Defense Health Care: Quality Assurance Process Needed to Improve
Force Health Protection and Surveillance (19-SEP-03,
GAO-03-1041).
Following the 1990-91 Persian Gulf War, many servicemembers
experienced health problems that they attributed to their
military service in the Persian Gulf. However, a lack of
servicemember health and deployment data hampered subsequent
investigations into the nature and causes of these illnesses.
Public Law 105-85, enacted in November 1997, required the
Department of Defense (DOD) to establish a system to assess the
medical condition of service members before and after
deployments. GAO was asked to determine whether (1) the military
services met DOD's force health protection and surveillance
requirements for servicemembers deploying in support of Operation
Enduring Freedom (OEF) in Central Asia and Operation Joint
Guardian (OJG) in Kosovo and (2) DOD has corrected problems
related to the accuracy and completeness of databases reflecting
which servicemembers were deployed to certain locations.
-------------------------Indexing Terms-------------------------
REPORTNUM: GAO-03-1041
ACCNO: A08537
TITLE: Defense Health Care: Quality Assurance Process Needed to
Improve Force Health Protection and Surveillance
DATE: 09/19/2003
SUBJECT: Data bases
Data collection
Data integrity
Health care services
Health hazards
Health resources utilization
Immunization programs
Medical examinations
Medical information systems
Medical records
Military operations
Military personnel
Military personnel records
Noncompliance
Persian Gulf War
******************************************************************
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GAO-03-1041
Report to the Chairman and Ranking Minority Member, Subcommittee on Total
Force, Committee on Armed Services, House of Representatives
United States General Accounting Office
GAO
September 2003 DEFENSE HEALTH CARE
Quality Assurance Process Needed to Improve Force Health Protection and
Surveillance
GAO- 03- 1041
The Army and Air Force* the focus of GAO*s review* did not comply with
DOD*s force health protection and surveillance policies for many active
duty servicemembers, including the policies that they be assessed before
and after deploying overseas, that they receive certain immunizations, and
that health- related documentation be maintained in a centralized
location. GAO*s review of 1,071 servicemembers* medical records from a
universe of 8,742 at selected Army and Air Force installations
participating in overseas operations disclosed that 38 to 98 percent of
servicemembers were missing one or both of their health assessments and 14
to 46 percent were missing at least one of the required immunizations (see
figure).
DOD also did not maintain a complete, centralized database of
servicemembers* medical assessments and immunizations. Health- related
documentation missing from the centralized database ranged from 0 to 63
percent for pre- deployment assessments, 11 to 75 percent for post-
deployment assessments, and 8 to 93 percent for immunizations. There is no
effective quality assurance program at the Office of the Assistant
Secretary of Defense for Health Affairs or at the Army or Air Force that
helps ensure compliance with policies. GAO believes that the lack of such
a program was a major cause of the high rate of noncompliance. Continued
noncompliance with these policies may result in servicemembers deploying
with health problems or delays in obtaining care when they return.
Finally, DOD*s centralized deployment database is still missing the
information
needed to track servicemembers* movements in the theater of operations. By
July 2003, the department*s data center had begun receiving location-
specific deployment information from the services and is currently
reviewing its accuracy and completeness.
Percent of Servicemembers Missing One or Both Health Assessments, and
Missing at Least One Required Immunization
Following the 1990- 91 Persian Gulf War, many servicemembers experienced
health problems that they attributed to their military service in the
Persian Gulf. However, a lack of servicemember health and deployment data
hampered subsequent investigations into the nature and causes of these
illnesses. Public Law 105- 85, enacted in November 1997, required the
Department of Defense (DOD) to establish a system to assess the medical
condition of service members before and after deployments. GAO was asked
to determine whether (1) the military services met DOD*s force health
protection and surveillance
requirements for servicemembers deploying in support of Operation Enduring
Freedom (OEF) in Central Asia and Operation Joint
Guardian (OJG) in Kosovo and (2) DOD has corrected problems related to the
accuracy and completeness of databases reflecting which servicemembers
were deployed to certain locations.
GAO recommends that the Secretary of Defense direct the Assistant
Secretary of Defense
for Health Affairs to establish an effective quality assurance program
that will help ensure that the military services comply with the
force health protection and surveillance requirements for all
servicemembers. DOD concurred with the recommendation.
www. gao. gov/ cgi- bin/ getrpt? GAO- 03- 1041. To view the full product,
including the scope and methodology, click on the link above. For more
information, contact Cliff Spruill at (202) 512- 4531. Highlights of GAO-
03- 1041, a report to the
Chairman and Ranking Minority Member, Subcommittee on Total Force,
Committee on Armed Services, House of Representatives
September 2003
DEFENSE HEALTH CARE
Quality Assurance Process Needed to Improve Force Health Protection and
Surveillance
Page i GAO- 03- 1041 Defense Health Care Letter 1 Results in Brief 3
Background 5 The Army and Air Force Did Not Comply with Deployment Health
Surveillance Policies for Many Servicemembers 9 Centralized Deployment
Database Still Missing Information Needed for Deployment Health
Surveillance 26 Conclusions 28 Recommendation for Executive Action 28
Agency Comments and Our Evaluation 28 Appendix I Scope and Methodology 30
Appendix II Comments from the Department of Defense 36
Appendix III GAO Contact and Staff Acknowledgments 39
Tables
Table 1: Deploying Servicemember Blood Serum Samples Held in Repository 18
Table 2: Servicemember Sample Sizes at Each Visited Installation 32
Figures
Figure 1: Percent of Servicemembers Missing One or Both Health Assessments
10 Figure 2: Percent of Health Assessments Not Completed Within
Required Time Frames 12 Figure 3: Completed Assessments That Were Not
Reviewed by Health Care Provider 13 Figure 4: Percent of Servicemembers
Missing Required Immunizations 15 Figure 5: Percent of Servicemembers That
Did Not Have Current Tuberculosis Screening 17 Contents
Page ii GAO- 03- 1041 Defense Health Care
Figure 6: Percent of Assessments Found in Centralized Database That Were
Not Found in Servicemembers* Medical Records 19 Figure 7: Percent of
Assessments and Immunizations Found in
Servicemembers* Medical Records That Were Not Found in the Centralized
Database 22 Abbreviations
AMSA Army Medical Surveillance Activity CITA Comprehensive Immunization
Tracking Application DCAPES Deliberate Crisis and Action Planning and
Execution
Segment DIMHRS Defense Integrated Military Human Resource System DMDC
Defense Manpower Data Center DOD Department of Defense MEDPROS Medical
Protection System OEF Operation Enduring Freedom OJG Operation Joint
Guardian SOCOM U. S. Special Operations Command TMIP Theater Medical
Information Program This is a work of the U. S. government and is not
subject to copyright protection in the
United States. It may be reproduced and distributed in its entirety
without further permission from GAO. However, because this work may
contain copyrighted images or other material, permission from the
copyright holder may be necessary if you wish to reproduce this material
separately.
Page 1 GAO- 03- 1041 Defense Health Care
September 19, 2003 The Honorable John McHugh Chairman The Honorable Vic
Snyder Ranking Minority Member Subcommittee on Total Force Committee on
Armed Services House of Representatives
Following the 1990- 91 Persian Gulf War, many servicemembers experienced
health problems that they attributed to their military service in the
Persian Gulf. However, subsequent investigations into the nature and
causes of these illnesses were hampered by a lack of servicemember health
and deployment data. Moreover, in May 1997, we reported on several similar
problems associated with the implementation of the Department of Defense*s
(DOD) deployment health surveillance policies for servicemembers deployed
to Bosnia in support of a peacekeeping operation. 1 In response, the
Congress enacted legislation 2 in November 1997 requiring
DOD to establish a system for assessing the medical condition of
servicemembers before and after their deployment to locations outside the
United States and requiring the centralized retention of certain health-
related data associated with the servicemember*s deployment. The system is
to include the use of pre- deployment medical examinations and post-
deployment medical examinations, including an assessment of mental health
and the drawing of blood samples. DOD has implemented specific force
health protection and surveillance policies. These policies include pre-
and post- deployment health assessments designed to identify health issues
or concerns that may affect the deployability of servicemembers or that
may require medical attention; pre- deployment immunizations to address
possible health threats in deployment locations; pre- deployment
1 See U. S. General Accounting Office, Defense Health Care: Medical
Surveillance Improved Since Gulf War, but Mixed Results in Bosnia, GAO/
NSIAD- 97- 136 (Washington, D. C.: May 13, 1997). 2 Section 765 of Pub. L.
