Testimony

Before the Committee on Veterans’ Affairs, U.S. Senate

United States General Accounting Office

GAO

For Release on Delivery

Expected at 2:30 p.m.

Tuesday, October 16, 2001 VA AND DEFENSE

HEALTH CARE

Progress and Challenges

DOD Faces in Executing a

Military Medical

Surveillance System

Statement for the Record by Stephen P. Backhus

Director, Health Care—Veterans’

 and Military Health Care Issues

GAO-02-173T
Page 1 GAO-02-173T

Mr. Chairman and Members of the Committee:

We are pleased to submit this statement for the record on the Department

of Defense’s (DOD) efforts to establish a medical surveillance system that

enables DOD—along with the Department of Veterans Affairs (VA)—to

respond to the health care needs of our military personnel and veterans. A

medical surveillance system involves the ongoing collection and analysis

of uniform information on deployments, environmental health threats,

disease monitoring, medical assessments, and medical encounters. It is

also important that this information be disseminated in a timely manner to

military commanders, medical personnel, and others. DOD is responsible

for developing and executing this system and needs this information to

help ensure the deployment of healthy forces and the continued fitness of

those forces. VA also needs this information to fulfill its missions of

providing health care to veterans, backing up DOD in contingencies, and

adjudicating veterans’ claims for service-connected disabilities. Scientists

at VA, DOD, and other organizations also use this information to conduct

epidemiological studies and research.1

Given our current military actions responding to the events of September

11, you asked us to describe the challenges DOD faces in establishing a

reliable medical surveillance system, based on what has been reported

about DOD’s medical surveillance activities during the Gulf War and

Operation Joint Endeavor. 2

 This statement focuses on reports GAO,3 the

Institute of Medicine (IOM), the Presidential Advisory Committee on Gulf

War Veterans’ Illnesses,4

 and others have issued over the past several

years. This statement is also based on interviews we held over the past 2

 1

Epidemiology is the scientific study of the incidence, distribution, and control of disease in

a population.

2

United States and allied nations deployed peacekeeping forces to Bosnia beginning in

December 1995 in support of Operation Joint Endeavor, the NATO-led Bosnian

peacekeeping force.

3

See list of related GAO products at the end of this statement.

4

The President established this committee in May 1995 to conduct independent, open, and

comprehensive examinations of health care concerns related to Gulf War service. The

committee consisted of physicians, scientists, and Gulf War veterans.
Page 2 GAO-02-173T

weeks with various Defense Health Program officials, including officials

from the Army Surgeon General’s Office.5

In summary, GAO, the Institute of Medicine, and others have reported

extensively on weaknesses in DOD’s medical surveillance capability and

performance during the Gulf War and Operation Joint Endeavor and the

challenges DOD faces in implementing a reliable medical surveillance

system. Investigations into the unexplained illnesses of Gulf War veterans

uncovered many deficiencies in DOD’s ability to collect, maintain, and

transfer accurate data describing the movement of troops, potential

exposures to health risks, and medical incidents during deployment. DOD

improved its medical surveillance system under Operation Joint Endeavor,

which provided useful information to military commanders and medical

personnel. However, we and others reported a number of problems with

this system. For example, information related to service members’ health

and deployment status—data critical to an effective medical surveillance

system—was incomplete or inaccurate. DOD’s numerous databases,

including those that capture health information, are currently not linked,

which further challenges the department’s efforts to establish a single,

comprehensive electronic system to document, archive, and access

medical surveillance data.

DOD has several initiatives under way to improve the reliability of

deployment information and to enhance its information technology

capabilities, as we and others have recommended, though some initiatives

are several years away from full implementation. Nonetheless, these

efforts reflect a commitment by DOD to establish a comprehensive

medical surveillance system. The ability of VA to fulfill its role in serving

veterans and providing backup to DOD in times of war will be enhanced as

DOD increases its medical surveillance capability.

An effective military medical surveillance system needs to collect reliable

information on (1) the health care provided to service members before,

during, and after deployment; (2) where and when service members were

deployed; (3) environmental and occupational health threats or exposures

during deployment (in theater) and appropriate protective and counter

measures; and (4) baseline health status and subsequent health changes.

 5

The Secretary of the Army is responsible for medical surveillance for DOD deployments,

consistent with DOD’s medical surveillance policy.

Background
Page 3 GAO-02-173T

This information is needed to monitor the overall health condition of

deployed troops, inform them of potential health risks, as well as maintain

and improve the health of service members and veterans.

