VA and Defense Health Care: Progress and Challenges DOD Faces in 
Executing a Military Medical Surveillance System (16-OCT-01,	 
GAO-02-173T).							 
								 
The Departments of Defense (DOD) and Veterans Affairs (VA) are	 
establishing a medical surveillance system for the health care	 
needs of military personnel and veterans. A medical surveillance 
system involves the ongoing collection and analysis of uniform	 
information on deployments, environmental health threats, disease
monitoring, medical assessments, and medical encounters. GAO has 
identified weaknesses in DOD's medical surveillance capability	 
and performance during the Gulf War and Operation Joint Endeavor.
Investigations into the unexplained illnesses of Gulf War	 
veterans uncovered many deficiencies in DOD's ability to collect,
maintain, and transfer accurate data describing the movement of  
troops, potential exposures to health risks, and medical	 
incidents during deployment. DOD has several initiatives under	 
way to improve the reliability of deployment information and to  
enhance its information technology capabilities, though some	 
initiatives are several years away from full implementation. The 
ability of VA to fulfill its role in serving veterans and	 
providing backup to DOD in times of war will be enhanced as DOD  
increases its medical surveillance capability.			 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-02-173T					        
    ACCNO:   A02322						        
  TITLE:     VA and Defense Health Care: Progress and Challenges DOD  
Faces in Executing a Military Medical Surveillance System	 
     DATE:   10/16/2001 
  SUBJECT:   Medical information systems			 
	     Military personnel 				 
	     Veterans benefits					 
	     Data collection					 
	     Information resources management			 
	     Data integrity					 
	     Health care services				 
	     Defense Health Program				 
	     Defense Manpower Data Center			 
	     DOD Force Health Protection Plan			 
	     DOD Operation Joint Endeavor			 
	     DOD Theater Medical Information Program		 
	     DOD Vaccine Adverse Event Reporting		 
	     System						 
								 
	     DOD/IHS/VA Government Computer-Based		 
	     Patient Record Project				 
								 
	     Persian Gulf War					 
	     DOD Global Expeditionary Medical System		 

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GAO-02-173T
     
Testimony Before the Committee on Veterans? Affairs, U. S. Senate

United States General Accounting Office

GAO For Release on Delivery Expected at 2: 30 p. m. Tuesday, October 16,
2001 VA AND DEFENSE

HEALTH CARE Progress and Challenges DOD Faces in Executing a Military
Medical Surveillance System

Statement for the Record by Stephen P. Backhus Director, Health Care-
Veterans?

and Military Health Care Issues

GAO- 02- 173T

Page 1 GAO- 02- 173T

Mr. Chairman and Members of the Committee: We are pleased to submit this
statement for the record on the Department of Defense?s (DOD) efforts to
establish a medical surveillance system that enables DOD- along with the
Department of Veterans Affairs (VA)- to respond to the health care needs of
our military personnel and veterans. A medical surveillance system involves
the ongoing collection and analysis of uniform information on deployments,
environmental health threats, disease monitoring, medical assessments, and
medical encounters. It is also important that this information be
disseminated in a timely manner to military commanders, medical personnel,
and others. DOD is responsible for developing and executing this system and
needs this information to help ensure the deployment of healthy forces and
the continued fitness of those forces. VA also needs this information to
fulfill its missions of providing health care to veterans, backing up DOD in
contingencies, and adjudicating veterans? claims for service- connected
disabilities. Scientists at VA, DOD, and other organizations also use this
information to conduct epidemiological studies and research. 1

Given our current military actions responding to the events of September 11,
you asked us to describe the challenges DOD faces in establishing a reliable
medical surveillance system, based on what has been reported about DOD?s
medical surveillance activities during the Gulf War and Operation Joint
Endeavor. 2 This statement focuses on reports GAO, 3 the Institute of
Medicine (IOM), the Presidential Advisory Committee on Gulf War Veterans?
Illnesses, 4 and others have issued over the past several years. This
statement is also based on interviews we held over the past 2

1 Epidemiology is the scientific study of the incidence, distribution, and
control of disease in a population. 2 United States and allied nations
deployed peacekeeping forces to Bosnia beginning in December 1995 in support
of Operation Joint Endeavor, the NATO- led Bosnian peacekeeping force.

