if it costs a little bit more, then they should be able to get it, if it fits them more appropriately and the concern that i have is yes, you got to look at saving costs but not at the cost of providing what our veterans need, and i do have a concern with contracting officers injecting more cost versus the clinician looking at the veterans' needs. >> yes, sir, i have a concern with that, too. i'm a clinician myself working in another area who provides rehab technologies to veterans, and it is critically important that what the clinician requests, and that of course is done in collaboration and in partnership with the veteran, these are choices and decisions about technologies that our veterans make with our clinicians, and we are absolutely, rehabilitation is not effective unless we are able

to provide the products and services that our veterans need, and our role in prosthetics and in rehabilitation is to assure that any -- that any contracts, the way we procure items enhances and -- not only enhances but provides high quality individualized care. we have done that successfully for a long time and we believe that we are able to do that as we move forward, and as mr. doyle has cited, we can certainly work within the framework of contracting requirements and the added authority that congress gave us many years ago for 8123 i think is the other piece of sole source procurement that we can do when we need to provide and

when we are providing highly individualized products and services. >> thank you. thank you, madam chair. >> thank you. i recognize the gentleman from texas, mr. reyes. >> thank you, madam chair. dr. beck, you mentioned the center of excellence. where is that located and how much of the work being done there is medical research as it pertains to prosthetics? >> the center of excellence that i spoke about is a joint va/dod center of excellence for extremity care. that actually will be a virtual center or is a virtual center. it will have locations in san antonio, texas and in washington, d.c. staff will be distributed across our system so that some of our staff will be in various centers, both va and dod centers around the country so that we

are collaborating, coordinating our efforts and i think you mentioned research earlier, sir, and one of the things that we talked about that we will be able to do by leveraging the capability with dod and va is that we will be able to do clinical trial type of evaluations at a number of different centers at the same time and that is one of the missions of this joint va/dod center of excellence is research coordination and studying and reporting on new technologies and developing better outcomes for care. >> and how will you ensure that at least the medical research that's going on is somehow tied back with the feedback being given back by the veterans?

their experiences with the different types of prosthetics, the challenges that they have and also, pain management. is that all part of that? >> it is. i will comment and i will ask dr. webster to comment. the participants in these studies will be our veterans and active duty service members so that they will be able to report to us firsthand what their experiences are, so that's how we will tie in the feedback. we also listen carefully to our veterans as we look at their outcomes of care and their successful use of prosthetic limbs and technologies to gain information about where the research needs are. i'm going to ask dr. webster to comment just for a minute on what we're doing with pain management.

>> thank you. i really appreciate the opportunity to be here today and provide this testimony. i would agree that it's extremely important that we get feedback and information from the veterans and service members with amputations on what is important in research. we can do research looking at various things but if it's not important to the veteran or service members, it's not going to do us much good. so it is critically important and that is done on a routine basis. captain pruden provided in his testimony earlier, kind of this expert panel that was put together previously that was looking at the amputation care as well as the prosthetic care, and that will continue to occur as we move forward with our research efforts. again, with the center of excellence, similar positions, more administrative headquarters will be in san antonio and the national capital region but many of the research staff are

actually located within our treatment facilities so they're located within walter reed, they're located within the center for the intrepid. they are completely integrated with the clinical staff and with the soldiers and veterans who are being treated in those facilities. >> and i'm curious how the process works. is there like a caseworker that will have a caseload of the particular veterans to make sure that feedback is coming to the caseworker and that feedback goes into the r & d component? how does the process work? >> i think it can occur both directly from the service member or veteran to the researchers. again, they're going to be co-located in the clinical areas so that feedback can come directly but there's also

opportunities for the feedback to the people who are doing the research to come from the case managers, to come from the other providers, whether it be a physical therapist or physician, any of those providers who are providing care for people with amputations can also provide that input into what's important for research and research initiatives. >> when will this process be implemented? is it already going on and if so, are there examples, an example of how that's working to make sure that the feedback of the veteran is taken into account? >> well, the center that we spoke about is standing up now. we expect it to be operational by the end of this year. i want to talk about i think a couple of research projects which are good examples of the work that we are doing and i think that one of them is what's

