VA and Defense Health Care
Progress Made, but DOD Continues To Face Military Medical Surveillance System Challenges Gao ID: GAO-02-377T January 24, 2002GAO, the Institute of Medicine, and others have cited weaknesses in the Defense Department's (DOD) medical surveillance during the Gulf War and Operation Joint Endeavor. DOD was unable to collect, maintain, and transfer accurate data on the movement of troops, potential exposures to health risks, and medical incidents during deployment in the Gulf war. DOD improved its medical surveillance system under Operation Joint Endeavor, providing useful information to military commanders and medical personnel. However, GAO found several problems with this system. For example, incomplete or inaccurate information related to service members' health and deployment status. DOD's has not established a single, comprehensive electronic system to document, archive, and access medical surveillance data. DOD has begun several initiatives to improve the reliability of deployment information and to enhance its information technology capabilities, but some initiatives are several years away from full implementation. Nonetheless, these efforts reflect a commitment by DOD to establish a comprehensive medical surveillance system. The ability of the Department of Veterans Affairs to fulfill its role in serving veterans and providing backup to DOD in times of war will be enhanced as DOD increases its medical surveillance capability.
GAO-02-377T, VA and Defense Health Care: Progress Made, but DOD Continues To Face Military Medical Surveillance System Challenges
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United States General Accounting Office:
GAO:
Testimony:
Before the Subcommittee on Health, Committee on Veterans' Affairs,
House of Representatives:
For Release on Delivery:
Expected at 9:00 p.m.
Thursday, January 24, 2002:
VA And Defense Health Care:
Progress Made, but DOD Continues To Face Military Medical Surveillance
System Challenges:
Statement for the Record by Cynthia A. Bascetta:
Director, Health Care”-Veterans' Health and Benefits Issues:
GAO-02-377T:
Mr. Chairman and Members of the Committee:
We are pleased to submit this statement for the record on the
Department of Defense's (DOD) efforts to establish a medical
surveillance system that enables DOD”along with the Department of
Veterans Affairs (VA)”to respond to the health care needs of our
military personnel and veterans. A medical surveillance system
involves the ongoing collection and analysis of uniform information on
deployments, environmental health threats, disease monitoring, medical
assessments, and medical encounters. It is also important that this
information be disseminated in a timely manner to military commanders,
medical personnel, and others. DOD is responsible for developing and
executing this system and needs this information to help ensure the
deployment of healthy forces and the continued fitness of those
forces. VA also needs this information to fulfill its missions of
providing health care to veterans, backing up DOD in contingencies,
and adjudicating veterans' claims for service-connected disabilities.
Scientists at VA, DOD, and other organizations also use this
information to conduct epidemiological studies and research.[Footnote
1]
Given our current military actions responding to the events of
September 11, and what has been reported about DOD's medical
surveillance activities during the Gulf War and Operation Joint
Endeavor, you expressed concern about the challenges DOD faces in
establishing a reliable medical surveillance system.[Footnote 2] This
statement focuses on reports GAO,[Footnote 3] the Institute of
Medicine (IOM), the Presidential Advisory Committee on Gulf War
Veterans' illnesses,[Footnote 4] and others have issued over
the past several years. This statement is also based on interviews we
held in early October 2001 with various Defense Health Program
officials, including officials from the Army Surgeon General's Office.
[Footnote 5]
In summary, GAO, the Institute of Medicine, and others have reported
extensively on weaknesses in DOD's medical surveillance capability and
performance during the Gulf War and Operation Joint Endeavor and the
challenges DOD faces in implementing a reliable medical surveillance
system. Investigations into the unexplained illnesses of Gulf War
veterans uncovered many deficiencies in DOD's ability to collect,
maintain, and transfer accurate data describing the movement of
troops, potential exposures to health risks, and medical incidents
during deployment. DOD improved its medical surveillance system under
Operation Joint Endeavor, which provided useful information to
military commanders and medical personnel. However, we and others
reported a number of problems with this system. For example,
information related to service members' health and deployment status”
data critical to an effective medical surveillance system”was
incomplete or inaccurate. DOD's numerous databases, including those
that capture health information, are currently not linked, which
further challenges the department's efforts to establish a single,
comprehensive electronic system to document, archive, and access
medical surveillance data.
