Military Personnel: Improvements Needed in the Management of Enlistees' Medical Early Separation and Enlistment Information
Published: 2017-07-14T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: For fiscal years 2005 through 2015, the military services enlisted over 1.7 million servicemembers at an estimated cost of approximately $75,000 each. Incomplete medical information or inadequate screening of enlistees at MEPS may result in them not fulfilling their initial terms of commitment and the military services losing their investment in them.
The House Report accompanying a proposed bill for the Fiscal Year 2017 National Defense Authorization Act included a provision for GAO to review applicant medical screening issues at the MEPS. This report assesses the extent to which (1) enlistees have not completed their initial terms of commitment due to medical reasons; (2) USMEPCOM obtains, analyzes, and uses information about enlistee medical early attrition; and (3) DOD has implemented its new electronic health record system at the MEPS. GAO analyzed accession and attrition data for fiscal years 2005 through 2015 (the most recent available), visited selected MEPS near services' training bases, and reviewed selected DOD, USMEPCOM, and service policies.
section_title: What GAO Found
paragraphs: GAO's analysis of Department of Defense (DOD) accession and attrition data found that early attrition rates due to medical reasons during an enlistee's initial term of commitment were generally stable for fiscal years 2005 through 2015. As shown in the figure, the medical early attrition rate at the 48-month point was an estimated 14.9 percent in fiscal year 2005 and an estimated 13.7 percent in fiscal year 2011—the most recent year for which 48 months of data were available. The leading category for early attrition was “unqualified for active duty, other,” which DOD defines as a nondisability condition such as obesity.
U.S. Military Entrance Processing Command (USMEPCOM), DOD's organization responsible for medically qualifying applicants for military service, does not fully obtain, analyze and use information about enlistees who separate early due to medical reasons. This is because DOD does not have a clearly defined process for the military services to provide USMEPCOM with all relevant medical records. Further, the database that USMEPCOM relies on to analyze these records is inoperable and no schedule has been developed to repair it. As a result, USMEPCOM has provided limited feedback to chief medical officers—responsible for the medical qualification decisions—that they could use to improve screening outcomes. Without addressing these issues, DOD has limited assurance that medically disqualifying conditions among new enlistees will be identified before the services invest substantial resources in their initial training.
DOD has not implemented its new electronic health record system at the Military Entrance Processing Stations (MEPS) and its schedule to do so is uncertain. Known as MHS GENESIS, this new system is intended to give DOD the capability to electronically share more complete medical data with and between both federal and private sector medical facilities that are similarly equipped. Without a clear and complete schedule for implementation of MHS GENESIS, DOD has limited assurance that the system will support the MEPS as planned.
section_title: What GAO Recommends
paragraphs: GAO recommends that DOD develop a clear process for USMEPCOM to obtain medical early separation records, a schedule to repair the database used to analyze the records, and a schedule to deploy MHS GENESIS at the MEPS. DOD concurred with the first two recommendations and partially concurred with the third, stating it is already developing such a schedule. GAO continues to believe action is needed as discussed in the report.

section_title: Letter
paragraphs: From fiscal year 2005 through fiscal year 2015, the military services  enlisted over 1.7 million servicemembers at an estimated cost of  approximately $75,000 per enlistee, according to the Department of  Defense (DOD). However, incomplete medical information or inadequate  medical screening of these enlistees may result in them not fulfilling their  initial terms of commitment, which often ranges from 4 and 6 years of  active duty. When early separation occurs, the military services lose their  investment in the enlistees and must recruit additional applicants to  replace them.
In January 1997, we reported that DOD could save millions of dollars by  employing better screening procedures of enlistees. Specifically, we  reported that DOD did not have consistent and complete data to allow it  to assess attrition trends and the factors behind changes in the trends.  Additionally, we reported that applicants often conceal their medical histories and that the military services were waiving medical conditions  that, according to DOD directives, were disqualifying. In the1997 report,  we made seven recommendations to DOD to help reduce the attrition of  enlistees during the first 180 days of their initial terms of commitment. Of  these seven recommendations, DOD concurred with and implemented  changes that addressed all but one—moving the review of the medical  early separation records away from the U.S. Military Entrance Processing  Command (USMEPCOM), which still requests and analyzes those  records. USMEPCOM operates under the direction of the Deputy  Assistant Secretary of Defense for Military Personnel Policy-Accession  Policy within the Office of the Under Secretary of Defense for Personnel  and Readiness. Its mission is to evaluate applicants by applying  established DOD standards during applicant processing for the military  service at 65 Military Entrance Processing Station (MEPS) locations  across the United States. To further address several of the  recommendations we made in our 1997 report, Congress enacted  changes in November 1997 to Title 10, the law governing the armed  forces, aimed at improving recruit quality and reducing recruit attrition.
House Report 114-537, which accompanied a proposed bill for the  National Defense Authorization Act for Fiscal Year 2017, included a  provision for us to conduct a review of applicant medical screening issues  at the MEPS. This report assesses the extent to which (1) enlistees have  been unable to complete their initial terms of commitment due to medical  reasons for fiscal years 2005 through 2015; (2) USMEPCOM obtains,  analyzes, and uses information about enlistee early attrition due to  medical reasons; and (3) DOD has implemented its new electronic health  record system at the MEPS to obtain and document applicants’ medical  information.
For the first objective, we analyzed data from the Defense Manpower  Data Center (DMDC) on accessions and the early attrition of active-duty  enlistees from the four military services during their first terms of  commitment, often between four and six years of active duty service, for  fiscal years 2005 through 2015. Fiscal year 2015 is the most recent year  for which an entire year’s worth of attrition data are available and, for  relevancy purposes, we obtained data not more than 10 years old,  beginning in fiscal year 2005. We analyzed these data to show early  attrition due to medical reasons and overall early attrition over selected  intervals by military service for each fiscal year as well as for the leading  causes of early attrition. We assessed the reliability of these data by  reviewing the data files and relevant data documentation and interviewing  knowledgeable officials, and found that the data were sufficiently reliable  for reporting the estimated number of accessions and attritions by military  service and time periods. We also interviewed DOD, USMEPCOM, and  military service officials to obtain their perspectives on early attrition rates.