known as the darpa arm, which is probably the most advanced research activity that is going on, and that's the defense agency project for the development of a prosthetic, upper extremity prosthetic arm, and the way that is working and va's participation, that of course has been funded by the defense department. >> that's the one that medal of honor winner -- >> yes. >> -- has, right? the one -- >> you have that arm? we're going to find out that for you. we're not exactly sure. >> i think that's right, because i visited with him in my office and he actually took the hand off and put it back on, and i'm not 100% sure but i think either he or somebody with him referred

to it as the darpa arm. >> did they. okay. we'll check on that for you and find out. one of the things, this is a good example of veteran feedback, in the first study that was done to evaluate the arm, our veterans participated in that study and actually came to va facilities and participated in the study. we anticipate the second part of the study which will now be a take-home study where veterans will actually be able to take the arm home and use it in their everyday activities and so they will then be providing feedback and -- on the arm and how it works and what design -- what is required next. we do that frequently with technologies. i think the genium knee, the

iwalk foot are two examples of technologies that va and dod have worked on together and had our veterans and active duty service members participate in those evaluations. >> so each veteran, again, so i can understand, is a case unto him or herself and the responsibility will be with the equivalent of a va caseworker to make sure that all of these things take place? >> okay. the va has in place a type of case manager for amputees or amputation care, and that person is known as an amputation rehabilitation coordinator, and at all of our major amputation care sites that we talked about, our seven regional centers, our additional 15 network sites spread throughout the country,

we have in place this special kind of case manager who is case managing our amputees and providing those services and seeing that their needs are met. so it is a case management kind of function similar to the other types of case manager but it is specialized to address the needs of our amputees and many of those case managers are therapists, either physical therapists or occupational therapists. >> very good. thank you for your indulgence in the time limit. i think this may be an area we as a subcommittee can follow up on. >> i was actually going to ask if you all would like second round of questioning or we can certainly have follow-up. so with that, i think we will start a second round of questioning, if you have the time and you would indulge us for a few more minutes.

>> of course. >> in the panel with mr. pruden, captain pruden, i should say, he talked about this new system that you're going to go to, the electronic contract management system, and talked to us about the fact that it requires 300 steps to get the request in. can you comment on that? >> i'm going to ask mr. doyle, who's our expert in this area, to comment on that, that electronic contract management system. >> ecms, that -- it's new in that we're putting in place as part of this system the module which is the part where they're requiring people, in this case, prosthetics can put in their requirements and that's how it's transferred over to the contracting office. we have had the electronic contract management system actually in va for several years and that's what our -- our contract writing tool in effect.

and that's what we will use to write the contracts for the prosthetics that come across to us. as for the 300 steps, i will say that i know it's not probably the easiest system to use and it can be laborious. i would have to sit with the individual to say how they came up with the 300 steps. that's a new figure on me, however. >> i guess my concern is when we're talking about light bulbs or tissues or any sort of items that we need to purchase and contract out within the va, that's one thing. but we're talking about actually in the whole scheme of things, a very small quantity, a very specialized product and this morning in the testimony, i heard the word "intimate." it becomes part of the veteran's body. it's not like some isolated product that we use. it is specific to that person and to take that request or

contract and to dump it into a system like this, it seems to me that it just, the opportunity for a lack of timeliness, a lack of personalization, you name it. this thing is rife with the possibilities that the strveter and you heard their testimony, means i can't walk my daughter down the aisle, means i can't put my baby in the crib. those are intimately personal that we, the va or whatever the system, we may run the risk of not allowing our veterans to do that. every day that goes by without a wheelchair, without a prosthetic, shame on us. shame on this country because we ought to be, if we are ever in our game it ought to be when we are providing for our veterans and our military. so my concern with this is as soon as you take away the personal piece of this, we run the risk of the government

bureaucracy and making sure that veteran has exactly what they need as soon as they need it, and it is state of the art and so that they can get back to the life that they had as best they can, and that we maximize for them and that's my concern. our responsibility is to maximize the quality of life for these veterans and when i hear this, i just think to myself you all know what it's like to deal with the government. you all know how impersonal even in a hospital in a smaller setting, you know, with prescriptions or anything else, but this goes right directly to the veteran's quality of life, and my concern is that this was -- this was an arbitrary, i will be anxious to see the results of the pilot studies, not enough thought was given to this, not enough consultation was had with the veterans and the vsos, not enough work was done before this change was being made, and we are not talking about 25,000 or 30,000