No. 105- 85 amended title 10 of the United States Code by adding section
1074f.
United States General Accounting Office Washington, DC 20548
Page 2 GAO- 03- 1041 Defense Health Care
screening for tuberculosis; and the retention of blood serum samples on
file prior to deployment. Given the many deployments of servicemembers to
overseas locations
since 1997, you asked us to examine the military services* implementation
of DOD*s force health protection and surveillance policies and its
progress in correcting the types of problems we found in 1997. 3 More
specifically, we focused our work on Army and Air Force active duty
deployments 4 for Operation Enduring Freedom (OEF) in Central Asia and
Operation Joint Guardian (OJG) in Kosovo to address the following two
questions:
1. Are the military services meeting DOD*s force health protection and
surveillance system requirements for servicemembers deploying in support
of OEF and OJG?
2. Has DOD corrected problems related to the accuracy and completeness of
databases reflecting which servicemembers deployed to certain locations?
To accomplish these objectives, we obtained the force health protection
and surveillance policies applicable to the OEF and OJG deployments from
the Army, Air Force, combatant commanders, the office of the Assistant
Secretary of Defense, and the services* Surgeons General. To test the
implementation of these policies, we reviewed statistical samples
totaling 1,071 active duty servicemembers selected from a universe of
8,742 active duty servicemembers at four military installations. To
provide assurances that our review of the selected medical records was
accurate, we requested the installations* medical personnel to reexamine
those
medical records that were missing required health assessments or
immunizations and adjusted our results where documentation was
subsequently identified. We also requested installation medical personnel
to check all possible sources for missing pre- and post- deployment health
3 Problems cited in our May 1997 report included the following: required
medical
assessments not prepared for many servicemembers; incomplete medical
record keeping; an incomplete centralized health assessment database; and
an inaccurate personnel deployment database.
4 In April 2003, we reported on problems experienced by the Army in
assessing the health status of all early- deploying reservists. See U. S.
General Accounting Office, Defense Health Care: Army Needs to Assess the
Health Status of All Early- Deploying Reservists,
GAO- 03- 437 (Washington, D. C.: Apr. 15, 2003); and U. S. General
Accounting Office, Defense Health Care: Army Has Not Consistently Assessed
the Health Status of Early- Deploying Reservists, GAO- 03- 997T
(Washington, D. C.: July 9, 2003).
Page 3 GAO- 03- 1041 Defense Health Care
assessments and missing immunizations. We also requested the U. S. Special
Operations Command (SOCOM) to query its database for health- related
documentation for servicemembers in our sample at one of the selected
installations. We also examined, for Army and Air Force servicemembers in
our samples, the completeness of the centralized records at the Army
Medical Surveillance Activity 5 (AMSA), which is tasked with centrally
collecting deployment health- related records. Further, we interviewed
officials at the office of the Deployment Health Support Directorate and
at the Defense Manpower Data Center (DMDC) regarding the accuracy and
completeness of DMDC*s personnel deployment database and planned
improvements. For more detailed information of our scope and methodology,
see appendix I.
The Army and Air Force did not comply with DOD*s force health protection
and surveillance policies for many of the servicemembers at the
installations we visited. Our review of medical records at those
installations disclosed that problems continue to exist in several areas.
Deployment health assessments. The percentage of Army and Air Force
servicemembers missing one or both of their pre- and post- deployment
health assessments ranged from 38 to 98 percent of our samples. Moreover,
when health assessments were conducted, as many as 45 percent of them were
not done within the required time frames. Furthermore, a health care
provider did not review all health assessments and, although only a small
number of assessments in our samples indicated a health concern, large
percentages of these assessments were not referred for further
consultations as required. Immunizations and other pre- deployment
requirements. Servicemembers missing evidence of receiving at least one of
the
pre- deployment immunizations required for their deployment location
ranged from 14 percent to 46 percent. Furthermore, servicemembers missing
current tuberculosis screening at the time of their deployment ranged from
7 to 40 percent. As many as 29 percent of the servicemembers in our
samples had blood serum samples in the repository older than the required
maximum age of 1 year at the time of deployment, ranging, on average, from
2 to 15 months out- of- date.
5 The Army Medical Surveillance Activity is DOD*s executive agent for
collecting and retaining the military services* deployment health- related
documents* including the pre- deployment and post- deployment health
assessments and immunizations. Results in Brief
Page 4 GAO- 03- 1041 Defense Health Care
Completeness of medical records and centralized data collection.
Servicemembers* permanent medical records at the Army and Air Force
installations we visited did not include documentation of the completed
health assessments that we found at AMSA and at the U. S. Special
Operations Command, ranging from 8 to 100 percent for pre- deployment
health assessments and from 11 to 62 percent for post- deployment health
assessments. Our review also disclosed that the AMSA database* designed to
function as the centralized collection location for deployment health-
related information for all military services* was still, over 5 years
after congressional action, lacking documentation of many health
assessments and immunizations that we found in the servicemembers* medical
records at the installations visited. Specifically, health- related
documentation missing from the centralized database ranged from 0 to 63
percent for pre- deployment health assessments, 11 to 75 percent for post-
deployment health assessments, and 8 to 93 percent for immunizations.
Furthermore, DOD did not have oversight of departmentwide efforts to
comply with health surveillance requirements. There is no effective
quality assurance program at the Office of the Assistant Secretary of
Defense for Health Affairs or at the Offices of the Surgeons* General of
the Army or Air Force that helps ensure compliance with force health
protection and surveillance policies. We believe the lack of such a system
was a major
cause of the high rate of noncompliance we found at the units we visited.
Continued noncompliance with these policies may result in servicemembers
being deployed with unaddressed health problems or without immunization
protection. Furthermore, incomplete and inaccurate medical records may
hinder DOD*s ability to investigate the causes of any future health
problems that may arise coincident with deployments.
DOD has not corrected the problems we identified in 1997 that were related
to the completeness and accuracy of a central personnel deployment
database that is designed to collect data reflecting which servicemembers
deployed to certain locations. The Defense Manpower Data Center*s (DMDC)
deployment database still does not include the information needed for
effective deployment health surveillance. Prior to April 2003, the
services were not reporting location- specific deployment data to the DMDC
because, according to a DMDC official, the data was not available from the
services. By July 2003, all of the services had begun submitting
classified deployment data to DMDC, which is currently reviewing the
deployment information received to determine its accuracy and
completeness. However, DMDC still does not have a system to track
the movement of servicemembers within a given theater, because this
Page 5 GAO- 03- 1041 Defense Health Care
information has not been available from the services and the development
of a new tracking system at the service unit level may be required. DOD is
developing a new system for tracking the movements of servicemembers and
civilian personnel in the theater of operation with plans for
implementation by about September 2005 for the Army and by 2007 or early
calendar year 2008 for the other services.
We are recommending that the Secretary of Defense direct the Assistant
Secretary of Defense for Health Affairs to establish an effective quality
assurance system to ensure that the military services comply with force
health protection and surveillance requirements for all servicemembers. In
commenting on a draft of this report, DOD concurred with the report*s
recommendation.
