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



 
       DEPARTMENT OF DEFENSE APPROPRIATIONS FOR FISCAL YEAR 2019

                              ----------                              


                        THURSDAY, APRIL 26, 2018

                                       U.S. Senate,
           Subcommittee of the Committee on Appropriations,
                                                    Washington, DC.
    The subcommittee met at 10:02 a.m., in room SD-192, Dirksen 
Senate Office Building, Hon. Richard C. Shelby (chairman) 
presiding.
    Present: Senators Shelby, Murkowski, Blunt, Murray, Tester, 
and Baldwin.

                         DEPARTMENT OF DEFENSE

                         Defense Health Program

STATEMENT OF LIEUTENANT GENERAL NADJA WEST, SURGEON 
            GENERAL, UNITED STATES ARMY


             opening statement of senator richard c. shelby


    Senator Shelby. Good morning.
    The subcommittee will come to order.
    Today, I am pleased to welcome our distinguished panel to 
review the funding request for the Military Health System and 
Medical Readiness of our service members. 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.
    The committee here supports the advancements that our 
military has made in treating our wounded from quicker 
treatment of injuries and medical evacuations through the 
battlefield, to medical research breakthroughs and technology-
assisted remote care. We support it all.
    Last year, the Department deployed its new Electronic 
Health Records system at four sites in the Pacific Northwest. 
The goals of this program are to provide better quality of care 
and a better value to the taxpayer by achieving an integrated 
Electronic Health Record for service members, veterans, and 
their families.
    The Department of Defense recently initiated a review of 
the program, and we look forward to hearing an update on what 
challenges remain to improve coordination with the Department 
of Veterans Affairs and private healthcare providers.
    We hope to hear more about your priorities and work to 
improve medical readiness, and to provide quality healthcare to 
our service members and their families.
    [The statement follows:]
            Prepared Statement of Senator Richard C. Shelby
    Good morning, the Subcommittee will come to order.
    I am pleased to welcome our distinguished panel to review the 
funding request for the military health system and medical readiness of 
our servicemembers: 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.
    This committee supports the advancements that our military has made 
in treating our wounded. From quicker treatment of injuries and medical 
evacuations from the battlefield, to medical research breakthroughs and 
technology-assisted remote care.
    Last year, the Department deployed its new electronic health 
records system at four sites in the Pacific Northwest. The goals of 
this program are to provide better quality of care and a better value 
to the taxpayer by achieving an integrated electronic health record for 
servicemembers, veterans, and their families.
    The Department of Defense recently initiated a review of the 
program and we look forward to hearing an update on what challenges 
remain ahead to improve coordination with the Department of Veterans 
Affairs and private healthcare providers.
    We hope to hear more about your priorities and work to improve 
medical readiness and provide quality healthcare to our servicemembers 
and their families.
    Now I turn to the Vice Chairman, Senator Durbin, for his opening 
remarks.

    Senator Shelby. Senator Durbin has not joined us yet. 
Senator Tester, do you have an opening statement?
    Senator Tester. I do not. I would love to hear from our 
witnesses.
    Senator Shelby. We will hear from our panel. Your written 
statement will be made part of the record in its totality.
    We will start with General West. General, thank you.

           SUMMARY STATEMENT OF LIEUTENANT GENERAL NADJA WEST

    General West. Thank you, Chairman Shelby and distinguished 
members of the subcommittee.
    Thank you for the opportunity to testify on the current 
state of Army Medicine.
    Your continued support enables us to remain ready and 
responsive in a complex and demanding global security 
environment.
    Our Army must remain prepared to respond when called upon 
and Army Medicine is postured to support our Joint Force with 
scalable medical capabilities to support the full range of 
military operations, as well as for natural and manmade 
disasters, and potential infectious disease threats.
    We have the opportunity to change and challenge the status 
quo and make significant improvements in healthcare as we 
implement the reforms outlined in the fiscal year 2017 NDAA 
(National Defense Authorization Act).
    We are working closely with the Defense Health agencies, my 
colleagues Forrest and Mark, and other members of the Joint 
Health Services enterprise to implement these legislative 
changes, and we are fully engaged in the transition efforts.
    In line with these changes, I would like to talk about how 
we are focusing on readiness, modernization, and our people to 
support the priorities of the Secretary and the Chief of Staff 
of the Army.
    Readiness permeates everything we do and has two essential 
components: an Army that is ready and a medical force within 
our Army that is ready. And so, readiness begins with a fit and 
healthy Army that serves as a foundation of a strong national 
defense.
    Since I last testified before this committee, the total 
Army has achieved the lowest medical non-deployable rates in 
our history. Considering how our Guard and Reserve colleagues, 
how difficult it is for them to always be ready, the numbers 
that they have now are phenomenal.
    We have operationalized and disseminated the performance 
triad throughout our Army focusing on optimizing sleep, 
nutrition, and activity to ensure that we have healthier 
soldiers.
    We have taken on the issue of treating acute and chronic 
pain through our comprehensive pain management program reducing 
our reliance upon opioids. And I am happy to say that there has 
been a reduction from 2007 to current on the use of opioids. 
Those within our ranks that have opioid use concerns is about 
0.15 compared to our national average, which is 0.9; so a very 
good comprehensive effort from our team for doing that.
    To sustain our medical force in addition to our military 
treatment facilities, which serve as our training platforms, we 
leverage our 21 medical simulation training centers that have 
realistic and challenging simulations to augment clinical care.
    We also maintain very high quality graduate medical 
education programs to generate to those required specialties. 
Three of our master's and doctoral programs have been ranked in 
the top 10 nationally by ``U.S. News and World Report''.
    Further, we have incorporated the lessons learned and 
lessons observed during operations in Afghanistan and Iraq to 
modify or create capabilities to better support the war 
fighter's needs.
    This includes our new Expeditionary Combat Medic program 
and our Expeditionary Resuscitation Surgery program, which we 
believe will decrease morbidity and mortality during high 
intensity conflicts, and will also increase our ability to 
provide prolonged battlefield care in the future environments 
that we will be operating in.
    In the area of modernization, Army Medicine has come a long 
way since the era of leeches and bloodletting, I am happy to 
say. We leverage the expertise that resides in our Medical 
Research and Materiel Command that is partnering with academic 
institutions and industry to develop innovative solutions and 
countermeasures to protect our forces in any environment that 
we are asked to operate in.
    We are also modernizing how healthcare is delivered. The 
Army has pioneered virtual health in Somalia and recently in 
response to Hurricane Maria. We linked virtual health 
capabilities in Puerto Rico with those clinicians in Texas and 
Georgia.
    Our virtual health capabilities span 30 specialties, 
delivered in 18 time zones, in over 30 countries and 
territories.
    With these virtual capacities and capabilities, we provide 
remote care in multiple environments. We can also coach the 
first responders at the point of injury on special lifesaving 
techniques such as methods to decrease intracranial pressure or 
pack and temporarily close an abdominal cavity in a gunshot 
wound survivor. Imagine just doing that all remotely with the 
person on the point of injury.
    We are collaborating with the Food and Drug Administration 
to bring freeze-dried plasma through the approval process as 
expeditiously as possible.
    Thanks to congressional funding, our researchers at Fort 
Detrick have developed a new blood test to evaluate mild TBI 
(traumatic brain injury) that has recently been approved by the 
FDA (Food and Drug Administration).
    None of these advancements could have been possible without 
the great people that I am honored to lead. The strength of our 
Army is our people. The ability to recruit, develop, employ, 
and retain our soldiers who are agile, adaptable, and skilled 
medical professionals is vital for us to accomplish our 
mission.
    As our Army stands up to futures command to ensure that the 
land component of the Joint Force is ready to dominate in the 
future environment, we have all but asked to change and 
challenge the status quo.
    As our new medicine evolves to transform in synchronization 
with our service, and implement the reforms of our joint and 
interagency partners, we must ensure that we remain ready to 
enable our force with lifesaving and life-sustaining medical 
capabilities at the point of need whenever and wherever our 
Nation asks us to provide them.
    I appreciate the subcommittee's work and continued support 
of our soldiers, Army Medicine, and our Army.
    I look forward to answering any questions you may have.
    Thank you.
    [The statement follows:]
          Prepared Statement of Lieutenant General Nadja West
    Chairman Shelby, Vice Chairman Durbin, distinguished members of the 
subcommittee, thank you for the opportunity to testify on the current 
state of Army Medicine and the opportunities and the challenges that 
lie ahead. Your continued support enables Army Medicine to remain ready 
and responsive in a complex and demanding global security environment. 
It has been a privilege serving as The 44th Army Surgeon General and 
Commanding General of U.S. Army Medical Command for the past 2 years, 
and I am incredibly proud to lead a team of talented and dedicated 
professionals. The strength of our Army is our people, Soldiers, 
Civilians and Families; and we have a solemn obligation to care for 
those who serve our Nation and their Families.
    The United States Army must be prepared for an increasingly complex 
world. Our senior defense leaders continually and clearly articulate 
the concerns from North Korea, Russia, China, Iran, and terrorist 
threats to the United States. In various ways, these potential 
adversaries challenge America's power, influence and interests. Army 
Medicine is prepared to support the Joint Force with scalable medical 
capabilities in all threat scenarios and across all domains. We know 
that future multi-domain conflicts will require enhanced capabilities, 
to provide care at the point of injury or illness. Due to tactical or 
operational circumstances, our healthcare teams may have to provide 
prolonged care in environments lacking robust medical infrastructure. 
Further, our mission requires that we respond to natural disasters and 
infectious diseases, including possible pandemics and emerging threats.
    Army Medicine has the opportunity to make significant improvements 
in healthcare as we implement the National Defense Authorization Act 
(NDAA) for fiscal year 2017, which will influence how we sustain 
readiness. We are working closely with the Defense Health Agency (DHA) 
and the rest of the Joint Health Services Enterprise (JHSE) to 
implement these legislative changes, with thorough analysis, deliberate 
planning and ongoing coordination. We wholeheartedly support the 
transition efforts and will continue to work diligently with our JHSE 
colleagues to implement NDAA requirements while improving medical 
readiness, meeting the operational requirements of our Combatant 
Commanders and providing quality healthcare to our patients.
    We are the Nation's premier, expeditionary and globally integrated 
medical force and readiness is my number one priority. We welcome the 
recent 2-year bipartisan budget agreement which promised predictable 
funding. With this funding, Army Medicine can provide the right medical 
capabilities our warfighters need and conserve the fighting strength of 
the Total Force. To that end, we will focus on Readiness, Modernization 
and People, in concert with Reform, to ensure we are always ready.
                          readiness and health
    The Army Medical Department (AMEDD) has over 180,000 patient 
contacts daily. To put this in perspective, it is roughly equivalent to 
reaching each person in Huntsville, Alabama every day. Yet, our 
readiness mission extends beyond the walls of our Military Treatment 
Facilities (MTFs). Readiness permeates everything we do from prevention 
and resilience to rehabilitation and transition. There are two 
essential components that make up readiness: an Army that is medically 
ready and a medical force that is ready to meet the ever-evolving 
challenges of today and tomorrow. First, AMEDD must ensure our Soldiers 
are physically and mentally fit, ready to deploy anywhere, anytime. 
Second, we must be a responsive medical capability with clinically 
proficient individuals who are also worldwide deployable and adept in 
their warrior tasks and drills. Many Army Medicine Soldier readiness 
initiatives such as the Performance Triad, which promotes proper sleep, 
nutrition and activity to improve overall health and reduce obesity; 
the comprehensive pain management program to reduce reliance upon 
opioids; and advances in traumatic brain injury care have garnered the 
interest of the U.S. Surgeon General.
Soldier Medical Readiness
    Readiness begins with a fit and healthy fighting force and is the 
foundation of a strong national defense. The strength of our Army is 
inextricably linked to our Soldiers' health and wellness. With that 
foremost in our minds, we have enhanced individual and unit readiness 
in several ways, to include: leveraging our health and readiness data, 
an electronic profile system and embedding athletic trainers and 
physical therapists at the unit level. We are also providing nutrition 
education; wellness centers; and research through all portions of the 
performance triad of sleep, activity, and nutrition. Medical readiness 
is a shared Soldier and command team responsibility. However, Army 
Medicine plays a decisive role in monitoring, assessing, and 
identifying key health- related indicators and outcomes, as well as 
providing recommendations to mitigate risks.
    Through Medical Readiness Transformation (MRT) initiative, Army 
Medicine focused on reducing the number of Soldiers in the most severe 
non-deployment category to increase readiness of the Total Force. As a 
result, the Total Force has achieved the lowest non-deployable 
percentage in recent history. Additionally, the medical readiness (MR) 
of the Total Army consistently improved over the past 12 months and the 
Army exceeded the DoD goal. Current endeavors include the new Health 
and Administrative Portal which expands MR visibility to additional 
healthcare personnel for their supported Soldier populations. Regarding 
the dental readiness of the force, the Total Army reached a remarkable 
rate of 97.6 percent. MRT allows for better decisionmaking and 
reporting, while improving communication and transparency between 
Commanders and healthcare providers.
    To assist in Soldier readiness and deployability, we maintain 14 
Warrior Transition Units (WTUs) across the country. Warrior Care and 
Transition embodies the Army's enduring promise to provide high-quality 
care to our wounded, ill and injured. Since the establishment of these 
organizations, nearly 77,000 Soldiers have completed the program with 
approximately 43 percent (33,000) returning to duty. This is roughly 
equivalent to six Brigade Combat Teams. Our WTUs have helped in 
increasing readiness and provided retention cost savings for the Army.
    The Integrated Disability Evaluation System (IDES) is also an 
important aspect of continually improving Army readiness. The Army 
average number of days for completing the Medical Evaluation Board 
(MEB) Phase is performing better than the Army standard. Resourcing DES 
staff at the MTFs ensures Soldiers are evaluated through the process 
expeditiously, but with care. This translates to increased readiness 
for the Army. Continuous process improvements and close coordination 
with external stakeholders are necessary for continued success.
    Readiness requires a broad and a carefully managed strategy to 
minimize pain during the healing process. Over the last two decades, 
Army Medicine has transformed its pain management strategy with great 
success. Our MTFs have addressed complex pain through multidisciplinary 
pain committees, which periodically review pain care plans for high 
risk patients such as those with complex, difficult injuries; high 
utilization of healthcare resources; or high risk pain-related 
behaviors. In treating acute and chronic pain, our holistic management 
system integrates traditional and non-traditional methods to ensure a 
decrease in the level of pain while restoring patients' quality of 
sleep, moods, and activity. In fiscal year 2016, the prevalence of 
Opioid Use Disorder among the active duty Army was 0.15 percent, much 
lower than the 0.90 percent rate in the overall U.S. adult population. 
Our pain management program is integral to sustaining this process by 
providing quality care, mitigating suffering and returning Soldiers to 
the fight.
    Next, in support of Army readiness, the Army has made several 
innovations in behavioral health (BH) care which cannot be replicated 
or purchased in the civilian healthcare system. Army Medicine has led 
the way with our Embedded Behavioral Health (EBH) program. The practice 
of assigning BH providers to operational units has consistently been 
recognized as a DoD-wide best practice. More Soldiers are receiving 
care in the outpatient setting, allowing clinicians to manage BH 
conditions earlier, before crises occur.
    The Behavioral Health Data Portal (BHDP) is recognized as the DoD 
frontrunner in BH outcomes monitoring, as it enables precision 
medicine, enhances quality and continuity of care, and contains systems 
for providing individual feedback and action at the point of care. 
Overall use of BH care increased from approximately 900,000 encounters 
in fiscal year 2007 to over 2.25 million in fiscal year 2017; precision 
BH care, enabled by the BHDP, enhanced the benefit level of treatment 
provided during these visits. Army Medicine will continue to refine and 
build on successes in the BHDP to enhance our ability to monitor 
clinical outcome metrics and refine BH programs based on their metrics. 
We are excited to report we have shared the BHDP with the DHA to 
implement throughout the Services, thereby benefitting all Service 
Members. Efforts continue to advance BHDP functional integration into 
MHS GENESIS, the new electronic health record for the DoD.
    Other key components of ensuring medical readiness are improving 
our ability to execute preventive medicine, public health, health 
surveillance and health risk assessment. This minimizes incidences or 
the severity of disease or illness. AMEDD works to protect our people 
against diseases or Chemical, Biological, Radiological, Nuclear, 
Explosives hazards by applying uniform and timely countermeasures in 
our Army and across the Joint Force.
Ready and Responsive Medical Capability and Force Development
    The demand signal from the Army and the Joint Force is the 
foundation of our ready and responsive medical force. Their 
requirements drive how Army Medicine recruits, trains and operates, 
from expeditionary and prehospital to primary and tertiary care. This 
means maintaining our skilled medical force through daily MTF 
operations, medical training, and education programs. Our training 
facilities are essential to that end.
    We use our Medical Simulation Training Centers at 21 locations to 
augment training outside of our MTFs. For example, the Anderson 
Simulation Center, located at Madigan Army Medical Center, Joint Base 
Lewis-McChord, WA, is the first DoD facility to be accredited both by 
the American College of Surgeons and the Society for Simulation in 
Healthcare. The Center is one of seven sites nationwide to hold Level 1 
accreditation by the Society for Simulation in Healthcare and the only 
site in Washington State and Northern Oregon that provides the 
Fundamentals of Laparoscopic Surgery (FLS), Endoscopic Surgery (FES), 
and Robotic Surgery (FRS) via simulation training. Anderson serves as 
the primary training site for FLS training in Washington State and 
certifies both military and civilian doctors in training to meet the 
simulation requirement for their residencies further embracing 
opportunities to collaborate with civilian partners; our Simulation 
Center at William Beaumont Army Medical Center in El Paso, TX also 
works with the University of Texas for its residency training programs. 
We are extremely proud of the world class medical education and 
training we provide.
    Army Medicine runs the largest Graduate Medical Education (GME) 
training program in the DoD. Annually, we train over 1,500 physicians 
in our MTFs. Our reputation for superior clinical training and 
leadership development boosts recruiting and retention efforts and our 
first time medical board certification pass rate of about 92 percent 
well exceeds the 86 percent national average in fiscal year 2017. Our 
GME programs are vital force generation and retention tools. 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, helping to offset civilian physician training 
shortages.
    In addition to GME, the Army Medical Department Center and School 
(AMEDDC&S) located in San Antonio, Texas is the largest civilian-
accredited service school. Annually, we train more than 31,000 U.S. 
students and 330 International students. This includes enlisted, 
officers, warrant officers and Civilians in diverse graduate, 
leadership and technical programs. The AMEDDC&S has 13 Master's Degree 
Programs and Doctoral Programs, three of which are ranked in the top 10 
nationally by U.S. News and World Report.
    Despite our GME reputation and efforts, we are challenged in our 
recruiting efforts to acquire some low density specialties. Orthopedic, 
thoracic, and general surgery are critically short specialties for Army 
Medicine across all components, as are emergency medicine, 
anesthesiology and psychiatry.
    We are actively working to adapt and align residency and fellowship 
training allocations to emphasize the sustainment of trauma care 
capability. Moving forward we will continue to expand partnerships with 
civilian institutions to establish enduring training agreements. We are 
also continuing to collaborate across the Services to leverage tri-
service training platforms to optimize individual and team training 
opportunities. Finally, in an effort to recruit and retain these 
critical skillsets, we maximize our use of student loan repayment and 
financial assistance programs, health professions scholarships, 
accession bonuses and special pay and incentives. Predictable, 
continued funding is essential to maintain and enhance these programs 
and keep them relevant to recruitment and retention efforts.
    The success of Army Medicine is ultimately determined by our 
ability to meet the operational requirements of the Combatant 
Commanders. The AMEDDC&S developed the curriculum for and graduated the 
first 10 students in December 2017 from the Expeditionary Combat Medic 
(ECM) program. The ECM is a force multiplier that will produce medics 
able to provide additional advanced medical services to include 
treatment of common conditions, prevention of disease and treatment of 
combat trauma casualties. We estimate that the Total Force requirement 
will be 2,600 ECMs by 2024. ECM represents the primary solution to 
developing prolonged casualty care. It addresses FORSCOM's needs and we 
believe this capability will decrease morbidity and mortality in a 
major conflict.
    The lessons of operations in Afghanistan and Iraq have informed 
requirements for medical capability and development of force structure. 
The Expeditionary Resuscitation Surgical Team (ERST) training also at 
San Antonio is an additional training set to increase the readiness of 
our medical force and meet the operational requirements for our Joint 
Force. The three-week course provides advance surgical, resuscitative 
and critical care training to surgical teams supporting operating 
forces in austere, remote environments.
    In the area of training, Army Medicine has developed Critical 
Clinical Training Task Lists (CCTTLs) for 98 AMEDD Officer Areas of 
Concentration and 24 enlisted military occupational specialties. This 
enhances individual and unit readiness in support of Army and Combatant 
Commanders' war plans and contingency operations by codifying unit 
specific mission essential tasks.
    Army Medicine is also able to increase its readiness through Army 
and Joint Global Health Engagement. These international programs are a 
form of medical cooperation, advancing best practices in military 
medicine while assuring our allies and partners of our commitment to 
their security. Army Medicine is postured to participate in 
humanitarian assistance and disaster relief activities when directed by 
our Nation.
    Each of our Services provide medical support to Combatant 
Commanders as directed in strategic and operational documents. During 
early phases of any operation, setting the theater is essential to 
mission success and enables successful transition to other military 
operations. For ground operations, Army medical forces are the likely 
force provider. Army medical personnel are integrated into all echelons 
of support from organic medical forces in the Brigade Combat Team to 
theater level hospitalization. The AMEDD makes up approximately 70 
percent of medical force structure allocated to Combatant Commanders 
and routinely provide support to the Joint Force. To reduce risk to 
ground-based operations, we must remain ready--manned, trained, and 
equipped, to support military operations.
    Although medical support is a shared responsibility, the Army is 
responsible for providing logistical support to Joint Forces assigned 
to areas of operation. Currently Army Medicine has been identified as 
the Theater Lead Agent for Medical Materiel for five of six Combatant 
Commands including the Korean peninsula. We ensure a coordinated and 
integrated medical logistics support plan for the Joint Force. For 
contingency operations, AMEDD forces are the lead for the medical 
logistics support essential to operational success.
                             modernization
    Army Medicine has a long history and proven record of support to 
our Nation, from Army surgeons operating independently during the 
Revolutionary War to our current Globally Integrated Operations. We are 
continually evolving to meet the environment we face. Thankfully, we 
have progressed from the era of leeches and bloodletting to now 
employing advanced technologies, such as virtual health and freeze 
dried plasma. In the process, the battlefield survivability rate and 
the overall health of the force has improved exponentially. Our 
successes are due to the great team of researchers and modern 
technologies we employ.
    The U.S. Army Medical Research and Materiel Command (MRMC) is 
unique to the Department of Defense and drives medical innovation. It 
combines Medical Research, Development and Acquisition capabilities 
with strategic and operational logistics as a total life cycle 
management command. MRMC activities ensure that our Soldiers remain in 
optimal health and are equipped to protect themselves from disease and 
injury. Cutting edge technology research by our professionals in six 
medical research laboratory commands in the continental United States 
and across the globe have added to the readiness, lethality and 
survivability of the Total Force. Proper funding has allowed MRMC to 
make advancements in combat casualty care, clinical rehabilitative 
medicine, medical training, health information, infectious disease 
prevention and operational medicine. There is no nation on earth that 
approaches the reach and scale of such support to deployable forces.
Virtual Health (VH)
    Our ability to bring care closer to our patients, deployed or 
stationed at home, through telecommunications is one of the most 
promising and cost effective developments in Army Medicine in a 
generation. In 1992, the Army pioneered portable virtual health (VH) 
systems for operations in Somalia. Twenty-five years later and in 
response to Hurricane Maria, the 14th Combat Support Hospital (14th 
CSH) deployed to Humacao, Puerto Rico where they established clinical 
operations for our fellow citizens including VH capabilities. The 14th 
CSH in Puerto Rico coordinated their care through providers at Brooke 
Army Medical Center in Texas and Eisenhower Army Medical Center in 
Georgia.
    Since 1992, there has been an exponential improvement in VH, and it 
is now a global endeavor. The Army designated its first Virtual Medical 
Center (V-MEDCEN) at Brooke Army Medical Center. We offer over 30 
clinical specialties across 18 time zones, in over 30 countries and 
territories, which enables providers to remotely monitor patient 
vitals, provide virtual consultations, and assist medics engaged in 
combat casualty care. VH is a way to transform access in garrison 
facilities, patients' homes or at points of injury. The operational 
benefits of this innovation include providing remote trauma and 
advanced burn care and coaching special lifesaving techniques such as 
methods to decrease intracranial pressure in a Soldier with a traumatic 
brain injury, packing and temporarily closing the abdominal cavity in a 
gunshot wound survivor accessing deep vessels to stop bleeding and save 
a limb in a Soldier with a severe leg wound. Technology now allows Army 
Medicine to mitigate the challenge of distance to save lives, limbs and 
eyesight.
Medical Protection
    Protecting the force through treatment or from infectious disease 
is essential to the AMEDD mission. The DoD, through the MRMC, is the 
largest sponsor of trauma and injury research and development in the 
Nation. In fact, no other private or Federal entity provides 
significant funding to advanced topics in acute casualty care. Through 
this research, the DoD spearheaded development of a first-of-its kind 
technique to control hemorrhaging from inside the blood vessel a 
balloon that temporarily stops blood flow from large blood vessels to 
the extremities while keeping intact the supply to vital organs. 
Additionally, MRMC is collaborating with the Food and Drug 
Administration (FDA) to bring life-saving products such as Freeze-Dried 
Plasma, through the approval process as expeditiously as possible. 
Future prolonged battlefield evacuation times will require these types 
of novel solutions to improve battlefield survivability.
    Malaria is still the number one infectious disease threat for 
deployed forces. Due to the efforts of Army infectious disease 
researchers, two anti-malaria drugs are in final stages of clinical 
trials and FDA license packages. Two malaria vaccines also continue 
testing in clinical trials as part of a broader DoD malaria vaccine 
portfolio. For the first time, these candidates demonstrate a greater 
than 85 percent efficacy, lasting up to 6 months against controlled 
human malaria infections. Continued support for these programs will 
result in a viable solution for Service members.
    Finally, our modernization efforts have generated tremendous 
progress regarding traumatic brain injuries (TBIs). Since 2000, Army 
personnel have sustained over 217,000 TBIs, 177,088 of which were 
classified as mild. Thanks to Congressional funding, the Army 
researchers at Fort Detrick, Maryland have discovered a new blood test 
to evaluate mild TBI, which was recently approved by the FDA. Soon, our 
medical personnel will no longer have to rely on the symptoms of 
concussions alone to diagnose TBIs, but will have access to an 
objective marker of injury to the brain, all from a simple blood test. 
This test has great potential to change the practice of medicine for 
brain injury, in particular, to quickly evaluate injured Soldiers in 
remote locations.
                                 people
    As previously mentioned, the strength of our Army is its people. 
Notably, we have a ready medical force capable of global deployment for 
the full range of military operations as we ensure the Total Force is 
ready to fight and win our Nation's wars.
    The recruitment, development, employment and retention of Soldiers 
who are adaptive, skilled medical professionals is critical to the 
ability of Army Medicine to conduct its mission across multiple 
domains. Properly managing talent management is of vital importance to 
enhancing readiness by aligning the unique talents of our people to the 
needs of our Army in supporting the JHSE and any operational 
requirements.
    Our Soldiers and Civilians must be developed and equipped with 
tools that enable effective, agile and adaptive leaders. Our education 
and training must be developed in tandem with development of a career 
progression model that identifies key assignments that impart the 
experience and knowledge crucial to understand and solve the complex 
and dynamic challenges associated with globally integrated health 
services. These steps will produce medical leaders and staffs who 
understand how to plan, coordinate and build synergy from medical 
capabilities inherent to all Services, interagency, multinational 
partners and nongovernmental organizations.
    The ultimate outcome is Army Soldiers who are medical professionals 
capable of operating within a joint framework and warfighting leaders 
informed of the force- multiplying capabilities of JHSE. To this end, 
we are committed to ensuring all Soldiers and Civilians are provided 
full career opportunities to reach their highest potential and their 
vast talent is realized.
                               conclusion
    There is no other health service support capability on the planet 
that compares to Army Medicine. We must be capable of transporting an 
entire hospital, moving it half way around the world at a moment's 
notice and establishing it where needed. We have been a reliable health 
enabler supporting our Army and the Joint Force since 1775 and will 
continue that mission as long as our Army and the Joint Force continue 
to call on us. Congressional support has enabled Army Medicine to 
advance military medical care in support of our Army, the Joint Force 
and that has also advanced the healthcare system of our Nation.
    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 weapon 
system alone; it originates from our people. Army Medicine is the 
driving force behind the medical innovations and technologies that 
allow us to adapt to future challenges that may arise at home or 
abroad. We will provide prolonged care at the point of need and through 
every echelon of care, while continuing to meet or exceed national 
quality of care standards. This is our solemn obligation to our Nation; 
our readiness to support our Nation's Army will always be assured.
    I remain committed working with all of our DoD, Joint, interagency, 
intergovernmental, multinational and civilian partners 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 
Soldiers, Army Medicine and our Army.