In times of conflict, a military medical surveillance system is particularly

critical to ensure the deployment of a fit and healthy force and to prevent

disease and injuries from degrading force capabilities. DOD needs reliable

medical surveillance data to determine who is fit for deployment; to

prepare service members for deployment, including providing

vaccinations to protect against possible exposure to environmental and

biological threats; and to treat physical and psychological conditions that

resulted from deployment. DOD also uses this information to develop

educational measures for service members and medical personnel to

ensure that service members receive appropriate care.

Reliable medical surveillance information is also critical for VA to carry

out its missions. In addition to VA’s better known missions—to provide

health care and benefits to veterans and medical research and education—

VA has a fourth mission: to provide medical backup to DOD in times of

war and civilian health care backup in the event of disasters producing

mass casualties. As such, VA needs reliable medical surveillance data from

DOD to treat casualties of military conflicts, provide health care to

veterans who have left active duty, assist in conducting research should

troops be exposed to environmental or occupational hazards, and identify

service-connected disabilities and adjudicate veterans’ disability claims.

Investigations into the unexplained illnesses of service members and

veterans who had been deployed to the Gulf uncovered the need for DOD

to implement an effective medical surveillance system to obtain

comprehensive medical data on deployed service members, including

Reservists and National Guardsmen. Epidemiological and health outcome

studies to determine the causes of these illnesses have been hampered due

to incomplete baseline health data on Gulf War veterans, their potential

exposure to environmental health hazards, and specific health data on

care provided before, during, and after deployment. The Presidential

Advisory Committee on Gulf War Veterans’ Illnesses’ and IOM’s 1996

investigations into the causes of illnesses experienced by Gulf War

Medical

Recordkeeping and

Surveillance During

the Gulf War Was

Lacking
Page 4 GAO-02-173T

veterans confirmed the need for more effective medical surveillance

capabilities.6

The National Science and Technology Council, as tasked by the

Presidential Advisory Committee, also assessed the medical surveillance

system for deployed service members. In 1998, the council reported that

inaccurate recordkeeping made it extremely difficult to get a clear picture

of what risk factors might be responsible for Gulf War illnesses.7

 It also

reported that without reliable deployment and health assessment

information, it was difficult to ensure that veterans’ service-related

benefits claims were adjudicated appropriately. The council concluded

that the Gulf War exposed many deficiencies in the ability to collect,

maintain, and transfer accurate data describing the movement of troops,

potential exposures to health risks, and medical incidents in theater. The

council reported that the government’s recordkeeping capabilities were

not designed to track troop and asset movements to the degree needed to

determine who might have been exposed to any given environmental or

wartime health hazard. The council also reported major deficiencies in

health risk communications, including not adequately informing service

members of the risks associated with countermeasures such as vaccines.

Without this information, service members may not recognize potential

side effects of these countermeasures and promptly take precautionary

actions, including seeking medical care.

 6

Health Consequences of Service During the Persian Gulf War: Recommendations for

Research and Information Systems, Institute of Medicine, Medical Follow-up Agency

(Washington, D.C.: National Academy Press, 1996); Presidential Advisory Committee on

Gulf War Veterans’ Illnesses: Interim Report (Washington, D.C.: U.S. Government Printing

Office, Feb. 1996); Presidential Advisory Committee on Gulf War Veterans’ Illnesses: Final

Report (Washington, D.C.: U.S. Government Printing Office, Dec. 1996).

7

National Science and Technology Council Presidential Review Directive 5 (Washington,

D.C.: Executive Office of the President, Office of Science and Technology Policy, Aug.

1998).
Page 5 GAO-02-173T

In response to these reports, DOD strengthened its medical surveillance

system under Operation Joint Endeavor when service members were

deployed to Bosnia-Herzegovina, Croatia, and Hungary. In addition to

implementing departmentwide medical surveillance policies, DOD

developed specific medical surveillance programs to improve monitoring

and tracking environmental and biomedical threats in theater. While these

efforts represented important steps, a number of deficiencies remained.

On the positive side, the Assistant Secretary of Defense (Health Affairs)

issued a health surveillance policy for troops deploying to Bosnia.8

 This

guidance stressed the need to (1) identify health threats in theater, (2)

routinely and uniformly collect and analyze information relevant to troop

health, and (3) disseminate this information in a timely manner. DOD

required medical units to develop weekly reports on the incidence rates of

major categories of diseases and injuries during all deployments. Data

from these reports showed theaterwide illness and injury trends so that

preventive measures could be identified and forwarded to the theater

medical command regarding abnormal trends or actions that should be

taken.

