Defense Health Care: DOD Needs to Improve Force Health Protection
and Surveillance Processes (16-OCT-03, GAO-04-158T).		 
                                                                 
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 reported on (1) the Army's and Air Force's	 
compliance with 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) the status of DOD efforts to	 
correct problems related to the accuracy and completeness of	 
databases reflecting which servicemembers were deployed to	 
certain locations. (Defense Health Care: Quality Assurance	 
Process Needed to Improve Force Health Protection and		 
Surveillance [GAO-03-1041, Sept. 19, 2003]) GAO was asked to	 
testify on its findings regarding the Army's and Air Force's	 
compliance with DOD's force health protection and surveillance	 
policies. For its report, GAO reviewed records for statistical	 
samples of active duty servicemembers at four military		 
installations.							 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-04-158T					        
    ACCNO:   A08708						        
  TITLE:     Defense Health Care: DOD Needs to Improve Force Health   
Protection and Surveillance Processes				 
     DATE:   10/16/2003 
  SUBJECT:   Data collection					 
	     Noncompliance					 
	     Data bases 					 
	     Data integrity					 
	     Medical examinations				 
	     Medical records					 
	     Medical information systems			 
	     Military operations				 
	     Military personnel 				 
	     Military personnel records 			 
	     Health care services				 
	     Health hazards					 
	     Health resources utilization			 
	     Operation Enduring Freedom 			 
	     Operation Joint Guardian				 
	     Persian Gulf War					 

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GAO-04-158T

United States General Accounting Office

GAO Testimony

Before the Committee on Veterans' Affairs, House of Representatives

For Release on Delivery Expected at 10:00 a.m. EDT Thursday, October 16,
2003

DEFENSE HEALTH CARE

    DOD Needs to Improve Force Health Protection and Surveillance Processes

Statement of Neal P. Curtin
Director, Defense Capabilities and Management

GAO-04-158T i

Highlights of GAO-04-158T, testimony before the Committee on Veterans'
Affairs, 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, 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 reported on
(1) the Army's and Air Force's compliance with 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) the status of DOD efforts to
correct problems related to the accuracy and completeness of databases
reflecting which servicemembers were deployed to certain locations.
(Defense Health Care: Quality Assurance Process Needed to Improve Force
Health Protection and Surveillance [GAO-03-1041, Sept. 19, 2003])

GAO was asked to testify on its findings regarding the Army's and Air
Force's compliance with DOD's force health protection and surveillance
policies. For its report, GAO reviewed records for statistical samples of
active duty servicemembers at four military installations.

www.gao.gov/cgi-bin/getrpt?GAO-04-158T.

To view the full testimony, click on the link above. For more information,
contact Neal Curtin at (757) 552-8100.

October 16, 2003

DEFENSE HEALTH CARE

DOD Needs to Improve Force Health Protection and Surveillance Processes

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 as many as 36 percent
were missing two or more of the required immunizations.

GAO found that many servicemembers' medical records did not include health
assessments found in DOD's centralized database. Similarly, DOD also did
not maintain a complete, centralized database of servicemembers' health
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 was 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 helped 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.

GAO's report recommended that DOD establish an effective quality assurance
program that will ensure that the military services comply with the force
health protection and surveillance policies for all servicemembers. DOD
agreed with the recommendation and outlined a number of actions the
military services are already taking to implement their quality assurance

programs. While we view these actions as responsive to our recommendation,
the effectiveness of these actions to ensure compliance will depend on
follow-through by DOD and the services.

Mr. Chairman and Members of the Committee:

I am pleased to be here as you discuss health assessments and the
importance of complete medical records for our servicemembers. Both the
Department of Defense (DOD) and the Department of Veterans Affairs (VA)
need this information to perform their missions. DOD needs health status
information and complete medical records to help ensure the deployment of
healthy forces and the continued fitness of those forces. VA's Veterans
Benefits Administration uses health information to adjudicate veterans'
claims for disability compensation related to service-connected injuries
or illnesses. As you know, VA's Veterans Health Administration needs
complete and accurate medical records documenting all medical care for
individual servicemembers are needed for the delivery of high-quality,
post-deployment care. In this context, you asked us to discuss our recent
report on the Army's and Air Force's compliance with DOD's force health
protection and surveillance policies that require servicemembers to be
assessed before and after deploying overseas, that require servicemembers
to receive certain immunizations, and that require health-related
documentation to be maintained in a centralized location.

