Defense Health Care: Force Health Protection and Surveillance Policy Compliance Was Mixed, but Appears Better for Recent Deployments
Published: 2004-11-12T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: A lack of servicemember health and deployment data hampered investigations into the nature and causes of illnesses reported by many servicemembers following the 1990-91 Persian Gulf War. Public Law 105-85, enacted in November 1997, required the Department of Defense (DOD) to establish a system to assess the medical condition of servicemembers before and after deployments. Following its September 2003 report examining Army and Air Force compliance with DOD's force health protection and surveillance policies for Operation Enduring Freedom (OEF) and Operation Joint Guardian (OJG), GAO was asked in November 2003 to also determine (1) the extent to which the services met DOD's policies for Operation Iraqi Freedom (OIF) and, where applicable, compare results with OEF/OJG; and (2) what steps DOD has taken to establish a quality assurance program to ensure that the military services comply with force health protection and surveillance policies.
section_title: What GAO Found
paragraphs: Overall compliance with DOD's force health protection and surveillance policies for servicemembers that deployed in support of OIF varied by service, installation, and policy requirement. Such policies require that servicemembers be assessed before and after deploying overseas and receive certain immunizations, and that health-related documentation be maintained in a centralized location. GAO reviewed 1,862 active duty and selected reserve component servicemembers' medical records from a universe of 4,316 at selected military service installations participating in OIF. Overall, Army and Air Force compliance for sampled servicemembers for OIF appears much better compared to OEF and OJG. For example, (1) lower percentages of Army and Air Force servicemembers were missing pre- and post-deployment health assessments for OIF; (2) higher percentages of Army and Air Force servicemembers received required pre-deployment immunizations for OIF; and (3) lower percentages of deployment health-related documentation were missing in servicemembers' permanent medical records and at DOD's centralized database for OIF. The Marine Corps installations examined generally had lower levels of compliance than the other services; however, GAO did not review medical records from the Marines or Navy for OEF and OJG. Noncompliance with the requirements for health assessments may result in deployment of servicemembers with existing health problems or concerns that are unaddressed. It may also delay appropriate medical follow-up for a health problem or concern that may have arisen during or after deployment. In January 2004, DOD established an overall deployment quality assurance program for ensuring that the services comply with force health protection and surveillance policies, and implementation of the program is ongoing. DOD's quality assurance program requires (1) reporting from DOD's centralized database on each service's submission of required pre-deployment and post-deployment health assessments for deployed servicemembers, (2) reporting from each service regarding the results of the individual service's deployment quality assurance program, and (3) joint DOD and service representative reviews at selected military installations to validate the service's deployment health quality assurance reporting. DOD officials believe that their quality assurance program has improved the services' compliance with requirements. However, the services are at different stages of implementing their own quality assurance programs as mandated by DOD. At the installations visited, GAO analysts observed that the Army and Air Force had centralized quality assurance processes in place that extensively involved medical personnel examining whether DOD's force health protection and surveillance requirements were met for deploying/re-deploying servicemembers. In contrast, GAO analysts observed that the Marine Corps installations did not have well-defined quality assurance processes for ensuring that requirements were met for servicemembers.

section_title: Letter
paragraphs: 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.
In response, the Congress enacted legislation in November 1997 requiring  the Department of Defense (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 was  also required to establish a quality assurance program to ensure  compliance. 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 screening for  tuberculosis; and the retention of blood samples on file prior to  deployment and the collection of a post-deployment blood sample.
In September 2003, we reported that the Army and Air Force, for  servicemembers deployed in support of Operation Enduring Freedom  (OEF) and Operation Joint Guardian (OJG), did not comply with DOD’s  force health protection and surveillance policies for many active duty  servicemembers, including the policies that the servicemembers be  assessed before and after deploying overseas, that the services document  receipt of certain immunizations, and that health-related documentation  be maintained in a centralized location. We had previously reported in  May 1997 on several similar problems associated with the implementation  of DOD’s deployment health surveillance policies for servicemembers  deployed to Bosnia in support of a peacekeeping operation.
Concerned about the repercussions of the military services’ failure to  comply with DOD’s force health protection and surveillance policies and  the need to better understand the adverse health effects of war, you asked  us, in November 2003, to examine the military services’ implementation of  DOD’s force health protection and surveillance policies for  servicemembers’ deployments to Iraq in support of Operation Iraqi  Freedom (OIF). More specifically, we focused our work on the military  services’ deployments to Southwest Asia for OIF to address the following  two questions:  1.  To what extent did the military services meet DOD’s force health  protection and surveillance system requirements for servicemembers  deployed to Southwest Asia in support of OIF and, where applicable,  did compliance improve compared to OEF/OJG?  2.  What steps has DOD taken to establish a quality assurance program to  ensure that the military services comply with force health protection  and surveillance policies?
