain Education Program (JPEP) modules specifically targeted to 
the non-pharmacological approach to pain management; (2) developing 
policy for our MTFs that details the requirements consistent with 
evidence-based procedures to improve clinical outcomes and patient 
safety for those receiving long-term opioid therapy; and (3) expanding 
our clinical capabilities to provide comprehensive, multidisciplinary 
pain management modalities as alternatives to opioid therapy. Our 
requirements align with those of the Centers for Disease Control (2016 
Guideline for Prescribing Opioids for Chronic Pain, 2016) and DoD/VA 
clinical practice guidelines. As NCPMP is fully stood up at seven MTFs 
in 2017, we will monitor restoration of function, patient safety 
through the percentage of patients on long term opioids, pain 
complexity, and continuity of care for the chronic pain population. 
Additionally, we will assess the utilization of services within the ED, 
outpatient and inpatient settings.
    Complementary and integrative medicine (CIM) modalities are 
provided by Navy Medicine at various MTFs, with access to a variety of 
specific therapies depending on provider training and availability. Our 
NCPMP incorporates CIM strategies as part of a multidisciplinary 
approach to treating pain including education on acupuncture, spinal 
manipulation, massage, meditation and movement therapies. Our 
successful programs like the Naval Medical Center San Diego's (NMCSD) 
``Mind Body'' Medicine (MBM) integrates CIM approaches and targets 
beneficiaries with chronic health conditions to gain control over their 
stress, improve their resilience and optimize their mind and body to 
best aid in their own recovery. To date, over 372 military personnel 
have been trained in the MBM curriculum with many bringing the training 
with them to operational platforms. Program evaluation data show that 
participants in the various MBM programs at NMCSD greatly value the 
experience, have created new healthy habits and made significant 
improvements in psychological health. NCPMP and MBM leaders are 
actively developing integration of MBM within all levels of the NCPMP 
stepped-care model.
    Navy Medicine implemented a pilot to actively manage Sailors and 
Marines on medical restricted duty. The Temporary Limited Duty 
Operations Program (TEMPO) started as a four month pilot at Naval 
Health Clinic (NHC) Cherry Point in June 2015 and resulted in an 
average reduction of 2.5 months on limited duty per service member. The 
program is currently being implemented across Navy Medicine with our 
focus on improved quality of care and earlier decisions on outcomes. 
All of us have a vested interest in ensuring all ill or injured service 
members are evaluated and treated in an expeditious nature, so they can 
return to duty at the earliest possible date. As a result, TEMPO is 
designed to provide the member time to heal, but with a 
multidisciplinary team approach overseen by both the member's command 
and the medical system, fostering Navy Medicine's mission to deliver a 
fit and effective fighting force.
    Since last year, we have also fully deployed LIMDU SMART (Limited 
Duty Sailor and Marine Readiness Tracker) at all our Navy MTFs. This IT 
solution provides improved visibility on temporary limited duty 
personnel and enables more active management of these service members.
    In support of the Navy's Sexual Assault Prevention and Response 
(SAPR) program, we initiated inter-Service training for our Sexual 
Assault Medical Forensic Examiners (SAMFE); an 80-hour SAMFE-A training 
course for healthcare providers. Our SAMFE providers require 
specialized training and clinical experience in medical-forensic 
evidence collection and treatment of sexual assault victims and 
suspects. This multidisciplinary and collaborative effort was 
undertaken to provide a tool to ensure our military providers 
conducting the Sexual Assault Medical Forensic Exam are uniformly 
trained, competent, and informed to the current standards of practice 
and state of the science.
    I want our Sailors, Marines and families to know that we are 
partnering with them in improving their health and wellness. Adopting a 
lifestyle of fitness, healthy eating, responsible use of alcohol and 
tobacco free living (to include electronic nicotine delivery systems 
such as e- cigarettes) can help reduce the incidence of disease and 
injury--and keep our personnel ready and on the job. Our efforts to 
reduce tobacco use include screening for tobacco use during every 
medical and dental visit, encouraging and assisting our active duty and 
beneficiaries to quit using FDA-approved medications and with 
counseling and promoting tobacco free living and work sites. Led by our 
Navy and Marine Corps Public Health Center, we also developed a robust 
tobacco free living website and produced new videos to encourage 
tobacco cessation free living. Simply put: Readiness, fitness and 
health are inextricably linked.
      building, sustaining and valuing the navy medicine workforce
    Navy Medicine is comprised of talented, dedicated and diverse 
healthcare professionals who serve around the world, in all 
environments, to support our Navy and Marine Corps forces. Our active 
duty and reserve military personnel--both officers and enlisted--and 
our Navy civilian colleagues are mission-ready and fully engaged in 
supporting our Navy and Marine Corps, regardless of location or 
assignment. They are fulfilling the promise we make to American 
families to provide the best care and support possible to those who 
serve. To this end, our human capital strategy must continue to 
emphasize the importance of recruiting, retaining, and rewarding our 
personnel.
    We are grateful to Congress for the sustained funding of both 
active component (AC) and reserve component (RC) recruiting and 
retention incentives for Medical Department officers. These resources 
continue to be crucial to our efforts to attract and retain high 
quality personnel. In fiscal year 2016, Navy Recruiting was successful 
in reaching 100 percent of the overall AC goal for Medical Corps, 
Dental Corps, Nurse Corps, Medical Service Corps and Hospital Corps. 
Correspondingly, overall AC manning in each Corps is good; however, we 
continue to focus on several challenging specialties within each Corps 
including: Medical Corps (general surgery, family medicine and 
psychiatry); Dental Corps (oral and maxillofacial surgery); Nurse Corps 
(critical care); Medical Service Corps (medical technology); and, 
Hospital Corps (submarine and dive independent duty corpsman, and Fleet 
Marine Force Reconnaissance). Careful assessment of these and other 
specialties is important as our support requirements to the Marine 
Corps increase and we expand programs such as embedded mental health in 
Fleet units.
    While overall RC recruiting efforts attained 78 percent of the 
fiscal year 2016 Medical Department goal, accessing RC Medical Corps 
officers, largely through the direct commission market, remains a 
challenge. Overall RC Medical Corps manning is 85 percent; however, 
specialty shortfalls exist for orthopedic surgery and general surgery. 
To address these needs, Navy Recruiting Command will focus on residents 
in these specialties for the Training in Medical Specialties (TMS) 
program, which is offered to trainees who are now in or categorically 
matched to a residency program in a critical wartime specialty needed 
by the Navy Reserves. As an enhanced incentive, the TMS program 
increased student loan repayment to $210,000 from $50,000 (while the 
stipend amount remains the same at $2,239/month). The Navy Recruiting 
Command's goal is to reach a younger physician audience by targeted 
recruiting efforts with the TMS program. For the RC Nurse Corps, the 
stipend program as well as retention and recruiting bonuses have had a 
significant impact in improving manning in the perioperative nurse, 
certified registered nurse anesthetist and mental health nurse 
practitioner communities. Navy Recruiting Command, in conjunction with 
the Navy Reserve, continues to emphasize enhanced incentives and 
targeted new programs to attract these medical professionals, 
recognizing the challenges inherent in an improving healthcare labor 
market.
    A healthy and diverse student accession pipeline is vital to Navy 
Medicine. In fiscal year 2016, a total of 48 Medical Corps officers 
graduated from Uniformed Services University of the Health Sciences 
(USUHS), 193 entered active duty from the Health Professions 
Scholarship Program (HPSP), 18 from the Health Services Collegiate 
Program (HSCP), 30 from the Navy Active Duty Delay for Specialist 
program, and 13 from the Financial Assistance Program. Additionally, 82 
Dental Corps officers entered active duty from HPSP and 26 from HSCP 
while eight Medical Service Corps officers entered from HPSP and 47 
from HSCP. Seventy-two Nurse Corps officers entered active duty from 
the Nurse Candidate Program.
    Within Navy Medicine, vibrant education and training programs are 
essential to providing confident and well-trained healthcare providers 
in any operating environment. Our leaders and the American public 
expect nothing less. We also recognize that training and credentialing 
opportunities serve as an important retention tool for retaining our 
best and brightest. Our officer programs are reviewed annually, and 
executed to ensure the requisite provider expertise to support the Navy 
and Marine Corps operational mission. Enlisted medical education and 
training complement the team approach to healthcare. In this regard, we 
continually review and adjust initial and advanced skills curricula to 
best meet current and future requirements. The CNO has clearly 
articulated his priority that all of us in the Navy must ``achieve high 
velocity learning at every level.'' For us, this imperative includes 
leveraging cost-effective technologies, including medical modeling and 
simulation capabilities, to accelerate learning and reduce re- work.
    Our Navy civilians have important responsibilities--providing care, 
conducting research, maintaining our clinical and business operations--
but one of the most important jobs is the training and professional 
mentorship they provide to our military staff. Our civilians represent 
the expertise and continuity in our MTFs, labs and supporting commands 
as the military staff regularly rotate to other assignments and 
locations.
    The healthcare occupations employed by Navy Medicine are in high 
demand in the private sector; therefore, we utilize an aggressive 
enterprise and command-level retention and recruitment strategy for 
these positions. We continue to leverage authorized flexibilities by 
utilizing several special hiring authorities including Expedited Hiring 
Authority (EHA) for Certain Health Care positions, and Direct Hire 
Authority (DHA) for hard-to-fill healthcare positions. In fiscal year 
2016, 378 positions were filled at Navy Medicine commands using EHA and 
DHA authorities. We recognize, however, that like other Department of 
Navy activities, our most significant demographic concern is an aging 
workforce with 30 percent of our civilians eligible for early or 
voluntary retirement. Navy Medicine uses the flexibilities and 
authorities given to us to mitigate losses due to retirement including 
Physician/Dentist Pay Plan Special Salary Rates and recruitment 
incentives.
    In support of the CNO's Navy Civilian Workforce Framework, I 
directed the establishment of a Navy Medicine Civilian Corps Chief, 
similar to the leadership model in place for our other Medical 
Department Corps, to strengthen the role of leading and managing our 
11,400 civilians, particularly in areas of recruiting, training and 
workforce development.
            advancing cutting-edge research and development
    Navy Medicine Research and Development (R&D) is essential to our 
force health protection mission and a key component to advancing global 
health engagement priorities. The facilities in the United States and 
overseas, staffed with talented researchers and clinicians, are vital 
to Navy Medicine as we keep pace with new and precision-based therapies 
for our patients. The Naval Medical Research Center (NMRC) and its 
subordinate laboratories have continued to make strong progress in 
addressing our military relevant research priorities in all areas of 
the globe so that we can better protect our deployed service members. 
These areas include, but are not limited to, warfighter performance, 
combat casualty care, aerospace medicine, infectious diseases, 
biological defense, and undersea medicine. During my site visits 
throughout Navy Medicine I have had the opportunity to see firsthand 
the innovative work being performed by our researchers.
    I cannot overstate the importance of collaborations and 
partnerships. They are fundamental to our work, both domestically and 
internationally. Our labs work extensively with outside partners, both 
academic and corporate, bringing in external researchers to contribute 
toward shared goals. Mechanisms such as Cooperative Research and 
Development Agreements (CRADAs), Material Transfer Agreements, 
Memoranda of Agreement, and Memoranda of Understanding now number in 
the hundreds and also provide a mechanism to support and accelerate 
Navy research--all focused on protecting, treating, and enhancing the 
health and performance of Sailors and Marines.
    A common mission for our OCONUS labs is to provide direct 
surveillance and subject matter expertise to host nation governments, 
enhancing regional security and stability through health engagements. 
Our commands work closely with their host nations' Ministries of Health 
and Ministries of National Defense to identify and prioritize regional 
disease threats of relevance to them and especially to our forces. 
Research efforts leverage these relationships to both strengthen host 
nation medical capacity and economize the efforts of DoD researchers.
    Our Navy Malaria Program continues to make progress in the 
development of a malaria vaccine. Our researchers focus on safety, 
tolerability, and efficacy results from clinical trials. We are 
partnering with Walter Reed Army Institute of Research (WRAIR), DoD 
OCONUS medical research laboratories, as well as government, academia, 
private foundations and biotechnology partners to develop a malaria 
vaccine to prevent malaria morbidity and mortality in military 
personnel and in vulnerable populations world-wide. In addition, NMRC-
Asia, headquartered in Singapore, is conducting anti-malarial drug 
efficacy and resistance studies in Thailand, Cambodia and Vietnam 
designed to evaluate optimal anti-malarial regimens.
    We are also actively engaged in initiatives to develop therapeutic 
antibodies to militarily relevant diseases caused by viruses such Zika, 
Middle Eastern Respiratory Syndrome Coronavirus (MERS-CoV), Chikungunya 
and others. This research supports the development of effective 
therapeutic antibodies for human use that can be prepared in as little 
as 3 months.
    We are partnering on two new initiatives to identify and counter 
emerging disease threats, such as Ebola, in West Africa. These 
programs, the Joint West Africa Research Group (JWARG) and the Joint 
Mobile Emerging Disease Intervention Clinical Capability (JMEDICC), 
seek to develop clinical and diagnostic capacities to both identify and 
respond to emerging disease threats. A key mission of both programs is 
the development of the in-country medical infrastructure to provide 
critical support toward the FDA licensure of therapeutics and vaccines 
against emergent diseases, including Ebola.
    Our researchers are also engaged in partnerships in the emerging 
area of precision medicine. Of particular note is work underway at NMRC 
with Weill Cornell Medical College of Cornell University and University 
of California, Davis to identify risk and optimize interventions for 
the treatment of post-traumatic stress disorder (PTSD) and mild TBI, as 
well as other, more chronic or progressive medical disorders. Their 
work in developing predictive and customized models derived from 
population data can help build resilience and target interventions 
specific to individuals at risk as well as those who have previously 
suffered a traumatic event.
                              way forward
    As the Navy Surgeon General, I have the privilege of meeting with 
Navy Medicine shipmates serving in the Fleet, with the Marines and in 
our MTFs, research labs and training commands. It's inspiring to see 
the outstanding work being done to support Sailors, Marines and their 
families. I always, however, reiterate that the demands on Navy 
Medicine will continue to increase. The operational tempo of our Navy-
Marine Corps remains high, with naval forces operating forward around 
the world. We have no greater calling than to ensure we are doing all 
we can to provide the best care our Nation can offer and do all in our 
power to return home alive, safe, and well those who have volunteered 
to defend our freedom. Whether on day one of combat, alongside them 
around the world, or ensuring they are healthy and ready here at home, 
we have no greater priority. This is what sets us apart from all 
others. I take seriously our commitment to ensure that the men and 
women of Navy Medicine have what they need and are able to do what they 
must to honor that trust placed in our hands to safeguard the health 
and wellbeing of those in uniform, one day and if at all humanly 
possible, returning them home safely to those they love with the 
gratitude and admiration of a thankful nation for their sacrifice.