In May 1997, we reported on DOD*s actions to improve deployment health
surveillance before, during, and after deployments, focusing on Operation
Joint Endeavor, which was conducted in the countries of Bosnia-
Herzegovina, Croatia, and Hungary. 6 We commented on the provisions of a
joint medical surveillance policy draft that called for a comprehensive
DOD- wide medical surveillance capability to monitor and assess the
effects of deployments on servicemembers* health. DOD subsequently
finalized its joint medical surveillance policy in August 1997. Our 1997
review disclosed problems with the Army*s implementation of the medical
surveillance plan for Operation Joint Endeavor in the following areas:
Medical assessments. Many Army personnel who should have received post-
deployment medical assessments did not receive them and the assessments
that were completed were frequently done late. Of the 618 servicemembers
in the 12 Army units whose medical records we reviewed, 24 percent did not
receive in- theater post- deployment medical assessments, and 21 percent
did not receive home station post- deployment medical assessments.
Servicemembers who received home station
post- deployment medical assessments received them, on average, nearly 100
days after they left theater instead of within 30 days as required by the
plan. Further, pre- deployment blood serum samples were not available for
9.3 percent of the 26, 621 servicemembers who had deployed to Bosnia as
6 GAO/ NSIAD- 97- 136. Background
Page 6 GAO- 03- 1041 Defense Health Care
of March 12, 1996. The most recent blood samples for 6.4 percent of the
pre- deployment blood samples were more than 5 years old. Medical record
keeping. Many of the servicemembers* medical records
that we reviewed were incomplete and missing documentation of in- theater
post- deployment medical assessments, medical visits during deployment,
and receipt of an investigational new vaccine. More specifically, we found
that 91 of the 473 servicemembers (19 percent) with a post- deployment in-
theater medical assessment and 9 of the 491 servicemembers (1.8 percent)
with a post- deployment home unit medical assessment did not have the
assessments documented in their medical records. Furthermore, about 29
percent of the 50 battalion aid station visits we reviewed were not
documented in the members* permanent medical records. Finally, 141 of 588
servicemembers (24 percent) who received an investigational drug vaccine
did not have the immunization documented in their medical records.
Centralized database. The centralized database for collecting in-
theater and home unit post- deployment medical assessments was incomplete
for many Army personnel. More specifically, the database omitted 12
percent of the in- theater medical assessments done and 52 percent of the
home unit medical assessments done for the 618 servicemembers whose
records we reviewed. Deployment information. DOD officials considered
the database used
for tracking the deployment of Air Force and Navy personnel inaccurate.
Following the publication of our report, the Congress, in November 1997,
included a provision in the Defense Authorization Act for Fiscal Year 1998
requiring the Secretary of Defense to establish a medical tracking system
for servicemembers deployed overseas as follows:
*( a) SYSTEM REQUIRED* The Secretary of Defense shall establish a system
to assess the medical condition of members of the armed forces (including
members of the reserve components) who are deployed outside the United
States or its territories or possessions as part of a contingency
operation (including a humanitarian operation, peacekeeping operation, or
similar operation) or combat operation.
*( b) ELEMENTS OF SYSTEM* The system described in subsection (a) shall
include the use of predeployment medical examinations and postdeployment
medical examinations (including an assessment of mental health and the
drawing of blood samples) to accurately record the medical condition of
members before their deployment and any changes in their
medical condition during the course of their deployment. The
postdeployment examination shall be conducted when the member is
redeployed or otherwise leaves an area in which the system is in operation
(or as soon as possible thereafter).
Page 7 GAO- 03- 1041 Defense Health Care
*( c) RECORDKEEPING* The results of all medical examinations conducted
under the system, records of all health care services (including
immunizations) received by members described in subsection (a) in
anticipation of their deployment or during the course of their deployment,
and records of events occurring in the deployment area that may affect the
health of such members shall be retained and maintained in a centralized
location to improve future access to the records. *( d) QUALITY ASSURANCE*
The Secretary of Defense shall establish a quality assurance program to
evaluate the success of the system in ensuring that members described in
subsection (a) receive predeployment medical examinations and
postdeployment medical examinations and that the recordkeeping
requirements with respect to the system are met.* 7 As set forth above,
these provisions require the use of pre- deployment and
post- deployment medical examinations to accurately record the medical
condition of servicemembers before deployment and any changes during their
deployment. In a June 30, 2003, correspondence with the General Accounting
Office, the Assistant Secretary of Defense for Health Affairs stated that
*it would be logistically impossible to conduct a complete physical
examination on all personnel immediately prior to deployment and still
deploy them in a timely manner.* Therefore, DOD required both pre- and
post- deployment health assessments for servicemembers who deploy for 30
or more continuous days to a land- based location outside the United
States without a permanent U. S. military treatment facility. Both
assessments use a questionnaire designed to help military healthcare
providers in identifying health problems and providing needed medical
care. The pre- deployment health assessment is generally administered at
the home station before deployment, and the post- deployment health
assessment is completed either in theater before redeployment to the
servicemember*s home unit or shortly upon redeployment.
As a component of medical examinations, the statute quoted above also
requires that blood samples be drawn before and after a servicemember*s
deployment. DOD Instruction 6490.3, August 7, 1997, requires that a pre-
deployment blood sample be obtained within 12 months of the
servicemember*s deployment. 8 However, it requires the blood samples be
7 Section 765 of Pub. L. No. 105- 85 amended title 10 of the United States
Code by adding section 1074f. 8 DOD Instruction 6490. 3, *Implementation
and Application of Joint Medical Surveillance for Deployments,* August 7,
1997.
Page 8 GAO- 03- 1041 Defense Health Care
drawn upon return from deployment only when directed by the Assistant
Secretary of Defense for Health Affairs. According to DOD, the
implementation of this requirement was based on its judgment that the
Human Immunodeficiency Virus serum sampling taken independent of
deployment actions is sufficient to meet both pre- and post- deployment
health needs, except that more timely post- deployment sampling may be
directed when based on a recognized health threat or exposure. Prior to
April 2003, DOD did not require a post- deployment blood sample for
servicemembers supporting the OEF and OJG deployments.
In April 2003, DOD revised its health surveillance policy for blood
samples and post- deployment health assessments. Effective May 22, 2003,
the services are required to draw a blood sample from each redeploying
servicemember no later than 30 days after arrival at a demobilization site
or home station. 9 According to DOD, this requirement for post- deployment
blood samples was established in response to an assessment of health
threats and national interests associated with current deployments. The
department also revised its policy guidance for enhanced post- deployment
health assessments to gather more information from deployed
servicemembers about events that occurred during a deployment. More
specifically, the revised policy requires that a trained health care
provider conduct a face- to- face health assessment with each returning
servicemember to ascertain (1) the individual*s responses to the health
assessment questions on the post- deployment health assessment form;
(2) the presence of any mental health or psychosocial issues commonly
associated with deployments; (3) any special medications taken during the
deployment; and (4) concerns about possible environmental or occupational
exposures.
9 Under Secretary of Defense for Personnel and Readiness Memorandum,
*Enhanced Post- Deployment Health Assessments,* April 22, 2003.
Page 9 GAO- 03- 1041 Defense Health Care
The Army and Air Force did not comply with DOD*s force health protection
and surveillance requirements for many of the servicemembers in our
samples at the selected installations we visited. Specifically, these Army
and Air Force servicemembers were missing: pre- deployment and/ or post-
deployment health assessments; evidence of receiving one or more of
the pre- deployment immunizations required for their deployment location;
and other pre- deployment requirements related to tuberculosis screening
and blood serum sample storage. Also, servicemembers* permanent medical
records were missing required health- related information, and DOD*s
centralized database did not include documentation of servicemember
health- related information. Neither the installations nor DOD had
monitoring and oversight mechanisms in place to help ensure that the force
health protection and surveillance requirements were met for all
servicemembers.
We found that servicemembers missing one or both of their pre- and post-
deployment assessments ranged from 38 to 98 percent in our samples. 10 For
example, at Fort Campbell for the OEF deployment we found that 68 percent
of the 222 active duty servicemembers in our sample were missing either
one or both of the required pre- deployment and postdeployment health
assessments. The results of our statistical samples for the deployments at
the installations visited are depicted in figure 1.
