VA and Defense Health Care: Progress Made, but DOD Continues To  
Face Military Medical Surveillance System Challenges (24-JAN-02, 
GAO-02-377T).							 
								 
GAO, the Institute of Medicine, and others have reported on	 
weaknesses in the Defense Department's (DOD) medical surveillance
during the Gulf War and Operation Joint Endeavor and the	 
challenges DOD faces in implementing a reliable medical 	 
surveillance system. DOD was unable to collect, maintain, and	 
transfer accurate data on the movement of troops, potential	 
exposures to health risks, and medical incidents during 	 
deployment during the Gulf war. DOD improved its medical	 
surveillance system under Operation Joint Endeavor, providing	 
useful information to military commanders and medical personnel. 
However, GAO found a number of problems with this system. For	 
example, incomplete or inaccurate information related to service 
members' health and deployment status. DOD's has not established 
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, but 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 the Department of Veterans	 
Affairs 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-02-377T					        
    ACCNO:   A02699						        
  TITLE:     VA and Defense Health Care: Progress Made, but DOD       
Continues To Face Military Medical Surveillance System Challenges
     DATE:   01/24/2002 
  SUBJECT:   Health care services				 
	     Medical information systems			 
	     Veterans						 
	     Information resources management			 
	     Data collection					 
	     Data bases 					 
	     Data integrity					 
	     Health hazards					 
	     Defense Health Program				 
	     DOD Force Health Protection Plan			 
	     DOD Operation Joint Endeavor			 
	     DOD Theater Medical Information Program		 
	     DOD Transportation Command Regulating		 
	     and Command and Control Evacuation 		 
	     System						 
								 
	     DOD Vaccine Adverse Event Reporting		 
	     System						 
								 
	     DOD/IHS/VA Government Computer-Based		 
	     Patient Record Project				 
								 
	     DOD Global Expeditionary Medical System		 
	     Persian Gulf War					 

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GAO-02-377T
     
Testimony Before the Subcommittee on Health, Committee on Veterans? Affairs,
House of Representatives United States General Accounting Office GAO

For Release on Delivery Expected at 9: 00 p. m. Thursday, January 24, 2002
VA AND DEFENSE

HEALTH CARE Progress Made, but DOD Continues To Face Military Medical
Surveillance System Challenges

Statement for the Record by Cynthia A. Bascetta Director, Health Care-
Veterans?

Health and Benefits Issues GAO- 02- 377T

Page 1 GAO- 02- 377T 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, and what has been reported about DOD?s medical surveillance
activities during the Gulf War and Operation Joint Endeavor, you expressed
concern about the challenges DOD faces in establishing a reliable medical
surveillance system. 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 in early

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- 377T October 2001 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- 377T 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- 377T 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- 377T 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- 377T 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 locations 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- 377T 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- 377T 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- 377T 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 Also, 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 that can document 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- 377T 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.

In October 2001, we met with officials from the Defense Health Program and
the Army Surgeon General?s Office who indicated 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 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- 377T TMIP has begun and field testing is expected to begin
in spring 2002, 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 Cynthia A. Bascetta 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- 377T 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).

(290166) Related GAO Products
*** End of document. ***