Report to the Chairman and Ranking 

Minority Member, Subcommittee on 

Total Force, Committee on Armed 

Services, House of Representatives 

United States General Accounting Office 

GAO 

September 2003 DEFENSE HEALTH 

CARE 

Quality Assurance 

Process Needed to 

Improve Force Health 

Protection and 

Surveillance 

GAO-03-1041 
The Army and Air Force—the focus of GAO’s review—did not comply with 

DOD’s force health protection and surveillance policies for many active duty 

servicemembers, including the policies that they be assessed before and 

after deploying overseas, that they receive certain immunizations, and that 

health-related documentation be maintained in a centralized location. 

GAO’s review of 1,071 servicemembers’ medical records from a universe of 

8,742 at selected Army and Air Force installations participating in overseas 

operations disclosed that 38 to 98 percent of servicemembers were missing 

one or both of their health assessments and 14 to 46 percent were missing at 

least one of the required immunizations (see figure). 

DOD also did not maintain a complete, centralized database of 

servicemembers’ medical assessments and immunizations. Health-related 

documentation missing from the centralized database ranged from 0 to 

63 percent for pre-deployment assessments, 11 to 75 percent for 

post-deployment assessments, and 8 to 93 percent for immunizations. 

There is no effective quality assurance program at the Office of the Assistant 

Secretary of Defense for Health Affairs or at the Army or Air Force that 

helps ensure compliance with policies. GAO believes that the lack of such a 

program was a major cause of the high rate of noncompliance. Continued 

noncompliance with these policies may result in servicemembers deploying 

with health problems or delays in obtaining care when they return. Finally, 

DOD’s centralized deployment database is still missing the information 

needed to track servicemembers’ movements in the theater of operations. By 

July 2003, the department’s data center had begun receiving location-specific 

deployment information from the services and is currently reviewing its 

accuracy and completeness. 

Percent of Servicemembers Missing One or Both Health Assessments, and Missing at Least 

One Required Immunization 

Following the 1990-91 Persian Gulf 

War, many servicemembers 

experienced health problems that 

they attributed to their military 

service in the Persian Gulf. 

However, a lack of servicemember 

health and deployment data 

hampered subsequent 

investigations into the nature 

and causes of these illnesses. 

Public Law 105-85, enacted in 

November 1997, required the 

Department of Defense (DOD) to 

establish a system to assess the 

medical condition of service 

members before and after 

deployments. GAO was asked to 

determine whether (1) the military 

services met DOD’s force health 

protection and surveillance 

requirements for servicemembers 

deploying in support of Operation 

Enduring Freedom (OEF) in 

Central Asia and Operation Joint 

Guardian (OJG) in Kosovo and 

(2) DOD has corrected problems 

related to the accuracy and 

completeness of databases 

reflecting which servicemembers 

were deployed to certain locations. 

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. 

Highlights of GAO-03-1041, a 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 
Page i GAO-03-1041 Defense Health Care 

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

Contents 
Page ii 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 

This is a work of the U.S. government and is not subject to copyright protection in the 

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other material, permission from the copyright holder may be necessary if you wish to 

reproduce this material separately. 
Page 1 GAO-03-1041 Defense Health Care 

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. 

United States General Accounting Office

Washington, DC 20548 
Page 2 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 3 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 

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. 

Results in Brief 
Page 4 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 5 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 

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. 

Background 
Page 6 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 7 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 

are met.”7

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 8 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 9 GAO-03-1041 Defense Health Care 

The Army and Air Force did not comply with DOD’s force health 

protection and surveillance requirements for many of the servicemembers 

in our samples at the selected installations we visited. Specifically, these 

Army and Air Force servicemembers were missing: pre-deployment and/or 

post-deployment health assessments; evidence of receiving one or more of 

the pre-deployment immunizations required for their deployment location; 

and other pre-deployment requirements related to tuberculosis screening 

and blood serum sample storage. Also, servicemembers’ permanent 

medical records were missing required health-related information, 

and DOD’s centralized database did not include documentation of 

servicemember health-related information. Neither the installations nor 

DOD had monitoring and oversight mechanisms in place to help ensure 

that the force health protection and surveillance requirements were met 

for all servicemembers. 

We found that servicemembers missing one or both of their pre- and 

post-deployment assessments ranged from 38 to 98 percent in our 

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 

were missing either one or both of the required pre-deployment and postdeployment 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. 

The Army and 

Air Force Did Not 

Comply with 

Deployment Health 

Surveillance 

Policies for Many 

Servicemembers 

Many Servicemembers 

Lacked Pre-deployment 

and Post-deployment 

Health Assessments 
Page 10 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 11 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 12 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 13 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 14 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. 

Based on our samples, the services did not fully meet immunization 

and other pre-deployment requirements. Evidence of pre-deployment 

immunizations receipt was missing from many servicemembers’ medical 

records. Servicemembers missing the required immunizations may not 

have the immunization protection they need to counter theater disease 

threats. Based on our review of servicemember medical records for the 

deployments at the four installations we visited, we found that between 

14 and 46 percent of the servicemembers were missing 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. 