For the second objective, we reviewed DOD memorandums and  USMEPCOM regulations related to obtaining, analyzing, and using  information about enlistee early attrition due to medical reasons. We  evaluated USMEPCOM practices for obtaining, analyzing, and using  information from enlistees’ medical records of enlistees who separated  within the first 180 days of service because of medical conditions that  existed prior to their service against requirements from our Schedule  Assessment Guide and the Standards for Internal Control in the Federal  Government. This included the importance of designing control activities  to achieve objectives and respond to risks and using quality information  by identifying information requirements, obtaining relevant data from  reliable internal and external sources in a timely manner, and processing  the obtained data into quality information. Additionally, we interviewed  officials at USMEPCOM and officials from basic training bases to further  understand the collection and reporting of early medical attrition  information. These bases were selected on the basis of geographical  dispersion and included one from each of the military services.
For the third objective, we reviewed selected DOD, USMEPCOM, and  military instructions and regulations related applicant medical screening  processes. Additionally, we selected a convenience sample of four MEPS  that were located in large geographically dispersed U.S. cities that were  also near a military service recruiting office and a basic training base to  observe medical-related MEPS operations and to interview officials.  During our visits to the selected MEPS locations, we interviewed officials  from nearby military service recruiting organizations to discuss their  perspectives on challenges with medically screening applicants. We  supplemented our visits to the large MEPS locations with questionnaires  sent to MEPS command officials, chief medical officers, and military  service recruiting liaisons of a nongeneralizable sample of eight small or  medium-sized MEPS as determined first by workload level, then sorted  randomly, and then chosen to ensure distribution across all MEPS  battalions. Further, regarding DOD’s effort to implement an electronic  health record system into MEPS locations, we interviewed officials from  Accession Policy within the Office of the Under Secretary of Defense for  Personnel and Readiness and USMEPCOM as well as contacted the  Program Executive Office Defense Healthcare Management System to  obtain information regarding the implementation status of DOD’s new  electronic health record within USMEPCOM at the MEPSs locations. We  compared their efforts against selected information technology project  management practices for developing well-planned schedules.
We conducted this performance audit from July 2016 to July 2017 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. Further details regarding our  scope and methodology are presented in appendix I.
subsections: section_title: Background
paragraphs: Various organizations across DOD perform functions related to the  recruiting, accessions, and training of active-duty enlistees as shown in  figure 1.
subsections: section_title: Each Military Service’s Recruiters Conduct Preliminary Screens of Applicants
paragraphs: Enlistment processing and qualification determinations for age,  citizenship, education, dependency status, and moral character are made  by each military service. Their respective recruiting entities conduct  preliminary screening of applicants to determine if they meet overall and  medical DOD enlistment requirements. Among other things, recruiters  also, for example, conduct a background review to screen an applicant for  potentially disqualifying moral factors, review the applicant’s education  credentials, and assist in completing a medical history report. When an  applicant answers any question on the preliminary medical screening  form affirmatively, they are expected to obtain, or authorize others within  DOD, which could be their recruiter who is assisting them, to obtain  additional documentation regarding that medical condition to include with  the medical prescreen questionnaire. Once completed, recruiters forward  the medical prescreening report and any other documentation collected to  military service recruiting liaisons located at a MEPS location to schedule  the applicant for further review prior to scheduling the applicant for a  medical examination.
section_title: USMEPCOM Provides More Detailed Medical Screening to Help Determine an Applicant’s Enlistment Eligibility
paragraphs: USMEPCOM officials perform various functions, which include verifying  personal identity; performing medical exams; documenting, reviewing,  and updating applicant medical history; determining the extent to which  applicants meet DOD’s medical qualification standards; supporting the  military service medical waiver review process; administering the Armed  Services Vocational Aptitude Battery and special purpose tests;  conducting pre-enlistment interviews; conducting the oath of enlistment;  and verifying signed enlistment contracts. The locations of the MEPS are  displayed in figure 2.
Each MEPS location is staffed with military and civilian personnel,  including a chief medical officer, with additional medical personnel and  recruiting liaisons representing each military service. MEPS medical  personnel collect blood and urine specimens to send for Human  Immunodeficiency Virus (HIV) and drug testing and examine applicants in  physical and behavioral health areas in accordance with DOD’s medical  qualification standards for enlistment. Finally, a MEPS physician will  make a final determination as to whether an applicant does or does not  meet accession medical standards based on applicant’s medical history,  a physical examination, and test results. USMEPCOM designated  physicians are the DOD medical authority for applicants processing with  USMEPCOM for determining if an applicant medically meets the  requirements of Title 10 to be qualified, effective, and able-bodied prior to  enlistment. For those found to have disqualifying conditions, the MEPS  physician will recommend for or against pursuing a medical waiver to the  military services’ medical waiver authorities, who are authorized to grant  medical waivers. Only applicants who are medically qualified are allowed  to go to basic training. Some enlistees leave for basic training from their  home towns and some return to the MEPS to undergo a brief follow-up  physical inspection to determine whether they continue to meet the  medical qualification standards for military service. For information on  selected DOD and military service instructions, policies and guidance  regarding medical screening of applicants, see appendix II.
