VA and Defense Health Care: Progress Made, but DOD Continues To Face Military Medical Surveillance System Challenges
Published: 2002-01-24T00:00:00

Fast Facts:

Highlights:
section_title: What GAO Found
paragraphs: GAO, the Institute of Medicine, and others have cited weaknesses in the Defense Department's (DOD) medical surveillance during the Gulf War and Operation Joint Endeavor. DOD was unable to collect, maintain, and transfer accurate data on the movement of troops, potential exposures to health risks, and medical incidents during deployment in the Gulf war. DOD improved its medical surveillance system under Operation Joint Endeavor, providing useful information to military commanders and medical personnel. However, GAO found several problems with this system. For example, incomplete or inaccurate information related to service members' health and deployment status. DOD's has not established a single, comprehensive electronic system to document, archive, and access medical surveillance data. DOD has begun several initiatives to improve the reliability of deployment information and to enhance its information technology capabilities, but some initiatives are several years away from full implementation. Nonetheless, these efforts reflect a commitment by DOD to establish a comprehensive medical surveillance system. The ability of the Department of Veterans Affairs to fulfill its role in serving veterans and providing backup to DOD in times of war will be enhanced as DOD increases its medical surveillance capability.

section_title: Letter
paragraphs: We are pleased to submit this statement for the record on the Department  of Defense’s (DOD) efforts to establish a medical surveillance system that  enables DOD—along with the Department of Veterans Affairs (VA)—to  respond to the health care needs of our military personnel and veterans. A  medical surveillance system involves the ongoing collection and analysis  of uniform information on deployments, environmental health threats,  disease monitoring, medical assessments, and medical encounters. It is  also important that this information be disseminated in a timely manner to  military commanders, medical personnel, and others. DOD is responsible  for developing and executing this system and needs this information to  help ensure the deployment of healthy forces and the continued fitness of  those forces. VA also needs this information to fulfill its missions of  providing health care to veterans, backing up DOD in contingencies, and  adjudicating veterans’ claims for service-connected disabilities. Scientists  at VA, DOD, and other organizations also use this information to conduct  epidemiological studies and research.
Given our current military actions responding to the events of   September 11, and what has been reported about DOD’s medical  surveillance activities during the Gulf War and Operation Joint Endeavor,  you expressed concern about the challenges DOD faces in establishing a  reliable medical surveillance system. This statement focuses on reports  GAO, the Institute of Medicine (IOM), the Presidential Advisory  Committee on Gulf War Veterans’ Illnesses, and others have issued over  the past several years. This statement is also based on interviews we held  in early   October 2001 with various Defense Health Program officials, including  officials from the Army Surgeon General’s Office.
In summary, GAO, the Institute of Medicine, and others have reported  extensively on weaknesses in DOD’s medical surveillance capability and  performance during the Gulf War and Operation Joint Endeavor and the  challenges DOD faces in implementing a reliable medical surveillance  system. Investigations into the unexplained illnesses of Gulf War veterans  uncovered many deficiencies in DOD’s ability to collect, maintain, and  transfer accurate data describing the movement of troops, potential  exposures to health risks, and medical incidents during deployment. DOD  improved its medical surveillance system under Operation Joint Endeavor,  which provided useful information to military commanders and medical  personnel. However, we and others reported a number of problems with  this system. For example, information related to service members’ health  and deployment status—data critical to an effective medical surveillance  system—was incomplete or inaccurate. DOD’s numerous databases,  including those that capture health information, are currently not linked,  which further challenges the department’s efforts to establish a single,  comprehensive electronic system to document, archive, and access  medical surveillance data.
DOD has several initiatives under way to improve the reliability of  deployment information and to enhance its information technology  capabilities, as we and others have recommended, though some initiatives  are several years away from full implementation. Nonetheless, these  efforts reflect a commitment by DOD to establish a comprehensive  medical surveillance system. The ability of VA to fulfill its role in serving  veterans and providing backup to DOD in times of war will be enhanced as  DOD increases its medical surveillance capability.
subsections: section_title: Background
paragraphs: An effective military medical surveillance system needs to collect reliable  information on (1) the health care provided to service members before,  during, and after deployment, (2) where and when service members were  deployed, (3) environmental and occupational health threats or exposures  during deployment (in theater) and appropriate protective and counter  measures, and (4) baseline health status and subsequent health changes.
This information is needed to monitor the overall health condition of  deployed troops, inform them of potential health risks, as well as maintain  and improve the health of service members and veterans.
