Defense Health Care
Comprehensive Oversight Framework Needed to Help Ensure Effective Implementation of a Deployment Health Quality Assurance Program Gao ID: GAO-07-831 June 22, 2007Overseas deployments expose servicemembers to a number of potential risks to their health and well-being. However, since the mid-1990s, GAO has highlighted shortcomings with respect to the Department of Defense's (DOD) ability to assess the medical condition of servicemembers both before and after their deployments. Following GAO's May 1997 report, Congress enacted legislation (10 U.S.C. 1074f) that required the Secretary of Defense to establish a medical tracking system for assessing the medical condition of servicemembers before and after deployments. GAO was asked to determine (1) whether DOD has established a medical tracking system to comply with requirements of 10 U.S.C. 1074f pertaining to pre- and postdeployment medical examinations, and (2) the extent to which DOD has effectively implemented a deployment health quality assurance program as part of its medical tracking system. In conducting this review, GAO analyzed pertinent documents and interviewed DOD officials.
DOD has established a system to comply with the requirements of 10 U.S.C. 1074f to perform predeployment and postdeployment medical examinations through a variety of deployment health activities. For example, DOD's system includes the use of pre- and postdeployment health assessment questionnaires along with reviews of servicemembers' medical records. The pre- and postdeployment health assessment questionnaires ask servicemembers to respond to a series of questions about their current medical and mental health conditions and any medical concerns they might have. Prior to deploying, the predeployment questionnaire and servicemembers' medical records are to be reviewed by a health care provider to confirm whether servicemembers have met applicable deployment health requirements. Also, prior to or after redeploying, the postdeployment questionnaires are to be reviewed by a health care provider, along with servicemembers' medical records, to determine whether additional clinical evaluation or treatment is needed. DOD has established a deployment health quality assurance program as part of its medical tracking system, but does not have a comprehensive oversight framework to help ensure effective implementation of the program. Thus, DOD does not have the information it needs to evaluate the effectiveness and efficiency of its deployment health quality assurance program. DOD policy specifies four elements of the program: (1) monthly reports on active and reserve component servicemembers' deployment health data from the Army Medical Surveillance Activity (AMSA), (2) quarterly reports on service-specific quality assurance programs, (3) DOD site visits to military installations, and (4) an annual report on the program. DOD guidance requires each of the services to create their own quality assurance programs based on these elements. However, GAO found weaknesses in each of these elements. For example, DOD's policy does not contain specific reporting requirements or performance measures that require AMSA to provide critical information needed to assess departmentwide compliance with deployment health requirements, such as tracking the total number of servicemembers who deploy overseas or return home during a specific time period. Also, DOD does not have quality controls in place to ensure the accuracy or completeness of the information it collects during site visits to military installations. Without a comprehensive oversight framework, DOD is not well-positioned to determine or assure Congress that active and reserve component servicemembers are medically and mentally fit to deploy and to determine their medical and mental condition upon return. Having an effective deployment health quality assurance program is critically important given DOD's long-standing problems with assessing the medical condition of servicemembers before and after their deployments. Such a program has become even more important in the current environment, where active and reserve component servicemembers continue to deploy overseas in significant numbers in support of ongoing military operations in Afghanistan and Iraq.
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Director: Team: Phone:GAO-07-831, Defense Health Care: Comprehensive Oversight Framework Needed to Help Ensure Effective Implementation of a Deployment Health Quality Assurance Program
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Report to the Ranking Member, Subcommittee on National Security and
Foreign Affairs, Committee on Oversight and Government Reform, House of
Representatives:
United States Government Accountability Office:
GAO:
June 2007:
Defense Health Care:
Comprehensive Oversight Framework Needed to Help Ensure Effective
Implementation of a Deployment Health Quality Assurance Program:
GAO-07-831:
GAO Highlights:
Highlights of GAO-07-831, a report to the Ranking Member, Subcommittee
on National Security and Foreign Affairs, Committee on Oversight and
Government Reform, House of Representatives
Why GAO Did This Study:
Overseas deployments expose servicemembers to a number of potential
risks to their health and well-being. However, since the mid-1990s, GAO
has highlighted shortcomings with respect to the Department of
Defense‘s (DOD) ability to assess the medical condition of
servicemembers both before and after their deployments. Following GAO‘s
May 1997 report, Congress enacted legislation (10 U.S.C. § 1074f) that
required the Secretary of Defense to establish a medical tracking
system for assessing the medical condition of servicemembers before and
after deployments. GAO was asked to determine (1) whether DOD has
established a medical tracking system to comply with requirements of 10
U.S.C. § 1074f pertaining to pre- and postdeployment medical
examinations, and (2) the extent to which DOD has effectively
implemented a deployment health quality assurance program as part of
its medical tracking system. In conducting this review, GAO analyzed
pertinent documents and interviewed DOD officials.
What GAO Found:
DOD has established a system to comply with the requirements of 10
U.S.C. § 1074f to perform predeployment and postdeployment medical
examinations through a variety of deployment health activities. For
example, DOD‘s system includes the use of pre- and postdeployment
health assessment questionnaires along with reviews of servicemembers‘
medical records. The pre- and postdeployment health assessment
questionnaires ask servicemembers to respond to a series of questions
about their current medical and mental health conditions and any
medical concerns they might have. Prior to deploying, the predeployment
questionnaire and servicemembers‘ medical records are to be reviewed by
a health care provider to confirm whether servicemembers have met
applicable deployment health requirements. Also, prior to or after
redeploying, the postdeployment questionnaires are to be reviewed by a
health care provider, along with servicemembers‘ medical records, to
determine whether additional clinical evaluation or treatment is
needed.
DOD has established a deployment health quality assurance program as
part of its medical tracking system, but does not have a comprehensive
oversight framework to help ensure effective implementation of the
program. Thus, DOD does not have the information it needs to evaluate
the effectiveness and efficiency of its deployment health quality
assurance program. DOD policy specifies four elements of the program:
(1) monthly reports on active and reserve component servicemembers‘
deployment health data from the Army Medical Surveillance Activity
(AMSA), (2) quarterly reports on service-specific quality assurance
programs, (3) DOD site visits to military installations, and (4) an
annual report on the program. DOD guidance requires each of the
services to create their own quality assurance programs based on these
elements. However, GAO found weaknesses in each of these elements. For
example, DOD‘s policy does not contain specific reporting requirements
or performance measures that require AMSA to provide critical
information needed to assess departmentwide compliance with deployment
health requirements, such as tracking the total number of
servicemembers who deploy overseas or return home during a specific
time period. Also, DOD does not have quality controls in place to
ensure the accuracy or completeness of the information it collects
during site visits to military installations. Without a comprehensive
oversight framework, DOD is not well-positioned to determine or assure
Congress that active and reserve component servicemembers are medically
and mentally fit to deploy and to determine their medical and mental
condition upon return. Having an effective deployment health quality
assurance program is critically important given DOD‘s long-standing
problems with assessing the medical condition of servicemembers before
and after their deployments. Such a program has become even more
important in the current environment, where active and reserve
component servicemembers continue to deploy overseas in significant
numbers in support of ongoing military operations in Afghanistan and
Iraq.
What GAO Recommends:
GAO is recommending that DOD develop a comprehensive oversight
framework with reporting requirements and results-oriented performance
measures to improve the implementation of its deployment health quality
assurance program. In reviewing a draft of this report, DOD concurred
with GAO‘s recommendations.
[Hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-07-831].
To view the full product, including the scope and methodology, click on
the link above. For more information, contact Brenda S. Farrell at
(202) 512-3604 or farrellb@gao.gov.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
DOD Has a System in Place to Comply with Requirements for Deployment
Medical Examinations:
DOD Has Established a Deployment Health Quality Assurance Program, but
the Lack of a Comprehensive Oversight Framework Hampers Effective
Implementation:
Conclusions:
Recommendations for Executive Action:
Agency Comments and Our Evaluation:
Appendix I: Scope and Methodology:
Appendix II: Pre-and Postdeployment Health Assessment Questionnaires:
Appendix III: Individual Medical Readiness:
Appendix IV: Comments from the Department of Defense:
Appendix V: GAO Contact and Staff Acknowledgments:
Related GAO Products:
Abbreviations:
AMSA: Army Medical Surveillance Activity:
DHSD: Deployment Health Support Directorate:
DMSS: Defense Medical Surveillance System:
DNA: Deoxyribonucleic Acid:
DOD: Department of Defense:
GPRA: Government Performance and Results Act of 1993:
HIV: Human Immunodeficiency Virus:
IPV: Inactivated Poliovirus:
MMR: Measles, Mumps, and Rubella:
United States Government Accountability Office:
Washington, DC 20548:
June 22, 2007:
The Honorable Christopher Shays:
Ranking Member:
Subcommittee on National Security and Foreign Affairs:
Committee on Oversight and Government Reform:
House of Representatives:
Dear Mr. Shays:
Overseas deployments expose servicemembers to a number of potential
risks to their health and well-being. However, since the mid-1990s we
have been reporting on DOD's shortcomings with respect to assessing the
medical condition of servicemembers both before and after their
deployments. Following our May 1997 report,[Footnote 1] Congress
enacted legislation[Footnote 2] that required the Secretary of Defense
to establish a medical tracking system to assess the medical condition
of servicemembers before and after deployments to locations outside the
United States. The elements of the system, as required by the law,
included, among other things, the use of pre-and postdeployment medical
examinations. As part of the system, the law also required DOD to
establish a quality assurance program to evaluate the success of the
system in ensuring that servicemembers receive pre-and postdeployment
medical examinations and that record-keeping requirements with respect
to the system are met. However, our September 2003 report highlighted
many instances of noncompliance with DOD's deployment health
requirements and reiterated the need for DOD to establish a quality
assurance program to ensure that these requirements are met.[Footnote
3] In September 2004, we reported similar findings for reserve
forces.[Footnote 4] Further, our November 2004 report raised concerns
that overall compliance with DOD's force health protection and
surveillance policies for servicemembers who deployed in support of
Operation Iraqi Freedom varied by service, by installation, and by
policy requirement.[Footnote 5] More recently, in October 2005 we
reported that evidence suggested that some reserve component members
have deployed into theater with preexisting medical conditions that
could not be adequately addressed in-theater.[Footnote 6]
In light of these long-standing problems, you asked us to examine DOD's
compliance with the legislative requirement to perform pre-and
postdeployment medical examinations on servicemembers and DOD's
deployment health quality assurance program. This report addresses (1)
whether DOD has established a medical tracking system to comply with
requirements of 10 U.S.C. § 1074f pertaining to pre-and postdeployment
medical examinations, and (2) the extent to which DOD has effectively
implemented a deployment health quality assurance program as part of
its medical tracking system.