3 See list of related GAO products at the end of this statement. 4 The
President established this committee in May 1995 to conduct independent,
open, and comprehensive examinations of health care concerns related to Gulf
War service. The committee consisted of physicians, scientists, and Gulf War
veterans.

Page 2 GAO- 02- 173T

weeks with various Defense Health Program officials, including officials
from the Army Surgeon General?s Office. 5

In summary, GAO, the Institute of Medicine, and others have reported
extensively on weaknesses in DOD?s medical surveillance capability and
performance during the Gulf War and Operation Joint Endeavor and the
challenges DOD faces in implementing a reliable medical surveillance system.
Investigations into the unexplained illnesses of Gulf War veterans uncovered
many deficiencies in DOD?s ability to collect, maintain, and transfer
accurate data describing the movement of troops, potential exposures to
health risks, and medical incidents during deployment. DOD improved its
medical surveillance system under Operation Joint Endeavor, which provided
useful information to military commanders and medical personnel. However, we
and others reported a number of problems with this system. For example,
information related to service members? health and deployment status- data
critical to an effective medical surveillance system- was incomplete or
inaccurate. DOD?s numerous databases, including those that capture health
information, are currently not linked, which further challenges the
department?s efforts to establish a single, comprehensive electronic system
to document, archive, and access medical surveillance data.

DOD has several initiatives under way to improve the reliability of
deployment information and to enhance its information technology
capabilities, as we and others have recommended, though some initiatives are
several years away from full implementation. Nonetheless, these efforts
reflect a commitment by DOD to establish a comprehensive medical
surveillance system. The ability of VA to fulfill its role in serving
veterans and providing backup to DOD in times of war will be enhanced as DOD
increases its medical surveillance capability.

An effective military medical surveillance system needs to collect reliable
information on (1) the health care provided to service members before,
during, and after deployment; (2) where and when service members were
deployed; (3) environmental and occupational health threats or exposures
during deployment (in theater) and appropriate protective and counter
measures; and (4) baseline health status and subsequent health changes.

5 The Secretary of the Army is responsible for medical surveillance for DOD
deployments, consistent with DOD?s medical surveillance policy. Background

Page 3 GAO- 02- 173T

This information is needed to monitor the overall health condition of
deployed troops, inform them of potential health risks, as well as maintain
and improve the health of service members and veterans.

In times of conflict, a military medical surveillance system is particularly
critical to ensure the deployment of a fit and healthy force and to prevent
disease and injuries from degrading force capabilities. DOD needs reliable
medical surveillance data to determine who is fit for deployment; to prepare
service members for deployment, including providing vaccinations to protect
against possible exposure to environmental and biological threats; and to
treat physical and psychological conditions that resulted from deployment.
DOD also uses this information to develop educational measures for service
members and medical personnel to ensure that service members receive
appropriate care.

Reliable medical surveillance information is also critical for VA to carry
out its missions. In addition to VA?s better known missions- to provide
health care and benefits to veterans and medical research and education- VA
has a fourth mission: to provide medical backup to DOD in times of war and
civilian health care backup in the event of disasters producing mass
casualties. As such, VA needs reliable medical surveillance data from DOD to
treat casualties of military conflicts, provide health care to veterans who
have left active duty, assist in conducting research should troops be
exposed to environmental or occupational hazards, and identify service-
connected disabilities and adjudicate veterans? disability claims.

Investigations into the unexplained illnesses of service members and
veterans who had been deployed to the Gulf uncovered the need for DOD to
implement an effective medical surveillance system to obtain comprehensive
medical data on deployed service members, including Reservists and National
Guardsmen. Epidemiological and health outcome studies to determine the
causes of these illnesses have been hampered due to incomplete baseline
health data on Gulf War veterans, their potential exposure to environmental
health hazards, and specific health data on care provided before, during,
and after deployment. The Presidential Advisory Committee on Gulf War
Veterans? Illnesses? and IOM?s 1996 investigations into the causes of
illnesses experienced by Gulf War Medical

Recordkeeping and Surveillance During the Gulf War Was Lacking

Page 4 GAO- 02- 173T

veterans confirmed the need for more effective medical surveillance
capabilities. 6

