Defense Health Care
DOD Needs to Improve Force Health Protection and Surveillance Processes Gao ID: GAO-04-158T October 16, 2003Following the 1990-91 Persian Gulf War, many servicemembers experienced health problems that they attributed to their military service in the Persian Gulf. However, a lack of servicemember health and deployment data hampered subsequent investigations into the nature and causes of these illnesses. Public Law 105-85, enacted in November 1997, required the Department of Defense (DOD) to establish a system to assess the medical condition of service members before and after deployments. GAO reported on (1) the Army's and Air Force's compliance with DOD's force health protection and surveillance requirements for servicemembers deploying in support of Operation Enduring Freedom (OEF) in Central Asia and Operation Joint Guardian (OJG) in Kosovo and (2) the status of DOD efforts to correct problems related to the accuracy and completeness of databases reflecting which servicemembers were deployed to certain locations. (Defense Health Care: Quality Assurance Process Needed to Improve Force Health Protection and Surveillance (GAO-03-1041, Sept. 19, 2003)) GAO was asked to testify on its findings regarding the Army's and Air Force's compliance with DOD's force health protection and surveillance policies. For its report, GAO reviewed records for statistical samples of active duty servicemembers at four military installations.
The Army and Air Force--the focus of GAO's review--did not comply with DOD's force health protection and surveillance policies for many active duty servicemembers, including the policies that they be assessed before and after deploying overseas, that they receive certain immunizations, and that health-related documentation be maintained in a centralized location. GAO's review of 1,071 servicemembers' medical records from a universe of 8,742 at selected Army and Air Force installations participating in overseas operations disclosed that 38 to 98 percent of servicemembers were missing one or both of their health assessments and as many as 36 percent were missing two or more of the required immunizations. GAO found that many servicemembers' medical records did not include health assessments found in DOD's centralized database. Similarly, DOD also did not maintain a complete, centralized database of servicemembers' health assessments and immunizations. Health-related documentation missing from the centralized database ranged from 0 to 63 percent for predeployment assessments, 11 to 75 percent for post-deployment assessments, and 8 to 93 percent for immunizations. There was no effective quality assurance program at the Office of the Assistant Secretary of Defense for Health Affairs or at the Army or Air Force that helped ensure compliance with policies. GAO believes that the lack of such a program was a major cause of the high rate of noncompliance. Continued noncompliance with these policies may result in servicemembers deploying with health problems or delays in obtaining care when they return. Finally, DOD's centralized deployment database is still missing the information needed to track servicemembers' movements in the theater of operations. By July 2003, the department's data center had begun receiving location-specific deployment information from the services and is currently reviewing its accuracy and completeness. GAO's report recommended that DOD establish an effective quality assurance program that will ensure that the military services comply with the force health protection and surveillance policies for all servicemembers. DOD agreed with the recommendation and outlined a number of actions the military services are already taking to implement their quality assurance programs. While we view these actions as responsive to our recommendation, the effectiveness of these actions to ensure compliance will depend on follow-through by DOD and the services.
GAO-04-158T, Defense Health Care: DOD Needs to Improve Force Health Protection and Surveillance Processes
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Testimony:
Before the Committee on Veterans' Affairs, House of Representatives:
United States General Accounting Office:
GAO:
For Release on Delivery:
Expected at 10:00 a.m. EDT:
Thursday, October 16, 2003:
Defense Health Care:
DOD Needs to Improve Force Health Protection and Surveillance
Processes:
Statement of Neal P. Curtin:
Director, Defense Capabilities and Management
GAO-04-158T:
GAO Highlights:
Highlights of GAO-04-158T, testimony before the Committee on Veterans‘
Affairs, House of Representatives
Why GAO Did This Study:
Following the 1990-91 Persian Gulf War, many servicemembers
experienced health problems that they attributed to their military
service in the Persian Gulf. However, a lack of servicemember health
and deployment data hampered subsequent investigations into the nature
and causes of these illnesses. Public Law 105-85, enacted in November
1997, required the Department of Defense (DOD) to establish a system
to assess the medical condition of service members before and after
deployments. GAO reported on (1) the Army‘s and Air Force‘s compliance
with DOD‘s force health protection and surveillance requirements for
servicemembers deploying in support of Operation Enduring Freedom
(OEF) in Central Asia and Operation Joint Guardian (OJG) in Kosovo and
(2) the status of DOD efforts to correct problems related to the
accuracy and completeness of databases reflecting which servicemembers
were deployed to certain locations. (Defense Health Care: Quality
Assurance Process Needed to Improve Force Health Protection and
Surveillance [GAO-03-1041, Sept. 19, 2003])
GAO was asked to testify on its findings regarding the Army‘s and Air
Force‘s compliance with DOD‘s force health protection and surveillance
policies. For its report, GAO reviewed records for statistical samples
of active duty servicemembers at four military installations.
What GAO Found:
The Army and Air Force”the focus of GAO‘s review”did not comply with
DOD‘s force health protection and surveillance policies for many
active duty servicemembers, including the policies that they be
assessed before and after deploying overseas, that they receive
certain immunizations, and that health-related documentation be
maintained in a centralized location. GAO‘s review of 1,071
servicemembers‘ medical records from a universe of 8,742 at selected
Army and Air Force installations participating in overseas operations
disclosed that 38 to 98 percent of servicemembers were missing one or
both of their health assessments and as many as 36 percent were
missing two or more of the required immunizations.
GAO found that many servicemembers‘ medical records did not include
health assessments found in DOD‘s centralized database. Similarly, DOD
also did not maintain a complete, centralized database of
servicemembers‘ health assessments and immunizations. Health-related
documentation missing from the centralized database ranged from 0 to
63 percent for pre-deployment assessments, 11 to 75 percent for post-
deployment assessments, and 8 to 93 percent for immunizations. There
was no effective quality assurance program at the Office of the
Assistant Secretary of Defense for Health Affairs or at the Army or
Air Force that helped ensure compliance with policies. GAO believes
that the lack of such a program was a major cause of the high rate of
noncompliance. Continued noncompliance with these policies may result
in servicemembers deploying with health problems or delays in
obtaining care when they return. Finally, DOD‘s centralized deployment
database is still missing the information needed to track
servicemembers‘ movements in the theater of operations. By July 2003,
the department‘s data center had begun receiving location-specific
deployment information from the services and is currently reviewing
its accuracy and completeness.
