Defense Health Care: Comprehensive Oversight Framework Needed to 
Help Ensure Effective Implementation of a Deployment Health	 
Quality Assurance Program (22-JUN-07, GAO-07-831).		 
                                                                 
Overseas deployments expose servicemembers to a number of	 
potential risks to their health and well-being. However, since	 
the mid-1990s, GAO has highlighted shortcomings with respect to  
the Department of Defense's (DOD) ability to assess the medical  
condition of servicemembers both before and after their 	 
deployments. Following GAO's May 1997 report, Congress enacted	 
legislation (10 U.S.C. 1074f) that required the Secretary of	 
Defense to establish a medical tracking system for assessing the 
medical condition of servicemembers before and after deployments.
GAO was asked to determine (1) whether DOD has established a	 
medical tracking system to comply with requirements of 10 U.S.C. 
1074f pertaining to pre- and postdeployment medical examinations,
and (2) the extent to which DOD has effectively implemented a	 
deployment health quality assurance program as part of its	 
medical tracking system. In conducting this review, GAO analyzed 
pertinent documents and interviewed DOD officials.		 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-07-831 					        
    ACCNO:   A71226						        
  TITLE:     Defense Health Care: Comprehensive Oversight Framework   
Needed to Help Ensure Effective Implementation of a Deployment	 
Health Quality Assurance Program				 
     DATE:   06/22/2007 
  SUBJECT:   Data collection					 
	     Health care programs				 
	     Health care services				 
	     Internal controls					 
	     Medical information systems			 
	     Medical records					 
	     Military personnel 				 
	     Program evaluation 				 
	     Quality assurance					 
	     Reporting requirements				 
	     Program implementation				 

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GAO-07-831

   

     * [1]Results in Brief
     * [2]Background
     * [3]DOD Has a System in Place to Comply with Requirements for De
     * [4]DOD Has Established a Deployment Health Quality Assurance Pr

          * [5]DOD Has Established a Deployment Health Quality Assurance Pr
          * [6]DOD Does Not Have a Comprehensive Oversight Framework to Det

               * [7]DOD Has Not Identified All Results-Oriented Performance
                 Meas
               * [8]DOD Has Not Enforced Its Policy Requiring the Services to
                 Re
               * [9]DOD Site Visits to Assess the Services' Deployment Health
                 Qu

     * [10]Conclusions
     * [11]Recommendations for Executive Action
     * [12]Agency Comments and Our Evaluation
     * [13]Appendix I: Scope and Methodology
     * [14]Appendix II: Pre- and Postdeployment Health Assessment Quest
     * [15]Appendix III: Individual Medical Readiness
     * [16]Appendix IV: Comments from the Department of Defense
     * [17]Appendix V: GAO Contact and Staff Acknowledgments

          * [18]GAO Contact
          * [19]Acknowledgments

     * [20]Related GAO Products

          * [21]Order by Mail or Phone

Report to the Ranking Member, Subcommittee on National Security and
Foreign Affairs, Committee on Oversight and Government Reform, House of
Representatives

United States Government Accountability Office

GAO

June 2007

DEFENSE HEALTH CARE

Comprehensive Oversight Framework Needed to Help Ensure Effective
Implementation of a Deployment Health Quality Assurance Program

GAO-07-831

Contents

Letter 1

Results in Brief 3
Background 6
DOD Has a System in Place to Comply with Requirements for Deployment
Medical Examinations 10
DOD Has Established a Deployment Health Quality Assurance Program, but the
Lack of a Comprehensive Oversight Framework Hampers Effective
Implementation 13
Conclusions 19
Recommendations for Executive Action 19
Agency Comments and Our Evaluation 20
Appendix I Scope and Methodology 22
Appendix II Pre- and Postdeployment Health Assessment Questionnaires 24
Appendix III Individual Medical Readiness 30
Appendix IV Comments from the Department of Defense 32
Appendix V GAO Contact and Staff Acknowledgments 35
Related GAO Products 36

Abbreviations

AMSA Army Medical Surveillance Activity
DHSD Deployment Health Support Directorate
DMSS Defense Medical Surveillance System
DNA Deoxyribonucleic Acid
DOD Department of Defense
GPRA Government Performance and Results Act of 1993
HIV Human Immunodeficiency Virus
IPV Inactivated Poliovirus
MMR Measles, Mumps, and Rubella

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United States Government Accountability Office
Washington, DC 20548

June 22, 2007

The Honorable Christopher Shays
Ranking Member
Subcommittee on National Security and Foreign Affairs
Committee on Oversight and Government Reform
House of Representatives

Dear Mr. Shays:

Overseas deployments expose servicemembers to a number of potential risks
to their health and well-being. However, since the mid-1990s we have been
reporting on DOD's shortcomings with respect to assessing the medical
condition of servicemembers both before and after their deployments.
Following our May 1997 report,1 Congress enacted legislation2 that
required the Secretary of Defense to establish a medical tracking system
to assess the medical condition of servicemembers before and after
deployments to locations outside the United States. The elements of the
system, as required by the law, included, among other things, the use of
pre- and postdeployment medical examinations. As part of the system, the
law also required DOD to establish a quality assurance program to evaluate
the success of the system in ensuring that servicemembers receive pre- and
postdeployment medical examinations and that record-keeping requirements
with respect to the system are met. However, our September 2003 report
highlighted many instances of noncompliance with DOD's deployment health
requirements and reiterated the need for DOD to establish a quality
assurance program to ensure that these requirements are met.3 In September
2004, we reported similar findings for reserve forces.4 Further, our
November 2004 report raised concerns that overall compliance with DOD's
force health protection and surveillance policies for servicemembers who
deployed in support of Operation Iraqi Freedom varied by service, by
installation, and by policy requirement.5 More recently, in October 2005
we reported that evidence suggested that some reserve component members
have deployed into theater with preexisting medical conditions that could
not be adequately addressed in-theater.6

1GAO, Defense Health Care: Medical Surveillance Improved Since Gulf War,
but Mixed Results in Bosnia, [22]GAO/NSIAD-97-136 (Washington, D.C.: May
13, 1997).

2National Defense Authorization Act for Fiscal Year 1998, Pub. L. No.
105-85, S 765 (1997) (codified at 10 U.S.C. S 1074f).

3GAO, Defense Health Care: Quality Assurance Process Needed to Improve
Force Health Protection and Surveillance, [23]GAO-03-1041 (Washington,
D.C.: Sept. 19, 2003).

4GAO, Military Personnel: DOD Needs to Address Long-term Reserve Force
Availability and Related Mobilization and Demobilization Issues,
[24]GAO-04-1031 (Washington, D.C.: Sept. 15, 2004).

In light of these long-standing problems, you asked us to examine DOD's
compliance with the legislative requirement to perform pre- and
postdeployment medical examinations on servicemembers and DOD's deployment
health quality assurance program. This report addresses (1) whether DOD
has established a medical tracking system to comply with requirements of
10 U.S.C. S 1074f pertaining to pre- and postdeployment medical
examinations, and (2) the extent to which DOD has effectively implemented
a deployment health quality assurance program as part of its medical
tracking system.

