Background

DOD policy states that each military service must administer the PDHRA  to active component, Reserve component, and separated servicemembers  90 to 180 days following deployment if they meet the following conditions:    deployed for greater than 30 days,    deployed to locations outside the continental United States, and    deployed to locations without permanent military treatment facilities.
The military services, using service-specific databases, identify active and  Reserve component servicemembers to whom the PDHRA requirement  applies and notify these servicemembers via various methods, such as  postcards, e-mail, telephone, and face-to-face contact.
The DOD policy that initiated the PDHRA program stated that the military  services should contact servicemembers who separate before or during  the reassessment period to offer them the opportunity to fill out the  PDHRA questionnaire. However, there is no mechanism in place to offer  separated servicemembers the opportunity to fill out the PDHRA  questionnaire. Once these servicemembers have separated from military  service, they have no further obligation to the military services and  accordingly, cannot be required to fill out the PDHRA questionnaire. It can  also be difficult to locate and contact servicemembers after they separate.  Instead, the military services, with the exception of the Air Force,  implemented policies to administer the PDHRA to active and Reserve  component servicemembers as part of the separation process from the  military. Although the Army formally implemented its policy to  administer the PDHRA to servicemembers before they separate in April  2008, the practice had been in effect as early as January 2006. The Navy  and Marine Corps implemented a similar policy in January 2009. According  to Air Force officials, there are plans to implement a policy by December  2009.
The PDHRA involves two steps—active or Reserve component  servicemembers fill out a PDHRA questionnaire and then discuss their  questionnaire health concern responses with health care providers. The  PDHRA questionnaire consists of a demographic section, a medical  section, and a third section for a health care provider to fill out and sign.  The demographic section asks for servicemembers to provide information  such as date of birth, gender, and marital status. The medical section of  the questionnaire asks servicemembers to self-report information on their  current physical and mental health condition and concerns. DOD  considers a PDHRA questionnaire complete when a health care provider  reviews and signs the questionnaire, regardless of whether  servicemembers fill out the entire PDHRA questionnaire or only the  demographic section. (See app. II for a sample PDHRA questionnaire.)

		Methods of PDHRA Administration

The Army, Air Force, Navy, and Marine Corps require active and Reserve  component servicemembers to whom the PDHRA requirement applies to  fill out at least the demographic section of the PDHRA questionnaire.  Although filling out the medical section is voluntary, DOD officials  estimate that less than 1 percent of servicemembers who fill out the  PDHRA questionnaire decline to fill out the medical section, with the  exception of the Air Force, which reported a higher declination rate.
Active component servicemembers typically fill out the PDHRA  questionnaire online either prior to PDHRA on-site events or during such  events, which are usually held at military installations. Similarly, Reserve  component servicemembers may fill out the PDHRA questionnaire— administered by the contractor, LHI—online, prior to or during on-site  events. In addition, LHI maintains call centers to administer the PDHRA to  Reserve component servicemembers. Reserve component  servicemembers who use LHI’s call centers may fill out the demographic  and medical sections of the questionnaire online or, with the help of call  center staff, may fill out both sections of the questionnaire through the call  centers.

		Health Care Provider Review and Referral for Further Evaluation

DOD requires that a health care provider review and discuss active and  Reserve component servicemembers’ health concern responses on the  PDHRA questionnaire, including any physical and mental health concerns  that servicemembers self-identify on their questionnaires. Health care  providers use professional judgment to decide whether a further  evaluation is needed, based on servicemembers’ responses and other  information revealed from the discussions with servicemembers. If  referrals for a further evaluation are recommended, health care providers  offer servicemembers information on obtaining a referral appointment.  For example, a health care provider may provide information on obtaining  an appointment at a military treatment facility or a Vet Center.
Once a referral for a further evaluation is made, DOD does not require the  military services to follow up to determine if active and Reserve  component servicemembers have made or attended an appointment  generated as a result of the health care provider’s assessment. However,  for Reserve component servicemembers, referral follow-up is part of LHI’s  administration of the PDHRA. LHI staff follow up within 72 hours with  Reserve component servicemembers who have been issued a referral for a  further evaluation through the call centers to ensure that these  servicemembers have the information needed to obtain an appointment  and to encourage servicemembers to schedule an appointment. In  addition, LHI staff attempt to contact Reserve component servicemembers  30 days after medical referrals are issued, whether issued through PDHRA  on-site events or through the call centers, to ask whether they scheduled  and attended an appointment. If servicemembers did not, LHI staff ask if  assistance is needed in scheduling an appointment.
Each of the military services is required to electronically submit PDHRA  questionnaires for both active and Reserve component servicemembers to  DOD’s central repository. The central repository is the single source of  DOD-level health surveillance information. The central repository contains  data on diseases and medical events and longitudinal data on personnel  and deployments, including information from DOD’s various deployment  health assessments, such as the PDHRA. For Reserve component  servicemembers who fill out PDHRA questionnaires through LHI, LHI staff  are responsible for verifying that the questionnaires are submitted to the  appropriate military service’s database. The military services are then  responsible for submitting the questionnaires from their respective  databases to DOD’s central repository.