GAO‘s report recommended that DOD establish an effective quality
assurance program that will ensure that the military services comply
with the force health protection and surveillance policies for all
servicemembers.
DOD agreed with the recommendation and outlined a number of actions
the military services are already taking to implement their quality
assurance programs. While we view these actions as responsive to our
recommendation, the effectiveness of these actions to ensure
compliance will depend on follow-through by DOD and the services.
www.gao.gov/cgi-bin/getrpt?GAO-04-158T.
To view the full testimony, click on the link above. For more
information, contact Neal Curtin at (757) 552-8100.
[End of section]
Mr. Chairman and Members of the Committee:
I am pleased to be here as you discuss health assessments and the
importance of complete medical records for our servicemembers. Both the
Department of Defense (DOD) and the Department of Veterans Affairs (VA)
need this information to perform their missions. DOD needs health
status information and complete medical records to help ensure the
deployment of healthy forces and the continued fitness of those forces.
VA's Veterans Benefits Administration uses health information to
adjudicate veterans' claims for disability compensation related to
service-connected injuries or illnesses. As you know, VA's Veterans
Health Administration needs complete and accurate medical records
documenting all medical care for individual servicemembers are needed
for the delivery of high-quality, post-deployment care. In this
context, you asked us to discuss our recent report on the Army's and
Air Force's compliance with DOD's force health protection and
surveillance policies that require servicemembers to be assessed before
and after deploying overseas, that require servicemembers to receive
certain immunizations, and that require health-related documentation to
be maintained in a centralized location.
Following the 1990-91 Persian Gulf War, many servicemembers experienced
health problems that they attributed to their military service in the
Persian Gulf. However, subsequent investigations into the nature and
causes of these illnesses were hampered by a lack of servicemember
health and deployment data. Moreover, in May 1997, we reported on
several similar problems associated with the implementation of the DOD
deployment health surveillance policies for servicemembers deployed to
Bosnia in support of a peacekeeping operation.[Footnote 1]
In response, the Congress enacted legislation[Footnote 2] in November
1997 requiring DOD to establish a system for assessing the medical
condition of servicemembers before and after their deployment to
locations outside the United States and requiring the centralized
retention of certain health-related data associated with the
servicemember's deployment. The system is to include the use of pre-
deployment and post-deployment medical examinations, including an
assessment of mental health and the drawing of blood samples. DOD has
implemented specific force health protection and surveillance
policies. These policies include pre-deployment and post-deployment
health assessments designed to identify health issues or concerns that
may affect the deployability of servicemembers or that may require
medical attention; pre-deployment immunizations to address possible
health threats in deployment locations; pre-deployment screening for
tuberculosis; and the retention of blood serum samples on file prior to
deployment. In February 2002, we testified before the Subcommittee on
Health of this Committee that DOD had several initiatives under way to
improve the reliability of deployment information and to enhance its
information technology capabilities, as we and others have
recommended.[Footnote 3] Although its recent policies and
reorganization reflect a commitment by DOD to establish a comprehensive
medical surveillance system, much needed to be done to implement
the system.
My testimony today is based on our September 2003 report on the Army's
and Air Force's compliance with DOD's force health protection and
surveillance policies for active duty deployments for Operation
Enduring Freedom (OEF) in Central Asia and Operation Joint Guardian
(OJG) in Kosovo.[Footnote 4] We also examined whether DOD has corrected
problems related to the accuracy and completeness of databases
reflecting which servicemembers deployed to certain locations.
To do our work, we obtained the force health protection and
surveillance policies applicable to the OEF and OJG deployments from
the Army, Air Force, combatant commanders, the office of the Assistant
Secretary of Defense, and the services' Surgeons General. To test the
implementation of these policies, we reviewed statistical samples
totaling 1,071 active duty servicemembers selected from a universe of
8,742 active duty servicemembers at four military
installations.[Footnote 5] To provide assurances that our review of the
selected medical records was accurate, we requested the installations'
medical personnel to reexamine those medical records that were missing
required health assessments or immunizations and adjusted our results
where documentation was subsequently identified. We also requested
installation medical personnel to check all possible sources for
missing pre-deployment and post-deployment health assessments and
missing immunizations. We also requested the U.S. Special Operations
Command (SOCOM) to query its database for health-related documentation
for servicemembers in our sample at one of the selected installations.
We also examined, for Army and Air Force servicemembers in our samples,
the completeness of the centralized records at the Army Medical
Surveillance Activity[Footnote 6] (AMSA), which is tasked with
centrally collecting deployment health-related records. Further, we
interviewed officials at the office of the Deployment Health Support
Directorate and at the Defense Manpower Data Center (DMDC) regarding
the accuracy and completeness of DMDC's personnel deployment database
and planned improvements. We conducted our work from June 2002 through
July 2003 in accordance with generally accepted government auditing
standards.
Summary:
In summary, the Army and Air Force did not comply with DOD's force
health protection and surveillance policies for many of the
servicemembers at the installations we visited. Our review of medical
records at those installations disclosed that problems continue to
exist in several areas.
* Deployment health assessments. The percentage of Army and Air Force
servicemembers missing one or both of their pre-deployment and post-
deployment health assessments ranged from 38 to 98 percent of our
samples. Moreover, when health assessments were conducted, as many as
45 percent of them were not done within the required time frames.
Furthermore, a health care provider did not review all health
assessments and, although only a small number of assessments in our
samples indicated a health concern, large percentages of these
assessments were not referred for further consultations as required.
