Defense Health Care: Quality Assurance Process Needed to Improve Force Health Protection and Surveillance
Published: 2003-09-19T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Following the 1990-91 Persian Gulf War, many servicemembers experienced health problems that they attributed to their military service in the Persian Gulf. However, a lack of servicemember health and deployment data hampered subsequent investigations into the nature and causes of these illnesses. Public Law 105-85, enacted in November 1997, required the Department of Defense (DOD) to establish a system to assess the medical condition of service members before and after deployments. GAO was asked to determine whether (1) the military services met DOD's force health protection and surveillance requirements for servicemembers deploying in support of Operation Enduring Freedom (OEF) in Central Asia and Operation Joint Guardian (OJG) in Kosovo and (2) DOD has corrected problems related to the accuracy and completeness of databases reflecting which servicemembers were deployed to certain locations.
section_title: What GAO Found
paragraphs: The Army and Air Force--the focus of GAO's review--did not comply with DOD's force health protection and surveillance policies for many active duty servicemembers, including the policies that they be assessed before and after deploying overseas, that they receive certain immunizations, and that health-related documentation be maintained in a centralized location. GAO's review of 1,071 servicemembers' medical records from a universe of 8,742 at selected Army and Air Force installations participating in overseas operations disclosed that 38 to 98 percent of servicemembers were missing one or both of their health assessments and 14 to 46 percent were missing at least one of the required immunizations. DOD also did not maintain a complete, centralized database of servicemembers' medical assessments and immunizations. Health-related documentation missing from the centralized database ranged from 0 to 63 percent for pre-deployment assessments, 11 to 75 percent for post-deployment assessments, and 8 to 93 percent for immunizations. There is no effective quality assurance program at the Office of the Assistant Secretary of Defense for Health Affairs or at the Army or Air Force that helps ensure compliance with policies. GAO believes that the lack of such a program was a major cause of the high rate of noncompliance. Continued noncompliance with these policies may result in servicemembers deploying with health problems or delays in obtaining care when they return. Finally, DOD's centralized deployment database is still missing the information needed to track servicemembers' movements in the theater of operations. By July 2003, the department's data center had begun receiving location-specific deployment information from the services and is currently reviewing its accuracy and completeness.

section_title: Letter
paragraphs: Following the 1990-91 Persian Gulf War, many servicemembers  experienced health problems that they attributed to their military  service in the Persian Gulf. However, subsequent investigations into  the nature and causes of these illnesses were hampered by a lack of  servicemember health and deployment data. Moreover, in May 1997, we  reported on several similar problems associated with the implementation  of the Department of Defense’s (DOD) deployment health surveillance  policies for servicemembers deployed to Bosnia in support of a  peacekeeping operation.
In response, the Congress enacted legislation in November 1997 requiring  DOD to establish a system for assessing the medical condition of  servicemembers before and after their deployment to locations outside  the United States and requiring the centralized retention of certain  health-related data associated with the servicemember’s deployment. The  system is to include the use of pre-deployment medical examinations and  post-deployment medical examinations, including an assessment of mental  health and the drawing of blood samples. DOD has implemented specific  force health protection and surveillance policies. These policies include  pre- and post-deployment health assessments designed to identify health  issues or concerns that may affect the deployability of servicemembers or  that may require medical attention; pre-deployment immunizations to  address possible health threats in deployment locations; pre-deployment  screening for tuberculosis; and the retention of blood serum samples on  file prior to deployment.
Given the many deployments of servicemembers to overseas locations  since 1997, you asked us to examine the military services’ implementation  of DOD’s force health protection and surveillance policies and its progress  in correcting the types of problems we found in 1997. More specifically,  we focused our work on Army and Air Force active duty deployments for  Operation Enduring Freedom (OEF) in Central Asia and Operation Joint  Guardian (OJG) in Kosovo to address the following two questions:  1.  Are the military services meeting DOD’s force health protection and  surveillance system requirements for servicemembers deploying in  support of OEF and OJG?  2.  Has DOD corrected problems related to the accuracy and  completeness of databases reflecting which servicemembers deployed  to certain locations?
To accomplish these objectives, we obtained the force health protection  and surveillance policies applicable to the OEF and OJG deployments  from the Army, Air Force, combatant commanders, the office of the  Assistant Secretary of Defense, and the services’ Surgeons General. To test  the implementation of these policies, we reviewed statistical samples  totaling 1,071 active duty servicemembers selected from a universe of  8,742 active duty servicemembers at four military installations. To provide  assurances that our review of the selected medical records was accurate,  we requested the installations’ medical personnel to reexamine those  medical records that were missing required health assessments or  immunizations and adjusted our results where documentation was  subsequently identified. We also requested installation medical personnel  to check all possible sources for missing pre- and post-deployment health  assessments and missing immunizations. We also requested the  U.S. Special Operations Command (SOCOM) to query its database for  health-related documentation for servicemembers in our sample at one  of the selected installations. We also examined, for Army and Air Force  servicemembers in our samples, the completeness of the centralized  records at the Army Medical Surveillance Activity (AMSA), which is  tasked with centrally collecting deployment health-related records.  Further, we interviewed officials at the office of the Deployment Health  Support Directorate and at the Defense Manpower Data Center (DMDC)  regarding the accuracy and completeness of DMDC’s personnel  deployment database and planned improvements. For more detailed  information of our scope and methodology, see appendix I.