To accomplish these objectives, we obtained the force health protection  and surveillance policies applicable to the OIF deployment from the  U.S. Central Command, the Office of the Assistant Secretary of Defense for  Health Affairs, and the services’ Surgeons General. For each service, we  identified those installations that had amongst the largest deployments or  redeployments of servicemembers during specified time frames. Because  of concerns about the reliability of overall personnel deployment data, we  obtained data from the selected installations on the universe of those  servicemembers who deployed or redeployed from the selected  installations. To test the implementation of these policies, we reviewed  samples or, in some instances, the entire universe of medical records for  servicemembers at seven military installations. In total, we reviewed  medical records of 1,328 active duty servicemembers—including 750 Army  servicemembers, 270 Marine Corps servicemembers, 146 Air Force  servicemembers, and 162 Navy servicemembers. In addition, we reviewed  medical records for 409 Army reserve servicemembers and 125 Army  National Guard servicemembers.
To provide assurances that the data were reliable and 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 assessments and missing immunizations.  We also examined, for all medical records within our review, the  completeness of the centralized records at the Army Medical Surveillance  Activity (AMSA), which is tasked with centrally collecting deployment  health-related information for all of the military services. Further, we  interviewed officials with the Office of the Deployment Health Support  Directorate within the Office of Assistant Secretary of Defense for Health  Affairs, the offices of the services’ Surgeons General, and the military  installations that we visited for medical records review regarding the  quality assurance processes established to ensure compliance with DOD  force health protection and surveillance policies. For more detailed  information of our scope and methodology, see appendix I. We performed  our work from November 2003 through August 2004 in accordance with  generally accepted government auditing standards.
subsections: section_title: Background
paragraphs: In September 2003, we reported that the Army and Air Force did not  comply with DOD’s force health protection and surveillance requirements  for many servicemembers deploying in support of OEF in Central Asia and  OJG in Kosovo at the installations we visited. Specifically, our review  disclosed problems with the Army and Air Force’s implementation of  DOD’s force health protection and surveillance requirements in the  following areas:    Deployment health assessments. Significant percentages of Army  and Air Force servicemembers were missing one or both of their pre-  and post-deployment health assessments and, when health assessments  were conducted, as many as 45 percent of them were not done within  the required time frames.
Immunizations and other pre-deployment requirements. Based  on the documentation we reviewed, as many as 46 percent of  servicemembers in our samples were missing one of the  pre-deployment immunizations required, and as many as 40 percent  were missing a current tuberculosis screening at the time of their  deployment. Up to 29 percent of the servicemembers in our samples  had blood samples in the repository older than the required limit of  1 year at the time of deployment.
Completeness of medical records and centralized data  collection. Servicemembers’ permanent medical records at the Army  and Air Force installations we visited did not always include  documentation of the completed health assessments that we found at  AMSA and at the U.S. Special Operations Command. In one sample,  100 percent of the pre-deployment health assessments were not  documented in the servicemember medical records that we reviewed.  Furthermore, our review disclosed that the AMSA database was lacking  documentation of many health assessments and immunizations that we  found in the servicemembers’ medical records at the installations  visited.
We also wrote in our 2003 report that DOD did not have oversight of  departmentwide efforts to comply with health surveillance requirements.  There was 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 helped ensure compliance  with force health protection and surveillance policies. We believed that the  lack of such a system was a major cause of the high rate of noncompliance  we found at the installations we visited, and thus recommended that the  department establish an effective quality assurance program to ensure that  the military services comply with the force health protection and  surveillance requirements for all servicemembers. The department  concurred with our recommendation. “(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).  “(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.”
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 GAO, 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. However, it requires the blood samples be  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 were required to draw a blood sample from each redeploying  servicemember no later than 30 days after arrival at a demobilization site  or home station. 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.
section_title: Services’ Compliance with Force Health Protection and Surveillance Requirements for OIF Was Mixed, but Appears Better Than for OEF/OJG
paragraphs: The overall record of the military services in meeting force health  protection and surveillance system requirements for OIF was mixed and  varied by service, by installation visited, and by specific policy  requirement; however, our data shows much better compliance with these  requirements in the Army and Air Force installations we reviewed  compared to the installations in our earlier review of OEF/OJG. Of the  installations reviewed for this report, the Marine Corps generally had  lower levels of compliance than the other services.
subsections: section_title: Services’ Compliance on All Requirements Uneven, but Marine Corps Lags Behind
paragraphs: None of the services fully complied with all of the force health protection  and surveillance system requirements, which include completing pre- and  post-deployment health assessments, receipt of immunizations, and  meeting pre-deployment requirements related to tuberculosis screening  and pre and post-deployment blood samples. Also, the services did not  fully comply with requirements that servicemembers’ permanent medical  records include required health-related information, and that DOD’s  centralized database includes documentation of servicemember  health-related information.
subsections: section_title: Health Assessments
paragraphs: Servicemembers in our review at the Army and Air Force installations  were generally missing small percentages of pre-deployment health  assessments, as shown in figure 1. In contrast, pre-deployment health  assessments were missing for an estimated 63 percent of the  servicemembers at one Marine Corps installation and for 27 percent at the  other Marine Corps installation visited. Similarly, the Navy installation we  visited was missing pre-deployment health assessments for about  24 percent of the servicemembers; however, we note that the  pre-deployment health assessments reviewed for Navy servicemembers  were completed prior to June 1, 2003, and may not reflect improvements  arising from increased emphasis following our prior review of the Army  and Air Force’s compliance for OEF/OJG.