* Immunizations and other pre-deployment requirements. Servicemembers
missing evidence of receiving one of the pre-deployment immunizations
required for their deployment location ranged from 14 percent to
46 percent. As many as 36 percent of the servicemembers were missing
two or more of their required immunizations. Furthermore,
servicemembers missing current tuberculosis screening at the time of
their deployment ranged from 7 to 40 percent. As many as 29 percent of
the servicemembers in our samples had blood serum samples in the
repository older than the required maximum age of 1 year at the time of
deployment, ranging, on average, from 2 to 15 months out-of-date.
* Completeness of medical records and centralized data collection.
Servicemembers' permanent medical records at the Army and Air Force
installations we visited did not include documentation of the completed
health assessments that we found at AMSA and at the U.S. Special
Operations Command, ranging from 8 to 100 percent for pre-deployment
health assessments and from 11 to 62 percent for post-deployment
health assessments. Our review also disclosed that the AMSA database
was still, over 5 years after congressional action, lacking
documentation of many health assessments and immunizations that we
found in the servicemembers' medical records at the installations
visited. Specifically, health-related documentation missing from the
centralized database ranged from 0 to 63 percent for pre-deployment
health assessments, 11 to 75 percent for post-deployment health
assessments, and 8 to 93 percent for immunizations.
Furthermore, DOD did not have oversight of departmentwide efforts to
comply with health surveillance requirements. There was no effective
quality assurance program at the Office of the Assistant Secretary of
Defense for Health Affairs or at the Offices of the Surgeons' General
of the Army or Air Force that helped ensure compliance with force
health protection and surveillance policies. We believe the lack of
such a system was a major cause of the high rate of noncompliance we
found at the units we visited. Continued noncompliance with these
policies may result in servicemembers being deployed with unaddressed
health problems or without immunization protection. Furthermore,
incomplete and inaccurate medical records may hinder DOD's and VA's
ability to investigate the causes of any future health problems that
may arise coincident with deployments.
Also, DOD has not corrected the problems we identified in 1997 that
were related to the completeness and accuracy of a central personnel
deployment database that is designed to collect data reflecting which
servicemembers deployed to certain locations. DMDC's deployment
database still does not include the information needed for effective
deployment health surveillance. Prior to April 2003, the services were
not reporting location-specific deployment data to the DMDC because,
according to a DMDC official, the services did not maintain the data.
By July 2003, all of the services had begun submitting classified
deployment data to DMDC, which is currently reviewing the deployment
information received to determine its accuracy and completeness.
However, DMDC still does not have a system to track the movement of
servicemembers within a given theater, because this information has not
been available from the services and the development of a new tracking
system at the service unit level may be required. DOD is developing a
new system for tracking the movements of servicemembers and civilian
personnel in the theater of operation with plans for implementation by
about September 2005 for the Army and by 2007 or early calendar year
2008 for the other services.
We recommended that the Secretary of Defense direct the Assistant
Secretary of Defense for Health Affairs to establish an effective
quality assurance system to ensure that the military services comply
with force health protection and surveillance requirements for all
servicemembers. DOD agreed with our recommendation and outlined a
number of actions the military services are already taking to implement
their quality assurance programs. While we view these actions as
responsive to our recommendation, the effectiveness of these actions to
ensure compliance will depend on follow-through by DOD and the
services.
Background:
In May 1997, we reported on DOD's actions to improve deployment
health surveillance before, during, and after deployments, focusing on
Operation Joint Endeavor, which was conducted in the countries of
Bosnia-Herzegovina, Croatia, and Hungary.[Footnote 7] Our 1997 review
disclosed problems with the Army's implementation of the medical
surveillance plan for Operation Joint Endeavor in the following areas:
* Medical assessments. Many Army personnel who should have received
post-deployment medical assessments did not receive them and the
assessments that were completed were frequently done late.
* Medical record keeping. Many of the servicemembers' medical records
that we reviewed were incomplete and missing documentation of
in-theater post-deployment medical assessments, medical visits during
deployment, and receipt of an investigational new vaccine.
* Centralized database. The centralized database for collecting in-
theater and home unit post-deployment medical assessments was
incomplete for many Army personnel.
* Deployment information. DOD officials considered the database used
for tracking the deployment of Air Force and Navy personnel inaccurate.
Following the publication of our report, the Congress, in November
1997, included a provision in the Defense Authorization Act for Fiscal
Year 1998 requiring the Secretary of Defense to establish a medical
tracking system for servicemembers deployed overseas as follows:
"(a) SYSTEM REQUIRED--The Secretary of Defense shall establish a system
to assess the medical condition of members of the armed forces
(including members of the reserve components) who are deployed outside
the United States or its territories or possessions as part of a
contingency operation (including a humanitarian operation,
peacekeeping operation, or similar operation) or combat operation.
"(b) ELEMENTS OF SYSTEM--The system described in subsection (a) shall
include the use of predeployment medical examinations and
postdeployment medical examinations (including an assessment of mental
health and the drawing of blood samples) to accurately record the
medical condition of members before their deployment and any changes in
their medical condition during the course of their deployment. The
postdeployment examination shall be conducted when the member is
redeployed or otherwise leaves an area in which the system is in
operation (or as soon as possible thereafter).
"(c) RECORDKEEPING--The results of all medical examinations conducted
under the system, records of all health care services (including
immunizations) received by members described in subsection (a) in
anticipation of their deployment or during the course of their
deployment, and records of events occurring in the deployment area that
may affect the health of such members shall be retained and maintained
in a centralized location to improve future access to the records.
"(d) QUALITY ASSURANCE--The Secretary of Defense shall establish a
quality assurance program to evaluate the success of the system in
ensuring that members described in subsection (a) receive predeployment
medical examinations and postdeployment medical examinations and that
the recordkeeping requirements with respect to the system
are met."[Footnote 8]
As set forth above, these provisions require the use of pre-deployment
and post-deployment medical examinations to accurately record the
medical condition of servicemembers before deployment and any changes
during their deployment. In a June 30, 2003, correspondence with the
General Accounting Office, the Assistant Secretary of Defense for
Health Affairs stated that "it would be logistically impossible to
conduct a complete physical examination on all personnel immediately
prior to deployment and still deploy them in a timely manner."
