DEFENSE HEALTH

Actions Needed to 

Help Ensure Combat 

Casualty Care 

Research Achieves 

Goals

Report to Congressional Committees

February 2013

GAO-13-209

United States Government Accountability Office

GAO
United States Government Accountability Office

Highlights of GAO-13-209, a report to 

congressional committees

February 2013

DEFENSE HEALTH

Actions Needed to Help Ensure Combat Casualty 

Care Research Achieves Goals

Why GAO Did This Study

DOD estimates that about 24 percent 

of servicemembers who die in combat 

could have survived if improved and

more timely medical care could be 

made available. Because multiple DOD 

organizations conduct research to 

develop medical products and 

processes to improve combat casualty 

care, it is critical that these 

organizations coordinate their work. It 

is also important that agencies monitor 

and assess their performance to help 

achieve organizational goals, which for 

DOD include addressing gaps in its 

capability to provide combat casualty 

care. The National Defense 

Authorization Act for Fiscal Year 2012 

directed GAO to review DOD’s combat 

casualty care research and 

development programs. This report 

assesses whether DOD (1) uses a 

coordinated approach to plan this 

research; and (2) monitors and 

assesses this research to determine 

the extent to which it fills capability 

gaps and achieves other goals. GAO 

reviewed DOD’s policies and 

documentation; interviewed officials 

from DOD and other federal agencies; 

and analyzed metrics DOD used to 

gauge the progress of its research.

What GAO Recommends

GAO recommends that DOD 

(1) communicate the importance of 

early coordination among DOD’s 

nonmedical organizations and 

(2) develop and implement a plan 

to determine the extent to which 

research fills gaps and achieves 

other goals. DOD concurred with 

these recommendations.

What GAO Found

The biomedical research organizations of the Department of Defense (DOD) use 

a coordinated approach to plan combat casualty care research and development, 

but not all of DOD’s nonmedical research organizations share information early in 

the research process. GAO has previously reported that federal agencies can 

enhance and sustain collaboration of efforts by using key practices, such as 

agreeing on roles and responsibilities and establishing the means to operate 

across organizational boundaries. In 2010, DOD established a planning 

committee to coordinate the efforts of organizations conducting combat casualty 

care research. The committee developed a draft charter in 2010 identifying 

members respective roles and responsibilities. DOD issued the final charter in 

early January 2013, while GAO was conducting its review. DOD also facilitated 

operation across organizational boundaries by colocating most of the 

organizations conducting combat casualty care research. However, DOD 

organizations that typically do not conduct biomedical research, such as the 

Army Research Laboratory, are not involved in DOD’s efforts to coordinate this 

research. When these organizations conduct research relevant to combat 

casualty care they do not always share information with appropriate officials early 

in the research process, as they are not aware of the need to coordinate early 

and may not fully understand medical research requirements. As a result, some 

researchers have had to repeat some work to adhere to these requirements. 

DOD has also taken steps to coordinate with other federal agencies that are 

involved in this research.

The Office of the Assistant Secretary of Defense for Health Affairs (Health 

Affairs) and the Army Medical Research and Materiel Command (MRMC) assess 

the progress of combat casualty care research and development projects, but 

they have not assessed the extent to which this research fills gaps in DOD’s 

capability to provide this care or achieves other DOD goals. Federal internal 

control standards state that agencies should assess their performance to ensure 

they meet the agency’s objectives. Health Affairs and Army MRMC—the two 

organizations that fund most combat casualty care research and development—

monitor research projects to determine whether to continue funding, make 

necessary corrections, or terminate these projects. However, in 2008 DOD 

identified gaps in its capability to provide combat casualty care, and although 

Health Affairs and Army MRMC have completed 44 research projects since then 

designed to address these gaps, they have not assessed whether the results of 

this research fill the gaps identified in 2008. In addition, Health Affairs and Army 

MRMC established other goals for this research portfolio to improve combat 

casualty care. For example, in 2010, Health Affairs set goals to improve DOD’s 

ability to control bleeding. However, neither organization has developed an 

assessment that comprehensively identifies each of the goals for the portfolio 

and includes information about the extent to which each goal has been met. 

Health Affairs and Army MRMC officials stated that they intend to complete a 

strategic roadmap for the portfolio, but GAO was unable to determine if the 

roadmap will include a plan for a comprehensive assessment of this portfolio. 

Without such a plan for a comprehensive assessment, these organizations 

cannot be sure the research they are conducting is producing results that most 

effectively improve combat casualty care to save lives on the battlefield.

View GAO-13-209. For more information, 

contact Linda T. Kohn (202) 512-7114 or 

kohnl@gao.gov, or Brenda S. Farrell, 

(202) 512-3604 or farrellb@gao.gov.
Page i GAO-13-209 Defense Health

Letter 1 

Background 3

DOD Uses a Coordinated Approach to Plan Its Combat Casualty 

Care Research and Development, but Not All of Its 

Organizations Share Information Early 8

DOD Monitors the Progress of Combat Casualty Care Research 

Projects, but Not Whether the Research Fills Gaps or Achieves 

Other Goals 14

Conclusions 16

Recommendations for Executive Action 17

Agency Comments and Our Evaluation 17

Appendix I Comments from the Department of Defense 21

Appendix II Comments from the Department of Health & Human 

Services 23

Appendix III GAO Contacts and Staff Acknowledgments 25

Figures

Figure 1: DOD Combat Casualty Care Research and Development 

Funding from Fiscal Year 2005 through Fiscal Year 2012 5

Figure 2: Percent of Fiscal Year 2012 Combat Casualty Care 

Research and Development Funding by Organization 6

Figure 3: Organizations That Oversee Combat Casualty Care 

Research and Development 7

Contents 
Page ii GAO-13-209 Defense Health

Abbreviations

DARPA Defense Advanced Research Projects Agency

DOD Department of Defense

FDA Food and Drug Administration

Health Affairs Office of the Assistant Secretary of Defense for 

 Health Affairs

HHS Department of Health and Human Services

JPC-6 Joint Program Committee for Combat Casualty 

 Care 

MRMC Army Medical Research and Materiel Command

NIH National Institutes of Health

VA Department of Veterans Affairs

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Page 1 GAO-13-209 Defense Health