    Senator Cochran. Thank you, Admiral Faison, for your 
opening statement. I now recognize Lieutenant General Mark 
Ediger, Surgeon General of the Air Force, for an opening 
statement.
STATEMENT OF LIEUTENANT GENERAL MARK EDIGER, SURGEON 
            GENERAL, UNITED STATES AIR FORCE
    General Ediger. Thank you, sir. Chairman Cochran, Vice 
Chairman Durbin, and distinguished members of the subcommittee, 
thank you for this opportunity to testify before you today. We 
are grateful for your steadfast support to the Military Health 
System, including Air Force Medicine, and to all of those we 
serve.
    The dynamics of military operations across the combatant 
commands demand that today's airmen innovate and perform 
reliably at a high tempo. In Air Force Medicine, we are 
adapting our capabilities to enhance the health and performance 
of airmen by taking our support directly to the airmen.
    We are also changing our deployable and aeromedical 
evacuation capabilities to bring more advanced care into the 
operational environment as part of the Joint Team.
    Today, we have 726 medical airmen deployed in 31 nations. 
Our current readiness challenge is to build our capability and 
capacity to support agile military operations across broad 
expanses of geography, while also sustaining the ability to 
deploy field hospitals in support of large scale combat 
operations. Answering this challenge requires the increased 
flexibility of our deployable medical teams.
    Current operations in CENTCOM and AFRICOM have expanded 
requirements for agile teams trained and equipped for forward 
trauma resuscitation and damage control surgery along with 
critical care, performed in near operating forces often without 
the benefit of the field hospital.
    In 2016, an Air Force medical team supported coalition 
forces under this construct and performed over 120 trauma 
resuscitations in a 7-week period, while successfully employing 
innovative trauma resuscitation techniques in a pre-hospital 
setting.
    We recently adapted Air Force mobile field surgical and 
critical care teams to this requirement, and completed 
successful operational tests. As part of the joint effort, we 
are currently training and equipping teams to be dually capable 
of this kind of austere agile support, and have worked within 
the Air Force Expeditionary Medical Support System, or EMEDS 
structure.
    Additionally, we are taking actions this year to train and 
equip teams to deliver in-flight surgical resuscitation 
capability.
    As research and innovation continue to enable more advanced 
care in the operational setting, we must keep our deployable 
medical teams at peak proficiency in trauma, emergency 
medicine, and critical care techniques.
    Partnerships that enable our deployable medical 
professionals to work within institutions outside the military, 
such as partner trauma centers and academic medical centers in 
the United States and in the United Kingdom, will continue to 
grow in importance.
    Since 2012, we have also gained experience from embedded 
medical support in mission areas that impose unique demands on 
airmen, including special operations, remotely piloted aircraft 
operations, intelligence operation centers and personnel 
recovery.
    We are now building plans to apply what we have learned in 
those areas more broadly across the Air Force, with a focus on 
units and career fields under high stress and demand, such as 
aircraft maintenance.
    Our concept for this adaptation involves multidisciplinary 
medical teams working beside our airmen in their duty sections 
to enhance performance, improve fitness, improve health, build 
stress management skills, and prevent injuries.
    In 2015, Air Force Medicine committed to a new approach to 
safe care, quality outcomes, and a greater experience of care 
for the 1.2 million patients enrolled in medical homes and our 
hospitals and clinics. We call this approach ``Trusted Care.'' 
Through it, we are employing the same principles that were 
applied in Air Force flying operations to produce a dramatic 
reduction in major flight mishaps over the past 8 years.
    The principles relate to clear purposeful team 
communication, vigilance for risk to patient safety, a system 
approach to variance, a responsibility to report hazards, a 
team approach to mitigating risk, and continuous process 
improvements.
    Our hospitals start their days with patient safety rounds. 
We measure and track patient safety at every level. We utilize 
these processes to enhance safety across the system, all in 
coordination with comparable efforts within the Military Health 
System.
    We are actively changing education and training curricula 
to develop medical airmen with skills in applying these 
principles and leading a patient-centered culture of safety.
    The implementation of the new electronic health record at 
Fairchild Air Force Base is the first step of what will be a 
transformational tool for our healthcare teams but also for all 
of those we serve.
    Air Force Medicine remains committed to the health, safety, 
performance, and resilience of those we serve across the Joint 
Force. We do this in close collaboration with our partners in 
the Military Health System. We are in the midst of mapping 
fundamental changes to our operations in order to ensure that 
we provide the capability and capacity to provide the 
innovative expeditionary medical and aeromedical evacuation 
support for current and future contingency operations.
    I thank the committee for your support and dedication to 
the welfare of the extraordinary people we are privileged to 
serve in the Military Health System. I look forward to 
answering any questions from the committee. Thank you.
    [The statement follows:]
       Prepared Statement of Lieutenant General (Dr.) Mark Ediger
    Chairman Cochran, Vice Chairman Durbin, and distinguished members 
of the Subcommittee, thank you for this opportunity to testify before 
you today.
    In Air Force Medicine, we are integral to the team of Airmen 
integrated into the Joint team defending our Nation through a broad 
array of capabilities, overcoming diverse challenges in demanding 
missions around the world. Today approximately 200,000 airmen are 
engaged in special operations, combat air operations, strategic 
reconnaissance, space operations, cyber operations, rapid global 
mobility, homeland defense, and nuclear deterrence in direct support to 
the warfighter in every region of the world. The Air Force is 
performing these tasks with 38 percent fewer active duty Airmen and 37 
percent fewer aircraft than during DESERT STORM.
    We ask much of our Airmen, and place great responsibility on them. 
In return, the Air Force Medical Service has a great responsibility to 
provide the best possible health services for our Airmen and their 
families; provide fit, healthy and medically ready Airmen; and 
sustaining an innovative expeditionary medical and aeromedical 
evacuation force in support of ongoing and emergent contingency 
operations.
    As today's Airmen meet the challenges of expanding operational 
capabilities evolving to meet changing threats, we call upon them for 
precise performance, technological prowess, innovation, sustained 
vigilance, physical endurance, spiritual strength, and mental 
resilience.
    Today's Airmen are doing what the mission requires but there are 
clear signs of stress on the force, including 9 years of rising suicide 
rates and diminished retention within heavily tasked career fields.
    The strategy for Air Force Medicine supports the Air Force 
Strategic Master Plan and is integrated with Military Health System 
strategic lines of effort. Focus areas within our strategy pertain to 
full spectrum readiness for the medical force, mission-specific 
operational outreach, high reliability health services and patient-
centered, precision care. Action within the focus areas are 
reconfiguring our medical force to efficiently align capabilities with 
operational requirements, cultivating a patient-centered culture, and 
improving our operational agility. My comments will touch upon each of 
these four focus areas.
    Full Spectrum Readiness addresses our greatest challenge--
sustaining a ready medical force with innovative capabilities to 
provide advanced care and prevention anytime, anyplace. Today we have 
726 medical Airmen deployed in 31 nations. Today's readiness challenge 
is adapting medical support to agile military operations across vast 
geographic expanses wherein a wounded service member may be 1,000 miles 
from a hospital with suitable trauma capabilities. Today's readiness 
challenge is also sustaining readiness for alternative conflict 
scenarios with potential to generate large numbers of casualties 
concentrated in specific locations.
    Today's operations in CENTCOM and AFRICOM have increased 
requirements for agile surgical and critical care teams trained and 
equipped for forward trauma resuscitation and damage control surgery in 
a pre-hospital (field) environment. We have completed successful 
operational tests of trauma teams tailored to this requirement. We are 
currently training and equipping teams such that enhanced capability 
and capacity for surgical and critical care in austere environments 
will be ready by the end of this year.
    During operational testing in 2016, such teams working in a shelter 
of opportunity in Africa surgically resuscitated and saved a wounded 
U.S. service member and an allied service member, each of whom arrived 
stable at hospitals in Europe after aeromedical evacuation over a 
distance of 1,000 miles.
    An Air Force Special Operations Surgical Teams (SOST) recently 
deployed to the vicinity of Syria in support of coalition forces. 
Finding that casualties had overwhelmed local civilian hospitals, SOST 
rapidly converted four buildings into triage, treatment, and surgical 
rooms. In just seven weeks, the team completed over 100 trauma 
resuscitations and treated more than 1,000 causalities. The SOST also 
saved four wounded coalition troops through use of resuscitative 
endovascular balloon occlusion of the aorta (REBOA). This was the first 
reported use of REBOA outside a hospital setting. REBOA, using an FDA 
approved balloon catheter invented by an Air Force Surgeon, Dr. Todd 
Rasmussen, is gaining use in trauma centers internationally. The 
innovative use of this tool in the field represents a new opportunity 
to reduce death due to traumatic hemorrhage.
    The Air Force continues the development and refinement of our 
Expeditionary Medical Support Health Response Teams (EMEDS-HRT), an 
evolution of our combat-proven and scalable Expeditionary Medical 
Support (EMEDS) system. EMEDS-HRT provides emergency care within one 
hour of arrival, surgery and critical care within six hours, and 
hospital capability within 12 hours of arrival.
    In 2016, the Air Force deployed EMEDS-HRT in joint exercises with 
East Asian partner nations simulating a major natural disaster in the 
Pacific. The scope of services in HRT is tailored to the mission, 
adding specialty care such as obstetrics/gynecology and pediatrics for 
humanitarian assistance or disaster relief missions.
    The Air Mobility Command has continued to refine and exercise the 
Transport Isolation System developed and fielded during the Ebola 
crisis in West Africa. This system enables response to an infectious 
disease crisis through capability to safely treat and transport 
multiple patients with infectious diseases of high concern in the C-17 
and C-130 aircraft. Through a research and training partnership with 
the University of Nebraska Medical Center, we continue to build our 
capabilities in this area.
    To build and sustain teams capable of advanced care in operational 
environments and safe aeromedical evacuation over great distances, we 
apply standards for clinical aspects of readiness as we manage our 
medical force within a program known as Sustained Medical and Readiness 
Trained (SMART). To meet these standards, we employ partnerships with 
multiple trauma centers outside the Department of Defense (DoD) within 
the U.S. and within major medical centers in the United Kingdom to 
ensure our deployable teams maintain clinical skills required in 
contingency operations. Most of our partner institutions have a full-
time presence of deployable Air Force clinicians in addition to 
rotational clinicians from Air Force hospitals. Included are three 
level one trauma centers serving as Centers for Sustainment of Trauma 
and Readiness Skills (C-STARS), the University of Maryland's R Adams 
Cowley Shock Trauma Center in Baltimore, the Saint Louis University 
Hospital, and the University of Cincinnati Medical Center, as well as 
level one trauma centers at the University of Nevada, the University of 
Alabama-Birmingham, the University of Miami Ryder Trauma Center, and 
University of California-Davis. We also have a large contingent of 
Airmen providing trauma care at Brooke Army Medical Center in San 
Antonio. Multiple Air Force hospitals and clinics maintain local 
partnerships to enable commanders to manage readiness through 
apportioned week-to-week clinical practice. These partnerships are 
critical to our readiness and their importance will grow over time.
    The SMART program offers expanded training opportunities for 
certain skills that require experience not available in our smaller 
military treatment (MTF) facilities. This includes skills for which a 
higher volume of cases is needed to remain current, or those with a 
greater complexity of hands-on care. The SMART program is tiered to 
provide commanders with options for each skill requirement. The first 
tier occurs at home station where medical personnel train with a 
standardized curriculum using routine operations and simulation-based 
training opportunities. The second tier utilizes local training 
affiliation agreements and partnerships with civilian, DoD or VA 
hospitals. The third tier, regional currency sites, such as the 
University Medical Center in Las Vegas, are utilized when Tier 1 or 
Tier 2 opportunities are inadequate to ensure the preservation of 
essential medical skills.
    We are responsible for enabling Airmen to successfully sustain 
health, fitness, resilience and strong performance across the spectrum 
of operations in an Air Force whose capabilities are in great demand. 
Since 2012, we have gain experience from embedded medical support in 
mission areas including special operations (SOCOM's Preservation of the 
Force and Family), remotely piloted aircraft operations, intelligence 
operations centers and personnel recovery. We are now building plans to 
apply what we have learned from embedded medical support to apply 
medical outreach more broadly across the Air Force mission employing 
expertise in exercise physiology, physical therapy, behavioral health, 
nutrition, and wellness.
    An example of our experience with embedded medical support comes 
from the 480th Intelligence, Surveillance, and Reconnaissance Wing 
(ISRW), a globally dispersed unit that specializes in time-dominant 
intelligence fusion. This Wing has employed embedded medical and 
chaplain support continuously since 2012 as its combat mission has 
grown considerably in complexity and scope. The embedded support 
interacts with Airmen individually and works across multiple domains to 
fix the processes that negatively impact Airmen, while increasing 
operational effectiveness of the Wing. The embedded presence ensures an 
intimate knowledge of the problems facing Airmen, a full understanding 
of the mission, and awareness of the impacts for Airmen. With this 
unique perspective, the embedded support can quickly advise and assist 
Airmen under stress, and coordinate specialty care when needed.
    An Airmen Resiliency Team's combined operational and medical 
knowledge, along with ties to research communities, dramatically 
shortens the research and development loop for new training and 
techniques in identifying and treating mental health challenges. Human 
Performance Optimization and Human System Integrations projects by the 
embedded 480th Intel Wing teams have led to a 6 percent reduction in 
errors while actually increasing production. The 480th ISRW ART is 
currently guiding operationally relevant research at the U.S. Air Force 
School of Aerospace Medicine, the Air Force Research Laboratory, 
Uniformed Services University of the Health Sciences, and Naval Medical 
Research Unit Dayton.
    Air Force primary care is provided in Air Force Medical Home 
clinics, consisting of 239 clinics at 76 installations. Air Force 
Medical Home clinics include family medicine, pediatrics, internal 
medicine, flight medicine, and associated graduate medical education 
(GME) clinics. There are 1,085,779 beneficiaries enrolled in Air Force 
Medical Homes. Overall satisfaction with the healthcare delivered at 
Air Force Medical Groups has consistently scored at or above 95 
percent, a strong rating but one we strive to improve every day.
    Every Air Force Medical Group provides medical support tailored to 
missions conducted from home station while sustaining the readiness of 
the deployable medical force. Every patient engagement is relevant to 
the performance and resilience of Airmen.
    While we have made great strides in partnership with our patients 
through the Air Force Medical Home, we are acting on opportunities for 
further progress. We have increased the number of same day 
appointments, embedded clinical pharmacists within the Medical Home, 
expanded direct patient access to physical therapy, improved MiCare 
registration for digital interaction, and streamlined patient transfers 
from the Nurse Advice Line. This year, we are piloting the use of 
health coaches in the Medical Home to assist patients with wellness 
actions prescribed by their Medical Home teams such as injury 
prevention, fitness improvement, stress management, tobacco cessation, 
weight loss and healthy nutrition.
    In accordance with the DoD strategy for pain management, and to 
reduce use of opioids, we are embracing integrative medicine by 
training clinicians to use non-pharmacologic tools such as acupuncture. 
Battlefield acupuncture or BFA, a highly effective rapid acupuncture 
treatment for pain, was developed by an Air Force physician and is now 
taught internationally. BFA has been taught in 59 classes, including 
3,855 clinicians and certified 119 instructors across DoD and VA. 
Eighty-one percent of all Air Force Medical Groups are providing 
acupuncture services today. We have doubled the number of physicians 
trained annually as medical acupuncturists in a 300-hour acupuncture 
course yielding robust skills in acupuncture. The Family Medicine 
Residency at Nellis AFB has successfully provided an advanced 
acupuncture course as a popular elective, a successful initiative we 
are now seeking to program resources in the future with expansion to 
another site. Col (Dr.) Paul Crawford, the Nellis Air Force Base 
Director of the Family Medicine Residency and his team are collecting 
data to measure impacts on patient outcomes and opioid usage with 
promising initial results.
    Air Force Medicine remains committed to improving access to primary 
care services. Actions in progress include additional primary care 
providers to enable ``gap fill'' contracts, improved fill rates for 
Medical Home positions, standards for managing schedules within the 
Medical Groups to meet forecasted demand, and a hub and spoke concept 
for filling temporarily gapped positions due to deployments.
    In 2015, Air Force Medicine committed to a new approach to patient 
safety we call Trusted Care, employing the principles for high 
reliability care. These principles are the same as those applied in 
aviation to produce the dramatic reduction in major aviation mishaps. 
The principles relate to clear, purposeful team communication, 
vigilance for risks to patient safety, a systems approach to variance, 
a responsibility to report risk and a team approach to mitigating risk. 
Application of these principles and their inclusion in developmental 
training along with continuous process improvement, is a powerful 
combination for attaining high reliability.
    As an illustration of how we apply these principles in Air Force 
medicine, a physician assistant with the 61st Medical Squadron at Los 
Angeles Air Force Base recently saved a life when he caught an error 
made two weeks earlier by a civilian emergency room physician. The 
civilian emergency room sent this patient home with routine primary 
care manager follow-up instructions. However, when the patient was seen 
by the Air Force physician assistant, he identified the patient as 
having a serious cardiac condition. This resulted in an emergency same-
day stent surgery. By not taking the previous diagnosis for granted, 
and having the vigilance and independence to perform and trust his own 
analysis, this Airman demonstrated Air Force Trusted Care principals 
and saved a life.
    We are an innovative system for contingency medical support, day-
to-day medical support to special missions, and delivery of team-based 
patient-centered health services. We are engaged in strategic 
programming actions to meet evolving and looming mission imperatives 
that will potentially significantly change our configuration and scope 
of services. In so doing, we remain committed to Trusted Care Anytime, 
Anyplace in support of the national defense, our Airmen, Sailors, 
Soldiers and Marines and our veterans.

    Senator Cochran. Thank you very much, General Ediger. I 
will now call on Ms. Stacy Cummings, Program Executive Officer 
of Defense Healthcare Management Systems. You may proceed with 
your opening statement.
STATEMENT OF STACY A. CUMMINGS, PROGRAM EXECUTIVE 
            OFFICER, OFFICE OF THE DEFENSE HEALTHCARE 
            MANAGEMENT SYSTEMS, DEPARTMENT OF DEFENSE
    Ms. Cummings. Thank you. Chairman Cochran, Ranking Member 
Durbin, and distinguished members of the subcommittee, thank 
you for the opportunity to testify before you today.
    I am honored to represent the Department of Defense as the 
Secretary's Program Executive responsible for modernizing the 
military's electronic health record system, and enhancing 
interoperability with the VA and private sector providers.
    Our mission is to transform the delivery of healthcare and 
advance data sharing through a modernized EHR (electronic 
health records) for servicemembers, veterans, and their 
families. To this end, DOD is committed to three equally 
important objectives--deploy a single integrated inpatient and 
outpatient electronic health record, improve data sharing with 
the VA and our private sector healthcare partners, and 
successfully transform the delivery of healthcare in the 
Military Health System through advanced tools that allow 
beneficiaries to have more control over their health care 
experience.
    As we work towards fully deploying a modern EHR across the 
MHS (Military Health System), I am excited to share that we 
reached an important milestone. On February 7, the DOD deployed 
MHS GENESIS at its first patient care facility at Fairchild Air 
Force Base in Spokane, Washington. This was a massive effort 
that took the coordination, guidance, and support of multiple 
DOD agencies and organizations.
    I would like to acknowledge the 92nd Air Refueling Wing, 
Air Force Medical Operations Agency, and the Defense Health 
Agency for their tremendous efforts to make the go-live effort 
at Fairchild a success.
    Here with us today is the Commander of the 92nd Medical 
Group at Fairchild, Colonel Margaret Carey. Colonel Carey has 
been instrumental in coordinating pre- and post-deployment 
activities, and embodies the leadership qualities necessary to 
ensure continued success of MHS GENESIS.
    In 2015, the DOD awarded a $4.3 billion contract to the 
Leidos Partnership for Defense Health to deliver a modern, 
interoperable EHR. MHS GENESIS is a state of the market 
commercial off-the-shelf solution consisting of Cerner 
Millennium, an industry leading EHR, and Henry Schein's Dentrix 
Enterprise, a best of breed dental module.
    MHS GENESIS is an integrated inpatient and outpatient 
solution that connects medical and dental information across 
the continuum of care. Over time, MHS GENESIS will replace DOD 
legacy healthcare systems and will support the availability of 
electronic health records for more than 9.4 million DOD 
beneficiaries and over 200,000 MHS personnel globally.
    Deploying and implementing MHS GENESIS is a team effort. 
DOD brought together stakeholders from across the MHS to 
standardize clinical workflows across the enterprise to 
minimize variation in the delivery of healthcare.
    Feedback from our users at Fairchild have been positive 
with many citing ease of use and integration into their daily 
work processes. Today, clinicians and dentists are documenting 
patient records in MHS GENESIS and ancillary capabilities, such 
as pharmacy, lab, and radiology, and are working as expected.
    Later this year, we will deploy to our three remaining 
initial fielding sites, Naval Hospital Oak Harbor, Naval 
Hospital Bremerton, and Madigan Army Medical Center, with full 
operational capability for medical and dental facilities 
worldwide scheduled for 2022.
    As the DOD transitions to MHS GENESIS, our commitment to 
expand our interoperability efforts with the VA and private 
sector providers remains unchanged. The DOD and VA are two of 
the largest healthcare providers in the world, and today, share 
more healthcare data than any other two major health systems.
    In April 2016, the DOD and the VA certified to Congress 
that we are fully interoperable, in accordance with the fiscal 
year 2014 NDAA. While the Department has met those objectives, 
interoperability is a spectrum where data sharing and 
functionality can and will be improved.
    Additionally, since more than 60 percent of beneficiary 
healthcare is provided by the private sector, we are also 
increasing our data sharing partnerships with private sector 
healthcare organizations through health information exchanges.
    With MHS GENESIS, clinicians and patients will benefit from 
the advanced tools and capabilities available from a modern 
EHR. Key features such as advanced analytics and an online 
patient portal increase efficiency, improve health outcomes, 
and enable patients to be more engaged in their healthcare 
decisions.
    Thank you again for the opportunity to share the progress 
that we have made to transform the delivery of healthcare for 
servicemembers, veterans, and their families.
    Successful deployment of MHS GENESIS at our first site is a 
first step in implementing what will be among the largest 
integrated inpatient and outpatient EHR in the United States. 
As a partner in our progress, we appreciate Congress' interest 
in this effort, and ask for your continued support as we 
deliver on our promise to provide world class care to those who 
faithfully serve our Nation. I look forward to your questions.
    [The statement follows:]
              Prepared Statement of Ms. Stacy A. Cummings
    Chairman Cochran, Ranking Member Durbin and distinguished Members 
of the Subcommittee, thank you for the opportunity to testify before 
you today. I am honored to represent the Department of Defense (DoD) as 
the Secretary's program executive responsible for modernizing the 
military's electronic health records (EHR) system and enhancing 
interoperability with the VA and private sector providers.
    The mission of the Program Executive Office Defense Healthcare 
Management Systems (PEO DHMS) is to transform the delivery of 
healthcare and advance data sharing through a modernized electronic 
health record for service members, veterans and their families. To this 
end, DoD is committed to three equally important objectives: deploy a 
single, integrated inpatient and outpatient electronic health record, 
branded MHS GENESIS; improve data sharing with the VA and our private 
sector healthcare partners; and successfully transform the delivery of 
healthcare in the Military Health System (MHS) through advanced tools 
that allow beneficiaries to have more control over their healthcare 
experience.
    The DoD was an early pioneer in the development of a centralized, 
global electronic health record when it introduced the AHLTA in 2004. 
At the time, the DoD's in-house EHR solution was looked to by private 
sector enterprises as the future of EHRs. Over the last decade, 
significant advances have been made in the technologies offered by the 
private sector. In 2013 the DoD made the decision to transition from 
home-grown government-developed EHRs to a single, integrated 
commercial-off-the-shelf (COTS) capability. Two factors contributed to 
this decision. First, the needs within the MHS could be better met by 
state-of-the-market commercial applications. Second, the DoD could 
leverage private sector investments in technology and established data 
sharing networks with civilian partners to reduce costs and improve the 
customer experience. Staying current with the latest advancements in 
technology without being the only investment stream enables the DoD to 
benefit from some of the best products in health IT without carrying 
the financial burden alone.
    As we work toward the goal of fully deploying a modem EHR across 
the MHS, I am excited to share that we hit an important milestone last 
month. On February 7, the DoD deployed MHS GENESIS at its first patient 
care facility at Fairchild Air Force Base (AFB) in Spokane, Washington. 
This was a massive effort that took the coordination, guidance and 
support of multiple DoD agencies and organizations. I'd also like to 
acknowledge the 92nd Air Refueling Wing, Air Force Medical Operations 
Agency (AFMOA) and Defense Health Agency (DHA) for their tremendous 
work to make the Go-Live at Fairchild AFB a success. With me today is 
the Commander of the 92nd Medical Group at Fairchild AFB, Colonel 
Margaret Carey. Colonel Carey's leadership has been instrumental in 
coordinating and implementing onsite deployment activities, including 
gathering site-specific information, training staff, overseeing change 
management, and providing post-deployment support. In our first month 
following deployment, we tracked user behavior and see progress in many 
areas, including patient portal utilization and improved clinician 
decisionmaking. MHS GENESIS isn't just a technology. It's a 
transformation of culture and process that is powered by strong 
leadership from inside the MHS. Colonel Carey embodies the proactive 
leadership qualities that will be required throughout DoD to ensure 
continued success of MHS GENESIS.
   modernize the electronic health record (ehr) software and systems 
                       supporting dod clinicians
    To streamline and improve healthcare delivery, MHS GENESIS 
integrates inpatient and outpatient best-of-suite solutions that 
connect medical and dental information across the continuum of care, 
from point of injury to the military treatment facility, providing a 
single patient health record. This includes garrison, operational, and 
en route care, increasing efficiencies for beneficiaries and healthcare 
professionals. Over time, MHS GENESIS will replace DoD legacy 
healthcare systems and will support the availability of electronic 
health records for more than 9.4 million DoD beneficiaries and 
approximately 205,000 MHS personnel globally.
    The deployment and implementation of MHS GENESIS across the MHS is 
a team effort. Complex business transformation requires constant 
coordination and communication with stakeholders and partners, 
including the medical and technical community, to ensure functionality, 
usability and data security. DoD engaged stakeholders across the MHS to 
identify requirements and standard workflows. The result was a 
collaborative effort across the Services and the Defense Health Agency 
to ensure the clinical workflows enabled by MHS GENESIS are standard 
and consistent across the enterprise to minimize variation in the 
delivery of healthcare.
    In July 2015, the DoD awarded a $4.3 billion contract to the Leidos 
Partnership for Defense Health (LPDH) to deliver a modem, interoperable 
EHR. The LPDH team consists of four core partners, Leidos Inc., as the 
prime developer, and three primary partners in Cemer Corporation, 
Accenture, and Henry Schein Inc. MHS GENESIS provides a state of the 
market COTS solution consisting of Cemer Millennium, an industry-
leading EHR, and Henry Schein's Dentrix Enterprise, a best of breed 
dental module.
    Through a tailored acquisition approach, DoD leveraged commercial 
best practices and its own independent test community to field a modem, 
secure and connected system that provides the best result for the end 
user with a positive experience from day one. One example of leveraging 
commercial best practices was opting to utilize commercial data 
hosting, which allowed DoD to combine private sector speed and 
technology with the Department's superior data security knowledge and 
provide advanced analytics for our end users and beneficiaries. While 
there is still much work to be done, the integration of the commercial 
data hosting into DoD networks and systems represents a new direction 
in Pentagon information technology (IT) culture and practice. This 
innovative approach has set the bar for COTS systems and commercial 
partnerships by the DoD and other Federal agencies in the future.
    Additionally, we are employing industry standards to deploy and 
optimize the delivery of MHS GENESIS. Rollout across the MHS follows a 
``wave'' model. Initial fielding sites in the Pacific Northwest are the 
first wave of Military Treatment Facilities (MTFs) to receive MHS 
GENESIS, which began on February 7, 2017 at Fairchild AFB. Fielding at 
the next three sites in Washington State--Naval Hospital Oak Harbor, 
Naval Hospital Bremerton and Madigan Army Medical Center--will begin at 
the end of fiscal year 2017. By deploying to four Initial Operating 
Capability (IOC) sites that span a cross section of size and complexity 
of MTFs, we are able to perform operational testing activities to 
ensure MHS GENESIS meets all requirements for effectiveness, 
suitability and data interoperability to support a full deployment 
decision in 2018. Deployment will occur by region--three in the 
continental U.S. and two overseas--in a total of 23 waves. Each wave 
will include an average of three hospitals and 15 physical locations, 
and last approximately 1 year. Regionally grouped waves will run 
concurrently. This approach allows DoD to take full advantage of 
lessons learned and experience gained from prior waves to maximize 
efficiencies in subsequent waves, increasing the potential to reduce 
the deployment schedule in areas where it makes sense to do so. Full 
Operational Capability (FOC), to include garrison medical and dental 
facilities worldwide, is scheduled for 2022.
    To support our first deployment to Fairchild AFB in February 2017, 
the MHS GENESIS program established an aggressive schedule, with 
concurrent system configuration, contractor testing, government 
testing, and cybersecurity risk management. Together, the DoD 
Healthcare Management System Modernization (DHMSM) Program Management 
Office, DHA, the U.S. Air Force and our industry partner, the Leidos 
Partnership for Defense Health (LPDH), developed interfaces and user-
approved workflows, and finalized the technical integration of the 
baseline operational system. Today, clinicians and dentists are 
documenting patient records in MHS GENESIS, and ancillary capabilities 
such as pharmacy, labs and radiology are working as expected. Feedback 
from providers at Fairchild has been positive, with many citing the 
ease of use and integration into their daily work practices.
    While initial feedback was positive, we also captured lessons 
learned to improve provider experience at our remaining fielding sites 
in the Pacific Northwest. Training is one area noted where we can make 
a few adjustments. Feedback indicated the training modules built into 
our deployment schedule were more than adequate to teach the 
functionality of MHS GENESIS. Providers felt comfortable using and 
documenting patient care in MHS GENESIS. However, more specialized 
training with a deeper dive into provider specialty areas such as 
laboratory and radiology, to name a few, was requested. We are 
evaluating our existing training curriculum and assessing enhancements 
based on this feedback.