		DOD’s Deployment Health Quality Assurance Program

DOD established a deployment health quality assurance program in  January 2004 to assess whether DOD’s deployment health assessments,  including the PDHRA, are conducted as required. The deployment health  quality assurance program relies on data from DOD’s central repository,  data from the military services, and site visits to military installations to  monitor and report on the extent of compliance among the military  services with DOD’s deployment health requirements, such as the number  of active and Reserve component servicemembers that filled out the  PDHRA questionnaire. According to DOD’s deployment health quality  assurance program manager, the program performed a site visit to Reserve  units to validate data provided by the military services for the first time in  October 2008, as part of its oversight of deployment health assessments,  including the PDHRA. Prior to that, the quality assurance program only  performed site visits to active component sites. On a quarterly basis, the  quality assurance program reports to the military services on each  service’s compliance with deployment health requirements. The quality  assurance program also reports annually to the Armed Services  Committees of the House of Representatives and Senate on site visit  findings and on deployment health assessment data, including the number  and percentage of servicemembers with PDHRA questionnaires in DOD’s  central repository. Through its monitoring and reporting, DOD’s quality  assurance program helps ensure that DOD’s deployment health  assessments are conducted for active and Reserve component  servicemembers as required.

		DOD’s Contract with LHI to Administer the PDHRA to Reserve Component Servicemembers

DOD contracts with LHI to administer the PDHRA to Reserve component  servicemembers. Although LHI administers the PDHRA to Reserve  component servicemembers on behalf of DOD, the military services are  responsible for identifying and notifying servicemembers to whom the  PDHRA requirement applies and for submitting questionnaires to DOD’s  central repository. DOD’s RHRP office is responsible for monitoring  DOD’s contract with LHI, which includes the administration of the PDHRA  to Reserve component servicemembers, as well as the provision of other  health services for this population, such as immunizations, physical  examinations, and dental examinations and X-rays.
DOD’s contract with LHI is a performance-based contract and, as such,  establishes performance standards that the RHRP office uses in  monitoring and assessing LHI’s performance in providing services to  Reserve component servicemembers, including the administration of the  PDHRA. For example, under its contract with DOD, LHI call center staff  are required to answer 80 percent of incoming calls within 120 seconds. In  monitoring LHI’s performance, DOD’s RHRP office helps ensure that the  objective of the PDHRA program—to identify and address  servicemembers’ health concerns, including mental health concerns, that  emerge over time following deployments—is achieved for Reserve  component servicemembers.

	DOD’s Central Repository Did Not Contain PDHRA Questionnaires for a Substantial Percentage of Servicemembers Who Returned from Deployment to Iraq or Afghanistan

On the two occasions we queried DOD’s central repository, we did not find  PDHRA questionnaires for a substantial percentage of the active and  Reserve component servicemembers in our population of interest. DOD  policy requires that the military services electronically submit  questionnaires to DOD’s central repository, which DOD uses as a key  source of health surveillance information. The first of our two queries of  DOD’s central repository occurred on April 15, 2009. On this date, we  found that the central repository contained PDHRA questionnaires for  only 77 percent of the roughly 319,000 active component, Reserve, and  National Guard servicemembers who, according to DOD DMDC  deployment data, returned from deployment to Iraq or Afghanistan  between January 1, 2007, and May 31, 2008.
We could not identify PDHRA questionnaires in DOD’s central repository  on April 15, 2009, for a large number of servicemembers in our  population—about 74,000 servicemembers—which represents the  remaining 23 percent of our population of interest. We made our query  nearly 1 year after the last servicemembers in our population returned  from deployment. The percentage of PDHRA questionnaires absent from  DOD’s central repository for our population of interest varied by military  service and component. For example, among military service components,  this percentage ranged from a low of about 10 percent to a high of about  61 percent. (For more information on the extent to which  servicemembers in our population of interest did not have PDHRA  questionnaires in DOD’s central repository as of April 15, 2009, see   app. III.)
After determining that about 74,000 servicemembers in our population of  interest did not have questionnaires in DOD’s central repository based on  our first query, we asked the military services whether these  servicemembers had PDHRA questionnaires that could be identified in the  services’ own databases. With the help of the services, we found that  approximately 7,000 servicemembers—or about 9 percent of the 74,000  servicemembers—had questionnaires in their respective military services’  databases, but not in DOD’s central repository. The number of  questionnaires identified in the military services’ databases that were not  in the central repository varied by military service—ranging from over 300  questionnaires for Air Force and Navy servicemembers to about 3,000 for  Army and Marine Corps servicemembers.
On September 4, 2009, we queried DOD’s central repository again to  update our April 2009 data and determine whether any progress had been  made in reporting questionnaires to the central repository. On this second  query—15 months after the last servicemembers in our population of  interest returned from deployment—we found that DOD’s central  repository was missing the same percentage of PDHRA questionnaires as  had been missing in April. As a result of our September 2009 query, we still  found PDHRA questionnaires for only 77 percent of the approximately  319,000 servicemembers in our original population of interest. While we  identified slightly more questionnaires than we identified in our April  query, we were still unable to identify questionnaires in the central  repository for about 72,000 servicemembers. (See table 1.)
The absence of 72,000 PDHRA questionnaires from DOD’s central  repository for servicemembers who should have filled them out hinders  DOD’s deployment health quality assurance program from effectively  assessing the military services’ compliance with PDHRA requirements.  The program, which DOD established to assess whether DOD’s  deployment health assessments are conducted as required, relies in part  on the presence of PDHRA questionnaires in the central repository. These  questionnaires document the extent to which servicemembers were given  the opportunity to fill out the questionnaire, as required under DOD policy.  DOD officials specifically cited the importance of this documentation for  helping the quality assurance program ensure that servicemembers have  the opportunity to have their health concerns identified and addressed.  However, the absence of questionnaires from the central repository for  servicemembers who should have filled them out suggests either that not  all of these servicemembers filled out the questionnaire or that  questionnaires were filled out, but were not incorporated into DOD’s  central repository. When questionnaires for servicemembers from our  population of interest are not in the central repository, DOD does not have  reasonable assurance that all members of this vulnerable population of  active component, Reserve, and National Guard servicemembers that  deployed to Iraq or Afghanistan were administered the PDHRA  questionnaire, which is intended to help identify deployment-related  health concerns that emerge over time and facilitate the opportunity for  servicemembers to address these concerns.