United States Government Accountability Office

Washington, DC 20548

February 13, 2013

Congressional Committees

The Department of Defense (DOD) estimates that approximately 

24 percent of all servicemembers who die in combat could have survived 

if improved and more timely medical care could be made available in the 

combat setting. To reduce the combat mortality rate as well as the impact

of the disabling medical conditions that servicemembers suffer as a result 

of combat wounds, multiple DOD organizations conduct medical research 

to develop medical devices, pharmaceuticals, and new methods or 

processes that are designed to improve combat casualty care.1 Using the 

results of this research, DOD intends to fill gaps that it identified in its 

capability to provide combat casualty care, such as its ability to control 

bleeding.2 The Office of the Assistant Secretary of Defense for Health 

Affairs (Health Affairs), the military departments, and the Defense 

Advanced Research Projects Agency (DARPA) are responsible for this 

research, with funding of over $537 million in fiscal year 2010, 

$272 million in 2011, and $321 million in 2012. Because multiple 

organizations plan this research and development, it is important that they 

coordinate their actions to maximize their effectiveness in conducting the 

research, applying its findings, and producing results that ultimately save 

lives on the battlefield. It is also important that agencies monitor and 

assess their performance to help address organizational goals. For DOD, 

organizational goals include filling gaps in its capability to provide combat 

casualty care, such as improving DOD’s ability to control bleeding, which 

is the primary cause of potentially survivable deaths on the battlefield. 

Such monitoring and assessment, as part of a system of effectively 

designed and implemented internal controls, provide reasonable 

assurance that an agency’s operations are effective and efficient.3

 

1

DOD officials define combat casualty care as the medical care provided to 

servicemembers from the time when they are wounded in combat through their 

hospitalization at a facility out of the combat theater, including evacuation and surgery. 

2

DOD, Guidance for the Development of the Force FY2010–2015, Program and Budget 

Assessment A4.16, Medical Research and Development Investments (June 2008).

3

GAO, Standards for Internal Control in the Federal Government, GAO/AIMD-00-21.3.1

(Washington, D.C.: November 1999).

 
 

Page 2 GAO-13-209 Defense Health

The National Defense Authorization Act for Fiscal Year 20124

To determine the extent to which DOD uses a coordinated approach to 

plan for combat casualty care research and development, we reviewed 

DOD’s policies and documentation on coordinating research, and we 

analyzed various pertinent documents, including DOD summaries of the 

portfolio of ongoing research designed to improve combat casualty care. 

We also interviewed knowledgeable officials from various DOD 

organizations involved in planning this research and from other relevant 

federal agencies, including the Food and Drug Administration (FDA), the 

National Institutes of Health (NIH), and the Department of Veterans 

Affairs (VA). The DOD officials we interviewed include those from Health 

Affairs, which is organizationally aligned under the Under Secretary of 

Defense for Personnel and Readiness; the Assistant Secretary of 

Defense for Research and Engineering, which is organizationally aligned 

under the Under Secretary of Defense for Acquisition, Technology and 

Logistics; the Army Medical Research and Materiel Command (MRMC); 

the Office of Naval Research; the Naval Medical Research Center; the Air 

Force Medical Support Agency; and DARPA. Furthermore, we analyzed 

DOD’s efforts to coordinate combat casualty care research and 

development by comparing those efforts to key collaboration practices 

that we previously reported, such as agreeing on roles and 

responsibilities and establishing a means to operate across organizational 

boundaries. We define both “collaboration” and “coordination” as any joint 

activity by two or more organizations intended to produce more public 

value than could be produced when the organizations act alone.

directed 

GAO to review DOD’s medical research and development programs 

designed to improve combat casualty care. The act requires GAO to 

evaluate aspects of DOD’s combat casualty care research programs, 

including the extent to which DOD organizations coordinate their efforts to 

plan this research. In response to the act, this report addresses the extent 

to which DOD (1) uses a coordinated approach to plan for combat 

casualty care research and development and (2) monitors and assesses 

whether combat casualty care research and development fill capability 

gaps or achieve other goals.

5

 

4

Pub. L. No. 112-81, § 1076, 125 Stat. 1298, 1595-1596 (2011).

To 

determine the extent to which DOD monitors and assesses whether 

5

GAO, Results-Oriented Government: Practices That Can Help Enhance and Sustain 

Collaboration among Federal Agencies, GAO-06-15 (Washington, D.C.: Oct. 21, 2005).
 

Page 3 GAO-13-209 Defense Health

combat casualty care research and development fill capability gaps or 

achieve other goals, we obtained and analyzed data from Health Affairs, 

the military departments, and DARPA regarding metrics the department 

uses that gauge the progress and performance of its research projects.

