Military Personnel: Army Needs to Better Enforce Requirements and Improve Record Keeping for Soldiers Whose Medical Conditions May Call for Significant Duty Limitations
Published: 2008-06-10T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: The increasing need for warfighters for the Global War on Terrorism has meant longer and multiple deployments for soldiers. Medical readiness is essential to their performing needed duties, and an impairment that limits a soldier's capacities represents risk to the soldier, the unit, and the mission. Asked to review the Army's compliance with its guidance, GAO examined the extent to which the Army is (1) adhering to its medical and deployment requirements regarding decisions to send soldiers with medical conditions to Iraq and Afghanistan, and (2) deploying soldiers with medical conditions requiring duty limitations, and assigning them to duties suitable for their limitations. GAO reviewed Army guidance, and medical records for those preparing to deploy between April 2006 and March 2007; interviewed Army officials and commanders at Forts Benning, Stewart, and Drum, selected for their high deployment rates; and surveyed deployed soldiers with medical limitations.
section_title: What GAO Found
paragraphs: Army guidance allows commanders to deploy soldiers with medical conditions requiring duty limitations, subject to certain requirements, but the Army lacks enforcement mechanisms to ensure that all requirements are met, and medical record keeping problems obstruct the Army's visibility over these soldiers' conditions. A soldier diagnosed with an impairment must be given a physical profile form designating numerically the severity of the condition and, if designated 3 or higher (more severe), must be evaluated by a medical board. Commanders must then determine proper duty assignments based on soldiers' profile and commanders' staffing needs. From a random projectable sample, GAO estimates that 3 percent of soldiers from Forts Benning, Stewart, and Drum who had designations of 3 did not receive required board evaluations prior to being deployed to Iraq or Afghanistan for the period studied. In some cases, soldiers were not evaluated because commanders lacked timely access to profiles; in other cases, commanders did not take timely actions. The Army also had problems with retention and completeness of profiles; although guidance requires that approved profiles be retained in soldiers' medical records, 213 profiles were missing from the sample of 685 records reviewed. The Army was not consistent in assigning numerical designations reflecting soldiers' abilities to perform functional activities. GAO estimates from a random projectable sample that 7 percent of soldiers from these three installations had profiles indicating their inability to perform certain functional activities, yet carrying numerical designators below 3. While medical providers can "upgrade" numerical designations discretionarily based on knowledge of soldiers' conditions, the upgrades can mask limitations and cause commanders to deploy soldiers without needed board evaluations. While GAO found no evidence of widespread revision in profile designations, some soldiers interviewed or surveyed disagreed with their designations yet were reluctant to express concerns for fear of prejudicial treatment. The Army has instituted a program to provide ombudsmen to whom soldiers can bring medical concerns, but it is targeted at returning soldiers and is not well publicized as a resource for all soldiers with medical conditions. Without timely board evaluations and retention of profile information for deploying soldiers with medical conditions, the Army lacks full visibility and commanders must make medical readiness, deployment, and duty assignment decisions without being fully informed of soldiers' medical limitations. GAO estimates that about 10 percent of soldiers with medical conditions that could require duty limitations were deployed from the three installations, but survey response was too limited to enable GAO to project the extent to which they were assigned to suitable duties. Along with interviews, however, responses suggest that both soldiers and commanders believe soldiers are generally assigned to duties that accommodate their medical conditions. Occasional exceptions have occurred when a profile did not reflect all necessary medical information or a soldier's special skill was difficult to replace. Officials said soldiers sometimes understate their conditions to be deployed with their units, or overstate them to avoid deployment.

section_title: Letter
paragraphs: From fiscal years 2004 through 2007, the average number of active and  reserve servicemembers deployed by the Department of Defense (DOD)  has increased about 19 percent, from 216,000 to 256,000 servicemembers,  in support of Operation Iraqi Freedom and the Global War on Terrorism.  The Army has been the major source of servicemembers supporting  continued operations, and the increasing need for able warfighters has  meant longer and multiple deployments for its soldiers. Serving in the  armed forces requires the medical readiness necessary to plan and execute  duties to meet operational goals. Any medical or psychological condition  that limits the ability of a servicemember to execute his or her duties  represents a risk to the servicemember, the unit, and the accomplishment  of the mission. Military commanders, medical providers, and  servicemembers share the responsibility for medical readiness as an  integrated effort to ensure that servicemembers are ready to fight in  support of ongoing operations.
Whenever a soldier is diagnosed with a medical condition, Army guidance  requires that medical providers document the soldier’s limitations in his or  her medical record with a permanent or temporary physical profile,  describing the soldier’s medical condition and physical capability. These  medical providers, who serve as the profiling officers, must also assign a  numerical designation reflecting the extent of any limitation on a scale  from 1 to 4, such that a designation of 1 indicates that a soldier has a high  level of medical fitness, while a designation of 4 signifies a drastically  limited ability to perform military duties due to one or more medical  conditions or defects. A designation of 3 indicates that a soldier has one  or more medical conditions that may require significant duty limitations,  and the soldier should receive duty assignments that are commensurate  with his or her limitations. Once soldiers receive a permanent profile  indicating that they have a permanent or chronic medical condition that  may require significant limitations in assignment, Army guidance generally  requires further evaluation of the soldiers’ ability to perform duties in their  current job assignments. Moreover, DOD guidance requires soldiers to be  evaluated for medical readiness prior to deployment.
In prior reports, we have highlighted long-standing issues with the medical  deployability of servicemembers. Specifically, we have found continuing  problems with the completion of pre- and post-deployment health  assessments. We also reported in October 2005 that we found reserve  component servicemembers were deploying with preexisting medical  conditions, and we provided various recommendations for more guidance  and better visibility over servicemembers with medical conditions in  theater. DOD has taken action based on these recommendations, such as  establishing tracking and reporting of key force health protection and  quality assurance elements such as immunizations and pre- and post- deployment health assessments.
From March through October 2007, the Army Office of the Inspector  General conducted an inquiry at Fort Benning based on media allegations  that soldiers were deployed with significant medical limitations. Army  Inspector General officials interviewed the soldiers named in the news  articles, numerous medical providers, and unit leaders to obtain their  testimonies regarding their pre-deployment medical reviews. The  Inspector General officials reviewed the standards for completing physical  profiles, the compliance with these standards, commanders’ decisions or  actions that were based on these profiles, and whether any reprisals may  have occurred against soldiers with regard to complaints and concluded  that the Army followed standards in all but one instance where a soldier’s  profile was changed without proper authority and the soldier deployed.  The soldier was reevaluated in theater and redeployed to Fort Benning.  They found no instances of reprisal. According to an Inspector General  official, further investigation of one medical provider led to no findings of  wrongdoing. The report recommended that the Army direct (1) a special  inspection of medical fitness procedures, which is ongoing; (2) leaders and  soldiers to review and follow Army standards for documenting and  assessing medical limitations; and (3) the Army Surgeon General to revise  the physical profile form to include a Privacy Act statement, instructions  for using the physical profile form, and definitions of key terms.
The Chairs of the House Armed Services Committee and the Military  Personnel Subcommittee requested that we review the Army’s compliance  with guidance on the deployment of soldiers with medical conditions. As  agreed with congressional staff, we examined:  1.  the extent to which the Army is adhering to its medical and  deployment requirements regarding decisions to send soldiers with  medical limitations to Iraq and Afghanistan; and  2.  the extent to which the Army is deploying soldiers with medical  conditions requiring duty limitations to Iraq and Afghanistan, and  whether it is assigning them to duties suitable to their limitations.
To address the extent to which the Army is adhering to its medical and  deployment requirements regarding decisions to send soldiers with  medical limitations to Iraq and Afghanistan, we reviewed Army guidance  regarding documentation of soldiers’ medical limitations prior to  deployment and conditions under which soldiers with medical conditions  are considered deployable. We selected three Army installations—Fort  Benning and Fort Stewart in Georgia, and Fort Drum in New York—that  met one or both of the following two factors: (1) these installations had a  large number of active component soldiers deployed from each  installation to Iraq or Afghanistan between April 1, 2006, and March 31,  2007; or (2) these installations had initial allegations of soldiers being  deployed with significant medical limitations from these installations. For  these locations, we prepared a random, projectable sample of active  component soldiers preparing for deployment who indicated that they may  be under a profile. We reviewed medical records of soldiers in this sample  and identified a subset of the soldiers who had received profiles  documenting medical conditions that may require significant duty  limitations prior to preparing to deployment. We interviewed medical  providers, personnel officials, Army commanders, and soldiers to identify  and evaluate the installation’s procedures for documenting medical  limitations in physical profiles and the training provided at each  installation. We did not review documentation of medical limitations other  than the physical profiles. To determine the extent to which the Army is  deploying soldiers with medical conditions requiring duty limitations to  Iraq and Afghanistan, and whether it is assigning them to duties suitable to  their limitations, we compared the medical data on the subset of soldiers  who had significant medical limitations from April 2001 to March 2007  with the soldiers’ deployment data from Forts Benning, Stewart, and  Drum. From this analysis, we identified the number of soldiers who had a  profile in effect at the time of their deployment from each installation. We  reviewed Army processes for tracking soldiers while deployed. We  interviewed Army officials and commanders about any procedures in  place to ensure that soldiers are assigned within their limitations. We also  surveyed 66 active component Army soldiers deployed with medical  conditions to Iraq and Afghanistan and received responses from 24 of  them, for a response rate of about 36 percent. While we cannot project the  results of the surveys to all soldiers with medical conditions across the  Army deployed to Iraq and Afghanistan, we present the information we  obtained to illustrate these issues.
