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entitled 'Defense Health Care: Force Health Protection and Surveillance 
Policy Compliance Was Mixed, but Appears Better for Recent Deployments' 
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Report to Congressional Requesters:

United States Government Accountability Office:

GAO:

November 2004:

Defense Health Care:

Force Health Protection and Surveillance Policy Compliance Was Mixed, 
but Appears Better for Recent Deployments:

GAO-05-120:

GAO Highlights:

Highlights of GAO-05-120, a report to Congressional Requesters:

Why GAO Did This Study:

A lack of servicemember health and deployment data hampered 
investigations into the nature and causes of illnesses reported by many 
servicemembers following the 1990-91 Persian Gulf War. 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. Following its September 2003 
report examining Army and Air Force compliance with DOD’s force health 
protection and surveillance policies for Operation Enduring Freedom 
(OEF) and Operation Joint Guardian (OJG), GAO was asked in November 
2003 to also determine (1) the extent to which the services met DOD’s 
policies for Operation Iraqi Freedom (OIF) and, where applicable, 
compare results with OEF/OJG; and (2) what steps DOD has taken to 
establish a quality assurance program to ensure that the military 
services comply with force health protection and surveillance policies.

What GAO Found:

Overall compliance with DOD’s force health protection and surveillance 
policies for servicemembers that deployed in support of OIF varied by 
service, installation, and policy requirement. Such policies require 
that servicemembers be assessed before and after deploying overseas and 
receive certain immunizations, and that health-related documentation be 
maintained in a centralized location. GAO reviewed 1,862 active duty 
and selected reserve component servicemembers’ medical records from a 
universe of 4,316 at selected military service installations 
participating in OIF. Overall, Army and Air Force compliance for 
sampled servicemembers for OIF appears much better compared to OEF and 
OJG. For example:

* Lower percentages of Army and Air Force servicemembers were missing 
pre- and post-deployment health assessments for OIF. 
* Higher percentages of Army and Air Force servicemembers received 
required pre-deployment immunizations for OIF. 
* Lower percentages of deployment health-related documentation were 
missing in servicemembers’ permanent medical records and at DOD’s 
centralized database for OIF.

The Marine Corps installations examined generally had lower levels of 
compliance than the other services; however, GAO did not review medical 
records from the Marines or Navy for OEF and OJG. Noncompliance with 
the requirements for health assessments may result in deployment of 
servicemembers with existing health problems or concerns that are
unaddressed. It may also delay appropriate medical follow-up for a 
health problem or concern that may have arisen during or after 
deployment.

In January 2004, DOD established an overall deployment quality 
assurance program for ensuring that the services comply with force 
health protection and surveillance policies, and implementation of the 
program is ongoing. DOD’s quality assurance program requires (1) 
reporting from DOD’s centralized database on each service’s submission 
of required pre-deployment and post-deployment health assessments for 
deployed servicemembers, (2) reporting from each service regarding the 
results of the individual service’s deployment quality assurance 
program, and (3) joint DOD and service representative reviews at 
selected military installations to validate the service’s deployment 
health quality assurance reporting. DOD officials believe that their 
quality assurance program has improved the services’ compliance with 
requirements. However, the services are at different stages of 
implementing their own quality assurance programs as mandated by DOD. 
At the installations visited, GAO analysts observed that the Army and 
Air Force had centralized quality assurance processes in place that 
extensively involved medical personnel examining whether DOD’s force 
health protection and surveillance requirements were met for 
deploying/re-deploying servicemembers. In contrast, GAO analysts 
observed that the Marine Corps installations did not have well-defined 
quality assurance processes for ensuring that requirements were met for 
servicemembers.

What GAO Recommends:

Because GAO has already made recommendations aimed to improve force 
health protection and surveillance and because of the recent 
implementation of DOD’s quality assurance program, GAO is not making 
any additional recommendations regarding the program at this time. DOD 
reviewed a draft of this report and concurred with its findings.

www.gao.gov/cgi-bin/getrpt?GAO-05-120.

To view the full product, including the scope and methodology, click on 
the link above. For more information, contact Clifton Spruill at (202) 
512-4531 or spruillc@gao.gov.

[End of section]

Contents:

Letter:

Results in Brief:

Background:

Services' Compliance with Force Health Protection and Surveillance 
Requirements for OIF Was Mixed, but Appears Better Than for OEF/OJG:

Implementation of DOD's Deployment Health Quality Assurance Program 
Is Ongoing:

Agency Comments and Our Evaluation:

Appendix I: Scope and Methodology:

Appendix II: Comments from the Department of Defense:

Appendix III: GAO Contact and Staff Acknowledgments:

Tables:

Table 1: Percent of Servicemember Pre-deployment Blood Samples Held in 
Repository:

Table 2: Blood Samples Drawn for Re-deploying Servicemembers Only:

Table 3: Documentation of In-theater Visits in Permanent 
Medical Records:

Table 4: Percent Distribution of Servicemembers by Number of Missing 
Required Immunizations Prior to Deployment:

Table 5: Percent of Servicemember Health Assessments and Immunizations 
Found in Centralized Database That Were Not Found in Servicemembers' 
Medical Records:

Table 6: Percent of Health Assessments and Immunizations Found in 
Servicemembers' Medical Records That Were Not Found in Centralized 
Database:

Table 7: Servicemember Sample Sizes at Each Visited Installation:

Figures:

Figure 1: Percent of Servicemembers Missing Pre-deployment Health 
Assessments:

Figure 2: Percent of Servicemembers Missing Post-deployment Health 
Assessments:

Figure 3: Percent of Servicemembers Missing Required Pre-deployment 
Immunizations:

Figure 4: Percent of Servicemembers That Did Not Have Current 
Tuberculosis Screening:

Figure 5: Percent of Health Assessments Found in Centralized Database 
That Were Not Found in the Servicemember's Medical Records:

Figure 6: Percent of Health Assessments and Immunizations Found in 
Servicemembers' Medical Records That Were Not Found in the Centralized 
Database:

Abbreviations:

AMSA: Army Medical Surveillance Activity:

CITA: Comprehensive Immunization Tracking Application:

DOD: Department of Defense:

GEMS: Global Expeditionary Medical Support:

MEDPROS: Medical Protection System:

OEF: Operation Enduring Freedom:

OIF: Operation Iraqi Freedom:

OJG: Operation Joint Guardian:

SAMS: Shipboard Non-tactical Automated Data Processing Automated 
Medical System:

TMIP: Theater Medical Information Program:

United States Government Accountability Office:

Washington, DC 20548:

November 12, 2004:

The Honorable Duncan L. Hunter: 
Chairman: 
Committee on Armed Services: 
House of Representatives:

The Honorable Christopher H. Smith: 
Chairman: 
Committee on Veterans' Affairs: 
House of Representatives:

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.

