[Senate Hearing 116-]
[From the U.S. Government Publishing Office]



 
       DEPARTMENT OF DEFENSE APPROPRIATIONS FOR FISCAL YEAR 2020

                              ----------                              


                        WEDNESDAY, APRIL 3, 2019

                                       U.S. Senate,
           Subcommittee of the Committee on Appropriations,
                                                    Washington, DC.
    The subcommittee met at 9:36 a.m. in room SD-192, Dirksen 
Senate Office Building, Hon. Richard Shelby (chairman) 
presiding.
    Present: Senators Shelby, Moran, Boozman, Durbin, and 
Tester.

                         DEPARTMENT OF DEFENSE

                         Defense Health Program

STATEMENT OF VICE ADMIRAL RAQUEL BONO, DIRECTOR OF THE 
            DEFENSE HEALTH AGENCY


             OPENING STATEMENT OF SENATOR RICHARD C. SHELBY


    Senator Shelby. Good morning. The subcommittee will come to 
order.
    Today we are pleased to welcome our distinguished panel to 
review the 2020 budget request for the Military Health System 
and the medical readiness of our servicemembers.
    Today the committee will hear from the following: Vice 
Admiral Raquel Bono, Director of the Defense Health Agency; 
Lieutenant General Nadja West, Surgeon General of the Army; 
Vice Admiral Forrest Faison, Surgeon General of the Navy; 
Lieutenant General Dorothy Hogg, Surgeon General of the Air 
Force; and Ms. Stacy Cummings, Program Executive Officer of the 
Defense Healthcare Management Systems.
    As this committee reviews the Department's fiscal year 2020 
request for funding, we acknowledge here that our Country 
expects our Military Health System to competently deliver 
medical care to our servicemembers while in theater and also 
provide health care to active-duty and retired U.S. military 
personnel and their families.
    More than 125,000 medical professionals are engaged in the 
work to ensure those that are in uniform are medically ready to 
deploy and provide healthcare to 9.6 million beneficiaries 
around the world. This is no small undertaking.
    At the same time, the committee here recently learned that 
the Department of Defense plans to reduce its uniformed 
military health personnel over the next few years. We expect to 
hear more about that today.


                        electronic health record


    In addition, the committee understands that the goal of the 
new electronic health record system is to provide a single, 
integrated electronic health record for servicemembers, 
veterans, and their families.
    The GENESIS system has been deployed for over a year now at 
four sites in the Pacific Northwest, and the Department is 
preparing to introduce the system to more sites this fall.
    We expect that you will keep this committee informed of the 
lessons learned and improvements to the technology and training 
that will be implemented in the next round to avoid some of the 
issues identified in the initial implementation.
    [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 
fiscal year 2020 budget request for the military health system and 
medical readiness of our servicemembers. Today the committee will hear 
from Vice Admiral Raquel Bono, Director of the Defense Health Agency; 
Lieutenant General Nadja West, Surgeon General of the Army; Vice 
Admiral Forrest Faison, Surgeon General of the Navy; Lieutenant General 
Dorothy Hogg, Surgeon General of the Air Force; and Ms. Stacy Cummings, 
Program Executive Officer of the Defense Healthcare Management Systems.
    As this Committee reviews the Department's fiscal year 2020 request 
for funding, we acknowledge that our country expects our Military 
Health System to competently deliver medical care to service members 
while in theater and also provide healthcare to active duty and retired 
U.S. military personnel and their families.
    More than 125,000 medical professionals are engaged in the work to 
ensure those in uniform are medically ready to deploy and provide 
healthcare to 9.6 million beneficiaries around the world. This is no 
small undertaking.
    At the same time, the Committee recently learned that the 
Department of Defense plans to reduce its uniformed military health 
personnel over the next few years. We expect to hear more about your 
analysis behind these cuts in your testimony today.
    In addition, the Committee understands that the goal of the new 
electronic health record system (MHS Genesis) is to provide a single, 
integrated electronic health record for service members, veterans, and 
their families.
    The Genesis system has been deployed for over a year now at four 
sites in the Pacific Northwest and the Department is preparing to 
introduce the system to more sites this fall.
    We expect that you will keep this committee informed of the lessons 
learned and improvements to the technology and training that will be 
implemented in this next round to avoid some of the issues identified 
in the initial implementation.
    Now I turn to the Vice Chairman, Senator Durbin, for his opening 
remarks. Thank you.

    Senator Shelby. Senator Durbin, I will turn to you now.

                 STATEMENT OF SENATOR RICHARD J. DURBIN

    Senator Durbin. Thanks, Mr. Chairman.
    Let me apologize. I thought it was a ten o'clock start, as 
usual.
    Senator Shelby. It is.
    Senator Durbin. But the Chairman understood we have a joint 
session with the NATO leaders, and so I apologize for coming in 
late.

                 DEFENSE HEALTH PROGRAM BUDGET INCREASE

    I am going to ask that my opening statement be placed in 
the record in its entirety and just say that we have made a 
pretty significant commitment from this subcommittee, a 46 
percent increase in this Defense Health Program over the last 5 
years.
    There have been critics who have said we should not have 
done that much or perhaps not at all, and we are counting on 
you to give us testimony that justifies our belief in what you 
are doing.
    I start with that premise, and I want to continue with this 
hearing to fortify it. So thank you for being here.
    Thanks, Mr. Chairman.
    [The statement follows:]
            Prepared Statement of Senator Richard J. Durbin
    Mr. Chairman, I am pleased to join you in welcoming today's 
witnesses, here to discuss the fiscal year 2020 Defense Health 
Program's budget request.
    Over the last few years, this Subcommittee has made significant 
investments in our military's readiness. But there is no readiness 
issue more important than continuing to ensure the physical and mental 
health of the force.
    Today, 71 percent of our Nation's young adults are not be eligible 
to enlist in the Armed Forces for reasons that include overall health 
and fitness.
    We need to improve that number. One way is through proper Federal 
investment in education and healthcare--which I'm sure the other 
Appropriations Subcommittees are working hard to do.
    In the meantime, this Subcommittee can do its part to ensure that 
the force we have is as healthy as possible. This means meeting the 
medical needs of service members and their families at home and abroad.
                            medical research
    While we often hear about challenges in the Military Health System, 
I believe we also need to celebrate its successes. Chief among these is 
the fact that our combat survival rate has never been higher.
    Breakthroughs in combat casualty care speak to the innovation are a 
large part of that success. We must build on that by tackling other 
challenges like infectious diseases, pain control, and prosthetic 
devices.
    In fact, work funded by Congressionally Directed Medical Research 
Program (CDMRP) managed grants led to development and application of at 
least 100 distinct medical devices, pharmaceuticals and clinical 
practice products that are now incorporated into standard clinical care 
in the DoD and civilian healthcare systems.
    Breakthroughs in these fields are improving the quality of life of 
our service members after the fight, and for the families of our 
troops. The spouses and children of our troops face their own 
healthcare issues, and taking care of them is every bit as important as 
taking care of our troops.
    With the support of as many of our Senate colleagues, we have 
increased research funding over 46 percent over the last 5 years--a 
trend that I continue to support.
                    tobacco, e-cigarettes and vaping
    Even though the defense budget is on the rise, we know there is a 
push to contain the rising costs of military healthcare. I know our 
panel will field questions on policy changes and bureaucratic 
reorganization, but let us also remember that overall individual health 
is a key component of the rising cost of healthcare, inside and outside 
the military.
    Further curbing the use of tobacco is a common-sense way to 
accomplish these goals.
    This includes the risks of new tobacco alternatives such as e-
Cigarettes and Vaporizers--we need to get ahead of understanding the 
health hazards that these products pose.
    I would like to hear from the Surgeons General about ongoing 
efforts to reduce tobacco use, and what you are doing to impede new 
tobacco alternatives before they become an enduring health threat to 
our servicemen and servicewoman.
                restructuring the military health system
    We are on the path to align the military treatment facilities under 
the Defense Health Agency.
    It makes sense that streamlining healthcare among the Army, Navy, 
and Air Force medical department can create efficiency and improve 
innovation--but we must do this smartly to ensure the individual 
services maintain their necessary level of operational readiness.
    I would like to hear from the Director of the Defense Health Agency 
and the Surgeons General about your perspectives on how this 
restructure is progressing, and what efforts are being made to ensure 
that our medical professionals continue to receive the training they 
need in order to deliver high-quality healthcare on the front lines as 
well as here at home.
                               conclusion
    Thank you for your service and for your work to better the lives of 
the personnel entrusted to your care. It is an essential part of 
maintaining a ready force.

    Senator Shelby. We will start with you, Admiral Bono.

             SUMMARY STATEMENT OF VICE ADMIRAL RAQUEL BONO

    Admiral Bono. Good morning. Chairman Shelby, Ranking Member 
Durbin, and members of the subcommittee, thank you for this 
opportunity to share the work of the Defense Health Agency in 
support of the combatant commands and the military departments.

                MILITARY TREATMENT FACILITY RE-ALIGNMENT

    I will briefly provide insight into the work of the DHA 
(Defense Health Agency) to execute our responsibilities under 
this proposed budget.
    Both Congress and the Secretary of Defense's guidance was 
clear: pursue efficiencies and create value for the Department 
by consolidating and standardizing military health care 
functions to support an integrated system of readiness and 
health. DHA is honored and privileged to facilitate that 
integration. We are a strategic enabler to the Department in 
supporting the readiness needs of our combatant commands and 
the military departments.
    Through our management of enterprise activities, the DHA is 
positioned to reduce unwarranted variation in costs in both 
clinical and administrative functions.
    On October 1st, 2019, all military treatment facilities in 
the eastern region of the United States will transition to the 
Defense Health Agency for administration and management, 
placing over 50 percent of the facilities, admissions, and 
enrollees under the Defense Health Agency.
    Support for medical logistics, health facilities, and 
acquisition will be fully managed for MTFs (Military Treatment 
Facilities) in the Military Health System by the DHA. We will 
also be preparing for the transition of the remaining 
facilities in the continental United States and Alaska on 
October 1st, 2020.

                      MILITARY MANPOWER REDUCTIONS

    With regards to the proposed military medical manpower 
reductions, the military departments and DHA are working 
closely together to ensure that access to care and availability 
of health services will be consistently maintained for all of 
our beneficiaries. As needed, alternative staffing models, 
contracts, military-civilian partnerships, and existing TRICARE 
networks will be utilized to best meet the needs of our 
patients.
    We will continue to meet all standards for timely access 
for beneficiaries, and while care delivery locations may 
change, our commitment to provide our patients with the high-
quality healthcare that they deserve will remain steadfast.
    I am particularly proud of how we have standardized our 
performance management systems providing all levels of the 
military with our performance measures in readiness, health, 
access, quality, safety, and cost.
    Our dashboards can be viewed at an enterprise level by 
service, by market, and by individual hospital or clinic. These 
dashboards help us assess performance and identify where we 
need to invest resources, training, and management in order to 
achieve further improvement.
    I look forward to working with you over the coming months, 
and I welcome any questions you may have about our plans, 
performance, and vision for the future.
    Thank you for inviting me to be here today.
    [The statement follows:]
             Prepared Statement of Vice Admiral Raquel Bono
    Chairman Shelby, Ranking Member Durbin and members of the 
Subcommittee, we are pleased to represent the Office of the Secretary 
of Defense and the Defense Health Agency (DHA) to present our medical 
program funding request for fiscal year 2020. We are honored to 
represent the dedicated military and civilian medical professionals in 
the Military Health System (MHS) providing direct support to our 
combatant commanders and delivering or arranging healthcare for our 9.6 
million beneficiaries.
    The Defense Health Program (DHP) request in the fiscal year 20 
President's Budget is fully aligned with our enduring commitments 
around the globe and with National Security and National Defense 
Strategies--along with the Department's 3 lines of effort: to increase 
the lethality of our fighting force; expand strategic partnerships; and 
bring business reforms to DoD.
    Consistent with the National Defense Authorization Acts (NDAA) for 
fiscal year 2017 and 2019, this budget reflects and supports a number 
of reforms to the Military Health System (MHS), including the multi-
year transition of the management of military medical treatment 
facilities to the DHA to better integrate our system of readiness and 
health.
    For fiscal year 2020, DoD is requesting approximately $33 billion 
for the DHP representing a 4 percent decrease from last year's enacted 
base budget. Almost $25 billion, or 77 percent, of our request directly 
supports patient care--delivered either in our military hospitals and 
clinics ($9.6 billion) or in the private sector ($15 billion).
    Over the last 8 years, the total Unified Medical Budget (UMB) has 
grown at a slower rate than overall medical inflation in the country. 
This successful management of cost growth can be attributed to a number 
of factors to include reforms to TRICARE reimbursement, the management 
of TRICARE contracts, healthcare delivery operations, pharmaceutical 
pricing, the migration to mandatory home delivery for many prescription 
drug refills, and the implementation of standardized business processes 
across the enterprise.
    Even with these successes, the Department remains vigilant about 
variation in year-to- year expenditures, and we are appreciative that 
Congress continues to grant the Department carryover authority each 
year. Carryover authority allows DoD to maintain better funding flows 
to minimize disruption of healthcare services to our beneficiaries. We 
are committed to making our healthcare cost projections even more 
transparent in the year of execution, providing regular updates to the 
committee, and providing full visibility to Congress on potential plans 
for reprogramming funds within the fiscal year should that possibility 
unfold. Furthermore, we will ensure that available funding is directed 
toward unfunded medical readiness and healthcare delivery requirements. 
Carryover authority is an invaluable tool that provides the Department 
with needed flexibility to manage issues that emerge during the year of 
budget execution. We request that it be continued in fiscal year 2020.
    There are several significant programmatic issues detailed in the 
proposed fiscal year 2020 budget that we wish to highlight today, 
following analyses and reforms, that Congress directed the Department 
to undertake. Taken together, these reforms represent the most 
significant change to the MHS in decades. They include: the realignment 
of our management structure for overseeing military medical treatment 
facilities (MTFs); the continued implementation and standardization of 
enterprise-wide activities in support of global medical support 
activities; and the restructuring of the Department's medical personnel 
end strength.
    The fiscal year 2017 National Defense Authorization Act (NDAA) 
enacted sweeping reforms to the organization and management of military 
medicine. The over-arching direction from Congress was to consolidate 
and standardize many military healthcare functions in a way that better 
integrates readiness and health delivery throughout the Department. 
Included among these reforms: the expanded authority and responsibility 
of the DHA to manage MTFs worldwide; the authority to convert military 
medical positions to civilian; and the authority to adjust medical end-
strengths and infrastructure in the MHS to maintain core competencies 
of healthcare providers.
    The DHA is a strategic enabler to the Department in supporting the 
readiness needs of our Combatant Commands and the Military Departments. 
By building a management structure with an enterprise focus, we are 
ensuring a medically ready force and ready medical force for any 
contingency for which our forces are called to serve.
    The DHA will enter fiscal year 2020 prepared to manage these 
expanded responsibilities for the delivery of care across the MHS. On 
October 1, 2019, our current plan is to have all MTFs in the eastern 
region of the United States transition to DHA administration and 
management--placing over 50 percent of facilities, admissions, and 
enrollees under the DHA. Enterprise activities for medical logistics, 
health facilities, and acquisition will be fully managed by the DHA. We 
will also be preparing for the transition of the remaining facilities 
in the continental United States and Alaska, targeting an effective 
date of October 1, 2020. The transition of overseas MTFs is planned for 
October 1, 2021.
    By consolidating management of MTFs under the DHA, the MHS is 
positioned to reduce unwarranted variation in both clinical and 
administrative functions. By standardizing approaches to quality 
management, the MHS seeks to improve health outcomes, reduce errors and 
allow service members and other patients to recover more quickly by 
reducing the incidence of hospital-based infections and other patient 
safety priorities. DHA's pharmacy operations established a standardized 
formulary, an enterprise-approach to managing the transition to 
mandatory refills of prescription drugs through its home delivery 
program, and movement to standardized pharmacy automation support in 
MTFs. Standardization in areas such as medical logistics and 
contracting help ensure the military medical work force functions with 
common equipment and supplies both in garrison and in the deployed 
environment.
    With the expansion of DHA responsibilities directed both by the 
Secretary and by Congress, the Department is also streamlining military 
medical headquarters and reducing personnel overhead across the 
Military Departments. A 10 percent (10 percent) reduction in 
headquarters medical personnel was applied across the Department in 
conjunction with the implementation of Section 702 of the NDAA for 
fiscal year 2017, which consolidated responsibilities for management of 
military hospitals and clinics under the DHA.
    The Department continues to manage other initiatives that reduce 
the growth in healthcare costs while ensuring our health benefit 
remains an exceptional tool for recruitment and retention of military 
personnel and their families. These DHA cost-saving initiatives 
strengthen the Department's financial posture without affecting access 
to care. We will continue to produce significant savings from the 
TRICARE contracts by restructuring terms and cost control initiatives 
for TRICARE contractors, and will continue to restructure contracts 
that incentivize greater risk-sharing. Payments to long-term care 
hospitals and inpatient rehabilitation facilities are being adjusted in 
a phased process to align with Medicare rates. We have increased IT 
savings through consolidation and rationalization of IT services and 
products. And, we have consolidated acquisition for education and 
training technologies and developed a DoD-wide common course catalog in 
our education and training programs.
    The modest increase in retiree copayments beginning in 2018 also 
continues to produce cost savings to the Department. The Department is 
not proposing any further changes to patient cost-sharing in fiscal 
year 2020.
    The Department's budget proposes to increase investments in medical 
programs and services that directly support our medical readiness 
obligations. Notable areas include: increases for Air Force patient 
movement equipment, combat casualty care training, medical material and 
increased support for operations in the European Command, Central 
Command, and Africa Command areas of operations; and expansion of 
physical therapists in Marine Center Medical homes.
    Another critical support component of our readiness mission is the 
fielding of a modernized Electronic Health Record (EHR)--MHS GENESIS. 
In August 2015, the Department awarded a multi-billion dollar contract 
for its new EHR system. In 2017, we began the initial deployment of MHS 
GENESIS in the Pacific Northwest. The purpose of the initial 
operational capability (IOC) deployment to four medical facilities in 
Washington State was to evaluate the system for full-scale deployment, 
identify additional change management issues, and resolve 
infrastructure and security concerns.
    We are encouraged with the initial success of this deployment. Ms. 
Cummings' testimony provides specific examples of how MHS GENESIS has 
improved patient care and patient safety--to include the reduction of 
thousands of duplicative lab tests, and improvements in medication 
reconciliation at the time of patient discharge. We are proceeding with 
full deployment of MHS GENESIS world-wide over the coming 5 years. 
Later in fiscal year 2019 we will begin deployment to additional sites 
in Northern California and Idaho. Together with the Department of 
Veterans Affairs' decision to deploy the same commercial product in 
their system.
    The DHA has also established an MHS Prescription Drug Monitoring 
Program (PDMP), similar to programs established by individual States 
and territories to help combat the national opioid crisis. Through this 
initiative, DHA will share prescription information with other State 
entities to ensure patients do not receive overlapping opioid 
prescriptions that can worsen an opioid use disorder or cause an 
overdose.
    We remain committed to sustaining the superb battlefield medical 
care we have provided to our Warfighters and the world-class treatment 
and rehabilitation for those who bear the wounds of past military 
conflicts. Our proposed fiscal year 2020 budget sustains the medical 
research and development portfolio, allowing us to continually improve 
our capability to reduce mortality from wounds, injuries, and illness 
sustained on the battlefield, and in the execution of our readiness 
responsibilities.
    Specific research programs support efforts in combat casualty care, 
traumatic brain injury, psychological health, extremity injuries, 
burns, vision, hearing and other medical challenges that are militarily 
relevant and support the warfighter. This budget proposes increased 
funding for battlefield injury research and establishes a permanent 
baseline for mission-essential research. Additionally, we have 
sustained funding for technology and advanced concept development. The 
successful investment of research dollars has also allowed us to move 
proven advances in areas such as clinical enterprise intelligence and 
the Defense Occupational and Environmental Health Readiness System into 
Operations and Maintenance funding lines, and out of medical research.
    The process established, through the Congressionally-Directed 
Medical Research Program (CDMRP), allows the Department to also ensure 
innovative, external research opportunities identified by Congress are 
well-managed. We intend to sustain our CDMRP management infrastructure 
into the future.
    As part of the reforms directed by the fiscal year 2017 and 2019 
NDAAs, the Department has undertaken several initiatives regarding our 
military medical personnel. First, the Military Departments, the Joint 
Staff, and organizations within the Office of the Secretary of Defense 
conducted the required assessment of the operational medical 
requirements needed to support the National Defense Strategy. As a 
result of this assessment, the Military Departments plan to reduce 
overall uniformed medical positions. This proposed restructuring will 
permit the Military Departments to repurpose active duty medical end 
strength for other operational/modernization efforts needed to support 
the National Defense Strategy.
    The Military Departments and DHA are working closely together on 
the process for implementing these reductions responsibly and 
carefully. We are now identifying the alternative models--civilian 
hires, contract staff, military-civilian partnerships, or use of 
existing TRICARE networks--that will best meet the needs of 
beneficiaries. We will continue to meet all standards for timely access 
for our beneficiaries, and while care delivery locations may change, 
our commitment to provide high quality healthcare will remain 
steadfast.
    As part of the MHS's effort to optimize our operations, we continue 
to standardize and strengthen our financial management tools. We are 
proud that the DHA was certified as audit compliant, as part of the 
broader Federal government and DoD goals to achieve full audit 
compliance. We are continuing our implementation of a common cost 
accounting methodology within the MHS that will improve accountability 
and transparency to the Department, the Services, Congress, and the 
public with improved insight into how resources are allocated in 
support of our mission. The DHA has adopted the Army's General Fund 
Enterprise Business System (GFEBS) as its cost accounting system, and 
the Uniformed Services University of Health Sciences has also migrated 
to this system. Navy Medicine is in the process of migrating from the 
Standard Accounting and Reporting System--Field Level in the coming 
years and we intend to begin transitioning the Air Force shortly after 
the Navy is complete.
    Similar to our cost accounting standardization, we are proud of our 
efforts to standardize and centralize our performance management 
systems. We have created standard MHS-wide performance dashboards that 
provide stakeholders--both medical and line leadership--at all levels 
of the military with visibility into how we are preforming on key 
metrics. These dashboards show longitudinal performance in measures of 
readiness, health, access, quality, safety and cost. For readiness, we 
monitor both the medical readiness of the force--particularly the 
number of individuals with deployment-limiting conditions, as well as 
the readiness of the medical forces. We are expanding our ability to 
assess the number of military providers who are meeting our established 
``Knowledge, Skills, and Abilities (KSAs)'' clinical competency and 
proficiency levels. We monitor critical indicators of quality and 
safety----that point us toward high reliability as a system of care. 
Access to primary care and specialty care are measured along with 
patient satisfaction to ensure we are meeting patient expectations. And 
``costs per member per month'' provide us with a metric used throughout 
the health industry to measure the efficiency with which we deliver 
needed medical services.
    Our dashboards can be viewed at an enterprise level, by Service, by 
market, and by individual hospital or clinic. We have adapted the 
dashboard to provide us with metrics on the 8 MTFs that now report 
directly to the DHA, and will continue to adapt this management system 
as the MTF transition progresses. Commanders can assess their 
performance against expected benchmarks, against peer institutions, 
and--where possible--against civilian sector performance as well. These 
dashboards help us to both assess how we are doing in these areas, and 
where we need to invest resources, training, or management attention in 
order to achieve further improvement.
    The fiscal year 2020 budget represents a balanced, comprehensive 
strategy that aligns with the Secretary's priorities and begins to 
fulfill our requirements associated with congressionally directed 
system reforms. We look forward to working with you over the coming 
months to further refine and articulate our objectives in a manner that 
improves value for everyone--our warfighters, our combatant commanders, 
our patients, our medical force, and the American taxpayer.
    Thank you for inviting us here today to speak with you about the 
essential integration between readiness and health, and about our plans 
to further improve our health system in support of the National Defense 
Strategy and for our beneficiary population.