	DOD Uses Four Methods to Monitor the Administration of the PDHRA to Reserve Component Servicemembers, but Does Not Clearly Document Its Monitoring

DOD’s Reserve Health Readiness Program (RHRP) office uses four  methods to monitor LHI’s administration of the PDHRA to Reserve  component servicemembers. However, in using these methods, DOD’s  RHRP office does not always clearly document its monitoring of the  PDHRA program. The office’s documentation does not allow DOD to have  reasonable assurance that potential problems that may relate to the  welfare and safety of servicemembers have been addressed and resolved.

		DOD Uses Four Methods to Monitor the Administration of the PDHRA to Reserve Component Servicemembers

DOD’s RHRP office uses four methods to monitor LHI’s performance in  administering the PDHRA to Reserve component servicemembers. More  broadly, the RHRP office also uses the four methods to monitor whether  the objective of the PDHRA program—to identify and address  servicemembers’ health concerns that emerge over time following  deployments—is being met for Reserve component servicemembers. The  four methods, which are identified in DOD’s contract with LHI, are the  following:    Reviews of periodic reports. The RHRP office receives several periodic  reports that DOD requires from LHI on LHI’s administration of the PDHRA  to Reserve component servicemembers. DOD requires LHI to report  aggregate information on LHI’s administration of the PDHRA, including  reports on its compliance with performance standards. For instance, the  RHRP office receives a report on LHI’s compliance with the performance  standard requiring that LHI call center staff answer 80 percent of incoming  calls within 120 seconds. In addition, LHI provides descriptive  information on the number of Reserve component servicemembers  administered the PDHRA, referred for a further evaluation, and contacted  by LHI staff 30 days after receiving referrals. An RHRP official told us  that the office reviews LHI’s reports to examine data related to the  administration of the PDHRA and identifies potential problems that could  pose risks to servicemembers and the objective of the PDHRA program.  For example, the number of servicemembers referred each month is  compared against historical data to monitor any changes in the rate at  which servicemembers receive referrals for physical and mental health  concerns.
Inspections of the administration of PDHRA. The RHRP office also  conducts inspections related to LHI’s administration of the PDHRA to  Reserve component servicemembers. The inspections have included  observing PDHRA on-site events, at which servicemembers are  administered the PDHRA, to assess the quality of LHI services delivered  during the events. For instance, an RHRP official told us that he checks  whether the events are staffed with a sufficient number of health care  providers and administrative staff. In another instance, an RHRP official  listened to LHI call center discussions between LHI staff and Reserve  component servicemembers to examine how LHI staff administer the  PDHRA.
Feedback on the administration of the PDHRA from military service  officials. The RHRP office obtains informal feedback about how the  PDHRA is being administered to Reserve component servicemembers  through e-mail correspondence, telephone conversations, and in-person  discussions with military service officials who are responsible for  managing the PDHRA for their respective services. These officials told us  that the RHRP office generally maintains open, informal communication  channels through which they can and do express their concerns.
Weekly telephone discussions with LHI staff. An RHRP official said that  weekly telephone discussions with LHI staff are held to obtain their  feedback on the administration of the PDHRA to Reserve component  servicemembers. In addition, during these discussions, an RHRP official  and LHI staff discuss and address potential problems identified through  the periodic reports, inspections, and military service feedback. The  potential problems staff discuss may include those that could pose a risk  to the PDHRA program objective and to the welfare and safety of Reserve  component servicemembers. For example, some problems concerned how  servicemembers were responding to questions on the PDHRA  questionnaire. According to an RHRP official, these discussions serve as a  forum to determine the actions DOD officials or LHI staff need to take to  address identified problems and to verify that problems raised during  previous discussions have been properly resolved.