The National Science and Technology Council, as tasked by the Presidential
Advisory Committee, also assessed the medical surveillance system for
deployed service members. In 1998, the council reported that inaccurate
recordkeeping made it extremely difficult to get a clear picture of what
risk factors might be responsible for Gulf War illnesses. 7 It also reported
that without reliable deployment and health assessment information, it was
difficult to ensure that veterans? service- related benefits claims were
adjudicated appropriately. The council concluded that the Gulf War exposed
many deficiencies in the ability to collect, maintain, and transfer accurate
data describing the movement of troops, potential exposures to health risks,
and medical incidents in theater. The council reported that the government?s
recordkeeping capabilities were not designed to track troop and asset
movements to the degree needed to determine who might have been exposed to
any given environmental or wartime health hazard. The council also reported
major deficiencies in health risk communications, including not adequately
informing service members of the risks associated with countermeasures such
as vaccines. Without this information, service members may not recognize
potential side effects of these countermeasures and promptly take
precautionary actions, including seeking medical care.

6 Health Consequences of Service During the Persian Gulf War:
Recommendations for Research and Information Systems, Institute of Medicine,
Medical Follow- up Agency (Washington, D. C.: National Academy Press, 1996
); Presidential Advisory Committee on Gulf War Veterans? Illnesses: Interim
Report (Washington, D. C.: U. S. Government Printing Office, Feb. 1996);
Presidential Advisory Committee on Gulf War Veterans? Illnesses: Final
Report (Washington, D. C.: U. S. Government Printing Office, Dec. 1996). 7
National Science and Technology Council Presidential Review Directive 5
(Washington, D. C.: Executive Office of the President, Office of Science and
Technology Policy, Aug. 1998).

Page 5 GAO- 02- 173T

In response to these reports, DOD strengthened its medical surveillance
system under Operation Joint Endeavor when service members were deployed to
Bosnia- Herzegovina, Croatia, and Hungary. In addition to implementing
departmentwide medical surveillance policies, DOD developed specific medical
surveillance programs to improve monitoring and tracking environmental and
biomedical threats in theater. While these efforts represented important
steps, a number of deficiencies remained.

On the positive side, the Assistant Secretary of Defense (Health Affairs)
issued a health surveillance policy for troops deploying to Bosnia. 8 This
guidance stressed the need to (1) identify health threats in theater, (2)
routinely and uniformly collect and analyze information relevant to troop
health, and (3) disseminate this information in a timely manner. DOD
required medical units to develop weekly reports on the incidence rates of
major categories of diseases and injuries during all deployments. Data from
these reports showed theaterwide illness and injury trends so that
preventive measures could be identified and forwarded to the theater medical
command regarding abnormal trends or actions that should be taken.

DOD also established the U. S. Army Center for Health Promotion and
Preventive Medicine- a major enhancement to DOD?s ability to perform
environmental monitoring and tracking. For example, the center operates and
maintains a repository of service members? serum samples for medical
surveillance and a system to integrate, analyze, and report data from
multiple sources relevant to the health and readiness of military personnel.
This capability was augmented with the establishment of the 520th Theater
Army Medical Laboratory- a deployable public health laboratory for providing
environmental sampling and analysis in theater. The sampling results can be
used to identify specific preventive measures and safeguards to be taken to
protect troops from harmful exposures and to develop procedures to treat
anyone exposed to health hazards. During Operation Joint Endeavor, this
laboratory was used in Tuzla, Bosnia, where most of the U. S. forces were
located, to conduct air, water, soil, and other environmental monitoring.