Therefore, DOD required both pre-deployment and post-deployment health
assessments for servicemembers who deploy for 30 or more continuous
days to a land-based location outside the United States without a
permanent U.S. military treatment facility. Both assessments use a
questionnaire designed to help military healthcare providers in
identifying health problems and providing needed medical care. The pre-
deployment health assessment is generally administered at the home
station before deployment, and the post-deployment health assessment is
completed either in theater before redeployment to the servicemember's
home unit or shortly upon redeployment.
As a component of medical examinations, the statute quoted above also
requires that blood samples be drawn before and after a servicemember's
deployment. DOD Instruction 6490.3, August 7, 1997, requires that a
pre-deployment blood sample be obtained within 12 months of the
servicemember's deployment.[Footnote 9] However, it requires the blood
samples be drawn upon return from deployment only when directed by the
Assistant Secretary of Defense for Health Affairs. According to DOD,
the implementation of this requirement was based on its judgment that
the Human Immunodeficiency Virus serum sampling taken independent of
deployment actions is sufficient to meet both pre-deployment and post-
deployment health needs, except that more timely post-deployment
sampling may be directed when based on a recognized health threat or
exposure. Prior to April 2003, DOD did not require a post-deployment
blood sample for servicemembers supporting the OEF and OJG deployments.
In April 2003, DOD revised its health surveillance policy for blood
samples and post-deployment health assessments. Effective May 22, 2003,
the services are required to draw a blood sample from each redeploying
servicemember no later than 30 days after arrival at a demobilization
site or home station.[Footnote 10] According to DOD, this requirement
for post-deployment blood samples was established in response to an
assessment of health threats and national interests associated with
current deployments. The department also revised its policy guidance
for enhanced post-deployment health assessments to gather more
information from deployed servicemembers about events that occurred
during a deployment. More specifically, the revised policy requires
that a trained health care provider conduct a face-to-face health
assessment with each returning servicemember to ascertain (1) the
individual's responses to the health assessment questions on the post-
deployment health assessment form; (2) the presence of any mental
health or psychosocial issues commonly associated with deployments; (3)
any special medications taken during the deployment; and (4) concerns
about possible environmental or occupational exposures.
The Army and Air Force Did Not Comply with Deployment Health
Surveillance Policies for Many Servicemembers:
The Army and Air Force did not comply with DOD's force health
protection and surveillance requirements for many of the servicemembers
in our samples at the selected installations we visited. Specifically,
these Army and Air Force servicemembers were missing: pre-deployment
and/or post-deployment health assessments; evidence of receiving one or
more of the pre-deployment immunizations required for their deployment
location; and other pre-deployment requirements related to tuberculosis
screening and blood serum sample storage. Also, servicemembers'
permanent medical records were missing required health-related
information, and DOD's centralized database did not include
documentation of servicemember health-related information. Neither the
installations nor DOD had monitoring and oversight mechanisms in place
to help ensure that the force health protection and surveillance
requirements were met for all servicemembers.
Many Servicemembers Lacked Pre-deployment and Post-deployment Health
Assessments:
We found that servicemembers missing one or both of their pre-
deployment and post-deployment assessments ranged from 38 to 98 percent
in our samples.[Footnote 11] For example, at Fort Campbell for the OEF
deployment we found that 68 percent of the 222 active duty
servicemembers in our sample were missing either one or both of the
required pre-deployment and post-deployment health assessments. The
results of our statistical samples for the deployments at the
installations visited are depicted in figure 1.
Figure 1: Percent of Servicemembers Missing One or Both Health
Assessments:
[See PDF for image]
Notes: = 95 percent confidence interval, upper and lower bounds for
each estimate.
These percentages reflect assessments from all sources and without
regard to timeliness.
[End of figure]
For those servicemembers in our samples who had completed
pre-deployment or post-deployment health assessments, we found that as
many as 45 percent of the assessments in our samples were not completed
on time in accordance with requirements. DOD policy requires that
servicemembers complete a pre-deployment health assessment form within
30 days of their deployment and a post-deployment health assessment
form within 5 days upon redeployment back to their home
station.[Footnote 12] These time frames were established to allow time
to identify and resolve any health concerns or problems that may affect
the ability of the servicemember to deploy, and to promptly identify
and address any health concerns or problems that may have arisen during
the servicemember's deployment. Additionally, DOD policy requires that
pre-deployment and post-deployment health assessments are to be
reviewed immediately by a health care provider to identify any medical
care needed by the servicemember.[Footnote 13] We found, however, that
not all health assessments were reviewed by a health care provider
as required.
The services did not refer some servicemember health assessments
that indicated a need for further consultation. According to DOD
policy, a medical provider, namely a physician, physician's assistant,
nurse, or independent duty medical technician is required to further
review a servicemember's need for specialty care when the member's
pre-deployment and/or post-deployment health assessment indicates
health concerns such as unresolved medical or dental problems or plans
to seek mental health counseling or care.[Footnote 14] This follow-up
may take the form of an interview or examination of the servicemember,
and forms the basis of a decision as to whether a referral for further
specialty care is warranted. In our samples, the number of assessments
that indicated a health concern was relatively small, but
large percentages of these assessments were not referred for further
specialty care. For example, our sample at Travis Air Force Base
included five pre-deployment health assessments that indicated a health
concern, but four (80 percent) of the health assessments were not
referred for further specialty care.
Noncompliance with the requirement for pre-deployment health
assessments may result in servicemembers with existing health problems
or concerns being deployed with unaddressed health problems. Also,
failure to complete post-deployment health assessments may risk a delay
in obtaining appropriate medical follow-up attention for a health
problem or concern that may have arisen during or following the
deployment.