In times of conflict, a military medical surveillance system is particularly  critical to ensure the deployment of a fit and healthy force and to prevent  disease and injuries from degrading force capabilities. DOD needs reliable  medical surveillance data to determine who is fit for deployment; to  prepare service members for deployment, including providing  vaccinations to protect against possible exposure to environmental and  biological threats; and to treat physical and psychological conditions that  resulted from deployment. DOD also uses this information to develop  educational measures for service members and medical personnel to  ensure that service members receive appropriate care.
Reliable medical surveillance information is also critical for VA to carry  out its missions. In addition to VA’s better known missions—to provide  health care and benefits to veterans and medical research and education— VA has a fourth mission: to provide medical backup to DOD in times of  war and civilian health care backup in the event of disasters producing  mass casualties. As such, VA needs reliable medical surveillance data from  DOD to treat casualties of military conflicts, provide health care to  veterans who have left active duty, assist in conducting research should  troops be exposed to environmental or occupational hazards, and identify  service-connected disabilities, and adjudicate veterans’ disability claims.
section_title: Medical Recordkeeping and Surveillance During the Gulf War Was Lacking
paragraphs: Investigations into the unexplained illnesses of service members and  veterans who had been deployed to the Gulf uncovered the need for DOD  to implement an effective medical surveillance system to obtain  comprehensive medical data on deployed service members, including  Reservists and National Guardsmen. Epidemiological and health outcome  studies to determine the causes of these illnesses have been hampered due  to incomplete baseline health data on Gulf War veterans, their potential  exposure to environmental health hazards, and specific health data on  care provided before, during, and after deployment. The Presidential  Advisory Committee on Gulf War Veterans’ Illnesses’ and IOM’s 1996  investigations into the causes of illnesses experienced by Gulf War  veterans confirmed the need for more effective medical surveillance  capabilities.
The National Science and Technology Council, as tasked by the  Presidential Advisory Committee, also assessed the medical surveillance  system for deployed service members. In 1998, the council reported that  inaccurate recordkeeping made it extremely difficult to get a clear picture  of what risk factors might be responsible for Gulf War illnesses. It also  reported that without reliable deployment and health assessment  information, it was difficult to ensure that veterans’ service-related  benefits claims were adjudicated appropriately. The council concluded  that the Gulf War exposed many deficiencies in the ability to collect,  maintain, and transfer accurate data describing the movement of troops,  potential exposures to health risks, and medical incidents in theater. The  council reported that the government’s recordkeeping capabilities were  not designed to track troop and asset movements to the degree needed to  determine who might have been exposed to any given environmental or  wartime health hazard. The council also reported major deficiencies in  health risk communications, including not adequately informing service  members of the risks associated with countermeasures such as vaccines.  Without this information, service members may not recognize potential  side effects of these countermeasures and promptly take precautionary  actions, including seeking medical care.
section_title: Medical Surveillance Under Operation Joint Endeavor Improved but Was Not Comprehensive
paragraphs: In response to these reports, DOD strengthened its medical surveillance  system under Operation Joint Endeavor when service members were  deployed to Bosnia-Herzegovina, Croatia, and Hungary. In addition to  implementing departmentwide medical surveillance policies, DOD  developed specific medical surveillance programs to improve monitoring  and tracking environmental and biomedical threats in theater. While these  efforts represented important steps, a number of deficiencies remained.
On the positive side, the Assistant Secretary of Defense (Health Affairs)  issued a health surveillance policy for troops deploying to Bosnia. This  guidance stressed the need to (1) identify health threats in theater,   (2) routinely and uniformly collect and analyze information relevant to  troop health, and (3) disseminate this information in a timely manner.  DOD required medical units to develop weekly reports on the incidence  rates of major categories of diseases and injuries during all deployments.  Data from these reports showed theaterwide illness and injury trends so  that preventive measures could be identified and forwarded to the theater  medical command regarding abnormal trends or actions that should be  taken.
DOD also established the U.S. Army Center for Health Promotion and  Preventive Medicine—a major enhancement to DOD’s ability to perform  environmental monitoring and tracking. For example, the center operates  and maintains a repository of service members’ serum samples for medical  surveillance and a system to integrate, analyze, and report data from  multiple sources relevant to the health and readiness of military personnel.  This capability was augmented with the establishment of the 520th Theater  Army Medical Laboratory—a deployable public health laboratory for  providing environmental sampling and analysis in theater. The sampling  results can be used to identify specific preventive measures and  safeguards to be taken to protect troops from harmful exposures and to  develop procedures to treat anyone exposed to health hazards. During  Operation Joint Endeavor, this laboratory was used in Tuzla, Bosnia,  where most of the U.S. forces were located, to conduct air, water, soil, and  other environmental monitoring.
