Military Personnel
Army Needs to Better Enforce Requirements and Improve Record Keeping for Soldiers Whose Medical Conditions May Call for Significant Duty Limitations Gao ID: GAO-08-546 June 10, 2008The increasing need for warfighters for the Global War on Terrorism has meant longer and multiple deployments for soldiers. Medical readiness is essential to their performing needed duties, and an impairment that limits a soldier's capacities represents risk to the soldier, the unit, and the mission. Asked to review the Army's compliance with its guidance, GAO examined the extent to which the Army is (1) adhering to its medical and deployment requirements regarding decisions to send soldiers with medical conditions to Iraq and Afghanistan, and (2) deploying soldiers with medical conditions requiring duty limitations, and assigning them to duties suitable for their limitations. GAO reviewed Army guidance, and medical records for those preparing to deploy between April 2006 and March 2007; interviewed Army officials and commanders at Forts Benning, Stewart, and Drum, selected for their high deployment rates; and surveyed deployed soldiers with medical limitations.
Army guidance allows commanders to deploy soldiers with medical conditions requiring duty limitations, subject to certain requirements, but the Army lacks enforcement mechanisms to ensure that all requirements are met, and medical record keeping problems obstruct the Army's visibility over these soldiers' conditions. A soldier diagnosed with an impairment must be given a physical profile form designating numerically the severity of the condition and, if designated 3 or higher (more severe), must be evaluated by a medical board. Commanders must then determine proper duty assignments based on soldiers' profile and commanders' staffing needs. From a random projectable sample, GAO estimates that 3 percent of soldiers from Forts Benning, Stewart, and Drum who had designations of 3 did not receive required board evaluations prior to being deployed to Iraq or Afghanistan for the period studied. In some cases, soldiers were not evaluated because commanders lacked timely access to profiles; in other cases, commanders did not take timely actions. The Army also had problems with retention and completeness of profiles; although guidance requires that approved profiles be retained in soldiers' medical records, 213 profiles were missing from the sample of 685 records reviewed. The Army was not consistent in assigning numerical designations reflecting soldiers' abilities to perform functional activities. GAO estimates from a random projectable sample that 7 percent of soldiers from these three installations had profiles indicating their inability to perform certain functional activities, yet carrying numerical designators below 3. While medical providers can "upgrade" numerical designations discretionarily based on knowledge of soldiers' conditions, the upgrades can mask limitations and cause commanders to deploy soldiers without needed board evaluations. While GAO found no evidence of widespread revision in profile designations, some soldiers interviewed or surveyed disagreed with their designations yet were reluctant to express concerns for fear of prejudicial treatment. The Army has instituted a program to provide ombudsmen to whom soldiers can bring medical concerns, but it is targeted at returning soldiers and is not well publicized as a resource for all soldiers with medical conditions. Without timely board evaluations and retention of profile information for deploying soldiers with medical conditions, the Army lacks full visibility and commanders must make medical readiness, deployment, and duty assignment decisions without being fully informed of soldiers' medical limitations. GAO estimates that about 10 percent of soldiers with medical conditions that could require duty limitations were deployed from the three installations, but survey response was too limited to enable GAO to project the extent to which they were assigned to suitable duties. Along with interviews, however, responses suggest that both soldiers and commanders believe soldiers are generally assigned to duties that accommodate their medical conditions. Occasional exceptions have occurred when a profile did not reflect all necessary medical information or a soldier's special skill was difficult to replace. Officials said soldiers sometimes understate their conditions to be deployed with their units, or overstate them to avoid deployment.
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Director: Team: Phone:GAO-08-546, Military Personnel: Army Needs to Better Enforce Requirements and Improve Record Keeping for Soldiers Whose Medical Conditions May Call for Significant Duty Limitations
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United States Government Accountability Office:
GAO:
Report to Congressional Requesters:
June 2008:
Military Personnel:
Army Needs to Better Enforce Requirements and Improve Record Keeping
for Soldiers Whose Medical Conditions May Call for Significant Duty
Limitations:
GAO-08-546:
GAO Highlights:
Highlights of GAO-08-546, a report to congressional requesters.
Why GAO Did This Study:
The increasing need for warfighters for the Global War on Terrorism has
meant longer and multiple deployments for soldiers. Medical readiness
is essential to their performing needed duties, and an impairment that
limits a soldier‘s capacities represents risk to the soldier, the unit,
and the mission. Asked to review the Army‘s compliance with its
guidance, GAO examined the extent to which the Army is (1) adhering to
its medical and deployment requirements regarding decisions to send
soldiers with medical conditions to Iraq and Afghanistan, and (2)
deploying soldiers with medical conditions requiring duty limitations,
and assigning them to duties suitable for their limitations. GAO
reviewed Army guidance, and medical records for those preparing to
deploy between April 2006 and March 2007; interviewed Army officials
and commanders at Forts Benning, Stewart, and Drum, selected for their
high deployment rates; and surveyed deployed soldiers with medical
limitations.
What GAO Found:
Army guidance allows commanders to deploy soldiers with medical
conditions requiring duty limitations, subject to certain requirements,
but the Army lacks enforcement mechanisms to ensure that all
requirements are met, and medical record keeping problems obstruct the
Army‘s visibility over these soldiers‘ conditions. A soldier diagnosed
with an impairment must be given a physical profile form designating
numerically the severity of the condition and, if designated 3 or
higher (more severe), must be evaluated by a medical board. Commanders
must then determine proper duty assignments based on soldiers‘ profile
and commanders‘ staffing needs. From a random projectable sample, GAO
estimates that 3 percent of soldiers from Forts Benning, Stewart, and
Drum who had designations of 3 did not receive required board
evaluations prior to being deployed to Iraq or Afghanistan for the
period studied. In some cases, soldiers were not evaluated because
commanders lacked timely access to profiles; in other cases, commanders
did not take timely actions. The Army also had problems with retention
and completeness of profiles; although guidance requires that approved
profiles be retained in soldiers‘ medical records, 213 profiles were
missing from the sample of 685 records reviewed. The Army was not
consistent in assigning numerical designations reflecting soldiers‘
abilities to perform functional activities. GAO estimates from a random
projectable sample that 7 percent of soldiers from these three
installations had profiles indicating their inability to perform
certain functional activities, yet carrying numerical designators below
3. While medical providers can ’upgrade“ numerical designations
discretionarily based on knowledge of soldiers‘ conditions, the
upgrades can mask limitations and cause commanders to deploy soldiers
without needed board evaluations. While GAO found no evidence of
widespread revision in profile designations, some soldiers interviewed
or surveyed disagreed with their designations yet were reluctant to
express concerns for fear of prejudicial treatment. The Army has
instituted a program to provide ombudsmen to whom soldiers can bring
medical concerns, but it is targeted at returning soldiers and is not
well publicized as a resource for all soldiers with medical conditions.
Without timely board evaluations and retention of profile information
for deploying soldiers with medical conditions, the Army lacks full
visibility and commanders must make medical readiness, deployment, and
duty assignment decisions without being fully informed of soldiers‘
medical limitations.
GAO estimates that about 10 percent of soldiers with medical conditions
that could require duty limitations were deployed from the three
installations, but survey response was too limited to enable GAO to
project the extent to which they were assigned to suitable duties.
Along with interviews, however, responses suggest that both soldiers
and commanders believe soldiers are generally assigned to duties that
accommodate their medical conditions. Occasional exceptions have
occurred when a profile did not reflect all necessary medical
information or a soldier‘s special skill was difficult to replace.
Officials said soldiers sometimes understate their conditions to be
deployed with their units, or overstate them to avoid deployment.
What GAO Recommends:
The Army needs to take specific measures, such as developing an
enforcement mechanism to ensure timely performance of medical board
evaluations and enhancing soldiers‘ and their families‘ access to an
ombudsman, to help safeguard soldiers with medical conditions from
being deployed and assigned to duties unsuitable to their medical
limitations. In written comments on a draft of the report, DOD
concurred with GAO‘s recommendations.
To view the full product, including the scope and methodology, click on
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-546]. For more
information, contact Brenda S. Farrell, (202) 512-3604 or
farrellb@gao.gov.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
Army Is Not Meeting All Requirements for Deploying Soldiers with
Medical Conditions and Has Unresolved Problems with Medical Record
Keeping:
Army Requirements for Deploying Soldiers with Medical Conditions Are
Not Always Being Met:
Soldiers' Medical Records Are Not Always Complete and Do Not Always
Retain Profiles, and Numerical Designations Are Not Consistently
Determined:
One In 10 Soldiers in the Projectable Sample Who Has a Medical
Condition Has Deployed, but We Were Unable to Determine Duty
Suitability:
Some Deploying Soldiers Have Medical Conditions:
Extent to Which Commanders Assigned Soldiers to Duties Suitable to
Their Medical Conditions Cannot Be Determined:
Conclusions:
Recommendations for Executive Action:
Agency Comments and Our Evaluation:
Appendix I: Scope and Methodology:
Appendix II: Army Physical Profile (DA Form 3349):
Appendix III: PULHES Definitions:
Appendix IV: Army Physical Profile Codes:
Appendix V: Department of Defense Pre-Deployment Health Assessment (DD
Form 2795):
Appendix VI: Comments from the Department of Defense:
Appendix VII: GAO Contact and Staff Acknowledgments:
Related GAO Products:
Tables:
Table 1: Number of Soldiers in the Sample with Permanent Physical
Profile Designations of 3 Who Did Not Receive Pre-Deployment Evaluation
by MMRB or MEB:
Table 2: Numbers and Percentages of Medical Conditions That May Require
Significant Duty Limitations, by Physical Profile Category, across
Profiles of Deployed Soldiers in the Sample:
Table 3: Soldier Sample Universe, Target Sample Sizes, and Number of
Records Reviewed at Each Visited Installation:
Figures:
Figure 1: Estimated Percentage of Soldiers with Physical Profile
Designations of Permanent 3 Who Deployed and Percentage of Soldiers Who
Did Not Receive Pre-Deployment Evaluation by MMRB or MEB:
Figure 2: Estimated Percentage of Soldiers Unable to Perform Functional
Activities Yet Designated as 2 in Their Profiles:
Figure 3: Comparison of Estimated Percentages of Soldiers with Profiles
Who May Require Significant Duty Limitations against Those Who Do Not:
Figure 4: Comparison of Estimated Percentages of Soldiers Having
Medical Conditions That May Require Significant Duty Limitations Who
Deployed against Those Who Did Not:
Abbreviations:
AHLTA: Armed Forces Health Longitudinal Technology Application:
DOD: Department of Defense:
MEB: Medical Evaluation Board:
MEDPROS: Army Medical Protection System:
MMRB: Military Occupational Specialty Medical Retention Board:
MOS: Military Occupational Specialty:
[End of section]
United States Government Accountability Office: Washington, DC 20548:
June 10, 2008:
The Honorable Ike Skelton:
Chairman:
Committee on Armed Services:
House of Representatives:
The Honorable Susan A. Davis:
Chairwoman:
Subcommittee on Military Personnel:
Committee on Armed Services:
House of Representatives:
The Honorable Vic Snyder:
Member of Congress:
House of Representatives:
From fiscal years 2004 through 2007, the average number of active and
reserve servicemembers deployed by the Department of Defense (DOD) has
increased about 19 percent, from 216,000 to 256,000 servicemembers, in
support of Operation Iraqi Freedom and the Global War on Terrorism. The
Army has been the major source of servicemembers supporting continued
operations, and the increasing need for able warfighters has meant
longer and multiple deployments for its soldiers. Serving in the armed
forces requires the medical readiness necessary to plan and execute
duties to meet operational goals. Any medical or psychological
condition that limits the ability of a servicemember to execute his or
her duties represents a risk to the servicemember, the unit, and the
accomplishment of the mission. Military commanders, medical providers,
and servicemembers share the responsibility for medical readiness as an
integrated effort to ensure that servicemembers are ready to fight in
support of ongoing operations.
Whenever a soldier is diagnosed with a medical condition, Army guidance
requires that medical providers document the soldier's limitations in
his or her medical record with a permanent or temporary physical
profile,[Footnote 1] describing the soldier's medical condition and
physical capability. These medical providers, who serve as the
profiling officers, must also assign a numerical designation reflecting
the extent of any limitation on a scale from 1 to 4, such that a
designation of 1 indicates that a soldier has a high level of medical
fitness, while a designation of 4 signifies a drastically limited
ability to perform military duties due to one or more medical
conditions or defects.[Footnote 2] A designation of 3 indicates that a
soldier has one or more medical conditions that may require significant
duty limitations, and the soldier should receive duty assignments that
are commensurate with his or her limitations. Once soldiers receive a
permanent profile indicating that they have a permanent or chronic
medical condition that may require significant limitations in
assignment, Army guidance generally requires further evaluation of the
soldiers' ability to perform duties in their current job assignments.
Moreover, DOD guidance requires soldiers to be evaluated for medical
readiness prior to deployment.
In prior reports, we have highlighted long-standing issues with the
medical deployability of servicemembers.[Footnote 3] Specifically, we
have found continuing problems with the completion of pre-and post-
deployment health assessments. We also reported in October 2005 that we
found reserve component servicemembers were deploying with preexisting
medical conditions, and we provided various recommendations for more
guidance and better visibility over servicemembers with medical
conditions in theater.[Footnote 4] DOD has taken action based on these
recommendations, such as establishing tracking and reporting of key
force health protection and quality assurance elements such as
immunizations and pre-and post-deployment health assessments.
From March through October 2007, the Army Office of the Inspector
General conducted an inquiry at Fort Benning based on media allegations
that soldiers were deployed with significant medical limitations. Army
Inspector General officials interviewed the soldiers named in the news
articles, numerous medical providers, and unit leaders to obtain their
testimonies regarding their pre-deployment medical reviews. The
Inspector General officials reviewed the standards for completing
physical profiles, the compliance with these standards, commanders'
decisions or actions that were based on these profiles, and whether any
reprisals may have occurred against soldiers with regard to complaints
and concluded that the Army followed standards in all but one instance
where a soldier's profile was changed without proper authority and the
soldier deployed. The soldier was reevaluated in theater and redeployed
to Fort Benning. They found no instances of reprisal. According to an
Inspector General official, further investigation of one medical
provider led to no findings of wrongdoing. The report recommended that
the Army direct (1) a special inspection of medical fitness procedures,
which is ongoing; (2) leaders and soldiers to review and follow Army
standards for documenting and assessing medical limitations; and (3)
the Army Surgeon General to revise the physical profile form to include
a Privacy Act statement, instructions for using the physical profile
form, and definitions of key terms.
The Chairs of the House Armed Services Committee and the Military
Personnel Subcommittee requested that we review the Army's compliance
with guidance on the deployment of soldiers with medical conditions.