To address our objectives, we obtained and reviewed pertinent documents,
reports, and information related to DOD's deployment health requirements
and deployment health quality assurance program from officials at the
Assistant Secretary of Defense for Health Affairs, Deployment Health
Support Directorate (DHSD); the Offices of the Surgeons General for the
Army, Air Force, and Navy; the Army Medical Surveillance Activity (AMSA);
and the Combined Fleet Forces Command and Naval Environmental Health
Center. To determine whether DOD has established a medical tracking system
to comply with requirements of 10 U.S.C. S 1074f pertaining to pre- and
postdeployment medical examinations, we reviewed 10 U.S.C. S 1074f to
identify system requirements and DOD policies and other guidance to
identify the measures DOD uses to establish the medical condition of
servicemembers as part of this system. In addition, we obtained a legal
opinion from DOD's Office of General Counsel regarding DOD's compliance
with the requirement of 10 U.S.C. S 1074f to perform pre- and
postdeployment medical examinations. To determine the extent to which DOD
has effectively implemented a deployment health quality assurance program
as part of its medical tracking system, we obtained and analyzed relevant
DOD policies to identify requirements of the program. We also interviewed
key officials with DHSD and the services' Offices of the Surgeon General
to obtain a comprehensive understanding of the processes, procedures, and
controls used for monitoring and overseeing the deployment health quality
assurance program. We obtained and analyzed the results of site visits
conducted by DHSD in calendar years 2005 and 2006. To determine the
reliability of DOD's quality assurance program reports, we obtained and
analyzed data collection instruments and other documentation used to
record, summarize, and report the services' compliance with deployment
health requirements. We also discussed with responsible DOD officials,
including representatives from the military services, their methodology
for ensuring that information collected and reported is as accurate and
reliable as possible. Where possible, we tested data by comparing
information from the data collection instruments or summary documents with
available source documents. We identified issues of inconsistency and
incompleteness in DOD's data and, therefore, determined the data to be
insufficiently reliable for the purpose of assessing compliance with
deployment health requirements and we are making a recommendation to
address this issue accordingly. In conducting our review, we limited our
focus to the procedures that DOD has in place to medically assess
servicemembers before and after their deployments. Other issues, such as
recent controversies associated with alleged deployments of medically
unfit servicemembers to Iraq, did not fall within the scope of this
review. These issues will be addressed as part of a separate review. We
performed our work from September 2006 through May 2007 in accordance with
generally accepted government auditing standards. For more detailed
information on our scope and methodology, see appendix I.

5GAO, Defense Health Care: Force Health Protection and Surveillance Policy
Compliance Was Mixed, but Appears Better for Recent Deployments,
[25]GAO-05-120 (Washington, D.C.: Nov. 12, 2004).

6GAO, Military Personnel: Top Management Attention Is Needed to Address
Long-standing Problems with Determining Medical and Physical Fitness of
the Reserve Force, [26]GAO-06-105 (Washington, D.C.: Oct. 27, 2005).

Results in Brief

DOD has established a medical tracking system to comply with the
requirements of 10 U.S.C. S 1074f to perform predeployment and
postdeployment medical examinations through a variety of deployment health
activities. This section of the law requires the Secretary of Defense to
establish a system to assess the medical condition of servicemembers
deployed outside the United States. According to the law, the system is to
include the use of medical examinations, including an assessment of mental
health and the drawing of blood samples, both before and after deployment.
DOD has established a medical tracking system to assess the medical
condition of servicemembers intended to ensure that only medically and
mentally fit servicemembers deploy outside of the United States. For
example, DOD's system includes the use of pre- and postdeployment health
assessment questionnaires and reviews of servicemembers' medical records
(e.g., physical examinations, immunizations, dental history). The
predeployment health assessment questionnaires, which are to be completed
no earlier than 60 days prior to deployment, are a series of questions
about servicemembers' current medical (including dental) and mental health
conditions, including prescriptions, vision issues, and any medical
concerns servicemembers might have. These questionnaires and
servicemembers' medical records are to be reviewed by a health care
provider to confirm whether servicemembers have received standard and
theater-specific immunizations and recent medical (physical) examinations
that identify diseases and medical conditions that may prevent them from
deploying. Based on the responses to the predeployment questionnaires and
the review of the medical records, servicemembers may be referred for
further testing and evaluation prior to deployment. Also, within 30 days
prior to or after redeploying,7 servicemembers are to complete the
postdeployment health assessment questionnaire. The postdeployment
questionnaires are to be reviewed by a health care provider, along with
servicemembers' medical records, to evaluate current health status,
deployment experiences, environmental exposures, and health concerns
related to their deployments. Based on these reviews, the health care
provider may recommend additional clinical evaluation or treatment as
needed. In response to an inquiry from our office, DOD's Office of General
Counsel explained that the health assessments the department performs meet
the requirement of 10 U.S.C. S 1074f for pre- and postdeployment medical
examinations. We conclude that DOD's interpretation is reasonable.

DOD has also established a deployment health quality assurance program as
part of its medical tracking system, but lacks a comprehensive oversight
framework to help ensure effective implementation of the program. Thus,
DOD does not have the information it needs to evaluate the effectiveness
and efficiency of its quality assurance program. The Government
Performance and Results Act of 19938 (GPRA) provides federal agencies with
a framework for developing oversight, which includes establishing
reporting requirements and performance measures. DOD's deployment health
quality assurance program policy specifies four elements of DOD's program:
(1) monthly reports on active and reserve component servicemembers'
deployment health assessment data from centralized databases maintained by
AMSA, (2) quarterly reports on service-specific deployment health quality
assurance programs, (3) periodic visits to military installations to
complement and validate the services' deployment health programs, and (4)
an annual report to the Assistant Secretary of Defense for Health Affairs
on the department's quality assurance program. DOD guidance requires each
of the services to create their own quality assurance programs based on
these elements. While DOD has established a program that includes these
four elements, DOD cannot determine whether the program has been
effectively implemented because DOD does not have a comprehensive
oversight framework with all the specific reporting requirements and
necessary performance measures to evaluate the services' compliance with
deployment health requirements or to help ensure that the services are
implementing the program consistently.

7For the purposes of this report, we use the terms "redeploying" and
"redeployed" to mean returning from deployment.

8Pub. L. No. 103-62 (1993).

           o Monthly AMSA reports: Although DOD requires monthly reports from
           AMSA on servicemembers' deployment health data, it does not
           provide AMSA with results-oriented performance measures and
           specific reporting requirements that would enable DOD to determine
           the departmentwide compliance with deployment health requirements.
           For example, DOD's policy does not require that AMSA provide
           critical information needed to assess compliance with deployment
           health requirements, such as the total number of servicemembers
           that deployed/redeployed during the reporting period. Without
           knowing the total number of servicemembers deployed/redeployed,
           DOD cannot determine the extent to which servicemembers completed
           the required pre- and postdeployment health assessment
           questionnaires.
           o Quarterly reports on the services' programs: While DOD's policy
           requires that the services report on service-specific compliance
           with deployment health requirements in their quarterly reports,
           DOD has not enforced this requirement. Consequently, each service
           is choosing to selectively report on requirements, which prevents
           the department from having a complete picture/assessment of
           compliance with deployment health requirements across the
           services. For example, while the Army reports on only a sample of
           servicemembers who deploy or redeploy during the reporting period,
           the Air Force reports on the total number of servicemembers who
           deploy or redeploy during the reporting period. However, the
           Army's report includes all overseas locations of deployment
           whereas the Air Force only reports on deployments in support of
           Operations Iraqi Freedom or Enduring Freedom.
           o Site visits: While DHSD conducts four visits per year to
           military installations to assess the services' deployment health
           quality assurance programs, it does not have quality controls in
           place to ensure the accuracy or completeness of the information it
           collects. DHSD representatives use data collection instruments to
           facilitate their program reviews, but DHSD officials told us that
           none of these instruments are reviewed by an independent or second
           reviewer. Independent reviews are a key aspect of quality controls
           that reduce the risk of errors in a quality assurance program. In
           our review of calendar years 2005 and 2006 DHSD site visit reports
           and supporting documentation, we found instances of incomplete
           data including missing dates for when pre- and postdeployment
           health assessment questionnaires were administered. Moreover, we
           found that DHSD did not always adhere to DOD's deployment health
           requirements when assessing the programs. For example, while not
           all servicemembers received blood draws upon redeployment within
           the required time frame, DHSD made determinations in their site
           visit reports that the services had adhered to the requirements.

