• Military Menu                       

• Introduction
• Systems
• Facilities
• Agencies
• Industry
• Operations
• Countries
• Hot Documents
• News
• Reports
• Policy
• Budget
• Congress
• Links

• WMD
• Intelligence
• Homeland Security
• Space

TESTIMONY OF
LIEUTENANT GENERAL JAMES B. PEAKE
SURGEON GENERAL
UNITED STATES ARMY

BEFORE THE
SUBCOMMITTEE ON TOTAL FORCE
HOUSE ARMED SERVICES COMMITTEE
UNITED STATES HOUSE OF REPRESENTATIVES

REGARDING
DEFENSE HEALTH PROGRAMS

 March 18, 2004 

Mr. Chairman and Members of the Committee, I am Lieutenant General James B. Peake.  I thank you for this opportunity to appear again before your committee.  This will likely be the last time I appear before your committee as the Army Surgeon General, and I wish to express my gratitude for your unwavering support for our military and especially for our medical personnel.

Our Nation is at War, and there is nothing that brings the missions of military medicine into focus like war.  Healthy and medically protected Soldiers; a trained and equipped Medical Force that deploys with the Soldiers, providing state-of-the-art medical care; and managing the health of all Soldiers and their families back home while keeping the covenant with our retirees - this is the mission of the United States Army Medical Department (AMEDD).  We are keeping our promise to all of our beneficiaries by providing quality and timely healthcare.

Healthy and Medically Protected Soldiers

This is a part of ongoing health maintenance informed by research in military relevant areas and about which few outside the military have much interest.  From the development of vaccines for diseases seldom seen in the United States to formulating an insect repellent that can serve as a sunscreen and camouflage paint all at the same time, to working with the Food and Drug Administration to establish workable protocols for new drugs in remote locations, we meet our obligations to medically protect soldiers.  It requires an integrated approach to educate soldiers about their health and about the things they can do to protect themselves day to day and in whatever region of the world they may find themselves deployed. 

Pre- and Post-Deployment Health

We place a high priority on maintaining the health of Soldiers before, during, and after deployment.  Before Soldiers deploy we closely monitor their Individual Medical Readiness (IMR).  That means up-to-date immunizations, periodic health assessments, screening tests and medical equipment (ear plugs, eyeglasses, etc.)  We are working on uniform metrics to inform commanders on the state of medical readiness of their troops.

For the first time in military history, there is a systematic process of capturing this information. All of this data is part of the pre-deployment health assessment, which provides baseline information on the Soldier's health status before deploying.  Upon redeployment all Soldiers are required to fill out a post-deployment health assessment form.  We are working on ways to improve the collection of this data, to include using hand-held devices that can electronically download the information into the central record-keeping repository.  Once the information is captured electronically, the TRICARE online web portal can be used by the Soldier's medical provider to access the record.  Department of Veterans Affairs can also access the information from the individual's medical record, which is available to the VA upon the Soldier's separation from the military.

Despite these advances in management and use of our databases, we in the Army recognized the need for improvement.  First and foremost, we realized the limitations of paper forms for pre- and post-deployment health assessment.  Completing, copying and shipping paper forms from a worldwide deployed and busy Army was a process that was difficult to comply with, and almost impossible to oversee.  In September 2002, we launched an initiative to improve our assessment process by automating the collection, distribution, and archiving of the data.  The first automated assessment form on the internet was activated on April 1, 2003.  A hand-held computer variant of the enhanced (four-page) post-deployment program was deployed to the Central Command Area of Operations (CENTCOM AOR) and to Europe beginning in August 2003.  From June 1, 2003 through February 27, 2004, we have received 127,696 automated health assessment forms, which comprise about one-third of all forms received during that period.  Automated pre-deployment health screening was accomplished for the entire Stryker Brigade Task Force before it deployed in November 2003, and is approaching 100 percent for the 39^th and 81^st enhanced Separate Brigades.  In Kuwait, all post-deployment health assessments are automated; in Iraq, about half of all screening is performed using the automated form.