subsections: section_title: Background
paragraphs: In May 1997, we reported on DOD’s actions to improve deployment  health surveillance before, during, and after deployments, focusing on  Operation Joint Endeavor, which was conducted in the countries of  Bosnia-Herzegovina, Croatia, and Hungary. We commented on the  provisions of a joint medical surveillance policy draft that called for a  comprehensive DOD-wide medical surveillance capability to monitor  and assess the effects of deployments on servicemembers’ health. DOD  subsequently finalized its joint medical surveillance policy in August 1997.  Our 1997 review disclosed problems with the Army’s implementation of  the medical surveillance plan for Operation Joint Endeavor in the  following areas:    Medical assessments. Many Army personnel who should have received  post-deployment medical assessments did not receive them and the  assessments that were completed were frequently done late. Of the  618 servicemembers in the 12 Army units whose medical records we  reviewed, 24 percent did not receive in-theater post-deployment medical  assessments, and 21 percent did not receive home station post-deployment  medical assessments. Servicemembers who received home station  post-deployment medical assessments received them, on average, nearly  100 days after they left theater instead of within 30 days as required by the  plan. Further, pre-deployment blood serum samples were not available for  9.3 percent of the 26,621 servicemembers who had deployed to Bosnia as  of March 12, 1996. The most recent blood samples for 6.4 percent of the  pre-deployment blood samples were more than 5 years old.
Medical record keeping. Many of the servicemembers’ medical records  that we reviewed were incomplete and missing documentation of  in-theater post-deployment medical assessments, medical visits during  deployment, and receipt of an investigational new vaccine. More  specifically, we found that 91 of the 473 servicemembers (19 percent)  with a post-deployment in-theater medical assessment and 9 of the  491 servicemembers (1.8 percent) with a post-deployment home unit  medical assessment did not have the assessments documented in their  medical records. Furthermore, about 29 percent of the 50 battalion aid  station visits we reviewed were not documented in the members’  permanent medical records. Finally, 141 of 588 servicemembers  (24 percent) who received an investigational drug vaccine did not have the  immunization documented in their medical records.
Centralized database. The centralized database for collecting in-theater  and home unit post-deployment medical assessments was incomplete for  many Army personnel. More specifically, the database omitted 12 percent  of the in-theater medical assessments done and 52 percent of the home  unit medical assessments done for the 618 servicemembers whose records  we reviewed.
Deployment information. DOD officials considered the database used  for tracking the deployment of Air Force and Navy personnel inaccurate. “(a) SYSTEM REQUIRED—The Secretary of Defense shall establish a system to assess the  medical condition of members of the armed forces (including members of the reserve  components) who are deployed outside the United States or its territories or possessions  as part of a contingency operation (including a humanitarian operation, peacekeeping  operation, or similar operation) or combat operation.  “(b) ELEMENTS OF SYSTEM—The system described in subsection (a) shall include the  use of predeployment medical examinations and postdeployment medical examinations  (including an assessment of mental health and the drawing of blood samples) to accurately  record the medical condition of members before their deployment and any changes in their  medical condition during the course of their deployment. The postdeployment examination  shall be conducted when the member is redeployed or otherwise leaves an area in which  the system is in operation (or as soon as possible thereafter).  “(c) RECORDKEEPING—The results of all medical examinations conducted under the  system, records of all health care services (including immunizations) received by members  described in subsection (a) in anticipation of their deployment or during the course of their  deployment, and records of events occurring in the deployment area that may affect the  health of such members shall be retained and maintained in a centralized location to  improve future access to the records.  “(d) QUALITY ASSURANCE—The Secretary of Defense shall establish a quality assurance  program to evaluate the success of the system in ensuring that members described in  subsection (a) receive predeployment medical examinations and postdeployment medical  examinations and that the recordkeeping requirements with respect to the system  are met.”
As set forth above, these provisions require the use of pre-deployment and  post-deployment medical examinations to accurately record the medical  condition of servicemembers before deployment and any changes during  their deployment. In a June 30, 2003, correspondence with the General  Accounting Office, the Assistant Secretary of Defense for Health Affairs  stated that “it would be logistically impossible to conduct a complete  physical examination on all personnel immediately prior to deployment  and still deploy them in a timely manner.” Therefore, DOD required both  pre- and post-deployment health assessments for servicemembers who  deploy for 30 or more continuous days to a land-based location outside the  United States without a permanent U.S. military treatment facility. Both  assessments use a questionnaire designed to help military healthcare  providers in identifying health problems and providing needed medical  care. The pre-deployment health assessment is generally administered at  the home station before deployment, and the post-deployment health  assessment is completed either in theater before redeployment to the  servicemember’s home unit or shortly upon redeployment.
As a component of medical examinations, the statute quoted above also  requires that blood samples be drawn before and after a servicemember’s  deployment. DOD Instruction 6490.3, August 7, 1997, requires that a  pre-deployment blood sample be obtained within 12 months of the  servicemember’s deployment. However, it requires the blood samples be  drawn upon return from deployment only when directed by the Assistant  Secretary of Defense for Health Affairs. According to DOD, the  implementation of this requirement was based on its judgment that the  Human Immunodeficiency Virus serum sampling taken independent of  deployment actions is sufficient to meet both pre- and post-deployment  health needs, except that more timely post-deployment sampling may be  directed when based on a recognized health threat or exposure. Prior to  April 2003, DOD did not require a post-deployment blood sample for  servicemembers supporting the OEF and OJG deployments.