DOD has several initiatives under way to improve the reliability of
deployment information and to enhance its information technology
capabilities, as we and others have recommended, though some
initiatives are several years away from full implementation.
Nonetheless, these efforts reflect a commitment by DOD to establish a
comprehensive medical surveillance system. The ability of VA to
fulfill its role in serving veterans and providing backup to DOD in
times of war will be enhanced as DOD increases its medical
surveillance capability.
Background:
An effective military medical surveillance system needs to collect
reliable information on (1) the health care provided to service
members before, during, and after deployment, (2) where and when
service members were deployed, (3) environmental and occupational
health threats or exposures during deployment (in theater) and
appropriate protective and counter measures, and (4) baseline health
status and subsequent health changes.
This information is needed to monitor the overall health condition of
deployed troops, inform them of potential health risks, as well as
maintain and improve the health of service members and veterans.
In times of conflict, a military medical surveillance system is
particularly critical to ensure the deployment of a fit and healthy
force and to prevent disease and injuries from degrading force
capabilities. DOD needs reliable medical surveillance data to
determine who is fit for deployment; to prepare service members for
deployment, including providing vaccinations to protect against
possible exposure to environmental and biological threats; and to
treat physical and psychological conditions that resulted from
deployment. DOD also uses this information to develop educational
measures for service members and medical personnel to ensure that
service members receive appropriate care.
Reliable medical surveillance information is also critical for VA to
carry out its missions. In addition to VA's better known missions”to
provide health care and benefits to veterans and medical research and
education”VA has a fourth mission: to provide medical backup to DOD in
times of war and civilian health care backup in the event of disasters
producing mass casualties. As such, VA needs reliable medical
surveillance data from DOD to treat casualties of military conflicts,
provide health care to veterans who have left active duty, assist in
conducting research should troops be exposed to environmental or
occupational hazards, and identify service-connected disabilities, and
adjudicate veterans' disability claims.
Medical Recordkeeping and Surveillance During the Gulf War Was Lacking:
Investigations into the unexplained illnesses of service members and
veterans who had been deployed to the Gulf uncovered the need for DOD
to implement an effective medical surveillance system to obtain
comprehensive medical data on deployed service members, including
Reservists and National Guardsmen. Epidemiological and health outcome
studies to determine the causes of these illnesses have been hampered
due to incomplete baseline health data on Gulf War veterans, their
potential exposure to environmental health hazards, and specific
health data on care provided before, during, and after deployment. The
Presidential Advisory Committee on Gulf War Veterans' Illnesses' and
IOM's 1996 investigations into the causes of illnesses experienced by
Gulf War veterans confirmed the need for more effective medical
surveillance capabilities.[Footnote 6]
The National Science and Technology Council, as tasked by the
Presidential Advisory Committee, also assessed the medical
surveillance system for deployed service members. In 1998, the council
reported that inaccurate recordkeeping made it extremely difficult to
get a clear picture of what risk factors might be responsible for Gulf
War illnesses.[Footnote 7] It also reported that without reliable
deployment and health assessment information, it was difficult to
ensure that veterans' service-related benefits claims were adjudicated
appropriately. The council concluded that the Gulf War exposed many
deficiencies in the ability to collect, maintain, and transfer
accurate data describing the movement of troops, potential exposures
to health risks, and medical incidents in theater. The council
reported that the government's recordkeeping capabilities were not
designed to track troop and asset movements to the degree needed to
determine who might have been exposed to any given environmental or
wartime health hazard. The council also reported major deficiencies in
health risk communications, including not adequately informing service
members of the risks associated with countermeasures such as vaccines.
Without this information, service members may not recognize potential
side effects of these countermeasures and promptly take precautionary
actions, including seeking medical care.