For a complete discussion of our scope and methodology, see appendix I.  We conducted this performance audit from April 2007 through April 2008  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.
subsections: section_title: Background
paragraphs: Various pieces of DOD guidance provide overall direction and require the  services to define medical deployment standards to ensure that  servicemembers deploying to a theater of operations are in optimal  health. DOD allows the military services to deploy servicemembers who  do not meet the services’ medical standards under certain conditions. For  example, a service is required to obtain a waiver from the Combatant  Command Surgeon if the service wishes to deploy a servicemember who  does not meet deployment standards and can receive medical treatment at  deployed locations that will render them fit for duty. DOD guidance  requires the services to continue to employ measures that ensure  servicemembers are medically and psychologically fit for worldwide  deployability, taking into account additional guidance provided by the  combatant commander on theater-specific medical limitations. The  Assistant Secretary of Defense for Health Affairs is planning to release  new guidance that provides more guidelines on medical conditions that, in  general, should preclude servicemembers from being deployed. Because  DOD has not determined the issue date and has not yet implemented this  new guidance, we were not able to evaluate its effect during our review.
The Offices of the Surgeon General of each military service have  established procedures to evaluate the health conditions of their  servicemembers according to service-specific medical standards. Our  prior work has shown that the Army, Air Force, Navy, and Marine Corps  all have different methods of assessing their servicemembers’ medical  readiness prior to deployment and documenting any medical conditions  and limitations. The Army’s guidance, similar to the other services’  guidance, allows the commander to have the ultimate authority to deploy  servicemembers and make proper duty assignments, if certain procedures  are followed, while taking into account the medical provider’s assessment  of a servicemember’s medical condition and duty limitations.
subsections: section_title: Army Guidance
paragraphs: The Army Office of the Surgeon General and Army Deputy Chief of Staff  (G-1) provide guidance on soldiers’ medical readiness. Regarding medical  matters, the Army Office of the Surgeon General heads the Army Medical  Command, which provides guidance to Army medical treatment facilities.  Medical Evaluation Boards (MEB) of soldiers are conducted at medical  treatment facilities at Army installations. Regarding command matters, the  Army Manpower and Reserve Affairs Office works with the Army Deputy  Chief of Staff G-1 to provide guidance to human resource directorates at  each installation. The Deputy Chief of Staff G-1 has overall responsibility  for the Physical Performance Evaluation System which involves an  administrative screening board known as the Military Occupational  Specialty Medical Retention Board (MMRB).
subsections: section_title: Physical Profiles
paragraphs: Army Regulation 40-501 requires that the Army document physical and  mental conditions that may limit a soldier’s ability to perform his or her  duties on the physical profile form. Using the physical profile, Army  medical providers, who serve as profiling officers, provide  recommendations on a soldier’s medical limitations in order to assist the  commander in properly assigning the soldier to duties that contribute to  the unit’s mission. A profiling officer creates a physical profile that  documents any limitations found during a medical examination, and  identifies whether the medical limitation is temporary, in which case a  short-term condition can be improved by further treatment, or permanent,  in which case a chronic condition will not improve with medical treatment  at that point in time. The profiling officer classifies the medical limitations  under six categories:    physical capacity    upper extremities  lower extremities  These categories are often abbreviated as the “PULHES” factors (see     app. III for further detail). The medical limitations in physical profiles are  also given a numerical designation from 1 to 4 to reflect the different levels  of functional capability and severity of impairment. Soldiers with physical  profiles designated by the number 1 are considered to have a high level of  medical fitness; a 2 indicates that a soldier has some medical condition or  physical defect that may require some activity limitations; a 3 under one or  more of the factors indicates that the soldier has a medical condition or  physical defect that may require significant limitations in duty assignment;  and soldiers designated by the number 4 must have their military duties  drastically limited. Profiling officers must also specify whether the  soldier can perform certain functional activities comprising the minimum  requirements needed in order to be medically qualified for worldwide  deployment.
Profiling officers should evaluate a soldier who has a temporary profile at  least once every 3 months to determine whether the soldier’s medical  condition has improved or, if not, whether an extension of up to 12 months  is needed. If an extension is needed beyond 12 months, a temporary  profile should be changed to a permanent profile. Permanent and  temporary profiles normally require the signature of only the profiling  officer. Both the signatures of the profiling officer and a higher level  medical provider, who is designated the approving authority, are required  when a permanent profile number is designated at 3 or 4, or when a  permanent profile designation has been changed from a 3 to a 2.
According to profiling officers, during the preparation of the physical  profile and medical evaluation of the soldier, the profiling officer may  communicate with the commander of the soldier for the purpose of better  identifying the soldier’s medical limitations. All permanent physical  profiles are coded to designate any assignment limitations, including  whether a soldier has been reviewed by an MMRB or a Physical Evaluation  Board. Once the physical profile is signed by profiling officer, and  approved by the designated approving authority as needed, Army  regulation 40-501 requires that the completed physical profile should be  retained in the soldier’s medical record and copies of it should be  distributed to the unit commander and the soldier. For permanent physical  profiles, one more copy is distributed to the military personnel office.
Army medical records comprise both hard copy documents and an  electronic system called the Armed Forces Health Longitudinal  Technology Application (AHLTA), the official system for retaining  soldiers’ medical documentation. AHLTA is used DOD-wide and gives  medical providers access to soldiers’ medical information, including  medical evaluation history, prescriptions, diagnostic tests, and physical  profile information. The Army also tracks soldiers’ medical readiness  information through the Army Medical Protection System (MEDPROS), in  order to allow commanders to have access to soldiers’ medical  information that might affect readiness, but this system retains limited  information only on permanent physical profiles and does not supply any  detailed description of medical limitations or incapacity to perform  functional activities.
section_title: MMRB and MEB Evaluations
paragraphs: Because physical profiles merely represent medical recommendations  made by the profiling officer to a soldier’s commander, physical profile  designations do not automatically determine whether a soldier is  deployable or not. Three Army regulations require higher levels of review  for soldiers with a numerical designation of at least a 3 in order to assist  commanders in properly assigning soldiers to duties suitable to their  medical limitations. Army guidance states that once soldiers receive a  permanent profile designation of at least a 3, they are not deployable for  the duration of the MMRB or MEB until the board is concluded.
If a soldier receives a permanent profile of at least a 3, the profiling officer  and approving authority must provide an initial determination of whether  the soldier meets Army medical standards or not. If they believe that a  soldier meets medical standards, Army regulation 600-60 requires that the  soldier be reviewed by an MMRB to determine whether the soldier is able  to complete the duties in his or her job assignment or needs to be  reassigned to a job that accommodates his or her limitations. The MMRB  consists of five voting members, including a medical provider, a senior  commander, and when reasonably available, soldiers of the same branch  or specialty as the soldier being evaluated as well as non-voting members  including a personnel advisor, a recorder, and anyone else to ensure a fair  hearing. Once the personnel office receives the permanent profile from the  medical administrative office and convenes an MMRB, the recorder will  assemble the soldier’s personnel records and medical records. The  commander will prepare an evaluation of the impact of the profile  limitations on the soldier’s ability to perform the full range of duties in the  soldier’s job assignment, known as a Military Occupational Specialty  (MOS). During the MMRB, the personnel advisor will summarize the  details of the soldier’s current MOS and common duties, and the medical  provider will brief the MMRB on the soldier’s physical profile. The soldier  will also present facts or call witnesses relevant to his or her physical  performance, current MOS retention, or MOS reclassification preference.  The MMRB can recommend either that (1) the soldier remain in the Army  under his or her current military occupational specialty or specialty code,  (2) the soldier be placed in probationary status for up to 6 months to  improve the condition of a disease or injury, (3) the soldier be reclassified  into another occupational specialty, or (4) the soldier be referred to the  MEB for medical disqualification processing.
