VA and Defense Health Care: Military Medical Surveillance Policies in Place, but Implementation Challenges Remain
Published: 2002-02-27T00:00:00

Fast Facts:

Highlights:
section_title: What GAO Found
paragraphs: The Department of Defense (DOD) and the Department of Veterans Affairs (VA) recently established a medical surveillance system to respond to the health care needs of both 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 and its timely dissemination to military commanders, medical personnel, and others. GAO and others have reported extensively on weaknesses in DOD's medical surveillance capability and performance during the Gulf War and Operation Joint Endeavor. Investigations into the unexplained illnesses of Gulf War veterans revealed DOD's inability to collect, maintain, and transfer accurate data on 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, several problems persist. DOD has several efforts under way to improve the reliability of deployment information and enhance its information technology capabilities. Although its recent policies and reorganization reflect a commitment to establish a comprehensive medical surveillance system, much needs to be done to implement the system. To the extent DOD's medical surveillance capability is realized, VA will be better able to serve veterans and provide backup to DOD in times of war.

section_title: Letter
paragraphs: We are pleased to be here today to discuss 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.
Given current military actions responding to the events of September 11,  and what has been reported about DOD’s medical surveillance activities,  you asked us to comment on DOD’s medical surveillance during the Gulf  War and Operation Joint Endeavor. You also asked us to review the  implementation status of DOD’s directives on military medical surveillance  that have been issued since the Gulf War. This statement is based on our  reports and reports issued by the Institute of Medicine (IOM), the  Presidential Advisory Committee on Gulf War Veterans’ Illnesses, and  others over the past several years. This statement is also based on  interviews we held in October 2001 and February 2002 with various  Defense Health Program officials, including officials from the Army  Surgeon General’s Office.
In summary, we, IOM, 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. Although its recent  policies and reorganization reflect a commitment by DOD to establish a  comprehensive medical surveillance system, much needs to be done to  implement the system. To the extent DOD’s medical surveillance  capability is realized, VA will be better able to serve veterans and provide  backup to DOD in times of war.
subsections: section_title: Background
paragraphs: 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  countermeasures, and (4) baseline health status and subsequent health  changes. 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  result 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. 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 to adjudicate veterans’ disability claims.
section_title: Medical Recordkeeping and Surveillance During the Gulf War Was Lacking
paragraphs: Investigations into the unexplained illnesses of service members and  veterans who had been deployed to the Persian 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 by  a lack of (1) complete baseline health data on Gulf War veterans; (2)  assessments of their potential exposure to environmental health hazards;  and (3) 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 veterans confirmed the need for more effective  medical surveillance capabilities.
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. 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 or take prompt precautionary  actions, including seeking medical care.
section_title: Medical Surveillance Under Operation Joint Endeavor Improved but Was Not Comprehensive
paragraphs: 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. 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 disease and non-battle-injury 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—the  largest serum repository in the world—for epidemiological studies to  examine potential health issues for services members and veterans. The  center also operates and maintains a system for integrating, analyzing, and  reporting 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  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  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.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 during Operation Joint Endeavor, locations  of deployed service members were still not systematically documented or  archived for future use.
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. 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 the 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, 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 indicated 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 vaccine lot in the event that health  concerns about the 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.
section_title: Current Policies and Programs Not Fully Implemented
paragraphs: 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  related to medical surveillance, and the system continues to evolve. In  addition, in 2000, DOD released its Force Health Protection plan, which  presents the Department’s vision for protecting deployed forces and  includes the goal of joint medical logistics support for all services by  2010. The vision articulated in this capstone document emphasizes force  fitness and health preparedness, casualty prevention, and casualty care  and management. A key component of the plan is improved monitoring  and surveillance of health threats in military operations and more  sophisticated data collection and recordkeeping before, during, and after  deployments. However, IOM criticized DOD’s progress in implementing its  medical surveillance program as well as its 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.
subsections: section_title: Recent IOM Report Concludes That DOD Has Made Slow Progress in Implementing Recommendations
paragraphs: 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. 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 that  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 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 communication  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  deployed populations.  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.
