oversight

Defense Health Care: Quality Assurance Process Needed to Improve Force Health Protection and Surveillance

Published by the Government Accountability Office on 2003-09-19.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

                 United States General Accounting Office

GAO              Report to the Chairman and Ranking
                 Minority Member, Subcommittee on
                 Total Force, Committee on Armed
                 Services, House of Representatives

September 2003
                 DEFENSE HEALTH
                 CARE
                 Quality Assurance
                 Process Needed to
                 Improve Force Health
                 Protection and
                 Surveillance




GAO-03-1041
                                                 September 2003


                                                 DEFENSE HEALTH CARE

                                                 Quality Assurance Process Needed
Highlights of GAO-03-1041, a report to the       to Improve Force Health Protection
Chairman and Ranking Minority Member,
Subcommittee on Total Force, Committee           and Surveillance
on Armed Services, House of
Representatives




Following the 1990-91 Persian Gulf               The Army and Air Force—the focus of GAO’s review—did not comply with
War, many servicemembers                         DOD’s force health protection and surveillance policies for many active duty
experienced health problems that                 servicemembers, including the policies that they be assessed before and
they attributed to their military                after deploying overseas, that they receive certain immunizations, and that
service in the Persian Gulf.                     health-related documentation be maintained in a centralized location.
However, a lack of servicemember
health and deployment data
                                                 GAO’s review of 1,071 servicemembers’ medical records from a universe of
hampered subsequent                              8,742 at selected Army and Air Force installations participating in overseas
investigations into the nature                   operations disclosed that 38 to 98 percent of servicemembers were missing
and causes of these illnesses.                   one or both of their health assessments and 14 to 46 percent were missing at
Public Law 105-85, enacted in                    least one of the required immunizations (see figure).
November 1997, required the
Department of Defense (DOD) to                   DOD also did not maintain a complete, centralized database of
establish a system to assess the                 servicemembers’ medical assessments and immunizations. Health-related
medical condition of service                     documentation missing from the centralized database ranged from 0 to
members before and after                         63 percent for pre-deployment assessments, 11 to 75 percent for
deployments. GAO was asked to                    post-deployment assessments, and 8 to 93 percent for immunizations.
determine whether (1) the military
services met DOD’s force health
                                                 There is no effective quality assurance program at the Office of the Assistant
protection and surveillance                      Secretary of Defense for Health Affairs or at the Army or Air Force that
requirements for servicemembers                  helps ensure compliance with policies. GAO believes that the lack of such a
deploying in support of Operation                program was a major cause of the high rate of noncompliance. Continued
Enduring Freedom (OEF) in                        noncompliance with these policies may result in servicemembers deploying
Central Asia and Operation Joint                 with health problems or delays in obtaining care when they return. Finally,
Guardian (OJG) in Kosovo and                     DOD’s centralized deployment database is still missing the information
(2) DOD has corrected problems                   needed to track servicemembers’ movements in the theater of operations. By
related to the accuracy and                      July 2003, the department’s data center had begun receiving location-specific
completeness of databases                        deployment information from the services and is currently reviewing its
reflecting which servicemembers                  accuracy and completeness.
were deployed to certain locations.
                                                 Percent of Servicemembers Missing One or Both Health Assessments, and Missing at Least
                                                 One Required Immunization
GAO recommends that the
Secretary of Defense direct the
Assistant Secretary of Defense
for Health Affairs to establish an
effective quality assurance program
that will help ensure that the
military services comply with the
force health protection and
surveillance requirements for
all servicemembers. DOD
concurred with the
recommendation.
www.gao.gov/cgi-bin/getrpt?GAO-03-1041.

To view the full product, including the scope
and methodology, click on the link above.
For more information, contact Cliff Spruill at
(202) 512-4531.
Contents


Letter                                                                                    1
               Results in Brief                                                           3
               Background                                                                 5
               The Army and Air Force Did Not Comply with Deployment Health
                 Surveillance Policies for Many Servicemembers                            9
               Centralized Deployment Database Still Missing Information
                 Needed for Deployment Health Surveillance                              26
               Conclusions                                                              28
               Recommendation for Executive Action                                      28
               Agency Comments and Our Evaluation                                       28

Appendix I     Scope and Methodology                                                    30



Appendix II    Comments from the Department of Defense                                  36



Appendix III   GAO Contact and Staff Acknowledgments                                    39



Tables
               Table 1: Deploying Servicemember Blood Serum Samples Held
                        in Repository                                                   18
               Table 2: Servicemember Sample Sizes at Each Visited Installation         32


Figures
               Figure 1: Percent of Servicemembers Missing One or Both Health
                        Assessments                                                     10
               Figure 2: Percent of Health Assessments Not Completed Within
                        Required Time Frames                                            12
               Figure 3: Completed Assessments That Were Not Reviewed by
                        Health Care Provider                                            13
               Figure 4: Percent of Servicemembers Missing Required
                        Immunizations                                                   15
               Figure 5: Percent of Servicemembers That Did Not Have Current
                        Tuberculosis Screening                                          17




               Page i                                       GAO-03-1041 Defense Health Care
Figure 6: Percent of Assessments Found in Centralized Database
         That Were Not Found in Servicemembers’
         Medical Records                                                                  19
Figure 7: Percent of Assessments and Immunizations Found in
         Servicemembers’ Medical Records That Were Not Found
         in the Centralized Database                                                      22




Abbreviations

AMSA              Army Medical Surveillance Activity
CITA              Comprehensive Immunization Tracking Application
DCAPES            Deliberate Crisis and Action Planning and Execution
                  Segment
DIMHRS            Defense Integrated Military Human Resource System
DMDC              Defense Manpower Data Center
DOD               Department of Defense
MEDPROS           Medical Protection System
OEF               Operation Enduring Freedom
OJG               Operation Joint Guardian
SOCOM             U.S. Special Operations Command
TMIP              Theater Medical Information Program



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Page ii                                                GAO-03-1041 Defense Health Care
United States General Accounting Office
Washington, DC 20548




                                   September 19, 2003

                                   The Honorable John McHugh
                                   Chairman
                                   The Honorable Vic Snyder
                                   Ranking Minority Member
                                   Subcommittee on Total Force
                                   Committee on Armed Services
                                   House of Representatives

                                   Following the 1990-91 Persian Gulf War, many servicemembers
                                   experienced health problems that they attributed to their military
                                   service in the Persian Gulf. However, subsequent investigations into
                                   the nature and causes of these illnesses were hampered by a lack of
                                   servicemember health and deployment data. Moreover, in May 1997, we
                                   reported on several similar problems associated with the implementation
                                   of the Department of Defense’s (DOD) deployment health surveillance
                                   policies for servicemembers deployed to Bosnia in support of a
                                   peacekeeping operation.1

                                   In response, the Congress enacted 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 medical examinations and
                                   post-deployment medical examinations, including an assessment of mental
                                   health and the drawing of blood samples. DOD has implemented specific
                                   force health protection and surveillance policies. These policies include
                                   pre- and post-deployment health assessments designed to identify health
                                   issues or concerns that may affect the deployability of servicemembers or
                                   that may require medical attention; pre-deployment immunizations to
                                   address possible health threats in deployment locations; pre-deployment




                                   1
                                     See U.S. General Accounting Office, Defense Health Care: Medical Surveillance
                                   Improved Since Gulf War, but Mixed Results in Bosnia, GAO/NSIAD-97-136
                                   (Washington, D.C.: May 13, 1997).
                                   2
                                    Section 765 of Pub. L. No. 105-85 amended title 10 of the United States Code by adding
                                   section 1074f.



                                   Page 1                                                  GAO-03-1041 Defense Health Care
screening for tuberculosis; and the retention of blood serum samples on
file prior to deployment.