    Senator Shelby. Lieutenant General West.
    I forgot to say, but I think it was implied, all of your 
written testimony will be made part of the record in its 
entirety.
    You may proceed.
STATEMENT OF LIEUTENANT GENERAL NADJA Y. WEST, SURGEON 
            GENERAL OF THE ARMY
    General West. Thank you.
    Good morning, Chairman Shelby, Vice Chairman Durbin, 
distinguished members of the subcommittee. It is my pleasure to 
address this committee a final time as the 44th Army Surgeon 
General and Commanding General of U.S. Army Medical Command. It 
has been my honor to serve with and lead our talented and 
dedicated soldiers, Army civilians, and all of our team members 
for more than 30 years.
    On behalf of my soldiers, their families, and Army 
civilians, I would like to sincerely thank you for your 
unwavering support.
    I would also like to thank my colleagues here, my sister 
services, my fellow Surgeons General here; Rocky, the Defense 
Health Agency. It has really been my honor to serve with you as 
part of the military health team.

                          ARMY MEDICAL MISSION

    Today I am proud to tell you with the utmost confidence 
that the Army's commitment to its medical mission and to our 
people remains steadfast. We are poised to delivery timely 
health services in the operational environment, comprehensive 
care at home station, and to remain on the cutting edge of 
medical research, development, and fielding, the components of 
a continuum of care that provides forces that are medically 
ready and enhances the readiness of our medical forces.
    America's Army stands ready today to deploy, fight, and win 
our Nation's wars, and as our Chief continually emphasizes, 
readiness is number one and there is no other number one.

                       ARMY MEDICAL DEPLOYABILITY

    A key component of the Joint Health Services Enterprise in 
a deployable Army, Army Medicine is ready to provide capability 
across unified land operations.
    We in Army Medicine, along with our colleagues, support 
combatant commanders across the globe in 10 named contingency 
operations, various exercises, and security cooperation 
activities.
    And we understand that Army readiness begins with a fit and 
healthy fighting force. Currently, medical issues account for 
about 3.7 percent of soldier non-deployability, which is a 
market improvement over the last 24 months. I am confident that 
we will continue to trend in the right direction as our Brigade 
Combat Teams have increased readiness over the last many 
months.
    The Army has made strides in improving mental resilience. 
Sixty-one embedded behavioral health teams support our 
operational units throughout the Army. In fiscal year 2019, we 
dedicated approximately $455 million to support behavioral 
health initiatives.

                         ARMY MEDICAL EVOLUTION

    Army's implementation of the Holistic Health and Fitness 
Program and our combat formations has increased readiness. The 
addition of physical therapists, strength trainers, and a 
dietitian to units is improving the Army's culture of fitness.
    Army Medicine is extremely proud also of our high-quality 
medical education and training. Annually, we train over 1,500 
physicians in our facilities. Our first-time medical board 
certification pass rate is approximately 92 percent, well 
exceeding the national average of 86 percent.
    The Army Medical Department Center and School in San 
Antonio, Texas, trains more than 31,000 U.S. students and 330 
international students annually in diverse programs to ensure 
that we have ready medical professionals to support whatever 
our Nation asks of us.
    Army Medicine has continually evolved to meet the global 
threats and to improve the battlefield survivability rates. Our 
researchers have focused on traumatic brain injury, behavioral 
health, combat casualty care, military operational medicine, 
military infectious diseases, radiation health effects, 
clinical and rehabilitative medicine, health services, global 
health engagements, medical training systems, and health 
informatics. It is a mouthful there.
    We have made great advances in such activities as 
peripheral nerve growth following amputation and a living anti-
infective human skin substitute, which is extremely important 
given the injuries that some of our servicemembers may be 
sustaining in the near-term environment if asked to serve in 
those areas.
    Most notably, in 2018, the Food and Drug Administration 
approved the first-ever blood test for traumatic brain injury. 
Continuous generous funding from Congress has made the steady 
advancement of military medicine possible.
    Finally, in keeping with congressional intent, Army 
Medicine supports and has committed resources towards reforming 
the Military Health System. We will divest responsibilities for 
the administration and management of all military treatment 
facilities to the DHA, as Admiral Bono just mentioned, in a 
phased approach which began 1 October of 2018 with the transfer 
of Womack Army Medical Center at Fort Bragg to the DHA, and we 
are committed to ensuring the transition is transparent to our 
soldiers, families, and retirees, and that we will contribute 
to the resources to ensure that that mission continues on as we 
look at our end-strength numbers.
    In closing, our Army and our Nation has relied on Army 
Medicine to conserve the fighting strengths since 1775. The 
lethality of our Army is derived from our soldiers who are 
strengthened by their families. That is why it is so important 
that we take care of them.
    We will continue to respond to our Nation's call with 
premier medical professionals high-quality care, and I 
appreciate the subcommittee's work and your continued support 
to our soldiers, Army Medicine, and to our Army. It has been my 
honor to serve with you.
    Again, thank you, and I really look forward to answering 
your questions.
    [The statement follows:]
         Prepared Statement of Lieutenant General Nadja Y. West
    Chairman Shelby, Ranking Member Durbin, distinguished members of 
the subcommittee, thank you for this opportunity to speak on behalf of 
United States Army Medical Department (AMEDD). It is my pleasure to 
come before this committee to address you as The 44th Army Surgeon 
General and Commanding General of U.S. Army Medical Command. I have 
been honored to serve with and lead our talented and dedicated Soldiers 
and Army Civilians for more than 30 years. They are our most valuable 
asset. It has also been my honor to work with the distinguished members 
of this committee and your staff. Your enduring support of Army 
Medicine has enabled the readiness of our Army and Soldiers to respond 
to the demands of the global security environment. On behalf of my 
Soldiers, their Families, and Army Civilians I would like to sincerely 
thank you for your steadfast support.
    I would also like to thank my colleagues serving on the panel 
today. Together with the Defense Health Agency and our sister services, 
the Army has provided medical support to globally dispersed forces 
while concurrently responding to natural disasters and other complex 
contingency operations. It has been an honor to serve with each of you 
and with the military medicine team.
    America's Army stands ready today to deploy, fight, and win our 
Nation's wars. As our Army Chief of Staff continually emphasizes, 
readiness is number one and there is no other number one. In order to 
sustain readiness, we must ensure our people are ready. We must provide 
Soldiers who are medically ready to deploy, and we must generate and 
maintain a rapidly responsive and broad spectrum of medical 
capabilities that include properly trained and equipped individuals and 
units. Army Medicine, as an integrated part of the Joint Health 
Services Enterprise (JHSE) and an essential part of a lethal and 
rapidly deployable Army, is ready for all operations. We support 
Combatant Commanders in 140 locations across five continents. As of 
February 2019, the Army has more than 180,000 Soldiers assigned or 
allocated to our Combatant Commanders in support of ten named 
contingency operations, various exercises, and theater security 
cooperation activities.
    We continue to focus efforts on the Army's priorities of readiness, 
modernization, and people, in concert with reform, to ensure that 
America's Army is always ready--today and into the future. This 
requires our Soldiers to be manned, trained, and equipped through 
timely, predictable, and sustained funding. At the same time, as part 
of the Joint Health Services Enterprise, Army Medicine continues to 
drive efforts to make significant improvements in healthcare as we 
implement the National Defense Authorization Acts (NDAA) for fiscal 
year 2017 and fiscal year 2019, which will influence how we sustain 
readiness. We are working closely with the Defense Health Agency (DHA) 
and the rest of the JHSE to implement these legislative changes, with 
thorough analysis, deliberate planning, and ongoing coordination. I 
want to thank this committee and Congress for its steadfast support, 
which has improved our Army's warfighting and lifesaving capability. 
Our enduring priorities, people and values, remind us that as we build 
the requisite readiness to succeed in combat we must take care of our 
Soldiers and their Families, and remain true to the principles of our 
Army values and warrior ethos.
Soldier Readiness
    Readiness begins with a fit and healthy fighting force and is the 
foundation of a strong national defense. With that foremost in our 
minds, the Army is improving personnel readiness and deployability by 
strengthening Soldiers, improving resilience, implementing the new Army 
Combat Fitness Test (ACFT), new deployability and fitness standards, 
and providing tools to fully inform command decisions.
    To further increase the quality of the Army force, the Secretary of 
the Army set a non-deployable goal in September 2018 of under 5 percent 
by the end of fiscal year 2019. The Army has reduced the number of non-
deployable Soldiers making thousands of additional Soldiers ready to 
deploy in support of contingency operations around the world. Medical 
issues account for 3.7 percent of Soldier non-deployability with 
temporary profiles over 30 days (1.5 percent), pregnancies (0.6 
percent) permanent profiles facing medical board processing (1.0 
percent), and other permanent profiles (0.6 percent). Army Medicine has 
begun a full revision of the standards of medical fitness and medical 
readiness regulations and guidance to inform future policy direction. 
Beyond reducing the number of non-deployable personnel, the published 
policies are establishing a culture of readiness. While the Army 
continues to monitor the impact of recent policy revisions and 
established initiatives, we are confident we are trending in the right 
direction, as evidenced by the increased readiness in our Brigade 
Combat Teams.
    Medical readiness is a shared Soldier and command team 
responsibility. Army Medicine plays a decisive role; however, in 
monitoring, assessing, and identifying key health-related indicators 
and outcomes; enabling command teams to understand the health of their 
formations; and providing recommendations to mitigate risks. While 
policy revisions have aided in increasing deployability and lethality, 
Army Medicine's support of additional Army initiatives continues to 
provide positive results. The establishment of the Commander's Portal 
for Medical Protection System integrated crucial medical readiness 
information into one easy-to-use application, giving Commanders (or a 
designee) the ability to review Soldiers' deployability status quickly. 
In short, the Commander's Portal significantly increased visibility of 
factors influencing Soldier medical readiness.
    Army readiness is strengthened across the force through the Warrior 
Care and Transition Program (WCTP). Army Warrior Care and Transition 
embodies the Army's enduring commitment to care for our wounded, ill 
and injured. Warrior Transition Units (WTU) provide an environment in 
which our Soldiers recover from wounds, injuries and illnesses, with 
the confidence that they, their families and caregivers will receive 
support. The program greatly benefits Army readiness through its high 
success rate in returning Soldiers to the force. Since the inception of 
the WCTP, over 82,000 Soldiers have entered the program with 42 percent 
returning to the force. As a result, nearly 33,000 Soldiers were able 
to return to their units, including senior noncommissioned officers 
(NCOs) and officers whose experience and knowledge would have taken 
years to replace. This is roughly equivalent to six Brigade Combat 
Teams. Our WTUs have assisted in increasing readiness and provided 
retention cost savings for the Army. The Army will continue to maintain 
a level of scalability and flexibility within the WCTP to meet the 
future needs for our Soldiers.
Behavioral Health (BH)
    Mental resilience is essential to Soldier health and readiness. 
Suicide continues to be an issue for our Nation and Army. We will 
continue to use all available assets to address the problem. The Army 
anticipates continued growth in the demand for BH care, even as 
overseas contingency operations decrease, due to the cumulative strain 
of over 17 years of sustained combat operations on Soldiers and 
Families, the unique stressors of military service, and the Army's 
continued emphasis on seeking help.
    An October 2017 Harvard Business Review article highlighted the 
best practices captured in the transformation of the BH System of Care. 
As of November 2018, sixty- one Embedded Behavioral Health (EBH) Teams 
support all operational units, including thirty-one Brigade Combat 
Teams (BCT) and an additional 156 battalion and brigade- sized units. 
Today, embedded behavioral health consists of 691 Medical Command 
(MEDCOM) dedicated staff members including Active Duty, Civilian, and 
contract providers--psychiatrists, psychiatric nurse practitioners, 
licensed clinical social workers, clinical psychologists, and other 
fields.
    The Army is continuing to work to decrease the stigma associated 
with seeking behavioral healthcare. The Behavioral Health System of 
Care (BHSOC) supports readiness by promoting health, identifying 
behavioral health issues early in the course of the illness, and 
delivering evidence-based treatment. Massachusetts Institute of 
Technology, Yale School of Management, RAND reports, and ongoing Army 
Public Health Center evaluations have validated the Army's approach.
    Soldiers have shown a willingness to use behavioral healthcare. 
Encounters (or visits) have increased from 900,000 in fiscal year 2007 
at the height of combat operations in Iraq and Afghanistan to over 2.25 
million in fiscal year 2017. To improve access and reduce stigma, many 
of our programs are available to Soldiers and Families in their 
communities and workplace. There are eleven at the Training and 
Doctrine Command (TRADOC) Centers of Excellence and fourteen 
installations with Brigade Combat Teams (BCTs) which host embedded BH 
specialists, to include twenty in Alaska, fifty-three in Europe, 119 at 
Fort Bragg, and 106 at Fort Hood to list a few. We have also embedded 
our Behavioral Health Specialists within operational Brigades and 
Special Forces Groups.
    In fiscal year 2019, the Army resourced approximately $455 million 
to support BH and sustain implementation of behavioral healthcare 
initiatives. These funds specifically support the eleven recognized 
enterprise Behavioral Health Service Line clinical programs under each 
Medical Treatment Facility's standardized Department of Behavioral 
Health. The Army estimates a requirement of approximately $462 million 
to support the same level of effort in fiscal year 2020.
    What is the effect of our BH programs? Accessible and effective 
behavioral healthcare has led to 65,975 fewer inpatient bed days for 
all types of behavioral health and Substance Use Disorder (SUD) 
conditions in 2017, a 41 percent decrease from 2012.
    The Army continues to lead the expansion of substance treatment 
that allows Soldiers meeting prescribed criteria to receive treatment 
and aftercare voluntarily for alcohol-related SUDs. Additionally, 
Soldiers can proactively re-enter Substance Use Disorder Clinical Care 
(SUDCC) without mandatory enrollment in a treatment program. This 
voluntary care process often fosters early intervention prior to an 
alcohol-related incident. Of note, 10,779 (62 percent) active duty 
Soldiers self-referred for voluntary care vs. mandatory enrollment in 
formal SUD treatment in fiscal year 2017. This significant increase of 
22 percent from the previous year indicates the recognized benefit of 
early intervention through voluntary care in support of individual 
readiness.
Soldier Performance
    A fit Soldier is a lethal Soldier. To further increase 
deployability, the Army established the Holistic Health and Fitness 
Program (H2F), which is a paradigm shift to a proactive injury 
prevention strategy. This program represents a comprehensive, 
integrated, and immersive health and fitness system of governance, 
personnel, equipment, facilities, and leader education that maximizes 
readiness and deployability through the reduction of injuries, 
attrition, and associated costs. The program fosters resilient Soldiers 
who are better prepared to conduct their wartime mission.
    Similar to professional athletes, Soldiers must train both mind and 
body for optimal performance. Since 2017, 71 percent of all Soldier 
injuries were cumulative micro- traumatic musculoskeletal (MSK) 
``overuse'' injuries. The addition of physical and occupational 
therapists, strength and conditioning trainers, and dietitians to our 
units will improve our fitness culture and increase physical toughness 
across the Army, which will render a more lethal, ready, and deployable 
force.
    I applaud the Army's implementation of H2F in our combat 
formations. Army Medicine will continue to collaborate with TRADOC and 
Forces Command (FORSCOM) in support of the Army's H2F Program. The 
Surgeon General's Physical Performance Service Line (PPSL), a team of 
experts who focus on the leading cause of Soldiers seeking medical 
care--traumatic and overuse MSK injuries, studies soldier performance. 
Roughly 30 percent of all medical evacuations from Iraq or Afghanistan 
were for non-battle MSK conditions and injuries; most Soldiers did not 
return to theater. Early intervention of an acute injury prevents 
development of a chronic condition or disability. The work of our 
Physical Performance experts allows Army clinicians to address 
individual patient risk factors contributing to musculoskeletal 
injuries.
The Ready and Responsive Medical Force
    The requirements established by the Army and the Joint Force set 
the bar for our ready and responsive medical force. The Army must 
maintain a rapidly responsive and broad spectrum of medical 
capabilities that can conduct rapid deployment in support of Combatant 
Commanders' requirements. This drives how Army Medicine recruits, 
trains, and operates from expeditionary and pre-hospital emergency 
medicine to primary and tertiary care. Our medical capabilities must be 
prepared to support the full range of military operations with mission 
ready personnel able to rapidly transition from garrison to delivering 
the appropriate health service support in an area of operation. We 
maintain our skilled medical force through daily Medical Treatment 
Facility (MTF) operations, medical training, and education programs. To 
make medical providers more readily available for training and 
contingency operations and to increase unit readiness, the Army has 
assigned healthcare providers to their operational unit with duty at 
the MTFs to maintain essential clinical competency. The assignment of 
deployable medical personnel to line units supports the operational 
commander's ability to evaluate and track the readiness of medical 
forces and establishes clear mission command of Army personnel working 
in MTFs.
    To enable commanders' ability to better track the training and 
readiness of the medical provider force, the Army adopted Individual 
Critical Task Lists (ICTLs) in 2018. These are a combination of Army 
specific and joint development of knowledge, skills and attributes (or 
JKSA) task standards. Army Medicine developed ICTLs for ninety- eight 
AMEDD Officer Areas of Concentration and twenty-four enlisted military 
occupational specialties. All Army MTFs will use them to define 
readiness requirements at each facility and to evaluate the gaps in 
providing that readiness to the Army and DHA. Further, all Army medical 
personnel assigned or attached to a DHA facility will be required to 
use ICTLs as the Army's requirement for assessing readiness.
    I am extremely proud of the world-class medical education and 
training we provide. Today, 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 the DoD. 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 bring experience and innovation to our 
Nation.
    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 and aligned under TRADOC. The Army trains 
more than 31,000 U.S. students and 330 International students annually. 
This includes enlisted Soldiers, officers, warrant officers, and Army 
Civilians in diverse graduate, leadership, and technical programs. The 
AMEDDC&S has thirteen Master's Degree Programs and Doctoral Programs, 
which provide an advanced education in areas such as Public Health, 
Health Administration, Social Work, Nursing, and other critical health 
related fields. U.S. News and World Report ranked four of these 
programs in the top ten nationally: the U.S. Army Graduate Program in 
Anesthesia Nursing, the Army-Baylor University Doctor of Physical 
Therapy, the Army-Baylor University Master of Health Administration, 
and the Master of Physician Assistant Studies Program.
    In 2018, Army Medicine created the AMEDD Medical Skills Sustainment 
Program. This gave Army trauma team members and enlisted healthcare 
providers the opportunity to serve and train for 2-3 years in 
prestigious civilian level-one trauma centers such as Cooper University 
Health Care in Camden, New Jersey; Oregon Health and Science University 
in Portland, Oregon; and other programs in Cincinnati, Ohio, and 
Hackensack, New Jersey. Finally, we will also rotate Army medics in 
select civilian hospitals over two- week rotations for ``hands-on'' 
immersive training.
Enabling a Ready Force Today and Tomorrow: Research and Modernization
    Army Medicine continually evolves in the face of global threats and 
challenges to improve the battlefield survivability rate, Soldier 
adaptability to the most austere and extreme environments, and overall 
health of the force. Army Medicine researchers at the Army Futures 
Command (AFC) employ the best crosscutting and cross-functional efforts 
to modernize medical procedures and equipment in accordance with the 
needs of our beneficiaries and Congressional priorities.
    The Army's Medical Research and Materiel Command (MRMC), is 
advancing the state of medical science to discover and explore 
innovative approaches to protect, support, and advance the health and 
welfare of Service members, Families, and communities. MRMC's research, 
development and acquisition elements, currently a vital part of the 
Army Futures Command, will become the Medical Research and Development 
Command (MRDC) this year. They will accelerate the transition of 
innovative medical technologies into deployable products and translates 
advances in knowledge into new standards of care for preventing injury 
and disease, treating casualties, overcoming infectious diseases, 
minimizing adverse radiation health effects, promoting rehabilitation, 
and developing medical training systems.
    The Defense Health Program (DHP) core research programs have 
focused on traumatic brain injury (TBI), behavioral health (including 
posttraumatic stress disorder (PTSD)), combat casualty care, military 
operational medicine, military infectious diseases, radiation health 
effects, clinical and rehabilitative medicine, health services, global 
health engagement, medical training systems, and health informatics. 
Research planning and research reviews are conducted jointly with the 
other Services, Department of Veterans Affairs (VA), and the National 
Institutes of Health (NIH).
    Researchers have made great advances, which will improve the 
lethality of the Army. Most notable in 2018, the Food and Drug 
Administration (FDA) approved the first ever blood test for TBI, and, 
after 15 years of research, Dsuvia (sufentanil), a tablet for severe 
pain/battlefield pain management. The FDA also approved a variance for 
DoD blood banks to extend the shelf life of platelets from 14 days to 
21 days and authorized access to civilian blood banks to supply the DoD 
with cold stored platelets in the event of a major conflict. 
Researchers have also advanced regenerative medicine for revolutionary 
changes such as peripheral nerve growth following traumatic amputation; 
a living, anti-infective human skin substitute; and generation of 
functional skin by either spraying the patient's harvested skin cells 
on a burn wound to enhance healing or by applying skin substitutes 
grown in tissue culture in place of a skin graft.
    Congressional funding has enabled MRMC to make advancements in the 
areas of combat casualty care, clinical rehabilitative medicine, 
medical training, health information, infectious disease prevention, 
and operational medicine. No nation on earth can approach the reach and 
scale of our medical support to deployed forces.
People
    The strength of our Army is our people. 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 adaptable, skilled medical professionals is 
critical to the ability of Army Medicine to conduct its mission across 
multiple domains. Talent management is vital to enhancing readiness by 
aligning the unique knowledge, skills, and attributes of our people to 
the needs of our Army in supporting the JHSE and any operational 
requirements.
    We must develop and equip our Soldiers and Army Civilians with 
tools that enable effective, agile and adaptive leaders. We must also 
develop our education and training 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 who 
understand how to plan, coordinate, and build synergy in medical 
capabilities provided by 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 
who are capable of employing the medical force. To this end, we are 
committed to ensuring all Soldiers and Army Civilians have full career 
opportunities to reach their highest potential and realize their vast 
talent.
Military Healthy System (MHS) Reform
    In keeping with Congressional intent, the goal of Military Health 
System (MHS) reform is an integrated, efficient, and effective system 
of readiness and health that best supports the lethality of the force. 
Transition of Army MTFs to DHA is an iterative process. Army Medicine 
will divest responsibilities for the administration and management of 
all MTFs to the DHA in a phased approach, which began 1 October 2018 
with the transfer of Womack Army Medical Center, at Fort Bragg, North 
Carolina, to DHA. The MHS transition plan calls for the transfer of 
MTFs in the eastern United States in 2019; MTFs in the western United 
States will be transferred in 2020; and overseas MTFs by the end of 
2021.
    We are supporting and have committed resources to 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.
    To support the Army's objectives to increase lethality and combat 
power, Army Medicine identified military medical and dental positions 
that do not pose high risk to mission for conversion to civilian 
positions. These carefully considered conversions will enable the Army 
to repurpose the converted billets across the operational force to 
increase lethality and strength of operational units and will lead to 
enhancing medical skills for the remaining military medical billets by 
concentrating patient treatment performed at installation hospitals and 
clinics among fewer military providers. Our intent is to make the 
transfer of Army MTFs to the DHA transparent to our Service Members, 
Families, and retirees, who will all continue to receive high-quality 
medical care throughout the enterprise.
Conclusion
    The Strength of our Army is our Soldiers and 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. I would like to 
offer my praise and admiration to our Soldiers doing the Nation's work 
and everyone, military and civilian, who support them. No other 
Military Health System in the world can compare. We can transport an 
entire hospital around the world at a moment's notice and establish it 
where needed. Congressional support has always provided Army Medicine 
with the resources necessary to support our Army.
    Our Army has relied on Army Medicine since 1775 to serve our 
fighting forces. We will continue to respond to the call with high 
quality care. This is our solemn obligation to our Nation--our 
readiness to support our Nation's Army will always be assured. I 
appreciate the subcommittee's work and your continued support to our 
Soldiers, Army Medicine, and our Army. It has been my honor to serve 
with you.