Medical Surveillance Under Operation Joint Endeavor Improved but Was
Not Comprehensive:
In response to these reports, DOD strengthened its medical
surveillance system under Operation Joint Endeavor when service
members were deployed to Bosnia-Herzegovina, Croatia, and Hungary. In
addition to implementing departmentwide medical surveillance policies,
DOD developed specific medical surveillance programs to improve
monitoring and tracking environmental and biomedical threats in
theater. While these efforts represented important steps, a number of
deficiencies remained.
On the positive side, the Assistant Secretary of Defense (Health
Affairs) issued a health surveillance policy for troops deploying to
Bosnia.[Footnote 8] This guidance stressed the need to (1) identify
health threats in theater, (2) routinely and uniformly collect and
analyze information relevant to troop health, and (3) disseminate this
information in a timely manner. DOD required medical units to develop
weekly reports on the incidence rates of major categories of diseases
and injuries during all deployments. Data from these reports showed
theaterwide illness and injury trends so that preventive measures
could be identified and forwarded to the theater medical command
regarding abnormal trends or actions that should be taken.
DOD also established the U.S. Army Center for Health Promotion and
Preventive Medicine”a major enhancement to DOD's ability to perform
environmental monitoring and tracking. For example, the center
operates and maintains a repository of service members' serum samples
for medical surveillance and a system to integrate, analyze, and
report data from multiple sources relevant to the health and readiness
of military personnel. This capability was augmented with the
establishment of the 520th Theater Army Medical Laboratory”a
deployable public health laboratory for providing environmental
sampling and analysis in theater. The sampling results can be used to
identify specific preventive measures and safeguards to be taken to
protect troops from harmful exposures and to develop procedures to
treat anyone exposed to health hazards. During Operation Joint
Endeavor, this laboratory was used in Tuzla, Bosnia, where most of the
U.S. forces were located, to conduct air, water, soil, and other
environmental monitoring.
Despite the department's progress, we and others have reported on
DOD's implementation difficulties during Operation Joint Endeavor and
the shortcomings in DOD's ability to maintain reliable health
information on service members. Knowledge of who is deployed and their
whereabouts is critical for identifying individuals who may have been
exposed to health hazards while deployed. However, in May 1997, we
reported that the inaccurate information on who was deployed and where
and when they were deployed”a problem during the Gulf War”continued to
be a concern during Operation Joint Endeavor.[Footnote 9] For example,
we found that the Defense Manpower Data Center (DMDC) database”where
military services are required to report deployment information”did
not include records for at least 200 Navy service members who were
deployed. Conversely, the DMDC database included Air Force personnel
who were never actually deployed. In addition, we reported that DOD
had not developed a system for tracking the movement of service
members within theater. IOM also reported that the locations of
service members during the deployments were still not systematically
documented or archived for future use.[Footnote 10]
We also reported in May 1997 that for the more than 600 Army personnel
whose medical records we reviewed, DOD's centralized database for
postdeployment medical assessments did not capture 12 percent of those
assessments conducted in theater and 52 percent of those conducted
after returning home.[Footnote 11] These data are needed by
epidemiologists and other researchers to assess at an aggregate level
the changes that have occurred between service members' pre- and
postdeployment health assessments. Further, many service members'
medical records did not include complete information on in-theater
postdeployment medical assessments that had been conducted. The Army's
European Surgeon General attributed missing in-theater health
information to DOD's policy of having service members hand carry paper
assessment forms from the theater to their home units, where their
permanent medical records were maintained. The assessments were
frequently lost en route.
We have also reported that not all medical encounters in theater were
being recorded in individual records. Our 1997 report identified that
this problem was particularly common for immunizations given in
theater. Detailed data on service members' vaccine history are vital
for scheduling the regimen of vaccinations and boosters and for
tracking individuals who received vaccinations from a specific lot in
the event health concerns about the vaccine lot emerge. We found that
almost one-fourth of the service members' medical records that we
reviewed did not document the fact that they had received a vaccine
for tick-borne encephalitis. In addition, in its 2000 report, IOM
cited limited progress in medical recordkeeping for deployed active
duty and reserve forces and emphasized the need for records of
immunizations to be included in individual medical records.
Current Policies and Programs Not Fully Implemented:
Responding to our and others' recommendations to improve information
on service members' deployments, in-theater medical encounters, and
immunizations, DOD has continued to revise and expand its policies
relating to medical surveillance, and the system continues to evolve.
