SEAMLESS TRANSITION: 

WHERE ARE WE NOW?

Hearing

before the

Committee on 

Veterans’ Affairs

House of Representatives

one hundred ninth congress

first session

September 28, 2005

Printed for the use of the Committee on Veterans’ Affairs

Serial No. 109-25

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Committee on Veterans’ Affairs

Steve Buyer, Indiana, Chairman

Michael Bilirakis, Florida Lane Evans, Illinois, Ranking

Terry Everett, Alabama Bob Filner, California

Cliff Stearns, Florida Luis V. Gutierrez, Illinois

dan burton, Indiana Corrine Brown, Florida

Jerry Moran, Kansas Vic Snyder, Arkansas

richard H. baker, Louisiana Michael H. Michaud, Maine

Henry E. Brown, Jr., South Carolina Stephanie Herseth, South 

Jeff Miller, Florida Dakota

John Boozman, Arkansas Ted Strickland, Ohio

Jeb Bradley, New Hampshire Darlene Hooley, Oregon

Ginny Brown-Waite, Florida Silvestre Reyes, Texas

Michael R. Turner, Ohio Shelley Berkley, Nevada

 Tom Udall, New Mexico

JAMES M. LARIVIERE, Staff Director

(II)
CONTENTS

September 28, 2005

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Seamless Transition: Where Are We Now? ............................

OPENING STATEMENTS

Chairman Buyer .........................................................................

Hon. Lane Evans, Ranking Member .........................................

Hon. John Boozman ...................................................................

Prepared statement of Mr. Boozman ........................................

Hon. Michael Michaud ...............................................................

Hon. Jeff Miller ..........................................................................

Prepared statement of Mr. Miller .............................................

Witnesses

Bascetta, Cynthia A., Director, Veterans Health and Benefits

Issues, U.S. Government Accountability Office .................

Prepared statement of Ms. Bascetta ......................................

Koontz, Linda D., Director, Information Manage-ment Issues,

U.S. Government Accountability Office .............................

Prepared statement of Ms. Koontz .....................................

Javitt, Jonathan, M.D., M.P.H. Former Presidential Appointee, President’s Information Technology Advisory Committee (PITAC), Health Care Delivery and Information Technology Subcommittee .............................................................

Prepared statement of Dr. Javitt .......................................

Dysert, Peter, M.D., Chief Medical Information Officer, Baylor

University Medical Center ..................................................

Prepared statement of Dr. Dysert ........................................

Mansfield, Gordon H., Deputy Secretary, U.S. Department of

Veterans Affairs ......................................................................

Prepared statement of Mr. Mansfield .......................................

Jones, Stephen L., Principal Deputy Assistant Secretary of 

 Defense for Health Affairs .....................................................

Prepared statement of Mr. Jones .............................................

Young, Ronald G., Major General, Director, National Guard 

 Bureau Joint Staff .................................................................

Prepared statement of Major General Young ..........................

(III)
Hobbs, Sheila G., Colonel, United States Army, Senior Patient

Administrator, Office of the Surgeon General .......................

Prepared statement of Colonel Hobbs .......................................

McAndrew, Susan D., J.D., Senior Advisor for Health Information Privacy Policy, Office of Civil Rights, U.S. Department 

of Health and Human Services ...............................................

Prepared statement of Ms. McAndrew ......................................

Information for the Record

Testimony of Colonel Deborah L. Carter, Human Resource 

Officer, New Hampshire National Guard before the Committee on Veterans’ Affairs, Subcommittee on Economic Opportunity on September 19, 2005 ................................................

Statements for the Record

Stroup, Theodore G., Jr., USA, (RET), Vice President, Association of the United States Army ..............................................

Atizado, Adrian M., Assistant National Legislative Director,

 Disabled American Veterans ..................................................

Jones, Rick, Legislative Director, National Association for Uniformed Services ........................................................................ 

King, James B., AMVETS National Executive Director ..........

The Air Force Association ...........................................................

King, John M., President, National Association of State Directors of Veterans Affairs ........................................................... 

Gaytan, Peter S., Director, Veterans Affairs and Rehabilitation 

Commission, The American Legion ........................................

Smith, Robert W., III, Major General, President, Reserve Officers Association .....................................................................

Paralyzed Veterans of America ..................................................

Military Officers Association of America ...................................

 (IV)

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(1)

SEAMLESS TRANSITION: WHERE ARE WE NOW?

Wednesday, September 28, 2005

U.S. House of Representatives, 

Committee on Veterans’ Affairs,

Washington, D.C.

 The Committee met, pursuant to notice, at 10:39 a.m., in room 334, 

Cannon House Office Building, Hon. Steve Buyer [Chairman of the 

Committee] presiding.

 Present: Representatives Buyer, Everett, Miller, Boozman, Evans, 

Snyder, and Michaud.

 The Chairman. The hearing of the the House Veterans’ Affairs Committee will come to order. The hearing will address Seamless Transition. The date is September 28, 2005.

 First of all, I would like for everyone to know that I also sit on Energy and Commerce, and we are in the middle of a markup right now 

on an energy bill relative to expanding our refinery, storage, pipeline, 

and investigation with regard to potential gas price gouging, and that 

is occurring right now, and we’re in an amendment process. So if I

am called out, Mr. Boozman will take the chair.

 Today’s hearing will provide the Committee with an update on the 

Department of Veterans Affairs and the Department of Defense in 

their efforts to implement Seamless Transition.

 Over the last year, myself and other distinguished members of this 

Committee, along with staff, have conducted numerous field and site 

visits at VA and military treatment facilities and military bases.

I am concerned that there is a significant disconnect between what 

Congress envisions, what the VA envisions, and what DOD policy 

makers envision, and what the three of us are initiating and what is 

actually taking place not only in Congress but also at all levels of the 

two departments.

 Unfortunately, this disconnect that I will refer to, I believe, is coming at a significant cost to our taxpayers and, more importantly, to 

our soldiers, sailors, airmen, and Marines, Coast Guardsmen, and 

their families that have unselfishly served and sacrificed to our na-
2

tion.

 It appears to me that the two departments continue to issue broad 

policy statements regarding Seamless Transition, VA-DOD sharing, 

and other initiatives, with little action on implementing congressionally mandated guidance from two different defense bills.

 Although the term “Seamless Transition” is a relatively new word 

that is thrown around in this town, the concept was codified into law 

in 1982, when Congress passed the Veterans Administration and the 

Department of Defense Health Resources Sharing and Emergency 

Operations Act, often referred to as the Sharing Act. The Sharing Act 

created the VA-DOD Health Care Resources Sharing Committee to 

supervise and manage opportunities to share medical resources.

 In 1996, the departments renamed the Sharing Committee the VADOD Executive Council.

 In 2002, the departments administratively created the VA-DOD

Joint Executive Council to provide oversight to the executive council 

on health care sharing.

 In 2002, Congress amended Title 38 to mandate that the departments’ under secretaries head the Joint Executive Council, and in 

2003, Congress codified the Joint Executive Council into law. Congress directed the JEC to review all aspects of both departments to 

include plans for the acquisition of additional resources, especially 

new facilities and major equipment and technology, in order to assess potential opportunities for the coordination and sharing of resources.

Congress also directed the Secretary of Veterans Affairs and the 

Secretary of Defense, in section 721 of Fiscal Year ‘03, National Defense Authorization Act, to develop a joint strategic vision and a strategic plan to shape, focus, and prioritize the coordination and sharing efforts among the appropriate elements of the two departments. 

Section 721 also required them to incorporate the goals and requirements of the joint sharing plan into strategic and performance plans 

of each department under the Government Performance and Results 

Act, herein referred to as the GPRA.

 Despite 20 years of congressional mandates for VA-DOD resource 

sharing, various name changes, other administrative actions, a presidential task force, the two departments are still operating, I believe, 

in separate worlds. Even though, yes, they are meeting, yes, they are 

talking, we are very anxious for some action.

 Equally troubling, the two departments have been working in this 

exchange of patient health information electronically for now over 

seven years.

 One of the largest and most far-reaching task force recommendation that VA and DOD developed and deployed this by 2005, the electronic medical records -- they asked that they be interoperable, bidirectional, and standards-based.
3

Currently, service members transitioning to veteran status must 

still make hard copies of their military medical records and handdeliver them to the VA, because each department is proceeding separately with the development of its own respective health information 

system, VA’s HealtheVet VistA, and DOD’s Composite Health Care 

System II.

 The estimated cost of these separate independent systems is approximately 1.2 billion and 3.8 billion respectfully.

 In addition, the two departments differ in their legal interpretations of HIPAA, the Health Insurance Portability and Accountability 

Act, Privacy Rule.

Quite frankly, I believe that is unacceptable.

 For these reasons, I have asked representatives from GAO and 

Health and Human Services to testify about their observations regarding HIPAA.

 So, when I visited the polytrauma center in Minneapolis, I was 

disturbed when I heard that certain things couldn’t be done because 

of HIPAA.

 In addition, the Committee will hear testimony from experts in the 

field of health information technology.

Lastly, I want the Committee to hear firsthand from VA and DOD 

regarding their efforts to collaborate and coordinate policy, people, 

and resources to achieve the Seamless Transition.

 Our service personnel and their families have faithfully and diligently served this nation well, providing for their benefits reflect the 

gratitude of a grateful nation.

It also serves to say thank you for your sacrifice and unselfish commitment in protecting America’s cherished freedoms and liberties. I

fully expect both departments to work together to fulfill this moral 

and legal mandate.

 Unfortunately, I sincerely question the level of commitment by 

DOD on making Seamless Transition a priority. Simply put, this 

Committee invited Under Secretary Chu to appear here today. He 

declined.

According to his office, his schedule could not accommodate this 

important hearing. Equally telling, Secretary Chu’s Assistant Secretary for Health Affairs, Dr. Winkenwerder, was equally not available 

to testify.

 Given the importance of this issue, I am deeply troubled by both of 

them omitting their appearance here today, but I welcome the testimony of the Principal Deputy Assistant Secretary of Health Affairs 

and the Office of Personnel and Readiness.

 It is more appropriate for this Committee, though, to hear from the 

Under Secretary Chu himself. After all, he serves as the legally appointed department head on the Joint Executive Council. His counterpart thought enough of this issue to appear.
4

 I would like to now recognize the Ranking Member, the gentleman 

from Illinois, Mr. Evans.

 Mr. Evans. Thank you, Mr. Chairman.

It is interesting that, after five recent hearings on this topic, why 

you must now ask DOD and VA to define what they mean by the term 

“Seamless Transition,” as you did in their letters of invitation to this 

hearing. We should be asking each agency to demonstrate achievement based on measured performance. That said, VA and DOD have 

agreed on procedures to achieve a more seamless transition than 

what has been proposed.

 They also have generally assured, for example, that the most seriously injured do not slip through the cracks in the medical system. 

We need to review performance to judge the real impact on veterans. 

Our efforts must appeal to a broad spectrum of our veterans needs.

 Mr. Chairman, clearly, there is progress, but some of these issues 

continue to impede further process and development.

 HIPAA, continues to impact information exchange between DOD

and VA. We should strive to resolve this and other impediments, 

and I appreciate you holding the hearing. Both the Democratic and 

Republican caucuses, I think, are in session. Technically, we should 

not be, but we need to get moving on this issue and not wait for the 

problem with the attendance at our respective caucuses.

 I yield back, Mr. Chairman.

The Chairman. I associate myself with the comments of Mr. Evans 

and appreciate his cooperation so we may proceed.

 At this point, I recognize Mr. Boozman for an opening statement.

 Mr. Boozman. Thank you, Mr. Chairman, and I thank you and Mr. 

Evans for holding this hearing. It is such an important topic.

I would like to comment briefly about the subCommittee meeting 

that we had in New Hampshire a week or so ago. We had a field hearing, and Mr. Bradley was there, and Mr. Michaud, and it really went 

very, very well.

 I was especially pleased with what we heard from our witnesses.

 In a nutshell, New Hampshire is doing it right, and I hope the witnesses from the National Guard Bureau and other Federal agencies 

will export those best practices nationwide.

I think the first lesson that we took away from the hearing is involving the families of the soldier pre-, during, and post-deployment 

in a program of education and counseling that is very vital.

 The second most important issue is that the Army must make several days of active duty drill time available to the returning Guard 

units to conduct this early intervention-type program.

 Thirdly, the VA vet center system plays a key role in minimizing 

post-deployment de-mobilization readjustment issues, and we heard 

that, I think, over and over again, and fourth, the National Guard 

Bureau needs to impose these best practices across the nation.
5

 The New Hampshire Guard has designed a program called Reunion and Entry for returning Guardsmen and their families. The 

program makes use of resources from VA vets, small business development centers, and state agencies such as the employment service 

and highway patrol.

 Guard personnel involved included those from combat arms and 

support units. The program truly is excellent.

Col. Deb Carter deserves an awful lot of credit. She met with leaders from the 82nd Airborne, Marines, and Navy, determined best 

practices going into this.

They lined up the agencies to train 300 full-time staff and 500 family members in suicide prevention, PTSD, and access to resources, 

and as a result, again, their efforts have been very, very good.

The soldiers went through a five-day Army de-mobilization at Fort 

Dix, returned home. Then they were given the day off to unite with 

their families and were called to participate in a three-day tap featuring educational and stress-related issues, and I want to submit the 

rest of this to the record so we can go ahead and move on and get the 

testimony, but again, I really do want to compliment the New Hampshire group. I think they are doing an excellent job.

 One of the problems that we have with the Guard units versus the 

regular units is that it’s unlike coming back with your unit and it’s 

kind of business as usual. These folks are going back to the civilian 

work place, and the transition is much more difficult, I think.

 So, again, thank you, Mr. Chairman and Mr. Evans, for having the 

hearing.

 Mr. Chairman, I would also like Col. Carter’s statement from the 

field hearing to be made part of the record, so that others may learn 

from her experience.

 The Chairman. Hearing no objection, so ordered.

 Mr. Boozman. Thank you.

[The attachment appears on p. 166]

 The Chairman. I would now like to yield to Dr. Snyder, and before I do that, let me thank you. I want to thank you and Chairman 

McHugh for the work that you did in the 2003 and 2004 defense bill, 

along with Lane Evans and others. I mean when you go through, and 

I had an opportunity to go in greater detail, exactly what you laid out 

to DOD and VA with regard to this issue, and you did it twice, and 

you have really -- it is a very fine product, and so, we’re going to get 

into this today about what they have picked and chosen to follow and 

not follow, and so, I am really pleased that you are here.

 Mr. Michaud?

 Mr. Michaud. Thank you very much, Mr. Chairman. I, too, want to 

thank you, Mr. Chairman, and Ranking Member Evans, for having 

this hearing.
6

 It is extremely important that we do have that seamless transition.

 We did have a very good hearing in New Hampshire, and I took 

a lot away from that hearing, and I appreciate Chairman Boozman 

for having it in New Hampshire, and I agree with -- associate myself 

with his remarks as far as what we heard in New Hampshire, and I

look forward to hearing from both panels today, as far as the seamless transition.

 I yield back the balance of my time.

 The Chairman. For the record, Dr. Snyder is the Ranking Member 

on the personnel Subcommittee of the House Armed Services Committee, and helped co-author the two provisions in the ‘03 and ‘04 

defense bills referencing collaboration and DOD-VA sharing.

 Mr. Miller, do you have an opening statement?

 Mr. Miller. I will enter it in the record, Mr. Chairman.

 The Chairman. Your statement will be submitted for the record.

[The statement of Mr. Miller appears on p. 64]

The Chairman. All members’ statements may be submitted for the 

record and have three days to do so.

At this point, we will recognize our first panel, Ms. Cynthia Bascetta, the Director of Veterans Health and Benefits Issues, United 

States Government Accountability Office; Ms. Linda Koontz, the Director of Information Management Issues, United States Government 

Accountability Office; Dr. Jonathan Javitt, the former presidential 

appointee to the President’s Information Technology Advisory Committee, Health Care Delivery and Information Technology SubCommittee; and Dr. Peter Dysert, the Chief Medical Information Office, 

Baylor University Medical Center.

I would ask our witnesses to limit their oral testimony to five minutes.

 Do each of you have a written statement?

They have all nodded their head in the affirmative, and I will ask 

that your written statement will be made part of the official hearing 

record, and I will ask all members to hold questions until the panel 

has completed, and I now recognize the first panel.

We may proceed first with Ms. Bascetta.
7

STATEMENTS OF MS. CYNTHIA BASCETTA, DIRECTOR, VET-

 ERANS HEALTH AND BENEFITS ISSUES, U.S. GOVERNMENT ACCOUNTABILITY OFFICE; ACCOMPANIED BY MS.

 LINDA KOONTZ, DIRECTOR, INFORMATION MANAGEMENT

ISSUES, U.S. GOVERNMENT ACCOUNTABILITY OFFICE;

JONATHAN JAVITT, M.D., M.P.H., FORMER PRESIDENTIAL

 APPOINTEE, PRESIDENT’S INFORMATION TECHNOLOGY

 ADVISORY COMMITTEE (PITAC), HEALTH CARE DELIVERY

AND INFORMATION TECHNOLOGY SUBCOMMITTEE; AND

 PETER DYSERT, M.D., CHIEF MEDICAL INFORMATION

 OFFICER, BAYLOR UNIVERSITY MEDICAL CENTER

STATEMENT OF MS. CYNTHIA BASCETTA

 Ms. Bascetta. Thank you, Mr. Chairman, and members of the Committee.