section_title: Military Service Training Commands Receive New Enlistees for Basic Training
paragraphs: New enlistee basic training varies between 7 to 12 weeks depending on  the military service. The Air Force basic training program lasts 7.5 weeks  and is given at one training site located at Joint Base San Antonio- Lackland in San Antonio, Texas. Navy recruits remain in basic training for  approximately 7 weeks at one training site, located at the Naval Station  Great Lakes in North Chicago, Illinois. The Marine Corps’ basic training is  12 weeks and recruits are trained in San Diego, California, or Parris  Island, South Carolina. The Army’s basic training is 10 weeks and recruits  are trained at Fort Benning, Georgia; Fort Jackson, South Carolina; Fort  Sill, Oklahoma; or Fort Leonard Wood, Missouri. After completing basic  training, most enlistees complete follow-on training in technical skills,  though the length of such training can vary widely by military service from  a few weeks to a year or more. Figure 3 summarizes the most common  recruiting, screening, and training process for new enlistees.
section_title: DOD’s Yearly Medical Early and Overall Attrition Rates Were Generally Stable for Fiscal Years 2005 through 2015
subsections: section_title: Medical Early Attrition Rates during Enlistees’ Initial Terms of Commitment Were Generally Stable for Fiscal Years 2005 through 2015
paragraphs: Based on our analysis of DOD accession and attrition data, early attrition  rates due to medical reasons during an enlistee’s initial term of  commitment were generally stable for fiscal years 2005 through 2015.  Although there were some increases and some decreases across the  years for each of the time intervals we assessed, these changes were  relatively small, with an average change of just over 1 percentage point.  Figure 4 shows the estimated cumulative medical early attrition rates at  the 6-month, 12-month, 24-month, 48-month, and 72-month points for  servicemembers who separated prior to fulfilling their first term of  commitment by accession year cohorts for fiscal years 2005 through  2015. For example, the medical early attrition rate at the 48-month point  of enlistees’ initial term of commitment was an estimated 14.9 percent in  fiscal year 2005 and an estimated 13.7 percent in fiscal year 2011—the  most recent year for which 48 months of data were available—with  fluctuations between these years. Additionally, the medical early attrition  rate at the 6-month point of enlistees’ initial term of commitment was an  estimated 5.2 percent in fiscal year 2005 and 3.6 percent in fiscal year  2015, with fluctuations between these years.
Based on our analysis of DOD separation categories that were explicitly  of a medical nature, we identified the leading categories of early attrition  due to medical reasons, as shown in figure 5. According to this analysis,  the leading category of early attrition due to medical reasons is  “Unqualified for active duty, other” which DOD defines as a nondisability  medical condition, such as obesity, motion sickness or allergies, that  interferes with the performance of duties and contributes to the failure to  meet physical readiness standards. Other leading categories of early  attrition due to medical reasons include drug abuse, disability with  severance pay, and failure to meet weight or body fat standards.
Military service officials stated they have taken numerous steps to  decrease early attrition due to medical reasons by taking steps to help  improve the new enlistees’ physical and mental condition while in basic  training. For example, Army officials at Fort Benning stated that they are  piloting a program called the Initial Entry Training Physical Resiliency  Enhancement Program. This program trains enlistees who may be prone  to injury for 3-5 weeks before shipping them to basic training in an  attempt to improve physical fitness and reduce injuries. Air Force officials  at Joint Base San Antonio-Lackland stated that they are piloting a  program to embed sports medicine experts throughout basic training to  identify poor physical fitness practices and intervene before injuries occur.  Moreover, Air Force officials also are piloting the use of a questionnaire  called the Lackland Behavioral Questionnaire. Under this pilot, Air Force  enlistees complete a questionnaire with over 70 questions on mental and  behavioral health in an attempt to identify recruits with potential mental or  behavioral issues so they can be interviewed by medical professionals  and provided any necessary help or counseling early. Marine Corps  officials stated that they place enlistees who fail the Marine Corps’ initial  strength test into a physical conditioning platoon for further physical  conditioning before they begin basic training to help improve physical  fitness and reduce injuries. Further, a Navy official stated that a  specialized machine is used to measure enlistees’ feet to select the  proper shoes in an attempt to reduce injuries.
section_title: Overall Early Attrition Rates during Enlistees’ Initial Terms of Commitment Were Generally Stable Overall for Fiscal Years 2005 through 2015
paragraphs: For comparison purposes, we also analyzed overall early attrition rates  during enlistees’ initial terms of commitment. Analyzing DOD accession  and attrition data, we found that, similar to early attrition rates for medical  reasons, overall early attrition rates during enlistees’ initial terms of  commitment were generally stable for fiscal years 2005 through 2015.  Although there were some increases and some decreases across years  for each of the time intervals we assessed, these changes were relatively  small, with an average change 2 percentage points. Figure 6 shows the  estimated cumulative overall early attrition rates at the 6-month, 12- month, 24-month, 48-month, and 72-month points of enlistees’ initial  terms of commitment by accession year cohorts for fiscal years 2005  through 2015. For example, the overall early attrition rate at the 48-month  point of enlistees’ initial terms of commitment was an estimated 29.9  percent in fiscal year 2005 and an estimated 26.9 percent in fiscal year  2011—the most recent year for which 48 months of data were available— with fluctuations between these years. Additionally, the 6-month overall  early attrition rate was an estimated 10.9 percent in fiscal year 2005 and  an estimated 10.2 percent in fiscal year 2015, with fluctuations between  these years.