    Senator Shelby. Admiral Faison.
STATEMENT OF VICE ADMIRAL C. FORREST FAISON, III, 
            SURGEON GENERAL, UNITED STATES NAVY
    Admiral Faison. Chairman Shelby, Vice Chairman Durbin, 
distinguished members of the subcommittee.
    Thank you for the opportunity to update you today on Navy 
Medicine.
    America's Navy and Marine Corps are busy, deployed and 
operating around the world. I want you to know that the men and 
women of Navy Medicine are serving alongside them providing 
world class care anytime, anywhere.
    On behalf of the Navy Medicine team, we remain grateful to 
all of you for your support and confidence that you have placed 
in us.
    While my written statement provides a detailed overview of 
Navy Medicine, I want to emphasize that our greatest 
responsibility continues to be the readiness and support of a 
highly deployed Navy and Marine Corps team.
    To this end, we are preparing Navy Medicine and working 
closely with our sister services and the Defense Health Agency 
for the future fight, and forging a system of integrated 
readiness and health.
    To ensure our personnel can meet the demands of combat 
casualty care in the maritime environment, and what will be a 
very different fight from OIF (Operation Iraqi Freedom) and OEF 
(Operation Enduring Freedom), we must leverage new, critical 
training and skill sustainment opportunities.
    Much of the success that we saw in saving lives on the 
battlefield during our most recent conflicts can be directly 
attributable to the heroic work of our first responders, our 
corpsmen, medics, and technicians.
    To address these emerging challenges, we have launched a 
series of comprehensive programs targeted at preparing our 
corpsmen to meet their lifesaving responsibilities and 
missions, whether aboard a destroyer at sea or embedded with 
the Marine Corps in conflict.
    Specifically, we modernized and expanded our hospital corps 
``A'' school curriculum, established a new Personal 
Qualification System, deployed a Connected Corpsmen in the 
Community pilot to increase competencies and confidence of our 
Corpsmen, and developed a trauma training partnership with 
Stroger Hospital of Cook County to provide our Corpsmen with 
experience in Level 1 trauma care. Senator Durbin, we are 
grateful for your support in this initiative.
    We have also identified an opportunity to expand trauma 
capabilities within Navy Medicine at the Naval Medical Center 
Camp Lejeune as we stand up a trauma center at that location 
and are actively pursuing designation as a Level 3 trauma 
center there.
    This effort will result in increased readiness and skill 
sustainment for our providers while providing a valuable 
service to the community.
    We continue to embed our mental health providers directly 
with the operational fleet and Marine Forces to support our 
Sailors and Marines. These efforts reduce the distance between 
providers and those seeking help, decreasing stigma, and 
improving resiliency.
    In addition, we are keenly focused on the importance of 
providing immediate support to psychological traumatic events 
that occur in operational environments. Most recently, we 
deployed our Special Psychiatric Rapid Intervention Teams, our 
SPRINT teams, to support the crews and families of the USS 
McCain and Fitzgerald following those ship collisions in the 
Pacific last year.
    Mental health issues after complex or catastrophic events 
frequently do not appear until later, sometimes much later. To 
address this, we have also implemented a new tracking registry 
for survivors to ensure that, as they continue to serve, they 
have rapid and easy access to mental health services when and 
where needed regardless of assignment in the future.
    Navy Medicine continues to conduct worldwide research and 
development in support of our warfighters and their deployment 
readiness. These efforts range from trials of a new malaria 
vaccine, to assessing the threats of newly discovered viruses 
in far reaching corners of the world.
    Our researchers are also directly engaged with the Naval 
Aviation community in conducting vital research aimed at 
understanding and mitigating physiologic episodes affecting 
aircrews in tactical aircraft.
    As I speak to you this morning, U.S. Naval Ship Mercy, one 
of our two hospital ships, is participating in Pacific 
Partnership 2018, a major multilateral humanitarian civic 
assistance mission in the Indo-Pacific. She is currently in Sri 
Lanka providing care in the region and working alongside our 
international partners.
    These missions are foundational to our global health 
engagement strategy and provide unmatched training for our 
medical personnel to respond to humanitarian assistance and 
disaster relief operations, both domestically and around the 
world.
    Navy Medicine is comprised of military and civilian 
personnel focused on caring for and protecting the health of 
Sailors, Marines, and their families. Our success is based on 
these skilled and dedicated professionals, and we appreciate 
your support in providing the special and incentive pays 
authorities and resources needed to recruit and retain this 
talented workforce in a highly competitive workplace.
    In closing, my guiding principles to the men and women of 
Navy Medicine remain consistent: honor the trust placed in our 
hands and the privilege of caring for America's sons and 
daughters, honor the uniform we wear, honor the privilege of 
leadership.
    The men and women of Navy Medicine live these principles 
every day and make me proud beyond words. Again, I thank you 
for your support and look forward to working with you during 
these transformational times in military medicine.
    [The statement follows:]
       Prepared Statement of Vice Admiral C. Forrest Faison, III
    Chairman Shelby, Vice Chairman Durbin, distinguished Members of the 
Subcommittee, thank you for the opportunity to update you on Navy 
Medicine. America's Navy and Marine Corps are busy--deployed and 
operating forward around the world. I can assure you that the men and 
women of Navy Medicine are serving with them and providing world-class 
care, anytime, anywhere. On behalf of the Navy Medicine team, we remain 
grateful to you for the strong support and confidence you have placed 
in us.
                          strategic construct
    Navy Medicine is fully aligned with the strategic imperatives set 
out by the Chief of Naval Operations (CNO) in his Design for 
Maintaining Maritime Superiority and by the Commandant of the Marine 
Corps (CMC) in his Planning Guidance. Our priorities are built on this 
framework and we are focused on ensuring Navy Medicine is that ready, 
rapidly responsive medical force that our Navy, Marine Corps, and Joint 
Forces need and expect to support them and their demanding operational 
missions. We protect the health and readiness of Sailors and Marines so 
they are medically ready to meet their missions. Given the current 
operational tempo of the Navy and Marine Corps, all of us in Navy 
Medicine understand the significance of these responsibilities and we 
will never waiver from our commitment to those entrusted to our care. 
We must do this within a culture of constructive self-assessment, 
improvement and innovation. My guiding principles to the men and women 
of Navy Medicine remain consistent: (1) Honor the trust placed in our 
hands to care for America's sons and daughters; (2) Honor the uniform 
we wear; and (3) Honor the privilege of leadership.
    The Department of Defense (DoD), Joint Staff and Services continue 
to focus on the congressionally-directed changes to the Military Health 
System (MHS) contained in the National Defense Authorization Act (NDAA) 
for fiscal year 2017. Careful and deliberate progress is being made in 
the ongoing transition. With any transition of this significance, 
foremost must be the opportunities that will allow the Services to more 
efficiently and effectively execute their respective readiness 
missions. Readiness and combat support remain our number one priority 
and mission. This is especially relevant for the maritime forces as we 
prepare for future conflicts that will be very different, and contested 
in various environments, than the Operation Iraqi Freedom and Operation 
Enduring Freedom ground war.
    The military treatment facility (MTF) has been the epicenter of 
readiness for decades. As we move forward to realize the many 
opportunities possible under NDAA fiscal year 2017, we must be mindful 
of our core responsibilities of readiness, fleet support and 
operational response and preserve those Service tenets necessary to 
meet mission including: command and control responsibilities of their 
uniformed personnel must be in place to ensure that our medical 
personnel are trained and organized to execute their readiness mission; 
oversight and control of the resources necessary to do those missions; 
providing operationally relevant training; and, ensuring we have the 
agility to get to our military personnel quickly.
    You expect our Nation's armed forces to be ready to fight tonight. 
That means being able to save lives tonight with medical forces that 
are ready, prepared, and present. You rightly hold me, CNO, CMC and the 
Secretary of the Navy accountable for this responsibility. Department 
of Navy (DON) leadership is fully engaged in developing an 
organizational construct that is responsive to Congressional intent, 
while maintaining critical capabilities and framework to support the 
Fleet and Fleet Marine Forces and, if needed, to be where it counts, 
when it counts to save lives.
    I fully support the President's Budget for fiscal year 2019 and the 
resources it provides to fulfill the medical mission of the Navy and 
Marine Corps. I assure you that we will continue to apply sound fiscal 
stewardship at all levels throughout Navy Medicine and derive best 
value from resources provided to us.
              preparing navy medicine for the future fight
    Navy Medicine is preparing our personnel to meet the demands of 
combat casualty care in the maritime environment and we must leverage 
current and new critical training and skills sustainment opportunities. 
Much of the success that we saw in saving lives on the battlefield 
during our most recent conflicts can be directly attributable to the 
heroic work of our first responders--Hospital Corpsmen. The Corpsman is 
the most important member of the medical team for combat survival. 
While building upon this success, we recognize the rapidly changing 
security environment dictates that we adapt and update our training at 
all levels to meet the demands of future conflicts. To address these 
emerging challenges, Navy Medicine launched a series of comprehensive 
programs targeted at preparing our Corpsmen to meet their lifesaving 
missions whether at sea aboard a destroyer or embedded with Marines 
operating forward. These efforts include:
  --Hospital Corps ``A'' School Curriculum: Implemented a modernized 
        and expanded Hospital Corps ``A'' School curriculum focused on 
        casualty care sustainment in sea- based and expeditionary 
        environments.
  --Hospital Corpsmen Personnel Qualification Standards (PQS): 
        Developed a new PQS program that targets the knowledge, skills 
        and abilities required for all Corpsmen to perform across the 
        spectrum of operations. Their clinical experience is vital to 
        their performance, and combat survival, on the battlefield.
  --Trauma Training Pilot: Initiated the Hospital Corpsmen Clinical 
        Trauma Experience Proof of Concept--a trauma training 
        partnership between Navy Medicine, the James H. Stroger Jr. 
        Hospital of Cook County (a Level 1 trauma center) and the 
        Department of Veterans Affairs. Our first cohort of 30 Corpsmen 
        completed training earlier this year and we are assessing 
        expansion opportunities with additional trauma centers 
        throughout the United States.
  --Connected Corpsmen in the Community: To save lives, a Corpsman must 
        have the confidence in themselves and their abilities. Nothing 
        provides confidence better than caring for patients. We 
        established a pilot program in Pensacola to increase 
        confidence, clinical experience and core competencies by 
        allowing Corpsmen to deliver care, with appropriate supervision 
        and guidelines, to active duty service members outside the MTF 
        and beyond normal working hours. In addition, Corpsmen provide 
        care using telemedicine capabilities with oversight provided by 
        licensed providers. Beyond helping Corpsmen, this initiative is 
        also keeping aviation students in class, not at the hospital. 
        Later this year, we will be implementing this program aboard 
        Marine Corps Base Camp Pendleton.
    In addition to our partnership with Cook County Trauma and Burn 
Unit, the Navy Trauma Training Center (NTTC) is a collaboration with 
the Los Angeles County + University of Southern California (LAC+USC) 
Medical Center where our teams are embedded in a high volume trauma 
environment. NTTC trained 266 Navy Medicine and Special Operations 
personnel in fiscal year 2017 and over 3,300 providers since 2002.
    We have also identified an opportunity to expand capabilities 
within Navy Medicine as the Naval Medical Center Camp Lejeune is 
actively pursuing designation as a Level III trauma center. This effort 
will result in increased readiness and skills sustainment for all our 
providers--particularly our trauma teams--while providing a valuable 
trauma response for Marine Corps Base Camp Lejeune and the local 
community.
    Importantly, graduate medical education programs in place at our 
teaching facilities remain critical to preparing Navy physicians to 
meet Combatant Commander requirements for full spectrum operations 
including combat casualty care and humanitarian assistance/disaster 
relief. We run some of the top programs in the country, allowing us to 
look into the eyes of America's moms and dads and confidently assure 
them that the men and women caring for their sons and daughters have 
the best training and preparation our Nation can provide. They are also 
our steady source of trained physicians to meet the needs of the Fleet 
and Fleet Marine Force during the vicissitudes of recruiting and 
retention.
    As part of our modernization efforts, we continue to address 
requirements for modular, scalable and adaptable expeditionary medical 
capabilities--both ashore and afloat--to reduce time/distance to care 
in distributed operations. This priority is evident in Navy Medicine's 
accelerated fielding (manned, trained and equipped) seven-person Role 2 
Light Maneuver (R2LM) capability which was recently tested in the 
amphibious exercise Dawn Blitz 2017. Smaller and more mobile, the R2LM 
capability is designed to provide advanced resuscitation and damage 
control surgery far forward ashore in support of conventional or 
special operations forces and afloat on any surface vessel. We achieved 
R2LM initial operating capability at the end fiscal year 2017, in just 
7 months. In addition, we are developing a provisional containerized 
Role 2 Enhanced capability for further testing and evaluation. This 
will provide the increased adaptability for primary surgery, intensive 
care, and acute care ward beds afloat on almost any cargo ship or 
ashore. Along with other important lines of effort, this work is 
focused on improving our expeditionary medical capabilities to meet 
warfighter requirements. We are taking and applying the lessons from 
Iraq and Afghanistan to the maritime domain.
    In addition, both Pacific Partnership 2017 and Continuing Promise 
2017, major humanitarian civic assistance (HCA) missions in the Pacific 
and Central/South America, respectively, utilized expeditionary fast 
transport vessels to move personnel and equipment ashore to provide 
medical support. Hospital ship, USNS MERCY (T-AH 19), is currently 
underway and participating in Pacific Partnership 2018. These HCA 
missions are an integral component of the global health engagement 
strategy, providing unmatched training and international exchange 
opportunities for Navy Medicine personnel as well as building local 
partner capacity.
              optimizing navy medicine for the warfighter
    Our mission is to keep the Navy and Marine Corps family ready, 
healthy and on the job. Sailors and Marines must be physically and 
mentally capable to meet their demanding mission and we want them to 
deploy confident that their families are well-cared for during their 
absence. One of CNO's guiding principles is toughness and the need to 
tap all sources of strength to succeed and win. Health is vital to 
building and sustaining this resiliency.
    We continue to leverage the success of our embedded mental health 
program. Embedding mental health assets directly within line units 
decreases the distance between providers and those seeking help, 
fostering improved support for Sailors and Marines while decreasing 
stigma. Embedded mental health providers now represent 25 percent of 
our mental health officer billets and roughly the same percentage for 
all enlisted behavioral health technician billets. These mental health 
providers are now permanently assigned throughout Fleet and Marine 
units and complemented by additional mental health providers in primary 
care settings and the expanded use of telebehavioral health.
    We are keenly focused on the importance of providing immediate 
support to psychological traumatic events that occur in the operational 
environments. We deployed our Special Psychiatric Rapid Intervention 
Teams (SPRINT) to support the crews and families following the ship 
collisions in the Pacific last year. Mental health issues after complex 
or catastrophic events frequently do not appear until later, sometimes 
much later. To address this, we have also implemented tracking 
registries for survivors to ensure that, as they continue to serve, 
they have rapid and ready access to mental health services when and 
where needed. In addition, we continue to work collaboratively within 
the Navy and Marine Corps on suicide prevention efforts. All active and 
reserve component Sailors and Marines are now screened for mental 
health concerns via the annual Periodic Health Assessment (PHA). In 
addition, our Psychological Health Outreach Program (PHOP) provides 
specific and valued access to important behavioral health services for 
reserve Sailors and Marines.
    Prevention, treatment and research of traumatic brain injury (TBI) 
are critical to keeping warfighters healthy. TBI programs throughout 
Navy Medicine, including those at the Intrepid Spirit Centers onboard 
Marine Corps Bases Camp Lejeune and Camp Pendleton, provide 
comprehensive treatment to Sailors and Marines impacted by TBI. The 
return to duty rate continues to be over 85 percent. Programs have been 
developed at Camp Lejeune and Camp Pendleton, along with Naval Medical 
Centers Portsmouth and San Diego, to address specific needs of special 
operators, including condensed comprehensive assessment, cohort 
treatment plans, and shortened treatment duration to expedite return to 
the unit. We continue to make progress while recognizing the importance 
of robust research collaborations with leading academic institutions 
and private sector partners in furthering our understanding of TBI and 
ways to improve exposure monitoring, diagnosis and treatment.
    I also want to highlight the Navy Comprehensive Pain Management 
Program (NCPMP) and our continued focus on enhancing the safety of 
opioid therapy for the treatment of pain. Earlier this year, we issued 
a comprehensive Long-term Opioid Therapy Safety Program policy that 
directs specific actions throughout Navy Medicine and emphasizes safe 
opioid prescribing practices including provider training requirements, 
patient screening, and surveillance protocols. Over the last 4 years 
(fiscal year 2013--fiscal year 2017), we saw a 35 percent decline in 
the number of opioid prescriptions for active duty Navy and Marine 
Corps personnel and a 30 percent decline in the number of personnel 
receiving those prescriptions as part of their treatment. We have also 
expanded the scope of this program with continued incorporation of 
complementary and integrative medicine modalities.
    The Navy Medicine Research and Development (R&D) enterprise is 
comprised of eight laboratories that conduct world-wide, operationally-
focused research in support of our warfighters and their deployment 
readiness. Key areas include infectious diseases, biological defense, 
combat casualty care, environmental health as well as undersea medicine 
and several other important and relevant areas. At all labs, 
researchers are confronting some of our most significant challenges 
that impact the health and readiness of our globally deployed service 
members. Emerging infectious diseases require constant attention 
throughout our R&D enterprise to protect the readiness of our forces. 
These efforts range from closing in on the development of a malaria 
vaccine to assessing the threat of newly discovered viruses in far 
reaching corners of the world. Researchers, led by the Navy Medical 
Research Unit--Dayton, are directly engaged with the Naval Aviation 
community in conducting vital research aimed at understanding and 
mitigating physiological episodes (PEs) affecting aircrew in tactical 
jet aircraft. In addition, our Navy Medicine flight surgeons and 
aerospace/operational physiologists are involved in all aspects of PE 
research, mitigation and treatment.
    For injured Sailors and Marines, we continue to implement process 
improvements to accelerate the disability screening process, while 
maintaining outstanding medical care. We fully deployed the new Sailor 
and Marine Readiness Tracking (SMART) program to document and track all 
temporarily medically-restricted Sailors and Marines at Navy MTFs. To 
foster earlier outcomes, we implemented a Temporary Limited Duty 
Operations (TEMPO) process to ensure a multi-disciplinary team actively 
reviews and manages all Sailors and Marines identified in a medically-
restricted status. An important developing component of the SMART 
portfolio is the Health Readiness Common Unfitting List Evaluation 
System (HERCULES) module which identifies Sailors and Marines with 
potentially deployment limiting medical conditions and supports 
providers as they assign the appropriate duty status. In addition, 
deployability will be a consideration at every encounter with Navy 
Medicine, particularly during the annual PHA. All these initiatives are 
making a difference in helping us get Sailors and Marines healthy and 
back on the job.
    Health promotion and disease prevention are essential to sustaining 
a medically ready force which is why promoting tobacco free living is 
so important. Tobacco use affects the health, fitness and readiness of 
the force and that of their families. Navy Medicine providers encourage 
all who use tobacco to quit, discourage others from starting and strive 
to protect everyone from the harmful effects of secondhand smoke. Navy 
MTFs and operational units provide counseling, a variety of FDA-
approved medications, and assistance to those who want to quit. We have 
more work to do but I can assure you that we are committed to reducing 
the prevalence of all forms of tobacco use in the Department of the 
Navy.
                       providing world-class care
    The healthcare landscape is rapidly changing. Convenience and 
experience of care, along with connected technologies, are often the 
primary drivers in our patient's healthcare decisions, particularly for 
our active duty service members and their families. We recognize these 
dynamics as they are particularly relevant and impactful as we progress 
in transforming the MHS.
    As part of these efforts moving forward, the DHA will assume 
administration, direction and control of the MTFs. In the meantime, in 
conjunction with the other Services and DHA, we are working to improve 
access to care for all beneficiaries to include reducing variability in 
appointing and scheduling processes across primary and specialty care 
to improve patient satisfaction and convenience of care. All of us 
recognize the importance of promoting additional options for accessing 
care and measuring our performance through a standardized set of 
metrics. These efforts are particularly important since we want Sailors 
and Marines to get the care they need when they need it so they are 
medically ready to deploy. We currently have 43 Marine- Centered 
Medical Home and Fleet-Centered Medical Homes in place to provide 
improved access for operational Marines and Sailors.
    We are making sustained progress in improving patient safety, 
clinical quality and high reliability thereby improving the care 
provided to service members both at MTFs and in operational settings. 
Navy Medicine providers working in MTFs today could be deployed 
tomorrow so our robust culture of patient safety remains foundational 
to the care we provide, anytime, anywhere. We recently created the 
position of Chief Medical Officer at all our MTFs. These are senior 
experienced physicians monitor quality and safety in all aspects of 
care delivery. They are led by the Navy Medicine Chief Quality Officer, 
a two-star admiral who meets with them monthly to review issues. That 
network also drives rapid dissemination of information about safety 
issues and risks to ensure information is quickly passed to all our 
MTFs worldwide for issues impacting patient safety or care quality. 
Correspondingly, we have established better analytics to link data and 
help improve risk identification, real-time decision- making and active 
surveillance at all levels. All of us in the MHS are committed to these 
efforts and will continue to build on the progress we are making to 
ensure our service members receive the safest and highest quality of 
care possible.
    Another important component of optimizing our care is the continued 
implementation and expansion of virtual health capabilities. Leveraging 
telehealth technology allows us to eliminate geographical barriers in 
providing care to Sailors and Marines in all environments including 
challenging operational settings. Employing the capabilities of Health 
Experts on-Line and other systems is expanding the reach of specialists 
to operational units, effectively reducing the number of medical 
evacuations and referrals to the private sector network. Virtual 
health, including the expanded use of smartphone and tablet 
applications, continues to be an important component of our care model 
as we work to ensure Sailors and Marines have access to high quality 
care, where and when they want it.
    Successful deployment of MHS GENESIS, DoD's new electronic health 
record, is critical for us all in military medicine. When fully 
implemented, MHS GENESIS will be transformative in that it will affect 
all aspects of how healthcare is delivered in our MTFs, as well as 
operational environments and well into the future. We must ensure that 
we get the deployment moving forward safely and be relentless in 
rapidly implementing corrective actions and lessons learned. Two of our 
Navy Medicine commands, Naval Health Clinic Oak Harbor and Naval 
Hospital Bremerton, implemented MHS GENESIS in the fourth quarter 
fiscal year 2017 as part of initial operating capability site 
deployment in the Pacific Northwest. Both commands are encouraged by 
the potential of MHS GENESIS and are diligently working hard to address 
the initial implementation challenges that are associated with a new 
EHR deployment. The Services continue to collaborate closely with the 
Program Executive Office, Defense Healthcare Management Systems (PEO 
DHMS) and the DHA in addressing important aspects related to MHS 
GENESIS deployment and the way forward.
              valuing an outstanding team of professionals
    CNO consistently emphasizes the strength of our one Navy team--our 
Sailors and Navy civilians--as a key line of effort in meeting mission. 
His message resonates with all of us in Navy Medicine as we are 
comprised of approximately 63,000 military and civilian personnel 
focused on caring for and protecting the health of Sailors, Marines and 
their families. Our success is based on these skilled and dedicated 
professionals and we appreciate your support in providing the special 
and incentive pays, authorities and resources needed to recruit and 
retain this talented workforce in a highly competitive marketplace.
    Recruiting Navy Medicine Department officers, both active component 
(AC) and reserve component (RC), remains an essential priority. In 
fiscal year 2017, Navy Recruiting was successful in meeting goals for 
AC officer corps (Medical, Dental, Nurse and Medical Service Corps) 
while RC recruiting met 70 percent of goal. Our most significant 
challenges continue to be in RC Medical Corps (62 percent), Nurse Corps 
(73 percent) and Medical Service Corps (78 percent). We are not immune 
to the pressures of American healthcare which is making it difficult 
for providers, especially those in solo practice, to have the time for 
reserve service. While overall manning in both the AC and RC is stable, 
we must remain focused on ensuring we have the proper specialty mix of 
personnel to meet operational missions, now and in the future. These 
efforts require us to be particularly attuned to increasing, and 
changing, requirements for both the Navy and Marine Corps, particularly 
in our critical wartime specialties. We are working hard to target 
these specialties in our training and accession plans while rigorously 
assessing our overall Medical Department manpower requirements to 
support our readiness mission. Importantly, this focus must also 
include our Hospital Corpsmen and we have identified several 
Independent Duty Corpsmen (IDC) Navy Enlisted Classification codes 
(NECs) for recruiting and retention incentives.
    Navy civilians continue to demonstrate their importance to Navy 
Medicine, fulfilling diverse and essential roles. They contribute as 
providers, researchers, instructors, program managers and in countless 
other key positions throughout the Navy Medicine enterprise. They 
provide continuity and stability in our facilities as well as skillful 
mentorship and training to assigned military personnel. To recognize 
their contribution and ensure they continue to grow professionally, we 
established a new Civilian Corps Chief position, filled by a member of 
the Senior Executive Service, to provide career guidance and 
opportunities for them. Navy Medicine continues to leverage authorized 
flexibilities using several special hiring authorities. In addition to 
Expedited Hiring Authority (EHA) for Certain Health Care positions, the 
Office of Personnel Management (OPM) has delegated Direct Hire 
Authority (DHA) for hard-to-fill healthcare positions such as 
physicians, nurses and pharmacists. In fiscal year 2017, 470 positions 
were filled using EHA and DHA for hard-to-fill occupations; an 
improvement of almost 100 hires over fiscal year 2016.
                             moving forward
    As the Navy Surgeon General, first and foremost, I am committed to 
ensuring that the Navy Medicine team is trained and equipped to keep 
Sailors and Marines healthy and on the job today, and, moving forward, 
that our personnel are ready with the skills and confidence necessary 
to meet the challenges of the next conflict. We do all in our power to 
return America's sons and daughters--who volunteer and sacrifice to 
defend us--home safely and alive. We are making solid progress on all 
fronts, from improving the training and preparation of our Hospital 
Corpsmen to save lives in combat, to force protection research 
initiatives around the world, to taking full advantage of MHS reform to 
refocus on our core mission and responsibility: Readiness and being 
where it counts, when it counts, to save lives wherever needed.
    We are honoring that trust placed in our hands. We are not ``Kaiser 
in uniform'' or ``the HMO that goes to war'' but a strong, trained, 
ready and formidable medical force integrated with and integral to our 
Nation's fighting forces, going wherever and whenever needed to 
protect, support and those in harm's way. We are part of a military 
health system that delivered the highest combat survival in history in 
the previous conflict and are working hard to build on that track 
record for the next conflict and beyond.
    Again, thank you for support and I look forward to working with you 
during this pivotal time in military medicine.