In response, the Congress enacted legislation in November 1997 
requiring the Department of Defense (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.[Footnote 1] 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 was also required to 
establish a quality assurance program to ensure compliance. 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 samples on file prior to deployment and the 
collection of a post-deployment blood sample.

In September 2003, we reported that the Army and Air Force, for 
servicemembers deployed in support of Operation Enduring Freedom (OEF) 
and Operation Joint Guardian (OJG), did not comply with DOD's force 
health protection and surveillance policies for many active duty 
servicemembers, including the policies that the servicemembers be 
assessed before and after deploying overseas, that the services 
document receipt of certain immunizations, and that health-related 
documentation be maintained in a centralized location.[Footnote 2] We 
had previously reported in May 1997 on several similar problems 
associated with the implementation of DOD's deployment health 
surveillance policies for servicemembers deployed to Bosnia in support 
of a peacekeeping operation.[Footnote 3]

Concerned about the repercussions of the military services' failure to 
comply with DOD's force health protection and surveillance policies and 
the need to better understand the adverse health effects of war, you 
asked us, in November 2003, to examine the military services' 
implementation of DOD's force health protection and surveillance 
policies for servicemembers' deployments to Iraq in support of 
Operation Iraqi Freedom (OIF).[Footnote 4] More specifically, we 
focused our work on the military services' deployments to Southwest 
Asia for OIF to address the following two questions:

1. To what extent did the military services meet DOD's force health 
protection and surveillance system requirements for servicemembers 
deployed to Southwest Asia in support of OIF and, where applicable, did 
compliance improve compared to OEF/OJG?

2. What steps has DOD taken to establish a quality assurance program to 
ensure that the military services comply with force health protection 
and surveillance policies?

To accomplish these objectives, we obtained the force health protection 
and surveillance policies applicable to the OIF deployment from the 
U.S. Central Command, the Office of the Assistant Secretary of Defense 
for Health Affairs, and the services' Surgeons General. For each 
service, we identified those installations that had amongst the largest 
deployments or redeployments of servicemembers during specified time 
frames. Because of concerns about the reliability of overall personnel 
deployment data, we obtained data from the selected installations on 
the universe of those servicemembers who deployed or redeployed from 
the selected installations. To test the implementation of these 
policies, we reviewed samples or, in some instances, the entire 
universe of medical records for servicemembers at seven military 
installations.[Footnote 5] In total, we reviewed medical records of 
1,328 active duty servicemembers--including 750 Army servicemembers, 
270 Marine Corps servicemembers, 146 Air Force servicemembers, and 162 
Navy servicemembers. In addition, we reviewed medical records for 409 
Army reserve servicemembers and 125 Army National Guard servicemembers.

To provide assurances that the data were reliable and 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 examined, for all medical records within 
our review, the completeness of the centralized records at the Army 
Medical Surveillance Activity (AMSA),[Footnote 6] which is tasked with 
centrally collecting deployment health-related information for all of 
the military services. Further, we interviewed officials with the 
Office of the Deployment Health Support Directorate within the Office 
of Assistant Secretary of Defense for Health Affairs, the offices of 
the services' Surgeons General, and the military installations that we 
visited for medical records review regarding the quality assurance 
processes established to ensure compliance with DOD force health 
protection and surveillance policies. For more detailed information of 
our scope and methodology, see appendix I. We performed our work from 
November 2003 through August 2004 in accordance with generally accepted 
government auditing standards.

Results in Brief:

Overall compliance with DOD's force health protection and surveillance 
policies for servicemembers who deployed in support of OIF varied by 
service, by installation, and by policy requirement. Army and Air Force 
compliance during OIF for the installations in our review appears much 
better compared to the installations included in our previous 
review[Footnote 7] of OEF and OJG. Installations we examined from the 
Marine Corps, on the other hand, generally had lower levels of 
compliance across the policy requirements we examined when compared to 
other services; however, we did not review medical records from the 
Marines or Navy in our previous review. Our review disclosed that the 
extent of policy compliance varied in the following areas:

* Deployment health assessments. The Army and the Air Force 
installations were generally missing small percentages (less than 
10 percent) of pre-deployment health assessments. In contrast, 
pre-deployment health assessments were missing for an estimated 
63 percent[Footnote 8] of the servicemembers at one Marine Corps 
installation and for about 27 percent at the other Marine Corps 
installation reviewed. The Navy installation in our review was missing 
pre-deployment health assessments for 24 percent of the servicemembers. 
Post-deployment health assessments were completed for most 
servicemembers (95 percent or more) in our samples, except at one of 
the Marine Corps installations we visited. While almost all 
post-deployment health assessments for the services were completed 
within DOD required time frames except for one Army installation, many 
of the pre-deployment health assessments in our samples were not. 
Except for servicemembers at one of the two Marine Corps installations 
visited, a health care provider reviewed all but small percentages of 
the completed health assessments as required by DOD policy.

* Immunizations and other health requirements. Servicemembers receiving 
all of the pre-deployment immunizations required for OIF, based on the 
documentation we reviewed, ranged from 52 percent to 98 percent at the 
installations visited. The percentage of servicemembers missing two or 
more of the required immunizations, based on the documentation 
reviewed, ranged from 0 to about 11 percent at the installations 
visited. Servicemembers missing current tuberculosis screening at the 
time of their deployment ranged from 3 percent to 64 percent at the 
installations visited. Between less than 1 and 14 percent of the 
servicemembers at the installations had blood samples in the repository 
that were older than the required limit of 1 year at the time of 
deployment. Many servicemembers in our review at the two Marine Corps 
installations visited were missing their required post-deployment blood 
draw--19 percent at one installation and 13 percent at the other.

* Completeness of medical records and centralized data collection. 
Generally, servicemembers' permanent medical records at the 
installations we visited were missing small percentages (less than 
11 percent) of pre-and post-deployment health assessments and 
immunizations we found at AMSA, with the exception of one Army and one 
Marine Corps installation in our review. We also checked whether 
servicemember in-theater health care visits were documented in the 
servicemember's medical record at two Army and two Marine Corps 
installations that used manual patient sign-in logs, and found varying 
levels of missing documentation of the visits we reviewed. The Air 
Force and Navy installations used automated systems for recording 
in-theater health care visits, but we found that 20 of 40 visits 
reviewed at one location were not also documented in servicemembers' 
medical records. Moreover, the AMSA database--designed to function as 
the centralized collection location for deployment health-related 
information for all military services--was lacking documentation of 
many health assessments and immunizations that we found in 
servicemembers' medical records at the installations we visited. For 
example, for one of the Marine Corps installations in our review, AMSA 
was missing all of the pre-deployment health assessments, 26 percent of 
the post-deployment health assessments, and 44 percent of the 
immunizations that we found in the servicemembers' medical records.