At three Army installations we visited, we also analyzed the extent to  which pre-deployment health assessments were completed for those  servicemembers who re-deployed back to their home unit after  June 1, 2003. Servicemembers associated with these re-deployment  samples deployed in support of OIF prior to June 1, 2003. For two of these  Army installations—Fort Eustis and Fort Campbell—we estimate that less  than 1 percent of the servicemembers were missing pre-deployment health  assessments. However, approximately 39 percent of the servicemembers  that redeployed back to Fort Lewis on or after June 1, 2003, were missing  their pre-deployment health assessments.
Post-deployment health assessments were missing for small percentages  of servicemembers, except at one of the Marine Corps installations we  visited, as shown in figure 2.
Although the Army provides for waivers for longer time frames, 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. For consistency and comparability between  services, our analysis uses the DOD policy for reporting results. 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. For servicemembers that had completed pre-deployment  health assessments, we found that many assessments were not completed  on time in accordance with requirements. More specifically, we estimate  that pre-deployment health assessments were not completed on time for:    47 percent of the pre-deployment health assessments for the active  duty servicemembers at Fort Lewis;    41 percent of the pre-deployment health assessments for the active  duty servicemembers and for 96 percent of the Army National Guard  unit at Fort Campbell; and    43 percent of the pre-deployment health assessments at Camp Lejeune  and 29 percent at Camp Pendleton.
For the most part, small percentages—ranging from 0 to 5 percent—of the  post-deployment health assessments were not completed on time at the  installations visited. The exception was at Fort Lewis, where we found  that about 21 percent of post-deployment health assessments for  servicemembers were not completed on time.
DOD policy also 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. Except for  servicemembers at one of the two Marine Corps installations visited, only  small percentages of the pre- and post-deployment health assessments,  ranging from 0 to 6 percent, were not reviewed by a health care provider.  At Camp Pendleton, we found that a health care provider did not review  33 percent of the pre-deployment health assessments and 21 percent of the  post-deployment health assessments for its servicemembers .
Noncompliance with the requirements 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.
section_title: Immunizations and Other Health Requirements
paragraphs: Based on our samples, the services did not fully meet immunization and  other health requirements for OIF deployments, although all  servicemembers in our sample had received at least one anthrax  immunization before they returned from the deployment as required.  Almost all of the servicemembers in our samples had a pre-deployment  blood sample in the DOD Serum Repository but frequently the blood  sample was older than the one-year requirement. The services’ record in  regard to post-deployment blood sample draws was mixed.
The U.S. Central Command required the following pre-deployment  immunizations for all servicemembers who deployed to Southwest Asia in  support of OIF: hepatitis A (two-shot series); measles, mumps, and rubella;  polio; tetanus/diphtheria within the last 10 years; typhoid within the last  5 years; and influenza within the last 12 months. Based on the  documentation we reviewed, the estimated percent of servicemembers  receiving all of the required pre-deployment immunizations ranged from  52 percent to 98 percent at the installations we visited (see fig. 3).  The percent of servicemembers missing only one of the pre-deployment  immunizations required for the OIF deployment ranged from 2 percent to  43 percent at the installations we visited. Furthermore, the percent of  servicemembers missing 2 or more of the required immunizations ranged  from 0 percent to 11 percent.
Figure 4 indicates that 3 to about 64 percent of the servicemembers at the  installations visited were missing a current tuberculosis screening at the  time of their deployment. A tuberculosis screening is deemed “current” if it  occurred within 1 year prior to deployment. Specifically, the Army, Navy,  and Marine Corps required servicemembers deploying to Southwest Asia  in support of OIF to be screened for tuberculosis within 12 months of  deployment. The Air Force requirement for tuberculosis screening  depends on the servicemember’s occupational specialty; therefore we did  not examine tuberculosis screening for servicemembers in our sample at  Moody Air Force Base due to the difficulty of determining occupational  specialty for each servicemember.
Although not required as pre-deployment immunizations, U.S. Central  Command policies require that servicemembers deployed to Southwest  Asia in support of OIF receive a smallpox immunization and at least one  anthrax immunization either before deployment or while in theater. For  the servicemembers in our samples at the installations visited, we found  that all of the servicemembers received at least one anthrax immunization  in accordance with the requirement. Only small percentages of  servicemembers at two of the three Army installations, the Air Force  installation, and the Navy installation visited did not receive the required  smallpox immunization. However, an estimated 18 percent of the  servicemembers at Fort Lewis, 8 percent at Camp Lejeune, and 27 percent  at Camp Pendleton did not receive the required smallpox immunization.
U.S. Central Command policies also require that deploying  servicemembers have a blood sample in the DOD Serum Repository not  older than 12 months prior to deployment. Almost all of the  servicemembers in our review had a pre-deployment blood sample in the  DOD Serum Repository, but frequently the blood samples were older than  the 1-year requirement. As shown in table 1 below, 14 percent of  servicemembers at Camp Pendleton had blood samples in the repository  older than 1 year.