section_title: Our Work Also Indicates Some DOD Programs for Improving Medical Surveillance Are Not Fully Implemented
paragraphs: 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. DOD  also recently established guidelines and additional policy initiatives for  improving military medical surveillance.
In October 1999, we reported that DOD’s Vaccine Adverse Event Reporting  System—which relies on medical staff or service members to provide  needed vaccine data—may not have included some information on  adverse reactions because these personnel had not received guidance  needed to submit reports to the system. According to DOD officials,  medical staff may also report any other reaction they think might be  caused by the vaccine, but because this is not stated explicitly in DOD’s  guidance on vaccinations, some medical staff may be unsure about which  reactions to report.
Also, in April 2000, we testified that vaccination data were not consistently  recorded in paper records and in a central database, as DOD requires.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  percent 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 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 that can document 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. 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.
DOD has several initiatives under way to link many of its information  systems—some with VA. For example, in an effort to create a  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), 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 described 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 access selected health data on  service members captured by DOD. According to DOD and VA officials,  full operation is expected to begin the third quarter of this fiscal year, once  testing of the near-term system has been completed. DOD health  information is an especially critical information source given VA’s fourth  mission to provide medical backup to the military health system in times  of national emergency and war. Under the near-term effort, VA will be able  to access laboratory and radiology results, outpatient pharmacy data, and  patient demographic information. This approach, however, will not  provide VA access to information on the health status of personnel when  they enter military service; on medical care provided to Reservists while  not on active duty; or on the care military personnel received from  providers outside DOD, including TRICARE providers. In addition,  because VA will only be able to view this information, physicians will not  be able to easily organize or otherwise manipulate the data for quick  review or research.
DOD has several other initiatives for improving its information technology  capabilities, which are in various stages of development. For example,  DOD is developing the Theater Medical Information Program (TMIP),  which is intended to capture medical information on deployed personnel  and link it with medical information captured in the Department’s new  medical information system. As of October 2001, officials told us that  they planned to begin field testing for TMIP in spring 2002, 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 (GEMS), which DOD characterizes as a stepping stone to an  integrated biohazard surveillance and detection system.
In addition to its ongoing information technology initiatives, DOD recently  issued two major policies for advancing its military medical surveillance  system. Specifically, in December 2001, DOD issued clinical practice  guidelines, developed collaboratively with VA, to provide a structure for  primary care providers to evaluate and manage patients with deployment- related health concerns. According to DOD, the guidelines were issued in  response to congressional concerns and IOM’s recommendations. The  guidelines are expected to improve the continuity of care and health-risk  communication for service members and their families for the wide variety  of medical concerns that are related to military deployments. Because the  guidelines became effective January 31, 2002, it is too early for us to  comment on their implementation.
Finally, DOD issued updated procedures on February 1, 2002, for  deployment health surveillance and readiness. These procedures  supersede those laid out in DOD’s December 1998 memorandum. The 2002  memorandum adds important procedures for occupational and  environmental health surveillance and updates pre- and postdeployment  health assessment requirements. These new procedures take effect on  March 1, 2002.
According to officials from DOD’s Health Affairs office, military medical  surveillance is a top priority, as evidenced by the Department’s having  placed responsibility for implementing medical surveillance policies with  one authority—the Deputy Assistant Secretary of Defense for Force  Health Protection and Readiness. However, these officials also  characterized force health protection as a concept made up of multiple  programs across the services. For example, we learned that each service is  responsible for implementing DOD’s policy initiatives for achieving force  health protection goals. This raises concerns about how the services will  uniformly collect and share core information on deployments and how  they will integrate data on the health status of service members. These  officials also confirmed that DOD’s military medical surveillance policies  will depend on the priority and resources dedicated to their  implementation.
section_title: Concluding Observations
paragraphs: Clearly, the need for comprehensive health information on service  members and veterans is compelling, 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 the frequency of troop movements.  Moreover, the outlook for successful surveillance is complicated by  scientific uncertainty regarding the health effects of exposures and  changes in technology that affect the feasibility of monitoring and tracking  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 and be vigilant in its oversight. VA’s ability to  perform its missions to care for veterans and compensate them for their  service-connected conditions will depend in part on the adequacy of  DOD’s medical surveillance system.
section_title: Contact and Acknowledgments
paragraphs: For further information, please contact Cynthia A. Bascetta at (202) 512- 7101. Individuals making key contributions to this testimony included Ann  Calvaresi Barr, Diana Shevlin, Karen Sloan, and Keith Steck.