We also interviewed knowledgeable officials from a variety of DOD 

organizations, including the Army Institute for Surgical Research and the 

Naval Medical Research Center, about their monitoring efforts to apply 

findings from research. In addition, we reviewed the relevant internal 

control standards for the federal government, which address monitoring 

and assessing performance, and compared DOD’s efforts to these 

standards.6

We conducted this performance audit from May 2012 to February 2013 in 

accordance with generally accepted government auditing standards. 

Those standards require that we plan and perform the audit to obtain 

sufficient, appropriate evidence to provide a reasonable basis for our 

findings and conclusions based on our audit objectives. We believe that 

the evidence obtained provides a reasonable basis for our findings and 

conclusions based on our audit objectives.

We focused this portion of our analysis on Health Affairs and 

the Army because they are responsible for the majority of combat 

casualty care research in DOD, with over 82 percent of DOD’s combat 

casualty care funding in 2012.

DOD’s combat casualty care researchers focus their efforts on the major 

causes of injury and death on the battlefield, and on improving medical 

care in specific battlefield conditions. For example, DOD estimates that 

approximately 84 percent of potentially survivable battlefield deaths are 

caused by bleeding. Therefore, DOD focuses a significant amount of its 

research on ways to control bleeding on the battlefield. Other areas on 

which DOD researchers focus include extremity trauma, diagnosis and 

treatment of traumatic brain injury, and ways to improve the care provided 

to casualties prior to and during evacuation to a hospital.

 

6

GAO/AIMD-00-21.3.1.

Background 

Application of Combat 

Casualty Care Research 

Findings 
 

Page 4 GAO-13-209 Defense Health

In order to improve medical care in these areas, DOD researchers use 

various means to apply findings from combat casualty care research to 

develop drugs or medical devices. For example, DOD researchers 

convene multidisciplinary teams to decide whether a research project is 

ready and feasible to support development of a drug or medical device, 

according to DOD officials. These teams consist of researchers and other 

DOD personnel who are involved in acquiring and maintaining drugs and 

medical devices. At multiple meetings, the teams make decisions on 

whether to allow the project to proceed. In addition, DOD researchers 

work with the FDA to understand and share general information about 

regulatory requirements for drugs and medical devices that DOD 

develops. DOD officials also told us that in some cases DOD researchers 

also share the results of DOD research with medical corporations, which 

develop these products. 

In addition to developing drugs or medical devices, DOD researchers 

apply findings from combat casualty care research by disseminating 

information on medical practices. For example, the Army Institute for 

Surgical Research publishes clinical-practice guidelines that clinical 

subject-matter experts develop in response to needs identified while 

providing care to combat casualties. These guidelines are based on the 

best existing clinical evidence and experience, approved by senior DOD 

medical officials, and are available to all military medical practitioners. In 

addition, DOD researchers share new medical knowledge and bestpractice information by publishing research results in medical journals 

and making presentations at conferences.

In May 2008, then–Secretary of Defense Robert Gates publicly expressed 

his commitment to improving medical care and support for wounded 

servicemembers. In that same month, DOD completed a program 

assessment of its medical research and development investments, which 

became the basis for DOD’s June 2008 Guidance for the Development of 

the Force report.7

 

7

DOD, Guidance for the Development of the Force FY2010–2015. 

Among other matters, this assessment identified gaps 

in DOD’s capabilities to protect the health of servicemembers, including 

health care provided to servicemembers who are wounded on the 

battlefield. For example, the 2008 report identified a gap in DOD’s 

capability to diagnose, resuscitate, and stabilize casualties with survivable 

Combat Casualty Care 

Research Capability Gaps 

and Funding
 

Page 5 GAO-13-209 Defense Health

wounds. DOD used the capability gaps identified in the 2008 report as the 

justification for funding requests that DOD subsequently made for medical 

research and development, including for research to address gaps in 

DOD’s capability to provide combat casualty care. This assessment also 

concluded that a consolidated medical research and development budget 

structure with a centralized planning, programming, and budget authority 

and with centralized management would provide the most efficient and 

effective process and governance for DOD’s medical research and 

development investment.8

To address the gaps in its capability to provide combat casualty care, 

DOD has increased this research funding overall, as shown in figure 1.

Figure 1: DOD Combat Casualty Care Research and Development Funding from

Fiscal Year 2005 through Fiscal Year 2012

 

8

GAO, Defense Health Care: Applying Key Management Practices Should Help Achieve 

Efficiencies within the Military Heath System, GAO-12-224 (Washington, D.C.: Apr. 12, 

2012).
 

Page 6 GAO-13-209 Defense Health

In fiscal year 2010, DOD’s funding for combat casualty care research 

increased to $537 million, and 2 years later it fell to $321 million. Health 

Affairs and the Army, with 82 percent of the funding in fiscal year 2012, 

were responsible for the majority of this research (see fig. 2). The Navy, 

the Air Force, and DARPA were responsible for the remainder.

Figure 2: Percent of Fiscal Year 2012 Combat Casualty Care Research and 

Development Funding by Organization

Note: Funding for combat casualty care research and development totaled $321 million in fiscal year 

2012. This amount does not include funding for other DOD organizations that do not typically conduct 

combat casualty care research but sometimes conduct research that is related to combat casualty 

care.

Multiple officials and organizations oversee DOD’s combat casualty care 

research and development. The Assistant Secretary of Defense for 

Research and Engineering—who reports to the Under Secretary of 

Defense for Acquisition, Technology and Logistics—is responsible for 

promoting coordination of all research and engineering within DOD, 

including health-related research such as combat casualty care research.

