[House Hearing, 111 Congress]
[From the U.S. Government Printing Office]
[H.A.S.C. No. 111-149]
DEPARTMENT OF DEFENSE MEDICAL CENTERS OF EXCELLENCE
__________
HEARING
BEFORE THE
MILITARY PERSONNEL SUBCOMMITTEE
OF THE
COMMITTEE ON ARMED SERVICES
HOUSE OF REPRESENTATIVES
ONE HUNDRED ELEVENTH CONGRESS
SECOND SESSION
__________
HEARING HELD
APRIL 13, 2010
[GRAPHIC] [TIFF OMITTED] TONGRESS.#13
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57-401 WASHINGTON : 2010
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MILITARY PERSONNEL SUBCOMMITTEE
SUSAN A. DAVIS, California, Chairwoman
VIC SNYDER, Arkansas JOE WILSON, South Carolina
LORETTA SANCHEZ, California WALTER B. JONES, North Carolina
MADELEINE Z. BORDALLO, Guam JOHN KLINE, Minnesota
PATRICK J. MURPHY, Pennsylvania THOMAS J. ROONEY, Florida
HANK JOHNSON, Georgia MARY FALLIN, Oklahoma
CAROL SHEA-PORTER, New Hampshire JOHN C. FLEMING, Louisiana
DAVID LOEBSACK, Iowa
NIKI TSONGAS, Massachusetts
David Kildee, Professional Staff Member
Jeanette James, Professional Staff Member
James Weiss, Staff Assistant
C O N T E N T S
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CHRONOLOGICAL LIST OF HEARINGS
2010
Page
Hearing:
Tuesday, April 13, 2010, Department of Defense Medical Centers of
Excellence..................................................... 1
Appendix:
Tuesday, April 13, 2010.......................................... 19
----------
TUESDAY, APRIL 13, 2010
DEPARTMENT OF DEFENSE MEDICAL CENTERS OF EXCELLENCE
STATEMENTS PRESENTED BY MEMBERS OF CONGRESS
Davis, Hon. Susan A., a Representative from California,
Chairwoman, Military Personnel Subcommittee.................... 1
Wilson, Hon. Joe, a Representative from South Carolina, Ranking
Member, Military Personnel Subcommittee........................ 3
WITNESSES
Green, Lt. Gen. Charles Bruce, USAF, Surgeon General, U.S. Air
Force.......................................................... 6
Rice, Dr. Charles L., President, Uniformed Services University of
Health Sciences, Performing the Duties of the Assistant
Secretary of Defense for Health Affairs, U.S. Department of
Defense........................................................ 4
Robinson, Vice Adm. Adam M., USN, Surgeon General, U.S. Navy..... 5
Schoomaker, Lt. Gen. Eric B., USA, Surgeon General, U.S. Army.... 4
APPENDIX
Prepared Statements:
Davis, Hon. Susan A.......................................... 23
Green, Lt. Gen. Charles Bruce................................ 56
Rice, Dr. Charles L.......................................... 29
Robinson, Vice Adm. Adam M................................... 49
Schoomaker, Lt. Gen. Eric B.................................. 41
Wilson, Hon. Joe............................................. 26
Documents Submitted for the Record:
[There were no Documents submitted.]
Witness Responses to Questions Asked During the Hearing:
[There were no Questions submitted during the hearing.]
Questions Submitted by Members Post Hearing:
[There were no Questions submitted post hearing.]
DEPARTMENT OF DEFENSE MEDICAL CENTERS OF EXCELLENCE
----------
House of Representatives,
Committee on Armed Services,
Military Personnel Subcommittee,
Washington, DC, Tuesday, April 13, 2010.
The subcommittee met, pursuant to call, at 5:30 p.m., in
room 2118, Rayburn House Office Building, Hon. Susan A. Davis
(chairwoman of the subcommittee) presiding.
OPENING STATEMENT OF HON. SUSAN A. DAVIS, A REPRESENTATIVE FROM
CALIFORNIA, CHAIRWOMAN, MILITARY PERSONNEL SUBCOMMITTEE
Mrs. Davis. Good afternoon. I was going to say good
evening. Good late afternoon.
Today the Military Personnel Subcommittee meets to receive
testimony on the progress of Medical Defense Centers of
Excellence. Three years ago, as different types of casualties
than had been initially anticipated mounted, Congress realized
that the Department of Defense [DOD] had to do a better job
preventing, diagnosing, mitigating, treating, and
rehabilitating these injuries.
One of these injuries, traumatic brain injury, or TBI, was
somewhat new for the military and, in truth, for medicine in
general. Advances in both protective armor and battlefield
medicine were saving lives that would have been lost in
previous wars. The knowledge and expertise to deal with TBI was
not resident anywhere. So, as has been the case in previous
wars, the Department of Defense will need to be at the leading
edge of medical research.
Another injury, post-traumatic stress disorder, or PTSD,
was better known, but the clinical expertise to deal with it
was more resident in the Department of Veterans Affairs [VA].
After many years of relative peace followed by an intense
period of conflict, the medical research and development
functions of the Department of Defense found themselves
inundated with requirements. The military medical establishment
has been made great, heroic even, improvements to trauma care
during this conflict, but more remains to be done both for
initial battlefield treatment and long-term rehabilitation.
This is why these Medical Centers of Excellence that we are
going to be talking about today are so important, and why our
frustration is so pronounced with the excessive amount of time
it has taken to get these centers up and running.
The first appropriation for this purpose was made almost
three years ago. Several months after that the House and Senate
Armed Services Committees included a requirement to establish
centers of excellence in TBI, PTSD, and vision in the National
Defense Authorization Act of 2008. Today, only two of these are
in actual operation, combined by the Department as the Defense
Center of Excellence.
Little apparent progress has been made in establishing the
Vision Center of Excellence nor, as far as we can tell, with
either the Hearing Center of Excellence or the Traumatic
Extremity Injuries and Amputation Center of Excellence required
by the National Defense Authorization Act for 2009. So clearly
we are concerned about the Department's slow pace in developing
such an important function.