In November 2003, the Army initiated a formal deployment health quality assurance program. This program includes audits of the deployment health assessment program on Army installations.  Audits have been conducted at six Army installations (Forts McCoy, Drum, Lewis, Hood, Stewart, and Bragg).  These audits reveal that compliance with the Army pre- and post-deployment health assessment program is generally higher than indicated by comparison with Army personnel databases, and is likely to rise further with automation support and standardization and centralization of Soldier readiness processing on installations and across the Army.

Data from health assessments before and after major deployments, and upon mobilization and demobilization are part of the digital longitudinal health record we are maintaining in the Defense Medical Surveillance System (DMSS).  The DMSS contains over 250 million records on 7.4 million service members who have served on active duty since January 1990.  These records include data on hospital admissions, outpatient visits, immunizations, and military deployments and assignments.  These data are also linked with the DoD Serum Repository, which contains more than 27 million specimens from active-duty service members.  This system provides an unmatched capability to study patterns of illness and injury in the active-duty population. 

Environmental Health Surveillance for those  Deployed

When Soldiers deploy, we identify potential environmental hazards by deploying survey teams early.  The U.S. Army Center for Health Promotion and Preventive Medicine (CHPPM) provides teams to assess and document the hazards, and provide recommendations for their control or mitigation.  CHPPM, in collaboration with the Armed Forces Medical Intelligence Center (AFMIC) and other elements of the Defense intelligence community, has improved the intelligence preparation of the battlefield so that commanders are informed about potential environmental health risks before they occupy a site that could cause their Soldiers to become ill.  Deployable preventive medicine units from CHPPM are currently assessing the occupational and environmental health (OEH) risks to our forces in Bosnia, Kosovo, Kuwait, Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF).  One of the key components of this capability is to reach back to the sustaining base and use special medical augmentation teams (SMART) to leverage world-class expertise to support the Warfighter.  SMART teams were called forward into theater to respond to an evolving concern in central Iraq last April.   Most importantly, all of this information is archived and retrievable so we can answer, not only the question of the day, but questions that might arise in the future. An infantry regiment was operating within a few kilometers of the Tuwaitha Nuclear Research Facility.  Concerns were raised about possible radiation and chemical exposures to U.S. service members and local civilians due to looting.  A SMART Preventive Medicine Team from CHPPM deployed into the area to assess the Tuwaitha facility, which included a site inspection and environmental sampling.  All of the field data, reports, and potential health risks were communicated to field commanders and Soldiers.  Due to weather conditions, short exposure time, conditions of exposure, and location of troops relative to the site, the resultant health risk was low based on U.S. peacetime standards.

Medical Transformation

As part of our mission to train, equip and deploy the Medical Force, we are in the middle of transforming our medical units into standardized, modular medical structures.  The process is called the Medical Reengineering Initiative (MRI), and is designed to support the Army Focus Areas of Modularity, Joint and Expeditionary Operations, Focused Logistics and the Soldier.  MRI is the application of scalable, modular, medical capability packages designed to rapidly deploy and provide essential care in theater and enhanced care during evacuation to definitive treatment facilities.  MRI provides medical units the capability to conduct split-based operations in support of highly mobile and dispersed Army or Joint forces. 

MRI initiatives have enabled the AMEDD to reduce the medical footprint while achieving increased capabilities.  We have employed this capability during combat operations in OIF, where we placed tailored medical forces to meet the needs on the battlefield.  We deployed Forward Surgical Teams (FST) as well as Combat Support Hospitals (CSH).  FSTs provided trauma surgery capability far forward where it is available to Soldiers within the first hour following injury.  These mobile teams can relocate quickly on a rapidly changing battlefield.  Our far-forward surgical capability is saving lives and using state-of-the-art combat casualty care techniques. Few casualties died after reaching an FST or a CHS. 

