```

[House Hearing, 114 Congress]
[From the U.S. Government Publishing Office]

                                    
 
                         [H.A.S.C. No. 114-101]

                       ENSURING MEDICAL READINESS

                             IN THE FUTURE

                               __________

                                HEARING

                               BEFORE THE

                   SUBCOMMITTEE ON MILITARY PERSONNEL

                                 OF THE

                      COMMITTEE ON ARMED SERVICES

                        HOUSE OF REPRESENTATIVES

                    ONE HUNDRED FOURTEENTH CONGRESS

                             SECOND SESSION

                               __________

                              HEARING HELD

                           FEBRUARY 26, 2016

                                     

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                             _________ 

                U.S. GOVERNMENT PUBLISHING OFFICE
                   
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____________________________________________________________________
 For sale by the Superintendent of Documents, U.S. Government Publishing Office,
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                   SUBCOMMITTEE ON MILITARY PERSONNEL

                    JOSEPH J. HECK, Nevada, Chairman
WALTER B. JONES, North Carolina      SUSAN A. DAVIS, California
JOHN KLINE, Minnesota                ROBERT A. BRADY, Pennsylvania
MIKE COFFMAN, Colorado               NIKI TSONGAS, Massachusetts
THOMAS MacARTHUR, New Jersey, Vice   JACKIE SPEIER, California
    Chair                            TIMOTHY J. WALZ, Minnesota
ELISE M. STEFANIK, New York          BETO O'ROURKE, Texas
PAUL COOK, California
STEPHEN KNIGHT, California
                 Dan Sennott, Professional Staff Member
                Craig Greene, Professional Staff Member
                           Colin Bosse, Clerk
                           
                           
                            C O N T E N T S

                              ----------                              
                                                                   Page

              STATEMENTS PRESENTED BY MEMBERS OF CONGRESS

Davis, Hon. Susan A., a Representative from California, Ranking 
  Member, Subcommittee on Military Personnel.....................     2
Heck, Hon. Joseph J., a Representative from Nevada, Chairman, 
  Subcommittee on Military Personnel.............................     1

                               WITNESSES

Caravalho, MG Joseph, USA, Joint Staff Surgeon General, U.S. 
  Department of Defense..........................................     3
D'Alleyrand, LTC Jean-Claude G., M.D., USA, Chief, Orthopaedic 
  Traumatology Service, Walter Reed National Military Medical 
  Center.........................................................    23
Hogg, Maj Gen Dorothy, USAF, Deputy Surgeon General, United 
  States Air Force...............................................     4
Lawrence, Col Linda, M.D., USAF, Special Assistant to the Air 
  Force Surgeon General for Trusted Care Transformation, Office 
  of the Air Force Surgeon General, United States Air Force......    20
Mabry, LTC Robert L., M.D., USA, Robert Wood Johnson Health 
  Policy Fellow, U.S. House Committee on Energy and Commerce.....    22
Moulton, RADM Terry J., USN, Deputy Surgeon General, United 
  States Navy....................................................     7
Tenhet, BG Robert, USA, Deputy Surgeon General, United States 
  Army...........................................................     6

                                APPENDIX

Prepared Statements:

    Caravalho, MG Joseph.........................................    39
    D'Alleyrand, LTC Jean-Claude G...............................    99
    Hogg, Maj Gen Dorothy........................................    46
    Lawrence, Col Linda..........................................    78
    Mabry, LTC Robert L..........................................    83
    Moulton, RADM Terry J........................................    68
    Tenhet, BG Robert............................................    59

Documents Submitted for the Record:

    [There were no Documents submitted.]

Witness Responses to Questions Asked During the Hearing:

    Mr. O'Rourke.................................................   109
    Mr. Zinke....................................................   109

Questions Submitted by Members Post Hearing:

    Mr. O'Rourke.................................................   113
    
                ENSURING MEDICAL READINESS IN THE FUTURE

                              ----------                              

                  House of Representatives,
                       Committee on Armed Services,
                        Subcommittee on Military Personnel,
                         Washington, DC, Friday, February 26, 2016.
    The subcommittee met, pursuant to call, at 9:28 a.m., in 
room 2212, Rayburn House Office Building, Hon. Joseph J. Heck 
(chairman of the subcommittee) presiding.

OPENING STATEMENT OF HON. JOSEPH J. HECK, A REPRESENTATIVE FROM 
      NEVADA, CHAIRMAN, SUBCOMMITTEE ON MILITARY PERSONNEL

    Dr. Heck. I will go ahead and call this subcommittee 
meeting of the Military Personnel Subcommittee to order.
    I want to welcome everyone to the hearing of the Military 
Personnel Subcommittee to receive views on how best to ensure 
our future military medical readiness. This hearing is part of 
the committee's ongoing project to comprehensively review the 
current state of the Military Health System and military health 
care and, based on this information, identify areas that need 
improvement.
    Our purpose today is to discuss the top priority of the 
Military Health System: to ensure the medical readiness of our 
military forces, while also ensuring a ready medical force 
prepared to deploy in support of combat operations.
    Over the past 14 years of conflict, the services have 
worked tirelessly to improve medical readiness, ensuring both 
service members and medical providers are able to deploy and 
accomplish their missions. The medical readiness rates for each 
of the services have seen double-digit growth, as commanders 
and healthcare providers work together to identify and 
eliminate barriers to deployability.
    Combat medicine has also seen extraordinary advances, 
resulting in service member survival rates that were once 
thought unachievable. In many areas, the standards of care have 
been redefined as advances in areas ranging from transfusion 
medicine to casualty transport care reshape combat medicine. 
These crucial advances have not only benefited the military but 
civilian medicine as well.
    Many of these advances were made possible by the tireless 
efforts of military practitioners. Even in peacetime, military 
healthcare providers have the complex job of maintaining the 
medical readiness of service members at home stations while 
also manning, equipping, and deploying medical units with 
medical personnel who are trained in both military skills and 
specialized medical skills needed for wartime medicine.
    The hard-fought advances in combat care over the past 14 
years must be preserved. The medical specialties needed during 
war are not limited to trauma; however, during periods of 
limited deployment, trauma skills can quickly degrade, which is 
why we must do everything possible to maintain proficiency in 
both trauma and emergency medicine. It is crucial that military 
trauma teams have the proper patient volume and case complexity 
during times of limited deployment so that they can maintain 
the skills needed in combat.
    We will hear today from two panels, the first panel 
consisting of the Joint Staff Surgeon and service Deputy 
Surgeons General who can provide valuable insights regarding 
service-wide initiatives, and the second panel comprised of 
practitioners who can provide perspectives on the current 
challenges facing military emergency medicine and trauma 
practitioners.
    I look forward to hearing from our panels about the current 
efforts underway by the services to ensure we maintain high 
service member readiness and provider readiness during periods 
of limited deployment. In addition, I am interested to hear how 
the services ensure medical providers maintain their 
specialties, particularly in areas where patient volume is 
limited. Finally, I look forward to hearing the challenges 
facing practitioners as they look for innovative ways to 
maintain proficiency during periods of limited deployment.
    Before I introduce our panel, let me offer the ranking 
member, Mrs. Davis, an opportunity to make her opening remarks.

    STATEMENT OF HON. SUSAN A. DAVIS, A REPRESENTATIVE FROM 
 CALIFORNIA, RANKING MEMBER, SUBCOMMITTEE ON MILITARY PERSONNEL

    Mrs. Davis. Thank you, Mr. Chairman. I also want to welcome 
our witnesses from both of our panels this morning.
    This hearing should afford us the opportunity to hear a 
variety of perspectives on medical readiness. And, as you all 
know very, very well, nothing that we have to tell you, medical 
readiness is the foundation for which the military services' 
medical systems are built, not just the readiness of service 
members who are trained and proficient but also the readiness 
of the providers who ensure those service members are always 
fit to perform their mission.
    So much of the discussion on military readiness has been 
focused on trauma specialties in combat and how to maintain the 
skills the medical community has gained over the last 15 years 
of persistent conflict. I am interested to follow up on the 
discussion in your written statements about the development of 
the essential medical capabilities, as well as how each of the 
services maintains visibility over provider readiness to ensure 
that we have the proper number of trained providers when 
needed, and how you manage the trauma specialties, trying to 
track that. And I think, for all of us who are not immersed in 
this in the way that you are every single day, understanding 
how that really occurs has got to be important as well.
    I also want to acknowledge and thank the chairman for 
mentioning the contribution to civilian medicine that our armed 
services have made and the medical providers have made to our 
country. Staggering and incalculable, and I appreciate that 
greatly.
    Thank you, Mr. Chairman, and I look forward to the hearing.
    Dr. Heck. Thank you, Mrs. Davis.
    We are joined again today by two outstanding panels. We 
will give each witness the opportunity to present his or her 
testimony and each member an opportunity to question the 
witnesses.
    I would respectfully remind the witnesses to summarize to 
the greatest extent possible the highpoints of your written 
testimony in 5 minutes. The lighting system will be green. At 1 
minute remaining, it will turn yellow. When it turns red, I ask 
you to quickly try to summarize and finish up your testimony so 
we can move on through.
    Let me welcome our first panel: Major General Joseph 
Caravalho, Joint Staff Surgeon, Office of the Chairman of the 
Joint Chiefs of Staff; Major General Dorothy Hogg, Deputy 
Surgeon General, United States Air Force; Brigadier General 
Robert Tenhet, Deputy Surgeon General, United States Army; and 
Rear Admiral Terry Moulton, Deputy Surgeon General, the United 
States Navy.
    I ask unanimous consent that non-subcommittee members be 
allowed to participate in today's hearing after all 
subcommittee members have had an opportunity to ask questions. 
Without objection, non-subcommittee members will be recognized 
at the appropriate time for 5 minutes.
    With that, Major General Caravalho, you are recognized for 
5 minutes.

  STATEMENT OF MG JOSEPH CARAVALHO, USA, JOINT STAFF SURGEON 
              GENERAL, U.S. DEPARTMENT OF DEFENSE

    General Caravalho. Thank you, Chairman Heck, Ranking Member 
Davis, and distinguished members of the subcommittee. I am 
pleased to be seated alongside my colleagues, and I am 
especially grateful for the opportunity to discuss medical 
readiness with you today.
    My written testimony has been submitted for the record. 
Today, I would like to highlight three points in my oral 
testimony.
    However, as this is my first opportunity to meet with this 
committee in my capacity as the Joint Staff Surgeon, I would 
like to first take a moment to tell you about my role. 
Essentially, I have the responsibility to provide the Chairman 
of the Joint Chiefs of Staff and other senior leaders with the 
best military medical advice in support of the joint force.
    In my role as the facilitator for global medical 
synchronization, I work with other Joint Staff directorates to 
service Surgeons General and the Assistant Secretary of Defense 
for Health Affairs to meet the Chairman's intent in delivering 
health services to the combatant commanders and the joint 
force.
    Now, first of all, I would like to say I am extremely proud 
of the accomplishments to date of the joint medical force 
across the full spectrum of military operations. And with the 
Chairman's vision of future security environments, my first 
point is military medicine must be better aligned to 
continually demonstrate its readiness posture to the 
Department's senior leaders.
    It is my observation the joint force expects military 
medicine to be more than interoperable and, at times, more than 
joint. I believe whenever and wherever feasible, while 
remaining cognizant of service responsibilities, to best 
support the joint force, the services' medical forces must be 
interchangeably aligned.
    The Chairman's recently published Joint Concept for Health 
Services moves us in that direction. Now, this document 
describes in broad terms the Chairman's vision for what the 
future joint force will need from military medicine to support 
globally integrated operations.
    To this end, the services have begun work on establishing 
core medical specialty requirements that will aid in creating a 
more interchangeable joint medical force. Readiness metrics 
will then reflect each medical specialty's ability to function 
across the full spectrum of military operations.
    Next, I have also observed an increasing number of requests 
for medical support to smaller, more widely dispersed ground 
forces, and I expect this trend to continue. With this, my 
second point is the medical community must adapt to new 
paradigms of health service support. To meet this challenge, we 
have already begun work towards a formalized and disciplined 
review to develop new organizations, training, policies, and 
doctrine.
    My third point is I view military medical centers, 
hospitals, and clinics as our home stations' front lines of 
care. They provide ready warfighters and medical forces alike, 
while delivering quality health care to our valued 
beneficiaries. Then, both during and following deployments, 
they offer continued high-quality care for those in need.
    Now, these platforms should not be compared directly to 
civilian healthcare facilities, as we are focused primarily on 
readiness.
    In conclusion, military medicine has but one mission, and 
that is to support the joint force with globally integrated 
health services. We will not lose focus on the world-class 
health care our service members and families deserve, but it 
will be performed in support of our primary mission of medical 
readiness.
    From home station to operational deployments to evacuation 
and post-deployment settings, I feel strongly the military 
medical team across all the services will remain relevant, 
adaptive, and highly valued members of the joint force.
    Thank you for the opportunity to address the committee and 
for your enduring support of our service members and their 
families.
    [The prepared statement of General Caravalho can be found 
in the Appendix on page 39.]

    STATEMENT OF MAJ GEN DOROTHY HOGG, USAF, DEPUTY SURGEON 
                GENERAL, UNITED STATES AIR FORCE

    General Hogg. Chairman Heck, Ranking Member Davis, and 
distinguished members of the committee, thank you for the 
opportunity to come before you today to discuss the future of 
Air Force medical readiness.