To address our objectives, we obtained and reviewed pertinent
documents, reports, and information related to DOD's deployment health
requirements and deployment health quality assurance program from
officials at the Assistant Secretary of Defense for Health Affairs,
Deployment Health Support Directorate (DHSD); the Offices of the
Surgeons General for the Army, Air Force, and Navy; the Army Medical
Surveillance Activity (AMSA); and the Combined Fleet Forces Command and
Naval Environmental Health Center. To determine whether DOD has
established a medical tracking system to comply with requirements of 10
U.S.C. § 1074f pertaining to pre-and postdeployment medical
examinations, we reviewed 10 U.S.C. § 1074f to identify system
requirements and DOD policies and other guidance to identify the
measures DOD uses to establish the medical condition of servicemembers
as part of this system. In addition, we obtained a legal opinion from
DOD's Office of General Counsel regarding DOD's compliance with the
requirement of 10 U.S.C. § 1074f to perform pre-and postdeployment
medical examinations. To determine the extent to which DOD has
effectively implemented a deployment health quality assurance program
as part of its medical tracking system, we obtained and analyzed
relevant DOD policies to identify requirements of the program. We also
interviewed key officials with DHSD and the services' Offices of the
Surgeon General to obtain a comprehensive understanding of the
processes, procedures, and controls used for monitoring and overseeing
the deployment health quality assurance program. We obtained and
analyzed the results of site visits conducted by DHSD in calendar years
2005 and 2006. To determine the reliability of DOD's quality assurance
program reports, we obtained and analyzed data collection instruments
and other documentation used to record, summarize, and report the
services' compliance with deployment health requirements. We also
discussed with responsible DOD officials, including representatives
from the military services, their methodology for ensuring that
information collected and reported is as accurate and reliable as
possible. Where possible, we tested data by comparing information from
the data collection instruments or summary documents with available
source documents. We identified issues of inconsistency and
incompleteness in DOD's data and, therefore, determined the data to be
insufficiently reliable for the purpose of assessing compliance with
deployment health requirements and we are making a recommendation to
address this issue accordingly. In conducting our review, we limited
our focus to the procedures that DOD has in place to medically assess
servicemembers before and after their deployments. Other issues, such
as recent controversies associated with alleged deployments of
medically unfit servicemembers to Iraq, did not fall within the scope
of this review. These issues will be addressed as part of a separate
review. We performed our work from September 2006 through May 2007 in
accordance with generally accepted government auditing standards. For
more detailed information on our scope and methodology, see appendix I.
Results in Brief:
DOD has established a medical tracking system to comply with the
requirements of 10 U.S.C. § 1074f to perform predeployment and
postdeployment medical examinations through a variety of deployment
health activities. This section of the law requires the Secretary of
Defense to establish a system to assess the medical condition of
servicemembers deployed outside the United States. According to the
law, the system is to include the use of medical examinations,
including an assessment of mental health and the drawing of blood
samples, both before and after deployment. DOD has established a
medical tracking system to assess the medical condition of
servicemembers intended to ensure that only medically and mentally fit
servicemembers deploy outside of the United States. For example, DOD's
system includes the use of pre-and postdeployment health assessment
questionnaires and reviews of servicemembers' medical records (e.g.,
physical examinations, immunizations, dental history). The
predeployment health assessment questionnaires, which are to be
completed no earlier than 60 days prior to deployment, are a series of
questions about servicemembers' current medical (including dental) and
mental health conditions, including prescriptions, vision issues, and
any medical concerns servicemembers might have. These questionnaires
and servicemembers' medical records are to be reviewed by a health care
provider to confirm whether servicemembers have received standard and
theater-specific immunizations and recent medical (physical)
examinations that identify diseases and medical conditions that may
prevent them from deploying. Based on the responses to the
predeployment questionnaires and the review of the medical records,
servicemembers may be referred for further testing and evaluation prior
to deployment. Also, within 30 days prior to or after
redeploying,[Footnote 7] servicemembers are to complete the
postdeployment health assessment questionnaire. The postdeployment
questionnaires are to be reviewed by a health care provider, along with
servicemembers' medical records, to evaluate current health status,
deployment experiences, environmental exposures, and health concerns
related to their deployments. Based on these reviews, the health care
provider may recommend additional clinical evaluation or treatment as
needed. In response to an inquiry from our office, DOD's Office of
General Counsel explained that the health assessments the department
performs meet the requirement of 10 U.S.C. § 1074f for pre-and
postdeployment medical examinations. We conclude that DOD's
interpretation is reasonable.
DOD has also established a deployment health quality assurance program
as part of its medical tracking system, but lacks a comprehensive
oversight framework to help ensure effective implementation of the
program. Thus, DOD does not have the information it needs to evaluate
the effectiveness and efficiency of its quality assurance program. The
Government Performance and Results Act of 1993[Footnote 8] (GPRA)
provides federal agencies with a framework for developing oversight,
which includes establishing reporting requirements and performance
measures. DOD's deployment health quality assurance program policy
specifies four elements of DOD's program: (1) monthly reports on active
and reserve component servicemembers' deployment health assessment data
from centralized databases maintained by AMSA, (2) quarterly reports on
service-specific deployment health quality assurance programs, (3)
periodic visits to military installations to complement and validate
the services' deployment health programs, and (4) an annual report to
the Assistant Secretary of Defense for Health Affairs on the
department's quality assurance program. DOD guidance requires each of
the services to create their own quality assurance programs based on
these elements. While DOD has established a program that includes these
four elements, DOD cannot determine whether the program has been
effectively implemented because DOD does not have a comprehensive
oversight framework with all the specific reporting requirements and
necessary performance measures to evaluate the services' compliance
with deployment health requirements or to help ensure that the services
are implementing the program consistently.
* Monthly AMSA reports: Although DOD requires monthly reports from AMSA
on servicemembers' deployment health data, it does not provide AMSA
with results-oriented performance measures and specific reporting
requirements that would enable DOD to determine the departmentwide
compliance with deployment health requirements. For example, DOD's
policy does not require that AMSA provide critical information needed
to assess compliance with deployment health requirements, such as the
total number of servicemembers that deployed/redeployed during the
reporting period. Without knowing the total number of servicemembers
deployed/redeployed, DOD cannot determine the extent to which
servicemembers completed the required pre-and postdeployment health
assessment questionnaires.
* Quarterly reports on the services' programs: While DOD's policy
requires that the services report on service-specific compliance with
deployment health requirements in their quarterly reports, DOD has not
enforced this requirement. Consequently, each service is choosing to
selectively report on requirements, which prevents the department from
having a complete picture/assessment of compliance with deployment
health requirements across the services. For example, while the Army
reports on only a sample of servicemembers who deploy or redeploy
during the reporting period, the Air Force reports on the total number
of servicemembers who deploy or redeploy during the reporting period.
However, the Army's report includes all overseas locations of
deployment whereas the Air Force only reports on deployments in support
of Operations Iraqi Freedom or Enduring Freedom.
* Site visits: While DHSD conducts four visits per year to military
installations to assess the services' deployment health quality
assurance programs, it does not have quality controls in place to
ensure the accuracy or completeness of the information it collects.
DHSD representatives use data collection instruments to facilitate
their program reviews, but DHSD officials told us that none of these
instruments are reviewed by an independent or second reviewer.
Independent reviews are a key aspect of quality controls that reduce
the risk of errors in a quality assurance program. In our review of
calendar years 2005 and 2006 DHSD site visit reports and supporting
documentation, we found instances of incomplete data including missing
dates for when pre-and postdeployment health assessment questionnaires
were administered. Moreover, we found that DHSD did not always adhere
to DOD's deployment health requirements when assessing the programs.
For example, while not all servicemembers received blood draws upon
redeployment within the required time frame, DHSD made determinations
in their site visit reports that the services had adhered to the
requirements.
Because of these weaknesses, DOD's annual report does not provide DOD
and congressional decision makers with complete, comprehensive, and
accurate information to determine if the department is complying with
its own deployment health requirements. Moreover, DOD and congressional
decision makers are unable to determine whether DOD has effectively
implemented a quality assurance program to determine or assure Congress
that servicemembers are medically and mentally fit to deploy and to
determine their medical and mental condition upon return. Having an
effective deployment health quality assurance program is critically
important given DOD's long-standing problems with assessing the medical
condition of active and reserve component servicemembers both before
and after their deployments, and has become even more important in the
current environment, where these servicemembers continue to deploy
overseas in significant numbers in support of ongoing military
operations.