 I am pleased to be here today to discuss our ongoing review of VA’s 

efforts to collaborate with DOD to ensure a seamless transition to VA

health care for service members. DOD recently reported that more 

than 15,000 OEF/OIF service members have been wounded in combat, and both the Congress and the President have urged the departments to ensure that service members experience a smooth transition 

to VA’s health care system.

 I would like to make two points today.

The first is that VA has instituted policies, procedures, and outreach efforts designed to provide OEF/OIF service members with 

timely access to health care. We will be evaluating the effectiveness 

of VA’s actions in our ongoing work.

 Since 2002, VA has taken important steps, some at the direction of 

this Committee, to improve service members’ transition.

 The Secretary’s April 2003 memorandum, for example, authorized 

VA to give service members who sustained combat injuries priority 

access to VA health care.

 Three subsequent directives put additional transition-related policies in place.

 One requires each VA medical facility to designate a clinically 

trained combat case manager to coordinate care.

 A second directive requires each medical facility to designate a 

point of contact to receive and expedite transfers from MTFs to VA

medical facilities, and a third directive expanded the scope of care at 

certain facilities to create four polytrauma rehabilitation centers.

 Notably, these centers provide psychological treatment for family 

members and use high-technology prosthetics to maximize the recovery of service members with severe and disabling trauma.

 Besides these directives, VA and DOD jointly established a program to place VHA social workers at selected MTFs to coordinate 
8

the transfers from military to VA health care for service members. 

VBA benefit counselors are also located in the MTFs to assist in filing claims for disability compensation, vocational rehabilitation, and 

other VA benefits.

 In addition, vet centers hired 50 peer counselors in 2004, and VA is 

planning to hire 50 more this year to provide outreach in home communities for those veterans in need of readjustment services, including counseling, employment assistance, and other social services.

 The second point I would like to make today concerns a vital transition issue involving the sharing of health care information between 

DOD and VA.

While progress has been made since we last testified on this issue 

about four months ago, the absence of specific data sharing procedures continues to hinder VA’s efforts to obtain needed health information from DOD.

Specifically, we have been tracking the progress VA and DOD have 

made in sharing health information. On the positive side, VA officials told us that DOD is expected to transmit deployment health 

assessment data to VA monthly beginning in October 2005.

 This routine data sharing will be useful to VA clinicians, who will 

be able to access the data in the course of treating OEF/OIF service 

members who arrive at the VA for care.

 The data includes, for example, service members’ answers to questions about potential exposures to toxic substances and psychological injuries that could benefit from mental health services. But, at 

this time, DOD does not have plans to transmit the same health assessment data for National Guard and reserve members, who, as you 

know, comprise about 35 percent of the OEF/OIF forces.

VA officials told us that it would be helpful to receive individual 

health assessment data in aggregate form, in addition to the individual data, to plan for the needs of current service members who 

may seek VA health care. Sharing this information would be consistent with the President’s task force finding that comprehensive 

health data is essential for VA to forecast and prepare for changes in 

the demand for health care services.

 Another shortcoming is the lack of a data sharing agreement on 

the specific types of health information that will be exchanged and 

when the information will be shared for those who may transition to 

VA health care.

VA and DOD signed an MOU in June this year, but it does not constitute an agreement for the routine sharing of health information.

For example, VA officials still do not receive a list of service members undergoing a physical evaluation board for separation from the 

military.

 With this information, VA believes it would be better positioned to 

make appropriate transfers to VA health care prior to discharge and 
9

to reduce the chance of interruption in medical treatment plans.

DOD officials told us they are working on a policy directive to do 

this, and I was informed this morning that it was signed yesterday.

 Mr. Chairman, this concludes my remarks, and I would be pleased 

to answer questions that you or the other members may have.

[The statement of Ms. Cynthia Bascetta appears on p. 66]

The Chairman. Thank you very much.

 Ms. Koontz?

STATEMENT OF MS. LINDA KOONTZ

 Ms. Koontz. Mr. Chairman and members of the Committee, I am 

pleased to participate in today’s discussion of the efforts of the Departments of Veterans Affairs and Defense to make transition of active duty personnel to veteran status as seamless as possible.

 One goal of these efforts is for the two departments to be able to 

exchange patient health information electronically, and ultimately, 

to have interoperable electronic medical records.

 Sharing of medical information can help ensure that active duty 

military personnel and veterans receive high-quality health care and 

assistance with disability claims, goals that, in the face of current 

military responses to national and foreign crises, are more essential 

than ever.

 As you know, for the past seven years, VA and DOD have been 

working to achieve these capabilities, beginning with a joint project 

in 1998 to develop a government computer-based patient record.

 As we have noted in previous testimony, the departments achieved 

a measure of success in sharing data through the one-way transfer 

of health information from DOD to VA. However, the longer-term 

objective of virtual medical record is more complex and challenging, 

and potentially much more rewarding. For example, the data in the 

virtual medical record are to be computable. That is, they are not just 

displayed as in a paper record. Computable data are powerful. They 

can trigger actions alerting clinicians of a drug allergy, for instance, 

or of a significant change in the vital signs, such as blood pressure.

 To achieve this longer-term objective, the departments have much 

work still to do.

 In the past year, VA and DOD have built on their previous efforts 

and begun to implement applications that exchange limited electronic medical information between the departments’ existing health information systems. These applications were developed through two 

information technology demonstration projects.

The first application, bi-directional health information exchange, 

enables the two-way exchange of health information on shared patients.
10

The departments have implemented this application at five sites, 

where it is being used for rapid exchange of information on shared 

patients, specifically pharmacy data, drug and food allergy information, patient demographics, and laboratory results.

 The second application, laboratory data sharing interface, allows 

the departments to use each other’s laboratory resources.

 It enables them to rapidly send and receive lab orders and results, 

all electronically. This application has been implemented at six 

sites.

The two applications have significant benefits, according to the 

departments, because they enable lower costs and better service to 

patients by saving time and avoiding errors.

 Since our last report on the department’s efforts to achieve a virtual medical record, VA and DOD have taken several actions, but 

the departments have not yet achieved the two-way electronic data 

exchange capability originally envisioned.

 They have implemented three recommendations that we made in 

June 2004.

 They have developed an architecture for the electronic interface 

between DOD’s clinical data repository and VA’s health data repository, which are to contain the medical record information that will be 

accessed by the department’s next-generation systems.

 They established the VA-DOD Health Executive Council as the 

lead entity for the interface project, and they established a joint project management structure to provide day-to-day guidance for the initiative.

 However, the department’s project management plan for the interface development is not yet sufficiently detailed.

 Moreover, the departments have experienced delays in their efforts 

to begin exchanging computable patient health data, and they have 

not yet fully populated their data repositories with the information 

that they intend to exchange.

 In summary, Mr. Chairman, developing an electronic interface that 

will enable VA and DOD to exchange computable patient medical records is a highly complex undertaking that could lead to substantial 

benefits.

VA and DOD have made progress in the electronic sharing of patient health data in their limited near-term demonstration projects.

 They have also taken an important step toward their long-term 

goals by improving the management of the program to develop the all 

important interface between the two data repositories.

However, the departments still face considerable work and significant challenged before they can achieve their long-term goals.

 This concludes my statement. I would be happy to answer questions at the appropriate time.

[The statement of Ms. Linda Koontz appears on p. 82]
11

 The Chairman. Thank you, Ms. Koontz.

 Dr. Javitt?

STATEMENT OF JONATHAN JAVITT, M.D., M.P.H.C

Dr. Javitt. Thank you, Mr. Chairman. Thank you for inviting me 

back to this Committee.

 You have asked me to bring your Committee up to date on mature, 

scaleable private sector technologies for two-way health data interchange.

 Now, I have founded and directed publicly-traded companies that 

deliver electronic health solutions. I have served as the senior executive of Fortune 100 companies that deliver such solutions, and my 

family’s financial security is tied to the premise that the private sector can ultimately construct and deliver e-health solutions that save 

money while they are saving lives and suffering.

 Despite my private sector credentials and experience, it is my duty 

to tell you that the current comprehensive electronic health environment of the Veterans Health Administration surpasses any capability available today on the planet, whether in the private sector, other 

departments of the U.S. Government, or the highly profiled activities 

of other countries.

 Let me be clear that I am speaking only about VistA CPRS and not 

about VA’s personnel or financial management software initiatives.

 I offer that opinion as one who strongly supports President Bush’s 

policies, including those expressed in OMB Circular A76, and who 

is proud to have been commissioned by the President to lead the 

PITAC’s Committee on health care and the report on revolutionizing 

health care through information technology.

 The Committee I chaired was composed entirely of individuals from 

the private sector, including former senior Microsoft and Oracle executives, the chairmen of computer science and electrical engineering 

at two prestigious universities, and we received extensive input from 

the entire IT community.

 I will admit that our initial working assumption was that the VA

approach to e-health, using MUMPS and other less-than-mainstream 

technologies, must be an example of government waste and inefficiency.

 Instead, after examining the VA’s achievement on paper, in testimony, and in numerous sites of care, we concluded that the VA had 

built something unique, something that should be considered a national treasure and a resource to be leveraged into the private sector.

 I had the honor of accompanying President Bush and senior members of his administration to examine the electronic health records 

system of the VA and their capabilities for health data interchange. 
12

On that occasion, the president noted information technology hasn’t 

really shown up in health care yet, but it has in one place, in one department, and that’s the Department of Veterans Affairs.

 Notably, Medicare administrator Mark McClellan, himself a physician and a conservative economist, who served on President Bush’s 

Council of Economic Advisors, came to the same conclusion in urging that the VA system be adopted by medical care givers across the 

country as a low-cost means of entering the e-health world.

 As I understand the issue before this Committee, there should 

be no question about whether the Veterans Health Administration 

has used homegrown information technology to create a miraculous 

transformation in our ability to move health care information where 

it needs to go. A pile of scholarly articles several feet high attests to 

the fact that medical errors occur in fewer than one in 10,000 prescriptions in veterans hospitals, compared to one in five prescriptions 

in paper-driven private sector hospitals. The article from the New 

England Journal that I have submitted to you documents that our 

nation’s veterans receive higher-quality care than is received under 

Medicare for conditions such as diabetes and heart disease, to name 

two of 12 conditions.

 Other studies point to the demonstrated improvements in diabetes 

management, care for patients with congestive heart failure, smoking cessation, cholesterol reduction, pneumonia, and influenza vaccination, and other health outcomes among Americans’ veterans that 

far surpass comparable measures in the private sector.

 The VA system is remarkably stable and secure. Most recently, the 

Department of Health and Human Services in the civilian sector has 

been forced to allocate hundreds of millions of dollars to reconstructing health records destroyed in the wake of Hurricane Katrina. In 

contrast, it took the Veterans Health Administration less than 100 

hours of staff time to safely transfer all records from the disaster zone 

to Texas. They would have done it electronically instead of by magnetic media had the regional private sector-run telecommunications 

infrastructure remained viable.

 Your Committee has heard testimony on this subject from former 

Secretary Principi and a host of others, and yet a parade of contractors from private sector interests come before you regularly and ask 

that you fix what is not broken in favor of the principle that small 

government is better than big government and that the private sector, given sufficient resources, will provide better quality, more efficient, lower-cost solutions than government employees. Despite 

the fact that these contractors have not yet built a viable distributed 

electronic health record that spans institutions, either in the private 

sector or for the Department of Defense, they will certainly promise 

to deliver on spec, on time, and on budget for the VA.

 As the article from the IEEE that I have brought you documents, 
13

such massive contractor-led Federal software projects are likely to 

fail.

 In fact, an honest look at the origins of the current CPRS program 

of the VA will readily discern that CPRS was born out of the ashes 

of a failed contractor-driven attempt to build a VA medical records 

system.

 In general, I believe in small government and out-sourcing, just as 

I believe in basic principles of aerodynamics.

 However, when I watch an aerodynamically implausible bumblebee fly across my back yard, my first impulse is not to legislate it out 

of existence.

 There are exceptions to every rule, and the electronic medical records system of the VA is a notable exception to the principles of OMB

Circular A76.

 The irony of this all is that card-carrying IT professionals would 

call the dedicated professionals within the VA dangerous amateurs, 

in the same way that the executives of major computer companies 

that no longer exist spoke with derision about Jobs, Wozniak, and 

Gates. To an IT professional, there is nothing fundamentally different about computerizing the traffic control system of London, England, and computerizing the English national health system, except 

that the Brits, after spending $10 billion, are finding out that there 

are substantial differences.

 In short, the answer to locating the best technology for two-way 

health data interchange is to look no further than the information 

technology apparatus of the Veterans Administration, and to continue to encourage and to demand two-way data interchange with 

the Department of Defense, and to lower whatever barriers can be 

lowered by congressional mandate that exist in HIPAA.

 I would advise this Committee to continue careful, thoughtful, and 

aggressive oversight to make private sector resources available to 

help the VA implement mainstream solutions that may be more scaleable than some of the current solutions built of necessity, and to 

allocate funds to leverage the pioneering concepts and solutions of 

the Veterans Health Care Administration into the private sector. To 

do anything else would be a disservice to our veterans and ultimately 

to our nation.

 Thank you.

[The statement of Jonathan Javitt, M.D., M.P.H., appears on p. 

104]

 The Chairman. Thank you, Dr. Javitt.

 Dr. Dysert?
14

STATEMENT OF PETER DYSERT, M.D.

 Dr. Dysert. Yes.

Chairman Buyer, Ranking Member Evans, and members of the 

Committee, thank you for the time to be here today to share my perspective and relay to you some of the experiences I have had in the 

private sector trying to successfully computerize clinical care.

 My written remarks are a matter of record, so I am not going to 

bore you with repeating those, and I am also not going to sit up here 

and read to you kind of my position. What I would like to do is take 

the five minutes you have granted me to have a conversation with 

you from my perspective as somebody who is really in the middle of 

a $140 million project of trying to convert our hospital from being 

paper-based to electronic-based.

 Let me start my remarks by telling you I am not going to use very 

technical terms, because in my opinion, a lot of these projects have 

kind of sunk to the level of pure technology, and words like transmission and interfaces and things like that have shifted the focus of 

these projects to a technical level in taking them away from the very 

human dimension of both the people who use the systems and the 

people who receive the care delivered by care providers.

 First of all, just some general observations about computer application designs.

 From my perspective, the rationale for making investments in 

technology is not at a feature and function level.

It is the ability of the application to support work flow, and the 

focus, in return for investment in technology, should be primarily 

focused to achieving efficiencies and improvements in productivity.

 When you look at a project, those should be the words you should 

be hearing played back to you. What’s this going to do to provider 

efficiency and productivity? Because then it gives you the context to 

ask a very non-technical and simple question: How effective can a 

computer system be when it takes an inherently mobile professional 

like a physician or a nurse, forces them to sit down at a computer 

terminal after the fact, and document work they’ve already done? In 

my opinion, there is a very important link in this goal for safety and 

quality that’s related to efficiency in productivity.

 The reason quality pays and the reason technology is a wise investment in supporting quality -- it will only deliver if it improves the 

efficiency and the productivity of the people trying to deliver care.

 The second point I will make is most existing technology solutions 

in health care are architected around computable or structured data, 

when, in reality, the practicalities of care involves all four information types of free text, data, speech, and image, and any successful 

solution needs to incorporate to the same level of value all of the information types.
15

 The human interface design, again around productivity and efficiency, is a very important consideration. Most physicians in my 

world tell me that any time a computer application relegates the interchange from their perspective to one of a clerk-type activity, that’s 

the -- they didn’t go to medical school to be a clerk. They went to 

medical school to be a physician.

 So, any time you transform the human interaction for care providers to one of being a clerk and documenting work they have already 

done, it is the best and most legitimate reason for providers of care to 

push back from using that technology.

 I would like to close my remarks -- and again, I have given you in 

my written testimony kind of the blueprint that we followed on a technology level, and there are probably terms you do not understand, but 

I will just tell you, if you are not hearing these terms played back to 

you as you look at investing in future solutions, then I think you are 

not buying the right product.

 The points I want to make are central.

Number one, efficiency and productivity, the value for the investment in technology needs to return in that space, and it will deliver 

quality.

 The whole concept of seamless and integration does not need to be 

bi-directional, does not need to be transmitted or any of those types 

of things, it needs to put the center of that, the human facet, and concepts like access need to become important.

Can I, through a browser link, simply get access to information in 

another system, and do not leave it to the technologist to integrate 

the data, but remember, I have got a brain, and cognitively, the whole 

idea of seamlessness needs to put the human user in the center of the 

discussion and relegate the technology terms to something technology people talk about.

 It needs to be focused on terms like access. Can I access this information?

 For example, if you have invested in creating a system to support 

all the VA hospitals, are all the records basically accessible, do not 

need to be moved or transmitted? Can we use internet families of 

technology to answer and access that kind of information?