    Fielding ready medics is the key to providing world-class 
health care at home and in the deployed environment. Let me 
illustrate this point.
    Last week, Craig Joint Theater Hospital in Afghanistan 
admitted a NATO [North Atlantic Treaty Organization] patient 
suffering from adult respiratory distress syndrome. The patient 
ultimately needed extracorporeal membrane oxygenation, or ECMO, 
and aeromedical evacuation to Landstuhl Regional Medical Center 
in Germany.
    While awaiting evacuation, the patient's oxygen levels 
decreased rapidly, leading to a life-threatening irregular 
heart rate, resulting in advanced cardiac life support and 
kidney dialysis. Craig's critical care medical team jumped into 
action to stabilize the patient and prep him for immediate 
evacuation.
    The complexities of this emergency illustrate the medical 
readiness skills required of our medics in managing not only 
trauma patients but nontrauma patients as well. This level of 
readiness is achieved through caring for complex patients with 
similar disease etiologies in our Military Health System.
    Every Air Force military treatment facility is a medical 
readiness platform aligned with an operational wing that 
directly enhances the medical readiness of warfighters and 
their families. The care we provide our beneficiaries enables 
us to sustain the readiness of our medical force. And our 
readiness is directly related to the volume, diversity, and 
acuity of our patient population.
    The Air Force Medical Service has a broad portfolio of 
readiness training programs to prepare individual medical 
specialists and deployable medical teams for reliable 
performance across the full range of military operations. The 
readiness portfolio spans care provided within our MTFs 
[military treatment facilities] to specialized advanced trauma 
training delivered in our civilian Level I trauma partnership 
platforms.
    Our Readiness Skills Verification Program establishes 
baseline skills required in a deployed environment. These 
skills are identified by senior clinical consultants and 
enlisted functional area managers based on combatant 
commanders' requirements and are updated with lessons learned 
and emerging medical evidence.
    In tandem, the Sustained Medical and Readiness Trained, or 
SMART, program expands training opportunities for skills 
requiring a higher volume and complexity of hands-on care than 
normally seen in our smaller military treatment facilities, 
utilizing local training affiliations or regional currency 
sites, such as the University Medical Center in Las Vegas, 
Nevada.
    For well over a decade, we have also had cadres of 
physicians, nurses, and technicians embedded in our Centers for 
Sustainment of Trauma and Readiness Skills, known as C-STARS, 
located in Baltimore, Cincinnati, and St. Louis. Hundreds of 
our medics have received elite trauma and critical care 
training and remain prepared to deploy anytime, anywhere.
    Similarly, Air Force graduate medical education programs 
develop the knowledge, skills, and attitudes of highly 
qualified medical personnel while supporting the Air Force 
Medical Service missions. These training programs deliver 
health care to our military members and other beneficiaries, 
ensures the competency and currency of medical personnel, and 
contributes to the readiness of medical airmen.
    The Air Force Medical Service is committed to preserving 
the medical skills obtained in the last 15 years of conflict 
and will continue to meet the evolving requirements of 
combatant commanders. With your support, we will continue to 
provide trusted and reliable health services to our airmen and 
their families for years to come.
    Thank you, and I look forward to your questions.
    [The prepared statement of General Hogg can be found in the 
Appendix on page 46.]

  STATEMENT OF BG ROBERT TENHET, USA, DEPUTY SURGEON GENERAL, 
                       UNITED STATES ARMY

    General Tenhet. Chairman Heck, Ranking Member Davis, and 
distinguished members of the subcommittee, thank you for this 
opportunity to provide the Army perspective on ensuring medical 
readiness now and into the future.
    Today's uncertain global environment continues to place 
high demands on the Army. Over the past year, the Army deployed 
over 190,000 soldiers to more than 140 countries around the 
world in support of various operations. Readiness is the Army's 
number one priority.
    And, as Ranking Member Davis mentioned earlier, our trained 
and ready medical force contributed to the highest 
survivability rate in the history of warfare despite the 
increasing severity of battle injuries. These advances in 
combat casualty care are primarily due to the integrated system 
of health that currently extends from the battlefield through 
Landstuhl Regional Medical Center in Germany to our in-patient 
hospitals in the United States.
    Today, we are faced with the question of how to sustain the 
competency of our medical force, which has performed so well in 
the past 14-plus years. During the second panel, you will hear 
from two combat-tested Army physicians, Lieutenant Colonel Bob 
Mabry, an emergency medical physician and certified pre-
hospital physician specialist, and Lieutenant Colonel Jean-
Claude D'Alleyrand, an Army trauma orthopedic surgeon, who will 
discuss challenges in pre-hospital care as well as maintaining 
surgical skills.
    However, we must not focus exclusively on the sustainment 
of combat trauma, surgery, and burn capabilities. Our Army and 
soldiers must be prepared for a multitude of contingency 
missions: to engage in conventional conflict against large 
armies and smaller, as mentioned by our Joint Surgeon; defend 
the homeland; and respond to a wide range of crises, ranging 
from peacekeeping to disaster relief and humanitarian 
assistance.
    The Army must maintain a broad range of medical 
capabilities to support this full range of military 
requirements. The 2014 deployment of 2,500 personnel to support 
Operation United Assistance in Liberia demonstrated the value 
of non-trauma-related medical specialities. Some argue these 
examples are not part of our mission set for ready and relevant 
medical support, but, invariably, when the task is unique and 
difficult, the Nation leans on its military.
    To ensure the readiness of the entire medical team for this 
broad range of missions, we must maintain and sustain our 
medical centers, hospitals, and clinics as our readiness and 
training platforms. This system ensures our medical force is 
trained, ready, and relevant to provide primary and specialty 
care in the myriad settings and conditions faced around the 
world.
    We must continue to develop innovative partnerships with 
the VA [Department of Veterans Affairs], civilian hospitals, 
and other organizations to ensure our entire medical team 
continues to be exposed to a varied and complex mix of 
patients. This is essential to train, challenge, and to hone 
the skills of our entire medical team.
    In addition, we must continue to train the next generation 
of the Army Medicine team through our graduate medical 
education programs. These programs are vital to our ability to 
recruit and retain highly skilled medical providers. Most 
importantly, these programs are the primary means of 
transferring knowledge from this generation of military 
providers to the next.
    While our system has proven to be very successful over the 
last 14 years, we must continue to improve and evolve it to 
meet the challenging needs of our Nation's Army. Since the 
beginning of our Nation's history, when we send our Nation's 
sons and daughters into harm's way, they need to know that the 
Army Medicine is there, relevant, and ready.
    I am committed to ensuring we maintain and improve the 
readiness of our medical force. I look forward to working with 
Congress in this endeavor. And I want to thank my partners in 
the DOD [Department of Defense], my colleagues here on the 
panel, and Congress for your continued support.
    [The prepared statement of General Tenhet can be found in 
the Appendix on page 59.]

    STATEMENT OF RADM TERRY J. MOULTON, USN, DEPUTY SURGEON 
                  GENERAL, UNITED STATES NAVY

    Admiral Moulton. Good morning, Chairman Heck, Ranking 
Member Davis, distinguished members of the committee. Thank you 
for providing me the opportunity to share some perspectives on 
Navy Medicine and our most important strategic priority, 
medical readiness. We are grateful to the committee for your 
leadership and strong support of military medicine.
    Force health protection is the bedrock of Navy Medicine. It 
is what we do and why we exist. And this mission spans the full 
spectrum of health care, from optimizing the health and fitness 
of the force, to maintaining robust disease surveillance and 
prevention programs, to saving lives on the battlefield.
    And on any given day, Navy Medicine is underway and 
operating forward with the fleet and the Marine forces around 
the globe. We operate in all warfare domains, in all 
environments, and must also deliver important specialized 
capabilities to the warfighters. Our personnel, whether an 
independent duty corpsman, a flight surgeon, an undersea 
medical officer serving aboard a submarine, a ship, or 
squadron, or a fleet Marine force corpsman in the field with a 
Marine unit, must be trained and equipped to execute their 
specific mission.
    Our readiness posture also requires us to be capable of 
meeting critical surge requirements in support of contingencies 
and combat operations. And Navy Medicine's expedition medical 
capabilities are important as we provide that care through all 
the echelons of care, from the battlefield to the bedside of 
our military treatment facilities.
    This is clearly evident as Navy Medicine continues to 
sustain unparalleled levels of mission success, competency, and 
professionalism while providing world-class trauma care and 
expeditionary force health protection to U.S. and coalition 
forces in southern Afghanistan.
    It also enables us to support humanitarian assistance and 
disaster response missions since our hospital ships have the 
capability to provide relief in the wake of catastrophic events 
like tsunamis and earthquakes. And our global health engagement 
strategy requires us to be ready to support these diverse 
missions around the globe.
    I cannot overstate the importance of our military treatment 
facilities in ensuring readiness of our personnel. The ability 
to deliver the full range of medical capabilities to the 
operational commander is highly dependent on the training and 
clinical currency of our personnel. And our MTFs are critical 
to providing these skills and competencies and must remain 
foundational to meeting our current and future operational 
requirements.
    Navy Medicine also continues to leverage our strategic 
partnerships with leading civilian trauma centers so our 
personnel can hone and sustain their skills, including the Navy 
Trauma Center at LA [Los Angeles] and USC [University of 
Southern California] Medical Center. And this program has 
trained over 2,800 of our deploying medical personnel since 
2002 and continues to enhance their combat trauma skills and 
medical readiness.
    And it is also important to recognize that our GME 
programs, graduate medical education programs, at our medical 
centers and our family medicine teaching hospitals support 
readiness by providing trained physicians to meet our 
operational requirements. And these programs rely on our MTFs 
having access to robust beneficiary populations and support our 
case number and complexity.
    The services, along with the Joint Staff and DOD, are 
working to identify, define, categorize, and prioritize 
essential medical capabilities, or EMCs. These refer to those 
health services that are required to deliver comprehensive 
health care in support of globally integrated operations and 
will provide the framework for maintaining the medical ready 
force.
    In the last 15 years of war, I have seen unprecedented 
advances in military medicine, and this progress was the result 
of a highly trained and well-equipped force dedicated to 
rapidly deploying the most effective lifesaving skills and 
techniques. And all of us in military medicine are committed to 
ensuring the lessons learned are sustained and effectively 
implemented throughout the MHS [Military Health System], and we 
are committed to continuous improvement. And these efforts 
require rigorous ongoing assessment of our capabilities, 
identification of gaps, and implementation of sound solutions. 
And all of us recognize that there is hard work ahead for that, 
to maintain medical readiness moving forward.
    Again, thank you for your support, and I look forward to 
your questions.
    [The prepared statement of Admiral Moulton can be found in 
the Appendix on page 68.]
    Dr. Heck. Thank you all for your testimony.
    We will begin the 5-minute round of questioning by members.
    A recent study of military medical staff concluded that the 
military seems to understaff operationally required specialties 
and overstaffs specialties more towards providing beneficiary 
care.
    So I would ask, how do the services balance maintaining 
that mix of having the docs needed or the entire healthcare 
spectrum needed to take care of military beneficiaries or to 
maintain their combat skills? And I would guess that part of 
the EMCs is going to help define that.
    For instance, you know, you look at certain facilities and 
there seems to be an abundance of OB-GYN [obstetrics and 
gynecology] and pediatrics, understanding that in humanitarian 
care we have to be prepared to provide those things, but not 
necessarily the level or the number of specialists or 
specialties required to provide combat casualty care.
    So that would be my first question.
    And to follow on to that, when we try to maintain the level 
of training of, let's say, our teams that are going to provide 
combat casualty care, I think, General, you mentioned your 
SMART program, and I appreciate the shout-out to University 
Medical Center, my former place of employment.
    But how do we ensure that the entire team--the 
anesthesiologist, the medic, the nurse, everybody--is trained, 
as opposed to just rotating out the trauma surgeon to a Level I 
trauma center?
    So whoever wants to tackle it first, we can just go down 
the line.
    General Hogg. Yes, sir, I will take that.
    So we need to maintain the readiness not only of our Active 
Duty members but of our families also. And the OB-GYN and the 
pediatric care that we provide help us to maintain that family 
readiness so that when that Active Duty member is deployed they 
have confidence that their family will be taken care of. And, 
also, those specialties will provide some military medical 
readiness due to complications that might occur during those 
episodes of care.
    The ability to get the whole team trained can be 
challenging at times. Most of the specialty care that we get 
within the Air Force Medical Service, we rely on our civilian 
partners to help achieve that. And it is at their mercy whether 
they want us to come into their facility. There is nothing 
compelling them, per se, to partner with us.
    We do have some challenges with our technicians, our 
technical specialties, getting them into the civilian 
facilities, because they are not equivalent. The civilian 
community doesn't really understand their equivalencies. Once 
we get them in the door, they are all on board and usually ask 
us, do you have more?
    And so we try by getting in the physician and the nurse, 
and then, once we get them into our partnerships, we tag along 
a technician. And once they see the capabilities of our 
technicians, usually that helps.
    Dr. Heck. Anybody else want to add?
    General Tenhet. I will add to General Hogg's comments here.