Immunizations and Other Pre-Deployment Health Requirements Not Met:
Based on our samples, the services did not fully meet immunization
and other pre-deployment requirements. Evidence of pre-deployment
immunizations receipt was missing from many servicemembers' medical
records. Servicemembers missing the required immunizations may not have
the immunization protection they need to counter theater disease
threats. Based on our review of servicemember medical records for the
deployments at the four installations we visited, we found that between
14 and 46 percent of the servicemembers were missing one of their
required immunizations prior to deployment (see fig. 2). Furthermore,
as many as 36 percent of the servicemembers were missing two or more of
their required immunizations.
Figure 2: Percent of Servicemembers Missing Required Immunizations:
[See PDF for image]
Notes: = 95 percent confidence interval, upper and lower bounds for
each estimate.
[End of figure]
The U.S. Central Command required the following pre-deployment
immunizations for all servicemembers that deployed to Central Asia
in support of OEF: hepatitis A (two-shot series); measles, mumps, and
rubella; polio; tetanus/diphtheria within the last 10 years; yellow
fever within the last 10 years; typhoid within the last 5 years;
influenza within the last 12 months; and meningococcal within the last
5 years.[Footnote 15] For OJG deployments, the U.S. European Command
required the same immunizations cited above, with the exception of the
yellow fever inoculation that was not required for Kosovo.[Footnote 16]
Furthermore, deploying servicemembers in our review that were missing a
current tuberculosis screening ranged from 7 to 40 percent. A screening
is deemed "current" if it occurred 1 to 2 years prior to deployment.
Specifically, the U.S. Central Command required servicemembers
deploying to Central Asia in support of OEF to be screened for
tuberculosis within 12 months of deployment.[Footnote 17] For OJG
deployments, the U.S. European Command required Army and Air Force
servicemembers to be screened for tuberculosis with 24 months of
deployment.[Footnote 18]
U.S. Central Command and U.S. European Command policies require that
deploying servicemembers have a blood serum sample in the serum
repository not older than 12 months prior to deployment.[Footnote 19]
While nearly all deploying servicemembers had blood serum samples held
in the Armed Services Serum Repository prior to deployment, as many as
29 percent had serum samples that were too old. The samples that were
too old ranged, on average, from 2 to 15 months out-of-date.
Servicemember Medical Records and Centralized Database
Were Not Complete:
Servicemembers' permanent medical records were not complete, and DOD's
centralized database did not include documentation of servicemember
health-related information. Many servicemembers' permanent medical
records at the Army and Air Force installations we visited did not
include documentation of completed health assessments and servicemember
visits to Army battalion aid stations. Similarly, the centralized
deployment record database did not include many of the deployment
health assessments and immunization records that we found in the
servicemembers' medical records at the installations we visited.
Many Completed Deployment Health Assessments and Medical Interventions
Were Not Documented in Servicemembers' Medical Record:
DOD policy requires that the original completed pre-deployment
and post-deployment health assessment forms be placed in the
servicemember's permanent medical record and that a copy be
forwarded to AMSA.[Footnote 20] Figure 3 shows that completed
assessments we found at AMSA and at the U.S. Special Operations Command
for servicemembers in our samples were not documented in the
servicemember's permanent medical record, ranging from 8 to
100 percent for pre-deployment health assessments and from 11 to
62 percent for post-deployment health assessments.
Figure 3: Percent of Assessments Found in Centralized Database That
Were Not Found in Servicemembers' Medical Records:
[See PDF for image]
Notes: = 95 percent confidence interval, upper and lower bounds for
each estimate.
[A] All three pre-deployment cases at Fort Campbell found in the
centralized database were missing from servicemembers' medical record,
but unable to compute confidence intervals due to insufficient size.
[End of figure]
Army and Air Force policies also require documentation in the
servicemember's permanent medical record of all visits to in-theater
medical facilities.[Footnote 21] Except for the OEF deployment at Fort
Drum, officials were unable to locate or access the sign-in logs for
servicemember visits to in-theater Army battalion aid stations and to
Air Force expeditionary medical support for the OEF and OJG deployments
at the installations we visited. Consequently, we limited the scope of
our review to two battalion aid stations for the OEF deployment at Fort
Drum. We found that 39 percent of servicemember visits to one battalion
aid station and 94 percent to the other were not documented in the
servicemember's permanent medical record. Representatives of the two
battalion aid stations said that the missing paper forms documenting
the servicemember visits may have been lost en route to Fort Drum.
Specifically, a physician's assistant for one of these battalion aid
stations said the battalion aid station moved three times in theater
and each time the paper forms used to document in-theater visits were
boxed and moved with the battalion aid station. Consequently, the forms
missing from servicemembers' medical records may have been lost en
route to Fort Drum.
The lack of complete and accurate medical records documenting
all medical care for the individual servicemember complicates the
servicemembers' post-deployment medical care. For example, accurate
medical records are essential for the delivery of high-quality medical
care and important for epidemiological analysis following deployments.
According to DOD and VA health officials, the lack of complete and
accurate medical records complicated the diagnosis and treatment of
servicemembers who experienced post-deployment health problems that
they attributed to their military service in the Persian Gulf in 1990-
91.
DOD is implementing the Theater Medical Information Program (TMIP) that
has the capability to electronically record and store in-theater
patient medical encounter data. TMIP is currently undergoing
operational testing by the military services and DOD intends to begin
fielding TMIP during the first quarter of fiscal year 2004.
Centralized Database Missing Health-Related Documentation:
Based on our samples, DOD's centralized database did not include
documentation of servicemember health-related information. As set forth
above, Public Law 105-85, enacted November 1997, requires the Secretary
of Defense to retain and maintain health-related records in a
centralized location. This includes records for all medical
examinations conducted to ascertain the medical condition of
servicemembers before deployment and any changes during their
deployment, all health care services (including immunizations) received
in anticipation of deployment or during the deployment, and events
occurring in the deployment area that may affect the health of
servicemembers. A February 2002 Joint Staff memorandum requires the
services to forward a copy of the completed pre-deployment and post-
deployment health assessments to AMSA for centralized
retention.[Footnote 22] Also, the U.S. Special Operations Command
(SOCOM) requires deployment health assessments for special forces units
to be sent to the Command for centralized retention in the Special
Operation Forces Deployment Health Surveillance System.[Footnote 23]
Figure 4 depicts the percentage of pre-deployment and post-deployment
health assessments and immunization records we found in the
servicemembers' medical records that were not available in a
centralized database at AMSA or SOCOM. Health-related documentation
missing from the centralized database ranged from 0 to 63 percent for
pre-deployment health assessments, 11 to 75 percent for post-deployment
health assessments, and 8 to 93 percent for immunizations.