Although the number of installations we visited was limited and 
different than those in our previous review with the exception of Fort 
Campbell, the Army and Air Force's compliance with the requirements for 
OIF appears much better compared to the services' compliance for the 
installations we reviewed for OEF and OJG. Because our previous report 
on compliance with requirements for OEF and OJG focused only on the 
Army and Air Force, we were unable to provide comparable data for the 
Navy and Marine Corps. To compare overall data from Army and Air Force 
active duty servicemembers reviewed for OEF/OJG with OIF, we aggregated 
data from all records examined in these two reviews to provide some 
perspective and determined that:

* Lower percentages of Army and Air Force servicemembers were missing 
pre-and post-deployment health assessments in OIF compared to OEF/OJF 
and, in some cases, the services were in full compliance. For example, 
Army servicemembers at the Army installation reviewed who were missing 
post-deployment health assessments upon return from OIF was 0 percent 
compared to an average of 29 for the installations we reviewed in OEF/
OJG.

* Higher percentages of Army and Air Force servicemembers received all 
of the required pre-deployment immunizations based on the documentation 
reviewed for OIF compared to OEF/OJG. In one notable example, 
98 percent of the Air Force active duty servicemembers received all of 
the required immunizations before deploying for OIF, compared with an 
average of 71 percent for OEF/OJG.

* Lower overall percentages of deployment health-related documentation 
were missing in the servicemembers' permanent medical records and at 
DOD's centralized database for OIF compared to OEF/OJG, for both the 
Army and the Air Force. Also, immunizations for Army servicemembers 
found in the medical record but missing from the centralized database 
was an average of 9 percent in OIF compared to an average of 62 percent 
in OEF/OJG.

In January 2004, DOD established an overall deployment quality 
assurance program for ensuring that the services comply with force 
health protection and surveillance policies, and implementation of the 
program is ongoing. DOD's quality assurance program requires 
(1) reporting from DOD's centralized database on each service's 
submission of required pre-deployment and post-deployment health 
assessments for deployed servicemembers, (2) reporting from each 
service regarding the results of the individual service's deployment 
health quality assurance program, and (3) joint DOD and service 
representative reviews at selected military installations to validate 
the service's deployment health quality assurance reporting. DOD 
officials believe that their quality assurance program has improved the 
services' compliance with requirements. However, the services are at 
different stages of implementing their own quality assurance programs 
as mandated by DOD. For example, as of September 2004, the Army had 
conducted quality assurance reviews to assess compliance with force 
health protection and surveillance requirements at 10 Army 
installations. However, according to an official in the office of the 
Surgeon General of the Navy, no decisions have been reached regarding 
whether periodic audits of Navy servicemembers' medical records will be 
conducted to assess compliance with DOD requirements. At the 
installations we visited, we observed that the Army and Air Force had 
centralized quality assurance processes in place that extensively 
involved medical personnel examining whether DOD's force health 
protection and surveillance requirements were met for deploying/re-
deploying servicemembers. In contrast, we observed that the Marine 
Corps installations we reviewed did not have well-defined quality 
assurance processes for ensuring that the requirements were met for 
servicemembers. We did not evaluate the effectiveness of DOD's 
deployment quality assurance program because of the relatively short 
time of its implementation.

In a September 2004 report, we made recommendations to improve the 
submission and timeliness of pre-and post-deployment health assessments 
to AMSA.[Footnote 9] Specifically, we recommended that the Secretary of 
Defense direct the Commandant of the Marine Corps to establish a 
mechanism to oversee the submission of pre-and post-deployment 
assessments to AMSA, and to direct the Under Secretary of Defense for 
Personnel and Readiness, in concert with the service secretaries, to 
take steps to improve the electronic submission of pre-and 
post-deployment health assessments. In a September 2003 report, we also 
recommended that DOD establish an effective quality assurance program 
and we continue to believe that implementation of such a program could 
help the Marine Corps improve its compliance with force health 
protection and surveillance requirements. Because of these prior 
recommendations and the recency of DOD's implementation of its quality 
assurance program, we are not making any additional recommendations 
regarding the program at this time.

DOD reviewed a draft of this report and concurred with its findings.

Background:

In September 2003, we reported that the Army and Air Force did not 
comply with DOD's force health protection and surveillance requirements 
for many servicemembers deploying in support of OEF in Central Asia and 
OJG in Kosovo at the installations we visited.[Footnote 10] 
Specifically, our review disclosed problems with the Army and Air 
Force's implementation of DOD's force health protection and 
surveillance requirements in the following areas:

* Deployment health assessments. Significant percentages of Army and 
Air Force servicemembers were missing one or both of their pre-and 
post-deployment health assessments and, when health assessments were 
conducted, as many as 45 percent of them were not done within the 
required time frames.

* Immunizations and other pre-deployment requirements. Based on the 
documentation we reviewed, as many as 46 percent of servicemembers in 
our samples were missing one of the pre-deployment immunizations 
required, and as many as 40 percent were missing a current tuberculosis 
screening at the time of their deployment. Up to 29 percent of the 
servicemembers in our samples had blood samples in the repository older 
than the required limit of 1 year at the time of deployment.

* Completeness of medical records and centralized data collection. 
Servicemembers' permanent medical records at the Army and Air Force 
installations we visited did not always include documentation of the 
completed health assessments that we found at AMSA and at the 
U.S. Special Operations Command. In one sample, 100 percent of the 
pre-deployment health assessments were not documented in the 
servicemember medical records that we reviewed. Furthermore, our review 
disclosed that the AMSA database was lacking documentation of many 
health assessments and immunizations that we found in the 
servicemembers' medical records at the installations visited.

We also wrote in our 2003 report that DOD did not have oversight of 
departmentwide efforts to comply with health surveillance requirements. 
There was no effective quality assurance program at the Office of the 
Assistant Secretary of Defense for Health Affairs or at the Offices of 
the Surgeons' General of the Army or Air Force that helped ensure 
compliance with force health protection and surveillance policies. We 
believed that the lack of such a system was a major cause of the high 
rate of noncompliance we found at the installations we visited, and 
thus recommended that the department establish an effective quality 
assurance program to ensure that the military services comply with the 
force health protection and surveillance requirements for all 
servicemembers. The department concurred with our recommendation.

The problems that we identified in our 2003 report were similar to 
those we had reported in May 1997 for Army servicemembers deployed to 
Bosnia in support of a peacekeeping operation.[Footnote 11] Following 
the publication of our May 1997 report, the Congress, in November 1997, 
included a provision in the National Defense Authorization Act for 
Fiscal Year 1998 requiring the Secretary of Defense to establish a 
medical tracking system for servicemembers deployed overseas as 
follows:

"(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."[Footnote 12]

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 GAO, 
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.[Footnote 13] 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 were required to draw a blood sample from each redeploying 
servicemember no later than 30 days after arrival at a demobilization 
site or home station.[Footnote 14] 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.