    In a deployed setting, trauma care takes up about 15 
percent of the numbers we see in theater, so 85 percent of 
those are disease/non-battle injury. In any given camp or FOB 
[forward operating base], you may have upwards of 30 percent 
females. So just with the OB-GYN, I mean, gynecologists in 
theater is not a misnomer.
    So, of the evacuations used in the wonderful Strat Air 
[Strategic Airlift] that the Air Force has, 80 percent of our 
evacs [evacuations] are disease/non-battle injury as well. So 
to sustain just within the trauma system itself, we have to 
look across the entire spectrum of medicine.
    And as you talked about the--or asked the question on the 
OR [operating room] piece, we estimate it takes up to 80 staff 
members to support 1 OR. So it becomes a convoluted system to 
try and train to standard using the team approach and 
collective training.
    So our forward surgical teams you are probably familiar 
with, we do take them into team training, collective training 
down at Ryder in Miami. And we are looking to expand that 
across the U.S. and maybe even globally as we go into the 
interwar years.
    Admiral Moulton. Sir, I would just comment to your first 
question, you know, about maintaining the balance, how do we 
ensure that we are meeting our operational requirements and 
then the peacetime care as well, for us, there are priorities 
for distribution of our resources.
    First of all, we are going to support the operational 
requirements. That is 100 percent staffing. And then we would 
look to our overseas activities, which are forward-deployed. 
And then, lastly, is our MTFs. And then they are augmented by 
civilians and contractors to maintain that skill and to build 
that credibility before deploying again.
    And then the second question, back to the entire team, 
rather than just the trauma surgeons or surgeons in general, 
you know, we are moving back to a platform readiness. And for 
the last 15 years, we have been doing a lot of individual 
augmentations, so now, moving back to platform readiness, we 
can train the whole unit. You will know where you are assigned, 
and you will know what the training requirements are for that 
platform, and then you will train as a team before deployment.
    Dr. Heck. Okay. Thank you all. My time has expired.
    Mrs. Davis.
    Mrs. Davis. Thank you, Mr. Chairman.
    And I wanted to go back just to the EMCs, the essential 
medical capabilities, for a second. Obviously, you have been 
working on it very hard, I think, but when do you expect to 
complete them? And how long will it take to implement across 
the individual force?
    General Hogg. Yes, ma'am. So the Air Force Medical Service 
supports the development of the EMCs, and we have been actively 
engaged in defining what those are.
    The timeframe, we will have the beginnings of some 
essential medical capabilities, I believe, in October of this 
year. And then the implementation, right now I really don't--we 
haven't got the timeline for that.
    General Caravalho. Ma'am, if I may say that the EMCs are 
primarily going to describe what is already being done by the 
services now, except that they are using the civilian 
healthcare model of are you board-certified, are you 
credentialed, licensed, and privileged. The EMCs is going to 
put it--I believe is going to be very helpful because it will 
put it into the DOD reporting system style so that now senior 
leaders can say are my medics ready, just like are my 
submariners ready and are my aviators ready.
    Mrs. Davis. Uh-huh.
    General Caravalho. I will speak--I think it will speak to--
it won't be too high-level, it won't be strategic, in that 
``take care of patients,'' of which everything falls within. 
And it won't be too tactical, to say what do our 
ophthalmologists do and what do our cardiologists do. It is 
going to be along the lines of providing hospitalization, 
providing patient movement, something along those lines, under 
which, then the essential task list will be generated by the 
services and the primary skills, attributes that everyone will 
need.
    And I believe each provider will then be able to say, 
regardless of my specialty as an NCO [noncommissioned officer] 
or as an officer, what do I bring to this fight. So I may not 
be a general surgeon, but I will be asked to be a surgeon; what 
are the skills I will need to be a surgeon in any realm that I 
am asked to participate, whether major combat operations, 
humanitarian assistance, or what have you.
    I think that is how that is going to play out. I think we 
will start to be, as was mentioned, start to be able to codify 
that in a Department's reporting system later this year.
    Mrs. Davis. Uh-huh. Do you think, I mean, you have pretty 
much described this right now, I think, that--do you see a 
major impact on training requirements then? Is that really 
going to----
    General Caravalho. I think we are going to--we are not 
going to create a new system. I think we already, I think the 
services already know proficiency and currency using the peer 
review, the systems that civilian healthcare industry uses. We 
are just going to codify it and report it so that the senior 
leaders know that, no matter what I ask you to do, fight 
tonight, sustain operation, are you able to do--are you able to 
fight. I am hoping then that, whether they ask for Army or Navy 
or Air Force, no matter what the Chairman is looking for, it 
won't matter because we are using the same codified skill sets.
    Mrs. Davis. Uh-huh.
    General Caravalho. And if we are truly interchangeable and 
one service is short a surgeon, for instance, using EMCs, we 
can look to another service and say, okay, you have met the 
standard, can you come in and fill, as opposed to it must be 
all Army or all Navy or all Air Force every time there is a 
requirement.
    Mrs. Davis. Yeah.
    Could you all respond? I mean, does that make a real 
difference?
    General Tenhet. So when we get into the KSAs [knowledge, 
skills, and abilities]--so you build the EMCs, that is the 
overarching codification of this. And we are looking at 10, 
primarily, at this point in time. We haven't solidified that 
yet, but that is where I think we are going to go with this. 
It, oh, by the way, mirrors into the joint concept of health 
support, so that is process and progress in that model.
    But concomitant with the EMC is the knowledge, skills, and 
abilities that we are aligning across the services. And that 
gets into both the operational and down to the tactical level 
of the individual. So, within that construct, it is going to be 
a scorecard, just like the infantry uses in their unit status 
reporting; are they green, amber, or red. We are going to apply 
that to medicine.
    Mrs. Davis. Yeah. But is this going to be on an individual 
basis then? Will you know whether one specific physician is 
ready?
    General Tenhet. Absolutely. Absolutely.
    General Hogg. Yes, ma'am.
    Mrs. Davis. And is that true, that you don't know today?
    General Hogg. No, ma'am, we do know today. In the Air Force 
Medical Service, we have, I mentioned in my oral statement 
about the Readiness Skills Verification Program. Every medic in 
the Air Force Medical Service has a readiness skills 
verification checklist, if you will, that identifies the skills 
that are necessary for them to be competent in wartime 
scenarios or over the full range of military operations.
    That is looked at on a regular basis. Some of the training 
is knowledge-based, some of the training is didactic, and some 
of the training is hands-on. And they are required to complete 
those skills, depending on the timeline, in order to stay 
current.
    Mrs. Davis. Uh-huh. But in terms of, once this is 
operational, I understand it is not new to the system, but 
there is added value to it.
    General Caravalho. Yes, ma'am. If I may give an example of 
where we are short now, if you have a general surgeon who goes 
on to a fellowship and does plastic surgery and now she is 
practicing as a plastic surgeon for 10 years, when we deploy 
her, we will need her as a general surgeon, and she may never 
have been in someone's belly operating for 10 or 15 years. We 
track her as a competent, board-certified, credentialed, 
privileged plastic surgeon, and we lose sight of the general 
surgery part.
    EMCs will say, no matter where you are, when you deploy, 
have you met the skills and attributes we are looking for in a 
deployed setting.
    Mrs. Davis. Okay. Great.
    And for our specialty nurses, just a yes or no, is it going 
to be the same?
    General Hogg. Yes, ma'am, it is the same.
    Mrs. Davis. Okay. Thank you.
    Dr. Heck. Mr. O'Rourke.
    Mr. O'Rourke. Thank you.
    Not sure to whom I should address this question, but I am 
interested in the IDES, or the Integrated Disability Evaluation 
System, that is supposed to ensure that a wounded or disabled 
service member is either reintroduced back into Active Duty or 
the appropriate Reserve Component or is able to seamlessly 
transition out into VA medical care. And, following the 
flowchart the Department of Defense has published, it looks 
like that process should take about 295 days.
    So I guess my first question is: Are we, in fact, returning 
service members to Active Duty status in that time or helping 
them to separate in that time with a VA disability rating, or 
are we at some other mark either above or below 295?
    General Hogg. Yes, sir. In the Air Force system, IDES 
system, it is a collaborative process between DOD and VA, and 
parts of those process are owned by those two entities.
    In the part that the Air Force owns, the Air Force Medical 
Service owns, we are doing actually very well with getting 
members through, but the total process still is a little bit 
over the 295 days.
    Mr. O'Rourke. Do you know what it is for the Air Force?
    General Hogg. No, sir. I would have to get back to you with 
that.
    Mr. O'Rourke. Okay, for the record.
    And for anyone else, if anyone has a specific number, I 
would love to hear it now. If not, we would just request that 
as a followup question for the record.
    [The information referred to can be found in the Appendix 
on page 109.]
    Mr. O'Rourke. General Tenhet, did you want to add to that?
    General Tenhet. I was just going to mention we are at 291. 
However, you know, the Army's injuries, we have had some 
complex issues that keep that number around that window there.
    Working with the VA, we have improved that significantly in 
the last 4 to 5 years. And some of that has been from the 
pressure from Congress to work more collaboratively together. 
And also it is being able to share the documentation through 
Legacy Viewer, et cetera. Any and all medical interaction is 
now documented and shared across both the VA and DOD.
    Mr. O'Rourke. That gets to a followup question I would like 
to ask you, which is, I don't know how to gauge whether 295 is 
a lot of time or the appropriate amount of time, but there are 
certainly several stages, dozens of stages actually, in this 
process, some of which the service member has the opportunity 
to appeal a decision or make some other decision on his or her 
part, and then decisions that are made by the Department of 
Defense, decisions that are made by the VA.
    Do you see any obvious opportunities to further streamline 
this process, gain greater efficiencies, and ensure that the 
service member returns to duty or is able to transition out 
effectively and be in the care, again effectively, of the VA so 
that nothing is dropped?
    General Tenhet. There is always room for improvement, as a 
learning organization. The medicine peace of that window is 
actually a very small piece. It is mostly administrative. And I 
think all the services, medically, are meeting their mark. I 
think the coordination with the VA and working with our G-1 
[Deputy Chief of Staff of the Army] through the administrative 
piece of this, we can always continue to tighten that piece up.
    But it is back on the soldier. Fifty percent of those just 
2 years ago were being returned to service. We are down to 
about 40 percent, again, because of the remaining complex 
issues that we have.
    But the ability to work with the VA, the warm handoff, and 
also implementing the case management structure into this has 
really enhanced the program.
    Mr. O'Rourke. I have another question that may, because of 
limited time for you to answer, be appropriate to get for the 
record or to have an offline conversation. But in terms of that 
warm handoff, anecdotally, in talking to veterans in El Paso 
who served at Fort Bliss and were treated at William Beaumont 
Army Medical Center, they talk about excellent care at the 
military treatment facility, especially when it comes to mental 
health. They then say that regimen of care which was so 
expertly executed at William Beaumont, once I transitioned to 
the VA, it was very hard to see a psychiatrist or a 
psychologist or even a social worker to continue that care.
    So I understand the goal. It is not happening. I would 
love--and there is not time for you to respond right now, but I 
would love to get your thoughts, either in writing or offline, 
about how we can do a better job and what role specifically the 
Army or Department of Defense could play in extending that care 
if somebody is already in treatment.
    Mr. O'Rourke. With that, I will yield back to the Chair.
    Dr. Heck. Mr. Knight.
    Mr. Knight. Thank you, Mr. Chair.
    I just have some basic questions.
    You know, in California, we have opened another medical 
school out there because of the deficiency for surgeons and 
doctors that we have in California and across the country. Are 
we finding that in Army and Navy and Air Force Medicine, that 
we are not getting enough applicants, that we are not having 
enough surgeons and doctors?
    General Hogg. No, sir. We staff to our requirements, and so 
we typically have plenty of applicants to attend our military 
medical programs.
    Admiral Moulton. And for the Navy, I would say, as well, 
that our recruiting efforts have been very successful over the 
last several years. So we are not facing any shortages there.
    General Tenhet. Same for the Army, sir.
    I think our challenge is the retention piece of this. 
Especially as the wars start to wane, especially in the trauma 
medicine arena, the retention portion of this becomes more 
challenging as we go forward.
    Mr. Knight. Okay.
    And as we have been at war now for 15 years, and for some 
purposes for the last 25 years, we have seen readiness be the 
number one goal. And I think that should always be the number 
one goal in the military, is readiness.
    But as our young men and women have gone into theater two, 
three, four, five times, we have started to see an awful lot of 
things that maybe we dealt with in other wars, maybe in Vietnam 
and Korea and World War II, but they are very prevalent today. 
We have renamed these things. I think in World War II we named 
it ``shell shock,'' and today we have ``PTSD'' [post-traumatic 
stress disorder] and ``traumatic brain'' and things like that. 
They are all an effect of seeing something that normal people 
don't ever want to see, and that affects someone.
    How are we treating that differently today than maybe we 
did 15 or 20 years ago?
    General Hogg. Yes, sir. I think that the biggest way that 
we are treating that differently is recognizing that it does 
exist and that it does have an effect on our members coming 
back from being exposed to those kinds of circumstances.
    We certainly have increased our mental health care, and we 
continually look to practice evidence-based medicine in 
relationship to PTSD and TBI [traumatic brain injury]. And we 
continue to care for those individuals coming back.
