Defense Health Care: DOD Needs to Clarify Policies Related to Occupational and Environmental Health Surveillance and Monitor Risk Mitigation Activities
Published: 2015-05-22T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: OEHS is the regular collection and reporting of occupational and environmental health hazard data that can be used to help prevent, treat, or control disease or injury. In 2005, GAO reported that DOD needed to make improvements with OEHS during deployments to address immediate and long-term health issues.
GAO was asked to assess DOD's current OEHS efforts. This report examines (1) the extent to which the military services centrally store OEHS data and verify its reliability; (2) how, if at all, DOD identifies potential occupational and environmental health risks for sites in Iraq and Afghanistan, and to what extent these risks are mitigated; and (3) the extent to which DOD and VA use OEHS data to address post-deployment health conditions. GAO reviewed and analyzed DOD and military service policies on OEHS data storage and quality assurance, as well as policies related to conducting and monitoring assessments for deployment sites. GAO also interviewed DOD, military service, and VA officials, as well as groups representing servicemembers and veterans.
section_title: What GAO Found
paragraphs: Inconsistencies between Department of Defense (DOD) and military service-specific policies regarding occupational and environmental health surveillance (OEHS) data storage have contributed to fragmentation and duplication of OEHS data between two information technology systems—the Military Exposure Surveillance Library (MESL) and the Defense Occupational and Environmental Health Readiness System (DOEHRS). Not having consistent policies for which system should be used to store OEHS data is contrary to federal standards for internal control. As a result, officials' efforts to store these data have resulted in both fragmentation and duplication, which GAO's prior work has shown may result in inefficiencies. Correspondingly, in some cases, similar types of unclassified OEHS data are being submitted to both MESL and DOEHRS, and in other cases, identical OEHS data are being submitted to both systems. However, neither system serves as a central repository for these data, and as a result, it is difficult to identify complete and comprehensive OEHS data sets, which may lead to problems when officials attempt to use these data in the future. Additionally, DOD's policy for OEHS data does not specifically address quality assurance. Consequently, some of the military services have developed their own guidance, resulting in inconsistent approaches and levels of effort, which has reduced DOD's ability to be confident that the data are sufficiently reliable. Federal standards for internal control state that management should continually monitor information captured and maintained for several factors, including reliability.
The military services use site assessments to identify and address potential occupational and environmental health risks at a deployment site. These assessments may include recommended countermeasures, such as the use of personal protective equipment. However, the extent to which these recommendations are being implemented is unclear because U.S. Central Command (CENTCOM)—the combatant command responsible for military operations in the geographic area that includes Iraq and Afghanistan—does not require base commanders to document their decisions on implementing them. Officials also said they are not monitoring these recommendations, and instead rely on others to elevate concerns, as necessary. In contrast, DOD's policy for its safety and occupational health program requires the department's components, including the combatant commands, to ensure that risk management decisions are documented and reevaluated. Federal standards for internal control also note that appropriate documentation is a key internal control activity and that agencies should monitor their activities for managing identified risks.
Both DOD and the Department of Veterans Affairs (VA) have used OEHS data to a limited extent to address post-deployment health conditions. For example, DOD officials said that the primary limitation with OEHS data collected during deployments continues to be the inability to capture exposure data at the individual servicemember level, although a method to do so is currently being explored. Additionally, DOD and VA use OEHS data to conduct research that may help determine service connections for post-deployment health conditions, but it has been difficult for researchers to establish a causal link between exposures and specific health conditions.
section_title: What GAO Recommends
paragraphs: GAO recommends that DOD clarify its policies for the storage and quality assurance of OEHS data, and require other related policies to be amended accordingly. GAO also recommends that CENTCOM revise its policy to require adequate documentation and consistent monitoring of deployment risk mitigation activities. In commenting on the report, DOD concurred with GAO's recommendations, and VA generally agreed with the conclusions.

section_title: Letter
paragraphs: Since the end of the 1991 Persian Gulf War, servicemembers’ and  veterans’ reports of unexplained illnesses that they attributed to service- related occupational and environmental exposures have led to increasing  interest in health effects related to military deployments. In 1997, the  Department of Defense (DOD) developed a military-wide health  surveillance framework that includes occupational and environmental  health surveillance (OEHS)—the regular collection and reporting of  occupational and environmental health hazard data by the military  services during deployments that can be used to help prevent, treat, or  control disease or injury. Despite this effort, attempts to research and  investigate whether post-deployment health conditions are the result of  military service continue to be hindered by a lack of sufficient OEHS data.  This is of particular concern because, as we previously reported in 2010,  some returning servicemembers and veterans have health concerns they  believe are related to their deployment, such as conditions related to  smoke inhalation from open-air burn pits—used for waste disposal—on  military bases in Iraq and Afghanistan. In an effort to better ascertain and  monitor the possible health effects related to burn pits, the Department of  Veterans Affairs (VA) established the Airborne Hazards and Open Burn  Pit Registry in June 2014 that allows eligible servicemembers and  veterans to document their exposures and report their health concerns.