    Senator Shelby. General Ediger.
STATEMENT OF LIEUTENANT GENERAL MARK A. EDIGER, SURGEON 
            GENERAL, UNITED STATES AIR FORCE
    General Ediger. Chairman Shelby, Vice Chairman Durbin, and 
distinguished members of the subcommittee.
    Thank you for this opportunity to testify before you today.
    Air Force Medicine is at a crossroads. Just as the U.S. 
military is mapping its adaptation to a changing security 
environment as described in our National Defense Strategy, Air 
Force Medicine is at the confluence of strategic drivers that 
mandate a path to newly defined future operational 
capabilities.
    Even as 730 medical airmen serve in deployed settings today 
and thousands more support daily operations from our bases, we 
see steadily increasing demands for Air Force capabilities 
making the health and performance of every airman in every 
environment vital to the mission.
    To meet shifting operational demands, we need a different 
mix of skills and capacity within the medical force that must 
be provided within existing end strength. Changes in our force 
mix are out of alignment with staffing requirements for legacy 
hospitals and clinics requiring that we embed more deployable 
teams in partner institutions, and reconsider the scope of 
services we offer.
    In 2017, we revamped our surgical teams by changing their 
composition, training, and equipment to increase independence 
and agility in coordination with our sister services in the 
Military Health System.
    They are known as Ground Surgical Teams consisting of only 
six airmen proven capable of trauma stabilization and damage 
control surgery in remote settings. We are building more Ground 
Surgical Teams to increase our capacity to respond to the 
combat and command.
    Critical care during air medical transportation has proven 
transformational for medical support and combat operations. We 
are responding to a significant increase in operational 
requirements for critical care air medical transport teams by 
repurposing end strength into critical care skill sets.
    The Chief of Staff of the Air Force directed us to expand 
day to day operational medical support to enhance the health, 
resilience, and fitness of airmen. We are using the experience 
we have gained with embedded medical teams in selected missions 
to build operational medical outreach teams through which we 
deliver mission-tailored support to any squadron.
    Outreach teams are currently operating at Joint Base 
Elmendorf-Richardson and Whiteman Air Force Base with 15 more 
teams to stand up in 2019.
    To keep trauma and critical care teams ready, we 
implemented in 2017 new standards for keeping deployable teams 
ready specifying the annual frequency and mix of clinical 
procedures necessary to sustain readiness.
    We also increased our use of partnerships with premiere 
institutions such as the University Medical Center in Las 
Vegas, Baltimore Shock Trauma, University of Cincinnati, St. 
Louis University, University of Alabama Birmingham, and 
Addenbrooke Hospital in Cambridge, England. These partner 
institutions have proven to be highly effective readiness 
platforms for our trauma and critical care teams.
    Even as we transform our medical force to meet these 
operational demands, we are working vigorously to achieve the 
reform specified in the fiscal year 2017 National Defense 
Authorization Act and the Department's reform of the Military 
Health System.
    We are working to implement a framework--in close 
collaboration with the Army, Navy, Joint Staff, and Defense 
Health Agency--that will produce meaningful reform to 
healthcare delivery while implementing a new approach to 
sustaining a ready medical force.
    We are in the process of a bottom-up restructuring of Air 
Force medicine at every level that will reduce headquarter size 
and consolidate units while enhancing our operational 
capability.
    We are excited about our culture of safety and continuous 
improvement that we call Trusted Care. Through Trusted Care, we 
have reduced serious patient safety events by more than 50 
percent and implemented system-wide standard processes, such as 
daily safety and process improvement huddles.
    An innovation that originated with a family health team at 
Ramstein Air Base has spread rapidly, significantly improving 
access to care, team satisfaction, and patient satisfaction in 
the primary care setting.
    Air Force Medical Groups have attained national performance 
recognition over the past year from entities such as the 
American College of Surgeons, the Joint Commission, and the 
Institute for Health Care Improvement.
    As we transition to DHA (Defense Health Agency) management 
of our hospitals and clinics, we will become more focused on 
our growing operational responsibilities. We will be relying on 
DHA's performance to support the readiness of our teams and to 
sustain the progress in our health services. As we map this 
transformation, we remain committed to the mission, airmen, the 
joint team, and the families we serve.
    This is my final appearance before the subcommittee, as I 
will complete 32 years of active duty service this summer. It 
has been my privilege to serve as an airman alongside the 
extraordinary medical professionals throughout the Joint Team.
    I thank the subcommittee for your steadfast support to the 
health and resilience to the airmen, sailors, soldiers, 
Marines, veterans, and families with serve.
    Thank you.
    [The statement follows:]
        Prepared Statement of Lieutenant General Mark A. Ediger
    Chairman Shelby, Vice Chairman Durbin, and distinguished members of 
the Subcommittee, thank you for this opportunity to testify before you 
today.
    Today, Air Force Medicine is at a crossroads. We support the health 
and performance of today's Airman as part of the Joint Team, delivering 
capabilities under years of steadily increasing demand. As Airmen apply 
innovation, expertise and vigilance to meet evolving challenges in the 
mission, our medical teams have done the same to provide Trusted Care 
and advanced medical interventions in difficult environments on the 
ground and in the air. Even as 730 medical Airmen serve in deployed 
settings today and thousands more support operations from our permanent 
bases, we see a future described in the National Defense Strategy and 
the evolution of operational plans in the combatant commands that 
mandates change in our operational capabilities. Provision of those 
capabilities is requiring new processes for sustaining a ready medical 
force more reliant on proven partnerships with trauma centers and 
critical care centers outside DoD. Provision of those capabilities will 
require a different mix of skill sets among medical Airmen that must be 
met within existing end strength, moving our medical force structure 
out of synchrony with staffing requirements for legacy hospitals and 
ambulatory military treatment facilities. This change is evolving as we 
work to reform the Military Health System under the direction specified 
in the fiscal year 2017 National Defense Authorization Act (NDAA), 
moving authority for management of the administration of military 
hospitals and clinics to the Defense Health Agency.
    Meeting the operational imperatives while achieving important 
efficiencies via reform is requiring that we reconsider the roles and 
distribution of medical Airmen, expand proven readiness partnerships, 
strengthen a mutually supportive partnership with the Defense Health 
Agency, and focus our healthcare operations on operational 
requirements. Simply put, increasing our operational capability within 
existing end strength will require that we repurpose part of the 
medical force, thereby reducing uniformed participation in 
nonoperational services where other options exist. This must be done 
judiciously and with careful analysis. This approach is consistent with 
the intent and language of fiscal year 2017 NDAA and DoD reform of 
business processes.
    So, this is our crossroads, shaped by a confluence of operational, 
health-related and economic strategic drivers. All must be duly 
honored. We are working to strike the needed balance to define the path 
for Air Force Medicine in close coordination with the Army, Navy, 
Defense Health Agency (DHA) and the Joint Staff. As we do this, we must 
remain committed to the quality and safety of the care we provide, 
something we call Trusted Care. We are 3 years into Trusted Care, in 
which we are applying principles borrowed from military aviation 
coupled with continuous process improvement to develop a culture of 
high performing teams, always vigilant for risk, with every Airman a 
problem solver every day.
    A prime example of evolved requirements changing our processes for 
sustaining a ready medical force is damage control surgery for 
stabilization of trauma near the point of injury. Over the past 17 
years, combat operations have focused largely on counterinsurgency and 
irregular warfare. Over that period, the geographic range of military 
operations has expanded considerably with dispersed forces operating in 
small, highly mobile force packages. The agile nature of these 
operations and geography over which they operate have generated a 
considerable evolution of requirements for medical support. This 
mission, primarily in CENTCOM and AFRICOM requires trauma stabilization 
teams capable of using state-of-the-art advanced trauma resuscitation 
techniques in a space of opportunity, rather than a field hospital, 
with the ability to relocate rapidly. The forward locations require the 
ability to hold and sustain a trauma patient post-operatively for 12-18 
hours in some cases even as the team stabilizes other patients. Air 
Force Medicine has been steadily adjusting its capabilities to provide 
the flexibility and agility required to bring excellent trauma 
stabilization into this operational environment and enhance critical 
care capabilities during aeromedical movement.
    Counterinsurgency and irregular warfare plus advances in field 
medical capabilities drove the evolution of battlefield medicine 
towards highly capable medical teams deployable into austere 
environments to provide trauma resuscitation and life-sustaining care 
at, or close to, the point-of-injury. Capabilities like Special 
Operations Surgical Teams, or SOSTs, and Ground Surgical Teams, or 
GSTs, fulfill that role admirably, and deploy around the globe to 
support unconventional operations by U.S. and coalition forces.
    Forward deployable teams use structures of opportunity in the field 
to treat critically injured patients, even when lacking access to basic 
requirements like clean water, air conditioning and electricity. Five 
SOST members recently received the Bronze Star for a four-month tour in 
support of Operation INHERENT RESOLVE, where they delivered combat 
casualty care out of a two-room, concrete-walled farmhouse in the 
Middle East. They treated more than 750 patients--mostly local 
residents and coalition forces--working around the clock to treat what 
one SOST member called ``a fast-moving river of trauma.''
    SOST teams typically consist of a trauma surgeon, emergency 
physician, nurse anesthetist, surgical scrub technician, critical-care 
nurse, and a respiratory technician. They also possess advanced 
tactical training, making them capable of far-forward support. GSTs are 
an adaptation (of the SOST) giving conventional field surgical support 
some of the characteristics and capabilities of the SOST while 
maintaining GST readiness for conventional missions.
    GSTs incorporate the damage control and surgical capabilities 
previously delivered by the Mobile Field Surgical Teams, or MFSTs, and 
build in organic critical care and logistical capacity. GSTs include a 
general surgeon, an emergency services physician, an anesthesiologist, 
a critical care nurse, a surgical technician, and a health services 
administrator/logistician. Making all these components organic to the 
GST delivers a leaner, more nimble platform that can deploy more 
rapidly, meeting operational demand. To better support the combatant 
commands, Air Force Medicine is currently training and equipping GSTs, 
with enhanced flexibility and capacity, to replace the legacy 
capability provided by MFSTs.
    Timely, evidence-based damage control surgery and trauma 
stabilization coupled with critical care in aeromedical evacuation have 
become the standard for U.S. medical support to military operations. 
The Air Force is currently training and equipping additional Critical 
Care Aeromedical Transport Teams (CCATTs), in response to requests from 
combatant commands to increase our critical care aeromedical evacuation 
capacity. This will require greater numbers of medical Airmen with 
critical care skills and keeping those Airmen ready will require a day-
to- day clinical practice of critical care beyond what our population 
of military beneficiaries will require.
    These deployable teams, Special Operations Surgical Teams, Ground 
Surgical Teams and Critical Care Aeromedical Transport Teams, were the 
primary drivers of a new concept for sustaining a ready medical team. 
New and evolving capabilities to bring advanced diagnostic and 
treatment capability into the field and into aeromedical evacuation 
demands a new process for keeping Air Force medical personnel 
clinically prepared for their deployed roles. This concept led the Air 
Force to implement new standards, known as the Comprehensive Medical 
Readiness Program or CMRP, specifying the case volume and case mix 
within the medical practice to keep a medical Airman's skills honed for 
deployment. This new readiness concept also led us to expand our use of 
partner institutions to sustain ready medical teams, a practice we 
believe will grow in order to meet new readiness standards. Commanders 
now balance practices in our hospitals and clinics with those in 
partner institutions in order to meet standards.
    These partnerships are critical to Air Force medical readiness. Air 
Force Medicine maintains numerous training affiliation agreements with 
civilian facilities, including the University Medical Center in Las 
Vegas, Baltimore Shock Trauma, University of Cincinnati, University of 
Miami, University of Nebraska, Miami Valley in Ohio, St Louis 
University, UC Davis Medical Center, Addenbrookes Hospital in 
Cambridge, England, and 54 agreements with U.S. Department of Veterans 
Affairs facilities.
    These readiness partnerships have proven effective in pre-
deployment preparation of teams, initial team training, and for long-
term sustainment of skills through either part-time or full-time 
embedded Air Force clinicians. The SOST team referenced earlier, that 
was awarded the Bronze Star, is fully embedded in the level-one trauma 
center at the University of Alabama- Birmingham. One such partnership 
with University Medical Center in Las Vegas demonstrated its value to 
the community and the Air Force in the response to the tragic 2017 mass 
shooting in Las Vegas. Air Force surgeons, as well as nurses and 
technicians from Nellis Air Force Base, were integral to the trauma 
care provided to victims.
    VA partnerships open access to Air Force specialty care to 
veterans, thereby sustaining the readiness of Air Force clinicians 
while enhancing efficient use of Federal healthcare capacity. However, 
contrary to expectations, implementation of the VA Choice Act led to a 
15 percent decrease in veteran referrals to Air Force hospitals. As we 
seek to efficiently sustain the readiness for specialty providers at 
our hospitals, this is an area of concern. The DHA's new authorities 
under the fiscal year 2017 NDAA will help our hospitals capture more 
specialty care via partnerships, efficiently utilizing specialty 
capacity while enhancing the readiness of deployable teams.
    CMRP establishes standards for a ready medical force at the 
individual Airman level, and allows commanders to manage their units to 
those standards. We developed checklists for each Air Force specialty 
code, which guide Airmen through their readiness requirements in three 
categories. The Air Force Medical Readiness Decision Support System 
tracks these individual tasks, which inform commanders' unit readiness 
reports in the Defense Readiness Reporting System. We are confident 
that management to CMRP standards will be important to putting forward 
advanced medical capabilities in support of deployed operations today 
and into the future.
    As the military medical services and the DHA continue to implement 
direction from the 2017 NDAA, the CMRP will be a vital tool to measure 
the impact of the transition on medical readiness standards. We look 
forward to partnering with the DHA as it leverages its new authorities 
to meet service readiness requirements, particularly for specialty care 
providers. Developing new avenues to bring specialty care into the MTFs 
so that our providers can maintain their skills should be a vital 
component of the future MHS model.
    Flexible deployable teams and equipment sets enable Air Force 
medics to respond to a diverse set of operational scenarios. When a 
field hospital is needed, the Air Force Medical Service deploys the 
Expeditionary Medical Support System, or EMEDS. EMEDS is a modular, 
scalable field hospital system. It has emergency, intensive care, 
recovery, laboratory, dental, and primary care capabilities. EMEDS 
enables the Air Force to deploy scalable capabilities. Smaller teams 
can provide trauma stabilization or primary care for a modest number of 
casualties. Bigger teams deploy as a medical system up to the size of 
an Air Force Theater Hospital that can provide specialized medical care 
to a patient population of several thousand, such as the Joint Theater 
Hospital at Bagram Air Base in Afghanistan.
    Air Force Medicine recently updated the EMEDS training curriculum 
to include the most current doctrine and lessons learned, incorporating 
tactics, techniques, and procedures for the new GSTs, as well as 
updated scenarios for the full spectrum of medical operations. An 
EMEDS+25 (capable of supporting 25 inpatients and an at-risk population 
of 5,000) deployed to San Juan, Puerto Rico this fall to aid in the 
relief efforts following Hurricane Maria. EMEDS plays a vital role in 
the Air Force Medical Service's wartime readiness mission and in 
humanitarian and disaster relief efforts around the world. In addition 
to delivering critically needed care, these efforts serve as vital 
training and readiness preparedness opportunities for Air Force medics. 
The skills required are similar to a combat deployment, especially 
since the lack of infrastructure in post-disaster environments can 
resemble austere combat deployments.
    Another platform, the En Route Patient Staging System, or ERPSS, 
deployed to the U.S. Virgin Islands for hurricane relief. ERPSS 
specializes in triaging and preparing patients for aeromedical 
evacuation, and can quickly deploy. The ERPSS team on St. Croix began 
clearing patients for transport back to the mainland within hours of 
arrival.
    An additional platform is the Transportation Isolation System, or 
TIS. Developed to support the 2014-2015 Ebola crisis outbreak in West 
Africa, the TIS allows the Air Force to transport patients with highly 
contagious diseases without risking contamination of aircraft or 
exposure to others. This platform can transport patients with hazardous 
biological, chemical, and even radiological exposures. The Air Force 
Medical Service is further developing this capability to support future 
humanitarian crises, and to enhance capabilities to move patients 
exposed to biologic warfare agents.
    Air Force commanders are asking us to expand operational medical 
support in the mission environment to enhance the health, resilience 
and fitness of Airmen through medical engagement in the environment in 
which they serve day-to-day. We have gained experience applying this 
concept, found it to be successful and are moving to apply it broadly 
across the Air Force in two forms: embedded medical support and 
operational medical outreach.
    Air Force Medicine is embedding growing numbers of medical 
specialists into operational units. There, they deliver preventive and 
rehabilitative support in the mission setting tailored to the Airman's 
operational role. Preventive measures, early intervention and teaching 
self-help techniques in a high tempo mission hold promise for 
significantly enhanced health, performance and resilience.
    We are also testing Operational Support Teams (OSTs), where Medical 
Groups deliver mission-focused support to line and squadron units. 
Teams rotate through different units at their base, with the goals of 
decreasing injuries while increasing psychological and physical 
resilience, Airmen mission availability and performance, and squadron 
mission effectiveness. Base OSTs will use evidence-based interventions 
to provide targeted engagement for units identified as ``higher risk'' 
for mission related psychological or physical injury. The teams include 
a licensed mental health provider, mental health technician, physical 
therapist, exercise physiologist or certified athletic trainer, and a 
human performance integrator.
    Base OSTs are currently operating at Joint Base Elmendorf-
Richardson and Whiteman Air Force Base. We plan to stand up OSTs at 13 
additional bases next year and continue adding teams until at least one 
is in place at each Air Force base, available to support any unit. 
These medics will know the mission, build relationships, and pursue 
opportunities to improve Airmen's health and performance.
    An additional change we are pursuing pertains to our operational 
health processes. These processes provide periodic assessments of the 
readiness of each individual Airman, communicate with commanders about 
duty limitations, assess deployment health and prepare reports for 
disability evaluation by the personnel system. These processes are 
currently conducted in family medicine and aerospace medicine clinics, 
which complicates access to timely primary care and negatively impacts 
the provision of timely and accurate fitness for duty determinations. 
Our remedy will be to establish dedicated operational health teams at 
each military treatment facility, which will require repurposing a 
portion of the medical force. Moving operational health processes into 
a dedicated lane will enable streamlined and accurate operational 
health services while permitting the Medical Homes to focus on timely 
access and team-oriented preventive care.
    In 2017, the Air Force implemented the annual person-to-person 
mental health assessments for all Airmen as required by statute. The 
annual mental health assessment consists of an evidence-based screening 
assessment with a patient interview. The mental health assessments are 
now incorporated in annual periodic health assessments. As of February 
13, 2018, Air Force Medicine has completed 148,000 Mental Health 
Assessments for Airmen. The Air Force continues to perform mental 
health assessments pre- and post-deployment as well, using the same 
standard assessment as the annual screening.
    Research is essential to continued advances in our deployable 
medical capabilities and to advising the Air Force on the optimal 
human-machine interface for safety and effective performance. The 711th 
Human Performance Wing at Wright-Patterson Air Force Base in Ohio 
researches human-centric capabilities to apply to future weapon system 
and sustain current systems. Human Systems Integration is the means by 
which the Department applies these research initiatives to optimize 
performance and minimize life-cycle costs in our weapon systems.
    Air Force medical researchers are working with the Air Force 
Research Lab to develop emerging medical applications of advanced 
wearable technologies for battlefield Airmen. The Battlefield Airmen 
Trauma Distributed Observation Kit, or BATDOK, is a new point-of-
injury, multi-patient monitoring capability. This technology resolves 
an urgent point of injury mass- casualty need for dismounted pararescue 
jumpers, or PJs. BATDOK enhances a PJ's ability to care for multiple 
patients by wirelessly monitoring five or more patient vitals 
simultaneously through a specially designed mobile interface. BATDOK 
has been operationally tested via several mass-casualty military 
exercises and Air Combat Command and Air Force Special Operations 
Command are currently evaluating it for use by their medical elements.
    Our researchers are also developing a portable capability to 
produce U.S. Pharmacopeia-quality sterile water for wound irrigation 
and injection in austere locations. This capability will allow medical 
units to use any water source at deployed locations and shipboard to 
reconstitute freeze-dried plasma, IV solutions, and perishable 
medications for immediate use to treat patients. This reduces the 
logistical burden of transporting and storing heavy water-based 
solutions and increases storage life of perishable medications. This 
capability follows breakthroughs in hollow-fiber ultrafiltration and 
resin-based filters, which replaces larger and more costly heat 
sterilization and the reverse osmosis process. We anticipate a 
deployable system will be available by 2021.
    En route care is another significant avenue of Air Force medical 
research efforts.
    Researchers with the 711th Human Performance Wing have developed a 
Critical Care Aeromedical Transport Team patient monitor that connects 
to hand-held smart tablets, allowing one medic to monitor several 
patients at once. These monitors continuously collect patient vital 
signs. The data from these monitors is then used to create trends over 
time. Initial studies suggest that these trends can be used to predict 
and prevent the development of life-threatening conditions before they 
occur. With the constrained resources available onboard an aircraft, 
the ability to stop a more serious condition before it emerges is 
especially vital.
    Air Force Medicine also engages in research to improve care for 
service members recovering from injury. Combat-related extremity and 
facial trauma are common injuries for deployed service members. 
Improving treatment for these traumas requires the development of more 
sophisticated techniques of surgical reconstruction. The Restorative 
Endeavor for Service members Through Optimization of Reconstruction, or 
RESTOR, group at the 59th Medical Wing is identifying cutting-edge 
cross-disciplinary strategies, technologies, and therapies for advanced 
management of combat trauma through tissue preservation and limb 
restoration. Ongoing efforts in this field are using novel therapies 
and techniques to support replanted and transplanted tissues during 
surgical reconstruction. Our researchers are exploring ``bio-
absorbable'' space-filling constructs as a revolutionary negative 
pressure wound therapy technique to save limbs. They are also 
facilitating long-term graft survival by evaluating custom immuno-
therapeutics to mitigate the risk that the body rejects the graft.
    Air Force Medicine is deeply engaged in reforms to the Military 
Health System established by Congress in the 2017 NDAA and pursuant to 
the Secretary of Defense's reform of DoD business processes. We 
continue to work with our Army, Navy, and Defense Health Agency 
partners in finalizing plans to implement the NDAA and continue with 
comprehensive reform of the Military Health System.
    We are embarking upon a phased implementation, moving one Air Force 
hospital and two clinics to direct DHA management. We are working hard 
to implement under a framework that will produce meaningful reform to 
healthcare delivery while implementing a new approach to building and 
sustaining a ready medical force.
    Just as the U.S. military is mapping its adaptation to a changing 
security environment as described in the National Defense Strategy, Air 
Force Medicine is at the confluence of strategic drivers that mandate a 
new path to newly defined future capabilities. This will require 
reassessment of the operational alignment of our legacy scope of 
services as we meet new operational imperatives. As we map this path, 
we remain firmly committed to serve the mission, Airmen, the Joint Team 
and families with Trusted Care, a ready medical force and operationally 
engaged health services.
    This is my final time appearing before the Subcommittee as I will 
complete 32 years of active duty service this summer. It has been my 
privilege to serve as an Airman and serve alongside the extraordinary 
medical professionals throughout the Joint Team. I thank the 
Subcommittee for your steadfast support to the health and resilience of 
the Airmen, Sailors, Soldiers and Marines we serve.