Our analysis of DOD separation categories for overall early attrition  indicated that, as with our analysis of early attrition due to medical  reasons, the leading category of overall early attrition is again  “Unqualified for active duty, other.” Other leading categories of overall  early attrition include drug abuse, poor entry level performance and  conduct, and commissions of serious offenses. Figure 7 shows the  reported leading categories of overall early attrition for enlistees by  accession year for fiscal year 2005 through fiscal year 2015.
section_title: USMEPCOM Does Not Fully Obtain, Analyze, and Use Information about Enlistees’ Early Attrition Due to Medical Reasons
paragraphs: USMEPCOM does not fully obtain, analyze, or use information for early  attrition due to medical reasons within enlistees’ first 180 days of service.  This is because DOD does not have a process for the military services’  training bases to provide USMEPCOM all of the medical records of  enlistees who separate early due to medical reasons. Additionally, the  database that USMEPCOM uses to perform complete statistical analyses  on the early separation medical records it does receive is inoperable,  impacting its ability to conduct such analyses. Finally, USMEPCOM does  not use the information from these medical records to provide regular and  specific feedback regarding early separations to MEPS medical personnel  to improve the quality of applicant screening.
subsections: section_title: The Military Services’ Training Bases Do Not Provide Complete Medical Records to USMEPCOM
paragraphs: A 2001 memorandum from the Assistant Secretary of Defense for Force  Management Policy requests that basic training bases send medical  records of enlistees who separated within the first 180 days of their  military career for disqualifying medical conditions determined to have  existed before the enlistee began military service (separations commonly  known as Existed Prior to Service or EPTS discharges) to USMEPCOM  for review and analysis. However, not all basic training bases provide  medical records in accordance with the memorandum. In fact, for fiscal  year 2015, the latest full fiscal year of data available, USMEPCOM  reported receiving medical records for only 2,017 of 8,592 EPTS  separations, a rate of 23 percent.
USMEPCOM officials and basic training site officials we met with  provided four reasons as to why all EPTS medical records are not  provided to USMEPCOM. First, USMEPCOM officials stated that no  uniform, standardized process to collect the necessary documentation  from basic training sites has been established by any higher level  headquarters. Standards for Internal Control in the Federal Government  state that management, in order to achieve its objectives, should design  control activities to achieve objectives and respond to risks. Moreover, the  standards state that management should document—in policies for each  unit—its responsibilities for all operational processes. Management  should also review related policies, procedures, and related control  activities for continued relevance and effectiveness in achieving the  entity’s objectives. Officials stated that no specific process or  instructions have been developed that clearly lay out the roles and  responsibilities of USMEPCOM and the military services as well as the  specific information that the services should provide to USMEPCOM. As  such, inconsistent information is sent to USMEPCOM, and in some  cases, certain medical records may not be sent at all, making analysis  difficult, if not impossible. For example, USMEPCOM officials told us that  Air Force officials were not sending medical records for psychological  EPTS separations and were told it was due to Air Force officials’  confusion as to whether these cases were considered medical  separations because of their interpretation of DOD separation  classifications and coding.
Second, language used in the 2001 memorandum has led to some  confusion by the military services as to whether the memorandum is  simply a request or a requirement for them to send medical records of  enlistees with EPTS separations at their training bases. Third, military  service officials stated that since the memorandum was very old, they  were unsure if it was still active or who was specifically responsible at the  training bases for sending the medical records to USMEPCOM— personnel officials or medical professionals. Fourth, USMEPCOM officials  stated that some military service officials cited Privacy Act and concerns  regarding their responsibilities for handling personal health information  and the ability of USMEPCOM to safeguard the information adequately as  reasons for their failure to send USMEPCOM the medical records for  EPTS separations. USMEPCOM officials acknowledge the reluctance to  send medical records because of the personal health information  contained. As such, they believe the use of electronic health records  would be useful in providing stronger safeguards that they believe should  mitigate concerns about the handling of enlistees’ medical records to  USMEPCOM. For example, recent discussions between USMEPCOM  and Navy training base officials have led the Navy to draft a  memorandum of understanding to clarify responsibilities regarding  sending EPTS records and handling medical information. As of April  2017, the Navy had not completed this memorandum of understanding  with USMEPCOM, and USMEPCOM was still not receiving the Navy  EPTS separation medical records.
DOD is planning to reissue a DOD instruction in July 2017 with changes  that would require basic training sites to forward EPTS medical  information to USMEPCOM, according to DOD officials. We obtained and  reviewed the draft instruction and noted that it does require the  submission of the medical records to USMEPCOM, but the draft  instruction does not contain specific instructions aimed at addressing  many of the reasons USMEPCOM and military service officials gave for  the current failure to provide records. Specifically, the draft instruction  does not identify a clear process with defined roles and responsibilities.  As a result, we were unable to determine if the draft instruction will  resolve any of the issues noted above, other than eliminating doubts  about the currency and mandatory nature of the direction to provide the  records to USMEPCOM. Without a clear process with defined roles and  responsibilities, USMEPCOM may continue to not receive the majority of  EPTS medical records for its review and analysis.
section_title: USMEPCOM’s Nonoperational Database Limits the Ability to Fully Analyze Medical Records for EPTS Separations
paragraphs: USMEPCOM has been unable to fully analyze the medical records it does  receive because its internal EPTS database has been nonoperational  since September 2015 due to technical issues. Prior to September 2015,  USMEPCOM officials told us that they scanned the paper medical  records for EPTS separations that they received from basic training bases  into this internal database. This allowed them to use information from  these medical records to analyze specific data points, such as the cause  of the separation and the MEPS location where the enlistee was  medically qualified. This analysis allowed them to examine trends over  time, such as a trend in separations due to errors related to a specific  medical diagnosis or trends in processing errors to gain insight into  problem areas. Without an operational EPTS database, USMEPCOM  officials said that they can only conduct a limited, manual analysis of  EPTS separation medical records, and are not able to fully analyze and  utilize this information.