We are recommending that DOD develop a comprehensive oversight
framework with reporting requirements and results-oriented performance
measures to improve the implementation of its deployment health quality
assurance program. In written comments on a draft of this report, DOD
concurred with our recommendations. DOD's comments are reprinted in
appendix IV.
Background:
In November 1997, Congress included a provision in the National Defense
Authorization Act for Fiscal Year 1998[Footnote 9] that required the
Secretary of Defense to establish a medical tracking system for
servicemembers deployed overseas. Specifically, the legislation
required the following:
"(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."
The Assistant Secretary of Defense for Health Affairs has the
responsibility for establishing the overall policy and guidance
necessary for DOD to implement the required medical tracking system,
including the associated quality assurance program. Within the Office
of the Assistant Secretary of Defense for Health Affairs, the Deputy
Assistant Secretary of Defense for Force Health Protection and
Readiness has responsibility for the day-to-day operations and
management of both the medical tracking system and the quality
assurance program. It is then the responsibility of the Offices of the
Surgeons General of the Army, Navy, and Air Force to implement and
manage the day-to-day operations of the medical tracking system and the
quality assurance program within the respective services.
Our prior work has highlighted weaknesses in DOD's assessment of
servicemembers' health before and after deployment. In September 2003,
we reported that the Army and Air Force did not comply with DOD's force
health protection and surveillance requirements for many servicemembers
deploying in support of Operation Enduring Freedom in Central Asia and
Operation Joint Guardian in Kosovo.[Footnote 10] Specifically, our
review disclosed problems with the Army's and Air Force's
implementation of DOD's force health protection and surveillance
requirements in the following areas: (1) deployment health assessments,
(2) immunizations and other predeployment requirements, and (3) the
completeness of medical records and centralized data collection. Our
September 2003 report also raised concerns over a lack of DOD oversight
of departmentwide efforts to comply with health surveillance
requirements. Specifically, we reported that an effective quality
assurance program had not been established 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 to help ensure compliance
with force health protection and surveillance policies. We believed
that the lack of such a system was a major cause of the high rate of
noncompliance and thus recommended that the department establish an
effective quality assurance program to ensure that the military
services comply with the force health protection and surveillance
requirements for all servicemembers. The department concurred with our
recommendation, and in January 2004 began implementation of its
deployment health quality assurance program.
In September 2004, we reported similar issues related to DOD's ability
to effectively manage the health status of its reserve forces.[Footnote
11] Specifically we noted that DOD's centralized database had missing
and incomplete predeployment health assessment questionnaires because
not all of the required health information collected from reserve
component members had reached DOD's central data collection point. We
recommended that the Secretary of Defense take steps to ensure that
predeployment health assessment questionnaires are submitted to the
centralized data collection point as required. DOD concurred with our
recommendation and noted that revised guidance was currently in
coordination to clarify the requirement for submitting predeployment
health assessments to the centralized database.
In November 2004, we reported that overall compliance with DOD's force
health protection and surveillance policies for servicemembers who
deployed in support of Operation Iraqi Freedom varied by service, by
installation, and by policy requirement.[Footnote 12] At that time, we
did not evaluate the effectiveness of DOD's deployment health quality
assurance program because of the relatively short time of its
implementation.
Finally, in October 2005 we reported that evidence suggested that
reserve component members have deployed into theater with preexisting
medical conditions that could not be adequately addressed in-
theater.[Footnote 13] We also reported that DOD had limited visibility
over the health status of reserve component members after they are
called to duty and is unable to determine the extent of care provided
to those members deployed with preexisting medical conditions despite
the existence of various sources of medical information. We recommended
that the Secretary of Defense determine what preexisting medical
conditions should not be allowed into specific theaters of operations
and to take steps to ensure that each service component consistently
utilizes these as criteria for determining the medical deployability of
its reserve component members. We also recommended that the Secretary
of Defense explore using existing tracking systems to track those who
have treatable preexisting medical conditions in theater. DOD partially
concurred with our recommendation concerning the identification of
preexisting medical conditions that would preclude deployment and noted
that the services had made advances in identifying some preexisting
conditions that would preclude deployment, but also stated that due to
the ever-changing nature of theater of operations this list could never
be fully comprehensive or fully enforceable. DOD also concurred with
our recommendation pertaining to the use of existing tracking systems
to track treatable preexisting medical conditions. Specifically, DOD
indicated that ongoing refinements to these systems based on lessons
learned would improve the documentation of medical conditions
throughout the military services including information concerning
reserve members with preexisting conditions.
DOD Has a System in Place to Comply with Requirements for Deployment
Medical Examinations:
DOD has established a medical tracking system to comply with the
requirement of 10 U.S.C. § 1074f to perform predeployment and
postdeployment medical examinations through a variety of deployment
health activities, including the use of pre-and postdeployment health
assessment questionnaires along with reviews of servicemembers' medical
records. This section of the law requires the Secretary of Defense to
establish a medical tracking system to assess the medical condition of
servicemembers deployed outside the United States. According to section
1074f(b)(1), the system is to include the use of medical examinations,
including an assessment of mental health and the drawing of blood
samples, both before and after deployment.
In DOD's May 1998 report to Congress, the department outlined its
approach to establish a medical tracking system for servicemembers
deployed overseas.[Footnote 14] As part of this approach, DOD performed
medical examinations using predeployment and postdeployment health
assessment questionnaires, including an assessment of mental health and
drawing of blood samples, both before and after deployment. The
predeployment assessment consisted of a series of questions about the
servicemembers' current medical (including dental) and mental health
conditions, including prescriptions, vision issues, and any medical
concerns servicemembers might have. In 2002, DOD established the
requirement that the predeployment assessment was to be completed
within 30 days prior to deployment. The postdeployment assessment
consisted of a series of questions about the servicemembers medical and
mental health condition resulting from having been deployed. It was to
be completed prior to leaving the theater of operation or within 30
days of final departure from theater. Examples of the pre-and
postdeployment questionnaires can be found in appendix II.
In August 2006, DOD replaced and expanded its approach with a
comprehensive deployment health program.[Footnote 15] Within the
programs, DOD required the military services to perform a number of
activities designed to monitor servicemembers' health before and after
deployments, including the following:
* Predeployment Activities. First, servicemembers are required to
complete a predeployment health assessment questionnaire no earlier
than 60 days prior to deployment. Second, the questionnaires are
required to be reviewed by a health care provider[Footnote 16] to
determine whether the servicemember is fit to deploy. To make this
determination, the health care provider should review both the
servicemembers' medical records and responses to the questions. The
medical records are reviewed and evaluated against the following six
individual medical readiness elements: whether the servicemember has
(1) received an annual assessment for changes in health status; (2) any
deployment-limiting conditions such as pregnancy, asthma, severe
traumatic injuries with incomplete rehabilitation, etc; (3) oral
conditions that if not treated could result in dental emergencies; (4)
received all required immunizations; (5) received medical readiness
laboratory tests such as HIV testing and has current DNA samples on
file, (6) all required individual medical equipment. For more detailed
information about individual medical readiness requirements see
appendix III. Prior to deployment, DOD requires that any condition that
causes a servicemember to receive a failing mark in any of these six
elements be corrected. Corrective actions could include providing the
servicemember with required immunizations, screening for tuberculosis,
or drawing serum specimens. Based on the health care provider review
and the responses to specific questions on the assessment,
servicemembers may be referred, prior to deploying, to the appropriate
health care provider(s) for further testing and evaluation, if needed,
for medical conditions or concerns (e.g., cardiac, mental health). DOD
requires that the completed questionnaire be placed in the
servicemember's medical record and a copy be sent to AMSA for record
keeping.
* Postdeployment Activities. DOD requires that a postdeployment health
assessment questionnaire be completed during the period from 30 days
prior to and 30 days after redeployment. The completed form is to be
placed in the servicemember's medical record and a copy sent to AMSA.
In addition, a review of the servicemembers' medical records and a face-
to-face meeting with a trained health care provider[Footnote 17] are to
be completed within 30 days of redeployment to discuss the individual's
responses on the postdeployment health assessment, mental health or
psychosocial issues commonly associated with deployments, prescription
medications taken during deployment, and concerns about possible
environmental or occupational exposures. Additional requirements
include documentation of medical referrals or concerns resulting from
deployment, documentation of the results of any follow- up
examinations, tuberculosis screening for high-risk servicemembers, and
blood serum sample collection within 30 days of redeployment. In 2005,
DOD issued a new policy requiring a postdeployment health reassessment
questionnaire as well.[Footnote 18] The purpose of the reassessment is
to identify health concerns that emerge over time after deployment and
is to be conducted between 90 and 180 days after servicemembers return
to their home station.