    General Tenhet. I will just add to the comments. I think 
just admitting that we do have these problems, Congress 
supporting the efforts--$184 million in the last 15 years in 
research. We are working with the NCAA [National Collegiate 
Athletic Association], the NFL [National Football League], with 
their programs, making tremendous strides there. I think it is 
450 research programs ongoing right now just in our Medical 
Research and Materiel Command.
    Mr. Knight. Admiral.
    Admiral Moulton. I was just going to also talk about the 
partnerships that we have had, reaching out to UCLA [University 
of California at Los Angeles] and our NICoE [National Intrepid 
Center of Excellence] and really approaching it across the 
system vice in isolated areas. So I think we are making good 
strides in that.
    Mr. Knight. And just in my last minute here, recently I 
have sat down with some folks that are working on new and 
innovative ways of treating our folks on the battlefield. Some 
of them are these bandages where you can see if they are 
actually healing or if it is not healing and things of that 
nature and under-the-skin type of treatments that we can check 
and we can monitor if it is working or if it is not working or 
if the skin is healing or not healing.
    Have we seen that because we have been at war in the last 
15 years more? Or is that just because we are getting more and 
more advanced in the medical field?
    General Hogg. I will take that one too.
    It is both. It is both. I think that as you are exposed to 
situations and you deliver care, you are always thinking about, 
could I do this better and, if so, how could I do that better? 
So our research programs are helping us to look at those 
specific care issues and figure out how could we do it better 
to improve the survivability of our warfighters downrange.
    So I think it is both. It is technology is advancing and we 
are able to capitalize on that. But the care that we are 
providing downrange and the kinds of things that we are seeing 
causes us to look inside and go, could we do that better?
    Mr. Knight. Thank you, General.
    And I yield back.
    Dr. Heck. Dr. Wenstrup.
    Dr. Wenstrup. Thank you, Mr. Chairman.
    I appreciate you all being here today.
    I want to talk a little bit about some of the process of 
implementing the things that we want to see as far as keeping 
the skill levels up and credentialing that, et cetera. And, as 
we know, so much of our military medicine is in the Reserve 
Component and so not quite as captive an audience to check all 
these boxes, if you will.
    And, for example, I spent time with CCATT [Critical Care 
Air Transport Team] in Cincinnati, and I thank the Air Force 
for letting an Army guy go in there and participate in that. 
But great training, pre-deployment training, and you really 
have to qualify to be able to go and serve on that mission. And 
I think, when I was there, everyone was Active Duty. They could 
be reservists, as well, to come into that scenario.
    But, by and large, too--so I served a year in Iraq at a CSH 
[combat support hospital]. And in the OR, I was the only one 
there for a year, and you had others rotating in 90 days. For 
some, it was been there, done that; you know, not the first 
time; they got it. For a young surgeon coming in, it was like, 
holy cow, I have never seen anything like this, I have never 
done anything like this.
    And even in the Reserve Component, as you mentioned, 
General, we have general surgeons that may be doing plastics, 
but you know what? At that time, that didn't matter, you are 
going to do this.
    And so how do we get the Reserve Component, in particular, 
to be able to check all these boxes, make sure that they are 
ready? And do we have enough surgeons to fill that void?
    Anyone.
    General Hogg. In the Air Force Medical Service, the 
training that we provide is opened up to the total force. So 
the Reserves and the Guard can attend C-STARS, they can attend 
SMART. They have the same requirements that we have, as far as 
our Readiness Skills Verification Program, to maintain 
competencies and currency.
    The professional medics in the Reserve, the physicians, the 
nurses, a little less concerning as far as competency, because 
oftentimes they are practicing in their specialties. Where we 
have a challenge is with our enlisted medics, because 
oftentimes they are not practicing within their specialty. And 
so they have a very robust program to, during their annual 
trainings and whatnots, to try to get them up to speed.
    Dr. Wenstrup. Thank you.
    General Caravalho. Sir, the intent, I believe, for the EMCs 
is going to be across all components. We shouldn't have an 
Active Duty standard and a Reserve Component standard. But I 
acknowledge that it is going to be difficult on your battle 
assembly to get after some of these things.
    So we may face an individual who doesn't have the right 
clinical mix, acuity, caseload to meet an EMC-type standard. I 
am hoping that across the board we are going to say, if you 
can't get it clinically, what are the reasonable facsimiles 
that you can then show your proficiency and currency? Online 
training, modeling; partnering, strategic partnering, with 
civilian or VA entities.
    I think if we do this correctly, when you mobilize the 
reservists, you must institute time. And we have done this with 
this war. We have learned that you have to provide some time to 
kind of get their mind into a--you are going to see not just a 
gunshot wound, not just a knife wound, but you are going to see 
blast injury, head injury and a gunshot wound and a knife wound 
at the same time--and a burn.
    So that is number one. So the Miami's [Ryder Trauma 
Center], the Cincinnati trainings of the world before you 
deploy is going to be critical.
    The second thing is there has to be a critical mass of 
expertise resident when the individuals show up. In other 
words, we have been successful, I believe, with one burn center 
in San Antonio rather than a burn center at every facility to 
ensure everyone has burn center skills. And you rotate staff 
through there, that that one person, whether it is a nurse, a 
tech, or doc, can say, this is the burn standard, everybody get 
on board.
    And I think we are going to have to use those types of 
creative skills to ensure that folks who may not be ready will 
get ready. Because we know, on the back end, they want to be 
ready. So when they are willing, it doesn't take long for them 
to get on board.
    Dr. Wenstrup. So maybe that can be their AT [annual 
training]?
    General Caravalho. Yes, sir. Yes, sir.
    Dr. Wenstrup. Thank you. I yield back.
    Dr. Heck. Mr. Zinke.
    Mr. Zinke. Thank you, Mr. Chairman. I appreciate you 
allowing me to talk before the committee.
    My background is SEALs [Sea, Air and Land teams]. And I 
have seen the evolution of casualty care, which has been 
impressive. I still remain a little concerned about the 
acquisition part. I don't think we are as fast as the private 
sector is at getting new techniques to the front. But my 
question really is about the training.
    In looking back at my career, with explosive breaching and 
TBI, and looking at what has happened in the NFL and all of a 
sudden an awareness of concussions over a period of time, I 
remember as a SEAL going into facilities, and we would do 400 
explosive breaches in a day and then do it continuously.
    What are we doing to examine our training regimen based on 
what we know today to make sure that we aren't creating, you 
know, situations, you know, like long-term concussion damage, 
TBI, in our training regimen? Are we looking at it actively? Do 
we need to put more resources in it? What can we do to make 
sure that it is being done?
    Because oftentimes, you know, what I call the meat-eaters, 
the frontline guys, don't pay a lot of attention to the support 
folks, and I want to make sure that they do. And what do we 
need to do to make sure that happens?
    Admiral.
    Admiral Moulton. Sir, I would have to take that. I am not 
familiar with that enough to talk intelligently about it.
    [The information referred to can be found in the Appendix 
on page 109.]
    General Tenhet. You have to look at the force structure 
piece of this, as well. So, as we are looking at medicine and 
ensuring we sustain skills as we go forward, the interwar 
years, the innovation that comes from some of that, applying 
this, we are not going to have the capability--this is just Bob 
Tenhet speaking about the future, where I see it going--we are 
not going to have that capability at our smaller facilities to 
have the high-complex, high-acuity-type patients going into 
those facilities.
    And we have already taken steps just at Fort Sill, Knox, 
and Jackson in removing our surgeons and using the surrounding 
capabilities there in the community areas and actually moving 
those surgeons to higher-acuity platforms, our health readiness 
platforms. We are going to have to see more of that as we go 
forward to ensure that we have the training capability. And I 
will tell you, it is even a challenge at some of the places we 
are moving them to look at high-complexity, high-acuity cases 
as well.
    So I think the sharing agreements, working with the 
civilian populace and, I mentioned earlier, even looking at 
international programs, we may have to go there. Because the 
Miami's, there are only so many of those that exist out there. 
So you are looking at individual skills, and you are also 
looking at the collective skills training.
    Mr. Zinke. Yeah. I guess my point is that, you know, there 
are a lot of preventative things that we should be doing up 
front rather than waiting until it is an acute problem. And 
especially with explosive breach, I assume it is getting very 
similar to going into a boxing match. So I just want to make 
sure we get ahead of it so we don't have the problems long 
term.
    General.
    General Hogg. Yes, sir. With the recent collaboration that 
we have with the sports industry and the academy, I feel that 
we will definitely start to see some of those changes coming 
out of those studies that will inform us on how to better 
prepare and to prevent these kinds of injuries.
    General Caravalho. Sir, in my experience with you 
carnivores, I agree that generally they don't like to listen to 
medical, and our approach has been ``it is easy to be hard but 
hard to be smart.''
    What I am excited about readiness nowadays is that we are 
following some of the soft truths that they are talking about, 
that you can't recreate someone overnight, so how do you keep 
someone in the fight for the duration of his or her career and 
then offer a full life after that career.
    So we are getting smarter in our training. The warfighters 
are bringing us in, on board, to help them understand how to do 
it right. And we are focusing, as well, on how do we prevent 
illness and how do we promote wellness so that you are 
survivable, agile, and resilient during your time in the 
military.
    Mr. Zinke. Well, certainly, if we can do anything to 
promote some interest and move in that direction, you know, let 
us know.
    General Caravalho. Yes, sir.
    Mr. Zinke. And thank you.
    Thank you, Mr. Chairman.
    Dr. Heck. Ms. Speier.
    Ms. Speier. Thank you, Mr. Chairman.
    And thank you all for being here.
    I would like to follow up on the questions that Congressman 
Zinke just offered up. There is a wealth of information about 
chronic traumatic encephalopathy [CTE]. It not the NFL that is 
researching it. The NFL is trying to sweep it under the rug. 
Boston University has now, I think, examined the brains of, I 
don't know, maybe 100 persons who were in the--some in the 
military but most in sports.
    There is a Dr. Omalu, who is the coroner who first kind of 
identified CTE, that is doing research now with a physician at 
USC on PET [positron emission tomography] scans of persons who 
are alive. And they have just done a number of PET scans on 
veterans, and each PET scan they did showed CTE. One of the 
problems is it is not just the concussions; it is the 
subconcussive hits that individuals receive.
    And I really think it is incumbent on us to start to do a 
much better job of identifying it and promoting research in 
this area as it relates to those who serve in the military. And 
I am kind of surprised and a little bit stunned that you 
haven't already undertaken this.
    I was told by someone very recently that SEALs now are 
actually wearing a monitor to determine how many--I don't know 
if they are concussions or just hits that they receive. Could 
someone speak to that?
    General Caravalho. Ma'am, in one of my last jobs in the 
medical research community, we were working with DARPA [Defense 
Advanced Research Projects Agency], and there were blast gauges 
and different types of devices that one could place across 
their body and on their helmet that would look at the--it was 
an accelerometer to get a sense if there was a rapid 
deceleration. And that would then codify how many events you 
had.
    Knowing that our troopers in general don't want to say, 
``Coach, take me out,'' so they will not complain of these 
hits, that is number one.
    Number two is IED [improvised explosive device]-related TBI 
probably represents less than 20 percent of all TBI that at 
least the Army has seen. So most of it is just in normal 
training, whether it is combatives or parachute jumping or just 
normal Army training.
    I think you are right that longitudinally we need to 
understand these concussive and subconcussive events and its 
effect over time. And the military is also looking at doing 
pathologic studies of CT. I cannot speak to PET scanning or 
pre-mortem studies as you described. But we have a keen 
interest in that in the Department, and we certainly want to 
partner with any academic center in getting after this. We 
don't care who finds out what the answer is; we want to get 
after the answer.
    Ms. Speier. All right. Thank you.
    I yield back.
    Dr. Heck. Well, I want to thank you all for your testimony 
here today. Again, the purpose for this hearing is that, as we 
undertake the reformation of the military healthcare system, we 
want to make sure that we keep readiness first and foremost in 
our minds and that we don't impede, one, the readiness of our 
military medical providers, but certainly that we don't hinder 
the medical readiness of our troops. So, again, we thank you 
very much.
    Mrs. Davis. May I ask a clarification----
    Dr. Heck. Certainly, Mrs. Davis.
    Mrs. Davis. Thank you.
    Thank you all, again, for being here.
    I wanted to clarify a little bit, because we were talking 
about moving physicians into civilian facilities and back and 
forth, and I understand how it important that is. We also know 
that a number of our military providers also moonlight for 
training.
    But if we are doing that--and, as I understand it, you are 
basically managing that within individual services. Is that 
correct? So don't we need a more centralized way to manage that 
and to be able to identify the different skill sets that you 
are using where you have a lot of movement of those providers, 
of those physicians?
    General Hogg. Yes, ma'am. I think as we define those 
essential military capabilities, we will be able to partner 
with our other services where we are co-located to utilize 
those civilian facilities.
    The providers that we send there, not all of them are there 
full-time all the time. Some are there as their primary duty in 
that civilian facility, but many of them, again, go back and 
forth. So they provide outpatient care in the MTF, the military 
treatment facility, but then provide the specialty care, 
because it is not available in the MTF, in the civilian 
facility.
    But I do believe that as we define what those essential 
medical capabilities are, we will find opportunities where we 
could collaborate in that area, as well.
    Mrs. Davis. Uh-huh.