    Another area noted is that of patient registration. While we did 
pre-register select patients in MHS GENESIS prior to the Go-Live 
deployment at Fairchild AFB, registering patients for the first time at 
the clinic resulted in a longer processing time. We anticipated this 
and provided the necessary resources to ensure patients were registered 
in a timely fashion with minimal impact to the care facility. With the 
experience gained at the first deployment site, we are now evaluating 
patient registration to determine the right course of action at our 
remaining fielding sites in the Pacific Northwest. We also have the 
opportunity to communicate with and educate patients about the many 
benefits of MHS GENESIS, including the MHS GENESIS Patient Portal.
                   interoperability and data sharing
    As the DoD transitions to MHS GENESIS, our commitment to expand our 
interoperability efforts with the VA and private sector providers 
remains unchanged. Service members and their families frequently move 
to new duty assignments, they deploy overseas, and eventually, 
transition out of the military. As a result, there are many different 
places where they may receive medical care. For instance, more than 60 
percent of all active duty and beneficiary healthcare is provided 
outside a MTF through TRICARE network providers. Healthcare providers 
need up-to-date and comprehensive healthcare information to facilitate 
informed decisionmaking whenever and wherever it is needed--from a 
stateside MTF to an outpost in Afghanistan, from a private care clinic 
within the TRICARE network to a VA hospital, and everywhere in between.
    The DoD and VA are two of the world's largest healthcare providers 
and today, they share more health data than any other two major health 
systems. In April 2016, DoD and VA certified to Congress that they are 
fully interoperable, in accordance with the fiscal year 2014 National 
Defense Authorization Act (NDAA). While the Departments met the 
required objectives, interoperability is a spectrum wherein data 
sharing and functionality can continually improve. As a result, we 
continue to expand interoperability beyond last April's DoD/VA Joint 
Certification of Interoperability. MHS GENESIS' s modem capabilities 
will allow DoD to share more complete data with similarly equipped 
Federal and private sector partners while simultaneously increasing the 
number of DoD data sharing partners by the thousands.
    The two Departments currently share health records through the 
Defense Medical Information Exchange (DMIX) program, which includes the 
Joint Legacy Viewer (JLV), a health information portal that provides 
access to medical information across multiple government and commercial 
data sources. In addition to enabling enhanced data sharing between DoD 
and VA, JLV allows DoD to leverage our expanding relationships with 
private-sector providers to give clinicians a comprehensive, single 
view of a patient's health history in real-time as they receive care in 
both military and commercial systems. JLV is currently available to DoD 
providers in AHLTA and is being incorporated into MHS GENESIS.
    Over the past 4 years, DoD steadily increased its data-sharing 
partnerships with private sector healthcare organizations. Since many 
service members and their beneficiaries receive specialized care 
outside of the MHS, seamless access to healthcare records from civilian 
providers supports clinical decisionmaking by delivering a 
comprehensive picture of patient health. Expanding these partnerships 
will enable medical providers to move away from a reliance on fax 
machines for patient record sharing and into a modem era with 
increased, current health data that's available anytime, anywhere on a 
computer screen. To date, DoD has partnered with members of the eHealth 
Exchange via the Sequoia Project, a network of exchange partners who 
securely share clinical information across the United States. There are 
over 20 exchange partners already connected with the DoD and another 10 
in the process of connecting. In the future, DoD plans to expand its 
data-sharing partnerships via CommonWell--an independent, not-for-
profit trade association with connections to more than 5,000 private 
sector healthcare sites. Leveraging this connection through MHS GENESIS 
will expand on the great work DoD has already accomplished through 
health information exchanges.
    Another phase of interoperability is connecting the benefits and 
capabilities of MHS GENESIS to operational forces in a deployed theater 
environment that includes more than 450 forward and resuscitative 
sites, 300 ships, six theater hospitals, and three aeromedical staging 
facilities. While each service currently uses the Theater Medical 
Information Program-Joint (TMIP-J), MHS GENESIS will be fully leveraged 
as the core application for accessing, capturing, and documenting 
medical and dental care through the Joint Operational Medical 
Information System (JOMIS) to provide continuum of care support in 
various treatment phases including combat casualty care, medical 
evacuation, and in-theater hospitals. The DoD is also employing modern 
tools for operational first responders to document patient status and 
treatments rendered at point of injury. The Mobile Computing Capability 
(MCC), released last year, is a medical application that operates on 
DoD-approved phones and tablets in no or low communication environments 
and allows first responders to document and transfer patient treatment 
information, access reference material as well as view diagnostic and 
treatment decision support tools.
    We fully recognize that health IT will keep evolving and that we 
must constantly improve our capabilities. The complexity of our 
interoperability mission takes time and steadfast commitment. To that 
end, DoD actively participates in forums with government and industry 
partners, including the U.S. Department of Health and Human Services, 
VA and commercial interoperability organizations, to outline and 
advance our common goals toward nationwide interoperability. It is 
DoD's hope and vision that driving a national approach with public and 
private community partners creates a viable economic model that allows 
us to make investments in industry and leverage their advances for 
long-term cost savings, with an end state of fully comprehensive and 
sharable data incorporated into modern EHRs throughout the industry. 
Through strong communication, collaboration, and technical leadership, 
we will continue to ensure that current and future health information 
is seamlessly shared across public and private healthcare networks.
                transforming the delivery of healthcare
    A modern EHR incorporates advanced tools and capability 
improvements that promote efficiencies, provide a higher quality of 
care, and improve population health outcomes. The suite of tools 
available through MHS GENESIS include robust data reporting and 
tracking capabilities, improved analytics, drug-to-drug interaction 
alerts, and a user-friendly patient portal. Taken together, these tools 
enable healthcare professionals to more easily monitor and respond to a 
patient's health status and facilitate good decisionmaking.
    Patients in the MHS, not unlike their civilian counterparts, want 
more medical information transparency and to be actively engaged in 
their healthcare experience. The MHS GENESIS patient portal, which will 
replace RelayHealth and TRICARE Online (TOL), is a secure one-stop 
website where patients can access their current medical and dental 
health records, manage appointments, and request prescription refills. 
It also allows patients to view doctor's notes from their appointment 
and ask questions through secure messaging while their visit is still 
fresh in their mind. Within the first month of operation at Fairchild 
AFB, more than 1,100 beneficiaries have signed up for the new patient 
portal.
    During the transition period, the MHS GENESIS patient portal and 
TRICARE Online (TOL) Patient Portal will co-exist, albeit with 
different functions. When service members move to a military hospital 
or clinic that has not started using MHS GENESIS, they will simply 
resume using RelayHealth and TOL.
    Ease of use for the provider is another key benefit of MHS GENESIS, 
which puts more integrated information at the healthcare professional' 
s fingertips for rapid decisionmaking, reducing duplication of data 
collection and procedures, such as ordering unnecessary labs or 
duplicate prescriptions. At Fairchild AFB, we have already seen 
evidence that the increased patient data, health alerts and tools to 
cross reference medical guidance has led MHS GENESIS clinicians to make 
changes to their behavior. More information in the patient's record has 
yielded better guidance for providers to make more informed patient 
decisions. MHS GENESIS's life cycle management and component 
modernization approach will minimize obsolescence, and promote adoption 
of emerging Health Industry Standards and new technologies, including 
compliance with the Office of the National Coordinator (ONC) meaningful 
use regulations.
                               conclusion
    Thank you again for the opportunity to come here today and share 
the progress that we've made to transform the delivery of healthcare 
for service members, veterans, and their families. The successful 
rollout of MHS GENESIS is an important first step in implementing what 
will be the largest integrated inpatient and outpatient EHR in the 
United States. Because DoD purchased lifetime upgrades with MHS 
GENESIS, our healthcare providers will always have the latest 
advancements in technology in a timely manner. DoD beneficiaries will 
have greater access to their information, allowing them to be more 
engaged in their own health-related activities. While we are well on 
our way, the road ahead is long, with many challenges that we will have 
to anticipate and respond to. As a partner in our progress, we 
appreciate the Congress' interest in this effort and ask for your 
continued support to help us deliver on our promise to provide world-
class care and services to those who faithfully serve our Nation. 
Again, thank you for this opportunity, and I look forward to your 
questions.

    Senator Cochran. Thank you very much for your statement. I 
will now recognize the distinguished minority member of the 
committee, Senator Durbin.

                                TOBACCO

    Senator Durbin. Thanks, Mr. Chairman. As I said in my 
opening statement, I want to ask you about the use of tobacco 
in the military. Among the Surgeon Generals, is there anyone 
who disagrees with the premise that tobacco use by our military 
is a significant challenge to their health and readiness? Do 
you all agree?
    [Nodding in agreement.]
    Senator Durbin. So, the next question is what are we doing 
about it? It turns out that 38 percent of the smokers in the 
military started after they enlisted. Clearly, the environment 
that they were brought into was one that gave them an 
opportunity, perhaps encouragement, to smoke.
    When they go through basic training, correct me if I am 
wrong, in each of your branches, it is a non-smoking 
environment. Is that correct? I understand that until the year 
2004, the next level of training, the advanced training, was 
also a non-smoking environment. Is that correct? I think it is.
    Can you tell me why that was changed? Why we went from 
prohibiting smoking during basic training and then allowing it 
as of 2004 in advanced training? Does anyone know the reason? 
The panel is quiet. Can you give me an explanation as to why it 
was changed? Does anyone know why it was changed?
    General Ediger. Senator, in Air Force technical training, 
it is still an environment that actively discourages smoking. 
The instructors are not permitted to use tobacco within the 
presence of the trainees. In accordance with the DOD policy, 
tobacco use on the installation is restricted to designated 
tobacco use areas.
    I know the Second Air Force Commander who oversees 
technical training in the Air Force has a very active program 
to discourage tobacco use among trainees.
    General West. Yes, Senator. We are trying to get after that 
as well. In talking with our Training and Doctrine Command that 
governs all that training, the AIT programs vary in length, 
some of them are 4 weeks long, some of them over 40 weeks. So, 
the consistency of having no smoking throughout the entire AIT 
training varies depending on the length of the course.
    I do not have the details of which courses, but there is 
some limitation based upon the length of the course, and those 
that are upwards of a year almost, it is kind of a different 
environment for some of those.
    But I concur, Senator. As I said before, there is no 
minimum daily requirement for tobacco products. Anything we can 
do is from the medical standpoint to encourage our members to 
not smoke with education, with smoking cessation classes, with 
smoking cessation support, with medication for those who choose 
to stop smoking, we highly encourage that and try to push that.
    Admiral Faison. Senator, in the Navy, like the Air Force, 
we do all of our training, many of our C schools included, down 
in San Antonio, which is a smoke free campus. We actively 
discourage that amongst our students, and it is prohibited 
amongst the faculty down there.
    In addition, we have put in place those that come on active 
duty who were smokers beforehand that then have recidivism and 
go back to smoking--we have support services in place at the 
school, and then at every Navy Medicine Command around the 
world to support them in their kicking the habit long term.
    So, we have actively pushed to minimize smoking in those 
environments, to include our C schools and follow on 
assignments. Thank you, sir.
    Senator Durbin. The Air Force Surgeon General who preceded 
you, Travis, in 2015, issued a report that the cost of tobacco 
to the military is $4.5 billion or more each year in 
preventable healthcare costs, not to mention the fact that many 
of these airmen, soldiers, sailors, and marines end up 
compromising their own personal health in missing their 
assignments because of their dependence on tobacco.
    The rest of the world seems to have awakened to this. Why 
is the military so slow in responding to what has been a 
phenomenon or trend across America for decades?
    General Ediger. Senator, we completely agree that tobacco 
is a serious detriment to the health and performance of our 
servicemembers, and we are tracking this very carefully. In the 
Air Force, since 2008, we have seen a 50 percent reduction in 
smoking among U.S. Air Force airmen.
    The area where are focusing a lot of our attention now in 
addition to that is on the use of smokeless tobacco, which 
remains at about a five to 6 percent rate among airmen, and 
that rate has not decreased.

                           NICOTINE ADDICTION

    Senator Durbin. Do you quarrel with the premise that 
nicotine is addictive?
    General Ediger. I do not.
    Senator Durbin. Most people do not. Switching from tobacco 
to these e-cigarettes and creating a new chemical dependency or 
a different chemical dependency cannot be an element of 
readiness as far as I see.
    General Ediger. We agree. We have started gathering data on 
the frequency with which airmen are using vaping, electronic 
cigarettes. So, we now have data that shows about four to 5 
percent of airmen are using electronic cigarettes in some 
fashion.

                       ELIMINATE TOBACCO DISCOUNT

    Senator Durbin. Mr. Chairman, this committee, with 
appropriations language, could eliminate the discount that was 
being given to the purchase of tobacco in the military, an 
incentive for more people to use tobacco.
    I am going to follow through on this. I think this is an 
issue which we can all agree on, and we just need to show some 
leadership. Thank you.
    Senator Cochran. Thank you, Senator. The time of the 
Senator has expired. I now recognize the distinguished Senator 
Roy Blunt.

                       FORT LEONARD WOOD HOSPITAL

    Senator Blunt. Thank you, Chairman. I have about three 
questions I want to cover here, and not a lot of time. First, I 
will just ask a question, General West, that I ask every year, 
about the Fort Leonard Wood Hospital.
    I know you have been to the Fort recently. I have been to 
the Fort recently. The hospital underwent major renovation 
about 40 years ago, and trying to keep up with minor 
renovations for right now. It has been ranked number one, I 
believe, on the MILCON medical priorities list. Is that still 
the case?
    General West. Yes, sir, it is still number one on our 
priority list.
    Senator Blunt. Is there any planning money available yet 
for that account?
    General West. Not right now, Senator. Again, it is our 
number one priority. We do the planning, construction, and 
outfitting once we get that construction project started to 
take approximately 5 years to go through, but we definitely 
have it as our number one priority and are continuing to work 
with the Defense Health Agency that has the MILCON 
prioritization to make sure that is continued----
    Senator Blunt. Would it help with that number one priority 
if we looked at a way to phase it in, or are you already 
looking at a phased approach?
    General West. So, we are looking at a phased approach, and 
that might help get the start of that if we can get the phasing 
started. That is one approach, Senator that would be helpful in 
getting that moving.
    Senator Blunt. I wonder what the record is for being the 
number one priority and never get to it. If we have not set it 
already, I hope we are not intent on setting that record, 
because it has been at the top of this list for a long time. 
They are trying to do the things they need to do, but the size 
of the operating rooms are no longer adequate for the kind of 
equipment that you put in operating rooms now, and there are 
just lots of questions.
    We are going to continue to be interested in that, and I 
know you are, too, and I am grateful.

                             TELE-MEDICINE

    One of the things that I am seeing there and in other 
hospitals and clinics is more tele-medicine. I want to ask 
about tele-medicine generally. On a specific topic, I think in 
all the branches of the Service now, there is a behavioral 
health exit interview. Would that be accurate everywhere?
    I think there is usually a choice there, it is just a 
little survey. When people exiting the military have a choice 
of seeing a person or going to tele-health, is the tele-health 
a big negative? What do you see on behavior health with tele-
health? General Ediger?
    General Ediger. Yes, sir. So, we do a separation health 
physical now on airmen who are either retiring or separating 
from the Air Force. That does include an assessment for 
behavioral health problems. That is a face-to-face.
    Senator Blunt. It is always face-to-face?
    General Ediger. Yes, sir.
    Senator Blunt. How about in the Navy, is it always face-to-
face, or do you have an option of talking to a tele-health 
person?
    Admiral Faison. No, sir, it is always face-to-face, and it 
is part of our annual health assessment, and it is part of the 
exit interview that is also face-to-face. If issues are 
uncovered, then we have handoff coaches to help them get 
plugged in with the VA.
    Senator Blunt. How about in the Army, General West?
    General West. Sir, we have both face-to-face and virtual, 
and we have seen in those that have the offering of virtual, 
that it is very well accepted. Our younger soldiers who are 
used to virtual interface, social media, actually do like the 
option of having the virtual behavioral health.

                     DEPARTMENT OF DEFENSE AND NIH

    Senator Blunt. It is something to think about as another 
option, but tele-health generally is a big issue. My third 
question, we also have NIH (National Institutes of Health) 
funding in this broader committee, could you talk in general--
Ms. Cummings, you may be the best person to do this--about the 
collaborations between the Department of Defense and NIH?
    One of the things we are constantly having to explain is 
that we believe in this area on this subcommittee, that there 
is not a duplication of effort that is a problem, but if there 
is any communication, it is positive.
    What I am asking is do you know of any concerns about 
duplication of effort in health research and health issues 
funded here, and health research funded through NIH?
    Ms. Cummings. I am personally unaware of any duplication of 
effort, but to be clear, my area of expertise is acquisitions, 
and that may be a better question for one of the Surgeon 
Generals.
    Senator Blunt. Let's just go right down the list. General 
Ediger, any thoughts on that criticism of some of the research 
we fund out of this committee, that, well, that would be better 
all focused on NIH instead of a health research focus through 
your offices?
    General Ediger. I know in Military Health System in general 
we have a strong linkage and collaboration with the NIH. There 
are a number of NIH related protocols in terms of clinically 
based research that we are a part of within our hospitals.
    Senator Blunt. If you were not part of that, would NIH be 
doing the specific work you need done in some of these areas?
    General Ediger. I believe the research we do actually 
builds and adds upon that done at the NIH. I think within the 
community of research there is a strong sharing of information, 
so I see it as building synergism.
    Senator Blunt. If anybody wants to add anything differently 
than that in writing later, but I am out of time, and thank 
you, Chairman.
    Senator Cochran. Thank you, Senator. The chair now 
recognizes the distinguished Senator from Hawaii, Mr. Schatz.

                     MENTAL HEALTH SERVICES STIGMA

    Senator Schatz. Thank you, Mr. Chairman. Thank you, Surgeon 
Generals, for your important work. I want to talk to you about 
mental health stigmatization. In 2006, GAO (Government 
Accountability Office) found that DOD is working to improve the 
stigma associated with servicemembers who want to access mental 
health services.
    But the same GAO study cited a 2014 and report that 
identified 203 different DOD policies and regulations that may 
conflict with the Defense Department's goal to eliminate 
stigma, and let me give you just a couple of examples 
stipulating that of the 203, maybe some of them have been--you 
are in the process of clearing the underbrush.
    The Army's regulation that governs a soldier's assignment 
to recruiting duty requires that he or she provide a mental 
evaluation statement proving no record of emotional or mental 
instability without defining ``instability.''
    AFRICOM and CENTCOM have policies that deny deployment or 
require waivers for individuals who have received ``a 
behavioral healthcare diagnosis or relevant prescription/
medication.''
    I understand we have a policy, and I imagine you are all on 
board with that, but I would like to talk to you, get your 
thoughts on the extent to which some of these individual 
Service branch policies, regs, and even sort of legacy 
processes and procedures, and cultural aspects tend to run 
against official OSD (Office of the Secretary of Defense) 
policy, official national defense authorization policy, and 
what we are going to do to clear that underbrush so that where 
the rubber hits the road, your servicemembers can access the 
care they need without jeopardizing their career. I will start 
with General West.
    General West. Senator, thank you for that question. The 
first part of it, reducing stigma, I think overall we have done 
a good job of that by increasing behavioral health assets at 
the unit level. So, when you have embedded behavioral health, 
it makes servicemembers/soldiers more likely to want to see 
their behavioral health provider without having to go to a 
facility, so they are right there in their units.
    A lot of the policy, I think, can be deconflicted if you 
have that behavioral health provider within the unit, because 
some of those policies, for example, the various combatant 
command policies, are for readiness issues, and they want to 
make sure that individuals in the environments that they are 
operating in are not put at risk or a disadvantage if they have 
certain medications they need.
    Senator Schatz. Sure, and there is attention there, right?
    General West. Yes.
    Senator Schatz. You do have to make a determination about 
the readiness of any soldier, sailor, or airman, but the 
problem here, I think, is that there is a tension----there are 
still old rules. It is not as though these rules have been 
updated or these evaluations have been updated to account for 
the fact that there is a new national policy on 
destigmatization.
    You are right to articulate there is a tension, you are 
right to say deploying behavioral health assets sort of as far 
and as deep as possible throughout all Service branches makes 
sense. You are still stuck with rules that are old, that are 20 
years old, that are 30 years old, that do not account for, I 
think, a more enlightened view of this matter.
    Would you agree with that?
    General West. Sir, I do not know all the rules and 
regulations. I will definitely take a look and make sure there 
are none that we have that we can work on changing, but I think 
what I have seen, and I think the good news is that more of our 
servicemembers, and not only our servicemembers but our family 
members, dependents and children, are getting more care, the 
care that they need because we are putting those assets far 
forward and putting them in schools for our children, in unit 
areas, with our brigade combat teams.
    So, the feedback we have received is they like those assets 
in their units, they are more likely to see them, and we have 
actually caught things much earlier. Our hospitalization rate 
for significant behavioral health conditions has decreased by 
40 percent. The number of individuals that have to actually get 
to a point where they are hospitalized did greatly decrease in 
our civilian population as well, our children.
    Senator Schatz. Let me sort of revise the question for the 
rest of the panel in my remaining 30 to 40 seconds. Do we have 
your collective commitment to look at these remaining 
regulations and any cultural issues and work across all Service 
branches to clear the sort of final batch of underbrush? I 
think that you are making progress, but we still have a way to 
go.
    Admiral Faison. Absolutely.
    General Ediger. Yes, sir.
    Senator Schatz. Thank you.
    Senator Cochran. Thank you. The distinguished Senator from 
Kansas, Mr. Moran.

                   MILITARY HOSPITALS FOR VA SERVICES

    Senator Moran. Mr. Chairman, thank you very much, I 
appreciate the service represented by the folks at the table in 
front of me. Let me begin with you, General West. Thank you 
very much for your help in the past with Irwin Army Hospital at 
Fort Riley in the efforts of getting that hospital completed.
    The question that it raises is the last time I was there, 
which is now just a few months ago, the conversation turned to 
including more veterans into patients at that hospital. Fort 
Riley is a military retiree as well as a veteran community.
    My question is are there talks ongoing, either in that 
instance, or with the VA generally about utilizing military 
hospitals for VA services?
    General West. Yes, sir. Thank you for that question. I 
think it is extremely important. Military Health System-wide, 
we are looking at opportunities to have all of our patient 
category types seen in our facilities, because that helps us 
with readiness. Our veterans that have complex medical 
conditions help our surgeons, help all of our trainees to get 
the proper patient mix that they need.
    We have been in dialogue with our--I know because of the 
VISN (Veterans Integrated Service Network) structure, locally, 
we talk with our VA partners on certain areas where we can 
collaborate. If we have a capability in our MTS to bring our 
patients in, then we will definitely look at bringing that 
population in, if our policies allow us to do that. That is 
definitely something we want to do.