In addition, the Assistant Secretary of Defense for Health Affairs serves 

as the principal advisor to the Under Secretary of Defense for Personnel 

and Readiness on a variety of health issues, including medical research, 

Multiple DOD 

Organizations Oversee and 

Plan Research and 

Development
 

Page 7 GAO-13-209 Defense Health

which includes research to improve combat casualty care. The Assistant 

Secretary of Defense for Research and Engineering and the Assistant 

Secretary of Defense for Health Affairs cochair the Armed Services 

Biomedical Research and Evaluation Management committee. This 

committee’s charter states that it was established to facilitate coordination 

and prevent unnecessary duplication of effort within DOD’s biomedical 

research and development program. Joint Technology Coordinating 

Groups9

Figure 3: Organizations That Oversee Combat Casualty Care Research and 

Development

support the committee in specific research areas, including 

combat casualty care. Joint Technology Coordinating Groups are 

responsible for coordinating plans for research in their areas and for 

submitting recommendations on the distribution of responsibility for 

program execution and resources. (See fig. 3 for organizations that 

oversee combat casualty care research and development.)

Note: The JPC-6 includes representatives from each military service (Army, Navy, Air Force, and 

Marine Corps) and is chartered by Army Medical Research and Materiel Command (MRMC).

 

9

Joint Technology Coordinating Groups are composed of a single member from each of 

the Army, Navy, and Air Force.
 

Page 8 GAO-13-209 Defense Health

With regard to planning, there are multiple DOD organizations specifically 

devoted to biomedical research, and these organizations plan research 

and development designed to improve the medical care provided to 

injured servicemembers. They include the Army MRMC, the Office of 

Naval Research, the Naval Medical Research Center, the Air Force Office 

of Scientific Research, the Air Force Medical Support Agency, and 

DARPA. In March 2011, Health Affairs signed an interagency support 

agreement with the Army MRMC to take advantage of existing Army 

MRMC staff and infrastructure. Under the agreement, the Army MRMC 

manages certain Health Affairs funds for medical research and 

development. To help manage these funds, the Army MRMC established 

Joint Program Committees for the major areas of medical research that 

DOD conducts, including combat casualty care, which is managed by the 

Joint Program Committee for Combat Casualty Care (JPC-6). The JPC-6 

includes representatives from the DOD biomedical research organizations 

within each military department, including the Marine Corps, as well as 

from DARPA, NIH, VA, and other DOD organizations that use the results 

of combat casualty care research—such as DOD’s Special Operations 

Command. These organizations coordinate to prioritize how to spend the 

Health Affairs funding for combat casualty care research.

Other DOD research organizations also conduct research that is at times 

related to combat casualty care. Typically these research organizations 

do not plan or conduct biomedical research, but sometimes they identify 

ways that applications of their research could improve combat casualty 

care. These organizations include the Army Research Laboratory and the 

Naval Postgraduate School.

DOD’s biomedical research organizations use a coordinated approach to 

plan for combat casualty care research and development in a manner that 

is consistent with key collaboration practices. Further, DOD research 

organizations do not always share information early in the research 

process. DOD has also taken steps to coordinate with other federal 

agencies that are involved in combat casualty care research.

DOD Uses a 

Coordinated 

Approach to Plan Its 

Combat Casualty Care 

Research and 

Development, but Not 

All of Its 

Organizations Share 

Information Early
 

Page 9 GAO-13-209 Defense Health

DOD’s biomedical research organizations coordinate combat casualty 

care research and development planning in a manner that is consistent 

with key collaboration practices identified in prior GAO work to enhance 

and sustain coordination.10

DOD’s biomedical research organizations responsible for combat 

casualty care research and development have agreed on their roles and 

responsibilities, including establishing a key leadership position 

responsible for combat casualty care research. As we have previously 

reported, agreement on roles and responsibilities among coordinating 

organizations is important because it enables each organization to stay 

informed about the others’ individual and joint efforts, and it facilitates 

decision making.

These key practices include agreeing on roles 

and responsibilities and establishing a means to operate across 

organizational boundaries.

DOD’s biomedical research organizations have agreed on the roles and 

responsibilities for the organizations involved in planning, overseeing, and 

executing this type of research. First, Health Affairs and the Army 

MRMC—the two organizations that fund most combat casualty care 

research and development—have outlined their roles in an Interagency 

Support Agreement, which designates the Army MRMC as the 

organization responsible for managing the day-to-day use of Health 

Affairs funding for medical research, including research to improve 

combat casualty care. Second, the JPC-6 developed a draft charter in 

2010 that explains the roles and responsibilities for all of the JPC-6 

member organizations, including the non-DOD organizations, such as VA 

and NIH. The draft charter was finalized in early January 2013, while we 

were conducting our review.11

 

10

Health Affairs and Army MRMC officials 

told us that the JPC-6 began using the charter in 2010, but that they 

delayed finalizing it in part because they wanted to have the opportunity 

to incorporate lessons learned during the operation of the committee 

during its first 2 years. The charter states that JPC-6 members represent 

the interests of their member organizations as well as provide subjectmatter expertise and advice to the JPC-6 chair on requirements, program 

GAO-06-15. 

11DOD, US Army Medical Research and Materiel Command Joint Program Committee-6 

Charter for the Combat Casualty Care JPC, (Jan. 2, 2013). 