Excessive delays are not our only issue, however. The
center that has been established, the Defense Center of
Excellence, while having achieved some notable small-scale
successes, has not inspired great confidence or enthusiasm thus
far. The great hope that it would serve as an information
clearinghouse has not yet materialized. The desire that the
center become the preeminent catalogue of what research has
been done, what is being done, and what needs to be done has
not been realized. Part of this is no doubt due to the fact
that the Department's Center of Excellence, what we know as
DCoE, has had to create or, more accurately, recreate all of
the administrative infrastructure and processes required to
oversee medical research on such a monumental scale. However,
the center has also made some serious management missteps that
call into question its ability to properly administer such a
large and important function.
We look forward to hearing how the Department plans to
improve this organization going forward so it can realize the
goals set for it by Congress.
Today we will hear from the senior medical leadership from
the Department of Defense. Dr. Charles Rice is the President of
the Uniformed Services University of Health Sciences and is
currently performing the duties of the Assistant Secretary of
Defense for Health Affairs. In this role, Dr. Rice directly
oversees the Defense Center of Excellence, as well as the
establishment of the other centers of excellence.
We are also fortunate to have with us Surgeons General,
Lieutenant General Eric Schoomaker from the Army, Vice Admiral
Adam Robinson from the Navy, and Lieutenant General Bruce Green
from the Air Force. They will all describe how well the current
centers support the requirements of their services.
Welcome, gentlemen.
General Green, I know this is not the first time you have
appeared before our panel, but it is the first time since your
promotion to Surgeon General of the Air Force, so we welcome
you. And thank you to all of you for being here.
Throughout our conversation today, it should go without
saying that all of us, members of the legislative and executive
branches, are committed to providing the very best care
possible to our wounded warriors. It is not hyperbole to say
that our military health system has made previously impossible
feats routine. This is a testament to the commitment displayed
on a daily basis by everyone who is associated with the
military health system. We must do our part to make this trend
continue.
Once again, thank you for being here. We look forward to an
active discussion, and I will turn now to Mr. Wilson for any
remarks he would like to make.
[The prepared statement of Mrs. Davis can be found in the
Appendix on page 23.]
STATEMENT OF HON. JOE WILSON, A REPRESENTATIVE FROM SOUTH
CAROLINA, RANKING MEMBER, MILITARY PERSONNEL SUBCOMMITTEE
Mr. Wilson. Thank you, Chairwoman Davis, and thank you for
holding this hearing. I cannot overemphasize the importance of
the four Department of Defense medical centers of excellence
established by Congress to meet the needs of our returning
wounded and injured service members. The medical centers of
excellence were intended to be the overarching body for each of
the focus areas that coordinates, inspects, and oversees the
tremendous amount of good work being done across the nation to
help our troops returning with brain injuries, mental health
problems, vision and hearing injuries, and extremity injuries
and amputations.
As a veteran myself and father of four sons currently
serving in the military, I particularly have an understanding
of what you are doing and I am so grateful that my second son
is a graduate of the Uniformed Services University. I am very
grateful that he has served as a Navy doctor with the SEALs and
the Rangers in Iraq. General Green, I also have to point out I
have a nephew who just concluded six months service in the Air
Force in Iraq. So our family is joint service.
I continue to be amazed by the dedication and remarkable
accomplishments of the health care and scientific community
both in the public and private sectors that have led to the
innovation and advancement of battlefield medicine in post
trauma care and rehabilitation.
Because of the volume of work being done, it is important
to make sure that the efforts are focused and coordinated to
avoid duplication and ensure the best use of our resources. In
my mind, that is the role of the centers of excellence.
With that, I recognize some of the centers of excellence
have been in existence longer than others and thereby there
will be a difference in the level of achievement among the
centers. I am concerned it takes such an inordinate amount of
time to establish a center and to get it up and running once it
has been legislated.
I am anxious to hear from our witnesses today how well the
centers of excellence are operating and how effective they are
in getting the best care and treatment available to our wounded
and injured service members. They deserve no less.
Finally, I would like to welcome our witnesses. All of you
are so well thought of in the military and by the citizens of
our country. Thank you for participating in the hearing today.
I echo Chairwoman Davis' welcome in particular to General
Green, and I look forward to your testimony.
[The prepared statement of Mr. Wilson can be found in the
Appendix on page 26.]
Mrs. Davis. Thank you, Mr. Wilson.
We will start with you, Dr. Rice.
STATEMENT OF DR. CHARLES L. RICE, PRESIDENT, UNIFORMED SERVICES
UNIVERSITY OF HEALTH SCIENCES, PERFORMING THE DUTIES OF THE
ASSISTANT SECRETARY OF DEFENSE FOR HEALTH AFFAIRS, U.S.
DEPARTMENT OF DEFENSE
Dr. Rice. Madam Chair, distinguished members of the
subcommittee, good afternoon and thank you for the opportunity
to discuss with you today the Department's Centers of
Excellence. I have submitted a much more comprehensive summary
of the accomplishments of the centers as well as an outline of
the major milestones for the coming year. So I will confine my
remarks to what needs to be accomplished during this year.
Of our four Centers of Excellence in the military health
care system, the Center for Psychological Health and Traumatic
Brain Injury has been established for the longest period of
time and is the furthest along in an operational sense. The
Hearing, Vision, and Traumatic Extremity Injuries and
Amputation Centers were designated more recently and they are
catching up in their organizational development.
Since stepping into my current role six weeks ago, I have
communicated to my staff and to the services that we must
execute our responsibilities expeditiously in order to meet our
obligations. Specifically, the most critical item is the
approval of a concept of operations that will be coming to me
for final approval very shortly.
Governance issues are equally critical, and we will seek to
exercise a consistent governance model across all of the
centers. I plan to have our governance structure developed and
approved by the end of May.
This summer we will open the National Intrepid Center of
Excellence at Bethesda, a major milestone.