In April 2003, DOD revised its health surveillance policy for blood samples  and post-deployment health assessments. Effective May 22, 2003, the  services are required to draw a blood sample from each redeploying  servicemember no later than 30 days after arrival at a demobilization site  or home station. According to DOD, this requirement for post-deployment  blood samples was established in response to an assessment of health  threats and national interests associated with current deployments. The  department also revised its policy guidance for enhanced post-deployment  health assessments to gather more information from deployed  servicemembers about events that occurred during a deployment.  More specifically, the revised policy requires that a trained health care  provider conduct a face-to-face health assessment with each returning  servicemember to ascertain (1) the individual’s responses to the health  assessment questions on the post-deployment health assessment form;  (2) the presence of any mental health or psychosocial issues commonly  associated with deployments; (3) any special medications taken during the  deployment; and (4) concerns about possible environmental or  occupational exposures.
section_title: The Army and Air Force Did Not Comply with Deployment Health Surveillance Policies for Many Servicemembers
paragraphs: The Army and Air Force did not comply with DOD’s force health  protection and surveillance requirements for many of the servicemembers  in our samples at the selected installations we visited. Specifically, these  Army and Air Force servicemembers were missing: pre-deployment and/or  post-deployment health assessments; evidence of receiving one or more of  the pre-deployment immunizations required for their deployment location;  and other pre-deployment requirements related to tuberculosis screening  and blood serum sample storage. Also, servicemembers’ permanent  medical records were missing required health-related information,  and DOD’s centralized database did not include documentation of  servicemember health-related information. Neither the installations nor  DOD had monitoring and oversight mechanisms in place to help ensure  that the force health protection and surveillance requirements were met  for all servicemembers.
subsections: section_title: Many Servicemembers Lacked Pre-deployment and Post-deployment Health Assessments
paragraphs: We found that servicemembers missing one or both of their pre- and  post-deployment assessments ranged from 38 to 98 percent in our  samples. For example, at Fort Campbell for the OEF deployment we  found that 68 percent of the 222 active duty servicemembers in our sample  were missing either one or both of the required pre-deployment and post- deployment health assessments. The results of our statistical samples for  the deployments at the installations visited are depicted in figure 1.
For those servicemembers in our samples who had completed pre- or  post-deployment health assessments, we found that as many as 45 percent  of the assessments in our samples were not completed on time in  accordance with requirements (see fig. 2). DOD policy requires that  servicemembers complete a pre-deployment health assessment form  within 30 days of their deployment and a post-deployment health  assessment form within 5 days upon redeployment back to their home  station. These time frames were established to allow time to identify  and resolve any health concerns or problems that may affect the ability of  the servicemember to deploy, and to promptly identify and address any  health concerns or problems that may have arisen during the  servicemember’s deployment.
Not all health assessments were reviewed by a health care provider  as required, as shown in figure 3. DOD policy requires that pre-deployment  and post-deployment health assessments are to be reviewed immediately  by a health care provider to identify any medical care needed by the  servicemember.
The services did not refer some servicemember health assessments  that indicated a need for further consultation. According to DOD  policy, a medical provider, namely a physician, physician’s assistant,  nurse, or independent duty medical technician is required to further  review a servicemember’s need for specialty care when the member’s  pre-deployment and/or post-deployment health assessment indicates  health concerns such as unresolved medical or dental problems or plans  to seek mental health counseling or care. This follow-up may take the  form of an interview or examination of the servicemember, and forms the  basis of a decision as to whether a referral for further specialty care is  warranted. In our samples, the number of assessments that indicated a  health concern was relatively small, but large percentages of these  assessments were not referred for further specialty care. For example,  our sample at Travis Air Force Base included five pre-deployment health  assessments that indicated a health concern, but four (80 percent) of  the health assessments were not referred for further specialty care.
Noncompliance with the requirement for pre-deployment health  assessments may result in servicemembers with existing health problems  or concerns being deployed with unaddressed health problems. Also,  failure to complete post-deployment health assessments may risk a delay  in obtaining appropriate medical follow-up attention for a health problem  or concern that may have arisen during or following the deployment.
section_title: Immunizations and Other Pre-Deployment Health Requirements Not Met
paragraphs: Based on our samples, the services did not fully meet immunization  and other pre-deployment requirements. Evidence of pre-deployment  immunizations receipt was missing from many servicemembers’ medical  records. Servicemembers missing the required immunizations may not  have the immunization protection they need to counter theater disease  threats. Based on our review of servicemember medical records for the  deployments at the four installations we visited, we found that between  14 and 46 percent of the servicemembers were missing at least one of their  required immunizations prior to deployment (see fig. 4). Furthermore, as  many as 36 percent of the servicemembers were missing two or more of  their required immunizations.
The U.S. Central Command required the following pre-deployment  immunizations for all servicemembers that deployed to Central Asia  in support of OEF: hepatitis A (two-shot series); measles, mumps, and  rubella; polio; tetanus/diphtheria within the last 10 years; yellow fever  within the last 10 years; typhoid within the last 5 years; influenza within  the last 12 months; and meningococcal within the last 5 years. For  OJG deployments, the U.S. European Command required the same  immunizations cited above, with the exception of the yellow fever  inoculation that was not required for Kosovo.