DOD’s Combat Casualty 

Care Research Planning Is 

Consistent with Key 

Collaboration Practices

Agreement on Roles and 

Responsibilities
 

Page 10 GAO-13-209 Defense Health

management, transition planning, and planning and programming for 

future investments.

In addition to establishing a JPC-6 charter, Health Affairs and Army 

MRMC have established a key leadership position responsible for combat 

casualty care research by having one official serve simultaneously in 

three complementary roles: JPC-6 chair, Director of the Army Combat 

Casualty Care Research Program, and chair of the Joint Technology

Coordinating Group for Combat Casualty Care. As noted in the JPC-6 

charter, the group’s chair is responsible for making recommendations to 

Health Affairs for planning, programming, budgeting, and executing 

research and development to improve medical care provided to combat 

casualties, and the chair is to make these recommendations with the 

advice and support of the JPC-6 members. Because the DOD official 

serving as JPC-6 chair also serves as Director of the Army Combat 

Casualty Care Research Program and chair of the Joint Technology

Coordinating Group for Combat Casualty Care, this official oversees the 

majority of this research in DOD. From fiscal years 2008 through 2011, 

this official oversaw approximately 600 research projects, constituting 

over 80 percent of DOD’s funding for combat casualty care research.

Health Affairs and Army MRMC officials told us they expect that one 

official will lead all three organizations in the future.

DOD’s biomedical research organizations responsible for combat 

casualty care research and development have established mechanisms 

to facilitate working across organizational boundaries—a step that, as we 

have previously reported, helps to enhance and sustain coordination.12

For example, DOD located nearly all of the DOD biomedical research 

organizations that conduct combat casualty care research at the Joint 

Center of Excellence for Battlefield Health and Trauma Research at Fort 

Sam Houston, Texas.13

 

12

The center includes the U.S. Army Institute for 

Surgical Research and other principal DOD biomedical research 

organizations that conduct combat casualty care research, such as the 

combat casualty care research functions from the Naval Medical 

Research Center and from Walter Reed Army Institute of Research. DOD 

GAO-06-15. 

13DOD established this center in response to a recommendation in the 2005 Base 

Realignment and Closure Report. DOD, 2005 Base Closure and Realignment Report, 

vol. X (Washington, D.C.: May 9, 2005). 

Means to Operate across 

Organizational Boundaries
 

Page 11 GAO-13-209 Defense Health

officials told us that being located in the same place is useful in enabling 

them to know what other DOD organizations are doing with their related 

research and development. Another example of a mechanism to facilitate 

working across organizational boundaries is the Military Health System 

Research Symposium, an annual conference that provides DOD 

researchers the opportunity to discuss and address multiple medical 

research topics, including combat casualty care, with researchers from 

other federal agencies, academia, and private industry. DOD officials told 

us that these annual conferences have led to interagency collaboration on 

research and development for combat casualty care.

DOD organizations that typically do not conduct biomedical research are 

generally not involved in DOD’s efforts to coordinate combat casualty 

care research. When these nonmedical research organizations conduct 

research relevant to combat casualty care, they do not always share 

relevant information with appropriate officials early in the research 

process. We have previously reported that organizations involved in 

similar missions should coordinate and share relevant information early to 

avoid unnecessary duplication of work.14

The JPC-6 chair, who is the lead official responsible for coordinating 

combat casualty care research, told us that he periodically has identified 

cases in which researchers began conducting research relevant to 

combat casualty care, but did not coordinate with him early in the 

process. He stated that in these cases, the research typically had been 

underway for a period of 1 to 5 years before he learned about it. He 

stated that he coordinates with nonmedical research organizations when 

he becomes aware of research relevant to combat casualty care. 

However, he stated that he has not always been aware of relevant 

research, and that there may be similar ongoing research projects about 

 

14GAO, Interagency Collaboration: Key Issues for Congressional Oversight of National 

Security Strategies, Organizations, Workforce, and Information Sharing, GAO-09-904SP

(Washington, D.C.: Sept. 25, 2009) and Managing for Results: Using the Results Act to 

Address Mission Fragmentation and Program Overlap, GAO/AIMD-97-146 (Washington, 

D.C.: Aug. 29, 1997). For more information on fragmentation, overlap, and duplication in 

federal programs see GAO, 2012 Annual Report: Opportunities to Reduce Potential 

Duplication in Government Programs, Save Tax Dollars, and Enhance Revenue, 

GAO-11-318SP (Washington, D.C.: Mar. 1, 2011) and Opportunities to Reduce 

Duplication, Overlap and Fragmentation, Achieve Savings, and Enhance Revenue, 

GAO-12-342SP (Washington, D.C.: Feb. 28, 2012). 

Other DOD Research 

Organizations Do Not 

Always Coordinate Early 

in the Research Process, 

Which Can Result in 

Inefficiencies
 

Page 12 GAO-13-209 Defense Health

which he is currently unaware. For example, the Army Research 

Laboratory, which typically conducts research in the physical,

engineering, and environmental sciences, started developing a product in 

2006 that had the potential to control the bleeding of wounded soldiers— 

the leading cause of preventable deaths on the battlefield—but did not 

inform the JPC-6 chair of this research until 2 years later. In addition, 

multiple DOD officials—including the JPC-6 chair and other officials 

responsible for health research—stated that other DOD research 

organizations, such as the Naval Postgraduate School, the Defense 

Threat Reduction Agency, and the Joint Improvised Explosive Device 

Defeat Organization, have conducted research related to combat casualty 

care in the past and have not always coordinated or shared information 

early in the research process.