 I would close my technology comment by saying that why in the 

world would anybody building a health care platform today ignore 

the success and the capabilities, the scaleability of the internet family of technologies? I think if the internet and the browser has done 

one thing, they have taken the role of the computer and moved it from 

something purely technical people saw value in so that us non-technical types see value in the computer using browser and internet technology, and I would just encourage this Committee to look forward 

and look at its investments and thing of things like inter-operability 

and communication in terms of things like access.
16

Can the user access this information?

 The last principle I would leave you with is one I try to operate 

against every day.

 Perfect is the enemy of good.

 Thank you very much for your valuable time and the opportunity 

to testify, and I would be glad to take your questions.

[The statement of Peter Dysert, M.D. appears on p. 107]

 The Chairman. Perfect is the enemy of good.

 Well, it is an inquisitive statement. I guess it is why I am so bothered that the torte lawyers have sort of moved America away from 

negligence to comparative negligence to now strict liability standards 

in almost every jurisdiction, you know.

 I am sorry. That is what I was thinking by your statement.

 Let me thank both of you, actually the entire panel, in particular 

-- I have heard from the ladies quite a bit, so let me just be complimentary to my other two witnesses, okay, for a second.

 It is refreshing.

 It is what we hope to expect when we ask people to testify before a 

congressional panel, not that I agree with everything that you said, 

but you stated your opinions, and you stated them professionally, and 

that is refreshing to me, and I am sure to my colleagues that were 

listening to you, because what you are sharing with us is helpful, and 

I appreciate that.

We get that from the General Accounting Office. We do not always 

get that from witnesses, and I just want you to know, personally, for 

me, it is very refreshing.

 Since you went last, Dr. Dysert, you had mentioned that IT must 

deliver on efficiency and productivity. If I may, I would add a preposition to it.

IT must deliver on efficiency and productivity to improve safety 

and quality patient care.

 You concur, right?

 Dr. Dysert. I agree, but I think -- 

 The Chairman. So that the -- well, let me just say this. So that the 

development of that system -- the computer is just a tool. It is an 

enabler to achieve greater standards and quality of care, right? Isn’t 

that what we are trying to do here -- 

 Dr. Dysert. Yes, sir.

 The Chairman. -- and trying to achieve?

 I do not think anyone has an -- I agree, doctors go to medical school, 

and you do your job, and to deliver on that quality patient care, part 

of this is when you are able to put down on the record your diagnosis 

and the prognosis in a manner that everybody understands, it sure 

helps the care givers, the follow-on or collaborative care givers, pretty 

important in seamlessness.
17

 Dr. Dysert. It is called communication and collaboration.

 The Chairman. Yeah.

 Dr. Dysert. It is not a technical term of interfacing.

 The Chairman. Well, all right, all right, all right. I am not going to 

quibble about words, even though I am a lawyer and love to do that, 

but all right.

 Dr. Javitt, in your written statement, you indicated that the VA

should not be allowed to continue ad hoc development and selective 

adoption of the VA health record at the regional or division level, and 

that IT budget authority should be centralized. You kind of get my 

attention.

Could you please explain and expand on your recommendations?

 Dr. Javitt. I think we have reached a point of maturity within the 

Veterans Health Administration that we know what works in VistA

CPRS. The whole country knows that we need to get to standardized 

medical terminology, and you have got a solution that demonstrably 

works, where the President of the United States looks at this, looks 

at what he can see at our universities, and says this is extraordinary, 

and yet, we still have some culture within the VA that allows people 

who direct regional-level operations to say I will implement this part 

but not that part, we will use this terminology but not that terminology.

 So, I think Congress could save a good bit of taxpayer money and 

further improve the care within the VA by giving the Under Secretary 

of Health and at central headquarters within the Veterans Health 

Administration, not outside the health administration, but within 

the top-level doctors at the VA, the authority to have one seamless 

electronic health record that is implemented the same way in every 

VISN.

 I would like to just take a moment to echo some of what Dr. Dysert 

said, because his points about the need for economic efficiency and the 

need for much more creative human computer interfaces are actually 

points one and point seven of the PITAC report to the President.

Clearly, it is a waste of time to have a nurse read a patient’s temperature on a thermometer and put it into the computer. We really 

need the R&D allocations to have thermometers that talk to computers, to have blood pressure cuffs that talk to computers, to free physicians and nurses and other medical personnel from clerical tasks, 

so they can spend their time actually working with, talking to, and 

taking care of their patients, but that is sort of the next frontier once 

we have stabilized an e-health environment where the most basic 

level can move seamlessly across the country, and it is a critical frontier, because at the end of the day, putting a computer and a screen 

between the doctor and a patient does nothing to contribute to the 

quality of that doctor-patient relationship.

 The Chairman. All right.
18

 I turn to the two doctors here for a moment.

 You, Dr. Dysert, are developing a system -- and I would submit that 

you are in a luxury. The reason I use the word “luxury” is that, with 

the DOD and VA, we have a patient that is moving rapidly through 

a system of care, and how do we move that patient through that system of care rapidly and touching a new doctor so many times, from 

the combat aid station to the combat support hospital, MEDEVAC to 

Landstuhl, brought to the United States, from the United States sent 

to a polytrauma center, in a matter of weeks.

 This is not the luxury of you receiving your patient and you getting 

to know everything about your patient. So, this issue about seamlessness is extraordinarily important in our health system.

 So, I wanted you to know that I am taking your words and your 

counsel, and I do not know if I can -- I am trying to figure out how I 

do that overlay onto our challenge.

 If you have any comments based on what I said, I invite them.

 Dr. Dysert. Yes, Mr. Chairman, if you would allow me.

 The whole idea of referral of patients -- we represent a quaternary, 

tertiary care hospital that gets many patients sent to us from rural 

communities for care.

 One of the central themes that led us to deciding that we would 

build our platform on internet families of technology was simply the 

personal experience that we all have today of being able to seamlessly 

access information anywhere in the world if it is known and in a computer system with relative ease.

 I will not discount the importance of systems being able to exchange 

data at machine levels through interfaces and other technologies.

 The good news is there is a great growing family of tools kits built 

the internet family uses every day to exchange information.

 I guess our point was -- and back to my “perfect is the enemy of good 

content” -- is that while we develop at a system level the interfaces 

-- and these things take time -- we felt it was better to provide the human direct access through the browser-based technology to getting at 

the answer, and let me give you a very specific example.

 We have a number of different types of digital radiology systems in 

our health care environment.

 Our approach, while we looked at the technical possibilities of making them all a single system, was to provide through a browser a link 

and a secure sign-on that would allow a physician to access all those 

radiology systems while the technology types figured out a way to get 

them to talk together at a technology level.

 We thought it was better not to wait on the technology at an interface level to deliver access, because it’s one of the biggest challenges 

physicians face in clinical decision-making, is simply having access 

to information that’s already known about the patient, and my point 

about contrasting technology-based interfaces with the human ver-
19

sion of that -- and that’s access -- is we think you do it every day in 

your private life; we do not think health care should be any different.

 So, while we develop at a technology level the ability to data exchange, we have tried to use internet families of technology to provide 

access for the human to that information, because it already exists.

 Does that address your question?

 The Chairman. My compliments to the VA, Secretary Mansfield, Dr. 

Pearl, and what you have done in your collaboration with the military 

health delivery system. Great. But what good is it when I take the 

patient -- the patient is taken from Landstuhl to Minneapolis and he 

does not have his records?

 What good is it if we are going to develop that type of system and 

hand-off, and if we could get to this enabling system; see what I 

mean?

 Every person along the way -- if you are the receiver at the polytrauma center, and five other doctors at five other sites have already 

touched your patient, you sure need to know what they have done, 

and you do not even have a record. Little frustrating for you, isn’t it, 

a little challenging? Unnecessarily challenging, right? That is why 

we are here today, and it is not just that particular reason. I just 

want to let you know that, as we develop these systems, your counsel 

is important, but I just want you to know our challenges here are 

great. Let me yield now to Mr. Evans, and I am anxious to hear from 

Dr. Snyder soon.

Mr. Evans. Mr. Chairman, thank you.

Are the five sites sharing bi-directional information and six sites 

sharing laboratory data doing so under local agreements or in comprehensive national agreements?

 Dr. Javitt. Could I hear the question again, please?

 Mr. Evans. Are the five sites sharing bi-directional information and 

six sites sharing laboratory data doing so under local agreements or 

in comprehensive national agreements?

 Dr. Javitt. I think that one is outside of my specific competence, but 

if it could be re-focused -- 

 The Chairman. Counsel, will you read this?

 Mr. Sistek. Yes.

The question is directed towards GAO and regards the five sites 

that are now sharing bi-directional health information and the six 

sites sharing laboratory data. Are these sites doing this sharing 

agreement under local agreements, between the local VA and DOD

facilities, or is there some sort of over-arching and national agreement?

 The Chairman. Thank you, Mr. Evans.

 Ms. Koontz. Thank you.

 My understanding, that these are at multiple sites, and the agree-
20

ments extend beyond just a single location.

 Mr. Evans. I yield back the balance of my time.

 The Chairman. Mr. Boozman?

 Mr. Boozman. [Presiding] Yes.

 Again, I appreciate you all being here. We had the opportunity 

to have you in earlier in a very informal session. I think we really 

learned a lot.

 You mentioned that one of the problems we have got is that the 

records are not -- they are kind of -- some physicians are doing -- are 

recording in one way, and others are recording in any other way, so 

it is incomplete.

 In the private sector now, because of Medicare and insurance plans 

and things, you really do not have that problem like you used to, because their attitude is, if it is not written, you do not get paid for it, 

and so, physicians are careful to document, you know, the things that 

they need to do for the level of exam and what they are doing.

 We do not really have the hammer like that in the VA system. 

Again, that is a pretty big hammer. You know, if they review your 

case and they say, well, you did not do that, and all the ones like this, 

you are not getting paid for.

 I guess, you know, kind of the challenge is how do we -- I mean, you 

know, what hammer do we have to get that done?

 Dr. Javitt. With all due respect, Mr. Boozman, from what I have 

seen, the consistency in the documentation of computerized medical 

records within the VA is far more consistent and comprehensive than 

it is within the civilian sector.

 I am currently an expert witness in a major health care fraud case 

in the State of Vermont brought by the U.S. Attorney there that involves consistency of medical records in the civilian sector, and the 

variability there, and the standards -- is extraordinary, and the standards there are practically non-existent, and it is true that, certainly, 

Medicare audits can be used as a club to encourage better documentation, but as long as documentation is done on paper, there will be as 

many ways of documenting as there are doctors and nurses out there 

practicing, whereas when I talk about differences in nomenclature 

from one VISN to another, I am talking about very technical differences that only matter not because you can’t understand what the 

doctors in one VISN meant versus what the doctors in another VISN

meant, but because in order for the data to become computable, in 

order for us to be able to apply the kind of medical decision rules that 

save lives every day -- for instance, identifying the patients who have 

had a heart attack but are not getting better blockers, the patients 

who are on blood thinners but may not have gotten the appropriate 

test to make sure those blood thinners are safe -- in order to be able to 

go the next generation of medical decision making and patient safety, 

you need nomenclature that is computable from one place to another, 
21

and that is the next challenge within the VA. The private sector, to 

the extent that it is still based on paper, cannot even begin to talk 

about that challenge.

 Mr. Boozman. Okay. Very good.

 The other thing is the -- as we try and work -- and again, I am not 

a -- I have trouble with e-mail, but as we try and communicate, you 

know, as you said earlier, that it is communicating and things back 

and forth with our computer systems, what system do we use?

 Do we dump all the information into a warehouse-type thing and 

then get it from that? I mean is that the system that we are trying to 

get up and running, or how are we approaching that?

 Ms. Koontz. Well, ultimately, in terms of VA’s and DOD’s longterm goals, what they hope to have is standardized data in each of 

their two data repositories which hold the data, and they will make 

-- and I now hesitate to use this word, but there will be an interface 

between these two repositories that will allow the information to be 

exchanged. So, yes, there is basically pools of data which will be standard to avoid the problems in, you know, interpretation, so we record 

it the same way, and also, as Dr. Javitt said, to make it computable.

Mr. Boozman. I know some of the -- like immigration, the border 

guards and things, you know, they have problems in having to collect a lot of data from a lot of agencies. They have been able to do 

that recently, or have a pilot project going on where they are able to 

interface that data, and the people still have ownership of their data 

without the central pooling.

 So, is the technology -- is it leap-frogging ahead where -- I mean do 

we need to look at that? That makes more sense than giving up your 

data.

 Do you understand what I am saying?

 Ms. Koontz. I do understand what you are saying. Not being familiar, though, with the specifics of that particular instance, it is difficult 

for me to comment about, you know, a particular situation like that, 

but -- 

 Mr. Boozman. But are you familiar with that type of technology 

that is available?

 Ms. Koontz. No, I am not familiar with that kind of technology, 

no.

 Mr. Boozman. Okay.

Dr. Javitt. I think, in the U.S., we have the tools. Secretary Thompson was prescient in licensing the vocabulary for the whole country, 

and Secretary Principi endorsed that. It is a very simple problem.

 If two doctors are talking and one says crushing sub-sternal chest 

pain and the other one says angina, each of those doctors knows that 

they are describing the same entity, or likely to be, but two computers 

talking to one another do not know that those are the same entities. 

So, it is just a matter of standardizing nomenclature and standard-
22

izing vocabulary in ways that we already know how to do but having 

the discipline to implement.

Mr. Boozman. Okay. Thank you.

 Dr. Dysert. Can I make one comment, Mr. Boozman?

 Mr. Boozman. Yes, sir.

Dr. Dysert. On the whole issue of computability of information, and 

I think you are a physician, as well. You know, the transition for physicians from what I would represent to be an analog thought process 

to a binary decision tree of documentation is no small challenge, and 

the problem that I hear played back from physicians is things like 

computability and converting to structured data is something that is 

seen to largely create value downstream from the point of care.

 The terms that resonate with providers of care when they are looking for a role of technology to serve in a meaningful way -- you have 

the terms I used before -- communication for the purpose of collaboration in the management of their patients.

 What I hope the government will do and what we are trying to 

do now -- and it is a mighty challenge -- is to not lose sight of where 

the value is, and have a balance between downstream aggregated 

data for the purpose of looking at outcomes versus enabling the care 

providers up front to do what they do in medical practice, and that is 

communicate and collaborate.

 Dr. Javitt. May I just take a moment to endorse what Dr. Dysert 

said but go one step further and point out that the world of natural 

language processing, the world of neuro-networks outside of medicine 

has progressed to where, with concerted R&D, we can have computers listen to one doctor say crushing sub-sternal chest pain, listen 

to another doctor say angina, and automatically code that to be the 

same thing. We do not have to force doctors to do things that are different from what they would like to do every day if we do this right.

 Mr. Boozman. Mr. Snyder, you are up.

 Mr. Snyder. I do not know who to direct this question to.

 My understanding is that in the sequelae from Katrina in which 

VA patients were -- had to be evacuated from several of the VA facilities, that whatever facility they ended up at -- and I think many of 

them ended up at another VA hospital -- that the electronic transfer 

of their medical records worked, and it worked well. Do any of you 

have any knowledge of that or any comment on that?

 Dr. Javitt. I did not see it happen firsthand. What I understand 

is that, had the local internet infrastructure not gone down, there 

would not have been a need for data transfer; the data would have 

actually been visible in whatever hospital these vets were evacuated 

to, but because of the failure of the internet infrastructure, VA was 

able to burn magnetic tapes and transport the magnetic tapes, so the 

records were preserved.

 Mr. Snyder. Is it your understanding, also, that then that worked 
23

well at the receiving facility? I mean it was essentially the same format, I would assume, at the receiving VA hospital?

 Dr. Javitt. To the best of my knowledge, there is no veteran whose 

electronic medical records were lost in the process.

 Mr. Snyder. That was my understanding.

 We also have an occasion going on now where -- several members 

have done on a similar thing, but on one of my visits to Iraq where I

visited a treatment facility at Camp Taji, and then we went to a hospital where we saw some -- that day -- some wounded soldiers from 

Arkansas, went to Landstuhl, and I visited with folks there, including another wounded Arkansan, who was unconscious at the time, 

and then he was subsequently moved to Walter Reed, where I visited 

with him there a week or so later, and then visited with him while he 

was still undergoing outpatient treatment when he was back in Arkansas at his home, and I may be wrong, but I don’t think the system 

is quite as smooth as the VA, as we were talking about, but I have 

not had major complaints about the transfer of medical records in a 

system that very rapidly moves people in the war situation.

They feel very confident about moving people at quite severe levels 

of injury with all kinds of machinery and medication support and 

putting them on a plane and moving them.

 I have not heard complaints about medical records transfers not 

working. Have you all heard anything about that, anything to the 

contrary within the military?

 Dr. Javitt. The challenge you have is that CHCS1, which is the 

current level of implementation for military inpatient records, is not 

yet at a point where a lot of what doctors need, the images, the cardiograms, all of the, you know, thousands of tests that are critical for 

caring for a patient, can be transmitted through that system. It is 

not there yet.