Figure 5 indicates that 7 to 40 percent of the deploying servicemembers  in our review were missing a current tuberculosis screening. A screening  is deemed “current” if it occurred 1 to 2 years prior to deployment.  Specifically, the U.S. Central Command required servicemembers  deploying to Central Asia in support of OEF to be screened for  tuberculosis within 12 months of deployment. For OJG deployments, the  U.S. European Command required Army and Air Force servicemembers to  be screened for tuberculosis with 24 months of deployment.
U.S. Central Command and U.S. European Command policies require that  deploying servicemembers have a blood serum sample in the serum  repository not older than 12 months prior to deployment. While nearly all  deploying servicemembers had blood serum samples held in the Armed  Services Serum Repository prior to deployment, as many as 29 percent  had serum samples that were too old (see table 1). The samples that were  too old ranged, on average, from 2 to 15 months out-of-date.
section_title: Servicemember Medical Records and Centralized Database Were Not Complete
paragraphs: Servicemembers’ permanent medical records were not complete,  and DOD’s centralized database did not include documentation of  servicemember health-related information. Many servicemembers’  permanent medical records at the Army and Air Force installations we  visited did not include documentation of completed health assessments  and servicemember visits to Army battalion aid stations. Similarly, the  centralized deployment record database did not include many of the  deployment health assessments and immunization records that we found  in the servicemembers’ medical records at the installations we visited.
subsections: section_title: Many Completed Deployment Health Assessments and Medical Interventions Were Not Documented in Servicemembers’ Medical Record
paragraphs: DOD policy requires that the original completed pre-deployment  and post-deployment health assessment forms be placed in the  servicemember’s permanent medical record and that a copy be  forwarded to AMSA. Figure 6 shows that completed assessments  we found at AMSA and at the U.S. Special Operations Command  for servicemembers in our samples were not documented in the  servicemember’s permanent medical record, ranging from 8 to 100 percent  for pre-deployment health assessments and from 11 to 62 percent for  post-deployment health assessments.
Army and Air Force policies also require documentation in the  servicemember’s permanent medical record of all visits to in-theater  medical facilities. Except for the OEF deployment at Fort Drum, officials  were unable to locate or access the sign-in logs for servicemember visits to  in-theater Army battalion aid stations and to Air Force expeditionary  medical support for the OEF and OJG deployments at the installations we  visited. Consequently, we limited the scope of our review to two battalion  aid stations for the OEF deployment at Fort Drum. We found that  39 percent of servicemember visits to one battalion aid station and  94 percent to the other were not documented in the servicemember’s  permanent medical record. Representatives of the two battalion aid  stations said that the missing paper forms documenting the  servicemember visits may have been lost en route to Fort Drum.  Specifically, a physician’s assistant for one of these battalion aid station  said the battalion aid station moved three times in theater and each  time the paper forms used to document in-theater visits were boxed and  moved with the battalion aid station. Consequently, the forms missing  from servicemembers’ medical records may have been lost en route to  Fort Drum.
The lack of complete and accurate medical records documenting  all medical care for the individual servicemember complicates the  servicemembers’ post-deployment medical care. For example, accurate  medical records are essential for the delivery of high-quality medical care  and important for epidemiological analysis following deployments.  According to DOD health officials, the lack of complete and accurate  medical records complicated the diagnosis and treatment of  servicemembers who experienced post-deployment health problems that  they attributed to their military service in the Persian Gulf in 1990-91.
DOD is implementing the Theater Medical Information Program (TMIP)  that has the capability to electronically record and store in-theater patient  medical encounter data. TMIP is currently undergoing operational testing  by the military services and DOD intends to begin fielding TMIP during the  first quarter of fiscal year 2004.
section_title: Centralized Database Missing Health-Related Documentation
paragraphs: Based on our samples, DOD’s centralized database did not include  documentation of servicemember health-related information. As set forth  above, Public Law 105-85, enacted November 1997, requires the Secretary  of Defense to retain and maintain health-related records in a centralized  location. This includes records for all medical examinations conducted to  ascertain the medical condition of servicemembers before deployment and  any changes during their deployment, all health care services (including  immunizations) received in anticipation of deployment or during the  deployment, and events occurring in the deployment area that may affect  the health of servicemembers. A February 2002 Joint Staff memorandum  requires the services to forward a copy of the completed pre-deployment  and post-deployment health assessments to AMSA for centralized  retention. Also, the U.S. Special Operations Command (SOCOM) requires  deployment health assessments for special forces units to be sent to the  Command for centralized retention in the Special Operation Forces  Deployment Health Surveillance System.
Figure 7 depicts the percentage of pre- and post-deployment health  assessments and immunization records we found in the servicemembers’  medical records that were not available in a centralized database at AMSA  or SOCOM. Health-related documentation missing from the centralized  database ranged from 0 to 63 percent for pre-deployment health  assessments, 11 to 75 percent for post-deployment health assessments,  and 8 to 93 percent for immunizations.
All but one of the servicemembers in our sample at Hurlburt Field were  special operations forces. A SOCOM official told us that pre-deployment  and post-deployment health assessment forms for servicemembers in  special operations force units are not sent to AMSA because the health  assessments may include classified information that AMSA is not equipped  to receive. Consequently, SOCOM retains the deployment health  assessments in its classified Special Operations Forces Deployment Health  Surveillance System. Also, a SOCOM medical official told us that the  system does not include pre-deployment immunization data. A  Deployment Health Support Directorate official told us that the  Directorate is examining how to remove the classified information from  the deployment health assessments so that SOCOM can forward the  assessments to AMSA. For presentation in figure 7, we combined the  health assessment and immunization data we found at AMSA and SOCOM  for Hurlburt Field.