Additionally, officials stated that the dependence on hard-copy medical  records requires a large amount of resources to perform the manual  analysis of these records and incurs large administrative costs associated  with organizing medical records as they arrive, scanning them, manually  coding results, and then repackaging the records. USMEPCOM officials  stated that they are currently in the process of repairing the database, but  they could not provide a schedule for its completion. We have previously  reported that having a well-planned schedule is a fundamental  management tool. In addition, the 2001 memorandum we previously  discussed states that the findings from EPTS analysis form an important  part of USMEPCOM’s quality control process, particularly in identifying  and correcting physician errors and reducing the number of erroneous  enlistments. Analyzing these particular separations provides insight into  medical conditions that were not detected during the medical qualification  process at a MEPS, allows USMEPCOM officials to identify trends in  errors related to specific diagnoses, and provides information to improve  the medical qualification process. According to USMEPCOM’s analysis of  the limited number of EPTS medical records it received for fiscal year  2015, 47 percent of all such separations occurred due to enlistees  concealing their medical history and 29 percent occurred due to the  enlistee being unaware of the medical condition. For the same year, only  3 percent of such separations occurred due to an error on the part of  MEPS personnel during the medical qualification process.
Given the importance of the database to the analyses that USMEPCOM  conducts, as long as it is unavailable, USMEPCOM will be hampered in  its ability to conduct these analyses. The lack of a schedule for  implementing the repairs to the database raises concerns about the  timeliness of these repairs. As we have previously noted, a well-planned  schedule is important for ensuring that projects, such as the database  repair, are completed on time. Without a schedule for these database  repairs, USMEPCOM has limited assurance that this tool will be available  to it expeditiously.
section_title: USMEPCOM Does Not Use EPTS Separation Information to Provide Regular Feedback to MEPS Medical Personnel
paragraphs: USMEPCOM’s regulation for its Medical Qualification Program states that  USMEPCOM will provide feedback to MEPS chief medical officers  regarding EPTS separations, but the feedback that USMEPCOM gives  them is limited due to the small number of EPTS separation medical  records received from the training bases and the partial manual analysis  being done on those received. Standards for Internal Control in the  Federal Government states that management, in order to achieve its  objectives, should use quality information by identifying information  requirements, obtaining relevant data from reliable internal and external  sources in a timely manner, and processing the obtained data into quality  information. However, USMEPCOM officials stated individual feedback  regarding EPTS separations has been limited to cases in which  USMEPCOM alerted chief medical officers to an obvious error at their  MEPS location during the medical qualification process. For example, two  chief medical officers we contacted reported receiving feedback at least  once regarding EPTS separations that were classified as “MEPS errors.”
While MEPS chief medical officers do receive feedback through other  methods, none of these methods are individually tailored to the  performance of MEPS chief medical officers as it relates to EPTS  separations. Specifically, USMEPCOM officials stated that feedback  regarding EPTS separations occurs during more general forums such as  the annual MEPS chief medical officer conference or during monthly  conference calls where USMEPCOM can discuss questions or concerns that could affect all MEPS. Additionally, USMEPCOM has implemented  its Peer Review Program where physicians at each MEPS review each  other’s medical qualification decisions on a daily basis, if possible, as a  local means of quality control. USMEPCOM officials also stated that they  can provide feedback if a MEPS chief medical officer contacts  USMEPCOM requesting clarification on an EPTS issue. However, these  methods of feedback, while useful, do not provide individual feedback to  MEPS chief medical officers regarding their specific decisions to  medically qualify applicants who ultimately separated from military service  within 180 days due to a medical reason. Six of the twelve MEPS medical  officers that we contacted stated that they receive very limited to no  feedback regarding EPTS cases specific to their MEPS and each said it  would be helpful if they did. USMEPCOM officials acknowledge that it has  been difficult for them to provide a large amount of feedback to the MEPS  because of having to rely on paper medical records from the training  bases and because of the technical difficulties they have had in analyzing  what records they have received. The USMEPCOM officials believe that if  they had an electronic medical record rather than the voluminous paper  medical records, it would be easier to analyze information and share the  results.
Receiving feedback on EPTS separations could allow MEPS chief  medical officers to refine and improve their performance during the  medical qualification process, thereby disqualifying applicants at the  MEPS rather than after the military services have invested significant  resources in enlistees at the basic training sites. As previously noted,  DOD’s Accession Medical Standards Analysis and Research Activity  estimates that the average cost to recruit, screen, and train each enlistee  is approximately $75,000. However, until USMEPCOM uses EPTS  separation information to provide regular and specific feedback to MEPS  chief medical officers, USMEPCOM may not be assured that it is  adequately identifying medically disqualifying conditions among  applicants for military service before the military services invest  substantial resources in the applicants’ initial training.
section_title: DOD Has Not Implemented Its New Electronic Health Record at MEPS Locations
paragraphs: DOD has not implemented its new electronic health record system at the  MEPS and its schedule to do so is uncertain. As a result, the MEPS rely  largely on self-disclosed medical conditions, history, and records from the  applicants to make their medical qualification decisions, and they use a  paper-based system for recording and processing applicant medical  information. DOD recognizes the need to upgrade the enlistee accession  process; however, its schedule for implementing a new electronic health  record system to support this process is uncertain.
subsections: section_title: The MEPS’ Medical Screening of Enlisted Applicants Relies on Self- Disclosure and the Processing of Paper Files
paragraphs: Without an electronic health record system that enables MEPS chief  medical officers to electronically obtain the medical history of applicants  and document health conditions in an electronic health record, MEPS  officials rely on applicant self-disclosure and a paper-based process to  evaluate the array of information related to each applicant’s medical  history and current condition to determine if an applicant is medically  qualified to join the military. At the beginning of the accession process, an  applicant must self-disclose personal medical information by answering a  medical prescreening questionnaire with over 160 questions covering  major body systems along with sleep disorders; learning, psychiatric, and  behavioral issues; and medicine usage. When an applicant answers any  of these questions affirmatively, they are expected to obtain—or authorize  others, such as their recruiter, to obtain—additional documentation  regarding that medical condition to include with the medical prescreen  questionnaire. While current medical processing provides valuable  information, reliance is placed heavily upon applicant self-disclosure of  his/her medical history, leaving a potential void in details if the applicant  does not disclose any known medical conditions. This creates the  possibility that an applicant could conceal a potentially disqualifying  medical condition that should be considered during the medical  qualification process. According to a DOD review, reliance on applicants’  self-disclosed material limits information for review, constrains analysis  and hampers efforts to identify applicants who do not meet standards  early in the military recruiting and accession process. As mentioned  previously, USMEPCOM analysis shows that, in 2015, about 75 percent  of early attrition due to medical reasons within the first 180 days of  service was attributed to either applicant concealment of known medical  conditions or due to the enlistee being unaware of the medical condition.