[Footnote 5] As agreed with congressional staff, we examined:
1. the extent to which the Army is adhering to its medical and
deployment requirements regarding decisions to send soldiers with
medical limitations to Iraq and Afghanistan; and:
2. the extent to which the Army is deploying soldiers with medical
conditions requiring duty limitations to Iraq and Afghanistan, and
whether it is assigning them to duties suitable to their limitations.
To address the extent to which the Army is adhering to its medical and
deployment requirements regarding decisions to send soldiers with
medical limitations to Iraq and Afghanistan, we reviewed Army guidance
regarding documentation of soldiers' medical limitations prior to
deployment and conditions under which soldiers with medical conditions
are considered deployable. We selected three Army installations--Fort
Benning and Fort Stewart in Georgia, and Fort Drum in New York--that
met one or both of the following two factors: (1) these installations
had a large number of active component soldiers deployed from each
installation to Iraq or Afghanistan between April 1, 2006, and March
31, 2007; or (2) these installations had initial allegations of
soldiers being deployed with significant medical limitations from these
installations. For these locations, we prepared a random, projectable
sample of active component soldiers preparing for deployment who
indicated that they may be under a profile. We reviewed medical records
of soldiers in this sample and identified a subset of the soldiers who
had received profiles documenting medical conditions that may require
significant duty limitations prior to preparing to deployment.[Footnote
6] We interviewed medical providers, personnel officials, Army
commanders, and soldiers to identify and evaluate the installation's
procedures for documenting medical limitations in physical profiles and
the training provided at each installation. We did not review
documentation of medical limitations other than the physical profiles.
To determine the extent to which the Army is deploying soldiers with
medical conditions requiring duty limitations to Iraq and Afghanistan,
and whether it is assigning them to duties suitable to their
limitations, we compared the medical data on the subset of soldiers who
had significant medical limitations from April 2001 to March 2007 with
the soldiers' deployment data from Forts Benning, Stewart, and Drum.
From this analysis, we identified the number of soldiers who had a
profile in effect at the time of their deployment from each
installation. We reviewed Army processes for tracking soldiers while
deployed. We interviewed Army officials and commanders about any
procedures in place to ensure that soldiers are assigned within their
limitations. We also surveyed 66 active component Army soldiers
deployed with medical conditions to Iraq and Afghanistan and received
responses from 24 of them, for a response rate of about 36 percent.
While we cannot project the results of the surveys to all soldiers with
medical conditions across the Army deployed to Iraq and Afghanistan, we
present the information we obtained to illustrate these issues.
For a complete discussion of our scope and methodology, see appendix I.
We conducted this performance audit from April 2007 through April 2008
in accordance with generally accepted government auditing standards.
Those standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe that
the evidence obtained provides a reasonable basis for our findings and
conclusions based on our audit objectives.
Results in Brief:
Commanders may deploy soldiers who have medical conditions that may
require significant limitations in duty assignment, subject to certain
requirements; however, the Army lacks enforcement mechanisms to ensure
that all requirements are met, and various other problems exist with
regard to record keeping of physical profiles. Based on a random
projectable sample of soldiers preparing to deploy during April 2006
through March 2007, we estimate that 3 percent[Footnote 7] of soldiers
from Fort Benning, Fort Stewart, and Fort Drum who met the criteria for
higher evaluation by a medical board did not receive needed evaluations
prior to being deployed to Iraq or Afghanistan. Army guidance requires
a soldier diagnosed with a limiting medical condition to be given a
physical profile indicating the severity of the limitation, and in
certain cases, to be reviewed by a Military Occupational Specialty
Medical Retention Board (MMRB) or a Medical Evaluation Board (MEB).
Commanders, with the assistance of personnel management officers, are
responsible for determining proper duty assignments for soldiers based
on their knowledge of the soldiers' physical profiles and assignment
limitations, and soldier's job duties. According to personnel
officials, in some cases soldiers do not receive needed board
evaluations prior to deployment because medical officials did not
distribute profiles to commanders in a timely way, or because
commanders did not take needed action prior to the soldiers'
deployments. Without performing required medical board evaluations, the
Army lacks a systematic method for ensuring that commanders recognize
all cases of medical limitations and assign soldiers to duty
assignments that suitably accommodate them. Additionally, the Army
continues to have problems with the completeness and retention of
physical profiles, and it has been inconsistent in its designations of
soldiers' abilities to perform certain functional activities. Once
physical profiles are prepared, signed, and approved as needed, Army
guidance requires that the physical profiles be retained in soldiers'
medical records. At Forts Benning, Stewart, and Drum, we found that 213
physical profiles were missing from the 685 medical records of soldiers
with medical conditions that may require significant limitations. Of
the physical profiles retained in the sample of these medical records,
we determined that 20 profiles were not complete, for example, they
lacked necessary approval signatures. We found that each installation
uses its own process for retaining physical profiles, leading to
inconsistencies in retention across Army installations. The Army
intends for all physical profiles to be processed and retained in its
official electronic medical record system, in an effort to correct
inconsistencies in profile procedures; however, steps have not been
taken to implement this change and current plans do not ensure that
information will be entered and distributed in a timely manner.
Moreover, from the random projectable sample of soldiers preparing to
deploy, we estimate that about 7 percent[Footnote 8] of soldiers from
Forts Benning, Stewart, and Drum had medical records that indicated
they could not perform certain functional activities and yet were not
designated accordingly. While Army medical providers have some
flexibility to upgrade soldiers' numerical designations to indicate
less severe medical conditions based on knowledge of the soldiers'
medical conditions, these discretionary upgrades can mask soldiers'
limitations and cause commanders to deploy soldiers without needed
medical board evaluations. While we found no evidence of widespread
revision in profile designations, some soldiers told us that they
disagreed with the numerical designations they were assigned yet were
reluctant to bring their concerns to their commanders for fear of
prejudicial treatment. The Army has instituted an ombudsman program to
provide a point of contact to whom soldiers and family members can
bring their concerns, but the program is targeted at returning rather
than deploying injured soldiers, and it is not well publicized as a
resource for active duty soldiers with medical conditions.
From our random projectable sample of soldiers preparing for deployment
between April 2006 and March 2007, we estimate that about 10 percent
[Footnote 9] of soldiers from Forts Benning, Stewart, and Drum who have
medical conditions that could require significant limitations in duty
assignments were deployed to Iraq and Afghanistan, but we were unable
to determine whether those soldiers were assigned to duties suitable to
their medical conditions. We were told that soldiers, at times,
understate their conditions or negotiate with medical providers in
order to be deployed with their units or to remain in the Army;
conversely, in some cases soldiers have overstated their medical
conditions in order to avoid deployment. We estimate that about 86
percent of soldiers from the three installations did not have profiles
indicating medical conditions that could require significant
limitations. Of the estimated 14 percent who had such medical
conditions, approximately two-thirds were deployed. Most of the
deploying soldiers whose medical records indicated a potential
requirement for significant duty limitations had conditions such as
herniated discs, various forms of back pain, or chronic knee pain. We
could not determine the extent to which the Army assigned soldiers with
medical conditions to duties that were suitable to their limitations
because of the limited response to our survey. However, our limited
survey responses and interviews with soldiers and commanders revealed
that most respondents in both surveys and interviews believed soldiers
were generally assigned to duties that were suitable to their
limitations. We spoke with commanders at Forts Benning, Stewart, and
Drum, and they reported that they were aware of the medical conditions
of the soldiers with whom they had deployed and always took these
conditions into account when assigning duties. Most soldiers whom we
interviewed or who responded to our survey revealed that they were able
to accomplish most of their duties. For example, one soldier who had
back pain limiting his ability to carry all necessary combat equipment
reported that he had discussed this problem with his commander while in
theater, and the commander had reassigned him to duties that did not
require wearing all his equipment. Commanders we interviewed noted that
they occasionally required their soldiers to perform duties potentially
exceeding the soldiers' medical limitations, in some cases because a
soldier's physical profile did not reflect all necessary medical
information, or in other cases because the soldier had special skills
that were difficult to replace.
We are recommending that the Army take several actions; first, to help
ensure that soldiers with medical conditions are appropriately
evaluated and assigned to suitable duties while deployed, and second,
to help ensure that active duty soldiers and their families have access
to a point of contact to whom they can bring concerns regarding
recognition of their medical limitations prior to and during
deployment. In commenting on a draft of this report, DOD concurred with
our recommendations; we summarize these comments and provide our
response in our Agency Comments section.
Background:
Various pieces of DOD guidance provide overall direction and require
the services to define medical deployment standards to ensure that
servicemembers deploying to a theater of operations are in optimal
health.[Footnote 10] DOD allows the military services to deploy
servicemembers who do not meet the services' medical standards under
certain conditions. For example, a service is required to obtain a
waiver from the Combatant Command Surgeon if the service wishes to
deploy a servicemember who does not meet deployment standards and can
receive medical treatment at deployed locations that will render them
fit for duty.[Footnote 11] DOD guidance requires the services to
continue to employ measures that ensure servicemembers are medically
and psychologically fit for worldwide deployability, taking into
account additional guidance provided by the combatant commander on
theater-specific medical limitations. The Assistant Secretary of
Defense for Health Affairs is planning to release new guidance that
provides more guidelines on medical conditions that, in general, should
preclude servicemembers from being deployed. Because DOD has not
determined the issue date and has not yet implemented this new
guidance, we were not able to evaluate its effect during our review.
The Offices of the Surgeon General of each military service have
established procedures to evaluate the health conditions of their
servicemembers according to service-specific medical standards.
[Footnote 12] Our prior work has shown that the Army, Air Force, Navy,
and Marine Corps all have different methods of assessing their
servicemembers' medical readiness prior to deployment and documenting
any medical conditions and limitations. The Army's guidance, similar to
the other services' guidance, allows the commander to have the ultimate
authority to deploy servicemembers and make proper duty assignments, if
certain procedures are followed, while taking into account the medical
provider's assessment of a servicemember's medical condition and duty
limitations.
Army Guidance:
The Army Office of the Surgeon General and Army Deputy Chief of Staff
(G-1) provide guidance on soldiers' medical readiness. Regarding
medical matters, the Army Office of the Surgeon General heads the Army
Medical Command, which provides guidance to Army medical treatment
facilities. Medical Evaluation Boards (MEB) of soldiers are conducted
at medical treatment facilities at Army installations. Regarding
command matters, the Army Manpower and Reserve Affairs Office works
with the Army Deputy Chief of Staff G-1 to provide guidance to human
resource directorates at each installation. The Deputy Chief of Staff
G-1 has overall responsibility for the Physical Performance Evaluation
System which involves an administrative screening board known as the
Military Occupational Specialty Medical Retention Board (MMRB).
Physical Profiles:
Army Regulation 40-501 requires that the Army document physical and
mental conditions that may limit a soldier's ability to perform his or
her duties on the physical profile form. Using the physical profile,
Army medical providers, who serve as profiling officers, provide
recommendations on a soldier's medical limitations in order to assist
the commander in properly assigning the soldier to duties that
contribute to the unit's mission. A profiling officer creates a
physical profile that documents any limitations found during a medical
examination, and identifies whether the medical limitation is
temporary, in which case a short-term condition can be improved by
further treatment, or permanent, in which case a chronic condition will
not improve with medical treatment at that point in time. The profiling
officer classifies the medical limitations under six categories:
* physical capacity;
* upper extremities:
* lower extremities;
* hearing;
* eyes;
* psychiatric.
These categories are often abbreviated as the "PULHES" factors (see
app. III for further detail). The medical limitations in physical
profiles are also given a numerical designation from 1 to 4 to reflect
the different levels of functional capability and severity of
impairment. Soldiers with physical profiles designated by the number 1
are considered to have a high level of medical fitness; a 2 indicates
that a soldier has some medical condition or physical defect that may
require some activity limitations; a 3 under one or more of the factors
indicates that the soldier has a medical condition or physical defect
that may require significant limitations in duty assignment; and
soldiers designated by the number 4 must have their military duties
drastically limited.[Footnote 13] Profiling officers must also specify
whether the soldier can perform certain functional activities
comprising the minimum requirements needed in order to be medically
qualified for worldwide deployment.
Profiling officers should evaluate a soldier who has a temporary
profile at least once every 3 months to determine whether the soldier's
medical condition has improved or, if not, whether an extension of up
to 12 months is needed. If an extension is needed beyond 12 months, a
temporary profile should be changed to a permanent profile. Permanent
and temporary profiles normally require the signature of only the
profiling officer. Both the signatures of the profiling officer and a
higher level medical provider, who is designated the approving
authority, are required when a permanent profile number is designated
at 3 or 4, or when a permanent profile designation has been changed
from a 3 to a 2.
According to profiling officers, during the preparation of the physical
profile and medical evaluation of the soldier, the profiling officer
may communicate with the commander of the soldier for the purpose of
better identifying the soldier's medical limitations. All permanent
physical profiles are coded to designate any assignment limitations,
including whether a soldier has been reviewed by an MMRB or a Physical
Evaluation Board.[Footnote 14] Once the physical profile is signed by
profiling officer, and approved by the designated approving authority
as needed, Army regulation 40-501 requires that the completed physical
profile should be retained in the soldier's medical record and copies
of it should be distributed to the unit commander and the soldier. For
permanent physical profiles, one more copy is distributed to the
military personnel office.
Army medical records comprise both hard copy documents and an
electronic system called the Armed Forces Health Longitudinal
Technology Application (AHLTA), the official system for retaining
soldiers' medical documentation. AHLTA is used DOD-wide and gives
medical providers access to soldiers' medical information, including
medical evaluation history, prescriptions, diagnostic tests, and
physical profile information. The Army also tracks soldiers' medical
readiness information through the Army Medical Protection System
(MEDPROS), in order to allow commanders to have access to soldiers'
medical information that might affect readiness, but this system
retains limited information only on permanent physical profiles and
does not supply any detailed description of medical limitations or
incapacity to perform functional activities.