           Because of these weaknesses, DOD's annual report does not provide
           DOD and congressional decision makers with complete,
           comprehensive, and accurate information to determine if the
           department is complying with its own deployment health
           requirements. Moreover, DOD and congressional decision makers are
           unable to determine whether DOD has effectively implemented a
           quality assurance program to determine or assure Congress that
           servicemembers are medically and mentally fit to deploy and to
           determine their medical and mental condition upon return. Having
           an effective deployment health quality assurance program is
           critically important given DOD's long-standing problems with
           assessing the medical condition of active and reserve component
           servicemembers both before and after their deployments, and has
           become even more important in the current environment, where these
           servicemembers continue to deploy overseas in significant numbers
           in support of ongoing military operations.

           We are recommending that DOD develop a comprehensive oversight
           framework with reporting requirements and results-oriented
           performance measures to improve the implementation of its
           deployment health quality assurance program. In written comments
           on a draft of this report, DOD concurred with our recommendations.
           DOD's comments are reprinted in appendix IV.
			  
			  Background

           In November 1997, Congress included a provision in the National
           Defense Authorization Act for Fiscal Year 19989 that required the
           Secretary of Defense to establish a medical tracking system for
           servicemembers deployed overseas. Specifically, the legislation
           required the following:
			  
9Pub. L. No. 105-85, S 765 (1997).			  

           "(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).

           "(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."

           The Assistant Secretary of Defense for Health Affairs has the
           responsibility for establishing the overall policy and guidance
           necessary for DOD to implement the required medical tracking
           system, including the associated quality assurance program. Within
           the Office of the Assistant Secretary of Defense for Health
           Affairs, the Deputy Assistant Secretary of Defense for Force
           Health Protection and Readiness has responsibility for the
           day-to-day operations and management of both the medical tracking
           system and the quality assurance program. It is then the
           responsibility of the Offices of the Surgeons General of the Army,
           Navy, and Air Force to implement and manage the day-to-day
           operations of the medical tracking system and the quality
           assurance program within the respective services.

           Our prior work has highlighted weaknesses in DOD's assessment of
           servicemembers' health before and after deployment. In September
           2003, we reported that the Army and Air Force did not comply with
           DOD's force health protection and surveillance requirements for
           many servicemembers deploying in support of Operation Enduring
           Freedom in Central Asia and Operation Joint Guardian in Kosovo.10
           Specifically, our review disclosed problems with the Army's and
           Air Force's implementation of DOD's force health protection and
           surveillance requirements in the following areas: (1) deployment
           health assessments, (2) immunizations and other predeployment
           requirements, and (3) the completeness of medical records and
           centralized data collection. Our September 2003 report also raised
           concerns over a lack of DOD oversight of departmentwide efforts to
           comply with health surveillance requirements. Specifically, we
           reported that an effective quality assurance program had not been
           established 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 to help ensure compliance with force health
           protection and surveillance policies. We believed that the lack of
           such a system was a major cause of the high rate of noncompliance
           and thus recommended that the department establish an effective
           quality assurance program to ensure that the military services
           comply with the force health protection and surveillance
           requirements for all servicemembers. The department concurred with
           our recommendation, and in January 2004 began implementation of
           its deployment health quality assurance program.

           In September 2004, we reported similar issues related to DOD's
           ability to effectively manage the health status of its reserve
           forces.11 Specifically we noted that DOD's centralized database
           had missing and incomplete predeployment health assessment
           questionnaires because not all of the required health information
           collected from reserve component members had reached DOD's central
           data collection point. We recommended that the Secretary of
           Defense take steps to ensure that predeployment health assessment
           questionnaires are submitted to the centralized data collection
           point as required. DOD concurred with our recommendation and noted
           that revised guidance was currently in coordination to clarify the
           requirement for submitting predeployment health assessments to the
           centralized database.

           In November 2004, we reported that overall compliance with DOD's
           force health protection and surveillance policies for
           servicemembers who deployed in support of Operation Iraqi Freedom
           varied by service, by installation, and by policy requirement.12
           At that time, we did not evaluate the effectiveness of DOD's
           deployment health quality assurance program because of the
           relatively short time of its implementation.
			  
10See [53]GAO-03-1041 .

11See [54]GAO-04-1031 .

           Finally, in October 2005 we reported that evidence suggested that
           reserve component members have deployed into theater with
           preexisting medical conditions that could not be adequately
           addressed in-theater.13 We also reported that DOD had limited
           visibility over the health status of reserve component members
           after they are called to duty and is unable to determine the
           extent of care provided to those members deployed with preexisting
           medical conditions despite the existence of various sources of
           medical information. We recommended that the Secretary of Defense
           determine what preexisting medical conditions should not be
           allowed into specific theaters of operations and to take steps to
           ensure that each service component consistently utilizes these as
           criteria for determining the medical deployability of its reserve
           component members. We also recommended that the Secretary of
           Defense explore using existing tracking systems to track those who
           have treatable preexisting medical conditions in theater. DOD
           partially concurred with our recommendation concerning the
           identification of preexisting medical conditions that would
           preclude deployment and noted that the services had made advances
           in identifying some preexisting conditions that would preclude
           deployment, but also stated that due to the ever-changing nature
           of theater of operations this list could never be fully
           comprehensive or fully enforceable. DOD also concurred with our
           recommendation pertaining to the use of existing tracking systems
           to track treatable preexisting medical conditions. Specifically,
           DOD indicated that ongoing refinements to these systems based on
           lessons learned would improve the documentation of medical
           conditions throughout the military services including information
           concerning reserve members with preexisting conditions.
			  
12See [55]GAO-05-120 .

13See [56]GAO-06-105 .

           DOD Has a System in Place to Comply with Requirements for Deployment
			  Medical Examinations

           DOD has established a medical tracking system to comply with the
           requirement of 10 U.S.C. S 1074f to perform predeployment and
           postdeployment medical examinations through a variety of
           deployment health activities, including the use of pre- and
           postdeployment health assessment questionnaires along with reviews
           of servicemembers' medical records. This section of the law
           requires the Secretary of Defense to establish a medical tracking
           system to assess the medical condition of servicemembers deployed
           outside the United States. According to section 1074f(b)(1), the
           system is to include the use of medical examinations, including an
           assessment of mental health and the drawing of blood samples, both
           before and after deployment.

           In DOD's May 1998 report to Congress, the department outlined its
           approach to establish a medical tracking system for servicemembers
           deployed overseas.14 As part of this approach, DOD performed
           medical examinations using predeployment and postdeployment health
           assessment questionnaires, including an assessment of mental
           health and drawing of blood samples, both before and after
           deployment. The predeployment assessment consisted of a series of
           questions about the servicemembers' current medical (including
           dental) and mental health conditions, including prescriptions,
           vision issues, and any medical concerns servicemembers might have.
           In 2002, DOD established the requirement that the predeployment
           assessment was to be completed within 30 days prior to deployment.
           The postdeployment assessment consisted of a series of questions
           about the servicemembers medical and mental health condition
           resulting from having been deployed. It was to be completed prior
           to leaving the theater of operation or within 30 days of final
           departure from theater. Examples of the pre- and postdeployment
           questionnaires can be found in appendix II.

           In August 2006, DOD replaced and expanded its approach with a
           comprehensive deployment health program.15 Within the programs,
           DOD required the military services to perform a number of
           activities designed to monitor servicemembers' health before and
           after deployments, including the following:
			  
14Department of Defense Report to Congress: Medical Tracking System for
Members Deployed Overseas (May 1998).