		DOD Generally Does Not Clearly Document Its Monitoring of the PDHRA Program

When monitoring the administration of the PDHRA to Reserve component  servicemembers, DOD does not maintain clear documentation that is  consistent with good management practices outlined in federal internal  control standards. According to these standards, internal control  activities such as monitoring should be clearly documented in a manner  that is accurate, timely, and helps provide reasonable assurance that  program objectives are being achieved. Further, such documentation  should be properly managed and maintained so that it is readily accessible  and should allow someone other than the assigned officials to understand  the identified potential problem, the actions taken to address the problem,  and whether these actions have resolved the problem.
Instead of adopting an approach that generated documentation consistent  with management practices outlined in federal internal control standards,  the RHRP office created an unsystematic, improvised approach for  documenting potential problems that were identified through review of  periodic reports, inspections, and feedback from military service officials  and LHI staff. These problems may pose a risk to the PDHRA program  objective. The RHRP office’s approach solely relies on agendas and e-mail  correspondence to document these potential problems and the actions  taken to resolve them.
Weekly agendas with related notes. Prior to the weekly discussions with  LHI staff, a typed agenda is prepared for discussion that lists the potential  problems identified through monitoring activities. During these  discussions, annotated brief handwritten notes are made on an agenda  item and these notes are used to indicate that certain actions need to be  taken by DOD officials or LHI staff to address an identified problem. When  it appears that problems have been resolved, instead of documenting how  the problem was resolved, the problem is not included on the agenda for  the next week’s discussion. A hard copy of the agenda is retained and  filed in the RHRP office after each weekly discussion with LHI staff.
E-mail correspondence. The RHRP office receives and generates e-mail  correspondence with LHI staff and military service officials that discusses  potential problems identified through monitoring the administration of the  PDHRA to Reserve component servicemembers.
We found that the RHRP office’s sole reliance on these agendas and e-mail  correspondence did not always result in clear documentation—that is,  documentation that is understandable and readily accessible to others  outside the RHRP office. In particular, the agendas and e-mail  correspondence we reviewed did not always clearly describe the decisions  made and the actions taken to address identified problems in a manner  that provides reasonable assurance that the problems have been  resolved. An RHRP official acknowledged that he could not consistently  rely on the agendas and e-mail correspondence to reconstruct information  obtained through the office’s internal control responsibility to monitor and  address problems associated with the administration of the PDHRA to  Reserve component servicemembers. Instead, this official relies on  memory to recall such information.
In our review of the documentation related to 15 potential problems we  selected, we found that the RHRP office’s documentation generally did not  clearly describe the problem, the actions taken to address the problem,  and whether these actions have resolved the problem. For example, on  two September 2008 agendas for the weekly discussions with LHI staff, the  agendas include a potential problem identified by DOD officials that 25 to  30 percent of servicemembers were not responding to questions on the  PDHRA questionnaire about the number of alcoholic drinks they  consumed on a typical day, and 18 percent were not responding to the  questions about whether they were depressed. The RHRP office asked LHI  staff if they were finding similar nonresponses to these questions from  Reserve component servicemembers. However, the subsequent agendas— which the RHRP office relies on to track problems—do not contain any  additional information about how this potential problem was resolved.  There is no further information, including any related e-mail  correspondence, on how this potential problem was addressed. This  example raises questions about whether Reserve component  servicemembers’ mental health concerns—specifically those related to  alcohol use and depression—are being consistently identified or whether  any follow-up actions are needed to address this problem.
We also reviewed e-mail correspondence related to the 15 selected  potential problems, dated between March 4, 2008, and May 19, 2009, and  found that it often contained vague information about the identified  problems and the actions taken to resolve them. Some of these problems  relate to the welfare and safety of servicemembers and require more  information than is present in the available documentation to understand  whether or how the problems were resolved. For example, we asked about  an instance in which a military service official reported that an LHI health  care provider failed to document on a Reserve component  servicemember’s PDHRA questionnaire why the servicemember with  reported suicidal ideations did not get an immediate referral. The e-mail  correspondence about this potential problem had gaps. For instance, while  the e-mail correspondence indicates that the RHRP office asked LHI staff  to look into the incident and contains a reply from LHI staff stating that  they would investigate further, the e-mail correspondence does not  document the final results of the LHI staff’s investigation, including  whether or how this potential problem was resolved. Although this  potential problem is listed on several agendas, the agendas do not provide  any more information about the problem or how it was resolved. Instead,  an RHRP official told us that he relied on his memory to explain to us what  happened and how it was resolved. This official told us he requested that  LHI staff remind its health care providers to fully document the results of  their physical and mental health assessments on Reserve component  servicemembers’ PDHRA questionnaires in the future. However, there is  no documentation of this request to LHI staff or any documentation of  plans to follow up to ensure that LHI staff carried out the request. (For  more information on the documentation related to the 15 potential  problems, see app. IV.)
In addition to being generally incomplete and unclear, the e-mail  correspondence related to the potential problems is not readily accessible.  E-mail correspondence about identified problems is placed into labeled  folders within the office’s e-mail system, but the labels are general and e- mail correspondence could appropriately be placed in a number of folders.  An official told us that, as a result, he struggles in remembering into which  folder a specific e-mail was placed. For example, e-mail correspondence  about an identified problem about an Army Reserve servicemember’s  PDHRA questionnaire may be placed in either an Army PDHRA folder, a  PDHRA complaints folder, or a standard operating procedures folder. Not  having documentation that is readily accessible hinders the RHRP office’s  ability to promptly ensure that identified problems have been properly  addressed. In addition, should LHI’s performance diminish—for example,  if LHI was not resolving identified problems—the lack of readily available  documentation could compromise DOD’s ability to take appropriate  action.

	Conclusions

DOD established the PDHRA program in order to identify and address  servicemembers’ health concerns—including mental health concerns— that emerge over time following deployments. The PDHRA questionnaire  is a key tool in DOD’s efforts to assess the physical and mental health  condition of servicemembers who have returned from deployments to Iraq  and Afghanistan, where exposure to intense combat can place  servicemembers at risk for developing conditions, such as post-traumatic  stress disorder. DOD’s deployment health quality assurance program  assesses the military services’ compliance with the requirement to  administer the PDHRA to active and Reserve component servicemembers  to help ensure that servicemembers have the opportunity to have their  health concerns identified and addressed through the PDHRA.
However, our current findings show that the concerns we previously  raised about DOD’s quality assurance program remain. Specifically, the  absence of PDHRA questionnaires in DOD’s central repository for  thousands of eligible active and Reserve component servicemembers  continues to hinder the program’s ability to assess the extent to which  these servicemembers fill out the PDHRA questionnaire and have the  opportunity to identify any health concerns that emerge over time  following deployments. DOD officials have identified the presence of  questionnaires in the central repository as important for the efforts of  DOD’s quality assurance program. Without this information, the program  may not be able to accurately determine completion rates among the  military services and thus provide reasonable assurance to DOD or to  Congress that one of DOD’s key health assessments is being administered  as required.
Ensuring that Reserve component servicemembers fill out the PDHRA  questionnaire may be particularly important, as some evidence suggests  that these servicemembers may be more likely to develop mental health  conditions after returning from deployment when compared with their  active component counterparts. Although DOD monitors the  administration of the PDHRA to Reserve component servicemembers,  documentation associated with this monitoring needs to be strengthened.  The RHRP office has not always clearly documented—in a way that is  consistent with federal internal control standards—information related to  problems that may pose risks to the objective of the PDHRA program.  Some of these potential problems also involve Reserve component  servicemembers’ welfare and safety. The office’s improvised, unsystematic  approach to documenting potential problems results in documentation  that does not provide DOD with reasonable assurance that these problems  have been resolved.