Immunizations and Other 

Pre-Deployment Health 

Requirements Not Met 
Page 15 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 16 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 17 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 18 GAO-03-1041 Defense Health Care 

Table 1: Deploying Servicemember Blood Serum Samples Held in Repository 

Status of Blood Serum 

Fort Campbell 

(OEF) 

Fort Campbell 

(OJG)

Fort Drum 

(OEF) 

Fort Drum 

(OJG) 

Hurlburt Field 

(OEF)

Travis AFB 

(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. 

Servicemembers’ permanent medical records were not complete, 

and DOD’s centralized database did not include documentation of 

servicemember health-related information. Many servicemembers’ 

permanent medical records at the Army and Air Force installations we 

visited did not include documentation of completed health assessments 

and servicemember visits to Army battalion aid stations. Similarly, the 

centralized deployment record database did not include many of the 

deployment health assessments and immunization records that we found 

in the servicemembers’ medical records at the installations we visited. 

DOD policy requires that the original completed pre-deployment 

and post-deployment health assessment forms be placed in the 

servicemember’s permanent medical record and that a copy be 

forwarded to AMSA.19 Figure 6 shows that completed assessments 

we found at AMSA and at the U.S. Special Operations Command 

for servicemembers in our samples were not documented in the 

servicemember’s permanent medical record, ranging from 8 to 100 percent 

for pre-deployment health assessments and from 11 to 62 percent for 

post-deployment health assessments. 

 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. 

Servicemember 

Medical Records and 

Centralized Database 

Were Not Complete 

Many Completed Deployment 

Health Assessments and 

Medical Interventions 

Were Not Documented 

in Servicemembers’ 

Medical Record 
Page 19 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 20 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. 

Based on our samples, DOD’s centralized database did not include 

documentation of servicemember health-related information. As set forth 

above, Public Law 105-85, enacted November 1997, requires the Secretary 

of Defense to retain and maintain health-related records in a centralized 

location. This includes records for all medical examinations conducted to 

ascertain the medical condition of servicemembers before deployment and 

any changes during their deployment, all health care services (including 

immunizations) received in anticipation of deployment or during the 

deployment, and events occurring in the deployment area that may affect 

the health of servicemembers. A February 2002 Joint Staff memorandum 

Centralized Database Missing 

Health-Related Documentation 
Page 21 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 22 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 23 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 does not have an effective quality assurance program to provide 

oversight of, and ensure compliance with, the department’s force health 

protection and surveillance requirements. Moreover, the installations we 

visited did not have ongoing monitoring or oversight mechanisms to help 

ensure that force health protection and surveillance requirements were 

met for all servicemembers. We believe that the lack of such a system was 

a major cause of the high rate of noncompliance we found at the units we 

visited. The services are currently developing quality assurance programs 

designed to ensure that force health protection and surveillance policies 

are implemented for servicemembers. 

 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). 

DOD and Installations 

Did Not Have Oversight of 

Force Health Protection 

and Surveillance 

Requirements 
Page 24 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 25 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 26 GAO-03-1041 Defense Health Care 

The DMDC deployment database still does not include the deployment 

information we identified in 1997 as needed for effective deployment 

health surveillance. In 1997, we reported that knowing the identity of 

servicemembers who were deployed during a given operation and tracking 

their movements within the theater of operations are major elements of a 

military medical surveillance system.28 The Institute of Medicine reported 

in 2000 that the documentation of the locations of units and individuals 

during a given deployment is important for epidemiological studies and for 

the provision of appropriate medical care during and after deployments.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. 

Centralized 

Deployment Database 

Still Missing 

Information Needed 

for Deployment 

Health Surveillance 
Page 27 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 28 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 

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 

surveillance policies, we recommend that the Secretary of Defense direct 

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 

this report, which are found in appendix II. DOD concurred with the 

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 

Conclusions 

Recommendation for 

Executive Action 

Agency Comments 

and Our Evaluation 
Page 29 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 
Appendix I: Scope and Methodology 

Page 30 GAO-03-1041 Defense Health Care 

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. 

Appendix I: Scope and Methodology 
Appendix I: Scope and Methodology 

Page 31 GAO-03-1041 Defense Health Care 

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. 
Appendix I: Scope and Methodology 

Page 32 GAO-03-1041 Defense Health Care 

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 

 OEF (post May 31)a 222 2,953 

 OJG (post May 31)a46 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. 
Appendix I: Scope and Methodology 

Page 33 GAO-03-1041 Defense Health Care 

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 
Appendix I: Scope and Methodology 

Page 34 GAO-03-1041 Defense Health Care 

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 
Appendix I: Scope and Methodology 

Page 35 GAO-03-1041 Defense Health Care 

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. 
Appendix II: Comments from the Department 

of Defense 

Page 36 GAO-03-1041 Defense Health Care 

Appendix II: Comments from the Department 

of Defense 
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 

Acknowledgments 

Page 39 GAO-03-1041 Defense Health Care 

Clifton E. Spruill (202) 512-4531 

In addition to the individual named above, Steve Fox, Rebecca Beale, 

Lynn Johnson, William Mathers, Terry Richardson, Kristine Braaten, 

Grant Mallie, Herbert Dunn, and R.K. Wild made key contributions to 

this report. 

Appendix III: GAO Contact and Staff 

Acknowledgments 

GAO Contact 

Acknowledgments 

(350216) 
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