An AMSA official believes that missing documentation in the centralized  database could be traced to the services’ use of paper copies of  deployment health assessments that installations are required to forward  to the centralized database, and the lack of automation to record  servicemembers’ pre-deployment immunizations. DOD has ongoing  initiatives to electronically automate the deployment health assessment  forms and the recording of servicemember immunizations. For example,  DOD is implementing a comprehensive electronic medical records system,  known as the Composite Health Care System II, which includes pre- and  post-deployment health assessment forms and the capability to  electronically record immunizations given to servicemembers. DOD  has deployed the system at five sites and will be seeking approval in  August/September 2003 for worldwide deployment. DOD officials  believe that the electronic automation of the deployment health-related  information will lessen the burden of installations in forwarding paper  copies and the likelihood of information being lost in transit.
section_title: DOD and Installations Did Not Have Oversight of Force Health Protection and Surveillance Requirements
paragraphs: DOD does not have an effective quality assurance program to provide  oversight of, and ensure compliance with, the department’s force health  protection and surveillance requirements. Moreover, the installations we  visited did not have ongoing monitoring or oversight mechanisms to help  ensure that force health protection and surveillance requirements were  met for all servicemembers. We believe that the lack of such a system was  a major cause of the high rate of noncompliance we found at the units we  visited. The services are currently developing quality assurance programs  designed to ensure that force health protection and surveillance policies  are implemented for servicemembers.
Although required by Public Law 105-85 to establish a quality assurance  program, neither the Assistant Secretary of Defense for Health Affairs  nor the offices of the Surgeons General of the Army or Air Force had  established oversight mechanisms that would help ensure that force  health protection and surveillance requirements were met for all  servicemembers. Following our visit to Fort Drum in October 2002, the  Army Surgeon General wrote a memorandum in December 2002 to the  commanders of the Army Regional Medical Commands that expressed  concern related to our sample results at Fort Drum. He emphasized the  importance of properly documenting medical care and directed them  to accomplish an audit of a statistically significant sample of medical  surveillance records of all deployed and redeployed soldiers at  installations supported by their regional commands, provide an  assessment of compliance, and develop an action plan to improve  compliance with the requirements.
At three of the four installations we visited, officials told us that new  procedures were implemented that they believe will improve compliance  with force health protection and surveillance requirements for  deployments occurring after those we reviewed. Specifically, following  our visit to Fort Drum in October 2002, Fort Drum medical officials  designed a pre-deployment and post-deployment checklist patterned after  our review that is being used as part of processing before servicemembers  are deployed and when they return. The officials told us that this process  has improved their compliance with force health protection and  surveillance requirements for deployments subsequent to our visit. Also,  the hospital commander at Fort Campbell told us that they implemented  procedures that now require all units located at Fort Campbell to use  the hospital’s medical personnel in their processing of servicemembers  prior to deployment. The hospital commander believes that this new  requirement will improve compliance with the force health protection and  surveillance requirements at Fort Campbell because the medical personnel  will now review whether all requirements have been met for the deploying  servicemembers. At Hurlburt Field, officials told us that they implemented  a new requirement in November 2002 to withhold payment of travel  expenses and per diem to re-deploying servicemembers until they  complete the post-deployment health assessment. Officials believe  that this change will improve servicemembers’ completion of the  post-deployment health assessments. While it is noteworthy that these  installations have implemented changes that they believe will improve  their compliance, the actual measure of improvements over time  cannot be known unless the installations perform periodic reviews of  servicemembers’ medical records to identify the extent of compliance with  deployment health requirements.
In March 2003, we briefed the Subcommittee on Total Force, House  Committee on Armed Services, about our interim review results at  selected military installations. Subsequently, at a March 2003  congressional hearing, the Subcommittee discussed our interim review  results with the Assistant Secretary of Defense for Health Affairs and the  services’ Surgeons General. Based on our interim results that DOD was  not meeting the full requirement of the law and the military services were  not effectively carrying out many of DOD’s force health protection and  surveillance policies, in May 2003 the House Committee on Armed  Services directed the Secretary of Defense to take measures to improve  oversight and compliance. Specifically, in its report accompanying the  Fiscal Year 2004 National Defense Authorization Act, the Committee  directed the Secretary of Defense “… to establish a quality control  program to begin assessing implementation of the force health protection  and surveillance program, and to provide a strategic implementation plan,  including a timeline for full implementation of all policies and programs,  to the Senate Committee on Armed Services and the House Committee on  Armed Services by March 31, 2004.”