Effective May 22, 2003, the services were required to draw a  post-deployment blood sample from each re-deploying servicemember no  later than 30 days after arrival at a demobilization site or home station.
Only small percentages of the servicemembers at the Army and Air Force  installations visited did not have a post-deployment blood sample drawn.  The Navy and Marine Corps installations visited had percentages of  servicemembers missing post-deployment blood samples ranging from 7 to  19 percent, and the post-deployment blood samples that were available  were frequently drawn later than required, as shown in table 2.
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. Also, the military services require that all  immunizations be documented in the servicemember’s medical record.  Figure 5 shows that small percentages of the completed health  assessments we found at AMSA for servicemembers in our samples were  not documented in the servicemember’s permanent medical record,  ranging from 0 to 14 percent for pre-deployment health assessments and  from 0 percent to 20 percent for post-deployment health assessments.  Almost all of the immunizations we found at AMSA for servicemembers in  our samples were documented in the servicemember’s medical record.
Service policies also require documentation in the servicemember’s  permanent medical records of all visits to in-theater medical facilities.
At six of the seven installations we visited, we sampled and examined  whether selected in-theater visits to medical providers—such as battalion  aid stations for the Army and Marine Corps and expeditionary medical  support for the Air Force—were documented in the servicemember’s  permanent medical record. Both the Air Force and Navy installations used  automated systems for recording servicemember in-theater visits to  medical facilities. While in-theater visits were documented in these  automated systems, we found that 20 of the 40 Air Force in-theater visits  we examined at Moody Air Force Base and 6 of the 60 Navy in-theater  visits we examined at the Naval Construction Battalion Center were not  also documented in the servicemembers’ permanent medical records. In  contrast, the Army and Marine Corps installations used manual patient  sign-in logs for servicemembers’ visits to in-theater medical providers and  relied exclusively on paper documentation of the in-theater visits in the  servicemember’s permanent medical record. The results of our review are  summarized in table 3.
Army and Marine Corps representatives associated with the battalion aid  stations we examined commented that the aid stations were frequently  moving around the theater, increasing the likelihood that paper  documentation of the visits might get lost and that such visits might not  always be documented because of the hostile environment. The lack of  complete and accurate medical records documenting all medical care for  the individual servicemember complicates the servicemember’s  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’s Theater Medical Information  Program (TMIP) has the capability to electronically record and store  in-theater patient medical encounter data. However, the Iraq war has  delayed implementation of the program. At the request of the services, the  operational test and evaluation for TMIP has been delayed until the second  quarter of fiscal year 2005.
In addition to the above requirements, Public Law 105-85, 10 U.S.C. 1074f,  requires the Secretary of Defense to retain and maintain health-related  records in a centralized location for servicemembers who are deployed.  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  requires the services to forward a copy of the completed pre-deployment  and post-deployment health assessments to AMSA for centralized  retention.
Figure 6 shows the estimated percentage of pre- and post-deployment  health assessments in servicemembers’ medical records that were not  available in a centralized database at AMSA. Our samples of  servicemembers at the installations visited show wide variation by  installation regarding pre-deployment health assessments missing from the  centralized database, ranging from zero at Fort Lewis to all of the  assessments at Camp Lejeune. Post-deployment health assessments were  missing for small percentages of servicemembers at the installations  visited, except at the Marine Corps installations visited. More specifically,  about 26 percent of the post-deployment health assessments at Camp  Lejeune and 24 percent at Camp Pendleton were missing from the  centralized database. Immunizations missing from the centralized  database that we found in the servicemembers’ medical records ranged  from 3 to 44 percent for the servicemembers in our samples.
DOD officials believe that automation of deployment health assessment  forms and recording of servicemember immunizations will improve the  completeness of deployment data in the AMSA centralized database, and  DOD has ongoing initiatives to accomplish these goals. DOD is currently  implementing worldwide 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. Also, the  Assistant Secretary of Defense for Health Affairs has established a  Deployment Health Task Force whose focus includes improving the  electronic capture of deployment health assessments. According to DOD,  about 40 percent of the Army’s pre-deployment health assessments and  50 percent of the post-deployment health assessments sent to AMSA since  June 1, 2003, were submitted electronically. 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.
section_title: Army and Air Force Compliance with Deployment Health Surveillance Policies Appears Better
paragraphs: Although the number of installations we visited was limited and different  than those in our previous review with the exception of Fort Campbell, the  Army and Air Force compliance with force health protection and  surveillance policies for active-duty servicemembers in OIF appears to be  better than for those installations we reviewed for OJG and OEF. To  provide context, we compared overall data from Army and Air Force  active duty servicemembers’ medical records reviewed for OEF/OJG with  OIF, by aggregating data from all records examined in these two reviews  to provide some perspective and determined that:    Lower percentages of Army and Air Force servicemembers were missing  pre- and post-deployment health assessments for OIF.