Services' Compliance with Force Health Protection and Surveillance 
Requirements for OIF Was Mixed, but Appears Better Than for OEF/OJG:

The overall record of the military services in meeting force health 
protection and surveillance system requirements for OIF was mixed and 
varied by service, by installation visited, and by specific policy 
requirement; however, our data shows much better compliance with these 
requirements in the Army and Air Force installations we reviewed 
compared to the installations in our earlier review of OEF/OJG. Of the 
installations reviewed for this report, the Marine Corps generally had 
lower levels of compliance than the other services.

Services' Compliance on All Requirements Uneven, but Marine Corps 
Lags Behind:

None of the services fully complied with all of the force health 
protection and surveillance system requirements, which include 
completing pre-and post-deployment health assessments, receipt of 
immunizations, and meeting pre-deployment requirements related to 
tuberculosis screening and pre and post-deployment blood samples. Also, 
the services did not fully comply with requirements that 
servicemembers' permanent medical records include required 
health-related information, and that DOD's centralized database 
includes documentation of servicemember health-related information.

Health Assessments:

Servicemembers in our review at the Army and Air Force installations 
were generally missing small percentages of pre-deployment health 
assessments, as shown in figure 1. In contrast, pre-deployment health 
assessments were missing for an estimated 63 percent of the 
servicemembers at one Marine Corps installation and for 27 percent at 
the other Marine Corps installation visited. Similarly, the Navy 
installation we visited was missing pre-deployment health assessments 
for about 24 percent of the servicemembers; however, we note that the 
pre-deployment health assessments reviewed for Navy servicemembers were 
completed prior to June 1, 2003, and may not reflect improvements 
arising from increased emphasis following our prior review of the Army 
and Air Force's compliance for OEF/OJG.[Footnote 15]

Figure 1: Percent of Servicemembers Missing Pre-deployment Health 
Assessments:

[See PDF for image]

Notes: = 95 percent confidence interval, upper and lower bounds for 
each estimate. Representations of data without confidence intervals 
indicate that the sample represents 100 percent of the eligible 
population.

These percentages reflect assessments from all sources and without 
regard to timeliness.

[End of figure]

At three Army installations we visited, we also analyzed the extent to 
which pre-deployment health assessments were completed for those 
servicemembers who re-deployed back to their home unit after 
June 1, 2003. Servicemembers associated with these re-deployment 
samples deployed in support of OIF prior to June 1, 2003. For two of 
these Army installations--Fort Eustis and Fort Campbell--we estimate 
that less than 1 percent of the servicemembers were missing 
pre-deployment health assessments. However, approximately 39 percent 
of the servicemembers that redeployed back to Fort Lewis on or after 
June 1, 2003, were missing their pre-deployment health assessments.

Post-deployment health assessments were missing for small percentages 
of servicemembers, except at one of the Marine Corps installations we 
visited, as shown in figure 2.

Figure 2: Percent of Servicemembers Missing Post-deployment Health 
Assessments:

[See PDF for image]

Notes: = 95 percent confidence interval, upper and lower bounds for 
each estimate. Representations of data without confidence intervals 
indicate that the sample represents 100 percent of the eligible 
population.

These percentages reflect assessments from all sources and without 
regard to timeliness.

[End of figure]

Although the Army provides for waivers for longer time frames, 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.[Footnote 16] For consistency and 
comparability between services, our analysis uses the DOD policy for 
reporting results. 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. For servicemembers that had completed 
pre-deployment health assessments, we found that many assessments were 
not completed on time in accordance with requirements. More 
specifically, we estimate that pre-deployment health assessments were 
not completed on time for:

* 47 percent of the pre-deployment health assessments for the active 
duty servicemembers at Fort Lewis;

* 41 percent of the pre-deployment health assessments for the active 
duty servicemembers and for 96 percent of the Army National Guard unit 
at Fort Campbell; and:

* 43 percent of the pre-deployment health assessments at Camp Lejeune 
and 29 percent at Camp Pendleton.

For the most part, small percentages--ranging from 0 to 5 percent--of 
the post-deployment health assessments were not completed on time at 
the installations visited. The exception was at Fort Lewis, where we 
found that about 21 percent of post-deployment health assessments for 
servicemembers were not completed on time.

DOD policy also 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.[Footnote 17] 
Except for servicemembers at one of the two Marine Corps installations 
visited, only small percentages of the pre-and post-deployment health 
assessments, ranging from 0 to 6 percent, were not reviewed by a health 
care provider. At Camp Pendleton, we found that a health care provider 
did not review 33 percent of the pre-deployment health assessments and 
21 percent of the post-deployment health assessments for its 
servicemembers .

Noncompliance with the requirements 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 Health Requirements:

Based on our samples, the services did not fully meet immunization and 
other health requirements for OIF deployments, although all 
servicemembers in our sample had received at least one anthrax 
immunization before they returned from the deployment as required. 
Almost all of the servicemembers in our samples had a pre-deployment 
blood sample in the DOD Serum Repository but frequently the blood 
sample was older than the one-year requirement. The services' record in 
regard to post-deployment blood sample draws was mixed.

The U.S. Central Command required the following pre-deployment 
immunizations for all servicemembers who deployed to Southwest Asia in 
support of OIF: hepatitis A (two-shot series); measles, mumps, and 
rubella; polio; tetanus/diphtheria within the last 10 years; typhoid 
within the last 5 years; and influenza within the last 
12 months.[Footnote 18] Based on the documentation we reviewed, the 
estimated percent of servicemembers receiving all of the required 
pre-deployment immunizations ranged from 52 percent to 98 percent at 
the installations we visited (see fig. 3). The percent of 
servicemembers missing only one of the pre-deployment immunizations 
required for the OIF deployment ranged from 2 percent to 43 percent at 
the installations we visited. Furthermore, the percent of 
servicemembers missing 2 or more of the required immunizations ranged 
from 0 percent to 11 percent.

Figure 3: Percent of Servicemembers Missing Required Pre-deployment 
Immunizations:

[See PDF for image]

Notes: = 95 percent confidence interval, upper and lower bounds for 
each estimate. Representations of data without confidence intervals 
indicate that the sample represents 100 percent of the eligible 
population.

[End of figure]

Figure 4 indicates that 3 to about 64 percent of the servicemembers at 
the installations visited were missing a current tuberculosis screening 
at the time of their deployment. A tuberculosis screening is deemed 
"current" if it occurred within 1 year prior to deployment. 
Specifically, the Army, Navy, and Marine Corps required servicemembers 
deploying to Southwest Asia in support of OIF to be screened for 
tuberculosis within 12 months of deployment. The Air Force requirement 
for tuberculosis screening depends on the servicemember's occupational 
specialty; therefore we did not examine tuberculosis screening for 
servicemembers in our sample at Moody Air Force Base due to the 
difficulty of determining occupational specialty for each 
servicemember.

Figure 4: Percent of Servicemembers That Did Not Have Current 
Tuberculosis Screening:

[See PDF for image]

Notes: = 95 percent confidence interval, upper and lower bounds for 
each estimate. Representations of data without confidence intervals 
indicate that the sample represents 100 percent of the eligible 
population.