We are working closely with our colleagues at the
Department of Veterans Affairs to ensure that our approach is
integrated and represents the clinical best practices and is
informed by the most current research to serve our wounded
warriors and our veterans.
We have embarked on a course that will result in more
patient centers and higher quality care and service to our
patients and to their families. The Department is appreciative
of the support and the guidance that the committee has made in
the establishment of our Centers of Excellence.
Thank you again, Madam Chair and members of the committee,
for the opportunity to be with you today. I look forward to
your questions.
[The prepared statement of Dr. Rice can be found in the
Appendix on page 29.]
Mrs. Davis. Thank you very much. I appreciate your being
brief. We are trying to do these special hearings in an hour
and to be able to pinpoint the most essential issues that we
need to address.
General Schoomaker.
STATEMENT OF LT. GEN. ERIC B. SCHOOMAKER, USA, SURGEON GENERAL,
U.S. ARMY
General Schoomaker. Chairwoman Davis, Representative
Wilson, and distinguished members of the Personnel
Subcommittee, thank you for inviting us to discuss the five
Centers of Excellence directed by Congress in the 2008 and 2009
National Defense Authorization Acts. Like my colleagues, I have
submitted a much lengthier statement, but anticipating that
your questions will be more illuminating, I will keep my
comments very brief.
These Centers of Excellence offer great promise to our
warriors and patients, to the Department of Defense and to the
nation. I foresee a day when these centers are acknowledged as
worldwide leaders in their respective disciplines. However, we
are not there yet; and we are moving slowly in some areas, as
should be expected of any undertaking of this magnitude.
Despite the growing pains we experienced standing up these
centers, I am confident the Department is now moving in the
right direction to provide the centers with the governance and
the support to allow them to flourish.
Like the Congress, I remain concerned about unnecessary
duplication of programs and unnecessary competition among the
services and federal agencies that are conducting research and
providing care.
Perhaps the greatest contribution offered by these centers
will be their role as the conduit for a two-way dialogue
receiving external expertise from federal agencies and private
industry and academia, and communicating the Department's
internal perspective to those same leaders in government,
science, education and industry.
These centers serve as what I call the catcher's mitt, a
single point of contact for vetting new ideas, for
synchronizing competing interests, and for standardizing
evidence-based practices and clinical guidelines. Alignment of
these programs under a single overarching construct would be
ideal to reduce the number of oversight groups and
administrative overhead, while ensuring agile and responsive
translational research and medical programs.
The Department and the services are working together to
establish favorable conditions for these five centers to be
models of health care excellence. Ultimately, the centers will
achieve their original vision and be critical enablers to
improving readiness, health and quality of life for our service
members, our veterans, and our family members.
Thank you for holding this hearing and for your steadfast
support of Army medicine and the entire military health system.
Thank you, ma'am.
[The prepared statement of General Schoomaker can be found
in the Appendix on page 41.]
Mrs. Davis. Thank you.
Admiral Robinson.
STATEMENT OF VICE ADM. ADAM M. ROBINSON, USN, SURGEON GENERAL,
U.S. NAVY
Admiral Robinson. Chairwoman Davis, Mr. Wilson, and
distinguished members of the subcommittee, thank you for the
opportunity to provide my perspective on the Defense Centers of
Excellence. More importantly, thank you for your leadership on
this issue. Your vision and direction provided us a solid
foundation on which to build the Centers of Excellence and
further support our responsibility and privilege for the care
of our wounded warriors and their families.
As our wounded warriors return from combat and begin the
healing process, they deserve a seamless and comprehensive
approach to their recovery. We want them to mend in body, mind,
and spirit. The Defense Centers of Excellence for Psychological
Health and Traumatic Brain Injury were established to leverage
the collective efforts of the services by bringing together
treatment, research and education and support of this
psychological health and traumatic brain injury.
In addition, the DOD has been working to establish three
additional Centers of Excellence which Congress directed. These
include the Traumatic Extremity Injuries and Amputation, the
Center of Excellence for Vision and the Center of Excellence
for Hearing.
I have often referred to our obligation to our wounded
warriors and their families as a commitment measured in
decades, not years. To meet our obligations, we much build
supporting organizations for the long haul and continuously
adapt our practices to meet the emerging needs of our patients.
Military medicine leadership must determine how to best to
maximize the operational efficacy of the DCoE and help
facilitate their important synchronization efforts. The DCoE
must be organized and aligned to provide for the efficient
delivery of services to our clinicians, to our patients, and to
our families. Our goal must be to enable the DCoE to focus on
its core competencies and operate efficiently with the
necessary supporting command and control elements in place.
Associated with review of options for the DCoE realignment,
there is consensus among the ASD-HA [Office of the Assistant
Secretary of Defense for Health Affairs] leadership and the
Surgeons General, that the National Intrepid Center of
Excellence, the NICoE, currently a DCoE component center,
should be organized under the Commander National Naval Medical
Center [NNMC] and subsequently the Commander Walter Reed
National Military Center Bethesda. As a clinical entity, the
model of NICoE being organizationally aligned in NNMC is
consistent with the construct of the Center for the Intrepid
currently in place at Brooke Army Medical Center, BAMC, in San
Antonio.
I, along with my fellow Surgeons General, and the ASDHA
leadership are committed to ensuring that we will build on the
vision advanced by the Members of Congress and the hard work of
the dedicated professionals at all the Centers of Excellence,
medical treatment facilities, research centers, and our
partners in both the public and private sector.
I want to thank the committee for your support, for your
confidence and your leadership. It has been my pleasure to
testify before you today. I look forward to your questions.
[The prepared statement of Admiral Robinson can be found in
the Appendix on page 49.]
Mrs. Davis. Thank you.
General Green.
STATEMENT OF LT. GEN. CHARLES BRUCE GREEN, USAF, SURGEON
GENERAL, U.S. AIR FORCE
General Green. Chairwoman Davis, Congressman Wilson, and
distinguished members of the committee, thank you for the
opportunity to discuss the DOD Centers of Excellence, and
specifically the plans for the Air Force Medical Service to
establish the Hearing Center of Excellence. We believe these
centers support the military health service strategic goals and
our mandate for trusted care to those who serve.
