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

Letter

Background

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.

The Army and Air Force Did Not Comply with Deployment Health Surveillance Policies for Many Servicemembers

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.

Many Servicemembers Lacked Pre-deployment and Post-deployment Health Assessments

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.

Immunizations and Other Pre-Deployment Health Requirements Not Met

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.

Servicemember Medical Records and Centralized Database Were Not Complete

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.

Many Completed Deployment Health Assessments and Medical Interventions Were Not Documented in Servicemembers’ Medical Record

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.

Centralized Database Missing Health-Related Documentation

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.

DOD and Installations Did Not Have Oversight of Force Health Protection and Surveillance Requirements

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.

Centralized Deployment Database Still Missing Information Needed for Deployment Health Surveillance

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.

Conclusions

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.

Recommendation for Executive Action

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.

Agency Comments and Our Evaluation

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.

Appendix I: Scope and Methodology

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.

Appendix II: Comments from the Department of Defense

Appendix III: GAO Contact and Staff Acknowledgments

GAO Contact

Acknowledgments

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.