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 DOD deployment health
surveillance policies for servicemembers deployed to Bosnia in support of
a peacekeeping operation.1

1 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).

In response, the Congress enacted legislation2 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 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-deployment 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 screening
for tuberculosis; and the retention of blood serum samples on file prior
to deployment. In February 2002, we testified before the Subcommittee on
Health of this Committee that DOD had several initiatives under way to
improve the reliability of deployment information and to enhance its
information technology capabilities, as we and others have recommended.3
Although its recent policies and reorganization reflect a commitment by
DOD to establish a comprehensive medical surveillance system, much needed
to be done to implement the system.

My testimony today is based on our September 2003 report on the Army's and
Air Force's compliance with DOD's force health protection and surveillance
policies for active duty deployments for Operation Enduring Freedom (OEF)
in Central Asia and Operation Joint Guardian (OJG) in Kosovo.4 We also
examined whether DOD has corrected problems related

2 Section 765 of Pub. L. No. 105-85 amended title 10 of the United States
Code by adding section 1074f.

3 U.S. General Accounting Office, VA and Defense Health Care: Military
Medical Surveillance Policies in Place, but Implementation Challenges
Remain, GAO-02-478T (Washington, D.C.: Feb. 27, 2002).

4 U.S. General Accounting Office, Defense Health Care: Quality Assurance
Process Needed to Improve Force Health Protection and Surveillance,
GAO-03-1041 (Washington, D.C.: Sept. 19, 2003). Moreover, we reported in
April 2003 and testified in July 2003 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).

to the accuracy and completeness of databases reflecting which
servicemembers deployed to certain locations.

To do our work, 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.5 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-deployment and post-deployment health 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
Activity6 (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. We conducted our work from
June 2002 through July 2003 in accordance with generally accepted
government auditing standards.

5 Includes samples of records for servicemembers who deployed from Fort
Drum, New York; Fort Campbell, Kentucky; Travis Air Force Base,
California; and Hurlburt Field, Florida.

6 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.

Summary 	In summary, 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.

o  	Deployment health assessments. The percentage of Army and Air Force
servicemembers missing one or both of their pre-deployment 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.

o  	Immunizations and other pre-deployment requirements. Servicemembers
missing evidence of receiving one of the pre-deployment immunizations
required for their deployment location ranged from 14 percent to 46
percent. As many as 36 percent of the servicemembers were missing two or
more of their required immunizations. 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.

o  	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 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 was 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 helped 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 and VA's ability to investigate the causes of any
future health problems that may arise coincident with deployments.

Also, 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. DMDC's 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 services did not maintain the data. 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
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 recommended 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.
DOD agreed with our recommendation and outlined a number of actions the
military services are already taking to implement their quality assurance
programs. While we view these actions as responsive to our recommendation,
the effectiveness of these actions to ensure compliance will depend on
follow-through by DOD and the services.

Background

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.7 Our 1997 review disclosed
problems with the Army's implementation of the medical surveillance plan
for Operation Joint Endeavor in the following areas:

o  	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.

o  	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.

o  	Centralized database. The centralized database for collecting
in-theater and home unit post-deployment medical assessments was
incomplete for many Army personnel.

o  	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).

7 GAO/NSIAD-97-136.

"(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."8

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-deployment 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.9 However, it requires the blood samples be

8 Section 765 of Pub. L. No. 105-85 amended title 10 of the United States
Code by adding section 1074f.

9 DOD Instruction 6490.3, "Implementation and Application of Joint Medical
Surveillance for Deployments," August 7, 1997.

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-deployment 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.10 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.

10 Under Secretary of Defense for Personnel and Readiness Memorandum,
"Enhanced Post-Deployment Health Assessments," April 22, 2003.

  The Army and
  Air Force Did Not
  Comply with
  Deployment Health
  Surveillance
  Policies for Many
  Servicemembers

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.

Many Servicemembers Lacked Pre-deployment and Post-deployment Health
Assessments

We found that servicemembers missing one or both of their pre-deployment
and post-deployment assessments ranged from 38 to 98 percent in our
samples.11 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
post-deployment health assessments. The results of our statistical samples
for the deployments at the installations visited are depicted in figure 1.

11 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.

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.

For those servicemembers in our samples who had completed pre-deployment
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. 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.12 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

12 Office of the Chairman, The Joint Chiefs of Staff, Memorandum
MCM-0006-2, "Updated Procedures for Deployment Health Surveillance and
Readiness," February 1, 2002.

servicemember's deployment. Additionally, 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.13 We found, however, that not all health assessments
were reviewed by a health care provider as required.