The creation of a Hearing Center of Excellence is relevant
and necessary for military members and veterans. Hearing loss
is a major cost incurring disability for both DOD and VA. In
fact, tinnitus and hearing loss were the most prevalent
service-connected disabilities for veterans who began receiving
compensation in 2009. The Hearing Center of Excellence will be
a collaborative DOD and VA team focused on prevention,
diagnosis, mitigation, treatment, and rehabilitation of hearing
loss and auditory problems. It will bring new technology and
research to current hearing conservation programs, but will not
replace existing efforts.
The Hearing Center of Excellence executive hub will be in
San Antonio at Wilford Hall Medical Center, leveraging the
robust Air Force and Army staffing of ENT [ear, nose, throat]
and audiology experts, as well as established partnerships with
VA hospitals and the University of Texas San Antonio Medical
School. San Antonio is a rich research environment with many
military and civilian research entities to help with the
outreach.
A central aspect of our Hearing Center of Excellence will
be a hearing loss and auditory system injury registry that will
record injury, diagnose surgical and other inventions for
hearing loss and auditory system injuries. An electronic
bidirectional exchange of information with the VA will ensure
tracking of hearing outcomes for veterans entered into the
registry who receive treatment, whether at DOD facilities or
the VA.
The Air Force is committed and well prepared to fulfill
this important mission. Our long experience with hearing
programs will serve as a strong foundation for this center, and
we will build upon the many outstanding DOD and VA efforts
already in progress. Plans are well underway, and we look
forward to exploring new opportunities with our colleagues in
DOD, our sister services, the VA, and civilian academic
institutions.
We truly appreciate the committee's support, and thank you
for this opportunity to testify. We stand ready for your
questions.
[The prepared statement of General Green can be found in
the Appendix on page 56.]
Mrs. Davis. Thank you very much.
To all of you, I appreciate your being here and the work
you are doing in the centers.
Dr. Rice, if I can just turn to you first, in your
testimony you say that the centers will lead our efforts to
identify gaps in our scientific knowledge about wounds,
injuries, and diseases, as well as prioritizing and
coordinating research efforts to fill those gaps. I think that
is really what Congress was intending because we know that
there is great interest, and I certainly appreciate my
colleagues in wanting to do all that we can for the service
members and also for their families who serve as chief
caregivers in many of these areas.
And yet that is really what the goal was three years ago,
and I know you have only been in this position and it is a
temporary one, and we want to acknowledge that. I want to know
how you see our ability to actually realize those goals. What
have you done since you have had a chance to just begin this,
and I know it has been very, very short, how much longer will
it take before the Department actually starts achieving some of
those goals and really have the kind of strategic plan to
prioritize and do exactly what I think the Surgeons General are
saying, we don't want to duplicate a lot of efforts. What do
you see more specifically?
Some of this was in your address but you had very brief
remarks, so we want to give you an opportunity to talk about
that more.
Dr. Rice. Thank you.
I bring to this my perspective from having spent much of my
career in the civilian academic world and understanding how
efforts like this come together. They are not easy to do when
you reach across disciplines, and as I am sure Dr. Snyder will
attest, the bringing together different specialties inside the
house of medicine and then reaching across into other
disciplines, psychology, engineering, pharmacology, what have
you, becomes an increasing challenge.
In fact, if you take probably the prototype in academic
centers, the canary in the mine, is cancer centers. And the
National Institutes of Health recognized the complexity of this
problem by actually awarding planning grants for universities
that want to establish Cancer Centers of Excellence. These
grants go up to five years in length. So the understanding is
that bringing a group of disparate professionals together is a
complex undertaking.
That said, we all recognize a sense of urgency and feel
that sense of urgency.
I think another level of complexity for this particular
constellation of injuries is that there is no gold standard
diagnostic test for traumatic brain injury or post-traumatic
stress, unlike say a myocardial infarction where we have an
array of screening tests and then more confirmatory tests,
including an angiogram or a technician scan to define precisely
the anatomy and the physiology of the injury. In the case of
traumatic brain injury or post-traumatic stress, we don't have
anything quite like that.
So bringing all of these aspects together has been a
complex undertaking. I think we have had some growing pains,
and I think we are beginning to get our arms around it. I am
very encouraged by what I have seen.
Mrs. Davis. Dr. Rice, as you look at organizationally what
we have tried to do, and there is discussion about whether the
program should basically nest or rest in any one of the
services and how that is organized, are there some things, even
in this relatively short time you have looked at and you have
said, I wonder why did they set that up that way? What were
they thinking? Where are those areas?
Dr. Rice. I think General Schoomaker very accurately
pointed out that we have an infrastructure for the management
of research that all the services share. Much of it is based up
at the Medical Research and Materiel Command at Fort Detrick.
It is a very well developed and organized operation, and one of
the options under consideration for us is to put much of the
infrastructure there. The three Surgeons General are discussing
that. That is what I alluded to in my testimony. We expect a
recommendation to come from them very shortly that will help us
get this organizational infrastructure in the right place so
that we can execute swiftly.
Mrs. Davis. Is there a sense that perhaps that discussion
needed to be much earlier? Is this a little delayed in terms of
where we are, and I will certainly give all of the Surgeons
General a chance to address that, but has it taken the
knowledge of trying to do this time for everyone to catch up in
terms of trying to figure out where the best is
organizationally?
Dr. Rice. Certainly in retrospect you can make that
argument. Prospectively, alluding back to my experience in the
civilian academic world, when you are bringing together
professionals from, say, the college of nursing, the college of
medicine, the college of pharmacy and the school of social
work, the only place that this winds up is in the office of
provost, which is not really well set up to manage an
operational organization.
I think that is analogous to what we saw with the
development of the Defense Centers of Excellence. And as time
has gone by, I think the realization has come that keeping an
operational responsibility inside of what is primarily intended
to be a policy development office was not the best choice.