MMRB and MEB Evaluations:
Because physical profiles merely represent medical recommendations made
by the profiling officer to a soldier's commander, physical profile
designations do not automatically determine whether a soldier is
deployable or not. Three Army regulations require higher levels of
review for soldiers with a numerical designation of at least a 3 in
order to assist commanders in properly assigning soldiers to duties
suitable to their medical limitations.[Footnote 15] Army guidance
states that once soldiers receive a permanent profile designation of at
least a 3, they are not deployable for the duration of the MMRB or MEB
until the board is concluded.[Footnote 16]
If a soldier receives a permanent profile of at least a 3, the
profiling officer and approving authority must provide an initial
determination of whether the soldier meets Army medical standards or
not.[Footnote 17] If they believe that a soldier meets medical
standards, Army regulation 600-60 requires that the soldier be reviewed
by an MMRB to determine whether the soldier is able to complete the
duties in his or her job assignment or needs to be reassigned to a job
that accommodates his or her limitations. The MMRB consists of five
voting members, including a medical provider, a senior commander, and
when reasonably available, soldiers of the same branch or specialty as
the soldier being evaluated as well as non-voting members including a
personnel advisor, a recorder, and anyone else to ensure a fair
hearing. Once the personnel office receives the permanent profile from
the medical administrative office and convenes an MMRB, the recorder
will assemble the soldier's personnel records and medical records. The
commander will prepare an evaluation of the impact of the profile
limitations on the soldier's ability to perform the full range of
duties in the soldier's job assignment, known as a Military
Occupational Specialty (MOS). During the MMRB, the personnel advisor
will summarize the details of the soldier's current MOS and common
duties, and the medical provider will brief the MMRB on the soldier's
physical profile. The soldier will also present facts or call witnesses
relevant to his or her physical performance, current MOS retention, or
MOS reclassification preference. The MMRB can recommend either that (1)
the soldier remain in the Army under his or her current military
occupational specialty or specialty code, (2) the soldier be placed in
probationary status for up to 6 months to improve the condition of a
disease or injury, (3) the soldier be reclassified into another
occupational specialty, or (4) the soldier be referred to the MEB for
medical disqualification processing.
Active component Army soldiers should appear before an MMRB within 60
days of the date the physical profile is signed by the medical provider
who is designated the approval authority. Army regulation 600-60
requires that personnel officials responsible for convening the MMRB
maintain statistics on each case in order to assess whether or not MMRB
evaluations are convened within the 60-day time limit. As of March
2008, officials now are required to report the statistics to the Deputy
Chief of Staff of the Army.
Alternatively, if a profiling officer and the approving authority
believe that a soldier with a permanent profile designation of at least
a 3 does not meet medical standards, Army regulation 40-501 requires
that the soldier should be reviewed by an MEB to fully ascertain the
soldier's medical condition and limitations. From the MEB results, a
subsequent Physical Evaluation Board determines whether the soldier is
to be retained in the Army or not, and the applicable disability
rating.[Footnote 18]
There are two ways in which an MEB is initiated: by referral from the
medical provider designated as the approving authority or by referral
from an MMRB. When an MEB is referred by an approving authority, the
soldier's physical profile is distributed to the Physical Evaluation
Board liaison officer at the medical treatment facility, who is
responsible for the case management of the soldier. A medical provider
reexamines the servicemember and reviews his or her medical history,
including prior test results, diagnoses, and treatments. The medical
provider will then complete a narrative summary to document the nature
and degree of severity of the soldier's condition. The commander also
provides a letter describing how the soldier's medical condition
affects job performance and deployability status. Also provided is a
summary of the soldier's chief complaint, stated in the soldier's own
words. MEBs are composed of two or more physicians, one being a senior
medical provider with detailed knowledge of Army medical standards and
procedures, and other members having familiarity with these matters.
MEB evaluations must be completed within 90 days of approval of the
physical profile, or of the date when the MMRB referral is received by
the liaison officer. The MEB could result in several outcomes,
including: (1) the soldier is returned to duty, with a profile marked
that he or she meets medical retention standards; or (2) the soldier is
referred to a Physical Evaluation Board to determine whether he or she
has lost the ability to perform assigned duties because of a medical
condition and thus is unfit for duty, or the soldier is fit for duty
and thus is retained in the Army.
An Army memorandum requires that the liaison officers track certain
statistics and use an electronic database system to ensure that MEB
evaluations are completed within 90 days.[Footnote 19] This information
is reported quarterly to the Deputy Under Secretary of Defense for
Military Personnel Policy.
Pre-deployment Health Assessments:
According to a DOD instruction,[Footnote 20] within 60 days prior to
deployment, soldiers complete a pre-deployment health assessment
form[Footnote 21] to reflect soldiers' medical readiness with respect
to immunizations, dental, hearing/eye exams, and medical limitations on
physical profiles. If a soldier indicates on the pre-deployment health
assessment form that he or she is on a profile, or light duty, or
undergoing a medical board, the soldier is referred to a medical care
provider for reevaluation and verification of the medical limitations
under the physical profile. If a soldier does not meet the medical
requirements under the pre-deployment health assessment, the soldier is
classified as not deployable, until the soldier receives further
treatment. Moreover, if a soldier is also undergoing an MMRB or MEB,
the soldier is considered not deployable until the evaluation is
completed and the soldier is found fit for duty. The pre-deployment
health assessment is updated to indicate that the soldier is deployable
once he or she receives treatment or undergoes a board screening and is
found fit for duty.
Under Army regulation 40-501, Army commanders have the ultimate
authority to deploy soldiers, but commanders are required to recognize
soldiers' limiting conditions and assign them duties consistent with
their limiting conditions, with the assistance of personnel management
officers from Army Forces Command and Human Resources Command.
Army Is Not Meeting All Requirements for Deploying Soldiers with
Medical Conditions and Has Unresolved Problems with Medical Record
Keeping:
The Army allows commanders to deploy soldiers who have medical
conditions that may require significant limitations in duty assignment
as long as they meet requirements in the guidance, including board
evaluations, suitable duty assignments, and available medical treatment
in deployed locations, if needed; however, the Army is not meeting all
requirements to ensure board evaluations are conducted within
prescribed time frames, and various problems exist with regard to
physical profile record keeping. Army requirements for deploying
soldiers with medical conditions are not always being met; commanders
are not always aware of medical limitations in a timely way, and in the
sample review, we found that commanders are not always adhering to
guidance to ensure that soldiers are not being deployed to Iraq or
Afghanistan prior to having needed MMRB or in some cases MEB
evaluations. Furthermore, the Army continues to have problems with
retention and completeness of its physical profiles, as well as a lack
of consistency in designations with regard to soldiers' abilities to
perform functional activities. While we did not find widespread
revision of profiles prior to deployment, we found that soldiers were
concerned about how the Army was addressing their medical problems
prior to deployment. While commanders may recognize medical limitations
on a case by case basis, without performing required medical board
evaluations, the Army lacks a method for ensuring that all such cases
are appropriately recognized.
Army Requirements for Deploying Soldiers with Medical Conditions Are
Not Always Being Met:
While Army guidance allows commanders to deploy soldiers with medical
conditions that may require significant limitations in duty
assignments, subject to certain requirements, we found that commanders
are not always aware of soldiers' medical limitations when making
deployment decisions, and they do not always adhere to these
requirements. Army guidance requires that whenever a new physical
profile is created, copies of physical profile documentation, once
authorized by the approving medical authority, should be added to a
soldier's medical record and given to the soldier, his or her
commander, and the command's personnel office.[Footnote 22] Army
guidance stipulates that soldiers with a permanent profile containing a
numerical designation of a 3 or 4 who meet Army medical retention
standards should be evaluated by an MMRB within 60 days of receiving
the approved physical profile, to determine whether the soldier is able
to complete all the duties in his or her current job assignment or
should alternatively be reassigned to a job that accommodates his or
her medical limitation(s).[Footnote 23] Alternatively, a soldier with a
permanent profile of a 3 or 4 who is believed by a profiling officer
not to meet medical standards must be evaluated by an MEB within 90
days to determine whether that soldier should be retained in the
Army.[Footnote 24] Moreover, within 60 days prior to deployment, DOD
guidance requires the Army to review soldiers for medical readiness.
[Footnote 25] During this pre-deployment assessment, soldiers who
report having a physical profile must be referred to a medical
provider, which according to medical providers may result in an updated
confirmation of their numerical designation. If a soldier receives a
new profile indicating a medical condition that may require significant
limitations in assignment, Army guidance categorizes the soldier as not
deployable until he or she is reviewed by an MMRB or in some cases
MEB.[Footnote 26] Commanders, with the assistance of personnel
management officers, are responsible for determining proper duty
assignments for soldiers based on their knowledge of soldiers' physical
profiles, assignment limitations, and the need for accomplishing
necessary duties within the soldiers' MOS. Commanders may also consider
the availability of medical treatment at deployed locations when
determining the deployability of soldiers with physical profiles.
At Forts Benning, Stewart, and Drum, we found that commanders are not
always adhering to requirements in Army guidance to ensure that needed
board evaluations are performed. After reviewing 685 medical records
and the deployment information of soldiers who were preparing for
deployment in the statistically valid sample, we estimate that 6
percent of soldiers from Forts Benning, Stewart, and Drum were deployed
with designations of permanent 3 in their physical profiles--signifying
to a commander that they have medical conditions that may require
significant limitations.[Footnote 27] These soldiers should have been
reviewed prior to deployment by a MMRB, or MEB as needed, in accordance
with Army regulations.[Footnote 28] Further, we estimate that about 3
percent of the soldiers from Forts Benning, Stewart, and Drum had
profiles that indicated that they met medical retention standards and
required an MMRB, or may not meet standards and required an MEB, but
were deployed without having been reviewed by an MMRB or MEB.[Footnote
29] Figure 1 summarizes percentages (and confidence intervals) of
soldiers with profile designations of permanent 3 who deployed from
Forts Benning, Stewart, and Drum, and the percentage of those soldiers
who did not receive evaluation by an MMRB or MEB prior to deployment.
Figure 1: Estimated Percentage of Soldiers with Physical Profile
Designations of Permanent 3 Who Deployed and Percentage of Soldiers Who
Did Not Receive Pre-Deployment Evaluation by MMRB or MEB:
This figure is a vertical bar graph, depicting the following data:
Installation: Ft. Benning (n=189);
Soldiers who deployed with a permanent 3 profile: 6%; 95 percent
confidence interval, upper and lower bounds for each estimate: 10%/3%;
Soldiers who deployed with a permanent 3 profile not reviewed by MEB or
MMRB: 3%; 95 percent confidence interval, upper and lower bounds for
each estimate: 6%/2%.
Installation: Ft. Stewart (n=259);
Soldiers who deployed with a permanent 3 profile: 6%; 95 percent
confidence interval, upper and lower bounds for each estimate: 10%/3%;
Soldiers who deployed with a permanent 3 profile not reviewed by MEB or
MMRB: 3%; 95 percent confidence interval, upper and lower bounds for
each estimate: 5%/2%.
Installation: Ft. Drum (n=237);
Soldiers who deployed with a permanent 3 profile: 6%; 95 percent
confidence interval, upper and lower bounds for each estimate: 10%/3%;
Soldiers who deployed with a permanent 3 profile not reviewed by MEB or
MMRB: 2%; 95 percent confidence interval, upper and lower bounds for
each estimate: 6%/2%.
Installation: Total (n=685);
Soldiers who deployed with a permanent 3 profile: 6%; 95 percent
confidence interval, upper and lower bounds for each estimate: 10%/3%;
Soldiers who deployed with a permanent 3 profile not reviewed by MEB or
MMRB: 3%; 95 percent confidence interval, upper and lower bounds for
each estimate: 5%/2%.
Source: GAO analysis of DOD data.
[See PDF for image]
[End of figure]
In our sample, we found that of the 42 soldiers who had profile
designations of permanent 3, 17 soldiers did not receive needed board
evaluations prior to their deployment. Although we could project this
as a percentage of the soldiers from Forts Benning, Stewart, and Drum,
we did not project this as a percentage of the 42 soldiers who had
profile designations of a permanent 3 because the size of this subgroup
in the sample is not sufficient to report a reliable confidence
interval for a population estimate. Table 1 shows the number of
soldiers in the sample with permanent physical designations of 3 who
did not receive pre-deployment evaluations by MMRB or MEB.
Table 1: Number of Soldiers in the Sample with Permanent Physical
Profile Designations of 3 Who Did Not Receive Pre-Deployment Evaluation
by MMRB or MEB:
Army installation: Fort Benning;
Number of soldiers who deployed with permanent profiles of 3: 11;
Number of deployed soldiers with permanent profiles of 3 not reviewed
by MMRB or MEB: 5.
Army installation: Fort Stewart;
Number of soldiers who deployed with permanent profiles of 3: 16;
Number of deployed soldiers with permanent profiles of 3 not reviewed
by MMRB or MEB: 7.
Army installation: Fort Drum;
Number of soldiers who deployed with permanent profiles of 3: 15;
Number of deployed soldiers with permanent profiles of 3 not reviewed
by MMRB or MEB: 5.
Army installation: Total;
Number of soldiers who deployed with permanent profiles of 3: 42;
Number of deployed soldiers with permanent profiles of 3 not reviewed
by MMRB or MEB: 17.
Source: GAO analysis of DOD data.
Notes: The size of this subgroup in the sample is not sufficient to
report a reliable confidence interval for a population estimate.
Therefore, we did not project this subgroup to the population of Forts
Benning Stewart, and Drum. MEB evaluations are conducted in cases where
retention is in question.
[End of table]
These needed evaluations may not be occurring because each of the three
installations lacked an enforcement mechanism to ensure all procedures
are followed. According to medical providers, commanders, and personnel
officials, in some cases soldiers do not receive their MMRB or MEB
evaluations because profiles were not distributed by the approving
authority or medical administrative office in time to inform commanders
of the existence of the profiles. In other cases, according to
personnel officials, commanders were given notice of the profiles but
did not take needed action on time, but we were not able to determine
why this occurred.
Moreover, we found that while Army personnel officials at the three
installations we visited were maintaining proper data on MEB
evaluations, they were not maintaining required statistics on the
performance of MMRB evaluations. Army guidance requires that medical
and personnel officials have to maintain certain statistics in order to
know whether MEB or MMRB evaluations are conducted within set time
frames.[Footnote 30] Personnel officials told us that they kept
informal data on each MMRB case in separate files, such as the date of
the approved profile, the date it was received, and the date of the
MMRB. However, this information was not summarized as would be needed
in order to calculate the period of time that elapsed between the
stages of MMRB evaluations. Prior to February 2008, the Army did not
require that these statistics be reported to anyone. The Army revised
its regulation 600-60 to require the reporting of quarterly statistics
to the Deputy Chief of Staff of the Army beginning in March 2008. That
change may lead to better oversight of the timeliness of the MMRB, but
we were not able to assess the impact of this recent change during this
review.
Without performing all required medical board evaluations or tracking
the timeliness of board evaluations, the Army lacks a systematic method
for confirming that commanders recognize all cases of medical
limitations and assign soldiers to duty assignments that suitably
accommodate them.
