Defense Health Care
Quality Assurance Process Needed to Improve Force Health Protection and Surveillance Gao ID: GAO-03-1041 September 19, 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 was asked to determine whether (1) the military services met 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) DOD has corrected problems related to the accuracy and completeness of databases reflecting which servicemembers were deployed to certain locations.
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 14 to 46 percent were missing at least one of the required immunizations. DOD also did not maintain a complete, centralized database of servicemembers' medical 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 is 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 helps 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.
RecommendationsOur recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.
Director: Team: Phone:GAO-03-1041, Defense Health Care: Quality Assurance Process Needed to Improve Force Health Protection and Surveillance
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Report to the Chairman and Ranking Minority Member, Subcommittee on
Total Force, Committee on Armed Services, House of Representatives:
United States General Accounting Office:
GAO:
September 2003:
Defense Health Care:
Quality Assurance Process Needed to Improve Force Health Protection and
Surveillance:
Defense Health Care:
GAO-03-1041:
GAO Highlights:
Highlights of GAO-03-1041, a report to the Chairman and Ranking
Minority Member, Subcommittee on Total Force, Committee on Armed
Services, 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 was asked to determine whether (1) the military
services met 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) DOD has corrected problems related to the
accuracy and completeness of databases reflecting which servicemembers
were deployed to certain locations.
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 14 to 46 percent were missing at
least one of the required immunizations (see figure).
DOD also did not maintain a complete, centralized database of
servicemembers‘ medical 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
is 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 helps 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.
What GAO Recommends:
GAO recommends that the Secretary of Defense direct the Assistant
Secretary of Defense for Health Affairs to establish an effective
quality assurance program that will help ensure that the military
services comply with the force health protection and surveillance
requirements for all servicemembers. DOD concurred with the
recommendation.
www.gao.gov/cgi-bin/getrpt?GAO-03-1041.
To view the full product, including the scope and methodology, click
on the link above. For more information, contact Cliff Spruill at
(202) 512-4531.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
The Army and Air Force Did Not Comply with Deployment Health
Surveillance Policies for Many Servicemembers:
Centralized Deployment Database Still Missing Information Needed for
Deployment Health Surveillance:
Conclusions:
Recommendation for Executive Action:
Agency Comments and Our Evaluation:
Appendix I: Scope and Methodology:
Appendix II: Comments from the Department of Defense:
Appendix III: GAO Contact and Staff Acknowledgments:
Tables:
Table 1: Deploying Servicemember Blood Serum Samples Held
in Repository:
Table 2: Servicemember Sample Sizes at Each Visited Installation:
Figures:
Figure 1: Percent of Servicemembers Missing One or Both Health
Assessments:
Figure 2: Percent of Health Assessments Not Completed Within Required
Time Frames:
Figure 3: Completed Assessments That Were Not Reviewed by Health
Care Provider:
Figure 4: Percent of Servicemembers Missing Required Immunizations:
Figure 5: Percent of Servicemembers That Did Not Have Current
Tuberculosis Screening:
Figure 6: Percent of Assessments Found in Centralized Database That
Were Not Found in Servicemembers' Medical Records:
Figure 7: Percent of Assessments and Immunizations Found in
Servicemembers' Medical Records That Were Not Found in the Centralized
Database:
Abbreviations:
AMSA: Army Medical Surveillance Activity:
CITA: Comprehensive Immunization Tracking Application:
DCAPES: Deliberate Crisis and Action Planning and Execution Segment:
DIMHRS: Defense Integrated Military Human Resource System:
DMDC: Defense Manpower Data Center:
DOD: Department of Defense:
MEDPROS: Medical Protection System:
OEF: Operation Enduring Freedom:
OJG: Operation Joint Guardian:
SOCOM: U.S. Special Operations Command:
TMIP: Theater Medical Information Program:
United States General Accounting Office:
Washington, DC 20548:
September 19, 2003:
The Honorable John McHugh
Chairman
The Honorable Vic Snyder
Ranking Minority Member
Subcommittee on Total Force
Committee on Armed Services
House of Representatives:
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
Department of Defense's (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 medical examinations 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-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.