    Senator Shelby. Admiral.
STATEMENT OF VICE ADMIRAL FORREST C. FAISON, III, 
            SURGEON GENERAL OF THE NAVY
    Admiral Faison. Chairman Shelby, Vice Chairman Durbin, 
distinguished members of the subcommittee, it is my honor to be 
with you here today.

                          NAVY MEDICAL MISSION

    My message this morning is straightforward. The operational 
tempo and global commitments of America's Navy and Marine Corps 
remains high. Sailors and Marines are deployed and operating 
forward around the world today. The Navy Medicine team is with 
them, working tirelessly to protect their health and readiness. 
On behalf of these dedicated men and women, thank you for your 
continued confidence and support.
    My written statement today provides you more details, but I 
want to highlight three key areas: readiness, transformation, 
and our people.
    We have no greater responsibility than providing medical 
forces that are ready, prepared, and present to save lives of 
those who volunteer to save our Nation, those servicemembers of 
our armed forces. Every sailor, every marine, and their 
families are depending on us to do all in our power to provide 
them the best care our Nation can offer and one day return them 
home safely.
    To honor this trust, we are continuing to develop new and 
improved capabilities to support the full range of operations 
today. These efforts are critical since we know that 
disaggregated operations pose unique challenges for timely 
access to lifesaving resuscitative surgery and care in the 
future.
    Integral to advancing our expeditionary combat casualty 
care capabilities is ensuring that our medical personnel 
sustain their clinical readiness skills. We are making solid 
progress in implementing our Navy Medicine trauma strategy.
    In July of 2018, our Naval Medical Center Camp Lejeune 
earned American College of Surgeons accreditation as a Level 
III trauma center, where the staff is now gaining valuable 
trauma experience while providing a valuable service to the 
community.

                  NAVY MEDICAL TRAINING COLLABORATION

    We expanded our Hospital Corpsman Trauma Training programs 
through partnerships with Stroger Trauma Hospital in Chicago as 
well as the University of Florida Medical Center in 
Jacksonville and anticipate adding other sites this year.
    We continue to embed our providers at L.A. County to get 
important trauma training experience in preparation for the 
future. The bottom line, these efforts are preparing us well 
for the next fight.
    Reform efforts continue within the Military Health System. 
The Department of the Navy is in full support of these, 
including the transferred administration of medical treatment 
facilities to the DHA, as required by recent NDAA (National 
Defense Authorization Act) Acts.
    This legislation has reshaped military medicine to best 
support the warfighter while improving the health care delivery 
system with greater standardization and consistency.
    Our leadership recognizes that both the services and DHA 
must be successful in this effort. For us, this transition 
represents an opportunity to laser-focus exclusively on the 
readiness of our sailors and our marines. This is especially 
critical as we return to competition between great powers and 
the reality that future conflicts will present challenges and 
combat casualty care and survival not seen in the recent past.
    These reforms are allowing us to establish our 
organizational constructs to support readiness requirements, 
while sustaining our critical responsibilities to man, train, 
and equip our forces.

                         NAVY MEDICAL READINESS

    A key component moving forward will be to ensure that Navy 
Medicine is resourced to meet our services--Navy and Marine 
Corps--responsibilities and authorities and readiness missions.
    Nothing is more critical to our mission than the Navy 
Medicine team, dedicated and talented men and women serving 
worldwide. A key priority for us is our human capital strategy. 
Both our military and our civilian colleagues comprise our team 
to ensure we have the proper mix of professionals that are 
trained, organized, and equipped to meet their 
responsibilities. This focus requires an emphasis on talent 
management at all levels as well as recruiting and retaining 
the best and brightest.
    Navy Medicine is grateful for your support in this area of 
our resource requirements to ensure that we continue to have a 
high-quality team to support our servicemembers, their 
families, and all who depend on us.
    In closing, our commitment to you is that we will never 
waver from our obligation to be ready to save the lives of 
those entrusted to your care. I am proud of our Navy Medicine 
team and remain appreciative of your strong support. I look 
forward to your questions.
    [The statement follows:]
       Prepared Statement of Vice Admiral C. Forrest Faison, III
    Chairman Shelby, Vice Chairman Durbin, distinguished Members of the 
Subcommittee, it is my honor to be with you today to provide an update 
on Navy Medicine including our strategic priorities, key transformation 
efforts, accomplishments and challenges. We are guided by our 
unwavering commitment to those entrusted to our care. I can assure you 
that the Navy Medicine team is working tirelessly to protect the health 
and improve the readiness of Sailors and Marines so they can expertly 
perform the demanding responsibilities around the world our Navy, 
Marine Corps and Nation need them to do. On behalf of these dedicated 
women and men, I want to thank you for your confidence and support of 
our resource requirements to keep them healthy and on the job.
Strategic Priorities--Alignment and Transformation
    Navy Medicine continues to be guided by the Chief of Naval 
Operations' Design for Maintaining Maritime Strategy, initially 
released in 2016 and updated in December 2018. His direction is clear: 
The current security environment demands that the Navy must be prepared 
at all levels for decentralized operations. To be successful, we must 
remain committed to our core attributes: integrity; accountability; 
initiative; and toughness. We are aligned with these tenets along with 
the Secretary of the Navy's priorities of People, Capabilities and 
Processes as the foundation of readiness in the Department of the Navy 
(DON).
    Our mission is to keep the Navy and Marine Corps ready, healthy, 
and on the job. We follow and adhere to important and enduring guiding 
principles in meeting these responsibilities: Honor the trust to care 
for America's sons and daughters; Honor the uniform we wear; and, Honor 
the privilege of leadership. Our strategic goals continue to provide us 
an important framework to build upon our success, adapt rapidly to 
changing operational demands and fully support and realize benefit from 
the transformation underway in the Military Health System (MHS). They 
are also pivotal to aligning our strategy and execution, as well as 
targeting level of effort to best support our readiness investments. 
Our goals include:
    Readiness: Navy Medicine provides a medically ready force and 
operational medical capabilities, at and from the sea, to support ready 
naval forces.
    High Velocity Organization: Relentlessly pursue high reliabilities 
and a high velocity learning culture, in all Navy Medicine environments 
to accelerate Fleet and Marine Corps performance.
    Human Capital: Strengthen our team through a readiness-focused 
human capital strategy to ensure a highly skilled, integrated 
workforce.
    Partnerships: Enhance our operational capability and meet mission 
through partnership with the Defense Health Agency (DHA), the other 
Services, Federal/public agencies and the private sector.
    We continue to make progress and recognize the work ahead to 
realize our vision to provide the Navy and Marine Corps family with the 
best readiness and health in the world.
    Reform efforts continue within the Military Health System (MHS). 
The Department of the Navy is in full support of the transfer of 
administration and management of military treatment facilities (MTFs) 
to the DHA as required by the fiscal year 2017 National Defense 
Authorization Act (NDAA). This legislation catalyzed the reshaping of 
military medicine to best support the warfighter while improving the 
healthcare delivery system with greater standardization and 
consistency. Our leadership recognizes that both the Services and the 
DHA must be successful in executing their responsibilities so, 
collectively, we can effectively optimize the MHS as an integrated 
system of readiness and health. For us, this transition represents an 
opportunity to focus exclusively on the readiness of Sailors and 
Marines--a medically ready force as well as a ready medical force. This 
is especially critical as we return to competition between Great Powers 
and the reality that future conflicts will present challenges to combat 
casualty care and survival not seen in recent past conflicts. These 
reforms are allowing us to establish our organizational constructs to 
support readiness requirements while sustaining the critical Services' 
responsibilities to man, train and equip our forces.
    The phased transition to DHA administration and management of MTFs 
began on October 1, 2018. Our first MTF, Naval Hospital Jacksonville, 
officially transitioned on this date to become a field activity of the 
Defense Health Agency. To preserve critical command and control 
responsibilities to meet Navy and Marine Corps mission, in parallel we 
established a new organizational construct, the Navy Medicine Readiness 
Training Command (NMRTC). The NMRTC is part of an integrated system of 
health that supports the Fleet and Fleet Marine Force.
    It has specific responsibilities to maintain the readiness of our 
assigned medical forces, support installation and operational 
commanders' requirements and provide a Navy command structure essential 
for proper execution of Service-specific requirements. Given the 
Services' will retain command and control of their uniformed medical 
forces, we must have a structure in place to meet these 
responsibilities and NMRTCs will provide this throughout our 
enterprise. Moving forward, additional NMTRCs will be established in 
association with the transition of our MTFs. There will be no 
organizational growth associated with these commands as existing 
functions and personnel have been aligned within the NMRTC to support 
our readiness mission, allowing us to better consolidate or coordinate 
readiness and fleet support functions already in existence.
    We will also be restructuring our headquarters in alignment with 
our readiness-centric responsibilities. The Navy and Marine Corps are 
forward deployed, expeditionary forces and Navy Medicine must be 
organized to support their missions. While we proceed with our own 
transformation, the Navy continues to support the DHA with their 
manpower requests. As of March 1, 2019, we have detailed the 143 
military and civilian personnel requested to date to support them as 
they assume their MTF administration and management responsibilities. 
We continue to work with the DHA on the transfer of 325 personnel as 
outlined in Section 702 due by October 1, 2019. We continue to work 
together to best support their requirements while moving forward to 
transform Navy Medicine to meet our readiness mission.
    Major organizational changes in large healthcare enterprises like 
the MHS are inherently complex. Deliberate planning, careful assessment 
and agile decisionmaking (and, to course correct as needed) are crucial 
to our success. A key component will be to ensure that Navy Medicine be 
resourced to meet our Services'--Navy and Marine Corps--authorities and 
readiness functions. Progress continues but there remains significant 
work ahead as we fully implement the congressional requirements 
contained in NDAAs fiscal year 2017 and fiscal year 2019.
Readiness Imperative--Now and Moving Forward
    We have no greater responsibility than providing medical forces 
that are ready, prepared and present to save lives of the Nation's 
armed forces. Every Sailor and Marine, and their families, are 
depending on us to do all in our power to provide the best care our 
Nation can offer and return their loved ones home safely and alive. You 
rightly hold us accountable to meet this mission and we must continue 
to develop new and improved capabilities to support the full range of 
operations in multiple domains and in varied operational environments. 
Maritime and land- based disaggregated operations pose unique 
challenges for damage control resuscitation/surgery (DCR/DCS) and 
patient movement through the continuum of care. As part of the CNO-
directed Naval Expeditionary Health Service Support Requirements 
Evaluation Team (RET), Navy Medicine, in partnership with Deputy Chief 
of Naval Operations for Naval Warfare (N9) conducted an assessment of 
how to optimize medical support to Fleet Design, Distributed Maritime 
Operations (DMO) and Littoral Operations in a distributed contested 
environment. A significant number of gaps were identified and the 
results demonstrate how ensuring Naval Health Service Support afloat 
and ashore can provide integrated solutions supporting the DMO concept. 
Through the development of modernized medical capabilities that are 
modular, scalable and distributable, we will improve patient outcomes 
meeting the Fleet and Fleet Marine Force's current and future needs.
    Key assessments in this area identify the need for small teams 
equipped with DCR/DCS capabilities as well as small container-based 
forward resuscitative care/primary surgery capabilities as a medical 
payload on a number of combat logistics/support platforms. With the 
additional congressional resources provided to us, we made system 
upgrades and safety improvements to include transitioning dated legacy 
systems to rapidly erectable hospital infrastructure that enhances unit 
deployment capability in our expeditionary medical facilities (EMFs).
    Knowledge Skills and Abilities (KSA) efforts are focused on 
sustainment of clinical readiness skill sets for the entire 
expeditionary combat casualty care team and supporting specialties. To 
meet the challenge of future warfighter requirements, clinical and non-
clinical currency must be maintained through robust readiness-centric 
work at MTFs, and augmented by partnerships with civilian health 
systems, when applicable. A seminal component of our efforts is the 
Navy Medicine Trauma Strategy. Our provider teams must be prepared to 
provide trauma care across the full range of military operations and it 
is incumbent on us to ensure they have access to this clinical 
experience either in our facilities or with civilian partners. Key 
initiatives include:
  --Naval Medical Center Camp Lejeune (NMCCL) received Level III 
        American College of Surgeons (ACS) accreditation in July 2018. 
        The trauma center was developed in partnership with the State 
        of North Carolina and provides trauma care to our beneficiaries 
        and other patients in the area. Our personnel are getting 
        valuable experience in treating traumatic injuries from motor 
        vehicle accidents, gunshot wounds, burns and falls. Key 
        partnerships are in place with local civilian medical centers.
  --Hospital Corpsman Trauma Training Course (HMTT) provides our junior 
        Corpsmen with first-hand trauma training at the James H. 
        Stroger Jr. Hospital of Cook County, a level I trauma center in 
        Chicago, Illinois. This pilot project was successful and has 
        been expanded to a second site, the University of Florida 
        Health Jacksonville. Additional sites are currently under 
        evaluation.
  --Navy Trauma Training Center (NTTC) at the Los Angeles County/
        University of Southern California Medical Center continues to 
        support trauma training for our provider teams. Over 232 
        personnel participated in NTTC training in fiscal year 2018 and 
        over 3,500 since its inception in 2002. In addition, NTTC 
        implemented the Navy Surgical Team Trauma and Resuscitation 
        (NSTTAR) course utilizing validated curriculum such as 
        Emergency War Surgery, Fundamentals of Critical Care and 
        Advanced Surgical Skills for Exposure of Trauma.
  --Integrated Trauma and Medical Readiness Exchange (ITMRE) with the 
        Vietnam People's Armed Forces provided Navy Medicine personnel 
        with the opportunity to work at the host nation's medical 
        treatment facility. Clinical work for the team focused on 
        emergency medicine, surgery and orthopedics. This initiative 
        aligns with U.S. Indo-Pacific Command theatre security 
        priorities.
  --Hospital Corpsmen Personnel Qualification System: A successful 
        trauma response is built on core knowledge and experience in 
        complex patient care. We implemented a new Corpsman Personnel 
        Qualification Standards program last year to ensure all 
        Corpsmen gain and maintain important clinical proficiencies in 
        patient care as a foundation for successful trauma and combat 
        resuscitation response.
    Supporting Combatant Commands' humanitarian assistance/disaster 
response missions provide our personnel with unmatched readiness 
training. These deployments are professionally challenging and 
personally rewarding. From October to December 2018, USNS COMFORT (T-AH 
20) deployed in support of U.S. Southern Command's Enduring Promise 
(EP2018). EP2018 was successful in demonstrating U.S. commitment to the 
people of Central and South America--and strengthening strategic 
alliances and regional partnerships. Navy Medicine personnel, working 
with personnel from the other Services, partner nations and non-
governmental organizations, provided medical care during a time of 
unprecedented movements of migrants and stress on host nation health 
services. Medical personnel treated over 26,000 patients and performed 
about 600 surgeries aboard the ship and in land-based clinics in 
Ecuador, Peru, Colombia and Honduras. The crew built trust and, in many 
cases, changed lives. We used valuable information from the KSA Combat 
Casualty Care Team (CCCT) analysis for required surgery and anesthesia 
proficiencies to improve provider currency with the case load presented 
during this mission. This approach adds significant value to future 
missions by the MERCY Class hospital ships that will ensure clinical 
skills are sustained. This marked COMFORT's sixth deployment to the 
region since 2007. I know these missions, along with those of USNS 
MERCY (T-AH 19) in support of Pacific Partnership, are instrumental in 
making our providers better prepared, particularly in the maritime 
environment. Drawing on the success of EP2018, the Commander, U.S. 
Southern Command indicated that the medical force is returning more 
ready, and capable of providing critical care to our warfighters.
    Each year, we train approximately 3,700 new Hospital Corpsmen. We 
work hard to prepare them for their demanding responsibilities and 
never let them forget that they are part of a Corps rich in tradition 
for bravery, skill and service. Their exemplary performance was 
instrumental in the unprecedented combat survivability rates during our 
most recent conflicts; however, we must continually adapt and reinforce 
training at all levels to meet the demands of future contingencies. It 
begins at Hospital Corps ``A'' School and continues with that rigorous 
Hospital Corpsmen Personnel Qualifications Standards and operationally-
relevant skills experience at MTFs and civilian partners. I want our 
Corpsmen clinically competent and professionally confident when they 
arrive at their first ship or deploy with their Marines. This priority 
is the same for all our uniform medical personnel which is why our 
nationally-recognized graduate medical education programs remain so 
important to preparing our officers to meet the needs of the Fleet and 
Fleet Marine Force.
Optimizing Health--Medically Ready Sailors and Marines
    Force health protection is foundational to Navy Medicine and we 
target all aspects from operationally-focused preventive medicine to 
life-saving combat casualty care at sea and on the battlefield. We ask 
a lot of our Sailors and Marines, and in turn, they can rightly expect 
to be cared for by Navy Medicine with the best care our Nation can 
offer--anytime, anywhere.
    Navy Medicine continues targeted efforts in the area of traumatic 
brain injury (TBI), particularly in support of our Special Warfare 
communities. We provide services through a network of TBI clinics, 
including our two Intrepid Spirit Centers at Marine Corps Bases Camp 
Lejeune and Camp Pendleton, as well as Naval Medical Centers San Diego 
and Portsmouth. Programs are in place to support the demanding training 
and deployment cycles of these personnel with an emphasis on 
identification of potential injury followed by rapid intervention, 
treatment and recovery. In addition, we are actively engaged with 
public and private entities on our research priorities, identifying 
knowledge gaps and working together to improve diagnosis and treatment 
protocols.
    Increasing access and decreasing stigma are vital to connecting our 
Sailors and Marines to mental health and substance use services. Our 
embedded mental health (EMH) program is focused directly on supporting 
the Fleet and Marine Forces by placing mental health providers--
psychiatrists, psychologists, clinical social workers, mental health 
nurse practitioners and behavioral health technicians--as close to our 
Sailors and Marines as possible to increase utilization and decrease 
stigma. Twenty-five percent of our active duty mental health providers 
are currently assigned to EMH billets, and this will continue to 
expand. EMH increases trust with commanders and connectedness with 
service members, leading to increased willingness to seek help early 
after the onset of combat or operational stress. In addition to 
reducing medical evacuations and unplanned losses, EMH also helps 
improve personnel readiness. Following USS Fitzgerald (DDG 62) and USS 
John S. Mccain (DDG 56) collisions at sea in 2017, Navy Medicine 
developed the Organizational Incident Operational Nexus (ORION) Trauma 
Tracking system to provide long-term tracking of Sailors and Marines 
involved in unit level traumas and to target outreach to service 
members at elevated risk for psychological injury, as well as providing 
priority access to care when needed and regardless of location or 
future assignment.
    These initiatives target providing care and support where and when 
they are needed most. All of us recognize that resiliency, toughness 
and mental health fitness are essential for operational effectiveness. 
We continue to partner with the Navy and Marine Corps line leadership 
in suicide prevention efforts. Every suicide is a tragedy and 
devastates families, shipmates and commands. All service members are 
screened annually for mental health concerns, including potential 
suicide risk, during the required Periodic Health Assessment. In 
addition, we have specific programs including Psychological Health 
Outreach Program (PHOP) and Returning Warriors Workshops to address the 
needs of our reserve component Sailors and Marines.
    The Navy Comprehensive Pain Management Program continues to advance 
an integrated, patient-centered approach to pain management and 
restoration of function. We are leveraging best practices and 
empowering clinicians through education and evidence-based preventive 
strategies. To minimize opioid use and impact on deployability, Navy 
Medicine's policy--Long-term Opioid Therapy Safety (LOTS)--established 
LOT committees at every MTF, along with clinical guidelines, training 
requirements and compliance reporting for patient management and 
safety. We are seeing solid results: From 2013--2018, we saw a 44 
percent reduction in the number of opioid prescriptions written for 
Sailors and Marines along with 30 percent fewer personnel receiving 
these prescriptions. Correspondingly, we continue to expand access to 
alternative pain management methods including the use of Complementary 
and Integrative Medicine (CIM) therapies.
    When our Navy and Marine Corps personnel do have deployment 
limiting medical conditions, we are continuing to improve clinical and 
administrative interfaces that impact readiness, deployability, and the 
tracking of each. Deployability of service members is considered at all 
healthcare encounters and any changes are communicated to the member's 
command and to Service headquarters through Limited Duty Sailor and 
Marine Readiness Tracking (LIMDU SMART) or the Veterans Tracking 
Application for permanent conditions requiring Disability Evaluation 
System (DES) processing. We are expanding access to LIMDU SMART to 
include all our operational providers so they can initiate appropriate 
actions and fully participate in active management of Sailors and 
Marines in a limited duty status to get those we can back to duty as 
quickly as possible.
    These efforts are important since we know that last year (2017-
2018), about 64 percent of the Navy and Marine Corps limited duty cases 
were related to musculoskeletal conditions. Building on the success of 
our Value-Based Care pilot project at Naval Hospital Jacksonville 
(which is currently presented as a best practice case study at the 
Harvard Business School) we created integrated practice units for lower 
back pain and osteoarthritis and broadened the focus to include 
musculoskeletal conditions, expanding this initiative to Naval Hospital 
Camp Pendleton. We recognize that coordination of care is critical in 
the prevention, treatment and recovery of these injuries so our efforts 
target multidisciplinary, integrated musculoskeletal care so our 
Sailors and Marines are ready to deploy. We are seeing solid gains from 
this approach.
    The evolving and expanding roles for women in the Navy and Marine 
Corps has catalyzed the need for a new focus on comprehensive women's 
health. Women's health services, though historically focused on 
obstetric and reproductive care, have expanded to incorporate gender- 
specific needs in areas including mental health, musculoskeletal 
injuries, and female healthcare needs in a deployment setting to ensure 
women have the care they need and are mission ready at all times. In 
November 2018, Navy Medicine opened a Comprehensive Women's Health 
Clinic in San Diego, California. This pilot program is aimed at serving 
the unique health needs of active duty female Sailors and Marines. In 
addition, family planning services are a critical component of women's 
health with key implications for readiness and retention. Through our 
Operation PINC (Process Improvement for Non-delayed Contraception), we 
have expanded full- scope contraceptive walk-in clinics to 16 Navy MTFs 
world-wide. These clinics allow for same day access to the full range 
of DoD-approved contraceptive options, thus reducing barriers to 
contraceptive care such as referral requirements and time delays. The 
high utilization of long acting reversible contraceptives (LARCs) 
provided in these clinics has significant implications for improved 
readiness for female Sailors and Marines, particularly those forward-
deployed.
    Navy Medicine continues to be a leader in providing trauma-informed 
compassionate and gender-responsive sexual assault medical response 
around the world. We have over 240 providers trained to conduct sexual 
assault medical forensic examinations (SAMFE) at our MTFs, aboard our 
large deck aircraft carriers, amphibious assault ships, and remote 
operational environments. In addition, we have 33 memoranda of 
understanding in place with civilian partners to ensure that our 
service members have ready access to these critical services when they 
are needed.
    Research and development is inextricably linked to our readiness 
mission. The Naval Medical Research Center (NMRC) enterprise is the 
Navy and Marine Corps' premier institution for biomedical research, 
infectious disease surveillance and response, and international public 
health research. Work done in our eight overseas and domestic 
laboratories by our scientists--in partnership with Army, Air Force and 
other government, academic, and private collaborators--have a direct 
impact on protecting the health of Sailors and Marines. Examples 
include the detection and constant surveillance and reporting of 
infectious pathogens including Ebola, influenza, dengue, malaria, 
antibiotic-resistant bacteria, drug-resistant parasites, and other 
militarily-relevant pathogens which regularly affect deployed service 
members. We see innovations in a full range of operationally-focused 
research such as the evaluation of blood substitutes, optimizing 
resuscitation strategies, guidelines for standoff distance from 
underwater blasts, and testing on a patient warming system for injured 
warfighters in isolated environments. Given their international scope, 
our research activities are integral components of our global health 
engagement and Fleet support efforts while this work with host nations 
helps build and sustain public health capacity. Our investments in 
their work help ensure we have the capability to respond to current 
challenges as well as those that present in the future.
    One area on which we are keenly focused in our operational labs is 
physiological episodes in tactical jet aircraft. Navy flight surgeons, 
aerospace/operational physiologists, and researchers are involved in 
all aspects of response, diagnosis, treatment, mitigation and research 
of physiological episodes. Navy Medicine developed and, continually 
updates, standardized clinical practice guidelines to ensure rapid and 
consistent evaluation wherever and whenever a physiological episode 
occurs. At Naval Medical Centers San Diego and Portsmouth, we 
established referral centers to rapidly assess and treat complicated 
physiological episode cases with a multi-disciplinary team approach 
providing immediate access to subspecialists and fast- track innovative 
treatment on both coasts. Earlier this year, Navy Medicine conducted a 
full day, world-wide Navy--USMC aeromedical synchronization 
teleconference to ensure that all our personnel are prepared with the 
most comprehensive information, tools and lessons learned to keep our 
aircrews healthy and safe. In addition, given their co-location onboard 
Wright Patterson Air Force Base, our researchers at the Naval Medical 
Research Unit--Dayton are working closely with their Air Force 
counterparts at the United States Air Force 711th Human Performance 
Wing on relevant hypoxia and physiological episode research. Diligent 
efforts to address this problem are also ongoing at the Navy and Marine 
Corps Public Health Center (NMCPHC), Navy Experimental Dive Unit (NEDU) 
and the Navy Aeromedical Institute (NAMI), among many entities.
    Active expansion of virtual health (VH) capabilities is important 
to caring for Sailors and Marines in all environments and mitigating 
the limitations of time, distance and access to specialists. 
Initiatives such as Health Experts online Portal (HELP) at Naval 
Medical Center Portsmouth continue to demonstrate high value in 
supporting U.S. and overseas commands, including helping to avoid 
medical evacuations. We have established Naval Medical Center San Diego 
as our first virtual medical center, and their work will capitalize on 
the availability of medical specialty expertise with an emphasis on 
Tele-Critical Care (TCC) and Operational Virtual Health (OVH). We are 
also using VH technology to keep our Corpsmen skills sharp. We expanded 
our Corpsmen in the Community initiative to three sites allowing our 
personnel to provide active duty Sailors and Marines care at convenient 
times outside normal clinic hours so there is reduced impact on 
training and work schedules. Corpsmen provide hands-on patient care 
outside the MTF and closer to our service members while connected 
virtually to providers at the local MTF. This allows for virtual 
reviews of the assessment and treatment plans and helps sustain 
Corpsmen skills sets.
    Progress continues with the deployment of MHS GENESIS, with 
emphasis on aggressively addressing configuration challenges in the 
initial roll-out of implementation in the Pacific Northwest MTFs. Navy 
Medicine is fully engaged and supportive of the joint implementation 
and optimization of MHS GENESIS with the other Services, DHA, and the 
Defense Healthcare Management System (DHMS) Program Executive Office 
(PEO). All of us recognize the criticality of MHS GENESIS as it will 
significantly help drive standardization throughout the MHS while 
providing a single platform to access accurate healthcare data in our 
MTFs and operational settings. MHS GENESIS is active at Naval Hospital 
Bremerton and Naval Health Clinic Oak Harbor and is scheduled for 
implementation at Naval Hospital Lemoore in Fiscal year 2019.
The Navy Medicine Team--A Ready Medical Force
    Nothing is more critical to our mission readiness than the Navy 
Medicine team--dedicated and talented men and women serving world-wide. 
Individually and collectively, they form a ready medical force that 
supports and cares for Sailors, Marines and their families.
    A key priority for us is our human capital strategy--for both 
military and civilian personnel--to ensure we have the proper mix of 
professionals that are trained, organized and equipped to execute their 
responsibilities. This focus requires an emphasis on talent management 
at all levels, as well as recruiting and retaining the best and 
brightest. We face formidable competition with the private healthcare 
sector and this trend is likely to continue. Navy Medicine is grateful 
for your support of our resources requirements needed for accession and 
retention incentives, particularly for many of our high demand wartime 
critical specialties. It is important to note that any significant 
changes in force structure, to include impact to medical personnel, 
requires us to assess risk and mitigate impact to our operational 
capabilities. We do this on an ongoing basis.
    Overall, current Navy Medicine Department manning (officer and 
enlisted) is healthy. We recognize, however, that ensuring we have the 
proper skill mix to meet our wartime mission requires continued 
attention, particularly for surgical, critical care and mental health 
specialties that face manning shortfalls. Special and incentive pays, 
successful student recruiting initiatives and attractive graduate 
medical/dental education opportunities have been key factors for 
meeting these manning levels.
    In fiscal year 2018, Navy Recruiting attained 96 percent of Navy 
Medicine's overall direct accession active component officer goal and 
71 percent for the reserve component. Recruiting reserve component 
Medical Corps officers remains a challenge and we continue to work on 
incentives to address these shortfalls. Our overall success in 
retaining active component medical officers leads to a smaller pool of 
officers available for affiliation with the reserves. This, in part, is 
impacting reserve officer recruiting. We had success in recruiting 100 
percent of our enlisted personnel for both active and reserve 
components. Within the active component, we remain focused on the 
manning levels of our independent duty Corpsmen (surface, submarine, 
dive and reconnaissance) given their key roles in supporting operating 
Fleet and Marine Force requirements. Importantly, Navy met 100 percent 
of our student accession program recruitment goals for all our officer 
Corps. These programs are critical to our overall accession pipeline.
    Within Navy Medicine, we are fortunate to have a talented and 
diverse civilian personnel workforce that bring unmatched knowledge, 
skills and abilities to their important work around the world. They 
work along-side their uniformed colleagues, and in many cases, provide 
unmatched training and mentorship to our officers and Corpsmen. Navy 
civilians are integral to our readiness mission and important to the 
success of the MHS transition activities currently underway. Recruiting 
and retaining our civilians, particularly in high demand occupations or 
remote locations, can be challenging particularly given strong 
competition from the private sector. We are grateful for the 
flexibilities and authorities, including Expedited Hiring Authority and 
Direct Hire Authority, that help us attract these personnel. In fiscal 
year 2018, we accessed over 480 hard-to-fill healthcare providers using 
these combined authorities.
Way Ahead
    In closing, I want to reiterate that Navy Medicine is laser focused 
on readiness--preparing our medical force to save lives at sea and on 
the battlefield and doing everything we can to ensure our Sailors and 
Marines are healthy and ready to perform their demanding missions. We 
will never waiver from this obligation: Readiness and being where it 
counts, when it counts, to save the lives of those entrusted to our 
care. I am proud of the Navy Medicine team beyond words and remain 
appreciative of your strong support. I look forward to your questions.