10 Because we checked all known possible sources for the existence of
deployment health assessments, we concluded that the assessments were not
completed in those instances where we could not find required health
assessments. The Army and
Air Force Did Not Comply with Deployment Health Surveillance Policies for
Many Servicemembers
Many Servicemembers Lacked Pre- deployment and Post- deployment Health
Assessments
Page 10 GAO- 03- 1041 Defense Health Care
Figure 1: Percent of Servicemembers Missing One or Both Health Assessments
Notes: . = 95 percent confidence interval, upper and lower bounds for each
estimate. These percentages reflect assessments from all sources and
without regard to timeliness.
Page 11 GAO- 03- 1041 Defense Health Care
For those servicemembers in our samples who had completed pre- or post-
deployment health assessments, we found that as many as 45 percent of the
assessments in our samples were not completed on time in accordance with
requirements (see fig. 2). DOD policy requires that servicemembers
complete a pre- deployment health assessment form within 30 days of their
deployment and a post- deployment health assessment form within 5 days
upon redeployment back to their home station. 11 These time frames were
established to allow time to identify and resolve any health concerns or
problems that may affect the ability of the servicemember to deploy, and
to promptly identify and address any health concerns or problems that may
have arisen during the servicemember*s deployment.
11 Office of the Chairman, The Joint Chiefs of Staff, Memorandum MCM-
0006- 2, *Updated Procedures for Deployment Health Surveillance and
Readiness,* February 1, 2002.
Page 12 GAO- 03- 1041 Defense Health Care
Figure 2: Percent of Health Assessments Not Completed Within Required Time
Frames
Notes: . = 95 percent confidence interval, upper and lower bounds for each
estimate. a Unable to compute because exact redeployment date was
unavailable.
b All three pre- deployment cases for Fort Campbell were completed within
the required time frame, but unable to compute confidence intervals due to
insufficient size. Not all health assessments were reviewed by a health
care provider
as required, as shown in figure 3. DOD policy requires that pre-
deployment and post- deployment health assessments are to be reviewed
immediately by a health care provider to identify any medical care needed
by the servicemember. 12 12 The Joint Staff, Joint Staff Memorandum MCM-
251- 98.
Page 13 GAO- 03- 1041 Defense Health Care
Figure 3: Completed Assessments That Were Not Reviewed by Health Care
Provider
Notes: . = 95 percent confidence interval, upper and lower bounds for each
estimate. a All three pre- deployment cases for Fort Campbell were
reviewed by the health care provider,
but unable to compute confidence intervals due to insufficient size. b
Zero cases: confidence level shown.
The services did not refer some servicemember health assessments that
indicated a need for further consultation. According to DOD policy, a
medical provider, namely a physician, physician*s assistant, nurse, or
independent duty medical technician is required to further review a
servicemember*s need for specialty care when the member*s pre- deployment
and/ or post- deployment health assessment indicates health concerns such
as unresolved medical or dental problems or plans
Page 14 GAO- 03- 1041 Defense Health Care
to seek mental health counseling or care. 13 This follow- up may take the
form of an interview or examination of the servicemember, and forms the
basis of a decision as to whether a referral for further specialty care is
warranted. In our samples, the number of assessments that indicated a
health concern was relatively small, but large percentages of these
assessments were not referred for further specialty care. For example, our
sample at Travis Air Force Base included five pre- deployment health
assessments that indicated a health concern, but four (80 percent) of the
health assessments were not referred for further specialty care.
Noncompliance with the requirement for pre- deployment health assessments
may result in servicemembers with existing health problems or concerns
being deployed with unaddressed health problems. Also, failure to complete
post- deployment health assessments may risk a delay in obtaining
appropriate medical follow- up attention for a health problem or concern
that may have arisen during or following the deployment.
Based on our samples, the services did not fully meet immunization and
other pre- deployment requirements. Evidence of pre- deployment
immunizations receipt was missing from many servicemembers* medical
records. Servicemembers missing the required immunizations may not have
the immunization protection they need to counter theater disease threats.
Based on our review of servicemember medical records for the deployments
at the four installations we visited, we found that between 14 and 46
percent of the servicemembers were missing at least one of their required
immunizations prior to deployment (see fig. 4). Furthermore, as many as 36
percent of the servicemembers were missing two or more of their required
immunizations.
13 Office of the Chairman, The Joint Chiefs of Staff, Memorandum MCM-
0006- 02, *Updated Procedures for Deployment Health Surveillance and
Readiness,* February 1, 2002. Immunizations and Other
Pre- Deployment Health Requirements Not Met
Page 15 GAO- 03- 1041 Defense Health Care
Figure 4: Percent of Servicemembers Missing Required Immunizations Notes:
. = 95 percent confidence interval, upper and lower bounds for each
estimate.
The U. S. Central Command required the following pre- deployment
immunizations for all servicemembers that deployed to Central Asia in
support of OEF: hepatitis A (two- shot series); measles, mumps, and
rubella; polio; tetanus/ diphtheria within the last 10 years; yellow fever
within the last 10 years; typhoid within the last 5 years; influenza
within the last 12 months; and meningococcal within the last 5 years. 14
For OJG deployments, the U. S. European Command required the same
immunizations cited above, with the exception of the yellow fever
inoculation that was not required for Kosovo. 15 14 U. S. Central Command,
*Personnel Policy Guidance for U. S. Individual Augmentation
Personnel in Support of Operation Enduring Freedom,* October 3, 2001. 15
Headquarters U. S. European Command, *Greece and the Balkans: Force Health
Protection Guidance,* January 4, 2002.
Page 16 GAO- 03- 1041 Defense Health Care
Figure 5 indicates that 7 to 40 percent of the deploying servicemembers in
our review were missing a current tuberculosis screening. A screening is
deemed *current* if it occurred 1 to 2 years prior to deployment.
Specifically, the U. S. Central Command required servicemembers deploying
to Central Asia in support of OEF to be screened for tuberculosis within
12 months of deployment. 16 For OJG deployments, the U. S. European
Command required Army and Air Force servicemembers to be screened for
tuberculosis with 24 months of deployment. 17 16 U. S. Central Command,
*Personnel Policy Guidance for U. S. Individual Augmentation
Personnel in Support of Operation Enduring Freedom,* October 3, 2001. 17
Headquarters U. S. European Command, *Greece and the Balkans: Force Health
Protection Guidance,* January 4, 2002.
Page 17 GAO- 03- 1041 Defense Health Care
Figure 5: Percent of Servicemembers That Did Not Have Current Tuberculosis
Screening
Notes: . = 95 percent confidence interval, upper and lower bounds for each
estimate.
U. S. Central Command and U. S. European Command policies require that
deploying servicemembers have a blood serum sample in the serum repository
not older than 12 months prior to deployment. 18 While nearly all
deploying servicemembers had blood serum samples held in the Armed
Services Serum Repository prior to deployment, as many as 29 percent had
serum samples that were too old (see table 1). The samples that were too
old ranged, on average, from 2 to 15 months out- of- date. 18 U. S.
Central Command, *Personnel Policy Guidance for U. S. Individual
Augmentation
Personnel in Support of Operation Enduring Freedom,* October 3, 2001; and
Headquarters U. S. European Command, *Greece and the Balkans: Force Health
Protection Guidance,* January 4, 2002.
Page 18 GAO- 03- 1041 Defense Health Care
Table 1: Deploying Servicemember Blood Serum Samples Held in Repository
Status of Blood Serum Fort Campbell (OEF) Fort Campbell (OJG) Fort Drum
(OEF) Fort Drum (OJG) Hurlburt Field (OEF) Travis AFB
(OEF)
Had serum sample in repository 100% 100% 100% 99.5% 100% 100% Serum out-
of date (older than 1- year requirement) at time of deployment 22% 7% 5%
1% 7% 29%
Average months out- of- date 8 2 11 5 15 14 Source: GAO analyses of DOD
data.