15Department of Defense Instruction 6490.03, Deployment Health (Aug. 11,
2006).

           o Predeployment Activities. First, servicemembers are required to
           complete a predeployment health assessment questionnaire no
           earlier than 60 days prior to deployment. Second, the
           questionnaires are required to be reviewed by a health care
           provider16 to determine whether the servicemember is fit to
           deploy. To make this determination, the health care provider
           should review both the servicemembers' medical records and
           responses to the questions. The medical records are reviewed and
           evaluated against the following six individual medical readiness
           elements: whether the servicemember has (1) received an annual
           assessment for changes in health status; (2) any
           deployment-limiting conditions such as pregnancy, asthma, severe
           traumatic injuries with incomplete rehabilitation, etc.; (3) oral
           conditions that if not treated could result in dental emergencies;
           (4) received all required immunizations; (5) received medical
           readiness laboratory tests such as HIV testing and has current DNA
           samples on file, (6) all required individual medical equipment.
           For more detailed information about individual medical readiness
           requirements see appendix III. Prior to deployment, DOD requires
           that any condition that causes a servicemember to receive a
           failing mark in any of these six elements be corrected. Corrective
           actions could include providing the servicemember with required
           immunizations, screening for tuberculosis, or drawing serum
           specimens. Based on the health care provider review and the
           responses to specific questions on the assessment, servicemembers
           may be referred, prior to deploying, to the appropriate health
           care provider(s) for further testing and evaluation, if needed,
           for medical conditions or concerns (e.g., cardiac, mental health).
           DOD requires that the completed questionnaire be placed in the
           servicemember's medical record and a copy be sent to AMSA for
           record keeping.
           o Postdeployment Activities. DOD requires that a postdeployment
           health assessment questionnaire be completed during the period
           from 30 days prior to and 30 days after redeployment. The
           completed form is to be placed in the servicemember's medical
           record and a copy sent to AMSA. In addition, a review of the
           servicemembers' medical records and a face-to-face meeting with a
           trained health care provider17 are to be completed within 30 days
           of redeployment to discuss the individual's responses on the
           postdeployment health assessment, mental health or psychosocial
           issues commonly associated with deployments, prescription
           medications taken during deployment, and concerns about possible
           environmental or occupational exposures. Additional requirements
           include documentation of medical referrals or concerns resulting
           from deployment, documentation of the results of any follow-up
           examinations, tuberculosis screening for high-risk servicemembers,
           and blood serum sample collection within 30 days of redeployment.
           In 2005, DOD issued a new policy requiring a postdeployment health
           reassessment questionnaire as well.18 The purpose of the
           reassessment is to identify health concerns that emerge over time
           after deployment and is to be conducted between 90 and 180 days
           after servicemembers return to their home station.
			  
16DOD defines "health care provider" as a nurse, medical technician,
medic, or corpsman.

17DOD defines a "trained health care provider" as a physician, physician
assistant, nurse practitioner, advanced practice nurse, independent duty
corpsman, independent duty medical technician, or Special Forces medical
sergeant.

           We requested the views of DOD's Office of General Counsel on DOD's
           compliance with the medical examination requirement of section
           1074f.19 DOD's Office of General Counsel noted that DOD's May 1998
           report to Congress provided the department's understanding that
           the medical examination requirement was satisfied by the plan to
           carry out health assessments. DOD's Office of General Counsel
           pointed out that subsequent to this report to Congress, Congress
           did not, until October of 2006,20 amend section 1074f or otherwise
           establish a requirement different than that described in the
           department's 1998 report. DOD's Office of General Counsel further
           pointed out that subsequent to DOD's 1998 report, Congress did
           enact other laws that refer to health assessments required by
           section 1074f.21 DOD's Office of General Counsel concluded that
           "although the term `medical examination' was not defined in the
           original 1997 statute, from 1998 until the present, both DOD and
           the Congress have used the terms `medical examination' and `health
           assessment' synonymously to describe the Military Health System
           pre- and postdeployment action required by section 1074f."
			  
18Assistant Secretary of Defense for Health Affairs Memorandum,
"Postdeployment Health Reassessment" (Mar. 10, 2005).

19Letter from Mr. John Casciotti, Associate Deputy General Counsel (Health
Affairs), DOD Office of General Counsel to Mr. John Van Schaik, Assistant
General Counsel, GAO Office of General Counsel, November 6, 2006.

20Section 1074f was amended by section 738 of the John Warner National
Defense Authorization Act for Fiscal Year 2007, Pub. L. No. 109-364, to
provide that the pre- and post-deployment medical examination should
include an "assessment" of mental health and traumatic brain injury as
well as further details on the elements of the quality assurance program
required under section 1074f(d)(1), including information on the types of
health care providers conducting "postdeployment health assessments."

21Ronald W. Reagan National Defense Authorization Act for Fiscal Year
2005, Pub. L. No. 108-375, SS 732(b) and 739 (2004).

           The term "medical examinations" in the statute could be
           interpreted to mean medical activities beyond those included in
           DOD's current deployment health program as described above.
           However, DOD's use of a variety of deployment health activities,
           including the use of pre- and postdeployment health assessment
           questionnaires along with reviews of servicemembers' medical
           records is a reasonable interpretation of section 1074f.
			  
			  DOD Has Established a Deployment Health Quality Assurance Program,
			  but the Lack of a Comprehensive Oversight Framework Hampers
			  Effective Implementation

           DOD has established a deployment health quality assurance program
           as part of its medical tracking system, but lacks a comprehensive
           oversight framework to help ensure effective implementation of the
           program. DOD's deployment health quality assurance program policy
           outlines four specific elements--such as monthly reports on
           servicemembers' deployment health data from a centralized database
           maintained by AMSA--and it requires each of the services to create
           their own quality assurance programs based on these elements.
           While DOD has established a program that includes these four
           elements, it cannot determine whether the program has been
           effectively implemented because DOD does not have a comprehensive
           oversight framework with all the specific reporting requirements
           and necessary performance measures to evaluate the services'
           compliance with deployment health requirements or to ensure that
           the services are implementing the program consistently.
			  
			  DOD Has Established a Deployment Health Quality Assurance Program

           In response to congressional mandates and a GAO recommendation, in
           January 2004 DOD established a deployment health quality assurance
           program, as part of its medical tracking system, designed to
           assess compliance with deployment health requirements. DOD's
           policy and implementing guidance for the program is contained in a
           memorandum from the Assistant Secretary of Defense for Health
           Affairs.22 DOD's policy delegates the responsibility for executing
           the program to the Deputy Assistant Secretary of Defense for Force
           Health Protection and Readiness, DHSD, and to the military
           services. According to the policy, DOD's program consists of the
           following four elements:

           o Periodic reporting on pre- and postdeployment health
           assessments. AMSA is required to provide (at a minimum) monthly
           reports to DHSD on active and reserve component servicemembers'
           deployment health assessment data.
			  
22Assistant Secretary of Defense for Health Affairs Memorandum, "Policy
for Department of Defense Deployment Health Quality Assurance Program"
(Jan. 9, 2004).
			  
           o Periodic reporting on service-specific deployment health quality
           assurance programs. The services are required to provide (at a
           minimum) quarterly reports to DHSD on the status and findings,
           including compliance with deployment health requirements, of their
           respective required quality assurance programs.
           o Periodic visits to military installations to assess deployment
           health programs. The program requires joint visits by
           representatives from DHSD and from service medical departments to
           military installations for the purpose of complementing and
           validating the services' deployment health quality assurance
           reporting.
           o An annual report on the DOD deployment health quality assurance
           program. The program requires that DHSD prepare and coordinate
           with the services an annual report on the status of the
           requirements of the program to the Assistant Secretary of Defense
           for Health Affairs.23
			  
			  DOD Does Not Have a Comprehensive Oversight Framework to Determine
			  Whether Its Deployment Health Quality Assurance Program Has Been
			  Effectively Implemented

           DOD has not established a comprehensive oversight framework for
           its deployment health quality assurance program, which is
           necessary to ensure the program's effective implementation. GPRA
           provides federal agencies with a model framework for developing
           program oversight.24 Specifically, GPRA establishes a
           results-oriented framework that identifies, among other things,
           performance measures and reporting requirements. However, DOD does
           not have a comprehensive oversight framework with all the specific
           reporting requirements and necessary performance measures to
           evaluate the services' compliance with deployment health
           requirements or to help ensure that the services are implementing
           the program consistently. Because DOD's deployment health quality
           assurance program lacks a comprehensive oversight framework, the
           program, as currently implemented, does not provide decision
           makers with the information they need to evaluate the
           effectiveness and efficiency of either DOD's or the services'
           respective quality assurance programs. In reviewing DOD's program,
           we found problems with its implementation of the monthly AMSA
           reports, the quarterly service-specific reports, and the DHSD site
           visits. Because DOD's annual report is based on information from
           these three elements, the department's annual report does not
           provide DOD or congressional decision makers with the complete,
           comprehensive, and accurate information necessary to determine
           whether the department is complying with its own deployment health
           requirements. Moreover, DOD and congressional decision makers are
           unable to determine whether DOD has effectively implemented a
           quality assurance program that reasonably assures that
           servicemembers are medically fit to deploy.
			  