Establishing a service connection for health conditions is important  because federal law generally entitles veterans with service-connected  disabilities to VA’s disability compensation benefits. However, as we  have previously reported, establishing a relationship between  occupational and environmental exposures and health issues can be  difficult. For example, despite servicemembers’ and veterans’ reports of  health concerns related to smoke inhalation from burn pits in Iraq and  Afghanistan, the Institute of Medicine was unable to determine whether  long-term health effects are likely to result from this exposure due to  limited or inadequate evidence of an association. In light of such  difficulties, Congress has, on several occasions, legislated “presumptive  service connections,” which allow veterans to receive compensation for   For example, for Gulf  certain conditions without having to prove cause.War veterans, certain illnesses with unexplained symptoms, such as  chronic fatigue syndrome and fibromyalgia, are considered presumptive  service-connected conditions that qualify them for disability compensation  from VA.
In 2005, we reported that improvements were needed with OEHS during  deployments to address immediate and long-term health issues.  Specifically, we recommended that DOD improve deployment OEHS data  collection and reporting, including the development of cross-service  guidance to facilitate more consistent implementation of OEHS policy.  Additionally, we recommended that DOD establish and implement  procedures to evaluate the effectiveness of risk management efforts, and  that DOD and VA work together to develop a federal research plan to  address the long-term health effects of these deployments. DOD  developed cross-service guidance in 2007, but did not implement the  other recommendations, although it partially concurred with them. Since  our July 2005 report, there have been about 2.1 million servicemember  deployments to Iraq and Afghanistan, involving about 1.4 million  individual servicemembers, as of December 31, 2014.
You requested that we assess the departments’ current OEHS efforts in  light of continuing health concerns related to recent deployments to Iraq  and Afghanistan. In this report, we examine (1) to what extent the military  services centrally store OEHS data and verify their reliability; (2) how, if at  all, DOD identifies potential occupational and environmental health risks  for sites in Iraq and Afghanistan, and to what extent these risks are  mitigated; and (3) to what extent DOD and VA use OEHS data to address  post-deployment health conditions.
To determine the extent to which the military services centrally store  OEHS data and verify their reliability, we reviewed and analyzed DOD  and service-specific policies that describe OEHS data storage and quality  assurance processes. We also obtained information on the  functionalities and capabilities of the two information technology (IT)  systems that DOD uses to store OEHS data: the Military Exposure  Surveillance Library (MESL) and the Defense Occupational and  Environmental Health Readiness System (DOEHRS). We reviewed the  numbers and types of OEHS data entries in each system to better  understand how OEHS data are being stored. We also interviewed DOD  and military service officials about their practices for storing and reviewing  OEHS data. Finally, for our evaluation, we used criteria from our prior  work on duplication, overlap, and fragmentation, and the federal  standards for internal control, including standards for risk assessment and  control activities to promote efficiency and effectiveness.
To determine how, if at all, DOD identifies potential occupational and  environmental health risks for sites in Iraq and Afghanistan, and the  extent to which these risks are mitigated, we reviewed and analyzed  relevant DOD and military services’ policies on risk assessment activities  for deployed locations, and how they are monitored. We also analyzed a  sample of 50 risk assessments for deployment sites in Iraq and  Afghanistan completed after November 2, 2007—the publication date of  the cross-service guide on deployment health surveillance in which a  uniform standard for assessing risks was established—to determine the  extent to which this sample of risk assessments contained  recommendations for mitigating servicemembers’ risks of exposure to  occupational and environmental health hazards. However, because of the  small sample size, which was not randomly selected, the results of this  analysis cannot be generalized to all risk assessments. We interviewed  DOD and military service officials about how they use risk assessments to  mitigate potential health risks at deployment sites, and the extent to which  recommended risk mitigation activities are being monitored. In addition,  we interviewed officials from the U.S. Environmental Protection Agency  and National Institute of Occupational Safety and Health with expertise in  occupational and environmental health risks to obtain their insights  regarding the extent to which OEHS data may be used to mitigate risks.  For our evaluation, we also used as criteria the federal standards for  internal control to evaluate risk assessment, such as identifying risks and  analyzing their potential effects.
To determine the extent to which DOD and VA use OEHS data to  address post-deployment health conditions, we reviewed relevant DOD  and VA documentation about the use of OEHS data. We also interviewed  DOD officials and officials with the Veterans Benefits Administration  (VBA) and the Veterans Health Administration (VHA) to identify the ways  in which OEHS data is being used, including its use in research and in  determining benefits eligibility, as well as limitations with the use of these  data. Working Group (DHWG), a collaborative DOD and VA group, to  determine how the departments collaborate in using OEHS data to  address deployment-health-related issues. Furthermore, we interviewed  officials from the Military Officers Association of America and Disabled  American Veterans to obtain their perspectives on how DOD and VA  have used OEHS data to address post-deployment health conditions.
