VA and Defense Health Care: Military Medical Surveillance Policies in Place, but Implementation Challenges Remain
Released: 2002-02-27T00:00:00

Letter

Background

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 countermeasures, 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 result 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. 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 to adjudicate veterans’ disability claims.

Medical Recordkeeping and Surveillance During the Gulf War Was Lacking

Investigations into the unexplained illnesses of service members and veterans who had been deployed to the Persian 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 by a lack of (1) complete baseline health data on Gulf War veterans; (2) assessments of their potential exposure to environmental health hazards; and (3) 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 or take prompt precautionary actions, including seeking medical care.

Medical Surveillance Under Operation Joint Endeavor Improved but Was Not Comprehensive

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 disease and non-battle-injury 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—the largest serum repository in the world—for epidemiological studies to examine potential health issues for services members and veterans. The center also operates and maintains a system for integrating, analyzing, and reporting 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 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 during Operation Joint Endeavor, locations of deployed service members 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 the 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 indicated 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 vaccine lot in the event that health concerns about the 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.

Current Policies and Programs Not Fully Implemented

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 related to medical surveillance, and the system continues to evolve. In addition, in 2000, DOD released its Force Health Protection plan, which presents the Department’s vision for protecting deployed forces and includes the goal of joint medical logistics support for all services by 2010. The vision articulated in this capstone document emphasizes force fitness and health preparedness, casualty prevention, and casualty care and management. A key component of the plan is improved monitoring and surveillance of health threats in military operations and more sophisticated data collection and recordkeeping before, during, and after deployments. However, IOM criticized DOD’s progress in implementing its medical surveillance program as well as its 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.

Recent IOM Report Concludes That DOD Has Made Slow Progress in Implementing Recommendations

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. 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 that 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 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 communication 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 deployed populations. 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.

Our Work Also Indicates Some DOD Programs for Improving Medical Surveillance Are Not Fully Implemented

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. DOD also recently established guidelines and additional policy initiatives for improving military medical surveillance.

In October 1999, we reported that DOD’s Vaccine Adverse Event Reporting System—which relies on medical staff or service members to provide needed vaccine data—may not have included some information on adverse reactions because these personnel had not received guidance needed to submit reports to the system. According to DOD officials, medical staff may also report any other reaction they think might be caused by the vaccine, but because this is not stated explicitly in DOD’s guidance on vaccinations, some medical staff may be unsure about which reactions to report.

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 percent 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 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 described 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 access selected health data on service members captured by DOD. According to DOD and VA officials, full operation is expected to begin the third quarter of this fiscal year, once testing of the near-term system has been completed. DOD health information is an especially critical information source given VA’s fourth mission to provide medical backup to the military health system in times of national emergency and war. Under the near-term effort, VA will be able to access laboratory and radiology results, outpatient pharmacy data, and patient demographic information. This approach, however, will not provide VA access to information on the health status of personnel when they enter military service; on medical care provided to Reservists while not on active duty; or on the care military personnel received from providers outside DOD, including TRICARE providers. In addition, because VA will only be able to view this information, physicians will not be able to easily organize or otherwise manipulate the data for quick review or research.

DOD has several other initiatives for improving its information technology capabilities, which are in various stages of development. For example, DOD is developing the Theater Medical Information Program (TMIP), which is intended to capture medical information on deployed personnel and link it with medical information captured in the Department’s new medical information system. As of October 2001, officials told us that they planned to begin field testing for TMIP 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 (GEMS), which DOD characterizes as a stepping stone to an integrated biohazard surveillance and detection system.

In addition to its ongoing information technology initiatives, DOD recently issued two major policies for advancing its military medical surveillance system. Specifically, in December 2001, DOD issued clinical practice guidelines, developed collaboratively with VA, to provide a structure for primary care providers to evaluate and manage patients with deployment- related health concerns. According to DOD, the guidelines were issued in response to congressional concerns and IOM’s recommendations. The guidelines are expected to improve the continuity of care and health-risk communication for service members and their families for the wide variety of medical concerns that are related to military deployments. Because the guidelines became effective January 31, 2002, it is too early for us to comment on their implementation.

Finally, DOD issued updated procedures on February 1, 2002, for deployment health surveillance and readiness. These procedures supersede those laid out in DOD’s December 1998 memorandum. The 2002 memorandum adds important procedures for occupational and environmental health surveillance and updates pre- and postdeployment health assessment requirements. These new procedures take effect on March 1, 2002.

According to officials from DOD’s Health Affairs office, military medical surveillance is a top priority, as evidenced by the Department’s having placed responsibility for implementing medical surveillance policies with one authority—the Deputy Assistant Secretary of Defense for Force Health Protection and Readiness. However, these officials also characterized force health protection as a concept made up of multiple programs across the services. For example, we learned that each service is responsible for implementing DOD’s policy initiatives for achieving force health protection goals. This raises concerns about how the services will uniformly collect and share core information on deployments and how they will integrate data on the health status of service members. These officials also confirmed that DOD’s military medical surveillance policies will depend on the priority and resources dedicated to their implementation.

Concluding Observations

Clearly, the need for comprehensive health information on service members and veterans is compelling, 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 the frequency of troop movements. Moreover, the outlook for successful surveillance is complicated by scientific uncertainty regarding the health effects of exposures and changes in technology that affect the feasibility of monitoring and tracking 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 and be vigilant in its oversight. VA’s ability to perform its missions to care for veterans and compensate them for their service-connected conditions will depend in part on the adequacy of DOD’s medical surveillance system.

Contact and Acknowledgments

For further information, please contact Cynthia A. Bascetta at (202) 512- 7101. Individuals making key contributions to this testimony included Ann Calvaresi Barr, Diana Shevlin, Karen Sloan, and Keith Steck.