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 to seek mental health
counseling or care.14 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.

13 The Joint Staff, Joint Staff Memorandum MCM-251-98.

14 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

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 one of their required
immunizations prior to deployment (see fig. 2). Furthermore, as many as 36
percent of the servicemembers were missing two or more of their required
immunizations.

Figure 2: 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.15
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.16

Furthermore, deploying servicemembers in our review that were missing a
current tuberculosis screening ranged from 7 to 40 percent. 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.17 For OJG deployments, the U.S. European Command
required Army and Air Force servicemembers to be screened for tuberculosis
with 24 months of deployment.18

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.19 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. The samples that were too old ranged, on average, from
2 to 15 months out-of-date.

15 U.S. Central Command, "Personnel Policy Guidance for U.S. Individual
Augmentation Personnel in Support of Operation Enduring Freedom," October
3, 2001.

16 Headquarters U.S. European Command, "Greece and the Balkans: Force
Health Protection Guidance," January 4, 2002.

17 U.S. Central Command, "Personnel Policy Guidance for U.S. Individual
Augmentation Personnel in Support of Operation Enduring Freedom," October
3, 2001.

18 Headquarters U.S. European Command, "Greece and the Balkans: Force
Health Protection Guidance," January 4, 2002.

19 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.

Servicemember Medical Records and Centralized Database Were Not Complete

Many Completed Deployment
Health Assessments and
Medical Interventions
Were Not Documented
in Servicemembers'
Medical Record

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.20 Figure 3 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.

20 Office of the Chairman, The Joint Chiefs of Staff, Memorandum
MCM-0006-02, "Updated Procedures for Deployment Health Surveillance and
Readiness," February 1, 2002.

Figure 3: 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.

aAll 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.21 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

21 Army Regulation 40-66, "Medical Records Administration," October 23,
2002, and Air Force Instruction 41-210, "Health Services Patient
Administration Functions," October 1, 2000.

Centralized Database Missing Health-Related Documentation

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 stations 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 and VA
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

requires the services to forward a copy of the completed pre-deployment
and post-deployment health assessments to AMSA for centralized
retention.22 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.23

Figure 4 depicts the percentage of pre-deployment 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.

22 Office of the Chairman, The Joint Chiefs of Staff, Memorandum
MCM-0006-02, "Updated Procedures for Deployment Health Surveillance and
Readiness," February 1, 2002.

23 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.

Figure 4: 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.

aZero 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

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 4, 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-deployment 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.24 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 and Installations Did Not Have Oversight of Force Health Protection
and Surveillance Requirements

DOD did 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.

24 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).

Although required by Public Law 105-85 to establish a quality assurance
program,25 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 the commanders 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

25 10 U.S.C. sec. 1074f(d).

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.26 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."27

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.28 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.

26 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 military services' Surgeons General or their
representatives about our interim review results.

27 H.R. Rep. No. 108-106 at 336 (2003).

28 Under Secretary of Defense for Personnel and Readiness Memorandum,
"Enhanced Post-Deployment Health Assessments," April 22, 2003.

  Centralized Deployment Database Still Missing Information Needed for
  Deployment Health Surveillance

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.29 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.30
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.31 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.32 This memorandum stressed that accurate

29 GAO/NSIAD-97-136.

30 Institute of Medicine, Protecting Those Who Serve: Strategies to
Protect the Health of Deployed U.S. Forces (National Academy Press,
Washington, D.C.: 2000).

31 DOD Instruction 6490.3, "Implementation and Application of Joint
Medical Surveillance for Deployments," August 7, 1997.

32 Office of the Chairman, The Joint Chiefs of Staff, Memorandum
MCM-0006-02, "Updated Procedures for Deployment Health Surveillance and
Readiness," February 1, 2002.

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.33

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

33 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.

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.

Concluding Observations

Contacts and Acknowledgments

(350454)

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 did 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 and
VA's ability to investigate the causes of any future health problems that
may arise coincident with deployments.

Mr. Chairman, this concludes my prepared statement. I will be pleased to
answer any questions you or other members of the committee may have at
this time.

For further information regarding this testimony, please contact Neal P.
Curtin at (757) 552-8100. Clifton Spruill, Steve Fox, Rebecca Beale, Lynn
Johnson, William Mathers, Terry Richardson, Kristine Braaten, Grant
Mallie, Herbert Dunn, and R.K. Wild also contributed to this testimony.

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