Figure 4: Percent of Assessments and Immunizations Found in
Servicemembers' Medical Records That Were Not Found in the Centralized
Database:
[See PDF for image]
Notes: = 95 percent confidence interval, upper and lower bounds for
each estimate.
Centralized database is AMSA for all but Hurlburt Field, which reports
to either AMSA or SOCOM based on classification of military personnel.
Hurlburt Field results reflect combined health assessment and
immunization data found at either AMSA or SOCOM.
[A] Zero cases found in servicemembers' medical record that were not
found in the centralized database.
[End of figure]
All but one of the servicemembers in our sample at Hurlburt Field were
special operations forces. A SOCOM official told us that pre-deployment
and post-deployment health assessment forms for servicemembers in
special operations force units are not sent to AMSA because the health
assessments may include classified information that AMSA is not
equipped to receive. Consequently, SOCOM retains the deployment health
assessments in its classified Special Operations Forces Deployment
Health Surveillance System. Also, a SOCOM medical official told us that
the system does not include pre-deployment immunization data. A
Deployment Health Support Directorate official told us that the
Directorate is examining how to remove the classified information from
the deployment health assessments so that SOCOM can forward the
assessments to AMSA. For presentation in figure 4, we combined the
health assessment and immunization data we found at AMSA and SOCOM for
Hurlburt Field.
An AMSA official believes that missing documentation in the centralized
database could be traced to the services' use of paper copies of
deployment health assessments that installations are required to
forward to the centralized database, and the lack of automation to
record servicemembers' pre-deployment immunizations. DOD has ongoing
initiatives to electronically automate the deployment health assessment
forms and the recording of servicemember immunizations. For example,
DOD is implementing a comprehensive electronic medical records system,
known as the Composite Health Care System II, which includes pre-
deployment and post-deployment health assessment forms and the
capability to electronically record immunizations given to
servicemembers. DOD has deployed the system at five sites and will be
seeking approval in August/September 2003 for worldwide
deployment.[Footnote 24] DOD officials believe that the electronic
automation of the deployment health-related information will lessen the
burden of installations in forwarding paper copies and the likelihood
of information being lost in transit.
DOD and Installations Did Not Have Oversight of Force Health Protection
and Surveillance Requirements:
DOD did not have an effective quality assurance program to provide
oversight of, and ensure compliance with, the department's force health
protection and surveillance requirements. Moreover, the installations
we visited did not have ongoing monitoring or oversight mechanisms to
help ensure that force health protection and surveillance requirements
were met for all servicemembers. We believe that the lack of such a
system was a major cause of the high rate of noncompliance we found at
the units we visited. The services are currently developing quality
assurance programs designed to ensure that force health protection and
surveillance policies are implemented for servicemembers.
Although required by Public Law 105-85 to establish a quality assurance
program,[Footnote 25] neither the Assistant Secretary of Defense for
Health Affairs nor the offices of the Surgeons General of the Army or
Air Force had established oversight mechanisms that would help ensure
that force health protection and surveillance requirements were met for
all servicemembers. Following our visit to Fort Drum in October 2002,
the Army Surgeon General wrote a memorandum in December 2002 to the
commanders of the Army Regional Medical Commands that expressed concern
related to our sample results at Fort Drum. He emphasized the
importance of properly documenting medical care and directed the
commanders to accomplish an audit of a statistically significant sample
of medical surveillance records of all deployed and redeployed soldiers
at installations supported by their regional commands, provide an
assessment of compliance, and develop an action plan to improve
compliance with the requirements.
At three of the four installations we visited, officials told us that
new procedures were implemented that they believe will improve
compliance with force health protection and surveillance requirements
for deployments occurring after those we reviewed. Specifically,
following our visit to Fort Drum in October 2002, Fort Drum medical
officials designed a pre-deployment and post-deployment checklist
patterned after our review that is being used as part of processing
before servicemembers are deployed and when they return. The officials
told us that this process has improved their compliance with force
health protection and surveillance requirements for deployments
subsequent to our visit. Also, the hospital commander at Fort Campbell
told us that they implemented procedures that now require all units
located at Fort Campbell to use the hospital's medical personnel in
their processing of servicemembers prior to deployment. The hospital
commander believes that this new requirement will improve compliance
with the force health protection and surveillance requirements at Fort
Campbell because the medical personnel will now review whether all
requirements have been met for the deploying servicemembers. At
Hurlburt Field, officials told us that they implemented a new
requirement in November 2002 to withhold payment of travel expenses and
per diem to re-deploying servicemembers until they complete the post-
deployment health assessment. Officials believe that this change will
improve servicemembers' completion of the post-deployment health
assessments. While it is noteworthy that these installations have
implemented changes that they believe will improve their compliance,
the actual measure of improvements over time cannot be known unless the
installations perform periodic reviews of servicemembers' medical
records to identify the extent of compliance with deployment health
requirements.