Mrs. Davis. Thank you. I want to follow up with one more
question. I guess my colleague had to leave already. I am sorry
he didn't have a chance to ask a question.
I know you are aware that the House Appropriations
Subcommittee on Defense was concerned about the fact that all
of the DCoE folks went from Washington to San Diego, and we are
always happy to have people in San Diego, for a conference, and
there was some concern that perhaps the entire department,
everybody involved, did not need to go to build the
relationships I happen to believe that are required when people
are working together, but there was a way to do this without
having it be so costly. Would you like to add to that in any
way because I know that they were concerned and they even asked
us to help answer that question better.
Dr. Rice. Well, I think we are certainly looking into
issues like that and putting management controls, better
management controls into place so we make sure that we don't
spend money unnecessarily. I can't speak to the decision making
that went into that particular conference at the time, but I
can assure you that we will make sure that the controls are in
place in the future.
Mrs. Davis. Thank you.
Mr. Rooney.
Mr. Rooney. Thank you, Madam Chair. Thank you to the panel.
I don't necessarily have any questions. I just want to thank
you personally for the work that we are trying to accomplish
here, I think together. Having worked on a few pieces of
legislation that specifically deal with post-traumatic stress
disorder and terminal brain injury, it is enlightening, and I
understand it can be as frustrating for you as it is for us.
But it is good news that we are able to sit here today and talk
about how we are going to get this done, and I know that is the
objective of everybody on the panel, as it is for this
committee.
With that being said, I just want to thank you for all of
the work you have put in and look forward to having a
continuous working relationship with all of you.
I yield back.
Mrs. Davis. Thank you. Dr. Snyder.
Dr. Snyder. Thank you, Madam Chair. I want to be sure I
understand the very basics. We have five Centers of Excellence
at least on paper, correct? Traumatic Brain Injury, Traumatic
Injury to Extremities; is that correct?
General Schoomaker. The Defense Center of Excellence for
Traumatic Brain Injury and Psychological Health are combined
into one center. So two of the centers are combined into one.
Dr. Snyder. They were authorized by separate
appropriations.
General Schoomaker. But the Department chose to put them as
a single center.
Dr. Snyder. Which makes sense. And then we have Extremities
Center?
General Schoomaker. Yes. Extremities and Amputation.
Dr. Snyder. So it was referred to as five, but two were
combined into one.
General Schoomaker. Yes.
Dr. Snyder. Regarding Dr. Rice's comments earlier, I think
these have all been set up or established or mandated to do
them by legislation and my question is: Did we make a mistake?
We are House Members. We are prepared to acknowledge that we
make mistakes sometimes. We didn't set up Centers of Excellence
for neurological problems or for orthopedic neck injuries or
Centers of Excellence for cancer or heart disease or lung
disease or toxicological injuries or from fires. We set up
these because we hear from constituents and we thought there
was a gap.
My question is a general one. Are we barking up the wrong
tree here? Perhaps we should not have mandated Centers of
Excellence, perhaps there should be other ways, maybe greater
funding of research, maybe oversight and coordination amongst
different health care institutions? I am almost asking your
personal opinion, did we make a mistake by requiring these
Centers of Excellence? Dr. Rice, do you want to start?
Dr. Rice. No, sir, I don't think so. I think what you did
was galvanize the Department's attention around a complex set
of injuries that we had not really dealt with very much in the
past, in part because this is a different kind of war with a
different kind of enemy and in part because our success rate
for resuscitation in the field is so much greater than it was
in previous engagements.
I do think that you bring up a very good point, and if I
may draw on my civilian academic experience, one of the things
that has served most institutions well is to require somewhere
around the five to seven-year mark a review to ask is this
structure really still the right one? Is it necessary for this
to continue as is? And if I might suggest, I would propose that
perhaps we have a discussion about whether undertaking
something like that might serve our patients well.
Dr. Snyder. At the five-year mark should this be continued
or completely discontinued, and recognize that there may be a
different way of getting at it or adjust it?
Dr. Rice. Or evolve into a different structure, yes.
General Schoomaker. Well, sir, I would have to agree with
Dr. Rice. I think that the Congress did not fundamentally make
an error in directing that these centers be established. But I
will concede that I don't think that we executed it flawlessly.
I think having said that, I believe there has been more
done than may be readily apparent to many folks. These are not
brick and mortar centers. We avoided deliberately the attempt
to put structure, physical structure, where it was not needed.
And I would point out that Congress preceded this in the NDAA
[National Defense Authorization Act] 2006 by mandating that the
Department look very proactively and exhaustively at all,
especially research dollars, that were directed to the same
language, prevention, mitigation, management, and treatment of
blast injury. That was without money attached to it, but it
forced us and the Department chose to take that legislative
mandate and to delegate that to the Army and then to Army
Medicine and then to the Medical Research and Materiel Command
[MRMC] where we did a gap and redundancy analysis and
identified what areas both in research and treatment we were
most lacking in.
I always saw that as an effort on the part of Congress and
the Department to create the highway for when moneys began to
flow to direct those efforts. When you all then created the
five centers, I saw that as highlighting areas within the blast
injury program we had identified as particularly vulnerable
areas and where we were getting most of our concerns for
patient care.
And it is at that point I think we began the internal
dialogue that you are hearing us talk about here in how do we
execute those centers. I do believe and I hope we have an
opportunity to talk about what the centers have achieved
because again, for example in the case of extremity injury and
amputation, I think we have done some terrific things, and that
your mandating in legislation that we have this center has
allowed us to align and cobble together efforts across all of
the three services and the Veterans Administration and the
private sector in I think a very positive and proactive way.
Admiral Robinson. First of all, I am not going to be the
only SG [Surgeon General] that says you made a mistake; you did
fine. And I mean that sincerely. I think what we have found is
in executing this we haven't been very facile in our attempts
to get the organizational structure to execute the plan. I
think that the MRMC, which is long established and has the
infrastructure, as already has been stated, was the right
thing. And once we got the DCoE, the psychological health, once
we got some of the DCoE studies there, we have made tremendous
progress. For example, hyperbaric oxygen therapy, does it work?