DOD also established the U.S. Army Center for Health Promotion and

Preventive Medicine—a major enhancement to DOD’s ability to perform

environmental monitoring and tracking. For example, the center operates

and maintains a repository of service members’ serum samples for medical

surveillance and a system to integrate, analyze, and report data from

multiple sources relevant to the health and readiness of military personnel.

This capability was augmented with the establishment of the 520th Theater

Army Medical Laboratory—a deployable public health laboratory for

providing environmental sampling and analysis in theater. The sampling

results can be used to identify specific preventive measures and

safeguards to be taken to protect troops from harmful exposures and to

develop procedures to treat anyone exposed to health hazards. During

Operation Joint Endeavor, this laboratory was used in Tuzla, Bosnia,

where most of the U.S. forces were located, to conduct air, water, soil, and

other environmental monitoring.

Despite the department’s progress, we and others have reported on DOD’s

implementation difficulties during Operation Joint Endeavor and the

 8

Health Affairs Policy 96-019 (DOD Assistant Secretary of Defense Memorandum, Jan. 4,

1996).

Medical Surveillance

Under Operation Joint

Endeavor Improved

But Was Not

Comprehensive
Page 6 GAO-02-173T

shortcomings in DOD’s ability to maintain reliable health information on

service members. Knowledge of who is deployed and their whereabouts is

critical for identifying individuals who may have been exposed to health

hazards while deployed. However, in May 1997, we reported that the

inaccurate information on who was deployed and where and when they

were deployed—a problem during the Gulf War—continued to be a

concern during Operation Joint Endeavor.9

 For example, we found that the

Defense Manpower Data Center (DMDC) database—where military

services are required to report deployment information—did not include

records for at least 200 Navy service members who were deployed.

Conversely, the DMDC database included Air Force personnel who were

never actually deployed. In addition, we reported that DOD had not

developed a system for tracking the movement of service members within

theater. IOM also reported that the location of service members during the

deployments were still not systematically documented or archived for

future use.10

We also reported in May 1997 that for the more than 600 Army personnel

whose medical records we reviewed, DOD’s centralized database for

postdeployment medical assessments did not capture 12 percent of those

assessments conducted in theater and 52 percent of those conducted after

returning home.11 These data are needed by epidemiologists and other

researchers to assess at an aggregate level the changes that have occurred

between service members’ pre- and postdeployment health assessments.

Further, many service members’ medical records did not include complete

information on in-theater postdeployment medical assessments that had

been conducted. The Army’s European Surgeon General attributed missing

in-theater health information to DOD’s policy of having service members

hand carry paper assessment forms from the theater to their home units,

 9

Defense Health Care: Medical Surveillance Improved Since Gulf War, but Mixed Results in

Bosnia (GAO/NSIAD-97-136, May 13, 1997).

10See Institute of Medicine, Protecting Those Who Serve: Strategies to Protect the Health of

Deployed U.S. Forces (Washington, D.C., National Academy Press, 2000).

11In many cases, we found that these assessments were not conducted in a timely manner

or were not conducted at all. For example, of the 618 personnel whose records we

reviewed, 24 percent did not receive in-theater postdeployment medical assessments and

21 percent did not receive home station postdeployment medical assessments. Of those

who did receive home station postdeployment medical assessments, the assessments were

on average conducted nearly 100 days after they left theater—instead of within 30 days, as

DOD requires.
Page 7 GAO-02-173T

where their permanent medical records were maintained. The assessments

were frequently lost en route.

We have also reported that not all medical encounters in theater were

being recorded in individual records. Our 1997 report identified that this

problem was particularly common for immunizations given in theater.

Detailed data on service members’ vaccine history are vital for scheduling

the regimen of vaccinations and boosters and for tracking individuals who

received vaccinations from a specific lot in the event health concerns

about the vaccine lot emerge. We found that almost one-fourth of the

service members’ medical records that we reviewed did not document the

fact that they had received a vaccine for tick-borne encephalitis. In

addition, in its 2000 report, IOM cited limited progress in medical

recordkeeping for deployed active duty and reserve forces and

emphasized the need for records of immunizations to be included in

individual medical records.

Responding to our and others’ recommendations to improve information

on service members’ deployments, in-theater medical encounters, and

immunizations, DOD has continued to revise and expand its policies

relating to medical surveillance, and the system continues to evolve. In

addition, in 2000, DOD released its Force Health Protection plan, which

presents its vision for protecting deployed forces.12 This vision emphasizes

force fitness and health preparedness and improving the monitoring and

surveillance of health threats in military operations. However, IOM

criticized DOD’s progress in implementing its medical surveillance

program and the failure to implement several recommendations that IOM

had made. In addition, IOM raised concerns about DOD’s ability to achieve

the vision outlined in the Force Health Protection plan. We have also

reported that some of DOD’s programs designed to improve medical

surveillance have not been fully implemented.