	Recommendations for Executive Action

To help DOD obtain reasonable assurance that all active and Reserve  component servicemembers to whom the PDHRA requirement applies are  provided the opportunity to have their health concerns identified, we  recommend that the Assistant Secretary of Defense for Health Affairs and  the military services take steps to ensure that PDHRA questionnaires are  included in DOD’s central repository for each of these servicemembers.
To ensure adequate documentation of problems that may pose risks to the  objective of the PDHRA program for Reserve component servicemembers,  we recommend that the Assistant Secretary of Defense for Health Affairs  require the RHRP office to document the information obtained through  monitoring the PDHRA program in a manner consistent with federal  internal control standards.

	Agency Comments and Our Evaluation

In written comments on a draft of this report, DOD concurred with our  two recommendations. Specifically, DOD agreed with our  recommendation that it take steps to ensure that PDHRA questionnaires  are included in DOD’s central repository for each servicemember to whom  the PDHRA requirement applies. DOD stated that to implement this  recommendation, it will take the following actions: work to correctly  identify servicemembers who need to receive the PDHRA and work to  identify and resolve any obstacles to transmission of data from the military  services to AFHSC. Additionally, DOD stated that it sent a memorandum  on October 15, 2009, to the military services’ Surgeons General re- emphasizing the importance of deployment health requirements. DOD also  agreed with our recommendation concerning documentation of problems  that may pose risks to the objective of the PDHRA program for Reserve  component servicemembers. DOD stated that during our engagement, the  RHRP office recognized a need to improve documentation of its  monitoring of the PDHRA program. DOD also stated in its response that  the RHRP office established a more distinct and clear electronic filing  system and began documenting not only potential problems with the  PDHRA program, but also their resolution in a manner that DOD reports is  sufficiently comprehensive, accessible, and understandable. We did not  assess this new approach to documentation. DOD’s written comments are  included in their entirety in appendix V. DOD did not provide technical  comments.
We are sending copies of this report to the Secretary of the Department of  Defense. The report will be available at no charge on GAO’s Web site at  http://www.gao.gov.
If you or your staff have questions about this report, please contact me at  (202) 512-7114 or williamsonr@gao.gov. Contact points for our Office of  Congressional Relations and Public Affairs may be found on the last page  of this report. GAO staff who made major contributions to this report are  listed in appendix VI.