Is it helpful in traumatic brain injuries? We don't have the
answers to that, but we have a really good prospective
randomized trial set up and ready to go and it is being
executed now. It took us a long time to get there but the
reason is we didn't have the proper infrastructure, which MRMC
had and we were looking at the wrong places.
We thought, General Schoomaker and I thought of that a
couple of months back, but it took a while to get there.
Also, and it has been alluded to, the Centers of Excellence
have to leverage the Department of Veterans Affairs as well as
the academic community, and I underline the Department of
Veterans Affairs because, as I have said repeatedly through the
year, the systematic rehabilitative care issues, which are now
becoming all of our responsibilities, need to be funded through
the traditional organization that had the responsibility for
systematic rehabilitative care. So I am not suggesting that it
is now only residing with DVA [Department of Veterans Affairs],
it resides with us also. But we need to leverage that
information and a lot of the resources, both intellectual,
academic, and research and practical that DVA has.
So I think to add onto this, I think it is a focused area
that we now have and we need to be very careful as to how we
proceed. I would also say in a five-year period or some period
of time, looking back and being honest with do we need this
center now, may be the thing to do or how should we change this
center as opposed to just letting it go in perpetuity.
General Green. Dr. Snyder, I would say on first blush I
agree with you, that we have looked at certain centers and
didn't take on a lot of other disease processes and perhaps
things that would be equally valuable to gain research and put
dollars towards. But I have to admit as I looked into this, and
I will talk more to the hearing, but even with all of the other
centers, it was an extremely wise thing to identify gaps and
get us thinking. And so with the five centers that have been
stood up, looking at what has happened over in the AOR [area of
responsibility] and the type of injuries that have been coming
back and the rehabilitative needs of those folks and our
wounded warriors, in essence what Congress was able to do for
us was to get us to improve our communication. The influx of
dollars gave the ability for us to not only talk better with
our civilian counterparts, but also amongst ourselves to
leverage the different assets that we had.
I think it was wise for us not to set up brick and mortar
structures to do this. I think this is really about
establishing research networks. So the tricky part is kind of
establishing what are those governance and the controls, if you
will, on how we are going to do that. Should it all be
conferences or research, or should it all be telemedicine in
terms of how we communicate? And the answer is it is taking a
little bit of all of them.
So what you are seeing evolve over the last two years is
the understanding that we don't necessarily need to build new
infrastructure to do this, that we need to take advantage of
the structures that are in place. We all recognize the large
dollars that are up at MRMC in terms of how they manage the
research agenda for us in large part. The Navy labs are also
quite large, and the Air Force is a fairly small player in
terms of how this works, and yet we have good programs just
like the other services and the civilian sector does. And so
when you get us all talking together, and similar to how the
NIH [National Institutes of Health] doles out dollars for
research based on the most promising technologies and ways we
can move forward, you now start seeing the progress that we are
hoping for.
So what we have learned is that we don't want to set up
duplicative infrastructure, that we do want these registries to
be attached, and we do want to be able to share information
even between the centers, and the way to do that is to kind of
look at front shop, back shop where not everybody needs to have
public affairs guidance and ways to interface with Congress but
there needs to be that back shop activity that knows the
questions that are being asked and knows how to formulate
solution sets to move forward and to get things out into the
public domain so that we can let contracts and seek researchers
who have promising technologies. So I think that is where we
are right now. We are realizing that we need to leverage the
services' existing capabilities, place back shop functions in
places where they have those skills, and take the research
agenda and perhaps the executive oversight for a particular
research area, one of these COEs [Centers of Excellence], and
now leverage that expertise to bring a whole different group of
people together rather than just putting money into some of the
older projects that have been ongoing because there may be new
things that haven't been considered simply because of how they
were funded.
So I think that is the advantage of doing the COEs. Whether
we pick the right gaps or not, I can't answer for you, sir, but
it is creating communication and it is moving us forward.
Dr. Snyder. Thank you.
Mrs. Davis. Thank you. I think that your responses get
largely into the interchange that I would love to see amongst
the three of you as thinking about perhaps ways in which the
Congress set this up or the way some of the organization moves
forward, it has created some inhibitions in terms of what you
have actually wanted to see accomplished or where you felt some
of the frustrations in not being able to move forward in the
way that you thought. Are there some things that we could even
at this point, because not all of this is so developed that you
cannot go back and say okay, there is another way to do this,
are there some areas in which you would really like to have it
move in somewhat of a different direction perhaps?
You mentioned the NIH, the way the NIH doles out grants. I
don't have a clear picture. If there is a really great idea out
there, how does that get heard and how are those grants
realized at this point, either within, among the services and
through the DCoE as a whole?
General Schoomaker. I think this is really one of the real
benefits of the approach that we now are taking. I talked about
that in my opening statement, we have a single catcher's mitt
now.
One of the things that we need to acknowledge, ma'am, I
think all of us do, is that none of this has been static. Even
battlefield injury hasn't been static. The definition of what
constitutes concussive injury, the fact that sequential
concussive injury, undiagnosed, unmanaged, untreated, as it is
on the sports field or in the civilian sector, has contributed
to some of our problems. And the overlap between concussive
injury and post-traumatic stress and post-traumatic stress
disorder, those are only being defined as the war has been
fought and as we have tried to grapple with these.
What I think the centers do offer us is an opportunity to
in a sense funnel in all of those interests and emerging ideas,
practices, research avenues and, as I said before, to focus the
dialogue internally from the standpoint of the provider and the
communities of our services in such a way that we vet and
prioritize rack and stack and how we go forward and, once those
have been established, to clearly establish practice
guidelines, standard policies as they apply to how we manage
them. And I think we are starting to get some experience with
that.