IOM’s 2000 report presented the results of its assessment of DOD’s

progress in implementing recommendations for improving medical

surveillance made by IOM and several others. IOM stated that, although

DOD generally concurred with the findings of these groups, DOD had

made few concrete changes at the field level. For example, medical

 12Joint Staff, Medical Readiness Division, Force Health Protection (2000).

Current Policies and

Programs Not Fully

Implemented

Recent IOM Report

Concludes Slow Progress

by DOD in Implementing

Recommendations
Page 8 GAO-02-173T

encounters in theater were still not always recorded in individuals’

medical records, and the locations of service members during

deployments were still not systematically documented or archived for

future use. In addition, environmental and medical hazards were not yet

well integrated in the information provided to commanders.

The IOM report notes that a major reason for this lack of progress is no

single authority within DOD has been assigned responsibility for the

implementation of the recommendations and plans. IOM said that because

of the complexity of the tasks involved and the overlapping areas of

responsibility involved, the single authority must rest with the Secretary of

Defense.

In its report, IOM describes six strategies that in its view demand further

emphasis and require greater efforts by DOD:

• Use a systematic process to prospectively evaluate non-battle-related risks

associated with the activities and settings of deployments.

• Collect and manage environmental data and personnel location, biological

samples, and activity data to facilitate analysis of deployment exposures

and to support clinical care and public health activities.

• Develop the risk assessment, risk management, and risk communications

skills of military leaders at all levels.

• Accelerate implementation of a health surveillance system that completely

spans an individual’s time in service.

• Implement strategies to address medically unexplained symptoms in

populations that have deployed.

• Implement a joint computerized patient record and other automated

recordkeeping that meets the information needs of those involved with

individual care and military public health.

DOD guidance established requirements for recording and tracking

vaccinations and automating medical records for archiving and recalling

medical encounters. While our work indicates that DOD has made some

progress in improving its immunization information, the department faces

numerous challenges in implementing an automated medical record.

In October 1999, we reported that DOD’s Vaccine Adverse Event Reporting

System, which relies on medical personnel or service members to provide

Our Work Also Indicates

Some DOD Programs for

Improving Medical

Surveillance Are Not Fully

Implemented
Page 9 GAO-02-173T

needed vaccine data, may not have included information on adverse

reactions because DOD did not adequately inform personnel on how to

provide this information.13

Additionally, in April 2000, we testified that vaccination data were not

consistently recorded in paper records and in a central database, as DOD

requires.14 For example, when comparing records from the database with

paper records at four military installations, we found that information on

the number of vaccinations given to service members, the dates of the

vaccinations, and the vaccine lot numbers were inconsistent at all four

installations. At one installation, the database and records did not agree 78

to 92 percent of the time. DOD has begun to make progress in

implementing our recommendations, including ensuring timely and

accurate data in its immunization tracking system.

The Gulf War revealed the need to have information technology play a

bigger role in medical surveillance to ensure that the information is readily

accessible to DOD and VA. In August 1997, DOD established requirements

that called for the use of innovative technology, such as an automated

medical record device for documenting inpatient and outpatient

encounters in all settings and that can archive the information for local

recall and format it for an injury, illness, and exposure surveillance

database.15 Also, in 1997, the President, responding to deficiencies in

DOD’s and VA’s data capabilities for handling service members’ health

information, called for the two agencies to start developing a

comprehensive, lifelong medical record for each service member. As we

reported in April 2001, DOD’s and VA’s numerous databases and electronic

systems for capturing mission-critical data, including health information,

are not linked and information cannot be readily shared.16

DOD has several initiatives under way to link many of its information

systems—some with VA. For example, in an effort to create a

 13Medical Readiness: DOD Faces Challenges in Implementing Its Anthrax Vaccine

Immunization Program (GAO/NSIAD-00-36, Oct. 22, 1999).

14Medical Readiness: DOD Continues to Face Challenges in Implementing Its Anthrax

Vaccine Immunization Program (GAO/T-NSIAD-00-157, Apr. 13, 2000).

15DOD Directive 6490.2, “Joint Medical Surveillance” (Aug. 30, 1997).