    Senator Shelby. General Hogg.
STATEMENT OF LIEUTENANT GENERAL DOROTHY A. HOGG, 
            SURGEON GENERAL OF THE AIR FORCE
    General Hogg. Chairman Shelby, Vice Chairman Durbin, 
members of the committee, thank you for this opportunity to 
testify today.

                       AIR FORCE MEDICAL MISSION

    The Air Force Medical Service is in a period of great 
change, driven by numerous factors. Throughout these 
transformations, our commitment to our patients we care for and 
our medical readiness mission has never been stronger.
    Today's Air Force operates the most effective patient 
movement system ever. We bring wounded servicemembers home in 
record time, deliver critical care at 30,000 feet, and push 
lifesaving care farther forward than ever before.
    Multiple efforts are under way to further improve our 
patient movement capabilities to better position us to execute 
the National Defense Strategy.
    We will increase our Critical Care Air Transport Teams 
based on the Aeromedical Requirements Analysis Study. These 
teams of doctors, nurses, and technicians turn aircraft into 
flying intensive care units that provide life-sustaining care, 
while moving patients hundreds, even thousands of miles away.
    We continue developing our Ground Surgical Teams, our 
primary battlefield surgical unit, for deployment to austere 
locations.
    We are also looking at our other deployment platforms to 
prepare and modernize them for what may be our next conflict as 
well as ways to make them lighter and leaner and more 
tailorable to current and future combatant commander 
requirements.
    We continue to collaborate with the Defense Health Agency 
in moving authority, direction, and control of the military 
treatment facilities.

         AIR FORCE MILITARY TREATMENT FACILITIES TRANSITION TO 
                         DEFENSE HEALTH AGENCY

    On October 1st, 2018, the Air Force transferred four 
military treatment facilities to the Defense Health Agency, and 
like any enterprise transformation, we have identified gaps in 
our current planning process and are working collaboratively to 
resolve these to improve the transition for subsequent military 
treatment facilities.
    In addition to the Military Health System transformation, 
the Air Force Medical Service will also transform itself to 
refocus on operational medical readiness. We will stand down 
two field operating agencies and stand up a single agency 
called the Air Force Medical Readiness Agency. This will 
eliminate redundancies and right-size my headquarters' 
capabilities to focus on medically-ready airmen and -ready 
medics who are current and competent to do their missions.
    We are also restructuring our medical squadrons. The Health 
Care Operations Squadron will focus on providing beneficiary 
care without the distractions of military medical requirements, 
such as periodic health assessments and waiver requirements.