In addition, in 2000, DOD released its Force Health Protection plan,
which presents its vision for protecting deployed forces.[Footnote 12]
This vision emphasizes force fitness and health preparedness and
improving the monitoring and surveillance of health threats in
military operations. However, IOM criticized DOD's progress in
implementing its medical surveillance program and the failure to
implement several recommendations that IOM had made. In addition, IOM
raised concerns about DOD's ability to achieve the vision outlined in
the Force Health Protection plan. We have also reported that some of
DOD's programs designed to improve medical surveillance have not been
fully implemented.
Recent IOM Report Concludes Slow Progress by DOD in Implementing
Recommendations:
IOM's 2000 report presented the results of its assessment of DOD's
progress in implementing recommendations for improving medical
surveillance made by IOM and several others. IOM stated that, although
DOD generally concurred with the findings of these groups, DOD had
made few concrete changes at the field level. For example, medical
encounters in theater were still not always recorded in individuals'
medical records, and the locations of service members during
deployments were still not systematically documented or archived for
future use. In addition, environmental and medical hazards were not
yet well integrated in the information provided to commanders.
The IOM report notes that a major reason for this lack of progress is
no single authority within DOD has been assigned responsibility for
the implementation of the recommendations and plans. IOM said that
because of the complexity of the tasks involved and the overlapping
areas of responsibility involved, the single authority must rest with
the Secretary of Defense.
In its report, IOM describes six strategies that in its view demand
further emphasis and require greater efforts by DOD:
* Use a systematic process to prospectively evaluate non-battle-
related risks associated with the activities and settings of
deployments.
* Collect and manage environmental data and personnel location,
biological samples, and activity data to facilitate analysis of
deployment exposures and to support clinical care and public health
activities.
* Develop the risk assessment, risk management, and risk
communications skills of military leaders at all levels.
* Accelerate implementation of a health surveillance system that
completely spans an individual's time in service.
* Implement strategies to address medically unexplained symptoms in
populations that have deployed.
* Implement a joint computerized patient record and other automated
recordkeeping that meets the information needs of those involved with
individual care and military public health.
Our Work Also Indicates Some DOD Programs for Improving Medical
Surveillance Are Not Fully Implemented:
DOD guidance established requirements for recording and tracking
vaccinations and automating medical records for archiving and
recalling medical encounters. While our work indicates that DOD has
made some progress in improving its immunization information, the
department faces numerous challenges in implementing an automated
medical record.
In October 1999, we reported that DOD's Vaccine Adverse Event
Reporting System, which relies on medical personnel or service members
to provide needed vaccine data, may not have included information on
adverse reactions because DOD did not adequately inform personnel on
how to provide this information.[Footnote 13]
Also, in April 2000, we testified that vaccination data were not
consistently recorded in paper records and in a central database, as
DOD requires.[Footnote 14] For example, when comparing records from
the database with paper records at four military installations, we
found that information on the number of vaccinations given to service
members, the dates of the vaccinations, and the vaccine lot numbers
were inconsistent at all four installations. At one installation, the
database and records did not agree 78 to 92 percent of the time. DOD
has begun to make progress in implementing our recommendations,
including ensuring timely and accurate data in its immunization
tracking system.