Active component Army soldiers should appear before an MMRB within 60  days of the date the physical profile is signed by the medical provider who  is designated the approval authority. Army regulation 600-60 requires that  personnel officials responsible for convening the MMRB maintain  statistics on each case in order to assess whether or not MMRB  evaluations are convened within the 60-day time limit. As of March 2008,  officials now are required to report the statistics to the Deputy Chief of  Staff of the Army.
Alternatively, if a profiling officer and the approving authority believe that  a soldier with a permanent profile designation of at least a 3 does not meet  medical standards, Army regulation 40-501 requires that the soldier should  be reviewed by an MEB to fully ascertain the soldier’s medical condition  and limitations. From the MEB results, a subsequent Physical Evaluation  Board determines whether the soldier is to be retained in the Army or not,  and the applicable disability rating.
There are two ways in which an MEB is initiated: by referral from the  medical provider designated as the approving authority or by referral from  an MMRB. When an MEB is referred by an approving authority, the  soldier’s physical profile is distributed to the Physical Evaluation Board  liaison officer at the medical treatment facility, who is responsible for the  case management of the soldier. A medical provider reexamines the  servicemember and reviews his or her medical history, including prior test  results, diagnoses, and treatments. The medical provider will then  complete a narrative summary to document the nature and degree of  severity of the soldier’s condition. The commander also provides a letter  describing how the soldier’s medical condition affects job performance  and deployability status. Also provided is a summary of the soldier’s chief  complaint, stated in the soldier’s own words. MEBs are composed of two  or more physicians, one being a senior medical provider with detailed  knowledge of Army medical standards and procedures, and other  members having familiarity with these matters. MEB evaluations must be  completed within 90 days of approval of the physical profile, or of the date  when the MMRB referral is received by the liaison officer. The MEB could  result in several outcomes, including: (1) the soldier is returned to duty,  with a profile marked that he or she meets medical retention standards; or  (2) the soldier is referred to a Physical Evaluation Board to determine  whether he or she has lost the ability to perform assigned duties because  of a medical condition and thus is unfit for duty, or the soldier is fit for  duty and thus is retained in the Army.
An Army memorandum requires that the liaison officers track certain  statistics and use an electronic database system to ensure that MEB  evaluations are completed within 90 days. This information is reported  quarterly to the Deputy Under Secretary of Defense for Military Personnel  Policy.
section_title: Pre-deployment Health Assessments
paragraphs: According to a DOD instruction, within 60 days prior to deployment,  soldiers complete a pre-deployment health assessment form to reflect  soldiers’ medical readiness with respect to immunizations, dental,  hearing/eye exams, and medical limitations on physical profiles. If a  soldier indicates on the pre-deployment health assessment form that he or  she is on a profile, or light duty, or undergoing a medical board, the soldier  is referred to a medical care provider for reevaluation and verification of  the medical limitations under the physical profile. If a soldier does not  meet the medical requirements under the pre-deployment health  assessment, the soldier is classified as not deployable, until the soldier  receives further treatment. Moreover, if a soldier is also undergoing an  MMRB or MEB, the soldier is considered not deployable until the  evaluation is completed and the soldier is found fit for duty. The pre- deployment health assessment is updated to indicate that the soldier is  deployable once he or she receives treatment or undergoes a board  screening and is found fit for duty.
Under Army regulation 40-501, Army commanders have the ultimate  authority to deploy soldiers, but commanders are required to recognize  soldiers’ limiting conditions and assign them duties consistent with their  limiting conditions, with the assistance of personnel management officers  from Army Forces Command and Human Resources Command.
section_title: Army Is Not Meeting All Requirements for Deploying Soldiers with Medical Conditions and Has Unresolved Problems with Medical Record Keeping
paragraphs: The Army allows commanders to deploy soldiers who have medical  conditions that may require significant limitations in duty assignment as  long as they meet requirements in the guidance, including board  evaluations, suitable duty assignments, and available medical treatment in  deployed locations, if needed; however, the Army is not meeting all  requirements to ensure board evaluations are conducted within prescribed  time frames, and various problems exist with regard to physical profile  record keeping. Army requirements for deploying soldiers with medical  conditions are not always being met; commanders are not always aware of  medical limitations in a timely way, and in the sample review, we found  that commanders are not always adhering to guidance to ensure that  soldiers are not being deployed to Iraq or Afghanistan prior to having  needed MMRB or in some cases MEB evaluations. Furthermore, the Army  continues to have problems with retention and completeness of its  physical profiles, as well as a lack of consistency in designations with  regard to soldiers’ abilities to perform functional activities. While we did  not find widespread revision of profiles prior to deployment, we found  that soldiers were concerned about how the Army was addressing their  medical problems prior to deployment. While commanders may recognize  medical limitations on a case by case basis, without performing required  medical board evaluations, the Army lacks a method for ensuring that all  such cases are appropriately recognized.
section_title: Army Requirements for Deploying Soldiers with Medical Conditions Are Not Always Being Met
paragraphs: While Army guidance allows commanders to deploy soldiers with medical  conditions that may require significant limitations in duty assignments,  subject to certain requirements, we found that commanders are not always  aware of soldiers’ medical limitations when making deployment decisions,  and they do not always adhere to these requirements. Army guidance  requires that whenever a new physical profile is created, copies of  physical profile documentation, once authorized by the approving medical  authority, should be added to a soldier’s medical record and given to the  soldier, his or her commander, and the command’s personnel office.  Army guidance stipulates that soldiers with a permanent profile containing  a numerical designation of a 3 or 4 who meet Army medical retention  standards should be evaluated by an MMRB within 60 days of receiving the  approved physical profile, to determine whether the soldier is able to  complete all the duties in his or her current job assignment or should  alternatively be reassigned to a job that accommodates his or her medical  limitation(s). Alternatively, a soldier with a permanent profile of a 3 or 4  who is believed by a profiling officer not to meet medical standards must  be evaluated by an MEB within 90 days to determine whether that soldier  should be retained in the Army. Moreover, within 60 days prior to  deployment, DOD guidance requires the Army to review soldiers for  medical readiness. During this pre-deployment assessment, soldiers who  report having a physical profile must be referred to a medical provider,  which according to medical providers may result in an updated  confirmation of their numerical designation. If a soldier receives a new  profile indicating a medical condition that may require significant  limitations in assignment, Army guidance categorizes the soldier as not  deployable until he or she is reviewed by an MMRB or in some cases  MEB. Commanders, with the assistance of personnel management  officers, are responsible for determining proper duty assignments for  soldiers based on their knowledge of soldiers’ physical profiles,  assignment limitations, and the need for accomplishing necessary duties  within the soldiers’ MOS. Commanders may also consider the availability  of medical treatment at deployed locations when determining the  deployability of soldiers with physical profiles.
At Forts Benning, Stewart, and Drum, we found that commanders are not  always adhering to requirements in Army guidance to ensure that needed  board evaluations are performed. After reviewing 685 medical records and  the deployment information of soldiers who were preparing for  deployment in the statistically valid sample, we estimate that 6 percent of  soldiers from Forts Benning, Stewart, and Drum were deployed with  designations of permanent 3 in their physical profiles—signifying to a  commander that they have medical conditions that may require significant  limitations. These soldiers should have been reviewed prior to  deployment by a MMRB, or MEB as needed, in accordance with Army  regulations.  Further, we estimate that about 3 percent of the soldiers  from Forts Benning, Stewart, and Drum had profiles that indicated that  they met medical retention standards and required an MMRB, or may not  meet standards and required an MEB, but were deployed without having  been reviewed by an MMRB or MEB. Figure 1 summarizes percentages  (and confidence intervals)  of soldiers with profile designations of  permanent 3 who deployed from Forts Benning, Stewart, and Drum, and  the percentage of those soldiers who did not receive evaluation by an  MMRB or MEB prior to deployment.
In our sample, we found that of the 42 soldiers who had profile  designations of permanent 3, 17 soldiers did not receive needed board  evaluations prior to their deployment.  Although we could project this as a  percentage of the soldiers from Forts Benning, Stewart, and Drum, we did  not project this as a percentage of the 42 soldiers who had profile  designations of a permanent 3 because the size of this subgroup in the  sample is not sufficient to report a reliable confidence interval for a  population estimate. Table 1 shows the number of soldiers in the sample  with permanent physical designations of 3 who did not receive pre- deployment evaluations by MMRB or MEB.