Given the many deployments of servicemembers to overseas locations
since 1997, you asked us to examine the military services'
implementation of DOD's force health protection and surveillance
policies and its progress in correcting the types of problems we found
in 1997.[Footnote 3] More specifically, we focused our work on Army and
Air Force active duty deployments[Footnote 4] for Operation Enduring
Freedom (OEF) in Central Asia and Operation Joint Guardian (OJG) in
Kosovo to address the following two questions:
1. Are the military services meeting DOD's force health protection and
surveillance system requirements for servicemembers deploying in
support of OEF and OJG?
2. Has DOD corrected problems related to the accuracy and completeness
of databases reflecting which servicemembers deployed to certain
locations?
To accomplish these objectives, 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. 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-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 5] (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. For more detailed information of our scope
and methodology, see appendix I.
Results in Brief:
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-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 at least one of the pre-deployment
immunizations required for their deployment location ranged from
14 percent to 46 percent. 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--
designed to function as the centralized collection location for
deployment health-related information for all military services--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 is 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 helps 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 ability to investigate
the causes of any future health problems that may arise coincident with
deployments.
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. The Defense Manpower Data
Center's (DMDC) 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
data was not available from the services. 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 are recommending 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. In commenting on a draft of this report, DOD concurred
with the report's recommendation.
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 6] We commented on
the provisions of a joint medical surveillance policy draft that called
for a comprehensive DOD-wide medical surveillance capability to monitor
and assess the effects of deployments on servicemembers' health. DOD
subsequently finalized its joint medical surveillance policy in August
1997. 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. Of the
618 servicemembers in the 12 Army units whose medical records we
reviewed, 24 percent did not receive in-theater post-deployment medical
assessments, and 21 percent did not receive home station post-
deployment medical assessments. Servicemembers who received home
station post-deployment medical assessments received them, on average,
nearly 100 days after they left theater instead of within 30 days as
required by the plan. Further, pre-deployment blood serum samples were
not available for 9.3 percent of the 26,621 servicemembers who had
deployed to Bosnia as of March 12, 1996. The most recent blood samples
for 6.4 percent of the pre-deployment blood samples were more than
5 years old.
* 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. More
specifically, we found that 91 of the 473 servicemembers (19 percent)
with a post-deployment in-theater medical assessment and 9 of the
491 servicemembers (1.8 percent) with a post-deployment home unit
medical assessment did not have the assessments documented in their
medical records. Furthermore, about 29 percent of the 50 battalion aid
station visits we reviewed were not documented in the members'
permanent medical records. Finally, 141 of 588 servicemembers
(24 percent) who received an investigational drug vaccine did not have
the immunization documented in their medical records.
* Centralized database. The centralized database for collecting in-
theater and home unit post-deployment medical assessments was
incomplete for many Army personnel. More specifically, the database
omitted 12 percent of the in-theater medical assessments done and
52 percent of the home unit medical assessments done for the 618
servicemembers whose records we reviewed.
* 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 7]
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-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 8] 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-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 9] 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-and
post-deployment assessments ranged from 38 to 98 percent in our
samples.[Footnote 10] 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-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 (see fig. 2). 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 11] 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.
Figure 2: Percent of Health Assessments Not Completed Within Required
Time Frames:
[See PDF for image]
Notes: = 95 percent confidence interval, upper and lower bounds for
each estimate.
[A] Unable to compute because exact redeployment date was unavailable.
[B] All three pre-deployment cases for Fort Campbell were completed
within the required time frame, but unable to compute confidence
intervals due to insufficient size.
[End of figure]
Not all health assessments were reviewed by a health care provider
as required, as shown in figure 3. 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 12]
Figure 3: Completed Assessments That Were Not Reviewed by Health
Care Provider:
[See PDF for image]
Notes: = 95 percent confidence interval, upper and lower bounds for
each estimate.