Appendix I: Scope and Methodology

To determine the extent to which post-deployment health reassessment  (PDHRA) questionnaires are contained in the Department of Defense’s  (DOD) central repository for active and Reserve component  servicemembers who returned from deployment to Iraq or Afghanistan, we  conducted a quantitative analysis using DOD data from two sources—the  Defense Manpower Data Center’s (DMDC) Contingency Tracking System  (CTS) and the Armed Forces Health Surveillance Center’s (AFHSC)  Defense Medical Surveillance System (DMSS). DMDC’s CTS contains data  on servicemembers deployed in support of the Overseas Contingency  Operations—including data on servicemembers’ deployment dates and  location of deployment. We used CTS data to identify a selected  population of interest: active component, Reserve, and National Guard  servicemembers who had returned from deployments of greater than 30  days to Iraq or Afghanistan between January 1, 2007, and May 31, 2008.
DMDC officials identified this population for us using servicemembers’  deployment dates and locations. If a servicemember had multiple  deployments during this period, we received data on a servicemember’s  most recent return from deployment during this time period. Although  DOD initiated the PDHRA program in March 2005, the military services  implemented the program at different times, with full implementation  across all services in late 2006. In addition, servicemembers are not  eligible to fill out a PDHRA questionnaire until 90 to 180 days after they  have returned from deployment. Thus, when we requested data from  DMDC in late fall 2008, we needed to focus on a population of  servicemembers who had returned from deployment at least 180 days  prior to our data request. Therefore, we focused our analysis on  servicemembers who returned from deployment on or after January 1,  2007, and on or before May 31, 2008. As a secondary check that this  population of interest had, in fact, deployed, we sent our population of  interest to AFHSC officials, who compared our population to two other  deployment rosters. The results of this match identified our final  population of interest of approximately 319,000 servicemembers.
AFHSC’s DMSS is DOD’s central repository for PDHRA questionnaires and  the military services are required to submit questionnaires to this central  repository. To determine the extent to which servicemembers in our  population of interest had PDHRA questionnaires in DOD’s central  repository, we sent personal identifying information and beginning and  end deployment dates from CTS for the servicemembers in our population  of interest to AFHSC. AFHSC officials matched our population of interest  to the PDHRA questionnaires in DMSS using a servicemember’s personal  identifying information and the beginning and end deployment dates as  recorded in CTS and as reported by the servicemember on the PDHRA  questionnaire. AFHSC officials then sent us data from identified  questionnaires that had been incorporated into DMSS as of April 15, 2009.
As the military services collect PDHRA questionnaires in their own  databases before transmitting them to AFHSC’s DMSS, we then asked  officials from the military services to query their own databases to identify  PDHRA questionnaires for servicemembers in our population of interest  for which a PDHRA questionnaire could not be identified in DMSS. We  provided the military services with a servicemember’s personal identifying  information and deployment end date from CTS and asked them to query  their databases for any questionnaires that they would consider to be  ready to transmit to AFHSC that were filled out after the deployment end  date listed in CTS. The military services then queried their own databases  and, for each servicemember that we sent to them for which they could  identify a PDHRA questionnaire, returned to us the end deployment date  listed on the PDHRA questionnaire and date of questionnaire completion.  If a servicemember filled out multiple PDHRA questionnaires after the  deployment end date listed in CTS, we received information from each of  these questionnaires. We received these data from the military services in  late May and June 2009. We then matched our population of interest to the  information from the PDHRA questionnaires received from the military  services’ databases using a servicemember’s personal identifying  information and the end deployment date as recorded in CTS and as  reported by the servicemember on the PDHRA questionnaire.
Finally, in September 2009, we obtained additional data from AFHSC to  update our April 2009 data. AFHSC officials matched information from the  servicemembers in our population of interest without a questionnaire in  DMSS as of April 15, 2009, to the PDHRA questionnaires in DMSS as of  September 4, 2009, using a servicemember’s personal identifying  information and the beginning and end deployment dates as recorded in  CTS and as reported by the servicemember on the PDHRA questionnaire.  AFHSC officials then sent us data from identified questionnaires that had  been incorporated into DMSS as of September 4, 2009.
We conducted data reliability assessments for each DOD and military  service data source we used by reviewing related documentation,  interviewing knowledgeable agency officials, and performing electronic  data testing for missing data, outliers, and obvious errors. We determined  that these data sources were sufficiently reliable for our purposes. We  determined only the extent to which questionnaires could be identified in  AFHSC’s DMSS or the military services databases for our population of  interest, and not the extent to which the servicemembers actually filled  out a PDHRA questionnaire.
We interviewed officials from DMDC and AFHSC, the DOD deployment  health quality assurance program, and Army, Air Force, Navy, and Marine  Corps officials involved in the collection and transfer of PDHRA  questionnaires from the military services’ databases to AFHSC. We also  reviewed DOD policies, as well as those of the Army, Air Force, Navy, and  Marine Corps, for submitting PDHRA questionnaires to DOD’s central  repository. Finally, we reviewed our prior work on DOD’s deployment  health quality assurance program.
To determine how DOD monitors the administration of the PDHRA to  Reserve component servicemembers, we reviewed DOD’s policies for  monitoring its contract with Logistics Health, Inc. (LHI), the contractor  that administers the PDHRA to Reserve component servicemembers. We  also interviewed officials with DOD’s Reserve Health Readiness Program  (RHRP)—the DOD office responsible for monitoring LHI—along with  military service officials responsible for managing the administration of  the PDHRA to Reserve component servicemembers. We reviewed DOD’s  contract with LHI and obtained and analyzed contractually required  reports and other documentation on LHI’s performance related to the  PDHRA portion of DOD’s contract with LHI. We visited LHI’s  headquarters in La Crosse, Wisconsin, where we interviewed LHI staff to  confirm our understanding of how LHI staff administers the PDHRA to  Reserve component servicemembers. We additionally interviewed officials  with the U.S. Army Medical Research Acquisition Activity, which provides  support to DOD for the contract with LHI. We reviewed DOD’s monitoring  of the administration of the PDHRA to Reserve component  servicemembers to determine the extent to which these monitoring efforts  met or were consistent with GAO’s Standards for Internal Control in the  Federal Government. Internal controls include components of an  organization’s management that provide reasonable assurance that  program objectives are being achieved.
The RHRP office receives contractually required reports from LHI on its  administration of the PDHRA and we obtained and reviewed monthly  reports from May 2008 through April 2009 for the following four required  reports: (1) the PDHRA monthly activity report, (2) the call center access  report, (3) the data entry report, and (4) the PDHRA customer satisfaction  survey report. We selected the PDHRA monthly activity and the call center  access reports to review because the RHRP office told us that these  reports provide information that is needed to monitor LHI’s activities in  administering the PDHRA to Reserve component servicemembers. The  PDHRA monthly activity report provides aggregate information on LHI’s  PDHRA administration, such as the number of Reserve component  servicemembers administered the PDHRA, referred for a further  evaluation, and contacted by LHI 30 days after receiving referrals. The call  center access report provides information on LHI’s performance in  operating its call center. In addition, we selected the data entry and  PDHRA customer satisfaction survey reports to review because both  reports provide information on performance standards associated with the  PDHRA that LHI must meet to comply with the contract. The data entry  report provides information on LHI’s performance in entering PDHRA data  into military services’ databases, and the PDHRA customer satisfaction  survey report provides information on whether LHI meets a performance  standard associated with servicemember feedback on LHI’s administration  of the PDHRA. We also reviewed the documentation associated with the  RHRP office’s inspections of LHI’s administration of the PDHRA from  October 1, 2007, through May 6, 2009. We reviewed a list, provided by the  RHRP office, of the feedback received from military service officials  between January 1, 2008, and April 30, 2009.
To obtain more in-depth information on how DOD documents the  information it obtains through its monitoring efforts, we examined  documentation maintained by the RHRP office on its monitoring.  Specifically, we reviewed the RHRP office’s agendas from the weekly  telephone discussions with LHI staff and the office’s e-mail  correspondence, which the RHRP office uses to document its monitoring.  We reviewed approximately 70 of the RHRP office’s agendas for the period  between October 1, 2007, and May 11, 2009. From the agendas and the  provided list of military service feedback, we judgmentally selected 15  potential problems to review in further detail and asked the RHRP office  to provide us with all of the documentation available on these problems,  including any e-mail correspondence that related to the problem. We  selected these 15 potential problems because the subject of each of these  may have involved welfare and safety concerns for Reserve component  servicemembers. The RHRP office provided us with e-mail  correspondence dated between March 4, 2008, and May 19, 2009, related to  the 15 potential problems. We reviewed the agendas and the available e- mail correspondence for the 15 selected problems to determine the actions  taken to resolve the problems and how this information is documented  and maintained. Our findings related to the documentation of the 15  potential problems are for illustrative purposes only and are not  generalizable to other RHRP office documentation.
We conducted this performance audit from October 2008 to October 2009  in accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.