These needed evaluations may not be occurring because each of the three  installations lacked an enforcement mechanism to ensure all procedures  are followed. According to medical providers, commanders, and personnel  officials, in some cases soldiers do not receive their MMRB or MEB  evaluations because profiles were not distributed by the approving  authority or medical administrative office in time to inform commanders  of the existence of the profiles. In other cases, according to personnel  officials, commanders were given notice of the profiles but did not take  needed action on time, but we were not able to determine why this  occurred.
Moreover, we found that while Army personnel officials at the three  installations we visited were maintaining proper data on MEB evaluations,  they were not maintaining required statistics on the performance of MMRB  evaluations. Army guidance requires that medical and personnel officials  have to maintain certain statistics in order to know whether MEB or  MMRB evaluations are conducted within set time frames. Personnel  officials told us that they kept informal data on each MMRB case in  separate files, such as the date of the approved profile, the date it was  received, and the date of the MMRB. However, this information was not  summarized as would be needed in order to calculate the period of time  that elapsed between the stages of MMRB evaluations. Prior to February  2008, the Army did not require that these statistics be reported to anyone.  The Army revised its regulation 600-60 to require the reporting of quarterly  statistics to the Deputy Chief of Staff of the Army beginning in March 2008.  That change may lead to better oversight of the timeliness of the MMRB,  but we were not able to assess the impact of this recent change during this  review.
Without performing all required medical board evaluations or tracking the  timeliness of board evaluations, the Army lacks a systematic method for  confirming that commanders recognize all cases of medical limitations and  assign soldiers to duty assignments that suitably accommodate them.
section_title: Soldiers’ Medical Records Are Not Always Complete and Do Not Always Retain Profiles, and Numerical Designations Are Not Consistently Determined
paragraphs: Medical records are intended to provide a soldier’s history of medical  treatment and limitations, and Army regulation 40-501 requires that once  physical profiles are prepared and signed, the profiles should be kept in a  soldier’s medical record. These completed profiles include the numerical  designation, a description of medical limitations, the signature of the  profiling officer and approving authority, as needed, and the dates of the  signatures. Medical records comprise both the hard copy and electronic  versions of medical information. Commanders use physical profiles to  assess soldiers’ physical ability to perform their duties.
When we compared records in the official electronic medical system,  AHLTA, and hard copy records with those in an electronic medical  readiness system, MEDPROS, we found that 213 physical profiles were  missing from the 685 medical records of soldiers in the sample who had a  medical condition that may require significant limitations at Forts  Benning, Stewart, and Drum. Further, of the physical profiles that were  retained in the sample of medical records of soldiers with medical  conditions that may require significant limitations, we found that 20 were  not complete. Specifically, both hardcopy and electronic medical records  lacked profiles with the appropriate signatures and dates of final approval.
These problems may be occurring because each installation uses its own  informal process for approving and distributing completed physical  profiles to the soldier, commander, and medical record. For example, at  Forts Benning and Stewart, a profiling officer would consult with the  soldier and his commander in creating the profile, and if the physical  profile were permanent and designated a 3 or 4, the medical provider who  created the profile would provide it to the approving medical provider.  The approving medical provider would then provide it to personnel  officials in order to initiate an MMRB or to the liaison officer to initiate an  MEB, if needed, and would also provide it to the medical administrative  office, to be retained in the medical record. Officials did not strictly adhere  to time frames during this process, and personnel officials expressed  doubt to us as to whether they received all physical profiles. Medical and  command officials at Fort Drum stated that their process was also  informal and they did not strictly adhere to timeframes, but they retained  hard copies of all permanent physical profiles separate from the soldiers’  medical records at the liaison officer’s administrative office. Without a  systematic method for approving and distributing profiles, current  informal processes have led to inconsistencies in retention of the physical  profiles in the medical record. The electronic personnel system also  contains medical information, and we found that it is not being routinely  updated. As a result, communication to commanders about physical  limitations in many cases comes from the soldiers themselves, rather than  the medical record system or personnel system.
Army officials intend to require that all physical profiles be processed and  retained in the AHLTA electronic medical system; however, steps have not  been taken to implement the system change. The system change will  require that physical profiles be approved and routed electronically to  commanders, medical providers, and the personnel offices to initiate MEB  and MMRB proceedings. This change is intended to correct the limited  visibility over profile information and inconsistencies in profile  procedures, similar to the issues we have found in this review at Forts  Benning, Stewart, and Drum. However, Army officials told us they have  not finalized plans for actions needed and associated milestones to  implement these changes. Moreover, current plans do not ensure that the  information will be entered and distributed in a timely manner, as officials  who convene the MMRB or MEB do not have authority to compel timely  system input by commanders and medical providers.
Finally, the Army is not consistent in its use of numerical designations in  profiles to reflect a soldier’s ability to perform certain functional activities.  Army guidance states that when soldiers are not able to meet certain  requirements they are given a numerical designation of at least 3, and this  designation should result, in most instances, in a review of their cases by  an MMRB or MEB. When profiling officers prepare physical profiles  carrying a designation of 2, these profiles do not generally receive further  review, until the soldier indicates he or she is under a physical profile at  the pre-deployment assessment. Based on our random projectable sample  of soldiers preparing to deploy between April 2006 and March 2007, we  estimate that about 7 percent of the soldiers who were preparing for  deployment at Forts Benning, Stewart, and Drum had physical profiles in  their medical record showing the inability to perform functional activities  yet were not designated with a score of at least 3. Figure 2 shows the  estimated percentage (and confidence intervals) of soldiers by Army  installation who had profiles that indicated that they were unable to  perform certain functional activities, yet the profiles had a designation  of 2.
The physical profile form defines performance of functional activities  according to whether the soldier is: (1) able to carry and fire his or her  individually assigned weapon; (2) able to move a fighting load of 48  pounds for at least 2 miles; (3) able to wear his or her protective mask and  all chemical defense equipment; (4) able to construct an individual fighting  position; (5) able to perform 3-5 second rushes under direct or indirect  fire; and (6) healthy, without any medical condition that prevents  deployment. Army regulation 40-501 allows for some flexibility in the  medical provider’s designation of numerical designation in a soldier’s  profile, and according to medical providers, they may upgrade  designations based on their knowledge of the soldier’s medical condition  and the soldier’s capacity to handle medical limitations. However,  discretionary upgrades can mask a soldier’s limitations such that a  commander might deploy the soldier without benefit of MMRB evaluation  and may place the soldier in duties unsuitable to his or her limitations.
We did not find widespread revision of profiles by profiling officers or  approving authorities prior to deployment. Only 1 percent of the physical  profiles we reviewed were changed from a permanent 3 to 2 within a few  months prior to the soldier’s deploying. Upgrades in numerical  designations are generally annotated by remarks in the descriptive text  included in a soldier’s profile, and they must include a second approving  medical provider’s signature. However, informal discussions between  soldier and medical provider can result in a change in the profile  designation that may not be noted in the profile. In one case, we found  that a soldier’s profile was changed from a 3 to a 2 without meaningful  annotation, and lacking the requisite second approving signature. This  soldier reported to us that she had not undergone a new medical diagnosis  prior to the profile upgrade; however, she also had told her medical  provider that she did not want to go through an MMRB or MEB and  thereby risk being removed from the Army. According to Army officials,  soldiers’ medical conditions may have improved for various reasons, such  as undergoing surgery or additional physical therapy.
Although we found no evidence of widespread revision in numerical  designations, in our surveys to deployed soldiers or our interviews with  Army personnel officials and family members of deployed soldiers, some  soldiers or family members expressed concerns to us that they were  uninformed about how the Army was addressing their medical problems  prior to deployment, and they knew of no venue to resolve their  complaints. In surveys, two additional soldiers also stated that they did not  feel they had been correctly graded in their physical profile designations,  but were reluctant to discuss the matter with their commanding officers  for fear of prejudicial treatment. One soldier stated that her physical  profile had been changed without further physical examination. The other  soldier noted that her physical profile designation was upgraded even  though a medical provider had added more limitations after examining  her, and she did not agree that the profile expressed all the limitations  caused by her back, knee, and shoulder ailments. We reviewed the  documentation in the physical profiles of these soldiers and the profiles  contained requisite approving signatures, dates, and descriptions of  limitations. However, our analysis did not evaluate the medical providers’  diagnoses of the medical conditions, because we are not qualified to  evaluate the providers’ medical judgment. Moreover, we would not be able  to determine from the documentation if the soldier did not agree with the  profile, whether the profile was changed without further physical  examination, or whether the medical provider or the soldier fully  communicated all of the issues involved.