The benefits of training our Surgical personnel as teams in civilian medical facilities with high numbers of trauma cases have been seen on the battlefield.  At the Ryder Trauma Center in Miami, Florida, the training rotations start with a mass casualty exercise to assess the team's ability.  Then the military personnel are integrated with the Ryder Trauma Center's people, working side-by-side treating patients.  Finally the forward surgical team takes charge of the trauma center for 48 hours, making decisions and working as a team, with Ryder Trauma personnel available as needed. 

Our partnerships and collaboration with civilian counterparts is crucial in training our medical force.  We recently co-sponsored a meeting on reducing medical errors through simulation with the American College of Surgeons.  This is an ongoing initiative to explore ways to improve medical training for both military and civilian healthcare personnel.

We are progressing in transforming the combat medic to the new 91W Military Occupational Specialty (MOS).  These medics train for 16 weeks versus the previous 10 week course and gain National Registered EMT-Basic certification. The 91W combat medic training is conducted at the Army Medical Department Center and School.  Active duty medical specialists and clinical specialists who have not converted to the 91W MOS are required to complete the training in their units that include not only EMT certification, but pre-hospital trauma training and advanced airway and IV management.

Not only are we improving our training for personnel, but we are also improving our capability to transport patients on the battlefield.  In order to treat Soldiers on the battlefield we have to be where they are.  The 507^th Medical Company (Air Ambulance) and the 126^th Company (Air Ambulance) took our most advanced casualty evacuation helicopter, the HH-60L Black Hawk, to support operations in Southwest Asia and Afghanistan.  These aircraft include a digital cockpit, on-board oxygen generation system, external electric hoist, advanced communications, improved litter support system, medical suction and electrical power for medical equipment.  We currently have nine HH-60Ls and are working on upgrading the entire medical evacuation fleet.  On the ground, we have the medical evacuation vehicle variant (MEV) of the Stryker.  This vehicle is integrated into the fighting formation of the 3^rd Brigade, 2^nd Infantry Division that deployed to Iraq last November.  The new ground ambulance can carry four litter patients or six ambulatory patients while its crew of three medics provides basic medical care.  It can be delivered to the battlefield in a C-130 aircraft, has the speed and mobility to keep up with fighting forces and can communicate with the most advanced combat formations.

Improving our military equipment and personnel training, is a part of the overall Transformation process.  We also are investing in our technical base by putting valuable resources towards improving vaccines, blood safety products, bandages, tissue repair and a number of other products.  The United States Army Medical Research Institute of Infectious Diseases (USAMRIID) has recently achieved a number of significant scientific milestones, advancing over 17 medical products that are in various stages of development.  Three vaccine candidates, one for anthrax, one for botulinum neurotoxin, and another for Venezuelan equine encephalitis (VEE) virus, have recently been transitioned to advanced development.  USAMRIID is also exploring novel technologies with several industry partners that may result in the ability to deliver multiple vaccines simultaneously and that induce protection more rapidly than conventional vaccines.  These initiatives will reduce the requirement for the number of stockpiled vaccines and could lead to a simpler vaccination schedule and a reduced medical logistical burden on the battlefield or in a national emergency.  USAMRIID, in collaboration with the National Institutes of Allergy and Infectious Diseases (NIAID) and the U.S. Department of Agriculture (USDA), is working towards building a synergistic biodefense campus at Fort. Detrick, Maryland.  The goal is to leverage the knowledge and capabilities of these research institutions by co-locating them on a single campus to fight the Global War on Terrorism (GWOT).

Executive Agent Responsibilities

The Army Medical Department manages over 30 Department of Defense (DoD) Executive Agencies.  These agencies are unique, tri-service organizations that support the DoD by protecting and sustaining the health for all service members whether they are at home or deployed.  The Executive Agencies (EA) are designed to assist the service members in their military lifecycle from induction through deployment to post-deployment care in a myriad of functions ranging from research, surveillance, education, field operations and direct care.  The EAs work on a tri-service level to support all the services.  Through this unique relationship, the AMEDD has the responsibility to look across the services for opportunities to better serve all military members.