23Subsequent legislation required that information on DOD's deployment
health quality assurance program be provided to Congress. Specifically,
section 739 of Pub. L. No. 108-375 (Oct. 28. 2004) amended title 10 of the
United States Code by adding section 1073b. Section 1073b requires that
DOD submit annually to the Armed Services Committees of the Senate and the
House of Representatives reports on health protection quality, including
the recording of health assessment data in military health records.

24GAO, Results-Oriented Government: GPRA Has Established a Solid
Foundation for Achieving Greater Results, [57]GAO-04-38 (Washington, D.C.:
Mar. 10, 2004).

             DOD Has Not Identified All Results-Oriented Performance Measures
				 and Has Not Provided AMSA with Specific Reporting Requirements

           DOD's deployment health quality assurance program requires that
           AMSA submit to DHSD monthly reports on active and reserve
           component servicemembers' deployment health assessment data. The
           deployment health assessment data that AMSA reports are collected
           individually by the services and maintained centrally in the
           Defense Medical Surveillance System (DMSS) at AMSA.25 However, in
           reviewing AMSA's reports we found that while the reports provide
           some data on servicemembers' deployment health, they do not
           provide all the essential information necessary to assess the
           services' compliance or determine departmentwide compliance with
           all deployment health requirements. This problem results largely
           because DOD has not identified all the necessary results-oriented
           performance measures and provided AMSA with specific reporting
           requirements for all deployment health requirements. DOD's policy
           identifies some performance measures that could be used to assess
           whether the services are complying with selected deployment health
           requirements, such as measures for the identification of
           deployed/redeployed personnel and whether pre- and postdeployment
           health assessment questionnaires are on file at AMSA. However,
           DOD's policy does not identify performance measures for additional
           deployment health requirements such as whether servicemembers
           received all required immunizations. In addition, DOD's policy
           does not identify reporting requirements related to all deployment
           health data needed to effectively assess compliance with its own
           deployment health requirements. For example, DOD's policy does not
           require that AMSA provide critical information needed to assess
           compliance with deployment health requirements, such as the total
           number of servicemembers that deployed/redeployed during the
           reporting period. Without knowing the total number of
           servicemembers deployed/redeployed, DOD cannot determine the
           extent to which servicemembers completed the required pre- and
           postdeployment health assessment questionnaires. Similarly, DOD's
           policy does not require that the AMSA reports specify whether
           servicemembers completed pre- and postdeployment questionnaires
           within required time frames (no earlier than 60 days prior to
           deployment, and during the period from 30 days prior to and 30
           days after redeployment), which is necessary to determine whether
           servicemembers are completing the required questionnaires in a
           timely manner. In addition, DOD's policy only specifies that
           AMSA's reports include information related to selected
           postdeployment health requirements, such as the accomplishment of
           blood samples, the number of referrals, and the number of
           referrals accomplished. As a result, DOD does not have all of the
           essential information necessary to assess the services' compliance
           or determine departmentwide compliance with all deployment health
           requirements.
			  
25According to AMSA, the DMSS database contains up-to-date and historical
data on diseases and medical events (e.g., hospitalizations, ambulatory
visits, reportable diseases, and health risk appraisals) for military
personnel and deployments.

             DOD Has Not Enforced Its Policy Requiring the Services to Report
				 on Compliance with Deployment Health Requirements

           DOD's deployment health quality assurance program requires that
           the services submit to DHSD quarterly reports regarding their
           compliance with deployment health requirements; however, DOD has
           not enforced its reporting requirements. DOD's policy specifies
           that the services' quarterly reports address three key elements:
           (1) the identification of deployed/redeployed personnel, (2)
           completion of applicable pre- and postdeployment health assessment
           questionnaires and related requirements (e.g., immunizations,
           blood samples, referrals), and (3) inclusion of deployment-related
           health documentation in permanent medical records. However, DOD's
           policy does not specify uniform standards that should be used in
           collecting and reporting the required information. Instead, DOD's
           policy directs the services to determine the scope and methodology
           of their respective programs, including associated performance
           measures. The services' differing interpretations of DOD's policy
           have resulted in the services utilizing different approaches for
           the collection and reporting of the required information in their
           quarterly reports.

           Our review of the services' quarterly reports for calendar years
           2004, 2005, and 2006 found that DHSD has not enforced the
           reporting requirements outlined in its policy. Specifically, we
           identified differences in the extent to which the services report
           compliance with applicable pre- and postdeployment health
           assessment questionnaires and related requirements such as drawing
           blood serum samples. For example, the Navy's reports only include
           its compliance with postdeployment requirements and do not include
           information regarding predeployment requirements. As another
           example, the Marine Corps' reports do not always include
           information regarding its compliance with pre- and postdeployment
           requirements for drawing blood serum samples. Furthermore, with
           regard to the inclusion of deployment-related health documentation
           in permanent medical records, only the Army and the Air Force
           provide DHSD with information in their quarterly reports regarding
           whether deployment-related health documentation is included in
           servicemembers' permanent medical records.

           In addition, we found that the services report information to DHSD
           using different criteria. For example, while the Army reports on
           only a sample of servicemembers who deploy or redeploy during the
           reporting period, the Air Force reports on the total number of
           servicemembers who deploy or redeploy during the reporting period.
           Moreover, the Army's report includes all locations of deployment
           whereas, according to Air Force officials, the Air Force only
           reports on deployments in support of Operations Iraqi Freedom or
           Enduring Freedom. Further, the Marine Corps' reports include the
           total number of Marines that deployed and redeployed during the
           reporting period in addition to those Marines who deployed in
           earlier reporting periods but who are still deployed.

           The lack of guidance or standards for providing the required
           information in the services' quarterly reports has created a
           number of problems for DOD. For example, the lack of standards
           hampers DOD's ability to compare compliance across the military
           services and therefore report overall departmentwide compliance
           because the services do not always provide DHSD with complete and
           consistent information regarding the status and findings of their
           respective programs.
			  
			    DOD Site Visits to Assess the Services' Deployment Health Quality
				 Assurance Programs Do Not Have Quality Controls in Place

           DOD's deployment health quality assurance program requires that
           DHSD conduct at least four visits per year to military
           installations for the purpose of assessing the services'
           deployment health quality assurance programs. While DHSD has
           conducted the minimum number of site visits required each year
           since 2004, it does not have the quality controls in place to
           ensure that the deployment health data collected and reported are
           complete and accurate. Federal internal control standards require
           that data control activities, such as edit checks, verification,
           and reconciliation, be conducted and documented to help provide
           reasonable assurance that program objectives are being met.26
           While not a formal audit, DOD's deployment health quality
           assurance program is designed to identify strengths and weaknesses
           with the program and, when appropriate, make changes to ensure
           that deployment health requirements are being met.