Soldiers' Medical Records Are Not Always Complete and Do Not Always
Retain Profiles, and Numerical Designations Are Not Consistently
Determined:
Medical records are intended to provide a soldier's history of medical
treatment and limitations, and Army regulation 40-501 requires that
once physical profiles are prepared and signed, the profiles should be
kept in a soldier's medical record. These completed profiles include
the numerical designation, a description of medical limitations, the
signature of the profiling officer and approving authority, as needed,
and the dates of the signatures. Medical records comprise both the hard
copy and electronic versions of medical information. Commanders use
physical profiles to assess soldiers' physical ability to perform their
duties.
When we compared records in the official electronic medical system,
AHLTA, and hard copy records with those in an electronic medical
readiness system, MEDPROS, we found that 213 physical profiles were
missing from the 685 medical records of soldiers in the sample who had
a medical condition that may require significant limitations at Forts
Benning, Stewart, and Drum. Further, of the physical profiles that were
retained in the sample of medical records of soldiers with medical
conditions that may require significant limitations, we found that 20
were not complete. Specifically, both hardcopy and electronic medical
records lacked profiles with the appropriate signatures and dates of
final approval.
These problems may be occurring because each installation uses its own
informal process for approving and distributing completed physical
profiles to the soldier, commander, and medical record. For example, at
Forts Benning and Stewart, a profiling officer would consult with the
soldier and his commander in creating the profile, and if the physical
profile were permanent and designated a 3 or 4, the medical provider
who created the profile would provide it to the approving medical
provider. The approving medical provider would then provide it to
personnel officials in order to initiate an MMRB or to the liaison
officer to initiate an MEB, if needed, and would also provide it to the
medical administrative office, to be retained in the medical record.
Officials did not strictly adhere to time frames during this process,
and personnel officials expressed doubt to us as to whether they
received all physical profiles. Medical and command officials at Fort
Drum stated that their process was also informal and they did not
strictly adhere to timeframes, but they retained hard copies of all
permanent physical profiles separate from the soldiers' medical records
at the liaison officer's administrative office. Without a systematic
method for approving and distributing profiles, current informal
processes have led to inconsistencies in retention of the physical
profiles in the medical record. The electronic personnel system also
contains medical information, and we found that it is not being
routinely updated. As a result, communication to commanders about
physical limitations in many cases comes from the soldiers themselves,
rather than the medical record system or personnel system.
Army officials intend to require that all physical profiles be
processed and retained in the AHLTA electronic medical system; however,
steps have not been taken to implement the system change. The system
change will require that physical profiles be approved and routed
electronically to commanders, medical providers, and the personnel
offices to initiate MEB and MMRB proceedings. This change is intended
to correct the limited visibility over profile information and
inconsistencies in profile procedures, similar to the issues we have
found in this review at Forts Benning, Stewart, and Drum. However, Army
officials told us they have not finalized plans for actions needed and
associated milestones to implement these changes. Moreover, current
plans do not ensure that the information will be entered and
distributed in a timely manner, as officials who convene the MMRB or
MEB do not have authority to compel timely system input by commanders
and medical providers.
Finally, the Army is not consistent in its use of numerical
designations in profiles to reflect a soldier's ability to perform
certain functional activities. Army guidance states that when soldiers
are not able to meet certain requirements they are given a numerical
designation of at least 3, and this designation should result, in most
instances, in a review of their cases by an MMRB or MEB. When profiling
officers prepare physical profiles carrying a designation of 2, these
profiles do not generally receive further review, until the soldier
indicates he or she is under a physical profile at the pre-deployment
assessment. Based on our random projectable sample of soldiers
preparing to deploy between April 2006 and March 2007, we estimate that
about 7 percent of the soldiers who were preparing for deployment at
Forts Benning, Stewart, and Drum had physical profiles in their medical
record showing the inability to perform functional activities yet were
not designated with a score of at least 3.[Footnote 31] Figure 2 shows
the estimated percentage (and confidence intervals) of soldiers by Army
installation who had profiles that indicated that they were unable to
perform certain functional activities, yet the profiles had a
designation of 2.
Figure 2: Estimated Percentage of Soldiers Unable to Perform Functional
Activities Yet Designated as 2 in Their Profiles:
This figure is a vertical var graph depicting the following data:
Installation: Ft. Benning (n=189);
Soldiers with profile designations of 2, unable to perform functional
activities: 14%;
95 percent confidence interval, upper and lower bounds for each
estimate: 21%/9%.
Installation: Ft. Stewart (n=259);
Soldiers with profile designations of 2, unable to perform functional
activities: 9%;
95 percent confidence interval, upper and lower bounds for each
estimate: 14%/6%.
Installation: Ft. Drum (n=237);
Soldiers with profile designations of 2, unable to perform functional
activities: 0;
95 percent confidence interval, upper and lower bounds for each
estimate: 2%/0.
Installation: Total (n=685);
Soldiers with profile designations of 2, unable to perform functional
activities: 7%
95 percent confidence interval, upper and lower bounds for each
estimate: 10%/5%.
[See PDF for image]
Source: GAO review of Army records.
[End of figure]
The physical profile form defines performance of functional activities
according to whether the soldier is: (1) able to carry and fire his or
her individually assigned weapon; (2) able to move a fighting load of
48 pounds for at least 2 miles; (3) able to wear his or her protective
mask and all chemical defense equipment; (4) able to construct an
individual fighting position; (5) able to perform 3-5 second rushes
under direct or indirect fire; and (6) healthy, without any medical
condition that prevents deployment. Army regulation 40-501 allows for
some flexibility in the medical provider's designation of numerical
designation in a soldier's profile, and according to medical providers,
they may upgrade designations based on their knowledge of the soldier's
medical condition and the soldier's capacity to handle medical
limitations. However, discretionary upgrades can mask a soldier's
limitations such that a commander might deploy the soldier without
benefit of MMRB evaluation and may place the soldier in duties
unsuitable to his or her limitations.
We did not find widespread revision of profiles by profiling officers
or approving authorities prior to deployment. Only 1 percent of the
physical profiles we reviewed were changed from a permanent 3 to 2
within a few months prior to the soldier's deploying. Upgrades in
numerical designations are generally annotated by remarks in the
descriptive text included in a soldier's profile, and they must include
a second approving medical provider's signature. However, informal
discussions between soldier and medical provider can result in a change
in the profile designation that may not be noted in the profile. In one
case, we found that a soldier's profile was changed from a 3 to a 2
without meaningful annotation, and lacking the requisite second
approving signature. This soldier reported to us that she had not
undergone a new medical diagnosis prior to the profile upgrade;
however, she also had told her medical provider that she did not want
to go through an MMRB or MEB and thereby risk being removed from the
Army. According to Army officials, soldiers' medical conditions may
have improved for various reasons, such as undergoing surgery or
additional physical therapy.
Although we found no evidence of widespread revision in numerical
designations, in our surveys to deployed soldiers or our interviews
with Army personnel officials and family members of deployed soldiers,
some soldiers or family members expressed concerns to us that they were
uninformed about how the Army was addressing their medical problems
prior to deployment, and they knew of no venue to resolve their
complaints. In surveys, two additional soldiers also stated that they
did not feel they had been correctly graded in their physical profile
designations, but were reluctant to discuss the matter with their
commanding officers for fear of prejudicial treatment. One soldier
stated that her physical profile had been changed without further
physical examination. The other soldier noted that her physical profile
designation was upgraded even though a medical provider had added more
limitations after examining her, and she did not agree that the profile
expressed all the limitations caused by her back, knee, and shoulder
ailments. We reviewed the documentation in the physical profiles of
these soldiers and the profiles contained requisite approving
signatures, dates, and descriptions of limitations. However, our
analysis did not evaluate the medical providers' diagnoses of the
medical conditions, because we are not qualified to evaluate the
providers' medical judgment. Moreover, we would not be able to
determine from the documentation if the soldier did not agree with the
profile, whether the profile was changed without further physical
examination, or whether the medical provider or the soldier fully
communicated all of the issues involved.
Army personnel officials told us that they were unable to assist
soldiers bringing complaints about not being evaluated by a medical
board when the soldiers received a new permanent profile prior to their
deployment, because the officials do not have access to soldiers'
medical information and do not have the authority to enforce time
frames. These officials had also been contacted by soldiers' family
members who were concerned that the soldiers would be deployed and
their conditions would worsen at deployed locations. An Army personnel
official told us that soldiers sometimes questioned whether they were
to be evaluated by a board prior to deployment, but by the time this
official received the physical profile to initiate an MMRB, the
soldiers had already been deployed. Because the officials do not have
access to all medical information, they would not be able to verify
whether soldiers' profiles were approved. These situations may be
occurring because physical profiles are not being distributed in a
timely manner. Also, because Army personnel officials do not have the
authority to enforce time frames, they could not compel commanders to
provide timely input for the approval of the profile or compel
designated approving authorities to distribute the approved profiles.
Thus, although Army personnel officials may believe that physical
profiles are not being delivered in a timely manner, they do not have
the ability to resolve these soldiers' complaints.
Issues regarding proper medical evaluation of soldiers prior to
deployment could be resolved by having a designated point of contact to
whom soldiers and family members can bring their concerns. Such a point
person would require access to the soldier's medical information and
the ability to resolve any problems and questions about a soldier's
medical readiness. This person would also need to work independently of
the operations commander in order to prevent bias or coercion by the
commander in resolving soldier issues.
In September 2007, the Army Medical Command created a program to
designate an ombudsman, or point of contact, available for each
installation to whom soldiers can bring concerns on issues such as
health care, pay, physical disability processing, and transition to the
Veterans Administration. The Army memorandum[Footnote 32] establishing
this program states that ombudsmen will resolve complaints, assist in
obtaining accurate information, and act as advocates specifically for
soldiers assigned to the Warrior Transition Unit and their families.
According to ombudsmen at Forts Benning, Stewart, and Drum, they may
also provide support for any soldier or family member of a soldier who
needs assistance, through walk-ins or through the Army Wounded Soldier
and Family Hotline. In accordance with the memorandum, the ombudsman
will be independent from commanders at the installation, and will work
closely with the Medical Assistance Group, which is part of the Army
Medical Command under the Army Surgeon General's leadership at Fort Sam
Houston, Texas. However, the ombudsman program is not broadly
publicized as a resource for active duty soldiers with medical
conditions or their family members. We were not able to fully evaluate
how effectively the ombudsman program would be able to resolve the
issues brought by deploying soldiers as opposed to soldiers in the
Warrior Transition Unit and their family members, as the ombudsman
program has only recently been implemented. It was not fully
implemented at the time of our review at Forts Benning, Stewart, and
Drum. Ensuring that soldiers who are not part of the Warrior Transition
Unit and their family members are aware of and have access to the
ombudsman program may help to alleviate some of these concerns brought
forth by deploying soldiers.
As a result of the various medical record deficiencies and
discretionary profile revisions discussed, commanders' visibility over
their soldiers' potential medical conditions cannot be ensured.
Furthermore, without a well-publicized ombudsman program, soldiers
preparing for deployment cannot be assured of having the opportunity to
air and resolve their medical concerns.
One In 10 Soldiers in the Projectable Sample Who Has a Medical
Condition Has Deployed, but We Were Unable to Determine Duty
Suitability:
Based our review of medical records from Forts Benning, Stewart, and
Drum, we estimate that about 10 percent of active duty soldiers with
profiles indicating medical conditions that could require significant
limitations in duty assignments were deployed to Iraq and Afghanistan.
Although Army guidance allows for the deployment of soldiers with
medical conditions, it requires commanders to assign soldiers to duties
that are suitable to their limitations. Because of the low response
rate to our survey, we were unable to determine the extent to which
these soldiers were in fact assigned duties suitable to their medical
conditions. From the limited responses to our survey and from
interviews with soldiers, most reported that they were able to
accomplish most of their duties, although they were sometimes required
to perform duties exceeding their medical limitations.
Some Deploying Soldiers Have Medical Conditions:
We reviewed 685 medical records taken from a random projectable sample
of active component soldiers who were preparing for deployment between
April 2006 and March 2007 from Forts Benning and Stewart, in Georgia,
and Fort Drum, in New York. From these installations, we estimate that
86 percent of soldiers, did not have profiles indicating medical
conditions that could require significant limitations in duty
assignments.[Footnote 33] We estimate that 14 percent of soldiers
preparing to deploy from Forts Benning, Stewart, and Drum had profiles
indicating conditions that could require significant limitations:
specifically, soldiers with physical profile designations of 3 or 4, or
who indicated that they could not perform certain functional
activities.[Footnote 34] Figure 3 shows the total number of records
reviewed and the estimated percentage (and confidence intervals) of
soldiers who had medical impairments that could require significant
limitations by installation from Forts Benning, Stewart, and Drum.
Figure 3: Comparison of Estimated Percentages of Soldiers with Profiles
Who May Require Significant Duty Limitations against Those Who Do Not:
This figure is a vertical bar graph depicting the following data:
Installation: Ft. Benning (n=189);
Soldiers who do not have medical conditions that may require
significant duty limitations: 84%; 95 percent confidence interval,
upper and lower bounds for each estimate: 90/78;
Soldiers who have medical conditions that may require significant duty
limitations: 16%; 95 percent confidence interval, upper and lower
bounds for each estimate: 22/12.
Installation: Ft. Stewart (n=259);
Soldiers who do not have medical conditions that may require
significant duty limitations: 87%; 95 percent confidence interval,
upper and lower bounds for each estimate: 92/82;
Soldiers who have medical conditions that may require significant duty
limitations: 13%; 95 percent confidence interval, upper and lower
bounds for each estimate: 18/10.
Installation: Ft. Drum (n=237);
Soldiers who do not have medical conditions that may require
significant duty limitations: 86%; 95 percent confidence interval,
upper and lower bounds for each estimate: 91/81;
Soldiers who have medical conditions that may require significant duty
limitations: 14%; 95 percent confidence interval, upper and lower
bounds for each estimate: 18/10.
Installation: Total (n=685);
Soldiers who do not have medical conditions that may require
significant duty limitations: 86%; 95 percent confidence interval,
upper and lower bounds for each estimate: 90/78;
Soldiers who have medical conditions that may require significant duty
limitations: 14%; 95 percent confidence interval, upper and lower
bounds for each estimate: 16/12.
Source: GAO review of Army records.