    Senator Shelby. Ms. Cummings.
STATEMENT OF STACY CUMMINGS, PROGRAM EXECUTIVE OFFICER, 
            DEFENSE HEALTHCARE MANAGEMENT SYSTEMS
    Ms. Cummings. Chairman Shelby, distinguished members of the 
subcommittee.
    Thank you for the opportunity to testify before you today.
    I am honored to be here with my MHS (Military Health 
System) colleagues, representing the Department of Defense as 
the Program Executive responsible for modernizing the 
military's Electronic Health Records system and enhancing 
interoperability with the VA (Department of Veterans Affairs) 
and private sector providers.
    The mission of PEO (Program Executive Office) DHMS (Defense 
Healthcare Management Systems) is to transform the delivery of 
healthcare and advanced data sharing through a modernized EHR 
(electronic health record) for service members, veterans, and 
their families.
    To this end, we are committed to three equally important 
objectives. Deploy a single, integrated, inpatient and 
outpatient EHR; improve data sharing with the VA and private 
sector healthcare partners; and successfully transform the 
delivery of healthcare to the Military Health System through 
advanced tools that give patients more control over their 
healthcare experience.
    As we work towards fully deploying a modern EHR across the 
MHS, I am excited to share that we reached an important 
milestone last year, completing full deployment to all four 
initial operational capability sites culminating with Madigan 
Army Medical Center in Tacoma, Washington. I would like to 
acknowledge and thank the Defense Health Agency, the initial 
site commanders, and the Surgeons General for their continued 
support. Active leadership engagement is a key driver in a 
successful EHR implementation.
    I would also like to acknowledge our great team of 
professionals at PEO DHMS, as well as the many functional 
representatives across the HMS involved since day one.
    To streamline and improve healthcare delivery, MHS Genesis 
delivers an integrated inpatient and outpatient solution that, 
for the first time, connects medical and dental information 
across the continuum of care. Over time, MHS Genesis will 
replace DoD (Department of Defense) legacy healthcare systems 
and support the availability of Electronic Health Records for 
more than 9.4 million beneficiaries, and over 200,000 MHS 
personnel worldwide.
    Our immediate focus is to gain approval to continue to 
deploy MHS Genesis beyond the Pacific Northwest beginning in 
2019.
    For an 8 week period, beginning in January, we sent 
representatives from PEO DHMS, the Leidos Partnership for 
Defense Health, and DHA to respond to end user feedback with a 
focus on MHS Genesis configuration, as well as training, 
adoption of workflows, and change management.
    Based on direct user feedback, we made immediate 
configuration updates and we provided training and support to 
system users. These activities, which were planned refinements 
based on lessons learned, were functionally led and frontline 
informed.
    Recognizing the need for an independent measure of the 
progress and effectiveness of MHS Genesis, we engaged HIMSS 
Analytics, widely recognized as the industry standard for 
measuring Electronic Health Record adoption, to assess adoption 
and conduct usability assessments at our four initial sites.
    Prior to MHS Genesis' deployment, inpatient and outpatient 
scores for our legacy systems averaged Stage 2 out of 7. Post-
deployment, MHS Genesis' sites scored at or above Stage 5, 
which is well above the national average.
    We continue to share these early successes, as well as our 
lessons learned, with the VA and other Federal agencies. This 
includes the United States Coast Guard who, earlier this month, 
committed to a partnership with the Department of Defense to 
deploy MHS Genesis.
    While we continue to focus on modernization, our commitment 
to expand interoperability with the VA and private sector 
providers remains unchanged. The departments share data through 
the Joint Legacy Viewer or JLV. Since the last time I updated 
this committee, JLV use increased by fivefold. Each month, over 
1 million patient records are viewed by DoD and VA users.
    The DoD also steadily increased its data sharing 
partnerships with private sector healthcare organizations. 
Today, we have almost 50 Health Information Exchange partners, 
more than doubled from this time last year.
    Another phase of interoperability is connecting the 
benefits and capabilities of MHS Genesis to operational forces 
in a deployed theater environment. Leveraging agile development 
practices, PEO DHMS will continue to support current readiness 
requirements, while we modernize the information technology 
that supports operational medical providers across the 
continuum of care.
    Thank you, again, for the opportunity to share the progress 
that we have made to transform the delivery of healthcare for 
service members, veterans, and their families.
    Deployment of MHS Genesis to our initial sites in the 
Pacific Northwest is a first step in implementing what will be 
the largest, integrated inpatient and outpatient EHR in the 
United States. As a partner in our progress, we appreciate 
Congress' interest in this effort. We 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 Shelby, 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 record (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 give beneficiaries more control over their 
healthcare experience.
    Our mission aligns with Secretary Mattis' National Defense Strategy 
(NDS) to modernize the Department of Defense and provide combat-
credible military forces. The threats facing our nation constantly 
evolve and a medically ready military force is critical to our national 
defense. MHS GENESIS advances that mission. This cutting edge 
technology will supply MHS providers with the necessary data to 
collaborate and make the best possible healthcare decisions for our 
service members to remain mission ready and mission focused; 
contributing to the NDS strategic approach to restore warfighting 
readiness and field a lethal force.
    The DoD was an early pioneer in the development of a centralized, 
global electronic health record when it introduced AHLTA in 2004. At 
the time, the DoD's in-house EHR solution was viewed by private sector 
enterprises as the future. However, over the last decade the private 
sector has made significant advances in technology. As result, in 2013 
the DoD made the decision to transition from multiple 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.
    In July 2015, the DoD awarded a $4.3 billion contract to the Leidos 
Inc. to deliver a modern, secure, and connected EHR. The Leidos 
Partnership for Defense Health (LPDH) team consists of four core 
partners, Leidos Inc., as the prime integrator, and three primary 
partners in Cerner Corporation, Accenture, and Henry Schein Inc. MHS 
GENESIS provides a state of the market COTS solution consisting of 
Cerner Millennium, an industry-leading EHR, and Henry Schein's Dentrix 
Enterprise, a best of breed dental module.
    As we work toward the goal of fully deploying a modern EHR across 
the MHS, I am excited to share that we hit an important milestone last 
year by deploying to all four Initial Operational Capability (IOC) 
sites, culminating with deployment to Madigan Army Medical Center 
(MAMC), the largest of the IOC sites, in Tacoma, Washington. This 
massive effort took the coordination, guidance, and support of multiple 
DoD agencies and organizations. I'd like to acknowledge all those 
involved in IOC including Mr. Thomas McCaffery, acting assistant 
secretary of defense for Health Affairs; Navy Vice Admiral Raquel Bono, 
director, Defense Health Agency (DHA); Air Force Colonel Michaelle 
Guerrero, 92nd Medical Group, Fairchild Air Force Base; Navy Captain 
Christine Sears, commanding officer, Naval Health Clinic Oak Harbor; 
Navy Captain. Jeffrey Bitterman, commanding officer, Naval Hospital 
Bremerton; and Army Colonel. Michael Place, commander, MAMC for their 
tremendous work to make the IOC in the Pacific Northwest a success. I 
would also like to thank our great team of professionals at PEO DHMS 
for acquisition and program excellence as well as the functional 
representatives across the Military Health System who were involved 
since day one in setting the strategy for modernization.
   go-live success, optimization, baseline configuration and common 
            deployment strategy (stabilization and adoption)
    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 DHA to ensure the 
clinical workflows enabled by MHS GENESIS are standard and consistent 
across the enterprise to minimize variation in the delivery of 
healthcare. Representatives from the functional community also 
collaborated to identify critical data to pull from legacy systems into 
MHS GENESIS: Problems, Allergies, Medications, Procedures, and 
Immunizations (PAMPI). Other data, including lab results, radiology 
results, discrete notes, discharge summaries, etc., is still available 
through the Joint Legacy Viewer (JLV) as we sunset legacy systems.
    Through a tailored acquisition approach, DoD leveraged commercial 
best practices and its own independent test community to field a 
modern, secure, and connected system that provides the best possible 
solution 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 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 optimize the 
delivery of MHS GENESIS. Rollout across the MHS follows a ``wave'' 
model. Initial fielding sites in the Pacific Northwest were the first 
wave of military treatment facilities (MTFs) to receive MHS GENESIS, 
which began February 2017 at Fairchild AFB, just 19 months after 
contract award, and officially concluded in January at MAMC. By 
deploying to four 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 
decision to continue MHS GENESIS deployments later this year. 
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 will last approximately 1 
year. Regionally grouped waves, such as the Pacific Northwest, 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 necessary. Full Operational 
Capability (FOC), to include garrison medical and dental facilities 
worldwide, is scheduled for 2022.
    As with any large scale IT transformation, there are training, user 
adoption, and change management opportunities. The configuration of MHS 
GENESIS deployed for IOC provided a minimally suitable starting point 
to assess the system as well as the infrastructure prior to full 
deployment. Now that DoD has the results from each service operating 
MHS GENESIS in a representative cross section of military hospitals and 
clinics, DoD can make adjustments to software, training, and workflows 
and be confident the changes are positive and impactful throughout the 
MHS.
    Our immediate focus is to gain approval to continue to deploy MHS 
GENESIS in 2019. This acquisition decision requires an MHS GENESIS 
baseline software configuration and a repeatable agile deployment 
strategy to support program deployments beyond the Pacific Northwest. 
To that end, we are working with our industry partner, LPDH, to engage 
representatives from the sites, the functional community, the technical 
community, and the test community with the goal to validate the MHS 
GENESIS baseline software configuration based on IOC lessons learned 
through an independent operational test at Madigan this year.
    For an eight-week period starting mid-January, we sent 
representatives from PEO DHMS, LPDH, and DHA to collaborate with 
initial fielding site users with a focus on MHS GENESIS configuration 
as well as training, adoption of workflows, and change management 
activities. Specific areas of refinement included: roles, clinical 
content, trouble ticket resolution, and workflow adoption. Following 
this period, we collected feedback, evaluated, and provided 
enhancements to the system. These activities were always part of our 
IOC process, and we are experiencing measurable results. End user 
feedback is positive. Our approach has and always will be functionally 
led and frontline informed.
                 measuring user adoption of mhs genesis
    Recognizing the sizeable investment in an EHR for its 9.4 million 
beneficiaries and more than 200,000 providers, the DoD needed a way to 
independently measure the progress and effectiveness of MHS GENESIS 
adoption. To that end, the DoD engaged the Healthcare Information and 
Management Systems Society (HIMSS) Analytics to assess adoption and 
conduct IOC usability assessments for MHS GENESIS. HIMSS provided 
adoption scoring and benchmarking gap analysis assessments on IOC sites 
to rate the top HIMSS usability principles including the Electronic 
Medical Record Adoption Model (EMRAM) and the Outpatient-Electronic 
Medical Record Adoption Model (O-EMRAM). The HIMSS Analytics EMRAM is 
widely recognized as the industry standard for measuring EHR adoption 
and rated from Stage 0 to Stage 7. The clinic at Fairchild Air Force 
Base was scored only on the O-EMRAM as an outpatient facility.
    Prior to MHS GENESIS deployment, the average score was below a 
Stage 2 EMRAM and slightly above Stage 2 O-EMRAM. Post deployment, the 
sites scored at or above a Stage 5 on the EMRAM and O-EMRAM, with 
Fairchild Air Force Base achieving an O-EMRAM Stage 6. These scores are 
well above the national averages of Stage 2 and Stage 3 respectively. 
It is important to note, Stage 6 obtained by Fairchild is an indicator 
that an organization is effectively leveraging the functionality of its 
EHR. Stage 6 is an accomplishment only 20 percent of ambulatory 
providers have attained. To achieve this level, the facility was 
required to demonstrate a number of technology functionalities that 
contribute to patient safety and care efficiency, including 
establishing a digital medication reconciliation process, a problem 
list for physicians, and the ability to send patient preventative care 
reminders.
          department of defense and other agency collaboration
    In June 2017, former VA Secretary Shulkin announced his decision to 
adopt the same EHR as the DoD. To facilitate that decision, he signed a 
``Determination and Findings'' that allows the VA to issue a 
solicitation directly to Cerner Corporation for the acquisition of the 
EHR currently being deployed by DoD, for deployment and transition 
across the VA enterprise in a manner that meets VA needs and enables 
seamless healthcare to veterans and qualified beneficiaries.
    This decision is the next step toward advancing EHR adoption across 
the nation and is in the best interest of our veterans. The VA's 
adoption of the DoD's EHR will fundamentally solve the problem of 
transitioning patient health record data between the Departments by 
eliminating the need for moving data altogether. The VA also is 
adopting DoD workflows to the greatest extent possible, while adding 
some necessary VA-specific tasks. The VA and DoD are committed to 
partnering in this effort and understand that the mutual success of 
this venture is dependent on the close coordination and communication 
between the two Departments which continues to be supported by the DoD/
VA Interagency Program Office.
    The DoD continues to support the VA's ongoing EHR modernization 
efforts. During fiscal year 2018, the DoD and VA collaborated to 
provide updates on the Departments' modernization efforts, technical 
challenges, and joint capabilities. The DoD also supported joint 
collaboration meetings between DoD and VA Chief Information Officers 
(CIO) and other senior leadership to facilitate other future activities 
relating to a single integrated EHR. As a result of these meetings, 
leadership established a DoD-VA CIO Executive Steering Committee as 
well as working groups focused on identity management, joint 
architecture, and cybersecurity. As the VA seeks to finalize a contract 
for their own COTS, it is critical for the DoD and VA to work together. 
This is the next logical step to support the congressional mandate for 
greater DoD and VA integration.
    In April 2018, the DoD announced a partnership with the United 
States Coast Guard for MHS GENESIS. The Coast Guard will adopt and 
deploy MHS GENESIS to its clinics and sick bays. Approximately 6,000 
active duty Coast Guard members receive care in DoD hospitals and 
clinics. A complete and accurate health record in a single common 
system is critical to providing high-quality, integrated care and 
benefits, and to improving patient safety. MHS GENESIS will supply 
Coast Guard providers with the necessary data to collaborate and 
deliver the best possible healthcare.
                   interoperability and data sharing
    As the DoD transitions to MHS GENESIS, our commitment to expand 
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. More than 60 percent of 
active duty and beneficiary healthcare is provided outside an 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 January 2017, 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 the DoD/VA Joint 
Certification of Interoperability. The modern capabilities of MHS 
GENESIS 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 aggregates 
data from across multiple data sources, to include MHS GENESIS, to 
provide read access to medical information across multiple government 
and commercial data sources. Since March 2017, the last time I updated 
the committee, patient data accessed through JLV increased more than 
fivefold; including over 1 million patient records viewed between the 
DoD and VA combined.
    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 still available to DoD 
providers in AHLTA and is now incorporated into MHS GENESIS.
    Over the past 5 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 from a reliance on paper records 
and into a modern era with increased, current health data available 
anytime, anywhere. In March 2017, there were over 20 Health Information 
Exchange (HIE) partners. Today, the number is more than doubled as the 
DoD has nearly 50 HIE partners. DoD leverages its partnership with the 
Sequoia Project, a network of exchange partners who securely share 
clinical information across the United States. We are also targeting 
CommonWell--an independent, not-for-profit trade association with 
connections to more than 5,000 private sector healthcare sites as a 
partner. Leveraging this connection through MHS GENESIS will expand the 
great work DoD accomplished through HIEs. As DoD and VA continue to 
improve data sharing between the Departments and with the private 
sector, deployment of MHS GENESIS will enable more advanced data 
sharing capabilities through the existing architecture. Securely 
sharing health data is a critical piece of the mission delivered today.
                          operational medicine
    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, 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 Systems 
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 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.
    Leveraging agile development practices, PEO DHMS will continue to 
modernize support to operational medical providers across the continuum 
of care, from point of injury to the military treatment facility.
                               conclusion
    Thank you again for the opportunity to come here today and share 
the progress we've made to transform the delivery of healthcare for 
service members, veterans, and their families. The successful 
deployment of MHS GENESIS to our four IOC sites was an important 
milestone 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.
    Research in 2017 from KLAS identifies leadership engagement, 
education, and good governance as factors that contribute to the 
success of an EHR implementation. Leadership from the DoD is heavily 
engaged and invested in the success of MHS GENESIS, and we continually 
take lessons learned from training, adoption of workflows, and change 
management activities. While we are well on our way, PEO DHMS continues 
to progress as an organization accepting nothing less than outstanding 
results and acquisition excellence. We are agile and iterative in our 
approach and are committed to identifying the right capabilities and 
delivering those capabilities to our customers. As a partner in our 
progress, we appreciate the Congress's 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 Shelby. Thank you.