One such EA is the Military Entrance Processing Command-Medical (MEPCOM).  MEPCOM is responsible for the service members' first set of immunizations.  In Fiscal Year 2003 more than 400,000 service members passed through the MEPCOM for medical in processing.  EAs support service members in times of war or contingency operations from Investigational New Drugs for Force Health Protection (IND) to DoD Food and Nutrition research on metabolism and hydration. The work of EAs has led to advances in the Meals Ready to Eat (MRE) that Service Members currently receive, which can sustain them for longer durations.  A newly establish EA, the Vaccine Healthcare Center Network, supports members of all services with a hotline to readily answer all vaccine related questions, immediate response to reported adverse vaccine reactions, and pre-immunization screening for smallpox and anthrax immunizations.  EAs assist in other pre-deployment functions such as ensuring all service members have their DNA specimen on file in the DNA Repository.  The DNA specimens are maintained at the Office of the Armed Forces Medical Examiners Office (OAFME), a department under the Armed Forces Institute of Pathology Executive Agency.  DNA specimens are critical for the rapid identification of a service member in the event of an untimely death.  Whether it is in the positive identification of the Hussein brothers, the Space Shuttle Columbia explosion in 2003, or any death of a Soldier, Sailor, Marine, Airman or Coast Guardsman, the OAFME has been there to serve.

The DoD  Pharmacoeconomic Center tracks the formulary requirements for deployed troops to ensure that the prescription medications are on hand and available to the service members while deployed.  The Armed Services Blood Program Office (ASBPO) ensures adequate blood supply by location, type and quantity for the deployed forces.  ASBPO received GWOT funding to support the increased demand for blood products needed for injured service members.  The DoD Veterinary Services Activity (DoD VSA), an operationally critical EA, inspects 100 percent of the food that arrives in theater for deployed forces, ensuring it is safe to consume.  DoD VSA maintains the health of the military working dogs that assist the military police in operations.  The Joint Readiness Clinical Advisory Board incorporates the joint standards from all services to medical equipment deployment packages for deploying forces.   All of these agencies are working towards managing and promoting the health of the military service member.

TRICARE

The AMEDD is committed to managing healthcare for all of its beneficiaries.  Recently the TRICARE Management Activity (TMA) awarded 3 contracts moving us forward into the next generation of TRICARE.  The new contracts will replace the current 7 regional contracts in the continental United States.  This consolidation will provide efficiencies and economies of scale for contractor performance, improve portability, achieve higher beneficiary satisfaction and help reduce administrative costs.  Within the fiscally constrained resources of the Defense Health Program, greater efficiencies are needed to reduce costs.  We are looking forward to leveraging partnerships with contractor support in providing healthcare not only to our active duty population, but also to the Reserve and National Guard forces. 

In an effort to protect direct care funds, the Congress passed legislation restricting the flow of funds from the direct care system to the private sector care system and vice versa.  With the new healthcare contracts using best business practices, there are incentives built into the system to use the direct care side as much as possible.  Restricting the movement of Defense Health Program funds will not allow the military treatment facilities the flexibility to manage their resources efficiently.  In the new management environment, military treatment facilities are incentivized to increase productivity by pulling more beneficiaries into their facilities.

As healthcare costs rise, the AMEDD has aggressively sought ways to improve business practices that positively impact the direct care system.  In 2001, with the help of Congressional support, the AMEDD received funds to start a business/entrepreneurial culture in the MTFs.   Treatment facilities submitted plans for improving specific sectors of their healthcare system that required an up front investment.  Their plans had to show that they would recoup that investment within three years through annual cost savings.  The rigorous analytical evaluation of over 216 submissions resulted in 54 initiatives that projected a net savings or cost avoidance to the military healthcare system.  This enterprise was effective in training our personnel to think in terms of business case analysis when making critical resource decisions.