Given the many deployments of servicemembers to overseas locations
since 1997, you asked us to examine the military services’ implementation
of DOD’s force health protection and surveillance policies and its progress
in correcting the types of problems we found in 1997.3 More specifically,
we focused our work on Army and Air Force active duty deployments4 for
Operation Enduring Freedom (OEF) in Central Asia and Operation Joint
Guardian (OJG) in Kosovo to address the following two questions:

1. Are the military services meeting DOD’s force health protection and
   surveillance system requirements for servicemembers deploying in
   support of OEF and OJG?

2. Has DOD corrected problems related to the accuracy and
   completeness of databases reflecting which servicemembers deployed
   to certain locations?

To accomplish these objectives, we obtained the force health protection
and surveillance policies applicable to the OEF and OJG deployments
from the Army, Air Force, combatant commanders, the office of the
Assistant Secretary of Defense, and the services’ Surgeons General. To test
the implementation of these policies, we reviewed statistical samples
totaling 1,071 active duty servicemembers selected from a universe of
8,742 active duty servicemembers at four military installations. To provide
assurances that our review of the selected medical records was accurate,
we requested the installations’ medical personnel to reexamine those
medical records that were missing required health assessments or
immunizations and adjusted our results where documentation was
subsequently identified. We also requested installation medical personnel
to check all possible sources for missing pre- and post-deployment health


3
 Problems cited in our May 1997 report included the following: required medical
assessments not prepared for many servicemembers; incomplete medical record keeping;
an incomplete centralized health assessment database; and an inaccurate personnel
deployment database.
4
 In April 2003, we reported on problems experienced by the Army in assessing the
health status of all early-deploying reservists. See U.S. General Accounting Office, Defense
Health Care: Army Needs to Assess the Health Status of All Early-Deploying Reservists,
GAO-03-437 (Washington, D.C.: Apr. 15, 2003); and U.S. General Accounting Office, Defense
Health Care: Army Has Not Consistently Assessed the Health Status of Early-Deploying
Reservists, GAO-03-997T (Washington, D.C.: July 9, 2003).




Page 2                                                  GAO-03-1041 Defense Health Care
                       assessments and missing immunizations. We also requested the
                       U.S. Special Operations Command (SOCOM) to query its database for
                       health-related documentation for servicemembers in our sample at one
                       of the selected installations. We also examined, for Army and Air Force
                       servicemembers in our samples, the completeness of the centralized
                       records at the Army Medical Surveillance Activity5 (AMSA), which is
                       tasked with centrally collecting deployment health-related records.
                       Further, we interviewed officials at the office of the Deployment Health
                       Support Directorate and at the Defense Manpower Data Center (DMDC)
                       regarding the accuracy and completeness of DMDC’s personnel
                       deployment database and planned improvements. For more detailed
                       information of our scope and methodology, see appendix I.


                       The Army and Air Force did not comply with DOD’s force health
Results in Brief       protection and surveillance policies for many of the servicemembers
                       at the installations we visited. Our review of medical records at those
                       installations disclosed that problems continue to exist in several areas.

                   •   Deployment health assessments. The percentage of Army and Air Force
                       servicemembers missing one or both of their pre- and post-deployment
                       health assessments ranged from 38 to 98 percent of our samples.
                       Moreover, when health assessments were conducted, as many as
                       45 percent of them were not done within the required time frames.
                       Furthermore, a health care provider did not review all health assessments
                       and, although only a small number of assessments in our samples
                       indicated a health concern, large percentages of these assessments were
                       not referred for further consultations as required.
                   •   Immunizations and other pre-deployment requirements.
                       Servicemembers missing evidence of receiving at least one of the
                       pre-deployment immunizations required for their deployment location
                       ranged from 14 percent to 46 percent. Furthermore, servicemembers
                       missing current tuberculosis screening at the time of their deployment
                       ranged from 7 to 40 percent. As many as 29 percent of the servicemembers
                       in our samples had blood serum samples in the repository older than the
                       required maximum age of 1 year at the time of deployment, ranging, on
                       average, from 2 to 15 months out-of-date.




                       5
                        The Army Medical Surveillance Activity is DOD’s executive agent for collecting and
                       retaining the military services’ deployment health-related documents—including the
                       pre-deployment and post-deployment health assessments and immunizations.




                       Page 3                                                 GAO-03-1041 Defense Health Care
•   Completeness of medical records and centralized data collection.
    Servicemembers’ permanent medical records at the Army and Air Force
    installations we visited did not include documentation of the completed
    health assessments that we found at AMSA and at the U.S. Special
    Operations Command, ranging from 8 to 100 percent for pre-deployment
    health assessments and from 11 to 62 percent for post-deployment
    health assessments. Our review also disclosed that the AMSA database—
    designed to function as the centralized collection location for deployment
    health-related information for all military services—was still, over 5 years
    after congressional action, lacking documentation of many health
    assessments and immunizations that we found in the servicemembers’
    medical records at the installations visited. Specifically, health-related
    documentation missing from the centralized database ranged from 0 to
    63 percent for pre-deployment health assessments, 11 to 75 percent
    for post-deployment health assessments, and 8 to 93 percent
    for immunizations.

    Furthermore, DOD did not have oversight of departmentwide efforts to
    comply with health surveillance requirements. There is no effective quality
    assurance program at the Office of the Assistant Secretary of Defense for
    Health Affairs or at the Offices of the Surgeons’ General of the Army or
    Air Force that helps ensure compliance with force health protection and
    surveillance policies. We believe the lack of such a system was a major
    cause of the high rate of noncompliance we found at the units we
    visited. Continued noncompliance with these policies may result in
    servicemembers being deployed with unaddressed health problems or
    without immunization protection. Furthermore, incomplete and inaccurate
    medical records may hinder DOD’s ability to investigate the causes of any
    future health problems that may arise coincident with deployments.

    DOD has not corrected the problems we identified in 1997 that were
    related to the completeness and accuracy of a central personnel
    deployment database that is designed to collect data reflecting which
    servicemembers deployed to certain locations. The Defense Manpower
    Data Center’s (DMDC) deployment database still does not include the
    information needed for effective deployment health surveillance. Prior to
    April 2003, the services were not reporting location-specific deployment
    data to the DMDC because, according to a DMDC official, the data was
    not available from the services. By July 2003, all of the services had
    begun submitting classified deployment data to DMDC, which is currently
    reviewing the deployment information received to determine its accuracy
    and completeness. However, DMDC still does not have a system to track
    the movement of servicemembers within a given theater, because this



    Page 4                                         GAO-03-1041 Defense Health Care
                 information has not been available from the services and the development
                 of a new tracking system at the service unit level may be required. DOD is
                 developing a new system for tracking the movements of servicemembers
                 and civilian personnel in the theater of operation with plans for
                 implementation by about September 2005 for the Army and by 2007 or
                 early calendar year 2008 for the other services.

                 We are recommending that the Secretary of Defense direct the Assistant
                 Secretary of Defense for Health Affairs to establish an effective quality
                 assurance system to ensure that the military services comply with force
                 health protection and surveillance requirements for all servicemembers.
                 In commenting on a draft of this report, DOD concurred with the report’s
                 recommendation.