We requested the views of DOD's Office of General Counsel on DOD's
compliance with the medical examination requirement of section
1074f.[Footnote 19] DOD's Office of General Counsel noted that DOD's
May 1998 report to Congress provided the department's understanding
that the medical examination requirement was satisfied by the plan to
carry out health assessments. DOD's Office of General Counsel pointed
out that subsequent to this report to Congress, Congress did not, until
October of 2006,[Footnote 20] amend section 1074f or otherwise
establish a requirement different than that described in the
department's 1998 report. DOD's Office of General Counsel further
pointed out that subsequent to DOD's 1998 report, Congress did enact
other laws that refer to health assessments required by section
1074f.[Footnote 21] DOD's Office of General Counsel concluded that
"although the term 'medical examination' was not defined in the
original 1997 statute, from 1998 until the present, both DOD and the
Congress have used the terms 'medical examination' and 'health
assessment' synonymously to describe the Military Health System pre-and
postdeployment action required by section 1074f."
The term "medical examinations" in the statute could be interpreted to
mean medical activities beyond those included in DOD's current
deployment health program as described above. However, DOD's use of a
variety of deployment health activities, including the use of pre-and
postdeployment health assessment questionnaires along with reviews of
servicemembers' medical records is a reasonable interpretation of
section 1074f.
DOD Has Established a Deployment Health Quality Assurance Program, but
the Lack of a Comprehensive Oversight Framework Hampers Effective
Implementation:
DOD has established a deployment health quality assurance program as
part of its medical tracking system, but lacks a comprehensive
oversight framework to help ensure effective implementation of the
program. DOD's deployment health quality assurance program policy
outlines four specific elements--such as monthly reports on
servicemembers' deployment health data from a centralized database
maintained by AMSA--and it requires each of the services to create
their own quality assurance programs based on these elements. While DOD
has established a program that includes these four elements, it cannot
determine whether the program has been effectively implemented because
DOD does not have a comprehensive oversight framework with all the
specific reporting requirements and necessary performance measures to
evaluate the services' compliance with deployment health requirements
or to ensure that the services are implementing the program
consistently.
DOD Has Established a Deployment Health Quality Assurance Program:
In response to congressional mandates and a GAO recommendation, in
January 2004 DOD established a deployment health quality assurance
program, as part of its medical tracking system, designed to assess
compliance with deployment health requirements. DOD's policy and
implementing guidance for the program is contained in a memorandum from
the Assistant Secretary of Defense for Health Affairs.[Footnote 22]
DOD's policy delegates the responsibility for executing the program to
the Deputy Assistant Secretary of Defense for Force Health Protection
and Readiness, DHSD, and to the military services. According to the
policy, DOD's program consists of the following four elements:
* Periodic reporting on pre-and postdeployment health assessments. AMSA
is required to provide (at a minimum) monthly reports to DHSD on active
and reserve component servicemembers' deployment health assessment
data.
* Periodic reporting on service-specific deployment health quality
assurance programs. The services are required to provide (at a minimum)
quarterly reports to DHSD on the status and findings, including
compliance with deployment health requirements, of their respective
required quality assurance programs.
* Periodic visits to military installations to assess deployment health
programs. The program requires joint visits by representatives from
DHSD and from service medical departments to military installations for
the purpose of complementing and validating the services' deployment
health quality assurance reporting.
* An annual report on the DOD deployment health quality assurance
program. The program requires that DHSD prepare and coordinate with the
services an annual report on the status of the requirements of the
program to the Assistant Secretary of Defense for Health
Affairs.[Footnote 23]
DOD Does Not Have a Comprehensive Oversight Framework to Determine
Whether Its Deployment Health Quality Assurance Program Has Been
Effectively Implemented:
DOD has not established a comprehensive oversight framework for its
deployment health quality assurance program, which is necessary to
ensure the program's effective implementation. GPRA provides federal
agencies with a model framework for developing program
oversight.[Footnote 24] Specifically, GPRA establishes a results-
oriented framework that identifies, among other things, performance
measures and reporting requirements. However, DOD does not have a
comprehensive oversight framework with all the specific reporting
requirements and necessary performance measures to evaluate the
services' compliance with deployment health requirements or to help
ensure that the services are implementing the program consistently.
Because DOD's deployment health quality assurance program lacks a
comprehensive oversight framework, the program, as currently
implemented, does not provide decision makers with the information they
need to evaluate the effectiveness and efficiency of either DOD's or
the services' respective quality assurance programs. In reviewing DOD's
program, we found problems with its implementation of the monthly AMSA
reports, the quarterly service-specific reports, and the DHSD site
visits. Because DOD's annual report is based on information from these
three elements, the department's annual report does not provide DOD or
congressional decision makers with the complete, comprehensive, and
accurate information necessary to determine whether the department is
complying with its own deployment health requirements. Moreover, DOD
and congressional decision makers are unable to determine whether DOD
has effectively implemented a quality assurance program that reasonably
assures that servicemembers are medically fit to deploy.
DOD Has Not Identified All Results-Oriented Performance Measures and
Has Not Provided AMSA with Specific Reporting Requirements:
DOD's deployment health quality assurance program requires that AMSA
submit to DHSD monthly reports on active and reserve component
servicemembers' deployment health assessment data. The deployment
health assessment data that AMSA reports are collected individually by
the services and maintained centrally in the Defense Medical
Surveillance System (DMSS) at AMSA.[Footnote 25] However, in reviewing
AMSA's reports we found that while the reports provide some data on
servicemembers' deployment health, they do not provide all the
essential information necessary to assess the services' compliance or
determine departmentwide compliance with all deployment health
requirements. This problem results largely because DOD has not
identified all the necessary results-oriented performance measures and
provided AMSA with specific reporting requirements for all deployment
health requirements. DOD's policy identifies some performance measures
that could be used to assess whether the services are complying with
selected deployment health requirements, such as measures for the
identification of deployed/redeployed personnel and whether pre-and
postdeployment health assessment questionnaires are on file at AMSA.
However, DOD's policy does not identify performance measures for
additional deployment health requirements such as whether
servicemembers received all required immunizations. In addition, DOD's
policy does not identify reporting requirements related to all
deployment health data needed to effectively assess compliance with its
own deployment health requirements. For example, DOD's policy does not
require that AMSA provide critical information needed to assess
compliance with deployment health requirements, such as the total
number of servicemembers that deployed/redeployed during the reporting
period. Without knowing the total number of servicemembers deployed/
redeployed, DOD cannot determine the extent to which servicemembers
completed the required pre-and postdeployment health assessment
questionnaires. Similarly, DOD's policy does not require that the AMSA
reports specify whether servicemembers completed pre-and postdeployment
questionnaires within required time frames (no earlier than 60 days
prior to deployment, and during the period from 30 days prior to and 30
days after redeployment), which is necessary to determine whether
servicemembers are completing the required questionnaires in a timely
manner. In addition, DOD's policy only specifies that AMSA's reports
include information related to selected postdeployment health
requirements, such as the accomplishment of blood samples, the number
of referrals, and the number of referrals accomplished. As a result,
DOD does not have all of the essential information necessary to assess
the services' compliance or determine departmentwide compliance with
all deployment health requirements.
DOD Has Not Enforced Its Policy Requiring the Services to Report on
Compliance with Deployment Health Requirements:
DOD's deployment health quality assurance program requires that the
services submit to DHSD quarterly reports regarding their compliance
with deployment health requirements; however, DOD has not enforced its
reporting requirements. DOD's policy specifies that the services'
quarterly reports address three key elements: (1) the identification of
deployed/redeployed personnel, (2) completion of applicable pre-and
postdeployment health assessment questionnaires and related
requirements (e.g., immunizations, blood samples, referrals), and (3)
inclusion of deployment-related health documentation in permanent
medical records. However, DOD's policy does not specify uniform
standards that should be used in collecting and reporting the required
information. Instead, DOD's policy directs the services to determine
the scope and methodology of their respective programs, including
associated performance measures. The services' differing
interpretations of DOD's policy have resulted in the services utilizing
different approaches for the collection and reporting of the required
information in their quarterly reports.
Our review of the services' quarterly reports for calendar years 2004,
2005, and 2006 found that DHSD has not enforced the reporting
requirements outlined in its policy. Specifically, we identified
differences in the extent to which the services report compliance with
applicable pre-and postdeployment health assessment questionnaires and
related requirements such as drawing blood serum samples. For example,
the Navy's reports only include its compliance with postdeployment
requirements and do not include information regarding predeployment
requirements. As another example, the Marine Corps' reports do not
always include information regarding its compliance with pre-and
postdeployment requirements for drawing blood serum samples.
Furthermore, with regard to the inclusion of deployment-related health
documentation in permanent medical records, only the Army and the Air
Force provide DHSD with information in their quarterly reports
regarding whether deployment-related health documentation is included
in servicemembers' permanent medical records.
In addition, we found that the services report information to DHSD
using different criteria. For example, while the Army reports on only a
sample of servicemembers who deploy or redeploy during the reporting
period, the Air Force reports on the total number of servicemembers who
deploy or redeploy during the reporting period. Moreover, the Army's
report includes all locations of deployment whereas, according to Air
Force officials, the Air Force only reports on deployments in support
of Operations Iraqi Freedom or Enduring Freedom. Further, the Marine
Corps' reports include the total number of Marines that deployed and
redeployed during the reporting period in addition to those Marines who
deployed in earlier reporting periods but who are still deployed.
The lack of guidance or standards for providing the required
information in the services' quarterly reports has created a number of
problems for DOD. For example, the lack of standards hampers DOD's
ability to compare compliance across the military services and
therefore report overall departmentwide compliance because the services
do not always provide DHSD with complete and consistent information
regarding the status and findings of their respective programs.