                             HEALTH SHARING

    Senator Moran. I appreciate your words. I am very 
interested in this, as chair of the Appropriations Subcommittee 
on Veterans, this is an issue I want to push.
    You point out its value for military readiness, which I 
fully acknowledge. I also would add the access to healthcare 
for veterans who live long distances from a VA facility, which 
is certainly the case in a State like ours. I want to take this 
commentary to a different plane and ask you this question 
because one of the things that is apparently going on is that 
DHA (Defense Health Agency) is assuming more and more authority 
over the Services and your ability to manage as Surgeon 
Generals the healthcare affairs of your military component.
    You can dissuade me if I do not have that understanding 
correctly, but that seems to me to be the direction you are 
going in. I think this is an example of where having the 
Commander at Irwin Army Hospital, the Hospital Commander, 
talking to the VA VISN Director in Kansas City, that is a 
better solution and more likely to find common ground than if 
there is a different level of authority making decisions like 
this.
    I would appreciate any commentary, General Ediger, or 
others would have.
    General Ediger. Yes, Senator. I agree completely that we 
really value providing care to veterans from our hospitals and 
clinics. It is good for the veterans, as you state, to provide 
access to care. It is good for the readiness of our deployable 
teams.
    Throughout DOD, all three Services, we have many sharing 
agreements. We have over 60 of them in the Air Force. I agree 
that those agreements are best managed locally and maintained 
to a common standard, because the opportunities vary by 
location in terms of the scope of services that are available.

                             DHA RUN SYSTEM

    Senator Moran. Let me ask this broader question. Would a 
DHA run system help or hinder the ability to make decisions 
quickly and efficiently to provide the best care for your 
military men and women?
    General Ediger. As you know, Senator, we are working right 
now to build a Department of Defense plan for implementing the 
fiscal year 2017 NDAA that gave the management of the Health 
Care Administration authority to the Defense Health Agency.
    I believe we can set that up in a way that we can continue 
to effectively manage the sharing agreements with the VA, and 
that is one of our priorities in terms of developing an optimal 
implementation plan, to set that up in a way where the health 
of those agreements is sustained.
    Senator Moran. I appreciate your comments about the ability 
to make it work. I would at least state for myself that I want 
to be certain it does not go too far in reducing the authority. 
Any comments in that regard?
    Admiral Faison. Sir, for the Navy, combat survival in the 
future conflict is going to depend on how well trained and 
prepared our medical forces are, and how quickly we can get 
them and get them out the door quickly.
    The MTF is the epicenter of that effort. There is no back-
up plan for that. As General Ediger said, we have to make that 
successful, agile, rapidly responsive, in a world that again 
increasingly calls upon us to get out the door, so we are 
working very hard to make sure that happens in a smart way, and 
at the same time, realize the benefits that can come 
potentially with that NDAA.
    I think all three of us are heavily engaged in that, to 
make sure that is a success. But it is readiness, making sure 
people are prepared to save lives tonight, and get out the door 
quickly if necessary. Thank you, sir.
    Senator Moran. Thank you.
    Senator Cochran. The time of the Senator has expired. The 
distinguished Senator from Montana, Mr. Tester, is recognized.

                       ELECTRONIC MEDICAL RECORDS

    Senator Tester. Thanks, Mr. Chairman. I want to thank all 
of you for your service, and I want to tell you it is nothing 
short of amazing the work that the Medical Corps are doing in 
the field of battle, saving lives, getting people to locations 
where they can get the treatment they need.
    I want to talk to you, Ms. Cummings, a little bit about 
electronic medical records. I serve as ranking member on the VA 
Committee, and I will tell you, as I am about to hold you 
accountable, we are going to be holding the VA very accountable 
on this issue, so it is not just you guys, so you know.
    You talked about interoperability on a very basic level 
over the electronic medical records. It is a read-only 
interoperability. It is not an interoperability that allows for 
computations or test results, edits or notes. So, it is not 
true interoperability. It is not where we need to be, let's 
just put it that way.
    We have spent over $1 billion on interoperability between 
the DOD and the VA. We have had committee meetings after 
committee meetings over the last 10 years on this, both the VA 
and this committee, this subcommittee, the Appropriations 
Committee as a whole. We still are not where we need to be.
    Could you comment a little bit--I will tell you that I hold 
both the DOD and the VA accountable. Could you tell me, you 
talked about a new MHS GENESIS system that is going to be good, 
how often do you talk to VA? The VA is about to put in a new 
system. Are these two systems going to be unequivocally 
compatible, that we will be able to do the things that are 
truly interoperable that electronic medical records will be 
able to do?
    Ms. Cummings. I will start out by saying I agree with you, 
where we are within interoperability is a first step, not a 
last step. We are working towards that level of 
interoperability that you and the committee are holding us 
accountable to get to.
    We are working with industry because we think the best way 
to get to true sematic interoperability is nationwide 
interoperability, and interoperability with the VA, but also 
with our private sector partners.
    Senator Tester. But you are not even there between the DOD 
and the VA.
    Ms. Cummings. Correct.
    Senator Tester. Keep going.
    Ms. Cummings. I, personally, speak to the VA on a regular 
basis. Last week, I gave a presentation at the Joint Executive 
Committee in front of senior leaders at both the Department of 
Defense and VA, and they reiterated their commitment to 
interoperability. I reiterated my commitment to providing 
technical assistance and information to the VA as they are 
making their decisions.
    The Secretary has announced July 1 for when they are going 
to publicly announce what their plan is to move forward with a 
new EHR solution/strategy.
    Senator Tester. Are you going to know when they make that 
announcement on July 1 whether you are going to be able to 
communicate between the two systems?
    Ms. Cummings. We will absolutely be able to have the same 
level of interoperability and build towards enhanced 
interoperability as we have been discussing in this 
conversation, because we are going to work together to make 
sure----
    Senator Tester. Let's just back up a little bit. So, when 
they make the announcement in July, and they buy this new 
system, you are fully confident that you will at least be where 
you are now and have the capability to get full 
interoperability within how many months?
    Ms. Cummings. I cannot commit to a number of months. I do 
not know what solution they are going to select, and whatever 
the solution is they select will impact how long it takes.
    Senator Tester. Here is the deal. We have been at this for 
a long, long time. One billion would buy multiple counties in 
the State of Montana. It is a lot of money. I have heard the 
same response now for 4 or 5 years, that no, we are not going 
to make the commitment as to when we are going to get this 
done, just trust me, it is going to happen.
    The problem is that the folks that are in the military and 
the veterans when they get home are the ones that are suffering 
because of this. We are spending more money than we need to be 
spending on healthcare because of this.
    You are right, it needs to also work with the private 
sector, too. We are not even to a point where we have true 
interoperability between the two government agencies that are 
both funded by this committee and other committees. Well, 
actually, this committee, the Appropriations Committee. So, is 
there any urgency that is being felt here?
    Ms. Cummings. There is absolutely a sense of urgency, and I 
do want to reiterate that the type of interoperability--I know 
it is not where we want to be--it is based on what the 
physicians have told us the most important information for them 
to be able to see at the time they are providing healthcare.
    We want to take it to the step where as you are going 
through your workflow in your electronic health record, the 
information comes into the record, and you can use it, just 
like data that was collected locally.
    We are doing some actual investigation into that with a 
tool called Commonwealth that is part of our solution that we 
bought with MHS GENESIS. We will be demonstrating that later 
this year, and as we have successes with our commercial 
partners, we will be able to leverage those successes to work 
with the VA to get that type of interoperability in the future.
    Senator Tester. There are at least three members on this 
subcommittee that are also on the VA Committee. I guarantee you 
we are going to hold the Veterans Affairs Administration 
accountable.
    I need you guys to be much more aggressive on your end, 
too. I know you have bigger jobs to do than electronic medical 
records, but the fact is this is really important, and we have 
wasted way too much money on this.
    Thank you, Mr. Chairman.
    Senator Cochran. The time of the Senator has expired. The 
distinguished Senator from Alabama, Mr. Shelby.

                        COORDINATION DOD AND NIH

    Senator Shelby. Thank you, Mr. Chairman. I want to follow 
up on some of Senator Blunt's areas, because he is the Chairman 
of the Subcommittee on NIH. I think the complementary and 
coordination of biomedical research with the Department of 
Defense, the VA, and NIH is very important. I think a lot of 
things have come out of that. We all have benefitted from it.
    We all know that a healthy soldier is a better soldier in 
many ways. It looks to me like there could be more 
coordination, some kind of task force, to decide something, who 
is doing what, are they complementary, is there coordination, 
rather than competing and going down parallel roads. Sometimes 
on parallel roads, somebody finds something, somebody does not. 
We all benefit from it.
    Admiral, what is your take on all that, and can we do 
better because this is a committee that funds things, and we 
are interested in biomedical research in all phases, civilian 
and military, and that coordination, because we all benefit 
from it.
    Admiral Faison. Yes, sir, absolutely. Our research 
portfolio is primarily singularly focused on threats to 
military readiness and military health. There is overlap 
opportunity with the research portfolio at NIH.
    We work hard on that. There is great opportunity to expand 
that. Some of the things that we do--I have liaison officers at 
the CDC (Centers for Disease Control and Prevention), at NIH, 
and in a variety of different health agencies in the Federal 
Government.
    We have partnerships with the NIH right now for Zika 
research, as well as disease surveillance and monitoring in 
South America, as well as some of the groundbreaking research 
we are doing in Western Africa to set the stage for an Ebola 
and Zika vaccine in the future.
    We are very heavily partnered with----
    Senator Shelby. Are you doing a lot of coordination, I have 
heard you were, with our European allies?
    Admiral Faison. Yes, sir, absolutely.
    Senator Shelby. We are all looking for something to help 
us.
    Admiral Faison. Absolutely. We have strong partnerships 
with our allies, not only in Europe, but also in Asia, where we 
get together on a regular basis to discuss these and identify 
opportunities.

                           BIOLOGICAL THREATS

    Senator Shelby. Admiral, in your area, let's get into 
biological threats. Could you describe for the committee here 
this morning how prepared we are as a nation to promptly 
respond to biological threats in the future, and whether there 
are additional steps that we need to take to help fund this 
threat, which a lot of us believe is real?
    Admiral Faison. Yes, sir. I am not sure I can speak about 
as a nation, but I can speak about our Navy.
    Senator Shelby. I know.
    Admiral Faison. I think it falls into three----
    Senator Shelby. You are an integral part.
    Admiral Faison. Yes, sir; absolutely. We have a robust 
research agenda that focuses on potential biological threats, 
both from pure competitors as well as asymmetric threats, and 
we do that in partnership amongst the three Services.
    I think those are robust. I think those are making 
progress. I think we are well positioned in the area of 
research. Then there are physical defenses. The Navy practices 
and invests in these on a regular basis, so that all of our 
platforms are ready should they be attacked or should they come 
under threat.
    Then there is surveillance and intelligence gathering where 
we look at future threats, again, to help inform those two 
previous areas of focus.
    I think we are making progress in those three areas.

                            THREATS RESEARCH

    Senator Shelby. Do you feel comfortable we are prepared as 
of today? There are so many threats out there that we do not 
know.
    Admiral Faison. Yes, sir. There are many threats that we do 
not know. I do not know that I am ever comfortable in a very 
uncertain world. I think continued surveillance, continued 
attention to the things that are going on in the world are 
going to be critical to maintain our posture so we can 
adequately protect our folks and ensure we can meet the needs 
of our Nation.
    Senator Shelby. General West, do you want to add to that?
    General West. Yes, Senator. Thank you so much for the 
question. At our United States Army Medical Research and 
Materiel Command at Fort Dietrick, about 80 percent of the 
research is done there, biosurveillance is extremely important.
    In fact, the reason we have a Zika virus----
    Senator Shelby. This is a potential real threat to our 
troops and everything, is it not?
    General West. Absolutely, it is a threat, and that is why 
we have researchers trying to determine what are those areas 
that our troops might be operating in, all of our 
servicemembers, so trying to look at countermeasures, look at 
forward thinking in trying to determine if there are any 
vaccine developments to prevent their exposure or to mitigate 
any exposure.
    Again, the Zika virus vaccine is as far along as it is 
because of the decades of research that the teams were doing on 
the Flaviviruses and all the different other types of viruses, 
malaria is the number one threat to where all our 
servicemembers are, and having sufficient treatment 
countermeasures and preventive measures for those is critical.
    We are also looking at all other types of research to 
provide even immune, boosting the immune system to kind of be 
an overall mechanism of countering any type of exposure we 
might have to biologics.
    There is much research going on, and it is coordinated. We 
do coordinate with NIH, we coordinate with civilian research 
academia, all those, to make sure we are not unnecessarily 
duplicating effort, and also our international partners.
    Senator Shelby. No substitute for a healthy soldier, is it?
    General West. No substitute at all.
    Senator Shelby. Thank you, Mr. Chairman.
    Senator Cochran. The time of the Senator has expired. The 
distinguished Senator from the State of Washington, Ms. Murray.

                                  IVF

    Senator Murray. Thank you very much, Mr. Chairman. Thank 
you all for your service.
    I was incredibly proud last year when we passed the MILCON 
VA appropriations bill that included a provision to provide IVF 
coverage to our veterans whose service to this country made 
having families on their own impossible because of their 
injuries.
    It brought VA's coverage in line with the Department of 
Defense, and with that provision in mind, I cannot begin to 
describe the frustration I felt when I learned that DOD 
proposes now to eliminate funding for the fertility pilot 
program in the amended budget submission.
    Thirty-eight million dollars that was originally included 
in the fiscal year 2017 budget request was singled out in the 
amended budget submission. The Administration is asking for $30 
billion in extra funding, but somehow cannot find a fraction of 
that money to get this pilot program off the ground, and this 
comes across as a very deliberate attack on a procedure for 
servicemembers who have been seriously hurt while fighting for 
our country.
    I wanted to ask each of our Surgeon Generals today, were 
you consulted on this change in the amended budget submission? 
Lieutenant General West?
    General West. No, Senator, I was not, and our team was not.
    Admiral Faison. Senator, we were involved in the pilot 
development and proposal, but not in the decisions to not go 
forward.
    Senator Murray. So, you were not.
    General Ediger. Senator, we were not.
    Senator Murray. And you were not. I just believe these men 
and women really deserve the best medical care we can give 
them, and it is unacceptable to me to withhold that because of 
political interests from this Administration, so I expect the 
Department to follow through on this program, and I just want 
to make it clear to everyone, I will fight any attempt to cut 
this funding, especially when the Department is asking for $30 
billion. I just want that on the record and clear to everyone.
    Lieutenant General West, I want to commend you and Army 
Medicine on a pilot program at Madigan Army Medical Center 
called JBLM CARES, the Joint Base Lewis-McChord Center for 
Autism Resources, Education, and Services. This is a pilot 
program. It is organized by Madigan Commanding Officer, Colonel 
Michael Place, and they converted an unused child development 
center into a centralized facility to make sure military 
children with autism have access to applied behavioral analysis 
therapy and other critical treatments.
    We should be looking to this innovative and resourceful 
pilot program as a model for the Military Health System to 
build and expand on. ABA therapy is critical to the development 
of children with developmental disabilities, but I do continue 
to hear from parents of children with other developmental 
disabilities like Down Syndrome, that they are locked out of 
ABA services under TRICARE.
    As JBLM CARES continues expanding its operations, how will 
you work to provide similar care to children with other 
developmental disabilities beyond autism at bases across the 
country or even overseas?
    General West. Thank you, Senator, appreciate the comments 
on that. The program at Madigan is an example of how we are 
looking at the best way to support our population with all 
types of disabilities or concerns. The fact that we have that 
there, there will be 150 patients that are going to be 
receiving therapy there, which is really amazing and 
remarkable.
    That was based upon seeing a need and filling the need the 
best way that we could, so that is the way we are going to 
approach when a need is brought to our attention, if we can 
fill that.
    With overseas, as far as our Exceptional Family Member 
Program and our EDIS or Education Program as well, making sure 
the first thing is that we do not put our families in a 
position where we are putting them in an area that does not 
have that resource if we cannot provide it ourselves, and then 
working and partnering with our civilian community where we 
can, where it is available, and if not, similar to what we did 
with the CARES Program, try to develop those, and working with 
the Defense Health Agency on the TRICARE Network to determine 
if we can get that more robust to support our population that 
needs that.
    We are committed to identifying those special needs and 
making sure we can meet that either internally or working with 
our partners.
    Senator Murray. Okay. I will be following that very 
closely.
    General West. Yes, ma'am. Thank you.
    Senator Murray. I want to thank all of our Surgeon Generals 
and Ms. Cummings for the work to roll out MHS GENESIS in 
military treatment facilities across my home State of 
Washington. I want to thank Colonel Meg Carey, who is here, 
Commander of the 92nd Medical Group at Fairchild Air Force 
Base, for traveling out here to be with us today, and for all 
of her work really on the MHS GENESIS that is operating at 
Fairchild.
    Ms. Cummings, Lieutenant West and Vice Admiral Faison both 
mentioned in their testimony the importance of the behavioral 
health data portal. That is software that helps our mental 
health providers evaluate and track patients, and provide 
consistent coordinated care, and helps providers get a more 
comprehensive and detailed picture of patients with mental 
health needs.
    This is a tool that is developed by the Services that helps 
military providers deliver better care to their patients, and 
it is incredibly important. This program has not been 
integrated into MHS GENESIS yet. When will that be done?
    Ms. Cummings. We are looking at how we can leverage the 
patient portal, which is inherent in the MHS GENESIS solution 
that we procured, and how we can leverage the patient portal to 
be able to share information from the patient directly to the 
provider.
    We get our priorities from across the Services and the DHA 
to make sure that we are meeting the highest priorities, so I 
am going to have to get back to you on the record on exactly 
when we are going to be able to incorporate that, but I know we 
are looking into how we can leverage that portal so that it is 
a single experience for our patients.
    Senator Murray. Okay. Can you give me the time line 
whenever you can?
    Ms. Cummings. I will.
    [Information follows:]

    Currently, patients visiting a behavioral health provider check in 
for their appointment and fill out Behavioral Health (BH)-specific 
questionnaires through the Behavioral Health Data Portal (BHDP) at 
private kiosks in their clinical care location, including Behavioral 
Health Outpatient, Intensive Outpatient, Inpatient, Child and Family 
Outpatient, Family Advocacy, and in Primary Care settings (Primary Care 
Managers and behavioral health providers embedded in Primary Care). The 
BHDP is a separate application from AHLTA and provides a single source 
for data capture and management, allowing data visualization during 
patient encounters and population-based data analysis beyond the 
encounter. As you know, DoD is in the process of deploying MHS GENESIS 
to four Initial Operating Capability (IOC) patient care sites in the 
Pacific Northwest. This limited rollout to a small number of sites 
allows DoD to assess the user experience and ensure that the 
capabilities of the new system are functioning as intended prior to 
deploying further across the Military Health System. As a part of this 
process, PEO DHMS is engaging with the functional community to gather 
feedback on the Patient Portal, including identifying areas where it's 
possible to expand the scope of the Patient Portal. Although no 
requirement currently exists to integrate BHDP into MHS GENESIS, PEO 
DHMS has been approached by the functional community regarding the 
feasibility of adding this capability. Given the sensitive nature of 
BHDP data, the transition of data to MHS GENESIS will require close 
coordination. Once the functional community establishes a requirement 
to integrate behavioral health information, PEO DHMS will work closely 
with the end users to prioritize adding this capability. A schedule 
would be developed following prioritization.

    Senator Murray. Thank you. Thank you very much, Mr. 
Chairman.
    Senator Shelby [presiding]. Senator Daines.
    Senator Daines. Senator Shelby, thank you. Thank you for 
your service today to our country in so many different 
capacities.
    The men and women under your charge such as those mighty 
medics of the 341st Medical Group of Malmstrom Air Force Base 
in Great Falls, Montana, are truly unsung heroes that do keep 
our forces focused and objective every day at home as well as 
abroad, and we are sure thankful for their service.
    As we work with the Administration to restore the very 
highest level of military readiness, it is important that we 
take time to review the medical readiness of our force, so 
truly, I appreciate your testimony here today. Thank you.
    General West, in your opening remarks you spoke a bit about 
the Army's leading role in medical innovation. I understand the 
developments in regenerative medicine with totipotent stem 
cells have strong potential to help servicemembers who have 
sustained serious injuries on the battlefield, or those who 
were diagnosed with diseases that might preclude their ongoing 
service.
    One example I heard recently was from a Montana Guardsman 
who is battling multiple sclerosis, for whom this treatment 
might have a life altering effect, and any time you interact 
with men and women who have these horrible diseases, who do not 
have a lot of options, they are looking to hang their hope on 
something.
    My question, General West, is how is the Army maximizing 
access to clinical trials of regenerative medicine and other 
leading edge technologies and treatments where no other viable 
treatment options exist?
    General West. Senator, thank you for that question. The 
Army is extremely dedicated and leaning forward in ensuring we 
can get the best care to our patients, and the leading-edge 
research that is out there, too, to ensure that we can take 
advantage of that for our patients.
    We partner with--for example, there is the Advanced 
Regenerative Manufacturing Institute, and we actually have a 
newly created Advanced Tissue Biofabrication Manufacturing 
Innovative Institute, where we are partnering with our civilian 
sectors to ensure that we get those technologies that are out 
there and have access to all the different clinical trials that 
are out there.

                             CLINICAL TRIAL

    Senator Daines. Let me ask a question on that. If we have a 
servicemember, because we are getting these inquiries, how 
would they engage if they wanted to have a chance at being part 
of a clinical trial? Where would they go?
    General West. Senator, I will have to get back to you on 
the record on that.
    [Information follows:]

    Clinical trial choices are dependent on patient and provider 
preferences and criteria established by the FDA and other regulatory 
and research oversight bodies. Not all patients/study participants 
qualify for all trials. If a study participant meets study-specific 
criteria for enrollment, the participant would then knowingly consent 
to participate with the study's many known and unknown risks and/or 
benefits, which may include the possibility of assignment to a placebo 
(non-treatment) study group for certain types of trials.
    Patients/family members/healthcare providers can search for and 
locate different types of clinical trials by searching the website: 
clinicaltrials.gov.
    Clinical trials funded by the Congressionally Directed Medical 
Research Programs (CDMRP), that are approved by required regulatory and 
ethical review bodies, are registered with the clinicaltrials.gov 
website.