[A] All three pre-deployment cases for Fort Campbell were reviewed by
the health care provider, but unable to compute confidence intervals
due to insufficient size.
[B] Zero cases: confidence level shown.
[End of figure]
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 13] 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 at least one of
their required immunizations prior to deployment (see fig. 4).
Furthermore, as many as 36 percent of the servicemembers were missing
two or more of their required immunizations.
Figure 4: 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 14] 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 15]
Figure 5 indicates that 7 to 40 percent of the deploying servicemembers
in our review were missing a current tuberculosis screening. 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 16]
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 17]
Figure 5: Percent of Servicemembers That Did Not Have Current
Tuberculosis Screening:
[See PDF for image]
Notes: = 95 percent confidence interval, upper and lower bounds for
each estimate.
[End of figure]
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 18]
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 (see table 1). The
samples that were too old ranged, on average, from 2 to 15 months out-
of-date.
Table 1: Deploying Servicemember Blood Serum Samples Held
in Repository:
Status of Blood Serum: Had serum sample in repository; Fort Campbell
(OEF): 100%; Fort Campbell (OJG): 100%; Fort Drum (OEF): 100%; Fort
Drum (OJG): 99.5%; Hurlburt Field (OEF): 100%; Travis AFB (OEF): 100%.
Status of Blood Serum: Serum out-of date (older than 1-year
requirement) at time of deployment; Fort Campbell (OEF): 22%; Fort
Campbell (OJG): 7%; Fort Drum (OEF): 5%; Fort Drum (OJG): 1%; Hurlburt
Field (OEF): 7%; Travis AFB (OEF): 29%.
Status of Blood Serum: Average months out-of-date; Fort Campbell (OEF):
8; Fort Campbell (OJG): 2; Fort Drum (OEF): 11; Fort Drum (OJG): 5;
Hurlburt Field (OEF): 15; Travis AFB (OEF): 14.
Source: GAO analyses of DOD data.
[End of table]
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 19] Figure 6 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 6: 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 20] 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
station 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 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 21] 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 22]
Figure 7 depicts the percentage of pre-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 7: 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 7, 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-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 23] 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 does 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 24] 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 them
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 25] 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
26]
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 27] 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 28] 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 29] 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 30] 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 31] 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 32]
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.
Conclusions:
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 do 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 ability to investigate the causes
of any future health problems that may arise coincident with
deployments.
Recommendation for Executive Action:
To improve compliance with DOD's force health protection and
surveillance policies, we recommend that the Secretary of Defense
direct the Assistant Secretary of Defense for Health Affairs to
establish an effective quality assurance program, as required by
section 765 of Public Law 105-85 (10 U.S.C. 1074f), that will ensure
that the military services comply with the force health protection and
surveillance requirements for all servicemembers.
Agency Comments and Our Evaluation:
The Department of Defense provided written comments on a draft of
this report, which are found in appendix II. DOD concurred with the
report's recommendation.
The Assistant Secretary of Defense for Health Affairs commented that
his office has already established a quality assurance program for pre-
and post-deployment health assessments. This program monitors pre-and
post-deployment health assessments and blood samples being archived
electronically at the Army Medical Surveillance Activity (AMSA) and
assures that indicated referrals on the post-deployment health
assessments are being conducted by all the services. However, the
Assistant Secretary of Defense for Health Affairs' comments did not
discuss how his office is using the monitoring activities to assure
the military services' compliance with force health protection and
surveillance policies.
According to the Assistant Secretary of Defense for Health Affairs, the
services have implemented their quality assurance programs. The Army
has developed automated versions of the pre-and post-deployment health
assessment forms, and has established a corporate monitoring system
that is built upon deployment personnel rosters and monitored weekly
by the Army Surgeon General. The Air Force is now receiving monthly
deployment health surveillance compliance reports from its medical
treatment facilities, and has scheduled a special compliance study
through the Air Force Inspection Agency in fiscal year 2004. Navy fleet
commanders have implemented their own quality assurance programs, with
anticipation of standardization through centralized automated systems.