    Admiral Moulton. Ma'am, I would also add, we are doing that 
in what we call multiservice markets, where we are working 
together in a multihospital system or multiclinic system where 
there are larger populations so we can bring in those kind of 
cases for us. And then are we adequately staffing, or what is 
that number of providers that ought to be in that area so that 
they get the amount of workload for their training.
    And then we look at more partnerships with the VA or more 
partnerships with the private sector. So we are doing some of 
that.
    Mrs. Davis. Okay. Well, that is good. I am glad. Sometimes 
it seems as if, maybe culture, what have you--that there are 
obstacles to doing that. And if that is the ideal--and, again, 
looking to all of you, is that ideal, is that much better, that 
there is that information-sharing so that we know that someone 
is at the proficiency level required? And if it is in the Army 
but you don't know it in the Navy, it is not going to do all of 
us any good, right?
    Okay. Great. I am glad that is at least improving. Thank 
you very much.
    Thank you, Chairman.
    Dr. Heck. Again, I thank the first panel for your 
participation today.
    And if we can now, we will just swap out panels and 
continue to move forward.
    I would now like to welcome our second distinguished panel. 
We heard from the, I think, 30,000-foot view. Now we are going 
to bring it down to a little bit more tactical and operational.
    With us this morning is Colonel Linda Lawrence, Special 
Assistant to the Air Force Surgeon General for Trusted Care 
Transformation, Office of the Air Force Surgeon General, but 
also past president of the American College of Emergency 
Physicians; Lieutenant Colonel Promotable Robert Mabry, who is 
here as a Robert Wood Johnson Health Policy Fellow with the 
U.S. House Committee on Energy and Commerce but has a long and 
distinguished past, beginning as an SF [Special Forces] medic; 
and Lieutenant Colonel Jean-Claude D'Alleyrand, Chief of 
Orthopaedic Traumatology Service at the Walter Reed National 
Military Medical Center.
    I appreciate all of you taking the time to be with us this 
morning.
    Colonel Lawrence, you are recognized for 5 minutes for your 
opening statement.

STATEMENT OF COL LINDA LAWRENCE, M.D., USAF, SPECIAL ASSISTANT 
       TO THE AIR FORCE SURGEON GENERAL FOR TRUSTED CARE 
TRANSFORMATION, OFFICE OF THE AIR FORCE SURGEON GENERAL, UNITED 
                        STATES AIR FORCE

    Colonel Lawrence. Thank you.
    Chairman Heck, Ranking Member Davis, and distinguished 
members of the committee, thank you for the opportunity to come 
before you today to discuss the future of Air Force Medical 
Service readiness.
    I am a residency-trained emergency medicine physician with 
over 23 years of Active Duty service in a variety of positions, 
such as academics, clinical leadership, 5 years as the Air 
Force Surgeon General Emergency Medicine Consultant, and in 
multiple command assignments, including command positions in 
the deployed environment.
    As an emergency physician, you learn early it takes more 
than your own individual skills to be successful. I like to 
look at medical readiness from a tiered approach. The basics 
are individual skills, which we assess through our Readiness 
Skills Verification Program. For an emergency physician, these 
involve many procedural skills common for resuscitation of 
patients, both medical and surgical, which ideally includes a 
daily practice environment that provides access to sick and 
critically ill patients.
    The next tier would be how we come together as teams, for 
which in emergency physician we have multiple deployable unit 
type codes that are found throughout the echelons of care. Just 
as any sports team of all-star athletes cannot be a winning 
team unless they practice together, the same analogy applies 
for our medical teams. On our deployable teams, we need to have 
skills around a common set of standards or guidelines which 
drive processes, where every member of the team knows their 
role as well as the role of others.
    We begin to build that capability or teamwork skills 
through processes in our day-to-day work in our MTFs. Many 
think we need to see the same type of patients--for example, 
trauma patients--to build those skills. That is not true. We 
build them every time we come together as a team to perform a 
procedure, respond to a complication or resuscitation. Even 
actions of coordination of care in handoff become critical 
skills.
    The best care can quickly be compromised by a lack of 
shared processes, poor communication and teamwork. Every day in 
our MTFs, we are constantly improving our processes, handoffs, 
and practicing the art of good communication and teamwork. 
Every patient engagement sustains the readiness of the medical 
force and an environment that promotes continuous learning and 
improvement.
    Our commitment to trusted care is based on a set of 
principles which promote high reliability and safety. These 
principles not only improve the care we deliver to our patients 
but also improve the processes and skills we bring to the 
deployed environment.
    Beyond our daily roles in our MTFs, we need the opportunity 
to challenge and assess our individual and team skills, which 
is provided through platforms like C-STARS and simulation. 
Through these training modalities, we can replicate some of the 
unique demands of the operational environment, reinforce the 
use of combat care clinical practice guidelines, and assess our 
performance as individuals and teams. This type of training is 
invaluable, and, while it takes us away from supporting the 24/
7 mission at our military treatment facilities we work in, it 
is the price of readiness.
    Finally, readiness is more than combat support. It includes 
global health engagement and the day-to-day work to maintain a 
medically ready force and ready medics. Every day, we support 
medical readiness in the care we deliver to our beneficiaries.
    I am grateful for your support and the opportunity to speak 
with you today and look forward to your questions.
    [The prepared statement of Colonel Lawrence can be found in 
the Appendix on page 78.]
    Dr. Heck. Thank you.
    Lieutenant Colonel Mabry.

   STATEMENT OF LTC ROBERT L. MABRY, M.D., USA, ROBERT WOOD 
 JOHNSON HEALTH POLICY FELLOW, U.S. HOUSE COMMITTEE ON ENERGY 
                          AND COMMERCE

    Colonel Mabry. Chairman Heck, Ranking Member Davis, 
distinguished members of the subcommittee, thank you for the 
opportunity to discuss battlefield medical readiness with you 
today.
    After nearly 15 years of war, the Military Health System 
has made tremendous advances. Today, if you are wounded in 
battle and arrive alive to a combat hospital, survival is 
virtually assured.
    Combat casualty care, however, does not begin at the 
hospital. It begins in the field at the point of injury and 
continues through the evacuation chain. Our research shows that 
up to one in four battlefield deaths are potentially 
survivable. However, the vast majority of these bleed to death 
before they even make it to a doctor. Care delivered on the 
battlefield outside of the hospital is the first and key link 
in the chain of survival and is the next frontier for making 
any significant advances in combat casualty care.
    I believe we face five challenges to improving battlefield 
survival.
    First and most importantly is ownership. Army Medicine 
trains and equips the medical force, but line commanders 
execute healthcare delivery on the battlefield. We must 
determine who is responsible for improving battlefield care 
delivery. The axiom, ``When everybody is responsible, no one is 
responsible,'' applies.
    Second, data and metrics. We can't improve what we don't 
measure. We continue to know very little about what happens to 
casualties before they arrive to the hospital.
    Third, expertise. We have very few clinical experts focused 
on care outside the hospital. Out of about 4,500 Army 
physicians, there are only 4 board-certified specialists in 
this field.
    Fourth, research and development. Our R&D efforts are 
focused on developing lifesaving drugs and devices, yet very 
little research is done on the delivery system or, in other 
words, how do you get the right care to the right patient at 
the right time.
    Finally, culture. Our organizational culture is centered on 
caring for military beneficiaries in our fixed facilities. This 
is our biggest mission, yet it is our wartime mission that 
makes us unique and justifies our cost to the Nation.
    I would like to highlight these challenges by briefly 
telling the story of the simple tourniquet. The most effective 
thing a soldier can do to save another soldier's life on the 
battlefield is to stop bleeding.
    The strap-and-buckle tourniquet was first issued during the 
Civil War, then again in World War I, World War II, Korea, and 
Vietnam. In 1993, I deployed to Mogadishu, Somalia, as a 
Special Forces medic in one of the most well-equipped, well-
trained units in the world with a strap-and-buckle tourniquet. 
We went to war in Iraq and Afghanistan with essentially the 
same tourniquet that was issued during the Civil War.
    There is only one problem with the strap-and-buckle 
tourniquet: It doesn't work.
    In 1945, Dr. Luther Wolff, an incredibly experienced Army 
surgeon who cared for thousands of patients fighting across 
Europe, wrote an article in the Army Medical Department Journal 
describing how the strap-and-buckle tourniquet was ineffective 
and should be removed from the inventory. That was in 1945.
    Yet it remained in the inventory. Death rates from 
extremity hemorrhage in Korea and Vietnam ranged from 7 to 9 
percent. That means that 7,000 sons, fathers, husbands, 
brothers lost their lives because they did not have an 
effective tourniquet. In the initial phase of Iraq and 
Afghanistan, our death rates from extremity hemorrhage were the 
same as the Korean war.
    In 2003, a Special Forces medic invented the combat 
applications tourniquet. This new tourniquet worked well and 
was widely adopted by U.S. forces, driving down deaths from 
extremity injury to virtually nothing.
    Meanwhile, the strap-and-buckle tourniquet, first issued 
during the Civil War, noted not to work during World War II, 
was finally removed from the DOD inventory in 2008.
    How did this happen? How did the most advanced military in 
the world miss this? More so, how do we prevent something like 
this from happening again? Ownership, data, expertise, 
research, culture.
    Thank you again for the opportunity to speak today. I look 
forward to your questions.
    [The prepared statement of Colonel Mabry can be found in 
the Appendix on page 83.]
    Dr. Heck. Thank you.
    Lieutenant Colonel D'Alleyrand.

STATEMENT OF LTC JEAN-CLAUDE G. D'ALLEYRAND, M.D., USA, CHIEF, 
ORTHOPAEDIC TRAUMATOLOGY SERVICE, WALTER REED NATIONAL MILITARY 
                         MEDICAL CENTER

    Colonel D'Alleyrand. Chairman Heck, Ranking Member Davis, 
and distinguished members of the subcommittee, thank you for 
the opportunity to speak today.
    During past conflicts, there have been delays in our 
ability to provide optimal care for our wounded, particularly 
when there have been many years since the previous conflict. 
These interwar years are typically associated with the decline 
in the funding and infrastructure of our trauma and 
rehabilitative systems as well as a lack of training for our 
trauma surgeons. Senior surgeons with experience in combat 
injuries may no longer be in the military by the time the next 
conflict arises, and those that remain have most likely been 
struggling to maintain their skills in the peacetime 
environment.
    In order to adequately care for wounded warriors, trauma 
surgeons need two different skill sets. They need to be able to 
treat conventional trauma, such as the injuries seen in the 
civilian sector, and they also need to be able to treat combat-
related trauma.
    Conventional trauma proficiency can be maintained with 
adequate exposure to civilian trauma by allowing surgeons and 
military hospitals to treat civilian patients and by 
facilitating the continuing medical education of trauma 
specialists. Combat-related trauma skills, however, can't be 
sustained during peacetime because injuries from explosions or 
machine guns are, thankfully, almost nonexistent in our 
society.
    Therefore, our focus should not be on the sustainment of 
these skills but, rather, on retention, specifically the 
retention of those providers who have the firsthand experience 
treating combat casualties, including not only the surgeons but 
also the wound care nurses, therapists, prosthetists, and the 
other specialists who form the chain between the point of 
injury and the final return to function.
    It has been only 3 years since the casualty flow slowed to 
a trickle, and, already, many, if not most, of the providers 
that I worked with during the peak of the war are gone. At this 
rate, there will be very few of us remaining when the next 
conflict comes around.
    I ask now that each of you think about what you would do if 
your spouse or child were gravely injured in a traffic 
accident. Without exception, each of you would do your research 
and you would take them to the best surgeons that you could 
find. Our combat-wounded can't choose; they go where we send 
them. So it is our responsibility to send them to the best 
trauma specialist that we can.
    But without aggressively maintaining their skills, who 
knows how many patients our specialists can optimally treat? 
Maybe 80 percent? Maybe? But 80 percent is a B-minus. And is a 
B-minus really the best that we can do for the young men and 
women that we send into harm's way to preserve our way of life? 
No. Our combat-wounded deserve A-plus trauma specialists, and 
we are morally obligated to provide them.
    To do so, we need to maximize our trauma specialists' 
experience and education and to retain those who have already 
been through the steep learning curve that we all face when we 
first learn to care for combat-wounded.
    Ladies and gentlemen, on behalf of my trauma colleagues and 
the wounded warriors who we serve, I thank you for your time 
and continued support.
    [The prepared statement of Colonel D'Alleyrand can be found 
in the Appendix on page 99.]
    Dr. Heck. I thank you all for your testimony, and I think 
it is great as a follow-on to the first panel.
    You know, we all understand that it is the small amount of 
care that we provide that is truly trauma care within the 
military, and, as was mentioned, 85 percent is disease and non-
battle injury, which we would expect that most physicians or 
healthcare providers would be able to take care of through 
their daily practice and be competent in.
    That is why I tend to focus more on that other 15 percent, 
where we potentially see the degradation of skills during the 
interwar years. And my greatest concern, as has been expressed 
by this panel, is how do we make sure that the lessons learned 
over the last 15 years of war don't get lost or we don't lose 
those providers who have gained that knowledge as we make sure 
we are ready for the hopefully-never-to-come next war.
    And part of that answer has been, well, we rotate folks out 
to different programs, whether it is C-STARS or down at Miami-
Dade or a university medical center. But I still have the 
concern that that is not adequately preparing the team in order 
to respond and be ready to perform.