                 In May 1997, we reported on DOD’s actions to improve deployment
Background       health surveillance before, during, and after deployments, focusing on
                 Operation Joint Endeavor, which was conducted in the countries of
                 Bosnia-Herzegovina, Croatia, and Hungary.6 We commented on the
                 provisions of a joint medical surveillance policy draft that called for a
                 comprehensive DOD-wide medical surveillance capability to monitor
                 and assess the effects of deployments on servicemembers’ health. DOD
                 subsequently finalized its joint medical surveillance policy in August 1997.
                 Our 1997 review disclosed problems with the Army’s implementation of
                 the medical surveillance plan for Operation Joint Endeavor in the
                 following areas:

             •   Medical assessments. Many Army personnel who should have received
                 post-deployment medical assessments did not receive them and the
                 assessments that were completed were frequently done late. Of the
                 618 servicemembers in the 12 Army units whose medical records we
                 reviewed, 24 percent did not receive in-theater post-deployment medical
                 assessments, and 21 percent did not receive home station post-deployment
                 medical assessments. Servicemembers who received home station
                 post-deployment medical assessments received them, on average, nearly
                 100 days after they left theater instead of within 30 days as required by the
                 plan. Further, pre-deployment blood serum samples were not available for
                 9.3 percent of the 26,621 servicemembers who had deployed to Bosnia as




                 6
                     GAO/NSIAD-97-136.




                 Page 5                                         GAO-03-1041 Defense Health Care
    of March 12, 1996. The most recent blood samples for 6.4 percent of the
    pre-deployment blood samples were more than 5 years old.
•   Medical record keeping. Many of the servicemembers’ medical records
    that we reviewed were incomplete and missing documentation of
    in-theater post-deployment medical assessments, medical visits during
    deployment, and receipt of an investigational new vaccine. More
    specifically, we found that 91 of the 473 servicemembers (19 percent)
    with a post-deployment in-theater medical assessment and 9 of the
    491 servicemembers (1.8 percent) with a post-deployment home unit
    medical assessment did not have the assessments documented in their
    medical records. Furthermore, about 29 percent of the 50 battalion aid
    station visits we reviewed were not documented in the members’
    permanent medical records. Finally, 141 of 588 servicemembers
    (24 percent) who received an investigational drug vaccine did not have the
    immunization documented in their medical records.
•   Centralized database. The centralized database for collecting in-theater
    and home unit post-deployment medical assessments was incomplete for
    many Army personnel. More specifically, the database omitted 12 percent
    of the in-theater medical assessments done and 52 percent of the home
    unit medical assessments done for the 618 servicemembers whose records
    we reviewed.
•   Deployment information. DOD officials considered the database used
    for tracking the deployment of Air Force and Navy personnel inaccurate.

    Following the publication of our report, the Congress, in November 1997,
    included a provision in the Defense Authorization Act for Fiscal Year 1998
    requiring the Secretary of Defense to establish a medical tracking system
    for servicemembers deployed overseas as follows:

    “(a) SYSTEM REQUIRED—The Secretary of Defense shall establish a system to assess the
    medical condition of members of the armed forces (including members of the reserve
    components) who are deployed outside the United States or its territories or possessions
    as part of a contingency operation (including a humanitarian operation, peacekeeping
    operation, or similar operation) or combat operation.

    “(b) ELEMENTS OF SYSTEM—The system described in subsection (a) shall include the
    use of predeployment medical examinations and postdeployment medical examinations
    (including an assessment of mental health and the drawing of blood samples) to accurately
    record the medical condition of members before their deployment and any changes in their
    medical condition during the course of their deployment. The postdeployment examination
    shall be conducted when the member is redeployed or otherwise leaves an area in which
    the system is in operation (or as soon as possible thereafter).




    Page 6                                                 GAO-03-1041 Defense Health Care
“(c) RECORDKEEPING—The results of all medical examinations conducted under the
system, records of all health care services (including immunizations) received by members
described in subsection (a) in anticipation of their deployment or during the course of their
deployment, and records of events occurring in the deployment area that may affect the
health of such members shall be retained and maintained in a centralized location to
improve future access to the records.

“(d) QUALITY ASSURANCE—The Secretary of Defense shall establish a quality assurance
program to evaluate the success of the system in ensuring that members described in
subsection (a) receive predeployment medical examinations and postdeployment medical
examinations and that the recordkeeping requirements with respect to the system
          7
are met.”

As set forth above, these provisions require the use of pre-deployment and
post-deployment medical examinations to accurately record the medical
condition of servicemembers before deployment and any changes during
their deployment. In a June 30, 2003, correspondence with the General
Accounting Office, the Assistant Secretary of Defense for Health Affairs
stated that “it would be logistically impossible to conduct a complete
physical examination on all personnel immediately prior to deployment
and still deploy them in a timely manner.” Therefore, DOD required both
pre- and post-deployment health assessments for servicemembers who
deploy for 30 or more continuous days to a land-based location outside the
United States without a permanent U.S. military treatment facility. Both
assessments use a questionnaire designed to help military healthcare
providers in identifying health problems and providing needed medical
care. The pre-deployment health assessment is generally administered at
the home station before deployment, and the post-deployment health
assessment is completed either in theater before redeployment to the
servicemember’s home unit or shortly upon redeployment.

As a component of medical examinations, the statute quoted above also
requires that blood samples be drawn before and after a servicemember’s
deployment. DOD Instruction 6490.3, August 7, 1997, requires that a
pre-deployment blood sample be obtained within 12 months of the
servicemember’s deployment.8 However, it requires the blood samples be



7
 Section 765 of Pub. L. No. 105-85 amended title 10 of the United States Code by adding
section 1074f.
8
 DOD Instruction 6490.3, “Implementation and Application of Joint Medical Surveillance
for Deployments,” August 7, 1997.




Page 7                                                   GAO-03-1041 Defense Health Care
drawn upon return from deployment only when directed by the Assistant
Secretary of Defense for Health Affairs. According to DOD, the
implementation of this requirement was based on its judgment that the
Human Immunodeficiency Virus serum sampling taken independent of
deployment actions is sufficient to meet both pre- and post-deployment
health needs, except that more timely post-deployment sampling may be
directed when based on a recognized health threat or exposure. Prior to
April 2003, DOD did not require a post-deployment blood sample for
servicemembers supporting the OEF and OJG deployments.

In April 2003, DOD revised its health surveillance policy for blood samples
and post-deployment health assessments. Effective May 22, 2003, the
services are required to draw a blood sample from each redeploying
servicemember no later than 30 days after arrival at a demobilization site
or home station.9 According to DOD, this requirement for post-deployment
blood samples was established in response to an assessment of health
threats and national interests associated with current deployments. The
department also revised its policy guidance for enhanced post-deployment
health assessments to gather more information from deployed
servicemembers about events that occurred during a deployment.
More specifically, the revised policy requires that a trained health care
provider conduct a face-to-face health assessment with each returning
servicemember to ascertain (1) the individual’s responses to the health
assessment questions on the post-deployment health assessment form;
(2) the presence of any mental health or psychosocial issues commonly
associated with deployments; (3) any special medications taken during the
deployment; and (4) concerns about possible environmental or
occupational exposures.




9
 Under Secretary of Defense for Personnel and Readiness Memorandum, “Enhanced
Post-Deployment Health Assessments,” April 22, 2003.




Page 8                                             GAO-03-1041 Defense Health Care
                        The Army and Air Force did not comply with DOD’s force health
The Army and            protection and surveillance requirements for many of the servicemembers
Air Force Did Not       in our samples at the selected installations we visited. Specifically, these
                        Army and Air Force servicemembers were missing: pre-deployment and/or
Comply with             post-deployment health assessments; evidence of receiving one or more of
Deployment Health       the pre-deployment immunizations required for their deployment location;
                        and other pre-deployment requirements related to tuberculosis screening
Surveillance            and blood serum sample storage. Also, servicemembers’ permanent
Policies for Many       medical records were missing required health-related information,
Servicemembers          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     We found that servicemembers missing one or both of their pre- and
Lacked Pre-deployment   post-deployment assessments ranged from 38 to 98 percent in our
and Post-deployment     samples.10 For example, at Fort Campbell for the OEF deployment we
                        found that 68 percent of the 222 active duty servicemembers in our sample
Health Assessments      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.




                        10
                          Because we checked all known possible sources for the existence of deployment health
                        assessments, we concluded that the assessments were not completed in those instances
                        where we could not find required health assessments.




                        Page 9                                                GAO-03-1041 Defense Health Care
Figure 1: Percent of Servicemembers Missing One or Both Health Assessments




Notes:  = 95 percent confidence interval, upper and lower bounds for each estimate.
These percentages reflect assessments from all sources and without regard to timeliness.