 So, you know, at some level, information -- 

 Mr. Snyder. It has got to be a hard record of some kind, somebody 

carries an envelope.

 Dr. Javitt. At another level, a lot of it has to be moved manually.

 Dr. Dysert. Can I add to the comment? Would you mind?

 Mr. Snyder. Sure.

 Dr. Dysert. I think this is a very important consideration as the 

future gets looked at from a system perspective.

 I applaud and I am certainly not here to criticize the efforts of the 

VA.

 As has been said already, they are a leader in many respects.

 I think, having not started a project over 20 years ago but started a 

project in the last couple of years, our approach is different, because 

we had a different set of tools to use to build our system.

 I think a question and something I would look for in the future is 

why would we have records in one location at risk that needed to be 
24

moved or accessed because they were physically associated with the 

application that supported patient care? I think the modern of families of technology gives you, at a national level, the ability to probably 

virtually store your records in more than one location without the 

need to physically transport and have a physical barrier to access.

 Mr. Snyder. I think that is right.

 The frustration, I think, for this Committee and the Armed Services Committee and other folks that follow this is we seem to have 

independent systems that work pretty well, but there just has been 

this frustration with why they can’t do such a good job of communicating with each other, which I think is what GAO has been following 

and you all are referring to.

 I trained at a couple of different VAs, both as a medical student and 

as a family practice resident, and I can remember when essentially 

the VA chart was pages and pages of illegibility, and 25 years ago, 

when I was a resident, I got in the habit of typing -- I would borrow 

the secretary’s typewriter and type my admission notes, and it created a stir, because it was the only typed note in a medical record, in, 

you know, literally, for some of the patients, decades of illegibility, 

and then there would be this typed note, and so, we have moved from 

that, but we still have this issue of the two government entities.

 What comments do you all have with regard to the fact that we 

talk about the military system and the VA system, as such, that are 

straightforward government -- I am sorry, I did not see my light -

- government entities. The fact that Tricare -- so many of them are 

private providers -- where does that fit into this issue of sharing of 

medical information?

 Dr. Javitt. I think, before getting into Tricare, you were asking 

about where is that gap between VA and DOD, and although I had no 

mandate to do so, I can honestly state that I led the first inspection 

of the VA’s electronic medical records system by an Army surgeon 

general since that system has existed.

Gen. Peak came to look at the VA system for the first time approximately a year-and-a-half ago, and he found that that system 

was vastly different in its capability and vastly richer in its capability 

than his career staff had been telling him.

 Now, fortunately, some of that career staff has now departed from 

the Department of Defense, and I have heard that there is a potential 

for more openness and more listening, but perhaps the most useful 

thing this Committee could do would be to bring the senior leadership 

of the Department of Defense’s medical establishment together with 

the VA and make them look at each other’s tools and see where there 

is room for sharing, and there is room for bilateral sharing. Some of 

the work that the Department of Defense has done in a structured 

outpatient note might have some value to the VA, but until somebody 

with, you know, three stars on his shoulders is willing to ignore what 
25

he is hearing from professional staff and go look and go see, there 

is probably not much hope for the kind of sharing you are talking 

about.

 The Tricare folks, unfortunately, are largely in an environment 

where they are going to get whatever care is available to them in the 

community.

 It could be that Tricare could help facilitate the use of electronic 

medical records in places where Tricare comprises a large part of individual doctors’ and hospitals’ business, but in places where Tricare 

is just a small part of a doctor’s business, Tricare has no more ability 

to help that doctor move to electronic medical records than any other 

insurance company does.

 Mr. Snyder. I am not sure where my time is, Mr. Chairman. Thank 

you.

 Mr. Boozman. Mr. Michaud?

 Mr. Michaud. Thank you very much, Mr. Chairman. This question 

is for the GAO.

 In your written testimony, you stated that DOD is providing postdeployment health assessment information of individuals who have 

been discharged from the military to the VA. The assessment has 

self-reported responses that can help identify individuals at risk of 

PTSD.

 To your knowledge, how is the VA planning to use this information, 

and will they use it to conduct targeted outreach to the veterans?

 Ms. Bascetta. They plan to use the information in two ways.

 First of all, for the information that is available now -- some of it 

was made available in July -- when a veteran or a service member 

comes to the VA for care, they have access to their post-deployment 

survey in their medical record, and they are supposed to be getting 

that monthly in October.

 What they would like, in addition, is that information in the aggregate, so that they can look at what the potential demand for mental 

health services might be coming down the road and where those services might be needed especially if service members are going to be 

returning disproportionately to certain areas.

 They do not have that aggregate information at this point.

 Mr. Michaud. Also in your testimony you state that DOD is not providing VA with the health assessment information for -- from reserve 

and National Guard members. These veterans actually represent 

roughly one in three of the OIF and OEF forces. Why is DOD not 

providing VA with this information, and how will this impact seamless transition for these veterans?

 Ms. Bascetta. It obviously has a negative impact on the transition 

for Guard and reserve members. Honestly, we are not clear on what 

the reason is. It has something to do with the legal status of Guard 

and reserve members, as opposed to active duty members, and I think 
26

if that were resolved, there is a solution to getting that information to 

VA, and I would encourage you to ask DOD that question.

 Mr. Michaud. I definitely will.

 In your opinion, when one in three are reserve and National Guard 

members that are putting their lives on the line, and a lot of them 

have lost their lives in this war, why would we want to treat them 

less than we would for an active member because of a legal status?

 Has GAO taken a position and has encouraged DOD to provide this 

information?

 Ms. Bascetta. Yes, we would.

 We would certainly not want to treat anyone differently who has, 

you know, put their life on the line in either of these conflicts.

 In the transition assistance program, where we also noted in a report that we issued in May differences between the way the Guard 

and reserve and the active duty members were transitioned, received 

transition assistance, DOD, to its credit, has been working to assure 

that there is equal treatment of Guard and reserve members, and 

there are logistical difficulties, but they are certainly not insurmountable.

 Mr. Michaud. Thank you very much.

 I yield back the balance of my time, Mr. Chairman.

 Mr. Boozman. One thing that came up in the testimony with Dr. 

Snyder -- I know we did a good job of, you know, saving things and 

stuff, but were the digital x-rays -- were they lost?

 Dr. Javitt. I do not have specific knowledge. I saw Dr. Kolodner in 

the room, and he probably knows the answer.

 Mr. Snyder. Okay. Very good.

 Dr. Dysert, the transfer of the digital x-rays really is not a problem. 

I know that people do that all the time.

 Dr. Dysert. Well, again, I hate to get down at a word and semantic 

level, but the notion of transfer feels like it is a technology movement 

-- using technology movement of a file from one system to another, 

and I think it is the framework for my comment earlier: Perfect is 

the enemy of good. Sometimes there is an equally effective way and 

it is an access thought.

 We are simply providing access to the information, creates value, 

without having to physically move at a system level, and the unfortunate thing with computer technology and interfaces -- sometimes 

they do require technical perfection to function in the exchange of information between systems versus you or I simply hitting a link that 

takes us to that PAX web viewer and you are able to see that image, 

even though it is resident on the original system. Nothing has been 

transferred at a system level. I am simply accessing where that image is. Does that make sense?

 Mr. Boozman. Yes, sir, very much.

 Ms. Bascetta, according to Dr. Jones’ testimony, VA and DOD
27

signed a memorandum of agreement in June regarding the resolution 

of the HIPPA privacy rule. Are you familiar with the agreement, and 

in your opinion, to what extent does it resolve the untimely sharing 

of medical records between the two departments?

 Ms. Bascetta. It does not resolve it at all, unfortunately. We testified about this in May, when we had a copy of the draft MOU, which 

is identical to the one that was signed in June.

 The MOU essentially restates the circumstances under which DOD

and VA can exchange individually identifiable health information, 

and it includes references to provisions of the HIPAA privacy rule, 

but it doesn’t constitute a data sharing agreement, and that is what 

they really need to move to a seamless system.

They need to know exactly which individually identifiable information they are going to share, and they need to know the point in the 

process that they will share that information for service members.

 It is interesting that they have apparently signed this directive to 

address the second part of the question, that at the point of the PEB, 

when, essentially, the military is pretty likely to medically discharge 

a service member, they are going to transfer information to VA, and 

that is important for the Veterans Benefits Administration, in particular, and probably is soon enough for them to get that information 

for processing disability compensation claims.

 We still have questions about how the two departments could work 

together, could collaborate to determine even earlier points in the 

process for other service members who, for example, might need 

medical rehabilitation. You know, is there a way for VHA to access 

information more broadly about service members who may be in that 

need of VA medical care?

 Mr. Boozman. I guess the next question would be, then, you know, 

since we are at this impasse again, how do we resolve that?

 Ms. Bascetta. Well, there are a couple of options.

 The presidential task force essentially recommended a few years 

ago that DOD and VA ask HHS to declare them a single health care 

system, and they said that if they were to do this, they could avoid 

what would otherwise be these cumbersome agreements that need to 

be put in place to be HIPAA compliant. In the JEC’s annual report 

last December, they have a response to the task force’s recommendation, and they essentially indicate that they do not need to do that, 

that they can handle their data sharing needs under HIPAA without 

going to HHS, but they have not done that, at least not to our satisfaction.

 Mr. Boozman. I guess since we have got the inability to obtain the 

health information on the reserve and national guard members from 

DOD, what is the byproduct of that? How does that affect timely access for care to the service members involved?

 Ms. Bascetta. Well, until some of the unique difficulties with in-
28

formation -- health information on Guard and reserve members are 

resolved, they will be at a disadvantage.

 Mr. Boozman. Dr. Snyder?

 Mr. Snyder. Help me with my ignorance on this, on the MOU. I

do not understand how it is supposed to work. I guess in my naivete 

when we first started hearing about it, I was like you, Doctor, where 

I thought that you are talking about information being in a location 

someplace and the person shows up at a VA facility and that treating 

facility accesses that information.

 If they are then transferred from Walter Reed and are getting some 

follow-up care at the VA, that facility accesses that information.

I do not understand the MOU. I mean it specifically talks about 

-- well, I do not understand how it is supposed to work according to 

this MOU.

 If I am a patient, are we assuming that, for legal purposes, these 

are separate entities and that a person in the military can refuse to 

have information transferred to the VA?

 Ms. Bascetta. Well, I suppose they could, but the way it works 

is that, right now, they are not considered a single entity, but that 

should not pose a barrier, and in the situation you just described, 

where someone is transferred from an MTF to a VA, there is no 

HIPAA problem, because under the continuity of care scenario, those 

records transfer. Under other situations, a service member could sign 

an authorization to have the records transferred. What we are talking about are -- and what DOD and VA are trying to negotiate are 

those situations in which a service member has not transferred to a 

VA facility but there is the potential for them to do that, and the issues that need to be worked out in those cases are what information 

VA needs to prepare for that patient and how soon they can get access 

to that information.

 Mr. Snyder. So, a line in the MOU talks -- am I taking too much 

time, Mr. Chairman? Where it says -- the Department of Veterans 

Affairs’ responsibilities -- and they both have responsibilities, which 

are about the same -- shall provide DOD Tricare with information 

necessary to provide medical treatment to veterans.

 Okay. Information necessary, but then, down below, it says that 

-- shall provide a veteran or service member’s information to DOD

pursuant to prior written authorization by the service member.

Are those two in conflict, or am I missing something, where it says 

shall provide information necessary to provide medical treatment, 

and then, down below, it says the disclosure of information pursuant 

to prior written authorization.

What I am getting at is if you have a difficult patient -- I mean we 

are all difficult patients at some point -- somebody who is -- I will 

make up something -- abusing oxycodone or something, and wants to 

-- did that in military service, and now -- and that is in the medical 
29

record, and now it is going to transfer to the VA. Can that person say 

no, I do not want my medical records to be accessed, I am not going 

to give you written authorization, or are we one entity in terms of 

providing treatment?

 Ms. Bascetta. No, they are definitely not one entity at this point. 

That is what the task force recommended that they ask HHS, to declare them one entity, but certainly somebody could -- under the scenario you describe, they could refuse to have their medical record 

transferred, but the more -- that is not, you know, the kind of situation that has come up.

 Mr. Snyder. No, I would think -- 

 Ms. Bascetta. What has come up is that, in fact, if someone is being 

transferred under continuity of care, the VA can get the information 

that they need, and they do not necessarily need the entire medical 

record. They probably only need, at least in the immediate term, the 

record that is pertinent to that episode of care, and HIPAA does not 

pose a barrier in that situation.

 Mr. Snyder. Which, if you believe in the concept of the total patient, 

would make some providers very apprehensive that I only want the 

information about the gun shot wound to his hand.

 Ms. Bascetta. Right.

 Mr. Snyder. I do not need the stuff about his antidepressants. I do 

not need the stuff about his suicidal gestures.

 Ms. Bascetta. Right.

 Mr. Snyder. That is, I would think, problematic.

 Thank you for your indulgence, Mr. Chairman.

 Mr. Boozman. Mr. Michaud?

[No response.]

 Mr. Boozman. Thanks very much to the panel. We certainly appreciate your being here, and now we are going to move on to our second 

panel.

[Pause.]

 Mr. Boozman. Thank you all very much for being here.

On the second panel, we have the Hon. Gordon H. Mansfield, Deputy Secretary, Department of Veterans Affairs; Dr. Stephen L. Jones, 

Principal Deputy Assistant, Office of Health Affairs, Office of Personnel and Readiness, U.S. Department of Defense; Maj. Gen Ronald G. 

Young, Acting Director, National Guard Bureau Joint Staff, National 

Guard Bureau; Col. Sheila Hobbs, Senior Patient Administrator, Office of the Surgeon General, United States Army; Ms. Susan McAndrew, Senior Health Information Privacy Policy Specialist, Office of 

Civil Rights, U.S. Department of Health and Human Services.

I would like for our witnesses to limit their oral testimony to five 

minutes, as your complete written statement will be made part of the 
30

official record of the hearing. I ask that the members hold all questions until the panelist has finished.

Mr. Mansfield.

STATEMENT OF HON. GORDON H. MANSFIELD, DEPUTY

SECRETARY, DEPARTMENT OF VETERANS AFFAIRS; 

 ACCOMPANIED BY ADM. DANIEL L. COOPER, UNDER

SECRETARY FOR BENEFITS; DR. MICHAEL KUSSMAN, 

DEPUTY UNDER SECRETARY FOR HEALTH; MR. JOHN

BROWN, DIRECTOR, SEAMLESS TRANSITION OFFICE; DR.

 BARBARA SIGFORD, CHIEF, PHYSICAL MEDICINE AND

 REHABILITATION PROGRAM MANAGER, VETERANS

HEALTH ADMINISTRATION; MS. KAREN OTT, VA/DOD 

LIAISON OFFICE; DR. STEPHEN L. JONES, PRINCIPAL DE-

 PUTY ASSISTANT IN THE OFFICE OF HEALTH AFFAIRS, 

 OFFICE OF PERSONNEL AND READINESS, U.S. DEPARTMENT OF DEFENSE; MAJ. GEN. RONALD G. YOUNG, DIREC-

 TOR, NATIONAL GUARD BUREAU JOINT STAFF, NATIONAL

GUARD BUREAU; COL. SHEILA HOBBS, SENIOR PATIENT

 ADMINISTRATOR, OFFICE OF THE SURGEON GENERAL, 

UNITED STATES ARMY; AND MS. SUSAN McANDREW, SE-

 NIOR HEALTH INFORMATION PRIVACY POLICY SPECIAL-

 IST, OFFICE OF CIVIL RIGHTS, U.S. DEPARTMENT OF

 HEALTH AND HUMAN SERVICES

STATEMENT OF HON. GORDON H. MANSFIELD

Secretary Mansfield. Thank you, Mr. Chairman, and members of 

the Committee, for this opportunity to appear before you.

 I am here as one individual representing a agency that has 230,000 

people. I am sitting here with representatives of an agency that has 

additional numbers.

 So, you have the two largest agencies in the government sitting at 

this table. The VA is lucky, very lucky.

 We have a single mission, and that is to take care of veterans, to 

take care of veterans’ health care, to take care of veterans’ benefits, 

and to give them repose in a national cemetery if they so wish, a national shrine that would honor their service.

 These two big bureaucracies are charged with working together to 

take that individual, that young man or young woman who steps forward to become a member of the armed services, and we should recognize that, when that person steps forward, as they progress through 

a career in DOD, at some point in time they are going to become the 

responsibility of the Department of Veterans Affairs.

 For these two agencies to work together, as the Chairman mentioned earlier, we have a bureaucratic entity, the Joint Executive 
31

Council, and I would mention here that the goals for that council, as 

evidenced in their latest strategic plan and report that came here to 

this Congress, include leadership, commitment, and accountability, 

high-quality health care, seamless coordination of benefits, integrated information sharing, efficiency of operations, and then goes on to 

joint contingency readiness capabilities and other issues.

I think, rather than read the statement -- I request that my official 

statement be included in the record and Iwill talk about some issues, 

as I mentioned, two big bureaucracies.

 So, how do we make this work?

 Again, I would tell you that, from the VA’s perspective, our one 

unique mission is that veteran and recognizing who and what they 

are, and we are required to take care of them.