                      AIR FORCE MEDICAL READINESS

    The Operational Medical Readiness Squadron will focus on 
active-duty airmen's mission capability. This new structure 
optimizes both functions and allows us to return airmen to 
full-mission capability as quickly as possible without 
decrementing care to our beneficiaries.
    As Robin Sharma once said, ``Change is hardest in the 
beginning, messiest in the middle, and easiest at the end.'' 
The Military Health System is in the middle of change. These 
challenges create opportunities to shape the future and to 
think without a box.
    Air Force medics are, first and foremost, warrior medics. 
As the Air Force Surgeon General, I am committed to achieving 
full-spectrum medical readiness, developing joint medical 
leaders, and driving Air Force Medical Service transformation 
to increase our agility and lifesaving capabilities required to 
execute the National Defense Strategy.
    Thank you for your support of Air Force Medicine and the 
opportunity to address you today, and I look forward to 
answering your questions.
    [The statement follows:]
        Prepared Statement of Lieutenant General Dorothy A. Hogg
    Chairman Shelby, Senator Durbin, and distinguished members of the 
Subcommittee, thank you for this opportunity to testify before you 
today.
    The Air Force Medical Service celebrates its 70th anniversary this 
year. Since separating from the Army Medical Department in 1949, Air 
Force Medicine has been an innovative force in the medical community, 
developing and implementing new ways to deliver ever higher levels of 
care in challenging environments, from remote, austere battlefields to 
the back of a plane at 30,000 feet.
    Today, the Air Force Medical Service supports a beneficiary 
population of more than 2.5 million from 63 clinics and 12 hospitals 
across the country and around the world. More than 850 Air Force medics 
are currently deployed in an operational theater worldwide, an increase 
of nearly 20 percent in the past 2 years. These deployed medics are 
backed by 29,000 active duty medics and a total medical force of 40,550 
personnel, including civilians and contractors.
    The Air Force Medical Service employs the greatest patient movement 
system in history. This system developed gradually, driven by the 
evolving requirements of delivering medical support in shifting 
battlefield environments, and improves continuously. Our current 
capabilities are tailored to our current and recent conflicts, and must 
be adjusted to meet anticipated future requirements. Expanding our 
aeromedical evacuation capacity and enhancing its versatility is vital 
to preparing for future conflicts that may involve more casualties than 
current operations.
    The Air Force of tomorrow must be able to compete with peer 
militaries; deter rogue states and opportunistic aggression; defeat 
terrorist threats wherever they arise; and defend American interests in 
air, space, cyberspace and other domains. As the Air Force looks to 
increase the number of operational squadrons, the Air Force Medical 
Service will remain a vital part of supporting and sustaining the 
effectiveness of those units. To accomplish this goal, the Air Force 
Medical Service must modernize and transform to stay aligned with a 
changing Air Force and our Joint partners.
    Our operational squadrons depend on the entire Air Force to ensure 
they are lethal, resilient and ready to fight. Today's combat 
environments require our forces to operate seamlessly across all 
domains with our Joint and allied partners. Medical integration and 
Joint training are critical, for while the human body is the same no 
matter what uniform it wears, the platforms, techniques, terminology 
and equipment vary. We do our medics a disservice when they have to 
learn unfamiliar systems on the fly during a deployment. The Air Force 
Medical Service is committed to relentlessly working with our Army, 
Navy and Defense Health Agency partners to increase Joint training and 
duty opportunities to minimize this challenge. Strengthening these 
bonds furthers the vision of an integrated, innovative, flexible, 
efficient and modern medical service that is responsive to the needs of 
combatant commanders.
    Last year, we told the Senate Subcommittee that the Air Force 
Medical Service was at a crossroad. That crossroad is now in our 
rearview mirror. The Air Force Medical Service is already moving 
quickly down the path that will define the next decade or more of Air 
Force medical support. We are undertaking multiple lines of readiness-
focused reform simultaneously, including:
  --Transitioning healthcare delivery at our Military Treatment 
        Facilities to the Defense Health Agency;
  --Restructuring our headquarters and field operating agencies;
  --Reorganizing our Military Treatment Facilities to focus on Airmen 
        availability;
  --Creating Operational Medical Readiness Squadrons;
  --Revising and expanding the practice and training for flight 
        medicine to additional provider types; and
  --Evolving our deployable medical platforms to meet the needs of our 
        combatant commanders.
    The National Defense Strategy makes restoring readiness the top 
priority for our Nation's armed forces. Each of the reform efforts 
underway in Air Force Medicine seeks to improve readiness. As we make 
our plans for the future and evaluate the courses of action available 
to us, our readiness mission is at the forefront of every discussion, 
matched by our commitment to providing our patients with high quality 
care.
    Using the National Defense Strategy and the Secretary of the Air 
Force's priorities as guidelines, the Air Force Medical Service 
unveiled a strategy map last summer outlining three goals to drive our 
future efforts--Achieve Full Spectrum Medical Readiness, Strengthen 
Joint Warrior Medical Teams and Drive Air Force Medical Service 
Transformation. Each goal aligns to the broader vision of the 
Department of Defense and the Secretary.
    Air Force medics are not ``trigger-pullers'' or ``bomb-droppers'' 
or even intelligence analysts, weapon system designers or cargo-movers. 
Our job is to make sure that the Airmen who execute those critical 
functions can most effectively accomplish their mission, contributing 
to the lethality of the force. We optimize their physical and mental 
health, and work to heal and return them to duty if they become ill or 
injured. We are the maintainers of the human weapon system.
    Our single biggest driver of change remains the readiness needs of 
combatant commanders. As the global security landscape evolves, the Air 
Force Medical Service must also evolve to ensure we deliver the medical 
support required to conduct global operations.
    In the last 20 years, the Air Force Medical Service has tailored 
our operational medical support to relatively small-scale and 
asymmetric conflicts. We built a world-class patient movement system 
that gets casualties from the frontline to higher levels of care in a 
remarkably short time. Since September 11, 2001, we have conducted 
nearly 340,000 global patient movements, saving many lives and 
contributing to an unprecedented 98 percent survival rate for U.S. 
service members injured in Iraq and Afghanistan.
    Sustaining and improving this high-level of support for tomorrow's 
conflicts will be difficult and requires adapting our force composition 
and our deployment, training and readiness models. As the Air Force 
Medical Service implements the reforms coming from Congress, the 
Department and the Air Force, these evolving operational readiness 
requirements are the prism we use to determine the best way forward.
    There is no better example than our efforts to implement the 
various medical reforms outlined by Congress in recent National Defense 
Authorization Acts.
    The Air Force is committed to the vision of a single, integrated 
Military Health System laid out in the fiscal year 2017 NDAA, and we 
have moved smartly to adopt these reforms. We are working hand-in-hand 
with the Defense Health Agency and our sister services to design a 
model that effectively transitions the authority, direction and control 
of the healthcare benefit at Air Force Military Treatment Facilities to 
the Defense Health Agency, as detailed in section 702 of that act. The 
resulting standardization and efficiencies will allow the Air Force 
Medical Service to focus our efforts on supporting the readiness of 
operational Airmen, and organizing, training and equipping deployable 
medical Airmen in support of combatant commander requirements.
    In October 2018, the first four Air Force Military Treatment 
Facilities--Keesler Air Force Base in Mississippi, Joint Base 
Charleston in South Carolina, and Seymour Johnson Air Force Base and 
Pope Field in North Carolina--transitioned to the Defense Health 
Agency. We are also in the process of transitioning initial 
headquarters functioning to the Defense Health Agency, including the 
Quadruple Aim Performance Plan (a tool to quantify resources required 
for Military Treatment Facility readiness activities), health plans and 
pharmacy operations.
    The run-up to and handover of the phase-one Military Treatment 
Facilities has not been without challenges. This is to be expected in 
any organization undergoing major structural and cultural change, and 
we do have noteworthy success stories. Participating in the 
collaborative transition Intermediate Management Organization with 
Army, Navy and the Defense Health Agency led to invaluable information 
sharing and gave the Air Force an opportunity to provide input as the 
Defense Health Agency built its processes.
    The Defense Health Agency and the Air Force Medical Service worked 
together to overcome some unanticipated challenges at phase-one 
Military Treatment Facilities. Keesler Medical Center experienced a 
shortfall in funding soon after the Oct. 1 transition. The transition 
Intermediate Management Organization worked with Keesler to revise its 
estimated funding requirements to cover all civilian workforce and 
nearly all contract requirements in one day, allowing Keeler to sustain 
normal business operations without interruption.
    In early March, a burst pipe flooded a building at Joint Base 
Charleston, affecting the mental health clinic, resource management 
office, and education and training facilities for the 628th Medical 
Group. The Medical Group worked with the Air Force Medical Operations 
Agency, the Defense Health Agency and the transition Intermediate 
Management Organization to secure funding for disaster management, 
flood restoration and the eventual facility repair and renovation, and 
reopen mental health services in a temporary facility.
    These examples demonstrate the potential the Military Treatment 
Facility transition provides--a resilient, flexible organizational 
structure with greater resources and a narrowed focus on 
administration, management and patient care. The structure we developed 
allowed us to overcome many of the initial hiccups presented by the 
transition. Significant strategic and operational challenges remain as 
we move toward transitioning more Military Treatment Facilities and 
additional headquarters functions to the Defense Health Agency. These 
future steps will be taken with the benefit of lessons learned from 
this first phase, but we will have challenges to overcome--some already 
identified, and some not foreseen.
    As we transition more organizational roles and move new structures 
from concept to operation, the key to ongoing success will be 
maintaining strong lines of communication with the Defense Health 
Agency and other partners and stakeholders. Only through close 
coordination and collaboration will we achieve the goal of an 
integrated Military Health System while maintaining the same commitment 
to readiness, continuity of care, and high level of service to our 
patients.
    The next phase of transition begins October 2019 with additional 
CONUS Military Treatment Facilities moving to the Defense Health 
Agency. We are fully engaged with the Defense Health Agency, affected 
Military Treatment Facilities, their wings and Major Commands to 
prepare for this action. Additional headquarters functions, including 
medical facility administration, and medical logistics will also 
transition to the Defense Health Agency during this phase. We are 
simultaneously communicating to Military Treatment Facilities in future 
phases to help them adapt to the coming changes.
    Concurrently, the Air Force Medical Service is preparing to 
implement section 703 of the fiscal year 2017 NDAA. Our team is 
evaluating ways to restructure Military Treatment Facilities in order 
to maintain appropriate support for their host wing's mission and 
ensure our providers have the opportunity to practice and maintain the 
essential skills needed to provide care downrange. Our teams are 
currently in the process of assessing each Air Force Military Treatment 
Facility, analyzing their current mission requirements, clinical 
performance, and ability to integrate care with network partners. We 
will build comprehensive assessments of each facility based on these 
criteria, which will inform our re-scoping recommendations, and be 
included in reports due to Congress.
    The Air Force Medical Service has also made significant progress 
reorienting our internal organizational structure in support of our 
full spectrum readiness mission. We are preparing to stand-down our two 
current Field Operating Agencies, the Air Force Medical Operations 
Agency and the Air Force Medical Support Agency, and replace them with 
the Air Force Medical Readiness Agency.
    The creation of the Air Force Medical Readiness Agency facilitates 
our renewed focus on the operational readiness of our Airmen and our 
medical forces, and will help us coordinate with the Defense Health 
Agency to align readiness requirements and avoid duplication. We have 
draft plans for the composition and location of the Air Force Medical 
Readiness Agency and will reach initial operating capacity this summer, 
with full operating capacity expected in autumn 2020.
    This new headquarters structure highlights our renewed readiness 
focus and commitment to efficiency. As the Defense Health Agency on-
boards additional functions, the Air Force Medical Service is taking a 
careful look at which parts of our organization will no longer be 
required, and which of these resources can be realigned to other parts 
of the Air Force. A more streamlined Air Force Medical Service supports 
the Secretary's plan to expand the Air Force's operational squadrons.
    This reorientation towards readiness goes far beyond headquarters. 
We are restructuring Air Force Military Treatment Facilities in support 
of the readiness mission, and to clearly demarcate full spectrum 
readiness activities from healthcare delivery to non-active duty 
patients. We anticipate that these changes will help the Air Force meet 
its 95 percent medical deployablity and 90 percent fully mission-
capable goals by reducing the number of Airmen deemed non- deployable 
due to preventable illness or injury.
    Per guidance issued by Secretary in February 2019, many Air Force 
Military Treatment Facilities will soon reorganize based on a model 
implemented in 2018 by the 366th Medical Group at Mountain Home Air 
Force Base, Idaho. The Air Force Medical Service Reform Model divides 
Military Treatment Facility staff into new squadron types, each with a 
distinct focus. Medics assigned to Operational Medical Readiness 
Squadrons will only treat active duty patients, while medics assigned 
to Health Care Operations Squadrons will only treat non-active duty 
patients. At larger Military Treatment Facilities, a third squadron 
type, Medical Operations Support Squadrons, will provide ancillary 
health services like laboratory, x-ray, and administrative functions. 
The Medical Operations Support Squadrons squadron will support both 
active duty and non-active duty patients.
    This new model will enhance our organizational readiness culture by 
allowing medics who treat active duty patients to focus on that patient 
population and their readiness needs. Over an initial six-month period 
in 2018, employing the Air Force Medical Service Reform Model at the 
366th MDG contributed to a 20 percent reduction in the percentage of 
Airmen deemed non- deployable at Mountain Home AFB at a time when the 
rest of the Air Force maintained a constant rate. We anticipate this 
will have similar effects at future sites.
    We are on track to implement the Air Force Medical Service Reform 
Model at 43 Military Treatment Facilities this summer. Some facilities 
will be exempt, including larger hospital facilities, overseas Military 
Treatment Facilities, some smaller Military Treatment Facilities, and 
Graduate Medical Education platforms.
    Airmen will be empaneled to Operational Medical Readiness Squadrons 
by unit. This allows providers to build relationships with squadron 
leaders and individual Airmen, and focus on squadron-specific needs to 
return Airmen to duty. The Air Force Medical Service Reform Model will 
allow our providers to get to know their active duty patients better, 
understand the challenges they face, prevent more injuries and 
illnesses, and return Airmen to full duty status more quickly.
    This structure will also allow medical groups to be more responsive 
to the shifting operational mission requirements of their wings. The 
Air Force Medical Service is working closely with the Defense Health 
Agency as we plan this reform, as it overlaps and complements the 
transition of healthcare delivery to that organization. Our partnership 
with the Defense Health Agency is vibrant and vital, and its strength 
will contribute greatly to the future successes of these efforts.
    The Air Force Medical Service is also modernizing its approach to 
aerospace and operational medicine capabilities. The definition of an 
operator has evolved over the years but flight medicine has not. We 
will use the traditional flight medicine model to reach the rest of our 
operational medics such as security forces, explosive ordinance 
disposal and intelligence, surveillance and reconnaissance operators. 
The traditional flight medicine model will remain as part of our 
operational medical readiness model and it will expand to include nurse 
practitioners and physician assistants as flight surgeons. This expands 
the pool of flight medicine-qualified practitioners, increasing our 
deployable medical assets and capability to ensure Airmen are mission 
ready.
    Another critical readiness component the Air Force Medical Service 
continues to develop is the concept of Integrated Operational Support. 
Integrated Operational Support embeds medical assets directly into 
operational units, enhancing access, building relationships and 
improving performance, fitness and overall health. In particular, 
embedded medics help in preventing and rapidly diagnosing 
musculoskeletal injuries. Integrated Operational Support has long been 
a staple of Air Force Medical Service support to operational squadrons, 
but we are developing new platforms to push the envelope.
    One such platform, the Operational Support Team, is designed to act 
as a ``strike team'' to deploy into units at the request of the 
commander to analyze and recommend solutions for medical and mental 
health issues that may impact the mission. These teams are typically 
composed of a physical therapist, a psychologist, two nutritionists, an 
exercise physiologist, and a human performance integrator. Working in 
partnership with squadron commanders, the Operational Support Team 
evaluates the unit as a whole, determining what behaviors or conditions 
may contribute to illness or injury, and recommending strategies for 
the unit to avoid or address preventable health issues.
    We rolled out the Operational Support Team model at two sites in 
2018, Whiteman Air Force Base in Missouri and Joint Base Elmendorf-
Richardson in Alaska. It will deploy to 15 additional sites in the Air 
Force in 2019, and we plan to continue rolling this model out Air 
Force-wide in coming years. These efforts aligns closely with the 
Secretary's goal of revitalizing the Air Force at the squadron level, 
our core unit, making them more lethal, resilient and ready.
    Even as we realign our medical support to the Air Force of the 
future, the Air Force Medical Service must recommit to training, 
nurturing and supporting our own medical personnel. One of the primary 
objectives in the new Air Force Medical Service strategy map is 
strengthening our Joint Warrior Medical Teams. The move towards an 
integrated Military Health System mirrors the Joint nature of most line 
deployments. It is increasingly more common for Airmen to serve side-
by-side with Soldiers, Sailors, Marines, Coast Guardsmen, National 
Guard and Reserve members outside deployments. We need to do a better 
job of preparing medical Airmen for these Joint environments. We also 
need to create career and professional opportunities that reflect that 
new normal and contribute to the recruiting and retention of qualified, 
valuable military medical personnel.
    Along these lines, the Air Force Medical Service is refining our 
career pyramids to align with future Joint training and fully develop 
an Air Force Medical Service continuum of learning to establish a clear 
framework for career evolution for medical Airmen. Throughout that 
process, it is vital for us to listen to our medical force to ensure we 
are meeting their needs as members of the military and medical 
professionals. This will also support our need to recruit, develop and 
retain the highest quality practitioners. We are committed to building 
a talent management structure for each of the seven officer, enlisted 
and civilian Air Force medical corps to meet current and future 
requirements.
    We are designing the plan to help us achieve these goals, and we 
know that making the proper investment of time, energy and resources 
today will pay off as we develop service and Joint leaders equipped to 
meet emerging challenges. Our goal to strengthen our Joint Warrior 
Medics is flexible and adaptive. We will continue to collaborate with 
our partners at Defense Health System and the other Services to find 
innovative ways to improve training and allow members to plot their 
professional and Joint development.
    Another major change affecting the Air Force Medical Service is the 
adoption of MHS GENESIS, the integrated, enterprise electronic health 
record for the Military Health System. MHS GENESIS was first fielded by 
the 92nd Medical Group at Fairchild Air Force Base, Washington, in 
February 2017. MHS GENESIS will deploy in a series of waves over the 
next several years, with Wave One sites coming in 2019. Air Force 
locations in Wave One include Travis and Mountain Home Air Force Bases.
    Electronic Health Record usage is a critical component of modern 
medicine, and replacing legacy electronic health records with MHS 
GENESIS is a significant additional mission for medical Airmen. 
Adoption requires broad systems and network improvements, as well as 
business process changes to achieve standardization and culture change. 
Fairchild provided a critical template and testing ground for MHS 
GENESIS adoption, and for the change management and systems processes 
needed to successfully implement it across the Military Health System.
    One key lesson from Fairchild's implementation of MHS GENESIS is 
that the transition to a new network has to happen at the Military 
Treatment Facility well in advance of actual MHS GENESIS training and 
Go-Live events. We are now implementing network updates at least 6 
months prior to these events at all future adoption sites. This 
significantly alleviates many of the technical problems that affected 
Fairchild's MHS GENESIS implementation. Another key lesson from 
Fairchild is the need to overhaul our training approach. Immature 
workflows limited training effectiveness for the entire staff, beyond 
the designated MHS GENESIS ``super-users'' who were tasked to help 
other members learn the system. We developed a new training approach in 
coordination with the Defense Health Agency, informed by the challenges 
and solutions from Fairchild and the other early sites.
    Although the 92nd Medical Group did suffer a temporary but 
significant decrease in productivity as their staff learned MHS 
GENESIS, Fairchild did not lose readiness capability during this 
period. 92nd Medical Group leadership prioritized that mission, another 
critical lesson for future Military Treatment Facilities. Access levels 
at Fairchild decreased during MHS GENESIS adoption, but rebounded by 
December 2018. We expect the duration of this decrease to shrink as our 
experience implementing MHS GENESIS grows. However, the readiness 
mission cannot and will not be allowed to suffer during implementation.
    We also learned that Fairchild's manning structure was insufficient 
in some areas to support MHS GENESIS workflows. Adoption of MHS GENESIS 
will require on-site program management and additional resources. As 
the number of sites using MHS GENESIS increases, the normal military 
cycle of permanent changes of station will find experienced MHS GENESIS 
users already working at Military Treatment Facilities as they begin 
implementation. This will provide a cadre of experienced users at new 
sites, easing transition.
    It has been more than 2 years since we started electronic health 
record modernization in the Military Health System, and that time has 
reaffirmed the knowledge that it requires significant collaboration 
between the services and the Defense Health Agency to effectively 
accomplish this modernization. We have learned a lot and the product 
has been improved greatly in that time. We will continue to strive 
towards standardizing and optimizing our use of MHS GENESIS and look 
for ways to streamline our business processes.
    Even while these transformation activities are underway, the day-
to-day mission of the Air Force Medical Service continues. Our medical 
Airmen remain resolute in their commitment to our culture of Trusted 
Care, wherever they serve. Above all else, we are focused on our 
patients, whether they are an Airman getting ready for deployment, a 
mother and newborn child at a hospital stateside, or an injured service 
member en route home from a faraway battlefield. I am always humbled 
and amazed by the incredible work medical Airmen do every day.
    Alongside the structural and organizational changes to the Air 
Force Medical Service outlined above, we continue to refine and grow 
our expeditionary medical and aeromedical evacuation platforms. These 
efforts are aligned with and in response to the requirements of our 
combatant commanders, with a strategic eye towards the next generation 
of conflicts. While this process is continuous, the past year saw 
significant progress in evolving our capabilities to support a global 
or regional peer-level conflict.
    In fiscal year 2018, the Air Force Medical Service initiated the 
Ground Surgical Team program to upgrade and enhance the capabilities of 
the Mobile Field Surgical Teams. This was accomplished by modifying 
training, equipment and personnel assigned and revising the tactics, 
techniques and procedures for employment. These enhancements provide 
ground force commanders with enhanced capabilities for damage control 
resuscitation, combat damage control surgery, life, limb and eye-sight 
saving care, and post-op critical care. When the transition is 
complete, the Air Force Medical Service will field a total of 65 Ground 
Surgical Teams.
    This new platform offers several improvements over the previous 
iteration. Ground Surgical Teams are designed to be flexible platforms 
that undergo robust training and have a scalable, modernized equipment 
augmentation package with enhanced capabilities to meet combatant 
commander requirements. While staging out of an Expeditionary Medical 
Support System near the front lines, these small, agile teams can drop 
into remote, austere locations to save lives. This forward deployable 
medical asset can prolong survivability for injured service members in 
denied environments, where typical patient movement and en route care 
is inaccessible.
    At this time, 92 percent of active duty Ground Surgical Team 
positions have been filled, with 63 percent of those individuals fully 
trained. We are currently on schedule to have the remaining positions 
manned and trained by the end of fiscal year 2019.
    Ground Surgical Teams form the core capability of the Expeditionary 
Medical System, which we are also making more flexible to support new 
requirements. A key component of the revised Expeditionary Medical 
System tactics, techniques and procedures is the addition of a second 
Ground Surgical Team to each Expeditionary Medical System +25 package. 
This will allow one team to forward deploy as a surgical element 
without rendering the entire Expeditionary Medical System non-mission 
capable.
    We are also growing our Critical Care Air Transport Team 
capability, which can turn an aircraft into a flying Intensive Care 
Unit, expanding our global patient movement capability. We are taking 
short- and long-term steps to build this capability by training 
additional active duty, Guard and Reserve Critical Care Air Transport 
Team crews, with plans to nearly double our current baseline of 124 
crews to 221 crews by the end of fiscal year 2020. Increasing our 
Critical Care Air Transport Team capability was identified as a 
requirement in the 2017 Air Force Aeromedical Requirements Analysis 
Study, and as a needed improved/enhanced medical mission in the 
deliberate planning process for existing Air Force Operation Plans.
    The Air Force Medical Service responded to this requirement by 
taking immediate and long-term steps to increase our Critical Care Air 
Transport Team capability. First, we increased the number of crews in 
our training pipeline. Second, we identified the lengthy and repetitive 
training process as a potential impediment to future growth. The 711th 
Human Performance Wing and the U.S. Air Force School of Aerospace 
Medicine at Wright-Patterson Air Force Base in Ohio unveiled a 
streamlined Critical Care Air Transport Team course in 2018, making it 
more efficient at training new crews and maintaining skills for 
existing crews. This allows the Air Force Medical Service to sustain 
our increased Critical Care Air Transport Team capability, and grow it 
further should this requirement arise.
    In addition to training more Critical Care Air Transport Team 
crews, the Air Force is expanding our standard aeromedical evacuation 
fleet. We are working to certify the C-5M Super Galaxy for regular 
aeromedical evacuation missions. The C-5M is currently used for 
emergency aeromedical evacuation missions, but certifying it for 
scheduled missions makes our aeromedical evacuation fleet larger and 
more flexible. The C-5M can accommodate up to 300 patients, with a mix 
of ambulatory and litter cases. Because this capacity is so large, we 
are also in the early planning stages of increasing our ground staging 
capability to take full advantage of the C-5M.
    Our commitment to restoring readiness exceeds the areas outlined 
above. I recently issued a new vision and guidance to the Air Force 
Medical Service that positions Full Spectrum Medical Readiness as our 
top priority and aligns with the Air Force's vision. We are 
institutionalizing our Comprehensive Medical Readiness Program, which 
establishes standards for a ready medical force at the individual 
Airman level, enabling Commanders to manage to those standards. We are 
clarifying and standardizing the readiness roles of our Major Command 
Surgeons, Air Force Medical Service headquarters staff and Military 
Treatment Facilities commanders.
    We are also taking another look at our readiness training 
exercises. This means reemphasizing the importance of medical 
participation in wing-level readiness exercises. We are recommitting to 
``training how we fight'' by conducting realistic and challenging 
training and exercises to ensure our medical personnel are ready 
perform to across a multi-domain environment. We are bringing back our 
readiness training exercises, known as ``Medical Red Flag'' to give 
medics additional training in battlefield casualty management. We want 
to ensure our medics are ready to ``fight tonight'' when called on.
    Working with our combatant commanders, we have also updated our 
medical resourcing to revise some of our deployable medical platforms. 
This includes configuration for Air Force Theater Hospitals, the 
Expeditionary Medical System, and the aforementioned increase in 
Critical Care Air Transport Team crews across our Total Force. These 
efforts allow us to improve our capability mix through cost-effective 
modernization, facilitate Joint operations, and build a more flexible 
operational medical force.
    Implementing these numerous, concurrent transformation efforts 
commanded an enormous amount of time, energy and attention. As a 
leader, it is my responsibility to help manage the natural concerns and 
anxieties Air Force Medical Service members are experiencing during 
this time. Author Robin Sharma says ``Change is hardest at the 
beginning, and messiest in the middle, and easiest at the end.'' We are 
in the middle of our change and it's messy and we are working are way 
through it.
    Many Air Force Medical Service members perceive the various ongoing 
transformations with concern and trepidation about how it will impact 
their careers, personal lives and, of course, patients. It is also a 
testament to the incredible talent, resiliency and character of our 
Airmen that we have made so much progress transforming the Air Force 
Medical Service in such a quick time. Despite the challenges and 
anxieties created by transformation, there is also a broad recognition 
of the opportunity before us. By renewing and recommitting our focus on 
operational medical readiness, we will build a stronger, more flexible, 
and healthier Air Force than ever before.
    As the Air Force Medical Service continues down the road of 
multiple, simultaneous modernizations, efficiencies and reforms, we 
will continue to innovate new ways to push medicine forward on the 
battlefield, higher into the sky, and improve it in traditional 
clinical settings. I regularly call on each and every medic, 
irrespective of rank, to be disruptive innovators in their workspace. 
This means finding new solutions that upend the established way of 
doing things. To take risks, to try new ideas, to think without a box. 
This spirit will see the Air Force Medical Service through this 
tremendous change, and will lead to an even stronger organization.
    Chairman Shelby, Senator Durbin, thank you again for the 
opportunity to address you today. I hope that my testimony gives a 
complete picture where Air Force Medicine is going, and the challenges 
we are overcoming to get there. Building an integrated Military Healthy 
System, focused on supporting the readiness and operational medical 
needs of U.S. Armed Forces, will take time and significant efforts from 
all involved, but I am confident we are on the right path to achieve 
that vision. None of this would be possible without the remarkable 
contributions, hard work and constant sacrifices made every day by the 
men and women of the Air Force Medical Service.
    I look forward to answering your questions.