The JPC-6 chair also stated that some DOD researchers do not share 

information with him early in the research process because they are not 

aware of the need to coordinate early and may not fully understand 

medical research requirements, such as those that are necessary to 

support FDA processes for approval of new drugs and medical devices. 

He also stated that a lack of awareness and understanding can result in 

researchers duplicating each other’s work. As discussed above, Army 

Research Laboratory researchers did not inform the JPC-6 chair of their 

work for 2 years, and as a result they learned that some of their initial 

testing did not fully adhere to medical testing protocols associated with 

wounds and wound severity. Subsequently, the researchers had to redo 

some steps in their research. An Army Research Laboratory official 

responsible for the project told us that they could have avoided the 

inefficiency of duplicating these steps if they had shared information with 

the JPC-6 chair at an earlier point. The JPC-6 chair stated that, since this 

occurrence, the Army Research Laboratory and Army MRMC now 

coordinate with one another regularly to identify Army Research 

Laboratory projects with potential implications for combat casualty care.

DOD coordinates medical research information with other federal 

agencies, including FDA, NIH, and VA. DOD coordinates with FDA with 

regard to drugs and medical devices it develops because FDA is 

responsible for overseeing the safety and effectiveness of these 

products—including those that are developed through DOD’s combat 

casualty care research—and DOD must obtain FDA’s regulatory review

and approval or clearance to field medical products. FDA officials stated 

that they regularly meet with the commanding general of the Army MRMC 

to review DOD’s medical research priorities and to share general 

DOD Takes Steps to 

Coordinate with the FDA 

and Federal Agencies That 

Conduct Research Related 

to Combat Casualty Care
 

Page 13 GAO-13-209 Defense Health

information about regulatory requirements. FDA officials also provide 

product-specific advice to DOD regarding regulatory requirements by 

meeting with DOD researchers throughout the development process. This 

coordination is consistent with FDA’s efforts, noted in previous GAO 

reports, to address concerns from industry and advocacy groups, 

including those related to the timeliness of the review process and the 

need to improve communication between FDA and stakeholders 

throughout the development process.15

Likewise, it is important for DOD, NIH, and VA to coordinate with each 

other because all of these agencies conduct research that is directly 

related to combat casualty care research. DOD, NIH, and VA conduct 

joint program reviews, prepare joint strategic documents, complete joint 

research projects, and attend joint symposiums and conferences to share 

their research. Our prior work identified some issues concerning the 

ability of DOD, NIH, and VA to readily access comprehensive medical 

research information funded by the other agencies.

DOD officials told us that FDA 

regulators were very responsive to their regulatory questions and 

concerns, and they reported that sometimes this communication helped 

to expedite the development process.

16

 

15GAO, Prescription Drugs: FDA Has Met Most Performance Goals for Reviewing 

Applications, 

We found that the 

three agencies could improve their ability to efficiently identify potential 

duplication if they improved access to each others’ comprehensive 

electronic information on funded health research. DOD officials recently 

stated that DOD and the other two agencies are working together to 

address these concerns. Specifically, NIH has provided a DOD official 

with access to an NIH database that contains information about funded 

health research projects, and it has also provided training and support so 

that the DOD official can search the database for potential duplicated 

research. If this effort is successful, DOD plans to identify additional 

medical research officials who will be granted access to NIH’s health 

research database. Because VA’s medical research information resides 

GAO-12-500 (Washington, D.C.: Mar. 30, 2012) and Medical Devices: FDA 

Has Met Most Performance Goals but Device Reviews Are Taking Longer, GAO-12-418

(Washington, D.C.: Feb. 29, 2012).

16GAO-12-342SP. 
 

Page 14 GAO-13-209 Defense Health

in this database, DOD will also be able to identify VA research that is 

directly related to DOD’s combat casualty care research.

17

Health Affairs and Army MRMC monitor and assess the progress of 

combat casualty care research and development projects, but they have 

not assessed the extent to which this research fills gaps in DOD’s 

capability to provide combat casualty care or achieves other goals for this 

research, including those related to improving DOD’s ability to control 

bleeding, which is the primary cause of death on the battlefield. Internal 

control standards for the federal government state that agencies should 

monitor and assess their performance over time to help ensure that they 

meet the agency’s missions, goals, and objectives.18

Health Affairs and Army MRMC monitor and assess the progress of 

combat casualty care research and development projects. For example, 

Health Affairs and Army MRMC monitor and assess cost, schedule, and 

performance metrics for individual research projects to determine whether 

to continue funding, make necessary corrections to, or terminate these 

projects. Senior leadership in these organizations reviews projects 

annually to determine whether they are meeting established cost, 

schedule, and performance baselines. In addition, these leaders assess 

technology readiness levels—which are measurements of maturity 

level—to determine whether findings from a research project are 

sufficiently mature to move to the next phase of development. Health 

Affairs and Army MRMC also monitor and assess some aspects of the 

progress of the overall combat casualty care research portfolio, such as 

the number of projects completed, ongoing, or canceled, as well as the 

number of products available to users in the field. These organizations 

have applied findings from combat casualty care research to field five 

such products between fiscal years 2008 and 2011. For example, Health 

Affairs and Army MRMC officials told us that DOD fielded a combat gauze 

Using performance 

information such as performance metrics can aid agencies with 

monitoring results, developing approaches to improve results, and helping 

determine progress in meeting the goals of programs or operations.