In March 2003, we briefed the Subcommittee on Total Force, House
Committee on Armed Services, about our interim review results at
selected military installations.[Footnote 26] Subsequently, at a
March 2003 congressional hearing, the Subcommittee discussed our
interim review results with the Assistant Secretary of Defense for
Health Affairs and the services' Surgeons General. Based on our interim
results that DOD was not meeting the full requirement of the law and
the military services were not effectively carrying out many of DOD's
force health protection and surveillance policies, in May 2003 the
House Committee on Armed Services directed the Secretary of Defense to
take measures to improve oversight and compliance. Specifically, in its
report accompanying the Fiscal Year 2004 National Defense Authorization
Act, the Committee directed the Secretary of Defense "— to establish a
quality control program to begin assessing implementation of the force
health protection and surveillance program, and to provide a strategic
implementation plan, including a timeline for full implementation of
all policies and programs, to the Senate Committee on Armed Services
and the House Committee on Armed Services by March 31, 2004."[Footnote
27]
In April 2003, the Under Secretary of Defense for Personnel and
Readiness issued an enhanced post-deployment health assessment policy
that required the services to develop and implement a quality assurance
program that encompasses medical record keeping and medical
surveillance data.[Footnote 28] In June 2003, the Office of Assistant
Secretary of Defense for Health Affairs' Deployment Health Support
Directorate began reviewing the services' quality assurance
implementation plans and establishing DOD-wide compliance metrics--
including parameters for conducting periodic visits--to monitor service
implementation.
Centralized Deployment Database Still Missing Information Needed for
Deployment Health Surveillance:
The DMDC deployment database still does not include the deployment
information we identified in 1997 as needed for effective deployment
health surveillance. In 1997, we reported that knowing the identity of
servicemembers who were deployed during a given operation and tracking
their movements within the theater of operations are major elements of
a military medical surveillance system.[Footnote 29] The Institute of
Medicine reported in 2000 that the documentation of the locations of
units and individuals during a given deployment is important for
epidemiological studies and for the provision of appropriate medical
care during and after deployments.[Footnote 30] This information allows
(1) epidemiologists to study the incidence of disease patterns across
populations of deployed servicemembers who may have been exposed to
diseases and hazards within the theater, and (2) health care
professionals to treat their medical problems appropriately. Because of
concerns about the accuracy of the DMDC database, we recommended in our
1997 report that the Secretary of Defense direct an investigation of
the completeness of the information in the DMDC personnel database and
take corrective actions to ensure that the deployment information is
accurate for servicemembers who deploy to a theater.
DOD's established policies notwithstanding, the services did not report
location-specific deployment information to DMDC prior to April 2003,
because, according to a DMDC official, the services did not maintain
the data. DOD Instruction 6490.3, issued in August 1997, requires DMDC,
under the Department's Under Secretary for Personnel and Readiness, to
maintain a system that collects information on deployed forces,
including daily-deployed strength, total and by unit; grid coordinate
locations for each unit (company size and larger); and inclusive dates
of individual servicemember's deployment.[Footnote 31] In addition, the
Joint Chief of Staff's Memorandum MCM-0006-02, dated February 1, 2002,
required combatant commands to provide DMDC with their theater-wide
rosters of all deployed personnel, their unit assignments, and the
unit's geographic locations while deployed.[Footnote 32] This
memorandum stressed that accurate personnel deployment data is needed
to assess the significance of medical diseases and injuries in terms of
the rate of occurrence among deployed servicemembers. The Under
Secretary of Defense for Personnel and Readiness expressed concern
about the services' failure to report complete personnel deployment
data to DMDC in an October 2002 memorandum.[Footnote 33]
To address the services' lack of reporting to DMDC, the Under Secretary
of Defense for Personnel and Readiness established a tri-service
working group that outlined a plan of action in March 2003 to address
the reporting issues. In July 2003, a DMDC official told us that
significant improvements had recently occurred and that all of the
services had begun submitting their classified deployment databases--
including deployment locations--to DMDC. DMDC is currently reviewing
the deployment information submitted by the services to determine its
accuracy and completeness. It plans to complete this review during the
summer of 2003.
With regard to DMDC's efforts to create a system for tracking the
movements of servicemembers within a given theater of operations, DMDC
officials told us that little progress has been made. They said that
the primary reason for a lack of progress in developing this system is
that the source information has generally not been available from the
services and this may require the development of new tracking systems
at the unit level. In June 2003, a DMDC official told us that it had
been recently determined that the Air Force has implemented a theater
tracking system that may have applicability to the other services. The
tracking system--known as the Deliberate Crisis and Action Planning and
Execution Segment (DCAPES)--enables field teams to enter classified
information about the whereabouts of deployed Air Force personnel at
the longitude/latitude level of detail. DMDC began receiving
information from this system in April 2003. The Under Secretary of
Defense for Personnel and Readiness is reviewing this system to
determine whether it could be used for the same purposes by the other
services.
Also, DOD is developing the Defense Integrated Military Human Resource
System (DIMHRS), which will have the capability to track the movements
of all servicemembers and civilians in the theater of operations. As of
June 2003, DOD plans to implement this system for the Army by about
September 2005 and for the other services by 2007 or early calendar
year 2008.
Concluding Observations:
While DOD and the military services have established force health
protection and surveillance policies, at the units we visited we found
many instances of noncompliance by the services. Moreover, because DOD
and the services did not have an effective quality assurance program in
place to help ensure compliance, these problems went undetected and
uncorrected. Continued noncompliance with these policies may result
in servicemembers with existing health problems or concerns being
deployed with unaddressed health problems or without the immunization
protection they need to counter theater disease threats. Failure to
complete post-deployment health assessments may risk a delay in
obtaining appropriate medical follow-up attention for a health problem
or concern that may have arisen during or following the deployment.
Similarly, incomplete and inaccurate medical records and deployment
databases would likely hinder DOD's and VA's ability to investigate the
causes of any future health problems that may arise coincident with
deployments.
Mr. Chairman, this concludes my prepared statement. I will be pleased
to answer any questions you or other members of the committee may have
at this time.
Contacts and Acknowledgments:
For further information regarding this testimony, please contact Neal
P. Curtin at (757) 552-8100. Clifton Spruill, Steve Fox, Rebecca Beale,
Lynn Johnson, William Mathers, Terry Richardson, Kristine Braaten,
Grant Mallie, Herbert Dunn, and R.K. Wild also contributed to this
testimony.