        MILITARY HEALTH SYSTEM--ELECTRONIC HEALTH RECORD SYSTEM

    I will start, again, with you Ms. Cummings. As I noted in 
my opening statement, the Department of Defense has deployed a 
new Electronic Health Record system called MHS Genesis.
    Ms. Cummings, could you please update the committee here 
today on this effort? Tell us whether it remains on track for 
full deployment across the Military Health System by 2022? Can 
you describe the lessons that you learned from the initial 
implementation? How you will ensure the deployment of the 
record to the remaining medical facilities will be successful?
    Ms. Cummings. Thank you.
    We have successfully deployed to our four initial sites, 
and we received a great deal of feedback and lessons learned 
from those deployments.
    We are on track to fully deploy by 2022 and to begin the 
remainder of our deployment in 2019, again, based on those 
lessons learned.
    So for 8 weeks, we spent some time looking at the user 
feedback and we sent teams directly to the Pacific Northwest to 
listen to the users and to make configuration changes based on 
their feedback.
    And while we still have a few challenging areas that, 
working with the Surgeons General, we have committed to making 
enhancements over the next year, we are on track to begin our 
next deployment on the West Coast in 2019, and to deploy fully 
in 2022.
    Through our lessons learned, there are two major areas that 
we learned from an enterprise perspective that we need to 
consider.
    One is the adoption of enterprise workflows, and we 
recognized that during our training, we focused more on 
training the IT as opposed to training the transformation and 
workflow that we are implementing through the IT. So that is 
one of our major lessons learned in working with the Surgeons 
General.
    We are revamping our training strategy so that we can first 
focus on workflows and then how to use the workflows within the 
system.
    The other lesson learned is around the infrastructure. The 
IT infrastructure is the backbone that MHS Genesis rides on, 
and it needs to be stable and reliable. And so, one of our 
pacing items for our full deployment will be that 
infrastructure, and our intention is to have infrastructure in 
place and stable for 6 months, so that we can do all of our 
testing, connect our medical devices, and make sure that we are 
delivering a secure, reliable, and fast Electronic Health 
Record that meets the needs of our providers. Thank you.
    Senator Shelby. What about Madigan Army Medical Center?
    Ms. Cummings. With the Madigan deployment, we have 
demonstrated the breadth of our capabilities within the MHS 
Genesis. Thanks.

TRANSITION FROM MILITARY DEPARTMENT SURGEONS GENERAL TO DEFENSE HEALTH 
                                 AGENCY

    Senator Shelby. The National Defense Authorization Act for 
2017 and 2018 contained a number of provisions that will 
transform the Military Health System, including moving some 
responsibilities from the Military Department Surgeons General 
to the Defense Health Agency.
    Would each one of the Surgeons General comment on how this 
transition is going from your perspective, and explain what 
concerns you have with the transition of management and 
administration responsibilities away from the military 
departments?
    General West, we will start with you and just move down the 
table.
    General West. Thank you, Mr. Chairman.
    I can tell you Army is 100 percent onboard with 
implementing the provisions of the NDAA; in fact, the total 
Army, not just Army Medicine.
    General Milley and our Secretary of the Army actually 
established an Army-led taskforce led by our Army G-3/5/7 along 
with all of the elements of our staff to ensure that this is a 
successful transition.
    Then we also have our line involved, Forces Command, who 
will be impacted by the first phase facility, which is for us, 
Womack Army Medical Center to ensure that there is no impact on 
readiness.
    And so, we are moving forward with teams to assist DHA 
working together with Air Force and Navy to ensure that we have 
processes in place. We are on multiple workgroups, multiple 
meetings to make sure that we are real time getting after the 
implementation plan and Ops to make sure that it is successful.
    The one thing that I know our Chief and our Secretary of 
the Army always say is readiness is number one. So the real 
concern is that if there is anything that would impact our 
ability to perform our missions in the things that I mentioned 
that we are responsible for to the Joint Force.
    Senator Shelby. Admiral Faison.
    Admiral Faison. Thank you, sir.
    We are all-in on this. We see enormous opportunity that 
comes from the changes that are mandated in the law, which 
would allow us to get back to our primary focus of readiness in 
preparing for the next conflict, as I share, will be a very 
different conflict for us than any conflict we have seen in the 
last 70-plus years.
    There is enormous value and benefit to doing this. And so, 
we are all-in.
    From my Secretary, CNO, Commandant on down, they are 
getting regular updates and are heavily engaged to make sure 
that we are fully supporting this and doing this right. All of 
us are engaged on a daily basis to work this.
    This is all transformation change in a time when optempo 
remains high. Our focus, as with my sister services, is to 
ensure we reap the benefits without the risk to readiness. We 
are proceeding very deliberately and carefully to ensure that 
we continue to support optempo, continue to do things necessary 
for a brighter future.
    Senator Shelby. Thank you. General Ediger.
    General Ediger. Thank you.
    The Air Force is fully onboard and we have been applying a 
great deal of energy and critical thought to working in the 
Military Health System to map this change.
    We see this as a great opportunity to achieve efficiencies, 
but also to set up a progressive Military Health System that 
provides healthcare within the best models for all of the 
opportunities that medicine is going to offer into the future.
    Our priorities for Air Force medicine, as we map this 
change, is to ensure that as we do this, we will be able to 
field a modernized, deployable medical force that meets the 
evolving requirements of the combat and command fully capable 
and ready. We know that that is going to require a use of new 
standards and new practices in terms of maintaining the 
readiness of deployable clinical teams.
    Our second priority is to ensure that we continue to 
provide operational medical support that is tailored to the Air 
Force mission.
    We know that as we go from base to base, and the mission 
varies from base to base that, in particular, aerospace 
medicine operations are tailored specifically to the 
requirements of the airmen in that missions to ensure their 
performance, their health, and their safety.
    And so, I am confident that as we map this change, we will 
be able to see to the readiness and operational support 
requirements while achieving the full intent of the National 
Defense Authorization Act.
    Senator Shelby. Thank you.
    In the area of medical research--and I am glad we have with 
us on the committee, Senator Blunt, who has more than a passing 
interest in medical research because he chairs the committee 
over NIH--this committee has consistently recommended funding 
for medical research, funding that is supported by a majority 
of the Senators.
    I will direct this to you, General West. Can you update the 
committee on how this funding has contributed to medical 
breakthroughs to the benefit of our service members? Is there 
some coordination between what you do in medical research and 
what, for example, the NIH and others do? Although it should 
be, I think.
    Go ahead, General West.
    General West. Mr. Chairman, thank you so much for that 
question and also, thank you for the phenomenal support that we 
have been receiving.
    Eighty-five percent of the congressional special interest 
funding goes to the MRMC, our Medical Research Materiel 
Command. I can tell you, it is used very wisely and 
cooperatively with our academic partners and with industry, and 
so, you mentioned with NIH.
    All of our programs, or research projects, are actually 
vetted through a recognized research protocol process, and we 
also make sure that we are not duplicating or unnecessarily 
duplicating research in other fields by ensuring that we use 
this stringent process with NIH, again, and with all of other 
partners.
    Some of the things that we have, there are multiple areas 
and breakthroughs. Recently, there has been a hand-sight-vision 
augmented touch system that are clinical trials that are 
helping with processing power and speech for those that have 
difficulty with trauma, that have sustained trauma.
    There are some funds with advanced ocular treatment for 
austere conditions, so basically where you can inject a 
hydrogel to sustain the eye while you are waiting to get the 
person to definitive care.
    There is targeted muscle regeneration for treatment of 
neuromas associated with amputations. Some of these, surgical 
nerve transfer procedures were actually developed with our 
civilian partners using practices that were used in kidney 
transplants. And so there is a lot of coordination with our 
civilian sectors.
    I can go on. There is more.
    Senator Shelby. Okay.
    General West. So there is quite a bit of research and we 
really do appreciate the support for that.
    Senator Shelby. Thank you.
    General West. Thank you.
    Senator Shelby. Senator Tester.
    Senator Tester. Yes, thank you, Chairman Shelby.
    I want to thank you all for being here.
    I have to ask you a question that I do not know the answer 
of.

                       TRICARE CONTRACT ISSUANCE

    Do any of you deal with a third party provider with 
TRICARE, as far as contract issuance?
    Admiral Faison. Sir that is the responsibility of the 
Defense Health Agency.
    Senator Tester. Okay. That is what I thought.
    Admiral Faison. I would be happy to take back any 
questions.
    Senator Tester. Well, we have some, but we will put them in 
written form for sure. We will not go down that line of 
questioning.

                       ELECTRONIC MEDICAL RECORDS

    I do want to talk about electronic medical records. Ms. 
Cummings, you said the rollout in the Northwest has gone well. 
That is good; kudos to you and your team.
    The VA is supposed to be utilizing the same health records. 
It is an issue that we have talked about on many committees is 
having a seamless medical record transition between active 
military and the VA. It appeared like it was going to happen, 
although I am not sure now, since the Secretary of the VA was 
fired a month or so ago.
    Are you aware of the VA's involvement with the DoD, because 
you are kind of the lead dog on this? Have they been proactive 
in moving that medical record across the platform?
    Ms. Cummings. So I will start by saying that I fully 
support the VA's decision----
    Senator Tester. As do I.
    Ms. Cummings [continuing]. To adopt the EHR, Electronic 
Health Record MHS Genesis.
    We have had regular engagement with the VA since that 
decision was made. We meet regularly. We share lessons learned. 
We talk about the technology implications.
    Senator Tester. And how often do you meet with them?
    Ms. Cummings. We have an entire day meeting scheduled once 
a month. We have meetings scheduled every week to catch up.
    Senator Tester. Good.
    Ms. Cummings. And then we have technical meetings at the 
CIO (Chief Information Officer) level, the DoD CIO and the VA 
CIO, and they meet every 6 weeks. So it is very regular 
engagement and we have been very open with sharing data.
    Senator Tester. Good.
    Ms. Cummings. And they have been very open too.
    Senator Tester. And have those meetings continued since 
Secretary Shulkin has been out?
    Ms. Cummings. They have.
    Senator Tester. I believe their CIO resigned last week.
    Ms. Cummings. He did.
    Senator Tester. And the meetings still are continuing?
    Ms. Cummings. They are.
    Senator Tester. And we are still moving the ball forward 
from your perspective?
    Ms. Cummings. From my perspective.
    Senator Tester. Good, thank you.