In addition, we interviewed the co-chairs of the Deployment Health  We conducted this performance audit from August 2014 to May 2015 in  accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.
VBA is charged with processing claims for veterans with service-connected disabilities  for disability compensation benefits. VHA operates VA’s health care system, which  includes VA medical centers and community-based outpatient clinics.
subsections: section_title: Background
subsections: section_title: Relevant DOD Organizational Structure
paragraphs: Within DOD’s Office of the Assistant Secretary of Defense for Health  Affairs, the office of Force Health Protection & Readiness provides  support for all medically related DOD policies, programs, and activities.  This includes responsibility for the development of most deployment- related health policies, including those related to OEHS.
The service component commands include U.S. Army Central (USARCENT), U.S. Air  Force Central Command, and U.S. Naval Forces Central Command. that unit. As of February 1, 2015, there was one preventive medicine  unit available to conduct OEHS activities in Iraq and one in Afghanistan,  which reported to USARCENT and U.S. Forces-Afghanistan,  respectively.
Each of the military services has a public health surveillance center that  provides support and technical guidance on reporting on potential  environmental risks to combatant commands and their subordinate  commands. These public health surveillance centers include the U.S.  Army Public Health Command, the U.S. Air Force School of Aerospace  Medicine, and the Navy & Marine Corps Public Health Center. In addition,  these centers provide technical expertise and support for the subordinate  commands’ preventive medicine units in theater. These surveillance  centers have also developed and adapted military exposure guidelines for  deployment using existing U.S. national standards for human health  exposure limits and technical monitoring procedures (e.g., standards of  the U.S. Environmental Protection Agency and the National Institute for  Occupational Safety and Health).
section_title: DOD’s Collection of OEHS Data
paragraphs: As part of DOD’s health surveillance framework, Force Health Protection  & Readiness deployment health policies require the preventive medicine  units to regularly collect and report a variety of data during deployments  to identify and respond to health threats that servicemembers may have  encountered. Health surveillance during deployments includes  identifying the deployed population at risk, recognizing and assessing  potentially hazardous health exposures and conditions, employing  specific preventive countermeasures, daily monitoring of real-time health  outcomes, and reporting of disease and injury data.
DOD collects and stores three types of data during deployments: (1) daily  individual servicemember location data—such as the duty station—which  is stored by DOD’s Defense Manpower Data Center; (2) medical data— including data on health outcomes acquired from servicemember medical  records—which is stored by DOD’s Armed Forces Health Surveillance  Center; and (3) OEHS data, including ambient air, water, and soil  samples. Once collected, DOD currently uses two separate IT systems  for the storage of OEHS data—MESL and DOEHRS:
MESL, originally implemented in 2003, contains both classified and  unclassified documents that have been scanned and uploaded into  the system.  Officials can use MESL for submitting OEHS  documents, conducting searches based on key words, and  downloading OEHS documents.
DOD subsequently began implementing DOEHRS in 2006. Unlike  MESL, DOEHRS is a database that incorporates additional  functionalities including OEHS data collection, management, and  assessment—including the ability to query data—in a single system. It  allows users in theatre to capture field data, such as air, water, and  soil samples; compare sample results with exposure guidelines; report  sampling data; and view laboratory data instantly once data are  loaded into the system. Unlike MESL, DOEHRS only contains  unclassified data.
While there are some departmental requirements for some OEHS reports  for deployment sites—such as an initial assessment—the total number of  OEHS reports for each deployment site varies because these reports  reflect the specific occupational and environmental circumstances unique  to each location.
section_title: Relevant VA Organizational Structure
paragraphs: VA is comprised of three administrations, two of which focus on benefits  for veterans: VBA and VHA.
VBA processes veterans’ claims for monthly compensation for  service-connected disabilities. VBA determines eligibility criteria for  disability compensation, which can include identifying specific health  conditions, like those associated with occupational and environmental  hazards in Iraq and Afghanistan, and determining whether these  conditions are service-connected.