In April 2003, the Under Secretary of Defense for Personnel and Readiness  issued an enhanced post-deployment health assessment policy that  required the services to develop and implement a quality assurance  program that encompasses medical record keeping and medical  surveillance data. In June 2003, the Office of Assistant Secretary of  Defense for Health Affairs’ Deployment Health Support Directorate began  reviewing the services’ quality assurance implementation plans and  establishing DOD-wide compliance metrics—including parameters for  conducting periodic visits—to monitor service implementation.
section_title: Centralized Deployment Database Still Missing Information Needed for Deployment Health Surveillance
paragraphs: The DMDC deployment database still does not include the deployment  information we identified in 1997 as needed for effective deployment  health surveillance. In 1997, we reported that knowing the identity of  servicemembers who were deployed during a given operation and tracking  their movements within the theater of operations are major elements of a  military medical surveillance system. The Institute of Medicine reported  in 2000 that the documentation of the locations of units and individuals  during a given deployment is important for epidemiological studies and for  the provision of appropriate medical care during and after deployments.  This information allows (1) epidemiologists to study the incidence of  disease patterns across populations of deployed servicemembers who  may have been exposed to diseases and hazards within the theater, and  (2) health care professionals to treat their medical problems appropriately.  Because of concerns about the accuracy of the DMDC database, we  recommended in our 1997 report that the Secretary of Defense direct  an investigation of the completeness of the information in the DMDC  personnel database and take corrective actions to ensure that the  deployment information is accurate for servicemembers who deploy to  a theater.
DOD’s established policies notwithstanding, the services did not report  location-specific deployment information to DMDC prior to April 2003,  because, according to a DMDC official, the services did not maintain the  data. DOD Instruction 6490.3, issued in August 1997, requires DMDC,  under the Department’s Under Secretary for Personnel and Readiness, to  maintain a system that collects information on deployed forces, including  daily-deployed strength, total and by unit; grid coordinate locations for  each unit (company size and larger); and inclusive dates of individual  servicemember’s deployment. In addition, the Joint Chief of Staff’s  Memorandum MCM-0006-02, dated February 1, 2002, required combatant  commands to provide DMDC with their theater-wide rosters of all  deployed personnel, their unit assignments, and the unit’s geographic  locations while deployed. This memorandum stressed that accurate  personnel deployment data is needed to assess the significance of  medical diseases and injuries in terms of the rate of occurrence among  deployed servicemembers. The Under Secretary of Defense for  Personnel and Readiness expressed concern about the services’  failure to report complete personnel deployment data to DMDC in  an October 2002 memorandum.
To address the services’ lack of reporting to DMDC, the Under Secretary  of Defense for Personnel and Readiness established a tri-service  working group that outlined a plan of action in March 2003 to address  the reporting issues. In July 2003, a DMDC official told us that significant  improvements had recently occurred and that all of the services had begun  submitting their classified deployment databases—including deployment  locations—to DMDC. DMDC is currently reviewing the deployment  information submitted by the services to determine its accuracy and  completeness. It plans to complete this review during the summer of 2003.
With regard to DMDC’s efforts to create a system for tracking the  movements of servicemembers within a given theater of operations,  DMDC officials told us that little progress has been made. They said that  the primary reason for a lack of progress in developing this system is that  the source information has generally not been available from the services  and this may require the development of new tracking systems at the  unit level. In June 2003, a DMDC official told us that it had been recently  determined that the Air Force has implemented a theater tracking  system that may have applicability to the other services. The tracking  system—known as the Deliberate Crisis and Action Planning and  Execution Segment (DCAPES)—enables field teams to enter classified  information about the whereabouts of deployed Air Force personnel at the  longitude/latitude level of detail. DMDC began receiving information from  this system in April 2003. The Under Secretary of Defense for Personnel  and Readiness is reviewing this system to determine whether it could be  used for the same purposes by the other services.
Also, DOD is developing the Defense Integrated Military Human Resource  System (DIMHRS), which will have the capability to track the movements  of all servicemembers and civilians in the theater of operations. As of  June 2003, DOD plans to implement this system for the Army by about  September 2005 and for the other services by 2007 or early calendar  year 2008.
section_title: Conclusions
paragraphs: While DOD and the military services have established force health  protection and surveillance policies, at the units we visited we found  many instances of noncompliance by the services. Moreover, because  DOD and the services do not have an effective quality assurance program  in place to help ensure compliance, these problems went undetected and  uncorrected. Continued noncompliance with these policies may result  in servicemembers with existing health problems or concerns being  deployed with unaddressed health problems or without the immunization  protection they need to counter theater disease threats. Failure to  complete post-deployment health assessments may risk a delay in  obtaining appropriate medical follow-up attention for a health problem  or concern that may have arisen during or following the deployment.  Similarly, incomplete and inaccurate medical records and deployment  databases would likely hinder DOD’s ability to investigate the causes of  any future health problems that may arise coincident with deployments.
section_title: Recommendation for Executive Action
paragraphs: To improve compliance with DOD’s force health protection and  surveillance policies, we recommend that the Secretary of Defense direct  the Assistant Secretary of Defense for Health Affairs to establish an  effective quality assurance program, as required by section 765 of Public  Law 105-85 (10 U.S.C. 1074f), that will ensure that the military services  comply with the force health protection and surveillance requirements for  all servicemembers.
section_title: Agency Comments and Our Evaluation
paragraphs: The Department of Defense provided written comments on a draft of  this report, which are found in appendix II. DOD concurred with the  report’s recommendation.
The Assistant Secretary of Defense for Health Affairs commented that his  office has already established a quality assurance program for pre- and  post-deployment health assessments. This program monitors pre- and  post-deployment health assessments and blood samples being archived  electronically at the Army Medical Surveillance Activity (AMSA) and  assures that indicated referrals on the post-deployment health  assessments are being conducted by all the services. However, the  Assistant Secretary of Defense for Health Affairs’ comments did not  discuss how his office is using the monitoring activities to assure  the military services’ compliance with force health protection and  surveillance policies.