[End of figure]

Although not required as pre-deployment immunizations, U.S. Central 
Command policies require that servicemembers deployed to Southwest Asia 
in support of OIF receive a smallpox immunization and at least one 
anthrax immunization either before deployment or while in theater. For 
the servicemembers in our samples at the installations visited, we 
found that all of the servicemembers received at least one anthrax 
immunization in accordance with the requirement. Only small percentages 
of servicemembers at two of the three Army installations, the Air Force 
installation, and the Navy installation visited did not receive the 
required smallpox immunization. However, an estimated 18 percent of the 
servicemembers at Fort Lewis, 8 percent at Camp Lejeune, and 27 percent 
at Camp Pendleton did not receive the required smallpox immunization.

U.S. Central Command policies also require that deploying 
servicemembers have a blood sample in the DOD Serum Repository not 
older than 12 months prior to deployment.[Footnote 19] Almost all of 
the servicemembers in our review had a pre-deployment blood sample in 
the DOD Serum Repository, but frequently the blood samples were older 
than the 1-year requirement. As shown in table 1 below, 14 percent of 
servicemembers at Camp Pendleton had blood samples in the repository 
older than 1 year.

Table 1: Percent of Servicemember Pre-deployment Blood Samples Held in 
Repository:

Army: Installation/type of sample: Ft. Campbell; 


Army: Installation/type of sample: Ft. Campbell: Active (Deploying 
sample); 
Had blood sample in repository: Percent: 100%; 
Had blood sample in repository: Confidence interval[A]: 99.01-100; 
Had blood sample in repository: N: 300; 
Blood sample older than 1 year: Percent: 4%; 
Blood sample older than 1 year: Confidence interval[A]: 2.08-6.88; 
Blood sample older than 1 year: N: 300.

Army: Installation/type of sample: Ft. Campbell: Reserve (Re-deploying 
sample); 
Had blood sample in repository: Percent: 100%; 
Had blood sample in repository: Confidence interval[A]: 98.21-100; 
Had blood sample in repository: N: 166; 
Blood sample older than 1 year: Percent: 8%; 
Blood sample older than 1 year: Confidence interval[A]: 4.69-13.75; 
Blood sample older than 1 year: N: 166.

Army: Installation/type of sample: Ft. Campbell: Guard (Deploying 
sample); 
Had blood sample in repository: Percent: 100%; 
Had blood sample in repository: Confidence interval[A]: [B]; 
Had blood sample in repository: N: 125; 
Blood sample older than 1 year: Percent: <1%; 
Blood sample older than 1 year: Confidence interval[A]: [B]; 
Blood sample older than 1 year: N: 125.

Army: Installation/type of sample: Ft. Eustis: Reserve (Deploying 
sample); 
Had blood sample in repository: Percent: 99%; 
Had blood sample in repository: Confidence interval[A]: [B]; 
Had blood sample in repository: N: 116; 
Blood sample older than 1 year: Percent: <1%; 
Blood sample older than 1 year: Confidence interval[A]: [B]; 
Blood sample older than 1 year: N: 115.

Army: Installation/type of sample: Ft. Eustis: Reserve (Re-deploying 
sample); 
Had blood sample in repository: Percent: [C]; 

Army: Installation/type of sample: Ft. Lewis: Active (Deploying 
sample); 
Had blood sample in repository: Percent: 100%; 
Had blood sample in repository: Confidence interval[A]: 98.48-100; 
Had blood sample in repository: N: 195; 
Blood sample older than 1 year: Percent: 6%; 
Blood sample older than 1 year: Confidence interval[A]: 2.85-9.87; 
Blood sample older than 1 year: N: 195.

Army: Installation/type of sample: Ft. Lewis: Active (Re-deploying 
sample); 
Had blood sample in repository: Percent: 99%; 
Had blood sample in repository: Confidence interval[A]: 96.6-99.76; 
Had blood sample in repository: N: 255; 
Blood sample older than 1 year: Percent: 13%; 
Blood sample older than 1 year: Confidence interval[A]: 8.85-17.45; 
Blood sample older than 1 year: N: 252.

Air Force: Installation/type of sample: Moody AFB: Active (Re-deploying 
sample); 
Had blood sample in repository: Percent: 100%; 
Had blood sample in repository: Confidence interval[A]: 97.97-100; 
Had blood sample in repository: N: 146; 
Blood sample older than 1 year: Percent: 8%; 
Blood sample older than 1 year: Confidence interval[A]: 3.82-13.08; 
Blood sample older than 1 year: N: 146.

Marine Corps: Installation/type of sample: Camp Lejeune: Active; 
Had blood sample in repository: Percent: 99%; 
Had blood sample in repository: Confidence interval[A]: [B]; 
Had blood sample in repository: N: 90; 
Blood sample older than 1 year: Percent: 12%; 
Blood sample older than 1 year: Confidence interval[A]: [B]; 
Blood sample older than 1 year: N: 89.

Marine Corps: Installation/type of sample: Camp Pendleton: Active; 
Had blood sample in repository: Percent: 100%; 
Had blood sample in repository: Confidence interval[A]: 98.35-100; 
Had blood sample in repository: N: 180; 
Blood sample older than 1 year: Percent: 14%; 
Blood sample older than 1 year: Confidence interval[A]: 9.19-19.82; 
Blood sample older than 1 year: N: 180.

Navy: Installation/type of sample: Naval Construction Battalion Center: 
Active (Re-deploying sample); 
Had blood sample in repository: Percent: 100%; 
Had blood sample in repository: Confidence interval[A]: 98.17-100; 
Had blood sample in repository: N: 162; 
Blood sample older than 1 year: Percent: 4%; 
Blood sample older than 1 year: Confidence interval[A]: 1.75-8.70; 
Blood sample older than 1 year: N: 162.

Source: GAO analyses of DOD data for the sample of servicemember 
medical records.

[A] 95 percent confidence interval, upper and lower bounds for each 
estimate.

[B] No confidence intervals reported because the sample represents 100 
percent of the eligible population.

[C] We did not collect pre-deployment blood sample data for 
servicemembers in this sample.

[End of table]
 
Effective May 22, 2003, the services were required to draw a post-
deployment blood sample from each re-deploying servicemember no later 
than 30 days after arrival at a demobilization site or home station.
[Footnote 20] Only small percentages of the servicemembers at the Army 
and Air Force installations visited did not have a post-deployment 
blood sample drawn. The Navy and Marine Corps installations visited had 
percentages of servicemembers missing post-deployment blood samples 
ranging from 7 to 19 percent, and the post-deployment blood samples 
that were available were frequently drawn later than required, as shown 
in table 2.