DOD Site Visits to Assess the Services' Deployment Health Quality
Assurance Programs Do Not Have Quality Controls in Place:
DOD's deployment health quality assurance program requires that DHSD
conduct at least four visits per year to military installations for the
purpose of assessing the services' deployment health quality assurance
programs. While DHSD has conducted the minimum number of site visits
required each year since 2004, it does not have the quality controls in
place to ensure that the deployment health data collected and reported
are complete and accurate. Federal internal control standards require
that data control activities, such as edit checks, verification, and
reconciliation, be conducted and documented to help provide reasonable
assurance that program objectives are being met.[Footnote 26] While not
a formal audit, DOD's deployment health quality assurance program is
designed to identify strengths and weaknesses with the program and,
when appropriate, make changes to ensure that deployment health
requirements are being met.
DHSD relies on the use of data collection instruments to facilitate the
collection of information, but does not provide for an independent
verification of the completeness and accuracy of data obtained from the
medical records. DHSD officials told us that none of the data
collection instruments from their site visits are reviewed by an
independent or second reviewer to ensure that the information recorded
is accurate or complete. Independent verification is an important
internal control activity under segregation of duties designed to
reduce the risk of errors. We identified numerous instances where the
information captured by DHSD's hard-copy and electronic data collection
instruments was incomplete. Specifically, for our review of hard-copy
data collection instruments from DHSD site visits in 2005, we found
that 99 of 140 data collection instruments (71 percent) from a site
visit to a Marine Corps' installation contained one or more incomplete
data fields, while for a site visit to an Air Force installation, 53 of
126 data collection instruments (42 percent) had one or more incomplete
data fields. In addition, we found some instances where either the
deployment date or the redeployment date data fields were not complete.
In addition, our review of electronic data collection instruments for
2006 found at least one incomplete data field in 53 of 299 data
collection instruments (18 percent) that we reviewed. Without
independent verification of the data recorded by the reviewer, DHSD
does not have any assurance that the compliance information recorded
accurately reflects the compliance status for the records reviewed.
In addition, our review of available DHSD site visit data for calendar
year 2005 found that DHSD did not always adhere to DOD's deployment
health requirements when assessing the services' programs.
Specifically, we identified numerous instances where the reviewing DHSD
officials did not consistently apply DOD's standards for completing pre-
and postdeployment health assessment questionnaires, drawing pre- and
postdeployment blood samples, and receiving required immunizations
within specified time frames. For example, our review of data from
DHSD's site visits identified a total of 99 out of 567 medical records
(17 percent) where one or more deployment health requirement had not
been completed within established time requirements, yet the site visit
summary indicated the requirement for those immunizations had been met.
In addition, our review of DHSD's site visit data verifying the
existence of data within DMSS and at the serum repository at AMSA found
that for 100 out of 295 records (34 percent), timeliness standards had
not been properly applied for at least one deployment health
requirement such as the completion of pre-and postdeployment health
assessment questionnaires or drawing pre-and postdeployment blood
samples. Because DHSD officials were not properly applying DOD's
timeliness standards, reported compliance for DHSD's site visit reports
for 2005 may be overstated.
Conclusions:
As servicemembers continue to deploy overseas in significant numbers in
support of ongoing military operations, it is increasingly important
that DOD be able to accurately assess the medical condition of those
servicemembers both before and after their deployments. Although DOD
has established a deployment health quality assurance program, it has
not developed a comprehensive oversight framework with all the specific
reporting requirements and performance measures needed to provide
oversight of, and ensure effective implementation of the program.
Having an effective deployment health quality assurance program is
critically important given DOD's long-standing problems with assessing
the medical condition of active and reserve forces both before and
after their deployments. Without such a framework, the ability of
decision makers--both within DOD and Congress--to make informed, fact-
based decisions regarding whether the department is complying with its
own deployment health requirements is limited. Moreover, until DOD
implements a more effective deployment health quality assurance
program, it will not be well positioned to determine or assure Congress
that servicemembers are medically and mentally fit to deploy and to
determine their medical and mental condition upon return.
Recommendations for Executive Action:
To improve DOD's ability to effectively implement its deployment health
quality assurance program, we recommend that the Secretary of Defense
direct the Assistant Secretary of Defense for Health Affairs to develop
a comprehensive oversight framework to evaluate the services'
compliance with deployment health requirements and to ensure that the
services are implementing the program consistently. Such a framework
should do the following:
* Provide AMSA with specific reporting requirements and results-
oriented performance measures to evaluate the services' adherence to
deployment health requirements, including identifying the total number
of servicemembers deployed/redeployed and administering pre-and
postdeployment health assessment questionnaires within required time
frames, which would enable AMSA to develop information regarding
departmentwide compliance.
* Enforce the requirement for the services to report on all deployment
health requirements on a quarterly basis.
* Establish quality controls, including independent reviews of data, to
ensure the accuracy or completeness of the information DHSD collects in
its site visits to military installations.
Agency Comments and Our Evaluation:
DOD provided written comments on a draft of this report and agreed with
our recommendations.
In commenting on our recommendations, the Assistant Secretary of
Defense for Health Affairs commented that the department recognizes the
need for a more comprehensive oversight framework to better ensure
effective implementation of the deployment health quality assurance
program. To that end, the Office of the Deputy Assistant Secretary of
Defense for Force Health Protection and Readiness recently published a
new instruction[Footnote 27] on force health protection quality
assurance. The Assistant Secretary further commented that the
department is now developing reporting requirements along with results-
oriented performance measures--as our report recommends--that will
serve to better evaluate compliance and facilitate consistent
implementation across the military services. Specifically, the
Assistant Secretary commented that the department will (1) work with
AMSA and the military services to specify reporting requirements,
jointly refine performance measures for critical deployment health
activities, and strive to achieve better alignment of deployment-
related information among AMSA, the services, and the Defense Manpower
Data Center to get a more accurate picture of compliance; and (2)
continue to perform joint site visits to military installations as a
critical complement to centralized monitoring through AMSA and DMSS,
while including independent verification as an internal quality control
mechanism during on-site medical records review. Our review of the
department's new instruction and its planned actions indicate that DOD
is taking steps in the right direction. If the department follows
through with its efforts, we believe that it will be responsive to our
recommendations. DOD's comments are reprinted in appendix IV.
As we agreed with your office, unless you publicly announce the
contents of this report earlier, we plan no further distribution of it
until 30 days from the date of this letter. We will then send copies of
the report to the Secretary of Defense, the Assistant Secretary of
Defense for Health Affairs, the Deputy Assistant Secretary of Defense
for Force Health Protection and Readiness, the Secretaries of the Army,
Navy, and Air Force. We will also send copies to others who are
interested and make copies available to others who request them. This
report will also be available at no charge on GAO's Web site at
http://www.gao.gov.
If you have any questions regarding this report, please contact me at
(202) 512-3604 or farrellb@gao.gov. Contact points for our Offices of
Congressional Relations and Public Affairs may be found on the last
page of this report. GAO staff who made major contributions to the
report are listed in appendix V.
Sincerely yours,
Signed by:
Brenda S. Farrell:
Director, Defense Capabilities and Management:
[End of section]
Appendix I: Scope and Methodology:
To address our objectives, we obtained and reviewed pertinent
documents, reports, and information related to the Department of
Defense's (DOD) deployment health requirements and deployment health
quality assurance program. We also interviewed responsible officials at
the Assistant Secretary of Defense for Health Affairs, Deployment
Health Support Directorate (DHSD); the Offices of the Surgeons General
for the Army, Air Force, and Navy; the Army Medical Surveillance
Activity (AMSA); and the Combined Fleet Forces Command and Naval
Environmental Health Center in the Washington, D.C., and Norfolk,
Virginia, areas.
To determine whether DOD has established a medical tracking system to
comply with requirements of 10 U.S.C. § 1074f pertaining to pre-and
postdeployment medical examinations, we compared statutory requirements
to DOD policies and requirements. Specifically, we reviewed relevant
sections of 10 U.S.C. § 1074f to identify system requirements and
system elements. We also reviewed DOD policies, directives, and
instructions to identify the measures that DOD uses to establish the
medical condition of servicemembers and compared these measures to the
system requirements and system elements. In addition, we obtained a
legal opinion from DOD's Office of General Counsel regarding DOD's
compliance with the requirement of 10 U.S.C. § 1074f to perform pre-and
postdeployment medical examinations.
To determine the extent to which DOD has effectively implemented a
deployment health quality assurance program as part of its medical
tracking system, we obtained and analyzed various documents, including
DOD's and the services' deployment health quality assurance program
policies establishing requirements for the program; the Government
Performance and Results Act of 1993;[Footnote 28] and federal internal
control standards.[Footnote 29] We also interviewed key officials with
DHSD and the services' Offices of the Surgeons General to obtain a
comprehensive understanding of the processes, procedures, and controls
used for monitoring and overseeing the deployment health quality
assurance program. We obtained and analyzed the results of the
program's periodic reporting for calendar years 2004, 2005, and 2006,
including monthly AMSA reports, the quarterly service-specific reports,
and DOD's annual report, to determine the content of the reports,
compliance rates with deployment health requirements, and any trends in
compliance rates, both within and among the services. We also obtained
and analyzed the results of site visits conducted by DHSD in calendar
years 2005 and 2006. To determine the reliability of DOD's quality
assurance program reports, we obtained and analyzed data collection
instruments and other documentation used to record, summarize, and
report the services' compliance with deployment health requirements. We
also discussed with responsible DOD officials, including
representatives from the military services, their methodology for
ensuring that information collected and reported is as accurate and
reliable as possible. Where possible, we tested data by comparing
information from the data collection instruments or summary documents
with available source documents. We identified issues of inconsistency
and incompleteness in DOD's data and, therefore, determined the data to
be insufficiently reliable for the purpose of assessing compliance with
deployment health requirements and we are making a recommendation to
address this issue accordingly.