VHA operates the VA health care system, which provides health care  to veterans through its various facilities, including outpatient clinics  and medical centers. VHA also may provide health coverage to  spouses, survivors, and children of veterans who are permanently and  totally disabled from a service-connected disability, or who died in the  line of duty or from a service-connected disability. VHA also conducts  or sponsors research on veterans’ illnesses related to military  occupational and environmental exposures.
section_title: Inconsistent and Ambiguous Policies Have Impeded Central Storage and Quality Assurance of OEHS Data Inconsistent DOD and Military Service-Specific Policies Have Resulted in Fragmentation and Duplication in the Storage of OEHS Data
paragraphs: Inconsistencies between DOD and military service-specific policies  regarding OEHS data storage has led to fragmentation and duplication of  OEHS data between the department’s two systems—MESL and  DOEHRS. Officials with Force Health Protection & Readiness told us that  DOD is transitioning from the use of MESL to DOEHRS, which has  greater functionality. However, the departmental policy developed by this  office—updated in 2011—states that all classified and unclassified OEHS  data should be stored in MESL even though DOEHRS was implemented  in 2006. Officials from the U.S. Army Public Health Command—the  office that maintains MESL and has technical expertise in DOEHRS— confirmed the department’s intent to transition from MESL to DOEHRS,  and told us that this transition would eventually include the transfer of all  unclassified documents currently in MESL to DOEHRS (once DOEHRS  had been sufficiently upgraded) while classified data would remain in  MESL. However, these same officials told us that resources have not  been obtained to complete this task, and that the upgrades are time- and  resource-intensive. Force Health Protection & Readiness officials  explained that DOD’s current policy does not reflect the potential  transition from MESL to DOEHRS because developing the functionality of  DOEHRS in archiving data from deployments was still under way when  the policy was last updated in 2011—about 5 years after DOEHRS was  implemented.being revised to require the storage of unclassified OEHS data in  DOEHRS, and they expect the updated policy to be released in 2016.
However, these officials told us that the policy is currently  Further, when we reviewed all of DOD’s relevant OEHS policies as well  as corresponding policies developed by each of the military services—all  dated after 2006—we identified inconsistencies about which system  should be used to store OEHS data. Only 3 of the 14 policies we  reviewed instruct officials to store OEHS data in DOEHRS, while 4  policies instruct officials to store OEHS data in MESL. Six of the policies  instruct the use of both systems as appropriate, depending on the type of  document being submitted and the availability of DOEHRS during a  deployment. Further, one of the policies does not list either system, as it  says that databases are necessary for OEHS data storage but does not  specifically mention DOEHRS or MESL. See Table 1 for the list of 14  policies related to OEHS data storage. Inconsistent policies are contrary  to federal standards for internal control, which state that management  should have policies in place that are both appropriate and clear.
MESL and DOEHRS store similar types of unclassified OEHS data, such  as environmental sample data (e.g., water and soil samples) and risk  assessments for deployment sites. (See table 2.) Our prior work has  found that inefficiencies can occur when there is fragmentation and  duplication, such as when more than one system offers the same  services.store unclassified OEHS data, officials’ efforts to store these data are  inefficient and have resulted in both fragmentation and duplication. This  has occurred because, in some cases, similar types of unclassified OEHS   Without consistent policies on which system should be used to  data have been submitted to both MESL and DOEHRS, and in other  cases, identical OEHS data has been submitted to both systems.  However, neither system serves as a central repository for these data. As  a result, it is difficult to identify complete and comprehensive data sets for  specific types of OEHS data, which may lead to problems when officials  attempt to use these data in the future.
A U.S. Army Public Health Command official who has technical expertise  in both systems confirmed that there is duplication of OEHS data storage,  but stated that there is no reasonable way to determine the extent  because only DOEHRS has specific data level querying capabilities.  Therefore, this could only be determined by comparing individual  documents, which is not feasible because there are thousands of records  in each system.
section_title: Military Services’ Inconsistent Quality Assurance Processes May Not Ensure the Reliability of OEHS Data
paragraphs: DOD’s department-wide policy that governs the collection and storage of  OEHS data during deployments does not specifically address quality  assurance for OEHS data. As a result, the military services lack specific  and consistent guidance on performing quality assurance reviews, which  may impact the reliability of these data. According to military service  officials, quality assurance reviews of OEHS data collected at deployment  sites are generally performed once the data have been submitted to  DOEHRS. As a result, it is not always feasible to verify the accuracy of  the samples, and the quality assurance reviews are focused more on the  completeness and reasonableness of data entry. Officials may perform  these quality assurance checks while at a deployment site. However, the  services’ public health surveillance centers in the United States may also  conduct these reviews. According to officials, quality assurance reviews  are limited to OEHS data that have been submitted to DOEHRS because  MESL only contains uploaded documents that cannot be edited or  modified. Data in DOEHRS can be reviewed for quality assurance  purposes after it has been submitted, and the system has the capability of  documenting that a quality assurance process has occurred.
A Force Health Protection & Readiness official told us that the  department’s deployment health policy was focused on monitoring the  implementation of the policy as a whole and did not specifically address  quality assurance for OEHS data in DOEHRS. As a result, some of the  military services developed their own guidance, which has resulted in  inconsistent approaches and levels of effort.