Higher percentages of Army and Air Force servicemembers received  required pre-deployment immunizations for OIF.
Lower percentages of deployment health-related documentation were  missing in the servicemembers’ permanent medical records and at DOD’s  centralized database for OIF.
Because our previous report on compliance with requirements for OEF  and OJG focused only on the Army and Air Force, we were unable to make  comparisons for the Navy and Marine Corps.
subsections: section_title: Health Assessments
paragraphs: Our data indicate that Army and Air Force compliance with requirements  for completion of pre- and post-deployment health assessments for  servicemembers for OIF appears to be much better than compliance for  OEF and OJG for the installations examined in each review. In some cases,  the services were in full compliance. As before, we aggregated data from  all records examined in the two reviews and determined, among the Army  and Air Force active duty servicemembers we reviewed for OIF compared  to those reviewed for OEF/OJG, the following:    Army servicemembers missing pre-deployment health assessments was an  average of 14 percent for OIF contrasted with 45 percent for OEF/OJG.    Air Force servicemembers missing pre-deployment health assessments  was 8 percent for OIF contrasted with an average of 50 percent for  OEF/OJG.
Army servicemembers missing post-deployment health assessments was  0 percent for OIF contrasted with an average of 29 percent for OEF/OJG.    Air Force servicemembers missing post-deployment health assessments  was 4 percent for OIF contrasted with an average of 62 percent for  OEF/OJG.
section_title: Immunizations and Other Health Requirements
paragraphs: Based on our samples, the Army and the Air Force had better compliance  with pre-deployment immunization requirements for OIF as compared to  OEF and OJG. The aggregate data from each of our OIF samples indicates  that an average of 68 percent of Army active duty servicemembers  received all of the required immunizations before deploying for OIF,  contrasted with an average of only 35 percent for OEF and OJG. Similarly,  98 percent of Air Force active duty servicemembers received all of the  required immunizations before deploying for OIF, contrasted with an  average of 71 percent for OEF and OJG. The percentage of Army active  duty and Air Force servicemembers missing two or more immunizations  appears to be markedly better, as illustrated in table 4.
Our data indicate that the Army and Air Force’s compliance with  requirements for completeness of servicemember medical records and of  DOD’s centralized database at AMSA for OIF appears to be significantly  better than compliance for OEF and OJG. Lower overall percentages of  deployment health-related documentation were missing in  servicemembers’ permanent medical records and at AMSA. We aggregated  the data from each of our samples and depicted the results in tables 5  and 6.
The data appear to indicate that, for active duty servicemembers, the Army  and the Air Force have made significant improvements in documenting  servicemember medical records. These data also appear to indicate that,  overall, both services have also made encouraging improvements in  retaining health-related records in DOD’s centralized database at AMSA,  although not quite to the extent exhibited in their efforts to document  servicemember medical records.
section_title: Implementation of DOD’s Deployment Health Quality Assurance Program Is Ongoing
paragraphs: In response to congressional mandates and a GAO recommendation, DOD  established a deployment health quality assurance program in January  2004 to ensure compliance with force health protection and surveillance  requirements and implementation of the program is ongoing. DOD officials  believe that their quality assurance program has improved the services’  compliance with requirements. However, we did not evaluate the  effectiveness of DOD’s deployment health quality assurance program  because of the relatively short time of its implementation.
Section 765 of Public Law 105-85 (10 U.S.C. 1074f) requires the Secretary  of Defense to establish a quality assurance program to evaluate the  success of DOD’s system for ensuring that members receive  pre-deployment medical examinations and post-deployment medical  examinations and that recordkeeping requirements are met. In May 2003,  the House Committee on Armed Services directed the Secretary of  Defense to take measures to improve oversight and compliance with force  health protection and surveillance requirements. 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 assess implementation of the force health protection  and surveillance program.
In January 2004, the Assistant Secretary of Defense for Health Affairs  issued policy and program guidance for the DOD Deployment Health  Quality Assurance Program. DOD’s quality assurance program requires:    Periodic reporting on pre- and post-deployment health assessments.
AMSA is required to provide (at a minimum) monthly reports to the  Deployment Health Support Directorate (Directorate) on deployment  health data. AMSA is providing the Directorate and the services with  weekly reports on post-deployment health assessments and publishes bi- monthly updates on pre- and post-deployment health assessments.
Periodic reporting on service-specific deployment health quality  assurance programs. The services are required to report (at a minimum)  quarterly reports to the Directorate on the status and findings of their  respective required deployment health quality assurance programs. Each  service has provided the required quarterly reports on its respective  quality assurance programs.
Periodic visits to military installations to assess deployment health  programs. The program requires joint visits by representatives from the  Directorate and from service medical departments to military installations  for the purpose of validating the service’s deployment health quality  assurance reporting. As of September 2004, Directorate officials had  accompanied service medical personnel to an Army, Air Force, and Marine  Corps installation for medical records review. Directorate officials  envision continuing quarterly installation visits in 2005, with possible  expansion to include reserve and guard sites.