prosthetics. we're talking about a much smaller group and i think the very least this government can do is make sure we're doing it right for these veterans. with that, i will yield to the ranking member if he has additional questions. >> thank you very much. just two additional questions. the first is does the va have an objective measure to evaluate the prosthetic outcome? >> may i? yes, sir, we do. our workload staffing, when we first entered into this project, we took the number of orders that were expected to come over to the acquisition and we had a workload factor model and we anticipated or assumed a number of people that would be required in procurement to staff that. turns out through the three pilots that our staffing model was wrong and we are hiring additional people. unfortunately for dr. beck, many of the people we're hiring in procurement are her purchasing agents who are coming across from the purchasing agent career

field to the contracting career field and will be now working procurement, which is probably good for them because there are much more career opportunities as what we say 1102 versus the purchasing agent, 1105. we are staffing to the level of i believe two to three complete orders per day. that's the metric. we will be tracking those metrics to ensure we don't fall behind on those metrics. as i mentioned earlier, if we do start falling behind, if the unexpected does happen, because we are approaching the fourth quarter as well, which is traditionally the busiest time of the year for contracting folks, we have the legacy system and those purchasing agents in prosthetics that we can fall back upon. >> what about the individual veteran themselves as far as are they really satisfied, if they don't come back, do you ever contact them to see why they haven't come back, the services

they received from the va? >> yes, sir. at all times the face to the veteran will remain the prosthetics, the prosthetics office. they should have no interaction with the contracting folks whatsoever. as the i.g. mentioned, it does come down to communication between the offices. we're actually in many cases setting up prosthetic cells where there are joint contracting and the prosthetics people working together to make sure we meet the needs of the veteran. again, the prosthetics people will be the up front face to the veteran, identifying what they need, the requirement will come to contracting, we will get under 8123, if it's a specific product, we will get that product for them and the product will come back to the prosthetics people for the follow-up aspect with the veteran. i'm sure there will be, if there are delays, the prosthetics folks will let us know and ensure that there's an issue. >> you're talking about delays in getting the limb. my question is the veteran

themselves, have you done an evaluation, is the customer, the veteran, satisfied with the service and if not, why not, or if they haven't come back, have you ever followed up with the veteran themselves to find out whether everything is satisfactory? >> i know in procurement, we have not because we're just getting into this ball game but i don't know if you do customer satisfaction surveys. >> in prosthetics, we have done a number of surveys over the years, some extensive ones where we've looked at using our va shep type surveys, our overall customer service and veteran satisfaction with care as we do for our medical centers. we've done two of those specialized surveys over the years. we also did a gallup poll survey in 2009 that looked at, evaluated what our amputees thought at that time.

the i.g. has actually, inspector general in this most recent report inspector general in this most recent report, also provides us with veterans satisfaction data. we realize we need to do more in that area and are now looking at a couple options that we have. one is a standardized survey that related to patient satisfaction that the committee on accreditation of rehab facilities uses. we intend to use that and for our system of care, we will be able to use that veteran satisfaction survey in all of our amputation care clinics. and we are also looking at other ways that we can assess veterans satisfaction. >> could you provide the committee with your latest survey for the veterans and their satisfaction? >> yes.

>> my last question is do you find it difficult, since this is a special field, to find and hire, you know, qualified clinical personnel? >> we have done a lot of hiring in the field of rehabilitation and for orttists and prosttists over the last several years. i think we have added a lot of new providers. providers who are highly experienced and very capable. for this profession as we have with physical therapy and occupational therapy and some of the rehab professions, the jobs are extremely competitive. we have done a couple of things in our system. one is our orttists and prosttists are title 38 so we

are able to vek news them for their clinical capabilities and advance them based on that performance and pay scale. and i -- so while it is a challenge, we have been able to attract high-quality providers and fill our positions. i'm going to ask dr. miller, who is our lead prosttist, to also give you some comment. >> thank you for allowing me to testify today. i am an iraqi vet. i have had the honor of serving as the chief of prosthetics there before serving here in the v.a. with regards to our work forest workforce, the va is very competitive. we are able to retain the orttists and prosttists. one reason is because we offer them the ability to treat and care for veterans and that's a mission that they enjoy and are wanting to do.