Army personnel officials told us that they were unable to assist soldiers  bringing complaints about not being evaluated by a medical board when  the soldiers received a new permanent profile prior to their deployment,  because the officials do not have access to soldiers’ medical information  and do not have the authority to enforce time frames. These officials had  also been contacted by soldiers’ family members who were concerned that  the soldiers would be deployed and their conditions would worsen at  deployed locations. An Army personnel official told us that soldiers  sometimes questioned whether they were to be evaluated by a board prior  to deployment, but by the time this official received the physical profile to  initiate an MMRB, the soldiers had already been deployed. Because the  officials do not have access to all medical information, they would not be  able to verify whether soldiers’ profiles were approved. These situations  may be occurring because physical profiles are not being distributed in a  timely manner. Also, because Army personnel officials do not have the  authority to enforce time frames, they could not compel commanders to  provide timely input for the approval of the profile or compel designated  approving authorities to distribute the approved profiles. Thus, although  Army personnel officials may believe that physical profiles are not being  delivered in a timely manner, they do not have the ability to resolve these  soldiers’ complaints.
Issues regarding proper medical evaluation of soldiers prior to deployment  could be resolved by having a designated point of contact to whom  soldiers and family members can bring their concerns. Such a point person  would require access to the soldier’s medical information and the ability to  resolve any problems and questions about a soldier’s medical readiness.  This person would also need to work independently of the operations  commander in order to prevent bias or coercion by the commander in  resolving soldier issues.
In September 2007, the Army Medical Command created a program to  designate an ombudsman, or point of contact, available for each  installation to whom soldiers can bring concerns on issues such as health  care, pay, physical disability processing, and transition to the Veterans  Administration. The Army memorandum establishing this program states  that ombudsmen will resolve complaints, assist in obtaining accurate  information, and act as advocates specifically for soldiers assigned to the  Warrior Transition Unit and their families. According to ombudsmen at  Forts Benning, Stewart, and Drum, they may also provide support for any  soldier or family member of a soldier who needs assistance, through walk- ins or through the Army Wounded Soldier and Family Hotline. In  accordance with the memorandum, the ombudsman will be independent  from commanders at the installation, and will work closely with the  Medical Assistance Group, which is part of the Army Medical Command  under the Army Surgeon General’s leadership at Fort Sam Houston, Texas.  However, the ombudsman program is not broadly publicized as a resource  for active duty soldiers with medical conditions or their family members.  We were not able to fully evaluate how effectively the ombudsman  program would be able to resolve the issues brought by deploying soldiers  as opposed to soldiers in the Warrior Transition Unit and their family  members, as the ombudsman program has only recently been  implemented. It was not fully implemented at the time of our review at  Forts Benning, Stewart, and Drum. Ensuring that soldiers who are not part  of the Warrior Transition Unit and their family members are aware of and  have access to the ombudsman program may help to alleviate some of  these concerns brought forth by deploying soldiers.
As a result of the various medical record deficiencies and discretionary  profile revisions discussed, commanders’ visibility over their soldiers’  potential medical conditions cannot be ensured. Furthermore, without a  well-publicized ombudsman program, soldiers preparing for deployment  cannot be assured of having the opportunity to air and resolve their  medical concerns.
section_title: One In 10 Soldiers in the Projectable Sample Who Has a Medical Condition Has Deployed, but We Were Unable to Determine Duty Suitability
paragraphs: Based our review of medical records from Forts Benning, Stewart, and  Drum, we estimate that about 10 percent of active duty soldiers with  profiles indicating medical conditions that could require significant  limitations in duty assignments were deployed to Iraq and Afghanistan.  Although Army guidance allows for the deployment of soldiers with  medical conditions, it requires commanders to assign soldiers to duties  that are suitable to their limitations. Because of the low response rate to  our survey, we were unable to determine the extent to which these  soldiers were in fact assigned duties suitable to their medical conditions.  From the limited responses to our survey and from interviews with  soldiers, most reported that they were able to accomplish most of their  duties, although they were sometimes required to perform duties  exceeding their medical limitations.
section_title: Some Deploying Soldiers Have Medical Conditions
paragraphs: We reviewed 685 medical records taken from a random projectable sample  of active component soldiers who were preparing for deployment between  April 2006 and March 2007 from Forts Benning and Stewart, in Georgia,  and Fort Drum, in New York. From these installations, we estimate that 86  percent of soldiers, did not have profiles indicating medical conditions  that could require significant limitations in duty assignments. We  estimate that 14 percent of soldiers preparing to deploy from Forts  Benning, Stewart, and Drum had profiles indicating conditions that could  require significant limitations: specifically, soldiers with physical profile  designations of 3 or 4, or who indicated that they could not perform  certain functional activities. Figure 3 shows the total number of records  reviewed and the estimated percentage (and confidence intervals) of  soldiers who had medical impairments that could require significant  limitations by installation from Forts Benning, Stewart, and Drum.
As shown in figure 4, of the estimated 14 percent of soldiers preparing to  deploy from Forts Benning, Stewart, and Drum who had medical  conditions that could require significant limitations in duty assignment,  approximately two-thirds—about an estimated 10 percent of the total  number of soldiers—were deployed to Iraq or Afghanistan. These  soldiers with medical conditions included soldiers having a physical  profile designation of at least a 3, or indicating that they could not perform  certain functional activities. The remaining estimated 4 percent of soldiers  with medical conditions that could require significant limitations did not  deploy.
Soldiers in the sample who deployed with medical conditions that could  require significant limitations had conditions such as herniated discs, back  pain, chronic knee pain, type 2 diabetes, or mild asthma. A soldier might  have a physical profile that indicates multiple medical limitations that fall  under different categories. Table 2 shows that of the 66 deployed soldiers  who had medical conditions that could require significant limitations,       55 percent deployed with defects of the lower extremities (under the “L”  category). For example, one soldier’s physical profile showed chronic hip  pain that restricted physical training pace and limited the soldier to lifting  no more than 48 pounds. Medical conditions of the eyes and psychiatric  conditions had the lowest rates of occurrence. While we did not review  documentation of medical limitations other than the soldiers’ physical  profiles, according to Army medical officials, mental health conditions are  not generally documented in physical profiles unless the conditions  limited a soldier’s ability to accomplish his or her duty. Commanders were  also notified of a soldier’s mental condition by medical providers if  commanders requested the mental health evaluation of the soldier.
section_title: Extent to Which Commanders Assigned Soldiers to Duties Suitable to Their Medical Conditions Cannot Be Determined
paragraphs: We were unable to determine the extent to which deployed soldiers in the  sample with medical conditions were assigned duties suitable to their  limitations. While Army guidance requires commanders to assign soldiers  to duties that are suitable to their medical conditions, it does not require  that they track the assignments of their soldiers to duties that  accommodate their limitations. In order to determine the extent to which  they had been assigned to duties suitable for those conditions, we  surveyed by e-mail a sample of deployed soldiers with medical conditions.  In our survey, we asked these soldiers for information on their ability to  perform the duties to which they were assigned. However, we did not get a  sufficiently high response rate to enable us to project findings from the  survey respondents. We sent the survey to 66 soldiers, but received  responses from only 24. Of the 24 soldiers who responded, 19 reported  that they were able to complete most or all of their duties, and 22 of the 24  said they wanted to deploy with their units. None said that they could  perform only a few or none of their duties. However, 5 of the soldiers we  surveyed indicated that they were able to perform only some of their  duties.
Survey responses indicated that some soldiers had experienced job  reassignments to accommodate the limitations of their medical conditions.  For example, one soldier had a shoulder injury that limited his ability to  wear all of his body armor. When his unit was deployed to Iraq, he was  assigned to duties in Kuwait so that he would not have to wear all of his  body armor. Another soldier with a hearing deficit had his occupational  category changed from infantry to supply specialist to protect him from  exposure to loud noise. One soldier had degenerative disc disease, with  lower back and leg pain, and his commander reassigned him from being  leader of his unit to base security to accommodate his medical condition  by limiting the time he had to wear his equipment. However, three of our  survey respondents reported that their duties or occupational categories  were not changed, although they believed they should have been. For  example, one soldier often fell asleep during guard duty because his sleep  apnea treatment was impaired by the irregularity of electric power  availability, which he needed to support his continuous positive airway  pressure machine.