    Senator Shelby. Ms. Cummings.
STATEMENT OF MS. STACY A. CUMMINGS, PROGRAM EXECUTIVE 
            OFFICER OF THE DEFENSE HEALTHCARE 
            MANAGEMENT 
            SYSTEMS
    Ms. Cummings. Chairman Shelby, Ranking Member Durbin, and 
distinguished members of the subcommittee, thank you for the 
opportunity to testify before you today.

                       ELECTRONIC HEALTH RECORDS

    I am honored to represent the Department of Defense as the 
former Program Executive Officer, Defense Healthcare Management 
Systems, PEO DHMS. The mission of PEO DHMS is to transform the 
delivery of healthcare and advance data sharing through a 
modernized electronic health record for servicemembers, 
veterans, and their families.
    In 2015, the DoD (Department of Defense) awarded a contract 
to the Leidos Partnership for Defense Health to deliver a 
modern interoperable EHR (electronic health record), MHS 
GENESIS. MHS GENESIS provides an integrated inpatient and 
outpatient state-of-the-market commercial solution consisting 
of Cerner Millennium, an industry-leading EHR, and Henry 
Schein's Dentrix Enterprise, a best-of-breed dental module.
    In 2017, DoD deployed MHS GENESIS to four pilot sites in 
Washington State. The deployment to these pilot sites allowed 
DoD to better understand technical configuration and adoption 
challenges that are typical in an EHR deployment. Today those 
four pilot sites are using MHS GENESIS to safely deliver, 
manage, and document health care, completing over 100,000 
patient encounters each month.
    In December of 2018, the Assistant Secretary of Defense for 
Acquisition, in coordination with MHS leadership, approved the 
further deployment of MHS GENESIS to the next six Waves 
beginning later this year.

                ELECTRONIC HEALTH RECORD IMPLEMENTATION

    MHS deployment will follow a regional Wave model, a total 
of 23 Waves across three regions in the United States and two 
overseas. This approach allows the DoD to take full advantage 
of lessons learned and experience gained to maximize 
efficiencies in subsequent Waves.
    As we work towards fully deploying MHS GENESIS across the 
DoD, we recognize the benefits of expanding our Federal 
partnerships. In 2018, the United States Coast Guard joined the 
DoD program, and the Department of Veterans Affairs awarded a 
contract to acquire, deploy, and adopt the same EHR as DoD. The 
result of these decisions will be a single integrated EHR for 
all servicemembers, veterans, and their families, fundamentally 
eliminating the need to exchange data between the Departments.
    As the granddaughter, daughter, and spouse of veterans and 
a beneficiary of the Military Health System, I can confidently 
say that PEO DHMS is equally committed to the successful 
deployment of a modern EHR, not just for the DoD, but also the 
Coast Guard and the VA (Department of Veterans Affairs).
    In closing, I would like to introduce and welcome PEO 
DHMS's new Program Executive Officer, Mr. Bill Tinston, who is 
with me today. Mr. Tinston joins us from the Defense Logistics 
Agency, where he served as the Program Executive Officer. He 
brings extensive executive-level experience in information 
technology, program management, and cybersecurity.
    Thank you again for the opportunity to share our progress. 
I look forward to your questions.
    [The statement follows:]
              Prepared Statement of Ms. Stacy A. Cummings
                              introduction
    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 former program executive officer responsible for modernizing the 
military's electronic health record (EHR) system and enhancing 
interoperability and data sharing with the Department of Veterans 
Affairs (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 EHR for 
service members, veterans, and their families. To this end, the DoD is 
committed to three equally important objectives: deploy a single, 
integrated inpatient and outpatient EHR, 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 provide beneficiaries 
more control over their healthcare experience. In June 2017, former VA 
Secretary Shulkin announced his decision to adopt the same EHR as the 
DoD. Since both departments will use the same commercial software 
solution, interoperability is no longer an issue. The DoD and VA will 
deploy one single instance. For the first time ever, medical data from 
the DoD and VA will be stored in a single database, reducing the burden 
for our service members and veterans, placing them in the center of 
their healthcare.
    Our mission aligns with the DoD's National Defense Strategy (NDS) 
to modernize the DoD 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.
                                history
Requirement from Congress
    The DoD was an early pioneer in the development of a centralized, 
global EHR when it introduced AHLTA in 2004. At the time, the private 
sector viewed the DoD's in-house EHR solution as the future of 
healthcare documentation. However, the DoD's health information 
technology (IT) systems are dated, are not integrated, and are not 
seamlessly interoperable with the VA. In the fiscal year 2008 National 
Defense Authorization Act, Congress directed the Secretaries of the DoD 
and VA to develop and implement EHR systems or capabilities that 
provide full interoperability of personal healthcare information 
between the DoD and VA. Additionally, it directed the establishment of 
an interagency program office for the DoD and VA.
    The DoD/VA Interagency Program Office (IPO) was established to lead 
EHR efforts between the DoD and VA to improve the quality of 
healthcare, improve clinical and patient experiences, and increase 
interoperability among the Departments and the private sector. From 
2010 to 2013, the DoD and VA executed a joint program called the 
integrated Electronic Health Record (iEHR) with the goal to create a 
single next-generation EHR system, led by the DoD/VA IPO.
    The iEHR allowed the DoD and VA to improve interoperability through 
a series of focused data sharing initiatives, including the deployment 
of the Joint Legacy Viewer (JLV), which provides an integrated view of 
VA and DoD clinical information. JLV allows the DoD to leverage our 
expanding relationships with private-sector providers, providing 
clinicians a real-time comprehensive, single view of a patient's health 
history whether they receive care in a military or commercial facility. 
JLV is available to DoD providers in AHLTA as well as MHS GENESIS, and 
statistics indicate more than one million patient records each month 
are viewed between the DoD and VA combined.
    Although the iEHR didn't progress beyond the first joint venture 
site, it was an important learning opportunity for the DoD and the VA. 
The Departments fully recognized that medical data interoperability 
requires a steadfast commitment and continuous improvement. Ultimately, 
it was the lack of standardization between the Departments' policies 
that inhibited the ability of the DoD and VA to implement the 
technologies available at the time and define long-term success.
    Capitalizing on the lessons learned, the DoD transitioned from 
multiple EHR systems to a single, integrated commercial-off-the-shelf 
(COTS) capability. The DoD determined the MHS requirements could be 
better met by a state-of-the-market commercial application that would 
allow the DoD to leverage private sector investments in technology and 
establish 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 solely carrying the financial burden.
    Throughout this process, the DoD/VA IPO continues to be jointly 
staffed and jointly funded with collaborative DoD and VA leadership and 
management. As the Departments' EHR missions evolved, the IPO was re-
chartered in December 2013 to lead the Departments' efforts to 
implement national health data standards and establish technical 
standards to increase health data interoperability.
2015 Contract
    In July 2015, the DoD competitively awarded a contract to the 
Leidos Partnership for Defense Health (LPDH) to deliver a modern, 
interoperable EHR. The LPDH team consists of four core partners: Leidos 
Inc., as the prime developer, and three primary partners in Cerner 
Corporation, Accenture, and Henry Schein Inc. This modern, secure, 
connected EHR, 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.
    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. The DoD engaged stakeholders across the 
MHS to identify requirements and standard workflows. The result was a 
collaborative effort across the Services and the Defense Health Agency 
(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.
    Through a tailored acquisition approach, the 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. While there is still much work to do, 
the integration of the commercial data hosting into DoD networks and 
systems represents a new direction in Pentagon IT culture and practice. 
This innovative approach set the bar for COTS systems and commercial 
partnerships with the DoD and other Federal agencies in the future.
Pilot Sites
    We employ industry standards to optimize the delivery of MHS 
GENESIS. Rollout across the MHS follows a ``wave'' model. Pilot sites 
in the Pacific Northwest were the first wave of military treatment 
facilities (MTFs) to receive MHS GENESIS, which began February 2017 at 
Fairchild Air Force Base (AFB) just 19 months after contract award, and 
officially concluded in January 2018 at Madigan Army Medical Center 
(MAMC). The DoD's deployment to four pilot sites spanned a cross 
section of size and complexity. The lessons learned from the DoD pilot 
sites will make worldwide deployment of MHS GENESIS to the DoD, the 
United States Coast Guard (USCG) and the VA successful. As of today, 
those four pilot sites continue to use MHS GENESIS to safely deliver, 
manage, and document healthcare--completing over 100,000 patient 
encounters each month.
    Deployment of MHS GENESIS 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 the 
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 2023.
                     expanding federal partnerships
    Last year, the USCG joined the DoD's EHR implementation and the VA 
entered into a contract to implement the same EHR as the DoD. The 
result of these decisions will be a single, integrated EHR for all 
service members, veterans, and their families. The deployment of a 
single integrated EHR for the DoD, VA, and the USCG will enable more 
efficient, highly reliable, safe, and quality care. This solution will 
focus on clinical services, interfaces, and a shared infrastructure to 
enable shared workflows, user roles, order sets, training, and 
cybersecurity standards. The health and safety of our most important 
asset--our people--is our highest priority. I recently spoke with the 
Commanding Officer at one of our pilot sites and he said:

    ``Despite the challenges of rolling out a new electronic health 
        record, the new EHR is much more integrated and capable than 
        our legacy systems. Features such as bar code scanning of 
        inpatient and Labor & Delivery medications and blood 
        transfusions, as well as enhanced medication reconciliation and 
        Patient Portal features are a few of the features that are 
        bringing our EHR into the 21st century. We are only beginning 
        to scratch the surface of what MHS GENESIS can do for our 
        patients to enhance safety and continuity of care across the 
        enterprise. We are excited about future interoperability and to 
        ultimately have the DoD and VA on the same electronic health 
        record platform. The future is bright.''

    Partnering with the VA and USCG fundamentally eliminates the need 
to exchange data while ensuring interoperability with private 
healthcare providers and continuity of care for all of our service 
members. A single, integrated EHR for the DoD, USCG, and VA for the 
first time provides the transitioning service member with the complete 
longitudinal record in one place at the time of need to support 
healthcare delivery and benefits adjudication seamlessly and without 
the need to move data from one system to another. This patent-centered 
approach allows us to drive national interoperability and data 
standards to benefit service members, veterans, and all Americans.
                            lessons learned
Change Management
    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.
    Following deployment to the pilot sites, PEO DHMS implemented an 
eight week stabilization and adoption period in January of 2018. During 
this time, we optimized MHS GENESIS to establish a baseline 
configuration, focusing on training, adoption of workflows, and change 
management activities. The DoD identified several lessons learned 
regarding training. MHS GENESIS training focused on ``buttonology'' 
rather than a workflow approach. The DoD is resolving the training 
approach through three fundamental changes to the MHS GENESIS training 
strategy. First, workflow adoption in key areas is being trained in 
advance of MHS GENESIS deployment and being led by the functional 
community. Second, training is being reconfigured to focus on role-
based workflow training that teaches the user how to perform key tasks 
using MHS GENESIS. Third, the MHS will utilize a peer expert program, a 
proven commercial best practice that utilizes an updated training 
environment to deliver team based training and just in time training 
during and after Go-Live. Our pilot deployments also provided lessons 
learned for future training by reducing redundant training content for 
users with multiple roles, transitioning from the aforementioned 
``buttonology'' based training to a scenario and workflow based 
approach, and ensuring the training technical environment is in sync 
with the production environment.
Operational Testing and User Feedback
    The DoD values the feedback from end users, stakeholders, and the 
test community. In December 2018, DoD leadership evaluated the cost, 
performance, and schedule of the MHS GENESIS program and made the 
decision to approve continued deployment. Among the many factors that 
informed this decision is the Initial Operational Test & Evaluation 
(IOT&E) report. Approximately 90 percent of the total Incident Reports 
(IR) captured at our pilot sites fall into workflow and configuration, 
end user knowledge of the system, policy issues, or recommendations for 
future enhancements. The remaining 10 percent of the total IRs can be 
traced to a defect in the software solution that makes up MHS GENESIS. 
Since the IOT&E report, the DoD continues to progress with responding 
to user feedback; 100 percent of the defect IRs that the functional 
community categorized as high priority have been resolved and 
recommended for closure. The DoD notes the report recommends we 
``conduct Follow-on Operational Testing & Evaluation at the next 
fielding to evaluate corrective actions and revised training, to inform 
future fielding decisions.'' The DoD concurs with this recommendation 
and believes follow-on testing will validate the improvements made to 
enterprise work processes, the system solution, and training that 
impacts end users at our next facilities.
Federal Electronic Health Record Modernization Working Group
    On September 28, 2018, the Secretaries of Defense and Veterans 
Affairs signed a Joint Commitment Statement pledging to align VA and 
DoD strategies to implement an interoperable EHR system. In response to 
this commitment, the DoD and VA evaluated program dependencies such as 
infrastructure, incorporation of clinical and business processes, and 
other requirements from the functional, technical, and programmatic 
communities. DoD and VA leadership determined the optimal and lowest 
risk alternative is to re-charter the DoD/VA IPO into the Federal 
Electronic Health Record Modernization (FEHRM) Program Office. The 
FEHRM, which will incorporate key members of the IPO as well as DoD and 
VA program office staff, will provide a more comprehensive, agile, and 
coordinated management authority to execute requirements necessary for 
a single, seamless integrated EHR.
Leadership Commitment is Critical to Success
    Change is always hard. This is especially true when deploying a 
single, integrated inpatient and outpatient EHR, while standardizing 
enterprise wide workflows across more than 400 military treatment 
facilities. Research in 2017 from KLAS identifies leadership 
engagement, education, and good governance as factors that contribute 
to the success of an EHR implementation. A recent study shows the JPS 
Health Network ranks in the 99th percentile for provider job 
fulfillment. This team credits their success to executive leadership, 
specifically highlighting that ``senior executives lead by example and 
expect all clinicians and employees to demonstrate service to others.'' 
The DoD leadership agrees and is heavily engaged and invested in the 
success of MHS GENESIS. We continually take lessons learned from 
training, adoption of workflows, and change management activities.
                                progress
Patient Safety and Cyber Focus
    We work closely with the MHS community to continuously refine and 
enhance the system to meet the needs of the military health community 
based on ongoing, real-time feedback from the testing sites. Patient 
safety and protecting beneficiaries' personal health data are the two 
highest priorities for the MHS and those priorities guide the 
implementation of MHS GENESIS.
    Since the inception of the MHS GENESIS program, PEO DHMS has worked 
closely with the DoD Chief Information Officer (CIO), the DHA CIO, and 
the MHS GENESIS vendor team to secure beneficiary data by leveraging 
commercial and DoD best practices, including architecture, tools, and 
processes. A commercial datacenter hosts MHS GENESIS. It is both 
physically and virtually segregated within the datacenter and undergoes 
continuous scanning to identify and mitigate risks. Further, DoD 
experts monitor and defend it to meet DoD cybersecurity standards, and 
as a result, DoD mitigated nearly 90 percent of all identified risk to 
moderate, low, or very low.
    The DoD strives to maintain the most advanced information assurance 
(IA) capabilities in the world. To leverage these capabilities, DoD IA 
tools and personnel are embedded within the datacenter boundary to 
ensure the data MHS GENESIS exchanges is monitored, protected, and 
defended from cyberattacks. The DoD also established continuous cyber 
assessments as a service, leveraging DoD's formal Cooperative 
Vulnerability and Penetration Assessment and Adversarial Assessment 
processes to improve the overall cyber posture of MHS GENESIS. This 
innovative approach to public/private partnering not only improves the 
cyber posture for the DoD but also the vendor's commercial customers 
and the healthcare industry in general.
    MHS GENESIS incorporates several IA improvements over the legacy 
systems it replaces, including mandatory use of the Common Access Card 
and Public Key Infrastructure, a single instance of software 
architected to replace hundreds of distributed legacy instances, and 
secure implementation of medical devices. On November 29, 2018, the DoD 
CIO, who serves as the Authorizing Official for MHS GENESIS, renewed 
the program's Authority to Operate with Conditions for 12 months.
Metrics, Global Trigger Tool, & Patient Safety Enhancements
    Cyber security and patient safety remain our top priorities, and we 
are committed to getting the deployment of MHS GENESIS right to ensure 
the delivery of safe, quality care to service members, veterans, and 
their families.
    Many improvements in the adoption of MHS GENESIS were seen in 2018 
that led to more effective care. For example, there was a 45 percent 
increase in referrals processed in one business day; a 38 percent 
decrease in the time nurses spent in the EHR in outpatient care 
settings; a 26 percent decrease in the total time providers spent in 
the EHR for ambulatory clinics; a 16 percent increase in operating room 
procedure volume; a 21 percent decrease in the provider order time per 
patient at all pilot sites; and 2,300 duplicate lab orders avoided.
    Patient care and medication safety improvements are being 
implemented in MHS GENESIS. Since 2018, the pilot sites realized the 
following achievements: a 32 percent increase with the number of 
patients seen in outpatient care settings; an 8.1 percent improvement 
in turnaround time for STAT chemistry lab tests; an 88.5 percent 
average in discharge medication reconciliation compliance; an 84 
percent average Bar Code Medication Administration compliance; and a 63 
percent increase in new prescriptions and refills.
    With any EHR deployment, there is potential for increased error. 
This is expected and seen in commercial marketplace deployments. The 
DoD carefully monitored patient safety throughout the deployment 
through its Joint Patient Safety Reporting System (JPSRS), as well as 
with the Global Trigger Tool (GTT). Both the JPSRS and the GTT are 
recognized safety monitoring processes and tools used throughout the 
healthcare industry. We continue to use the GTT, which was developed by 
the Institute for Healthcare Improvement to leverage chart review by 
trained clinical abstractors of ``triggers'' or indicators of adverse 
events. Once a trigger is identified, the record is examined more 
closely for evidence of harm. While it is measured as a rate, GTT data 
can also be used as a baseline for ongoing safety monitoring during 
deployment of MHS GENESIS. Comparing the data from our pilot sites to 
other military treatment facilities using legacy systems, there was no 
increase in patient safety harm events prior to and following the 
deployment of MHS GENESIS at the pilot sites.
Service to Enterprise Transition
    Lessons learned from the pilot site fielding indicate that 
enterprise level management is a more effective way to field MHS 
GENESIS. Standard workflows and processes continue to prove beneficial 
to system implementation and end user adoption. As the DoD implements 
Congressional direction to transition from service unique to 
enterprise-managed healthcare, MHS GENESIS will enable further 
standardization and drive increased efficiency across the enterprise.
Waves 1-6 Status & Defense Acquisition Board Update
    MHS GENESIS completed deployment to our pilot sites, applied 
lessons learned and feedback from users and the test community, and is 
on track for full deployment by the end of calendar year 2023. Our 
deployment to four pilot sites in 2017 enabled the DoD to gather 
feedback in order to further configure MHS GENESIS for future wave 
deployments. PEO DHMS received exciting news in December 2018 when 
participating in the DoD EHR Defense Acquisition Board assessment of 
the DoD Healthcare Management System Modernization Program Management 
Office's readiness for a Limited Fielding Decision. The Assistant 
Secretary of Defense for Acquisition affirmed MHS GENESIS met the 
criteria for approved deployment to Waves 1-6 fielding sites, which is 
in line with the full deployment schedule. The next deployment Wave 
includes: Travis Air Force Base, Naval Health Clinic Lemoore, Presidio 
of Monterey, Mountain Home Air Force Base, and surrounding clinics.
                               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 pilot sites was an important 
milestone in implementing what will be the largest integrated inpatient 
and outpatient EHR in the United States. Because of its tremendous 
impact not only on military healthcare, but on healthcare across the 
United States, I personally traveled to the Pacific Northwest on 12 
separate occasions ahead of and during the rollout to our pilot sites. 
I engaged with the leadership as well as system users to gain a better 
understanding of the overall impact on providers. While we experienced 
some challenges, we continue to progress, and providers as well as the 
DoD are seeing the benefit. I recently received a quote from a 
provider:

    ``Modernization of the DoD Electronic Health Record was a 
        necessity. MHS GENESIS became our opportunity. It shined a 
        light onto the Military Health System, illuminating the best 
        practices throughout the MHS and identifying areas needing 
        improvement. It caused us to breakdown not only the barriers 
        between services and the barriers between the DoD and the VA, 
        but also the barriers between all specialists within a 
        hospital's or clinic's care continuum. Never before have I seen 
        nurses, physicians, surgeons, and transfusion technicians sit 
        side-by-side and collaborate as intensely as I witness daily 
        with MHS GENESIS. Every day, multi-disciplinary teams work 
        across the pilot sites and the country to bring timely, 
        relevant, evidenced-based practice to MHS GENESIS. This is more 
        than an Electronic Health Record; it is a collaborative health 
        record serving our nation's service members, veterans, and 
        their families. There is much work to be done to deploy and 
        optimize MHS GENESIS, but it is a great leap forward in support 
        of the healthcare of this deserving population''.

    In closing, I welcome PEO DHMS' new program executive officer, Mr. 
William J. Tinston. Mr. Tinston joins us from the Defense Logistics 
Agency (DLA), where he served as Program Executive Officer. In this 
role, he was responsible for the management and oversight of DLA's 
Major Automated Information Systems programs and special interest 
programs. His strong acquisition, business systems, and executive 
experience will provide superior leadership as we continue to deploy 
relevant health IT solutions to the DoD along with our Federal 
partners. Mr. Tinston is fully engaged with the progress of the FEHRM 
Working Group and will work with this team to re-charter the IPO, 
integrate acquisition management, and coordinate the EHR deployment in 
support of the DoD, USCG, and VA. We began official turnover March 11, 
and I transitioned to my new position in the Office of the Assistant 
Secretary of Defense for Acquisition on March 25.
    While we are well on our way, PEO DHMS continues to progress as an 
organization striving for 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 them 
to our customers. As a partner in our progress, we appreciate Congress' 
interest 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 MEDICAL MANPOWER REDUCTIONS

    I will start again with Admiral Bono. Can you explain, 
Admiral, why the Department is reducing its uniform military 
health professionals and how reductions will be tailored to 
create the appropriate force mix of health specialists that you 
need?
    Admiral Bono. Yes, sir, Mr. Chairman. Thank you very much.
    So this is an area that we have been working very closely 
with the services. While I cannot speak directly to those exact 
billets that the services have identified, what I can speak to 
is how we are working together to make sure that our patients 
continue to have the access to the care that they need as well 
as the specialty services. So, in that regard, we will be 
looking at different models of either hiring, contracting, or 
the use of our networks.
    We are also moving to a market-based approach to the 
delivery of our care, where we will be sharing resources across 
all of the services within geographic areas.
    Senator Shelby. Thank you.
    Admiral Bono. Thank you, sir.