[See PDF for image]
[End of figure]
As shown in figure 4, of the estimated 14 percent of soldiers preparing
to deploy from Forts Benning, Stewart, and Drum who had medical
conditions that could require significant limitations in duty
assignment, approximately two-thirds--about an estimated 10 percent of
the total number of soldiers[Footnote 35]--were deployed to Iraq or
Afghanistan. These soldiers with medical conditions included soldiers
having a physical profile designation of at least a 3, or indicating
that they could not perform certain functional activities. The
remaining estimated 4 percent of soldiers with medical conditions that
could require significant limitations did not deploy.[Footnote 36]
Figure 4: Comparison of Estimated Percentages of Soldiers Having
Medical Conditions That May Require Significant Duty Limitations Who
Deployed against Those Who Did Not:
This figure is a vertical bar graph depicting the following data:
Installation: Ft. Benning (n=189);
Soldiers with medical conditions that may require significant medical
limitations who did not deploy: 6%;
95 percent confidence interval estimate: 10/3;
Soldiers with medical conditions that may require significant medical
limitations who were deployed: 10%;
95 percent confidence interval estimate: 15/5.
Installation: Ft. Stewart (n=259);
Soldiers with medical conditions that may require significant medical
limitations who did not deploy: 5%;
95 percent confidence interval estimate: 8/2;
Soldiers with medical conditions that may require significant medical
limitations who were deployed: 8%;
95 percent confidence interval estimate: 13/5.
Installation: Ft. Drum (n=237);
Soldiers with medical conditions that may require significant medical
limitations who did not deploy: 3%;
95 percent confidence interval estimate: 7/1;
Soldiers with medical conditions that may require significant medical
limitations who were deployed: 11%;
95 percent confidence interval estimate: 15/8.
Installation: Total (n=685);
Soldiers with medical conditions that may require significant medical
limitations who did not deploy: 4%;
95 percent confidence interval estimate: 6/3;
Soldiers with medical conditions that may require significant medical
limitations who were deployed: 9%;
95 percent confidence interval estimate: 13/8.
Source: GAO review of Army records.
[See PDF for image]
[End of figure]
Soldiers in the sample who deployed with medical conditions that could
require significant limitations had conditions such as herniated discs,
back pain, chronic knee pain, type 2 diabetes, or mild asthma. A
soldier might have a physical profile that indicates multiple medical
limitations that fall under different categories.[Footnote 37] Table 2
shows that of the 66 deployed soldiers who had medical conditions that
could require significant limitations, 55 percent deployed with defects
of the lower extremities (under the "L" category). For example, one
soldier's physical profile showed chronic hip pain that restricted
physical training pace and limited the soldier to lifting no more than
48 pounds. Medical conditions of the eyes and psychiatric conditions
had the lowest rates of occurrence. While we did not review
documentation of medical limitations other than the soldiers' physical
profiles, according to Army medical officials, mental health conditions
are not generally documented in physical profiles unless the conditions
limited a soldier's ability to accomplish his or her duty. Commanders
were also notified of a soldier's mental condition by medical providers
if commanders requested the mental health evaluation of the soldier.
Table 2: Numbers and Percentages of Medical Conditions That May Require
Significant Duty Limitations, by Physical Profile Category, across
Profiles of Deployed Soldiers in the Sample:
Category of medical conditions in physical profiles: "P" Physical
Capacity;
Number of medical conditions: 15;
Percentage of medical conditions: 23%.
Category of medical conditions in physical profiles: "U" Upper
Extremities;
Number of medical conditions: 7;
Percentage of medical conditions: 11%.
Category of medical conditions in physical profiles: "L" Lower
Extremities;
Number of medical conditions: 36;
Percentage of medical conditions: 55%.
Category of medical conditions in physical profiles: "H" Hearing and
Ears;
Number of medical conditions: 10;
Percentage of medical conditions: 15%.
Category of medical conditions in physical profiles: "E" Eyes;
Number of medical conditions: 3;
Percentage of medical conditions: 5%.
Category of medical conditions in physical profiles: "S" Psychiatric;
Number of medical conditions: 2;
Percentage of medical conditions: 3%.
Source: GAO review of Army soldiers' medical records.
Note: The 73 total occurrences of medical limitations in the sample
were indicated in the physical profiles of 66 soldiers with medical
conditions that may require significant limitations who were deployed
to Iraq and Afghanistan. The percentages of occurrences do not equal
100 percent because some soldiers have a medical condition that may
require significant limitations in more than one category.
[End of table]
Extent to Which Commanders Assigned Soldiers to Duties Suitable to
Their Medical Conditions Cannot Be Determined:
We were unable to determine the extent to which deployed soldiers in
the sample with medical conditions were assigned duties suitable to
their limitations. While Army guidance requires commanders to assign
soldiers to duties that are suitable to their medical conditions, it
does not require that they track the assignments of their soldiers to
duties that accommodate their limitations. In order to determine the
extent to which they had been assigned to duties suitable for those
conditions, we surveyed by e-mail a sample of deployed soldiers with
medical conditions. In our survey, we asked these soldiers for
information on their ability to perform the duties to which they were
assigned. However, we did not get a sufficiently high response rate to
enable us to project findings from the survey respondents. We sent the
survey to 66 soldiers, but received responses from only 24. Of the 24
soldiers who responded, 19 reported that they were able to complete
most or all of their duties, and 22 of the 24 said they wanted to
deploy with their units. None said that they could perform only a few
or none of their duties. However, 5 of the soldiers we surveyed
indicated that they were able to perform only some of their duties.
Survey responses indicated that some soldiers had experienced job
reassignments to accommodate the limitations of their medical
conditions. For example, one soldier had a shoulder injury that limited
his ability to wear all of his body armor. When his unit was deployed
to Iraq, he was assigned to duties in Kuwait so that he would not have
to wear all of his body armor. Another soldier with a hearing deficit
had his occupational category changed from infantry to supply
specialist to protect him from exposure to loud noise. One soldier had
degenerative disc disease, with lower back and leg pain, and his
commander reassigned him from being leader of his unit to base security
to accommodate his medical condition by limiting the time he had to
wear his equipment. However, three of our survey respondents reported
that their duties or occupational categories were not changed, although
they believed they should have been. For example, one soldier often
fell asleep during guard duty because his sleep apnea treatment was
impaired by the irregularity of electric power availability, which he
needed to support his continuous positive airway pressure machine.
Although we were unable to speak with the commanders of the particular
soldiers surveyed in the sample, we spoke with other commanders at
Forts Benning, Stewart, and Drum to help explain these survey
responses. These commanders reported that they were aware of the
medical conditions of the soldiers with whom they had deployed and that
they always considered these conditions in their duty assignments. Army
commanders told us that soldiers with medical impairments may on
occasion be required to perform job duties exceeding their limitations
because they have special skills that are hard to replace using other
personnel. Commanders may also sometimes assign soldiers to duties
exceeding their limitations because they are unaware of the extent of
the limitations, as soldiers' physical profiles may not reflect all of
their medical information. Furthermore, according to both soldiers and
senior medical officials whom we interviewed, soldiers may conceal the
extent of their medical limitations or may negotiate with medical
providers in order to remain with their units or in the Army. For
example, one soldier did not agree with the upgrading of her physical
profile designation, but also did not want to fully disclose her
medical condition for fear of not meeting Army medical standards. Two
soldiers stated that they agreed with their physical profile
designation, which masks the severity of their limitations, and they
were deployed although their medical condition was progressively
worsening while at deployed locations. In both these cases, the
soldiers stated that they were nearing retirement and did not want to
be discharged from the Army due to a medical board evaluation before
they were eligible to receive their full retirement pensions, and they
confirmed that their commanders accommodated their medical conditions.
Conversely, Army officials have stated that soldiers may overstate
their medical conditions in order to avoid deployment and they must
take into account their other experiences with the soldiers'
limitations when evaluating their medical deployability. For example,
one commander told us that one soldier brought up a foot injury to
delay her deployment, although it was diagnosed by a medical provider
outside the military and it was not in her military medical record. The
commander allowed the soldier time to recuperate and allowed her to
purchase a specific type of boot to accommodate her injury. However,
when the soldier did not purchase the boots in a timely manner in order
to further delay her deployment, the commander found the boots at a
nearby supply store and deployed the soldier into theater.
Although we were not able to determine the extent to which Army
commanders have assigned soldiers to duties that are suitable for their
limitations, there may be soldiers who had proper evaluations performed
prior to deployment yet still have concerns about the suitability of
their assigned duties. Soldiers should have access to a program at
deployed locations that is similar to the ombudsman program available
at Army installations. The soldiers who have medical conditions that
develop or worsen while at deployed locations and may not believe they
are assigned to appropriate duties should have access to a contact
person who can address their concerns. This person should have access
to the soldier's medical information and the authority to resolve any
problems, and he or she should work independently from the soldier's
commander.
Conclusions:
Long-standing issues regarding the medical deployability of
servicemembers have become increasingly important as the Global War on
Terrorism continues and large numbers of servicemembers are deployed.
The Army is hampered by its lack of an enforcement mechanism from
ensuring that soldiers' MMRB or MEB evaluations are conducted within
prescribed time frames and not delayed by the failure of commanders or
medical providers to provide required information on time. Of the 6
percent of soldiers from Forts Benning, Stewart, and Drum that we
estimate were deployed with medical conditions that required further
evaluation by a MMRB or MEB, we estimate that 3 percent of these
soldiers did not receive these needed evaluations prior to deployment.
Furthermore, the commanders and medical providers who must make medical
readiness and deployment decisions about soldiers do not always have
full visibility over the soldiers' medical limitations because physical
profile documentation is not always properly retained or complete. The
Army intends to establish centralized electronic documentation and
distribution of physical profiles to improve visibility, but it has not
finalized plans for needed actions, associated milestones, and
timeliness of the process. Without timely MMRB or MEB evaluations and
the retention of complete physical profile information for deploying
soldiers with medical conditions, commanders who assign duties can not
be fully informed of soldiers' medical limitations. We did not find
widespread cases of improper duty assignments for deployed soldiers
with medical conditions; however, the weaknesses in the Army procedures
could permit this to occur. Although the Army ombudsman program may
help alleviate concerns from soldiers and family members, they should
be made aware of the program and the program should be made available
for soldiers prior to and during deployment. Unless soldiers have been
fully evaluated, have an independent contact person to promote their
concerns, and commanders have full knowledge of the soldiers'
limitations, the Army cannot safeguard soldiers with medical conditions
from being deployed and assigned to duties unsuitable for their
limitations.
Recommendations for Executive Action:
To safeguard soldiers with significant medical limitations from being
deployed and assigned to duties unsuitable for their limitations, we
recommend that the Secretary of the Army:
1. direct the Office of the Army Surgeon General and the Army Deputy
Chief of Staff G-1 to collaboratively develop an enforcement mechanism
to ensure that medical providers and commanders follow procedures so
that soldiers whose permanent physical profiles indicate significant
medical limitations are properly referred to and complete MEB and MMRB
evaluation boards prior to deployment;
2. direct the Office of the Army Surgeon General and the Army Deputy
Chief of Staff G-1 to move forward with plans to electronically process
and retain physical profiles, including specific actions and
milestones, and to implement guidance to help ensure:
* the timely distribution of profiles to commanders and the military
personnel office and;
* that the medical record keeping system include all information in the
approved physical profiles, and that all profiles be retained in
soldiers' medical records;
3. direct the Army Human Resources Command to disseminate information
and provide soldiers and their families access to an independent
ombudsman program prior to and during deployment to ensure that they
are fully informed about this resource for addressing their concerns
and to add independent oversight of Army medical and deployment
processes in the interests of the soldiers.
Agency Comments and Our Evaluation:
DOD provided written comments on a draft of this report and concurred
with each of our recommendations. In commenting on our first
recommendation, DOD stated that our findings do not suggest the
existence of a widespread problem throughout the Army, as the number of
soldiers in our sample deployed without appearing before a medical
evaluation board was 17; and furthermore, that survey and interview
responses indicate that commanders appear to be assigning soldiers with
medical limitations to suitable duties. However, we note that the 17
soldiers who deployed without receiving proper board evaluations
represent a sizeable proportion of the 42 soldiers in our sample who
should have received such a review prior to deployment. These 17
soldiers, furthermore, can be projected from our sample to represent
approximately 3 percent of the soldiers who were preparing for
deployment at the three installations; we are providing further
clarification regarding this figure in the body of this report.
Furthermore, as we have noted in our report, ad hoc measures to assign
soldiers to suitable duties are not as reliable as an enforcement
mechanism for ensuring that soldiers are so assigned. While we could
not determine the number of soldiers who may have been assigned to
unsuitable duties, as the Army does not track this information and our
survey responses were limited, neither could we confirm that soldiers
with medical limitations were consistently assigned to suitable duties.
DOD noted that it had actions planned or underway to conduct a thorough
inspection of the policies and procedures supporting a commander's
determination of soldier deployability, and to release new guidance
regarding medical conditions that should preclude affected
servicemembers from deployment, along with other initiatives, and we
commend these efforts.
In commenting on our second recommendation, DOD stated that the Office
of the Army Surgeon General has identified and submitted requirements
for the automation of physical profiles, beginning development by the
end of 2008, and we commend this planned initiative. We note that it is
important for these plans to have specific actions and milestones, and
for the Army to implement guidance to ensure timely distribution of
profiles to commanders and military personnel officials through the
automated system.
In commenting on our third recommendation, DOD stated that two
programs, the Army Ombudsman Program and the Wounded Soldier and Family
Hotline, are available to assist all soldiers (and their families)
whether preparing to deploy, deployed, or redeploying. However, we note
that the Wounded Soldier and Family Hotline does not constitute a
resource independent of the command. Although DOD states that
retribution is not tolerated against those using the hotline, we
maintain our view that soldiers should be able to turn to a resource
independent of the command. With regard to the Ombudsman Program,
though it is independent of the command, we continue to assert our view
that broad advertisement is needed for soldiers and their families to
be made aware of this resource for those soldiers not only returning
from deployment, but also prior to and during deployment.
The Army's comments are reprinted in appendix VI. In addition, the Army
provided technical comments, which we have incorporated as appropriate.
We are sending copies of this report to interested congressional
committees; the Secretary of Defense; the Secretaries of the Army, the
Navy, and the Air Force; and the Commandant of the Marine Corps. We
will also make copies available to others upon request. In addition,
the report will be available at no charge on the GAO Web site at
[hyperlink, http://www.gao.gov].
If you or your staff have any questions concerning 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. Key contributors to this report are
listed in appendix VII.
Signed by:
Brenda S. Farrell, Director:
Defense Capabilities and Management:
[End of section]
Appendix I: Scope and Methodology:
To address the extent to which the Army is adhering to its medical and
deployment requirements regarding decisions to send soldiers with
medical limitations to Iraq and Afghanistan, we reviewed relevant DOD
and Army guidance related to medical standards and deployment
procedures. We discussed the deployment of servicemembers with medical
conditions with a variety of officials from the Office of the Assistant
Secretary of Defense for Health Affairs, the Department of the Army,
and the Office of the Army Surgeon General. As agreed with
congressional staff, we also met with the Offices of the Air Force and
Navy Surgeons General as well as the Navy Bureau of Medicine and
Surgery to gain an understanding of those services' guidance on medical
standards and deployment procedures. In December 2007, we provided a
briefing to congressional staff that included a discussion of these
services' guidance regarding deployment of servicemembers with medical
conditions.