The Army’s policy that discusses quality assurance for OEHS data  states that data should be collected to ensure reliability and  completeness, but does not discuss how these data should be  reviewed. U.S. Army Public Health Command officials told us that  they check OEHS data submissions in DOEHRS for completion in all  relevant data fields and for general reasonableness of the data.
The Air Force’s policy that addresses quality assurance for OEHS  data states that procedures for quality assurance should be  developed, but does not give any specifics as to how this should be  done. Officials from the Air Force Medical Support Agency—an  entity that provides guidance for U.S. Air Force Central Command on  how to execute Air Force policy—told us that they did not think that  quality assurance of OEHS data in DOEHRS collected by the Air  Force was occurring to any large extent.
A Navy & Marine Corps Public Health Center official told us that the  Navy and Marine Corps do not have policies on quality assurance for  OEHS data. Despite having no policy, however, Navy & Marine Corps  Public Health Center officials told us that they check for completion  and general reasonableness of the data.
These inconsistent quality assurance processes reduce DOD’s ability to  be confident about the reliability of OEHS data—especially because these  reviews do not always occur—and potentially limit the usefulness of these  data for monitoring the health of servicemembers and veterans. This runs  counter to federal standards for internal control, which state that  management should continually monitor information captured and  maintained for several factors, including its reliability.
section_title: Site Assessments Are Used to Identify Potential Health Risks, but the Extent to Which These Risks Are Mitigated for Deployed Servicemembers Is Unclear
subsections: section_title: Site Assessments Are Used to Identify Potential Health Risks for Servicemembers Deployed to Iraq and Afghanistan
paragraphs: The military services use site assessments to identify and address  potential occupational and environmental health risks at deployment  locations. In 2007, DOD established the Occupational and Environmental  Health Site Assessment (OEHSA) as the standardized process for  assessing and reporting occupational and environmental health site  conditions at deployment sites. While the OEHSA is DOD’s primary and  most comprehensive process for assessing risks, other methods may  also be used, as needed. OEHSAs are completed by preventive medicine  units and generally include the initial evaluation of the following conditions  with continued surveillance as deemed necessary: ambient air, soil,  water, radiological surveys, noise, occupational health hazards, waste   OEHSAs also may contain location-specific  disposal, and sanitation.findings and can include recommended countermeasures for mitigating  these potential occupational and environmental health threats. These  recommendations may include a wide range of activities, such as  specifying any necessary education for servicemembers on how to  identify potential health threats, the use of personal protective equipment  to minimize exposure, or the need for new or continued testing of ambient  air or water. In our review of 50 OEHSAs for sites in Iraq or Afghanistan,  we found that almost all (46 of 50 OEHSAs) contained recommendations  for mitigating potential health risks for servicemembers in these locations.  For example, a 2011 OEHSA for a site in Afghanistan found that  particulate matter concentrations exceeded military guidelines, and  consequently, air quality was at moderate risk for a significant health  concern. As a result, the OEHSA recommended, among other things,  that personal protective equipment be worn during periods when  conditions were very dusty and that methods to suppress dust be  instituted, such as using large rocks and gravel in high-traffic areas within  a deployment site. In another example, a 2011 OEHSA for a site in Iraq  noted that burn-pit exposure posed a moderate risk. As a result, the  OEHSA recommended additional burn-pit air monitoring during the next  assessment and that servicemembers fueling the burn pit wear  respiratory personal protective equipment.
Officials from USARCENT and U.S. Forces-Afghanistan told us that their  respective Force Health Protection Officers ensure that OEHSAs are  being completed—as required by CENTCOM policy—and perform quality  assurance reviews for completion and reasonableness.USARCENT’s Force Health Protection Officer told us that they check  OEHSAs for completeness and reasonableness by reviewing relevant  historical data documented in DOEHRS and by using their subject matter  expertise. U.S. Forces-Afghanistan officials told us that their Force Health  Protection Officer uses similar methods to monitor the completion of  OEHSAs. In addition, the CENTCOM official responsible for OEHS has  recently begun holding and documenting monthly meetings with the   For example,  service component commands to further monitor OEHS activities,  including the completion of OEHSAs for deployment sites.
section_title: The Extent to Which Potential Health Risks Identified in Site Assessments Are Mitigated Is Unclear Due to a Lack of Documentation and Monitoring
paragraphs: Although OEHSAs identify recommended countermeasures to mitigate  some potential occupational and environmental health risks, the extent to  which these recommendations are being implemented is unclear due to a  lack of documentation and monitoring. According to CENTCOM policy,  base commanders are responsible for using completed OEHSAs to make  decisions about local deployment health activities. This could include,  for example, whether and how to implement recommendations to mitigate  identified risks. However, this policy does not require that base  commanders document their decisions in these instances, and as a  result, USARCENT and U.S. Forces-Afghanistan officials told us that they  could not readily identify whether documentation of these decisions  exists. In contrast, DOD’s policy for its safety and occupational health  program requires that the department’s components, including the  combatant commands, establish procedures to ensure that decisions  related to risk management are documented, archived, and reevaluated  on a recurring basis. Furthermore, clear and appropriate documentation  is a key component of internal controls, according to the federal  standards for internal control. Without such documentation, it is difficult  to determine whether and how recommendations identified in site  assessments are being implemented. USARCENT and U.S. Forces- Afghanistan officials told us that they are not monitoring the  implementation of these recommendations, and instead rely on  preventive medicine units to elevate any concerns about implementing  these recommendations through the chain of command, as necessary.