Servicemembers* permanent medical records were not complete, and DOD*s
centralized database did not include documentation of servicemember
health- related information. Many servicemembers* permanent medical
records at the Army and Air Force installations we visited did not include
documentation of completed health assessments and servicemember visits to
Army battalion aid stations. Similarly, the centralized deployment record
database did not include many of the deployment health assessments and
immunization records that we found in the servicemembers* medical records
at the installations we visited.
DOD policy requires that the original completed pre- deployment and post-
deployment health assessment forms be placed in the servicemember*s
permanent medical record and that a copy be forwarded to AMSA. 19 Figure 6
shows that completed assessments we found at AMSA and at the U. S. Special
Operations Command for servicemembers in our samples were not documented
in the servicemember*s permanent medical record, ranging from 8 to 100
percent for pre- deployment health assessments and from 11 to 62 percent
for post- deployment health assessments.
19 Office of the Chairman, The Joint Chiefs of Staff, Memorandum MCM-
0006- 02, *Updated Procedures for Deployment Health Surveillance and
Readiness,* February 1, 2002. Servicemember
Medical Records and Centralized Database Were Not Complete
Many Completed Deployment Health Assessments and Medical Interventions
Were Not Documented in Servicemembers* Medical Record
Page 19 GAO- 03- 1041 Defense Health Care
Figure 6: Percent of Assessments Found in Centralized Database That Were
Not Found in Servicemembers* Medical Records
Notes: . = 95 percent confidence interval, upper and lower bounds for each
estimate. a All three pre- deployment cases at Fort Campbell found in the
centralized database were
missing from servicemembers* medical record, but unable to compute
confidence intervals due to insufficient size.
Army and Air Force policies also require documentation in the
servicemember*s permanent medical record of all visits to in- theater
medical facilities. 20 Except for the OEF deployment at Fort Drum,
officials were unable to locate or access the sign- in logs for
servicemember visits to in- theater Army battalion aid stations and to Air
Force expeditionary medical support for the OEF and OJG deployments at the
installations we
20 Army Regulation 40- 66, *Medical Records Administration,* October 23,
2002, and Air Force Instruction 41- 210, *Health Services Patient
Administration Functions,* October 1, 2000.
Page 20 GAO- 03- 1041 Defense Health Care
visited. Consequently, we limited the scope of our review to two battalion
aid stations for the OEF deployment at Fort Drum. We found that 39 percent
of servicemember visits to one battalion aid station and 94 percent to the
other were not documented in the servicemember*s permanent medical record.
Representatives of the two battalion aid stations said that the missing
paper forms documenting the servicemember visits may have been lost en
route to Fort Drum. Specifically, a physician*s assistant for one of these
battalion aid station said the battalion aid station moved three times in
theater and each
time the paper forms used to document in- theater visits were boxed and
moved with the battalion aid station. Consequently, the forms missing from
servicemembers* medical records may have been lost en route to Fort Drum.
The lack of complete and accurate medical records documenting all medical
care for the individual servicemember complicates the servicemembers*
post- deployment medical care. For example, accurate medical records are
essential for the delivery of high- quality medical care
and important for epidemiological analysis following deployments.
According to DOD health officials, the lack of complete and accurate
medical records complicated the diagnosis and treatment of
servicemembers who experienced post- deployment health problems that they
attributed to their military service in the Persian Gulf in 1990- 91.
DOD is implementing the Theater Medical Information Program (TMIP) that
has the capability to electronically record and store in- theater patient
medical encounter data. TMIP is currently undergoing operational testing
by the military services and DOD intends to begin fielding TMIP during the
first quarter of fiscal year 2004.
Based on our samples, DOD*s centralized database did not include
documentation of servicemember health- related information. As set forth
above, Public Law 105- 85, enacted November 1997, requires the Secretary
of Defense to retain and maintain health- related records in a centralized
location. This includes records for all medical examinations conducted to
ascertain the medical condition of servicemembers before deployment and
any changes during their deployment, all health care services (including
immunizations) received in anticipation of deployment or during the
deployment, and events occurring in the deployment area that may affect
the health of servicemembers. A February 2002 Joint Staff memorandum
Centralized Database Missing
Health- Related Documentation
Page 21 GAO- 03- 1041 Defense Health Care
requires the services to forward a copy of the completed pre- deployment
and post- deployment health assessments to AMSA for centralized retention.
21 Also, the U. S. Special Operations Command (SOCOM) requires deployment
health assessments for special forces units to be sent to the Command for
centralized retention in the Special Operation Forces Deployment Health
Surveillance System. 22 Figure 7 depicts the percentage of pre- and post-
deployment health
assessments and immunization records we found in the servicemembers*
medical records that were not available in a centralized database at AMSA
or SOCOM. Health- related documentation missing from the centralized
database ranged from 0 to 63 percent for pre- deployment health
assessments, 11 to 75 percent for post- deployment health assessments, and
8 to 93 percent for immunizations.
21 Office of the Chairman, The Joint Chiefs of Staff, Memorandum MCM-
0006- 02, *Updated Procedures for Deployment Health Surveillance and
Readiness,* February 1, 2002. 22 U. S. Special Operations Command
Directive 40- 4, *Medical Surveillance,* October 18, 2000; Appendix 1 to
Annex Q to U. S. Central Command Operations Order, *Special Operation
Forces Deployment Health Surveillance System,* November 30, 2001.
Page 22 GAO- 03- 1041 Defense Health Care
Figure 7: Percent of Assessments and Immunizations Found in
Servicemembers* Medical Records That Were Not Found in the Centralized
Database
Notes: . = 95 percent confidence interval, upper and lower bounds for each
estimate. Centralized database is AMSA for all but Hurlburt Field, which
reports to either AMSA or SOCOM based on classification of military
personnel. Hurlburt Field results reflect combined health assessment and
immunization data found at either AMSA or SOCOM. a Zero cases found in
servicemembers* medical record that were not found in the
centralized database.
All but one of the servicemembers in our sample at Hurlburt Field were
special operations forces. A SOCOM official told us that pre- deployment
and post- deployment health assessment forms for servicemembers in special
operations force units are not sent to AMSA because the health assessments
may include classified information that AMSA is not equipped
to receive. Consequently, SOCOM retains the deployment health assessments
in its classified Special Operations Forces Deployment Health Surveillance
System. Also, a SOCOM medical official told us that the
Page 23 GAO- 03- 1041 Defense Health Care
system does not include pre- deployment immunization data. A Deployment
Health Support Directorate official told us that the Directorate is
examining how to remove the classified information from the deployment
health assessments so that SOCOM can forward the
assessments to AMSA. For presentation in figure 7, we combined the health
assessment and immunization data we found at AMSA and SOCOM for Hurlburt
Field.
An AMSA official believes that missing documentation in the centralized
database could be traced to the services* use of paper copies of
deployment health assessments that installations are required to forward
to the centralized database, and the lack of automation to record
servicemembers* pre- deployment immunizations. DOD has ongoing initiatives
to electronically automate the deployment health assessment forms and the
recording of servicemember immunizations. For example, DOD is implementing
a comprehensive electronic medical records system, known as the Composite
Health Care System II, which includes pre- and post- deployment health
assessment forms and the capability to
electronically record immunizations given to servicemembers. DOD has
deployed the system at five sites and will be seeking approval in August/
September 2003 for worldwide deployment. 23 DOD officials believe that the
electronic automation of the deployment health- related information will
lessen the burden of installations in forwarding paper copies and the
likelihood of information being lost in transit.