The Defense Center of Excellence for Traumatic Brain Injury
and Psychological Health, for example, has helped us with
battlefield protocols, with how we identify and manage at the
point of injury concussive injury and such mundane matters as
what do you do with your soldiers, sailors, airmen and marines
who have had a concussive injury when it comes time to drive a
vehicle.
Those kinds of standard protocols and standard practice
guidelines are now being generated by the centers, and I
anticipate that is going to be more and more the work while the
services execute how the programs are done sort of in the
field.
Admiral Robinson. I would then say taking that broad view
and taking a much less broad view and one that is going into
the administration and the process, something that General
Green talked about in terms of the infrastructure, don't create
five registries, create one and make sure that we can overlap
those. Don't create an IT [information technology] system for
each new center, have one and make sure that we are
interconnected. Don't create practice guidelines in one center
and find out they are sort of contradictory with a center over
here. Put them together and make sure that we have this
integrated from an infrastructure and a process point of view
from the beginning as we start this.
I think part of the slowness in getting the centers up, I
will just comment, we were trying to figure out in some
respects how to execute this, and it became very clear to
General Schoomaker and myself a while back that there were--
MRMC was in place and there were processes and there was
infrastructure that was in place at the Navy Medical Command
and the Air Force has similar things, we didn't have to
recreate or create new things, but we needed to get these
centers into the right places so we could actually execute what
we had. That was making sure that we were in alignment and that
was Health Affairs and others giving us that policy guidance to
make sure that we were together, and then leveraging our
interagency partners and the academic community in addition.
So it has been slow, but it has been fruitful in that this
has been an ongoing and a very robust discussion within the
services.
Dr. Rice. One of the issues, one of the opportunities that
we have had the opportunity at the university in a parallel
effort was given to us by the 2008 appropriation which
established the Center for Neuro Regenerative Medicine, also
focused on traumatic brain injury and post-traumatic stress.
But from much more of a basic point of view, I alluded earlier
that there is no gold standard for the diagnosis of these
injuries, and this is an effort to help identify those.
That language in the appropriation specifically authorized
the Department of Defense to reach across Wisconsin Avenue to
collaborate with the National Institutes of Health and that has
proven to have a galvanic effect. The people at the National
Institutes of Health were eager to assist us in dealing with
these injuries, and that particular language made that easy to
do without the constraints of using part of a defense
appropriation at another agency. So that is one example of
something that the Congress might consider.
Mrs. Davis. General Green, did you want to add to that?
General Green. Briefly, I think it is important to
understand whenever you are trying to arrive at a common
vision, you have to basically explore where you are coming
from. And so the trick with the COEs are when you bring a lot
of different efforts together, especially when you go outside
of medicine, each person thinks that they have the answer. So
then you have to design the studies to try and find out what
the evidence truly says is correct.
You folks, probably much more than us, are approached by
lobbyists and special interest groups from all over who think
that they have a solution set for what we need. And what this
effort is about is trying to find out what is it we need and
how do we prove that this will actually do what it is said it
will do. That takes a lot of time actually to design some of
these things. Although I would love for us to have this
infrastructure set up a little more robustly so that we could
move forward, I am not too surprised that it has taken us some
time to reach a common vision and that vision I think is to use
our existing resources and now start defining these problems
more closely.
General Schoomaker. Ma'am, two more comments, quickly
because I think there are some features of how we are now
operating these three services in health affairs at the DOD
level that are very, very favorable. The first is the rapidity
with which we are making clinical improvements in battlefield
medicine, evacuation, and care back here in CONUS [continental
United States] based upon what my colleague, Admiral Robinson,
just talked about is the creation of a single database. The
Joint Theater Trauma Registry and its application through the
three services and the DOD to look comprehensively across all
services in all venues at how we manage traumatic care is
almost unprecedented. We have essentially established what a
large metropolitan community in the United States would have
but across three continents and 8,000 miles. In doing that, we
have created the framework for rapid movement of new knowledge
and standardization of practices that has resulted in some of
the unprecedented survival that you see today. And that has
penetrated all of the way into areas like amputee care, which
really quite frankly begins at the battlefield. Amputation
medicine and extremity injury medicine begins in Balad, it
begins in Bagram, at the first--in the corpsmen and the medic
forward. Penetrating head injury is another good example in
which the services have collaborated in advancing very rapidly
the science and the clinical practice of penetrating injury.
The second area that I think you need to recognize as a
Congress that we are doing very well within the services is
translational medicine: taking bench insights and basic science
insights that are historically the purview of the Academy and
groups like the NIH, and rapidly moving them across into
applications, either intellectual products as in the case of
battlefield medicine, or in the creation of new material
products. That really requires the focus that these centers can
provide for us. That is that we are not going to stop simply at
proliferating new ideas and new basic science insights, we are
going to rapidly move them across the chasm into the kind of
advanced development, clinical trials and material development
of new products that we need.
Mrs. Davis. Thank you. I appreciate that. I guess the one
question and sort of the bottom line on this is whether or not
the work that is being done and the data that is being
collected is being translated in the field to the extent that
unit commanders are respectful of that data. Is that a concern
that maybe I shouldn't be worried about? When we hear about the
number of traumas, or even the multiple deployments for that
matter that people have sustained, and we know that that
cumulative effect has obviously--is going to have an impact on
the service member. I don't know whether that is in your
purview, to have a sense of whether people are really listening
to that information you are working so hard to obtain. It
obviously can restrict the commander in the field in terms of
their ability to mobilize units to do the work that needs to be
done out there.
Admiral Robinson. Well, I will speak for the Marine Corps
in one example, and that is with blast injuries. With blast
injuries, there are a couple of examinations that can be given,
the ANAM [Automated Neurological Assessment Metric] and the
MACE [Mild Acute Concussive Evaluation]. The key here is that
with the Marine Corps in the field, the Marine Corps leadership
has recognized that there are a number of men and women who are
subjected to blast that aren't unconscious or don't have any
outward effects and we don't necessarily know that they are not
injured. So there is a database in theater in Afghanistan in
which they are looking at the number of personnel and the
number of people that have three blasts. And three blasts, it
doesn't mean that you come all of the way back to the states,
but you come out and get a complete neurological exam and
actually get looked at professionally to decide and determine
if you have been injured and that injury was just unseen.