    Senator Daines. Okay. That would help us because we do get 
those inquiries, and they are doing some great innovative work 
there, but how to make that connection from folks in the field 
who are looking for something, and how do we get them in touch 
with folks who might be organizing that clinical trial.
    General West. On a case by case basis, I can tell you 
sometimes there are questions--I will get emails literally as 
the Surgeon General saying do you know of any clinical trials, 
talk to my team at MRMC, the Materiel Research Command. There 
is a section there that does have kind of a view of all the 
clinical trials that are going on, kind of a consortium, and we 
pair them up that way.
    I will make sure we can get the----
    Senator Daines. That would be helpful. Any family member 
here who has had somebody who had a disease where there is not 
a lot of hope and they are looking for hope, making that 
connection would be helpful. Thank you.
    General West. Thank you.

                       ELECTRONIC HEALTH RECORDS

    Senator Daines. Ms. Cummings, I am pleased to see progress 
has been made on electronic health record system 
implementation. Echoing Chairman Cochran's sentiments, I feel 
this is critically important and should be fielded certainly 
without delay. I think you have heard a little bit of that 
consternation here today from the committee.
    How are you prioritizing sites within each region for 
implementation, and when will the system be completely fielded 
throughout the Military Health Care System?
    Ms. Cummings. We are leveraging some commercial best 
practices in putting together our waiver schedule, so we have 
three regions in the Continental United States, two regions 
outside the Continental United States, and we are leveraging 
the--we want to make sure that as we convert a military 
treatment facility that we are capturing that entire region 
where servicemembers and their families might be seen at sister 
facilities. The Pacific Northwest is a great example.
    So, we are moving from the smaller to the larger 
facilities, and when we get to Madigan, and we deploy at 
Madigan, we will have a single record, whether the 
servicemember is up at Oak Harbor and they need to come down to 
Madigan for care, or at Bremerton, so that is why we are using 
this regional approach, which is how we prioritized how we are 
deploying.
    So, we are starting in the West, and then we are moving to 
the North and the South in the United States, and then moving 
outside of the United States, so we can take the lessons 
learned from our Continental United States' deployments.
    Senator Daines. When do you think you will have the West 
implementation completed?
    Ms. Cummings. We are looking at the West being completed by 
about the end of fiscal year 2019.
    Senator Daines. 2019. I assume Montana is in the West?
    Ms. Cummings. It is.

                             CYBERSECURITY

    Senator Daines. All right. Thank you. Regarding 
cybersecurity, this is always a concern, what measures have 
been incorporated in the GENESIS system to protect 
servicemembers' most sensitive data?
    Ms. Cummings. Protecting personnel health information is 
very important to the DoD and to myself as the PEO. So, we have 
worked with the DoD CIO as well as the DHA CIO, and our 
commercial hosting partner, to come up with a hosting solution 
that takes cybersecurity to a very high level.
    So, we are looking at the architecture so we are able to 
inspect and defend the military, inspect and defend any 
information that goes in and out of our data center, the part 
that stores our own personal data.
    We are also looking at tools and we are looking at how we 
can leverage processes, so having 24/7 watches, and being able 
to work together with our commercial hosting partner to 
identify vulnerabilities and to eliminate them before they 
become problems.
    Senator Daines. Thank you. Thank you, Mr. Chairman.
    Senator Cochran [presiding]. The time of the Senator has 
expired. The distinguished Senator from Alaska, Ms. Murkowski.

                            MEDICAL RESEARCH

    Senator Murkowski. Thank you, Mr. Chairman, and thanks to 
each of you for your leadership and all that you do.
    General West, I will direct this question to you, it is 
kind of a follow on from what Senator Daines has raised about 
those who are afflicted with these horrible diseases to which 
there is seemingly no hope.
    One issue that I choose to raise here before this 
appropriations subcommittee every year is the peer reviewed 
medical research accounts. This is a program that I have 
supported over the years, and one component of that program 
that I have great interest in is the ALS research program.
    I think we know that unfortunately our military members 
have a higher incidence of ALS, a 60 percent higher rate, than 
the civilian population for reasons that we do not know, but 
what we do know is that currently, there is no cure, there is 
no treatment for ALS, and it is a horrible, horrible disease 
for an individual to live with.
    We have seen over the past few years a funding level for 
that component of about $7.5 million a year, we are kind of 
stuck at that level. Again, when you recognize the connection 
to our military, to our veterans, with this disease, it just 
seems to me this ought to be an area where perhaps we should be 
looking at better resourcing.
    I would like your comments this morning in terms of first, 
the effectiveness of the important research program that we 
have going, both in terms of identifying causes and cures, but 
also in terms of identifying some therapies that might help ALS 
patients live more productive lives, and whether you are 
satisfied with the funding levels that we have seen over the 
years for this component.
    General West. Senator Murkowski, thank you so much, and I 
really appreciate the support that you have had on this topic 
and this condition over the years.
    I do appreciate since 2007 about $62 million to help us 
identify research projects, and during that time, there has 
been 54 projects that involved the country's leading experts on 
ALS, to determine where we can get more information on cures 
and the etiology, why 60 percent of our veterans, what is it 
about our veteran population that they are higher, and actually 
Gulf War vets are two times more likely to have ALS for reasons 
unknown.
    So, the good news is there is some progress that we can 
report. The development of small molecules, stem cell 
therapies, biologic, and then there are some gene therapies 
that are showing promise. Right now, there are four of these 
that have progressed to industry-backed advanced drug 
development or at least advancement in determining that and one 
has actually moved into early phase clinical trials.
    So, I am happy to report that investment has led to some 
very promising potential therapies in the future, so I 
appreciate the support of that, and we will continue to work 
diligently to determine with those experts more results for 
that, but I do appreciate the funding levels that have been put 
towards this very devastating disease. Thank you.
    Senator Murkowski. This will continue to be a priority of 
mine as well as other members here, but I appreciate the 
continuing efforts. Again, we do not understand the connection 
but what we do know for a certainty is this is a deadly, 
horrifying disease, and we have to be doing more, and what we 
are able to do working with DoD has been significant over the 
years. You note the progress. For those who are living with 
ALS, it is pretty dire right now.
    General West. Thank you.

                      ARCTIC ENVIRONMENT RESEARCH

    Senator Murkowski. I want to ask another question about 
cold weather environments, and this is again directed to you, 
General West. You know this is a priority of mine. I take care 
of our men and women in uniform who are up in an Arctic 
environment, and sometimes it is cold, and sometimes it is 
very, very cold.
    There was an exercise just a few weeks ago. I think they 
called it Arctic Pegasus, if I recall. It was an air operation 
where soldiers parachuted out over the North Slope doing an 
exercise, and it was much colder up on the slope than anyone 
had anticipated. I think they said it was 30 or 40 below.
    The exercise mission that they designed actually did not 
prove to be so successful because what they ended up doing was 
helping retrieve many who either encountered frostbite or were 
threatened by frostbite, and they needed to get them out of 
there.
    These are learning lessons that are pretty important, but 
it is a reminder to me that when we think about warfare, it is 
not always in the desert, and are we prepared? I do not think 
we have really focused on this aspect of warfare since the end 
of the Cold War.
    Last year, we discussed the U.S. Army Research Institute of 
Environmental Medicine's work in this area. Can you briefly 
discuss where we are with that, along with future research 
efforts that are being developed for cold weather warfighting 
protection?
    General West. Yes, Senator, and thank you for the question 
on that. Just as we have said before, our environment is 
unknown and unknowable. We do not know where we are going to be 
asked to fight, so we need to be prepared in all environments.
    USARIEM, as you mentioned, has been looking at areas to 
increase the dexterity, because of course, in those 
environments, the dexterity of the fingertips and the freezing 
of the face, the difficulty for communication, are two areas 
that will diminish servicemembers' ability to use their weapons 
or whatever sophisticated systems required.
    So, there are actually strategies they are using, different 
technologies to increase the blood flow to the fingertips and 
also having systems that will help increase warmth and blood 
flow to the mouth and face area.
    There is a research collaboration with actually the Army 
Mountain Warfare School. We are using the individuals there for 
some of these research areas, also partnering with U.S. Army 
Alaska to ensure any of these techniques and modalities that we 
are seeing from the cold weather initiative that we started in 
fiscal year 2017 to actually develop a program for sustaining 
the performance in these environments.
    So, I believe we are going to be coming up with additional 
modalities to help. Again, it is mainly to try to increase 
blood flow to the areas to maintain dexterity. That is an area 
that is ongoing with research.
    I had the opportunity also yesterday to go to the 
demonstration of the combat feeding of the soldiers, and there 
were special rations designed specifically for soldiers 
operating in cold environments. There was a calculation of the 
calories needed, the different types of nutritional supplements 
that can help our servicemembers be maintained in those 
environments as well.
    So, it is an extremely important area of research for our 
teams there. Thank you.
    Senator Murkowski. General, I thank you for that. Mr. 
Chairman, you come from a warm part of the country, so you may 
not appreciate as much what this research really allows us to 
do. I am often reminded, and we talk about the need for 
sophisticated technologies to work in an Arctic and cold 
weather environment, but it is not even sophisticated 
technologies. It is utilizing a pen. A pen will not work in the 
cold.
    So, you say we are going to use a pencil. If you cannot 
hold the pencil because your glove or your mitten is so boxy 
that you cannot even pick it up, it is just a reminder to us 
how debilitating the cold can be, but yet not only do we expect 
our men and women in uniform to be able to pick up that pencil, 
we expect them to be able to pick up that weapon, to untie 
something.
    So, this is research that again is critically important. I 
appreciate the update, and I look forward to learning more 
about the advances that you have made.
    Thank you, Mr. Chairman. Thank you for allowing me to go 
over my time.

                     ADDITIONAL COMMITTEE QUESTIONS

    Senator Cochran. Thank you very much, Senator, for your 
participation, and the participation of all of our members 
during this hearing.
    We would be happy to receive written statements from 
members of the committee, which will be included in the record. 
We will request that we have them within a reasonable time so 
they can be included in the record of the hearing.
    [The following questions were not asked at the hearing, but 
were submitted to the Department for response subsequent to the 
hearing:]
          Questions Submitted to Lieutenant General Nadja West
               Question Submitted by Senator Thad Cochran
                            medical research
    Question. This Committee has consistently recommended funding for 
increased medical research. In the fiscal year 2017 Defense 
Appropriations agreement that has passed the House of Representatives 
and is awaiting action by the Senate, Congress appropriated more than 
$2.1 billion for medical research, a 7 percent increase over last 
year's level. How has increased medical research funding contributed to 
breakthroughs or positive outcomes that benefit our service members and 
society as a whole?
    Answer. The increased medical research funding has contributed to 
numerous breakthroughs and positive outcomes that have been 
incorporated into practice or improved clinical care along the entire 
spectrum from prevention, detection, diagnosis, treatment, and 
rehabilitation. These advances have made a significant impact on 
healthcare and quality of life for Service Members, their Families, 
Veterans, and society as a whole. Below are a few examples of 
successes: Prevention efforts include an algorithm to diagnose 
precursor carcinoma lesions to inform treatment and help prevent later 
development of ovarian cancer; a novel listeria-based live recombinant 
booster vaccine to provide enhanced protection against tuberculosis; 
and further development of a Malaria vaccine to prevent the severe form 
of the disease in military personnel and travelers. Detection and 
diagnostics accomplishments include novel devices and assays like a 
fiber optic sensor system to determine when a patient has internal 
bleeding and may be in danger of going into hemorrhagic shock; portable 
systems for rapid assessment of traumatic brain injuries on sports or 
battlefields; an FDA-approved blood test to help determine the 
malignancy of ovarian masses prior to surgery; and assays to guide 
prostate cancer patients in their treatment decisionmaking 
(personalized medicine). Treatment achievements include Prazosin, an 
evidence-based treatment option approved for combat trauma nightmares 
and daytime hyperarousal symptoms; groundbreaking standard of care, 
FDA-approved drugs for treatment of ovarian, breast and prostate 
cancer; or novel drug treatments for infectious diseases such as 
norovirus, leishmaniasis, malaria, and fungal infections. 
Rehabilitation achievements include improved prosthetic sockets' 
cooling and fit which provide better care and functional performance to 
amputees; an FDA-cleared non-surgical assistive device for the blind 
that provides visual information via sensory substitution; biomaterial-
based bone graft that facilitate bone-healing; and human skin 
substitutes that improve wound healing and minimizes risk infection.
                                 ______
                                 
              Question Submitted by Senator Lindsey Graham
 transfer of oversight and management of military treatment facilities 
                      to the defense health agency
    Question. Section 702 of the fiscal year 2017 NDAA transferred 
oversight and management of military hospitals and clinics from the 
military services to the Defense Health Agency (DHA), and I understand 
that the Department is now developing courses of action for the Deputy 
Secretary to consider.--Will each of you assure me that you will 
facilitate a rapid and efficient transfer of the operations of those 
medical facilities to the DHA, and will each of you assure me that you 
will reduce the number of personnel in your headquarters and 
subordinate organizations to reflect the changing scope and size of 
your missions?
    Answer. I am committed to rapidly and efficiently implementing the 
NDAA provisions through a Component Model with Service-specific 
intermediary commands and Service-specific medical treatment facilities 
(MTFs) that are aligned under the DHA for the management of healthcare 
delivery. The Component Model will accelerate the Military Health 
System's progress towards developing an operating model that reduces 
total management costs including reducing the total number of Service 
Members, civilian employees and contractors relating to headquarters 
activities, supports improved and efficient delivery of healthcare at 
military MTFs and enhances the Army's readiness capabilities.
                                 ______
                                 
               Question Submitted by Senator Jerry Moran
                    defense health agency's new role
    Question. LtGen West, I understand that Defense Health Agency is 
assuming more responsibility over the services. Would a DHA run system 
help or hinder your ability to make decisions quickly and efficiently 
to provide the best care for our military men and women?
    Answer. Deliberate planning using the Joint Staff Action Process 
with coordinated analysis incorporating input from all the Services and 
the DHA is essential to enhance decisionmaking associated with the 
transfer of management responsibilities for the delivery of healthcare 
in the MTFs to the DHA. DHA will be assuming more responsibility over 
the Services and quick and effective decisionmaking will require a 
Component Model with Service-specific Intermediary Commands and 
Service-specific MTFs that ensures the Department has the agility and 
flexibility to provide medically ready forces and a ready medical force 
to ensure the best care is provided for our military men and women.
                                 ______
                                 
            Questions Submitted by Senator Patrick J. Leahy
                        chronic pain and opioids
    Question. Both service members and veterans suffer from chronic 
pain as a result of their dedication to protecting this country. 
Whether through combat-related injuries, or a result of the stress that 
is placed on their bodies while carrying equipment and managing 
multiple deployments, pain is a reality for many who serve in the 
military. With little known alternatives to treat pain other than 
through the use of prescription opioids, our military is increasingly 
relying on prescription painkillers to manage chronic pain. According 
to the 2008 Department of Defense Survey of Health Related Behaviors 
among Active Duty Military Personnel, 11 percent of service members 
reported misusing prescription drugs--a majority of which are opioid 
pain medications--up from 2 percent in 2002, and 4 percent in 2005. The 
amount of prescriptions written for pain relief by military physicians 
also quadrupled between 2001 and 2009, with nearly 3.8 million 
prescriptions written for pain as a result of combat injuries. 
Furthermore, with suicide rates in the military on the rise, a reported 
third of suicide deaths in 2009 were a result of prescription drugs. 
The numbers reported by the Department of Veterans Affairs are even 
more staggering, with the amount of prescriptions written for opioid 
painkillers having increased 77 percent between 2004 and 2012, and more 
than 1 and 3 veterans in 2012 having received prescription opioids to 
manage their pain. In recent years, States like Vermont have seen an 
increase in opioid substance abuse, which is why I have worked to 
strengthen resources for law enforcement and health agencies to address 
the epidemic. But more must be done to address this issue at the 
Federal level, especially as it relates to our service members and 
veterans. As the opioid crisis worsens among members of the military 
and our veteran population, why is finding opioid alternatives to 
treating pain important to the DoD? What has been the value been for 
creating new research programs through the Congressionally Directed 
Medical Research Program (CDMRP), such as the breast cancer research 
program, on military personnel and their families? What is the DoD 
doing to address opioid abuse and addiction to opioid painkillers? Has 
the DoD considered expanding research on opioid-alternative methods to 
addressing chronic pain as a result of combat and deployment-related 
injury and stress?
    Answer. Army Medicine is focused on non-opioid pain management 
alternatives in order to improve the health of our Soldiers and 
increase readiness of the force. Reducing opioids is important as 
opioid use impacts readiness and increases a Soldier's risk at becoming 
dependent on medications. In 2009, Army Medicine recognized the concern 
with the opioid crisis and realized a need for opioid-alternatives. 
Army Medicine's recognition that opioids are not the sole treatment for 
pain resulted in the development of the Army Comprehensive Pain 
Management Program (CPMP) and strategically located Interdisciplinary 
Pain Management Clinics (IPMCs). The Army utilizes the ``Stepped Care'' 
approach to pain care beginning with self-care, moving through the Army 
Medical Homes (AMH), medical neighborhoods and the IPMC. The IPMCs 
provide integrative and complementary therapies that include: 
interventional pain management, primary care provider support, nurse 
case managers, chiropractors, behavioral health providers, clinical 
pharmacists, occupational therapists, physical therapists, movement 
therapists, acupuncture and medical massage. In calendar year 2016, the 
Army IPMCs provided 125,000 pain visits. Additionally, the IPMCs serve 
as the hub for subject matter expert (SME) support to the primary care 
providers and AMH. New research programs through CDMRP have provided 
great value to the Army, the Department of Defense and the Nation by 
providing research that advances service-connected and military family 
relevant disease, injury and wellness efforts; enhancing investments in 
underfunded research areas; filling research gaps; and stimulating new 
lines of scientific inquiry. For over two decades CDMRP has been a 
steward of these funds, on behalf of Congress. These programs are 
coordinated among the Services and with significant input from experts 
within other federally funded agencies and civilian institutions. Pain 
is an important aspect of injury and disease related to many of the 
research programs within the CDMRP, particularly those focused on 
orthopaedic, spinal cord and traumatic brain injuries, psychological 
health, Gulf War illness, neurofibromatosis, multiple sclerosis, and 
various cancers. In addition, in some years the CDMRP's Peer Reviewed 
Medical Research Program has Congressionally-mandated topic areas 
relevant to pain management. In fiscal year 2016, for example, these 
included Chronic Migraine and Post-Traumatic Headache, Non-Opioid Pain 
Management, Post-Traumatic Osteoarthritis, Psychotropic Medications and 
Rheumatoid Arthritis. Information on fiscal year 2016 awards will be 
available later this year. Through fiscal year 2015, CDMRP has funded 
more than 100 awards for over $140 million in research relevant to pain 
management, including studies understanding the experience, physiology, 
mechanisms, and treatment of pain. Ongoing research exploring 
alternatives to the treatment of pain with opioids includes 
identification of novel therapeutic targets as well as studies of 
acupuncture/acupressure and electrical stimulation. CDMRP coordinates 
primarily with Clinical and Rehabilitative Medicine/Joint Program 
Committee 8 (JPC-8) and secondarily with Military Operational Medicine/
JPC-5 and Combat Casualty Care/JPC-6 to leverage the advances and 
outcomes from these projects for military needs. In October 2016, in 
order to improve access, continuity and quality for substance abuse and 
addiction, the Army began relocating and integrating Substance Use 
Disorder Clinical Care with behavioral health clinics, including 
Embedded Behavioral Health Teams. This approach brings substance use 
and behavioral health providers together to form teams organized around 
the patient. All providers now use the electronic health record to 
share information and coordinate care. Teams can better identify and 
address co-occurring mental and physical illness in patients with 
Substance Use Disorders, to include opioid use disorders. Army Medicine 
established 5 intensive outpatient programs to deliver care to Soldiers 
who require an increased level of treatment than a standard outpatient 
clinic. Addiction Medicine Intensive Outpatient Programs (AMIOP) 
improve care integration, increase the opportunity for Command 
involvement, and create earlier, more ready access to higher level 
care. At end state in OCT 2017, the Army will have 11 AMIOPs located in 
MTFs at installations with the greatest need. Army Medicine is actively 
exploring opportunities for improvements and advancements in opioid-
alternative chronic pain treatment modalities through various research 
projects. These projects include: ``Integrative Modalities Plus 
Psychological Physical Occupational Restoration Therapies (IMPPPORT) 
Trial;'' ``An Observational Safety and Efficacy Study Comparing a Non-
Equipment Based Exercise Protocol to an Equipment Based Exercise 
Protocol for the Treatment of Chronic Low Back Pain;'' and 
``Rehabilitation of Neuro-musculoskeletal Injuries within an Intensive 
Outpatient mTBI and Pain Rehabilitation Program: Outcome Success for 
Special Operators.''
                toxic exposure and preventative measures
    Question. Over 100,000 veterans have registered with the VA's 
Airborne Hazards and Open Burn Pit Registry, with this number 
increasing each year. I commend the VA and the Department for 
acknowledging this problem and creating a program that identifies those 
who were exposed, so that treatments can be delivered. I also believe, 
as I hope you do as well, that our Soldiers, Sailors, Marines and 
Airmen, should never have been exposed to such toxic conditions in the 
first place. With the staggering human and financial costs of toxic 
exposure more apparent than ever, do you believe the Department fully 
recognizes the importance of ensuring healthy environmental conditions 
for our service members? What measures are in place to protect both 
those currently deployed and future generations of service members from 
similar exposures?
    Answer. Protecting Soldiers, Sailors, Marines, and Airmen from 
exposures to occupational and environmental health hazards is essential 
to maintaining the readiness of our Service Members while they are 
deployed. Operational requirements may prevent us from ensuring 
completely healthy environmental conditions during deployment, but we 
strive to minimize those threats when possible and to document and 
archive exposures when they occur. We also strive not to make 
environmental conditions worse through our own actions. The Army is 
committed to protecting its' Soldiers and Civilians from environmental 
hazards to the extent that military operations allow. Most Army combat 
and peacekeeping deployments are to developing or former industrialized 
nations with rudimentary or older industrial technology that produces 
elevated levels of toxic emissions while lacking effective pollution 
control measures. We work diligently to identify and assess these 
hazards and to make recommendations to commanders on how to reduce 
exposure risks. Public Health teams, both deployed and stationed 
worldwide, work closely with the Combatant Commands to continuously 
assess and address identified health risks. A key component of the 
Army's public health mission is to conduct initial occupational and 
environmental health surveillance to determine what potential hazards 
may exist at a given location. These hazards may include: toxic 
industrial chemicals and toxic industrial materials from local sources 
in the air, water, or soil; ionizing radiation; non-ionizing radiation; 
physical hazards such as extreme noise, heat, cold, and altitude; food-
, water-, vector-, and arthropod-borne threats; endemic diseases; and 
any by-products of US forces activities (i.e., noise, smoke from burn 
pits, exhaust). Identified hazards are documented in a site-specific 
Occupational and Environmental Health Site Assessment and are assessed 
for potential impacts on the current mission and for long-term health 
risks to exposed Soldiers. Identified hazards are eliminated, reduced, 
or otherwise avoided as much as possible within mission constraints. 
Occupation and Environmental Health hazard surveillance activities are 
conducted when hazards cannot be eliminated. A decision must be made by 
commanders to accept the health risks associated with the exposure to 
support the operational mission. The mandatory post-deployment health 
assessment process asks Soldiers (and other Service Members) to 
identify and discuss with a healthcare provider any concerns they have 
about exposures during deployment. We are also committed to preserving 
records of exposure measurements that will provide individual personnel 
histories of both occupational and environmental health exposures. 
Environmental data from deployments are entered in the Defense 
Occupational and Environmental Health Readiness System--Industrial 
Hygiene, or DOEHRS-IH. This database is collecting and building a 
lifetime record of exposures to environmental hazards such as 
industrial and urban pollution. When possible, it also identifies 
personnel who have been exposed to each hazard. Ongoing research into 
wearable technology will provide the future capability to directly 
monitor individual exposure data for all Soldiers and to more closely 
assess links between occupational and environmental exposures and 
health outcomes.
                                 ______
                                 