 The Executive Council, in providing leadership, looks at things at a 

high level, and let me talk about some of the issues that we are dealing with right now, some of which have been covered here.

 For example, we know that there is concern here on the Hill, as 

there is in our agency and at DOD, about the issue of PTSD.

 So, that issue has been a subject of discussions both off the record 

and on the record with the senior leadership, but I can tell you right 

now that we are tracking -- keeping track of the OIF/OEF veterans, 

393,407 that have been separated, how many of those come from National Guard or how many come from active duty, how many of those 

have asked for or are seen for readjustment counseling service, how 

many have been evaluated or treated for PTSD, and how many have 

ongoing treatment, and that is a subject matter that this council, at 

its senior level, has been able to look at, deal with, and try and get the 

message out all the way to the field that this is an important issue.

Benefits: The fact that these individuals coming into service at 

some point in time are going to be veterans is important. We have 

an effort underway to make sure that not just OEF and OIF but all 

members leaving the service are seen, are given an opportunity to be 

briefed on what those benefits are, how they can be accessed, and how 

VA can assist them.

 Medical facilities: We’re doing an awful lot of work. As has been 

mentioned here in the area of seamless transition, as the Chairman 

mentioned and other members mentioned, the road from Iraq or Afghanistan to Landstuhl to Walter Reed to a VA hospital is one that 

we have spent a lot of work, energy, and effort on in the last few years 

to make sure that this works.

 Then in the areas, for example, as mentioned, in the records area, 

HIPPA has come up and some questions have been asked.

 It has been up and down the line a number of times, questions 

asked about what are the ability to withhold information or what 

are the ability to exchange information, what are the points where 

information stops, what is the information that can be asked for and 
32

required.

 We have moved forward to the point where we have had general counsels from HHS and general counsels from DOD and general 

counsels from the VA sitting down at a table and talking about how 

do we handle this, and we have got an agreement now at that high 

level, but we still need to move it down to the bottom line.

 There is a piece of legislation, S. 1182, I believe it is, on the other 

side, that deals with this issue, and it would resolve it once and for 

all by saying that health care information can be moved back and 

forth between DOD and VA. I would make the point, seeing the red 

light, Mr. Chairman, that I do believe that Dr. Chu and myself and 

the members of the Joint Executive Council, the subCommittees on 

health care and the subCommittees on benefits, have done a lot of 

work. We have tried to get the message out that we have to make 

this work, have tried to get the message out that that person coming 

on duty from day one is going to be a veteran, and we need to consider 

that, and we need to make sure that the effort is there to ensure that 

the benefits, as you mentioned, sir, that have been earned by that service member are delivered in a timely and accurate manner. We are 

making sure that we take care of these young men and women, and 

I think that I can say that we have done, over the course of the last 

year, the last two years, the last three years, a better job than had 

been done in the past, but I would also say that we still have a long 

run to go. There is, I see, a commitment by VA and DOD to travel 

together down that road, and we are working on that.

 Thank you very much.

[The statement of Secretary Gordon H. Mansfield appears on p. 

120]

 The Chairman. [Presiding] Thank you, Secretary Mansfield.

 Secretary Jones?

STATEMENT OF DR. STEPHEN L. JONES

 Dr. Jones. Thank you, Mr. Chairman.

 Mr. Chairman and distinguished members of the Committee, 

thank you for inviting us to meet with you today. It is my honor to 

represent the Military Health System. I am especially pleased with 

the opportunity to discuss how we work together with the Department of Veterans Affairs to streamline the transition from military 

to veterans health care for our service members and their families. 

With your approval, I will summarize for you my written statement, 

touching on some of the noteworthy defense programs and assuring 

you of our commitment to work with the VA to meet the needs of our 

service members and their families as they move back to their civilian lives.
33

 We have endeavored to encompass and integrate the many steps 

involved with transitioning from the battlefield to military hospitals 

to hometown communities. We have accomplished much, but we 

know that we can do more.

 Many of our transition initiatives with the VA support recommendations found in the President’s task force to improve health care 

delivery for our nation’s veterans. These recommendations align into 

three broad categories: medical care and disability benefits, transitioning to home and the community, and sharing of service member 

personnel and health information.

 Each of these areas, military medicine plays a role. Let me offer 

just a few examples.

Under medical care, by any measure, our war fighters who need 

medical treatment are receiving exceptional treatment and care by 

a dedicated health professional. One such example is the Army’s 

collaborative program with the VA’s polytrauma rehabilitation center, which you are familiar with, Mr. Chairman, which is a boots-onthe-ground program to aid in our severely injured service members 

who need assistance during the long recovery and rehabilitation program.

This program, an Army liaison officer at each of the polytrauma 

centers works with VA personnel to support service members and 

their families in addressing a broad array of issues such as travel, 

housing, and military pay, and Col. Hobbs is here from the Office of 

the Army Surgeon General, who can address specific questions that 

you may have, sir.

 In the transition process, the DOD-VA Seamless Transition program features VA social workers and benefits counselors assigned to 

eight military medical facilities around the country to guide service 

members through the transition process.

 The VA staff briefs service members while still on active duty about 

their VA benefits, including health care and disability compensation 

claims.

 They also enable the smooth transfer of care to VA medical centers 

located near the service member’s home and then maintain contact 

with patients to ensure success of the discharge plan.

 Another example is the free counseling provided under the transition assistance program and the disabled transition assistance program.

 Both DOD and VA counselors offer extensive information on numerous issues, to include health coverage and insurance programs, 

as well as a full range of benefits available to them.

 To ensure we meet the particular needs of our reserve component 

members who transition and who are disabled and transition back to 

civilian life, we established an interagency demobilization working 

group which works to improve the process.
34

 One of the policy changes that they are considering recommending 

is mandating attendance at the VA benefits briefings, and I might 

mention, Mr. Chairman, I was up at Fort Drum yesterday and was 

pleased to see, with the VA counselors, are in the same building, that 

the medical clinical there, with the Fort Drum soldiers, as they seek 

health care.

 Another transition initiative created within DOD is military severely injured center established in February 2005 to operate on a 

24/7 toll-free hot line for service members and families.

 The mission of the center is, quote, “to prepare severely injured 

service members to return to duty or to reintegrate successfully into 

their home towns.” To meet this mission, this center assists injured 

service members to achieve the highest level of functioning and quality of life by offering advice and help and a full spectrum of benefits, 

connecting the service members and their families with helpful resources in solving problems.

Currently, the center’s health care managers, case managers, are 

working on more than 1,200 active cases. Issues of top concern are 

financial resources, education, employment, and family services.

 This center, in concert with those operated by the individual services, provides a greater resource to cut through administrative obstacles and help ease the transition to civilian life.

 Mr. Chairman, we have materials outside on the table and have 

additional materials on this military severely injured center that is 

available for you, and I see I am getting a red light, too. If I could 

have two more pages here, I would appreciate it.

 Under information sharing, which has been discussed here considerably this morning, is the third category of interest.

 We in the defense believe that sharing of necessary information is 

absolutely critical to an effective and transparent transition process.

Again, together with the VA, we have made significant strides.

 Today, we have a memorandum of agreement that governs the 

sharing of protected health information and other individually identifiable information, and as I understand some of the discussions this 

morning, we were unaware of some of these difficulties, and we would 

like to work with the GAO and others to try to address some of these 

issues and attempt to solve the problems as quickly as we can.

 The Bi-directional Health Information Exchange operations in Seattle, and being tested in El Paso, enables near real-time sharing of 

outpatient prescription and demographic data between DOD and VA

for patients treated in both health care systems.

 Inter-operability between our clinical data repository and VA’s 

health data repository is getting much closer.

 We routinely share with the VA service member contact information when they separate from military service. It may not be as timely 

as needed sometimes, but we are sharing that data.
35

 While there are some discrepancies in this process, I understand 

that technical changes made last year resolve many of those problems. The next step in this effort will result in sharing the member’s 

name, Social Security number, unit ID, current location, contact information, and a brief explanation of medical condition. Sharing this 

information with the VA at an earlier point in the transition process 

will allow expedited delivery of benefits to transitioning service members and reduce the chance of overlooking a particular individual.

 With the VA, we will continue to enhance our electronic information sharing structure in order to further enhance seamless transition for all who move from military service to civilian communities.

 Mr. Chairman, I would just like to emphasize what Secretary Mansfield stated.

 We are committed at DOD to working with the VA in meeting the 

goals which you have expressed in your statement this morning, and 

we have many people throughout the agency working. We have people assigned with authority to try to -- and points of contact to work 

on the various issues, and I think, with good will and open communications, we are trying to do that.

 We appreciate your Committee holding this hearing. We appreciate your outstanding support for our American heroes, and we will be 

happy to answer any questions at your convenience.

[The statement of Dr. Stephen L. Jones appears on p. 140]

 The Chairman. All right.

 For the witnesses and my colleagues, we are going to have to recess 

for about 15 minutes.

 We have a vote on the motion to instruct on the Department of 

Homeland Security appropriations act, thereby followed by adoption 

of the rule on the Department of Justice appropriations authorization 

act.

 So, the Committee will be in recess for 15 minutes. I apologize to 

my colleagues for not giving a witness from the low country of South 

Carolina 10 minutes because of his dialect.

Dr. Jones. I apologize.

[Recess.]

 The Chairman. The Committee will come back to order.

 I would ask unanimous consent to strike the word “speech” that 

was used right before the break and insert the word “dialect.”

 Hearing no objection, so ordered.

 I had no objection with regard to your speech that you gave.

 It is just the dialect of the low country is a little slower than what 

perhaps I was used to and calculated. The word “tea” in Indiana has 

one syllable, not three.

 Let me now turn to Maj. Gen. Young for testimony.
36

STATEMENT OF MAJ. GEN. RONALD G. YOUNG

Maj. Gen. Young. Mr. Chairman, distinguished members of the 

Committee, thank you for the opportunity to speak with you today 

about these vitally important programs.

 Today the National Guard has over 78,000 soldiers and airmen mobilized around the world for the global war on terrorism, over 325,000 

since 9/11.

 That is why the transition assistance program is so critically important to our efforts to take care of service members and their families.

The information received during TAP briefings and the opportunity to enroll in these vital benefits programs has long-lasting effects 

on our men and women in uniform, their families, and their communities.

 The effectiveness of transition assistance holds implications for the 

long-term health of our entire organization. Transition assistance 

must be comprehensive, a continuum of care that begins before the 

service member deploys, continues while he or she is away, and follows through after their return. TAP must provide a seamless transition from active duty back to the citizen soldier environment and 

thereafter.

 That is why the National Guard Bureau fully supports the recommendations contained in the recent GAO report and why we support programs such as the New Hampshire reunion and reentry program.

 The National Guard plans to continue to build on pilot programs 

like the one in New Hampshire. Many of the decisions made during 

the transition assistance program process are family-based, as opposed to individual choices. This necessitates that the service member be united with his or her family during the process.

 In addition to the pressing need for the delivery of TAP information 

at or near the home station, there exists a need for more effective follow-through support in the period immediately following demobilization.

 To be truly effective, this follow-on support requires close coordination by TAP representatives at the state and local levels. The New 

Hampshire model accomplishes this and much more.

 While the efforts at the demobilization station are essential, New 

Hampshire experienced great success with local management and coordination with veteran centers and the VA hospital counselors in 

providing counseling and education to returning members and their 

families.

Returning soldiers testified that the one-on-one counseling which 

occurred during the additional transition days was very effective in 
37

helping them identify and/or cope with their reintegration back into 

the local community.

 This effort also educates the family on signs to look for when dealing with the stress and emotions of their service member’s experiences. This coordinated effort makes it easy for the service member 

to seek and receive the help that they may need.

 While New Hampshire should be applauded for their efforts, I

would like to point out that there are other states, particularly Washington and New York, that are making great strides in their efforts, 

as well.

 Now more than ever, taking care of soldiers and airmen must be 

our highest priority. Leveraging the benefits available to National 

Guard soldiers and their families through the transition assistance 

program is a key part of this commitment.

 As I stated earlier this year, TAP is a readiness issue. The way 

we take care of service members and their families today will have a 

direct impact on how well we recruit and retain them in the future.

 Working with the members of this Committee, I believe that the 

Guard, along with DOD, Department of Labor, and the Department 

of Veterans Affairs, as well as state and local agencies, can dramatically enhance the effectiveness of the transition assistance program 

and thereby improve the quality of life of our service members and 

their families.

 I want to thank you again for the opportunity to be here today, and 

I look forward to your questions.

[The statement of Maj. Gen. Ronald G. Young appears on p. 151]

The Chairman. Thank you very much.

Col. Hobbs?

STATEMENT OF COL. SHEILA HOBBS

Col. Hobbs. Mr. Chairman, distinguished members of the Committee, thank you for the opportunity to come before you to discuss invitational travel orders and support of family members of wounded 

and ill soldiers sent from VA medical centers and military treatment 

facilities.

 This is an area we have recognized is in need of work, and we appreciate the opportunity to share with you our systemic improvements.

 An invitational travel order is a mechanism used by the Army to 

cover transportation and sustainment costs. A non-medical attendant order is a particular type of invitational travel order that allows 

family members of injured soldiers to travel from home or military 

treatment facilities or another medical treatment facility, including 

civilian and VA facilities.

 Non-medical attendant orders are issued when the medical author-
38

ities determine that a non-medical attendant is in the best interest 

of the patient. They are normally issued when patients are unable to 

travel alone due to physical or mental disability.

 The orders are issued and funded by the military treatment facility 

responsible for providing care. Non-medical attendant orders authorize reimbursement for travel, lodging, and meals, but the extensions 

are possible if required.

 Since the beginning of the global war on terrorism, the Army’s Human Resources Command Casualty Branch has issued invitation 

travel orders to bring family members to the bedside of the injured 

soldiers while they are hospitalized.

 Invitational travel orders differ from the non-medical attendant orders that are issued by the military treatment facilities.

 In the past, there has been some overlap between the invitational 

travel orders used by Human Resources Command and the non-medical attendant orders used by the military treatment facilities.

 Once the soldiers are transferred to the VA medical centers, human 

resources command no longer has visibility over the soldiers and the 

family members. When invitational travel orders expired, Human 

Resources Command was unaware of the situation.

Once this was identified, a systemic flaw, action was taken immediately to correct the process. Instead of extending the existing 

invitational travel orders by Human Resources Command to cover 

the soldiers and the family members at the VA medical facilities, the 

Army, MTFs, or military treatment facilities, are issued non-medical 

attendant orders to authorize family members’ travel at the facility. 

This allows the military treatment facilities to transfer the soldier 

and the family members.

 The military treatment facilities have the authority required to issue these orders upon request by the attending physician.

 Although this is a new process, it has only been in place for about 

two months, we already are seeing improvements.

 In addition, we have placed Army Medical Department representatives at four polytrauma centers to provide continuous support to our 

soldiers and family members.

 The seamless transition of soldiers and their family members that 

are treated at the VA medical centers is an integral part of providing care to our soldiers. Non-medical attendant invitational travel 

orders are issued and tracked by the military treatment facilities will 

improve the transition.

 Whether the soldiers are receiving care at the military treatment 

facilities or at the VA medical center, the Army is committed to providing world-class compassionate care to our wounded warriors.

 Thank you for the opportunity to appear.

[The statement of Col. Sheila Hobbs appears on p. 156]
39

The Chairman. Thank you very much.

 Mrs. McAndrew?

STATEMENT OF MS. SUSAN McANDREW

 Ms. McAndrew. Thank you, Mr. Chairman and members of the 

Committee.

 I am pleased to be here today to help clarify the application of the 

HIPPA privacy rule to the transfer of medical information between 

the Departments of Defense and the Veterans Affairs.

Briefly, by way of background, the HIPPA privacy rule establishes for the first time a set of national standards for the protection of 

health information. These standards were issued in final form in 

December of 2000, and have been in operation widely since April of 

2003.

 They are relevant to today’s hearings, because the health care programs of both DOD and Veterans Affairs are subject to the suite of 

HIPPA requirements, including the privacy rule.

 I want to emphasize that the privacy rule has been carefully balanced to ensure that, while there are strong privacy protections for 

the health information of individuals, that those protections are not 

so strict as to interfere with the needed flow of information to provide 

individuals with quality access to care.

 One of the ways in which this balance is most effectively evidenced 

is in the provisions in the rule that make clear information is able 

to flow freely from provider to provider for the treatment of the individual.

 There has been discussions here in terms of the service member 

that is being transported and sees many doctors in the course of coming from overseas back to the United States and is in this -- is passed 

from facility to facility. The privacy rule, in fact, anticipates that and 

does allow that patient’s treatment information to follow with him as 

he moves from one care setting to another, and I believe the GAO also 

made clear that, for that kind of treatment, the provision of treatment, there is really no HIPPA issue with regard to the VA’s access 

to information in order to accomplish that.

I would also emphasize that our definition of treatment is quite 

broad, and it does also cover the provision of related services, as well 

as the direct provision of care, the coordination of that care, consultation with other providers, and referrals to other treatment settings, 

so that an individual, if there is a transfer of the treatment of a soldier from a DOD medical facility into the VA’s system, that treatment 

information can flow, and that is permitted, clearly, by the HIPPA 

rules.