Although we were unable to speak with the commanders of the particular  soldiers surveyed in the sample, we spoke with other commanders at Forts  Benning, Stewart, and Drum to help explain these survey responses. These  commanders reported that they were aware of the medical conditions of  the soldiers with whom they had deployed and that they always  considered these conditions in their duty assignments. Army commanders  told us that soldiers with medical impairments may on occasion be  required to perform job duties exceeding their limitations because they  have special skills that are hard to replace using other personnel.  Commanders may also sometimes assign soldiers to duties exceeding their  limitations because they are unaware of the extent of the limitations, as  soldiers’ physical profiles may not reflect all of their medical information.  Furthermore, according to both soldiers and senior medical officials  whom we interviewed, soldiers may conceal the extent of their medical  limitations or may negotiate with medical providers in order to remain  with their units or in the Army. For example, one soldier did not agree  with the upgrading of her physical profile designation, but also did not  want to fully disclose her medical condition for fear of not meeting Army  medical standards. Two soldiers stated that they agreed with their physical  profile designation, which masks the severity of their limitations, and they  were deployed although their medical condition was progressively  worsening while at deployed locations. In both these cases, the soldiers  stated that they were nearing retirement and did not want to be discharged  from the Army due to a medical board evaluation before they were eligible  to receive their full retirement pensions, and they confirmed that their  commanders accommodated their medical conditions.
Conversely, Army officials have stated that soldiers may overstate their  medical conditions in order to avoid deployment and they must take into  account their other experiences with the soldiers’ limitations when  evaluating their medical deployability. For example, one commander told  us that one soldier brought up a foot injury to delay her deployment,  although it was diagnosed by a medical provider outside the military and it  was not in her military medical record. The commander allowed the  soldier time to recuperate and allowed her to purchase a specific type of  boot to accommodate her injury. However, when the soldier did not  purchase the boots in a timely manner in order to further delay her  deployment, the commander found the boots at a nearby supply store and  deployed the soldier into theater.
Although we were not able to determine the extent to which Army  commanders have assigned soldiers to duties that are suitable for their  limitations, there may be soldiers who had proper evaluations performed  prior to deployment yet still have concerns about the suitability of their  assigned duties. Soldiers should have access to a program at deployed  locations that is similar to the ombudsman program available at Army  installations. The soldiers who have medical conditions that develop or  worsen while at deployed locations and may not believe they are assigned  to appropriate duties should have access to a contact person who can  address their concerns. This person should have access to the soldier’s  medical information and the authority to resolve any problems, and he or  she should work independently from the soldier’s commander.
section_title: Conclusions
paragraphs: Long-standing issues regarding the medical deployability of  servicemembers have become increasingly important as the Global War on  Terrorism continues and large numbers of servicemembers are deployed.   The Army is hampered by its lack of an enforcement mechanism from  ensuring that soldiers’ MMRB or MEB evaluations are conducted within  prescribed time frames and not delayed by the failure of commanders or  medical providers to provide required information on time. Of the   6 percent of soldiers from Forts Benning, Stewart, and Drum that we  estimate were deployed with medical conditions that required further  evaluation by a MMRB or MEB, we estimate that 3 percent of these  soldiers did not receive these needed evaluations prior to deployment.   Furthermore, the commanders and medical providers who must make  medical readiness and deployment decisions about soldiers do not always  have full visibility over the soldiers’ medical limitations because physical  profile documentation is not always properly retained or complete. The  Army intends to establish centralized electronic documentation and  distribution of physical profiles to improve visibility, but it has not  finalized plans for needed actions, associated milestones, and timeliness of  the process. Without timely MMRB or MEB evaluations and the retention  of complete physical profile information for deploying soldiers with  medical conditions, commanders who assign duties can not be fully  informed of soldiers’ medical limitations. We did not find widespread  cases of improper duty assignments for deployed soldiers with medical  conditions; however, the weaknesses in the Army procedures could permit  this to occur. Although the Army ombudsman program may help alleviate  concerns from soldiers and family members, they should be made aware  of the program and the program should be made available for soldiers  prior to and during deployment. Unless soldiers have been fully evaluated,  have an independent contact person to promote their concerns, and  commanders have full knowledge of the soldiers’ limitations, the Army  cannot safeguard soldiers with medical conditions from being deployed  and assigned to duties unsuitable for their limitations.
section_title: Recommendations for Executive Action
paragraphs: To safeguard soldiers with significant medical limitations from being  deployed and assigned to duties unsuitable for their limitations, we  recommend that the Secretary of the Army:  1.  direct the Office of the Army Surgeon General and the Army Deputy  Chief of Staff G-1 to collaboratively develop an enforcement  mechanism to ensure that medical providers and commanders follow  procedures so that soldiers whose permanent physical profiles  indicate significant medical limitations are properly referred to and  complete MEB and MMRB evaluation boards prior to deployment;  2.  direct the Office of the Army Surgeon General and the Army Deputy  Chief of Staff G-1 to move forward with plans to electronically process  and retain physical profiles, including specific actions and milestones,  and to implement guidance to help ensure  the timely distribution of profiles to commanders and the military  personnel office and  that the medical record keeping system include all information in the  approved physical profiles, and that all profiles be retained in soldiers’  medical records;  3.  direct the Army Human Resources Command to disseminate  information and provide soldiers and their families access to an  independent ombudsman program prior to and during deployment to  ensure that they are fully informed about this resource for addressing  their concerns and to add independent oversight of Army medical and  deployment processes in the interests of the soldiers.
section_title: Agency Comments and Our Evaluation
paragraphs: DOD provided written comments on a draft of this report and concurred  with each of our recommendations.  In commenting on our first  recommendation, DOD stated that our findings do not suggest the  existence of a widespread problem throughout the Army, as the number of  soldiers in our sample deployed without appearing before a medical  evaluation board was 17; and furthermore, that survey and interview  responses indicate that commanders appear to be assigning soldiers with  medical limitations to suitable duties.  However, we note that the 17  soldiers who deployed without receiving proper board evaluations  represent a sizeable proportion of the 42 soldiers in our sample who  should have received such a review prior to deployment.  These 17  soldiers, furthermore, can be projected from our sample to represent  approximately 3 percent of the soldiers who were preparing for  deployment at the three installations; we are providing further clarification  regarding this figure in the body of this report. Furthermore, as we have  noted in our report, ad hoc measures to assign soldiers to suitable duties  are not as reliable as an enforcement mechanism for ensuring that soldiers  are so assigned. While we could not determine the number of soldiers who  may have been assigned to unsuitable duties, as the Army does not track  this information and our survey responses were limited, neither could we  confirm that soldiers with medical limitations were consistently assigned  to suitable duties.
DOD noted that it had actions planned or underway to conduct a thorough  inspection of the policies and procedures supporting a commander’s  determination of soldier deployability, and to release new guidance  regarding medical conditions that should preclude affected  servicemembers from deployment, along with other initiatives, and we  commend these efforts.
In commenting on our second recommendation, DOD stated that the  Office of the Army Surgeon General has identified and submitted  requirements for the automation of physical profiles, beginning  development by the end of 2008, and we commend this planned initiative.   We note that it is important for these plans to have specific actions and  milestones, and for the Army to implement guidance to ensure timely  distribution of profiles to commanders and military personnel officials  through the automated system.
In commenting on our third recommendation, DOD stated that two  programs, the Army Ombudsman Program and the Wounded Soldier and  Family Hotline, are available to assist all soldiers (and their families)  whether preparing to deploy, deployed, or redeploying. However, we note  that the Wounded Soldier and Family Hotline does not constitute a  resource independent of the command. Although DOD states that  retribution is not tolerated against those using the hotline, we maintain  our view that soldiers should be able to turn to a resource independent of  the command.  With regard to the Ombudsman Program, though it is  independent of the command, we continue to assert our view that broad  advertisement is needed for soldiers and their families to be made aware  of this resource for those soldiers not only returning from deployment, but  also prior to and during deployment.
The Army’s comments are reprinted in appendix VI.  In addition, the Army  provided technical comments, which we have incorporated as appropriate.
We are sending copies of this report to interested congressional  committees; the Secretary of Defense; the Secretaries of the Army, the  Navy, and the Air Force; and the Commandant of the Marine Corps. We  will also make copies available to others upon request. In addition, the  report will be available at no charge on the GAO Web site at  http://www.gao.gov.
If you or your staff have any questions concerning 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. Key contributors to this report are listed in  appendix VII.
section_title: Appendix I: Scope and Methodology
paragraphs: To address the extent to which the Army is adhering to its medical and  deployment requirements regarding decisions to send soldiers with  medical limitations to Iraq and Afghanistan, we reviewed relevant DOD  and Army guidance related to medical standards and deployment  procedures. We discussed the deployment of servicemembers with  medical conditions with a variety of officials from the Office of the  Assistant Secretary of Defense for Health Affairs, the Department of the  Army, and the Office of the Army Surgeon General. As agreed with  congressional staff, we also met with the Offices of the Air Force and Navy  Surgeons General as well as the Navy Bureau of Medicine and Surgery to  gain an understanding of those services’ guidance on medical standards  and deployment procedures. In December 2007, we provided a briefing to  congressional staff that included a discussion of these services’ guidance  regarding deployment of servicemembers with medical conditions.