Table 2: Blood Samples Drawn for Re-deploying Servicemembers Only:

Army: Installation/type of sample: Ft. Campbell: Reserve (Re-deploying 
sample); 
Had blood sample drawn: Percent: 100%; 
Had blood sample drawn: Confidence interval[A]: 98.21-100; 
Had blood sample drawn: N: 166; 
Blood sample drawn later than required: Percent: 1%; 
Had blood sample drawn: Confidence interval[A]: 0.15-4.28; 
Blood sample drawn later than required: N: 166.

Army: Installation/type of sample: Ft. Eustis: Reserve (Re-deploying 
sample); 
Had blood sample drawn: Percent: 97%; 
Had blood sample drawn: Confidence interval[A]: 92.13-99.14; 
Had blood sample drawn: N: 127; 
Blood sample drawn later than required: Percent: 2%; 
Had blood sample drawn: Confidence interval[A]: 0.51-6.96; 
Blood sample drawn later than required: N: 123.

Army: Installation/type of sample: Ft. Lewis: Active (Re-deploying 
sample); 
Had blood sample drawn: Percent: 98%; 
Had blood sample drawn: Confidence interval[A]: 96.03-99.57; 
Had blood sample drawn: N: 255; 
Blood sample drawn later than required: Percent: 4%; 
Had blood sample drawn: Confidence interval[A]: 2.21-7.71; 
Blood sample drawn later than required: N: 251.

Air Force: Installation/type of sample: Moody AFB: Active (Re-deploying 
sample); 
Had blood sample drawn: Percent: 98%; 
Had blood sample drawn: Confidence interval[A]: 94.11-99.57; 
Had blood sample drawn: N: 146; 
Blood sample drawn later than required: Percent: 7%; 
Had blood sample drawn: Confidence interval[A]: 3.40-12.48; 
Blood sample drawn later than required: N: 143.

Marine Corps: Installation/type of sample: Camp Lejuene: Active; 
Had blood sample drawn: Percent: 87%; 
Had blood sample drawn: Confidence interval[A]: [B]; 
Had blood sample drawn: N: 90; 
Blood sample drawn later than required: Percent: 12%; 
Had blood sample drawn: Confidence interval[A]: [B]; 
Blood sample drawn later than required: N: 78.

Marine Corps: Installation/type of sample: Camp Pendleton: Active; 
Had blood sample drawn: Percent: 81%; 
Had blood sample drawn: Confidence interval[A]: 74.01- 86.07; 
Had blood sample drawn: N: 180; 
Blood sample drawn later than required: Percent: 26%; 
Had blood sample drawn: Confidence interval[A]: 20.30-30.73; 
Blood sample drawn later than required: N: 145.

Navy: Installation/type of sample: Naval Construction Battalion Center: 
Active (Re-deploying sample); 
Had blood sample drawn: Percent: 93%; 
Had blood sample drawn: Confidence interval[A]: 87.42-96.11; 
Had blood sample drawn: N: 162; 
Blood sample drawn later than required: Percent: 72%; 
Had blood sample drawn: Confidence interval[A]: 67.19-76.81; 
Blood sample drawn later than required: N: 150. 

Source: GAO analyses of DOD data for the sample of servicemember 
medical records.

[A] 95 percent confidence interval, upper and lower bounds for each 
estimate.

[B] No confidence intervals reported because the sample represents 
100 percent of the eligible population.

[End of table]

Completeness of Medical Documentation:

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.[Footnote 21] Also, the military services require 
that all immunizations be documented in the servicemember's medical 
record.[Footnote 22] Figure 5 shows that small percentages of the 
completed health assessments we found at AMSA for servicemembers in our 
samples were not documented in the servicemember's permanent medical 
record, ranging from 0 to 14 percent for pre-deployment health 
assessments and from 0 percent to 20 percent for post-deployment health 
assessments. Almost all of the immunizations we found at AMSA for 
servicemembers in our samples were documented in the servicemember's 
medical record.

Figure 5: Percent of Health Assessments Found in Centralized Database 
That Were Not Found in the Servicemember's Medical Records:

[See PDF for image]

Notes: = 95 percent confidence interval, upper and lower bounds for 
each estimate. Representations of data without confidence intervals 
indicate that the sample represents 100 percent of the eligible 
population.

[A] Not applicable for post-deployment health assessments since 
servicemembers were still deployed at the time of our review.

[End of figure]

Service policies also require documentation in the servicemember's 
permanent medical records of all visits to in-theater medical 
facilities.[Footnote 23] At six of the seven installations we visited, 
we sampled and examined whether selected in-theater visits to medical 
providers--such as battalion aid stations for the Army and Marine Corps 
and expeditionary medical support for the Air Force--were documented in 
the servicemember's permanent medical record. Both the Air Force and 
Navy installations used automated systems for recording servicemember 
in-theater visits to medical facilities. While in-theater visits were 
documented in these automated systems, we found that 20 of the 40 Air 
Force in-theater visits we examined at Moody Air Force Base and 6 of 
the 60 Navy in-theater visits we examined at the Naval Construction 
Battalion Center were not also documented in the servicemembers' 
permanent medical records. In contrast, the Army and Marine Corps 
installations used manual patient sign-in logs for servicemembers' 
visits to in-theater medical providers and relied exclusively on paper 
documentation of the in-theater visits in the servicemember's permanent 
medical record. The results of our review are summarized in table 3.

Table 3: Documentation of In-theater Visits in Permanent 
Medical Records:

Army: Installation: Fort Campbell; 
Number of in-theater visits reviewed: 50; 
Number with no documentation in medical record: 9.

Army: Installation: Fort Lewis; 
Number of in-theater visits reviewed: 33; 
Number with no documentation in medical record: 30.

Marine Corps: Installation: Camp Lejeune; 
Number of in-theater visits reviewed: 64; 
Number with no documentation in medical record: 24.

Marine Corps: Installation: Camp Pendleton; 
Number of in-theater visits reviewed: 30; 
Number with no documentation in medical record: 24. 

Source: GAO analyses of DOD data.

[End of table]

Army and Marine Corps representatives associated with the battalion aid 
stations we examined commented that the aid stations were frequently 
moving around the theater, increasing the likelihood that paper 
documentation of the visits might get lost and that such visits might 
not always be documented because of the hostile environment. The lack 
of complete and accurate medical records documenting all medical care 
for the individual servicemember complicates the servicemember's 
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's Theater 
Medical Information Program (TMIP) has the capability to electronically 
record and store in-theater patient medical encounter data. However, 
the Iraq war has delayed implementation of the program. At the request 
of the services, the operational test and evaluation for TMIP has been 
delayed until the second quarter of fiscal year 2005.