Even if an applicant self-discloses that they have or previously had a  medical condition to either a recruiter or later to MEPS medical physicians  and provides their medical records for further review, the MEPS use a  largely paper-based documentation system that requires manual  processing of the medical information collected on applicants. DOD has  noted that enlistment across the military force requires processing 70 to  80 million pieces of paper every year—a slow, duplicative, and expensive  process. Throughout the accession process for enlistees, paper is still  mailed, faxed, hand-carried, and scanned, often multiple times, to the  MEPS for use in processing the applicant for further review. In addition to  the applicants’ hard copy medical prescreen questionnaire and any  supporting medical documents that are submitted to the MEPS, MEPS  medical personnel record on paper forms the additional medical history  and physical examination results and comments they obtain during their  evaluation of the applicant. Additionally, there may be numerous other  forms used during an applicant’s medical processing that are not  captured electronically, including authorizations for medical testing,  consultation requests and results, and chain of custody documents.  Officials at each of the MEPS locations we visited or contacted  characterized the volume of paper they deal with on a daily basis as  being challenging, overwhelming, an administrative burden, or time- consuming. Further, they said that handling, transferring, and manual  processing of the paper records is often done multiple times in order to  advance an applicant through the medical qualification process. Figure 8  illustrates examples of the possible paper forms and documentation that  may be used for enlisted applicants and accession processing activities.
section_title: DOD’s Schedule for Deploying the New Electronic Health Record System to Support Enlistee Accessions at MEPS Locations Is Uncertain
paragraphs: DOD is in the process of implementing a new integrated electronic health  record system, but DOD’s schedule for deploying this system at MEPs to  assist with the medical screening of enlisted applicants is uncertain. In  July 2015, the Program Executive Office, DOD Healthcare Management  System, under the authority and direction of the Under Secretary of  Defense for Acquisition, Technology, and Logistics, awarded a $4.3 billion  contract for a new integrated electronic health record system known as  MHS GENESIS. This new system is intended to give DOD the capability  to electronically share more complete medical data with and between  both federal and private sector medical facilities that are similarly  equipped. More specifically, currently USMEPCOM has no electronic  interfaces to electronic medical information holders for it to independently  obtain medical history information on applicants including information held  by other DOD (e.g., Military Health System), government (e.g. Veterans  Affairs, Social Security Administration, etc.), and public/private sector  (e.g., medical insurance, pharmacy beneficiary, etc.) entities. If  implemented within USMEPCOM, this new electronic health record  system could provide this electronic interface as well as other capabilities  to improve USMEPCOM’s ability to access data and share medical  information.
A USMEPCOM concept of operations paper discusses how USMEPCOM  believes the use of an electronic health record system could reduce both  its reliance on applicant self-disclosure and its paper-based process of  recording applicant medical information. For example, with MHS  GENESIS’ planned interoperability and data exchange capabilities,  USMEPCOM officials could reduce their reliance on applicant self- disclosure and improve the medical qualification decision-making process  by interfacing with and accessing applicant electronic medical records  that may exist to independently obtain and verify applicant medical history  information. Additionally, the ability to electronically exchange information  would allow USMEPCOM to share the information more quickly with other  accession stakeholders like service medical waiver review authorities.  Further, a transition to an electronic health record system would begin to  reduce the use of the paper-based system—and its associated costs and  challenges—for recording the medical information obtained or generated  during the accession process. Thus, integration of an electronic health  record system into the accession community could enhance DOD’s ability  to obtain and document complete, accurate, detailed medical information  that is fully accessible, could be used to improve USMEPCOM officials’  medical qualification decisions, and perhaps affect early attrition rates.
Recognizing the potential for MHS GENESIS to support the MEPS, in  June 2016 the Acting Principal Deputy Under Secretary of Defense for  Personnel and Readiness emphasized that the modernization of  accession processes is a priority and requested that the MHS GENESIS  program management office coordinate with the accession community to  include the MEPS in the deployment schedule for the new system. In  response to this request, in August 2016 the program management office  issued a memorandum stating it fully intends to work with USMEPCOM to  ensure MEPS locations are included in the implementation of MHS  GENESIS. Subsequently, officials from Accession Policy within the  Office of the Under Secretary of Defense for Personnel and Readiness  and USMEPCOM stated that they had initial coordination meetings in  January and April 2017 with MHS GENESIS program management  officials to discuss the inclusion of MEPS locations into the system  deployment plans. According to USMEPCOM officials, the latest meeting  produced an expectation that MHS GENESIS will meet its initial operating  capability at one MEPS location in the fall of 2018. However, according to  a MHS GENESIS program management official, detailed plans for  deploying MHS GENESIS to the MEPS are in the earliest stages of  development and no deployment decisions or timelines have been  established. Thus, DOD’s schedule for deploying MHS GENESIS at  MEPS locations and ensuring that the system supports its accession  programs is uncertain.