In addition, we reviewed Army guidance covering documentation of  soldiers’ medical limitations prior to deployment and conditions under  which soldiers with medical conditions are considered deployable. We  reviewed a sample of medical records and interviewed medical providers,  Army commanders, and soldiers at selected installations to identify and  evaluate installation procedures for documenting medical limitations and  training provided regarding this issue at each installation.
We selected three Army installations—Fort Benning, Fort Stewart, and  Fort Drum. We selected Fort Stewart and Fort Drum based on the number  of active component soldiers deployed from each installation to Iraq or  Afghanistan between April 1, 2006, and March 31, 2007; and we selected  Fort Benning based on initial allegations of active component soldiers  being deployed with significant medical limitations from this installation.
For our medical records review, we selected random samples of active  component soldiers at Fort Benning, Fort Stewart, and Fort Drum. In  order to create the sample, we used the universe of soldiers from each  installation who were preparing for deployment from April 1, 2006, to  March 31, 2007, to Iraq or Afghanistan and answered “yes” to question  number 3 on the pre-deployment health assessment (form DD 2795)  which asks, “Are you currently on a profile, or light duty, or are you  undergoing a medical board?” Our statistical samples are representative of  soldiers at these installations who meet our eligibility criteria.  Those who  did not complete a pre-deployment health assessment during this time  frame had no chance of being selected. Of the soldiers preparing to  deploy, soldiers may have their deployment delayed or may ultimately not  be deployed for various reasons, such as not completing required training  and not having proper security clearances for deployment, as well as not  meeting medical readiness standards.
For various reasons, medical records were not always available for review.  Therefore, we reviewed more medical records than our target sample size  on the assumption we might not meet our desired precision. Specifically,  there were seven reasons identified for not being able to physically secure  soldiers’ medical records for review:  1.  Charged to patient. When a patient visits a clinic (on-post or off- post), the medical record is physically given to the patient. The  procedure is that the medical record will be returned by the patient  following their clinic visit.  2.  Charged out to Medical Evaluation Board. Soldier is in the process  of a medical review board and their medical record is retained by the  board members.  3.  Charged out to Physical Evaluation Board. Soldier is in the  process of a physical review board and their medical record is retained  by the board members.  4.  Expired term of service. Soldier separates from the Army and their  medical record is sent to the Veterans Administration Records  Management Center St. Louis, Missouri.  5.  Record is missing and not accounted for by the medical records  department. No tracking sheet is in the file system to indicate the  patient has checked it out or otherwise.  6.  Permanent change of station. Soldier is still in the Army, but has  transferred to another installation. The medical record was sent to the  new installation with the soldier.
The sample size for our medical record review was determined to provide  a 95 percent confidence interval for an attribute measure with a precision  of at least 5 percent. Because we followed a probability procedure based  on random selections, the sample is only one of a large number of samples  that we might have drawn. Since 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 5 percent of the samples we could have drawn.  As a result, we are 95 percent confident that each of the confidence  intervals will include the true values in the study population. At two of the  three installations we visited, we reviewed more records than needed to  meet our target sample size because medical officials made available more  medical records than our targeted sample amount. The number of soldiers  in the samples and the total records reviewed of soldiers at the  installations visited are shown in table 3.
At each location, we examined medical documentation for evidence of  physical profiles (form DA 3349) that were created between April 2001  and March 2007. We selected this time frame because it would include any  profile in effect when a soldier in the sample deployed. We reviewed both  hard copy soldier medical records for evidence of physical profiles as well  as any profiles located in Armed Forces Health Longitudinal Technology  Application (AHLTA), the department of defense’s electronic medical  record. In addition, we requested that installation medical personnel  provide any information on profiles from the Army’s Medical Protection  System (MEDPROS) for each of the soldiers in the sample to ensure that  our review of medical records was complete and that we identified all  physical profiles. Even though MEDPROS is not an official medical record,  it is used in the determination of medical readiness in preparation for  deployment and contains medical limitation information and dates of  physical profiles. After gathering all physical profiles, we reviewed them  for completeness, and analyzed them to determine if they were completed  in accordance with Army guidance. From the soldiers that received a  physical profile between April 2001 and March 2007, we identified the  subset of soldiers with medical conditions that may require significant  medical limitations, specifically soldiers with permanent or temporary  profile designation of at least a 3, or a designation of 2 showing inability to  do certain functional activities. We did not review documentation of  medical limitations other than the physical profiles. According to Army  officials, mental health conditions are not generally documented in  physical profiles unless the conditions limited a soldier’s ability to  accomplish his or her duty. Commanders were also notified of their  soldiers’ mental conditions by medical providers if they requested a mental  health evaluation of the soldiers.
Although we have taken many steps to ensure accurate data analysis of  active component soldiers with a physical profile, previous GAO reviews  have found that Army medical records do not contain all medical  documentation as required, thus, our review may not encompass the full  extent of soldiers with physical profiles.
To determine the extent to which the Army is deploying soldiers to Iraq  and Afghanistan with medical conditions requiring duty limitations, and  whether it is assigning them to duties suitable to their limitations, we  requested deployment data on the subset of soldiers who we identified as  having a significant medical limitation from the time period of April 2001  to March 2007. We then compared data from our medical record review at  Forts Stewart, Benning, and Drum to deployment data for soldiers in the  sample provided by Army officials to identify soldiers with a medical  condition that may require significant limitations who had deployed to Iraq  or Afghanistan. We reviewed Army processes for tracking soldiers while  deployed. We interviewed Army officials including commanders and  medical providers about established procedures in place to ensure soldiers  are assigned within their limitations. We also surveyed by e-mail 66  soldiers we identified who had deployed with medical conditions to Iraq  and Afghanistan. We received responses from 24 of these soldiers, for a  response rate of about 36 percent. These responses do not allow us to  project the extent to which deployed soldiers with medical conditions  across the Army were assigned to duties suitable to their medical  limitations in Iraq and Afghanistan; nevertheless, we present the  information we obtained to illustrate these issues.
We conducted this performance audit from April 2007 through April 2008  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: Army Physical Profile (DA Form 3349)
paragraphs: Appendix II: Army Physical Profile (DA Form  3349)
section_title: Appendix III: PULHES Definitions
paragraphs: Appendix III: PULHES Definitions Normally includes conditions of the heart; respiratory system; gastrointestinal system,  genitourinary system; nervous system; allergic, endocrine, metabolic and nutritional diseases;  diseases of the blood and blood forming tissues; dental conditions; diseases of the breast, and  other organic defects and diseases that do not fall under other specific factors of the system.
Concerns the hands, arms, shoulder girdle, and upper spine (cervical, thoracic, and upper  lumbar) in regard to strength, range of motion, and general efficiency.
Refers to the feet, legs, pelvic girdle, lower back musculature and lower spine (lower lumbar  and sacral) in regard to strength, range of motion, and general efficiency.
Relates to auditory acuity and disease and defects of the ear.
Centers on visual acuity and diseases and defects of the eye.
Concerns personality, emotional stability, and psychiatric diseases.
Indicates a high level of medical fitness.
Refers to some medical condition or physical defect that may require some activity limitations.
Signifies one or more medical conditions or physical defects that may require significant  limitations. The individual should receive assignments commensurate with his or her physical  capability for military duty.
Indicates one or more medical conditions or physical defects of such severity that performance  of military duty must be drastically limited.
section_title: Appendix IV: Army Physical Profile Codes
paragraphs: Medical criteria (examples)
No assignment limitation.
No demonstrable anatomical or  physiological impairment  within standards established in table 7–1.
May have assignment limitations that are intended to protect  against further physical damage/injury. May have minor  impairments under one or more PULHES factors that disqualify  for certain MOS training or assignment.
Possesses impairments that limit functions or assignments. The  codes listed below are for military personnel administrative  purposes. Corresponding limitations are general guidelines and  are not to be taken as verbatim limitations. (For example, a  Soldier with a code C may not be able to run but may have no  restrictions on marching or standing.) Item 3 of DA Form 3349  will contain the specific limitations.
Limitations in running, marching, standing for long periods etc.  Orthopedic or neurological conditions  Limitations in any type of strenuous physical activity.
Limitations requiring dietary restrictions preventing consumption  of combat rations.
Endocrine disorders–recent or repeated  peptic ulcer activity–chronic  gastrointestinal disease requiring dietary  management.
Limitations prohibiting assignment or deployment to OCONUS  areas where definitive medical care is not available.