                         MENTAL HEALTH SERVICES

    Admiral Faison, thank you for being here. In your 
testimony, you talked about, in verbal and written, it said, 
``Mental health issues after complex or catastrophic events 
frequently do no appear until later, sometimes much later.''
    Mental health is a huge issue. It is a huge issue for our 
active military. It is a huge issue for our Guardsman and 
Reservists because of access. They have almost no access, if 
they have not been deployed and they lose the DoD services if 
they are outside their deployment window. Right?
    So about 4 months ago, the President directed the DoD--this 
is not new information to you--the VA and DHS to come up with a 
plan for mental health. The plan probably should have been out 
long before now.
    I still have not seen it and it is for our Guardsman and 
Reservists that are transitioning from service member to 
civilian. It happens many times over in this day and age.
    My concern is we are not--and I think it was in your 
written and verbal testimony too--that we are not doing what we 
need to do for the Guards and Reserve.
    Will the plan, which I have not seen, for transitioning 
service members help Guardsmen and Reservists with mental 
health services when they are outside the deployment window?
    Admiral Faison. Sir, yes, sir. Thank you very much for that 
question. I defer to my Army colleague.
    Senator Tester. It is okay. You can go anywhere you want to 
go.
    Admiral Faison. For the Reservists for the Navy, we have 
implemented a series of efforts with Returning Warrior 
Workshops, and other outreach initiatives, to be able to care 
for our returning warriors who will then go back to civilian 
life.
    In the active component, about 25 percent of my mental 
health workforce is actually embedded in operational units now 
to provide the care and support, and decrease the distance 
between need and the provider, and reduce stigma. That has 
actually borne fruit for us.
    We have also increased our hiring of mental health 
providers to be able to provide that network of support.
    Senator Tester. Okay.
    Admiral Faison. So there are several efforts going on.
    Senator Tester. So the real issue is the one you brought 
up. By the way, thank you for what you are doing from an active 
component standpoint.
    But what about the issues that come up after the job is 
done, after they go home? Is there any potential with the plan 
or any other method out there, to be able to get these folks 
help?
    Admiral Faison. Yes, sir. Thank you very much for that.
    Senator Tester. After their days, this is down the line, as 
you spoke of, which I agree with one hundred percent, by the 
way.
    Admiral Faison. The Department has done several 
initiatives, but as you know, mental health in our Nation is a 
challenge right now.
    Senator Tester. It is a big problem. Outside of that 
deployment window is what I am talking about.
    Admiral Faison. Right. Yes, sir.
    Senator Tester. Is there any help out there?
    Admiral Faison. Yes, sir. We have put in place several 
initiatives with help lines and things like that when people go 
back to areas that are underserved for mental health services.
    I can get you specifics on that and respond back to you 
more fully.
    Senator Tester. I would like that.
    I think that you all realize, more than anybody else, the 
issues that revolve around mental health in civilian life, but 
we are talking about the military here, and it is a big, big, 
big issue.
    If we do not do what we need to do, and I think you put 
your finger on it. We have problems during service and we have 
problems outside the deployment window, and I just think that 
we owe it to these folks to make sure that they have access.
    I come from Montana and there are not a lot of mental 
health providers out there, which is another challenge that we 
have to deal with. We ask them to serve and they serve. They do 
a heck of a job in that capacity. We owe them this.
    Go ahead.
    General Ediger. Senator, if I could add a little bit from 
the Air National Guard perspective.
    Senator Tester. Yes.
    General Ediger. To build on what Admiral Faison provided is 
the Air National Guard has created Director of Psychological 
Health positions in every wing, and Air Force Reserve is doing 
the same. That is the behavioral health provider who is 
assigned full time to the Air National Guard Wings to help the 
members at any time during their service with the Air National 
Guard in terms of securing mental health support.
    If, in fact, their mental health problem turns out to be 
service connected, in other words, it is related to Title 10 
duty, then we will facilitate their referral into our system 
for care, but also help them with obtaining care in the private 
sector as required.
    Senator Tester. Okay.
    General West. Yes, sir. I agree with my colleagues. This is 
an issue that we really need to get after. I think there are 
many opportunities, especially in virtual health.
    Some of the lessons learned, I had the opportunity to visit 
Mercy Virtual in Missouri and to see how they have health 
navigators to help get rural patients care virtually.
    Since we established, in January, we just cut the ribbon 
for the first DoD virtual health med center in San Antonio, 
Brooke Army Medical Center. We can use and established that as 
hubs to get that care, at least virtually, out to our Guard and 
Reserve colleagues.
    So we are working very closely. We have our Reserve and 
Guard surgeons to determine, how can we do that? It is very 
difficult in the States when there are individual States for 
our Guard. So we are getting after it now.
    In fact, our Guard down in Arkansas is at a conference for 
medical personnel for our National Guard. And so, we are going 
to make sure to tackle the issue and come up with a solution to 
get after that.
    Senator Tester. Thank you for your work.
    General West. Thank you.
    Senator Tester. I look forward to working with you to do 
what we can do to solve this problem. Thank you.
    Senator Shelby. Thank you, Senator.
    Senator Blunt.
    Senator Blunt. Thank you, Chairman.
    Senator Tester, I totally agree with him and with you on 
the importance of continuity on these electronic records. I 
have spent some time on this issue, and I do think that we are 
held back by a decision, maybe, as to whether or not the Deputy 
Acting VA Administrator can sign the contract that is waiting 
to be signed. But it is very much negotiated as the Defense 
contract was, and I know you are on top of that.
    The memory act, that we passed a few years ago, requires 
some greater commitment to what a person in the service went 
through in their service activities, which later, when you are 
trying to qualify for behavioral health, will become much more 
important than it is probably at the time that that is being 
filled out.
    I have two topics I want to be sure and get to here, 
though, and three counting just a mention to General West. 
Appreciate your trip to Fort Leonard Wood. You are looking at 
Mercy Virtual and the importance of telemedicine.
    I know that the three times you have been before this 
committee, the other two times, we talked about the hospital at 
Fort Leonard Wood, which you visited, being the top medical 
facility priority. I am glad we have the first phase of that 
underway now, the first $100 million committed to that.
    For the record, I would like to see some sense of the way 
we would phase the full facility in. Again, glad that you have 
spent the time you have on this.

                          TELEHEALTH SERVICES

    Let us talk about telehealth for a minute generally. I 
think also I would be particularly interested, Admiral, in 
telehealth as it relates to the ships at sea; both mental 
telehealth as well as other telehealth services.
    If you want to start, General West, with that.
    General West. Thank you, Senator.
    I do appreciate your support. Because of your advocacy, we 
were able to get the Leonard Wood facility moving forward. So I 
really appreciate that.
    You have my commitment that we will continue to ensure that 
that facility comes to fruition because our population there 
deserves that facility.
    For virtual health, again, as I mentioned, it is really 
exciting to cut the ribbon on the first virtual med center. 
That actually is joint, because we had linkages with our Navy 
and Air Force colleagues, and even our inter-agencies. So that 
is really a very positive, I think, advancement for that.
    The number of visits that we have of virtual health, we 
have about 17.9 million visits per year in our facilities. 
Right now, about 20 percent of those are virtual, by the 
definition of virtual, and that is e-mails, secure e-mail, and 
telephone.
    But when you talk about the real virtual, we mean the video 
or the synchronous, it is a lot smaller, but we are actually 
improving that.
    We demonstrated that just recently with our teams that were 
deployed. We deployed a virtual health satellite package with 
the teams that supported our citizens in Puerto Rico and the 
Virgin Islands. They actually were linked with providers back 
in Texas and Georgia to provide that virtual care. So that was 
just recently when we did that.
    We do that operationally for the deployed forces and for 
behavioral health. We find that our young soldiers, especially, 
really prefer that method. When we do post-deployment mental 
health or behavioral health screenings, initially they were 
given options of either the face to face or the virtual, and 
they actually seized that because I think that their generation 
likes that.
    Senator Blunt. Thank you.
    Admiral, do you want to talk a little bit about what your 
deployed service personnel benefit from and are challenged by 
the virtual health concept?
    Admiral Faison. Yes, sir. Thank you very much.
    As you know, 40 percent of the Navy and the Marine Corps is 
forward deployed or at sea every day to protect our interests 
around the world.
    We also have the most highly trained, specialized, and 
educated Navy and Marine Corps in our Nation's history. Every 
sailor and Marine is critical to the mission. So we have used 
telemedicine to great effect to keep them healthy and to keep 
them on the job.
    Ships at sea have that capability. We have a network out of 
Naval Medical Center in Portsmouth that provides specialty 
access on-demand to any ship around the world to care for those 
Sailors and to provide care for them without having to evacuate 
them; to keep them on station and on the job.
    We have also used telemedicine to great effect in our shore 
stations. So our hospital at Guam has the busiest Intensive 
Care Unit in DoD, and they are supported by my colleagues, the 
doctors in the Intensive Care Unit at Tripler Army Medical 
Center in Hawaii. That allows us to take care of patients on 
Guam without medical evacuation, give them the best care that 
we can, and get them back to duty quickly.
    And you are citing an issue that we just started this year 
called Connected Corpsmen in the Community. As I shared with 
you, our Corpsmen are our most critical member of the medical 
team for combat survival.
    To give them increased experience and exposure, and to help 
build confidence in their ability to take care of patients, at 
the same time keeping students in our schools, we have put 
clinics run by Corpsmen in our schoolhouses down in Pensacola 
where our aviation students are going through school. 
Previously, if they got sick, they had to go to the hospital, 
which was on another base, to get their care.
    By having Corpsmen-run clinics connected virtually to 
physicians back at the hospital, they are able to provide care 
to those students and keep those students in school. So 
telemedicine has been a big success for us.

                 DEPARTMENT OF DEFENSE HEALTH RESEARCH

    Senator Blunt. Excellent. I have one other question I want 
to cover before we are done, and I may have some more questions 
for the record.
    I did intend to ask about the research in defense. This is 
a fight that Senator Shelby leads every year to try to continue 
to be sure that we have that research component available to 
us.
    But there was an article yesterday in the ``U.S. News and 
World Report,'' the headline was, ``Military Health System 
Acknowledges Risk.'' And the point of that article was that 
many people in military facilities do not do the same 
procedures as often as they might in other places, and a strong 
suggestion in that, that because of that, we need to take a 
closer look at that.
    One of the people, at least, that was mentioned in the 
article that said he thought they warranted a closer look was a 
retired Air Force surgeon.
    So General Ediger, do you want to start with that? The idea 
was that hip replacements, knee replacements, some cancer 
surgeries that are infrequently done may not be as well done in 
military hospitals as they would other places.
    I think I would like to give you all a chance to respond to 
that.
    General Ediger. Yes, Senator. Thank you.
    Naturally, there is increasing interest in the relevance of 
volume of a certain procedure, particularly a surgical 
procedure, done in volume at a hospital as it relates to the 
quality of outcome. We think that is a very important 
consideration.
    Recently, the Assistant Secretary of Defense for Health 
Affairs asked the Defense Health Board to actually study this 
issue specifically in regards to the Military Health System.
    I know that the Defense Health Board met just this week and 
they have embarked upon a very detailed study of the volume of 
surgical procedures as it relates to the readiness of our 
surgeons, but also as it relates to the quality of the outcome.
    This is something that has led us to increase our use of 
partnerships with trauma centers and critical care centers in 
order to give our surgeons and critical care specialists the 
opportunity, through affiliation agreements, to actually take 
trauma calls and do surgical procedures in partner institutions 
in order to increase their volume to maintain proficiency.
    We need to really work to maintain the proficiency of the 
entire surgical and critical care team; that includes nurses 
and technicians. And so now, we are expanding those 
partnerships in Air Force Medicine to involve the nurses and 
the technicians in those abilities to do that.
    We believe the question about volume and its relevance to 
the outcome and the reliability of the care we provide is very 
important. So we fully support and are participating in the 
Defense Health Board's study of that with recommendations due 
back to the Department later this year.
    Senator Shelby. Senator Murray.
    Senator Murray. Well, thank you very much to all of you for 
being here and for your comments.

                        ELECTRONIC HEALTH RECORD

    Ms. Cummings, I wanted to start with you because, as you 
know, my home State of Washington was chosen as one of the 
initial test sites for the deployment of the MHS Genesis, the 
new Electronic Health Record.
    As we know, the Department has invested over $4 billion 
into this system. So I was very concerned when I started 
hearing at home disturbing reports about the rollout plagued by 
technical problems.
    I was out there. I heard issues about inaccurate 
prescription submissions, misdirected patient referrals, long 
waits to resolve problems in the program that were identified 
by the clinicians. And some practitioners recorded that they 
could not even open the program in a timely manner.
    And worse, I have received reports that staff has received 
inadequate training on the system and fear they may have to 
take money out of their own operating budget to pay for that 
training.
    So, as you can imagine, this has had a significant morale 
impact on the practitioners in my State, not to mention serious 
concern about putting patients' lives at risk.
    In your testimony, you sounded pretty positive. User 
feedback was positive. There are change management 
opportunities with any large scale IT transformation.
    I just want to emphasize, this is not just a normal IT 
problem. Patients' lives and safety are really at stake here.
    So I wanted to ask you specifically what you are doing to 
address those issues.
    Ms. Cummings. Sure. Thank you for the opportunity to talk 
about that.
    We did get feedback across multiple parts of the MHS 
Genesis deployment. Some of the lessons learned, I specifically 
talked about around technology as well as training.
    So just last night, we did an implementation of a 
technology upgrade that significantly is bringing down the time 
to log on. We recognized that login time was a huge challenge, 
especially with doing documentation with the patient in the 
room. And so, that was one of the things that we partnered with 
the DoD CIO as well as the DHA CIO to make sure that we were 
bringing the technology together in a way that would help ease 
the adoption of MHS Genesis.
    Some of the other issues that you mentioned were what we 
have tackled in the optimization period from January to March. 
We sent several hundred specialists from the Leidos partner in 
Defense Health to actually sit with the users, and walk 
through, and determine what was the technology configuration 
versus what was a training issue. And so, we were able to work 
with the users to make some significant improvements there. 
There are still a couple of challenging areas.

                           TIMELINE OF FIXES

    Senator Murray. My understanding is there was a backlog of 
issues that need to be addressed. Do you have a timeline to get 
those done?
    Ms. Cummings. Sure. So we have currently, when we began the 
optimization period, we had about 7,000 trouble tickets. I 
think that is the backlog that you are referring to.
    Out of those 7,000 tickets, we have been able to, we are in 
the process of closing about 1,000 of them. The remainder are 
broken up into two halves. Half of them are functional 
decisions that need to be made. We have done some configuration 
of our management structure on the functional side to be able 
to make those decisions quicker.
    What we want to make sure we are doing is we are making 
enterprise decisions, and that represents about 2,500 of the 
tickets. Those are enterprise decisions.
    Senator Murray. Okay. Let us go back. There were 7,000 
tickets.
    Ms. Cummings. Seven thousand tickets.
    Senator Murray. You have addressed 1,000.
    Ms. Cummings. Correct.
    Senator Murray. You are talking about 2,500 right now. That 
leaves a lot out there.
    Ms. Cummings. So that leaves about 2,000 that remain that 
are currently in work by the Leidos partnership that we have 
approved to have changed, and we are in the process of making 
those changes.
    Depending on the level of complexity and how much needs to 
be done directly with the user, those changes will be made over 
the remainder of the year.
    Senator Murray. The remainder of this year, okay.
    Ms. Cummings. Right.
    Senator Murray. My understanding was that a lot of these 
were identified long before the deployment of that. They should 
have been addressed prior to people all of a sudden using them 
when peoples' lives are at stake.
    We are following this very closely. I just do not want 
everybody to think this is ``happy-rosy'' because there are a 
lot of issues that need to be addressed and we need to stay on 
top of this.

                       WASHINGTON VACCINE PROGRAM

    Let me ask you while you are here too. My home State of 
Washington implemented a State vaccine program that has been 
providing vaccines to children, including military dependents 
since 2010.
    The National Defense Authorization Act requires TRICARE to 
reimburse Washington and other States' vaccine programs just 
like other insurers do. But despite the law, despite the intent 
of Congress, and despite these programs routinely providing 
savings of up to 30 percent, TRICARE has not been a reasonable 
partner.
    It has taken years, multiple acts of Congress for my State 
to get any reimbursement at all. Washington State even had to 
put out a line of credit to keep this program solvent because 
of this obstruction.
    Now, TRICARE is refusing to reimburse more than $2 million 
that is owed to the State of Washington and is now daring to 
sue it.
    So this is really unacceptable for the Department to treat 
our States this way. I know your office does not have direct 
control over this, but as the Defense wide person who is 
sitting here today, I do want you to take this back to the 
Department, and I want to know when that payment for $2.2 
million will be paid to Washington State. If you could take 
that back----
    Ms. Cummings. I will.
    Senator Murray [continuing]. And get an answer to me, I 
would really appreciate it.

                          EMBED HEALTH PROGRAM

    Finally, I just want to go back to embed behavioral health. 
This is a critical issue. I worked really hard back in 2011 to 
pass legislation to create the embed program in the Guard and 
Reserves. We have seen real progress in fighting the stigma, 
and building credibility, and improving quality of care for our 
soldiers.
    We know that since the implementation of that, soldiers and 
family members now spend about 40 percent fewer days admitted 
to the hospital for inpatient care than they did 5 years ago.
    I think this is really the right way to go. We talked about 
it when you were in office. Admiral Faison, I think you 
mentioned it, that you are doing embeds as well.
    General, you mentioned that you have them assigned to every 
wing. Does that mean they are embedded with the soldiers?
    General Ediger. Yes, Senator. So the directors of the 
psychological health for the Guard and Reserve, Air Guard and 
Reserve wings are actually assigned at the wing level. 
Typically, a wing will have multiple squadrons. So they support 
all the squadrons in the wing.
    Senator Murray. Okay.
    And General, as we talked about this the other day, share 
with us the experience of some of the members you have that 
have seen this work.
    General West. Thank you, Senator.
    We are really pleased with the results that we have seen 
from this program. Embedded Behavioral Health, instead of 
having our soldiers go to the hospitals for care, several years 
ago, we decided to embed them with teams, some 12 member teams 
depending on the size of the unit, out in the unit areas.
    As of today, we have 61 of these teams embedded with our 
Brigade Combat Teams. They are operational units; 31 with BCT's 
and then another 156 battalion and brigade sized units other 
than Brigade Combat Teams.
    We have seen an increase in the usage of them; so back from 
2012, when the number of visits that we had was 900,000 visits 
to about 2.2 million visits. Not that there is more pathology, 
but people just feel more comfortable using them because they 
are in their area.
    We have also seen a decrease in the admission rates by 
about 41 percent. So 69,000 less admissions for acute 
behavioral health because we have been able to handle it at the 
local level and intervene earlier before it becomes an 
admitable condition.
    We have also seen that with our schools. I know it is not 
so much readiness for soldiers, but we have actually had some 
embeds in the schools that have a predominant number of 
military children. There has been a really positive response 
back to that as well.
    Senator Murray. I really hope that in the long run, this 
takes away some of the stigma. So as Senator Tester alluded to, 
when they are back in civilian life that that stigma will not 
be a barrier for them for seeking care as well. So I really 
hope we continue to do this in a lot of ways.
    Thank you.
    Senator Shelby. Senator Murkowski.
    Senator Murkowski. Thank you, Mr. Chairman.
    Thank you to each of you for your leadership. I appreciate 
all that you do as we are talking about mental health, and ways 
that we can be there for our men and women in uniform, and 
their families.
    I think we recognize that there are different ways that we 
can reach out and provide a level of services.
    I have been really pleased with the healing arts program 
that was begun a couple of years ago; this partnership between 
the NEA (National Endowment for the Arts), between DoD, the VA, 
our States' arts programs. We started out with 4 different 
sites. We are now up to 11, I understand.
    But not only has this proven to be a way for those who are 
dealing with PTSD and other forms of trauma through expression, 
perhaps not verbal, but to express in different ways. I think 
we are seeing some very positive results.
    The other thing that we are seeing is the support from the 
community in a way where they feel that they can help with 
those who have dealt with this level of trauma to bring the 
community into the healing process. My observation has been 
that this has been very good.
    So I bring that to the attention of the committee because I 
think it is an important part of how we deal with so many of 
the issues associated with mental and behavioral health.
    General West, I want to speak today about the concerns that 
we have with Bassett Army Community Hospital and whether they 
will be prepared to address the influx of airmen and military 
families that will be coming to Eielson in the 2020 timeframe 
with the bed down of the F-35. We are very excited about this.
    When the Air Force stands up a new mission, it creates a 
Site Activation Task Force to assess the readiness of the base 
to receive the new mission. My understanding is that last year, 
the Task Force scored healthcare as a red item. Now, I think 
that that may have been upgraded to yellow; I hope so.

        WILL HEALTHCARE AVAILABILITY IMPEDE THE ARRIVAL OF F-35

    But my question is whether Army Medicine is prepared to 
commit the necessary resources to ensure that the availability 
of healthcare does not impede the timely arrival of the F-35 
squadrons there at Eielson, and whether you see any gaps that 
we need to address as we prepare for that influx?
    General West. Yes, Senator. Thank you for the question.
    We are excited as well to support any expansions that our 
Nation needs. And so, for the medical care for those service 
members and their families is very important to us as well.
    And so, as part of that, and I know working with the Air 
Force, when we are given a demand signal of what is required, 
that energizes us and mobilizes us to ensure that we have the 
end strength to place in those areas. If we need to increase 
construction at the facility or any type of other things to 
accommodate additional end strength, we will definitely work on 
that.
    We have a team that actually looks at, based upon the 
patient mix, the patient population, what types of skill sets, 
what services need to be provided. So we do have a team that 
looks at that as a methodical way of increasing the capability 
based upon the requirements. That is how we place our providers 
and our capabilities at each one of our facilities.
    Some of the things that we were seeing, that may be an 
area, are the ENT physicians. And so, we are looking at what 
the local facilities can provide. If there is any lack of 
capability there, then those are things we might have a 
uniformed person establish there, since there is not an off-
post alternative.
    So our teams are looking for that, and we are committed to 
making sure we have those gaps identified, and then mitigation 
strategies to fill those gaps.
    Senator Murkowski. And I appreciate that. I also recognize 
that we can have real challenges when it comes to recruiting 
the healthcare professionals up into the region. On the 
civilian side, as you know, it is an issue.
    But again, I think we have some lead time here and if we 
have identified where those gaps are, we can be working to try 
to address it.
    I do not know, General Ediger, if you have anything further 
you would like to add to that?
    General Ediger. Yes, Senator.
    In regards to the mission change at Eielson, we are 
tracking the findings of the SATAF and we are working with the 
Air Force/A1 and the programmers. So we see the projected 
population growth in terms of military population. We are 
programming the resources into the Eielson Medical Group to be 
able to support the primary care requirements.
    We are going to flow bioenvironmental engineers into 
Eielson early. They are going to come in during this coming 
fiscal year so that they can put the occupational health 
programs in place that are associated with the F-35 mission.
    We are working with the Army. We work together. We have a 
good deal of joint staffing between Army and Air Force 
hospitals. Anything that we can do to assist the shortfall that 
they may be struggling with, we will look to see if we can 
contribute to the solution as well.
    Senator Murkowski. Appreciate that.
    I have two more questions here before my time is up. 
Senator Blunt raised the issue of how we ensure that we 
maintain sufficiency when we, perhaps, do not have the volume 
of surgical procedures.
    We, again, raised this issue in Alaska. The difficulty to 
keep or to find a specialist assigned to Alaska to maintain the 
currency. That the healthy soldier population in Fairbanks does 
not present any medical challenges, as the populations 
available to the Army doctors, in some of the larger cities 
across the country, face.
    There has been a proposal that would allow Army specialists 
to consult on Indian Health Service cases, which are a little 
more challenging than you might see at Bassett. The question 
then presents itself about reimbursement and it seems to kill 
off the idea.

