dr. kudler do you want to add to that? >> at the time the gao was conducting the study the behavioral health autopsy program was just being launched. the forms were new. they were in need of refinement. they've been continuously refined as has the training of the suicide prevention coordinators, 300 of them across the country at over 150 facilities, who fill them out. there were questions about what data goes where and how do you count this or where do you go with that? that's now been addressed through training and upgrading of our manuals. we're now reviewing all of these centrally at national level. we've also created software that cross walks these to another suicide prevention tracking system the span system so that we can make sure we're accurately looking at these for multiple perspective. this is continuously improving and progressed a great deal since the original report and we will continue to work on it. >> dr. clancy this subcommittee has requested the behavioral health autopsies for numerous veterans who have

dr. kudler said something dr. williamson said. there is not that much follow-up on the behavior of health autopsy program. remind me what you said in your testimony. >> we were talking about oversight. very little oversight of the program at a local or national level to see whether there was accurate and complete. >> you said you are doing oversight. mr. williamson said you are not. what is exactly going on? >> the differences the two years that passed i'm not questioning the report at all. i find the report helpful as a spur to do more. at this point we're making a difference. >> show me the results of the oversight done in the last two years. did you get back to me in a reasonable period of time, like a month? >> that is not quite the way it is. there is still to respond recommendations on oversight. i don't think va has completed yet. it is not a two or three-year lag at all. there have been changes made. there is now a box checked on the behavioral autopsy report that indicates oversight has been done. that is one of the thing

dr. harold kudler, chief consultant, mental health services, veterans health administration. mr. randall williamson, director of gao's health care team. and dr. jacqueline maffucci research director for the iraq and afghanistan veterans of america. dr. clancy you are now recognized for five minutes. >> good morning chairman, ranking member kuster members, thank you for the opportunity to discuss the overuse of medication for veterans particularly for those at risk of suicide. one of our most important priorities at va is to keep our veteran patients free from harm at all times. i'm deeply saddened by the tragic outcome involving a veteran, so to families here today or watching this hearing who have lost a loved one i want to express my sorrow and regret for your loss. i appreciate you sharing your experiences with us. we will honor your loved ones by learning from those experiences and improving care for veterans in the future. we acknowledge up front that we have more work to do to reduce opioid use, meet the increasing demands for mental health care and prevent suicides and we'v

dr. harold kudler chief consultant, mental health services, veterans health administration. esther randall williamson, director of gao's health care team, and doctor jacqueline maffucci research director for the iraq and afghanistan veterans of america. dr. clancy are now recognized for five minutes. >> good morning, mr. chairman coffman, ranking member kuster mbs of the committee. thank you for the opportunity to discuss the overuse of medication and the provision of mental health care to veterans particularly for those at risk of suicide. one of our most important priorities at the agency keep our veterans patients free from harm at all times. i am deeply saddened by the tragic outcome involving a veteran. so the families here today are watching these hearings who have lost a loved one, i want to express my sorrow and regret for your loss. i appreciate you are sharing your experience is with us and we will honor your loved ones by learning from those experiences and improving care for veterans in the future. we acknowledge up front we have more work to do to reduce opioid u