In conducting our review, we limited our focus to the procedures that
DOD has in place to medically assess servicemembers before and after
their deployments. Other issues, such as recent controversies
associated with alleged deployments of medically unfit servicemembers
to Iraq, did not fall within the scope of this review. These issues
will be addressed as part of a separate review.
We performed our work from September 2006 through May 2007 in
accordance with generally accepted government auditing standards.
[End of section]
Appendix II: Pre-and Postdeployment Health Assessment Questionnaires:
Pre-Deployment Health Assessment:
Authority. 10 U.S.C. 136 Chapter 55. 1074f, 3013, 5013, 8013 and E.O.
9397:
Principal Purpose: To assess your state of health before possible
deployment outside the United States in support of military operations
and to assist military healthcare providers in identifying and
providing present and future medical care to you.
Routine Use: To other Federal and State agencies and civilian
healthcare providers, as necessary, in order to provide necessary
medical care and treatment.
Disclosure: (Military personnel and DoD civilian Employees Only)
Voluntary. If not provided, healthcare WILL BE furnished, but
comprehensive care may not be possible.
INSTRUCTIONS: Please read each question completely and carefully before
marking your selections. Provide a response for each question. If you
do not understand a question, ask the administrator.
Demographics:
Last Name:
MI:
First Name:
Today's Date (d/mm/yyyy):
Social Security Number:
Deploying Unit:
DOB (dd/mm/yyyy):
Gender:
Male or Female?
Service Branch:
Air Force, Army, Coast Guard, Marine Corps, Navy, or Other?
Component:
Active duty, National Guard, Reserves, or Civilian Government Employee?
Pay Grade:
E1, E2, E3, E4, E5, E6, E7, E8, E9, O1, O2, O3, O4, O5, O6, O7, O8, O9,
O10, W1, W2, W3, W4, W5, or Other?
Location of Operation:
Europe, Australia, SW Asia, Africa, SE Asia, Central America, Asia
(Other), Unknown, or South America?
Deployment Location (If Known) (City, Town, or Base):
List Country (If Known):
Name of Operation:
Administrator Use Only.
Indicate the status of each of the following:
Yes, No, or N/A for the following:
Medical threat briefing completed?
Medical information sheet distributed?
Serum for HIV drawn within 12 months?
Immunizations current?
PPD screening within 24 months?
Health Assessment:
1. Would you say your health in general is:
Excellent, Very Good, Good, Fair, or Poor?
2. Do you have any medical or dental problems?
Yes or No:
3. Are you currently on a profile, or light duty, or are you undergoing
a medical board?
Yes or No:
4. Are you pregnant? (Females Only)
Don't Know, Yes, or No:
5. Do you have a 90-day supply of your prescription medication or birth
control pills?
NIA, Yes, or No:
6. Do you have two pairs of prescription glasses (if worn) and any
other personal medical equipment?
NIA, Yes, or No:
7. During the past year, have you sought counseling or care for your
mental health?
Yes or No.
8. Do you currently have any questions or concerns about your health?
Yes or No:
Please list your concerns:
I certify that responses on this form are true.
Service Member signature:
Pre-Deployment Health Provider Review (For Health Provider Use Only):
After interview/exam of patient, the following problems were noted and
categorized by Review of Systems. More than one may be noted for
patients with multiple problems. Further documentation of problem to be
placed in medical records.
Referral Indicated:
None:
GI:
Cardiac:
Combat 1 Operational Stress Reaction:
Dental:
Dermatologic:
GU:
GYN:
Mental Health:
Neurologic:
Orthopedic:
Pregnancy:
Pulmonary:
Other:
ENT:
Eye:
Family Problems:
Fatigue, Malaise, Multisystem complaint:
FINAL MEDICAL DISPOSITION:
Deployable or Not Deployable:
Comments (If not deployable, explain):
I certify that this review process has been completed. Provider's
signature and stamp:
Date (dd/mm/yyyy):
Post-Deployment Health Assessment:
Authority: 10 U.S.C. 136 Chapter 55. 1074f, 3013, 5013, 8013 and E.O.
9397:
Principal Purpose: To assess your state of health after deployment
outside the United States in support of military operations and to
assist military healthcare providers in identifying and providing
present and future medical care to you.
Routine Use: To other Federal and State agencies and civilian
healthcare providers, as necessary, in order to provide necessary
medical care and treatment.
Disclosure: (Military personnel and DoD civilian Employees Only)
Voluntary. If not provided, healthcare WILL BE furnished, but
comprehensive care may not be possible.
Instructions: Please read each question completely and carefully before
marking your selections. Provide a response for each question. If you
do not understand a question, ask the administrator.
Demographics:
Today's Date (dd/mm/yyyy):
Last Name:
MI:
First Name:
Social Security Number:
Name of Your Unit or Ship during this Deployment:
DOB (dd/mm/yyyy):
Date of arrival in theater (dd/mm/yyyy):
Date of departure from theater (dd/mm/yyyy):
Gender:
Male or Female?
Service Branch:
Air Force, Army, Coast Guard, Marine Corps, Navy, or Other?
Component:
Active Duty, National Guard, Reserves, or Civilian Government Employee?
Pay Grade:
E1, E2, E3, E4, E5, E6, E7, E8, E9, 001, 002, 003, 004, 005, 006, 007,
008, 009, 010, W1, W2, W3, w4, W5, or other?
Location of Operation:
Europe, Australia, South America, SW Asia, Africa, North America, SE
Asia, Central America, Other, Asia (Other), or Unknown:
To what areas were you mainly deployed: (mark all that apply - list
where/date arrived):
Kuwait:
Iraq:
Qatar:
Turkey:
Afghanistan:
Uzbekistan:
Bosnia:
Kosovo:
On a ship:
CONUS:
Other:
Name of Operation:
Occupational specialty during this deployment (MOS, NEC or AFSC):
Combat specialty:
Administrator Use Only:
Indicate the status of each,of the following:
Answer the following questions with either Yes, No, or NIA:
Medical threat debriefing completed?
Medical information sheet distributed?
Post Deployment serum specimen collected?
Please answer all questions in relation to This deployment:
1. Did your health change during this deployment?
Health stayed about the same or got better or Health got worse:
2. How many times were you seen in sick call during this deployment?
No. of times:
3. Did you have to spend one or more nights in a hospital as a patient
during this deployment?
No:
Yes, reason/dates:
4. Did you receive any vaccinations just before or during this
deployment?
Smallpox (leaves a scar on the arm):
Anthrax:
Botulism:
Typhoid:
Meningococcal:
Other, list:
Don't know:
None:
5. Did you take any of the following medications during this
deployment?
(mark all that apply):
PB (pyridostigmine bromide) nerve agent pill:
Mark-1 antidote kit:
Anti-malaria pills:
Pills to stay awake, such as dexedrine:
Other, please list:
Don't know:
6. Do you have any of these symptoms now or did you develop them
anytime during this deployment?
Check one for each of the following:
No;
Yes During;
Yes Now;
Chronic cough.
Runny nose.
Fever.
Weakness.
Headaches.
Swollen, stiff or painful joints.
Back pain.
Muscle aches.
Numbness or tingling in hands or feet.
Skin diseases or rashes.
Redness of eyes with tearing.
Dimming of vision, like the lights were going out.
Chest pain or pressure.
Dizziness, fainting, light headedness.
Difficulty breathing.
Still feeling tired after sleeping.
Difficulty remembering.
Diarrhea.
Frequent indigestion.
Vomiting.
Ringing of the ears.
7. Did you see anyone wounded, killed, or dead during this deployment?
(mark all that apply
No.
Yes - coalition.
Yes-enemy.
Yes-civilian.
No.
Yes.
8. Were you engaged in direct combat where you discharged your weapon?
No.
Yes.
(land, sea, or air)
9. During this deployment, did you ever feel that you were in great
danger of being killed?
No.
Yes. O No O Yes: O.
10. Are you currently interested in receiving help for a stress,
emotional, alcohol or family problem?
No.
Yes.
11. Over the last 2 weeks, how often have you been bothered by any of
the following problems? Please respond with None, some, or a lot.
Little interest or pleasure in doing things?
Feeling down, depressed, or hopeless?
Thoughts that you would be better off dead or hurting yourself in some
way?
12. Have you ever had any experience that was so frightening, horrible,
or upsetting that, In The Past Month, you...
Please respond with yes or no.
Have had any nightmares about it or thought about it when you did not
want to?
Tried hard not to think about it or went out of your way to avoid
situations that remind you of it?
Were constantly on guard, watchful, or easily startled?
Felt numb or detached from others, activities, or your surroundings?
13. Are you having thoughts or concerns that...
Please respond yes, no, or unsure.
You may have serious conflicts with your spouse, family members, or
close friends?
You might hurt or lose control with someone?
14. While you were deployed, were you exposed to: (mark all that
apply):
Please respond No, Sometimes, or Often.
DEET insect repellent applied to skin.
Pesticide-treated uniforms.
Environmental pesticides (like area fogging).
Flea or tick collars.
Pesticide strips.
Smoke from oil fire.
Smoke from burning trash or feces.
Vehicle or truck exhaust fumes.
Tent heater smoke.