                       PARTNERSHIP REIMBURSEMENT

    But given the discussion that you have had today with the 
focus on increased partnerships, affiliation agreements to help 
maintain sufficiency to really be supportive.
    Is this an idea that may now have some currency? Because if 
it is just an issue of reimbursement, we have worked, certainly 
with the VA and the IHS (Indian Health Service) to figure out 
how we can deal with reimbursement.
    Is this something that you think we can start exploring?
    General West. Yes, Senator.
    And I understand now that there are opportunities for the 
providers there to actually provide care to that population, 
again, on a reimbursable basis. But looking at any ways that we 
can increase the workload of our providers to increase their 
readiness, we would definitely want to explore.
    The one quick concern, I know that the Army had about the 
pilots that went on for a period of time without reimbursement 
would be difficult to sustain that, to sustain the personnel 
and the infrastructure.
    That would become an unfunded requirement, which would be 
potentially not reimbursed, which would put our funding of our 
other facilities, all the facilities, at-risk. We would have to 
find a way to cover that unfunded requirement.
    But as far as the concept of getting those opportunities to 
increase the readiness of our providers; absolutely.
    Senator Murkowski. Well, I think it is worthy of further 
exploration.

AMYOTROPHIC LATERAL SCLEROSIS RESEARCH--PEER REVIEWED MEDICAL RESEARCH 
                                PROGRAM

    Mr. Chairman, you have indicated your support for the Peer 
Reviewed Medical Research Program at every one of these 
hearings. I bring up the issue of ALS (Amyotrophic Lateral 
Sclerosis) and the recognition that ALS has been designated as 
a service-connected disease. Our military veterans are twice as 
likely to develop ALS as those who have not served in the 
military.
    I have been a firm advocate of making sure that we can 
continue this focus and certainly would encourage the support. 
I am not convinced that there is enough research that is being 
done right now through this program.
    If you disagree with me, I would like to know why you feel 
confident that we are making some headway, but would hope that 
we would continue to have the level of support focused on this 
very, very, very difficult disease.
    General West. Absolutely, Senator.
    And we really do appreciate the support for this. Our 
researchers at the Medical Research and Materiel Command have 
actually made headway, made some progress. The $69.4 million 
that has been provided since fiscal year 2007, has actually 
funded 62 projects for the country's leading researchers. So 
this is not just MRMC. This is on multiple fronts with the NIH 
(National Institutes of Health).
    We actually have four drug candidates which have progressed 
to industry-backed advanced drug development. So I believe that 
there is some good news and promising results coming out of 
this.
    Again, the relevance to the military, as you mentioned, 
ma'am, is that there is a 60 percent higher rate in those that 
have served. Our Gulf War period veterans have shown to be 
twice as likely to have ALS as not. We do not know the reasons 
why, but that is why, I think, this research is so important.
    So we do appreciate it, Senator, that you have been really 
advocating for that.
    Senator Murkowski. Thank you for your continued focus.
    And again, thank you all for your service.
    Thank you, Mr. Chairman.
    Senator Shelby. Senator Baldwin.
    Senator Baldwin. Thank you, Mr. Chairman.
    I want to thank our witnesses today for your service and 
for taking our questions.

          JASONS LAW/ADDITION RESEARCH/PRESCRIPTION PRACTICES

    In 2016, the Congress passed the Comprehensive Addiction 
and Recovery Act. In that measure, we included my bipartisan 
bill called the Jason Simcakoski Memorial Opioid Safety Act, 
now known as Jason's Law, to reform opioid prescribing 
practices at the VA and the Department of Defense.
    Included within that was enhancing the Pain Management 
Working Group of the two departments' Joint Health Executive 
Committee on which, I believe, the three Surgeons General 
before us today sit.
    Specifically, Jason's Law requires the Working Group to 
focus on opioid prescribing practices, pain management and 
provider training, complementary and integrative health, 
concurrent prescribing of opioids and drugs to treat mental 
health disorders, transitions between inpatient and outpatient 
settings from the Department of Defense to the VA, and the 
screening and treatment of patients with substance abuse 
disorders.
    Jason's Law also required the update, which is now 
complete, of the VA/Department of Defense Clinical Practice 
Guidelines for opioid therapy to include a greater emphasis on 
all of these issues.
    Can each Surgeon General please provide me with an update 
on the following, your perspective of the Pain Management 
Working Group's progress on these opioid-related issues and how 
your service is translating the Group's effort into improved 
care at the patient and provider level?
    Secondly, your service's implementation of the updated 
Clinical Practice Guideline, including the methods used to 
measure compliance by providers.
    May I start with you, General West?
    General West. Thank you so much for the question.
    I have to say that I am really excited about the pain 
management programs that we have within the Army to get after 
all of these things that you mentioned. The opioid use, the 
opioid prescribing amongst our providers has dramatically 
decreased, I think, since 2012 currently.
    The opioid use rate amongst our active duty has also 
decreased from a high of 2007, it is now about 0.15 percent 
versus the national average of 0.9 percent. So we have actually 
really decreased that a lot.
    We have these interdisciplinary pain management centers at 
most of our larger facilities and in some of our smaller 
clinics some aspects of it where we use a lot of alternative 
therapies other than opioid prescriptions or even medication.
    So we have chiropractors within our facilities that we have 
actually in some--it is not universal--acupuncture, yoga, 
mindfulness therapy, other alternative methods that actually 
have shown improvement.
    So we have a lot of our wounded warriors that were on a lot 
of prescription medications that we were able to decrease the 
numbers based upon other things, even like aqua therapy, equine 
therapy. So there is a whole range of therapies that we 
actually have incorporated into our facilities.
    And so, as far as prescribing management, that also has 
been something we have stressed to ensure that our providers 
use or look at other mechanisms of treating pain other than 
prescriptions.
    We have our Pharm.D.'s, our clinical pharmacists. We have 
hired more that are able to monitor the population and 
determine what prescribing practices are amongst populations 
and can intervene or make suggestions based upon that.
    We also have an ability to look at what our beneficiary 
populations are being prescribed. So we can look in databases 
to see if we have chronic users, and then put them in more of a 
clinical management or practice, case management process to see 
if we can wean them off of those medications.
    So there is a lot of work still to be done, but I think 
that we are getting after it because we realize the concern 
with it. And actually, my colleagues and I met with the Surgeon 
General of the U.S., Admiral Adams, to determine if there was 
something we could do collaboratively to get after this 
nationally.
    Thank you for the question.
    Senator Baldwin. Thank you.
    Admiral Faison. Ma'am, this is an important issue for the 
Navy as well. We are very tightly linked with our sister 
services to reduce opioid dependence and use amongst our armed 
forces.
    Our approach has been more to avoid putting these folks on 
these types of medications in the first place, and explore 
alternatives instead of treating dependence later on.
    And so, we have embraced the work of the Work Group. We 
have adopted all of our clinical practice guidelines that the 
Work Group has identified. We have put in place robust patient 
education for our providers that not only is initial education, 
but ongoing refresher training as well.
    At each of our medical centers, we have established a pain 
management consultant group to be able to be a resource for 
primary care and other providers in pain management decisions.
    We have invested heavily in alternative therapies. We have 
educated or trained almost 100 providers in acupuncture, as one 
example, in looking at alternative therapies for that.
    As a result of that and other efforts that we have done, we 
have seen a 38 percent reduction in active duty personnel on 
opioid therapy. Our rate of opioid use is very similar to the 
Army. It is one-tenth of what we see in the civilian sector; 
seven to ten times less.
    In addition, I just signed out an instruction that puts 
specific guidelines and restrictions on opioid prescribing and 
required follow up and assessments to be done for any patient 
that got over 90 days worth of opioid therapies.
    Then finally, our safety net; last year, I identified and 
appointed a two star medical Corps flag officer as the Chief 
Quality Officer for Navy Medicine.
    Then we have assigned senior O6-level physicians, 
experienced physicians, as Chief Medical Officers at every one 
of our facilities. Their job is to look at quality and safety, 
of which opioid utilization is one factor. So they review, on a 
monthly basis, medication profiles of the databases to identify 
high uses and get them into case management and alternative 
therapies.
    We have been blessed with some good work.
    Senator Baldwin. Great. General.
    General Ediger. Thank you, Senator.
    We also have adopted and trained to the clinical practice 
guidelines and we also have seen a reduction in opioid 
prescribing among Air Force providers.
    Senator, you highlighted the fact that part of the DoD 
strategy is the increasing use of integrative medicine. We have 
made integrative medicine a priority in Air Force medicine over 
the past 3 years.
    We have trained over 3,000 clinicians on integrative 
medicine techniques, and we have built integrative medicine 
into our family medicine residency at Nellis Air Force Base, 
and we actually have residents going there from other sites to 
make integrative medicine skills a standard part of the 
armamentarium of an Air Force primary care provider.
    In addition, on 1 August, we are going to cut the ribbon on 
our first specialized PTSD traumatic brain injury treatment 
center at Eglin Air Force Base in Florida to treat DoD missions 
along the Gulf Coast. It is built on the model of the spirit 
centers that the Army and Navy operate under the National 
Intrepid Center of Excellence.
    The one addition we have made to that capability is that we 
have put pain management in there as a featured service within 
that center. And so, we are building the staff with a highly 
experienced, integrative medicine capability. Then using 
telehealth to be able to connect to Air Force medical groups 
everywhere and be able to assist them with pain management 
techniques to reduce opioid use.
    Senator Baldwin. Thank you.
    Senator Shelby. Thank you, Senator Baldwin.
    That will conclude today's hearing. I want to thank our 
witnesses for your testimony.

                     ADDITIONAL COMMITTEE QUESTIONS

    Senators may submit additional written questions to the 
subcommittee, and we would request your response to them, if we 
get them to you, within 30 days.
    [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
            Questions Submitted by Senator Richard C. Shelby
            uniformed services university of health sciences
    Question. Please comment on the value of the Uniformed Services 
University of Health Sciences (USUHS) to the Department, particularly 
in recruiting and retaining medical professionals.
    Answer. The Uniformed Services University of Health Sciences 
(USUHS) continues to be a strategic asset for the Army Medical 
Department (AMEDD). Beyond recruiting and accessions, USUHS conducts 
unique, military-relevant training and improves retention of medical 
professionals. USUHS directly supports the Medical Corps (MC), Army 
Nurse Corps (AN), Medical Service Corps (MS) and Enlisted Corps (EC). 
USUHS provides military acculturation while training, allowing 
graduates to ``hit the ground running'' following completion of 
studies.
    USUHS physician graduates have historically become board-certified 
at a higher rate than graduates of civilian medical schools, directly 
contributing to quality of care and medical readiness. The two main 
sources of MC accession--the Health Professions Scholarship Program 
(HPSP) and USUHS--are both highly successful at meeting mission, but 
neither is sufficient to produce 100 percent of the AMEDD's needs. 
USUHS typically provides approximately 20 percent of the Army's needs. 
Because individuals with prior military service are more likely to 
apply to USUHS and because of the longer initial training obligation 
USUHS graduates undertake (7 years for USUHS vs 4 years for HPSP), a 
higher percentage of USUHS graduates stay in the Army until retirement. 
Thus, a significant number of senior officers in the Medical Corps are 
USUHS graduates.
    USUHS Graduate School of Nursing (GSN) students complete over 1800 
clinical hours, exceeding the clinical hour requirements for national 
board certification. The benefit of this experience is demonstrated in 
the 100 percent board certification pass rate of USUHS GSN graduates. 
Additionally, USUHS training experiences encompass operational 
readiness in changing environments, clinical decisionmaking in the 
Federal Health Care Delivery System, and consideration of global, 
environmental, cultural and political context. These attributes 
directly contribute to quality of care and medical readiness. Advanced 
Practice Registered Nurses (APRNs) for the AMEDD are commissioned 
through civilian and Federal programs. Both types of programs are 
highly successful at meeting mission, but neither is sufficient to 
produce 100 percent of the AMEDD's needs. When considering 
Perioperative Clinical Nurse Specialists, Family Nurse Practitioners, 
and Psychiatric/Behavioral Health Nurse Practitioners, USUHS is 
currently training 100 percent, 64 percent and 53 percent of these AN 
Officers, respectively. In upcoming academic years, USUHS is projected 
to train 82 percent of these populations.
    USUHS conducts distinctive training programs for MS Officers in the 
fields of Clinical Psychology, Nuclear Medical Science, Entomology, 
Environmental Science and Engineering, and Research Psychology. These 
programs provide critical education and professional development 
necessary to maintain ready medical clinicians and leaders in the 
Military Health System (MHS). The AMEDD utilizes the USUHS Tri-Service 
Clinical Psychology Program to recruit and train Army Clinical 
Psychologists, providing up to 15 percent of the annual accession 
mission. USUHS also supports retention by focusing research topics and 
clinical care modalities pertinent to current behavioral health issues. 
Nuclear Medical Science Officers have opportunities to work with a 
nuclear reactor and large amounts of radioactive materials; they also 
train on the medical effects of ionizing radiation and radiation 
casualty management. These programs and courses are extremely limited 
in the civilian sector; thereby increasing recruitment efforts. The 
Entomology Officers customize their Master in Public Health and PhD in 
Medical Zoology degree projects to address critical research and 
operational gaps. USUHS offers a Master of Science in Public Health and 
a PhD in Environmental Health Sciences that are accredited by the 
Accreditation Board of Engineering and Technology. These programs align 
with the core competencies of the Environmental Sciences and 
Engineering military career fields. The training provides a unique 
perspective to occupational and environmental health education that 
many civilian programs lack. The programs expose our officers to 
technical and professional situations that will mimic their career 
paths, thereby allowing them to analyze and overcome complex problems 
related to military service.
    The Uniformed Services University College of Allied Sciences (USU 
CAHS) has pilot programs for five Enlisted Military Occupational 
Specialties, including: Operating Room Specialist; Physical Therapy 
Specialist; Medical Laboratory Specialist; Preventive Medicine 
Specialist and Nuclear Medicine. Also, CAHS is working with the 68C 
Program and the Board of Nursing for the State of Texas to approve an 
ASHS degree in Practical Nursing. USU CAHS's degree producing programs 
serves as a platform for continuing civilian education, allowing 
students to earn a degree in the health sciences ranging from the 
Associate Degree level to the Post-Doctorate Degree level. The awarding 
of undergraduate credit hours serves as both a recruitment and 
retention tool for Army Medicine. USU CAHS places high priority on the 
unique training needs of military medical personnel in contingency, 
combat, tropical and deployment healthcare.
        musculoskeletal injuries and orthopedic health training
    Question. As you know our greatest military assets are our fighting 
forces. We send our soldiers into harm's way and then assume that they 
will receive medical care that is at parity with the civilian medical 
system. However, a recent U.S. News and World report analysis found 
worse outcomes in 10 common procedures in military surgeries as 
compared to the same surgery in a private clinical setting. The report 
suggests that since military doctors have fewer opportunities to refine 
complex surgical skills and that they are not at the same level as 
their private sector counterparts.
    To all of the Surgeons General, these concerns date back years. For 
the past 2 years, this committee has included report language 
encouraging DHA to ensure orthopedic health professionals in particular 
have adequate advanced surgical training after learning about the 
burden of musculoskeletal injuries in our fighting men and women. What 
are you doing to address this?
    Answer. The quality of surgical care in Army Military Treatment 
Facilities (MTFs) is comparable to, and in some cases better than that 
received from civilian hospitals; however, while we perform above the 
national benchmark average, we continually strive for improvements to 
ensure the best quality care for our patients. We have several 
initiatives aimed at providing our surgeons with regular advanced 
sustainment training.
    The quality of surgical care may vary from individual hospitals. 
The American College of Surgeons (ACS) National Surgical Quality 
Improvement Program (NSQIP) program is a nationally recognized, 
scientifically validated, objective avenue used by U.S. hospitals to 
measure the quality of surgical care. This program compares (among 
other measures) the morbidity index of all participating hospitals. 
Over 600 hospitals (12 percent) in the U.S. participate in this 
program; all 19 Army surgical facilities are voluntary participants. 
The latest NSQIP Semi-Annual report, indicates that Army facilities 
perform above the national benchmark average for all participating 
facilities. Additionally, the ACS awards a meritorious award to the top 
10 percent participating facilities. Eisenhower Army Medical Center 
(EAMC) received this award from 2015 through 2017 and Brooke Army 
Medical Center (BAMC) received the award last year.
    The need for competent and professional care for our wounded and 
injured soldiers is well recognized by the Army. We recently created 
the Army Medical Department (AMEDD) Military-Civilian Trauma Team 
Training Task Force, under the office of the Medical Command (MEDCOM) 
G3/5/7. Its aim is to expand on the current partnership we have with 
University of Miami Ryder Trauma Center to other trauma centers across 
the United States. The Army currently has two general surgeons and in 
2019 will have an orthopedic surgeon embedded at Ryder. These surgeons 
work alongside their civilian counterparts treating trauma patients and 
facilitate the training of Forward Surgical Teams that rotate though 
Ryder monthly for their two-week pre-deployment training. This year, 
the Army added Cooper University Hospital in Camden, New Jersey and 
Oregon Health & Science University Hospital in Portland, Oregon as 
training partners. Beginning in the summer of 2018, surgical teams--
surgeons, nurses and anesthesia personnel--will be embedded full-time 
in these facilities. The Task Force is currently seeking similar 
arrangements with other civilian facilities.
    Last year, the Army created Critical Clinical Training Task Lists 
for each of the Medical Corps Specialties. This list delineates 
required training, knowledge and experience that medical providers must 
possess. This task list includes a minimum case volume as well as a 
minimum level of trauma experience. In an effort to increase the 
preparedness of our orthopedic surgeons, the Medical Corps has funded 
an expansion of the Combat Extremity Surgeons Course to four courses 
per year at four locations across the United States--San Diego Naval 
Medical Center, Portsmouth Naval Medical Center, San Antonio Military 
Medical Center and William Beaumont Army Medical Center. These courses, 
hosted by the Army, train tri-service orthopedic, general and vascular 
surgeons as well as physician assistants in the care of extremity 
injuries in austere environments. Currently, every orthopedic surgeon 
attends this course before their first deployment and every 3 to 4 
years thereafter.
    With regard to advanced training in surgical skills utilized in 
garrison practice, such as spine surgery, total joint replacements and 
arthroscopic surgery, the Army offers individuals the opportunity to 
attend specialty society meetings and other training courses during the 
year. The Army remains committed to providing the absolute best and 
state-of-the art care to our trauma injured soldiers serving in harm's 
way. We recognize the value of having a trained and ready medical force 
to support the warfighter. Army Medicine has processes in place to 
continue to develop additional training opportunities and will continue 
to expand on these in the future.
      military-civilian partnerships in orthopedic health training
    Question. Lieutenant General West, a recent U.S. News and World 
Report analysis found in many instances our soldiers receive surgical 
care with outcomes that are worse than in the civilian population. 
Lieutenant General Ediger was quoted saying Air Force relies heavily on 
military-civilian partnerships to ensure that surgeons perform enough 
surgery to stay proficient. Could you please discuss Army's approach to 
mil-civ partnerships and whether you are taking advantage of the 
opportunities presented to you?
    Answer. The quality of surgical care in Army Military Treatment 
Facilities (MTFs) is comparable to, and in some cases better than that 
received from civilian hospitals; however, while we perform above the 
national benchmark average, we continually strive for improvements to 
ensure the best quality care for our patients. Army medicine has a 
number of agreements in place and is developing new training agreements 
with civilian agreements that address surgical skills sustainment and 
proficiency.
    The quality of surgical care may vary from individual hospitals. 
The American College of Surgeons (ACS) National Surgical Quality 
Improvement Program (NSQIP) program is a nationally recognized, 
scientifically validated, objective avenue used by U.S. hospitals to 
measure the quality of surgical care. This program compares (among 
other measures) the morbidity index of all participating hospitals. 
Over 600 hospitals (12 percent) in the U.S. participate in this 
program; all 19 Army surgical facilities are voluntary participants. 
The latest NSQIP Semi-Annual report, indicates that Army facilities 
perform above the national benchmark average for all participating 
facilities. Additionally, the ACS awards a meritorious award to the top 
10 percent participating facilities. Eisenhower Army Medical Center 
(EAMC) received this award from 2015 through 2017 and Brooke Army 
Medical Center (BAMC) received the award last year.
    Army Medicine's approach to military-civilian partnerships is well-
established and highly successful with a wide range of thriving 
exchanges, agreements and programs with hospitals, companies, 
educational institutions and professional bodies. Through several 
hundreds of partnerships codified in Memoranda of Agreement , Training 
Affiliation Agreements , Medical Training Agreements and External 
Resource Sharing Agreements (ERSA), we vigorously pursue cooperative 
and complementary services, robust training and enhanced proficiency, 
leveraging any opportunity with the public and private sectors.
    In your home State, for instance, Fox Army Health Center in 
Huntsville has a track record of medical training agreements with 
Auburn University and the University of Alabama among others, and 
Lyster Army Health Clinic at Fort Rucker has active agreements with 19 
distinct universities across several States. Some of our larger Medical 
Treatment Facilities such as those at Fort Bragg and Fort Sam Houston 
each have hundreds of such agreements. These partnerships bring 
together the brightest minds in medicine (in uniform and out), 
invigorating current care and adding potential recruiting benefit for 
the long-term enhancement of our Medical Corps.
    In keeping with the Service's overall approach, surgical care is a 
conspicuous component of military-civilian engagements alongside 
programs from social work to advanced prosthetic development. Army 
maintains arrangements ranging from surgical residency programs up to 
ERSA for military use of civilian facilities for surgery and even a 
trauma services cooperative agreement between Brooke Army Medical 
Center and Bexar County Hospital for shared trauma services 
responsibility in the Greater San Antonio region. Much like the Sister 
Service you cite, Army uses military-civilian partnerships to the great 
benefit of surgical proficiency and overall capability.
                  medical technology for brain injury
    Question. Lieutenant General West, are there any Food and Drug 
Administration (FDA)-cleared medical devices available today that could 
help the military objectively assess the full spectrum of brain injury 
in urgent settings which DoD has broadly fielded?
    Answer. There are no FDA-cleared devices available today that 
assess the full spectrum of traumatic brain injury (TBI), although 
there are FDA-cleared devices that assess subsets of the spectrum of 
TBI. Computerized tomography (CT) scan remains the hallmark assessment/
diagnostic device within military hospitals. However, there are two 
mobile point-of-need devices (Infrascanner 2000, and BrainScope One), 
and one emerging hospital-based capability (blood biomarkers), that are 
FDA-cleared to aid in the evaluation of patients being considered for 
CT after closed head injury; all three capabilities received funding 
from the Department of Defense (DoD) for research and development. 
BrainScope One has expanded utility beyond assessment of CT positive 
bleeds, due to the fact that it includes a series of tests appropriate 
to support multimodal evaluation of a concussion/mild TBI. Those tests 
include: the Military Acute Concussion Evaluation (MACE), vestibular 
oculomotor screening (VOMS), and reaction time/cognitive testing (a 
computerized test of cognition).
    Fielding: The BrainScope One and Infrascanner 2000 devices are not 
``broadly fielded'' at this time. However, since February 2018, the 
Army has purchased 132 BrainScope One devices, as well as the 
associated disposable headsets. Twelve of those devices are in 
Afghanistan with the 1st Security Forces Assistance Brigade (SFAB); the 
rest are at Medical Treatment Facilities and operational commands. In 
parallel to the initial ordering of BrainScope One and Infrascanner, 
noted above, the Army is conducting environmental testing.
    Question. A checklist called the Military Acute Concussion 
Evaluation (MACE) is used today for screening of warfighters for 
potential TBI by medics in urgent settings. Is this the only tool they 
have, and how effective is it for such an important and complex with 
long-term ramifications for our service members?
    Answer. The MACE remains the primary tool available to soldiers to 
assess mild TBI. However, it is currently undergoing significant 
updates for a September 2018 release that will incorporate the 
evolution of recent advances and be used in a complimentary ``low-
tech'' fashion to the new TBI assessment devices. The original MACE 
remains relevant because it includes a concussion recognition tool, 
inclusive of a history of the injury event; this information is key to 
standardized documentation of the injury in a soldier's record. The 
revised product, ``MACE2'', will add multimodal assessment capability 
for vestibular dysfunction, cognitive/fatigue, cervicogenic pain, 
oculomotor dysfunction and history of migraine/anxiety/behavioral 
health. These enhancements are driven by the anticipation that earlier 
identification of specific causes of symptoms will allow for a targeted 
and more effective treatment plan. Therefore, in addition to the MACE2 
update, the concussion management tools are under revision to achieve 
individualized clinical management/rehabilitation based on information 
gleaned from the enhancements of the MACE2. Simultaneous to MACE 
updates, the Army is investing in parallel capabilities (the new 
``high-tech'' devices: BrainScope One and Infrascanner) to supplement 
the MACE.
    Question. Are you seeing the adoption of advanced technology using 
artificial intelligence and signal processing as seen in our daily 
lives (e.g., Google, Waze, or Open Table) to help address the 
complexities of traumatic brain injury assessment?
    Answer. Yes, the military research & development and the clinical 
communities are using artificial intelligence, such as advances in 
signal processing, to address the complexities of TBI. Signal 
processing is the foundation of many devices and tests of cognition, 
balance and eye movements that address the complex and multi-
disciplinary assessment of traumatic brain injury. A few recent 
advances in signal processing that improve our ability to identify 
brain hemorrhage and injury include innovative use of near-infrared 
spectroscopy and novel computer algorithms incorporating clinical and 
electroencephalographic signals. These technological advances support 
and enhance the clinical evaluation of traumatic brain injury. In 
addition to DoD investments, the Army will continue to assesses the 
commercial market for emerging technologies that can benefit the 
Warfighter.
                                 ______
                                 