We have previously reported that projects such as MHS GENESIS can  benefit from the effective use of project planning and management  practices. These practices can significantly increase the likelihood of  delivering promised capabilities on time and within budget. Additionally,  we and others have issued guidance calling for the development of  essential documentation needed for project planning execution and  management. According to this guidance, project planning involves,  among other things, establishing a schedule of actions required to attain  project objectives. We have also reported that a well-planned schedule is  a fundamental management tool that can help government programs use  public funds effectively by specifying when work will be performed in the  future and measuring program performance against an approved plan.  Moreover, an integrated and reliable schedule can show when major  events are expected as well as the completion dates for all activities  leading up to them, which can help determine if the program’s parameters  are realistic and achievable. Further, a reliable schedule can contribute  to an understanding of the cost impact if the program does not finish on  time.
Until DOD completes development of a schedule that includes dates for  MHS GENESIS’ deployment to MEPS locations, the department will not  have assurance that its efforts to modernize the department’s medical  screening process through reducing its reliance on self-disclosure and the  processing of paper files is moving forward expeditiously and as planned.
section_title: Conclusions
paragraphs: The military services enlist thousands of new servicemembers each year,  but if incomplete medical information is gathered or if inadequate medical  screening is performed, the military services may increase the likelihood  that some of these enlistees may leave the military before their initial  terms of commitment are fulfilled. Early separation is costly, and enlistee  early attrition during their initial term of commitment due to medical  reasons—many of which may be either not disclosed or unknown— constitutes a significant loss to the military services. Even when an  enlistee separates from military service within the first 180 days due to a  medical reason, DOD can use information from those cases to improve its  accession medical qualification process; however, DOD does not have a  clear process to ensure that complete medical information is available  about early separation cases from the military services. Moreover, it has  not set a schedule to repair a key database at USMEPCOM to analyze  this information. As a result, DOD may not be able to review and analyze  information that could help improve the medical qualification decision  process and ensure that MEPS are adequately identifying medically  disqualifying conditions among applicants for military service.
Further, DOD primarily relies on the self-disclosure of medical information  by enlisted applicants and a paper-based system to process and obtain  medical information for new enlistees. As DOD begins its planning efforts  for integrating a new multibillion dollar electronic health record system  and transforming the current manual accession medical process to an  automated one, it is important that DOD have a clear and complete  schedule and plan in place to effectively manage this effort. Without a  clear and complete schedule for implementation of its new system, DOD  has limited assurance that the system will be support the MEPS as  planned.
section_title: Recommendations for Executive Action
paragraphs: We recommend that the Secretary of Defense direct the Under Secretary  of Defense for Personnel and Readiness to take the following three  actions:  In coordination with the Director, USMEPCOM, and the military  services develop a clear process with defined roles and  responsibilities to ensure that complete EPTS separation medical  records for enlistees who separated within 180 days of service from  the military services’ basic training sites are provided to USMEPCOM.
In coordination with the Director, USMEPCOM, establish a schedule  to repair the internal EPTS database so that USMEPCOM can provide  more regular and specific feedback to MEPS chief medical officers.
In coordination with the Under Secretary of Defense for Acquisition,  Technology, and Logistics and the DOD Healthcare Management  Systems Program Executive Office, develop a schedule of actions for  deploying its new electronic health record system, MHS GENESIS,  within USMEPCOM that includes key activities such as the major  actions required to accomplish this effort, completion dates for all  actions leading up to these events, and dates for the system’s  deployment to MEPS locations.
section_title: Agency Comments and Our Evaluation
paragraphs: We provided a draft of this report to DOD for review and comment. In  written comments, reproduced in appendix III, DOD concurred with two  recommendations; partially concurred with one recommendation; and  separately provided technical comments, which we incorporated as  appropriate.
DOD concurred with our first recommendation to develop a clear process  with defined roles and responsibilities to ensure that complete EPTS  separation medical records are provided to USMEPCOM and described  actions that the department plans to take to implement this  recommendation.
DOD concurred with our second recommendation to establish a schedule  to repair the internal database it uses to analyze medical records for  EPTS separations so that USMEPCOM can provide more regular and  specific feedback to MEPS chief medical officers. In its comments, DOD  stated that the database is being reviewed as part of a multi-year  information technology modernization effort that includes the use of  business intelligence tools found within DOD’s new electronic health  record system known as MHS GENESIS. DOD stated that once these  tools are available, USMEPCOM will be able to conduct the EPTS  medical record reviews and provide detailed feedback to the MEPS chief  medical officers. We believe that having access to MHS GENESIS’  business intelligence tools should improve USMEPCOM’s ability to  conduct a more thorough analysis of EPTS separation medical records.  However, the MHS GENESIS implementation schedule within  USMEPCOM has not been finalized and is not expected to be approved  until a Full Deployment Decision certification is issued some time in 2018.  This means that the phased implementation of MHS GENESIS at the  MEPS is likely to be several years away at a minimum. Therefore, we  continue to believe that in the interim it would be beneficial for  USMEPCOM to establish a schedule specific to repairing its current  database that will allow for a more thorough analysis of EPTS separation  medical records.
DOD partially concurred with our recommendation to develop a schedule  for deploying the new electronic health record system, MHS GENESIS,  within USMEPCOM. After receiving our draft report, DOD officials  expressed concerns regarding the office to which this recommendation  was directed. DOD officials stated that since the Under Secretary of  Defense for Personnel and Readiness is the functional owner of the new  electronic health record system, the recommendation should be directed  to that office, instead of to the Under Secretary of Defense for Acquisition,  Technology and Logistics. After consideration of this information and a  discussion with these officials, we agreed to revise the recommendation  to be directed to the Under Secretary of Defense for Personnel and  Readiness in conjunction with officials from the Office of the Under  Secretary of Defense for Acquisition, Technology and Logistics.