    So, as those who, you know, have worked where the rubber 
really meets the road, how do you address this issue? How would 
you propose we ensure that the entire team, from the trauma 
surgeon to the anesthesiologist to the trauma nurse to the x-
ray tech to the phlebotomist, all know how to operate as a team 
in the stressful situation of the trauma activation, whether it 
is at a FST [forward surgical team] or a combat support 
hospital, soon to be a field hospital? How would you address 
that problem that I am fearful we will see over the next 
decade?
    Colonel Lawrence. I think it comes back to do we maintain 
robust medical ecosystems in our large military treatment 
facilities. And with that, what I am trying to say is we must 
maintain hospitals that have a diverse patient population that 
is sick, that is complex.
    And I hear you, Chairman Heck, that I agree, we need to see 
trauma, but, you know, if I put a chest tube in for a trauma 
patient or I put a chest tube in for a congestive heart failure 
patient, my team gets the same experience, and that procedure 
is a procedure.
    And so, in order to maintain some of the lessons learned 
and have the best, we need to maintain GME [graduate medical 
education] hospitals. And sometimes there has been challenges. 
Well, that costs too. If we ever consider removing GME, I 
believe that will be the death knell to our robust hospitals 
maintaining those lessons learned, bringing up the next 
generation of researchers and training our own.
    I saw the opportunity when I was the Chief of Emergency 
Medicine down at Wilford Hall. The research we did was in 
collaboration with NIH [National Institutes of Health] and 
others, and we taught that to our residents, and we were able 
to teach them the lessons learned. But not only did the 
residents get it, all the staff would get it.
    And so I encourage that we look at those platforms and we 
looked at USUHS, our Uniformed Services University, and how do 
we strengthen with our academic partners in the outside as 
well.
    Dr. Heck. You know, Colonel Mabry, you alluded to the 
issues of care from the point of injury to the receiving 
facility. And so, while it may be easier to address some of the 
training needs within a fixed facility because a team is a team 
regardless of the procedure or how the procedure is being 
performed, how would you address the concerns? Because, you 
know, having the 68 Whiskey [combat medic] respond on post to 
some medical emergency isn't the same as responding to a 
battlefield casualty.
    Colonel Mabry. Sir, thank you for the question.
    So what you are getting at, Dr. Heck, is one of the 
quintessential challenges of military medicine, which is how do 
you train providers to deal with horrifically injured combat 
casualties when you don't see horrifically injured combat 
casualties on a day-to-day basis.
    So some of that is going to be simulation. Some of that is 
going to be taking care of sick patients with other conditions 
like Colonel Lawrence has described. But you have to have that 
exposure.
    And so one of the challenges with our medics is, under the 
current regimen, the first time they are going to see a 
seriously injured casualty is when they are on the battlefield. 
And it may be dark, they may be being shot at, and it may be 
their best friend.
    So I think we have to figure out ways to expose our medics 
to critically ill patients before that time. One of the bright 
spots is the Critical Care Flight Paramedic Program, which we 
have instituted. That requires medics to gain a civilian 
paramedic credential and hands-on critical care training in the 
hospital to be critical care paramedics like you would see in a 
traditional air ambulance system in the United States. By 
virtue of that training, they are required to do hands-on 
patient care and they are required to see sick patients in the 
hospital.
    So it is going to be some mix of simulation, some mix of, 
if you have a civilian credential, you, like some of the 
doctors do, can moonlight as an EMT [emergency medical 
technician]. But just seeing casualties every day and seeing 
patients every day and doing that thinking out in the field 
with another medic on the ambulance is very valuable even when 
you deal with sick trauma patients.
    Dr. Heck. And then, Colonel D'Alleyrand, as an orthopedist, 
do you believe that being able to take an orthopedic surgeon 
out of a fixed facility, let's say has not previously deployed, 
and then all of a sudden throwing them into an FST, how are we 
going to assure that that orthopedist is prepared to function 
as an FST member in a situation similar to the pre-hospital 
care provider that they never may have been put into 
previously?
    Colonel D'Alleyrand. Well, I think that is a very difficult 
question to answer. The majority of, let's put it this way: 
There are roughly 130 to 150 orthopods within the Army. Maybe 
six of us, seven of us are trauma specialists. So the person 
that you are going to deploy is a total joint surgeon, a sport 
surgeon, and there really is no effective way to transfer an 
entire body of knowledge, a career's worth of knowledge to that 
person.
    I think that if you retain senior personnel and if these 
people go through their residency programs with senior trauma 
surgeons who have been there and done that and have had those 
experiences, then you can bring them up along the way with 
these life lessons so it becomes part of what they know about 
orthopedists. Because the military orthopedist programs have 
somewhat of a deployment-related slant in some part of its DNA 
[deoxyribonucleic acid] regardless of how isolated you are from 
the war.
    So I think that, you know, that is a key cornerstone. And I 
think on a systems level, which Dr. Mabry can speak at length 
about, about having a Joint Trauma System that establishes good 
clinical practice guidelines and establishes dogma, that they 
can at least have an algorithm that may be not the perfect 
substitute for being a traumatologist at Walter Reed but at 
least can give them a path towards doing the right thing at the 
right time.
    Dr. Heck. Okay. Thank you.
    My time has more than expired. Mrs. Davis.
    Mrs. Davis. Thank you, Mr. Chairman.
    Again, thank you all very much for being here.
    I am going to ask you to do something that is kind of 
difficult. Could you respond to what you heard earlier in 
terms, particularly, of exactly what you just said, Colonel, 
the systems-level organization that is going to give us what is 
required? You know, kind of getting at that question, what is 
it going to take in order to try and be sure that the skill 
sets that are going all the way through the nurse specialties, 
all of the people that are involved in trauma, so that we 
really maximize what I understand. We actually have 80 trauma 
surgeons that are certified in this way across the services? I 
am not sure if that is correct.
    But you heard, and I tried to ask this question, I am not 
sure if I asked it so artfully, but should we be doing more in 
terms of that more central organization so that we actually do 
get the best use of the, you know, exceptionally well-qualified 
people that we have, knowing that they are not getting the 
exposure either in the future?
    Colonel D'Alleyrand. I think it is beneficial to look at it 
at three different levels, the tactical, at the strategic 
level.
    So myself, as a surgeon, there are certain skill sets that 
I need to have to handle the very broad range of injuries that 
come back from theater, be it from the upper limits of 
survivability in terms of multi-extremity amputee, blast wound, 
open pelvic injuries, to things that more resemble what you 
would take off the highway. And those sort of ebb and flow over 
the years.
    So there are things that can be done for me as an 
individual, be it working at a civilian trauma center, and 
making it easier for me to continue my own education and 
ongoing training, which, currently, I mostly subsidize myself. 
That only makes me as one member of the team proficient. 
Everyone around me, the x-ray techs, scrub techs, ICU 
[intensive care unit] nurses, et cetera, basically go from a 
civilian setting straight into a war setting with no training, 
if I am the only one who is trained.
    So I think making key hospitals that might be expected to 
see war casualties, making them trauma centers during peacetime 
or throughout even in and out of conflict, that makes the whole 
team more efficiently trained.
    But then, finally, on the system level, which, again, is 
Dr. Mabry's wheelhouse, I think that is going to be an 
overriding entity that can at least help establish the 
evidence-based guidelines to help guide our practice.
    Mrs. Davis. Uh-huh.
    Dr. Mabry.
    Colonel Mabry. So one of the biggest challenges we have, 
ma'am, is that, unlike the warfighter, when we are home, we are 
providing health care in our fixed facilities day-to-day. The 
warfighter is going to the range and training. And so we are 
doing our civilian beneficiary mission, for the most part, 
whereas the infantry soldier and the special forces soldier are 
out training, preparing for the next war.
    So we have to figure out how to kind of thread the needle 
where we can maintain our healthcare benefit but, at the same 
time, go to war ready and prepared for the next set of 
conflicts or next war without a learning period, a learning 
curve, which is traditionally what happens.
    Mrs. Davis. Uh-huh. But the systems piece, though, in terms 
of who organizes, who has the oversight to be sure that things 
are moving properly. You mention, I thought that was, you can't 
approve what you don't measure.
    Colonel Mabry. Yes, ma'am.
    Mrs. Davis. So to the extent that there is--whether it is 
the DHA [Defense Health Agency]--where does that system 
organization lie? Is it there today? Is it being utilized the 
way that it should? Is it covering, you know, all aspects of 
research and development, or at least aware of it?
    Colonel Mabry. Yeah, so there is a challenge where there is 
some lack of interconnectivity. So, in other words, during the 
start of this war, a lot of talented surgeons recognized we 
needed a trauma system. We went to war initially in 2001 
without a trauma system. And so it took about 4 years to build 
the trauma system. That became the Joint Trauma System, the 
Joint Theater Trauma System, where we had senior trauma 
surgeons deployed in conference and advising and coaching, 
developing clinical practice guidelines, which, really, you can 
trace the improvement to our battlefield casualty outcomes to 
two things; that is one of them.
    And so the Joint Trauma System is currently the repository 
for the system, but that is only in one command. It is only in 
CENTCOM's [Central Command's] AOR [area of responsibility]. And 
it is uncertain whether we will continue to have the Joint 
Trauma System as the conflict winds down.
    Mrs. Davis. Uh-huh.
    Yes, Colonel Lawrence.
    Colonel Lawrence. I would like to expand on what Dr. 
Mabry----
    Mrs. Davis. I am sorry, my time is up. Should we go ahead--
--
    Dr. Heck. There are just a few of us here, so we can go 
further.
    Mrs. Davis. Okay.
    Colonel Lawrence. Dr. Mabry is correct, that is a very 
important part. And the Joint Theater Trauma System, it 
encompasses more than the surgeons. And how are we going to 
preserve that? There are discussions, I am told, at the senior 
level with our MHS senior leaders, and they are discussing 
that.
    I think, to get back, what you are hearing is there needs 
to be a value placed on readiness. And my concern and I have 
been in for almost 24 years of Active Duty is, as the conflicts 
decline, we are going back to measuring health care competitive 
with the civilian sector, and we are going to lose that 
quotient of readiness.
    And in the healthcare system today, we are shifting away, 
too, from looking at productivity to looking at value and 
value-based care. And I believe that is what we are getting at. 
It is, how do we preserve outcomes not just on the battlefield 
but in our MTFs as well? And if we look at the value equation, 
which is health and care over cost, where do you put readiness? 
I would argue readiness needs to be up on the top with health 
and care.
    And if we design the system that is going to allow that 
because all of us have talked and we heard the panel earlier--
about the need for our people to spend time away. I mentioned 
that, that, you know, you will never get everything in our 
Military Health System, so we need a synergistic system that is 
going to allow us to spend some time at the C-STARS and SMART 
platforms. But where do you put that if you are going to 
measure our productivity on what we do in the MTFs?
    So, as we build that system that has sustained and endured 
as, hopefully, the need for conflict declines, we need to say, 
where is that value equation?
    Mrs. Davis. Yeah. Okay. Thank you.
    Dr. Heck. Dr. Wenstrup.
    Dr. Wenstrup. Thank you, Mr. Chairman.
    It is a pleasure to have you all here today.
    You know, a friend of mine is an Air Force trauma surgeon, 
a reservist. You may know Dr. Joe Hannigman. And we went to 
high school together. But he shares the thought, there was 
multiple deployments, and at first he used to say, ``I am going 
to try and get you everything here that you would get at 
home.'' Now he comes home and says, ``I am going to try to get 
you everything here at home that I would get one of our troops 
in theater,'' and that is how far we have come in the last 10 
to 15 years. And I don't think there has been any greater 
privilege for me, in my lifetime, as to be any part of that and 
to take care of our troops.
    One of the things that I read in my friend Dr. 
D'Alleyrand's testimony, what Hippocrates said, ``War is the 
only proper school for surgeons.'' And I think there is a lot 
to be said for that. It is how do we capture all this knowledge 
and maintain it and share it. And I think we all recognize the 
dilemma; it is where do we go from here.
    First, I would like to ask Colonel D'Alleyrand, I think you 
take the opportunity every chance you get when I have seen you 
at Walter Reed, with the residents in particular: this is what 
you do here, but this is not what you would do downrange. 
Because it is a different set of circumstances, right? You talk 
about fungal infections, you talk about open wounds, you don't 
put a rod in here, and this and that.
    So how much of an opportunity do you get to carry that over 
and try to make sure that it is sustained in a resident, a new 
doctor coming up?
    Colonel D'Alleyrand. We do have a it is called the Combat 
Extremity Surgery Course, and it is a joint course that we run 
with the Navy as well. And so that is taught a couple times a 
year, typically with upper-level residents or general orthopods 
who are looking at an upcoming deployment.
    It is difficult, though. It is a 2-day course, and we teach 
a lot of, sort of, doctrine and, sort of, hard-fought lessons, 
but, I mean, how good can you be at anything in 2 days if you 
have never really been exposed to it?
    So it is difficult to communicate that body of knowledge to 
anyone, even--you know, I trained at Shock Trauma in Baltimore. 
I thought I had seen, you know, the worst energy injuries that 
you could have, and it wasn't even remotely in the ballpark of 
what we are seeing at Walter Reed.
    So I don't think there is any way to truly prepare them, 
but I think having senior faculty who have had multiple 
deployments, who have had those hard-won life lessons that 
don't always work out well when you are operating in a tent in 
the middle of the night, having those guys around, especially 
during the interwar periods, to impart that knowledge is the 
best thing you can get to some sort of corporate memory.
