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 7 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 veterans -- 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 sales 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 upfront 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 that 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 also provides us with veteran satisfaction data. we realized we need to do more in that area, and are now looking at a couple of options that we have. one is with -- is a standardized survey that is related to patient satisfaction, that the committee on accreditation on rehab facilities uses. we intend to use that and for our amputation set of care we intend to use that satisfaction survey in all of our amputation care clinics. and we are also looking at other ways with can access veteran

satisfaction. >> can you provide the committee with your latest survey for the veteran and their satisfaction? >> yes. >> my last question is, do you found it difficult, since this is a special field, to find and hire, you know, qualified clinical personnel? >> we -- we have done a lot of hiring in the field of rehabilitation. and for orthodists and prosthetists over the past few years and i think we added a lot of snu providers, providers that are highly experienced and very capable for this profession as we have with physical therapy and occupational therapy and some of the hiring we have professions. the jobs are extremely competitive. we've done a couple of things in our system.

one is our orthodists and prosthodists are hyper clinical 48, so we can advance them based on that performance and pay scale. and i -- so while it is a challenge we've been able to attract high quality providers and fill our positions. i'm going to ask dr. miller, who is our lead prosthetist to comment. >> thank you very much for allowing many we to testify today. i am an iraqi vet and i've had an honor of serving both at walter reed medical center before coming here and serving in the va. with regards to our workforce, the va is very competitive in that we're able to attract and retain quite a few of the private sector orthodists and

prosthed prosthedists. one is that they treat veterans, and that is what they want to do. we also offer training and education, we offer the accessibility to the nenlg thte that the veteran receives and a lot of times that technology is only available in the dod. and that's enticive to those doctors who like to practice and do clinical care. >> mr. reyes, do you have any additional questions? >> just, i think, a couple of brief points. of the 600 vendors that you mentioned, are those -- the contact with our veterans, are they independent of the va or are they through the va, is it like 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 vendors have contact with our -- with our wounded warriors? >> yes, sir. the 600 contracted vendors are our community partners. so they're active within our own va facilities. they attend clinics, and they help in the prescription rationale of that item for that veteran. so they are involved extensively with us in the care. >> so they would not have independent contact with the vet raps themselves? >> yes, sir, they would, if the vendor was selected to provide that limb, the veteran then would typically go to their private facility and have that prog thesis designed for them independent of what's going on at the va medical center. >> okay. and do those vendors, are they

just doing these prosthetics based to va specs or do they do them independent? >> 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 va providers do. >> for a specific product? >> that's correct. >> the other thing is, on the surveys, part of -- part of what i think doesn't reflect the sentiments of the veteran base -- and i say this from experience that we've had there in el paso. the veterans that are not getting either access to health care or upset about something, they're very good about taking these sure pries and sending them back in. it's been my experience, and i

say this because i've had even some of the members of my family that have gotten those surveys because that's they're satisfied, they haven't even returned them. they just chuck them. so is there a way or a process that you factor that in, into that? in other words, if you send out 20,000 sure fayes. and you only get back one thousand, how old -- is there some way to factor in those fet veterans that don't pit it in because they're satisfied? these are multiple pages and they don't want to take time or can't take the time to answer all of those questions. i think that really skews the results for the va 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. i'm going to answer that a couple of ways. i think that when any of us used surveys or when we publish surveys or read about surveys. we'll very often see a statement about the response way. because if the response rate is very low, if you send out 20,000 questionnaires and 2,000 people respond, your questionnaire doesn't have a lot of validity because of the number of people that you sample. gallop polls and every way we do surveys. and i think our survey folks try to design surveys that will be easy so that people return them. and i think we, you know, need to do better with that. i think as we're developing outcome measures and satisfaction measure, veer were

po focused. and i think that is what we're trying to do as we address patient satisfaction, veteran pats faction, and even nut woman measures. >> if you include a coast guard that basically says, hey, i'm cats fid. can't or don't want too go through the whole survey. count me as sats side or something like that because i believe -- that -- the results are being skewed because veterans don't want to go through those put approximately age. whoever is designing those to be short is failing. i've gotten them myself. let me tell you, 60 pages is not short. >> no. and i don't want to fill them, either. >> thank you, madam chair. >> thank you. before we adjourned this afternoon's hearing i would

respectfully request -- earl lerks dr. beck, you mentioned slin call clothes. so much concern we have had is that dod has taken the lead in tros thet tick and you're asharing us that prs that on dod and ana. all the initiatives are going to ensure that the va is working with them 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 not any further question, i just want to thank this fourth panel for your endurance. this because long hearing, and for your willingness to be here. thank you. thank the both of you, dr. miller and mr. doyle, for your service to this country. and before we adjourn the meeting this is always a good opportunity for this committee, this subcommittee, so say thank to the vert rans for your service and for your crackfy

vase to the country. the united states is the greatest country in the history of the world and it is because of the service and served this have served this country. thank you very much. with that i ask unanimous consent that all members have five legislative days to revise and extend their remarks and include extraneous materials. thank you again to all of our witnesses and participants and our audience members for joining in today's conversation. the hearing is now adjourned. >> the supreme court issued decisions in several cases today. the court did not announce the ruling in the constitutional challenge to the president's health care law.