       Questions Submitted to Vice Admiral C. Forrest Faison, III
            Questions Submitted by Senator Richard C. Shelby
        musculoskeletal injuries and orthopedic health training
    Question. As you know our greatest military assets are our fighting 
forces. We send our soldiers into harm's way and then assume that they 
will receive medical care that is at parity with the civilian medical 
system. However, a recent U.S. News and World report analysis found 
worse outcomes in 10 common procedures in military surgeries as 
compared to the same surgery in a private clinical setting. The report 
suggests that since military doctors have fewer opportunities to refine 
complex surgical skills and that they are not at the same level as 
their private sector counterparts.
    To all of the Surgeons General, these concerns date back years. For 
the past 2 years, this committee has included report language 
encouraging DHA to ensure orthopedic health professionals in particular 
have adequate advanced surgical training after learning about the 
burden of musculoskeletal injuries in our fighting men and women. What 
are you doing to address this?
    Answer. We share the Chairman's concern about military treatment 
facilities (MTFs). We must ensure that our surgeons (and staff) are 
provided complex surgical cases that sustain their clinical competency 
to meet their readiness missions. In March 2018, the Acting Assistant 
Secretary of Defense requested that the President, Defense Health Board 
provide recommendation to the Department of Defense in order to improve 
policies for managing facility surgical capabilities and surgeon 
proficiency. Within Navy Medicine, we have recently identified an 
opportunity to expand capabilities within Navy Medicine as the Naval 
Medical Center Camp Lejeune is actively pursuing designation as a Level 
III trauma center. This effort will result in increased readiness and 
skills sustainment for all our providers--particularly our trauma 
teams--while providing a valuable trauma response for Marine Corps Base 
Camp Lejeune and the local community. In addition, we have implemented 
Knowledge Skills and Abilities (KSA)Readiness Currency Development 
focused on specialty community supported, data driven metrics and 
process that link MTF based clinical practice to deployed clinical 
experience. The KSA program provides an evidence-based methodology that 
is being applied to assure baseline currency and competency of the 
entire expeditionary and combat casualty care team. The KSA effort will 
inform sustainment of currency and competency through direct practice 
prioritization of high readiness value beneficiary care that may be 
augmented by partnerships with civilian health systems when applicable. 
This underpins an integrated strategy for assurance of combat casualty 
care team readiness by the Military Health System.
    Regarding orthopedic services, all Navy Orthopaedic surgeons 
complete initial surgical training provided via graduate medical 
education (GME) to include Accreditation Council for Graduate Medical 
Education (ACGME) accredited orthopedic surgery residency training for 
all surgeons, and additional ACGME accredited fellowship training is 
offered for the eight surgical subspecialties comprising the field of 
Orthopaedic surgery. Additional advanced surgical skills training is 
available to all Navy Orthopaedic surgeons via Continuing Medical 
Education (CME), funded by Navy medicine, for surgical skills courses 
sponsored by numerous Orthopaedic subspecialty societies, including the 
American Academy of Orthopaedic Surgeons (AAOS).
            uniformed services university of health sciences
    Question. Please comment on the value of the Uniformed Services 
University of Health Sciences (USUHS) to the Department, particularly 
in recruiting and retaining medical professionals.
    Answer. As a graduate of USUHS myself, I can personally attest to 
the outstanding medical and military education I received at the 
University. It has prepared me exceptionally well for a career in Navy 
Medicine. As Surgeon General, I can tell you that USUHS is a critical 
and reliable source of well-trained, prepared physician leaders on whom 
we absolutely depend to support the Fleet and the Marine Corps. As a 
top-tier medical school, admission to USUHS is highly competitive with 
more than 3,000 applicants competing for 171 positions. USUHS students' 
first-time pass rate on the United States Medical Licensing Examination 
(USMLE) exceeds the national average. In addition, USUHS graduates have 
a higher board certification rate than their national peers.
    Navy Medicine values graduates from USUHS as an important and 
reliable pipeline for generating physicians and leaders. These 
graduates comprise a segment of all military physicians who understand 
the dynamic military environment and the diverse settings in which they 
will be expected to lead people and practice medicine. Developing that 
combination of valuable qualities cannot be accomplished with the same 
consistency and efficiency in the civilian sector. Having a core group 
of physicians with that training background provides an element of 
stability to the Military Health System. Students who apply to USUHS 
are often more career orientated and commit to a longer obligation. 
USUHS graduates continue on active duty longer than any other accession 
source. Approximately 88 percent of USUHS graduates remain on active 
duty at the 12-year mark, and 48 percent of medical officers graduating 
from USUHS remain on active duty for at least 20 years. As a result of 
higher continuation rates, USUHS trained Navy physicians comprise a 
significant proportion of Navy Medicine leadership. USUHS, in 
conjunction with our other accession sources, is an important component 
of recruiting and retaining our outstanding Medical Corps officers.
                                 ______
                                 
        Questions Submitted to Lieutenant General Mark A. Ediger
            Questions Submitted by Senator Richard C. Shelby
        musculoskeletal injuries and orthopedic health training
    Question. As you know our greatest military assets are our fighting 
forces. We send our soldiers into harm's way and then assume that they 
will receive medical care that is at parity with the civilian medical 
system. However, a recent U.S. News and World report analysis found 
worse outcomes in 10 common procedures in military surgeries as 
compared to the same surgery in a private clinical setting. The report 
suggests that since military doctors have fewer opportunities to refine 
complex surgical skills and that they are not at the same level as 
their private sector counterparts.
    To all of the Surgeons General, these concerns date back years. For 
the past 2 years, this committee has included report language 
encouraging DHA to ensure orthopedic health professionals in particular 
have adequate advanced surgical training after learning about the 
burden of musculoskeletal injuries in our fighting men and women. What 
are you doing to address this?
    Answer. The Air Force relies on graduate medical education to 
provide advanced orthopeadic surgical training. All surgeons are 
required to graduate from an accredited residency program of 5 years 
duration. Furthermore, of the 76 active duty Air Force orthopedic 
surgeons, 41 percent of them have completed a fellowship in one of the 
various orthopedic sub-specialties to include sports, trauma, hand, 
spine, oncology, joint replacement, foot & ankle, and pediatrics. The 
fellowship trained surgeon trend has been increasing. Historically, 
approximately 2-4 surgeons per year were offered fellowship training, 
however, in each of the last 2 years the number of fellowship trained 
surgeons has increased to an average of 12 per year. This represents a 
trend toward having a much higher percentage of the orthopedic surgery 
force fellowship trained in the most advanced surgical techniques. 
These fellowships are accomplished in civilian institutions, many at 
some of the most prestigious hospitals in the country.
    In addition to residency and fellowship training, there are 
opportunities for surgeons to attend continuing medical educations 
programs both in and outside of the military. An example of this is the 
yearly Society of Military Orthopaedic Surgeons (SOMOS)--Arthroscopy 
Association of North America Arthroscopy (AANA) Course that is offered 
to military orthopedic surgeons. A new opportunity is the newly 
developed Orthopaedic Trauma Association (OTA)--SOMOS Military 
Traveling Fellowship which offers up to 4 weeks of a traveling 
fellowship to some of the best trauma centers in the country. Air Force 
orthopedic surgeons are not limited to these programs, but can apply 
for funding to travel to a variety of other courses, meetings, and 
conferences, most of which are held by premier orthopedic surgical 
societies and associations.
    With regards to the US News and Report article, it is true the 
surgical volumes at Air Force treatment facilities are significantly 
lower than their civilian counterparts. Unfortunately, it is difficult 
to ascertain whether this in fact translates into worse outcomes. 
Efforts are underway to better capture patient outcome measures as 
exemplified by MOTION (Military Orthopaedics Tracking Injuries and 
Outcomes Network). This new program is a DoD-wide data driven approach 
to musculoskeletal injury and treatment outcomes evaluation. It is 
intended to optimize medical readiness and increase both healthcare 
value and cost effectiveness.
    While Air Force orthopedic surgeons are appropriately trained and 
highly skilled, the Air Force would agree that increased case volumes 
would improve the proficiency of our surgeons.
            uniformed services university of health sciences
    Question. Please comment on the value of the Uniformed Services 
University of Health Sciences to the Department, particularly in 
recruiting and retaining medical professionals.
    Answer. The Air Force Medical Service (AFMS) values the diversity 
of medical officers who enter active duty through our two main 
physician accession sources: the Uniformed Services University (USU) 
and the Health Professions Scholarship Program (HPSP). Each year USU 
generates approximately 50 Air Force physicians while approximately 300 
Air Force physicians are generated via HPSP. The quality of both 
pipelines remains strong. The number of candidates for both remain 
robust, allowing us to meet our quotas for each. Likewise, each 
pipeline has strong GPAs & MCATs at entrance. We have no evidence that 
USU produces a stronger (or weaker) physician than their civilian 
school counterparts.
    There are some differences between the USU & HPSP pipelines. Since 
USU students are on Active Duty (with military pay and benefits and 
credit towards retirement at 20 years), some students (especially those 
with prior military service) are drawn to choosing USU. Other students 
are hesitant to accept USU's longer active duty service commitment 
(ADSC) of 7 years and prefer the HPSP scholarship commitment of 3-4 
years. Thus, the HPSP pathway attracts students who may otherwise be 
intimidated by the 7 year commitment, as well as those who do not have 
prior military exposure. Others may prefer to attend medical school in 
geographic areas other than the Washington DC metro area where USU is 
located.
    More analysis is needed to determine the return on investment (ROI) 
for USU degrees. Determining the ROI requires knowledge of the cost of 
a USU education (to include pay, travel to clinical rotations, 
``tuition'' costs, supplies, etc.) and the average years of clinical 
service post-training. The analysis must also eliminate selection 
biases. With approximately 40 percent of USU students having prior 
military service, longevity date (serving until a 20-year retirement) 
must be reanalyzed to focus on the number of years serving as a 
physician. We appreciate the ongoing work being accomplished by the 
Defense Health Reform group and the McKinsey group on this topic.
    While we value the military-unique curriculum provided at USU, we 
also value the diversity of thought that is provided by HPSP students 
being trained by a diverse set of high-quality schools. We appreciate 
USU's research and Centers of Excellence and we also value the 
partnerships the Air Force has formulated with our civilian 
counterparts and their commitment to serving our Nation's military 
through their research and expertise. While we appreciate USU's 
commitment to leadership training, we also value the civilian medical 
schools leadership focus as well (some of which offer dual-degree 
programs with MBAs).
    In summary, the combination of USU and our civilian training 
programs have served us well. As USU has not been able to quantify the 
cost of their medical school education, it is difficult to objectively 
analyze their return on investment. This will hopefully be better 
defined by the Defense Health Reform Group's current study.
                                 ______
                                 
               Question Submitted by Senator John Hoeven
          military clinicians and the veterans choice program
    Question. In your testimony, you mention that partnerships between 
the Air Force and Department of Veterans Affairs (VA) give our veterans 
greater access to care at Military Treatment Facilities (MTFs) while 
also sustaining the readiness of Air Force clinicians. You also share 
your concern that due to the implementation of the Veterans Choice 
Program, veteran referrals to Air Force hospitals have decreased by 15 
percent.
    As Congress works to implement the next phase of the Veterans 
Choice Program, how can we best leverage the experience and skillset of 
our Air Force and military clinicians while ensuring all of our 
veterans are able to receive high quality healthcare in a more timely 
manner and closer to home in their communities?
    Answer. Future VA Choice legislation must address the 
prioritization of Veteran care referrals via a mandated Right of First 
Refusal (ROFR) process. A legislatively mandated ROFR prioritization 
that refers Veteran care first within the VA, then with proximal DoD 
MTFs, and lastly with the civilian network through VA Choice would 
ensure both timely and quality care for our Veterans, as well as the 
right complexities and case mix military providers require.
    Through already established Resource Sharing Agreements, Veterans 
are currently able to access care at a reduced cost to the VA. The 
proposed ROFR process would help ensure both the VA and DoD utilize 
existing, paid for systems first. Many Air Force MTFs have seen a 
reduction in the use of these Resource Sharing Agreements since the 
implementation of the VA Choice Program. Data over the past 5 months 
shows approximately 20 percent, or 179,000, specialty care appointments 
across the Air Force Medical Service went unbooked. While not all 
unbooked appointments are due to VA choice, these appointments 
represent missed currency and readiness case opportunities for Air 
Force providers.
                                 ______
                                 
                Question Submitted to Ms. Stacy Cummings
            Question Submitted by Senator Richard C. Shelby
                            medical devices
    Question. The Defense Health Agency (DHA) runs a significant amount 
of IoT (Internet of things) technology--which includes many ip-enabled 
medical devices and building equipment, as well as traditional laptops, 
desktops and servers--on its hospital networks. These networks roll up 
to the DHA Medical Community of Interest (MEDCOI) network. Portions of 
DHA including Army MEDCOM and some Naval hospitals have begun to 
implement a cybersecurity framework called Comply to Connect* that 
combines existing and new capabilities to ensure that every device that 
connects to DHA's networks is secure and compliant with the 
Department's policies and remains so as long as it is connected. What 
approach is DHA taking to secure medical devices on its networks as 
part of the MEDCOI migration plan? What are the unique requirements 
medical devices have from a cybersecurity perspective? How does DHA 
track and account for IoT/networked medical devices? There have been 
several instances in the private sector where medical devices have been 
hacked and in some instances held for ransom. How is DHA addressing the 
challenge of IoT/medical device security in order to ensure that 
warfighter care is never interrupted or their health put at risk?
    Answer. The DHA Medical Community of Interest (Med-COI) network and 
associated Desktop to Datacenter (D2D) program is implementing the 
technical components required to allow modern Internet of Things (IoT) 
to work properly and securely. Med-COI plays a critical role in 
achieving centralized, standardized cybersecurity protections by 
providing a standard, comprehensive security architecture. Central to 
the approach is a standard ``isolation architecture'' of twelve well-
defined Virtual Local Area Networks (VLANS). Security is a combination 
of device hygiene (e.g.: how well the device's design satisfies 
cybersecurity requirements) and the network it is connected to. Our 
isolation architecture allows devices of various levels of cyber 
hygiene to operate with various levels of network ``trust''. The 
isolation architecture, combined with DoD Risk Management Framework 
(RMF) assessments of devices, and our D2D standard network monitoring 
toolset will provide real time visibility of the operational 
environment and continuous monitoring of the security of the Military 
Health System (MHS). Medical devices, much like ``facilities devices'' 
such as heating and air conditioning units, security systems (cameras), 
and printers have almost all become ``network aware'' or ``network 
enabled'' in the last 10 years. Unfortunately, cyber security was not a 
driving force in their development. Typically, these devices have 
operating systems and software that is vendor controlled, tightly 
integrated to the hardware, and unable to keep pace with the security 
patching required to stave off today's cyber threats. Our DHA isolation 
architecture, combined with DoD RMF assessments of devices, and our D2D 
standard network monitoring toolset will ensure MHS systems operate 
effectively and safely. In accordance with current policy, DHA tracks 
and accounts for IoT/networked medical devices using device inventories 
maintained by our Medical Logistics community and local asset 
inventories in combination with the results of required scans of our 
networks for both known and unknown (or rogue) devices. As discussed 
above, DHA will address the challenge of IoT/medical device security 
through implementation of Med-COI and our DHA isolation architecture 
combined with DoD RMF assessments of devices, and our D2D standard 
network monitoring toolset. Further, DHA will continue to work with 
Industry partners, as well as device manufacturers, to find effective 
solutions to any emerging threats related to IoT/medical device 
security to ensure we can secure these devices without compromising 
their effectiveness and utility in the patient care setting.

                          SUBCOMMITTEE RECESS

    Senator Shelby. The Defense subcommittee will reconvene on 
Wednesday, May 9 at 10:00 a.m., to receive testimony from the 
Secretary of Defense and the Chairman of the Joint Chiefs of 
Staff.
    Until then, we stand in recess. Thank you.
    [Whereupon, at 11:41 a.m., Thursday, April 26, the 
subcommittee was recessed, to reconvene at 10:00 a.m., 
Wednesday, May 9.]