    Dr. Wenstrup. And to that point that you have made, there 
are opportunities to take those that have left wearing the 
uniform to be part of the teaching process, those that have 
actually served in combat. I think maybe we need to take a look 
at that.
    I really would love all of you to weigh in, because we are 
talking about different ideas of military just providing trauma 
services, like at SAMMC [San Antonio Military Medical Center], 
and then also moonlighting. Is there a hybrid out there? I 
think we need some guidance in how can we help you here to 
fulfill that role.
    Colonel Mabry. Sir, I will take a stab at that.
    So I was at the Staff College doing a research paper, and I 
came across a book where they were addressing some of the same 
concerns following World War II. And they were talking about 
bonuses for physicians. And then there was a paragraph in there 
that talked about the way to keep physicians in the military is 
to give them meaningful work. And so, if you have the surgeons 
who are doing the kind of surgery they like to do on a high-
volume basis, what they find meaningful, then that is going to 
help with retention.
    With regard to training in civilian centers, I guess I 
would say, if you crash your car and you have to have your 
spleen removed, do you want a surgeon that is familiar, 
proficient, or expert in removal of the spleen?
    And so I think our challenge is how to have on the--toward 
the expert spectrum, you know, when we go to the next conflict. 
Because, usually, again, there is a learning curve for the 
first couple of years, and our challenge this time is to go to 
war next time without a learning curve.
    Dr. Wenstrup. Colonel.
    Colonel Lawrence. And I would say that learning curve is 
going to constantly be there. Because, as we have seen the 
advances that we have had in these last 15 years, I think that 
is what we are all talking about. How do we preserve that 
mindset and how do we preserve the system that allows us to 
continue to advance?
    And so, again, I will go back to the extreme importance, 
you have heard, of GME and not just graduate medical education 
but our nurse training programs, our technician training 
programs. We need to keep that. And that is where we can pass 
some of these lessons learned.
    But we need money to continue research. And we need to look 
at where can we partner with academic institutions and 
professional organizations to take these lessons learned and 
continue to grow. How do we sustain the Joint Theater Trauma 
System? I mean, if we tuck that away in a closet and pull it 
out, it is not going to be any good, all right? But if we 
continue--there is a partnership right now with the American 
College of Surgeons and the MHS. And they are talking about 
looking at similar partnership right now with the American 
College of Emergency Physicians.
    So, you know, when we start to bring in the professional 
organizations, we don't only help our military, we are going to 
translate those lessons learned into society and vice versa. We 
are going to keep that learning cycle going, and we are going 
to continue those partnerships.
    So those partnerships, though, cost money. Research costs 
money. And time away from our clinical practices to engage 
costs time.
    But that is what I find when I talk to physicians, 
particularly emergency physicians. Anything they can do which 
shows value of them and that opportunity to go out there and 
continue to partner with their colleagues and learn and make 
the entire system better, that is going to keep them in the 
suits.
    Dr. Wenstrup. Thank you.
    I yield back.
    Dr. Heck. Dr. D'Alleyrand, when was the last time that you 
deployed?
    Colonel D'Alleyrand. I just got back 2 months ago from a 
deployment to East Africa.
    Dr. Heck. Okay. So, you know, as one of the handful of, you 
know, orthopedic traumatologists within the Military Health 
System, now that you are at Walter Reed, which does not receive 
civilian trauma, how do you envision the ability to maintain, 
just on a personal basis, your trauma-level skills that you 
have developed over the past several deployments?
    Colonel D'Alleyrand. It is a problem that I have been 
struggling with for a number of years now. So I do a number of 
things in order to maintain what I consider to be an acceptable 
level of proficiency. I spend two of my weekends a month 
moonlighting at local trauma centers. I pay my own way to go to 
trauma courses. I teach at trauma courses. I basically do 
everything that I can just to try to maintain a certain level. 
Is it enough? I wish it were more, frankly. It is what it is.
    And, you know, certainly, in the deployed setting, those 
are always difficult questions because it is always a different 
experience. I was at a couple different places in Afghanistan, 
and it is very different if you are operating in a rocket-proof 
Role 3 facility compared to operating in flip-flops in a tent 
that has, you know, helicopter prop wash knocking the tent 
around. And Africa was very different entirely.
    So I definitely have used my trauma skill set specifically 
for blast wounds, et cetera, on deployment, but deployment also 
lots of times is where you have intense degradation of your 
skill set as well, long periods of just disuse and waiting for 
something to happen, too.
    Dr. Heck. So, in your opinion, if Walter Reed was 
integrated into the civilian EMS [emergency medical system] 
system as a receiving facility for civilian trauma, similar to 
Madigan or Brooke, would that help you and others like you be 
able to maintain your skills to a higher level?
    Colonel D'Alleyrand. I think without question. If you look 
at any job, any skill that you can think of, a musician, a 
professional athlete, et cetera, you would never consider being 
excellent in that field by dabbling in that field. You know, 
the weekend athlete is, by definition, a weekend athlete.
    So, as I said earlier, and it is obviously common sense, if 
I were to work full time at a civilian trauma center and be 
given the opportunity to do sabbaticals and rotate at other 
facilities where there are regional experts in certain 
techniques, that would make me, you know, ideally suited for my 
profession, but I would still only be one piece in the big 
machine. And by opening the doors to key facilities, Walter 
Reed being one of them, as difficult an undertaking as that may 
be, that at least gets the entire hospital ready for some 
measure of trauma.
    It is not going to necessarily be ready for blast wound, 
open pelvis, fungus-infested--the stuff we were seeing when 
Helmand province was really going off in the winter of 2011, 
2010 to 2011. But a facility that is used to seeing high-energy 
constant flow of trauma is going to be the best-suited that we 
could have for that situation.
    Dr. Heck. I appreciate that.
    And I just want to go back to something that both Colonel 
Mabry and then Colonel Lawrence alluded to, which is, you know, 
the cost of readiness. And I agree that we cannot compare the 
military healthcare system to the civilian healthcare system, 
because you have a unique role and mission to fulfill that the 
civilian sector does not have.
    And, Colonel Mabry, you said it. You know, when you are 
back or the medics are back from deployment, they are doing 
their job in beneficiary care and not necessarily getting the 
ability to go train like the 11 Bravo [infantryman] does, where 
their only job is really to train for the next war.
    And I appreciate what you said, Colonel Lawrence, about our 
move toward value-based care and where do we put readiness into 
that equation. You know, earlier this week, we had a briefing 
from DHA on how they are trying to look at, you know, 
increasing efficiencies and capability in the military 
healthcare system by increasing hours, increasing throughput.
    So the balance that we have to come up with is, how does 
that impact the ability for the military healthcare provider to 
be able to go do those other things that they need to do to be 
able to execute their military mission?
    And so I have always said and will continue to say that 
military healthcare readiness comes with a cost, and we have to 
be ready to assume that cost if we want to be prepared to go to 
war both with a ready medical force and a medically ready 
combat force.
    So I appreciate you folks being here.
    Mrs. Davis.
    Mrs. Davis. Thank you, Mr. Chairman.
    And just really quickly, and going back to you, Colonel 
Mabry, on the ownership issue that you mentioned, is that in 
conflict in any way with jointness?
    Colonel Mabry. No, ma'am. It is just unique to the 
battlefield. So, you know----
    Mrs. Davis. And we do jointness on the battlefield. I guess 
I am wondering as we move to nothing on the battlefield.
    Colonel Mabry. The point being is, outside of the hospital, 
outside of the combat support hospital, it is the operational 
commander who owns that real estate. It is the operational 
commander who owns the medics, the battalion medical officers, 
the critical care flight paramedics, the flight nurses. They 
work for the combat commander. But yet we defer medical 
expertise to the medical departments. But they don't have 
ownership of those assets.
    And so there is a friction point there, in that we are 
responsible for developing the doctrine and the training but 
the line commander is responsible for the execution. So who 
owns battlefield medicine is kind of one of our quintessential 
challenges. And so who is then able to organize the data, the 
training, the research to feed back into the system to improve 
care?
    And, during this war, it has taken a lot of very strong 
personalities over a decade to get to those systems in place--
--
    Mrs. Davis. But you want the institution to be there to do 
that.
    Colonel Mabry. So how does the institution do that is going 
to be a big challenge.
    Mrs. Davis. What do you think?
    Colonel Mabry. I think we need to have a senior person in 
charge of it. So, in the Army Medical Department, we have a 
brigadier general that is in charge of veterinary medicine, the 
Veterinary Corps. I think combat casualty care would equally 
benefit from senior leadership. Whether that is a line officer 
or a medical officer, I think that would have to be worked out.
    Mrs. Davis. Uh-huh.
    Is there any disagreement with that?
    Colonel Lawrence, do you think that is--what would you say?
    Colonel Lawrence. I would say one of the things that we 
need to realize is it is not either/or. And sometimes we look 
at in-garrison health care, what we deliver in our MTFs, and 
our training and currency that we need there, to what do we 
need in a deployed environment; and, oh, that is our medical 
readiness training, and that is over here. And we need to say, 
how is it all one part of the system?
    Mrs. Davis. Right.
    Colonel Lawrence. And I think, you know, there are 
different--I can't speak to the Army. I can speak to the Air 
Force. We respond to the line, you know. And when I was a 
hospital commander, I worked for a wing commander, a line 
commander, but they did understand the importance of our 
training.
    And so getting back to how do we take and have that system, 
which is I think what you are saying. We need to stop looking 
at readiness is a price over here we pay and health care is 
over here, but how are they merged together, and how do we look 
at that delivery benefit to have it so that there is a training 
piece in there that you do in your day-to-day but there is also 
a training piece that you are not going to get there, and how 
do you explain that to the mission commander.
    Mrs. Davis. Uh-huh.
    Colonel, did you just want to add anything to that?
    Colonel D'Alleyrand. I have nothing substantial to add.
    Mrs. Davis. Okay.
    Colonel D'Alleyrand. I think there is definitely precedent 
for----
    Mrs. Davis. Thank you. I feel like we have asked the same 
question many different ways, but we really feel a 
responsibility to help and get this right.
    Colonel Mabry. Ma'am, in the pre-hospital setting, I can 
point to one Army unit that has done this exceptionally well. 
That is the 75th Ranger Regiment. When General McChrystal was 
the Ranger regimental commander, he added battlefield medicine 
or tactical combat casualty care as one of his big four command 
priorities.
    And, since then, the Ranger regimental commander has owned 
that casualty response system, and they have detailed 
documentation on what happens to every Ranger casualty. They 
are very well-trained. Their line leaders, their squad leaders, 
platoon sergeants, first sergeants are trained in the tactical 
medical system. And they have been able to demonstrate a 
remarkable survival rate and exceptional care to all of their 
Ranger casualties because of the commander's ownership of the 
system.
    Mrs. Davis. All right. Great. Thank you very much. And I am 
sure that even when we look internationally to our partners, 
our allies, the kind of exchanges that go on, maybe that is 
another area to look at more in terms of getting that kind of 
experience.
    Thank you very much.
    Dr. Heck. Well, again, I want to thank you all, both the 
first and the second panel, for taking the time to spend with 
us this morning to provide us with your views on how we can 
help maintain military medical readiness. It is most 
instructive. And, certainly, the comments you have made will 
help inform this subcommittee's decisions as we move forward.
    Again, I appreciate everybody's participation.
    There being no further business, the subcommittee stands 
adjourned.
    [Whereupon, at 11:15 a.m., the subcommittee was adjourned.]

      
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                            A P P E N D I X

                           February 26, 2016

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              PREPARED STATEMENTS SUBMITTED FOR THE RECORD

                           February 26, 2016

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[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
      
  
    
    

      
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              WITNESS RESPONSES TO QUESTIONS ASKED DURING

                              THE HEARING

                           February 26, 2016

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            RESPONSES TO QUESTIONS SUBMITTED BY MR. O'ROURKE

    General Hogg. Together the Air Force and VA have met the 295-day 
goal for IDES Active Component members since October 2014 and since 
November 2015 for AF Reserve Component members. Active Component Airmen 
who completed the IDES in January 2016 averaged 248 days from referral 
for disability evaluation to receipt of a VA benefits decision or 
return to duty, which was within the 295-day standard. Reserve 
Component Airmen averaged 300 days, which was within the 305-day 
standard.   [See page 13.]
    Admiral Moulton. The Department of the Navy (DON) fully supports 
the goals behind the Integrated Disability Evaluation System (IDES) and 
remains fully engaged with the Department of Defense (DOD), the 
Department of Veterans Affairs (VA), and the other Military Departments 
to continue to improve and enhance this Service member-centric program 
to eliminate the post-separation ``benefit gap'' for wounded, ill, and 
injured Service members. For the Active Component (AC), the DON has 
approximately 4,383 Service members (roughly 56% Marines and 44% Navy) 
enrolled in IDES. This number represents less than 1% of the combined 
service end-strengths of the Navy and Marine Corps. For the Reserve 
Component (RC), the DON currently has approximately 114 active cases 
for the Navy and 120 for the Marine Corps enrolled in IDES.