And the Marine Corps has also established unit/command
quality assurance procedures. We view these actions as responsive to
our recommendation and commend the department for taking quick action
to address the compliance issues we found during our audit. However, it
remains to be seen how effective these activities will be in ensuring
that force health protection and surveillance policies are implemented
for all servicemembers.
We are sending copies of this report to the Secretary of Defense and
the Secretaries of the Army and the Air Force. We will also make copies
available to others upon request. In addition, the report is available
at no charge on GAO's Web site at http://www.gao.gov.
If you or your staff have any questions regarding this report, please
contact me on (757) 552-8100. Key contributors to this report are
listed in appendix III.
Neal P. Curtin,
Director
Defense Capabilities and Management:
Signed by Neal P. Curtin:
[End of section]
Appendix I: Scope and Methodology:
To meet our objectives, we interviewed responsible officials and
reviewed pertinent documents, reports, and information related to force
health protection and deployment health surveillance requirements
obtained from officials at the Office of the Assistant Secretary of
Defense for Health Affairs; the Office of the Deputy Assistant
Secretary of Defense for Force Health Protection and Readiness; the
Office of the Assistant Secretary of Defense for Reserve Affairs; the
Joint Staff; the Marine Corps Force Health Protection Office; and the
Offices of the Surgeons General for the Army and Air Force Headquarters
in the Washington, D.C., area. We also performed additional work at the
Deployment Health Support Directorate, Falls Church, Virginia; the U.S.
Army Center for Health Promotion and Preventive Medicine, Aberdeen,
Maryland; the Armed Forces Medical Intelligence Center, Fort Dietrick,
Maryland; the Army Medical Surveillance Activity, Walter Reed Army
Medical Center, Washington, D.C.; the Navy Environmental Health Center
in Portsmouth, Virginia; the Defense Manpower Data Center in Monterey,
California; and the U.S. Central Command and the U.S. Special
Operations Command at MacDill Air Force Base, Tampa, Florida.
To determine whether the military services were meeting DOD's force
health protection and surveillance requirements for servicemembers
deploying in support of OEF and OJG, we identified DOD and each
service's overall deployment health surveillance policies. We also
obtained the specific force health protection and surveillance
requirements applicable to all servicemembers deploying to Central Asia
in support of OEF from the U.S. Central Command and these requirements
for all servicemembers deploying to Kosovo in support of OJG from the
U.S. European Command. We tested the implementation of these
requirements at selected Army and Air Force installations. To identify
locations within each service where we would test implementation of the
policies, the Assistant Secretary of Defense for Health Affairs
requested the services to identify, by military installation, the
number of active duty servicemembers who met the following criteria:
* For OEF, those servicemembers who deployed to Central Asia for 30 or
more continuous days to areas without permanent U.S. military treatment
facilities following September 11, 2001, and redeployed back to their
home unit by May 31, 2002.
* For OJG, those servicemembers who deployed to Kosovo for 30 or more
continuous days to areas without permanent U.S. military treatment
facilities from January 1, 2001, and redeployed back to their home unit
by May 31, 2002.
Based on deployment data obtained from the services, we decided to
limit our testing of the force health protection and surveillance
policy implementation to selected Army and Air Force military
installations with the largest numbers of servicemembers meeting our
selection criteria (described above). We limited our review of medical
records for servicemembers deploying in support of OJG to the two Army
locations. We decided not to review Navy installations because there
were only small numbers of servicemembers who met our selection
criteria. We decided not to review Marine Corps installations because
officials at the Marine Corps headquarters had difficulty identifying
the number of servicemembers who went ashore 30 or more continuous days
consistent with our selection criteria.
The largest deployers for OEF and OJG were selected and are
listed below:
OEF:
* 10th Mountain Division, Fort Drum, N.Y.
* 101st Airborne Division, Fort Campbell, Ky.
* Travis Air Force Base, Calif.
* Hurlburt Field, Fla.
OJG:
* 10th Mountain Division, Fort Drum, N.Y.