The services are at different stages of developing their deployment quality  assurance programs. Following the issuance of our September 2003  report and subsequent testimony before the House Committee on  Veterans’ Affairs in October 2003, the Surgeon General of the Army  directed that the U.S. Army Center for Health Promotion and Preventive  Medicine (the Center) lead reviews of servicemember medical records at  selected Army installations to assess compliance with force health  protection and surveillance requirements. As of September 2004, the  Center had conducted reviews at 10 Army installations. Meanwhile, the  Center developed the Army’s deployment health quality assurance  program that parallels closely the DOD’s quality assurance program.  According to a Center official, this quality assurance program is currently  under review by the Surgeon General.
In the Air Force, public health officers at each installation report monthly  compliance rates with force health protection and surveillance  requirements to the office of the Surgeon General of the Air Force. These  data are monitored by officials in the office of the Air Force Surgeon  General for trends and for identification of potential problems. Air Force  Surgeon General officials told us that, as of May 2004, the Air Force  Inspector General’s periodic health services inspections—conducted every  18 to 36 months at each Air Force installation—includes an examination of  compliance with deployment health surveillance requirements. Also, the  Air Force Audit Agency is planning to examine in 2004 whether AMSA  received all of the required deployment health assessments and blood  samples for servicemembers who deployed from several Air Force  installations.
According to an official in the office of the Surgeon General of the Navy,  no decisions have been reached regarding whether periodic audits of  servicemember medical records will be conducted to assess compliance  with DOD requirements. DOD’s April 2003 enhanced post-deployment  health assessment program expanded the requirement for  post-deployment health assessments and post-deployment blood samples  to all sea-based personnel in theater supporting combat operations for  Operations Iraqi Freedom and Enduring Freedom. Navy type commanders  (e.g., surface ships, submarine, and aircraft squadrons) are responsible for  implementing the program.
The Marine Corps has developed its deployment health assessment quality  assurance program that is now under review by the Commandant of the  Marine Corps. It reemphasizes the requirements for deployment health  assessments and blood samples and requires each unit to track and report  the status of meeting these requirements for their servicemembers.
At the installations we visited, we observed that the Army and Air Force  had centralized quality assurance processes in place that extensively  involved installation medical personnel examining whether DOD’s force  health protection and surveillance requirements were met for deploying/  redeploying servicemembers. In contrast, we observed that the Marine  Corps installations did not have well-defined quality assurance processes  for ensuring that the requirements were met for servicemembers. The  Navy installation visited did not have a formal quality assurance program;  compliance depended largely on the initiative of the assigned medical  officer. We believe that the lack of effective quality assurance processes at  the Marine Corps installations contributed to lower rates of compliance  with force health protection and surveillance requirements. In our  September 2003 report, we recommended that DOD establish an effective  quality assurance program and we continue to believe that implementation  of such a program could help the Marine Corps improve its compliance  with force health protection and surveillance requirements.
section_title: Agency Comments and Our Evaluation
paragraphs: In commenting on a draft of this report, the Assistant Secretary of Defense  for Health Affairs concurred with the findings of the report. He suggested  that the word “Appears” be removed from the title of the report to more  accurately reflect improvements in compliance with force health  protection and surveillance requirements for OIF. We do not agree with  this suggestion because the number of installations we visited for OIF was  limited and different than those in our previous review for OEF/OJG with  the exception of Fort Campbell. As pointed out in the report, the data for  OIF were limited in some instances to only one sample at one installation.  We believe that it is important for the reader to recognize the limitations of  this comparison.
The Assistant Secretary also commented that the department is aware of  variations in progress among the services and is committed to  demonstrating full compliance through the continued application of  aggressive quality assurance measures. He further commented that the  department is focusing on and supporting recent policy efforts by the  Marine Corps to improve its deployment health quality assurance program.  He commented that plans have been initiated to conduct a joint quality  assurance visit to Camp Pendleton, Calif., in early 2005, following the  implementation of an improved quality assurance program and the return  of significant numbers of Marines currently deployed in support of OIF.
The department’s written comments are incorporated in their entirety in  appendix II.
We are sending copies of this report to the Secretary of Defense; the  Secretaries of the Army, the Air Force, and the Navy; and the Commandant  of the Marine Corps. 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 (202) 512-5559 or Clifton Spruill on (202) 512-4531. Key  contributors to this report are listed in appendix III.
section_title: Appendix I: Scope and Methodology
paragraphs: 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 Deployment Health Support Directorate; the National Guard  Bureau; and the Offices of the Surgeons General for the Army, Air Force,  and Navy Headquarters in the Washington, D.C., area. We also performed  additional work at AMSA and the U.S. Central Command.