DOD does not have an effective quality assurance program to provide
oversight of, and ensure compliance with, the department*s force health
protection and surveillance requirements. Moreover, the installations we
visited did not have ongoing monitoring or oversight mechanisms to help
ensure that force health protection and surveillance requirements were met
for all servicemembers. We believe that the lack of such a system was a
major cause of the high rate of noncompliance we found at the units we
visited. The services are currently developing quality assurance programs
designed to ensure that force health protection and surveillance policies
are implemented for servicemembers. 23 In September 2002, we reported that
DOD had experienced delays and cost overruns in implementing the Composite
Health Care System II. See U. S. General Accounting Office, Information
Technology: Greater Use of Best Practices Can Reduce Risk in Acquiring
Defense Health Care System, GAO- 02- 345 (Washington, D. C.: Sept. 26,
2002). DOD and Installations
Did Not Have Oversight of Force Health Protection and Surveillance
Requirements
Page 24 GAO- 03- 1041 Defense Health Care
Although required by Public Law 105- 85 to establish a quality assurance
program, 24 neither the Assistant Secretary of Defense for Health Affairs
nor the offices of the Surgeons General of the Army or Air Force had
established oversight mechanisms that would help ensure that force health
protection and surveillance requirements were met for all servicemembers.
Following our visit to Fort Drum in October 2002, the Army Surgeon General
wrote a memorandum in December 2002 to the commanders of the Army Regional
Medical Commands that expressed concern related to our sample results at
Fort Drum. He emphasized the importance of properly documenting medical
care and directed them to accomplish an audit of a statistically
significant sample of medical
surveillance records of all deployed and redeployed soldiers at
installations supported by their regional commands, provide an assessment
of compliance, and develop an action plan to improve compliance with the
requirements.
At three of the four installations we visited, officials told us that new
procedures were implemented that they believe will improve compliance with
force health protection and surveillance requirements for deployments
occurring after those we reviewed. Specifically, following our visit to
Fort Drum in October 2002, Fort Drum medical officials designed a pre-
deployment and post- deployment checklist patterned after our review that
is being used as part of processing before servicemembers
are deployed and when they return. The officials told us that this process
has improved their compliance with force health protection and
surveillance requirements for deployments subsequent to our visit. Also,
the hospital commander at Fort Campbell told us that they implemented
procedures that now require all units located at Fort Campbell to use the
hospital*s medical personnel in their processing of servicemembers prior
to deployment. The hospital commander believes that this new requirement
will improve compliance with the force health protection and surveillance
requirements at Fort Campbell because the medical personnel will now
review whether all requirements have been met for the deploying
servicemembers. At Hurlburt Field, officials told us that they implemented
a new requirement in November 2002 to withhold payment of travel expenses
and per diem to re- deploying servicemembers until they complete the post-
deployment health assessment. Officials believe that this change will
improve servicemembers* completion of the
post- deployment health assessments. While it is noteworthy that these 24
10 U. S. C. sec. 1074f( d).
Page 25 GAO- 03- 1041 Defense Health Care
installations have implemented changes that they believe will improve
their compliance, the actual measure of improvements over time cannot be
known unless the installations perform periodic reviews of
servicemembers* medical records to identify the extent of compliance with
deployment health requirements. In March 2003, we briefed the Subcommittee
on Total Force, House Committee on Armed Services, about our interim
review results at selected military installations. 25 Subsequently, at a
March 2003 congressional hearing, the Subcommittee discussed our interim
review results with the Assistant Secretary of Defense for Health Affairs
and the services* Surgeons General. Based on our interim results that DOD
was not meeting the full requirement of the law and the military services
were not effectively carrying out many of DOD*s force health protection
and surveillance policies, in May 2003 the House Committee on Armed
Services directed the Secretary of Defense to take measures to improve
oversight and compliance. Specifically, in its report accompanying the
Fiscal Year 2004 National Defense Authorization Act, the Committee
directed the Secretary of Defense ** to establish a quality control
program to begin assessing implementation of the force health protection
and surveillance program, and to provide a strategic implementation plan,
including a timeline for full implementation of all policies and programs,
to the Senate Committee on Armed Services and the House Committee on Armed
Services by March 31, 2004.* 26 In April 2003, the Under Secretary of
Defense for Personnel and Readiness
issued an enhanced post- deployment health assessment policy that required
the services to develop and implement a quality assurance program that
encompasses medical record keeping and medical surveillance data. 27 In
June 2003, the Office of Assistant Secretary of Defense for Health
Affairs* Deployment Health Support Directorate began reviewing the
services* quality assurance implementation plans and establishing DOD-
wide compliance metrics* including parameters for conducting periodic
visits* to monitor service implementation.
25 Prior to briefing the Subcommittee, we also briefed the Senior Military
Medical Advisory Committee including the Assistant Secretary of Defense
for Health Affairs and the Surgeons General or their representatives about
our interim review results. 26 H. R. Rep. No. 108- 106 at 336 (2003).
27 Under Secretary of Defense for Personnel and Readiness Memorandum,
*Enhanced Post- Deployment Health Assessments,* April 22, 2003.
Page 26 GAO- 03- 1041 Defense Health Care
The DMDC deployment database still does not include the deployment
information we identified in 1997 as needed for effective deployment
health surveillance. In 1997, we reported that knowing the identity of
servicemembers who were deployed during a given operation and tracking
their movements within the theater of operations are major elements of a
military medical surveillance system. 28 The Institute of Medicine
reported in 2000 that the documentation of the locations of units and
individuals during a given deployment is important for epidemiological
studies and for the provision of appropriate medical care during and after
deployments. 29 This information allows (1) epidemiologists to study the
incidence of disease patterns across populations of deployed
servicemembers who
may have been exposed to diseases and hazards within the theater, and (2)
health care professionals to treat their medical problems appropriately.
Because of concerns about the accuracy of the DMDC database, we
recommended in our 1997 report that the Secretary of Defense direct an
investigation of the completeness of the information in the DMDC personnel
database and take corrective actions to ensure that the deployment
information is accurate for servicemembers who deploy to a theater.
DOD*s established policies notwithstanding, the services did not report
location- specific deployment information to DMDC prior to April 2003,
because, according to a DMDC official, the services did not maintain the
data. DOD Instruction 6490.3, issued in August 1997, requires DMDC,
under the Department*s Under Secretary for Personnel and Readiness, to
maintain a system that collects information on deployed forces, including
daily- deployed strength, total and by unit; grid coordinate locations for
each unit (company size and larger); and inclusive dates of individual
servicemember*s deployment. 30 In addition, the Joint Chief of Staff*s
Memorandum MCM- 0006- 02, dated February 1, 2002, required combatant
commands to provide DMDC with their theater- wide rosters of all deployed
personnel, their unit assignments, and the unit*s geographic locations
while deployed. 31 This memorandum stressed that accurate
28 GAO/ NSIAD- 97- 136. 29 Institute of Medicine, Protecting Those Who
Serve: Strategies to Protect the Health of Deployed U. S. Forces (National
Academy Press, Washington, D. C.: 2000).
30 DOD Instruction 6490. 3, *Implementation and Application of Joint
Medical Surveillance for Deployments,* August 7, 1997. 31 Office of the
Chairman, The Joint Chiefs of Staff, Memorandum MCM- 0006- 02, *Updated
Procedures for Deployment Health Surveillance and Readiness,* February 1,
2002. Centralized
Deployment Database Still Missing Information Needed for Deployment Health
Surveillance
Page 27 GAO- 03- 1041 Defense Health Care
personnel deployment data is needed to assess the significance of medical
diseases and injuries in terms of the rate of occurrence among deployed
servicemembers. The Under Secretary of Defense for Personnel and Readiness
expressed concern about the services* failure to report complete personnel
deployment data to DMDC in an October 2002 memorandum. 32 To address the
services* lack of reporting to DMDC, the Under Secretary
of Defense for Personnel and Readiness established a tri- service working
group that outlined a plan of action in March 2003 to address the
reporting issues. In July 2003, a DMDC official told us that significant
improvements had recently occurred and that all of the services had begun
submitting their classified deployment databases* including deployment
locations* to DMDC. DMDC is currently reviewing the deployment information
submitted by the services to determine its accuracy and completeness. It
plans to complete this review during the summer of 2003. With regard to
DMDC*s efforts to create a system for tracking the
movements of servicemembers within a given theater of operations, DMDC
officials told us that little progress has been made. They said that the
primary reason for a lack of progress in developing this system is that
the source information has generally not been available from the services
and this may require the development of new tracking systems at the unit
level. In June 2003, a DMDC official told us that it had been recently
determined that the Air Force has implemented a theater tracking
system that may have applicability to the other services. The tracking
system* known as the Deliberate Crisis and Action Planning and Execution
Segment (DCAPES)* enables field teams to enter classified information
about the whereabouts of deployed Air Force personnel at the longitude/
latitude level of detail. DMDC began receiving information from this
system in April 2003. The Under Secretary of Defense for Personnel and
Readiness is reviewing this system to determine whether it could be used
for the same purposes by the other services. Also, DOD is developing the
Defense Integrated Military Human Resource
System (DIMHRS), which will have the capability to track the movements of
all servicemembers and civilians in the theater of operations. As of
32 This memorandum was dated October 25, 2002, and sent to the Vice Chief
of Staff of the Army, Vice Chief of Staff of the Air Force, Vice Chief of
Naval Operations, and the Assistant Commandant of the Marine Corps.