* 101st Airborne Division, Fort Campbell, Ky.
For our medical records review, we selected statistical samples of
servicemembers at the selected installations to be representative of
those deploying from those military installations for those specific
operations.
For various reasons, medical records were not always available for
review. We, therefore, sampled without replacement, to choose
additional records when we were unable to meet our sampling threshold
of cases for review. Specifically, there were five reasons identified
for not being able to physically secure the servicemember's medical
record for review:
1. Charged to patient. When a patient visits a clinic (on-post or
off-post), the medical record is physically given to the patient. The
procedure is that the medical record will be returned by the patient
following their clinic visit.
4. Expired term of service. Servicemember separates from the military
and their medical record is sent to St. Louis, Missouri, and therefore
not available for review.
5. Record is not accounted for by the medical records department. No
tracking sheet is in the file system to indicate the patient has
checked it out or otherwise. (Note: There were not any cases for which
the medical record could not be accounted.):
6. Permanent change of station. Servicemember is still in the military,
but has transferred to another base. Medical record transfers with the
servicemember.
7. Temporary duty off site. Servicemember has left military
installation, but is expected to return. The temporary duty is long
enough to warrant that the medical record accompany the servicemember.
The sample size for deployments was determined to provide 95 percent
confidence with a 5-percent precision. The number of servicemembers in
our samples and the applicable universe of servicemembers for the OEF
and OJG deployments at the installations visited are shown in table 2.
Table 2: Servicemember Sample Sizes at Each Visited Installation:
[See PDF for image]
[A] In order to obtain a larger universe of servicemembers from which
to select medical records for review, we extended our date for
redeployment to home unit from May 31, 2002, to October 31, 2002.
[End of table]
At Fort Campbell, there were only 333 servicemembers identified as
having met our criteria based on a redeployment date of May 31, 2002;
however, only 8 charts were available for review due to rotation of
soldiers to other military locations or departure from the military. It
was, therefore, necessary to extend our redeployment date to October
31, 2002. Doing so provided an additional 2,953 servicemembers who met
all criteria except for a redeployment by May 31, 2002. At Fort
Campbell, there were 92 servicemembers who deployed in support of OJG
and met our selection criteria if we extended the redeployment date to
October 31, 2002. Because the number of servicemembers for OJG at Fort
Campbell was small, we reviewed the medical records for all of
servicemembers who were still at Fort Campbell.
At each sampled location, we examined servicemember medical records for
evidence of the following force health protection and deployment
health-related documentation required by DOD's force health protection
and deployment health surveillance policies:
* Pre-and post-deployment health assessments,
* Tuberculosis screening test (within 1 year of deployment for OEF and
2 years for OJG):
* Pre-deployment immunizations:
* hepatitis A;
* influenza (within 1 year of deployment);
* measles, mumps, and rubella;
* meningococcal (within 5 years of deployment);
* polio;
* tetanus-diphtheria (within 10 years of deployment);
* typhoid (within 5 years of deployment); and:
* yellow fever (within 10 years of deployment), not required for OJG.
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 that
installation medical personnel check all possible sources for missing
pre-and post-deployment health assessments and immunizations. These
sources included the Army's Soldier Readiness Check folders and
automated immunization sources, including the Army's Medical Protection
System (MEDPROS) and the Air Force's Comprehensive Immunization
Tracking Application (CITA). We checked all known possible sources for
the existence of deployment health assessments related to
servicemembers in our samples. In those instances where we did not find
a deployment health assessment, we concluded that the assessments were
not completed. Furthermore, installation officials were unable to
logistically access the servicemembers' individual records of
immunizations, commonly referred to as yellow-shot records that may
have provided documentation for missing immunizations. Consequently,
our analyses of the immunization records was based on our examination
of the servicemember's permanent medical record and immunizations that
were in the Army's MEDPROS and the Air Force's CITA. In analyzing our
review results at each location, we considered documentation from all
identified sources (e.g., servicemember's medical record, soldier
readiness check folder, Army Medical Surveillance Activity, and
immunization tracking systems) in presenting data on compliance with
deployment health surveillance policies.