we're expecting that decision on thursday. but the court did make a decision in the challenged arizona's illegal immigration law. the court struck down parts of that law, but justices are allowing one part to go forward. the law's requirement that police check the status of someone they suspect is in the country illegally. also today, the justices overturned a montana law limiting corporate campaign spending and the high court found that juveniles cannot be sentenced to life in prison without the possibility of parole. some reaction to the arizona decision from attorney general eric holder. he said he's concerned that section two of the law will stand. that allows police to question anyone they suspect is in the country illegally. in a statement, the attorney general said section two is not a license so engage in racial profiling. and he wants to assure communities around the country that the department of justice will continue to vigorously enforce federal prohibitions

against racial and ethnic discrimination. and from republican presidential candidate mitt romney, today's decision underscores the need for a president who will lead on this critical issue and work in a bipartisan fashion to pursue a national immigration strategy. president obama has failed to provide any leadership on immigration. on that 5-3 supreme court decision striking down some of arizona's immigration law, we're asking your opinion on our facebook page. you can weigh in at facebook.com/c-span. . >> sunday, david pietrusza is our guest on "in-depth." a dozen books including "1920," 1960: lbj versus jfk versus

nixon, join us live with your calls, e-mails, and tweets. sunday at noon eastern, book tv it depth on c-span 2. >> we welcome you to missouri governor's mansion. >> the first governor was b. grass brown. and here we have a photograph of he, his wife, and his child. what's interesting about b. grass brown is his granddaughter wrote the book "good night moon" which is a favorite of many of the school children not only here in missouri but all over the united states. >> july 7th and 8th, american history tv explore the heritage and literary culture of missouri's state capital, jefferson city with c-span's local content vehicle and inside the governor's mansion. >> there was a governor steward,

the story says he rode his horse up the steps of the mansion, into the dining room and proceeded to feed his horse oats out of this plate warmer as part of the side board. now, the comment was that he probably should not be feeding the horse in the governor's mansion. and his comment was, i have had to feed more people in this home with probably less manners than my horse has. >> watch for book tv and american history tv in jefferson city, missouri, july 7th and 8th on c-span 2 and 3. >> this is c-span 3, with politics and public affairs programming every week. and every weekend, 48 hours of people and events telling the american story on american history tv. get our schedules and see past programs on our websites. and you can join in the conversation on social media sites. now to boulder, colorado, for a discussion on climate change and its effects on the world economy and people's

health. we'll hear from the head of the national wildlife federation, environmental activists and scientists. this is almost an hour and a half. >> let's get started, boulder. welcome to living in a new climate paradigm at 9:00, wednesday morning at old main chapel. this is an issue near and dear to a lot of our hearts, especially folks in boulder, an issue we're all wrestling with and an especially exciting panel we have to prompt us into an exciting dialogue. everything we do this morning is being filmed by c-span and it's especially important that everything we say get captured on a microphone. so especially when we get to q &

a, we're going to speak into a microphone so it can be recorded for posterity. so bear with us on that one. so let me introduce the panel, it's a good one. we are going to start off by hearing from larry swagger, the president of the national wildlife organization. and in addition to his long and impressive resume on conservation and climate change issues, one of his other claims of fame is that he's inspired and mentored a whole generation of conservationists, myself included. i used to work down the hall from larry at one of my other jobs. second up, we're going to hear from doug ray, he is an associate lab director for the department of energy's national laboratory in pacific northwest. he's one of those smart people that deals with science and technology and all things having to do with energy and ramifications on climate change. doug, if you're looking for a job, we need your kind in boulder. and third, we're going to hear

from dan ferber who is an independent award-winning journalist with several biology degrees who seems to have a knack for taking scientific issues and making them understandable to the reading public. in other words, a science geek that can communicate. that's a rare breed and we're happy to have him with us. he also just published a book called "changing climate, changing health." hopefully we'll hear some of the insights from that book. and levcoff. she's president of an ngo in santa fe that deals with all things complex. she applies complex, adaptive systems thinking to complex conflicts in complicated parts of the globe. why not climate change, huh? this woman likes a challenge. that's our line ulineup, and we start off with larry.

we'll hear from each speaker for about 10 to 12 minutes and then open it up to all of you. >> thank you, susan. and it's great to be here this morning to share this urgent issue with you. for the last 11,000 years, humans have existed in a climate where the carbon dioxide levels in our atmosphere were about 280 parts per million. today we have succeeded in moving that number to about 391 parts per million, probably about 393 by the time this year's out, which is about a 40% increase in the amount of carbon dioxide in the atmosphere. and that's important because even though it's a minor constituent in the atmosphere, it is a major player in trapping heat. and carbon dioxide has been visibly trapping heat for some time. nature actually is one of the first responders to climate change. rachel carson in 1950 wrote a book called "the sea around us." and in that book she devoted a

chapter to the global thermostat in which she laid out in quite good detail the fact that fish and wildlife were, in fact, moving further north in the northern hemisphere and further south in the southern hemisphere. and she said in her book at this very moment we are witnessing a startling alteration of climate. and that's what she said in 1950. that happens to be the year that i was born. so she was precedent in her observations that nature was responding to a shifting climate. and nature has always been the front line of our warning systems of changing planetary conditions. the -- that's what scientists call this 11,000-year period we've enjoyed, is really the period where all of the great things that humans have accomplished has occurred. so our civilization is really bound by this period.