In addition, we reviewed Army guidance covering documentation of
soldiers' medical limitations prior to deployment and conditions under
which soldiers with medical conditions are considered deployable. We
reviewed a sample of medical records and interviewed medical providers,
Army commanders, and soldiers at selected installations to identify and
evaluate installation procedures for documenting medical limitations
and training provided regarding this issue at each installation.
We selected three Army installations--Fort Benning, Fort Stewart, and
Fort Drum. We selected Fort Stewart and Fort Drum based on the number
of active component soldiers deployed from each installation to Iraq or
Afghanistan between April 1, 2006, and March 31, 2007; and we selected
Fort Benning based on initial allegations of active component soldiers
being deployed with significant medical limitations from this
installation.
For our medical records review, we selected random samples of active
component soldiers at Fort Benning, Fort Stewart, and Fort Drum. In
order to create the sample, we used the universe of soldiers from each
installation who were preparing for deployment from April 1, 2006, to
March 31, 2007, to Iraq or Afghanistan and answered "yes" to question
number 3 on the pre-deployment health assessment (form DD
2795)[Footnote 38] which asks, "Are you currently on a profile, or
light duty, or are you undergoing a medical board?" Our statistical
samples are representative of soldiers at these installations who meet
our eligibility criteria. Those who did not complete a pre-deployment
health assessment during this time frame had no chance of being
selected. Of the soldiers preparing to deploy, soldiers may have their
deployment delayed or may ultimately not be deployed for various
reasons, such as not completing required training and not having proper
security clearances for deployment, as well as not meeting medical
readiness standards.
For various reasons, medical records were not always available for
review. Therefore, we reviewed more medical records than our target
sample size on the assumption we might not meet our desired precision.
Specifically, there were seven reasons identified for not being able to
physically secure soldiers' medical records for review:
1. Charged to patient. When a patient visits a clinic (on-post or off-
post), the medical record is physically given to the patient. The
procedure is that the medical record will be returned by the patient
following their clinic visit.
2. Charged out to Medical Evaluation Board. Soldier is in the process
of a medical review board and their medical record is retained by the
board members.
3. Charged out to Physical Evaluation Board. Soldier is in the process
of a physical review board and their medical record is retained by the
board members.
4. Expired term of service. Soldier separates from the Army and their
medical record is sent to the Veterans Administration Records
Management Center St. Louis, Missouri.
5. Record is missing and not accounted for by the medical records
department. No tracking sheet is in the file system to indicate the
patient has checked it out or otherwise.
6. Permanent change of station. Soldier is still in the Army, but has
transferred to another installation. The medical record was sent to the
new installation with the soldier.
7. Temporary duty off site. Soldier has left the Army installation, but
is expected to return. The temporary duty is long enough to warrant
that the medical record accompany the soldier. (Note: In the sample,
there were no cases for which the soldier was on temporary duty off
site.)
The sample size for our medical record review was determined to provide
a 95 percent confidence interval for an attribute measure with a
precision of at least 5 percent. Because we followed a probability
procedure based on random selections, the sample is only one of a large
number of samples that we might have drawn. Since each sample could
have provided different estimates, we express our confidence in the
precision of our particular sample's results as a 95 percent confidence
interval (e.g., plus or minus 5 percentage points). This is the
interval that would contain the actual population value for 5 percent
of the samples we could have drawn. As a result, we are 95 percent
confident that each of the confidence intervals will include the true
values in the study population. At two of the three installations we
visited, we reviewed more records than needed to meet our target sample
size because medical officials made available more medical records than
our targeted sample amount. The number of soldiers in the samples and
the total records reviewed of soldiers at the installations visited are
shown in table 3.
Table 3: Soldier Sample Universe, Target Sample Sizes, and Number of
Records Reviewed at Each Visited Installation:
Installation: Fort Benning;
Number of soldiers who fit the criteria for the sample (universe): 336;
Target sample sizes: 180;
Total records reviewed: 189.
Installation: Fort Stewart;
Number of soldiers who fit the criteria for the sample (universe): 794;
Target sample sizes: 259;
Total records reviewed: 259.
Installation: Fort Drum;
Number of soldiers who fit the criteria for the sample (universe): 552;
Target sample sizes: 227;
Total records reviewed: 237.
Installation: Total;
Number of soldiers who fit the criteria for the sample (universe):
1682;
Target sample sizes: 666;
Total records reviewed: 685.
Source: GAO analysis of Army soldiers' records.
[End of table]
At each location, we examined medical documentation for evidence of
physical profiles (form DA 3349)[Footnote 39] that were created between
April 2001 and March 2007. We selected this time frame because it would
include any profile in effect when a soldier in the sample deployed. We
reviewed both hard copy soldier medical records for evidence of
physical profiles as well as any profiles located in Armed Forces
Health Longitudinal Technology Application (AHLTA), the department of
defense's electronic medical record. In addition, we requested that
installation medical personnel provide any information on profiles from
the Army's Medical Protection System (MEDPROS) for each of the soldiers
in the sample to ensure that our review of medical records was complete
and that we identified all physical profiles. Even though MEDPROS is
not an official medical record, it is used in the determination of
medical readiness in preparation for deployment and contains medical
limitation information and dates of physical profiles. After gathering
all physical profiles, we reviewed them for completeness, and analyzed
them to determine if they were completed in accordance with Army
guidance. From the soldiers that received a physical profile between
April 2001 and March 2007, we identified the subset of soldiers with
medical conditions that may require significant medical limitations,
specifically soldiers with permanent or temporary profile designation
of at least a 3, or a designation of 2 showing inability to do certain
functional activities. We did not review documentation of medical
limitations other than the physical profiles. According to Army
officials, mental health conditions are not generally documented in
physical profiles unless the conditions limited a soldier's ability to
accomplish his or her duty. Commanders were also notified of their
soldiers' mental conditions by medical providers if they requested a
mental health evaluation of the soldiers.
Although we have taken many steps to ensure accurate data analysis of
active component soldiers with a physical profile, previous GAO reviews
have found that Army medical records do not contain all medical
documentation as required, thus, our review may not encompass the full
extent of soldiers with physical profiles.
To determine the extent to which the Army is deploying soldiers to Iraq
and Afghanistan with medical conditions requiring duty limitations, and
whether it is assigning them to duties suitable to their limitations,
we requested deployment data on the subset of soldiers who we
identified as having a significant medical limitation from the time
period of April 2001 to March 2007. We then compared data from our
medical record review at Forts Stewart, Benning, and Drum to deployment
data for soldiers in the sample provided by Army officials to identify
soldiers with a medical condition that may require significant
limitations who had deployed to Iraq or Afghanistan. We reviewed Army
processes for tracking soldiers while deployed. We interviewed Army
officials including commanders and medical providers about established
procedures in place to ensure soldiers are assigned within their
limitations. We also surveyed by e-mail 66 soldiers we identified who
had deployed with medical conditions to Iraq and Afghanistan. We
received responses from 24 of these soldiers, for a response rate of
about 36 percent. These responses do not allow us to project the extent
to which deployed soldiers with medical conditions across the Army were
assigned to duties suitable to their medical limitations in Iraq and
Afghanistan; nevertheless, we present the information we obtained to
illustrate these issues.
We conducted this performance audit from April 2007 through April 2008
in accordance with generally accepted government auditing standards.
Those standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe that
the evidence obtained provides a reasonable basis for our findings and
conclusions based on our audit objectives.
[End of section]
Appendix II: Army Physical Profile (DA Form 3349):
Physical Profile:
For use of this form, see AR 40-501; the proponent agency is the Office
of the Surgeon General.
1. Medical Condition: (Description in lay terms):
Injury?
Illness/disease?
2. CODES (Table 7-2 AR 40-501):
3. Temporary:
P:
U:
L:
H:
E:
S:
Permanent:
P:
U:
L:
H:
E:
S:
4. Profile Type:
a. Temporary Profile (expiration date YYYYMMDD) Limited to 3 months
duration:
Yes:
No:
b. Permanent Profile (reviewed and validated with every periodic exam
or after 5 years from the data of issue):
Yes:
No:
c. If A Permanent Profile With A 3 Or 4 PULHES, Does The Soldier Meet
Retention Standards Law Chapter 3 AR 40-501? (If USAR/ARNG/ARNGUS
Soldier Not On Active Duty See Para. 9.10 & 10.28, Ar 40501 if Soldier
Does Not Meet Retention Standards).
Needs MMRB:
Needs MEB/PEB:
5. FUNCTIONAL ACTIVITIES FOR PERMANENT AND TEMPORARY PROFILES (If any
answer (a-f) is No then the profile should be at least a 3):
a. Able To Carry And Fire Individual Assigned Weapon:
Yes:
No:
b. Able To Move With A Fighting Load At Least 2 Miles (48 lbs. includes
helmet, boots, uniform, LBE, weapon, protective mask, pack, etc.):
Yes:
No:
e. Able To Wear Protective Mask And All Chemical Defense Equipment:
Yes:
No:
d. Able To Construct An Individual Fighting Position (Dig, fill and
lift sandbags, etc.):
Yes:
No:
e. Able To Do 3-5 Second Rushes Under Direct And Indirect Fire:
Yes:
No:
f. Is Soldier Healthy Without Any Medial Condition That Prevents
Deployment?
Yes:
No:
6. APFT:
2 MILE RUN:
Yes:
No:
APFT SIT-UPS:
Yes:
No:
APFT PUSH UPS:
Yes:
No:
ALTERNATE APFT (Fill out if unable to do APFT run otherwise N/A):
APFT WALK:
N/A:
Yes:
No:
APFT SWIM:
APFT BIKE:
N/A:
Yes:
No:
7. Standard Or Modified Aerobic Conditioning Activities (Check all
applicable boxes):
Unlimited Running:
Yes:
No:
Or Run At Own Pace & Distance:
Yes:
No:
Unlimited Walking:
Yes:
No:
Or Walk At Own Pace & Distance:
Yes:
No:
Unlimited Biking:
Yes:
No:
Or Bike At Own Pace & Distance:
Yes:
No:
Unlimited Swimming:
Yes:
No:
Or Swim At Own Pace & Distance:
Yes:
No:
8. Upper Body Weight Training (See FM 21-20):
Yes:
No:
9. Lower Body Weight Training (See FM 21-20):
Yes:
No:
10. Other: e.g. Functional limitations and capabilities and other
comments: (May continue on page two):
[This temporary profile is an extension of a temporary profile first
issued on:]
11. These Parameters Are Optional, Use As Needed:
Lifting or carrying max weight ________ or ______ distance:
Running maximum distance:
Prolonged standing - maximum time per episode:
Marching with standard field gear except rucksack max distance:
Impact activities such as jumping max # reps in one day:
12. Type Name & Grade Of Profiling Officer:
13. Signature:
14. Date (YYYYMMDD):
15. Action By Approving Authority:
Approved:
Not Approved:
16. Type Name & Grade Of Senior Profiling Officer Or Approving
Authority:
17. Signature:
18. Date (YYYYMMDD):
19. Action By Unit Commander (See Pro 7-12, Ar 46501):
Yes: No:
This Profile Requires A Change In This Soldier's MOS Or Duty
Assignment:
20. Comment:
If this is a permanent profile with a PULHES serial of 3 or 4 refer to
block 4c.
21. Type Name & Grade Of Unit Commander:
22. Signature:
23. Date (YYYYMMDD):
24. Patient's Identification (For typed or written entries give: Name
(Last, First); grade; SSN; hospital or medical facility):
25. Unit:
26. Issuing Clinic, Provider E-Mail & Phone Number:
Profiling Officer (Or Approving Authority If Applicable) Is Responsible
For Ensuring The PULHES & Date Of Profile Is Entered Into MEOPROS.
Original Copy Posted In Medical Records, 1 Copy To Unit Commander, 1
Copy Given To Soldier, 1 Copy To MLPO.
DA FORM 3349, FEB 2004:
DA FORM 3349, MAY 86, IS OBSOLETE:
Page 1 of 2 APD BV1.020:
Physical Profile - Page 2 (Optional):
Continuation (From Page 1, Item 10):
Source: U.S. Army.
[See PDF for image]
[End of section]
Appendix III: PULHES Definitions:
Table:
Category definitions: P--Physical Capacity or Stamina;
Normally includes conditions of the heart; respiratory system;
gastrointestinal system, genitourinary system; nervous system;
allergic, endocrine, metabolic and nutritional diseases; diseases of
the blood and blood forming tissues; dental conditions; diseases of the
breast, and other organic defects and diseases that do not fall under
other specific factors of the system.
Category definitions: U--Upper Extremities;
Concerns the hands, arms, shoulder girdle, and upper spine (cervical,
thoracic, and upper lumbar) in regard to strength, range of motion, and
general efficiency.
Category definitions: L--Lower Extremities;
Refers to the feet, legs, pelvic girdle, lower back musculature and
lower spine (lower lumbar and sacral) in regard to strength, range of
motion, and general efficiency.
Category definitions: H--Hearing and Ears;
Relates to auditory acuity and disease and defects of the ear.
Category definitions: E--Eyes;
Centers on visual acuity and diseases and defects of the eye.
Category definitions: S--Psychiatric;
Concerns personality, emotional stability, and psychiatric diseases.
Source: Army Regulation 40-501.
[End of table]
Profile numerical designations:
Numerical: 1;
Designation definitions: Indicates a high level of medical fitness.
Profile numerical designations:
Numerical: 2; Designation definitions: Refers to some medical condition
or physical defect that may require some activity limitations.
Profile numerical designations:
Numerical: 3; Designation definitions: Signifies one or more medical
conditions or physical defects that may require significant
limitations. The individual should receive assignments commensurate
with his or her physical capability for military duty.
Profile numerical designations: Numerical: 4;
Designation definitions: Indicates one or more medical conditions or
physical defects of such severity that performance of military duty
must be drastically limited.
Source: Army Regulation 40-501.
[End of table]
[End of section]
Appendix IV Army Physical Profile Codes:
Table:
Code: Code A;
Description/assignment limitation: No assignment limitation;
Medical criteria (examples): No demonstrable anatomical or
physiological impairment; within standards established in table 7-1.
Code: Code B;
Description/assignment limitation: May have assignment limitations that
are intended to protect against further physical damage/injury. May
have minor impairments under one or more PULHES factors that disqualify
for certain MOS training or assignment;
Medical criteria (examples): Minimal loss of joint motion, visual and
hearing loss.