To identify whether required blood serum specimens were in storage
at the Armed Services Serum Repository, we requested that the Army
Medical Surveillance Activity staff query the Repository to identify
whether the servicemembers in our samples had a blood serum sample
in the repository and the date of the specimen.
To determine whether the Army and Air Force are documenting in-theater
medical interventions in servicemembers' medical records, we requested,
at each installation visited for medical records review, the patient
sign-in logs for in-theater medical care providers, namely the Army's
battalion aid station and the Air Force's expeditionary medical
support, when they were deployed to central Asia in support of OEF and
for the two Army installations we visited that deployed in support of
OJG. Officials were unable to locate or access the logs at all of our
selected installations except for Fort Drum for the OEF deployment.
Consequently, we were able to perform our planned examination for this
objective at only Fort Drum for the OEF deployment. From these logs, we
selected a random sample of 36 patient visits from one battalion aid
station and 18 patient visits from another battalion aid station. We
did not attempt to judge the importance of the patient visit in making
our selections. For the selected patient visits, we then reviewed the
servicemember's medical record for any documentation--such as the
Army's Standard Form 600--of the servicemember's visit to the battalion
aid station.
To determine whether the Army and Air Force's deployment health-related
records are retained and maintained in a centralized location, we
requested that officials at the Army Medical Surveillance Activity
(AMSA) query the AMSA database for the servicemembers included in our
samples at the selected Army and Air Force installations. For
servicemembers in our samples, AMSA officials provided us with copies
of deployment health assessments and immunization data found in the
AMSA database. We analyzed the completeness of the AMSA database by
comparing the deployment health assessments and the pre-deployment
immunization data we found during our medical records review with those
in the AMSA database. Since Air Force special operations force units
use the Hurlburt Field, we also requested the U.S. Special Operations
Command (SOCOM) to query their Special Operation Forces Deployment
Health Surveillance System database for servicemembers in our sample at
Hurlburt Field for deployment health assessments and pre-deployment
immunization data. We then compared the data identified from the SOCOM
and AMSA queries with the data we found during our medical records
review.
To determine whether DOD has corrected problems related to the accuracy
and completeness of databases reflecting which servicemembers deployed
to certain locations, we interviewed officials within the Deployment
Health Support Directorate and the Defense Manpower Data Center and
reviewed documentation related to the completeness of deployment
databases and planned improvements in capabilities.
Our review was performed from June 2002 through July 2003 in accordance
with generally accepted government auditing standards.
[End of section]
Appendix II: Comments from the Department of Defense:
HEALTH AFFAIRS:
THE ASSISTANT SECRETARY OF DEFENSE:
WASHINGTON, D. C. 20301-1200:
SEP 11 2003:
Mr. Neal P. Curtin Director:
Defense Capabilities and Management U. S. General Accounting Office
Washington, DC 20548:
Dear Mr. Curtin:
This is the Department of Defense (DoD) response to the GAO draft
report, "DEFENSE HEALTH CARE: Quality Assurance Process Needed to
Improve Force Health Protection and Surveillance," dated August 12,
2003, (GAO Code 350216/GAO-03-1041). The Department concurs with the
GAO draft report. Comments to the recommendation are enclosed.
Protecting the health of military personnel before, during, and after
their deployment is a paramount concern of the Department of Defense
and my office. Working with other OSD offices as well as the Military
Services, the Joint Staff, and the Combatant Commands, my office has
already established a quality assurance program for pre-and post-
deployment health assessments. This program monitors pre-and post-
deployment health assessments and blood samples being archived
electronically at the Army Medical Surveillance Activity (AMSA) and
assures that indicated referrals on the post-deployment health
assessment are being conducted by all the Services. The Deployment
Health Support Directorate has been monitoring the flow of pre-and
post-deployment health assessments going to AMSA on a weekly basis
since June 2003. We have also implemented several recent force health
protection initiatives such as establishing an automated theater-wide
health surveillance data collection and reporting system and developing
DoD-wide individual medical readiness standards and reporting metrics.