                    ELECTRONIC HEALTH RECORD ROLLOUT

    Senator Shelby. Ms. Cummings, could you provide a little 
more detail on the lessons learned from the initial rollout and 
the corrective actions that will be put in place to ensure a 
smooth deployment of the record to the remaining medical 
facilities? In other words, is MHS GENESIS still on track for 
full deployment across the Military Health System by 2023, or 
has it slipped?
    Ms. Cummings. Yes, it is on track for full deployment by 
the end of calendar year 2023.
    Some of the lessons that we learned through our pilot 
sites, and that we have made mitigations for, is first the 
network infrastructure. We need to have a stable network 
infrastructure in place several months prior to----
    Senator Shelby. That was a valuable lesson, was it not?
    Ms. Cummings. It was a very valuable lesson.
    Senator Shelby. Putting it out like a pilot program.
    Ms. Cummings. Yes. At our pilot sites, we were deploying 
the modern network at the same time we were deploying the 
modern EHR, and that ended up being too much change and too 
much instability for the sites to be able to handle and react 
to. So we have put in place a 6-month buffer. So we will deploy 
the modern network.
    Admiral Bono has responsibility for that. She is on track, 
and we have laid out our future deployment schedule based on 
that requirement of 6-month stability for the network.
    Senator Shelby. What will this do for this uniform service?
    Ms. Cummings. So the modern network is actually built in 
with cybersecurity in mind. So what we are doing is we are 
creating the bandwidth required to be able to have fast access 
to the system, but at the same time, we are creating security 
that is built in around the way the network is designed as well 
as the medical devices that are on the network. Under MHS 
GENESIS, we will be able to connect and transfer data with 
medical devices at a much higher rate than we are able to do in 
our legacy systems.
    Senator Shelby. Thank you.
    The recent National Defense Authorization Act contained a 
number of provisions that substantially transformed the 
Military Health System, including transferring responsibility 
for managing more than 400 military treatment facilities 
currently operated by the services to the Defense Health 
Agency.

   MILITARY TREATMENT FACILITIES TRANSITION FROM SERVICES TO DEFENSE 
                             HEALTH AGENCY

    We will start with you, Admiral Bono. Could each of the 
Surgeons General comment on how this transition is going, and 
are there concerns in the transition in the management and 
administration? Admiral.
    Admiral Bono. Yes, sir. Thank you very much.
    First, I would like to be able to thank Congress for giving 
us this opportunity. This allows us to modernize----
    Senator Shelby. Talk into the mic a little bit.
    Admiral Bono. Sorry.
    I would like to thank Congress for giving us this 
opportunity. This allows us to transform our Military Health 
System to start marrying some of the best practices that we see 
in industry, and that is, as we know, that by collectively and 
concentrating some back-office functions, we are able to get to 
better standardization and more reliable outcomes.
    So, as we are looking at that and taking advantage of those 
opportunities in the NDAA, we have been working very closely 
with the services to make sure that we identify those best 
practices that we can apply to our Military Health System.
    Senator Shelby. General West, do you have a comment?
    General West. Yes, Mr. Chairman. Thank you for that 
question.
    Again, the success of our MTFs is 100 percent for I think 
all of us sitting here because we know that it is a no-fail 
mission, because our family members, our servicemembers, our 
retirees are seen in these facilities. So it is imperative that 
the DHA is successful, and so we have been working with Admiral 
Bono and her team, with our fellow services to ensure that 
there is no gap in care when that occurs.
    As Dot, my colleague, mentioned, the change in the middle, 
the middle part is a little bit messy, so that is when you 
identify those areas during the transition that need to be 
worked on, alternate solutions, more attention placed on.
    So the transition that we are seeing at Womack Army Medical 
Center, we have the dual-hatted commander that is there now is 
looking through the processes of making sure that the 
operational requirements and the senior commander requirements 
for the installation are met as well as the healthcare delivery 
piece, so it is the mix of readiness and healthcare delivery 
benefit, and I think that is progressing well. With the path 
that we have forward, I know we will be successful in that as 
long as we make sure we look at those gaps and then provide 
resources and alternatives to make them successful.
    Thank you.
    Senator Shelby. Admiral.
    Admiral Faison. Sir, I think the transformation is 
incredibly complex, but it also offers incredible 
opportunities.
    Senator Shelby. What is the biggest challenge?
    Admiral Faison. I think we are doing something very new. We 
are taking----
    Senator Shelby. Because it is new?
    Admiral Faison. Sir?
    Senator Shelby. Because it is new?
    Admiral Faison. Well, it is basically taking three global 
health systems and merging them into one, and there are 
enormous benefits to be had. So we are working through the 
complexities. As General West said and as Admiral Bono 
mentioned, there is a lot of moving parts to this, but I think 
it is going well, to be honest with you. We are learning some 
valuable lessons through Phase I that we can apply to this.
    The opportunity for us is to be able to refocus exclusively 
on readiness of our medical servicemembers to get them ready 
for combat casualty care in the next fight and to provide 
better care and support for our servicemembers who did not get 
a break in operational tempo. So I think there is enormous 
opportunities as we work through this together.
    At the same time, we all know that we have to be successful 
together because that represents----
    Senator Shelby. How much more efficient will it be?
    Admiral Faison. That is a great question, sir.
    I am hopeful we will see increased efficiencies as we 
standardize provision of care, as we standardize how clinics 
are run.
    The good news is for our servicemembers, they ought not to 
have to guess what clinic hours are or how clinics operate or 
pharmacies operate as they PCS from station to station. There 
is enormous opportunities and efficiencies to be had there.
    As we hand that off to DHA to do for us that will allow us 
to focus on getting ready for the next fight.
    Senator Shelby. General. General Hogg.
    General Hogg. Yes, sir.
    So the transformation, I believe is going well with some 
difficulties because you are working with three different----
    Senator Shelby. Explain what you mean by difficulties. We 
know they are going to be difficult.
    General Hogg. Yes. Again, as----
    Senator Shelby. The challenges.
    General Hogg. As Admiral Faison said, you have three health 
systems that you are trying to merge into one health system, 
and that health system not only delivers benefit, but also 
delivers medical readiness.
    We also do that a little bit differently because our core 
missions are different. So, in the Air Force, our core mission 
in medical readiness is our medical evaluation. Navy is sea and 
under sea. Army is ground medicine. So we are a little bit 
different, and so trying to bring all those four cultures 
together is challenging.
    But the one thing is we are committed to making this 
successful. It is the right thing to do, to allow the services 
to really focus in on readiness and bring that to the next--
future, and to be supportive of the Defense Health Agency in 
delivering the benefit.
    These are mutually supportive. They are not exclusive. We 
are not divesting of the benefit.
    Senator Shelby. Senator Durbin.
    Thank you.
    Senator Durbin. Thank you, Mr. Chairman.
    General West, thank you for your service. You mentioned 
this may be your last opportunity to testify. Thank you for the 
relationship and information you provided our office. I wish 
you the very best.

                       SERVICEMEMBER TOBACCO USE

    Currently now, fewer than 14 percent of American adults use 
tobacco. Does anyone know what the percentage is of members of 
our military who use tobacco products?
    General West. Sir, I can speak to that. In our recent 
report, our Health of the Force, where we look installation by 
installation, there is a wide range, a low of 10 percent at 
some of our installations, up to a high of in the mid-20s. So 
there is a higher use of tobacco, I know in the Army, within 
our servicemembers.
    Senator Durbin. A November 2017 report, as you mentioned, 
an installation-specific review found that 26.4 percent of 
soldiers use tobacco, almost twice the national average.
    Since most of you are medical doctors, have a background in 
medicine, is there anyone on this panel who believes that is a 
good thing, that over a fourth of our military are using 
tobacco?
    General West. Sir, absolutely not, from my perspective, and 
I have mentioned before, there is no minimum daily requirement 
for nicotine. There is not a nutritional need or need for 
anyone to have tobacco in their system, so that is--and I think 
the Surgeon General of the United States back over 50 years ago 
identified that tobacco is not good for you, and it is even 
printed on the cigarette packages.
    Senator Durbin. So it turns out that about a third of the 
military smokers took up the habit after they joined the 
military. It appears that there is a pro-tobacco culture in our 
military, which has more and more of our men and women in 
uniform who are using tobacco which all of us I hope concede is 
not a good thing for them individually or for our military in 
general in relation to their performance of duty and their 
ability to live long and healthy lives.
    What will it take? I mean, when they go through basic 
training and every one of the branches of the service, they are 
prohibited from using tobacco products, so it appears that 
after they are finished with basic training, all bets are off. 
It is tobacco in every direction. What am I missing here? If 
the rest of the world is discovering the danger of tobacco, why 
is not our military?
    Admiral Bono.
    Admiral Bono. Thank you, sir.
    Actually, we do recognize the dangers of tobacco, and while 
we recognize also that we have a higher rate than the normal 
population, there are several efforts that are ongoing.
    First, we had the Healthy Base Initiative, where we have 
declared several bases as tobacco-free areas, tobacco-free 
zones. We have taken out tobacco sales out of many of our 
nearby shops that make it very easy to get access to that.
    Then the other aspect that we provide our servicemembers is 
tobacco cessation, not only training, but also products, and we 
do see that when we put people through tobacco cessation 
programs, that we are able to drop the usage of tobacco 
products, not just smoking inhalation products, but all tobacco 
products by 10 percent.
    Now, being able to sustain that means we have to continue 
to create the environment in which they continue to choose to 
avoid tobacco. So we recognize the dangers. We do have some 
places. We do have some mitigations in place, but you are 
absolutely correct. Part of what we have to do is continue to 
create that environment that encourages----
    Senator Durbin. Admiral, are you aware that it is because 
this committee has added specific language that we finally 
eliminated the discount that was being offered----
    Admiral Bono. Yes.
    Senator Durbin [continuing]. On tobacco products on base 
exchanges?
    Admiral Bono. Yes, sir. That is why I threw that in there.
    Senator Durbin. Thank you for doing that.
    [Laughter.]
    Senator Durbin. So let us move to the next level. Let us 
get beyond tobacco into the real world of vaping and e-
cigarettes, an addiction to nicotine. It may not include 
tobacco, but it is an addiction.
    There have been some instances, I think more than 60 cases, 
where members of our military were using these vape oils, and 
it turned out to be serious. Does anyone have any knowledge of 
that experience?
    General Hogg. Sir, I do not have knowledge, specific 
knowledge. I know our members are turning to vaping.
    What we are doing in the Air Force Medical Service as well 
as concentrating on cessation, I think we are missing part of 
the puzzle, and that is more about preventing initiation of 
smoking. So we have partnered with the University of Virginia 
to look at developing programs that are focused on behaviors 
that would decrease members' desire or thought process in even 
starting to use tobacco products, whether it is smoke or 
smokeless or vaping. So we are in the process of doing that and 
using evidence-based practices to try to reduce that.
    Senator Durbin. I know this will not make me popular with a 
fourth of the military and others, but we have got to get much 
more aggressive on this. In the rest of the world, the 
nonmilitary world, we are seeing an inundation of vaping and e-
cigarettes in junior high schools and high schools across the 
United States.
    These kids are taking this up because JUUL, which is now 
owned largely by a tobacco company, has decided they want to 
transition people from cigarettes into an addiction to nicotine 
with their vaping products, and although they proclaim 
publicly, ``Oh, we are not appealing to children,'' give me a 
break. Ask any teacher or principal in the school near your 
home what is going on with vaping.
    It is no wonder it is now in the military. Does it not 
stand to reason that we would make dependence on tobacco or 
vaping one of the conditions when we grade a soldier or sailor 
or airman's performance and eligibility for promotion?
    General West. Sir, that is something that I think our 
senior leaders would have to weigh in on to consider, but I 
know back to the question that you had, sir, about the 
experience with the vaping, the vape oils and the concerns and 
the adverse health events we had, the Sergeant Major of the 
Army actually put out a bulletin to all the servicemembers 
regarding that and the usage of that warning against the 
hazards of it.
    But it is going to be education, education, education, and 
then changing the culture of the, I guess, glamorization of 
tobacco use.
    Senator Durbin. I do not want to come down too hard, but he 
did not just put out a bulletin. He reissued the bulletin----
    General West. Yes, absolutely.
    Senator Durbin [continuing]. From an earlier time. So, 
clearly, there is progress that needs to be made here.
    I do not understand if we are concerned about public 
health--and you are medical professionals--why this is not 
front and center. We can just see the obvious problem that we 
have in our military, and it appears that the culture of 
tobacco in the military is so engrained that we cannot attack 
this, we cannot deal with it head on, and it troubles me. The 
rest of the world seems to be waking up, but why is our 
military so far behind?
    Thank you, Mr. Chairman.
    Senator Shelby. Senator Moran.
    Senator Moran. Chairman, thank you and Senator Durbin for 
the hearing today, and thanks to our panelists for being with 
us.
    I want to start with General West. General West, you did me 
a favor, although I hope you think I did you a favor, but thank 
you for presenting the Meritorious Unit Commendation to the 
women of the 688th here in Washington, D.C., last week.
    General West. Thank you, sir. It was my honor to do it, 
and, yes, sir, you did do me a favor. It was awesome.
    Senator Moran. I really was not fishing, but I know it 
was--I met with these women soldiers at Fort Leavenworth. It 
was a great experience for me, and I hope--I just know it was 
for you as well.
    General West. Yes, sir.
    Senator Moran. Thank you. And I know your presence there 
would be very meaningful to them. This is a group of African 
American women who in World War II delivered the mail in Europe 
in a segregated way and honored their country and did their job 
so well. It was a great moment to meet these women. I 
appreciate your presence.
    General West. Well, thank you. Thank you, sir.

                             TOXIC EXPOSURE

    Senator Moran. In a couple of issues for all of you--I 
guess one of them for all of you--I am working with a number of 
my colleagues but have an interest in the issue of toxic 
exposure.
    I would like to know that each of you would support our 
efforts to get the DoD and the VA on a similar page and working 
together as we do a couple of things.
    First of all, research. We have introduced legislation that 
became law. One of the things we are paying attention to is 
intergenerational consequences of exposure to toxic substances. 
The scientific community has--in a study that was required--a 
study outside of the VA has indicated that there is a need for 
additional research into this topic, and that, of course--that 
research will require information.
    We have worked to get DoD to make records, location, and 
exposure circumstances available certainly to veterans and to 
retired military, but it would be useful to me to hear from 
each of you that you are understanding of this issue and 
willing to devote your staff's time with the Department of 
Veterans Affairs toward response to toxic exposure from Vietnam 
to Iraq and Afghanistan.
    General West and Admiral.
    General West. Yes, sir, absolutely. The U.S. Army Medical 
Commands--the Public Health Center really devotes a large 
amount of their time to that toxic exposure, burn pits, for 
example, registries to determine whether or not our 
servicemembers and even family members as well are exposed to 
any toxic agents, not only where they work, where they are 
deployed, but also where they live.
    We have been asked to check air samples. We have an 
industrial hygiene team, members under the Public Health Center 
that goes out, and they do EPICONs, where they actually go to 
see if there is any epidemiological--case-by-case, if 
requested, to look to see if there are any issues in an 
individual's environment.
    Then on a strategic level, again, those registries that 
identify locations and try to triangulate locations with 
symptoms and in any type of research that might assist us in 
determining any countermeasures or mitigating strategies, if 
individuals are going to be in that environment.
    Senator Moran. Thank you for those details.
    I am interested in making certain that the Department of 
Defense sees this as an issue, both for DoD and for the VA. Is 
that true, Admiral and General?
    Admiral Faison. Yes, sir, absolutely.
    As I shared in my opening statement, we view care of our 
servicemembers and their families as a sacred trust that is 
placed in our hands, and part of that is making sure that we 
understand the environments from which they go and serve and 
that we understand the health consequences of that.
    As General West said, we have public health commands, all 
of us, that are very actively engaged in research, in 
epidemiological surveys and studies to understand the potential 
impacts of toxins and other environmental factors on the health 
and wellness of our servicemembers, their families, not only 
during service, but after service, as you know, since many of 
these do not manifest for quite some time, so absolutely 
engaged in those partnerships.
    Thank you.
    General Hogg. Yes, sir. The Air Force Medical Service is 
also actively engaged and understands the need to not only 
research exposure and what that does to our airmen and our 
families and the community and having registries available so 
that it can be tracked. As Admiral Faison said, many of these 
do not manifest themselves until later down----
    Senator Moran. Thank you very much.
    The National Academy of Sciences did the most recent study, 
and they are suggesting, encouraging that DoD start monitoring 
exposure so that we can prevent the exposure obviously from 
occurring in the future.
    The second issue I want to raise, this one perhaps to you, 
General West, is suicide prevention and mental health issues.
    Senator Tester, who just joined us, he and I have 
introduced legislation related to these two issues, to suicide 
prevention and mental health issues. It is again a request that 
the Department of Defense and the services commit to working 
with the Department of Veterans Affairs so that we can 
coordinate.

             DOD/VA COLLABORATION AND WOUNDED WARRIOR CARE

    Much of what we seem to know today is that there has to be 
a continuum of care, treatment, attention, love, compassion for 
those who are departing our military and becoming veterans, and 
that the space in that time is one of the most important as we 
find opportunities for our servicemen and -women to pursue 
careers outside the military. And so, again, I would highlight 
the importance of DoD and VA cooperating.
    General West, you were of extreme help to me, and I am 
extremely proud of what I see at Fort Riley today, Fort Riley, 
Kansas, in regard to Irwin Army Hospital, and I thank you for 
your help in that regard.
    Just next door to that new hospital, though, is one of the 
few remaining Warrior Transition Units, and I would expect you 
to be familiar with the National Intrepid Center for 
Excellence, NICoE.
    I would like to see the opportunity for a NICoE to exist at 
Fort Riley in part because of the warrior transition, the new 
Army hospital and 25,000 veterans that surround Fort Riley, and 
I would ask you to help me understand the process by which the 
Army works with the foundation to make determinations. There 
are eight sites across the country. We would like to see, to 
learn why we cannot be on a short list of a place for a next 
facility, and I would appreciate your willingness to work with 
me to understand how you, the Army, and I can be of help in 
making that case to the foundation.
    General West. Yes, sir. I appreciate the opportunity to 
answer that.
    As our wounded warrior population has thankfully decreased 
from a high of over 20,000 when we had 45 Warrior Transition 
Units across the Army down to the current 14 that we have Army-
wide for about a population of about 2,000, where we have our 
assets located throughout our installations is determined again 
by the population density for those areas.
    I know working with the foundation, not only with the Army, 
but they work with the other services because they also try to 
pick if there is a location, if there is joint, if there are 
other services that can benefit from that. But I will, sir, get 
with you on the Intrepid Foundation.
    Senator Moran. Thank you. That is a good point. Not every 
veteran of those 25,000 are Army veterans around Fort Riley.
    General West. Yes.
    Senator Moran. Admiral Bono, just to conclude, I would ask 
your help in our veterans committee. It seems to be a theme in 
my conversations today, but we are having a hearing next week 
in regard to access standards for the new John McCain MISSION 
Act.
    Admiral Bono. Yes, sir.
    Senator Moran. Part of the efforts that went into that 
legislation were to study, to inform ourselves about DoD and 
how they allow military retirees to access healthcare, and so 
the access standards in that legislation are based upon what I 
think is pretty sound science. And I would welcome your input 
to the Department of Veterans Affairs. I hope that you would be 
asked to testify, and if I can get you to assist me in 
informing my colleagues about this topic, I would welcome that.
    Admiral Bono. Sir, I would be very happy and delighted to 
do so, and I am very much in support of what you are trying to 
do.
    Senator Moran. Thank you.
    I will submit for the record a request for information from 
you, Admiral, about physical therapist regulations and the 
timeframe we are on in getting those completed.
    Admiral Bono. Yes, sir.
    Senator Moran. Thank you, ma'am.
    Admiral Bono. Thank you.
    Senator Moran. Thank you, Chairman.
    Senator Shelby. Senator Tester.
    Senator Tester. Thank you, Mr. Chairman.
    Thank you all for being here. It appears that you are going 
to get hit by VA committee people back to back to back with 
Moran, myself, and then probably Senator Boozman, but I 
appreciate you all being here.