 I wanted also to emphasize that there is one other provision of 

the HIPPA privacy rules that was intended to expressly recognize 
40

the need for the transfer of medical information as an active duty 

service member makes the transition to veteran status, and there 

is an express provision in the HIPPA privacy rule that does allow 

this information to be shared by DOD to VA upon the separation or 

discharge of the active duty service member, and the VA can use that 

information to determine the individual’s eligibility for entitlement 

to veterans’ benefits.

 When the privacy rule was being drafted, we were aware of the 

transfer programs in effect at that time as between the two departments.

 Through the comment period, we heard that there were no real objections to the transfer of this information and that it was being protected both within DOD and within VA, and so, there was an express 

provision to allow that program to continue unimpeded.

 As part of my statement for the record, I have included the actual 

regulatory provisions that are most relevant to this, and some of the 

regulatory discussion of this particular transfer provision, and so, I

-- that is there in the record for reference, and I just want to say that 

we do appreciate the opportunity and the careful attention that both 

departments have been paying both to the achievement of the seamless transition of this information, as well as attention to the privacy 

interests at stake in the individual’s information and that they have 

found solutions consistent with the privacy rule in order to have the 

seamless transition go forward, and I would be glad to answer any 

questions that you or the Committee members may have.

[The statement of Ms. Susan McAndrew appears on p. 159]

 The Chairman. Thank you very much for your appearance before 

the Committee, Ms. McAndrew.

 This is going to be a very good discussion, and I am going to yield 

as much time as Dr. Snyder would like to have, because there is a 

good overlay here between the two of us, in his work on the personnel 

Committee of Armed Services. I realize that we are dancing within 

your jurisdiction on armed services, but this is all about our seamlessness, and I also have oversight on the health subCommittee on 

Energy and Commerce with regard to Health and Human Services, 

and it just makes me stand on end when I go out into the field and I 

hear someone at the local level saying, well, I can’t because of HIPPA, 

and I just go crazy, and so, your appearance here -- I was paying very 

close attention to the two principals at the table while you were testifying.

 The purpose of your testimony was not just for me. It is for both of 

you, both of the two secretaries here, and that is the reason I wanted 

Secretary Chu here. So, please convey that to him, and also Secretary Winkenwarder, because they are in very responsible positions, 

and they can send it down line.
41

 We should not be hearing I can’t because of HIPPA. We have just 

heard -- okay? I have not heard that, Secretary Mansfield, from the 

-- well, strike that.

 I did hear at the VA facility with regard to -- in Minneapolis -- with 

regard to these records, but I just want to make sure that the two 

principals are comfortable with what you have just heard.

 Do both of you acknowledge and are comfortable with what you just 

heard?

Secretary Mansfield. Yes, sir.

The Chairman. All right.

 Secretary Jones?

 Dr. Jones. Yes, sir.

 The Chairman. All right.

 Maj. Gen. Young, it is my understanding that the National Guard 

Bureau has entered into a memorandum of agreement with the Department of Veterans Affairs regarding transition assistance. Could 

you please provide the Committee with more details on the nature of 

the agreement, in greater detail?

 Maj. Gen. Young. Yes, sir, Mr. Chairman. We started working with 

the Department of Veterans Affairs at the National Guard Bureau 

back in 2004, when Secretary Principi was still there, and after Secretary Principi left, we formed a joint working group, or during that 

time-line, we formed a joint working group, and it has continued and 

still continues today to work on the seamless transition between the 

two departments.

 We signed a memorandum of agreement, the two under secretaries for health administration and benefits administration, Dr. Perlan 

and Mr. Cooper, signed that memorandum, and then Gen. Blaum 

signed it on May the 19th out in Omaha, Nebraska, in front of all the 

adjutants general from around the country.

 The Chairman. So, he did this on his own initiative?

 Maj. Gen. Young. Yes, sir. Well, Gen. Blaum and Secretary Principi started the discussions, and then it followed through in the new 

administration over at Department of Veterans Affairs, and it came 

to conclusion with the signing ceremony out at Omaha, Nebraska, on 

May the 19th.

 Now, what that memorandum of agreement does -- it commits both 

of the departments to various things, one of them being establishing two offices, a seamless transition office, and at National Guard 

Bureau, we have appointed a program manager, and hired him even 

before the signature on the two documents.

 It establishes that the two departments will establish mutually 

beneficial opportunities to exchange and educate and train our families and our service members about the benefits with VA, because it 

is a complex system, and guardsmen, as you know, until after 9/11, 

now that we have got over 300,000 veterans, did not play into that 
42

system too much. So, now, with this many veterans, it is absolutely 

critical that they understand all their entitlements, all their benefits, 

and how to get that seamlessly without much difficulty.

 Part of the agreement -- on National Guard Bureau’s behalf, we 

took out of hide about $5 million from our other programs to establish 

state benefits advisors at every state, at the joint force headquarters 

level.

 So, we are in the process of hiring the remaining -- to have 54 state 

benefits advisors at the joint force headquarters level, sir, not only to 

take care of Guard families but all families and all service members 

that are back in a state and need some assistance in getting their VA

benefits.

 That program, I believe, because of some of the initial states that, 

early on, took it out of hide and hired that person, they are getting 

lots of business, and I believe that in the future we are going to have 

to add to that one-or-two-person office to help take care of all the 

work load.

 In addition, sir, as part of our effort at National Guard Bureau, we 

have across the country over 400 family assistance centers.

 We have 92 wings and wing family program coordinators. We have 

54 state family program directors.

 Each of those entities, when you add them all together with our 

state benefits advisors, accounts to about 600 different service areas out there, service centers, that we can assist families and service 

members. So, we are in the process of bringing their level of expertise 

up to a higher level as it relates to veterans affairs, their benefits, and 

their entitlements.

So, this has been a mutually very beneficial relationship and agreement, and we think it is paying great dividends.

The Chairman. Now, I realize you do not have operational control 

over various state adjutant generals. So, do we have a patchwork going on out there, a quilt, or how is this on the implementation?

 Maj. Gen. Young. Sir, when we were out at Omaha, of course, all 

the adjutant generals -- I spoke to all the chiefs of staff, who were 

there at the same time, about the New Hampshire model.

 I had seen it earlier and been briefed on it, and the experience in 

New Hampshire with 900 returning soldiers has been just absolutely 

phenomenal, and the continuation of care and counseling that they 

have received is going to pay great dividends in the future for those 

families and stuff.

 So, we are sharing that model at Guard Bureau, and I am also the 

J1, the personnel officer, at National Guard Bureau. I believe that 

model is the best we have in the country, but I do not want to say that 

the other adjutant generals are not doing the same types of things.

 In Ohio, where I am from, the adjutant general there has worked 

very closely with the Department of Health and Human Services.
43

 He has worked with several other state agencies, the governor’s 

office, and they have a program very similar, but the uniqueness of 

what happened in New Hampshire was that they went to the First 

Army commander, and they were able to get five additional days of 

Title 10 active duty service once they returned from the demobilization station, which was up at Fort Dix, and they were able to keep 

them on active duty, bring them home, have a very short welcome 

home ceremony with the leadership, give them a day off with their 

families immediately when they got home, and then bring them in for 

three days’ worth of activities.

The first day, they broke their groups down into three different 

groups. The first day was a group of more of administrative details, 

checking over all the records, the pay records, all those types of 

things.

 Day two was a day at the VA hospital that the VA conducted, actually giving them VA physicals, enrolling them and getting them enrolled in the program at that very setting, going through one-on-one 

counseling, and sir, you know that soldiers are macho-type people, 

male or female. They do not like to admit a weakness, especially 

to military superiors. The one-on-one counseling provided at the VA

hospitals and the opportunity to meet with -- at the vet centers with 

a veteran and talk issues brought many things out that our service 

members, their commanders, their senior NCOs did not even know 

was going on with those individuals, and in some cases do not even 

know it today because it is protected-type communication.

The Chairman. You said this was funded out of hide. What was the 

money taken from?

 Maj. Gen. Young. It was funded out of hide, sir.

 The Chairman. The money was taken from what?

 Maj. Gen. Young. Well, sir, what they did in -- sir, I can’t talk all 

the particulars about exactly where they took the money from.

 They had -- with the global war on terrorism, our states have some 

additional money for active duty special work-type days.

 The Chairman. What type of an account was the money taken 

from?

Maj. Gen. Young. Well -- 

The Chairman. If you don’t know the answer today, you can submit 

it for the record.

Maj. Gen. Young. Yes, sir, I will

 The Chairman. All right.

 Maj. Gen. Young. I will do that.

 The Chairman. To you and to your team -- and please extend to the 

chief of the Guard Bureau that this is leadership, when you take an 

initiative and you do something like this, and I want to compliment 

the VA for signing this agreement.

 My question is where is the rest of DOD?
44

 Secretary Jones, we know what the Guard Bureau is doing, and 

they have entered this agreement, they have taken initiative.

 So, where is the Department of Defense?

 Dr. Jones. Well, Mr. Chairman, as Secretary Mansfield stated, our 

agreements are all centered around the joint planning process that 

we have underway, and as alluded to, we have six major goals, 21 

objectives, and I think it is, 125 specific action items.

 As part of the presidential management agenda, 10 of those objectives are green; 11 of those objectives are yellow, which means we 

need additional work. I am pleased to say none of them are red.

 So, I mean 123 action items, sir -- I mean I think a lot of activity is 

going on.

 Now, whether we are being as successful as we would all like to be 

in, as you say, bringing those to fruition, the answer would be no, but 

a lot of good hard work is going on between the two agencies to try to 

reach the ultimate goal.

 The Chairman. Well, the gentleman to your left, in his opening 

statement, referred to the Executive Council as bureaucratic. Would 

you agree with that?

 Dr. Jones. I would like to think not, sir, but I mean we are two large 

organizations.

 The Chairman. Well, if that is happening, you are the principals 

responsible, right?

 Dr. Jones. Yes, sir.

 The Chairman. If you recognize that, you have got to somehow cut 

through it to perfect change, right?

 Dr. Jones. Yes, sir, and we are trying to do that. I have been here 

less than a year, and I enjoy going to work every day, because as you 

know, we are working on important things.

 The Chairman. I don’t mean to put you in an awkward position, Dr. 

Jones.

 My question really dealt more on the personnel side, and that is not 

your level of expertise, and again, that is why we wanted Secretary 

Chu here.

 Dr. Jones. Yes, sir.

 The Chairman. My last question dealing with the Guard -- and then, 

Dr. Snyder, I am going to yield to you -- is a key to the successful transition during the demobilization the ability to use the drill time.

 I think that is what we have learned on the reserve component 

side, especially in your ramp-up, and then as you also return home.

 The New Hampshire guard was authorized several drill days immediately after their return home, and I would like to know, though, 

whether or not this is a Guard policy -- is this a Guard Bureau policy, 

or is this one that each state is using based on their own resources?

Col. Hobbs. Sir, it is more a each-state initiative using their own 

resources.
45

The five days, sir, immediately after demobilization for the New 

Hampshire model was all Federally funded Title 10 man days, and as 

you know, our soldiers are on a transition leave period anyway, and 

depending on one year boots on the ground and 18-month mobilization orders, that can extend out to about 45 days, but First Army allowed them to stay and not be on leave for five extra days when they 

got back to home station. So, that was all Federally funded.

 Now, they come back to drill at about the 60-day mark. So, they 

come back to their IDT status about 60 days after they return from 

a deployment.

 So, other states have the same opportunity to go to the Army commanders and ask for that same type of program, and I have no reason 

to believe that it would not be allowed.

 The Chairman. Mr. Snyder?

 Mr. Snyder. Thank you, Mr. Chairman.

 Ms. McAndrew, I wanted to have you explain the memorandum of 

understanding for me, please, with regard to data sharing.

Is this the first memorandum of understanding, or does this replace something that was there before?

 Ms. McAndrew. Actually, we are not a party to the memorandum of 

understanding, and I just saw it for the first time today at the hearing.

 Mr. Snyder. So, when you testified just a while ago that information can be freely provided provider to provider, I thought you were 

stating that based on your understanding of what is in the memorandum of understanding.

 Ms. McAndrew. No. That was one of the provisions in the rule itself, the standards itself.

 Mr. Snyder. The HIPPA standards.

 Ms. McAndrew. Right.

 Mr. Snyder. So, you have not read the -- so I have got a fresh mind 

there to explain this language, then, since you have not looked at it 

before. It says here the Department of Veterans Affairs shall provide 

DOD with information necessary for DOD to provide medical treatment to veterans. That is consistent with what you said, correct, that 

information can flow freely from provider to provider.

 Ms. McAndrew. Right. I would interpret that as referencing the 

ability to use and disclose protected health information in order to 

provide treatment to the patient.

 Mr. Snyder. What I don’t understand, then, is where this provision 

comes into effect, where it says that Veterans Affairs shall provide a 

veteran or service member’s information to DOD pursuant to prior 

written authorization by the service member.

 Ms. McAndrew. That is another means by which information nay 

be used and disclosed. They are not mutually exclusive.

The way the privacy rule is structured, it identifies uses and disclo-
46

sures of identifiable health information, where the entity, the covered 

entity may make those uses and disclosures without the individual’s 

agreement.

 Where they want to make a use or disclosure that is not within one 

of those express permissions in the rule, they can do it provided they 

obtain the individual’s written authorization to make that use or disclosure with the information.

 Mr. Snyder. You said earlier that it is a very broad -- 

 Ms. McAndrew. Treatment is a very broad -- 

 Mr. Snyder. It is very broad.

 Ms. McAndrew. -- definition, because I mean the purpose the individual is coming to a covered entity, a health care provider, is to be 

treated, and we did not want the privacy protections, which really are 

to keep that information confidential within the health care system, 

to interfere with the doctor’s ability to be able to use the information 

to treat the patient or to consult with others as necessary to make 

sure that the patient gets the best quality of care.

 Mr. Snyder. Secretary Mansfield, I was not here when you -- I had 

to step out for a few minutes. I was not here when you gave your 

opening statement, but in your written statement, you state that the 

whole concept of seamless transition came about to help the OIF/OEF

returning servicemen and veterans and women transition seamlessly, but aren’t we really like the end of about a -- or in the middle of 

a 20-plus-year process of trying to have DOD and VA work better 

together for providing the services?

Secretary Mansfield. Yes, sir, you are correct. As the Chairman 

stated in his opening statement, that goes back to the ‘80s.

 Mr. Snyder. Yes.

Secretary Mansfield. I think what I was trying to say in the statement -- and excuse me if it didn’t come across -- was that the current 

focus on the seriously injured that are in military treatment facilities has been treated by us in the concept of a seamless transfer in 

that system, although the big picture--seamless transition--has been 

there, and we have attempted to work on it for a longer period of time, 

and that involves whether you have been in Iraq or Afghanistan or 

anywhere and are departing the service.

 Mr. Snyder. In your opening statement -- I assume your opening 

statement, like every other opening statement from the administration, went to OMB first before it came here?

Secretary Mansfield. Yes, that is the process, procedure -- 

 Mr. Snyder. Yes.

Secretary Mansfield. -- and requirement.

 Mr. Snyder. I understand.

I have difficulty finding, you know, the future challenges and where 

the problems are. I am always suspicious those kind of get buffed 

away when they go through the OMB process, but could you give 
47

me a list of what you see as the obstacles ahead of you in the area of 

medical records, you know, all those kinds of issues where -- that you 

see as being a challenge for both -- you can join in, too, Dr. Jones, if 

you like -- where you see the challenges ahead of us, particularly ones 

where you think there may need to be congressional help?

Secretary Mansfield. If you go back to the document I did refer 

to in my comments, sir -- it is the Joint Executive Council annual 

report.

 Mr. Snyder. Right.

Secretary Mansfield. I talked about the goals, leadership, commitment, and accountability. That is a requirement to start with, and 

as I indicated, we need that at the top to be able to force these issues 

down through these two massive bureaucracies to make sure that 

people everywhere, at every level and position in these organizations, 

understand that the importance of the organizations rests on those 

individuals that come into DOD, raise their right hand, go on active 

duty, and then at some point in time are going to become veterans. 

We need to recognize that as the starting point, and then we need 

to work together to move the information on those folks across that 

spectrum of care, maybe sometimes even back and forth, to make 

sure that we have the information available to ensure health care in 

one sense and benefits in the other sense, and that’s the first requirement.

 Mr. Snyder. So, you are saying that is still a problem.

Secretary Mansfield. Well, I am saying it’s still something that we 

have to focus on and make sure that we make it work.

 The Chairman, at a previous hearing -- and I wasn’t here, although 

I read it -- made a comment about an issue, IT. I think he said what 

we have to deal with here is the commitment of leadership to get the 

job done, and that is the first starting point that has to be done for 

all of this stuff, and we are making the point that it is bureaucratic, 

but it is the nature of how these organizations work, that we put this 

organization together, and we have to make the bureaucracy work, 

but sometimes, at the top, we have to know when to reach out and 

go around the bureaucracy and find out what is going on down at the 

bottom and then make a corrective action, bring it back up to the 

top.