Reserve Component Healthcare

An integral part to the successful mobilization of our Army Reserve (USAR) and National Guard (ARNG) troops is providing medical and dental services by using the Federal Strategic Health Alliance (FEDS_HEAL) Program.  The FEDS_HEAL program brings together resources of the DoD, Department of Health and Human Services and Veterans Health Administration to create a robust provider network.  FEDS_HEAL delivers readiness services to USAR, ARNG, and United States Air Force Reserve service members in all 50 states and territories. The FEDS_HEAL provider network performs medical examinations, dental examinations and treatment, immunizations, and other medical readiness services through Veterans Administration medical centers, Federal Occupational Health clinics, and a network of over 1,100 physicians and nearly 2,250 dentists.  In addition to exams and treatment, FEDS_HEAL provides a data management service and inputs patient care data into the Army's Medical Protection System (MEDPROS). The FEDS_HEAL Program Office provides 100 percent Quality Assurance Reviews prior to MEDPROS reporting.  In Calendar Year 2003, Reserve and Guard forces received 42,624 dental exams, 44,730 dental treatments, 29,971 physical exams, 54,108 immunizations, and 2,427 vision exams.

In addition to enhanced TRICARE benefits the Department offered to activated Reserve Component members and their families during FY 2003, the National Defense Authorization Act of FY 2004 included even more new benefits.  Because the new reserve health program is temporary, it offers us the ability to assess the impact of these benefits after the trial period.  We will review the effects of these programs on reservists and their families as they transition to and from active duty and look at the overall effect on retention and readiness.  We have concerns that health care benefits will be enhanced permanently before a full assessment of the impact can be completed, as well as concerns over the
potential cost of new entitlements for reservists who have not been activated.
Consideration must also be given to the impact on the active duty force if
similar health care benefits are offered to reservists who are not activated.
OMB, DoD, and CBO are working together to develop a model and a resulting
five-year cost estimate to price the proposal to expand TRICARE health benefits
for all reservists without regard to employment, medical coverage, or
mobilization status as proposed in the Reserve and Guard Recruitment and
Retention legislation.  Preliminary results indicate that this could range from
$6 billion to $14 billion over five years.   Final scoring of this proposal
should be completed by the end of March.

Behavioral Health Initiatives

Our experience in Desert Shield/Storm showed that there were  deployment-related impacts on Soldiers' behavioral/mental health associated with that conflict. Based on that experience, the Chief of Staff (CSA) of the Army directed the development of a comprehensive program to decrease post-deployment difficulties. The Deployment Cycle Support (DCS) initiative is the Army's multi-agency response to that directive.  DCS is an ongoing, longitudinal series of program elements that cover the entire deployment cycle, specifically designed to create a comprehensive safety net that integrates and maximally leverages existing soldier support programs.

The AMEDD plays a crucial role in several of the new program elements.  Soldiers participating in Operations Iraqi Freedom and Enduring Freedom (OIF/OEF) will benefit from the newest initiative in social work support.   Our plan is to contract 58 licensed clinical social workers (47 positions currently already filled) to provide services in primary care clinics, medical holding companies, and mobilization processing facilities.  There are 22 sites identified, not only in the Continental United States (CONUS) Army installations, but also locations in Europe and Korea.  Some of the social workers' duties and responsibilities will be to assess and resolve complex social, economic and psychosocial problems that may impact service members and their families' healthcare.  For example, social workers will assist in conducting psychosocial evaluations and provide therapeutic intervention to include crisis counseling to individuals and their families.  They will assist healthcare providers, military commanders and community agencies in the development and implementation of deployment-related health programs at the installation and/or clinic level.  Placing these services at the primary care clinic allows the social worker to function as an advocate for behavioral and mental health concerns without the stigma that may be associated with seeking this care in other venues. 