The Gulf War revealed the need to have information technology play a
bigger role in medical surveillance to ensure that the information is
readily accessible to DOD and VA. In August 1997, DOD established
requirements that called for the use of innovative technology, such as
an automated medical record device that can document inpatient and
outpatient encounters in all settings and that can archive the
information for local recall and format it for an injury, illness, and
exposure surveillance database.[Footnote 15] Also, in 1997, the
President, responding to deficiencies in DOD's and VA's data
capabilities for handling service members' health information, called
for the two agencies to start developing a comprehensive, lifelong
medical record for each service member. As we reported in April 2001,
DOD's and VA's numerous databases and electronic systems for capturing
mission-critical data, including health information, are not linked
and information cannot be readily shared.[Footnote 16]
DOD has several initiatives under way to link many of its information
systems”some with VA. For example, in an effort to create a
comprehensive, lifelong medical record for service members and
veterans and to allow health care professionals to share clinical
information, DOD and VA, along with the Indian Health Service (IHS),
[Footnote 17] initiated the Government Computer-Based Patient Record
(GCPR) project in 1998. GCPR is seen as yielding a number of potential
benefits, including improved research and quality of care, and
clinical and administrative efficiencies. However, our April 2001
report describes several factors”including planning weaknesses,
competing priorities, and inadequate accountability”that made it
unlikely that DOD and VA would accomplish GCPR or realize its benefits
in the near future. To strengthen the management and oversight of
GCPR, we made several recommendations, including designating a lead
entity with a clear line of authority for the project and creating
comprehensive and coordinated plans for sharing meaningful, accurate,
and secure patient health data.
For the near term, DOD and VA have decided to reconsider their
approach to GCPR and focus on allowing VA to view DOD health data.
However, under the interim effort, physicians at military medical
facilities will not be able to view health information from other
facilities or from VA”now a potentially critical information source
given VA's fourth mission to provide medical backup to the military
health system in times of national emergency and war.
In October 2001, we met with officials from the Defense Health Program
and the Army Surgeon General's Office who indicated that the
department is working on issues we have reported on in the past,
including the need to improve the reliability of deployment
information and the need to integrate disparate health information
systems. Specifically, these officials informed us that DOD is
developing a more accurate roster of deployed service members and
enhancing its information technology capabilities. For example, DOD's
Theater Medical Information Program (TMIP) is intended to capture
medical information on deployed personnel and link it with medical
information captured in the department's new medical information
system, now being field tested.[Footnote 18] Developmental testing for
TMIP has begun and field testing is expected to begin in spring 2002,
with deployment expected in 2003. A component system of TMIP”-
Transportation Command Regulating and Command and Control Evacuation
System”-is also under development and aims to allow casualty tracking
and provide in-transit visibility of casualties during wartime and
peacetime. Also under development is the Global Expeditionary Medical
System, which DOD characterizes as a stepping stone to an integrated
biohazard surveillance and detection system.
Concluding Observations:
Clearly, the need for comprehensive health information on service
members and veterans is very great, and much more needs to be done.
However, it is also a very difficult task because of uncertainties
about what conditions may exist in a deployed setting, such as
potential military conflicts, environmental hazards, and frequency of
troop movements. While progress is being made, DOD will need to
continue to make a concerted effort to resolve the remaining
deficiencies in its surveillance system. Until such a time that some
of the deficiencies are overcome, VA's ability to perform its missions
will be affected.
Contact and Acknowledgments:
For further information, please contact Cynthia A. Bascetta at (202)
5127101. Individuals making key contributions to this testimony
included Ann Calvaresi Barr, Karen Sloan, and Keith Steck.
[End of section]
Related GAO Products:
Computer-Based Patient Records.: Better Planning and Overnight by VA,
DOD, and IHS Would Enhance Health Data Sharing [hyperlink,
http://www.gao.gov/products/GA0-01459], Apr. 30, 2001.
Medical Readiness: DOD Continues To Face Challenges in Implementing
Its Anthrax Vaccine Immunization Program [hyperlink,
http://www.gao.gov/products/GAO/T-NSIAD-00-157],
Apr. 13, 2000.
Medical Readiness: DOD Faces Challenges in Implementing Its Anthrax
Vaccine Immunization Program [hyperlink,
http://www.gao.gov/products/GAO/NSIAD-00-36], Oct. 22, 1999.
Chemical and Biological Defense: Observations on DOD's Plans to
Protect U.S. Forces [hyperlink, http://www.gao.gov/products/GAO/T-
NSIAD-98-83], Mar. 17, 1998.
Gulf War Veterans: Incidence of Tumors Cannot Be Reliably Determined
From Available Data [hyperlink,
http://www.gao.gov/products/GAO/NSIAD-98-89], Mar. 3, 1998.
Gulf War Illnesses: Federal Research Strategy Needs Reexamination
[hyperlink, http://www.gao.gov/products/GAO-T-NSIAD-98-104], Feb. 24,
1998.