To determine the extent to which the military services were meeting the  Department of Defense’s (DOD) force health protection and surveillance  requirements for servicemembers deploying in support of Operation Iraqi  Freedom (OIF), we identified DOD’s 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 Southwest Asia in support of OIF required  by the U.S. Central Command. We tested the implementation of these  requirements at selected Army, Air Force, Marine Corps, and Navy  installations. To identify military installations within each service where  we would test implementation of the policies, we reviewed deployment  data showing the location of units, by service and by military installation  that deployed to Southwest Asia in support of OIF or redeployed from  Southwest Asia in support of OIF from June 1, 2003, through November 30,  2003.  After examining these data, we selected the following military  installations for review of selected servicemembers’ medical records,  because the installations had amongst the largest numbers of  servicemembers who deployed or re-deployed back to their home unit  from June 1, 2003, through November 30, 2003:    Fort Lewis, Wash.    Fort Campbell, Ky.    Fort Eustis, Va.
Camp Lejeune, N.C.    Camp Pendleton, Calif.
Moody Air Force Base, Ga.
Naval Construction Battalion Center, Gulfport, Miss.
In comparing compliance rates for OIF with those for Operation Enduring  Freedom (OEF) and Operation Joint Guardian (OJG), we reviewed active  duty servicemembers’ medical records for Army servicemembers and Air  Force servicemembers at selected installations. For OIF, we reviewed  active duty Army servicemembers’ medical records at Fort Campbell and  Fort Lewis and active duty Air Force servicemembers at Moody Air Force  Base. For OEF and OJG, we reviewed active duty Army servicemembers’  medical records at Fort Drum and Fort Campbell and active duty Air  Force servicemembers at Travis Air Force Base and Hurlburt Field.
Due to the length of Army deployments in support of OIF, we sampled two  groups at the military installations consisting of (1) servicemembers who  deployed within the selected time frame and (2) servicemembers who re- deployed back to their home unit within the selected time frame.
For the selected military installations, we requested officials in the  Deployment Health Support Directorate, in the services’ Surgeon General  offices, or at the installations to provide a listing of those active-duty  servicemembers who deployed to Southwest Asia in support of OIF for  30 or more continuous days to areas without permanent U.S. military  treatment facilities or redeployed back to the military installation from  June 1, 2003, through November 30, 2003. For Army reserve and National  Guard servicemembers, we requested listings of those servicemembers  who deployed during the period June 1, 2003, through January 31, 2004,  and those servicemembers who redeployed from Southwest Asia in  support of OIF from June 1, 2003, through December 31, 2003.
For Marine Corps servicemembers at Camp Lejeune and Camp Pendleton,  we modified our selection criteria to draw one sample because a number  of servicemembers met the definition for both deployment and  redeployment within our given time frames. Specifically, servicemembers  at these installations had both deployed to Southwest Asia in support of  OIF and redeployed back to their home unit from June 1, 2003, through  November 30, 2003, staying for 30 or more continuous days.
For our medical records review, we selected samples of servicemembers  at the selected installations. Five of our servicemember samples were  small enough to complete reviews of the entire universe of medical  records for the respective location. For the other locations, we drew  probability samples from the larger universe. In all cases, records that  were not available for review were researched in more detail by medical  officials to account for the reason for which the medical record was not  available so that the record could be deemed either in-scope or out-of- scope. For installations in which a sample was drawn, all out-of-scope  cases were then replaced with another randomly selected record until the  required sample size was met. For installations in which the universe was  reviewed, the total number in the universe was adjusted accordingly.  There were four reasons for which a medical record was unavailable and  subsequently deemed out-of-scope for purposes of this review:  1.  Charged to patient. When a patient goes to be seen in 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 following their  clinic visit.   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.  Permanent change of station. Servicemember is still in the military,  but has transferred to another base. Medical record transfers with the  servicemember.  4.  Temporary duty off site. Servicemember has left military  installation, but is expected to return. The temporary duty is long  enough to warrant medical record to accompany servicemember.
There were a few instances in which medical records could not be  accounted for by the medical records department. These records were  deemed to be in-scope, counted as non-responses, and not replaced in the  sample. The number of servicemembers in our samples and the applicable  universe of servicemembers for the OIF deployments at the installations  visited are shown in table 7.
Because we followed a probability procedure based on random selections,  our sample is only one of a large number of samples that we might have  drawn from the sampled installations. Because each sample could have  provided different estimates, we express our confidence in the precision  of our particular sample’s results as a 95 percent confidence interval  (e.g., plus or minus 5 percentage points). This is the interval that would  contain the actual population value for 95 percent of the samples we could  have drawn. As a result, we are 95 percent confident that each of the  confidence intervals in this report will include the true values in the study  population. The 95 percent confidence intervals for percentage estimates  are presented along with the estimates in figures and tables in this report.
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, as applicable;    Tuberculosis screening test (within 1 year of deployment);    Pre-deployment immunizations:    hepatitis A;   influenza (within 1 year of deployment);    measles, mumps, and rubella;    polio;  tetanus-diphtheria (within 10 years of deployment); and  typhoid (within 5 years of deployment); and  Immunizations required prior to deployment or in theater:    anthrax (at least one immunization); and    smallpox  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 automated  immunization sources, including the Army’s Medical Protection System  (MEDPROS), the Navy’s Shipboard Non-tactical Automated Data  Processing Automated Medical System (SAMS), and the Air Force’s  Comprehensive Immunization Tracking Application (CITA). In  those instances where we did not find a deployment health assessment,  we concluded that the assessments were not completed. Our analyses of  the immunization records was based on our examination of  servicemembers’ permanent medical records and immunizations that were  in the Army’s MEDPROS, the Navy’s SAMS, and the Air Force’s CITA. In  analyzing our review results at each location, we considered  documentation from all identified sources (e.g., the servicemember’s  medical record, AMSA, and immunization tracking systems) in presenting  data on compliance with deployment health surveillance policies.