Appendix II: Sample Post-Deployment Health Reassessment Questionnaire (DD 2900), January 2008

Servicemembers fill out the post-deployment health reassessment (PDHRA)  questionnaire electronically on form DD 2900, which was originally issued in June  2005. The Department of Defense (DOD) issued a revised form DD 2900 in January  2008.

Appendix III: Post-Deployment Health Reassessment Questionnaires in DOD’s Central Repository and Services’ Databases

Department of Defense (DOD) policy requires that the military services electronically  submit post-deployment health reassessment (PDHRA) questionnaires to DOD’s  central repository, which DOD uses as a key source of health surveillance  information. We queried DOD’s central repository on two occasions—April 2009 and  September 2009. On April 15, 2009, we found that for approximately 23 percent of the  roughly 319,000 servicemembers who, according to DOD deployment data, returned  from deployment to Iraq or Afghanistan between January 1, 2007, and May 31, 2008,  we could not identify questionnaires in the central repository (see table 2).
After determining that about 74,000 servicemembers in our population of interest did  not have questionnaires in DOD’s central repository based on our first query, we  asked the military services whether these servicemembers had PDHRA  questionnaires that could be identified in the services’ own databases. With the help  of the services, we found that approximately 7,000 servicemembers had  questionnaires in their respective military services’ databases, but not in DOD’s  central repository (see table 3). On our second query of the central repository, which  occurred on September 4, 2009, questionnaires for about 1,000 of these 7,000  servicemembers were in the central repository.

Appendix IV: DOD’s Documentation of Its Monitoring of the Administration of the Post- Deployment Health Reassessment

The Department of Defense (DOD) contracts with Logistics Health, Inc. (LHI) to  administer the post-deployment health reassessment (PDHRA) to Reserve component  servicemembers. DOD’s Reserve Health Readiness Program (RHRP) is responsible  for monitoring LHI’s administration of the PDHRA. To obtain more in-depth  information on how the RHRP office documents the information it obtains through its  monitoring of the administration of the PDHRA to Reserve component  servicemembers, we examined documentation maintained by the RHRP office on its  monitoring efforts. Specifically, from the potential problems that the RHRP office had  identified as possibly posing a risk to the objective of PDHRA program, we  judgmentally selected 15 to review in detail and obtained all available RHRP  documentation from the RHRP office on those problems. We selected these 15  potential problems because the subject of each of these may have involved welfare  and safety concerns for Reserve component servicemembers.
We reviewed RHRP’s documentation to determine the extent to which RHRP  maintains documentation in a manner consistent with GAO’s federal internal control  standards. In particular, we examined the extent to which RHRP’s documentation  clearly documented any actions taken to address a problem and indicated whether  the problem had been resolved. In general, the selected RHRP documentation we  reviewed did not meet these standards. Nine of the 15 selected potential problems  lacked documentation on the actions taken to address the problems and/or lacked  documentation of the problems’ resolutions. Four of the 15 problems had  documentation of the actions taken and their resolutions, however, RHRP’s  documentation was not sufficiently clear to allow us to independently understand  what actions had been taken to address the problem or the problems’ resolutions.  Rather, an RHRP official had to explain to us what had occurred. Two of the 15  problems had documentation that allowed us to understand the actions taken to  address the problems and the problems’ resolutions. Table 4 summarizes the results  of our analysis of RHRP’s documentation.
For these potential problems,  documented the nature of a servicemember’s  suicidal ideations on the PDHRA questionnaire. documentation was lacking on the actions  taken to address the problem and/or the  problem’s resolution.
For these potential problems, the RHRP  call center to be administered the PDHRA may  have been denied LHI PDHRA services and not  administered the PDHRA. office had some available documentation,  but this documentation was not sufficiently  clear to allow us to independently  determine the actions taken to address  each problem and to determine the ultimate  resolution of each problem.
11.  Servicemembers who should not have been called  by LHI may have been inappropriately called by  LHI.   12.  A PDHRA event may have lacked sufficient staff.  13.  Health care providers may not have been  documenting needed referrals for further  evaluations when servicemembers declined the  referrals.
For these potential problems, the RHRP  through the LHI call center were not receiving the  same informational brochures as servicemembers  administered the PDHRA at PDHRA on-site  events. office had documentation of the actions  taken to address each problem and the  problem’s resolution.
15.  Reserve component servicemembers did not know  what to do to set up an appointment for a further  evaluation.

Appendix V: Comments from the Department of Defense

Appendix VI: GAO Contact and Staff Acknowledgments

	GAO Contact

	Staff Acknowledgments

In addition to the contact named above, Mary Ann Curran, Assistant  Director; Katherine L. Amoroso; Helen T. Desaulniers; Michael Erhardt;  Martha A. Fisher; Krister Friday; Martha Kelly; Carolyn Kirby; Carolina  Morgan; Lisa A. Motley; Julie E. Pekowski; William Woods; and Suzanne  Worth made key contributions to this report.