According to the Assistant Secretary of Defense for Health Affairs, the  services have implemented their quality assurance programs. The Army  has developed automated versions of the pre- and post-deployment health  assessment forms, and has established a corporate monitoring system  that is built upon deployment personnel rosters and monitored weekly  by the Army Surgeon General. The Air Force is now receiving monthly  deployment health surveillance compliance reports from its medical  treatment facilities, and has scheduled a special compliance study  through the Air Force Inspection Agency in fiscal year 2004. Navy fleet  commanders have implemented their own quality assurance programs,  with anticipation of standardization through centralized automated  systems. And the Marine Corps has also established unit/command  quality assurance procedures. We view these actions as responsive to our  recommendation and commend the department for taking quick action  to address the compliance issues we found during our audit. However, it  remains to be seen how effective these activities will be in ensuring that  force health protection and surveillance policies are implemented for  all servicemembers.
We are sending copies of this report to the Secretary of Defense and the  Secretaries of the Army and the Air Force. We will also make copies  available to others upon request. In addition, the report is available at no  charge on GAO’s Web site at http://www.gao.gov.
If you or your staff have any questions regarding this report, please  contact me on (757) 552-8100. Key contributors to this report are listed in  appendix III.
section_title: Appendix I: Scope and Methodology
paragraphs: To meet our objectives, we interviewed responsible officials and reviewed  pertinent documents, reports, and information related to force health  protection and deployment health surveillance requirements obtained  from officials at the Office of the Assistant Secretary of Defense for Health  Affairs; the Office of the Deputy Assistant Secretary of Defense for Force  Health Protection and Readiness; the Office of the Assistant Secretary of  Defense for Reserve Affairs; the Joint Staff; the Marine Corps Force Health  Protection Office; and the Offices of the Surgeons General for the Army  and Air Force Headquarters in the Washington, D.C., area. We also  performed additional work at the Deployment Health Support Directorate,  Falls Church, Virginia; the U.S. Army Center for Health Promotion and  Preventive Medicine, Aberdeen, Maryland; the Armed Forces Medical  Intelligence Center, Fort Dietrick, Maryland; the Army Medical  Surveillance Activity, Walter Reed Army Medical Center, Washington,  D.C.; the Navy Environmental Health Center in Portsmouth, Virginia;  the Defense Manpower Data Center in Monterey, California; and the  U.S. Central Command and the U.S. Special Operations Command at  MacDill Air Force Base, Tampa, Florida.
To determine whether the military services were meeting DOD’s force  health protection and surveillance requirements for servicemembers  deploying in support of OEF and OJG, we identified DOD and each  service’s overall deployment health surveillance policies. We also obtained  the specific force health protection and surveillance requirements  applicable to all servicemembers deploying to Central Asia in support of  OEF from the U.S. Central Command and these requirements for all  servicemembers deploying to Kosovo in support of OJG from the  U.S. European Command. We tested the implementation of these  requirements at selected Army and Air Force installations. To identify  locations within each service where we would test implementation of the  policies, the Assistant Secretary of Defense for Health Affairs requested  the services to identify, by military installation, the number of active duty  servicemembers who met the following criteria:    For OEF, those servicemembers who deployed to Central Asia for 30 or  more continuous days to areas without permanent U.S. military treatment  facilities following September 11, 2001, and redeployed back to their home  unit by May 31, 2002.
For OJG, those servicemembers who deployed to Kosovo for 30 or more  continuous days to areas without permanent U.S. military treatment  facilities from January 1, 2001, and redeployed back to their home unit by  May 31, 2002.
Based on deployment data obtained from the services, we decided to  limit our testing of the force health protection and surveillance policy  implementation to selected Army and Air Force military installations  with the largest numbers of servicemembers meeting our selection  criteria (described above). We limited our review of medical records for  servicemembers deploying in support of OJG to the two Army locations.  We decided not to review Navy installations because there were only  small numbers of servicemembers who met our selection criteria. We  decided not to review Marine Corps installations because officials at  the Marine Corps headquarters had difficulty identifying the number of  servicemembers who went ashore 30 or more continuous days consistent  with our selection criteria.
The largest deployers for OEF and OJG were selected and are  listed below:    10th Mountain Division, Fort Drum, N.Y.    101st Airborne Division, Fort Campbell, Ky.     Travis Air Force Base, Calif.    Hurlburt Field, Fla.    10th Mountain Division, Fort Drum, N.Y.    101st Airborne Division, Fort Campbell, Ky.
For our medical records review, we selected statistical samples of  servicemembers at the selected installations to be representative of those  deploying from those military installations for those specific operations.
For various reasons, medical records were not always available for review.  We, therefore, sampled without replacement, to choose additional records  when we were unable to meet our sampling threshold of cases for review.  Specifically, there were five reasons identified for not being able to  physically secure the servicemember’s medical record 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.  Expired term of service. Servicemember separates from the military  and their medical record is sent to St. Louis, Missouri, and therefore  not available for review.  3.  Record is not accounted for by the medical records department.  4.  Permanent change of station. Servicemember is still in the military,  but has transferred to another base. Medical record transfers with the  servicemember.  5.  Temporary duty off site. Servicemember has left military  installation, but is expected to return. The temporary duty is long  enough to warrant that the medical record accompany the  servicemember.
The sample size for deployments was determined to provide 95 percent  confidence with a 5-percent precision. The number of servicemembers in  our samples and the applicable universe of servicemembers for the OEF  and OJG deployments at the installations visited are shown in table 2.