           DHSD relies on the use of data collection instruments to
           facilitate the collection of information, but does not provide for
           an independent verification of the completeness and accuracy of
           data obtained from the medical records. DHSD officials told us
           that none of the data collection instruments from their site
           visits are reviewed by an independent or second reviewer to ensure
           that the information recorded is accurate or complete. Independent
           verification is an important internal control activity under
           segregation of duties designed to reduce the risk of errors. We
           identified numerous instances where the information captured by
           DHSD's hard-copy and electronic data collection instruments was
           incomplete. Specifically, for our review of hard-copy data
           collection instruments from DHSD site visits in 2005, we found
           that 99 of 140 data collection instruments (71 percent) from a
           site visit to a Marine Corps' installation contained one or more
           incomplete data fields, while for a site visit to an Air Force
           installation, 53 of 126 data collection instruments (42 percent)
           had one or more incomplete data fields. In addition, we found some
           instances where either the deployment date or the redeployment
           date data fields were not complete. In addition, our review of
           electronic data collection instruments for 2006 found at least one
           incomplete data field in 53 of 299 data collection instruments (18
           percent) that we reviewed. Without independent verification of the
           data recorded by the reviewer, DHSD does not have any assurance
           that the compliance information recorded accurately reflects the
           compliance status for the records reviewed.

           In addition, our review of available DHSD site visit data for
           calendar year 2005 found that DHSD did not always adhere to DOD's
           deployment health requirements when assessing the services'
           programs. Specifically, we identified numerous instances where the
           reviewing DHSD officials did not consistently apply DOD's
           standards for completing pre- and postdeployment health assessment
           questionnaires, drawing pre- and postdeployment blood samples, and
           receiving required immunizations within specified time frames. For
           example, our review of data from DHSD's site visits identified a
           total of 99 out of 567 medical records (17 percent) where one or
           more deployment health requirement had not been completed within
           established time requirements, yet the site visit summary
           indicated the requirement for those immunizations had been met. In
           addition, our review of DHSD's site visit data verifying the
           existence of data within DMSS and at the serum repository at AMSA
           found that for 100 out of 295 records (34 percent), timeliness
           standards had not been properly applied for at least one
           deployment health requirement such as the completion of pre- and
           postdeployment health assessment questionnaires or drawing pre-
           and postdeployment blood samples. Because DHSD officials were not
           properly applying DOD's timeliness standards, reported compliance
           for DHSD's site visit reports for 2005 may be overstated.
			  
26See GAO, Standards for Internal Control in the Federal Government,
[58]GAO/AIMD-00-21.3.1 (Washington, D.C.: November 1999) and Internal
Control Management and Evaluation Tool, [59]GAO-01-1008G (Washington,
D.C.: August 2001).

           Conclusions

           As servicemembers continue to deploy overseas in significant
           numbers in support of ongoing military operations, it is
           increasingly important that DOD be able to accurately assess the
           medical condition of those servicemembers both before and after
           their deployments. Although DOD has established a deployment
           health quality assurance program, it has not developed a
           comprehensive oversight framework with all the specific reporting
           requirements and performance measures needed to provide oversight
           of, and ensure effective implementation of the program. Having an
           effective deployment health quality assurance program is
           critically important given DOD's long-standing problems with
           assessing the medical condition of active and reserve forces both
           before and after their deployments. Without such a framework, the
           ability of decision makers--both within DOD and Congress--to make
           informed, fact-based decisions regarding whether the department is
           complying with its own deployment health requirements is limited.
           Moreover, until DOD implements a more effective deployment health
           quality assurance program, it will not be well positioned to
           determine or assure Congress that servicemembers are medically and
           mentally fit to deploy and to determine their medical and mental
           condition upon return.
			  
			  Recommendations for Executive Action

           To improve DOD's ability to effectively implement its deployment
           health quality assurance program, we recommend that the Secretary
           of Defense direct the Assistant Secretary of Defense for Health
           Affairs to develop a comprehensive oversight framework to evaluate
           the services' compliance with deployment health requirements and
           to ensure that the services are implementing the program
           consistently. Such a framework should do the following:

           o Provide AMSA with specific reporting requirements and
           results-oriented performance measures to evaluate the services'
           adherence to deployment health requirements, including identifying
           the total number of servicemembers deployed/redeployed and
           administering pre- and postdeployment health assessment
           questionnaires within required time frames, which would enable
           AMSA to develop information regarding departmentwide compliance.
           o Enforce the requirement for the services to report on all
           deployment health requirements on a quarterly basis.
           o Establish quality controls, including independent reviews of
           data, to ensure the accuracy or completeness of the information
           DHSD collects in its site visits to military installations.
			  
			  Agency Comments and Our Evaluation

           DOD provided written comments on a draft of this report and agreed
           with our recommendations.

           In commenting on our recommendations, the Assistant Secretary of
           Defense for Health Affairs commented that the department
           recognizes the need for a more comprehensive oversight framework
           to better ensure effective implementation of the deployment health
           quality assurance program. To that end, the Office of the Deputy
           Assistant Secretary of Defense for Force Health Protection and
           Readiness recently published a new instruction27 on force health
           protection quality assurance. The Assistant Secretary further
           commented that the department is now developing reporting
           requirements along with results-oriented performance measures--as
           our report recommends--that will serve to better evaluate
           compliance and facilitate consistent implementation across the
           military services. Specifically, the Assistant Secretary commented
           that the department will (1) work with AMSA and the military
           services to specify reporting requirements, jointly refine
           performance measures for critical deployment health activities,
           and strive to achieve better alignment of deployment-related
           information among AMSA, the services, and the Defense Manpower
           Data Center to get a more accurate picture of compliance; and (2)
           continue to perform joint site visits to military installations as
           a critical complement to centralized monitoring through AMSA and
           DMSS, while including independent verification as an internal
           quality control mechanism during on-site medical records review.
           Our review of the department's new instruction and its planned
           actions indicate that DOD is taking steps in the right direction.
           If the department follows through with its efforts, we believe
           that it will be responsive to our recommendations. DOD's comments
           are reprinted in appendix IV.
			  
			  27Department of Defense Instruction 6200.05, Force Health
			  Protection (FHP) Quality Assurance (QA) Program (Feb. 16, 2007).

           As we agreed with your office, unless you publicly announce the
           contents of this report earlier, we plan no further distribution
           of it until 30 days from the date of this letter. We will then
           send copies of the report to the Secretary of Defense, the
           Assistant Secretary of Defense for Health Affairs, the Deputy
           Assistant Secretary of Defense for Force Health Protection and
           Readiness, the Secretaries of the Army, Navy, and Air Force. We
           will also send copies to others who are interested and make copies
           available to others who request them. This report will also be
           available at no charge on GAO's Web site at [27]http://www.gao.gov
           .

           If you have any questions regarding this report, please contact me
           at (202) 512-3604 or [28][email protected] . Contact points for our
           Offices of Congressional Relations and Public Affairs may be found
           on the last page of this report. GAO staff who made major
           contributions to the report are listed in appendix V.

           Sincerely yours,

           Brenda S. Farrell
			  Director, Defense Capabilities and Management
			  
			  Appendix I: Scope and Methodology

           To address our objectives, we obtained and reviewed pertinent
           documents, reports, and information related to the Department of
           Defense's (DOD) deployment health requirements and deployment
           health quality assurance program. We also interviewed responsible
           officials at the Assistant Secretary of Defense for Health
           Affairs, Deployment Health Support Directorate (DHSD); the Offices
           of the Surgeons General for the Army, Air Force, and Navy; the
           Army Medical Surveillance Activity (AMSA); and the Combined Fleet
           Forces Command and Naval Environmental Health Center in the
           Washington, D.C., and Norfolk, Virginia, areas.