Nonetheless, CENTCOM is ultimately responsible for overseeing the  coordination of force health protection programs and compliance with all  DOD requirements within its area of responsibility. CENTCOM officials  also told us that they are not monitoring the implementation of  recommendations contained in OEHSAs because they, too, rely on  preventive medicine units to elevate concerns as needed. However,  CENTCOM’s policy on risk management requires the implementation of  internal controls and, subsequently, the supervision and evaluation of the  effectiveness of these controls. Similarly, federal standards for internal  control note that once an agency has identified areas of risk, it should  determine how to manage the risk and what actions should be taken.  Without relevant documentation on whether OEHSAs’ recommendations  are being implemented, neither the combatant command nor the  subordinate commands can readily determine the extent to which  potential health risks for deployed servicemembers are being mitigated in  Iraq or Afghanistan.
section_title: DOD’s and VA’s Use of OEHS Data to Address Post- Deployment Health Conditions Has Been Limited
paragraphs: Despite the ongoing collection of OEHS data, both DOD and VA have  used OEHS data to a limited extent to address post-deployment health  conditions. Force Health Protection & Readiness officials told us that the  primary limitation with OEHS data collected during deployments  continues to be the inability to capture individual servicemembers’  exposures—an issue that we reported on in 2012. These officials told us  that this limitation has impeded the department’s ability to evaluate or  treat some servicemembers who have been exposed to occupational or  environmental hazards. To address this issue, DOD officials have been  conducting research on the use of dosimeters—sensor devices that  individuals wear to monitor real-time exposure to hazardous materials— which would allow the collection of individual exposure data. However,  the logistics of using dosimeters during deployments is complicated  because current technology allows for a dosimeter to be used for a single  known hazard, and in deployed settings, servicemembers may be  exposed to multiple hazards and unknown exposures. U.S. Army Public  Health Command officials also told us that the type of dosimeter used  depends on the type of hazard that the servicemember would be exposed  to and the method of exposure. During deployments, these factors are  often unknown; therefore it is difficult to determine the type of dosimeter  that should be used. Additionally, it may not always be feasible to have  servicemembers wear dosimeters while performing deployment duties,  and the resources needed for monitoring may not always be available,  according to these officials.
DOD also creates Periodic Occupational and Environmental Monitoring  Summaries (POEMS), which summarize historical environmental health  surveillance monitoring efforts and identify possible short- and long-term  health risks at deployed locations. While these summaries do not  represent confirmed exposures or individual exposure levels, they are an  indication of possible exposures, which can inform diagnosis, treatment,  and the determination of disability benefits. According to U.S. Army Public  Health Command officials, POEMS are made available to medical  providers to help inform diagnosis and treatment of servicemembers.  However, these officials said that providers’ use of POEMS may be  limited because they do not provide information on the types of illnesses  that may result from an exposure. VBA officials told us that they have  access to unclassified POEMS through a MESL website. A VBA official  told us that disability officials have been made aware of this website  through a newsletter distributed to benefit managers throughout the  country. However, this official could not tell us the extent to which  POEMS are used in making disability determinations. In September 2014,  DOD implemented a new review process for the completion of POEMS,  which includes making these records publicly available via a MESL   As of March 2015, 23 of the approximately 40 POEMS from  website.Iraq and Afghanistan have been made available. DOD officials told us  that they intend to promote the website once all completed POEMS have  been posted, although officials could not provide a timeline for this effort.
VA also uses OEHS data to supplement information used to educate  veterans on specific deployment issues, although its use of these data is  limited. Specifically, VA’s Office of Public Health developed a website to  help veterans learn about potential occupational and environmental   In doing  hazards during deployments and their potential health effects.so, VA’s Office of Public Health officials told us they develop the content  of the website through environmental hazard information obtained from  several sources, including the U.S. Environmental Protection Agency.  These officials told us they may also use OEHS data about a specific  incident to supplement their information. For example, the website  includes detailed information about Gulf War veterans’ unexplained  illnesses, including available benefits and links to relevant research. VA  supplements this information with OEHS data about potential types of  occupational hazards that Gulf War veterans may have experienced,  such as exposures to industrial solvents and radiation.