Page 10                                                       GAO-03-1041 Defense Health Care
For those servicemembers in our samples who had completed pre- or
post-deployment health assessments, we found that as many as 45 percent
of the assessments in our samples were not completed on time in
accordance with requirements (see fig. 2). DOD policy requires that
servicemembers complete a pre-deployment health assessment form
within 30 days of their deployment and a post-deployment health
assessment form within 5 days upon redeployment back to their home
station.11 These time frames were established to allow time to identify
and resolve any health concerns or problems that may affect the ability of
the servicemember to deploy, and to promptly identify and address any
health concerns or problems that may have arisen during the
servicemember’s deployment.




11
  Office of the Chairman, The Joint Chiefs of Staff, Memorandum MCM-0006-2, “Updated
Procedures for Deployment Health Surveillance and Readiness,” February 1, 2002.




Page 11                                              GAO-03-1041 Defense Health Care
Figure 2: Percent of Health Assessments Not Completed Within Required
Time Frames




Notes:  = 95 percent confidence interval, upper and lower bounds for each estimate.
a
Unable to compute because exact redeployment date was unavailable.
b
 All three pre-deployment cases for Fort Campbell were completed within the required time frame,
but unable to compute confidence intervals due to insufficient size.


Not all health assessments were reviewed by a health care provider
as required, as shown in figure 3. DOD policy requires that pre-deployment
and post-deployment health assessments are to be reviewed immediately
by a health care provider to identify any medical care needed by the
servicemember.12




12
     The Joint Staff, Joint Staff Memorandum MCM-251-98.




Page 12                                                       GAO-03-1041 Defense Health Care
Figure 3: Completed Assessments That Were Not Reviewed by Health
Care Provider




Notes:  = 95 percent confidence interval, upper and lower bounds for each estimate.
a
 All three pre-deployment cases for Fort Campbell were reviewed by the health care provider,
but unable to compute confidence intervals due to insufficient size.
b
Zero cases: confidence level shown.


The services did not refer some servicemember health assessments
that indicated a need for further consultation. According to DOD
policy, a medical provider, namely a physician, physician’s assistant,
nurse, or independent duty medical technician is required to further
review a servicemember’s need for specialty care when the member’s
pre-deployment and/or post-deployment health assessment indicates
health concerns such as unresolved medical or dental problems or plans




Page 13                                                       GAO-03-1041 Defense Health Care
                          to seek mental health counseling or care.13 This follow-up may take the
                          form of an interview or examination of the servicemember, and forms the
                          basis of a decision as to whether a referral for further specialty care is
                          warranted. In our samples, the number of assessments that indicated a
                          health concern was relatively small, but large percentages of these
                          assessments were not referred for further specialty care. For example,
                          our sample at Travis Air Force Base included five pre-deployment health
                          assessments that indicated a health concern, but four (80 percent) of
                          the health assessments were not referred for further specialty care.

                          Noncompliance with the requirement for pre-deployment health
                          assessments may result in servicemembers with existing health problems
                          or concerns being deployed with unaddressed health problems. Also,
                          failure to complete post-deployment health assessments may risk a delay
                          in obtaining appropriate medical follow-up attention for a health problem
                          or concern that may have arisen during or following the deployment.


Immunizations and Other   Based on our samples, the services did not fully meet immunization
Pre-Deployment Health     and other pre-deployment requirements. Evidence of pre-deployment
Requirements Not Met      immunizations receipt was missing from many servicemembers’ medical
                          records. Servicemembers missing the required immunizations may not
                          have the immunization protection they need to counter theater disease
                          threats. Based on our review of servicemember medical records for the
                          deployments at the four installations we visited, we found that between
                          14 and 46 percent of the servicemembers were missing at least one of their
                          required immunizations prior to deployment (see fig. 4). Furthermore, as
                          many as 36 percent of the servicemembers were missing two or more of
                          their required immunizations.




                          13
                            Office of the Chairman, The Joint Chiefs of Staff, Memorandum MCM-0006-02, “Updated
                          Procedures for Deployment Health Surveillance and Readiness,” February 1, 2002.




                          Page 14                                              GAO-03-1041 Defense Health Care
Figure 4: Percent of Servicemembers Missing Required Immunizations




Notes:  = 95 percent confidence interval, upper and lower bounds for each estimate.


The U.S. Central Command required the following pre-deployment
immunizations for all servicemembers that deployed to Central Asia
in support of OEF: hepatitis A (two-shot series); measles, mumps, and
rubella; polio; tetanus/diphtheria within the last 10 years; yellow fever
within the last 10 years; typhoid within the last 5 years; influenza within
the last 12 months; and meningococcal within the last 5 years.14 For
OJG deployments, the U.S. European Command required the same
immunizations cited above, with the exception of the yellow fever
inoculation that was not required for Kosovo.15



14
 U.S. Central Command, “Personnel Policy Guidance for U.S. Individual Augmentation
Personnel in Support of Operation Enduring Freedom,” October 3, 2001.
15
  Headquarters U.S. European Command, “Greece and the Balkans: Force Health
Protection Guidance,” January 4, 2002.




Page 15                                                       GAO-03-1041 Defense Health Care
Figure 5 indicates that 7 to 40 percent of the deploying servicemembers
in our review were missing a current tuberculosis screening. A screening
is deemed “current” if it occurred 1 to 2 years prior to deployment.
Specifically, the U.S. Central Command required servicemembers
deploying to Central Asia in support of OEF to be screened for
tuberculosis within 12 months of deployment.16 For OJG deployments, the
U.S. European Command required Army and Air Force servicemembers to
be screened for tuberculosis with 24 months of deployment.17




16
 U.S. Central Command, “Personnel Policy Guidance for U.S. Individual Augmentation
Personnel in Support of Operation Enduring Freedom,” October 3, 2001.
17
  Headquarters U.S. European Command, “Greece and the Balkans: Force Health
Protection Guidance,” January 4, 2002.




Page 16                                             GAO-03-1041 Defense Health Care
Figure 5: Percent of Servicemembers That Did Not Have Current
Tuberculosis Screening




Notes:  = 95 percent confidence interval, upper and lower bounds for each estimate.


U.S. Central Command and U.S. European Command policies require that
deploying servicemembers have a blood serum sample in the serum
repository not older than 12 months prior to deployment.18 While nearly all
deploying servicemembers had blood serum samples held in the Armed
Services Serum Repository prior to deployment, as many as 29 percent
had serum samples that were too old (see table 1). The samples that were
too old ranged, on average, from 2 to 15 months out-of-date.




18
  U.S. Central Command, “Personnel Policy Guidance for U.S. Individual Augmentation
Personnel in Support of Operation Enduring Freedom,” October 3, 2001; and Headquarters
U.S. European Command, “Greece and the Balkans: Force Health Protection Guidance,”
January 4, 2002.




Page 17                                                       GAO-03-1041 Defense Health Care
Table 1: Deploying Servicemember Blood Serum Samples Held in Repository

                                    Fort Campbell Fort Campbell        Fort Drum       Fort Drum Hurlburt Field        Travis AFB
 Status of Blood Serum                      (OEF)        (OJG)              (OEF)          (OJG)         (OEF)              (OEF)
 Had serum sample in repository            100%            100%             100%           99.5%            100%             100%
 Serum out-of date (older than
 1-year requirement) at time
 of deployment                              22%               7%              5%              1%               7%             29%
 Average months out-of-date                      8             2               11               5              15               14
Source: GAO analyses of DOD data.




Servicemember                               Servicemembers’ permanent medical records were not complete,
Medical Records and                         and DOD’s centralized database did not include documentation of
Centralized Database                        servicemember health-related information. Many servicemembers’
                                            permanent medical records at the Army and Air Force installations we
Were Not Complete                           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.

Many Completed Deployment                   DOD policy requires that the original completed pre-deployment
Health Assessments and                      and post-deployment health assessment forms be placed in the
Medical Interventions                       servicemember’s permanent medical record and that a copy be
Were Not Documented                         forwarded to AMSA.19 Figure 6 shows that completed assessments
in Servicemembers’                          we found at AMSA and at the U.S. Special Operations Command
Medical Record                              for servicemembers in our samples were not documented in the
                                            servicemember’s permanent medical record, ranging from 8 to 100 percent
                                            for pre-deployment health assessments and from 11 to 62 percent for
                                            post-deployment health assessments.