Despite the department’s progress, we and others have reported on DOD’s  implementation difficulties during Operation Joint Endeavor and the  shortcomings in DOD’s ability to maintain reliable health information on  service members. Knowledge of who is deployed and their whereabouts is  critical for identifying individuals who may have been exposed to health  hazards while deployed. However, in May 1997, we reported that the  inaccurate information on who was deployed and where and when they  were deployed—a problem during the Gulf War—continued to be a  concern during Operation Joint Endeavor. For example, we found that the  Defense Manpower Data Center (DMDC) database—where military  services are required to report deployment information—did not include  records for at least 200 Navy service members who were deployed.  Conversely, the DMDC database included Air Force personnel who were  never actually deployed. In addition, we reported that DOD had not  developed a system for tracking the movement of service members within  theater. IOM also reported that the locations of service members during  the deployments were still not systematically documented or archived for  future use.
We also reported in May 1997 that for the more than 600 Army personnel  whose medical records we reviewed, DOD’s centralized database for  postdeployment medical assessments did not capture 12 percent of those  assessments conducted in theater and 52 percent of those conducted after  returning home. These data are needed by epidemiologists and other  researchers to assess at an aggregate level the changes that have occurred  between service members’ pre- and postdeployment health assessments.  Further, many service members’ medical records did not include complete  information on in-theater postdeployment medical assessments that had  been conducted. The Army’s European Surgeon General attributed missing  in-theater health information to DOD’s policy of having service members  hand carry paper assessment forms from the theater to their home units,  where their permanent medical records were maintained. The assessments  were frequently lost en route.
We have also reported that not all medical encounters in theater were  being recorded in individual records. Our 1997 report identified that this  problem was particularly common for immunizations given in theater.  Detailed data on service members’ vaccine history are vital for scheduling  the regimen of vaccinations and boosters and for tracking individuals who  received vaccinations from a specific lot in the event health concerns  about the vaccine lot emerge. We found that almost one-fourth of the  service members’ medical records that we reviewed did not document the  fact that they had received a vaccine for tick-borne encephalitis. In  addition, in its 2000 report, IOM cited limited progress in medical  recordkeeping for deployed active duty and reserve forces and  emphasized the need for records of immunizations to be included in  individual medical records.
section_title: Current Policies and Programs Not Fully Implemented
paragraphs: Responding to our and others’ recommendations to improve information  on service members’ deployments, in-theater medical encounters, and  immunizations, DOD has continued to revise and expand its policies  relating to medical surveillance, and the system continues to evolve. In  addition, in 2000, DOD released its Force Health Protection plan, which  presents its vision for protecting deployed forces. This vision emphasizes  force fitness and health preparedness and improving the monitoring and  surveillance of health threats in military operations. However, IOM  criticized DOD’s progress in implementing its medical surveillance  program and the failure to implement several recommendations that IOM  had made. In addition, IOM raised concerns about DOD’s ability to achieve  the vision outlined in the Force Health Protection plan. We have also  reported that some of DOD’s programs designed to improve medical  surveillance have not been fully implemented.
subsections: section_title: Recent IOM Report Concludes Slow Progress by DOD in Implementing Recommendations
paragraphs: IOM’s 2000 report presented the results of its assessment of DOD’s  progress in implementing recommendations for improving medical  surveillance made by IOM and several others. IOM stated that, although  DOD generally concurred with the findings of these groups, DOD had  made few concrete changes at the field level. For example, medical  encounters in theater were still not always recorded in individuals’  medical records, and the locations of service members during  deployments were still not systematically documented or archived for  future use. In addition, environmental and medical hazards were not yet  well integrated in the information provided to commanders.
The IOM report notes that a major reason for this lack of progress is no  single authority within DOD has been assigned responsibility for the  implementation of the recommendations and plans. IOM said that because  of the complexity of the tasks involved and the overlapping areas of  responsibility involved, the single authority must rest with the Secretary of  Defense.
In its report, IOM describes six strategies that in its view demand further  emphasis and require greater efforts by DOD:    Use a systematic process to prospectively evaluate non-battle-related risks  associated with the activities and settings of deployments.
Collect and manage environmental data and personnel location, biological  samples, and activity data to facilitate analysis of deployment exposures  and to support clinical care and public health activities.
Develop the risk assessment, risk management, and risk communications  skills of military leaders at all levels.
Accelerate implementation of a health surveillance system that completely  spans an individual’s time in service.  Implement strategies to address medically unexplained symptoms in  populations that have deployed.  Implement a joint computerized patient record and other automated  recordkeeping that meets the information needs of those involved with  individual care and military public health.
section_title: Our Work Also Indicates Some DOD Programs for Improving Medical Surveillance Are Not Fully Implemented
paragraphs: DOD guidance established requirements for recording and tracking  vaccinations and automating medical records for archiving and recalling  medical encounters. While our work indicates that DOD has made some  progress in improving its immunization information, the department faces  numerous challenges in implementing an automated medical record.