             DOD/VA ELECTRONIC HEALTH RECORD IMPLEMENTATION

    I am going to start with you, Ms. Cummings. The Department 
of Defense continues to move forward the deployment of your new 
electronic health record. There is no top governance in place 
between the DoD and the VA. I think every decision you make is 
going to impact not only the Department of Defense but the VA.
    So the question becomes about interoperability between the 
two, and we have been here for 10 years or longer talking about 
this and, quite frankly, probably have more money invested in 
this, this year, than is in Montana's entire budget. So it is a 
fair amount of dough.
    Who are you working with, with the VA, when it comes to 
EHR?
    Ms. Cummings. So we actually have a very close relationship 
with the VA. I have been working with the EHR Executive 
Director, who is John Windom; the Under Secretary of Health, 
Dr. Stone; the VA CIO, Mr. Gfrerer; as well as other senior 
leaders across the VA.
    Senator Tester. So you feel--and this is just your opinion, 
but you feel pretty confident that what has been going on right 
now, VA has--the communication has been there so that you and 
the VA know what direction you are headed and so that it works 
for both the Department of Defense and for the VA?
    Ms. Cummings. So I think up until now, we have been focused 
on governance, which allows us to make decisions through a 
structured process.
    Senator Tester. Yes.
    Ms. Cummings. My personal opinion is that we should 
actually be working much closely together, and we have been 
talking to the----
    Senator Tester. How can I help?
    Ms. Cummings. So we have been working, looking at the 
language associated with the Interagency Program Office, the 
DoD-VA Interagency Program Office, and how we can use that 
office to be more of a management structure than a governance 
structure. I think we have made a lot of progress with the VA, 
and I think we are very, very close to a decision that we will 
be able to communicate that will create more of an integrated, 
programmatic, and technical, organizational construct so that 
we can make decisions together.
    Senator Tester. Okay. I am always concerned about 
technology because the 20 years I have been involved in State 
and Federal Government, I cannot tell you how many tens of 
billions, if not hundreds of billions of dollars have gone out 
the window, and we have not ended up with a damn thing.
    I really hope that you hold contractors accountable to the 
dime and make sure that if communication is not happening 
between the VA and you and you and the VA that you get a hold 
of the folks on this committee and the VA committee to make 
sure it happens. This is too important to screw up.
    Ms. Cummings. I agree.
    Senator Tester. Okay.
    Ms. Cummings. And we have a system that is currently 
operating, and so, clearly, there have been some decisions we 
already made in order to support those pilot sites.
    Senator Tester. That is fine.
    Ms. Cummings. But we are making decisions together with the 
VA as we speak, and I think we can continue to do that in a 
very equal way where both the DoD and the VA get the best 
possible----
    Senator Tester. And I look forward to the day when this 
program is implemented and there is seamless conversation 
between the DoD and the VA for these veterans when they move 
into this private sector because I think it is going to offer 
better healthcare, and it is going to cost less money. And that 
is a beautiful thing.
    Ms. Cummings. I agree. And I think the beauty of having the 
DoD, the VA, and the Coast Guard all in a single-instance 
electronic health record, it allows us to be a very strong 
customer towards that national interoperability with commercial 
providers.
    Senator Tester. Yes.
    Ms. Cummings. And we can focus on that interoperability 
instead of trying to focus on interagency interoperability, to 
your point.

                      MILITARY AND VETERAN SUICIDE

    Senator Tester. Okay. Thank you very, very much.
    I want to talk about suicides. I want to talk to you about 
it, Admiral Bono, the mental health conditions, servicemembers 
that are separating from the military without a plan for care 
at the VA.
    It is my understanding that there is a spike in suicides 
the first 12 months following separation. I think that is an 
important statistic to pay attention to. So what is in this 
budget that helps DoD do a warm handoff to the VA so that 
recent veterans do not fall through the crack?
    Admiral Bono. Yes, sir. Well, thank you very much for that 
question.
    I think it is also important to recognize that part of that 
warm handoff is how we are coordinating care across the 
services as well as with the VA.
    Certainly, you have spent a few minutes talking about the 
interoperability of our electronic health record, and that goes 
a long way to being able to help us keep, front and center, the 
data that apply to both of our transitioning servicemembers and 
our veterans to make sure that we are identifying those people 
that are most at risk.
    Senator Tester. So let me get specific so you can get a 
little more specific, as briefly as you can. Is there anything 
that we are doing different to pay particular attention to 
those folks who are being discharged immediately, that first 
year?
    Admiral Bono. Yes, sir. So--well, in terms of being able to 
make sure that the warm handoff is happening.
    Senator Tester. Yes. That is correct. And to make sure that 
the VA understands that if there has been any traumatic brain 
injury or PTSD issues that it is brought to their attention.
    Admiral Bono. Yes. And so that case management between our 
handoff between the services and the VA is extremely important 
for that.
    Senator Tester. Okay. Time flies when you are having fun. 
Thank you, Mr. Chairman.
    Senator Shelby. Thank you.
    Senator Boozman.
    Senator Boozman. Thank you, Mr. Chairman, and thank you all 
for being here. We really do appreciate all of your hard work 
and your expertise.

             DOD/VA ELECTRONIC HEALTH RECORD IMPLEMENTATION

    Ms. Cummings, in your statement, you talked about the Joint 
Program Office. Can you tell us a little bit more about the 
role that the Joint Program Office is playing and the 
responsibilities between DoD and VA?
    These are always issues, and hopefully, you all are coming 
together and have figured out your various responsibilities. 
Can you reassure us in that regard?
    Ms. Cummings. So the Interagency Program Office was 
established by Congress back in 2008 and has changed its role 
several times over the last several years.
    Over the last year, since the VA made the decision to buy 
and adopt the same electronic health record, the Interagency 
Program Office has really been focused on how to bring the DoD 
and VA together in a governance construct so that we can make 
decisions together.
    I can give you several examples of decisions where the DoD 
had one strategy, technical strategy. The VA came in with a 
different strategy, and we actually adopted the VA strategy 
because it was going to work better for the joint DoD, VA, and 
Coast Guard, of course, implementation.
    So what we are looking at now is how can we make that joint 
management structure even stronger so that we are not making 
decisions in the DoD and VA and then bringing them together to 
adjudicate them, but we are actually making decisions together, 
where the engineers are sitting with the engineers, the cost 
people are sitting with the cost people, basically so that we 
can do what you and what Senator Tester asked of us, which is 
hold our vendor team accountable to a solution that is going to 
work for all of our customers.
    And I personally think that we have a lot to learn from the 
VA, just as the VA has a lot to learn from us, and so I feel 
very confident that senior leadership in the DoD and senior 
leadership in the VA are committed to getting this right.
    Senator Boozman. So we have had this situation for a long, 
long time. We have spent a lot of money, again, talking and 
trying to move forward and interoperability. Is the Joint 
Force--there is systems in the VA, what they need, such as 
scheduling pharmacy and things like that. It is different than 
the DoD. We have got a little bit different systems within the 
common system, different features.
    Ms. Cummings. So I think----
    Senator Boozman. VA is structured a little different. I 
think theirs is going to cost a little bit more, if you can say 
a couple billion dollars is a little bit more.
    But tell us how that is getting worked out.
    Ms. Cummings. Sure. So I actually think we have a lot more 
in common that we have different. We have 9.5 million 
beneficiaries. The VA has a similar amount. We are both very 
large, complex medical systems.
    The things that the VA has bought on their contract that 
might be unique to the VA, there are things that we and the DoD 
may choose to take advantage of in the future, but there are 
some things that the DoD is going to take advantage of or 
deploy, especially around operational medicine, that does not 
have that equivalency on the VA side.
    But I would say that probably 85 to 95 percent of our 
requirements are actually much more similar than they are 
different, and so what we have done is we have put together a 
governance structure where the two--on the functional side, 
where the clinical and business folks are actually getting 
together and looking at joint requirements, and where we can, 
we do things the same. Where we cannot, we do them differently, 
but we do that with purpose.
    So when a servicemember is transitioning to veteran, they 
have that consistent experience. Whether they are dealing with 
a military doctor or a VA doctor, they have that same common 
experience, and we think that that is a benefit to the 
servicemember and the veteran.
    Senator Boozman. Very good. Thank you.

                       MILITARY MEDICAL READINESS

    I agree with you, General West, in the sense that you 
talked about the foundation of a strong national defense is a 
strong healthy force, and everything now has combat readiness. 
Can you talk about how you are working with DHA to determine 
force structure to support readiness to make sure that we have 
combat capability?
    General West. Absolutely.
    Senator Boozman. Does that make sense?
    General West. Absolutely. Again, as I mentioned, it is a 
team effort. We are all part of an integrated team. That we 
rely on each other to make sure that we have got a formidable 
medical capability in whatever construct that our Nation asks 
us to be able to perform in.
    As far as getting the readiness piece as the land component 
of the Joint Force, the types of injuries and the types of 
illnesses that we may see require a lot of trauma specialists, 
but also those that can take care of disease, non-battle 
injury.
    So, as part of that, we have partnerships that we have 
established. I know that we are working with the DHA to take 
advantage of those global partnerships that we can have our 
members train. That if we do not have the workload within our 
direct care system in the MTFs, that we can have those 
partnerships with our external partners.
    We are also working with the Joint Staff as well to 
establish those skills that are required, those minimum skills 
in each occupational specialty, along with our services, so 
they are joint, and they are similar amongst the services to 
ensure that we train our individuals on those to have them 
ready for the next fight, so for the training part, for the 
requirements that our Nation and our combatant commands have 
for those to make sure that we have got the right mix of those 
in the facilities and also within our operational units as 
well. So we are working with DHA and our fellow services.
    Senator Boozman. That is great.
    We can be very proud of the effort in the past, and again, 
anything we can do to help you, such that as we do, reconfigure 
forces that that is going to be there in the future.
    General West. Absolutely. Thank you.
    Senator Boozman. Thank you, Mr. Chairman.

                     ADDITIONAL COMMITTEE QUESTIONS

    Senator Shelby. Thank you.
    If there are no further questions, I want to thank the 
panel for your appearance here today. We have got some other 
Senators who might want to submit questions to you, and I would 
hope you would respond to them within a reasonable time.
    [The following questions were not asked at the hearing, but 
were submitted to the Department for response subsequent to the 
hearing:]
               Questions Submitted by Senator Jerry Moran
    Question. The fiscal year 2018 National Defense Authorization Act 
allows Physical Therapy Assistants and Occupational Therapy Assistants 
to be TRICARE-authorized providers to help increase access to physical 
and occupational therapy for TRICARE-beneficiaries. The Department 
released a proposed rule in December of last year, and the comment 
period closed just this past February. I want to make certain that the 
final rule is published in a timely manner so that TRICARE 
beneficiaries can start utilizing these providers to get the care that 
they need.
    When can we expect publication of a final rule and if it is not 
within this year, what is preventing you from being able to publish a 
final rule within this timeframe?
    Answer. The Department is confident that the final rule will be 
published by the end of 2020, the standard timeframe expected for a 
regulatory action of this nature. Due to the regulatory requirements of 
the rulemaking process, it is unlikely that the final rule will be 
published within this year. The draft document must be appropriately 
reviewed within the Department of Defense and the Office of Management 
and Budget prior to publication.
    Question. I recently had the opportunity to learn about Sparta 
Science which is a company that uses diagnostic software to accurately 
assess a person's musculoskeletal health. With a clientele primarily 
consisting of athletes, Sparta Science discloses this data to the 
athlete and their coaches and trainers in order to build training plans 
specific to the athlete's needs which in turns helps to prevent 
injuries and optimize training and performance. As the services 
continue to look for ways to increase personnel readiness by improving 
physical fitness and reducing injury rates through prevention and 
rehabilitation, what technologies are you leveraging or looking to 
leverage in the future to accomplish this goal?
    Answer. The DHP RDT&E supports training and Operational Commands by 
investing in Science and Technology capabilities that will deliver 
screening and injury prevention tools for musculoskeletal injury. It is 
expected that this research will lead to validated ways of providing 
training tools and predict injury risk including identification of 
gene, protein, and other potential biomarkers. These tools can 
integrate into larger health optimization programs such as the Army's 
Holistic Health and Fitness and the DoD's efforts to embed personal 
trainers.
    Examples of the technologies for future leverage include the 
research by Sparta Science and others such as the Dynamic Athletic 
Research Institute (DARI) motion capture system which the Air Force is 
using as a tool to screen for musculoskeletal injury and Conflict 
Kinetics which multiple labs are working with as a potential tool to 
measure and optimize performance.
    Question. How much money is spent each year on healthcare for 
injuries or conditions that are preventable via physical fitness?
    Answer.
    All beneficiaries:
    --Direct care ambulatory cost: $28.8M
    --Purchased care ambulatory paid: $3.5M
    --Direct care inpatient cost: $3.2M
    --Purchased care inpatient paid: $47k
    --Total: $35.5M
    Active Duty and Guard:
    --Direct care ambulatory cost: $17.5M
    --Purchased care ambulatory paid: $1.4M
    --Direct care inpatient cost: $2.4M
    --Purchased care inpatient paid: $0
    --Total: $21.3M
    Question. As we collectively work together to improve mental 
healthcare and suicide prevention efforts in both the VA and the DoD, I 
would like to know what authorities you or local commanders might need 
in order to coordinate with law enforcement to gain visibility on 
incidents that serve as an indicator or precursor for suicidal 
ideations.
    Answer. We agree that certain behaviors or incidents can serve as 
precipitants and predispose an individual to suicide. It is vitally 
important that commands, police forces and medical entities work 
together to communicate about persons at risk to better intervene.
    Local commanders have broad and sufficient authority to coordinate 
with law enforcement and medical entities. Current policy in DoD 
Instructions (6490 series) buttresses these authorities. For instance, 
commanders and supervisors have a wide berth in ordering command-
directed mental health evaluations, and need not fear automatic 
investigation of their actions.
                                 ______
                                 
            Questions Submitted to Vice Admiral Raquel Bono
            Questions Submitted by Senator Patrick J. Leahy
    Question. In the fiscal year 2019 defense appropriations bill, the 
Committee created a line item in Congressionally Directed Medical 
Research Programs for Chronic Pain Mitigation, in order to seek 
alternatives to treating pain in service members with opioids.
    What projects have you funded or are you planning to fund with that 
amount?
    Answer. No projects have currently been funded and no funding 
decisions have been made to date. The Chronic Pain Management Research 
Program (CPMRP) as a new addition to the Congressionally Directed 
Medical Research Programs is in the process of drafting program 
announcements regarding fiscal year 2019 funding opportunities. It is 
anticipated that the program announcements will be released soon with 
applications receipt occurring in the fall of 2019 and recommendations 
for funding following in spring of 2020.
    Question. What gaps can you identify in non-opioid pain mitigation 
research?
    Answer. Gaps include the lack of known effective treatments for 
chronic pain and in the understanding of the ``chronification'' of pain 
process.
    Question. How will you leverage research with these funds with 
other government pain mitigation programs, such as at NIH?
    Answer. The Chronic Pain Management Research Program (CPMRP) 
programmatic panel currently has representation from the Department of 
Veterans Affairs (VA) and National Institutes of Health (NIH)--National 
Center for Complementary and Integrative Health. Inclusion of 
representation from other agencies allows the program to understand the 
priorities and initiatives of other government programs, preventing 
duplication of areas of emphasis, and also improves in the 
identification of novel knowledge gaps that are either currently not 
being addressed or are specifically well suited for funding by the 
Department of Defense (DoD). At this time no joint funding 
opportunities or cost sharing initiatives have been planned for the 
CPMRP fiscal year 2019 appropriations; however, the VA and NIH 
representation on the panel are also involved in the existing 
interagency NIH/DoD/VA Pain Management Collaboratory. The program would 
be open to participating in similar endeavors in the future providing 
an appropriate opportunity arose.
    Question. To fully understand the challenges we face, we must 
assess the prevalence and use of opioids.
    How many service members are prescribed opioids in the Department?
    Answer. For fiscal year 2018, during the average month, 1,306,308 
members were classified as Active Duty and of this cohort 33,725 
received an opiate prescription. This means that 2.58 percent of Active 
Duty Service Members (ADSM) received an Opiate Prescription in fiscal 
year 2018.
    Question. What are the rates of opioid abuse or addiction among 
service members?
    Answer. The prevalence of Opioid Use Disorders (Abuse and 
Dependence) remains very low among Active Duty Service Members (ASDM). 
There were approximately 1,000 ADSM per year who are diagnosed with an 
Opioid Use Disorder (OUD), a prevalence rate of less than 0.1 percent. 
The rate is significantly lower than the U.S. adult population where 8-
12 percent develop an Opioid Use Disorder (OUD).
    Question. What guidance or direction are practitioners within 
Department given with regards to prescribing opioids?
    Answer. To combat opioid overuse, misuse, and diversion, DoD is 
addressing the problem at all touch points through implementation of 
improved pain management strategies and procedural instructions, 
efforts to improve DoD prescriber and beneficiary education, 
prescription monitoring and safeguards, treatment and emergency 
response systems.
    Provider opiate prescription guidance is contained in DHA-PI 
6025.04 Pain Management and Opioid Safety in the MHS. DHA-PI 6025.04 
provides specific guidance for limited supply amounts based on patient 
presentation as well as non-opioid alternatives. For example, an 
uncomplicated, opioid-naive patient should be limited to no more than 5 
day supply of short-acting opioids for acute pain episodes.
    The Military Health Service Opioid Registry supports providers, 
staff, and decision-makers in improving safety and quality of care of 
patients on opioid prescriptions. The registry offers MHS leaders and 
providers' access to near-real time demographic, clinical, and 
pharmaceutical data related to opioids such as morphine equivalent 
daily dosages. High-risk opioids and other medications such as 
antidepressants, benzodiazepines, and sleep medications concurrently 
prescribed with opioids are flagged, alerting staff of potential fatal 
drug interactions.
    The Military Health System uses a Stepped Care Model for Pain. 
``Stepped care'' starts in the Patient-Centered Medical Home (PCMH) or 
primary care, moving patients forward on the continuum of care only as 
clinically required. The Stepped Care Model for Pain uses a three 
tiered approach consisting of early identification, leveraging primary 
care champions and embedded specialties (pharmacy and behavioral 
health) for primary and secondary levels of care, and interdisciplinary 
Pain Management Centers in the tertiary level of care to ensure 
holistic care.
                                 ______
                                 
              Questions Submitted by Senator Patty Murray
    Question. Recent reports indicate that a significant number of 
uniformed medical positions will be cut across all four services.
    How many positions are currently slated for elimination?
    Answer. Authorizations will be repurposed by the Services for 
higher priority readiness requirements. The table below provides the 
number and timing of when the authorizations will be transferred to the 
line:

                               Table 1. PB20 Active Force Authorization Reductions
----------------------------------------------------------------------------------------------------------------
                                                                       FY20            FY21         Total FYDP
----------------------------------------------------------------------------------------------------------------
Army DHP........................................................           6,935               -           6,935
Air Force DHP...................................................           4,684               -           4,684
Navy DHP & non-DHP*.............................................           3,230           2,156           5,386
DoD Total.......................................................          14,849           2,156          17,005
----------------------------------------------------------------------------------------------------------------
* Non-DHP includes 592 transient/patients/prisoners/and holdees (TPPH) and students.

    Question. What is the timeline for these cuts to occur?
    Answer. The transfer of the authorizations will occur in fiscal 
year 2020 and fiscal year 2021. The personnel will transition as they 
retire, leave the military or transfer to another posting over the 
following 3-5 years.
    Question. What are the specific positions that will be affected by 
these cuts?
    Answer. The Department intends that the transition of personnel 
will not impact access or quality of care. The DHA and the Services are 
in the process of identifying and mitigating any impacts to healthcare 
delivery and will include replacing lost capabilities through 
replacement civilian, contract staff, or by transition to purchased 
care where available.
    Question. Are there plans to convert any of those services to 
civilian positions?
    Answer. The Department intends that the transition of personnel 
will not impact access or quality of care. Converting to civilian staff 
is one option along with converting to contract staff or transition of 
care to our purchased care network. The DHA and Services are 
collaboratively currently evaluating the impacts and developing our 
mitigation approaches. Table 2 provides the estimated timing of the end 
strength reductions.

                            Table 2. Preliminary Medical End Strength Reduction Plans
----------------------------------------------------------------------------------------------------------------
                                                   FY20       FY21       FY22       FY23       FY24      Total
----------------------------------------------------------------------------------------------------------------
Army..........................................        694      2,082      2,082      2,077          -      6,935
Army..........................................        694      2,082      2,082      2,077          -      6,935
Navy..........................................      1,991      2,476        501        253        165      5,386
Air Force.....................................        866      2,363      1,455          -          -      4,684
Total.........................................      3,551      6,921      4,038      2,330        165     17,005
----------------------------------------------------------------------------------------------------------------
There are 4,176 unencumbered authorizations that will be repurposed in the first 2 years.

    Question. Vision requirements are among some of the most unique to 
servicemembers. Each year, the Air Force alone issues 300,000 optical 
devices, including over 67,000 prescription inserts for protective 
masks and 37,000 flight frames for aircrew members, These devices can 
only be issued through a military clinic. Additionally, across the DoD, 
a high percentage of TBI patients experience visual disorders leaving a 
need for, in some cases, a lifetime of follow up care.
    How many of the expected medical personnel cuts are coming from 
these critical ophthalmic services?
    Answer. The reductions in uniformed ophthalmic providers and 
ophthalmology/optometry technicians represent 2 percent of the total 
uniformed manpower reductions. The DHA and Service are jointly 
evaluating the impacts of these reductions on mission readiness with 
the intent of developing mitigations where required that may include 
hiring civilian and contract staff.
    Question. How do you plan on maintaining a ready force if 
servicemembers cannot get the protective equipment or the aftercare 
services they need to save or restore vision?
    Answer. The DHA and Services are working together to identify and 
mitigate readiness impacts resulting from the transition of personnel. 
This would include ensuring access to the medical devices and care 
needed to support a medically ready force. To minimize any gaps we are 
including replacement with civilian or contract staff as well as 
utilization of the purchased care network where appropriate and 
available.
    Question. If the uniformed ophthalmic personnel are converted to 
civilian positions, how will you ensure the level of care is not 
disrupted for the servicemember and that these positions are filled in 
a timely manner?
    Answer. The DHA has developed contracts that will allow the 
procurement of professional services to cover any gaps that may occur 
during the transition of personnel. In addition, we are not planning on 
repurposing encumbered authorizations until fiscal year 2021 allowing 
time to hire civilian staff if deemed necessary.

                          SUBCOMMITTEE RECESS

    Senator Shelby. Subject to that, the Defense Subcommittee 
will reconvene on Wednesday, April the 10th, at 10:00 a.m., to 
receive testimony from the Chiefs of the National Guard and 
Reserve components.
    The committee stands in recess. Thank you.
    [Whereupon, at 10:37 a.m., Wednesday, April 3, the 
subcommittee was recessed, to reconvene at 10:00 a.m., 
Wednesday, April 10.]