           To determine whether DOD has established a medical tracking system
           to comply with requirements of 10 U.S.C. S 1074f pertaining to
           pre- and postdeployment medical examinations, we compared
           statutory requirements to DOD policies and requirements.
           Specifically, we reviewed relevant sections of 10 U.S.C. S 1074f
           to identify system requirements and system elements. We also
           reviewed DOD policies, directives, and instructions to identify
           the measures that DOD uses to establish the medical condition of
           servicemembers and compared these measures to the system
           requirements and system elements. In addition, we obtained a legal
           opinion from DOD's Office of General Counsel regarding DOD's
           compliance with the requirement of 10 U.S.C. S 1074f to perform
           pre- and postdeployment medical examinations.
			  
1Pub. L. No. 103-62 (1993).

2See GAO, Standards for Internal Control in the Federal Government,
[60]GAO/AIMD-00-21.3.1 (Washington, D.C.: November 1999) and Internal
Control Management and Evaluation Tool, [61]GAO-01-1008G (Washington,
D.C.: August 2001).			  

           To determine the extent to which DOD has effectively implemented a
           deployment health quality assurance program as part of its medical
           tracking system, we obtained and analyzed various documents,
           including DOD's and the services' deployment health quality
           assurance program policies establishing requirements for the
           program; the Government Performance and Results Act of 1993;1 and
           federal internal control standards.2 We also interviewed key
           officials with DHSD and the services' Offices of the Surgeons
           General to obtain a comprehensive understanding of the processes,
           procedures, and controls used for monitoring and overseeing the
           deployment health quality assurance program. We obtained and
           analyzed the results of the program's periodic reporting for
           calendar years 2004, 2005, and 2006, including monthly AMSA
           reports, the quarterly service-specific reports, and DOD's annual
           report, to determine the content of the reports, compliance rates
           with deployment health requirements, and any trends in compliance
           rates, both within and among the services. We also obtained and
           analyzed the results of site visits conducted by DHSD in calendar
           years 2005 and 2006. To determine the reliability of DOD's quality
           assurance program reports, we obtained and analyzed data
           collection instruments and other documentation used to record,
           summarize, and report the services' compliance with deployment
           health requirements. We also discussed with responsible DOD
           officials, including representatives from the military services,
           their methodology for ensuring that information collected and
           reported is as accurate and reliable as possible. Where possible,
           we tested data by comparing information from the data collection
           instruments or summary documents with available source documents.
           We identified issues of inconsistency and incompleteness in DOD's
           data and, therefore, determined the data to be insufficiently
           reliable for the purpose of assessing compliance with deployment
           health requirements and we are making a recommendation to address
           this issue accordingly.

           In conducting our review, we limited our focus to the procedures
           that DOD has in place to medically assess servicemembers before
           and after their deployments. Other issues, such as recent
           controversies associated with alleged deployments of medically
           unfit servicemembers to Iraq, did not fall within the scope of
           this review. These issues will be addressed as part of a separate
           review.

           We performed our work from September 2006 through May 2007 in
           accordance with generally accepted government auditing standards.
			  
			  Appendix II: Pre- and Postdeployment Health Assessment Questionnaires
			  
			  Appendix III: Individual Medical Readiness

           In January 2006, DOD published an instruction,1 requiring that the
           services report individual medical readiness. Individual medical
           readiness is intended to provide operational commanders, military
           department leaders, and primary care managers the ability to
           monitor the medical readiness status of their personnel, ensuring
           a healthy and fit fighting force that is medically ready to
           deploy. DOD Instruction 6025.19 requires quarterly individual
           medical readiness reports submitted by the Surgeons General of the
           services to the Force Health Protection Council summarizing the
           individual medical readiness status of active and selected reserve
           members (both officers and enlisted) who are available to deploy.
           Assessing individual medical readiness status is a continuous
           process and contains six key elements for which servicemembers are
           rated as either pass or fail. These elements include the
           following:

           o Periodic Health Assessment: An annual assessment for changes in
           health status, especially changes that could affect a member's
           ability to perform military duties.2 Each service is responsible
           for determining how it will meet DOD's requirement for the
           completion of the Periodic Health Assessment.

                        o Pass: current Periodic Health Assessment
                        o Fail: overdue Periodic Health Assessment (not
                        accomplished within 3 months after the month in which
                        it is due)

           o Deployment-limiting Conditions: Defined by military
           department-specific policies. Examples include pregnancy, asthma,
           and severe traumatic injury with incomplete rehabilitation.

                        o Pass: no deployment limiting conditions
                        o Fail: deployment limiting conditions exist

           o Dental Readiness: All services use the same classification
           system to assess and monitor dental readiness.

                        o Pass: class 1 (no dental treatment or reevaluation
                        required within the next 12 months) or 2 (patients
                        have the potential for dental emergencies with the
                        next 12 months but it is not likely if certain
                        treatments are obtained)
                        o Fail: class 3 (patients with oral conditions that
                        if not treated are expected to result in dental
                        emergencies within the next 12 months) or 4 (patients
                        requiring a dental examination and whose dental
                        classification is unknown)
								
1Department of Defense Instruction 6025.19, Individual Medical Readiness
(Jan. 3, 2006).

2The assessment records general information such as blood pressure,
weight, height; screenings for hearing, vision, and depression; as well as
counseling on leading health indicators. In addition the assessment
includes testing and evaluations based on risk factors such as age, sex,
occupation, and personal habits such as smoking.

           o Immunization Status: Required immunizations include hepatitis A,
           tetanus-diphtheria, MMR (measles, mumps, and rubella), inactivated
           poliovirus (IPV), hepatitis B, and influenza (once per season).

                        o Pass: all immunizations current
                        o Fail: overdue for one or more immunizations

           o Medical Readiness Laboratory Tests: Includes human
           immunodeficiency virus (HIV) testing and deoxyribonucleic acid
           (DNA) sample on file.

                        o Pass: HIV testing, with one result on file within
                        the past 24 months and a DNA sample on file
                        o Fail: Missing or past-due HIV test or DNA sample
                        not on file

           o Individual Medical Equipment: Core requirement is one pair of
           gas mask inserts for all deployable personnel needing visual
           correction.

                        o Pass: one pair of gas mask inserts for all
                        deployable personnel needing visual correction
                        o Fail: no gas mask inserts for all deployable
                        personnel needing visual correction

           Servicemembers are then placed into one of the following four
           readiness categories based on the pass/fail grades in the six
           elements:
           o Fully medically ready: current in all categories including
           dental class 1 or 2
           o Partially medically ready: lacking one or more immunizations,
           readiness laboratory studies, or medical equipment
           o Not medically ready: existence of a chronic or prolonged
           deployment-limiting condition (per service-specific physical
           standards guidelines), including servicemembers who are
           hospitalized or convalescing from serious illness or injury, or
           individuals in dental class 3
           o Medical readiness indeterminate: inability to determine the
           servicemember's current health status because of missing health
           information such as a lost medical record, an overdue Periodic
           Health Assessment or being in dental class 4

           The minimum goal for overall medical readiness is to have more
           than 75 percent of servicemembers fully medically ready for
           deployment.
			  
			  Appendix IV: Comments from the Department of Defense
			  
			  Appendix V: GAO Contact and Staff Acknowledgments
			  
			  GAO Contact

           Brenda S. Farrell, (202) 512-3604 or [29][email protected]
			  
			  Acknowledgments

           In addition to the contact named above, Sandra B. Burrell,
           Assistant Director; Alissa H. Czyz; Steve J. Fox; Wesley A.
           Johnson; Susan J. Mason; Julie C. Matta; Terry L. Richardson; Kate
           Robertson; Norris W. Smith; and John C. Wren made key
           contributions to this report.
			  