               Questions Submitted by Senator Jon Tester
                       national guard and suicide
    Question. Montana is home to over 4,000 Guardsmen and reservists. 
There are currently referral resources available to Guardsmen on drill 
weekends, but no dedicated resources for ongoing care and support. Last 
summer, I wrote to Defense Secretary Carter about efforts being made by 
the Defense Suicide Prevention Office. My concern was that over 60 
percent of Army Guard suicides were folks who had never deployed, and 
had limited access to mental healthcare. Unfortunately, DoD had the 
National Guard Bureau respond to the letter, which I think gets to the 
root of the problem. Issues like suicide prevention and mental care 
need to be monitored and coordinated at the highest level and across 
the services. They should not be delegated. How are your respective 
services ensuring that your reserve and Guard components are able to 
tap into your collective mental and behavioral healthcare resources? Is 
DSPO tracking the amount of operation and maintenance funds required to 
fund behavioral health support programs for the reserve components as 
mandated in the fiscal year 2012 NDAA? When will the services implement 
a Program Element Code for suicide prevention?
    Answer. The USAR Psychological Health Program's website provides 
resources for Commanders, Soldiers, and Families in order to ensure 
that Soldiers maintain optimum mental health (http://www.usarphp.org/
home.aspx). The program is administered by six contracted Coordinators 
for Psychological Health located at six locations within CONUS. The 
USARC Psychological Health Program serves to enhance resilience and 
assist with recovery of US Army Reserve Service Members and their 
Families through outreach, education and training, non-stigmatizing 
behavioral health screenings and referral resources. The program 
provides support for psychological health concerns to ensure Service 
Members and their Families are ready and resilient to carry out their 
mission. We connect geographically dispersed Service Members and their 
Families with relevant resources within their community. The National 
Guard 54 States and territories each have, at a minimum, one Director 
of Psychological Health (DPH) whose primary responsibility is 
assessment, referral, and case management of service members with 
Behavioral Health conditions. Each DPH works collaboratively with any 
embedded Behavioral Health Officers (BHO) assigned at the unit level. 
The DPHs coordinate/partner with local, State and Federal programs to 
establish an effective (comprehensive?) referral network for their 
Soldiers. The Chief of Behavioral Health assigned to the National Guard 
Bureau provides oversight to the NG Behavioral Health Program. NGB 
helps to procure and distribute resources down to the State level to 
retain a workforce with a comparable ratio. NGB also works to create an 
effective, standardized holistic program of Behavioral Health. The 
Defense Suicide Prevention Office (DSPO) provides advocacy, program 
oversight, and policy for Department of Defense suicide prevention, 
intervention and postvention efforts to reduce suicidal behaviors in 
Service Members, Civilians and their Families. DSPO actively engages 
and partners with the Military Services, other Governmental Agencies, 
Non-Governmental Agencies, non-profit organizations, and the community 
to reduce the risk of suicide for Service Members, Civilians, and their 
Families. As such, the DSPO portfolio includes data surveillance, 
program assessment, policy oversight, and outreach. With respect to 
operation and maintenance funds required for Reserve Component 
behavioral health support programs, DSPO reports it is currently not 
tracking this requirement as it falls under the Health Affairs section 
of the fiscal year 2012 NDAA. Compliant with the fiscal year 2012 NDAA, 
US Army Reserve Command (USARC) has established a program funding line 
for their Psychological Health Program, but USARC reports the funding 
line has not been fully funded. With respect to a specific Program 
Element Code for suicide prevention, coordination with Army G-1 staff 
in ongoing. Of note, USARC reports tracking funding execution of the 
Suicide Prevention Program through the Management Decision Package 
(MDEP), and the MDEP code for Suicide Prevention is VSPV.
                   national guard healthcare coverage
    Question. According to the 2014 Status of Forces Survey, 28 percent 
of National Guardsmen stated that they had no medical coverage. This 
would mean roughly 128,000 National Guardsmen do not have health 
insurance. Especially in rural areas with limited options, younger 
Guardsmen have a tough time with Tricare Reserve Select monthly 
premiums. I have also heard of problems with gaps in coverage when 
their families switch to Tricare Prime while activated. What can be 
done to make Tricare Reserve Select less expensive for younger 
Guardsmen and how can Tricare Prime limit gaps in coverage around 
activation?
    Answer. TRICARE Reserve Select (TRS) is the premium-based health 
plan available for purchase by qualified members of the Selected 
Reserve. TRS coverage is similar to TRICARE Standard and TRICARE Extra. 
Covered Service Members and Family Members under TRS may access care 
from any TRICARE authorized provider, hospital or pharmacy, whether in 
the TRICARE network or not. The government subsidizes the cost of the 
program with members paying 28 percent of the cost of the premiums. For 
calendar year 2017, premiums were $47.82 per month for member only 
coverage and $217.51 per month for member and family coverage. Section 
748 of the fiscal year 2017 National Defense Authorization Act (NDAA) 
directed the Defense Health Agency (DHA) to conduct an assessment of 
transition to TRICARE program by Families of members of reserve 
components called to active duty. We must defer to the DHA to see how 
they will address any concerns with TRS costs or to ease transition 
issues for activated members of the Reserve and National Guard based on 
Section 748 of the fiscal year 2017 NDAA.
                             tricare issues
    Question. Montana is home to a disproportionate number of military 
retirees. Many of them have adult children and call my office to ask 
why Tricare Young Adult is so expensive and has so many conditions. ? 
How can Tricare better provide for this population to bring it more in 
line with the same standard as ACA?
    Answer. The TRICARE Young Adult (TYA) program is a premium-based 
healthcare plan available for purchase by qualified dependents. TYA 
offers TRICARE Prime and TRICARE Standard coverage worldwide and meets 
the definition of ``minimum essential coverage'' under the Affordable 
Care Act (ACA). TYA provides coverage up to age 26 and requires payment 
of monthly premiums in addition to the cost shares and copayments for 
each respective plan. The National Defense Authorization Act of 2011 
mandated that TRICARE set TYA premiums to cover the full cost of 
healthcare received by the program's beneficiaries. In 2016, TYA 
premiums rose substantially due to the fact that 2016 marked the first 
time TRICARE had enough actual cost data to set the premiums based on 
actual costs rather than predicted cost. On January 1, 2017, the 
monthly payment for beneficiaries using TYA Prime rose from $306 to 
$319, while the monthly premium for TYA Standard decreased from $228 to 
$216 per month. We must defer to the Defense Health Agency to see how 
they will address any concerns with TYA costs.
                                 ______
                                 
              Questions Submitted by Senator Brian Schatz
                            opioid epidemic
    Question. The opioid epidemic is one that spans the entire country, 
with some of the most vulnerable populations being active service 
members and veteran's battling injuries sustained in our most recent 
wars. We owe it to the men and women who have already sacrificed so 
much to construct a viable plan to combat this epidemic. Each service 
must have a holistic understanding of opioid use--both prescriptive and 
illegal abuse--within their formations, and should apply progressive 
thought towards non-opioid pain management alternatives. What are you 
seeing with respect to the use of opioids across the force, and how 
does this compare to national trends?
    Answer. The Office of The Surgeon General does not collect 
information on opioid abuse similar to that which is collected in 
civilian sector. Despite this limitation, the Army and other Services 
have implemented many programs intended to reduce the use of opioids in 
our populations, including the Comprehensive Pain Management Program. 
In fact the latest report from the Army's Pharmacovigilance Center's 
showed that opioid use peaked in 2012 with 26 percent of the total 
active duty population, and 29 percent of Army Service Members, 
receiving at least one opioid prescription during the previous 12 
months of the fiscal year. Since that time, opioid use has declined 
each year with fiscal year 2016 rates at 21 percent for the total 
active duty population and 23 percent for Army Service Members. This 
same analysis also evaluated chronic opioid use, which is defined as a 
Service Member who received 90 days or more of opioids within a 6-month 
timeframe during a fiscal year. Chronic opioid use peaked in fiscal 
year 2007, with use rates for the Army and total active duty population 
at 12 percent and 10 percent respectively. Chronic opioid use, in 
fiscal year 2016, has declined to 6 percent for the Army and 5 percent 
for the total active duty population.
                       non-opioid pain management
    Question. Are there any efforts within military medicine to develop 
non-opioid pain management alternatives? If so, when are those 
alternatives most appropriate as replacement therapies?
    Answer. Yes, Army Medicine continually strives to provide 
alternatives to opioid therapy through holistic, integrative and 
complementary therapies at all levels of the medical continuum of care. 
The utilization of a stepped care model for pain management ensures the 
appropriate level of pain care, including alternatives, is available 
and delivered to patients through the continuum of acute and chronic 
pain. Army Medicine pain management begins at the Army Medical Home 
where a multidisciplinary team led by the Primary Care Pain Champion 
supports Primary Care Managers utilizing a stepped care approach, self-
care and emphasizing mindfulness to all beneficiaries. The pain care 
continuum progresses to the Army Integrative Pain Management Centers 
(IPMC) where additional consultative interventional and complementary 
therapies further support the patient's pain care needs. These 
therapies include interventional medicine, physical therapy, 
occupational therapy, chiropractic, nutrition, medical massage, 
acupuncture, and movement therapy such as Yoga and Tai Chi). Through 
the availability of these therapies, the twelve IPMCs provide 
alternatives to opioid treatment for acute pain and minimize 
progression to chronic pain.
                         opioid abuse education
    Question. How are you educating service members on the risks of 
opioid abuse? Are these mandatory for individuals receiving opiate 
prescriptions?
    Answer. Each Soldier who obtains new prescriptions from a medical 
treatment facility (MTF) will receive instructions for that medication. 
The instructions are mandatory for each new prescription and controlled 
medications. In addition, all providers who prescribe opioids are 
required to complete Opioid Prescriber Safety Training which 
incorporates the necessity of provider education to the patient about 
opioid use, side effects, and alternate therapies available for pain 
control. The Comprehensive Pain Management Program provides information 
to Soldiers and clinicians on alternatives for pain therapy but does 
not directly provide Soldier education on opioid use or abuse. Our 
marketing efforts on opioid alternative therapies are primarily in the 
form of brochures, open house and informational booths during pain 
awareness month.
                          infectious diseases
    Question. Men and women in the military often find themselves in 
these hot zones where emerging infectious diseases are endemic. In the 
Asia Pacific, for example, malaria, dengue, TB, and other emerging 
infectious diseases pose a risk to our soldiers, sailors, airmen, and 
Marines in the region, whether they are stationed there or are 
supporting theatre security cooperation exercises. Continued research 
and prototyping is necessary as we continue to build medical defenses 
for our service members as they execute missions in at-risk 
environments--and this is not an endeavor the DHP should go alone. 
Invaluable relationships have formed with departments across the 
government like the CDC and HHS, and have brought to fruition 
incredible advances for our service members and citizenry alike. How 
important is bio-surveillance to protecting our troops from diseases 
when they are deployed?
    Answer. Bio-surveillance is essential in the fight against known 
and emerging infectious diseases, as witnessed during the recent Zika 
virus outbreak. Molecular methods currently available and under 
development allow healthcare providers to appropriately tailor patient 
treatment, allow public health personnel to select proper control 
methods for specific disease vectors, and support education on the 
possible dangers and effects of disease for individuals in impacted 
areas. Effective bio-surveillance encompasses diverse but coordinated 
activities such as field and laboratory analyses focused on 
identification and characterization of naturally-occurring and man-
directed disease threats. Military operational readiness requires 
protection of our Service members and military service animals from 
these threats. Early identification of disease threats allows us to 
employ countermeasures to preserve our fighting strength. These 
countermeasures include vaccines, early disease detection systems, 
laboratory testing, surveillance, prophylactic medications, therapies, 
and personal protective equipment. Additional surveillance capabilities 
for chemical and radiological threats are also essential for force 
protection.
                     partnerships with cdc and hhs
    Question. How do you work with partners like CDC and HHS to promote 
prevention and treatment through their international bio-surveillance 
programs? So would you say it puts more or less risk on your ability to 
protect our troops when these partner agencies have their budgets cut, 
jeopardizing their international bio-surveillance programs?
    Answer. An effective bio-surveillance system requires a network of 
military and non-military experts and tools. We work closely with the 
Centers for Disease Control (CDC) and other governmental agencies, our 
allies, host nation partners, academia, and non-governmental 
organizations to ensure we collect and analyze as much relevant 
information as possible. We share methods and data, using many of the 
same tools as our partners, and collaborate closely on lab-based 
surveillance. One example is tracking emerging influenza strains: the 
DoD is the single largest contributor of influenza specimens acquired 
around the globe to inform component strains for each year's national 
influenza vaccine. We collaborate with our DoD liaison officer at CDC 
on large-scale responses to epidemics such as Zika and to pandemic 
influenza preparedness. We also respond jointly to more localized 
disease outbreaks which impact Soldiers. Our installation public health 
personnel work closely with their civilian counterparts at all levels 
to synchronize surveillance and response activities. We are working to 
strengthen our relationship with the CDC in the areas of understanding 
and surveillance of vector-borne diseases (VBD), such as Zika or Lyme 
Disease, by linking Army public health entomological and laboratory 
efforts with the CDC-supported VBD academic centers of excellence. We 
also work closely with the Defense Health Agency--Armed Forces Health 
Surveillance Branch--Bio-surveillance Division and the Defense Threat 
Reduction Agency's Bio-surveillance Ecosystem (BSVE). The BSVE is a 
``Whole of Government'' capability with partners in industry and 
academia that provides a suite of common tools for analyzing and 
predicting global outbreaks from a variety of structured and 
unstructured data sources. Ultimately, the collaborative and 
synergistic nature of bio-surveillance activities that supports our 
ability to protect our troops is jeopardized when partner agencies such 
as HHS/CDC have fewer resources. A lack of funding in the area of 
international bio-surveillance negatively impact our ability to protect 
those who serve our Nation. Diseases do not recognize borders and bio-
surveillance requires a whole of government approach. The ability to 
track a disease internationally is likely to decrease as partner 
agencies' budgets grow smaller.
                          partnering with hhs
    Question. I know DoD works closely with HHS to develop medical 
countermeasures, including the programs managed by the Biomedical 
Advanced Research and Development Authority--BARDA. You have been able 
to share costs and reduce redundancies. Will each of you elaborate more 
on DoD's partnership with HHS on developing medical countermeasures and 
discuss the potential impacts to DoD's efforts if HHS funding, 
including BARDA, is reduced?
    Answer. Significant reductions in HHS funding will impact DoD 
Medical Countermeasure (MCM) efforts, including those within Army and 
Defense Health Medical Research, Development and Acquisition (RDA) 
programs. The greatest impacts will affect efforts developing MCM for 
detection, prevention and treatment of biological warfare threat 
agents, global endemic and emerging infectious diseases. DoD invests in 
applied and advanced technology development research focused on 
delivery of MCM solutions to the Warfighter. Thus, DoD relies on and 
leverages the basic research supported by the National Institutes of 
Health (NIH) to feed the pipeline for subsequent DoD research and 
development activities. In addition, the majority of products in our 
development pipeline are FDA-regulated products. Funding reductions 
within the FDA would impact the development progress and timeline for 
those regulated products and delay our ability to deliver needed 
capabilities to the warfighter. The Military Infectious Diseases 
Research Program (MIDRP) has several areas of research and development 
where the HHS provides significant funding to the Army supporting 
countermeasure efforts for: Hantavirus and other lethal viruses, 
Malaria, Bacterial Diarrheal Diseases, Zika Virus and the Military HIV 
Research Program. HHS also funds research and development in the 
broader medical research community which enhances and accelerates 
Army's MIDRP efforts. A decrease in HHS funding may also threaten the 
funding and support of military overseas medical research laboratories 
which are on the forefront of early warning and are vital infectious 
disease research infrastructure platforms for the military and the 
Nation.
                     hhs's medical countermeasures
    Question. DoD has been able to leverage HHS' medical 
countermeasures development by providing funding to HHS, including 
adding studies to an existing development program to address a DoD-
specific need. This ensures that HHS's final medical countermeasure 
product can be used by DoD as well, saving the military time and money. 
Can you comment on this and discuss how a reduction in HHS funding 
could impact DoD's ability to address the CBRN [chemical, biological, 
radiological, and nuclear] threats that our military currently faces 
abroad?
    Answer. The Army leverages Department of Defense (DoD) and 
Department of Health and Human Services (HHS) medical countermeasure 
(MCM) research, development, and acquisition (RDA) activities to not 
only save time and money, but also to collaborate in meeting both 
civilian and DoD-specific chemical, biological, radiological and 
nuclear defense needs. For example, DoD purchases anthrax vaccines and 
smallpox vaccines from the HHS Strategic National Stockpile (SNS) for 
vaccination of DoD forces at high risk of exposure. In addition, the 
DoD funds studies to HHS development activities when these additional 
studies will address a DoD-specific need (e.g., MCM animal model 
development to address the Ebola virus). DoD also has a relationship 
with Biomedical Advanced Research and Development Authority (BARDA) to 
fulfill the requirement to ``establish stockpiles of vaccine against 
H5N1 and other influenza subtypes determined to represent a pandemic 
threat...adequate to immunize approximately 1.35M persons for military 
use''. DoD has a support agreement with BARDA and uses their 
acquisition to purchase pandemic influenza vaccine, and once purchased 
for the storage and stability testing of that bulk vaccine with the 
manufacturer. DoD coordinates with and considers recommendations from 
BARDA before purchasing vaccines, saving valuable time. Reductions in 
HHS funding will impact the opportunities for collaboration between HHS 
and DoD in MCM RDA activities if critical product research or 
development is delayed or cancelled. For example, reductions in HHS 
funding against the ongoing work in Nerve Agent Antidotes or vaccines 
and drugs for Zika, Ebola, Middle East Respiratory Syndrome 
Coronavirus, and Acute Radiation Syndrome may lead to unnecessary risk 
to our troops. It may also reduce the ability of the DoD to obtain SNS 
MCM for both routine use or wartime contingency purposes.
                                 ______
                                 