Further, in its comments, DOD stated that it has already taken actions to  implement our recommendation, as the Program Executive Office for  DOD Healthcare Management Systems has developed proposed  schedules for incorporating MHS GENESIS into the MEPS. DOD also  stated that because these schedules were unofficial and unapproved, it  could not share them with us. We are very concerned with DOD’s  statement that the department is unable to share this unapproved  information with us. Throughout the audit, we were repeatedly told by the  Program Executive Office that details for the MHS GENESIS deployment  to MEPS facilities did not exist. When we asked for clarification about  whether schedules really did not exist or rather if officials were refusing to  provide any existing schedules to us, we received no response.
Our access authority under 31 U.S.C. § 716 provides us authority to  obtain documents that may be “pre-decisional” in nature.  Absent our  ability to review these schedules, we continue to believe that our  recommendation remains valid and  we will continue to monitor DOD’s  actions in this area related to the development, approval and  implementation of a schedule for deploying the department’s new  electronic health record system, MHS GENESIS, within USMEPCOM.
We are sending copies of this report to the appropriate congressional  committees; the Secretary of Defense; the Under Secretary of Defense  for Personnel and Readiness; the Under Secretary of Defense for  Acquisition, Technology, and Logistics; the Commander, U.S. Military  Entrance Processing Command; the Secretaries of the Army, the Navy,  and the Air Force; and the Commandant of the Marine Corps. In addition,  the report is available at no charge on the GAO website at  http://www.gao.gov.
If you or your staff have any questions about this report, please contact  me at (202) 512-3604 or farrellb@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 who made key contributions to this report  are listed in appendix IV.
section_title: Appendix I: Scope and Methodology
paragraphs: The scope of our review included Department of Defense (DOD) offices  involved in the accession, training, or separation of enlisted active-duty  servicemembers in the Army, the Air Force, the Navy, and the Marine  Corps. Table 1 contains a list of the organizations, offices, and military  installations that we visited or contacted during the course of our review.
To determine the extent to which servicemembers are unable to complete  their initial terms of commitment because of medical reasons, we  analyzed data from the Defense Manpower Data Center (DMDC) on  accessions and early attrition of active-duty enlistees from the four  military services during their first terms of commitment, often between 4  and 6 years of active-duty service, for fiscal years 2005 through 2015.  Fiscal year 2015 is the most recent year for which an entire year’s worth  of attrition data are available and, for relevancy purposes, we obtained  data not more than 10 years old, beginning in fiscal year 2005. We  analyzed these data to show overall early attrition and early attrition due  to medical reasons over selected intervals by military service for each  fiscal year. We also analyzed DOD separation codes assigned to each  separation to examine the leading categories of early attrition. We  reviewed the data to check for their completeness and for obvious errors  such as out-of-range date values. We also interviewed a knowledgeable  official from DMDC regarding data quality and reliability. We determined  that the data were sufficiently reliable for reporting historical early attrition  trends. We also interviewed DOD, USMEPCOM, and military service  officials to obtain their perspectives on early attrition rates.
To determine the extent to which USMEPCOM obtains, analyzes, and  uses information about enlistee early attrition due to medical reasons, we  reviewed DOD memorandums and USMEPCOM regulations related to  obtaining, analyzing, and using information about enlistee early attrition  due to medical reasons. We also compared USMEPCOM practices for  obtaining, analyzing, and using information from medical records for  enlistees who separated within the first 180 days of their service due to  medical conditions that existed prior to their service with the Standards for  Internal Control in the Federal Government. This included the  importance of designing control activities to achieve objectives and  respond to risks and using quality information by identifying information  requirements, obtaining relevant data from reliable internal and external  sources in a timely manner, and processing the obtained data into quality  information. Additionally, we interviewed officials at USMEPCOM and  officials from four of the military services’ training bases to further  understand the collection and reporting of early medical attrition  information. These bases were selected on the basis of geographical  dispersion and included one from each of the military services.
To determine the extent to which DOD has implemented its new  electronic health record system at the MEPS to obtain and document  applicants’ medical information, we reviewed selected DOD,  USMEPCOM, and military regulations related to applicant medical  screening processes. Additionally, we selected a convenience sample of  four MEPS that were located in large geographically dispersed U.S. cities  that were also near a military service recruiting office and a basic training  base to observe medical-related MEPS operations and interview officials.  During our visits to the selected MEPS locations, we also interviewed  officials from nearby military service recruiting organizations to discuss  their perspectives on recruiting potential applicants and the process and  challenges associated with medically screening applicants. We  supplemented our visits to the large MEPS locations with questionnaires  sent to MEPS command officials, chief medical officers, and military  service recruiting liaisons of a nongeneralizable selection of eight small or  medium-sized MEPS as determined first by workload level, then sorted  randomly, and then chosen to ensure distribution across all MEPS  battalions. Further, regarding DOD’s efforts to implement an electronic  health record into MEPS locations, we interviewed officials from  Accession Policy within the Office of the Under Secretary of Defense for  Personnel and Readiness and USMEPCOM as well as contacted the  Program Executive Office Defense Healthcare Management System to  obtain information regarding the implementation status of DOD’s new  electronic health record within USMEPCOM at the MEPS locations. We  compared their efforts against selected information technology project  management practices for developing well-planned schedules.
We conducted this performance audit from July 2016 to July 2017 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.
section_title: Appendix II: Selected Policies for Medically Screening and Processing Military Applicants
paragraphs: Table 2 provides a selected list of DOD and military service instructions,  guidance, and policies regarding the medical screening and processing of  military applicants.
section_title: Appendix III: Comments from the Department of Defense
section_title: Appendix IV: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Kimberly C. Seay (Assistant  Director), Vijay Barnabas, Rebecca Beale, Vincent Buquicchio, Cynthia  Grant, Mae Jones, Amie Lesser, Josh Ormond, Amber Sinclair, Rachel  Stoiko, Wade Tanner, and Sabrina Willard made major contributions to  this report.