 A good example of that is the dental care issue that we had, mostly 

involving National Guard and reserve troops that came through our 

reporting process at VA, where all of a sudden it started spiking, and 

I was looking at it for a couple of months, then I had them go and do 

a review, and found out folks were getting treated before they went 

overseas with -- I don’t know what you call it. They were extracting teeth and then sending them over for a year’s duty, no care over 

there, coming back, requiring extensive treatment, but at double the 

numbers that we had projected we would have to deal with.
48

So, we had to reach around that, find out what was going on, get 

our dental -- our medical professionals involved in that. They came 

up with a report. We brought it back to this council, and we had the 

problem solved.

 We now have a better understanding of what the requirements 

that DOD has to do with the money that they are being given to do it 

and what we have to do in that process.

 So, it requires the leadership to be involved, to be focused, and to 

keep looking always, not at these reports and these papers, down at 

those individuals that are standing there, those men and women that 

are serving, and recognizing, from my point, as I said, that they are 

going to become veterans, and we need to start as soon as we can to 

line it up, so that when they do become veterans, as soon as we can 

do it, we present them with the benefits that they have earned for the 

health care that they need.

 The Chairman. Will the gentleman yield to me for a second?

 Mr. Snyder. Yes.

 The Chairman. On the dental, I think this Committee has to accept 

some responsibility, and let me extend an apology to the Veterans 

Affairs.

 There are some unintended consequences by some action that we 

took on this Committee, and that we recognized after the first Gulf 

war that we were also going to have veterans coming back, we didn’t 

know how they were going to be doing, and we wanted to make sure 

that the VA was open and accessible to them. An unintended consequence is that we did not anticipate that DOD would not take care of 

the dental services with regard to these individuals that were brought 

on active duty, Dr. Jones, and so, what happened is that DOD, who 

gets their payments through the supplemental -- we don’t do supplemental on VA.

 So, we are thinking, when we passed on the supplemental, that 

these call-ups and things are going to be taken care of out of DOD.

 DOD does a cost shift and takes that -- these guardsmen and reservists and then -- dumping is a hard word, but you cost shift these 

individuals into the VA, and it was a struggle and was also a deficit 

for which we then had to make up, Dr. Jones.

 I yield back to the gentleman.

 Mr. Snyder. I think we were all surprised, too, by the number of 

Guard and reservists who were not medically fit for deployment at 

the time of their activation. This was like a couple of years ago, and it 

was a little over 20 percent were not medically fit for deployment, and 

I think the overwhelming majority of that was dental, and so, they 

did get fixed up so they could go, but my guess is that there was work 

to be done when they got back, and you all had to bear the burden.

 I am not going to belabor it. My time is up, but I want to be sure I

understood what you are saying.
49

 Are you saying that we still are having a problem at the highest 

levels of leadership in terms of commitment to this process?

Secretary Mansfield. No, sir. I made the point early on, I believe, 

right now, we do have the commitment.

 Mr. Snyder. All right.

Secretary Mansfield. It is just we have to make sure that we reach 

out and follow through and get it done. HIPPA is a good example.

 I mean we are talking about patients in a bed that have come back 

from a war with serious wounds, and we have got general counsels 

at the departmental level sitting there talking about who can get the 

information to treat them. That is not the way we should be doing 

business.

 Mr. Snyder. Well, I mean I think your point is a good one.

 I mean I am coming in the middle of this, but the memorandum of 

understanding is not that old.

Secretary Mansfield. Well, sir, part of that, too, though, if you look 

at it, as a, you know, fellow brother at the bar, you have got a law 

that went on the books in April of 2003, and lawyers look at it, and 

they want to look at case histories and see how many decisions have 

been made and what it means, and they are looking at that while the 

doctor is looking at the patient in the bed, and we have to work our 

way through this, but you know, if it requires the highest level to deal 

with it, we need to deal with it, but it needs to, again, be forced back 

down through the system so everybody understands what they have 

to do, and it is not what they have to do, it is what they ought to be 

doing that we are talking about.

 Mr. Snyder. Thank you, Mr. Chairman.

 Dr. Jones. Congressman, can I add on? I think the issue you 

brought up with the dental care is an issue of how the system does 

work, though. Dr. Mansfield called Dr. Chu, said he thought there 

was a concern. We brought that to the HEC, pulled together a joint 

Committee between the two agencies.

 It was then briefed to the Health Executive Council, and we are 

continuing to work that issue now to make sure that we aren’t dumping.

 So, I mean that’s an example of how the process, while it might not 

be perfect, is working.

 We are able to surface problems and try to deal with those problems.

 The Chairman. Col. Hobbs, you are representing the Army Surgeon 

General’s office here. Is that correct?

Col. Hobbs. That is correct, sir.

 The Chairman. What is your background?

Col. Hobbs. I am a patient administrator, sir, patient administration, medical records, sir.

 The Chairman. Are you Medical Service Corps?
50

Col. Hobbs. Yes, sir.

 The Chairman. Your prior assignment was what?

Col. Hobbs. Prior assignment -- I have worked at Walter Reed, the 

Office of the Army Surgeon General previously, and I am there now, 

sir.

 The Chairman. Is the Dental Corps a combat multiplier?

Col. Hobbs. Indeed, it is, sir.

 The Chairman. Indeed it is.

Col. Hobbs. It is, sir.

 The Chairman. I like that answer. Indeed it is.

 That is a great answer, isn’t it, Dr. Snyder? Indeed. Indeed it is.

Col. Hobbs. Yes, sir.

 The Chairman. No, I liked your answer. I loved the answer. So does 

Maj. Gen. Webb, he would probably like that answer, too.

 We recognize that when soldiers go to war, they are focused on a 

lot of things, and it is doing the job and the mission, essential tasks 

at hand, saving a buddy, fighting, grabbing a meal when they can, 

and they are not brushing their teeth, and they come back with gum 

disease and dental problems.

Most of the guys pulled off the battlefield, dental. Is that right, Col. 

Hobbs?

Col. Hobbs. Yes, sir.

 The Chairman. Dental.

 So, if we know that going in, Dr. Jones, we have got to know that 

going out.

 So, if you said that you are working on it, if I were to, in the second 

week of October -- we are not going to be in session, and I go to one of 

the demobilization sites, what am I going to see?

 Am I going to see guardsmen and reservists having gotten their 

dental taken care of on active duty prior to discharge, or am I going 

to see that these individuals were eager to get out of service, ended 

up with a physical assessment, and were informed that they can just 

get their dental at the VA? What am I going to find out?

 Dr. Jones. Well, for one, I hope that you would find out that we 

are being responsive and that we are making changes and that the 

system is working the way it is intended to work, and as you know, 

in the demobilization process, where you do have an individual, all 

of the boxes has to be checked, you go through the computer screen, 

and you sit with an individual who is then saying are you sure this is 

going, are you sure that all the information is in there that we need, 

are there any other concerns that you may have, and if there is dental 

concerns, hopefully we are going to be addressing them then, but I

will be pleased to follow through with you, sir, and see where we are 

on October 2, if that is appropriate.

 The Chairman. You know, when it comes to medical ailments that 

that soldier may have, we don’t discharge them and say just go to the 
51

VA, all right? We try to hold them -- we take care of our own. It is 

the philosophy, it is the values, correct?

 Dr. Jones. Correct.

 The Chairman. Of all services.

 Dr. Jones. Correct.

 The Chairman. My only point is -- I will stop beating on this one -- 

dental needs to be included in that whole person holistic approach to 

medical care. Would you agree?

 Dr. Jones. Yes, sir.

 The Chairman. All right.

 Mr. Snyder. If I might put on my family doctor hat, that is a problem 

that we have throughout health care in America, that years ago, decades ago, probably a century or two ago, we just separated this part 

of the -- the teeth from the body, and it plagues all kinds of people. It 

makes it difficult to control all kinds of diseases, that our insurance 

system handles teeth differently than it handles other things, and it 

is a problem, and I appreciate you pointing it out.

 The Chairman. Thank you.

 Let me move to the issue on physical separation or separation 

physicals, assessments.

 I have no interest in revisiting the quibble that Dr. Winkenwarder 

and I had, and we had to bring in, then, Ed Wyatt, who was with me 

when we wrote the law, to figure out exactly what all this is.

 It is kind of interesting.

This comes down to, when I chaired Personnel, what I intended; 

Ed Wyatt, when he wrote it, what did he mean by what he wrote, and 

then he is having to implement -- I mean it was one of these kind of 

things we went through, and then there was a population at large, 

too, including military organizations and veterans service organizations, who also interpreted one way, and I just want to ask this. Do 

you think it is a good idea that we should make these mandatory, 

these separation physicals, or should we just keep them as assessments?

 What is your counsel to the Committee? I am going to ask the two 

principals.

Secretary Mansfield. I will go back to my original comments, sir, 

which said that I think we need to start keeping track of these folks 

as soon as they raise their right hand, and go forward, and in the 

process of doing that, probably when they leave the military, I would 

definitely go for making it mandatory and then giving it to us directly, immediately.

 The Chairman. Dr. Jones?

 Dr. Jones. Sir, as you know, it is controversial within the medical 

community as to the cost involved and whether hands-on physicals 

are necessary, and at this point in time, of course, the decision is the 

assessment is satisfactory unless additional -- unless items come up 
52

that need additional follow-through.

 I guess I would stand by the position that we have now, sir.

Secretary Mansfield. Sir, I might have to add an amendment at 

the end that that was my personal opinion and probably not an administration opinion.

 The Chairman. Well, all right, I am going to get into this, because 

I authored some of this stuff, and you know, it goes back to a living 

history of first Gulf war, guys coming back, and ladies, gee, it was in 

their head, it really wasn’t physical; oh, gosh, perhaps they really do 

have some concerns here.

 We do compensation on undiagnosed illnesses, a lot of money put 

into research. Then my concerns about establishing a baseline, pretty important.

 So, then, on the Armed Services Committee, we say, okay, we are 

going to do these physical exams; oh, I meant physical assessments. 

We don’t want to delay mobilizations, okay, but it is really important 

that a baseline be achieved at some point, because part of this whole 

transition is into a benefits side.

 So, if an individual, then, is discharged and all you have is a physical assessment, or you don’t even have that, maybe that record is 

gone, then, years later, they come back, and now they file a claim on 

the VA, and we have no baseline.

 So, when you say, oh, my gosh, I don’t think we should do mandatory physical exams, because it is going to cost too much, really? Cost 

too much. To whom?

 We here in Congress have a perspective in that the Federal dollar 

here is fungible, because we see it going into many different agencies 

and departments.

 So, when you don’t put that cost on us, but if we don’t do it, then 

what cost are we putting on the VA later on, not only by processing 

multiple claims later on, without a baseline, and that is why I asked 

the question about mandatory. Right now, it is just voluntary.

So, let me ask Secretary Mansfield if I may turn to Adm. Cooper. 

May I?

Secretary Mansfield. Yes, sir.

 The Chairman. What is VBA’s position on the utilization of the BDD

physical exam process?

 Adm. Cooper. I am not sure I understand. We are very strong -- and 

for the same reason you say -- by having people come into our benefits 

delivery at discharge, because we do get that baseline.

 As you know, we signed an MOU to conduct the physical, primarily for the service persons themselves, either at a VA facility or at 

the military facility, whichever might be closer or more convenient, 

but the primary point is, even if they have a discharge physical, our 

requirements for a VA physical are a little more extensive, and quite 

specific.
53

 The Chairman. I apologize. My question really wasn’t asked right. 

I kind of put two things together. You are very kind.

 Let me take a step back. Let me ask it this way. If Congress were 

to mandate these physicals, separation physical, whether the individual may have a particular ailment, we are just saying if you are 

being discharged from the -- if you are going to be discharged from the 

United States military, you are going to get a physical, is that a good 

idea or not a good idea?

 Adm. Cooper. I personally think it is a good idea.

I certainly got one when I left. I mean I was an officer and got the 

physical when I left.

 I, frankly, honestly, was not aware that we were not doing it these 

days.

 The Chairman. Well, it is voluntary right now.

 Isn’t that correct, Dr. Jones?

 Dr. Jones. Yes, sir.

 The Chairman. It is voluntary. So, we are not setting a baseline for 

you.

 Adm. Cooper. No, and that is the reason I am very strong for our 

BDD process, because that way, anybody who even thinks they might 

have a physical problem will come to us and we can get a good solid 

baseline physical, and thereby, 10, 15, 20 years later, if they come 

back in and say not only am I worse on that particular problem but I

have this other thing, then we can go back and use that as a base.

 The Chairman. This BDD discharge is done at the military medical 

treatment facility?

 Adm. Cooper. We have 140 sites around the country where we have 

people who take in the claims when the people come in and register, 

and then we will try to get them the physical at the closest place. 

We do on the military base or if a VA medical hospital is nearby, we 

will do it there. We have this MOU that I mentioned that allows, if 

discharge physicals were being done, for either one of those places to 

do it, and they would adhere to our more rigid physical requirements 

for the physical exam.

 The Chairman. I don’t want to get too far out in front of the Disability Commission, but I think our quest here is to the soldier that 

has been injured or wounded in some capacity, and now he’s facing 

his physical discharge, seamless -- I want to make sure we are all on 

the same sheet of music -- seamless transition would be that he gets 

a physical discharge and his rating is then immediate. Is that not 

the goal?

 Adm. Cooper. That is the goal, absolutely.

 Now, let me interject something here. So that the service person 

can get paid as soon as legally possible, it is important that we have 

that medical information on their disabilities before they get out, because it takes us a certain discrete amount of time to complete the 
54

compensation process.

 The Chairman. Let me for a moment entertain a discussion with Dr. 

Snyder from the personnel Committee standpoint. I have not spoken 

with John McHugh about this. Have you touched on this issue at all? 

Maybe this is something we should have some further conversations 

about it.

 Mr. Snyder. I have not had recent discussions with him either.

 The Chairman. With Chairman McHugh?

 Mr. Snyder. Chairman McHugh. Maybe it might be one of those 

topics we would want to consider having a joint hearing.

 The Chairman. All right.

 Maj. Gen. Young. Mr. Chairman?

 The Chairman. Yes.

 Maj. Gen. Young. Could I share just a few observations from the 

900 soldiers that went to the VA hospital -- 

 The Chairman. Absolutely.

 Maj. Gen. Young. -- in New Hampshire that I think are kind of 

pertinent here?

 Five points, sir.

 Almost 50 percent of the 900 soldiers requested follow-up support 

after their initial counseling back in New Hampshire at the VA hospital one-on-one counseling session, 50 percent of them.

 Now, they had just came from the demobilization station and the 

transition assistance program there and had checked all the blocks 

and came back to New Hampshire.

Second point: Almost half of the soldiers filed VA claims during the 

three-day process conducted back in New Hampshire.

 One of every 10 returning soldiers received acute care through the 

VA emergency room while processing.

 All soldiers were provided a safe environment to disclose medical 

issues, and 2 percent were actually retained on active duty in a medical hold status. So, they were not allowed to go off of active duty but 

were kept on active duty and sent back in a medical hold.

 The last point is all soldiers completed a dental assessment through 

the VA, securing their dental benefits for the next two years. Just a 

couple of points there.

 The Chairman. Secretary Mansfield and Secretary Jones, after 20 

years of working DOD-VA sharing issues to include seamless transition, seamless care, and all the resources allocated towards this effort, staff, time, and money, you know, I almost have to ask what do 

we show for our efforts?

 Now, you gave your testimony, so I don’t want to be too openly 

critical, and I know that we have military liaisons at the VA trauma 

centers, we have VA reps at Walter Reed in Bethesda, but I mean 

look at what remains, the recommendations out of the presidential 

task force, even, the medical records, the physicals, the sharing of 
55

information between the two departments that, as we just discussed, 

that could benefit the soldier now or later on in life.

 I guess let me just boil it down to where are we going from here? 

Tell me what is in front of you right now, between now and the next 

six months.

 What is in front of the joint Committee?

Secretary Mansfield. Sir, I think that you have focused in again on 

the IT issue, and we had a hearing here not too long ago about that 

that I recollect, and we are moving forward on that.

 That obviously is a big issue, one that we have not produced what 

we should have produced, one that we are -- we at the VA are moving forward to deal with, and I know one that DOD is also moving 

forward to deal with. It is again one of those issues that is going to 

continue to require high-level attention and management concern to 

make sure that it happens as required.

 So, that is a key area, and the other issues here, where we are dealing with health care, as I mentioned, I think we can say that we are 

doing a good job in that area and we are moving towards doing an 

even better job.

The benefits area is also one where I think we have cooperated a 

lot more than we had in the past. We have got VA benefits counselors on Navy ships that are steaming home from battle areas. We 

have got them at, you know, hundreds of posts around the country 

and the world, preparing these soldiers for the transition, and we are 

continuing to work on those efforts, and I think, again, it comes down 

to focused leadership, dealing with the specific issues, making sure, 

again, as I said, that we do recognize that seamless transfer means 

from the start to the end, and that we just keep working on it, recognizing that we are here, you know, not for this report or not for the 

reams of paper that gets submitted -- we are here for that individual, 

as I said, that started out by he or she raising their right hand and 

moved forward, and they became a veteran, and we are required to 

take over and give them the medical care and the benefits that they 

have earned and needed, and we need to do it the best way we possibly can.