Code: Codes C through P*;
Description/assignment limitation: Possesses impairments that limit
functions or assignments. The codes listed below are for military
personnel administrative purposes. Corresponding limitations are
general guidelines and are not to be taken as verbatim limitations.
(For example, a Soldier with a code C may not be able to run but may
have no restrictions on marching or standing.) Item 3 of DA Form 3349
will contain the specific limitations;
Medical criteria (examples): [Empty].
Code: Code C;
Description/assignment limitation: Limitations in running, marching,
standing for long periods etc.;
Medical criteria (examples): Orthopedic or neurological conditions.
Code: CODE D;
Description/assignment limitation: Limitations in any type of strenuous
physical activity;
Medical criteria (examples): Organic cardiac disease; pulmonary
insufficiency.
Code: Code E;
Description/assignment limitation: Limitations requiring dietary
restrictions preventing consumption of combat rations;
Medical criteria (examples): Endocrine disorders-recent or repeated
peptic ulcer activity-chronic gastrointestinal disease requiring
dietary management.
Code: Code F;
Description/assignment limitation: Limitations prohibiting assignment
or deployment to OCONUS areas where definitive medical care is not
available;
Medical criteria (examples): Individuals who require continued medical
supervision with hospitalization or frequent outpatient visits for
serious illness or injury.
Code: Code G;
Description/assignment limitation: Limitations prohibiting wearing
Kevlar, LBE, lifting heavy materials required of the MOS, overhead
work;
Medical criteria (examples): Arthritis of the neck or joints of the
extremities with restricted motion; disk disease; recurrent shoulder
dislocation.
Code: Code H;
Description/assignment limitation: Limitations on duty where sudden
loss of consciousness would be dangerous to self or to others such as
work on scaffolding, vehicle driving, or near moving machinery;
Medical criteria (examples): Seizure disorders; other disorders
producing syncopal attacks of severe vertigo, such as Ménierč's
syndrome.
Code: Code J;
Description/assignment limitation: Given known handicaps associated
with high frequency hearing loss similar to this, Commanders are highly
recommended to make an individual risk assessment of any Soldier with
hearing loss that might be tasked to perform duties that require good
hearing, for example; localization and detection of friend or foe
sounds, scout, point, sentry, forward listening, post/observer,
radio/telephone operator, and so forth. (See DA Pam 40-501, Chapter 2-
4, Combat Readiness Effects.) Hearing Protection Measures required to
prevent further hearing loss;
1. No exposure to noise in excess of 85 dBA (decibels measured on the A
scale) or weapon firing without use of properly fitted hearing
protection. Annual hearing test required;
2. Further exposure to noise is hazardous to health. No duty or
assignment to noise levels in excess of 85 dBA or weapon firing (not to
include firing for preparation of replacements for overseas movement
qualification or annual weapons qualification with proper ear
protection). Annual hearing test required;
3. No exposure to noise in excess of 85 dBA or weapon firing without
use of properly fitted hearing protection. This individual is 'deaf' in
one ear. Any permanent hearing loss in the good ear will cause a
serious handicap. Annual Hearing test required;
4. Further duty requiring exposure to high intensity noise is hazardous
to health. No duty or assignment to noise levels in excess of 85 dBA or
weapon firing (not to include firing for overseas movement or weapon
firing without use of properly ear protection). No duty requiring acute
hearing. A hearing aid must be worn to meet medical fitness standards;
Medical criteria (examples): Susceptibility to acoustic trauma.
Code: Code L;
Description/assignment limitation: Limitations restricting assignment
to cold climates;
Medical criteria (examples): Documented history of cold injury;
vascular insufficiency; collagen disease, with vascular or skin
manifestations.
Code: Code M;
Description/assignment limitation: Limitations restricting exposure to
high environmental temperature;
Medical criteria (examples): History of heat stroke; history of skin
malignancy or other chronic skin diseases that are aggravated by
sunlight or high environmental temperature.
Code: Code N;
Description/assignment limitation: Limitations restricting wearing of
combat boots;
Medical criteria (examples): Any vascular or skin condition of the feet
or legs that, when aggravated by continuous wear of combat boots, tends
to develop unfitting ulcers.
Code: Code P;
Description/assignment limitation: Limitations restricting wearing or
being exposed to required items necessary to perform duty (for example,
Latex, wool);
Medical criteria (examples): Established allergy to wool, latex.
Code: CODE T*;
Description/assignment limitation: Waiver granted for a disqualifying
medical condition/standard for initial enlistment or appointment. The
disqualifying medical condition/standard for which a waiver was granted
will be documented in the Soldier's accession medical examination;
Medical criteria (examples): [Empty].
Code: Code U;
Description/assignment limitation: Limitation not otherwise described,
to be considered individually. (Briefly define limitation in item 8);
Medical criteria (examples): Any significant functional assignment
limitation not specifically identified elsewhere.
Code: Code V*;
Description/assignment limitation: Deployment. This code identifies a
Soldier with restrictions on deployment. Specific restrictions are
noted in the medical record;
Medical criteria (examples): [Empty].
Code: Code W*; Description/assignment limitation: MMRB. This code
identifies a Soldier with a permanent profile who has been returned to
duty by an MMRB (MOS Medical Review Board);
Medical criteria (examples): [Empty].
Code: Code X*; Description/assignment limitation: This code identifies
a Soldier who is allowed to continue in the military service with a
disease, injury, or medical defect that is below medical retention
standards; pursuant to a waiver of retention standards under chapter 9
or 10 of this publication, or waiver of unfit finding and continued on
active duty or in active; Reserve status under AR 635-40;
Medical criteria (examples): [Empty].
Code: Code Y*;
Description/assignment limitation: Fit for duty. This code identifies
the case of a Soldier who has been determined to be fit for duty (not
entitled to separation or retirement because of physical disability)
after complete processing under AR 635-40;
Medical criteria (examples): [Empty].
Source: Army Regulation 40-501.
Notes: (1) Profile codes are indicated under item 2 of the physical
profile form for all permanent physical profiles. (2) Codes do not
automatically correspond to a specific numerical designation of the
profile but are based on the general physical/assignment limitations.
*The Army regulation does not provide medical criteria for these codes.
[End of table]
[End of section]
Appendix V: Department of Defense Pre-Deployment Health Assessment (DD
Form 2795):
[See PDF for image]
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 personal 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:
Social Security Number:
First Name:
Last Name:
Today's Date (dd/mm/yyyy):
Deploying Unit:
DOB (dd/mm/yyyy):
Gender:
Male:
Female:
Service Branch:
Air Force:
Army:
Coast Guard:
Marine Corps:
Navy:
Other:
Component:
Active Duty:
National Guard:
Reserves:
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:
Other:
Location of Operation:
Europe:
SW Asia:
SE Asia:
Asia (Other):
South America:
Australia:
Africa:
Central America:
Unknown:
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:
Medical threat briefing completed:
Yes:
No:
N/A:
Medical information sheet distributed:
Yes:
No:
N/A:
Serum for HIV drawn within 12 months:
Yes:
No:
N/A:
Immunizations current:
Yes:
No:
N/A:
PPD screening within 24 months:
Yes:
No:
N/A:
Please fill in Social Security Number:
Health Assessment:
1. Would you say your health in general is:
Excellent:
Very good:
Good:
Fair:
Poor:
2. Do you have any medical or dental problems?
Yes:
No:
3. Are you currently on a profile, or light duty, or are you undergoing
a medical board?
Yes:
No:
4. Are you pregnant? (Females only):
Yes:
No:
5. Do you have a 90-day supply of your prescription medication or birth
control pills?
N/A:
Yes:
No:
6. Do you have two pairs of prescription glasses (if worn) and any
other personal medical equipment
N/A:
Yes:
No:
7. During the past year, have you sought counseling or care for your
mental health?
Yes:
No:
8. Do you currently have any questions or concerns about your health?
Yes:
No:
Please list your concerns:
I certify that the responses on this form are true:
Service Members 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 problems to
be placed in medical records.
Referral indicated:
None:
Cardiac:
Combat/Operational Stress Reaction:
Dental:
Dermatological:
ENT:
Eye:
Family Practice:
Fatigue. Malaise, Multisystem complaint:
GI:
GU:
GYN:
Mental Health:
Neurologic:
Orthopedic:
Pregnancy:
Pulmonary:
Other:
Deployable:
Not Deployable:
I certify that this review process has been completed.
Provider's signature and stamp:
Date (dd/mm/yyyy):
[End of Health Review]
DD FORM 2795, MAY 1999:
ASD (HA) Approved September 1998 Ver 1.3:
Source: U.S. Army:
[End of section]
Appendix VI: Comments from the Department of Defense:
Department Of The Army:
Office Of The Deputy Chief Of Staff, G-1:
300 Army Pentagon:
Washington, DC 20310-0300:
Reply to the Director of Military Personnel Management:
Ms. Brenda S. Farrell:
Director, Defense Capabilities and Management:
U.S. Government Accountability Office:
Washington, D.C. 20548:
Dear Ms. Farrell:
This is the Department of Defense (DoD) response to the Government
Accountability Office Draft Report, "Military Personnel: Army Needs to
Better Enforce Requirements and Improve Recordkeeping for Soldiers
Whose Medical Conditions May Call for Significant Duty Limitations,"
dated May 9, 2008 (GAO Code 351152; GAO-08-546).
The Department appreciates the opportunity to comment on the draft
report. We greatly value GAO's efforts in examining this important and
complex issue. As written, the Department agrees with the GAO report
and its recommendations. Detailed comments to each of GAO's
recommendations are enclosed.
As you may be aware, the Secretary of the Army has directed the Army
Inspector General to conduct a broad and thorough inspection of these
same issues. The results of this inspection will validate our new
initiatives that we are instituting which will help adequately address
your cited concerns and recommendations.
Sincerely,
Signed by:
Gina S. Farrisee:
Brigadier General, U.S. Army:
Director of Military Personnel Management:
GAO Draft Report - Dated May 9, 2008:
GAO Code 351152/GAO-08-546:
"Military Personnel: Army Needs to Better Enforce Requirements and
Improve Recordkeeping for Soldiers Whose Medical Conditions May Call
for Significant Duty Limitations"
Department Of Defense Comments To The Recommendations:
Recommendation 1: The GAO recommends that the Secretary of the Army
direct the Office of the Army Surgeon General and the Army Deputy Chief
of Staff G-1 to collaboratively develop an enforcement mechanism to
ensure commanders and medical providers follow procedures to make sure
Soldiers whose permanent physical profiles indicate significant medical
limitations are properly referred to and complete MMRB and MEB
evaluation boards prior to deployment. (pg. 34/GAO Draft Report)
DOD Response:
DoD concurs. However, the findings of the GAO report do not suggest a
widespread problem throughout the Army and commanders appear to be
adhering to the current procedures regarding the medical fitness of
Soldiers identified to deploy. A sample taken from Forts Benning,
Stewart, and Drum, showed a total of 17 Soldiers found with a P3 or
higher profile who had not appeared before a medical evaluation board
and had deployed. The report could not confirm that these Soldiers, who
deployed from these installations, had not been assigned to duties
suitable to their medical condition. Survey and interview responses
indicate that Soldiers generally felt they had been assigned to
suitable duties and commanders reported they were aware of deployed
Soldiers' medical conditions and these conditions had been taken into
account when assigning duties.
In addition, the Secretary of the Army recently directed that the
Inspector General conduct a thorough inspection of the medical policies
and procedures that support a commander's determination of Soldier
deployability. The inspection will occur over several months including
both CONUS and OCONUS units and agencies. Also, the Assistant Secretary
of Defense for Health Affairs is planning to release new guidance, as
mentioned in the GAO report, providing more guidelines on medical
conditions that should preclude affected service members from being
deployed.
The Army and DoD are in the process of instituting a number of
initiatives to improve the process for completion of permanent physical
profiles and referral to an MMRB or MEB, if medically indicated.
Physical profile information must be entered into the Medical
Protection System (MEDPROS) which tracks all immunization, medical
readiness, and deployability data for Soldiers in order to assist the
chain of command in determining their medical and dental readiness. The
Army's Periodic Health Assessment (PHA) policy requires that Soldiers'
physical profiles be reviewed by privileged providers on an annual
basis. Once the profile process is automated, the enforcement mechanism
will be accomplished using the interplay between MEDPROS and the
Medical Nondeployable Module already in use in the Reserve Component
(United States Army Reserve and National Guard). The effort to automate
this interplay will result in a program referred to as EProfile. The
program highlights Soldiers without correct profile codes (Box 2 on the
DA 3349) indicating MMRB or MEB board completion. Where codes are
missing, Soldiers will be categorized as nondeployable and unit
commanders will be alerted. Once the physical profile is fully
automated, the MEB or MMRB referral process will be generated
automatically (built into the logic of the program). Until then, it is
the responsibility of the hospital commander to educate and enforce
compliance with MEB/MMRB referral and profile routing requirements. The
MEDCOM Commander allows hospital commanders to determine which
management strategies work best for their organization.
In addition, DoD and the Department of Veterans Affairs are
reevaluating the complete Physical Disability Evaluation Process which
includes the Medical Evaluation Board (MEB). The intent is to
streamline the process and return the Soldier to duty or determine
his/her disability. For the first quarter of FY08, the Department of
the Army average processing time for an MEB was 40 days, with the goal
being 30 days.
Recommendation 2: The GAO recommends that the Secretary of the Army
direct the Office of the Army Surgeon General and the Army Deputy Chief
of Staff G-1 to move forward with plans to electronically process and
retain physical profiles, including specific actions and milestones,
and to implement guidance to help ensure the timely distribution of
profiles to commanders and the military personnel office and that the
medical recordkeeping system include all information in the approved
physical profiles and that all profiles be retained in Soldiers'
medical records. (pg. 34/GAO Draft Report)
DOD Response:
DoD Concurs. The Office of the Army Surgeon General identified and
submitted the functional requirements for the automation of physical
profiles for Defense Business Transformation Certification. This DoD
mandated business certification is expected in July 2008 with
appropriate funds obligated for development in the fourth quarter of
FY08.
Current requirements for processing and distributing paper copies of
profiles are addressed in AR 40-501, chapter 7. One copy is forwarded
to the unit commander, one copy to the installation Military Personnel
Office, one copy is given to the Soldier, and one copy is retained in
the medical record. Methods of distribution vary based on installation
resources and support. Provider generated profile information is also
recorded in the military's electronic health record or AHLTA (Armed
Forces Health Longitudinal Technology Application). Profile information
in AHLTA is not yet available to unit commanders; however, the
automated physical profile is designed to correct this deficiency.