In October 1999, we reported that DOD’s Vaccine Adverse Event Reporting  System, which relies on medical personnel or service members to provide  needed vaccine data, may not have included information on adverse  reactions because DOD did not adequately inform personnel on how to  provide this information.
Also, in April 2000, we testified that vaccination data were not consistently  recorded in paper records and in a central database, as DOD requires.  For example, when comparing records from the database with paper  records at four military installations, we found that information on the  number of vaccinations given to service members, the dates of the  vaccinations, and the vaccine lot numbers were inconsistent at all four  installations. At one installation, the database and records did not agree 78  to 92 percent of the time. DOD has begun to make progress in  implementing our recommendations, including ensuring timely and  accurate data in its immunization tracking system.
The Gulf War revealed the need to have information technology play a  bigger role in medical surveillance to ensure that the information is readily  accessible to DOD and VA. In August 1997, DOD established requirements  that called for the use of innovative technology, such as an automated  medical record device that can document inpatient and outpatient  encounters in all settings and that can archive the information for local  recall and format it for an injury, illness, and exposure surveillance  database. Also, in 1997, the President, responding to deficiencies in  DOD’s and VA’s data capabilities for handling service members’ health  information, called for the two agencies to start developing a  comprehensive, lifelong medical record for each service member. As we  reported in April 2001, DOD’s and VA’s numerous databases and electronic  systems for capturing mission-critical data, including health information,  are not linked and information cannot be readily shared.
DOD has several initiatives under way to link many of its information  systems—some with VA. For example, in an effort to create a  comprehensive, lifelong medical record for service members and veterans  and to allow health care professionals to share clinical information, DOD  and VA, along with the Indian Health Service (IHS), initiated the  Government Computer-Based Patient Record (GCPR) project in 1998.  GCPR is seen as yielding a number of potential benefits, including  improved research and quality of care, and clinical and administrative  efficiencies. However, our April 2001 report describes several factors— including planning weaknesses, competing priorities, and inadequate  accountability—that made it unlikely that DOD and VA would accomplish  GCPR or realize its benefits in the near future. To strengthen the  management and oversight of GCPR, we made several recommendations,  including designating a lead entity with a clear line of authority for the  project and creating comprehensive and coordinated plans for sharing  meaningful, accurate, and secure patient health data.
For the near term, DOD and VA have decided to reconsider their approach  to GCPR and focus on allowing VA to view DOD health data. However,  under the interim effort, physicians at military medical facilities will not be  able to view health information from other facilities or from VA—now a  potentially critical information source given VA’s fourth mission to provide  medical backup to the military health system in times of national  emergency and war.
In October 2001, we met with officials from the Defense Health Program  and the Army Surgeon General’s Office who indicated that the department  is working on issues we have reported on in the past, including the need to  improve the reliability of deployment information and the need to  integrate disparate health information systems. Specifically, these officials  informed us that DOD is developing a more accurate roster of deployed  service members and enhancing its information technology capabilities.  For example, DOD’s Theater Medical Information Program (TMIP) is  intended to capture medical information on deployed personnel and link it  with medical information captured in the department’s new medical  information system, now being field tested. Developmental testing for  TMIP has begun and field testing is expected to begin in spring 2002, with  deployment expected in 2003. A component system of TMIP— Transportation Command Regulating and Command and Control  Evacuation System—is also under development and aims to allow casualty  tracking and provide in-transit visibility of casualties during wartime and  peacetime. Also under development is the Global Expeditionary Medical  System, which DOD characterizes as a stepping stone to an integrated  biohazard surveillance and detection system.
section_title: Concluding Observations
paragraphs: Clearly, the need for comprehensive health information on service  members and veterans is very great, and much more needs to be done.  However, it is also a very difficult task because of uncertainties about  what conditions may exist in a deployed setting, such as potential military  conflicts, environmental hazards, and frequency of troop movements.  While progress is being made, DOD will need to continue to make a  concerted effort to resolve the remaining deficiencies in its surveillance  system. Until such a time that some of the deficiencies are overcome, VA’s  ability to perform its missions will be affected.
section_title: Contact and Acknowledgments
paragraphs: For further information, please contact Cynthia A. Bascetta at (202) 512- 7101. Individuals making key contributions to this testimony included Ann  Calvaresi Barr, Karen Sloan, and Keith Steck.