16Computer-Based Patient Records: Better Planning and Oversight by VA, DOD, and IHS

Would Enhance Health Data Sharing (GAO-01-459, Apr. 30, 2001).
Page 10 GAO-02-173T

comprehensive, lifelong medical record for service members and veterans

and to allow health care professionals to share clinical information, DOD

and VA, along with the Indian Health Service (IHS),17 initiated the

Government Computer-Based Patient Record (GCPR) project in 1998.

GCPR is seen as yielding a number of potential benefits, including

improved research and quality of care, and clinical and administrative

efficiencies. However, our April 2001 report describes several factors—

including planning weaknesses, competing priorities, and inadequate

accountability—that made it unlikely that DOD and VA would accomplish

GCPR or realize its benefits in the near future. To strengthen the

management and oversight of GCPR, we made several recommendations,

including designating a lead entity with a clear line of authority for the

project and creating comprehensive and coordinated plans for sharing

meaningful, accurate, and secure patient health data.

For the near term, DOD and VA have decided to reconsider their approach

to GCPR and focus on allowing VA to view DOD health data. However,

under the interim effort, physicians at military medical facilities will not be

able to view health information from other facilities or from VA—now a

potentially critical information source given VA’s fourth mission to provide

medical backup to the military health system in times of national

emergency and war.

Recent meetings with officials from the Defense Health Program and the

Army Surgeon General’s Office indicate that the department is working on

issues we have reported on in the past, including the need to improve the

reliability of deployment information and the need to integrate disparate

health information systems. Specifically, these officials informed us that

DOD is in the process of developing a more accurate roster of deployed

service members and enhancing its information technology capabilities.

For example, DOD’s Theater Medical Information Program (TMIP) is

intended to capture medical information on deployed personnel and link it

with medical information captured in the department’s new medical

information system, now being field tested.18 Developmental testing for

 17IHS was included in the effort because of its population-based research expertise and its

long- standing relationship with VA.

18Composite Health Care System II (CHCS II) is expected to capture information on

immunizations; allergies; outpatient encounters, such as diagnostic and treatment codes;

patient hospital admission and discharge; patient medications; laboratory results; and

radiology. CHCS II is expected to support best business practices, medical surveillance,

and clinical research.
Page 11 GAO-02-173T

TMIP is about to begin and field testing is expected to begin next spring,

with deployment expected in 2003. A component system of TMIP—

Transportation Command Regulating and Command and Control

Evacuation System—is also under development and aims to allow casualty

tracking and provide in-transit visibility of casualties during wartime and

peacetime. Also under development is the Global Expeditionary Medical

System, which DOD characterizes as a stepping stone to an integrated

biohazard surveillance and detection system.

Clearly, the need for comprehensive health information on service

members and veterans is very great, and much more needs to be done.

However, it is also a very difficult task because of uncertainties about

what conditions may exist in a deployed setting, such as potential military

conflicts, environmental hazards, and frequency of troop movements.

While progress is being made, DOD will need to continue to make a

concerted effort to resolve the remaining deficiencies in its surveillance

system. Until such a time that some of the deficiencies are overcome, VA’s

ability to perform its missions will be affected.

For further information, please contact Stephen P. Backhus at (202) 512-

7101. Individuals making key contributions to this testimony included Ann

Calvaresi Barr, Karen Sloan, and Keith Steck.

Concluding

Observations

Contact and

Acknowledgments
Page 12 GAO-02-173T

Computer-Based Patient Records: Better Planning and Oversight by VA,

DOD, and IHS Would Enhance Health Data Sharing (GAO-01-459, Apr. 30,

2001).

Medical Readiness: DOD Continues to Face Challenges in Implementing

Its Anthrax Vaccine Immunization Program (GAO/T-NSIAD-00-157, Apr.

13, 2000).

Medical Readiness: DOD Faces Challenges in Implementing Its Anthrax

Vaccine Immunization Program (GAO/NSIAD-00-36, Oct. 22, 1999).

Chemical and Biological Defense: Observations on DOD’s Plans to Protect

U.S. Forces (GAO/T-NSIAD-98-83, Mar. 17, 1998).

Gulf War Veterans: Incidence of Tumors Cannot Be Reliably Determined

From Available Data (GAO/NSIAD-98-89, Mar. 3, 1998).

Gulf War Illnesses: Federal Research Strategy Needs Reexamination

(GAO-T-NSIAD-98-104, Feb. 24, 1998).

Gulf War Illnesses: Research, Clinical Monitoring, and Medical

Surveillance (GAO/T-NSIAD-98-88, Feb. 5, 1998).

Defense Health Care: Medical Surveillance Improved Since Gulf War, but

Mixed Results in Bosnia (GAO/NSIAD-97-136, May 13, 1997).

(290139)

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