                                            19
                                              Office of the Chairman, The Joint Chiefs of Staff, Memorandum MCM-0006-02, “Updated
                                            Procedures for Deployment Health Surveillance and Readiness,” February 1, 2002.




                                            Page 18                                              GAO-03-1041 Defense Health Care
Figure 6: Percent of Assessments Found in Centralized Database That Were Not
Found in Servicemembers’ Medical Records




Notes:  = 95 percent confidence interval, upper and lower bounds for each estimate.
a
 All three pre-deployment cases at Fort Campbell found in the centralized database were
missing from servicemembers’ medical record, but unable to compute confidence intervals
due to insufficient size.


Army and Air Force policies also require documentation in the
servicemember’s permanent medical record of all visits to in-theater
medical facilities.20 Except for the OEF deployment at Fort Drum, officials
were unable to locate or access the sign-in logs for servicemember visits to
in-theater Army battalion aid stations and to Air Force expeditionary
medical support for the OEF and OJG deployments at the installations we


20
  Army Regulation 40-66, “Medical Records Administration,” October 23, 2002, and
Air Force Instruction 41-210, “Health Services Patient Administration Functions,”
October 1, 2000.




Page 19                                                       GAO-03-1041 Defense Health Care
                               visited. Consequently, we limited the scope of our review to two battalion
                               aid stations for the OEF deployment at Fort Drum. We found that
                               39 percent of servicemember visits to one battalion aid station and
                               94 percent to the other were not documented in the servicemember’s
                               permanent medical record. Representatives of the two battalion aid
                               stations said that the missing paper forms documenting the
                               servicemember visits may have been lost en route to Fort Drum.
                               Specifically, a physician’s assistant for one of these battalion aid station
                               said the battalion aid station moved three times in theater and each
                               time the paper forms used to document in-theater visits were boxed and
                               moved with the battalion aid station. Consequently, the forms missing
                               from servicemembers’ medical records may have been lost en route to
                               Fort Drum.

                               The lack of complete and accurate medical records documenting
                               all medical care for the individual servicemember complicates the
                               servicemembers’ post-deployment medical care. For example, accurate
                               medical records are essential for the delivery of high-quality medical care
                               and important for epidemiological analysis following deployments.
                               According to DOD health officials, the lack of complete and accurate
                               medical records complicated the diagnosis and treatment of
                               servicemembers who experienced post-deployment health problems that
                               they attributed to their military service in the Persian Gulf in 1990-91.

                               DOD is implementing the Theater Medical Information Program (TMIP)
                               that has the capability to electronically record and store in-theater patient
                               medical encounter data. TMIP is currently undergoing operational testing
                               by the military services and DOD intends to begin fielding TMIP during the
                               first quarter of fiscal year 2004.

Centralized Database Missing   Based on our samples, DOD’s centralized database did not include
Health-Related Documentation   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




                               Page 20                                        GAO-03-1041 Defense Health Care
requires the services to forward a copy of the completed pre-deployment
and post-deployment health assessments to AMSA for centralized
retention.21 Also, the U.S. Special Operations Command (SOCOM) requires
deployment health assessments for special forces units to be sent to the
Command for centralized retention in the Special Operation Forces
Deployment Health Surveillance System.22

Figure 7 depicts the percentage of pre- and post-deployment health
assessments and immunization records we found in the servicemembers’
medical records that were not available in a centralized database at AMSA
or SOCOM. Health-related documentation missing from the centralized
database ranged from 0 to 63 percent for pre-deployment health
assessments, 11 to 75 percent for post-deployment health assessments,
and 8 to 93 percent for immunizations.




21
   Office of the Chairman, The Joint Chiefs of Staff, Memorandum MCM-0006-02, “Updated
Procedures for Deployment Health Surveillance and Readiness,” February 1, 2002.
22
  U.S. Special Operations Command Directive 40-4, “Medical Surveillance,”
October 18, 2000; Appendix 1 to Annex Q to U.S. Central Command Operations Order,
“Special Operation Forces Deployment Health Surveillance System,” November 30, 2001.




Page 21                                              GAO-03-1041 Defense Health Care
Figure 7: Percent of Assessments and Immunizations Found in Servicemembers’
Medical Records That Were Not Found in the Centralized Database




Notes:  = 95 percent confidence interval, upper and lower bounds for each estimate.

Centralized database is AMSA for all but Hurlburt Field, which reports to either AMSA or
SOCOM based on classification of military personnel. Hurlburt Field results reflect combined
health assessment and immunization data found at either AMSA or SOCOM.
a
 Zero cases found in servicemembers’ medical record that were not found in the
centralized database.


All but one of the servicemembers in our sample at Hurlburt Field were
special operations forces. A SOCOM official told us that pre-deployment
and post-deployment health assessment forms for servicemembers in
special operations force units are not sent to AMSA because the health
assessments may include classified information that AMSA is not equipped
to receive. Consequently, SOCOM retains the deployment health
assessments in its classified Special Operations Forces Deployment Health
Surveillance System. Also, a SOCOM medical official told us that the



Page 22                                                       GAO-03-1041 Defense Health Care
                            system does not include pre-deployment immunization data. A
                            Deployment Health Support Directorate official told us that the
                            Directorate is examining how to remove the classified information from
                            the deployment health assessments so that SOCOM can forward the
                            assessments to AMSA. For presentation in figure 7, we combined the
                            health assessment and immunization data we found at AMSA and SOCOM
                            for Hurlburt Field.

                            An AMSA official believes that missing documentation in the centralized
                            database could be traced to the services’ use of paper copies of
                            deployment health assessments that installations are required to forward
                            to the centralized database, and the lack of automation to record
                            servicemembers’ pre-deployment immunizations. DOD has ongoing
                            initiatives to electronically automate the deployment health assessment
                            forms and the recording of servicemember immunizations. For example,
                            DOD is implementing a comprehensive electronic medical records system,
                            known as the Composite Health Care System II, which includes pre- and
                            post-deployment health assessment forms and the capability to
                            electronically record immunizations given to servicemembers. DOD
                            has deployed the system at five sites and will be seeking approval in
                            August/September 2003 for worldwide deployment.23 DOD officials
                            believe that the electronic automation of the deployment health-related
                            information will lessen the burden of installations in forwarding paper
                            copies and the likelihood of information being lost in transit.


DOD and Installations       DOD does not have an effective quality assurance program to provide
Did Not Have Oversight of   oversight of, and ensure compliance with, the department’s force health
Force Health Protection     protection and surveillance requirements. Moreover, the installations we
                            visited did not have ongoing monitoring or oversight mechanisms to help
and Surveillance            ensure that force health protection and surveillance requirements were
Requirements                met for all servicemembers. We believe that the lack of such a system was
                            a major cause of the high rate of noncompliance we found at the units we
                            visited. The services are currently developing quality assurance programs
                            designed to ensure that force health protection and surveillance policies
                            are implemented for servicemembers.



                            23
                              In September 2002, we reported that DOD had experienced delays and cost overruns in
                            implementing the Composite Health Care System II. See U.S. General Accounting Office,
                            Information Technology: Greater Use of Best Practices Can Reduce Risk in Acquiring
                            Defense Health Care System, GAO-02-345 (Washington, D.C.: Sept. 26, 2002).




                            Page 23                                              GAO-03-1041 Defense Health Care
Although required by Public Law 105-85 to establish a quality assurance
program,24 neither the Assistant Secretary of Defense for Health Affairs
nor the offices of the Surgeons General of the Army or Air Force had
established oversight mechanisms that would help ensure that force
health protection and surveillance requirements were met for all
servicemembers. Following our visit to Fort Drum in October 2002, the
Army Surgeon General wrote a memorandum in December 2002 to the
commanders of the Army Regional Medical Commands that expressed
concern related to our sample results at Fort Drum. He emphasized the
importance of properly documenting medical care and directed them
to accomplish an audit of a statistically significant sample of medical
surveillance records of all deployed and redeployed soldiers at
installations supported by their regional commands, provide an
assessment of compliance, and develop an action plan to improve
compliance with the requirements.