I will leave that.
There is the attempt to have baseline studies for the ANAM
and other neurologic exams so that as we put people in theater
we will have a baseline so we know if it does change.
My point is there are attempts to look exactly at some of
the things that you are saying, real-time actually today based
upon what we have learned over the last two, three, four, five,
six years regarding how we are taking care of individuals.
Dr. Schoomaker. In the Army, ma'am, there is a growing and
profound recognition on the part of the field commanders of the
value of the joint medical system for the well-being of their
soldiers and by extension their families.
I have had field commanders tell me that it goes down to
the detail of support, say, of medical evacuation in theater in
Iraq and Afghanistan today. That combat aviation brigades, in
whom we now embed Army medical evacuation, have organized much
of their battlefield processes around support of the medical
evacuation.
What has been more difficult, because this is a learning
process for us, is the impact of psychological health and such
injuries as concussion. You know, I have said before we are in
unfamiliar terrain: an Army entering into its ninth year of war
in a cycle of deployment and redeploying soldiers that has
never been experienced in history, with a dwell time back at
home that is well below where we would like to see it. So I
think this is a very active process of learning.
But to answer your question directly, the respect that I
think our line commanders have for this all of the way up to
the senior leadership of the Army is very profound.
Mrs. Davis. Dr. Snyder.
Dr. Snyder. Just a follow-up question that maybe can be
answered just with a nod of the head or shaking of the head.
Going back to how Congress should provide oversight of this, I
came into the hearing today thinking we have got five different
centers and two of them combined and established at different
times. If I heard you correctly, would a more helpful way for
Congress to look at this and follow this along in the next
several years would be to see this as five different centers
but they are all attacking the same problem which is the blast
injury? There are clearly going to be things that each of these
centers look at that are apart from blast injuries, but we
should see each of these centers of attacking the same problem
of blast injury and we ought to look at all them together, not
as five separate entities. Is that a fair statement, Dr. Rice?
Dr. Rice. Yes, sir, I think it is. The fact is that
patients don't get just a single injury. They may very well
have mild TBI as well as hearing loss and loss of an extremity.
So I think it is very important that these centers work
together in a cohesive manner.
Dr. Snyder. Thank you.
General Schoomaker. Sir, I have rejected the notion that we
have a signature injury of this war. We have a signature weapon
of this war, and it is blast. That blast burns, it blinds, it
deafens, it takes off limbs, and it causes enormous extremity
injury. And I fully agree with what you said.
Mrs. Davis. Thank you. The bells are ringing, but just a
quick question.
General, you mentioned the Joint Center of Excellence for
Battlefield Health and Trauma Research that is under
construction in San Antonio. What is that supposed to do when
it is finished?
General Schoomaker. We didn't mention this, but it was
alluded to by General Green that in addition to the alignment
of clinical and research efforts through things like the blast
injury program and now these centers, is the alignment
physically and collocation through the base realignment and
closure of many of our assets. So Navy medicine and trauma is
being relocated with Army medicine and trauma along with the
Air Force.
That includes things like biodefense assets which are being
collocated in some laboratories in Fort Detrick and other
places. So we are going to see an alignment, as in the Joint
Battlefield Trauma Center down in San Antonio of the Army's
Institute of Surgical Research along with the Air Force and the
Navy's efforts in dental research and in other aspects of
trauma.
Mrs. Davis. And that doesn't represent any kind of
duplication then?
General Schoomaker. No, ma'am. I think that is the physical
brick and mortar of this.
Mrs. Davis. The ability to focus it together. Okay. Thank
you.
And Admiral Robinson, could you just provide us a little
bit more detail on the hyperbaric oxygen therapy clinical
trials that are being conducted right now? Is there something
particular that we should know about that?
Admiral Robinson. Nothing except we have now with the help
of Colonel Scott Miller, who is an infectious disease physician
at MRMC, he is also an Army physician, we have been able to
actually develop prospective randomized trials to look at
patients who have had had traumatic brain injuries, mild
traumatic brain injuries, and whether they would benefit from
having hyperbaric oxygen therapy. We have several centers where
this is now occurring--Pendleton, LeJeune, Fort Carson I think,
and also San Antonio. It is a tri-service event. We have now
included more patients in the studies that we have to date than
we have had in any of the literature that has been describing
it for the last many years. And I think we have--it is blinded
and it actually has a cohort that is a sham which means we are
going to see if this actually works or if this is just a
placebo effect.
So I think we have good science and a good study in place
that over the course of the next 24 to 36 months is going to
actually give us definitive information as to whether
hyperbaric oxygen works, at what tour it works, and also if it
is harmful because that is the other question that people have.
And from this, I think we can develop practical and successful
and reproducible clinical guidelines or not based upon science
and not anecdotal evidence.
Mrs. Davis. Thank you.
General Schoomaker. And, ma'am, for the record, lest our
critics point out that we are using an infectious disease
expert to run hyperbaric oxygen research, his expertise in
infectious disease gave him great skills in randomized
prospective trials and in FDA [Food and Drug Administration]
certification of trials. So we have leveraged that.
Mrs. Davis. Great. Thank you. As we look at the next
authorization, maybe for the record some things that you would
particularly like us to focus on, if we were to even have a
hearing even six or nine months from now, you know, just
thinking a little bit more about shortcomings that you think we
might be talking about at that time that are of concern to you
but also where we might place some additional resources to help
you further do your jobs and to make certain that this does all
the things that we really would like it to do for our service
members. If you could be thinking some about that and get us
that information, that would be helpful.
Anything you want to add right off the bat to that? Or we
will come back. All right. Thank you very much for all of you
for being here. Thank you for the work that you do.
General Schoomaker. Thank you.
[Whereupon, at 6:45 p.m., the subcommittee was adjourned.]
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A P P E N D I X
April 13, 2010
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