              Questions Submitted by Senator Tammy Baldwin
             role of west point in dod-funded tbi research
    Question. The Medical College of Wisconsin plays a leading role in 
a long-term joint longitudinal study sponsored by both DoD and the NCAA 
that will build a deeper and richer understanding of concussion 
injuries. This public-private partnership is being led by the CARE 
Consortium, which is comprised of more than 30 institutions, including 
the four military service academies, and is close to achieving the goal 
of enrolling 30,000 individuals in the study. This total includes 
servicemembers at the military academies. The House DoD Appropriations 
committee reports for fiscal year 2016 and fiscal year 2017 included 
language affirming congressional support for the public-private 
partnership designed to understand and improve treatment of traumatic 
brain injuries and to support further studies. What has been West 
Point's involvement in the study to date? How has West Point leadership 
viewed the public-private partnership aspect of the study? What are 
West Point's plans for continued involvement in the research grant?
    Answer. The leadership and research expertise at West Point are 
pivotal to the successful execution of the NCAA study, Concussion 
Assessment Research and Education Consortium (CARE), and a second 
parallel study (the Service Academy Study) which looks at the effects 
of concussion of non-NCAA athlete Students. The CARE study recruits 
NCAA athletes from 29 schools; 26 civilian schools and 3 Service 
Academies (USMA, USAFA and USCGA). Together they have recruited 22,366 
athletes, and nearly 5 percent are West Point Cadets. Of the 1,513 
concussions captured in the CARE population, about 4.3 percent are West 
Point cadets. The second concussion study ongoing at West Point, the 
Service Academy Study, parallels the CARE study in many ways. However, 
it involves students at the Service Academies not civilian 
institutions. The Service Academy study enrolled 7,089 non-NCAA 
students and West Point's efforts represent nearly 50 percent of the 
subjects. Approximately 508 concussions have been captured in this 
population, and 40 percent of those injuries are in West Point Cadets. 
West Point has clinical researchers on both studies, and is, therefore, 
facilitating collaboration and sharing of the data from the Service 
Academy study to the civilian investigators on the CARE study. West 
Point leadership is supportive of the partnership, noting that the 
outcomes of the study will provide benefit to both the civilian and 
military sectors. The Superintendent, Commandant, and Military Medical 
Treatment Facility Commander have been supportive and synchronous in 
the communication and coordination of the NCAA-DoD CARE and Service 
Academy Concussion Study. In February, the Superintendent and West 
Point researchers demonstrated commitment to the study through 
involvement with the NCAA Sports-Related Concussion Summit in 
California. Additionally, West Point will be hosting a Concussion 
Summit in April of this year. The West Point leadership has also met 
with The Surgeon General of the Army on multiple occasions to discuss 
and ensure support to the ongoing DoD-NCAA collaboration. The West 
Point clinical research team plans for continued collaboration with the 
NCAA group in order to conduct additional concussion-related research 
at the USMA. Now that the initial CARE Study questions have been 
answered, the Army understands that the principal investigators plan to 
submit CARE 2.0 for funding from the DoD (with matching funding offered 
from the NCAA). West Point also plans to maintain involvement in the 
DoD Service Academy study of the effects of concussion on Military 
performance, which parallels the DoD-NCAA CARE study. The Service 
Academy study will continue to leverage the infrastructure of the 
``Longitudinal Study on Traumatic Brain Injury Incurred by Members of 
the Armed Forces in Operation IRAQI FREEDOM and Operation ENDURING 
FREEDOM,'' a 15-year longitudinal study that was Congressionally 
Mandated in 2007.
                            gulf war illness
    Question. I have been proud to help champion funding for the Gulf 
War Illness Research Program (GWIRP) within the Congressionally 
Directed Medical Research Program (CDMRP), and I continue to be 
heartened by the remarkable progress researchers have made toward 
healing our Gulf War veterans. That is why I am alarmed by reports from 
CDMRP-funded medical researchers that they are facing barriers to 
continuing this progress, namely that the Defense Manpower Data Center 
(DMDC) repeatedly denies their requests to access the data required to 
reach potential volunteer research study subjects. Making matters 
worse, many researchers report that DMDC has not provided definitive 
information regarding the current requirements for providing data to 
nonFederal entities. I fully support the need to secure the private 
information of servicemembers and veterans. For example, last year I 
authored the Veterans' Identity Theft Protection Act to direct VA to 
discontinue the use of Social Security numbers to identify veterans. It 
is critical that private information be managed securely by authorized 
users only. I also believe that if a federally-funded research 
institution has adequate IT security systems in place, as determined by 
the Federal Government, the interests of Gulf War veterans are best 
served by the secure sharing of data. In this context, such data 
includes veterans' contact information, but does not include medical 
histories or personnel records. Lieutenant General West, do you agree 
that CDMRP-funded GWIRP researchers need access to DMDC data to ensure 
sufficient and statistically significant numbers of research study 
subjects? What do you understand to be DMDC's policies for sharing data 
with Federal and non-Federal entities? What IT security standards are 
required? What can you do to help establish procedures to allow CDMRP-
funded researchers and VA-funded researchers to utilize DMDC data?
    Answer. Yes, access to information about Veterans within the 
Defense Manpower Data Center (DMDC) would facilitate research 
recruiting efforts and may help researchers gain statistically 
significant numbers of subjects who chose to take part in GWIRP 
research. DoD policy dictates that sensitive information (to include 
Name, Address, SSN, DoD ID, etc.) must be protected and that protection 
involves security assurances relative to: transport or transmission of 
information, the enclave in which information is housed, personnel with 
access to information, and disposition or release of information. 
Requesters must be U.S. Federal Government (military and civilian) or 
U.S. Federal Government contractors. Non-DoD investigators must have a 
DoD sponsor (DoD Civilian or Military Officer). The system receiving 
DMDC data must be DoD accredited or have other Federal equivalent 
accreditation (DIACAP or RMF). If networks do not meet these 
accreditation standards, DMDC is unable to authorize the release of the 
requested sensitive information. To help CDMRP-funded researchers 
utilize DMDC data, we can encourage our funded investigators to 
collaborate with DoD investigators and even assist in establishing 
these collaborations. There are two possible options to facilitate 
increased access to DMDC information: (1) A DoD investigator with 
access to DMDC information could allow a collaborating non-Federal 
researcher to access and use the data physically on the accredited 
Federal system; or (2) allow a virtual private network connection for 
the nonFederal researchers to access the data via DoD networks. Once 
collaboration with a DoD investigator is established, the DMDC would 
confirm that any 3rd party systems are DIACAP or RMF accredited before 
the information is shared. The DMDC would then enter into a Memorandum 
of Understanding with the DoD investigator stating that accreditation 
will be confirmed prior to sharing of data and that the data will be 
protected in accordance with the Privacy Act of 1974.
                                 ______
                                 
       Questions Submitted to Vice Admiral C. Forrest Faison, III
              Question Submitted by Senator Lindsey Graham
 transfer of oversight and management of military treatment facilities 
                      to the defense health agency
    Question. Section 702 of the fiscal year 2017 NDAA transferred 
oversight and management of military hospitals and clinics from the 
military services to the Defense Health Agency (DHA), and I understand 
that the Department is now developing courses of action for the Deputy 
Secretary to consider. Will each of you assure me that you will 
facilitate a rapid and efficient transfer of the operations of those 
medical facilities to the DHA, and will each of you assure me that you 
will reduce the number of personnel in your headquarters and 
subordinate organizations to reflect the changing scope and size of 
your missions?
    Answer. Navy Medicine is committed to working with Congress, the 
Defense Health Agency, and the other Military Departments to improve 
the Military Health System (MHS). As such, the Military Departments are 
actively engaged in implementing the major transformation of the MHS as 
directed by Section 702 of the fiscal year 2017 NDAA. An interim 
report, as required by law, was submitted March 31, 2017. This report 
reflects the comprehensive evaluation of a number of courses of action 
and supports the Department's decision to implement the component 
model. While developing the component model that will fulfill these 
statutory requirements, the Services continue to work towards 
harmonizing the roles and responsibilities of the DHA and Military 
Departments. As part of the requirement for the second interim report, 
opportunities to streamline duplicative processes will be highlighted. 
It is expected that there will be reductions in the total personnel as 
the MHS eliminates unnecessary duplication and captures efficiencies. 
Opportunities to reduce specific headquarters-related personnel will 
occur as a result of the transition of MTF administration and 
management responsibilities from the Service Medical Departments to the 
DHA.
                                 ______
                                 
                Question Submitted by Senator Jon Tester
                             tricare issues
    Question. Montana is home to a disproportionate number of military 
retirees. Many of them have adult children and call my office to ask 
why Tricare Young Adult is so expensive and has so many conditions. How 
can Tricare better provide for this population to bring it more in line 
with the same standard as ACA?
    Answer. The TRICARE Young Adult (TYA) program is a premium-based 
health plan available for purchase by eligible dependents. The National 
Defense Authorization Act for Fiscal Year 2011 (NDAA for Fiscal Year 
2011) directed the Department of Defense (DoD) establish the TRICARE 
Young Adult (TYA) program to provide an extended TRICARE Program 
coverage opportunity to most unmarried children under the age of 26 of 
uniformed services sponsors. TYA aligns with health insurance coverage 
requirements established by the Affordable Care Act (ACA). Two health 
plans are available for purchase, TRICARE Prime (managed care option) 
or TRICARE Standard (preferred provider option), which provides robust 
health insurance benefits, worldwide coverage, and meets the ACA's 
definition of minimum essential coverage. As directed in 10 U.S.C. 
Sec. 1110b, DoD is required to establish and align TYA monthly premiums 
to cover the full cost of the program. Previous years' premiums were 
lower because TRICARE did not have sufficient cost data to set annual 
premiums. These premiums were adjusted in 2016 to be cost-neutral to 
the government. They are adjusted annually and are not subsidized by 
the DoD, unlike other TRICARE entitlement programs. While TYA is the 
only option for eligible dependents to access and purchase a TRICARE 
health plan that would otherwise not be available, beneficiaries can 
consider alternative healthcare insurance options to meet the ACA's 
individual mandate. Other health plan options that TYA-eligible 
beneficiaries could consider include, but are not limited to: parent's 
commercial health insurance plan, employer-sponsored health plans, 
State or Federal health insurance exchanges, college or university 
student health plans, or Medicaid.
                                 ______
                                 
              Questions Submitted by Senator Brian Schatz
                           opioid epidemic 2
    Question. The opioid epidemic is one that spans the entire country, 
with some of the most vulnerable populations being active service 
members and veteran's battling injuries sustained in our most recent 
wars. We owe it to the men and women who have already sacrificed so 
much to construct a viable plan to combat this epidemic. Each service 
must have a holistic understanding of opioid use--both prescriptive and 
illegal abuse--within their formations, and should apply progressive 
thought towards non-opioid pain management alternatives. What are you 
seeing with respect to the use of opioids across the force, and how 
does this compare to national trends?
    Answer. In contrast to national trends, which are increasing, 
opioid prescribing and use within the Navy is on the decline. The Navy 
Comprehensive Pain Management Program (NCPMP) has focused on addressing 
the challenges presented by opioids across Navy Medicine. In December 
2013, a Long-term Opioid Therapy Safety (LOTS) working group, began 
developing a methodology to monitor the Navy's compliance with the VA/
DoD Opioid Therapy Clinical Practice Guidelines (CPG). This CPG was 
released in February 2017 by the Department of Veterans Affairs and 
Department of Defense, with guidance to manage opioid therapy for 
chronic pain and provides critical decision points, along with clear 
evidence-based recommendations on minimizing harm and increasing 
patient safety in patients requiring opioid therapy. For the Navy, a 
patient is considered a long-term opioid therapy (LOT) patient if they 
are consistently taking opioids for at least 90 days. For fiscal year 
2016, the Navy beneficiary population had approximately 366,569 
patients who were prescribed an opioid. Of those patients, 4,153 were 
considered to be LOT patients, which is approximately 0.4 percent of 
the Navy beneficiary population. In comparison, the nationally reported 
numbers list approximately 2 million Americans as having abused or been 
dependent on prescription opioids--approximately 0.6 percent of the 
population.
                       non-opioid pain management
    Question. Are there any efforts within military medicine to develop 
non-opioid pain management alternatives? If so, when are those 
alternatives most appropriate as replacement therapies?
    Answer. Navy Medicine continues to develop and implement a 
biopsychosocial model for a more holistic approach to treating pain. We 
optimize medication management, complementary integrative medicine 
(CIM) strategies, and psychological interventions to address a 
patient's pain. Acupuncture, part of the Navy's Comprehensive Pain 
Management Program, has demonstrated particular benefit in the 
treatment of certain pain conditions, such as low back and neck pain. 
In addition, Naval Medical Center San Diego (NMCSD) conducted outcome 
studies of the Functional Restoration Pain Program (FRPP). FRPP is an 
intensive, interdisciplinary, medically supervised program, consisting 
of clinically structured healthcare over eight weeks, intended to 
restore service members back to their full readiness potential. This 
integrative approach provides optimized medication management, 
complementary integrative medicine strategies, and psychological 
interventions to specifically address patient's pain. This program is 
available to Active Duty Navy and Marine Corps service members who have 
been diagnosed with musculoskeletal-related pain lasting longer than 3 
months and who have failed standard treatments. NMCSD is the first Navy 
Medicine Command to launch a FRPP and has developed the leading 
practices for other commands to adopt. As of March 2017, a total of 
thirteen cohorts have completed the FRPP course at NMCSD, with 85 
percent of patients achieving a fit for full duty status upon 
successful graduation from the FRPP. We are also actively training 
personnel at NMCSD's Mind Body Medicine (MBM) Program--which integrates 
CIM into the overall healthcare delivery system and targets 
beneficiaries with chronic health conditions. This approach helps 
patients gain control over their stress, improve their resiliency, and 
optimize their mind and body for recovery. As of April 2017, 372 people 
have been trained in the MBM curriculum, and these practices have been 
applied at other military treatment facilities and deployed healthcare 
settings such as United States Ship (USS) Pearl Harbor, USS Essex, USS 
Nassau, and Wounded Warrior Battalion West.
                         opioid abuse education
    Question. How are you educating service members on the risks of 
opioid abuse? Are these mandatory for individuals receiving opiate 
prescriptions?
    Answer. Navy Medicine issues each patient a printed patient 
education drug monograph. The monograph provides information on how to 
take the medication, the side effects caused by the medication, 
precautionary warnings, and guidance to seek medical help if needed. 
Additionally, the Military Health System continues to work with the 
Defense Veterans Center for Integrative Medicine (DVCIPM) on developing 
more patient information pamphlets and videos on various pain related 
information self-management techniques. In addition, Navy Medicine 
continues to focus significant effort on providing necessary clinical 
education and training support for pain management to providers. One of 
these efforts is focused on increasing the reach of pain specialists 
and expanding capacity for pain management services in primary care 
through use of the internationally recognized Extension for Community 
Healthcare Outcomes (ECHO) tele-mentoring model. Navy initiated ECHO 
tele-mentoring clinics in 2014. Analysis of patients' opioid 
prescriptions received 6 months before and 6 months after presentation 
of their case at ECHO reveals the average daily supply of prescriptions 
fell by 10 percent after being presented. Moreover, the total 
prescriptions written to patients following their presentation in ECHO 
fell by 30 percent. For individuals receiving opiate prescriptions, the 
Navy's Comprehensive Pain Management Program (NCPMP) assembled the 
Long-term Opioid Therapy Safety (LOTS) Working Group (WG) to review the 
2010 Veteran Affairs/Department of Defense Clinical Practice Guidelines 
(VA/DoD CPG) for the Management of Opioid Therapy for Chronic Pain. The 
LOTS WG, which included family medicine, pharmacy, pain medicine, and 
other relevant specialties, assessed the CPGs identify and assess best 
practices for the safe prescription and use of opioid therapy for pain 
management. The outcome of this assessment was the selection of four 
key recommendations focused on: (1)Screening for past psychiatric 
history and substance use history for patients on LOT; (2)Screening for 
concurrent use of benzodiazepines; (3)Recommending the use and annual 
renewal of opioid care agreements; and, (4)Recommending the 
administration of annual urine drug screening for every patient on LOT. 
The LOTS WG completed a draft of a Navy Medicine Long-term Opioid 
Therapy Safety policy codifying the recommendations from the 2010 VA/
DoD CPG and lessons learned from the CPG Compliance initiative. The 
formal requirements for the management of patients on long-term opioid 
therapy, is expected to be released by the end of fiscal year 2017.
                          infectious diseases
    Question. Men and women in the military often find themselves in 
these hot zones where emerging infectious diseases are endemic. In the 
Asia Pacific, for example, malaria, dengue, TB, and other emerging 
infectious diseases pose a risk to our soldiers, sailors, airmen, and 
Marines in the region, whether they are stationed there or are 
supporting theatre security cooperation exercises. Continued research 
and prototyping is necessary as we continue to build medical defenses 
for our service members as they execute missions in at-risk 
environments--and this is not an endeavor the DHP should go alone. 
Invaluable relationships have formed with departments across the 
government like the CDC and HHS, and have brought to fruition 
incredible advances for our service members and citizenry alike. How 
important is bio-surveillance to protecting our troops from diseases 
when they are deployed?
    Answer. Certain diseases can compromise mission execution by 
degrading mission readiness. Bio-surveillance is the critical first 
step to protecting our deployed troops from infectious diseases. Bio-
surveillance comprises a critical element towards maintaining force 
health protection for deployed personnel subject to a broad spectrum of 
diseases, whether they occur naturally or are weaponized. An essential 
component of the Navy's ability to conduct bio-surveillance is the 
Forward Deployable Preventive Medicine Unit (FDPMU), a consolidated 
preventive medicine unit that conducts force health protection and 
collection across the conflict continuum in complex operational 
environments. The information collected by the FDPMU is used to assess 
population health risks associated with deployment related exposures 
and determine appropriate preventative measures such as prophylaxis and 
advising military clinicians. Long term value of bio-surveillance 
provides key input to the development of disease mitigation strategies 
such as vaccine development (strain selection for the annual influenza 
vaccine, development of malaria and dengue vaccines, etc.), monitoring 
of antibiotic resistance (multi-drug resistance TB, malaria drug 
resistance, resistant bacteria in wound infections), and the detection 
and response to emerging infectious diseases (ebola, MERS-CoV). The 
knowledge of current and emerging threats enables Combatant Commands to 
make pertinent and timely decisions regarding troop deployments into at 
risk areas. The DoD bio-surveillance program specifically focuses on 
warfighter-relevant threats. Areas where our troops are deployed such 
as SE Asia and Africa are hot spots for Emerging Infectious Diseases 
and we cannot rely on local governments or infrastructures to detect 
and report their prevalence. Therefore, in order to best protect our 
troops from known, novel, and newly emergent diseases as well as 
traditional and synthetic biological threat agents, it is necessary to 
continue to have state-of-the-art bio-surveillance detection techniques 
and forecasting methods.
                     partnerships with cdc and hhs
    Question. How do you work with partners like CDC and HHS to promote 
prevention and treatment through their international bio-surveillance 
programs? So would you say it puts more or less risk on your ability to 
protect our troops when these partner agencies have their budgets cut, 
jeopardizing their international bio-surveillance programs?
    Answer. Partner agency budget reductions may not affect troop 
protection unless it was specific to funding international bio-
surveillance programs. Historically, the CDC has provided the DoD with 
diagnostic laboratory components for novel strains of influenza and the 
Zika virus. The DoD utilizes CDC's clinical guidance to inform its 
force health protection policies such as CDC's Advisory Committee on 
Immunization Practices to military vaccine recommendations or CDC's 
Zika virus recommendations for DoD use. CDC funding cuts to these 
specific areas may compromise the ability to provide continued support. 
While the specific focus of the DoD bio-surveillance program is on the 
warfighter, the CDC and HHS programs provide the public health and 
medical intelligence perspectives that are integrated into the 
decisionmaking process for any engagement. We maintain a robust DoD 
bio-surveillance capability regardless of institutional partnerships, 
but a reduction in funding or a lapse in service of our partners at the 
CDC and HHS may have immediate impacts in terms of force health 
protection, non-combatant health engagement, and our ability to provide 
meaningful force depletion estimates that would lead to a significant 
degradation of DoD bio-surveillance capability. No single agency 
``owns'' the bio-threat space, particularly with respect to 
international bio-surveillance programs. The DoD oversees labs and the 
CDC's embedded bio-surveillance activities world-wide, regularly share 
expertise, and cooperate on regional emergencies. DoD and HHS have 
developed an interagency MOU to share health surveillance information, 
which has created a more comprehensive picture of global pandemic 
events while avoiding redundant surveillance efforts. The U.S. Navy 
conducts bio-surveillance programs in all the Geographical Combatant 
Commands in part due to the ability to build upon programs established 
by the CDC and HHS. These collaborative efforts with CDC and HHS 
partners occur at the Navy's overseas medical research commands greatly 
enhancing Navy's bio-surveillance reach. Due to the complimentary, but 
distinct bio-surveillance missions of Navy, CDC and HHS, the partners 
are able to leverage bio-surveillance efforts through these productive 
collaborations and complimentary strategic programs. Any reduction in 
the abilities of the CDC and HHS to support their international bio-
surveillance programs will directly impact the amount and quality of 
medically-relevant information available to protect our troops. Just as 
we have experienced West Nile virus and now Zika spreading through the 
continental US, the world is experiencing rapid and dramatic changes of 
pathogen range. The international bio-surveillance programs are 
critical for this information to be kept up to date to protect our 
troops deployed world-wide. Loss of funding to CDC and HHS for 
international bio-surveillance programs may directly impact the U.S. 
Navy and DoD bio-surveillance efforts and downgrade the ability to 
generate timely data, putting our troops at risk from infectious 
disease threats.
                          partnering with hhs
    Question. I know DoD works closely with HHS to develop medical 
countermeasures, including the programs managed by the Biomedical 
Advanced Research and Development Authority--BARDA. You have been able 
to share costs and reduce redundancies. Will each of you elaborate more 
on DoD's partnership with HHS on developing medical countermeasures and 
discuss the potential impacts to DoD's efforts if HHS funding, 
including BARDA, is reduced?
    Answer. The DoD and BARDA are interagency partners of the HHS-led 
Public Health Emergency Medical Countermeasures Enterprise (PHEMCE), 
which coordinates U.S. Government efforts on the development of medical 
countermeasures (MCM) to address the risks and consequences posed by 
chemical, biological, radiological, and nuclear (CBRN) agents as well 
as emerging infectious diseases. This interagency interaction involves 
coordination, collaboration, and leveraging of the outcomes from 
investments by both Departments in MCM research, development, and 
acquisition (RDA) activities. Reductions in funding to HHS agencies 
directly involved in MCM RDA activities (e.g., BARDA, National 
Institute of Allergy and Infectious Diseases, the Food and Drug 
Administration, and Centers for Disease Control and Prevention) may 
jeopardize national security and the DoD mission due to impacts on the 
MCM RDA pipeline and U.S. Government stockpiles, and may reduce private 
sector incentives to continue partnering with the U.S. Government to 
develop and sustain MCM. HHS through BARDA, the Division of 
Microbiology and Infectious Diseases at NIAID (DMID NIAID), and the 
Integrated Research Facility at NIAID (IRF NIAID) have provided crucial 
support to several Navy-DoD-NIAID-University and Industry 
collaborations to rapidly and economically develop medical 
countermeasures that threaten the Warfighter, DoD beneficiaries, and 
the U.S. civilian community at large. For example, Navy Medicine 
provided initial support to determine if transfusion of human plasma 
with high titer anti-influenza antibodies acquired from routine blood 
donors at the Red Cross or other non-profit blood bank centers could 
reduce mortality and morbidity of those with severe influenza. BARDA 
and NIAID, in collaboration with Naval Medical Research Center (NMRC) 
and industry, provided the financial and other resources that enabled a 
Phase II trial to demonstrate impressive safety and efficacy in a 
multi-center study conducted in the United States. BARDA, IRF and DMID 
NIAID, in collaboration with NMRC and industry, funded, produced and 
pre-clinically tested a medical countermeasure against Middle Eastern 
Respiratory Syndrome Coronavirus (MERS CoV) and then initiated a 
clinical trial at the NIAID clinical trial center. This countermeasure 
is the furthest in clinical development of any novel therapy for MERS 
CoV. Phase II clinical trials will require continued support from HHS 
and DoD. IRF and DMID NIAID, in collaboration with NMRC and industry, 
funded, produced and tested a medical countermeasure against Ebola in 
response to the outbreak in West Africa. This product was produced in 
less than 1 year and IRF NIAID demonstrated 100 percent efficacy in 
treating Non-human primates infected with Ebola. The NMRC Bone Marrow 
Research does extensive work with HHS Assistant Secretary for 
Preparedness and Response (ASPR) programs (BARDA and other ASPR 
radiation/nuclear units) and serves as a technical expert and 
radiation/nuclear program member. The Navy supports the National Marrow 
Donor Program (NMDP) to act as a medical countermeasure for casualties 
of radiation exposure within the Radiation Injury Treatment Network 
(RITN) that would be activated during an IND detonation in an American.
                        medical countermeasures
    Question. DoD has been able to leverage HHS' medical 
countermeasures development by providing funding to HHS, including 
adding studies to an existing development program to address a DoD-
specific need. This ensures that HHS's final medical countermeasure 
product can be used by DoD as well, saving the military time and money. 
Can you comment on this and discuss how a reduction in HHS funding 
could impact DoD's ability to address the CBRN [chemical, biological, 
radiological, and nuclear] threats that our military currently faces 
abroad?
    Answer. The Office of Secretary of Defense (OSD) is the lead for 
the Chemical-Biological Defense Program (CBDP), which also includes 
medical countermeasures (MCMs) for radiological threats. The CBDP 
employs coordination, cooperation, and integration with industry and 
academia, interagency partners, and international defense departments 
as well as within the Department of Defense to ensure a prudent use of 
fiscal resources. The DoD leverages Health and Human Services (HHS) MCM 
research, development, and acquisition (RDA) activities to not only 
save time and money, but also to collaborate in meeting both civilian 
and DoD-specific CBRN defense needs. For example, DoD purchases several 
vaccine and therapeutics from the HHS Strategic National Stockpile 
(SNS) for vaccination and treatment of DoD forces. In addition, the DoD 
contributes resources and data to HHS development activities for DoD-
specific needs (e.g., MCM development to address aerosol weapon-
delivered filovirus infection, such as Ebola virus disease). Reductions 
in HHS MCM funding may reduce the opportunities for HHS and DoD MCM RDA 
activities if critical product research or development is delayed or 
cancelled. It may also reduce the ability of the DoD to obtain SNS MCM 
for both routine use or wartime contingency purposes.
                                 ______
                                 