In addition to the above requirements, Public Law 105-85, 10 U.S.C. 
1074f, requires the Secretary of Defense to retain and maintain health-
related records in a centralized location for servicemembers who are 
deployed. 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.[Footnote 24]

Figure 6 shows the estimated percentage of pre-and post-deployment 
health assessments in servicemembers' medical records that were not 
available in a centralized database at AMSA. Our samples of 
servicemembers at the installations visited show wide variation by 
installation regarding pre-deployment health assessments missing from 
the centralized database, ranging from zero at Fort Lewis to all of the 
assessments at Camp Lejeune. Post-deployment health assessments were 
missing for small percentages of servicemembers at the installations 
visited, except at the Marine Corps installations visited. More 
specifically, about 26 percent of the post-deployment health 
assessments at Camp Lejeune and 24 percent at Camp Pendleton were 
missing from the centralized database. Immunizations missing from the 
centralized database that we found in the servicemembers' medical 
records ranged from 3 to 44 percent for the servicemembers in our 
samples.

Figure 6: Percent of Health Assessments and Immunizations Found in 
Servicemembers' Medical Records That Were Not Found in the Centralized 
Database:

[See PDF for image]

Notes: = 95 percent confidence interval, upper and lower bounds for 
each estimate. Representations of data without confidence intervals 
indicate that the sample represents 100 percent of the eligible 
population.

[A] Not applicable for post-deployment health assessments since 
servicemembers were still deployed at the time of our review.

[End of figure]

DOD officials believe that automation of deployment health assessment 
forms and recording of servicemember immunizations will improve the 
completeness of deployment data in the AMSA centralized database, and 
DOD has ongoing initiatives to accomplish these goals. DOD is currently 
implementing worldwide 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.[Footnote 
25] Also, the Assistant Secretary of Defense for Health Affairs has 
established a Deployment Health Task Force whose focus includes 
improving the electronic capture of deployment health assessments. 
According to DOD, about 40 percent of the Army's pre-deployment health 
assessments and 50 percent of the post-deployment health assessments 
sent to AMSA since June 1, 2003, were submitted electronically. 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.

Army and Air Force Compliance with Deployment Health Surveillance 
Policies Appears Better:

Although the number of installations we visited was limited and 
different than those in our previous review with the exception of Fort 
Campbell, the Army and Air Force compliance with force health 
protection and surveillance policies for active-duty servicemembers in 
OIF appears to be better than for those installations we 
reviewed[Footnote 26] for OJG and OEF.[Footnote 27] To provide context, 
we compared overall data from Army and Air Force active duty 
servicemembers' medical records reviewed for OEF/OJG with OIF, by 
aggregating data from all records examined in these two reviews to 
provide some perspective and determined that:

* Lower percentages of Army and Air Force servicemembers were missing 
pre-and post-deployment health assessments for OIF.

* Higher percentages of Army and Air Force servicemembers received 
required pre-deployment immunizations for OIF.

* Lower percentages of deployment health-related documentation were 
missing in the servicemembers' permanent medical records and at DOD's 
centralized database for OIF.

Because our previous report on compliance with requirements for OEF and 
OJG focused only on the Army and Air Force, we were unable to make 
comparisons for the Navy and Marine Corps.

Health Assessments:

Our data indicate that Army and Air Force compliance with requirements 
for completion of pre-and post-deployment health assessments for 
servicemembers for OIF appears to be much better than compliance for 
OEF and OJG for the installations examined in each review. In some 
cases, the services were in full compliance. As before, we aggregated 
data from all records examined in the two reviews and determined, among 
the Army and Air Force active duty servicemembers we reviewed for OIF 
compared to those reviewed for OEF/OJG, the following:

Pre-deployment Health Assessments:

* Army servicemembers missing pre-deployment health assessments was an 
average of 14 percent for OIF contrasted with 45 percent for OEF/OJG.

* Air Force servicemembers missing pre-deployment health assessments 
was 8 percent for OIF contrasted with an average of 50 percent for OEF/
OJG.

Post-deployment Health Assessments:

* Army servicemembers missing post-deployment health assessments was 
0 percent for OIF contrasted with an average of 29 percent for OEF/OJG.

* Air Force servicemembers missing post-deployment health assessments 
was 4 percent for OIF contrasted with an average of 62 percent for OEF/
OJG.

Immunizations and Other Health Requirements:

Based on our samples, the Army and the Air Force had better compliance 
with pre-deployment immunization requirements for OIF as compared to 
OEF and OJG. The aggregate data from each of our OIF samples indicates 
that an average of 68 percent of Army active duty servicemembers 
received all of the required immunizations before deploying for OIF, 
contrasted with an average of only 35 percent for OEF and OJG. 
Similarly, 98 percent of Air Force active duty servicemembers received 
all of the required immunizations before deploying for OIF, contrasted 
with an average of 71 percent for OEF and OJG. The percentage of Army 
active duty and Air Force servicemembers missing two or more 
immunizations appears to be markedly better, as illustrated in table 4.

Table 4: Percent Distribution of Servicemembers by Number of Missing 
Required Immunizations Prior to Deployment:

Number missing: None; 
Army Active: OEF/OJG: 35; 
Army Active: OIF: 68; 
Air Force: OEF/OJG: 71; 
Air Force: OIF[A]: 98.

Number missing: Only 1; 
Army Active: OEF/OJG: 41; 
Army Active: OIF: 26; 
Air Force: OEF/OJG: 26; 
Air Force: OIF[A]: 2.

Number missing: 2 or more; 
Army Active: OEF/OJG: 24; 
Army Active: OIF: 6; 
Air Force: OEF/OJG: 3; 
Air Force: OIF[A]: 0.

Number missing: Total; 
Army Active: OEF/OJG: 100; 
Army Active: OIF: 100; 
Air Force: OEF/OJG: 100; 
Air Force: OIF[A]: 100.

Source: GAO analyses of documentation from the sample of servicemember 
medical records and DOD medical databases.

[A] Only one sample at a single installation was available for this 
comparison.

[End of table]
 
Completeness of Medical Documentation:

Our data indicate that the Army and Air Force's compliance with 
requirements for completeness of servicemember medical records and of 
DOD's centralized database at AMSA for OIF appears to be significantly 
better than compliance for OEF and OJG. Lower overall percentages of 
deployment health-related documentation were missing in servicemembers' 
permanent medical records and at AMSA. We aggregated the data from each 
of our samples and depicted the results in tables 5 and 6.

Table 5: Percent of Servicemember Health Assessments and Immunizations 
Found in Centralized Database That Were Not Found in Servicemembers' 
Medical Records:

Service: Army Active; 
Pre-deployment health assessments missing from medical records: 
OEF/OJG: 54; 
Pre-deployment health assessments missing from medical records: 
OIF: 7; 
Post-deployment health assessments missing from medical records: 
OEF/OJG: 38; 
Post-deployment health assessments missing from medical records: 
OIF: 0[A]; 
Immunizations missing from medical records: OEF/OJG: 12; 
Immunizations missing from medical records: OIF: 1.

Service: Air Force Active; 
Pre-deployment health assessments missing from medical records: 
OEF/OJG: 28; 
Pre-deployment health assessments missing from medical records: 
OIF: 1[A]; 
Post-deployment health assessments missing from medical records: 
OEF/OJG: 28; 
Post- deployment health assessments missing from medical records: 
OIF: 4[A]; 
Immunizations missing from medical records: OEF/OJG: 12; 
Immunizations missing from medical records: OIF: 2[A].