 

17As noted in GAO-12-342SP, NIH also maintains a public database containing award 

data on NIH-funded health research, which DOD officials could search for potential 

duplicative research.

18GAO/AIMD-00-21.3.1.

DOD Monitors the 

Progress of Combat 

Casualty Care 

Research Projects, 

but Not Whether the 

Research Fills Gaps 

or Achieves Other 

Goals 
 

Page 15 GAO-13-209 Defense Health

product that was the result of combat casualty care research. This gauze 

includes a mineral to help form blood clots and is designed to stop severe 

bleeding in less than 4 minutes. Following the annual combat casualty 

care research portfolio review in September 2012, Health Affairs and 

Army MRMC reported that they plan to identify new performance metrics, 

such as data related to peer-reviewed publications and FDA approved 

drugs and medical devices that will provide additional information on the 

overall portfolio’s progress.

However, Health Affairs and Army MRMC have not assessed the extent 

to which the results of combat casualty care research fill gaps in DOD’s 

capability to provide care to combat casualties. As we discussed earlier, 

DOD identified a number of gaps in its capability to provide combat 

casualty care in the 2008 Guidance for the Development of the Force

analysis and report.19

In addition, Health Affairs and Army MRMC have not developed an 

assessment of the extent to which the results of combat casualty care 

research have achieved other goals for this research. Both Health Affairs 

and Army MRMC have established goals for the combat casualty care 

research portfolio including several related to improving DOD’s ability to 

Since 2008, Health Affairs and Army MRMC told us 

that they have completed about 44 combat casualty care research 

projects that are each designed to address one or more of these 

capability gaps. Health Affairs and Army MRMC officials told us that in 

2010 they attempted to measure the extent to which the 2008 capability 

gaps had been filled on the basis of the research results. However, they 

abandoned that effort because, according to officials, in 2010 researchers 

had not completed a sufficient amount of research designed to fill the 

2008 capability gaps. In addition, these officials indicated that the 

capability gaps were not specific, were not organized to correspond with 

DOD’s research areas, and did not reflect the state of medical knowledge 

at the time. Health Affairs officials told us that they are currently revising 

these capability gaps and they expect to complete the revision in 2013. 

Following the Health Affairs revision, the Joint Staff—a group of senior 

military leaders in DOD—will then validate the capability gaps. Health 

Affairs and Army MRMC officials told us that they plan to assess whether 

the results of future research fill the revised capability gaps once the Joint 

Staff validates them.

 

19DOD, Guidance for the Development of the Force FY2010–2015. 
 

Page 16 GAO-13-209 Defense Health

control bleeding, which is the primary cause of death on the battlefield. 

For example, Health Affairs set a goal for DOD to improve its ability to 

control bleeding in areas of the human body where it is not feasible to

apply a tourniquet, such as on internal organs or the groin. Health Affairs 

and Army MRMC officials told us that they periodically review and discuss 

progress toward these research goals for certain research topics. 

However, these officials have not developed an assessment that 

comprehensively identifies each of the goals for the portfolio and includes 

information about the extent to which each goal has been met. They 

acknowledged that more work is needed to do this. Following a review 

and analysis of the combat casualty care research portfolio in September 

2012, Health Affairs and Army MRMC officials reported to us that they 

intended to complete an overarching strategic roadmap for the portfolio 

by March 2013. They told us that they expect the roadmap could include 

specific project timelines and goals, among other things. However, on the 

basis of the information provided by DOD officials, we were unable to 

determine if the plan will clearly delineate how Health Affairs and Army 

MRMC will assess the extent to which results from combat casualty care 

projects fill capability gaps and achieve other goals. Until Health Affairs 

and Army MRMC assess the results of DOD’s research against revised 

capability gaps and other goals, DOD will not have reasonable assurance

that the research it is conducting meets its needs.

Coordination among the various organizations that plan and conduct 

combat casualty care research and development is important to 

effectively produce medical solutions to save or improve the lives of 

injured servicemembers. DOD has taken important steps to agree on 

roles and responsibilities and to establish the means for coordination and 

collaboration across organizational boundaries. However, DOD’s 

research organizations can only coordinate with each other when they 

become aware of relevant research. Without communicating to 

nonmedical research organizations about the importance of coordinating 

with the JPC-6 chair early in the research process, DOD research 

organizations may have to redo some steps of their research to address 

medical research requirements that they may not fully understand. 

Moreover, while DOD assesses the progress of combat casualty care 

research projects, it is also important that DOD monitor and assess the 

extent to which the results of its combat casualty care research fill the 

gaps in DOD’s capability to provide combat casualty care and achieve 

other goals that it established for the research. However, without a plan 

for monitoring and assessment, DOD runs the risk that it may not be 

Conclusions 
 

Page 17 GAO-13-209 Defense Health

producing results that most effectively improve combat casualty care to 

save lives on the battlefield.

1. To ensure that nonmedical DOD research organizations coordinate 

with the Assistant Secretary of Defense for Health Affairs early in the 

research process to understand medical research requirements and 

avoid inefficiencies that may lead to duplicative work, we recommend 

that the Secretary of Defense direct the Under Secretary of Defense 

for Acquisition, Technology and Logistics to

• communicate to DOD’s nonmedical research organizations the 

importance of coordination with the JPC-6 chair on combat casualty 

care issues, and require this coordination early in the research 

process when these organizations conduct research with implications 

for combat casualty care.