Gulf War Illnesses: Research, Clinical Monitoring, and Medical
Surveillance [hyperlink,
http://www.gao.gov/products/GAO/T-NSIAD-98-88], Feb. 5, 1998.
Defense Health Care: Medical Surveillance Improved Since Gulf War, but
Mixed Results in Bosnia [hyperlink,
http://www.gao.gov/products/GAO/NSIAD-97-136], May 13, 1997.
[End of section]
Footnotes:
[1] Epidemiology is the scientific study of the incidence,
distribution, and control of disease in a population.
[2] United States and allied nations deployed peacekeeping forces to
Bosnia beginning in December 1995 in support of Operation Joint
Endeavor, the NATO-led Bosnian peacekeeping force.
[3] See list of related GAO products at the end of this statement.
[4] The President established this committee in May 1995 to conduct
independent, open, and comprehensive examinations of health care
concerns related to Gulf War service. The committee consisted of
physicians, scientists, and Gulf War veterans.
[5] The Secretary of the Army is responsible for medical surveillance
for DOD deployments, consistent with DOD's medical surveillance policy.
[6] Health Consequences of Service During the Persian Gulf War.
Recommendations for Research and Information Systems Institute of
Medicine, Medical Follow-up Agency (Washington, D.C.: National Academy
Press, 1996); Presidential Advisory Committee on Gulf War Veterans'
Illnesses: Interim Report (Washington, D.C.: U.S. Government Printing
Office, Feb. 1996); Presidential Advisory Committee on Gulf War
Veterans' Illnesses: Final Report (Washington, D.C.: U.S. Government
Printing Office, Dec. 1996).
[7] National Science and Technology Council Presidential Review
Directive 5(Washington, D.C.: Executive Office of the President,
Office of Science and Technology Policy, Aug. 1998).
[8] Health Affairs Policy 96-019 (DOD Assistant Secretary of Defense
Memorandum, Jan. 4, 1996).
[9] Defense Health Care: Medical Surveillance Improved Since Gulf War,
but Mixed Results in Bosnia [hyperlink,
http://www.gao.gov/products/GAO/NSIAD-97-136], May 13, 1997.
[10] See Institute of Medicine, Protecting Those Who Serve: Strategies
to Protect the Health of Deployed U.S. Forces (Washington, D.C.,
National Academy Press, 2000).
[11] In many cases, we found that these assessments were not conducted
in a timely manner or were not conducted at all. For example, of the
618 personnel whose records we reviewed, 24 percent did not receive in-
theater postdeployment medical assessments and 21 percent did not
receive home station postdeployment medical assessments. Of those who
did receive home station postdeployment medical assessments, the
assessments were on average conducted nearly 100 days after they left
theater”-instead of within 30 days, as DOD requires.
[12] Joint Staff, Medical Readiness Division, Force Health Protection
(2000).
[13] Medical Readiness: DOD Faces Challenges in Implementing Its
Anthrax Vaccine Immunization Program [hyperlink,
http://www.gao.gov/products/GAO/NSIAD-00-36], Oct. 22, 1999.
[14] Medical Readiness: DOD Continues to Face Challenges in
Implementing Its Anthrax Vaccine Immunization Program [hyperlink,
http://www.gao.gov/products/GAO/T-NSIAD-00-157], Apr. 13, 2000.
[15] DOD Directive 6490.2, "Joint Medical Surveillance" (Aug. 30,
1997).
[16] Computer-Based Patient Records: Better Planning and Oversight by
VA, DOD, and IHS Would Enhance Health Data Sharing [hyperlink,
http://www.gao.gov/products/GA0-01-459], Apr. 30, 2001.
[17] IHS was included in the effort because of its population-based
research expertise and its long-standing relationship with VA.
[18] Composite Health Care System II (CHCS II) is expected to capture
information on immunizations; allergies; outpatient encounters, such
as diagnostic and treatment codes; patient hospital admission and
discharge; patient medications; laboratory results; and radiology.
CHCS II is expected to support best business practices, medical
surveillance, and clinical research.
[End of section]