At three of the four installations we visited, officials told us that new
procedures were implemented that they believe will improve compliance
with force health protection and surveillance requirements for
deployments occurring after those we reviewed. Specifically, following
our visit to Fort Drum in October 2002, Fort Drum medical officials
designed a pre-deployment and post-deployment checklist patterned after
our review that is being used as part of processing before servicemembers
are deployed and when they return. The officials told us that this process
has improved their compliance with force health protection and
surveillance requirements for deployments subsequent to our visit. Also,
the hospital commander at Fort Campbell told us that they implemented
procedures that now require all units located at Fort Campbell to use
the hospital’s medical personnel in their processing of servicemembers
prior to deployment. The hospital commander believes that this new
requirement will improve compliance with the force health protection and
surveillance requirements at Fort Campbell because the medical personnel
will now review whether all requirements have been met for the deploying
servicemembers. At Hurlburt Field, officials told us that they implemented
a new requirement in November 2002 to withhold payment of travel
expenses and per diem to re-deploying servicemembers until they
complete the post-deployment health assessment. Officials believe
that this change will improve servicemembers’ completion of the
post-deployment health assessments. While it is noteworthy that these


24
     10 U.S.C. sec. 1074f(d).




Page 24                                       GAO-03-1041 Defense Health Care
installations have implemented changes that they believe will improve
their compliance, the actual measure of improvements over time
cannot be known unless the installations perform periodic reviews of
servicemembers’ medical records to identify the extent of compliance with
deployment health requirements.

In March 2003, we briefed the Subcommittee on Total Force, House
Committee on Armed Services, about our interim review results at
selected military installations.25 Subsequently, at a March 2003
congressional hearing, the Subcommittee discussed our interim review
results with the Assistant Secretary of Defense for Health Affairs and the
services’ Surgeons General. Based on our interim results that DOD was
not meeting the full requirement of the law and the military services were
not effectively carrying out many of DOD’s force health protection and
surveillance policies, in May 2003 the House Committee on Armed
Services directed the Secretary of Defense to take measures to improve
oversight and compliance. Specifically, in its report accompanying the
Fiscal Year 2004 National Defense Authorization Act, the Committee
directed the Secretary of Defense “… to establish a quality control
program to begin assessing implementation of the force health protection
and surveillance program, and to provide a strategic implementation plan,
including a timeline for full implementation of all policies and programs,
to the Senate Committee on Armed Services and the House Committee on
Armed Services by March 31, 2004.”26

In April 2003, the Under Secretary of Defense for Personnel and Readiness
issued an enhanced post-deployment health assessment policy that
required the services to develop and implement a quality assurance
program that encompasses medical record keeping and medical
surveillance data.27 In June 2003, the Office of Assistant Secretary of
Defense for Health Affairs’ Deployment Health Support Directorate began
reviewing the services’ quality assurance implementation plans and
establishing DOD-wide compliance metrics—including parameters for
conducting periodic visits—to monitor service implementation.


25
  Prior to briefing the Subcommittee, we also briefed the Senior Military Medical Advisory
Committee including the Assistant Secretary of Defense for Health Affairs and the
Surgeons General or their representatives about our interim review results.
26
     H.R. Rep. No. 108-106 at 336 (2003).
27
  Under Secretary of Defense for Personnel and Readiness Memorandum,
“Enhanced Post-Deployment Health Assessments,” April 22, 2003.




Page 25                                                 GAO-03-1041 Defense Health Care
                      The DMDC deployment database still does not include the deployment
Centralized           information we identified in 1997 as needed for effective deployment
Deployment Database   health surveillance. In 1997, we reported that knowing the identity of
                      servicemembers who were deployed during a given operation and tracking
Still Missing         their movements within the theater of operations are major elements of a
Information Needed    military medical surveillance system.28 The Institute of Medicine reported
                      in 2000 that the documentation of the locations of units and individuals
for Deployment        during a given deployment is important for epidemiological studies and for
Health Surveillance   the provision of appropriate medical care during and after deployments.29
                      This information allows (1) epidemiologists to study the incidence of
                      disease patterns across populations of deployed servicemembers who
                      may have been exposed to diseases and hazards within the theater, and
                      (2) health care professionals to treat their medical problems appropriately.
                      Because of concerns about the accuracy of the DMDC database, we
                      recommended in our 1997 report that the Secretary of Defense direct
                      an investigation of the completeness of the information in the DMDC
                      personnel database and take corrective actions to ensure that the
                      deployment information is accurate for servicemembers who deploy to
                      a theater.

                      DOD’s established policies notwithstanding, the services did not report
                      location-specific deployment information to DMDC prior to April 2003,
                      because, according to a DMDC official, the services did not maintain the
                      data. DOD Instruction 6490.3, issued in August 1997, requires DMDC,
                      under the Department’s Under Secretary for Personnel and Readiness, to
                      maintain a system that collects information on deployed forces, including
                      daily-deployed strength, total and by unit; grid coordinate locations for
                      each unit (company size and larger); and inclusive dates of individual
                      servicemember’s deployment.30 In addition, the Joint Chief of Staff’s
                      Memorandum MCM-0006-02, dated February 1, 2002, required combatant
                      commands to provide DMDC with their theater-wide rosters of all
                      deployed personnel, their unit assignments, and the unit’s geographic
                      locations while deployed.31 This memorandum stressed that accurate


                      28
                           GAO/NSIAD-97-136.
                      29
                       Institute of Medicine, Protecting Those Who Serve: Strategies to Protect the Health of
                      Deployed U.S. Forces (National Academy Press, Washington, D.C.: 2000).
                      30
                        DOD Instruction 6490.3, “Implementation and Application of Joint Medical Surveillance
                      for Deployments,” August 7, 1997.
                      31
                        Office of the Chairman, The Joint Chiefs of Staff, Memorandum MCM-0006-02, “Updated
                      Procedures for Deployment Health Surveillance and Readiness,” February 1, 2002.



                      Page 26                                                 GAO-03-1041 Defense Health Care
personnel deployment data is needed to assess the significance of
medical diseases and injuries in terms of the rate of occurrence among
deployed servicemembers. The Under Secretary of Defense for
Personnel and Readiness expressed concern about the services’
failure to report complete personnel deployment data to DMDC in
an October 2002 memorandum.32

To address the services’ lack of reporting to DMDC, the Under Secretary
of Defense for Personnel and Readiness established a tri-service
working group that outlined a plan of action in March 2003 to address
the reporting issues. In July 2003, a DMDC official told us that significant
improvements had recently occurred and that all of the services had begun
submitting their classified deployment databases—including deployment
locations—to DMDC. DMDC is currently reviewing the deployment
information submitted by the services to determine its accuracy and
completeness. It plans to complete this review during the summer of 2003.

With regard to DMDC’s efforts to create a system for tracking the
movements of servicemembers within a given theater of operations,
DMDC officials told us that little progress has been made. They said that
the primary reason for a lack of progress in developing this system is that
the source information has generally not been available from the services
and this may require the development of new tracking systems at the
unit level. In June 2003, a DMDC official told us that it had been recently
determined that the Air Force has implemented a theater tracking
system that may have applicability to the other services. The tracking
system—known as the Deliberate Crisis and Action Planning and
Execution Segment (DCAPES)—enables field teams to enter classified
information about the whereabouts of deployed Air Force personnel at the
longitude/latitude level of detail. DMDC began receiving information from
this system in April 2003. The Under Secretary of Defense for Personnel
and Readiness is reviewing this system to determine whether it could be
used for the same purposes by the other services.