The military recognizes that Soldiers and family members perceive a stigma to accessing mental healthcare.  Based on numerous surveys, the Army developed and implemented an Employees Assistance Program (EAP) called the Army One Source (AOS).  This program is open to Active and Reserve component Soldiers, deployed civilians, family members worldwide.  Among the AOS benefits is the opportunity for 6 sessions of face-to-face counseling, at no cost to the service member and family.  This counseling is provided off-post and does not require command notification unless there is serious abuse.  Individual counseling records do not become a part of the service member's personnel or medical record.  As a result, AOS provides a source of early care for Soldiers, civilians, and family members, which can be directly accessed by them while problems are still manageable.

Behavioral Health is important across the spectrum of operations.  In July last year, in partnership with the G-1, we sent a Mental Health Advisory Team (MHAT) into Iraq and Kuwait to look at the mental health support in theater, the evacuation chain for mental health patients returned to CONUS, the suicide prevention program in theater and combat stress control doctrine.  The team was comprised of behavior health specialists, psychologists, a chaplain, a personnel specialist, researchers, psychiatrists, social workers, an occupational therapist and a psychiatric nurse.  This was an unprecedented event, never before has the mental health of our forces been assessed during combat.  The amount of support and cooperation provided to the team by the combatant commanders in theater demonstrated the concern they had in the mental health of their forces.  The team took a snapshot survey in August and September 2003 to see how Soldiers felt and to see if they were experiencing behavioral health problems with which they wanted assistance.  Overall 15 percent of Soldiers reported interest in receiving behavioral health assistance.  Soldiers reported multiple combat and deployment stressors, which contributed to behavioral health problems and low morale.  The survey indicated that the way combat stress teams were deployed could be improved upon, which started an initiative to re-write combat doctrine and training for our Combat Stress Control teams.  Historically the CSC teams expected patients to travel to their location for care, but with a non-linear, expeditionary battlefield it became apparent to the MHAT that CSC teams need to go to the patient or to the units and not wait for them to come to a treatment area.  Many Soldiers would not seek care due to the stigma of mental health needs; they did not want to be perceived by their peers as weak.  The timing of the survey is critical to keep in perspective.  Soldiers completing this survey were first experiencing 130 degree heat, the length of their tour was unknown or kept changing, infrastructure for hot meals and showers had not been established yet.  There is no comparison study to show if the survey results are high, medium or low, but the Army leadership and the AMEDD will continue this kind of surveillance to find the best way to care for Soldiers. 

One of the most important elements of our doctrine was confirmed. That is, the closer the Army can provide mental health services to the Soldier, the more likely it is the Soldier will recover quickly and return to duty.  The team found that forward-deployed behavioral health units returned to duty 97 percent of the Soldiers they saw.  But, only 11 percent of Soldiers evacuated to Kuwait for treatment were returned to duty, and only 3.6 percent of those evacuated to Landstuhl Regional Medical Center returned to duty.  Overall the team advised senior Army Leaders that treating behavioral health issues far forward is better for the Soldier. 

The team also recommended that the Army Suicide Prevention Program developed for a garrison type setting could be adapted and used in combat.  Training leaders at the company and squad level to look for signs of stress and provide early on intervention will preserve the mental health of our Soldiers.  Training programs have been implemented on Suicide prevention and stress reduction for leaders, Soldiers, and mental health care providers for combat and garrison environments. 