The Millennium Cohort Study is the largest prospective study designed to assess the  long-term health effects of military service both during and after deployment. As part of  this study, DOD and VA conducted another study that found that, among other things, a  servicemember located within 3 miles of a documented burn pit was not significantly  associated with increased risk for respiratory symptoms or conditions compared to those  servicemembers located greater than 3 miles from a burn pit. See Smith et al., “The  Effects of Exposure to Documented Open-Air Burn Pits on Respiratory Health Among  Deployers of the Millennium Cohort,” Journal of Environmental Medicine, vol. 54, no. 6  (2012): 708-716. deployment to Iraq and Kuwait and the development of respiratory  conditions post-deployment. However, neither study was able to identify  a causal link between exposures to burn pits and respiratory conditions.  Additionally, in its 2011 report, the Institute of Medicine was unable to  determine whether certain long-term health effects are likely to result from  exposure to burn pits during deployments because the studies it reviewed  lacked the support to conclude the absence or existence of an  association. As a result, it recommended that additional studies of  health effects in veterans deployed to Iraq or Afghanistan were needed.  Both VA and DOD have begun additional research as a result of this  recommendation.
Since 2003, DOD and VA have collaborated through the DHWG on  deployment health issues related to occupational and environmental  hazards. For example, the DHWG sponsored an initiative related to  DOD’s work on the individual longitudinal exposure record (ILER), the  intention of which is to provide linkages between different types of data— environmental monitoring, biomarkers of exposure, and troop locations  and activity—and an individual’s medical records. As a result, the ILER  would create a complete record of servicemembers’ exposures over the  course of their careers, which could support disability benefits claims, as  well as retrospective studies. In April and May 2014, DOD outlined the  users of the data, the sources of the data, guidance on developing a  system to meet the needs of those who would use an ILER, and its  intended functions. DOD officials told us that the project is currently in the  second phase of its pilot program, and they are 6 to 8 years away from  completing its development.
In 2013, the DHWG helped develop a data transfer agreement that was  intended to facilitate the exchange of data identified to assist both  departments in several ways, including making clinical decisions for  care. One aspect of the agreement specifies that DOD is to transfer to  VA lists of servicemembers or veterans determined by DOD to have had  an actual or potential environmental, occupational, or military-related  exposure that has the potential for adverse long-term health effects.  According to VA officials, DOD has not been proactively providing these  lists. However, a VA official told us that the department considers all  deployed servicemembers to have had potential exposures, and as a  result, they have been requesting lists of all servicemembers deployed to  an area with a burn pit. Further, VA officials said that when they learn of  an exposure incident and request data, DOD has generally fulfilled that  request. In addition, VA officials told us that DOD sends data on  servicemembers’ and veterans’ deployment status as requested by VA to  verify eligibility of those who have signed up for its Burn Pit Registry.
In August 2014, DOD officials established the Exposure Related Data  Transfer Agreement Subgroup to improve the department’s efforts in  proactively meeting the data transfer requirements. Specifically, the  workgroup met in January 2015 to finalize its objectives, which are to  determine the appropriateness and timeliness of sharing specific  exposure-related data and information with VA and to develop  recommendations for any medically relevant follow-up actions for  servicemembers or veterans exposed to occupational and environmental  health hazards. DOD officials did not have a time frame for when this  work would be completed.
section_title: Conclusions
paragraphs: In the wake of veterans’ unexplained illnesses such as from the Persian  Gulf War, the collection of OEHS data has become increasingly important  because of its critical role in helping to identify exposures and determine  the causes of post-deployment health issues. Servicemembers deployed  to Iraq and Afghanistan have continued to express concerns about health  conditions they attribute to exposures during their deployment, and their  eligibility to obtain certain benefits is based on whether these conditions  can be connected to their military service. However, problems with the  storage and quality assurance for OEHS data compromise the  departments’ ability to use them in determining service-connections for  specific health conditions, or in conducting other important research.  Specifically, fragmentation and duplication in the storage of unclassified  OEHS data—due to inconsistent policies across DOD and the military  services—hinder the use of these data, as there is no single repository  from which to retrieve them. Moreover, the reliability of OEHS data is also  potentially problematic as the military services have developed varying  approaches for quality assurance reviews in the absence of departmental  guidance. Of additional concern, DOD does not know the extent to which  recommended countermeasures for mitigating exposures to occupational  and environmental health hazards are being implemented at deployment  sites because CENTCOM does not require the documentation of these  decisions. Consequently, CENTCOM and its subordinate commands— USARCENT and U.S. Forces-Afghanistan—do not proactively monitor  the extent to which base commanders are mitigating potential health risks  in Iraq or Afghanistan. The approach instead is to wait for concerns to be  elevated—potentially putting servicemembers at risk for harmful  exposures. While the health and well-being of our servicemembers and  veterans is paramount, DOD’s and VA’s ability to prevent, diagnose, and  study post-deployment health conditions is compromised without  accessible and reliable information about risk mitigation activities and  OEHS data.
section_title: Recommendations for Executive Action
paragraphs: To eliminate the fragmentation and duplication in the storage of  unclassified OEHS data we recommend that the Secretary of Defense  determine which IT system—DOEHRS or MESL—should be used to  store specific types of unclassified OEHS data, clarify the department’s  policy accordingly, and require all other departmental and military-service- specific policies to be likewise amended and implemented to ensure  consistency.