    As of January 2016, AC Sailors spend on average 255 days and AC 
Marines spend on average 230 days in IDES, which includes the completed 
transition to the VA. As of January 2016, RC Sailors spend on average 
204 days and RC Marines spend on average 307 days in IDES. We continue 
to explore ways to reduce the time Service members spend in the AC 295-
day goal and RC 305-day goal IDES processes without compromising the 
integrity or accuracy of the system.   [See page 13.]
    General Tenhet. The Army has met the 295 day IDES processing 
standards for the past 12 months. The average processing time for total 
Army (all compos and appealed cases) is 256 days as of 20 Mar 16.   
[See page 13.]
                                 ______
                                 
              RESPONSE TO QUESTION SUBMITTED BY MR. ZINKE
    Admiral Moulton. Congressman Zinke, Navy Medicine has a concerted 
effort to address how we manage concussions, TBI, and blast energy 
effects on our service men and women. As you are all too aware, 
cumulative effects of blast exposures can play a critical role in the 
longevity of our readiness. We have previous and ongoing studies on 
blast research and noise hazards to prevent, track, and monitor the 
effect of impact forces. The Naval Medical Research Center has been 
working with Marine breachers such as Combat Engineers and Explosive 
Ordnance Disposal since 2008 to assess the impact of blast exposures 
during dynamic entry training. As a result of the initial observations, 
they are now assessing neurocognitive effects in the most experienced 
Marine breachers. The Naval Health Research Center, in collaboration 
with Walter Reed Army Institute of Research, has conducted a number of 
observational studies assessing overpressure exposures during training, 
using sensors mounted on combat helmets and body armor for the last 
three years. These studies have included communities such as Navy EOD, 
Army Special Forces, and civilian law enforcement tactical teams. 
Current efforts are examining blast exposure effects in human brain 
surrogates. Future studies will longitudinally examine overpressure 
exposures on medical outcomes within specific military occupations. The 
Naval Submarine Medical Research Laboratory has two ongoing studies to 
better understand noise hazards experienced during training evolutions 
as they relate to impulse exposure. They are researching why firing 
range exposures are causing quickly and dramatically causing hearing 
loss despite multiple combat tours without hearing loss. The second 
study addresses hearing protection device fit testing at accession 
where the initial training environment begins. Most recently, Navy 
Medicine established research collaborations with the University of 
Pittsburgh's world-renowned Sports Concussion program. Although there 
have been no implemented changes in protocol for negating the 
cumulative effects of blast exposures, Navy Medicine continues to 
collaborate with academic and civilian sector partners for research and 
defining best practices. We are grateful for your strong and unwavering 
support to our service members and our ability to deliver world-class 
care to the best warfighters in the world.   [See page 17.]

      
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              QUESTIONS SUBMITTED BY MEMBERS POST HEARING

                           February 26, 2016

=======================================================================

      

      

                  QUESTIONS SUBMITTED BY MR. O'ROURKE

    Mr. O'Rourke. In your opinion, what can be done to ensure that 
service members that are receiving mental healthcare from MTFs, under 
TRICARE, have the same access and quality of care when they transition 
to the VA healthcare system? Do you have any specific ideas on what can 
be done to improve the quality of care during and following this 
handoff?
    General Caravalho. I would like to defer this answer to the 
Services, as care at our MTFs is fully in their Title X 
responsibilities
    Unfortunately, once a Soldier has transitioned into the care of the 
VA or another healthcare system the Army loses the ability to effect 
the care that is received.
    Mr. O'Rourke. 1. Enclosure 8 to Department of Defense Manual 
1332.18 (Volume 2), Disability Evaluation System (DES) Manual: 
Integrated Disability Evaluation System (IDES), depicts the standard 
timeline for IDES. According to the enclosure, the overall IDES process 
should take 295 calendar days for Active Component service members and 
305 calendar days for Reserve Component service members. The enclosure 
also shows that, during the Physical Evaluation Board Phase, the 
jurisdiction for the process transitions from the Department of Defense 
to the Department of Veteran's Affairs (VA) and that this transition 
should occur between the 115 and 190 day mark, depending on whether or 
not the service members rebuts the results of the board. Where does 
each service component stand in terms of the amount of days, on 
average, that it takes to make the transition to the VA? Please include 
both cases when the service member rebuts the findings of the Physical 
Evaluation Board and when the service member does not.
    General Hogg. The Air Force Active component takes 248 days for the 
IDES process, which is within the 295 day standard. The Air Force 
Reserve component takes 300 days for the IDES process, which is within 
the 305 day standard. For the two medical related stages of the IDES 
process, referral and MEB stages, both the Active and Reserve 
Components have met standards since October 2012. The Air Force Surgeon 
General's office does not track cases separately.
    Mr. O'Rourke. In your opinion, what can be done to ensure that 
service members that are receiving mental healthcare from MTFs, under 
TRICARE, have the same access and quality of care when they transition 
to the VA healthcare system? Do you have any specific ideas on what can 
be done to improve the quality of care during and following this 
handoff?
    General Hogg. The ``inTransition'' program has been instrumental in 
enhancing the continuity and support of service members throughout 
their transition from military mental healthcare to the VA. We continue 
to make improvements to the process specifically with timely access and 
communication. The hallmarks of clinical quality of care are timeliness 
of treatment and appropriate follow up intervals which is largely 
dependent on access to care. Tracking adherence to appropriate access 
standards for behavioral health care is essential. Additionally, 
enhancing communication and integration between the military healthcare 
and VA systems is vital to ensuring both continuity and quality care. 
Utilizing a shared or, mutually accessible electronic health record and 
continued open dialogue between DOD and VA facilitates care 
integration. Continuing education of DOD and VA medical personnel on 
programs, policies and procedures within the other agency will improve 
the transition process and allow staff on both sides to address patient 
concerns and provide accurate and timely information to transitioning 
service members.
    Mr. O'Rourke. 1. Enclosure 8 to Department of Defense Manual 
1332.18 (Volume 2), Disability Evaluation System (DES) Manual: 
Integrated Disability Evaluation System (IDES), depicts the standard 
timeline for IDES. According to the enclosure, the overall IDES process 
should take 295 calendar days for Active Component service members and 
305 calendar days for Reserve Component service members. The enclosure 
also shows that, during the Physical Evaluation Board Phase, the 
jurisdiction for the process transitions from the Department of Defense 
to the Department of Veteran's Affairs (VA) and that this transition 
should occur between the 115 and 190 day mark, depending on whether or 
not the service members rebuts the results of the board. Where does 
each service component stand in terms of the amount of days, on 
average, that it takes to make the transition to the VA? Please include 
both cases when the service member rebuts the findings of the Physical 
Evaluation Board and when the service member does not.
    General Tenhet. The Army has met the 295 day IDES processing 
standards for the past 12 months. The average processing time for total 
Army (all compos and appealed cases) is 256 days as of 20 Mar 16. IDES 
consists of three distinct phases, each of which includes involvement 
from the Department of Veteran's Affairs (VA).
    Phase1 is the Medical Evaluation Board (MEB) which determines 
whether a Soldier meets medical retention standards. The Army has 100 
days to complete this phase, of which 55 days are allotted to the VA 
for claim development and to complete the disability examinations. The 
Soldier has an opportunity to request an impartial medical review and/
or to appeal the MEB findings before the case is sent to the Physical 
Evaluation Board (PEB) for adjudication. Phase2 is the PEB which 
determines if the Soldier's failing conditions make him unfit for 
continued Service. The first stage of the PEB is the informal PEB 
(IPEB) which determines if the Service member is fit for duty. If the 
IPEB determines that a Service member is unfit, the case is transferred 
to the VA to be rated by the VA Disability Rating Activity Site (DRAS). 
The Service member's first opportunity to appeal the PEB findings 
occurs after the ratings are initiated.
    Phase3 is the Transition Phase which allows time for the Soldier to 
be returned to duty, if found fit, or to process out of the Army, if 
found unfit.
    The average IDES processing time for those cases with no MEB or PEB 
appeal is 250 days. The average processing time is 289 days when 
Soldiers appeal only the MEB findings, 381 days when only the PEB is 
appeal, and 422 days when the MEB and PEB are appealed.
    Mr. O'Rourke. In your opinion, what can be done to ensure that 
service members that are receiving mental healthcare from MTFs, under 
TRICARE, have the same access and quality of care when they transition 
to the VA healthcare system? Do you have any specific ideas on what can 
be done to improve the quality of care during and following this 
handoff?
    General Tenhet. It is critical to ensure that Soldiers with 
behavioral health conditions are engaged in care immediately after 
leaving active duty. Early engagements with the VA or another 
healthcare system reduce the chance that a Soldier's behavioral health 
condition will be adversely impacted during transition.
    Soldiers with behavioral health conditions leaving the Army are 
automatically enrolled in the Department of Defense ``In Transition'' 
program, which links the Soldier and his/her Family with a care 
coordinator. The coordinator assists the Soldier by locating behavioral 
healthcare resources in the VA or another healthcare system.
    Unfortunately, once a Soldier has transitioned into the care of the 
VA or another healthcare system the Army loses the ability to effect 
the care that is received.
    Mr. O'Rourke. 1. Enclosure 8 to Department of Defense Manual 
1332.18 (Volume 2), Disability Evaluation System (DES) Manual: 
Integrated Disability Evaluation System (IDES), depicts the standard 
timeline for IDES. According to the enclosure, the overall IDES process 
should take 295 calendar days for Active Component service members and 
305 calendar days for Reserve Component service members. The enclosure 
also shows that, during the Physical Evaluation Board Phase, the 
jurisdiction for the process transitions from the Department of Defense 
to the Department of Veteran's Affairs (VA) and that this transition 
should occur between the 115 and 190 day mark, depending on whether or 
not the service members rebuts the results of the board. Where does 
each service component stand in terms of the amount of days, on 
average, that it takes to make the transition to the VA? Please include 
both cases when the service member rebuts the findings of the Physical 
Evaluation Board and when the service member does not.
    Admiral Moulton. The Department of the Navy (DON) fully supports 
the goals behind the Integrated Disability Evaluation Department (IDES) 
and remains fully engaged with the Department of Defense (DOD), the 
Department of Veterans Affairs (VA), and the other Military 
Departments, to continue to improve and enhance this Service member-
centric program to eliminate the post-separation ``benefit gap'' for 
wounded, ill, and injured Service members. For the Active Component 
(AC), the DON has approximately 4,383 Service members (roughly 56% 
Marines and 44% Navy) enrolled in IDES. This number represents less 
than 1% of the combined service end-strengths of the Navy and Marine 
Corps. For the Reserve Component (RC), the DON currently has 
approximately 114 active cases for the Navy and 120 for the Marine 
Corps enrolled in IDES.
    As of January 2016, AC Sailors spend on average 255 days and AC 
Marines spend on average 230 days in IDES, which includes the completed 
transition to the VA. As of January 2016, RC Sailors spend on average 
204 days and RC Marines spend on average 307 days in IDES. While we do 
not track cases separately when the Service member rebuts the findings 
of the Physical Evaluation Board and when the Service member does not; 
we do know approximately 10% of servicemembers request a formal 
Physical Evaluation Board which adds 58 days to the process. The 58 
days are included in the averages listed within this paragraph. While 
this is much faster than the AC 295-day goal or RC 305-day goal for RC 
Navy, it is still longer than we would like. We are working diligently 
on improving our RC Marines Corps numbers to align closer to the RC 
Navy results. We also continue to explore ways to reduce the time 
Service members spend in IDES without compromising the integrity or 
accuracy of the system.
    Mr. O'Rourke. In your opinion, what can be done to ensure that 
service members that are receiving mental healthcare from MTFs, under 
TRICARE, have the same access and quality of care when they transition 
to the VA healthcare system? Do you have any specific ideas on what can 
be done to improve the quality of care during and following this 
handoff?
    Admiral Moulton. Continued efforts to ensure interoperability and 
communication between DOD and VA healthcare systems, as well as 
TRICARE, are instrumental to ensuring same access and quality of care 
for service members when they transition to the VA healthcare system. 
Specific efforts which will continue to support the quality of care 
during and following this handoff include:
      Automatic enrollment in the DOD's InTransition program 
for all service members seen for a mental health concern during the 12 
months preceding their separation from military service. InTransition 
ensures connection with the gaining healthcare provider to introduce 
the service member and facilitate appointments; follow up with gaining 
providers to ensure continuum of care; and provide the patient with 
support and resource location should members encounter a crisis 
situation.
      DOD and VA electronic health records that are 
interoperable and facilitate communication between DOD and VA 
providers.
      Quick access (5 7 days) to the VA health system for 
military personnel leaving active duty.
      Assignment of a DOD/VA Lead Coordinator (LC) to any 
patient with mental health concerns, not just those with diagnosed 
mental health conditions. Currently, the LC serves as the primary point 
of contact for the service member and their family or caregiver during 
the transition between DOD and VA. The LC ensures that when a patient 
with complex care needs a transfer, that a ``warm hand-off'' to another 
LC and Care Management Team (CMT) on the receiving end of the transfer 
is accomplished.
      NDAA 2016, Section 715 requires that DOD and VA establish 
a joint uniform formulary that at a minimum includes medications 
related to control of pain, sleep disorders, and psychiatric 
conditions, including PTSD. While those efforts are underway to 
establish a Continuity of Care Drug List, the Report to Congress will 
be submitted no later than July 2016. Further, VA issued a directive in 
January 2015 that establishes policy to continue mental health 
medications initiated by DOD authorized providers for recently 
discharged service members.
```