Care of Seriously Injured

At the outset of GWOT, the AMEDD developed plans to manage potentially large numbers of military amputee patients that were expected as a result of military operations, first in Afghanistan and subsequently in Iraq.  Building on the military's previous combat experience and the latest advances in surgical treatment, rehabilitation and prosthetic technologies, a group of internationally known civilian, military, and Department of Veterans Affairs clinicians met to evaluate existing facilities, programs, policies, and procedures. The group identified and addressed some of our deficiencies within the existing healthcare delivery system and assisted in establishing the Military Amputee Patient Care Program (MAPCP).   The MAPCP mission is to rehabilitate amputee patients to the highest level of physical function and return them to active duty if possible.  The MAPCP, headquartered at Walter Reed Army Medical Center, provides a center of expertise for state-of-the-art treatment for complex blast injuries that involve loss of limb.  It is the focal point of a new system for coordinating long-term care for military amputee patients that will extend to regional medical centers throughout the Department of Defense and the Veterans Administration.  Improved surgical techniques on the battlefield, faster evacuation to definitive care, highly advanced prosthetic devices, and advances in physical medicine and rehabilitation have all contributed to a much higher level of achievement of today's amputees. 

Continuity of Care

The advancement in medical care would not be possible without our civilian workforce.  Government Service (GS) employees comprise about 50 percent of our workforce.  They provide the continuity base for our treatment facilities when uniform personnel deploy.  In the past we have had challenges in hiring certain medical specialties in the civilian personnel system.  Congress assisted us by giving us limited Direct Hire Authority (DHA) for certain crucial healthcare occupations.  We have had some success in leveraging the DHA to fill eleven healthcare occupations that are crucial to our mission accomplishment, most notably the critical nursing positions.  Between May 2002 and December 2003, the AMEDD filled 1,225 jobs using DHA, with an average fill time of 20 days.  The fill time for these occupations before the DHA was over 100 days.  This 80 percent decrease in the time it takes to make a firm job offer to a qualified candidate has been invaluable in our ability to hire critical health care workers.  DHA is an effective recruitment tool we cannot afford to lose.  The AMEDD is looking forward to the full implementation of the National Security Personnel System, but until that time, the DHA is an invaluable interim tool to hire civilian employees.

Another valuable tool in providing consistent healthcare is the implementation of the next generation of the Composite Health Care System, CHCS II, across the Military Healthcare System.  CHCS II is a longitudinal electronic medical record that captures patient care from the first medical visit to the last visit as a soldier, including all care provided from foxhole to medical center.

The first step in this complex effort is the deployment of outpatient care functionality found in CHCS II Block 1, which the Senior Military Medical Advisory Committee recently approved for a 30-month accelerated fielding beginning in January 2004.  Using spiral development processes that are closely tied to evolving medical requirements, additional CHCS II functionality blocks are under development and testing, and will collectively represent all patient care provided across the entire healthcare continuum.  MHS patient care data will be deposited into the Clinical Data Repository and because of a joint DoD/VA effort will be available for a two-way interface with the VA Health Data Repository in Fiscal Year 2005, thus establishing the seamless electronic record envisioned by all.

OIF Medical Holdover

During the recent mobilization and deployment of our forces for OIF, the AMEDD was faced with the challenge of caring for those Reserve Soldiers who were not medically fit for deployment.  The AMEDD seeks to return sick or injured Soldiers to duty whenever possible.  When return to duty is not possible, the AMEDD is committed to allowing each Soldier to attain optimum therapeutic benefit from treatment.  Once this is achieved, the AMEDD strives for compassionate and expeditious disposition of the Soldier.