Also, DOD is developing the Defense Integrated Military Human Resource
System (DIMHRS), which will have the capability to track the movements
of all servicemembers and civilians in the theater of operations. As of



32
 This memorandum was dated October 25, 2002, and sent to the Vice Chief of Staff of the
Army, Vice Chief of Staff of the Air Force, Vice Chief of Naval Operations, and the Assistant
Commandant of the Marine Corps.




Page 27                                                  GAO-03-1041 Defense Health Care
                     June 2003, DOD plans to implement this system for the Army by about
                     September 2005 and for the other services by 2007 or early calendar
                     year 2008.


                     While DOD and the military services have established force health
Conclusions          protection and surveillance policies, at the units we visited we found
                     many instances of noncompliance by the services. Moreover, because
                     DOD and the services do not have an effective quality assurance program
                     in place to help ensure compliance, these problems went undetected and
                     uncorrected. Continued noncompliance with these policies may result
                     in servicemembers with existing health problems or concerns being
                     deployed with unaddressed health problems or without the immunization
                     protection they need to counter theater disease threats. Failure to
                     complete post-deployment health assessments may risk a delay in
                     obtaining appropriate medical follow-up attention for a health problem
                     or concern that may have arisen during or following the deployment.
                     Similarly, incomplete and inaccurate medical records and deployment
                     databases would likely hinder DOD’s ability to investigate the causes of
                     any future health problems that may arise coincident with deployments.


                     To improve compliance with DOD’s force health protection and
Recommendation for   surveillance policies, we recommend that the Secretary of Defense direct
Executive Action     the Assistant Secretary of Defense for Health Affairs to establish an
                     effective quality assurance program, as required by section 765 of Public
                     Law 105-85 (10 U.S.C. 1074f), that will ensure that the military services
                     comply with the force health protection and surveillance requirements for
                     all servicemembers.


                     The Department of Defense provided written comments on a draft of
Agency Comments      this report, which are found in appendix II. DOD concurred with the
and Our Evaluation   report’s recommendation.

                     The Assistant Secretary of Defense for Health Affairs commented that his
                     office has already established a quality assurance program for pre- and
                     post-deployment health assessments. This program monitors pre- and
                     post-deployment health assessments and blood samples being archived
                     electronically at the Army Medical Surveillance Activity (AMSA) and
                     assures that indicated referrals on the post-deployment health
                     assessments are being conducted by all the services. However, the
                     Assistant Secretary of Defense for Health Affairs’ comments did not


                     Page 28                                      GAO-03-1041 Defense Health Care
discuss how his office is using the monitoring activities to assure
the military services’ compliance with force health protection and
surveillance policies.

According to the Assistant Secretary of Defense for Health Affairs, the
services have implemented their quality assurance programs. The Army
has developed automated versions of the pre- and post-deployment health
assessment forms, and has established a corporate monitoring system
that is built upon deployment personnel rosters and monitored weekly
by the Army Surgeon General. The Air Force is now receiving monthly
deployment health surveillance compliance reports from its medical
treatment facilities, and has scheduled a special compliance study
through the Air Force Inspection Agency in fiscal year 2004. Navy fleet
commanders have implemented their own quality assurance programs,
with anticipation of standardization through centralized automated
systems. And the Marine Corps has also established unit/command
quality assurance procedures. We view these actions as responsive to our
recommendation and commend the department for taking quick action
to address the compliance issues we found during our audit. However, it
remains to be seen how effective these activities will be in ensuring that
force health protection and surveillance policies are implemented for
all servicemembers.


We are sending copies of this report to the Secretary of Defense and the
Secretaries of the Army and the Air Force. We will also make copies
available to others upon request. In addition, the report is available at no
charge on GAO’s Web site at http://www.gao.gov.

If you or your staff have any questions regarding this report, please
contact me on (757) 552-8100. Key contributors to this report are listed in
appendix III.




Neal P. Curtin, Director
Defense Capabilities and Management




Page 29                                         GAO-03-1041 Defense Health Care
                Appendix I: Scope and Methodology
Appendix I: Scope and Methodology


                To meet our objectives, we interviewed responsible officials and reviewed
                pertinent documents, reports, and information related to force health
                protection and deployment health surveillance requirements obtained
                from officials at the Office of the Assistant Secretary of Defense for Health
                Affairs; the Office of the Deputy Assistant Secretary of Defense for Force
                Health Protection and Readiness; the Office of the Assistant Secretary of
                Defense for Reserve Affairs; the Joint Staff; the Marine Corps Force Health
                Protection Office; and the Offices of the Surgeons General for the Army
                and Air Force Headquarters in the Washington, D.C., area. We also
                performed additional work at the Deployment Health Support Directorate,
                Falls Church, Virginia; the U.S. Army Center for Health Promotion and
                Preventive Medicine, Aberdeen, Maryland; the Armed Forces Medical
                Intelligence Center, Fort Dietrick, Maryland; the Army Medical
                Surveillance Activity, Walter Reed Army Medical Center, Washington,
                D.C.; the Navy Environmental Health Center in Portsmouth, Virginia;
                the Defense Manpower Data Center in Monterey, California; and the
                U.S. Central Command and the U.S. Special Operations Command at
                MacDill Air Force Base, Tampa, Florida.

                To determine whether the military services were meeting DOD’s force
                health protection and surveillance requirements for servicemembers
                deploying in support of OEF and OJG, we identified DOD and each
                service’s overall deployment health surveillance policies. We also obtained
                the specific force health protection and surveillance requirements
                applicable to all servicemembers deploying to Central Asia in support of
                OEF from the U.S. Central Command and these requirements for all
                servicemembers deploying to Kosovo in support of OJG from the
                U.S. European Command. We tested the implementation of these
                requirements at selected Army and Air Force installations. To identify
                locations within each service where we would test implementation of the
                policies, the Assistant Secretary of Defense for Health Affairs requested
                the services to identify, by military installation, the number of active duty
                servicemembers who met the following criteria:

            •   For OEF, those servicemembers who deployed to Central Asia for 30 or
                more continuous days to areas without permanent U.S. military treatment
                facilities following September 11, 2001, and redeployed back to their home
                unit by May 31, 2002.
            •   For OJG, those servicemembers who deployed to Kosovo for 30 or more
                continuous days to areas without permanent U.S. military treatment
                facilities from January 1, 2001, and redeployed back to their home unit by
                May 31, 2002.




                Page 30                                        GAO-03-1041 Defense Health Care
    Appendix I: Scope and Methodology




    Based on deployment data obtained from the services, we decided to
    limit our testing of the force health protection and surveillance policy
    implementation to selected Army and Air Force military installations
    with the largest numbers of servicemembers meeting our selection
    criteria (described above). We limited our review of medical records for
    servicemembers deploying in support of OJG to the two Army locations.
    We decided not to review Navy installations because there were only
    small numbers of servicemembers who met our selection criteria. We
    decided not to review Marine Corps installations because officials at
    the Marine Corps headquarters had difficulty identifying the number of
    servicemembers who went ashore 30 or more continuous days consistent
    with our selection criteria.

    The largest deployers for OEF and OJG were selected and are
    listed below:

    OEF:
•   10th Mountain Division, Fort Drum, N.Y.
•   101st Airborne Division, Fort Campbell, Ky.
•   Travis Air Force Base, Calif.
•   Hurlburt Field, Fla.

    OJG:
•   10th Mountain Division, Fort Drum, N.Y.
•   101st Airborne Division, Fort Campbell, Ky.

    For our medical records review, we selected statistical samples of
    servicemembers at the selected installations to be representative of those
    deploying from those military installations for those specific operations.

    For various reasons, medical records were not always available for review.
    We, therefore, sampled without replacement, to choose additional records
    when we were unable to meet our sampling threshold of cases for review.
    Specifically, there were five reasons identified for not being able to
    physically secure the servicemember’s medical record for review:

    1. Charged to patient. When a patient visits a clinic (on-post or
       off-post), the medical record is physically given to the patient. The
       procedure is that the medical record will be returned by the patient
       following their clinic visit.