To identify whether required blood samples were drawn for  servicemembers prior to and after deployments, we requested that the  AMSA staff query the DOD Serum Repository to identify whether the  servicemembers in our samples had a blood sample in the repository not  older than 1 year prior to their deployment, and to provide the dates that  post-deployment blood samples were drawn.
To determine whether the services were documenting in-theater medical  interventions in servicemembers’ medical records, we requested, at six of  the seven installations visited for medical records review, the patient  sign-in logs for in-theater medical care providers—such as the Army’s and  Marine Corps’ battalion aid stations—when they were deployed to  Southwest Asia in support of OIF. At the Army and Marine Corps  locations, we randomly selected sick call visits from non-automated  patient sign-in logs, but we randomly selected visits from the automated  Global Expeditionary Medical Support (GEMS) at Moody Air Force Base  and from the automated SAMs at the Naval Construction Battalion Center.  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  Standard Form 600—of the servicemember’s visit to the in-theater medical  care providers.
To determine whether the service’s deployment health-related records  were retained and maintained in a centralized location, we requested that  officials at the AMSA query the AMSA database for the servicemembers  included in our samples at the selected 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  data we found during our medical records review with those in the AMSA  database. To identify the completeness of servicemember medical records,  we then compared the data identified from the AMSA queries with the data  we found during our medical records review.
To determine whether DOD has established an effective quality assurance  program for ensuring that the military services comply with force health  protection and surveillance policies, we interviewed officials within the  Deployment Health Support Directorate, the offices of the services’  Surgeons General, and at the installations we visited for medical records  review about their internal management control processes. We also  reviewed quality assurance policies and other documentation for ensuring  compliance with force health protection and surveillance requirements.
We took several steps to ensure the reliability of the data we used in our  review. DOD electronic lists of servicemembers who either deployed or  redeployed within certain time frames were used to generate random  samples for which primary data was then collected. It was our premise  that no systematic errors for inclusion or exclusion of cases in the  database existed and the randomness of the sample generated controlled  for those records selected for review. The final universe for which sample  size was based was adjusted to account for out-of-scope cases. In addition,  we took mitigating measures to (1) avoid relying exclusively on the  automated databases and (2) identify and resolve inconsistencies, as  described below:  Personnel Deployment Databases. Because of concerns about the  reliability of deployment data maintained by the Defense Manpower Data  Center, we requested, in consultation with officials at the Deployment  Health Support Directorate, personnel deployment data from the military  installations selected for medical records review. DOD officials believed  that the military installations were the most reliable sources for accurate  personnel deployment data because servicemembers are deployed from,  or redeployed to, these sites. However, we decided to be alert for  indications of errors as we reviewed servicemember medical records and  to investigate situations that appeared to be questionable.
Automated Immunization Databases. Service policies require that  immunizations be documented in the servicemember’s medical record. For  the most part, immunizations are documented on Department of Defense  Form 2766. The services also use automated immunization systems—the  Army uses MEDPROS, the Air Force uses CITA, and the Navy/Marine  Corps use SAMS. We did not rely exclusively on either of these sources  (Department of Defense Form 2766 or automated immunization systems).  For servicemembers in our samples, we reviewed both the  servicemembers’ medical records and queries of the services’ automated  immunization system for each servicemember. If we found documentation  of the required immunizations in either source, we considered the  immunization documented because it was evident that the immunization  was given.
AMSA Centralized Database. DOD policy requires that pre- and  post-deployment health assessments be documented in the  servicemember’s medical record and also that a copy be sent to AMSA for  inclusion in the centralized database. We did not rely exclusively on the  AMSA centralized database for determining compliance with force health  protection and surveillance policies. For servicemembers in our samples,  we reviewed both the servicemember’s medical record and queries of the  AMSA centralized database for health assessments and immunizations for  the servicemember. If we found documentation of the required pre- or  post-deployment health assessments or immunizations in either source,  we considered the servicemember as having met the requirement for  health assessments and immunizations.
Our review was performed from November 2003 through August 2004 in  accordance with generally accepted government auditing standards.
section_title: Appendix II: Comments from the Department of Defense
section_title: Appendix III: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Acknowledgments
paragraphs: In addition to the individual named above, Steve Fox, Rebecca Beale,  Margaret Holihan, Lynn Johnson, Susan Mason, William Mathers, Clara  Mejstrik, Christopher Rice, Terry Richardson, Kristine Braaten,  Grant Mallie, Jean McSween, Julia Matta, John Van Schaik, and R.K. Wild  made key contributions to this report.