JP8 or other fuels.
Fog oils (smoke screen).
Solvents.
Paints.
Ionizing radiation.
Raderimicrowaves.
Lasers.
Loud noises.
Excessive vibration.
Industrial pollution.
Sand/dust.
Depleted Uranium ((f yes, explain).
Other exposures.
15. On how many days did you wear your MOPP over garments?
No. of days:
16. How many times did you put on your gas mask because of alerts and
NOT because of exercises?
No. of times:
17. Were you in or did you enter or closely inspect any destroyed
military vehicles?
No.
Yes:
18. Do you think you were exposed to any chemical, biological, or
radiological warfare agents during this deployment?
No.
Don't know:
Yes, explain with date and location:
[End of table]
Health Care Provider Only:
Post-Deployment Health Care Provider Review, Interview, and Assessment:
Interview:
1. Would you say your health in general is:
Excellent, Very good, Good, Fair, or Poor.
2. Do you have any medical or dental problems that developed during
this deployment?
3. Are you currently on a profile or light duty?
4. During this deployment have you sought, or do you now intend to
seek, counseling. or care for your mental health?
5. Do you have concerns about possible exposures or events during this
deployment that you feel may affect your health?
Please list concerns:
6. Do you currently have any questions or concerns about your health?
Please list concerns:
Health Assessment:
After my interview/exam of the service member and review of this form,
there is a need for further evaluation as indicated below. (More than
one may be noted for patients with multiple problems. Further
documentation of the problem evaluation to be placed in the service
member's medical record.)
Referral Indicated For:
None;
GI;
Cardiac;
GU;
Combat/Operational Stress Reaction;
GYN;
Dental;
Mental Health;
Dermatologic;
Neurologic;
ENT;
Orthopedic;
Eye;
Pregnancy;
Family Problems;
Pulmonary;
Fatigue, Malaise, Multisystem complaint;
Other.
Exposure Concerns (During deployment):
Environmental;
Occupational;
Combat or mission related;
None;
Comments:
I certify that this review process has been completed. Provider's
signature and stamp:
End of Health Review:
[End of section]
Appendix III: Individual Medical Readiness:
In January 2006, DOD published an instruction,[Footnote 30] requiring
that the services report individual medical readiness. Individual
medical readiness is intended to provide operational commanders,
military department leaders, and primary care managers the ability to
monitor the medical readiness status of their personnel, ensuring a
healthy and fit fighting force that is medically ready to deploy. DOD
Instruction 6025.19 requires quarterly individual medical readiness
reports submitted by the Surgeons General of the services to the Force
Health Protection Council summarizing the individual medical readiness
status of active and selected reserve members (both officers and
enlisted) who are available to deploy. Assessing individual medical
readiness status is a continuous process and contains six key elements
for which servicemembers are rated as either pass or fail. These
elements include the following:
* Periodic Health Assessment: An annual assessment for changes in
health status, especially changes that could affect a member's ability
to perform military duties.[Footnote 31] Each service is responsible
for determining how it will meet DOD's requirement for the completion
of the Periodic Health Assessment.
- Pass: current Periodic Health Assessment:
- Fail: overdue Periodic Health Assessment (not accomplished within 3
months after the month in which it is due):
* Deployment-limiting Conditions: Defined by military department-
specific policies. Examples include pregnancy, asthma, and severe
traumatic injury with incomplete rehabilitation.
- Pass: no deployment limiting conditions:
- Fail: deployment limiting conditions exist:
* Dental Readiness: All services use the same classification system to
assess and monitor dental readiness.
- Pass: class 1 (no dental treatment or reevaluation required within
the next 12 months) or 2 (patients have the potential for dental
emergencies with the next 12 months but it is not likely if certain
treatments are obtained):
- Fail: class 3 (patients with oral conditions that if not treated are
expected to result in dental emergencies within the next 12 months) or
4 (patients requiring a dental examination and whose dental
classification is unknown):
* Immunization Status: Required immunizations include hepatitis A,
tetanus-diphtheria, MMR (measles, mumps, and rubella), inactivated
poliovirus (IPV), hepatitis B, and influenza (once per season).
- Pass: all immunizations current:
- Fail: overdue for one or more immunizations:
* Medical Readiness Laboratory Tests: Includes human immunodeficiency
virus (HIV) testing and deoxyribonucleic acid (DNA) sample on file.
- Pass: HIV testing, with one result on file within the past 24 months
and a DNA sample on file:
- Fail: Missing or past-due HIV test or DNA sample not on file:
* Individual Medical Equipment: Core requirement is one pair of gas
mask inserts for all deployable personnel needing visual correction.
- Pass: one pair of gas mask inserts for all deployable personnel
needing visual correction:
- Fail: no gas mask inserts for all deployable personnel needing visual
correction:
Servicemembers are then placed into one of the following four readiness
categories based on the pass/fail grades in the six elements:
* Fully medically ready: current in all categories including dental
class 1 or 2:
* Partially medically ready: lacking one or more immunizations,
readiness laboratory studies, or medical equipment:
* Not medically ready: existence of a chronic or prolonged deployment-
limiting condition (per service-specific physical standards
guidelines), including servicemembers who are hospitalized or
convalescing from serious illness or injury, or individuals in dental
class 3:
* Medical readiness indeterminate: inability to determine the
servicemember's current health status because of missing health
information such as a lost medical record, an overdue Periodic Health
Assessment or being in dental class 4:
The minimum goal for overall medical readiness is to have more than 75
percent of servicemembers fully medically ready for deployment.
[End of section]
Appendix IV: Comments from the Department of Defense:
The Assistant Secretary Of Defense:
1200 Defense Pentagon:
Washington, DC 20301-1200:
Health Affairs:
Jun 8 2007:
Ms. Brenda S. Farrell:
Director, Defense Capabilities and Management:
U. S. Government Accountability Office:
441 G Street, N.W.
Washington, DC 20548:
Dear Ms. Farrell:
Thank you for the opportunity to review the GAO draft report, GAO-07-
831, "Defense Health Care: Comprehensive Oversight Framework Needed to
Help Ensure Effective Implementation of Deployment Health Quality
Assurance Program," dated May 21, 2007 (GAO Code 350897).
The Department concurs with the findings and recommendation contained
in this report. We are pleased your review found that our systematic
approach to performing pre-and post-deployment health assessments
through a variety of deployment health activities complies with enacted
legislation requiring a medical tracking system for assessing the
conditions of Service members before and after deployments. We
recognize the need for a more comprehensive oversight framework to
better ensure effective implementation of our deployment health quality
assurance program. To that end, the Office of the Deputy Assistant
Secretary of Defense for Force Health Protection and Readiness recently
published a new DoD Instruction on force health protection quality
assurance. We are now developing reporting requirements along with
results-oriented performance measures-as your report recommends-that
will serve to better evaluate compliance and facilitate consistent
implementation across the military Services. Our detailed comments are
enclosed.
My points of contact are Dr. Michael Kilpatrick at 703-578-8510
(functional) and Mr. Gunther Zimmerman (audit liaison) at 703-681-3492.
Sincerely,
Signed by:
S. Ward Casscells, MD:
Enclosure:
As stated:
GAO Draft Report - Dated May 21, 2007 GAO Code 350897/GAO-07-831:
"Defense Health Care: Comprehensive Oversight Framework Needed to Help
Ensure Effective Implementation of Deployment Health Quality Assurance
Program"
Department Of Defense Comments To The Recommendation:
Recommendation: The GAO recommends that the Secretary of Defense direct
the Assistant Secretary of Defense for Health Affairs to develop a
comprehensive oversight framework to evaluate the Services' compliance
with deployment health requirements and to ensure that the Services are
implementing the program consistently. Such a framework should do the
following:
* Provide the Army Medical Surveillance Activity (AMSA) with specific
reporting requirements and results-oriented performance measures to
evaluate the Services' adherence to deployment health requirements,
including identifying the total number of Service members deployed/
redeployed and administering pre-and post-deployment health assessment
questionnaires within required timeframes, which would enable AMSA to
develop information regarding Department-wide compliance;
* Enforce the requirement for the Services to report on all deployment
health requirements on a quarterly basis; and:
* Establish quality controls, including independent reviews of data, to
ensure the accuracy or completeness of the information the Deployment
Health Support Directorate (DHSD) collects in its site visits to
military installations.
DOD Response: The Department concurs and offers the following comments.
The Department recognizes that the DoD deployment health quality
assurance program established in 2004 needs to evolve into a more
structured and results-oriented framework for assessing compliance, and
we appreciate that GAO's efforts during this review will guide us in
directions that ultimately should improve the health of Service members
who deploy in harm's way. To enhance our deployment health quality
assurance components per your recommendation, and as part of our more
comprehensive force health protection quality assurance program
initiative, we will:
* Work with and through the Army Medical Surveillance Activity (AMSA)
and the military Services to specify reporting requirements and jointly
refine performance measures for critical deployment health activities.
We see this as an essential step to increasing consistency among the
Services' programs. At the same time, we recognize that each Service
benefits from some degree of flexibility in tailoring its deployment
health quality assurance activities to accommodate differences in
operational environment, size and complexity, managerial judgment, and
the reliability, availability, and performance of their respective
information systems. Further, we will strive to achieve better
alignment of deployment-related information among AMSA, the Services,
and the Defense Manpower Data Center, to get a more accurate picture of
the deployer "denominator" upon which to measure compliance.