    Page 31                                       GAO-03-1041 Defense Health Care
Appendix I: Scope and Methodology




2. Expired term of service. Servicemember separates from the military
   and their medical record is sent to St. Louis, Missouri, and therefore
   not available for review.

3. Record is not accounted for by the medical records department.
   No tracking sheet is in the file system to indicate the patient has
   checked it out or otherwise. (Note: There were not any cases for which
   the medical record could not be accounted.)

4. Permanent change of station. Servicemember is still in the military,
   but has transferred to another base. Medical record transfers with the
   servicemember.

5. Temporary duty off site. Servicemember has left military
   installation, but is expected to return. The temporary duty is long
   enough to warrant that the medical record accompany the
   servicemember.

The sample size for deployments was determined to provide 95 percent
confidence with a 5-percent precision. The number of servicemembers in
our samples and the applicable universe of servicemembers for the OEF
and OJG deployments at the installations visited are shown in table 2.

Table 2: Servicemember Sample Sizes at Each Visited Installation

    Installation                   Deployment                   Sample                 Universe
    Fort Campbell                           OEF                         8                    333
                                                 a
                            OEF (post May 31)                        222                   2,953
                            OJG (post May 31)a                        46                      92
    Fort Drum                               OEF                      184                     491
                                            OJG                      211                   2,754
    Hurlburt Field                          OEF                      184                     927
    Travis Air Force Base                   OEF                      215                   1,192
    Total                                                          1,071                   8,742
a
 In order to obtain a larger universe of servicemembers from which to select medical records for
review, we extended our date for redeployment to home unit from May 31, 2002, to October 31, 2002.


At Fort Campbell, there were only 333 servicemembers identified as
having met our criteria based on a redeployment date of May 31, 2002;
however, only 8 charts were available for review due to rotation of
soldiers to other military locations or departure from the military. It was,
therefore, necessary to extend our redeployment date to October 31, 2002.



Page 32                                                     GAO-03-1041 Defense Health Care
    Appendix I: Scope and Methodology




    Doing so provided an additional 2,953 servicemembers who met all criteria
    except for a redeployment by May 31, 2002. At Fort Campbell, there were
    92 servicemembers who deployed in support of OJG and met our selection
    criteria if we extended the redeployment date to October 31, 2002.
    Because the number of servicemembers for OJG at Fort Campbell was
    small, we reviewed the medical records for all of servicemembers who
    were still at Fort Campbell.

    At each sampled location, we examined servicemember medical records
    for evidence of the following force health protection and deployment
    health-related documentation required by DOD’s force health protection
    and deployment health surveillance policies:

•   Pre- and post-deployment health assessments,
•   Tuberculosis screening test (within 1 year of deployment for OEF and
    2 years for OJG)
•   Pre-deployment immunizations:
    • hepatitis A;
    • influenza (within 1 year of deployment);
    • measles, mumps, and rubella;
    • meningococcal (within 5 years of deployment);
    • polio;
    • tetanus-diphtheria (within 10 years of deployment);
    • typhoid (within 5 years of deployment); and
    • yellow fever (within 10 years of deployment), not required for OJG.

    To provide assurances that our review of the selected medical records was
    accurate, we requested the installations’ medical personnel to reexamine
    those medical records that were missing required health assessments or
    immunizations and adjusted our results where documentation was
    subsequently identified. We also requested that installation medical
    personnel check all possible sources for missing pre- and post-deployment
    health assessments and immunizations. These sources included the Army’s
    Soldier Readiness Check folders and automated immunization sources,
    including the Army’s Medical Protection System (MEDPROS) and the
    Air Force’s Comprehensive Immunization Tracking Application (CITA).
    We checked all known possible sources for the existence of deployment
    health assessments related to servicemembers in our samples. In
    those instances where we did not find a deployment health assessment,
    we concluded that the assessments were not completed. Furthermore,
    installation officials were unable to logistically access the
    servicemembers’ individual records of immunizations, commonly referred
    to as yellow-shot records that may have provided documentation for



    Page 33                                      GAO-03-1041 Defense Health Care
Appendix I: Scope and Methodology




missing immunizations. Consequently, our analyses of the immunization
records was based on our examination of the servicemember’s
permanent medical record and immunizations that were in the Army’s
MEDPROS and the Air Force’s CITA. In analyzing our review results at
each location, we considered documentation from all identified sources
(e.g., servicemember’s medical record, soldier readiness check folder,
Army Medical Surveillance Activity, and immunization tracking
systems) in presenting data on compliance with deployment health
surveillance policies.

To identify whether required blood serum specimens were in storage
at the Armed Services Serum Repository, we requested that the Army
Medical Surveillance Activity staff query the Repository to identify
whether the servicemembers in our samples had a blood serum sample
in the repository and the date of the specimen.

To determine whether the Army and Air Force are documenting in-theater
medical interventions in servicemembers’ medical records, we requested,
at each installation visited for medical records review, the patient sign-in
logs for in-theater medical care providers, namely the Army’s battalion aid
station and the Air Force’s expeditionary medical support, when they were
deployed to central Asia in support of OEF and for the two Army
installations we visited that deployed in support of OJG. Officials were
unable to locate or access the logs at all of our selected installations
except for Fort Drum for the OEF deployment. Consequently, we were
able to perform our planned examination for this objective at only Fort
Drum for the OEF deployment. From these logs, we selected a random
sample of 36 patient visits from one battalion aid station and 18 patient
visits from another battalion aid station. We did not attempt to judge the
importance of the patient visit in making our selections. For the selected
patient visits, we then reviewed the servicemember’s medical record for
any documentation—such as the Army’s Standard Form 600—of the
servicemember’s visit to the battalion aid station.

To determine whether the Army and Air Force’s deployment health-related
records are retained and maintained in a centralized location, we
requested that officials at the Army Medical Surveillance Activity (AMSA)
query the AMSA database for the servicemembers included in our samples
at the selected Army and Air Force installations. For servicemembers in
our samples, AMSA officials provided us with copies of deployment health
assessments and immunization data found in the AMSA database. We
analyzed the completeness of the AMSA database by comparing the
deployment health assessments and the pre-deployment immunization


Page 34                                       GAO-03-1041 Defense Health Care
Appendix I: Scope and Methodology




data we found during our medical records review with those in the AMSA
database. Since Air Force special operations force units use the Hurlburt
Field, we also requested the U.S. Special Operations Command (SOCOM)
to query their Special Operation Forces Deployment Health Surveillance
System database for servicemembers in our sample at Hurlburt Field for
deployment health assessments and pre-deployment immunization data.
We then compared the data identified from the SOCOM and AMSA queries
with the data we found during our medical records review.

To determine whether DOD has corrected problems related to the
accuracy and completeness of databases reflecting which servicemembers
deployed to certain locations, we interviewed officials within the
Deployment Health Support Directorate and the Defense Manpower Data
Center and reviewed documentation related to the completeness of
deployment databases and planned improvements in capabilities.

Our review was performed from June 2002 through July 2003 in
accordance with generally accepted government auditing standards.




Page 35                                      GAO-03-1041 Defense Health Care
             Appendix II: Comments from the Department
Appendix II: Comments from the Department
             of Defense



of Defense




             Page 36                                     GAO-03-1041 Defense Health Care
Appendix II: Comments from the Department
of Defense




Page 37                                     GAO-03-1041 Defense Health Care
Appendix II: Comments from the Department
of Defense




Page 38                                     GAO-03-1041 Defense Health Care
                  Appendix III: GAO Contact and Staff
Appendix III: GAO Contact and Staff
                  Acknowledgments



Acknowledgments

                  Clifton E. Spruill (202) 512-4531
GAO Contact
                  In addition to the individual named above, Steve Fox, Rebecca Beale,
Acknowledgments   Lynn Johnson, William Mathers, Terry Richardson, Kristine Braaten,
                  Grant Mallie, Herbert Dunn, and R.K. Wild made key contributions to
                  this report.




(350216)
                  Page 39                                      GAO-03-1041 Defense Health Care
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