 The Chairman. Secretary Jones?

 Dr. Jones. Yes, sir, Mr. Chairman. I would echo Secretary Mansfield’s remarks, and one issue that -- you asked what have we done.

 The joint incentive fund, where, as you realize, we -- DOD puts in 

15 million and VA puts in 15 million, and I know you have visited a 

lot of the VAs and a lot of the MTFs, and I haven’t had a chance to 

visit as many as you, but I have had an opportunity to go to about five 

or six of them, and what impresses me is the creativity and the willingness and the people wanting to work together at the local level. 

So, I mean I think that fund allows us to capture some of the creativity and to remove some of the obstacles at the local level, where they 
56

want to try to work together and make things happen in the local 

health care market.

So, you know, that is one specific issue.

 Another issue I think we have made progress is in the joint purchasing, and as you are aware, just on the joint purchase in the pharmaceuticals, I think the estimate is that, together, we have saved 

over 420 million last year by combining the VA and the DOD, but I

would echo -- 

 The Chairman. On what?

 Dr. Jones. Joint pharmaceutical purchases, sir.

 The Chairman. You don’t even want to come close to that issue with 

me. You understand that, right?

 Dr. Jones. Yes, sir, but I would echo Secretary Mansfield’s remark, 

and Mr. Duffy and myself are trying to go back, with others, on the 

strategic plan and to make sure that we are able to focus on those 

issues, on those elements that aren’t moving forward, that, as you 

say, the bureaucracy is getting in the way, and to give that leadership focus so that we can move those forward and make sure that we 

reach resolution.

The Chairman. It is just really unfortunate that you have created 

something out there, then sucked yourself in a lawsuit unnecessarily 

and going against things that I have actually written, which I wrote, 

and I intended to do. It just blows my mind that DOD would go out 

and do such things. I just can’t even fathom nor even begin to comprehend.

 Dr. Jones. I understand, sir.

 The Chairman. I know. It is why we are in litigation.

 In the GEC annual report, one of the objectives of strategic goal 

five, efficiency of operations, was identifying of collaborative opportunities for joint construction activity in 2007 to 2010 time-frame. 

According to the objective, the list of opportunities for joint construction was to be identified after the release of the BRAC list. Can you 

testify as to what is the status of the list?

Secretary Mansfield. The status of the BRAC list is that it is submitted to Congress by the President, waiting the 45-day time-line.

 I would make the point, sir, that -- 

 The Chairman. No, the list of your opportunities of joint construction.

Secretary Mansfield. I am sorry. We are still waiting the BRAC 

decision.

 We also have moved forward in the BRAC arena with the VA forming a senior-level task force, and that issue, with the BRAC being 

on the agenda at the last two meetings and scheduled to be on for a 

meeting when the final decision, whatever that is, is made, which is 

-- 

 The Chairman. All right. You are waiting until after the Congress 
57

acts and the President signs, then you go. Is that what you are -- 

Secretary Mansfield. Yes, sir.

 The Chairman. Okay. That is fine. I just wanted to know where it 

is proceeding.

 Dr. Kussman, may I ask you a question, if we can do musical chairs 

here?

 How valuable is it to you to receive, if you could get them, the preand post-deployment physical assessments? Is that of any value to 

you?

 Dr. Kussman. Yes, sir, it is of obvious value to us, as was mentioned, 

both from an aggregate point of view, looking at demographic issues, 

as well as the specific issue, because as the individual transitions 

from DOD to the VA, they may come to us at certain points, and 

having the information that is on the post -- particularly the postdeployment screen, would help the provider who is assessing that 

individual who comes to know what things that they mentioned that 

they -- symptoms they may have had or experiences they may have 

had during that deployment.

 The Chairman. Compare that value to the value of receiving a postdeployment and/or discharge examination. Compare the physical assessment to an examination.

Dr. Kussman. Are you asking me whether I think that the actual 

physical examination is needed for people both in the post-deployment or prior to discharge?

 The Chairman. I want to know if you think it is valuable to the VA

if we were to mandate -- this Committee -- 

 Dr. Kussman. I understand.

 The Chairman. -- mandate, in conjunction with the Armed Services 

Committee, mandates the discharge physical exam, I want you to be 

able to tell me your opinion. Is that valuable to us, or do you say no, 

we just -- the physical assessments are fine?

 Dr. Kussman. Without trying to equivocate, I think, if you asked me 

about -- as a clinician, as a physician -- of whether I think that this is 

needed or not, I think that the literature shows very clearly that routine physicals, without symptom-directed indications, are not very 

valuable, particularly in young people.

 Having said that, a thorough assessment that could result in the 

actual hands-on or physical exam is appropriate in those settings. Because if a certain person says they have back pain, then that should 

be evaluated, and if they say they can’t hear, it should be.

 But if they say they don’t have anything and they are young, then 

the actual putting a stethoscope on the chest or poking the abdomen 

or doing a neurologic exam has been shown not to be very productive.

It is not matter of saving money. It is a matter of efficiency of 

evaluating people, that you do not find anything from it.
58

The Chairman. Okay. That is fair enough. I asked you from a clinician standpoint, but now, when you couple that with the fact that, 

when somebody goes into the military, we, the government, accept 

responsibility over that person’s body and mind, all right, so when we 

accept that responsibility and then when they discharge, we say unto 

them that our responsibility is to make you whole, if it is not, and we 

do that in some measurements.

 Now, I mean there are some related measurements that I think 

would be pretty important -- hearing test, eye test, some basics out 

there that we don’t even get from physical assessments -- and suppose, because we link this to what I have just described, outside of the 

clinician’s point of view, establishing this baseline would be pretty 

important given our liability exposure.

 Dr. Kussman. Yes, sir, and I think that, generally speaking -- and I

would have to defer to Dr. Jones because I can’t remember now, because I am getting old and retired five years ago, but there is a physical evaluation that is done on active duty people on a regular basis. 

I think it is every three to five years, or is it every five years? I can’t 

remember exactly when it is. Five years. Okay.

 So, there are repeated baselines for someone who stays in for an 

extended period of time -- hearing, blood pressure, eye exam, dental 

exam, and all those other things.

 So, there is a track record of that repeatedly during a 20-year -- if 

you are only in for four or five years or three years, that probably 

wouldn’t be repeated, but having said that, I would agree with you 

that there probably is a set of data that would be very nice to have, 

like a hearing test, because that is a very common thing that somebody complains about, and it would be nice to know that their hearing 

was fine when they transitioned.

 Blood pressure might be a good thing to check, and so, I think that 

the thing that we probably ought to look at, or I would suggest to look 

at, -- from Mike Kussman’s individual opinion is -- is to determine 

what data sets would be of great value longitudinally to track people 

but not necessarily doing everything to everybody.

 The Chairman. That is fair. Thanks.

Col. Hobbs, to what extent is the issue of ITOs and NMAs an issue 

of manpower or resources?

Col. Hobbs. Yes, sir. It is not an issue of manpower or resources. 

It is a process that we are working to continue to -- 

 The Chairman. So, it is an issue of leadership?

Col. Hobbs. It is the process that -- it is a process.

 The Chairman. Who commands the process?

Col. Hobbs. The leadership does command the process, sir.

 The Chairman. So, it is neither an issue of manpower or resources.

 This is an issue of leadership.

 Well, I am going to extend some compliments, because you identi-
59

fied a problem, and then took actions to correct the problem, right?

Col. Hobbs. Yes, sir.

The Chairman. In the Army’s evaluation of determining where 

some of the problems lie in regards to the ITOs and NMAs, was this 

-- I know you said a systemic problem. When you use that word “systemic,” you are saying to me that, you know, Steve, this was not just 

isolated, this was not just regional, this was CONUS-wide or even 

worldwide. Is that what I am to interpret from the word “systemic” 

that you used in your opening testimony?

Col. Hobbs. Sir, I would say inconsistency throughout our system.

We would find that we would see the most problems where we have 

our larger volumes.

 The Chairman. Dr. Sigford, could you come forward? Would you 

state your background and credentials, please?

 Dr. Sigford. Yes, sir.

 The Chairman. Your full name.

 Dr. Sigford. Barbara Jean Sigford. I am a physician, physical medicine and rehabilitation, a physiatrist. I am chief of physical medicine 

and rehabilitation at the Minneapolis VA and also national program 

director for physical medicine and rehabilitation.

 The Chairman. Are you affiliated with the polytrauma center in 

Minneapolis?

 Dr. Sigford. Yes, I am.

 The Chairman. On my trip to the Minneapolis VA -- in particular, 

the polytrauma center -- I asked you what some of the problems you 

were having with some of the patients, and I appreciated your candor. You expressed some concern with regard to the medical records 

on patients from Landstuhl, Germany.

 So, before you answer this question on this premise, will you, for 

the record, explain what the polytrauma center is, how many we 

have, what is the purpose of the polytrauma center?

 Dr. Sigford. Yes, sir. We have four polytrauma rehabilitation centers which were designated in February, our first meeting in -- 

 The Chairman. Where are they located?

 Dr. Sigford. I am sorry?

 The Chairman. Where are they located?

 Dr. Sigford. They are located in Richmond, Virginia; Tampa, Florida; Minneapolis, Minnesota; and Palo Alto, California.

 Their purpose is to provide rehabilitation care for severely injured 

service members or National Guard, reservists.

 The Chairman. Now the purpose of the polytrauma center is what?

 Dr. Sigford. To provide rehabilitation care and associated medical 

care that is a continuing need after their transfer from a military 

treatment facility.

 The Chairman. So, these are active duty soldiers.

 Dr. Sigford. The majority are, yes.
60

 The Chairman. So, they are with you for a point in time, and then 

they transfer back to a military medical treatment facility or they 

could be potentially discharged on-site

 Dr. Sigford. That is correct.

 The Chairman. The issue on medical records -- can you tell me about 

it?

 Dr. Sigford. Our current access to medical records is through a 

paper copy of medical records. We do not have access to an -- through 

an electronic system for medical records. So, we rely on paper copies, 

hard copies of the medical records to provide the care for the individuals that are transferred to our facilities.

 We receive that information either via fax or physically accompanying the service member when they arrive.

 The Chairman. These patients -- now we are getting in on the issue 

of seamless. We are going to go right down to it on patient care.

 What kind of problems are some of the doctors running into when, 

all of a sudden, you receive that active duty patient and you do not 

have all the medical records? What is happening?

 Dr. Sigford. Well, I believe probably the example I gave you when 

you visited Minneapolis about the soldier who was transferred to 

us from Landstuhl was perhaps the most complex problem we have 

faced, and that was an individual who had had emergency surgery, 

abdominal surgery, in Landstuhl. Those records did not follow him to 

the military treatment facility and, thusly, did not follow him to the 

VA. We then had to use teleconferencing to receive the information 

we needed to provide the continued required care for his abdominal 

injuries, and I think that is probably the most complex situation, 

but we do follow up with phone calls and direct one-to-one conversations.

 The Chairman. These active duty liaisons that are at the four polytrauma centers -- pretty important?

 Dr. Sigford. Yes.

 The Chairman. Why?

 Dr. Sigford. They provide us with a military presence for individuals, our active duty individuals, which is greatly appreciated by the 

men and women who have served in the armed forces, as well as their 

families. They really appreciate having this military presence. They 

also are able to make connections back to the military treatment facility, often assisting us with accessing the information in medical records which may not have followed the individual directly, and then 

they are also able to help with benefits, the boarding process, the 

travel orders, invitational travel orders, and other processes like that 

in the seamless transition process.

 The Chairman. Having the opportunity to speak to some of the families, you know, they expressed some real concern. They were in an 

I don’t know land, and VA extending support, Fisher House support 
61

-- you have heard the testimony of Col. Hobbs, representing the Office 

of the Surgeon General, United States Army, and corrective action 

taken. What is happening on the ground, though? Are you able to 

testify with regard to that?

 Dr. Sigford. In terms of support to families?

 The Chairman. Support to the families.

 Dr. Sigford. I can speak mostly from my experience at Minneapolis, and that is we do have a Fisher House. We have a very active 

voluntary services program, many people who want to donate and 

support these families, and I believe, while I don’t know the specifics at each of the polytrauma centers, each has developed their own 

programs individually and specific to their areas.

 We have case managers who are assigned to the service members 

and their families to be at their disposal, to help problem solve and 

provide support.

 We provide them with lodging, and often additional activities and 

amenities as needed.

 The Chairman. All right.

 Seamless Transition is this large umbrella term. It is, isn’t it? So 

many things are covered underneath it, and the structure is very 

large.

I know, Secretary Mansfield, you have an office dedicated, but it is 

for a limited scope, is it not? It is regarding the active being treated 

in your facilities and those with whom you may have contractual relationships with at large.

Secretary Mansfield. The office that Mr. Brown heads up is concentrated on the seriously injured active duty member that is coming 

from a military treatment facility.

 The Chairman. Okay.

 Well, this is going to be -- the seamless transition issue, I just want 

all of you to know, is going to be a continuous dialogue.

I mean there are -- Secretary Mansfield, you have been around the 

block a few times, and so, you know that there are certain issues out 

there that are called maintenance issues, right, and you are aware of 

the interest of the full Committee on a bipartisan basis on the issue, 

not only of this Committee but also of the Armed Services Committee, and Dr. Jones, if you can please express up the chain to Secretary Chu with regard to our concerns about the two defense bills and 

implementation, we think it is important. I know there is a lot on 

your plate, and there is a lot of contingencies and a lot of things that 

you are doing, a lot of things that the nation calls upon you to do, and 

you are stretched pretty thin.

 So, I am not here to beat up on you. I am just concerned, as you 

are, about the soldier and the sailor, the airman, Marine, the Coast 

Guardsman, and the reserve components, and they should never be 

caught in bureaucracies, right, and it is how we move them from one 
62

system to the other.

 So, we have got these systems that try to have their separate identities, yet there needs to be that cohesion, a system that is synergistically intertwined, pretty important, and figuring out how to do all 

that is not easy.

 Let me shift gears.

 Does anybody have anything they would like to comment with regard to the issues on seamless transition before I move into a separate, completely different area?

[No response.]

 The Chairman. No?

 Hearing none, let me ask a question with regard to -- under this 

issue on seamless and collaboration, is there anything going on right 

now between DOD and VA with regard to Hurricane Katrina and 

Rita that I should know about with regard to collaboration between 

VA and DOD?

Secretary Mansfield. Sir, I would make the point that I think, 

although I would have to go back to the operations office and double-check, that we were collaborating at the point in time over the 

weekend, as required both under the plan and, as we usually do, informally, and had the VA, I think, can say we had our needs met as 

far as DOD goes.

 Dr. Jones. Mr. Chairman, one of the things that we were working 

on early, before the storm, was to move approximately 3,000 patients 

who were in hospitals or in nursing homes to other facilities who 

were not in harm’s way, and of course, the VA military health treatment facilities, and of course, commercial hospitals, were used to 

move those patients very successfully, and so, that was one instance 

where the plan worked and we worked together, along with others in 

the community.

 The Chairman. All right.

 I know this was not the subject area of this hearing. Congress is 

also a large organization, and we all have different responsibilities.

 I also serve on the Katrina Committee, and I am going to ask that 

you also pass this word along that the time-lines of the response, prelandfall and post-landfall, with regard to Hurricane Katrina is going 

to be important, and Congressman Thornberry of the Armed Services 

Committee is also on the Katrina Committee.

 Our responsibility is to look at the facts, not about assessing 

blame.

We want to figure out who did what, when, where, and then we can 

get into the issues of what changes, if any, need to be made.

 So, please recognize that I will be coming with regard to obtaining 

the facts from DOD, the Guard Bureau, equally, please extend this, 

and to the VA.
63

 I will also be into the Coast Guard and the medical side on this 

one.

 So, I know that, VA, you had standing up an operations center, 

and I am sure that you have got to have a paper trail here at the ops 

center, do you not, Secretary Mansfield?

Secretary Mansfield. Yes, sir. We have a chronological, you know, 

day-by-day report that comes out of that center. They are working 

right now on the lessons learned, which is a built-in part of our system, also.

 The Chairman. I just want you gentlemen to know that that tasking 

is coming, all right? So, this report has to be done by mid-February.

 So, when I show up with a team, I don’t want you to say, okay, we 

will get you the answers.

 Please put together what is necessary, and we are going to have to 

do -- obviously, the logistical function on DOD is pretty important.

 We are focusing this to your role and mission with regard to the 

national response plan, okay? That is where I am going with this, 

okay?

 All right.

 I want to thank you for coming. I want to thank you for your testimony.

 Ms. McAndrew, thank you very much for coming here. The two 

principals have heard your testimony. That is extremely important, 

and please extend my regards to Lt. Gen. Kiley and Maj. Gen. Webb, 

all right?

 Again, let me thank you for the leadership in the Guard Bureau 

and the VA for that memorandum; pretty important.

 Dr. Jones?

 Dr. Jones. Thank you, sir.

 The Chairman. Thank you very much for being here.

 This hearing is now concluded.

[Whereupon, at 2:24 p.m., the Committee was adjourned.]

 
(64)

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