        Questions Submitted to Lieutenant General Mark A. Ediger
              Question Submitted by Senator Lindsey Graham
 transfer of oversight and management of military treatment facilities 
                      to the defense health agency
    Question. Section 702 of the fiscal year 2017 NDAA transferred 
oversight and management of military hospitals and clinics from the 
military services to the Defense Health Agency (DHA), and I understand 
that the Department is now developing courses of action for the Deputy 
Secretary to consider.--Will each of you assure me that you will 
facilitate a rapid and efficient transfer of the operations of those 
medical facilities to the DHA, and will each of you assure me that you 
will reduce the number of personnel in your headquarters and 
subordinate organizations to reflect the changing scope and size of 
your missions?
    Answer. The Air Force, in concert with the Army, Navy, Joint Staff 
Surgeon and the Defense Health Agency (DHA) is developing a construct 
to ensure the transfer of medical care operations and facilities to the 
DHA. A significant element of this blueprint is to delineate, to the 
installation level, where medical services for patient care, medical 
care for readiness, and non-patient care readiness operations will 
occur. After fully comprehending the associated impacts of this 
alignment, the Services will be able to responsibly transfer medical 
care operations to DHA and reduce redundant headquarters functions 
without negatively affecting the Services' mission.
                                 ______
                                 
               Questions Submitted by Senator Jon Tester
                       national guard and suicide
    Question. Montana is home to over 4,000 Guardsmen and reservists. 
There are currently referral resources available to Guardsmen on drill 
weekends, but no dedicated resources for ongoing care and support. Last 
summer, I wrote to Defense Secretary Carter about efforts being made by 
the Defense Suicide Prevention Office. My concern was that over 60 
percent of Army Guard suicides were folks who had never deployed, and 
had limited access to mental healthcare. Unfortunately, DoD had the 
National Guard Bureau respond to the letter, which I think gets to the 
root of the problem. Issues like suicide prevention and mental care 
need to be monitored and coordinated at the highest level and across 
the services. They should not be delegated. How are your respective 
services ensuring that your reserve and Guard components are able to 
tap into your collective mental and behavioral healthcare resources? Is 
DSPO tracking the amount of operation and maintenance funds required to 
fund behavioral health support programs for the reserve components as 
mandated in the fiscal year 2012 NDAA? When will the services implement 
a Program Element Code for suicide prevention?
    Answer. The Air Force is fully committed to promoting resilience 
and preventing suicides across the total force and recognizes that 
access to support services and mental healthcare are an essential 
element of this effort. Both the Air Force Reserve Command and Air 
National Guard, collectively referred to as the Air Reserve component 
(ARC), provide mental health support to Airmen through their Directors 
of Psychological Health (DPH). These full-time mental health 
professionals are available to provide assessment and consultation to 
Airmen and families, regardless of duty status, while proactively 
establishing a robust referral network within their local community. 
ARC DPHs utilize their unique education, knowledge, training, and 
expertise to increase individual, unit, and wing readiness. DPHs also 
assist Airmen and their families in maximizing psychological health, 
resilience, and wellbeing to prevail over the unique challenges of the 
mission and maintain balance as they transition in and out of duty 
status. Per Air Force regulations, DPHs are credentialed and privileged 
by the nearest supporting military treatment facility to provide short 
term non-clinical counseling to address current issues and implement 
plans to manage and/or prevent emergencies. DPHs also establish 
referrals or linkages to longer-term care in the community, if needed. 
DPHs provide support via face-to-face and/or telephonic contact to meet 
the needs of their Airmen who perform reserve duties outside their 
local communities. This NDAA requirement falls under the Assistant 
Secretary of Defense for Health Affairs (ASD/HA) vs. the Defense 
Suicide Prevention Office (DSPO). The Air Force Reserve Command & Air 
National Guard budget for and monitor the expenditure of operations and 
maintenance (O&M) funds for behavioral health support programs and make 
this information available to ASD/HA upon request. Suicide prevention 
requirements are currently captured in their entirety under the mental 
health program in Program Element Code 87700. The Air Force Medical 
Service will continue to partner with the Defense Health Agency to 
determine if a specific Program Element Code for suicide prevention is 
necessary.
                   national guard healthcare coverage
    Question. According to the 2014 Status of Forces Survey, 28 percent 
of National Guardsmen stated that they had no medical coverage. This 
would mean roughly 128,000 National Guardsmen do not have health 
insurance. Especially in rural areas with limited options, younger 
Guardsmen have a tough time with Tricare Reserve Select monthly 
premiums. I have also heard of problems with gaps in coverage when 
their families switch to Tricare Prime while activated. What can be 
done to make Tricare Reserve Select less expensive for younger 
Guardsmen and how can Tricare Prime limit gaps in coverage around 
activation?
    Answer. TRICARE Reserve Select is a premium-based health plan 
available for purchase for qualified members of the Reserve Components 
and their family members. Monthly premiums paid by the Reserve 
Component member are calculated at 28 percent of the total government 
cost per 10 USC Sec. 1076d and determined on an appropriate actuarial 
basis. Sections 712 and 748 of the fiscal year 2017 National Defense 
Authorization Act require the Department of Defense to complete an 
assessment of the extent to which families of members of the Reserve 
components experience difficulties in transitioning to and from 
healthcare arrangements between Active Duty periods and to study 
options for improving their continuity of healthcare. These studies 
will provide the Department of Defense current information on the 
extent of the issue and how to move forward with improving continuity 
of healthcare for Reserve Component families.
                             tricare issues
    Question. Montana is home to a disproportionate number of military 
retirees. Many of them have adult children and call my office to ask 
why Tricare Young Adult is so expensive and has so many conditions. How 
can Tricare better provide for this population to bring it more in line 
with the same standard as ACA?
    Answer. TRICARE Young Adult is similar to extended dependent 
coverage offered to non-military families by the Patient Protection and 
Affordable Care Act. The law requires the Department of Defense to 
charge qualified young adult dependents TRICARE Young Adult premiums 
that represent the full government cost of providing such coverage. The 
statute does not allow incremental premium increases below the level 
needed to equal the cost of coverage on an appropriate actuarial basis.
                                 ______
                                 
              Questions Submitted by Senator Brian Schatz
                            opioid epidemic
    Question. The opioid epidemic is one that spans the entire country, 
with some of the most vulnerable populations being active service 
members and veteran's battling injuries sustained in our most recent 
wars. We owe it to the men and women who have already sacrificed so 
much to construct a viable plan to combat this epidemic. Each service 
must have a holistic understanding of opioid use--both prescriptive and 
illegal abuse--within their formations, and should apply progressive 
thought towards non-opioid pain management alternatives. What are you 
seeing with respect to the use of opioids across the force, and how 
does this compare to national trends?
    Answer. Since 2012, there has been a 34 percent decrease in opioid 
prescriptions. In 2012, 217,897 opioid prescriptions were written for 
103,495 Active Duty Air Force Service members. This represents 33.9 
percent of the Active Duty Air Force population. In 2016, 143,446 
opioid prescriptions were written for 77,732 Active Duty Service 
members, representing 24.7 percent of the Active Duty Air Force 
population. Air Force data was calculated based on one or more opioid 
prescriptions for an individual service member. As a comparison, in 
2015, 39 percent of the national population over the age of 18 was 
prescribed opioids.
                       non-opioid pain management
    Question. Are there any efforts within military medicine to develop 
non-opioid pain management alternatives? If so, when are those 
alternatives most appropriate as replacement therapies?
    Answer. The Air Force is actively involved in providing integrative 
medicine that does not involve the use of opioids in our service 
members. Our five pain management clinics, including three integrative 
pain management centers, utilize a whole-person approach to treatment 
offering massage therapists, pain management psychologists, physical 
therapists, and yoga instruction. A variety of non-pharmacological 
modalities are utilized and tailored to the unique military medical 
environment. These modalities include cold laser therapy, osteopathic 
and/or chiropractic manipulation, and acupuncture. The Joint Base 
Andrews Acupuncture and Integrative Medicine Clinic is the flagship 
program for integrative medicine, executing many of these modalities, 
as well as testing new alternative therapies. Currently, 24 physicians 
have completed a 300-hour certification course in medical acupuncture. 
As of June 2017, 65 family medicine residents will have completed all 
or part of the medical acupuncture course. Since 2009, 1,124 providers 
have been trained in battlefield acupuncture, a minimally invasive 
technique used to treat acute and chronic pain. This technique has been 
widely utilized in both garrison and deployed locations, as well as in 
remote settings. Alternative therapies are now being implemented as 
part of a stepped-care approach to pain management. This approach may 
include alternative practices early on in the treatment plan or at any 
time when the patient and/or provider feels that conventional therapy 
has failed to achieve treatment goals.
                         opioid abuse education
    Question. How are you educating service members on the risks of 
opioid abuse? Are these mandatory for individuals receiving opiate 
prescriptions?
    Answer. Our Air Force providers maintain the standard of care when 
prescribing medications in general, and in particular when prescribing 
opioids, which includes utilizing the following clinical guidelines: 
The Centers for Disease Control and Prevention (CDC) Guideline for 
Prescribing Opioids for Chronic Pain (March 2016) and the VA/DoD 
Clinical Practice Guideline for Opioid Therapy for Chronic Pain 
(February 2017). Non-opioid and non-pharmacological methods are 
discussed with the patient as first line therapies to treat acute pain. 
In the event an opioid is prescribed, the risks, benefits, and 
potential adverse effects are discussed with the patient at the time of 
the visit. The lowest possible dose is selected, not to exceed three to 
seven days duration. If an opioid is prescribed for chronic pain 
therapy (exceeding 3 months) the provider and patient will also discuss 
the long term goals aligned with the biopsychosocial model of pain. 
These goals consider not only the pain level experienced, but also the 
level of functioning the patient hopes to achieve. The patient will 
sign the Opioid Care Agreement (formerly known as a Pain Contract) 
found in the Tri-Service Workflow for Chronic Pain Management, the 
electronic health record currently utilized by the Department of 
Defense Military Health System. A similar agreement will be found in 
the new electronic health record known as MHS GENESIS. The primary care 
provider serves as the sole provider responsible for prescribing the 
opioid and for re-assessing the patient at regular intervals, as well 
as tapering the opioid when indicated. This process is mandatory across 
the Air Force Medical Service. In addition, clinical pharmacists are 
being embedded in our primary care clinics to assist with patient 
education and counseling on proper use and disposal of medications. 
Twenty-six military treatment facilities (34 percent) currently have a 
full time clinical pharmacist providing direct support to the Air Force 
Medical Home.
                          infectious diseases
    Question. Men and women in the military often find themselves in 
these hot zones where emerging infectious diseases are endemic. In the 
Asia Pacific, for example, malaria, dengue, TB, and other emerging 
infectious diseases pose a risk to our soldiers, sailors, airmen, and 
Marines in the region, whether they are stationed there or are 
supporting theatre security cooperation exercises. Continued research 
and prototyping is necessary as we continue to build medical defenses 
for our service members as they execute missions in at-risk 
environments--and this is not an endeavor the DHP should go alone. 
Invaluable relationships have formed with departments across the 
government like the CDC and HHS, and have brought to fruition advances 
for our service members and citizenry alike. How important is bio-
surveillance to protecting our troops from diseases when they are 
deployed?
    Answer. Bio-surveillance plays a vital role in maintaining the 
health of U.S. service members. It provides potential early 
identification of known and emerging health threats, allowing for early 
response to protect our service members and support mission readiness.
                     partnerships with cdc and hhs
    Question. How do you work with partners like CDC and HHS to promote 
prevention and treatment through their international bio-surveillance 
programs? So would you say it puts more or less risk on your ability to 
protect our troops when these partner agencies have their budgets cut, 
jeopardizing their international bio-surveillance programs?
    Answer. The Air Force has a direct link to the CDC via the 
Department of Defense liaison officer physically located at the CDC in 
Georgia. The Air Force also engages with other HHS agencies, such as 
the Office of the Assistant Secretary for Preparedness and Response 
(ASPR) and the Food and Drug Administration (FDA). Any realignment of 
resources would require a risk assessment by the Air Force to ensure 
continuation of force health protection measures.
                          partnering with hhs
    Question. I know DoD works closely with HHS to develop medical 
countermeasures, including the programs managed by the Biomedical 
Advanced Research and Development Authority--BARDA. You have been able 
to share costs and reduce redundancies. Will you elaborate more on 
DoD's partnership with HHS on developing medical countermeasures and 
discuss the potential impacts to DoD's efforts if HHS funding, 
including BARDA, is reduced?
    Answer. The Air Force partners with HHS on medical countermeasures 
(MCM) development through multiple channels and a variety of levels, 
from the secretarial level down to the action officer level. The 
Department of Defense (DoD) and BARDA are interagency partners of the 
HHS-led Public Health Emergency Medical Countermeasures Enterprise 
(PHEMCE) established in 2006, which coordinates U.S. Government efforts 
on development of MCM to address the risks and consequences posed by 
chemical, biological, radiological, and nuclear agents as well as 
emerging infectious diseases. This interagency interaction involves 
coordination, collaboration, and reciprocal leveraging of the outcomes 
from investments by both Departments in MCM research, development, and 
acquisition (RDA) activities. The intent of HHS activities is to 
protect the health of the civilian population. Such activities may 
involve work on MCM that are or may be used by DoD for force health 
protection purposes and to better ensure readiness and operational 
effectiveness. Reductions in funding to BARDA and other elements of HHS 
directly involved in MCM RDA activities may jeopardize national 
security and the Air Force's ability to complete its DoD directed 
mission due to impacts on the MCM RDA pipeline and U.S. Government 
stockpiles, and would very likely reduce private sector incentives to 
continue partnering with the U.S. Government to develop and sustain 
MCM. Therefore, such reductions in funding may have the unintended 
consequence of posing risks to military readiness and modernization 
efforts as described in the ``Presidential Memorandum on Rebuilding the 
U.S. Armed Forces.''
                        medical countermeasures
    Question. DoD has been able to leverage HHS' medical 
countermeasures development by providing funding to HHS, including 
adding studies to an existing development program to address a DoD-
specific need. This ensures that HHS's final medical countermeasure 
product can be used by DoD as well, saving the military time and money. 
Can you comment on this and discuss how a reduction in HHS funding 
could impact DoD's ability to address the CBRN [chemical, biological, 
radiological, and nuclear] threats that our military currently faces 
abroad?
    Answer. The Air Force leverages Department of Defense (DoD)/HHS 
medical countermeasure (MCM) research, development, and acquisition 
activities to save not only time and money, but also to collaborate in 
meeting both civilian and DoD-specific chemical, biological, 
radiological and nuclear defense needs. For example, DoD purchases 
anthrax vaccines and smallpox vaccines from the HHS Strategic National 
Stockpile (SNS) for vaccination of DoD forces at high-risk of exposure. 
In addition, the DoD adds studies to HHS development activities when 
these additional studies will address a DoD-specific need (e.g., MCM 
animal model development to address filovirus infection, such as Ebola 
virus disease). DoD also has a relationship with Biomedical Advanced 
Research and Development Authority (BARDA) to fulfill the requirement 
to ``establish stockpiles of vaccine against H5N1 and other influenza 
subtypes determined to represent a pandemic threat...adequate to 
immunize approximately $1.35 million persons for military use.'' DoD 
has a support agreement with BARDA and uses their acquisition to 
purchase pandemic influenza vaccine, and once purchased, for the 
storage and stability testing of that bulk vaccine with the 
manufacturer. DoD coordinates with and considers recommendations from 
BARDA before making a purchase of vaccine, saving valuable time. 
Reductions in HHS MCM funding may reduce the opportunities for HHS and 
DoD MCM research, development, and acquisition activities if critical 
product research or development is delayed or cancelled. For example, 
if there was a reduction in funding, the ongoing work in relation to 
nerve agent antidotes, Zika vaccine, Ebola vaccine, Middle East 
Respiratory Syndrome Coronavirus, and Acute Radiation Syndrome may lead 
to unnecessary risk to our troops. It may also reduce the ability of 
the DoD to obtain SNS MCM for both routine use or wartime contingency 
purposes.
                                 ______
                                 
               Questions Submitted to Ms. Stacy Cummings
               Question Submitted by Senator Thad Cochran
                    electronic health record system
    Question. The Department of Defense awarded a $4.3 billion contract 
for its new electronic health record system in July 2015. This new 
system was first deployed just last month. Is the electronic health 
record program still on track for full deployment across the military 
health system by 2022? What is being done to ensure the new electronic 
health record system will be interoperable with the Department of 
Veterans Affairs? How will this new electronic health record transform 
the delivery of healthcare by the Department of Defense?
    Answer. MHS GENESIS was deployed to its first patient care site at 
Fairchild Air Force Base in Spokane, Washington in February 2017. 
Fielding at the next three sites in Washington State--Naval Hospital 
Oak Harbor, Naval Hospital Bremerton and Madigan Army Medical Center--
will begin at the end of fiscal year 2017. Further deployments will 
occur by region--three in the continental U.S. and two overseas--in a 
total of 23 waves. This approach allows DoD to take full advantage of 
lessons learned and experience gained from prior waves to maximize 
efficiencies in subsequent waves, increasing the potential to reduce 
the deployment schedule in areas where it makes sense to do so. Full 
Operational Capability (FOC), to include garrison medical and dental 
facilities worldwide, is currently scheduled for 2022. While we are in 
the early stages of the fielding process, we do not anticipate any 
schedule changes at this time. The DoD and VA are two of the world's 
largest healthcare providers, and today, they share more health data 
than any other two major health systems. In April 2016, DoD and VA 
certified to Congress that they are fully interoperable, in accordance 
with the fiscal year 2014 National Defense Authorization Act (NDAA). 
While the Departments met the required objectives, interoperability is 
a spectrum wherein data sharing and functionality can continually 
improve. As a result, we continue to expand interoperability beyond 
last April's DoD/VA Joint Certification of Interoperability. MHS 
GENESIS's modern capabilities will allow DoD to share more complete 
data with similarly equipped Federal and private sector partners while 
simultaneously increasing the number of DoD data sharing partners by 
the thousands. A modern EHR incorporates advanced tools and capability 
improvements that promote efficiencies, provide a higher quality of 
care, and improve population health outcomes. The suite of tools 
available through MHS GENESIS include robust data reporting and 
tracking capabilities, improved analytics, drug-to-drug interaction 
alerts, and a user-friendly patient portal. MHS GENESIS puts more 
integrated information at the healthcare professional's fingertips for 
rapid decisionmaking, reducing duplication of data collection and 
procedures, such as ordering unnecessary labs or duplicate 
prescriptions. At Fairchild AFB, we have already seen evidence that the 
increased patient data, health alerts and tools to cross reference 
medical guidance has led MHS GENESIS clinicians to make changes to 
their behavior. More information in the patient's record will continue 
to yield better guidance for providers to make more informed patient 
decisions.
                                 ______
                                 
               Question Submitted by Senator Brian Schatz
                  joint information technology center
    Question. The Pacific Joint Information Technology Center, or JITC, 
on Maui has a long record of rapidly delivering medical solutions to 
the warfighter in the Pacific, supporting PACOM and its components. The 
JITC also has untapped potential to support DoD's work to improve the 
interoperability of its electronic health record with the VA. The 
Pacific JITC actually created the Joint Legacy Viewer that has allowed 
the DoD and VA to share read-only electronic health records. However, 
budget constraints have forced the Defense Health Agency to ramp down 
funding for the center by the end of this fiscal year. Given Secretary 
Mattis' commitment to restoring military readiness, is it still wise to 
stand down the center--especially in light of the JITC's demonstrated 
promise to support DoD's work toward a full interoperable electronic 
health record with the VA?
    Answer. This topic is outside of the Defense Health Management 
Systems' portfolio and has been addressed by the office of the 
Undersecretary of Defense for Personnel and Readiness: The Pacific 
Joint Information Technology Center has had a long record of rapidly 
delivering medical solutions to the DoD. However, the DoD plans to 
close Pacific JITC, effective 30 September 2017. The decision to close 
Pacific JITC was based on the Department's larger comprehensive Zero-
based Budget Review (ZBR) which was conducted by the DoD Chief 
Information Officer, the Office of Cost Assessment and Program 
Evaluation, and Military Health System (MHS) information technology 
leaders and analysts, and signed by the Deputy Secretary of Defense. 
Through the ZBR, Pacific JITC was determined as not essential to meet 
future MHS testing and interoperability needs. The Department remains 
committed to MHS research in the areas of joint service and joint DoD/
VA concept technology development, prototyping, and piloting of 
products and services to support medical readiness requirements and 
information technology modernization needs.

                          SUBCOMMITTEE RECESS

    Senator Cochran. The Defense Subcommittee will reconvene on 
Wednesday, April 5, at 10:30 a.m., and at that time, we will 
receive testimony from the intelligence community.
    Until then, this subcommittee stands in recess.
    [Whereupon, at 11:59 a.m., Wednesday, March 29, the 
subcommittee was recessed, to reconvene at 10:30 a.m., 
Wednesday, April 5.]