Despite the department?s progress, we and others have reported on DOD?s
implementation difficulties during Operation Joint Endeavor and the

8 Health Affairs Policy 96- 019 (DOD Assistant Secretary of Defense
Memorandum, Jan. 4, 1996). Medical Surveillance

Under Operation Joint Endeavor Improved But Was Not Comprehensive

Page 6 GAO- 02- 173T

shortcomings in DOD?s ability to maintain reliable health information on
service members. Knowledge of who is deployed and their whereabouts is
critical for identifying individuals who may have been exposed to health
hazards while deployed. However, in May 1997, we reported that the
inaccurate information on who was deployed and where and when they were
deployed- a problem during the Gulf War- continued to be a concern during
Operation Joint Endeavor. 9 For example, we found that the Defense Manpower
Data Center (DMDC) database- where military services are required to report
deployment information- did not include records for at least 200 Navy
service members who were deployed. Conversely, the DMDC database included
Air Force personnel who were never actually deployed. In addition, we
reported that DOD had not developed a system for tracking the movement of
service members within theater. IOM also reported that the location of
service members during the deployments were still not systematically
documented or archived for future use. 10

We also reported in May 1997 that for the more than 600 Army personnel whose
medical records we reviewed, DOD?s centralized database for postdeployment
medical assessments did not capture 12 percent of those assessments
conducted in theater and 52 percent of those conducted after returning home.
11 These data are needed by epidemiologists and other researchers to assess
at an aggregate level the changes that have occurred between service
members? pre- and postdeployment health assessments. Further, many service
members? medical records did not include complete information on in- theater
postdeployment medical assessments that had been conducted. The Army?s
European Surgeon General attributed missing in- theater health information
to DOD?s policy of having service members hand carry paper assessment forms
from the theater to their home units,

9 Defense Health Care: Medical Surveillance Improved Since Gulf War, but
Mixed Results in Bosnia (GAO/ NSIAD- 97- 136, May 13, 1997). 10 See
Institute of Medicine, Protecting Those Who Serve: Strategies to Protect the
Health of Deployed U. S. Forces (Washington, D. C., National Academy Press,
2000). 11 In many cases, we found that these assessments were not conducted
in a timely manner or were not conducted at all. For example, of the 618
personnel whose records we reviewed, 24 percent did not receive in- theater
postdeployment medical assessments and 21 percent did not receive home
station postdeployment medical assessments. Of those who did receive home
station postdeployment medical assessments, the assessments were on average
conducted nearly 100 days after they left theater- instead of within 30
days, as DOD requires.

Page 7 GAO- 02- 173T

where their permanent medical records were maintained. The assessments were
frequently lost en route.

We have also reported that not all medical encounters in theater were being
recorded in individual records. Our 1997 report identified that this problem
was particularly common for immunizations given in theater. Detailed data on
service members? vaccine history are vital for scheduling the regimen of
vaccinations and boosters and for tracking individuals who received
vaccinations from a specific lot in the event health concerns about the
vaccine lot emerge. We found that almost one- fourth of the service members?
medical records that we reviewed did not document the fact that they had
received a vaccine for tick- borne encephalitis. In addition, in its 2000
report, IOM cited limited progress in medical recordkeeping for deployed
active duty and reserve forces and emphasized the need for records of
immunizations to be included in individual medical records.

Responding to our and others? recommendations to improve information on
service members? deployments, in- theater medical encounters, and
immunizations, DOD has continued to revise and expand its policies relating
to medical surveillance, and the system continues to evolve. In addition, in
2000, DOD released its Force Health Protection plan, which presents its
vision for protecting deployed forces. 12 This vision emphasizes force
fitness and health preparedness and improving the monitoring and
surveillance of health threats in military operations. However, IOM
criticized DOD?s progress in implementing its medical surveillance program
and the failure to implement several recommendations that IOM had made. In
addition, IOM raised concerns about DOD?s ability to achieve the vision
outlined in the Force Health Protection plan. We have also reported that
some of DOD?s programs designed to improve medical surveillance have not
been fully implemented.

IOM?s 2000 report presented the results of its assessment of DOD?s progress
in implementing recommendations for improving medical surveillance made by
IOM and several others. IOM stated that, although DOD generally concurred
with the findings of these groups, DOD had made few concrete changes at the
field level. For example, medical

12 Joint Staff, Medical Readiness Division, Force Health Protection (2000).
Current Policies and

Programs Not Fully Implemented

Recent IOM Report Concludes Slow Progress by DOD in Implementing
Recommendations

Page 8 GAO- 02- 173T

encounters in theater were still not always recorded in individuals? medical
records, and the locations of service members during deployments were still
not systematically documented or archived for future use. In addition,
environmental and medical hazards were not yet well integrated in the
information provided to commanders.