Individuals who require continued medical  supervision with hospitalization or frequent  outpatient visits for serious illness or injury.
Limitations prohibiting wearing Kevlar, LBE, lifting heavy  materials required of the MOS, overhead work.
Arthritis of the neck or joints of the  extremities with restricted motion; disk  disease; recurrent shoulder dislocation.
Limitations on duty where sudden loss of consciousness would  be dangerous to self or to others such as work on scaffolding,  vehicle driving, or near moving machinery.
Seizure disorders; other disorders  producing syncopal attacks of severe  vertigo, such as Ménierè’s syndrome.
Medical criteria (examples)
Given known handicaps associated with high frequency hearing  loss similar to this, Commanders are highly recommended to  make an individual risk assessment of any Soldier with hearing  loss that might be tasked to perform duties that require good  hearing, for example; localization and detection of friend or foe  sounds, scout, point, sentry, forward listening, post/observer,  radio/telephone operator, and so forth. (See DA Pam 40–501,  Chapter 2–4, Combat Readiness Effects.) Hearing Protection  Measures required to prevent further hearing loss.
Susceptibility to acoustic trauma.
1. No exposure to noise in excess of 85 dBA (decibels  measured on the A scale) or weapon firing without use of  properly fitted hearing protection. Annual hearing test required.  2. Further exposure to noise is hazardous to health. No duty or  assignment to noise levels in excess of 85 dBA or weapon firing  (not to include firing for preparation of replacements for  overseas movement qualification or annual weapons  qualification with proper ear protection). Annual hearing test  required.  3. No exposure to noise in excess of 85 dBA or weapon firing  without use of properly fitted hearing protection. This individual  is ‘deaf’ in one ear. Any permanent hearing loss in the good ear  will cause a serious handicap. Annual Hearing test required.  4. Further duty requiring exposure to high intensity noise is  hazardous to health. No duty or assignment to noise levels in  excess of 85 dBA or weapon firing (not to include firing for  overseas movement or weapon firing without use of properly ear  protection). No duty requiring acute hearing. A hearing aid must  be worn to meet medical fitness standards.
Limitations restricting assignment to cold climates.
Documented history of cold injury; vascular  insufficiency; collagen disease, with  vascular or skin manifestations.
Limitations restricting exposure to high environmental  temperature.
History of heat stroke; history of skin  malignancy or other chronic skin diseases  that are aggravated by sunlight or high  environmental temperature.
Limitations restricting wearing of combat boots.
Any vascular or skin condition of the feet or  legs that, when aggravated by continuous  wear of combat boots, tends to develop  unfitting ulcers.
Limitations restricting wearing or being exposed to required  items necessary to perform duty (for example, Latex, wool).
Established allergy to wool, latex.
WAIVER granted for a disqualifying medical condition/standard  for initial enlistment or appointment. The disqualifying medical  condition/standard for which a waiver was granted will be  documented in the Soldier’s accession medical examination.
Limitation not otherwise described, to be considered individually.  (Briefly define limitation in item 8.)
Any significant functional assignment  limitation not specifically identified  elsewhere.
Medical criteria (examples)
Deployment. This code identifies a Soldier with restrictions on  deployment. Specific restrictions are noted in the medical  record.
MMRB. This code identifies a Soldier with a permanent profile  who has been returned to duty by an MMRB (MOS Medical  Review Board.)
This code identifies a Soldier who is allowed to continue in the  military service with a disease, injury, or medical defect that is  below medical retention standards,  pursuant to a waiver of retention standards under chapter 9 or  10 of this publication, or waiver of unfit finding and continued on  active duty or in active  Reserve status under AR 635–40.
Fit for duty. This code identifies the case of a Soldier who has  been determined to be fit for duty (not entitled to separation or  retirement because of physical disability) after complete  processing under AR 635–40. *The Army regulation does not provide medical criteria for these codes.
section_title: Appendix V: Department of Defense Pre- Deployment Health Assessment (DD Form 2795)
paragraphs: Appendix V: Department of Defense Pre- Deployment Health Assessment (DD Form  2795)
section_title: Appendix VI: Comments from the Department of Defense
section_title: Appendix VII: GAO Contact and Staff Acknowledgments
paragraphs: Brenda S. Farrell, (202) 512-3604 or farrellb@gao.gov.
subsections: section_title: Acknowledgments
paragraphs: In addition to the contact named above, Marilyn Wasleski, Assistant  Director; Gina Hoffman; LaToya King; Grace Materon; Elisha Matvay;  Sonya Phillips; Jeanett Reid; Norris Smith III; and Cheryl Weissman made  significant contributions to the report. In addition, Terry Richardson, Carl  Barden, and Steven Putansu provided guidance and assistance with design  and analysis; Nicole Harms provided legal advice; Steve Fox, Marcia  Crosse, and Tom Conahan advised on message preparation; and Clara  Mejstrik, Adam Smith, Maria Storts, and John Wren provided assistance  during medical file reviews.
section_title: Related GAO Products
paragraphs: DOD Civilian Personnel: Medical Policies for Deployed DOD Federal  Civilians and Associated Compensation for Those Deployed. GAO-07- 1235T. Washington, D.C.: September 18, 2007.
Defense Health Care: Comprehensive Oversight Framework Needed to  Help Ensure Effective Implementation of a Deployment Health Quality  Assurance Program. GAO-07-831. Washington, D.C.: June 22, 2007.
DOD Civilian Personnel: Greater Oversight and Quality Assurance  Needed to Ensure Force Health Protection and Surveillance for Those  Deployed. GAO-06-1085. Washington, D.C.: September 29, 2006.
Military Personnel: DOD and the Services Need to Take Additional Steps  to Improve Mobilization Data for the Reserve Components. GAO-06-1068.  Washington, D.C.: September 20, 2006.
Military Disability System: Improved Oversight Needed to Ensure  Consistent and Timely Outcomes for Reserve and Active Duty Service  Members. GAO-06-362. Washington, D.C.: March 31, 2006.
Military Personnel: Top Management Attention Is Needed to Address  Long-standing Problems with Determining Medical and Physical  Fitness of the Reserve Force. GAO-06-105. Washington. D.C.: October 27,  2005.
Defense Health Care: Improvements Needed in Occupational and  Environmental Health Surveillance during Deployments to Address  Immediate and Long-term Health Issues. GAO-05-632. Washington, D.C.:  July 14, 2005.
Defense Health Care: Force Health Protection and Surveillance Policy  Compliance Was Mixed, but Appears Better for Recent Deployments.  GAO-05-120. Washington, D.C.: November 12, 2004.
Military Personnel: DOD Needs to Address Long-term Reserve Force  Availability and Related Mobilization and Demobilization Issues. GAO- 04-1031. Washington, D.C.: September 15, 2004.
Defense Health Care: DOD Needs to Improve Force Health Protection and  Surveillance Processes. GAO-04-158T. Washington, D.C.: October 16, 2003.
Defense Health Care: Quality Assurance Process Needed to Improve  Force Health Protection and Surveillance. GAO-03-1041. Washington,  D.C.: September 19, 2003.
Military Personnel: DOD Needs More Data to Address Financial and  Health Care Issues Affecting Reservists. GAO-03-1004. Washington, D.C.:  September 10, 2003.
Defense Health Care: Army Has Not Consistently Assessed the Health  Status of Early-Deploying Reservists. GAO-03-997T. Washington, D.C.:    July 9, 2003.
Defense Health Care: Army Needs to Assess the Health Status of All  Early-Deploying Reservists. GAO-03-437. Washington, D.C.: April 15, 2003.
VA And Defense Health Care: Military Medical Surveillance Policies in  Place, but Implementation Challenges Remain. GAO-02-478T.  Washington, D.C.: February 27, 2002.
Gulf War Illnesses: Research, Clinical Monitoring, and Medical  Surveillance. GAO/T-NSIAD-98-88. Washington, D.C.: February 5, 1998.
Gulf War Illnesses: Improved Monitoring of Clinical Progress and  Reexamination of Research Emphasis Are Needed. GAO/NSIAD-97-163.  Washington, D.C.: June 23, 1997.
Defense Health Care: Medical Surveillance Improved Since Gulf War, but  Mixed Results in Bosnia. GAO/NSIAD-97-136. Washington, D.C.: May 13,  1997.
Reserve Forces: DOD Policies Do Not Ensure That Personnel Meet  Medical and Physical Fitness Standards. GAO/NSIAD-94-36. Washington,  D.C.: March 23, 1994.
Operation Desert Storm: War Highlights Need to Address Problem of  Nondeployable Personnel. GAO/NSIAD-92-208. Washington, D.C.: August  31, 1992.