These initiatives will serve as the foundation of a broader more
comprehensive force health protection and surveillance quality
assurance program which will ensure compliance with DoD-wide force
health protection policies, programs and metrics.
The Department appreciates the opportunity to comment on the GAO draft
report. Our primary point of contact is Ellen Embrey, DASD/Force Health
Protection and Readiness, at 703-578-8504.
Sincerely,
Signed by:
William Winkenwerder, Jr., MD:
Enclosure: As stated:
GAO DRAFT REPORT DATED AUGUST 12, 2003 GAO-03-1041 (GAO CODE 350216):
"DEFENSE HEALTH CARE: Quality Assurance Process Needed to Improve Force
Health Protection and Surveillance":
Department of Defense Comments to the GAO Recommendation:
RECOMMENDATION: The GAO recommended that the Secretary of Defense
direct the Assistant Secretary of Defense/Health Affairs to establish
an effective quality assurance program as required by section 795 of
Public Law 105-85 (10 U.S.C. 1074f). (p.22/GAO Draft Report):
DoD RESPONSE: The Department concurs that an effective quality
assurance program is essential to ensure compliance with force health
protection and surveillance requirements.
The ASD/Health Affairs has already established a quality assurance
program for pre-and post-deployment health assessments. This program
monitors pre-and post-deployment health assessments and blood samples
being archived electronically at Army Medical Surveillance Activity
(AMSA) and assures that indicated referrals from the post-deployment
health assessment are being conducted. The Deployment Health Support
Directorate has been monitoring the flow of pre-and post-deployment
health assessments going to AMSA on a weekly basis since June 2003.
The ASD/Health Affairs is also establishing and coordinating the
parameters of a DoD force health protection and surveillance QA program
with the Services. The elements of this comprehensive program include:
* The DASD/Force Health Protection and Readiness, on behalf of the ASD/
Health Affairs, is responsible for developing and executing the DoD
Force Health Protection and Health Surveillance Quality Assurance
Program.
* An automated theater-wide health surveillance data collection and
reporting system has been established. Theater-wide health surveillance
data is now available on a near real-time basis to operational
commanders and OSD medical leadership. The joint-Service system was
established in January of this year and includes daily reports and
weekly analyses prepared by the Air Force Institute for Operational
Health.
* Individual medical readiness standards and metrics have been developed
to provide operational commanders, Service headquarters, and OSD staff
with the ability to monitor individual medical readiness across six key
elements. Reporting by the Services to the Force Health Protection
Council began in July.
* Metrics indicating degree of Service and Combatant Command compliance
with ongoing theater health surveillance reporting requirements will be
assessed at least monthly.
Metrics indicating degree of Service compliance to individual medical
readiness reporting requirements will be assessed at least quarterly
based on inputs from the Services.
Periodic audits of each Service QA program performance will be
scheduled and performed. Specific focus will be on assurance that
medical records have been appropriately updated with relevant
deployment-related health and medical data. Periodic visits to Service
installations and Combatant Command theaters will be conducted to
assess effectiveness of their Force Health Protection programs,
processes, and procedures.
Recommendations derived from the DoD quality assurance program
assessments, audits, and visits will be brought to the Force Health
Protection Council prior to submission to the ASD/Health Affairs for
approval.
The Services have implemented their QA programs. The Army has developed
automated versions of the pre-and post-deployment health assessment
forms, and has established a corporate monitoring system that is built
upon deployment personnel rosters and monitored weekly by the Army
Surgeon General. The Air Force Surgeon General is now receiving monthly
deployment health surveillance compliance reports from its medical
treatment facilities, and has scheduled an Eagle Look special
compliance study through the Air Force Inspection Agency in FY2004.
Navy fleet commanders have implemented their own QA programs, with
anticipation of standardization through centralized automated systems.
The Marine Corps has also established unit/command quality assurance
procedures.