The IOM report notes that a major reason for this lack of progress is no
single authority within DOD has been assigned responsibility for the
implementation of the recommendations and plans. IOM said that because of
the complexity of the tasks involved and the overlapping areas of
responsibility involved, the single authority must rest with the Secretary
of Defense.

In its report, IOM describes six strategies that in its view demand further
emphasis and require greater efforts by DOD:

 Use a systematic process to prospectively evaluate non- battle- related
risks associated with the activities and settings of deployments.

 Collect and manage environmental data and personnel location, biological
samples, and activity data to facilitate analysis of deployment exposures
and to support clinical care and public health activities.

 Develop the risk assessment, risk management, and risk communications
skills of military leaders at all levels.

 Accelerate implementation of a health surveillance system that completely
spans an individual?s time in service.

 Implement strategies to address medically unexplained symptoms in
populations that have deployed.

 Implement a joint computerized patient record and other automated
recordkeeping that meets the information needs of those involved with
individual care and military public health.

DOD guidance established requirements for recording and tracking
vaccinations and automating medical records for archiving and recalling
medical encounters. While our work indicates that DOD has made some progress
in improving its immunization information, the department faces numerous
challenges in implementing an automated medical record.

In October 1999, we reported that DOD?s Vaccine Adverse Event Reporting
System, which relies on medical personnel or service members to provide Our
Work Also Indicates

Some DOD Programs for Improving Medical Surveillance Are Not Fully
Implemented

Page 9 GAO- 02- 173T

needed vaccine data, may not have included information on adverse reactions
because DOD did not adequately inform personnel on how to provide this
information. 13

Additionally, in April 2000, we testified that vaccination data were not
consistently recorded in paper records and in a central database, as DOD
requires. 14 For example, when comparing records from the database with
paper records at four military installations, we found that information on
the number of vaccinations given to service members, the dates of the
vaccinations, and the vaccine lot numbers were inconsistent at all four
installations. At one installation, the database and records did not agree
78 to 92 percent of the time. DOD has begun to make progress in implementing
our recommendations, including ensuring timely and accurate data in its
immunization tracking system.

The Gulf War revealed the need to have information technology play a bigger
role in medical surveillance to ensure that the information is readily
accessible to DOD and VA. In August 1997, DOD established requirements that
called for the use of innovative technology, such as an automated medical
record device for documenting inpatient and outpatient encounters in all
settings and that can archive the information for local recall and format it
for an injury, illness, and exposure surveillance database. 15 Also, in
1997, the President, responding to deficiencies in DOD?s and VA?s data
capabilities for handling service members? health information, called for
the two agencies to start developing a comprehensive, lifelong medical
record for each service member. As we reported in April 2001, DOD?s and VA?s
numerous databases and electronic systems for capturing mission- critical
data, including health information, are not linked and information cannot be
readily shared. 16

DOD has several initiatives under way to link many of its information
systems- some with VA. For example, in an effort to create a

13 Medical Readiness: DOD Faces Challenges in Implementing Its Anthrax
Vaccine Immunization Program (GAO/ NSIAD- 00- 36, Oct. 22, 1999). 14 Medical
Readiness: DOD Continues to Face Challenges in Implementing Its Anthrax
Vaccine Immunization Program (GAO/ T- NSIAD- 00- 157, Apr. 13, 2000). 15 DOD
Directive 6490. 2, ?Joint Medical Surveillance? (Aug. 30, 1997). 16
Computer- Based Patient Records: Better Planning and Oversight by VA, DOD,
and IHS Would Enhance Health Data Sharing (GAO- 01- 459, Apr. 30, 2001).

Page 10 GAO- 02- 173T

comprehensive, lifelong medical record for service members and veterans and
to allow health care professionals to share clinical information, DOD and
VA, along with the Indian Health Service (IHS), 17 initiated the Government
Computer- Based Patient Record (GCPR) project in 1998. GCPR is seen as
yielding a number of potential benefits, including improved research and
quality of care, and clinical and administrative efficiencies. However, our
April 2001 report describes several factors- including planning weaknesses,
competing priorities, and inadequate accountability- that made it unlikely
that DOD and VA would accomplish GCPR or realize its benefits in the near
future. To strengthen the management and oversight of GCPR, we made several
recommendations, including designating a lead entity with a clear line of
authority for the project and creating comprehensive and coordinated plans
for sharing meaningful, accurate, and secure patient health data.