At Fort Campbell, there were only 333 servicemembers identified as  having met our criteria based on a redeployment date of May 31, 2002;  however, only 8 charts were available for review due to rotation of  soldiers to other military locations or departure from the military. It was,  therefore, necessary to extend our redeployment date to October 31, 2002.
Doing so provided an additional 2,953 servicemembers who met all criteria  except for a redeployment by May 31, 2002. At Fort Campbell, there were  92 servicemembers who deployed in support of OJG and met our selection  criteria if we extended the redeployment date to October 31, 2002.  Because the number of servicemembers for OJG at Fort Campbell was  small, we reviewed the medical records for all of servicemembers who  were still at Fort Campbell.
At each sampled location, we examined servicemember medical records  for evidence of the following force health protection and deployment  health-related documentation required by DOD’s force health protection  and deployment health surveillance policies:    Pre- and post-deployment health assessments,    Tuberculosis screening test (within 1 year of deployment for OEF and  2 years for OJG)  influenza (within 1 year of deployment);    measles, mumps, and rubella;    meningococcal (within 5 years of deployment);    polio;   tetanus-diphtheria (within 10 years of deployment);   typhoid (within 5 years of deployment); and     yellow fever (within 10 years of deployment), not required for OJG.
To provide assurances that our review of the selected medical records was  accurate, we requested the installations’ medical personnel to reexamine  those medical records that were missing required health assessments or  immunizations and adjusted our results where documentation was  subsequently identified. We also requested that installation medical  personnel check all possible sources for missing pre- and post-deployment  health assessments and immunizations. These sources included the Army’s  Soldier Readiness Check folders and automated immunization sources,  including the Army’s Medical Protection System (MEDPROS) and the  Air Force’s Comprehensive Immunization Tracking Application (CITA).  We checked all known possible sources for the existence of deployment  health assessments related to servicemembers in our samples. In  those instances where we did not find a deployment health assessment,  we concluded that the assessments were not completed. Furthermore,  installation officials were unable to logistically access the  servicemembers’ individual records of immunizations, commonly referred  to as yellow-shot records that may have provided documentation for  missing immunizations. Consequently, our analyses of the immunization  records was based on our examination of the servicemember’s  permanent medical record and immunizations that were in the Army’s  MEDPROS and the Air Force’s CITA. In analyzing our review results at  each location, we considered documentation from all identified sources  (e.g., servicemember’s medical record, soldier readiness check folder,  Army Medical Surveillance Activity, and immunization tracking  systems) in presenting data on compliance with deployment health  surveillance policies.
To identify whether required blood serum specimens were in storage  at the Armed Services Serum Repository, we requested that the Army  Medical Surveillance Activity staff query the Repository to identify  whether the servicemembers in our samples had a blood serum sample  in the repository and the date of the specimen.
To determine whether the Army and Air Force are documenting in-theater  medical interventions in servicemembers’ medical records, we requested,  at each installation visited for medical records review, the patient sign-in  logs for in-theater medical care providers, namely the Army’s battalion aid  station and the Air Force’s expeditionary medical support, when they were  deployed to central Asia in support of OEF and for the two Army  installations we visited that deployed in support of OJG. Officials were  unable to locate or access the logs at all of our selected installations  except for Fort Drum for the OEF deployment. Consequently, we were  able to perform our planned examination for this objective at only Fort  Drum for the OEF deployment. From these logs, we selected a random  sample of 36 patient visits from one battalion aid station and 18 patient  visits from another battalion aid station. We did not attempt to judge the  importance of the patient visit in making our selections. For the selected  patient visits, we then reviewed the servicemember’s medical record for  any documentation—such as the Army’s Standard Form 600—of the  servicemember’s visit to the battalion aid station.
To determine whether the Army and Air Force’s deployment health-related  records are retained and maintained in a centralized location, we  requested that officials at the Army Medical Surveillance Activity (AMSA)  query the AMSA database for the servicemembers included in our samples  at the selected Army and Air Force installations. For servicemembers in  our samples, AMSA officials provided us with copies of deployment health  assessments and immunization data found in the AMSA database. We  analyzed the completeness of the AMSA database by comparing the  deployment health assessments and the pre-deployment immunization  data we found during our medical records review with those in the AMSA  database. Since Air Force special operations force units use the Hurlburt  Field, we also requested the U.S. Special Operations Command (SOCOM)  to query their Special Operation Forces Deployment Health Surveillance  System database for servicemembers in our sample at Hurlburt Field for  deployment health assessments and pre-deployment immunization data.  We then compared the data identified from the SOCOM and AMSA queries  with the data we found during our medical records review.
To determine whether DOD has corrected problems related to the  accuracy and completeness of databases reflecting which servicemembers  deployed to certain locations, we interviewed officials within the  Deployment Health Support Directorate and the Defense Manpower Data  Center and reviewed documentation related to the completeness of  deployment databases and planned improvements in capabilities.
Our review was performed from June 2002 through July 2003 in  accordance with generally accepted government auditing standards.
section_title: Appendix II: Comments from the Department of Defense
section_title: Appendix III: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Acknowledgments
paragraphs: In addition to the individual named above, Steve Fox, Rebecca Beale,  Lynn Johnson, William Mathers, Terry Richardson, Kristine Braaten,  Grant Mallie, Herbert Dunn, and R.K. Wild made key contributions to  this report.