Paper copies of profiles continue to be maintained in existing paper-
based medical records.
Recommendation 3: The GAO recommends that the Secretary of the Army
direct the Army Human Resources Command to disseminate information and
provide Soldiers and their Families access to an independent ombudsman
program prior to and during deployment to ensure they are fully
informed about this resource for addressing their concerns and to add
independent oversight of Army medical and deployment processes in the
interests of the Soldiers. (pg. 34/GAO Draft Report)
DOD Response:
DoD concurs with the concerns expressed in the above recommendation;
however, these concerns can be addressed using an existing Army
program. In 2007, the Army established two programs to assist wounded
or ill Soldiers and their Family members: The Wounded Soldier and
Family Hotline and an Ombudsman Program. The Wounded Soldier and Family
Hotline in particular, could effectively address GAO's concerns and
assist all Soldiers (and Families), whether preparing to deploy,
deployed, or redeployed. The Army senior leadership supports the use of
the existing Hotline and Ombudsman programs, as they already serve as
independent resources for addressing Soldier and Family member
concerns.
In March 2007, Army senior leadership established the Wounded Soldier
Family Hotline, the purpose of which was two-fold: To offer wounded,
injured, or ill Soldiers and their Family members a way to seek help to
resolve medical issues and to provide an information channel of Soldier
medical related issues directly to Army senior leadership to enable
them to improve the way the Army serves the medical needs of Soldiers
and their Families. The hotline was not established to circumvent the
chain of command, but rather to give Soldiers and Family members an
additional means to resolve medical-related issues and navigate through
the medical care system. Retribution directed towards those who use the
hotline is not tolerated. The hotline is managed and operated by the
U.S. Army Human Resources Command in Alexandria, VA. Since inception,
the hotline has fielded more than 12,000 calls, involving approximately
3000 issues. The WSFH addresses issues for all components, Veterans,
and Retirees. All callers' issues are captured and addressed; we have
not turned a caller away. Callers' issues are staffed to the
organization which can best resolve the issue which includes the
appropriate Army Commands, Army Service Component Commands, or Direct
Reporting Units for resolution and follow-up within three business
days. The hotline operates 24 hours a day, seven days a week. It is
staffed by 11 Soldiers, 34 Contractors and one DA Civilian. Many of the
Contractors are either former Soldiers or Family members of current or
formerly serving Soldiers. The Army Wounded Soldier and Family Hotline
can be accessed by phone (1-800-984-8523 or DSN 312-328-0002) or email
(wsfsupport@conus.army.mil).
In April 2007, the Army established an Ombudsman Program to serve
Soldiers and Family members assigned to Warrior Transition Units
(WTUs). Ombudsman work as advocates to resolve issues related to health
care, physical disability processing, Reserve Component medical
retention issues, transition to the Veterans Administration, pay
issues, and more. Ombudsman link Soldiers and Family members with the
appropriate individual and/or agency that can fully address their
concerns or questions. There are currently 48 Ombudsman supporting 29
sites and two more will soon be added to Germany supporting two
additional sites. To date, this program has assisted over 5,400
Soldiers. Ombudsman work directly for the Army Medical Command (MEDCOM)
and are independent from local commands and all information between the
Soldier and Ombudsman are confidential in compliance with the Health
Insurance Portability and Accountability Act of 1996 (HIPAA). While the
majority of cases are opened directly by the Ombudsman on site, the
MEDCOM Medical Assistance Group works closely with the Wounded Soldier
Family Hotline to resolve any WTU medical issues called into the
hotline.
The Army in 2008 is entering its seventh year of persistent conflict.
Many wounded and injured Soldiers, who have supported the Global War on
Terror, as well as their Families, are enduring hardships in navigating
our medical care system. Our Army is committed to providing outstanding
medical care for the men and women who have volunteered to serve this
great nation. Recent events at Walter Reed Army Medical Center made it
clear the Army needs to revise how it meets the needs of our wounded
and injured Soldiers and their Families. Part of the response by Army
senior leaders was the creation of the two programs mentioned. The Army
Wounded Soldier and Family Hotline is poised to assist all wounded,
injured or ill Soldiers and their Family members regardless of whether
the Soldier has already deployed, is currently deployed, or preparing
to deploy. As a matter of fact, the hotline is already receiving calls
from Soldiers who are deployed, and from their Families. The Army will
continue to aggressively advertise the availability of this critical
resource and established metrics will continue to be reported to Army
senior leaders.
[End of section]
Appendix VII: 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, Marilyn Wasleski, Assistant
Director; Gina Hoffman; LaToya King; Grace Materon; Elisha Matvay;
Sonya Phillips; Jeanett Reid; Norris Smith III; and Cheryl Weissman
made significant contributions to the report. In addition, Terry
Richardson, Carl Barden, and Steven Putansu provided guidance and
assistance with design and analysis; Nicole Harms provided legal
advice; Steve Fox, Marcia Crosse, and Tom Conahan advised on message
preparation; and Clara Mejstrik, Adam Smith, Maria Storts, and John
Wren provided assistance during medical file reviews.
[End of section]
Related GAO Products:
DOD Civilian Personnel: Medical Policies for Deployed DOD Federal
Civilians and Associated Compensation for Those Deployed. [hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO-07-1235T]. Washington, D.C.:
September 18, 2007.
Defense Health Care: Comprehensive Oversight Framework Needed to Help
Ensure Effective Implementation of a Deployment Health Quality
Assurance Program. [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-07-
831]. Washington, D.C.: June 22, 2007.
DOD Civilian Personnel: Greater Oversight and Quality Assurance Needed
to Ensure Force Health Protection and Surveillance for Those Deployed.
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?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. [hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO-06-1068]. Washington, D.C.:
September 20, 2006.
Military Disability System: Improved Oversight Needed to Ensure
Consistent and Timely Outcomes for Reserve and Active Duty Service
Members. [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-06-362].
Washington, D.C.: March 31, 2006.
Military Personnel: Top Management Attention Is Needed to Address Long-
standing Problems with Determining Medical and Physical Fitness of the
Reserve Force. [hyperlink, http://www.gao.gov/cgi-bin/getrpt?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. [hyperlink,
http://www.gao.gov/cgi-bin/getrpt?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.
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?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.
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-04-1031]. Washington,
D.C.: September 15, 2004.
Defense Health Care: DOD Needs to Improve Force Health Protection and
Surveillance Processes. [hyperlink, http://www.gao.gov/cgi-
bin/getrpt?GAO-04-158T]. Washington, D.C.: October 16, 2003.
Defense Health Care: Quality Assurance Process Needed to Improve Force
Health Protection and Surveillance. [hyperlink, http://www.gao.gov/cgi-
bin/getrpt?GAO-03-1041]. Washington, D.C.: September 19, 2003.
Military Personnel: DOD Needs More Data to Address Financial and Health
Care Issues Affecting Reservists. [hyperlink, http://www.gao.gov/cgi-
bin/getrpt?GAO-03-1004]. Washington, D.C.: September 10, 2003.
Defense Health Care: Army Has Not Consistently Assessed the Health
Status of Early-Deploying Reservists. [hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO-03-997T]. Washington, D.C.: July
9, 2003.
Defense Health Care: Army Needs to Assess the Health Status of All
Early-Deploying Reservists. [hyperlink, http://www.gao.gov/cgi-
bin/getrpt?GAO-03-437]. Washington, D.C.: April 15, 2003.
VA And Defense Health Care: Military Medical Surveillance Policies in
Place, but Implementation Challenges Remain. [hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO-02-478T]. Washington, D.C.:
February 27, 2002.
Gulf War Illnesses: Research, Clinical Monitoring, and Medical
Surveillance. [hyperlink, http://www.gao.gov/cgi-bin/getrpt?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. [hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO/NSIAD-97-163]. Washington, D.C.:
June 23, 1997.
Defense Health Care: Medical Surveillance Improved Since Gulf War, but
Mixed Results in Bosnia. [hyperlink, http://www.gao.gov/cgi-
bin/getrpt?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. [hyperlink, http://www.gao.gov/cgi-
bin/getrpt?GAO/NSIAD-94-36]. Washington, D.C.: March 23, 1994.
Operation Desert Storm: War Highlights Need to Address Problem of
Nondeployable Personnel. [hyperlink, http://www.gao.gov/cgi-
bin/getrpt?GAO/NSIAD-92-208]. Washington, D.C.: August 31, 1992.
[End of section]
Footnotes:
[1] See appendix II for a copy of the physical profile form DA 3349.
[2] See appendix III for descriptions of the physical profile numerical
designations and categories.
[3] GAO, Defense Health Care: Comprehensive Oversight Framework Needed
to Help Ensure Effective Implementation of a Deployment Health Quality
Assurance Program, GAO-07-831 (Washington, D.C.: June 22, 2007);
Defense Health Care: Quality Assurance Process Needed to Improve Force
Health Protection and Surveillance, GAO-03-1041 (Washington, D.C.:
Sept. 19, 2003); and Reserve Forces: DOD Policies Do Not Ensure That
Personnel Meet Medical and Physical Fitness Standards, GAO/NSIAD-94-36
(Washington, D.C.: Mar. 23, 1994). See the Related GAO Products section
for more GAO reports pertaining to medical deployability.
[4] 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).
[5] Representative Vic Snyder was Chair of the Subcommittee on Military
Personnel at the time of the request.
[6] GAO has reported in the past that military health records are often
incomplete and do not contain all necessary documentation. GAO, Defense
Health Care: DOD Needs to Improve Force Health Protection and
Surveillance Processes, GAO-04-158T (Washington, D.C.: Oct. 16, 2003);
and Gulf War Illnesses: Research, Clinical Monitoring, and Medical
Surveillance, GAO/T-NSIAD-98-88, (Washington, D.C.: Feb. 5, 1998). Our
analysis for this report is considered to be baseline data and cannot
be considered comprehensive.
[7] All percentage estimates of soldiers at these installations are
based on random samples and are subject to sampling error. For this
estimate, we are 95 percent confident that between 1 percent and 4
percent of soldiers from these installations did not receive required
evaluations prior to deployment.
[8] The 95 percent confidence interval for this estimate is from 5 to
10 percent of soldiers.
[9] The 95 percent confidence interval for this estimate is from 7 to
12 percent of soldiers.
[10] Under Secretary of Defense for Personnel and Readiness, Department
of Defense Instruction 6490.03, Deployment Health (Aug. 11, 2006);
Under Secretary of Defense for Personnel and Readiness, Memorandum,
Policy Guidance for Medical Deferral Pending Deployment to Theaters of
Operation (Feb. 9, 2006); Under Secretary of Defense for Personnel and
Readiness, Department of Defense Instruction 6025.19, Individual
Medical Readiness (IMR) (Jan. 3, 2006); Under Secretary of Defense for
Personnel and Readiness, Department of Defense Instruction 6200.05,
Force Health Protection Quality Assurance Program (Feb. 16, 2007);
Assistant Secretary of Defense, Memorandum, Policy for Department of
Defense Deployment Health Quality Assurance Program (Jan. 9, 2004);
U.S. Central Command, Individual Protection and Individual/Unit
Deployment Policy, PPG Modification 8 (July 2007).
[11] In our review, we did not find that soldiers in our sample who had
deployed were considered not deployable due to their medical condition
and thus, we did not find instances of waivers in order to deploy
soldiers in our sample.
[12] U.S. Army Regulation 40-501, Standards of Medical Fitness (Jan.
18, 2007); U.S. Air Force Instruction 10-203, Duty Limiting Conditions
(Oct. 25, 2007); and U.S. Navy Manual of the Medical Department NAVMED
p-117 (Aug. 12, 2005).
[13] During our review at the three installations, we only reviewed one
physical profile designated at level 4. It was a temporary profile and
the soldier did not deploy with it in effect.
[14] Currently, no code exists for soldiers reviewed by an MEB who were
not also reviewed by a subsequent Physical Evaluation Board. The Army
plans to correct this oversight in the next revision of Army regulation
40-501. See appendix IV for full description of profile codes from AR
40-501.
[15] Army Regulation 40-501; Army Regulation 600-60, Physical
Performance Evaluation System (June 25, 2002); Army Regulation 40-400,
Patient Administration (Feb. 6, 2008).
[16] Army Regulation 600-60 (June 25, 2002).
[17] Army Regulation 40-501, chapter 3, lists certain diseases or
medical conditions that could severely limit a soldier's ability to
perform his or her duties, such as heart disease, cirrhosis of the
liver, chronic asthma, and epilepsy.
[18] The MEB and Physical Evaluation Board processes are together
called the Physical Disability Evaluation System, but because a soldier
is not evaluated by a Physical Evaluation Board without first going
through an MEB, we refer to this in the report as the MEB process.
[19] Chief of Staff of the United States Army, Memorandum, Metrics and
Continuous Process Improvements for Medical Evaluation Board (MEB) and
Physical Evaluation Board (PEB) Processing (Sept. 26, 2007).
[20] Department of Defense Instruction 6490.03 (Aug. 11, 2006).
[21] See appendix V for a copy of the pre-deployment assessment form DD
2795.
[22] Army Regulation 40-501 (Jan. 18, 2007).
[23] Army Regulation 600-60 (June 25, 2002).
[24] Army Regulation 40-400 (Feb. 6, 2008).
[25] DOD Instruction 6490.03 (Aug. 11, 2006).
[26] Army Regulation 600-60 (June 25, 2002).
[27] The 95 percent confidence interval for this estimate is from 4 to
8 percent of soldiers.
[28] Although the Army may obtain a waiver in order to deploy soldiers
that do not meet medical fitness standards if medical treatment is
available in theater according to DOD guidance, we did not find
evidence of any waivers.
[29] The 95 percent confidence interval for this estimate is from 1
percent to 4 percent of soldiers.
[30] Army regulation 600-60 (June 25, 2002); Chief of Staff of the
United States Army, Memorandum (Sept. 26, 2007).
[31] The 95 percent confidence interval for this estimate is from 5 to
10 percent of soldiers.
[32] Army Office of the Surgeon General/Army Medical Command Policy
Memorandum, Ombudsman Program in Support of Warriors in Transition
(Sept. 6, 2007).
[33] The 95 percent confidence interval for this estimate is from 84 to
88 percent of soldiers.
[34] The 95 percent confidence interval for this estimate is from 12 to
16 percent of soldiers.
[35] The 95 percent confidence interval for this estimate is from 7 to
12 percent of soldiers.
[36] The 95 percent confidence interval for this estimate is from 3 to
6 percent of soldiers.
[37] See appendix III for descriptions of the physical profile
categories.
[38] See appendix V for a copy of the pre-deployment health assessment
form 2795.
[39] See appendix II for a copy of the Army physical profile form 3349.
[End of section]
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