2. To improve DOD’s ability to assess the overall performance of its 

combat casualty care research portfolio, we recommend that the 

Secretary of Defense direct the Under Secretary of Defense for 

Personnel and Readiness to direct the Assistant Secretary of Defense 

for Health Affairs to

• develop and implement a plan to assess the extent to which combat 

casualty care research and development fills gaps in DOD’s capability 

to provide combat casualty care and achieves DOD’s other goals for 

this portfolio of research.

We provided a draft of this report to DOD, VA, and the Department of 

Health and Human Services (HHS), which includes FDA and NIH. In 

response, we received written comments from DOD and HHS, which are 

reprinted in appendixes I and II, respectively. VA did not comment on this 

report. DOD and HHS also provided technical comments that we have 

incorporated as appropriate.

In its written comments, DOD concurred with the recommendations we 

made to the department and also described steps it had taken or planned 

to take in response to our recommendations. Specifically, DOD concurred 

with our first recommendation to communicate to nonmedical research 

organizations the importance of coordination with the JPC-6 chair and 

require this coordination early in the research process. DOD also 

concurred with our second recommendation to develop and implement a 

plan to assess the extent to which combat casualty care research 

Recommendations for 

Executive Action

Agency Comments 

and Our Evaluation

Department of Defense
 

Page 18 GAO-13-209 Defense Health

addresses DOD’s capability gaps and achieves its other goals. In its 

comments on our second recommendation, DOD stated that it planned to 

revise its process to better assess the extent to which each combat 

casualty care research project closes capability gaps. Moreover, when we 

sent our draft report to DOD for comment in December 2012, Health 

Affairs and Army MRMC had not yet finalized the JPC-6 charter. 

Therefore, we included a recommendation in our draft report that DOD 

issue the final charter. In early January 2013, after we sent the draft 

report to DOD, the commanding general of Army MRMC signed and 

issued the final JPC-6 charter. As a result, we did not include the 

recommendation to finalize the charter in our final report.

In its written comments, HHS responded to a statement in the draft report 

that DOD, NIH, and VA could improve their ability to efficiently identify 

potentially duplicative research with improved access to each agency’s 

electronic health research information, as noted in a 2012 GAO report.20

HHS stated that DOD has access, to varying degrees, to NIH and VA 

medical research information. Consistent with our 2012 report, HHS 

stated that NIH and VA need access to DOD medical research 

information to reduce the risk of potentially duplicative research. HHS 

also stated that the agencies continue to evaluate the best approach to 

providing NIH and VA with access to DOD’s medical research 

information.

We are sending copies of this report to the appropriate congressional 

committees; the Secretary of Defense, the Deputy Under Secretary of 

Defense for Personnel and Readiness; the Deputy Under Secretary of 

Defense for Acquisitions, Technology and Logistics; the Assistant 

Secretary of Defense for Health Affairs; the Secretaries of the Army, 

Navy, and Air Force and the Commandant of the Marine Corps; the 

Secretary of Health and Human Services; the Secretary of Veterans 

Affairs; and other interested parties. In addition, the report is available at 

no charge on the GAO website at http://www.gao.gov. 

 

20GAO-12-342SP. 

Department of Health and 

Human Services
 

Page 19 GAO-13-209 Defense Health

If you or your staff have any questions about this report, please contact 

Linda Kohn at (202) 512-7114 or kohnl@gao.gov or Brenda Farrell at 

(202) 512-3604 or farrellb@gao.gov. Contact Points for our Offices of 

Congressional Relations and Public Affairs may be found on the last page 

of this report. GAO staff who made key contributions to this report are 

listed in appendix III.

Linda T. Kohn

Director, Health Care

Brenda S. Farrell

Director, Defense Capabilities

 and Management
Page 20 GAO-13-209 Defense Health

List of Committees

The Honorable Carl Levin

Chairman

The Honorable James Inhofe

Ranking Member

Committee on Armed Services

United States Senate

The Honorable Chairman

The Honorable Ranking Member

Subcommittee on Defense

Committee on Appropriations

United States Senate

The Honorable Howard P. “Buck” McKeon

Chairman

The Honorable Adam Smith

Ranking Member

Committee on Armed Services

House of Representatives

The Honorable C.W. “Bill” Young

Chairman

The Honorable Pete Visclosky

Ranking Member

Subcommittee on Defense

Committee on Appropriations

House of Representatives
Appendix I: Comments from the Department of 

Defense

Page 21 GAO-13-209 Defense Health

Appendix I: Comments from the Department 

of Defense
Appendix I: Comments from the Department of 

Defense

Page 22 GAO-13-209 Defense Health
Appendix II: Comments from the Department 

of Health & Human Services

Page 23 GAO-13-209 Defense Health

Appendix II: Comments from the Department 

of Health & Human Services
Appendix II: Comments from the Department 

of Health & Human Services

Page 24 GAO-13-209 Defense Health
Appendix III: GAO Contacts and Staff 

Acknowledgments

Page 25 GAO-13-209 Defense Health

Linda T. Kohn, (202) 512-7114 or kohnl@gao.gov

Brenda S. Farrell, (202) 512-3604 or farrellb@gao.gov

In addition to the contacts named above, Will Simerl, Assistant Director; 

Steve Boyles; La Sherri Bush; James P. Klein; Monica Perez-Nelson; 

Michael Pose; Mike Silver; Sarah Veale; and Cheryl Weissman made key 

contributions to this report.

Appendix III: GAO Contacts and Staff 

Acknowledgments 

GAO Contacts

Staff 

Acknowledgments 

(291032)
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