we also offer training in education. we offer the accessibility to the technology that the veteran receives and many times that technology is only available within the d.a. or dod. that's enticive to those that would like to practice and do clinical care. >> do you have any additional questions? >> just, i think, a couple brief points. of the 600 venders that you mentioned, are those -- the contact with our veterans, are they independent of the v.a. or are they through the va? is it sometimes happens that a patient will be contacted outside of the system and be convinced that maybe this product is something they ought to try? how do those 600 venders have

contact with our wounded warriors? >> yes, sir. the 600 contracted venders are our community partners and so they are active within our own v.a. facilities. they attend clinics and they help in the prescription rational in the item for that veteran. they are involved extensively with us in the care. >> so they would not have independent contact with the veterans themselves? >> yes, sir, they would. if the vender was selected to provide that limb, the veteran then would typically go to their private facility and have that prosthesis fabricated and designed for them independent of what's going on at the v.a. medical center. >> okay. and do those venders -- are they just doing these prosthetics based to v.a. specks?

or do they do them independent? >> so whenever a prescription is written for that, it's done to what we refer to as the industry standards. so we contract with those providers that have accreditation and certification just like the v.a. providers do. >> for a specific product? >> that's correct. >> the other thing is on the surveys, part of what i think doesn't reflect the sentiments of the veteran base, and i say this from experience that we have had in el paso, the veterans that are not getting either access to health care or are upset about something, they are very good about taking these surveys and sending them back in. it's been my experience, and i say this because i had even some of the members of my family that it have gotten those surveys and

because they are satisfied, they don't even return them, they chuck them. so is there a way or a process that you factor that into that? in other words, if you send out 20,000 surveys and you only get back a thousand, is there some way to factor in those veterans that don't send it in because they are satisfied? these surveys are multiple pages and they don't want to take the time, or can't take the time, to answer all those questions. and i think that really skews the results for the v.a. facility. so is there some way that can be done? or is that being done? is that taken into consideration? >> that's a very challenging question, and i'm going to answer that a couple of ways. i think when any of us use

surveys or when we publish surv surveys or when we read about surveys, you'll very often see a statement about the response rate because if the response rate is very low, if you send out 20,000 questionnaires and only a thousand people respond, then your questionnaire doesn't have a lot of validity because the number of people that you sample, and i think that's a challenge in our gallup polls, so that would be the first thing that we do. and i think our survey folks try to design surveys that will be easy so that people return them. and i think, you know, need to do better with that. as we're developing outcome measures, we're very focused on making them short and easy for the clinicians and for the veterans to fill out. and i think that is what we're trying to do as we address

patient satisfaction, veteran satisfaction, and even outcome measures. >> because i think if you just include a postcard that basically says, hey, i'm satisfied, i can't or don't want to go through the whole survey, count me as satisfied or somehow like that. because i believe that the results are being skewed because veterans don't want to go through those multiple page. whoever is designing those to be short is failing. i've gotten them myself, and let me tell you, 16 pages is not short. >> i don't want to fill those out either, so thank you. >> thank you, madame chair. >> thank you. before we adjourn this afternoon's hearing, i would just respectfully request that you provide us -- earlier dr. beck you mentioned there's shared practice guidelines.

so much of the testimony is saying dod is taking the lead and you're assuring us there's collaboration between dod and the v.a. if you could provide all of the initiatives that are going to ensure that the v.a. at least is working with and trying to emulate and catch up to dod's prosthetic programs i think that would be helpful for us. >> thank you. yes. we will do that. >> if there are no further questions, we want to thank this fourth panel for your endurance. this was a long hearing and your willingness to be here. thank the both of you dr. miller and dr. doyle for your service to this country. this is always a good opportunity for this subcommittee to say thank you to all of the veterans, to the service organizations for your service and sacrifice to this country. the united states is the greatest