The DASD/Force Health Protection and Readiness will formally publish
the Department's force health protection and surveillance quality
assurance program policies by the end of the current calendar year. The
ODASD/FHP&R and the Deployment Health Support Directorate will execute
the DoD force health protection quality assurance program.
[End of section]
Appendix III: GAO Contact and Staff Acknowledgments:
GAO Contact:
Clifton E. Spruill (202) 512-4531:
Acknowledgments:
In addition to the individual named above, Steve Fox, Rebecca Beale,
Lynn Johnson, William Mathers, Terry Richardson, Kristine Braaten,
Grant Mallie, Herbert Dunn, and R.K. Wild made key contributions to
this report.
FOOTNOTES
[1] See 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] Problems cited in our May 1997 report included the following:
required medical assessments not prepared for many servicemembers;
incomplete medical record keeping; an incomplete centralized health
assessment database; and an inaccurate personnel deployment database.
[4] In April 2003, we reported 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] 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.
[6] GAO/NSIAD-97-136.
[7] Section 765 of Pub. L. No. 105-85 amended title 10 of the United
States Code by adding section 1074f.
[8] DOD Instruction 6490.3, "Implementation and Application of Joint
Medical Surveillance for Deployments," August 7, 1997.
[9] Under Secretary of Defense for Personnel and Readiness Memorandum,
"Enhanced Post-Deployment Health Assessments," April 22, 2003.
[10] 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.
[11] Office of the Chairman, The Joint Chiefs of Staff, Memorandum MCM-
0006-2, "Updated Procedures for Deployment Health Surveillance and
Readiness," February 1, 2002.
[12] The Joint Staff, Joint Staff Memorandum MCM-251-98.
[13] Office of the Chairman, The Joint Chiefs of Staff, Memorandum MCM-
0006-02, "Updated Procedures for Deployment Health Surveillance and
Readiness," February 1, 2002.
[14] U.S. Central Command, "Personnel Policy Guidance for U.S.
Individual Augmentation Personnel in Support of Operation Enduring
Freedom," October 3, 2001.
[15] Headquarters U.S. European Command, "Greece and the Balkans: Force
Health Protection Guidance," January 4, 2002.
[16] U.S. Central Command, "Personnel Policy Guidance for U.S.
Individual Augmentation Personnel in Support of Operation Enduring
Freedom," October 3, 2001.
[17] Headquarters U.S. European Command, "Greece and the Balkans: Force
Health Protection Guidance," January 4, 2002.
[18] 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.
[19] Office of the Chairman, The Joint Chiefs of Staff, Memorandum MCM-
0006-02, "Updated Procedures for Deployment Health Surveillance and
Readiness," February 1, 2002.
[20] Army Regulation 40-66, "Medical Records Administration," October
23, 2002, and Air Force Instruction 41-210, "Health Services Patient
Administration Functions," October 1, 2000.
[21] Office of the Chairman, The Joint Chiefs of Staff, Memorandum MCM-
0006-02, "Updated Procedures for Deployment Health Surveillance and
Readiness," February 1, 2002.
[22] 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.
[23] 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).
[24] 10 U.S.C. sec. 1074f(d).
[25] 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 Surgeons General or their
representatives about our interim review results.
[26] H.R. Rep. No. 108-106 at 336 (2003).
[27] Under Secretary of Defense for Personnel and Readiness Memorandum,
"Enhanced Post-Deployment Health Assessments," April 22, 2003.
[28] GAO/NSIAD-97-136.
[29] Institute of Medicine, Protecting Those Who Serve: Strategies to
Protect the Health of Deployed U.S. Forces (National Academy Press,
Washington, D.C.: 2000).
[30] DOD Instruction 6490.3, "Implementation and Application of Joint
Medical Surveillance for Deployments," August 7, 1997.
[31] Office of the Chairman, The Joint Chiefs of Staff, Memorandum MCM-
0006-02, "Updated Procedures for Deployment Health Surveillance and
Readiness," February 1, 2002.
[32] 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.
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