Page 28 GAO- 03- 1041 Defense Health Care
June 2003, DOD plans to implement this system for the Army by about
September 2005 and for the other services by 2007 or early calendar year
2008.
While DOD and the military services have established force health
protection and surveillance policies, at the units we visited we found
many instances of noncompliance by the services. Moreover, because DOD and
the services do not have an effective quality assurance program in place
to help ensure compliance, these problems went undetected and uncorrected.
Continued noncompliance with these policies may result in servicemembers
with existing health problems or concerns being deployed with unaddressed
health problems or without the immunization protection they need to
counter theater disease threats. Failure to complete post- deployment
health assessments may risk a delay in obtaining appropriate medical
follow- up attention for a health problem or concern that may have arisen
during or following the deployment. Similarly, incomplete and inaccurate
medical records and deployment databases would likely hinder DOD*s ability
to investigate the causes of any future health problems that may arise
coincident with deployments.
To improve compliance with DOD*s force health protection and surveillance
policies, we recommend that the Secretary of Defense direct the Assistant
Secretary of Defense for Health Affairs to establish an effective quality
assurance program, as required by section 765 of Public Law 105- 85 (10 U.
S. C. 1074f), that will ensure that the military services comply with the
force health protection and surveillance requirements for all
servicemembers.
The Department of Defense provided written comments on a draft of this
report, which are found in appendix II. DOD concurred with the report*s
recommendation.
The Assistant Secretary of Defense for Health Affairs commented that his
office has already established a quality assurance program for pre- and
post- deployment health assessments. This program monitors pre- and post-
deployment health assessments and blood samples being archived
electronically at the Army Medical Surveillance Activity (AMSA) and
assures that indicated referrals on the post- deployment health
assessments are being conducted by all the services. However, the
Assistant Secretary of Defense for Health Affairs* comments did not
Conclusions
Recommendation for Executive Action
Agency Comments and Our Evaluation
Page 29 GAO- 03- 1041 Defense Health Care
discuss how his office is using the monitoring activities to assure the
military services* compliance with force health protection and
surveillance policies.
According to the Assistant Secretary of Defense for Health Affairs, the
services have implemented their quality assurance programs. The Army has
developed automated versions of the pre- and post- deployment health
assessment forms, and has established a corporate monitoring system
that is built upon deployment personnel rosters and monitored weekly by
the Army Surgeon General. The Air Force is now receiving monthly
deployment health surveillance compliance reports from its medical
treatment facilities, and has scheduled a special compliance study through
the Air Force Inspection Agency in fiscal year 2004. Navy fleet commanders
have implemented their own quality assurance programs,
with anticipation of standardization through centralized automated
systems. And the Marine Corps has also established unit/ command quality
assurance procedures. We view these actions as responsive to our
recommendation and commend the department for taking quick action to
address the compliance issues we found during our audit. However, it
remains to be seen how effective these activities will be in ensuring that
force health protection and surveillance policies are implemented for all
servicemembers.
We are sending copies of this report to the Secretary of Defense and the
Secretaries of the Army and the Air Force. We will also make copies
available to others upon request. In addition, the report is available at
no charge on GAO*s Web site at http:// www. gao. gov.
If you or your staff have any questions regarding this report, please
contact me on (757) 552- 8100. Key contributors to this report are listed
in appendix III.
Neal P. Curtin, Director Defense Capabilities and Management
Appendix I: Scope and Methodology Page 30 GAO- 03- 1041 Defense Health
Care
To meet our objectives, we interviewed responsible officials and reviewed
pertinent documents, reports, and information related to force health
protection and deployment health surveillance requirements obtained from
officials at the Office of the Assistant Secretary of Defense for Health
Affairs; the Office of the Deputy Assistant Secretary of Defense for Force
Health Protection and Readiness; the Office of the Assistant Secretary of
Defense for Reserve Affairs; the Joint Staff; the Marine Corps Force
Health Protection Office; and the Offices of the Surgeons General for the
Army
and Air Force Headquarters in the Washington, D. C., area. We also
performed additional work at the Deployment Health Support Directorate,
Falls Church, Virginia; the U. S. Army Center for Health Promotion and
Preventive Medicine, Aberdeen, Maryland; the Armed Forces Medical
Intelligence Center, Fort Dietrick, Maryland; the Army Medical
Surveillance Activity, Walter Reed Army Medical Center, Washington, D. C.;
the Navy Environmental Health Center in Portsmouth, Virginia; the Defense
Manpower Data Center in Monterey, California; and the U. S. Central
Command and the U. S. Special Operations Command at MacDill Air Force
Base, Tampa, Florida.
To determine whether the military services were meeting DOD*s force health
protection and surveillance requirements for servicemembers deploying in
support of OEF and OJG, we identified DOD and each service*s overall
deployment health surveillance policies. We also obtained the specific
force health protection and surveillance requirements applicable to all
servicemembers deploying to Central Asia in support of OEF from the U. S.
Central Command and these requirements for all servicemembers deploying to
Kosovo in support of OJG from the U. S. European Command. We tested the
implementation of these requirements at selected Army and Air Force
installations. To identify locations within each service where we would
test implementation of the policies, the Assistant Secretary of Defense
for Health Affairs requested
the services to identify, by military installation, the number of active
duty servicemembers who met the following criteria: For OEF, those
servicemembers who deployed to Central Asia for 30 or
more continuous days to areas without permanent U. S. military treatment
facilities following September 11, 2001, and redeployed back to their home
unit by May 31, 2002. For OJG, those servicemembers who deployed to
Kosovo for 30 or more
continuous days to areas without permanent U. S. military treatment
facilities from January 1, 2001, and redeployed back to their home unit by
May 31, 2002. Appendix I: Scope and Methodology
Appendix I: Scope and Methodology Page 31 GAO- 03- 1041 Defense Health
Care
Based on deployment data obtained from the services, we decided to limit
our testing of the force health protection and surveillance policy
implementation to selected Army and Air Force military installations with
the largest numbers of servicemembers meeting our selection criteria
(described above). We limited our review of medical records for
servicemembers deploying in support of OJG to the two Army locations. We
decided not to review Navy installations because there were only small
numbers of servicemembers who met our selection criteria. We decided not
to review Marine Corps installations because officials at the Marine Corps
headquarters had difficulty identifying the number of servicemembers who
went ashore 30 or more continuous days consistent with our selection
criteria.
The largest deployers for OEF and OJG were selected and are listed below:
OEF: 10th Mountain Division, Fort Drum, N. Y. 101st Airborne Division,
Fort Campbell, Ky. Travis Air Force Base, Calif. Hurlburt Field, Fla.
OJG: 10th Mountain Division, Fort Drum, N. Y. 101st Airborne Division,
Fort Campbell, Ky.
For our medical records review, we selected statistical samples of
servicemembers at the selected installations to be representative of those
deploying from those military installations for those specific operations.
For various reasons, medical records were not always available for review.