FOOTNOTES
[1] U.S. General Accounting Office, Defense Health Care: Medical
Surveillance Improved Since Gulf War, but Mixed Results in Bosnia, GAO/
NSIAD-97-136 (Washington, D.C.: May 13, 1997).
[2] Section 765 of Pub. L. No. 105-85 amended title 10 of the United
States Code by adding section 1074f.
[3] U.S. General Accounting Office, VA and Defense Health Care:
Military Medical Surveillance Policies in Place, but Implementation
Challenges Remain, GAO-02-478T (Washington, D.C.: Feb. 27, 2002).
[4] U.S. General Accounting Office, Defense Health Care: Quality
Assurance Process Needed to Improve Force Health Protection and
Surveillance, GAO-03-1041 (Washington, D.C.: Sept. 19, 2003). Moreover,
we reported in April 2003 and testified in July 2003 on problems
experienced by the Army in assessing the health status of all early-
deploying reservists. See U.S. General Accounting Office, Defense
Health Care: Army Needs to Assess the Health Status of All Early-
Deploying Reservists, GAO-03-437 (Washington, D.C.: Apr. 15, 2003); and
U.S. General Accounting Office, Defense Health Care: Army Has Not
Consistently Assessed the Health Status of Early-Deploying Reservists,
GAO-03-997T (Washington, D.C.: July 9, 2003).
[5] Includes samples of records for servicemembers who deployed from
Fort Drum, New York; Fort Campbell, Kentucky; Travis Air Force Base,
California; and Hurlburt Field, Florida.
[6] The Army Medical Surveillance Activity is DOD's executive agent for
collecting and retaining the military services' deployment health-
related documents--including the pre-deployment and post-deployment
health assessments and immunizations.
[7] GAO/NSIAD-97-136.
[8] Section 765 of Pub. L. No. 105-85 amended title 10 of the United
States Code by adding section 1074f.
[9] DOD Instruction 6490.3, "Implementation and Application of Joint
Medical Surveillance for Deployments," August 7, 1997.
[10] Under Secretary of Defense for Personnel and Readiness Memorandum,
"Enhanced Post-Deployment Health Assessments," April 22, 2003.
[11] Because we checked all known possible sources for the existence of
deployment health assessments, we concluded that the assessments were
not completed in those instances where we could not find required
health assessments.
[12] Office of the Chairman, The Joint Chiefs of Staff, Memorandum MCM-
0006-2, "Updated Procedures for Deployment Health Surveillance and
Readiness," February 1, 2002.
[13] The Joint Staff, Joint Staff Memorandum MCM-251-98.
[14] Office of the Chairman, The Joint Chiefs of Staff, Memorandum MCM-
0006-02, "Updated Procedures for Deployment Health Surveillance and
Readiness," February 1, 2002.
[15] U.S. Central Command, "Personnel Policy Guidance for U.S.
Individual Augmentation Personnel in Support of Operation Enduring
Freedom," October 3, 2001.
[16] Headquarters U.S. European Command, "Greece and the Balkans: Force
Health Protection Guidance," January 4, 2002.
[17] U.S. Central Command, "Personnel Policy Guidance for U.S.
Individual Augmentation Personnel in Support of Operation Enduring
Freedom," October 3, 2001.
[18] Headquarters U.S. European Command, "Greece and the Balkans: Force
Health Protection Guidance," January 4, 2002.
[19] U.S. Central Command, "Personnel Policy Guidance for U.S.
Individual Augmentation Personnel in Support of Operation Enduring
Freedom," October 3, 2001; and Headquarters U.S. European Command,
"Greece and the Balkans: Force Health Protection Guidance,"
January 4, 2002.
[20] Office of the Chairman, The Joint Chiefs of Staff, Memorandum MCM-
0006-02, "Updated Procedures for Deployment Health Surveillance and
Readiness," February 1, 2002.
[21] Army Regulation 40-66, "Medical Records Administration," October
23, 2002, and Air Force Instruction 41-210, "Health Services Patient
Administration Functions," October 1, 2000.
[22] Office of the Chairman, The Joint Chiefs of Staff, Memorandum MCM-
0006-02, "Updated Procedures for Deployment Health Surveillance and
Readiness," February 1, 2002.
[23] U.S. Special Operations Command Directive 40-4, "Medical
Surveillance," October 18, 2000; Appendix 1 to Annex Q to U.S. Central
Command Operations Order, "Special Operation Forces Deployment Health
Surveillance System," November 30, 2001.
[24] In September 2002, we reported that DOD had experienced delays and
cost overruns in implementing the Composite Health Care System II. See
U.S. General Accounting Office, Information Technology: Greater Use of
Best Practices Can Reduce Risk in Acquiring Defense Health Care System,
GAO-02-345 (Washington, D.C.: Sept. 26, 2002).
[25] 10 U.S.C. sec. 1074f(d).
[26] Prior to briefing the Subcommittee, we also briefed the Senior
Military Medical Advisory Committee including the Assistant Secretary
of Defense for Health Affairs and the military services' Surgeons
General or their representatives about our interim review results.
[27] H.R. Rep. No. 108-106 at 336 (2003).
[28] Under Secretary of Defense for Personnel and Readiness Memorandum,
"Enhanced Post-Deployment Health Assessments," April 22, 2003.
[29] GAO/NSIAD-97-136.
[30] Institute of Medicine, Protecting Those Who Serve: Strategies to
Protect the Health of Deployed U.S. Forces (National Academy Press,
Washington, D.C.: 2000).
[31] DOD Instruction 6490.3, "Implementation and Application of Joint
Medical Surveillance for Deployments," August 7, 1997.
[32] Office of the Chairman, The Joint Chiefs of Staff, Memorandum MCM-
0006-02, "Updated Procedures for Deployment Health Surveillance and
Readiness," February 1, 2002.
[33] This memorandum was dated October 25, 2002, and sent to the Vice
Chief of Staff of the Army, Vice Chief of Staff of the Air Force, Vice
Chief of Naval Operations, and the Assistant Commandant of the Marine
Corps.