Related GAO Products

Federal Contractors: Better Performance Information Needed to Support Agency  Contract Award Decisions. GAO-09-374. Washington, D.C.: April 23, 2009.
Military Operations: DOD Needs to Address Contract Oversight and Quality  Assurance Issues for Contracts Used to Support Contingency Operations.   GAO-08-1087. Washington, D.C.: September 26, 2008.
DOD Systems Modernization: Maintaining Effective Communication Is Needed to  Help Ensure the Army’s Successful Deployment of the Defense Integrated Military  Human Resources System. GAO-08-927R. Washington, D.C.: September 8, 2008.
Defense Health Care: Oversight of Military Services’ Post-Deployment Health  Reassessment Completion Rates Is Limited. GAO-08-1025R. Washington, D.C.:  September 4, 2008.
Electronic Health Records: DOD and VA Have Increased Their Sharing of Health  Information, but More Work Remains. GAO-08-954. Washington, D.C.: July 28, 2008.
VA and DOD Health Care: Administration of DOD’s Post-Deployment Health  Reassessment to National Guard and Reserve Servicemembers and VA’s Interaction  with DOD. GAO-08-181R. Washington, D.C.: January 25, 2008.
Defense Health Care: Comprehensive Oversight Framework Needed to Help Ensure  Effective Implementation of a Deployment Health Quality Assurance Program.  GAO-07-831. Washington, D.C.: June 22, 2007.
Military Personnel: DMDC Data on Officers’ Commissioning Programs is  Insufficiently Reliable and Needs to be Corrected. GAO-07-372R. Washington, D.C.:  March 8, 2007.
Military Personnel: Actions Needed to Strengthen Management of Imminent Danger  Pay and Combat Zone Tax Relief Benefits. GAO-06-1011. Washington, D.C.:  September 28, 2006.
Post-Traumatic Stress Disorder: DOD Needs to Identify the Factors its Providers  Use to Make Mental Health Evaluation Referrals for Servicemembers. GAO-06-397.  Washington, D.C.: May 11, 2006.
Military Pay: Inadequate Controls for Stopping Overpayments of Hostile Fire and  Hardship Duty Pay to Over 200 Sick or Injured Army National Guard and Army  Reserve Soldiers Assigned to Fort Bragg. GAO-06-384R. Washington, D.C.: April 27,  2006.
Contract Management: Opportunities to Improve Surveillance on Department of  Defense Service Contracts. GAO-05-274. Washington, D.C.: March 17, 2005.
VA and Defense Health Care: More Information Needed to Determine If VA Can  Meet an Increase in Demand for Post-Traumatic Stress Disorder Services.   GAO-04-1069. Washington, D.C.: September 20, 2004.
Military Pay: Army Reserve Soldiers Mobilized to Active Duty Experienced  Significant Pay Problems. GAO-04-911. Washington, D.C.: August 20, 2004.
Defense Health Care: Quality Assurance Process Needed to Improve Force Health  Protection and Surveillance. GAO-03-1041. Washington, D.C.: September 19, 2003.

Summary:
Why GAO Did This Study

The Department of Defense (DOD) implemented the post-deployment health reassessment (PDHRA), which is required to be administered to servicemembers 90 to 180 days after their return from deployment. DOD established the PDHRA program to identify and address servicemembers' health concerns that emerge over time following deployments. This report is the second in response to a Senate Armed Services Committee report directing the Government Accountability Office (GAO) to review DOD's administration of the PDHRA, and to additional congressional requests. In this report, GAO examined (1) the extent to which DOD's central repository contains PDHRA questionnaires for active and Reserve component servicemembers who returned from deployment to Iraq or Afghanistan and (2) how DOD monitors the administration of the PDHRA to Reserve component servicemembers. To conduct this review, GAO performed a quantitative analysis using DOD deployment and PDHRA data, reviewed relevant PDHRA policies, and interviewed DOD officials.

What GAO Found

DOD policy requires that the military services electronically submit PDHRA questionnaires to DOD's central repository. Based on two separate queries to this repository in 2009, GAO did not find PDHRA questionnaires for a substantial percentage of the 319,000 active and Reserve component servicemembers who returned from deployment to Iraq or Afghanistan between January 1, 2007, and May 31, 2008. GAO's first query on April 15, 2009, showed that only 77 percent of this population of interest had questionnaires in the central repository, leaving approximately 74,000 servicemembers without questionnaires in the repository. On September 4, 2009, GAO queried DOD's central repository again to update its April 2009 data and found that DOD's central repository was still missing PDHRA questionnaires for about 72,000 servicemembers, or 23 percent of the servicemembers in GAO's original population of interest. When PDHRA questionnaires are not in DOD's central repository, DOD does not have reasonable assurance that servicemembers to whom the PDHRA requirement applies were given the opportunity to fill out the questionnaire and identify and address health concerns that could emerge over time following deployment. DOD uses four methods to monitor the contractor, Logistics Health, Inc. (LHI), that administers the PDHRA to Reserve component servicemembers. The four monitoring methods are: (1) reviews of periodic reports from LHI; (2) inspections of LHI's administration of the PDHRA; (3) feedback on LHI's administration of the PDHRA from military service officials; and (4) weekly telephone discussions with LHI staff. These methods are used to help ensure that the objective of the PDHRA program is being met for Reserve component servicemembers. Through these methods, DOD identified a number of potential problems that may pose risks to the PDHRA program objective and to the welfare and safety of Reserve component servicemembers. However, GAO found that when monitoring the administration of the PDHRA to Reserve component servicemembers, DOD does not maintain clear documentation that is consistent with federal internal control standards. GAO found that the documentation generated by DOD generally did not clearly describe the potential problems, the actions taken to address the problems, and whether these actions had resolved the problems. Overall, this lack of clear documentation does not allow DOD to have reasonable assurance that potential problems related to the administration of the PDHRA to Reserve component servicemembers have been addressed and resolved.