			  Related GAO Products

           DOD Civilian Personnel: Greater Oversight and Quality Assurance
           Needed to Ensure Force Health Protection and Surveillance for
           Those Deployed. [30]GAO-06-1085 . Washington, D.C.: September 29,
           2006.

           Military Personnel: DOD and the Services Need to Take Additional
           Steps to Improve Mobilization Data for the Reserve Components.
           [31]GAO-06-1068 . Washington, D.C.: September 20, 2006.

           Military Personnel: Top Management Attention Is Needed to Address
           Long-standing Problems with Determining Medical and Physical
           Fitness of the Reserve Force. [32]GAO-06-105 . Washington. D.C.:
           October 27, 2005.

           Defense Health Care: Improvements Needed in Occupational and
           Environmental Health Surveillance during Deployments to Address
           Immediate and Long-term Health Issues. [33]GAO-05-632 .
           Washington, D.C.: July 14, 2005.

           Defense Health Care: Force Health Protection and Surveillance
           Policy Compliance Was Mixed, but Appears Better for Recent
           Deployments. [34]GAO-05-120 . Washington, D.C.: November 12, 2004.

           Military Personnel: DOD Needs to Address Long-term Reserve Force
           Availability and Related Mobilization and Demobilization Issues.
           [35]GAO-04-1031 . Washington, D.C.: September 15, 2004.

           Defense Health Care: DOD Needs to Improve Force Health Protection
           and Surveillance Processes. [36]GAO-04-158T . Washington, D.C.:
           October 16, 2003.

           Defense Health Care: Quality Assurance Process Needed to Improve
           Force Health Protection and Surveillance. [37]GAO-03-1041 .
           Washington, D.C.: September 19, 2003.

           Military Personnel: DOD Needs More Data to Address Financial and
           Health Care Issues Affecting Reservists. [38]GAO-03-1004 .
           Washington, D.C.: September 10, 2003.

           Defense Health Care: Army Has Not Consistently Assessed the Health
           Status of Early-deploying Reservists. [39]GAO-03-997T .
           Washington, D.C.: July 9, 2003.

           Defense Health Care: Army Needs to Assess the Health Status of All
           Early-Deploying Reservists. [40]GAO-03-437 . Washington, D.C.:
           April 15, 2003.

           VA And Defense Health Care: Military Medical Surveillance Policies
           in Place, but Implementation Challenges Remain. [41]GAO-02-478T .
           Washington, D.C.: February 27, 2002.

           Gulf War Illnesses: Research, Clinical Monitoring, and Medical
           Surveillance. [42]GAO/T-NSIAD-98-88 . Washington, D.C.: February
           5, 1998.

           Gulf War Illnesses: Improved Monitoring of Clinical Progress and
           Reexamination of Research Emphasis Are Needed.
           [43]GAO/NSIAD-97-163 . Washington, D.C.: June 23, 1997.

           Defense Health Care: Medical Surveillance Improved Since Gulf War,
           but Mixed Results in Bosnia. [44]GAO/NSIAD-97-136 . Washington,
           D.C.: May 13, 1997.

           Reserve Forces: DOD Policies Do Not Ensure That Personnel Meet
           Medical and Physical Fitness Standards. [45]GAO/NSIAD-94-36 .
           Washington, D.C.: March 23, 1994.

           Operation Desert Storm: War Highlights Need to Address Problem of
           Nondeployable Personnel. [46]GAO/NSIAD-92-208 . Washington, D.C.:
           August 31, 1992.
			  
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(350897)

[62]www.gao.gov/cgi-bin/getrpt?GAO-07-831 .

To view the full product, including the scope
and methodology, click on the link above.

For more information, contact Brenda S. Farrell at (202) 512-3604 or
[email protected].

Highlights of [63]GAO-07-831 , a report to the Ranking Member,
Subcommittee on National Security and Foreign Affairs, Committee on
Oversight and Government Reform, House of Representatives

June 2007

DEFENSE HEALTH CARE

Comprehensive Oversight Framework Needed to Help Ensure Effective
Implementation of a Deployment Health Quality Assurance Program

Overseas deployments expose servicemembers to a number of potential risks
to their health and well-being. However, since the mid-1990s, GAO has
highlighted shortcomings with respect to the Department of Defense's (DOD)
ability to assess the medical condition of servicemembers both before and
after their deployments. Following GAO's May 1997 report, Congress enacted
legislation (10 U.S.C. S 1074f) that required the Secretary of Defense to
establish a medical tracking system for assessing the medical condition of
servicemembers before and after deployments. GAO was asked to determine
(1) whether DOD has established a medical tracking system to comply with
requirements of 10 U.S.C. S 1074f pertaining to pre- and postdeployment
medical examinations, and (2) the extent to which DOD has effectively
implemented a deployment health quality assurance program as part of its
medical tracking system. In conducting this review, GAO analyzed pertinent
documents and interviewed DOD officials.

[64]What GAO Recommends

GAO is recommending that DOD develop a comprehensive oversight framework
with reporting requirements and results-oriented performance measures to
improve the implementation of its deployment health quality assurance
program. In reviewing a draft of this report, DOD concurred with GAO's
recommendations.

DOD has established a system to comply with the requirements of 10 U.S.C.
S 1074f to perform predeployment and postdeployment medical examinations
through a variety of deployment health activities. For example, DOD's
system includes the use of pre- and postdeployment health assessment
questionnaires along with reviews of servicemembers' medical records. The
pre- and postdeployment health assessment questionnaires ask
servicemembers to respond to a series of questions about their current
medical and mental health conditions and any medical concerns they might
have. Prior to deploying, the predeployment questionnaire and
servicemembers' medical records are to be reviewed by a health care
provider to confirm whether servicemembers have met applicable deployment
health requirements. Also, prior to or after redeploying, the
postdeployment questionnaires are to be reviewed by a health care
provider, along with servicemembers' medical records, to determine whether
additional clinical evaluation or treatment is needed.

DOD has established a deployment health quality assurance program as part
of its medical tracking system, but does not have a comprehensive
oversight framework to help ensure effective implementation of the
program. Thus, DOD does not have the information it needs to evaluate the
effectiveness and efficiency of its deployment health quality assurance
program. DOD policy specifies four elements of the program: (1) monthly
reports on active and reserve component servicemembers' deployment health
data from the Army Medical Surveillance Activity (AMSA), (2) quarterly
reports on service-specific quality assurance programs, (3) DOD site
visits to military installations, and (4) an annual report on the program.
DOD guidance requires each of the services to create their own quality
assurance programs based on these elements. However, GAO found weaknesses
in each of these elements. For example, DOD's policy does not contain
specific reporting requirements or performance measures that require AMSA
to provide critical information needed to assess departmentwide compliance
with deployment health requirements, such as tracking the total number of
servicemembers who deploy overseas or return home during a specific time
period. Also, DOD does not have quality controls in place to ensure the
accuracy or completeness of the information it collects during site visits
to military installations. Without a comprehensive oversight framework,
DOD is not well-positioned to determine or assure Congress that active and
reserve component servicemembers are medically and mentally fit to deploy
and to determine their medical and mental condition upon return. Having an
effective deployment health quality assurance program is critically
important given DOD's long-standing problems with assessing the medical
condition of servicemembers before and after their deployments. Such a
program has become even more important in the current environment, where
active and reserve component servicemembers continue to deploy overseas in
significant numbers in support of ongoing military operations in
Afghanistan and Iraq.

References

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  24. http://www.gao.gov/cgi-bin/getrpt?GAO-04-1031
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  28. mailto:[email protected]
  29. mailto:[email protected]
  30. http://www.gao.gov/cgi-bin/getrpt?GAO-06-1085
  31. http://www.gao.gov/cgi-bin/getrpt?GAO-06-1068
  32. http://www.gao.gov/cgi-bin/getrpt?GAO-06-105
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