To ensure the reliability of OEHS data, we recommend that the Secretary  of Defense establish clear policies and procedures for performing quality  assurance reviews of the OEHS data collected during deployment, to  include verifying the completeness and the reasonableness of these data,  and require that all other related military-service-specific policies be  amended and implemented to ensure consistency.
To ensure that potential occupational and environmental health risks are  mitigated for servicemembers deployed to Iraq and Afghanistan, we  recommend that the Secretary of Defense require CENTCOM to revise its  policy to ensure that base commanders’ decisions on whether to  implement risk mitigation recommendations identified in OEHSAs are  adequately documented and consistently monitored by the appropriate  command.
section_title: Agency Comments and Our Evaluation
paragraphs: We requested comments on a draft of this report from DOD and VA. Both  departments provided written comments that are reprinted in appendixes I  and II. DOD also provided technical comments that we incorporated as  appropriate.
In commenting on this draft, DOD concurred with all of our  recommendations, and VA generally agreed with our conclusions. DOD  also provided the following responses to each of our recommendations:  In responding to the first recommendation to clarify the department’s  policy on which IT system (DOEHRS or MESL) should be used to  store specific types of unclassified OEHS data, DOD noted that it will  clarify DOD Instruction 6490.03 in a subsequent revision and will  issue appropriate guidance on the use of DOEHRS and MESL. DOD  also noted that we identified fragmentation and duplication, but that  our only evidence was the use of two systems to store data. However,  our evidence of fragmentation and duplication was based on the  storage of OEHS data, which results from the inconsistent use of two  systems. Specifically, as stated in our report, in some cases, similar  types of unclassified OEHS data have been submitted to both MESL  and DOEHRS, which would result in fragmentation of data storage. In  other cases, identical OEHS data has been submitted to both  systems, resulting in duplicate data storage.
Additionally, in response to our recommendation that DOD require all  other departmental and military-service-specific policies to be likewise  amended, DOD stated that once a new policy is published, the entire  department, including the military services, revises related policies  accordingly. As stated in our report, the other departmental and  military service policies that are linked to the main DOD Instruction  are inconsistent in identifying which system to use for storing OEHS  data. Therefore, we believe that it is important for the department to  ensure that the appropriate revisions are made to all related policies.
In responding to the second recommendation to establish clear  policies and procedures for performing quality assurance reviews of  OEHS data collected during deployment, DOD noted that the  implementation of such a process would be complex, in that it would  need to include definitions of completeness and reasonableness,  among other items. DOD also noted this would require additional  resources. While we appreciate DOD’s comments, an appropriate  level of quality assurance needs to be performed to ensure the  reliability of the OEHS data being collected. Otherwise, these data will  not be useful for the intended purposes.
In responding to the third recommendation to require CENTCOM to  revise its policy to ensure that base commanders' decisions on  whether to implement risk-mitigation recommendations are  documented and consistently monitored, DOD noted that DOD  Instruction 6055.01 already requires this. Specifically, DOD noted that  the Instruction requires that the DOD Components must establish  procedures to ensure these decisions are documented, archived, and  reevaluated on a recurring basis. However, as stated in our report,  current CENTCOM policy does not require documentation of risk- mitigation decisions, as is required by DOD Instruction 6055.01.  Further, CENTCOM officials told us that they are not monitoring the  implementation of these recommendations. Therefore, we continue to  believe that CENTCOM should revise its policy to align with  Instruction 6055.01.
As agreed with your office, unless you publicly announce the contents of  this report earlier, we plan no further distribution until 30 days from the  report date. At that time, we will send copies of this report to the  appropriate congressional committees and the Secretaries of Defense  and Veterans Affairs. In addition, the report will be available at no charge  on GAO’s website at http://www.gao.gov.
If you or your staff members have any questions about this report, please  contact me at (202) 512-7114 or draperd@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs may be found on  the last page of this report. GAO staff members who made key  contributions to this report are listed in appendix III.
section_title: Appendix I: Comments from the Department of Defense
section_title: Appendix II: Comments from the Department of Veterans Affairs
section_title: Appendix III: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Bonnie Anderson,   Assistant Director; Amy Andresen; Jennie Apter; LaKendra Beard;  Danielle Bernstein; Muriel Brown; Jacquelyn Hamilton; and   Jeffrey Mayhew made key contributions to this report.