For the near term, DOD and VA have decided to reconsider their approach to
GCPR and focus on allowing VA to view DOD health data. However, under the
interim effort, physicians at military medical facilities will not be able
to view health information from other facilities or from VA- now a
potentially critical information source given VA?s fourth mission to provide
medical backup to the military health system in times of national emergency
and war.

Recent meetings with officials from the Defense Health Program and the Army
Surgeon General?s Office indicate that the department is working on issues
we have reported on in the past, including the need to improve the
reliability of deployment information and the need to integrate disparate
health information systems. Specifically, these officials informed us that
DOD is in the process of developing a more accurate roster of deployed
service members and enhancing its information technology capabilities. For
example, DOD?s Theater Medical Information Program (TMIP) is intended to
capture medical information on deployed personnel and link it with medical
information captured in the department?s new medical information system, now
being field tested. 18 Developmental testing for

17 IHS was included in the effort because of its population- based research
expertise and its long- standing relationship with VA. 18 Composite Health
Care System II (CHCS II) is expected to capture information on
immunizations; allergies; outpatient encounters, such as diagnostic and
treatment codes; patient hospital admission and discharge; patient
medications; laboratory results; and radiology. CHCS II is expected to
support best business practices, medical surveillance, and clinical
research.

Page 11 GAO- 02- 173T

TMIP is about to begin and field testing is expected to begin next spring,
with deployment expected in 2003. A component system of TMIP- Transportation
Command Regulating and Command and Control Evacuation System- is also under
development and aims to allow casualty tracking and provide in- transit
visibility of casualties during wartime and peacetime. Also under
development is the Global Expeditionary Medical System, which DOD
characterizes as a stepping stone to an integrated biohazard surveillance
and detection system.

Clearly, the need for comprehensive health information on service members
and veterans is very great, and much more needs to be done. However, it is
also a very difficult task because of uncertainties about what conditions
may exist in a deployed setting, such as potential military conflicts,
environmental hazards, and frequency of troop movements. While progress is
being made, DOD will need to continue to make a concerted effort to resolve
the remaining deficiencies in its surveillance system. Until such a time
that some of the deficiencies are overcome, VA?s ability to perform its
missions will be affected.

For further information, please contact Stephen P. Backhus at (202) 5127101.
Individuals making key contributions to this testimony included Ann
Calvaresi Barr, Karen Sloan, and Keith Steck. Concluding

Observations Contact and Acknowledgments

Page 12 GAO- 02- 173T

Computer- Based Patient Records: Better Planning and Oversight by VA, DOD,
and IHS Would Enhance Health Data Sharing (GAO- 01- 459, Apr. 30, 2001).

Medical Readiness: DOD Continues to Face Challenges in Implementing Its
Anthrax Vaccine Immunization Program (GAO/ T- NSIAD- 00- 157, Apr. 13,
2000).

Medical Readiness: DOD Faces Challenges in Implementing Its Anthrax Vaccine
Immunization Program (GAO/ NSIAD- 00- 36, Oct. 22, 1999).

Chemical and Biological Defense: Observations on DOD?s Plans to Protect U.
S. Forces (GAO/ T- NSIAD- 98- 83, Mar. 17, 1998).

Gulf War Veterans: Incidence of Tumors Cannot Be Reliably Determined From
Available Data (GAO/ NSIAD- 98- 89, Mar. 3, 1998).

Gulf War Illnesses: Federal Research Strategy Needs Reexamination (GAO- T-
NSIAD- 98- 104, Feb. 24, 1998).

Gulf War Illnesses: Research, Clinical Monitoring, and Medical Surveillance
(GAO/ T- NSIAD- 98- 88, Feb. 5, 1998).

Defense Health Care: Medical Surveillance Improved Since Gulf War, but Mixed
Results in Bosnia (GAO/ NSIAD- 97- 136, May 13, 1997).

(290139) Related GAO Products
*** End of document. ***