* Continue to perform joint site visits to military installations as a
critical complement to centralized monitoring through AMSA and the
Defense Medical Surveillance System (DMSS). Independent verification
will be included as an internal quality control mechanism during our on-
site medical records reviews to ensure the information gathered on
these visits is both accurate and complete. We strongly believe these
jointly-conducted visits offer significant opportunities for first-
hand looks at deployment health processes and are for many locations-
the only way to review medical records pending full implementation of
automated recordkeeping in garrison and in theater. One of the key
goals in this regard is to better balance the efficiency of centralized
monitoring through AMSA with the effectiveness of on-site visits.
The Department determined in 2004 that a collaborative, multi-faceted
approach with the Services and AMSA was the appropriate means for
bringing the deployment health quality assurance program on-line. Joint
site visits (at that time quite unprecedented, now generally accepted)
combined with periodic reports served initially as a balanced means for
tracking Service compliance-looking for reasonable assurances rather
than absolute assurances that deployment health requirements were being
met.
[End of section]
Appendix V: GAO Contact and Staff Acknowledgments:
GAO Contact:
Brenda S. Farrell, (202) 512-3604 or farrellb@gao.gov:
Acknowledgments:
In addition to the contact named above, Sandra B. Burrell, Assistant
Director; Alissa H. Czyz; Steve J. Fox; Wesley A. Johnson; Susan J.
Mason; Julie C. Matta; Terry L. Richardson; Kate Robertson; Norris W.
Smith; and John C. Wren made key contributions to this report.
[End of section]
Related GAO Products:
DOD Civilian Personnel: Greater Oversight and Quality Assurance Needed
to Ensure Force Health Protection and Surveillance for Those Deployed.
GAO-06-1085. Washington, D.C.: September 29, 2006.
Military Personnel: DOD and the Services Need to Take Additional Steps
to Improve Mobilization Data for the Reserve Components. GAO-06-1068.
Washington, D.C.: September 20, 2006.
Military Personnel: Top Management Attention Is Needed to Address Long-
standing Problems with Determining Medical and Physical Fitness of the
Reserve Force. GAO-06-105. Washington. D.C.: October 27, 2005.
Defense Health Care: Improvements Needed in Occupational and
Environmental Health Surveillance during Deployments to Address
Immediate and Long-term Health Issues. GAO-05-632. Washington, D.C.:
July 14, 2005.
Defense Health Care: Force Health Protection and Surveillance Policy
Compliance Was Mixed, but Appears Better for Recent Deployments. GAO-
05-120. Washington, D.C.: November 12, 2004.
Military Personnel: DOD Needs to Address Long-term Reserve Force
Availability and Related Mobilization and Demobilization Issues. GAO-
04-1031. Washington, D.C.: September 15, 2004.
Defense Health Care: DOD Needs to Improve Force Health Protection and
Surveillance Processes. GAO-04-158T. Washington, D.C.: October 16,
2003.
Defense Health Care: Quality Assurance Process Needed to Improve Force
Health Protection and Surveillance. GAO-03-1041. Washington, D.C.:
September 19, 2003.
Military Personnel: DOD Needs More Data to Address Financial and Health
Care Issues Affecting Reservists. GAO-03-1004. Washington, D.C.:
September 10, 2003.
Defense Health Care: Army Has Not Consistently Assessed the Health
Status of Early-deploying Reservists. GAO-03-997T. Washington, D.C.:
July 9, 2003.
Defense Health Care: Army Needs to Assess the Health Status of All
Early-Deploying Reservists. GAO-03-437. Washington, D.C.: April 15,
2003.
VA And Defense Health Care: Military Medical Surveillance Policies in
Place, but Implementation Challenges Remain. GAO-02-478T. Washington,
D.C.: February 27, 2002.
Gulf War Illnesses: Research, Clinical Monitoring, and Medical
Surveillance. GAO/T-NSIAD-98-88. Washington, D.C.: February 5, 1998.
Gulf War Illnesses: Improved Monitoring of Clinical Progress and
Reexamination of Research Emphasis Are Needed. GAO/NSIAD-97-163.
Washington, D.C.: June 23, 1997.
Defense Health Care: Medical Surveillance Improved Since Gulf War, but
Mixed Results in Bosnia. GAO/NSIAD-97-136. Washington, D.C.: May 13,
1997.
Reserve Forces: DOD Policies Do Not Ensure That Personnel Meet Medical
and Physical Fitness Standards. GAO/NSIAD-94-36. Washington, D.C.:
March 23, 1994.
Operation Desert Storm: War Highlights Need to Address Problem of
Nondeployable Personnel. GAO/NSIAD-92-208. Washington, D.C.: August 31,
1992.
FOOTNOTES
[1] GAO, 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] National Defense Authorization Act for Fiscal Year 1998, Pub. L.
No. 105-85, § 765 (1997) (codified at 10 U.S.C. § 1074f).
[3] GAO, Defense Health Care: Quality Assurance Process Needed to
Improve Force Health Protection and Surveillance, GAO-03-1041
(Washington, D.C.: Sept. 19, 2003).
[4] GAO, Military Personnel: DOD Needs to Address Long-term Reserve
Force Availability and Related Mobilization and Demobilization Issues,
GAO-04-1031 (Washington, D.C.: Sept. 15, 2004).
[5] GAO, Defense Health Care: Force Health Protection and Surveillance
Policy Compliance Was Mixed, but Appears Better for Recent Deployments,
GAO-05-120 (Washington, D.C.: Nov. 12, 2004).
[6] GAO, Military Personnel: Top Management Attention Is Needed to
Address Long-standing Problems with Determining Medical and Physical
Fitness of the Reserve Force, GAO-06-105 (Washington, D.C.: Oct. 27,
2005).
[7] For the purposes of this report, we use the terms "redeploying" and
"redeployed" to mean returning from deployment.
[8] Pub. L. No. 103-62 (1993).
[9] Pub. L. No. 105-85, § 765 (1997).
[10] See GAO-03-1041.
[11] See GAO-04-1031.
[12] See GAO-05-120.
[13] See GAO-06-105.
[14] Department of Defense Report to Congress: Medical Tracking System
for Members Deployed Overseas (May 1998).
[15] Department of Defense Instruction 6490.03, Deployment Health (Aug.
11, 2006).
[16] DOD defines "health care provider" as a nurse, medical technician,
medic, or corpsman.
[17] DOD defines a "trained health care provider" as a physician,
physician assistant, nurse practitioner, advanced practice nurse,
independent duty corpsman, independent duty medical technician, or
Special Forces medical sergeant.
[18] Assistant Secretary of Defense for Health Affairs Memorandum,
"Postdeployment Health Reassessment" (Mar. 10, 2005).
[19] Letter from Mr. John Casciotti, Associate Deputy General Counsel
(Health Affairs), DOD Office of General Counsel to Mr. John Van Schaik,
Assistant General Counsel, GAO Office of General Counsel, November 6,
2006.
[20] Section 1074f was amended by section 738 of the John Warner
National Defense Authorization Act for Fiscal Year 2007, Pub. L. No.
109-364, to provide that the pre-and post-deployment medical
examination should include an "assessment" of mental health and
traumatic brain injury as well as further details on the elements of
the quality assurance program required under section 1074f(d)(1),
including information on the types of health care providers conducting
"postdeployment health assessments."
[21] Ronald W. Reagan National Defense Authorization Act for Fiscal
Year 2005, Pub. L. No. 108-375, §§ 732(b) and 739 (2004).
[22] Assistant Secretary of Defense for Health Affairs Memorandum,
"Policy for Department of Defense Deployment Health Quality Assurance
Program" (Jan. 9, 2004).
[23] Subsequent legislation required that information on DOD's
deployment health quality assurance program be provided to Congress.
Specifically, section 739 of Pub. L. No. 108-375 (Oct. 28. 2004)
amended title 10 of the United States Code by adding section 1073b.
Section 1073b requires that DOD submit annually to the Armed Services
Committees of the Senate and the House of Representatives reports on
health protection quality, including the recording of health assessment
data in military health records.
[24] GAO, Results-Oriented Government: GPRA Has Established a Solid
Foundation for Achieving Greater Results, GAO-04-38 (Washington, D.C.:
Mar. 10, 2004).
[25] According to AMSA, the DMSS database contains up-to-date and
historical data on diseases and medical events (e.g., hospitalizations,
ambulatory visits, reportable diseases, and health risk appraisals) for
military personnel and deployments.
[26] See GAO, Standards for Internal Control in the Federal Government,
GAO/AIMD-00-21.3.1 (Washington, D.C.: November 1999) and Internal
Control Management and Evaluation Tool, GAO-01-1008G (Washington, D.C.:
August 2001).
[27] Department of Defense Instruction 6200.05, Force Health Protection
(FHP) Quality Assurance (QA) Program (Feb. 16, 2007).
[28] Pub. L. No. 103-62 (1993).
[29] See GAO, Standards for Internal Control in the Federal Government,
GAO/AIMD-00-21.3.1 (Washington, D.C.: November 1999) and Internal
Control Management and Evaluation Tool, GAO-01-1008G (Washington, D.C.:
August 2001).
[30] Department of Defense Instruction 6025.19, Individual Medical
Readiness (Jan. 3, 2006).
[31] The assessment records general information such as blood pressure,
weight, height; screenings for hearing, vision, and depression; as well
as counseling on leading health indicators. In addition the assessment
includes testing and evaluations based on risk factors such as age,
sex, occupation, and personal habits such as smoking.
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