A small percentage of Reserve Component Soldiers who mobilized in support of Operation Iraqi Freedom were not medically fit to deploy.  Personnel guidance prior to October 25, 2003 stated Soldiers who were not medically fit to deploy would remain on active duty until maximum therapeutic benefit had been accomplished. If the Soldier's condition was still not at the point where he or she could deploy, then a Medical Evaluation Board would ensue and the Soldier would be released from active duty.  By the end of October 2003 there were 4,452 Soldiers in the Medical Holdover (MHO) population and the numbers were growing.  Personnel guidance changed on October 25, 2003 and the Army now returns Soldiers to their units and their homes if they are found medically unfit during the first 25 days of mobilization.  The number of Soldiers who enter MHO during mobilization is now less than 1 percent.  In October 2003 the Army also instituted enhanced access standards for MHO Soldiers, realizing these Soldiers were not near their homes and family, were living in quarters that were intended for short-term housing, and that the process of providing maximum therapeutic benefit was taking too long.  The enhanced standards include 72 hours for specialty referrals, one week for magnetic resonance imaging and other diagnostic studies, two weeks for surgery, 30 days for the medical portions of the medical evaluation board processing, and one case manager for every 50 MHO Soldiers.  Currently the AMEDD is meeting or exceeding those standards more than 90 percent of the time.  Of the Soldiers in MHO on November 1, 2003, 1,582 or 35 percent remain on active duty.  The total number of MHO Soldiers is 4,135, which is what our modeling predicted given the number of Soldiers mobilizing for OIF2 and the number of Soldiers demobilizing from OIF1.  It is important to note the military is in the middle of the one of the largest troop movement operations since World War II.

Medical Reconstruction of Iraq

The breadth and depth of military healthcare does not stop with the services and care provided to our beneficiaries.  The AMEDD has been called upon to assist in the rebuilding of Iraq.  The Army Medical Department has played a key role in the re-establishment and reconstruction of the healthcare infrastructure within the country of Iraq. The AMEDD has provided vital expertise and experience to the Ministry of Health (MOH) and the Coalition Provisional Authority (CPA).  Several members of our AMEDD were selected to assist the appointed staff of the MOH in developing a strategic vision and direction for Iraq's healthcare system. 

Over 240 hospitals, 1,200 health clinics and a medical supply system within the country were affected by years of neglect and corruption.  Physicians and nurses from the AMEDD have been on the front lines assessing clinical needs and requirements throughout the nation.  They are working with their Iraqi counterparts, developing systems, assessing technology and changing the face of healthcare in Iraq.

Our health facility planners have been vital in the assessment of infrastructure, prioritization of power generation and reconstruction and refurbishment of hospitals and clinics throughout the country. They have teamed with Iraqi engineers, developed a thorough assessment of needs for each and every hospital within Iraq and begun the process of rebuilding healthcare infrastructure.

Our medical logisticians took a corrupt supply system and revamped existing contracts, distribution and tracking procedures and developed a system of checks and balances that enabled the MOH to assume full responsibility for the procurement, storage and distribution of pharmaceuticals and medical supplies throughout Iraq in November 2003.

Our operations officers have worked challenging issues surrounding reconstruction of a country still at war. They have planned and executed countless medical missions throughout the country. Traveling from Basra to Mosul, they recruited, trained, manned and equipped Iraq's "Facility Protective Services" responsible for providing security to hospitals throughout the country.   They developed a program that allowed Iraqis in need of medical care above and beyond the country's capabilities to receive charitable care outside of Iraq. In a country that had no communication capability, they proved a vital link between the military and MOH civilian staff that provided tremendous insight into the challenges being faced throughout the country.

Our Soldiers have not done this without cost. Of the 15 AMEDD personnel deployed in support of the Ministry of Health since June 2003, four of them have been wounded.  However, their efforts have not been in vain. The Ministry of Health will be one of, if not the first, Iraqi Ministries to be turned over completely to the Iraqi people.

Summary

In summary, the Army Medical Department recognizes its responsibility to the men and women who defend our nation, to their families who support them, and to the retirees who have contributed so much to our country.  We are committed to providing all of them exceptional healthcare.  Army medicine is more than an HMO.  Our system of integrated care includes teaching centers, research and development organizations, health clinics, field hospitals, and much more.  The direct care system is truly the medical force projection platform for our Army; the Army we support across the world and across the spectrum of conflict.  We do this quietly and on a daily basis all the while integrating active, guard and reserve units in support of the Chief of Staff's vision of THE Army.

I would like to thank my fellow Surgeons General.  Their support, teamwork, and camaraderie are much appreciated.  I would also like to thank the Committee for its continued commitment to our men and women in uniform, the civilian workforce, and our beneficiaries.