We, therefore, sampled without replacement, to choose additional records
when we were unable to meet our sampling threshold of cases for review.
Specifically, there were five reasons identified for not being able to
physically secure the servicemember*s medical record for review:
1. Charged to patient. When a patient visits a clinic (on- post or off-
post), the medical record is physically given to the patient. The
procedure is that the medical record will be returned by the patient
following their clinic visit.
Appendix I: Scope and Methodology Page 32 GAO- 03- 1041 Defense Health
Care
2. Expired term of service. Servicemember separates from the military and
their medical record is sent to St. Louis, Missouri, and therefore not
available for review. 3. Record is not accounted for by the medical
records department. No tracking sheet is in the file system to indicate
the patient has
checked it out or otherwise. (Note: There were not any cases for which the
medical record could not be accounted.)
4. Permanent change of station. Servicemember is still in the military,
but has transferred to another base. Medical record transfers with the
servicemember.
5. Temporary duty off site. Servicemember has left military installation,
but is expected to return. The temporary duty is long enough to warrant
that the medical record accompany the servicemember.
The sample size for deployments was determined to provide 95 percent
confidence with a 5- percent precision. The number of servicemembers in
our samples and the applicable universe of servicemembers for the OEF and
OJG deployments at the installations visited are shown in table 2.
Table 2: Servicemember Sample Sizes at Each Visited Installation
Installation Deployment Sample Universe
Fort Campbell OEF 8 333 OEF (post May 31) a 222 2,953 OJG (post May 31) a
46 92 Fort Drum OEF 184 491
OJG 211 2,754 Hurlburt Field OEF 184 927 Travis Air Force Base OEF 215
1,192
Total 1,071 8,742
a In order to obtain a larger universe of servicemembers from which to
select medical records for review, we extended our date for redeployment
to home unit from May 31, 2002, to October 31, 2002. At Fort Campbell,
there were only 333 servicemembers identified as
having met our criteria based on a redeployment date of May 31, 2002;
however, only 8 charts were available for review due to rotation of
soldiers to other military locations or departure from the military. It
was, therefore, necessary to extend our redeployment date to October 31,
2002.
Appendix I: Scope and Methodology Page 33 GAO- 03- 1041 Defense Health
Care
Doing so provided an additional 2,953 servicemembers who met all criteria
except for a redeployment by May 31, 2002. At Fort Campbell, there were 92
servicemembers who deployed in support of OJG and met our selection
criteria if we extended the redeployment date to October 31, 2002. Because
the number of servicemembers for OJG at Fort Campbell was small, we
reviewed the medical records for all of servicemembers who were still at
Fort Campbell.
At each sampled location, we examined servicemember medical records for
evidence of the following force health protection and deployment health-
related documentation required by DOD*s force health protection and
deployment health surveillance policies:
Pre- and post- deployment health assessments, Tuberculosis screening
test (within 1 year of deployment for OEF and
2 years for OJG) Pre- deployment immunizations:
hepatitis A; influenza (within 1 year of deployment); measles,
mumps, and rubella; meningococcal (within 5 years of deployment);
polio; tetanus- diphtheria (within 10 years of deployment); typhoid
(within 5 years of deployment); and yellow fever (within 10 years of
deployment), not required for OJG.
To provide assurances that our review of the selected medical records was
accurate, we requested the installations* medical personnel to reexamine
those medical records that were missing required health assessments or
immunizations and adjusted our results where documentation was
subsequently identified. We also requested that installation medical
personnel check all possible sources for missing pre- and post- deployment
health assessments and immunizations. These sources included the Army*s
Soldier Readiness Check folders and automated immunization sources,
including the Army*s Medical Protection System (MEDPROS) and the Air
Force*s Comprehensive Immunization Tracking Application (CITA). We checked
all known possible sources for the existence of deployment health
assessments related to servicemembers in our samples. In those instances
where we did not find a deployment health assessment, we concluded that
the assessments were not completed. Furthermore, installation officials
were unable to logistically access the servicemembers* individual records
of immunizations, commonly referred to as yellow- shot records that may
have provided documentation for
Appendix I: Scope and Methodology Page 34 GAO- 03- 1041 Defense Health
Care
missing immunizations. Consequently, our analyses of the immunization
records was based on our examination of the servicemember*s permanent
medical record and immunizations that were in the Army*s MEDPROS and the
Air Force*s CITA. In analyzing our review results at each location, we
considered documentation from all identified sources (e. g.,
servicemember*s medical record, soldier readiness check folder, Army
Medical Surveillance Activity, and immunization tracking systems) in
presenting data on compliance with deployment health surveillance
policies.
To identify whether required blood serum specimens were in storage at the
Armed Services Serum Repository, we requested that the Army Medical
Surveillance Activity staff query the Repository to identify whether the
servicemembers in our samples had a blood serum sample in the repository
and the date of the specimen.
To determine whether the Army and Air Force are documenting in- theater
medical interventions in servicemembers* medical records, we requested, at
each installation visited for medical records review, the patient sign- in
logs for in- theater medical care providers, namely the Army*s battalion
aid station and the Air Force*s expeditionary medical support, when they
were deployed to central Asia in support of OEF and for the two Army
installations we visited that deployed in support of OJG. Officials were
unable to locate or access the logs at all of our selected installations
except for Fort Drum for the OEF deployment. Consequently, we were able to
perform our planned examination for this objective at only Fort Drum for
the OEF deployment. From these logs, we selected a random sample of 36
patient visits from one battalion aid station and 18 patient visits from
another battalion aid station. We did not attempt to judge the importance
of the patient visit in making our selections. For the selected patient
visits, we then reviewed the servicemember*s medical record for any
documentation* such as the Army*s Standard Form 600* of the
servicemember*s visit to the battalion aid station. To determine whether
the Army and Air Force*s deployment health- related
records are retained and maintained in a centralized location, we
requested that officials at the Army Medical Surveillance Activity (AMSA)
query the AMSA database for the servicemembers included in our samples at
the selected Army and Air Force installations. For servicemembers in our
samples, AMSA officials provided us with copies of deployment health
assessments and immunization data found in the AMSA database. We analyzed
the completeness of the AMSA database by comparing the deployment health
assessments and the pre- deployment immunization
Appendix I: Scope and Methodology Page 35 GAO- 03- 1041 Defense Health
Care
data we found during our medical records review with those in the AMSA
database. Since Air Force special operations force units use the Hurlburt
Field, we also requested the U. S. Special Operations Command (SOCOM) to
query their Special Operation Forces Deployment Health Surveillance System
database for servicemembers in our sample at Hurlburt Field for deployment
health assessments and pre- deployment immunization data. We then compared
the data identified from the SOCOM and AMSA queries with the data we found
during our medical records review.
To determine whether DOD has corrected problems related to the accuracy
and completeness of databases reflecting which servicemembers deployed to
certain locations, we interviewed officials within the Deployment Health
Support Directorate and the Defense Manpower Data Center and reviewed
documentation related to the completeness of deployment databases and
planned improvements in capabilities.
Our review was performed from June 2002 through July 2003 in accordance
with generally accepted government auditing standards.
Appendix II: Comments from the Department of Defense
Page 36 GAO- 03- 1041 Defense Health Care
Appendix II: Comments from the Department of Defense
Appendix II: Comments from the Department of Defense
Page 37 GAO- 03- 1041 Defense Health Care
Appendix II: Comments from the Department of Defense
Page 38 GAO- 03- 1041 Defense Health Care
Appendix III: GAO Contact and Staff Acknowledgments
Page 39 GAO- 03- 1041 Defense Health Care
Clifton E. Spruill (202) 512- 4531 In addition to the individual named
above, Steve Fox, Rebecca Beale, Lynn Johnson, William Mathers, Terry
Richardson, Kristine Braaten, Grant Mallie, Herbert Dunn, and R. K. Wild
made key contributions to this report. Appendix III: GAO Contact and Staff
Acknowledgments GAO Contact Acknowledgments
(350216)
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