Source: GAO analyses of documentation from the sample of servicemember 
medical records and DOD medical databases.

[A] Only one sample at a single installation was available for this 
comparison.

[End of table]
 
Table 6: Percent of Health Assessments and Immunizations Found in 
Servicemembers' Medical Records That Were Not Found in Centralized 
Database:

Service: Army Active; 
Pre-deployment health assessments missing from AMSA database: 
OEF/OJG: 52; 
Pre-deployment health assessments missing from AMSA database: 
OIF: 23; 
Post-deployment health assessments missing from AMSA database: 
OEF/OJG: 40; 
Post-deployment health assessments missing from AMSA database: 
OIF: 0[A]; 
Immunizations missing from AMSA database: OEF/OJG: 62; 
Immunizations missing from AMSA database: OIF: 9.

Service: Air Force Active; 
Pre-deployment health assessments missing from AMSA database: 
OEF/OJG: 26; 
Pre-deployment health assessments missing from AMSA database: 
OIF: 32[A]; 
Post-deployment health assessments missing from AMSA database: 
OEF/OJG: 49; 
Post-deployment health assessments missing from AMSA database: 
OIF: 4[A]; 
Immunizations missing from AMSA database: OEF/OJG: 7; 
Immunizations missing from AMSA database: OIF: 8[A].

Source: GAO analyses of documentation from the sample of servicemember 
medical records and DOD medical databases.

[A] Only one sample at a single installation was available for this 
comparison. 

[End of table]

The data appear to indicate that, for active duty servicemembers, the 
Army and the Air Force have made significant improvements in 
documenting servicemember medical records. These data also appear to 
indicate that, overall, both services have also made encouraging 
improvements in retaining health-related records in DOD's centralized 
database at AMSA, although not quite to the extent exhibited in their 
efforts to document servicemember medical records.

Implementation of DOD's Deployment Health Quality Assurance Program 
Is Ongoing:

In response to congressional mandates and a GAO recommendation, DOD 
established a deployment health quality assurance program in January 
2004 to ensure compliance with force health protection and surveillance 
requirements and implementation of the program is ongoing. DOD 
officials believe that their quality assurance program has improved the 
services' compliance with requirements. However, we did not evaluate 
the effectiveness of DOD's deployment health quality assurance program 
because of the relatively short time of its implementation.

Section 765 of Public Law 105-85 (10 U.S.C. 1074f) requires the 
Secretary of Defense to establish a quality assurance program to 
evaluate the success of DOD's system for ensuring that members receive 
pre-deployment medical examinations and post-deployment medical 
examinations and that recordkeeping requirements are met. In May 2003, 
the House Committee on Armed Services directed the Secretary of Defense 
to take measures to improve oversight and compliance with force health 
protection and surveillance requirements. 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 assess implementation of the force health protection 
and surveillance program.[Footnote 28]

In January 2004, the Assistant Secretary of Defense for Health Affairs 
issued policy and program guidance for the DOD Deployment Health 
Quality Assurance Program. DOD's quality assurance program requires:

* Periodic reporting on pre-and post-deployment health assessments. 
AMSA is required to provide (at a minimum) monthly reports to the 
Deployment Health Support Directorate (Directorate) on deployment 
health data. AMSA is providing the Directorate and the services with 
weekly reports on post-deployment health assessments and publishes bi-
monthly updates on pre-and post-deployment health assessments.

* Periodic reporting on service-specific deployment health quality 
assurance programs. The services are required to report (at a minimum) 
quarterly reports to the Directorate on the status and findings of 
their respective required deployment health quality assurance programs. 
Each service has provided the required quarterly reports on its 
respective quality assurance programs.

* Periodic visits to military installations to assess deployment health 
programs. The program requires joint visits by representatives from the 
Directorate and from service medical departments to military 
installations for the purpose of validating the service's deployment 
health quality assurance reporting. As of September 2004, Directorate 
officials had accompanied service medical personnel to an Army, Air 
Force, and Marine Corps installation for medical records review. 
Directorate officials envision continuing quarterly installation 
visits in 2005, with possible expansion to include reserve and guard 
sites.

The services are at different stages of developing their deployment 
quality assurance programs. Following the issuance of our September 
2003 report[Footnote 29] and subsequent testimony[Footnote 30] before 
the House Committee on Veterans' Affairs in October 2003, the Surgeon 
General of the Army directed that the U.S. Army Center for Health 
Promotion and Preventive Medicine (the Center) lead reviews of 
servicemember medical records at selected Army installations to assess 
compliance with force health protection and surveillance requirements. 
As of September 2004, the Center had conducted reviews at 10 Army 
installations. Meanwhile, the Center developed the Army's deployment 
health quality assurance program that parallels closely the DOD's 
quality assurance program. According to a Center official, this quality 
assurance program is currently under review by the Surgeon General.

In the Air Force, public health officers at each installation report 
monthly compliance rates with force health protection and surveillance 
requirements to the office of the Surgeon General of the Air Force. 
These data are monitored by officials in the office of the Air Force 
Surgeon General for trends and for identification of potential 
problems. Air Force Surgeon General officials told us that, as of May 
2004, the Air Force Inspector General's periodic health services 
inspections--conducted every 18 to 36 months at each Air Force 
installation--includes an examination of compliance with deployment 
health surveillance requirements. Also, the Air Force Audit Agency is 
planning to examine in 2004 whether AMSA received all of the required 
deployment health assessments and blood samples for servicemembers who 
deployed from several Air Force installations.

According to an official in the office of the Surgeon General of the 
Navy, no decisions have been reached regarding whether periodic audits 
of servicemember medical records will be conducted to assess compliance 
with DOD requirements. DOD's April 2003 enhanced post-deployment health 
assessment program expanded the requirement for post-deployment health 
assessments and post-deployment blood samples to all sea-based 
personnel in theater supporting combat operations for Operations Iraqi 
Freedom and Enduring Freedom. Navy type commanders (e.g., surface 
ships, submarine, and aircraft squadrons) are responsible for 
implementing the program.

The Marine Corps has developed its deployment health assessment quality 
assurance program that is now under review by the Commandant of the 
Marine Corps. It reemphasizes the requirements for deployment health 
assessments and blood samples and requires each unit to track and 
report the status of meeting these requirements for their 
servicemembers.

At the installations we visited, we observed that the Army and Air 
Force had centralized quality assurance processes in place that 
extensively involved installation medical personnel examining whether 
DOD's force health protection and surveillance requirements were met 
for deploying/ redeploying servicemembers. In contrast, we observed 
that the Marine Corps installations did not have well-defined quality 
assurance processes for ensuring that the requirements were met for 
servicemembers. The Navy installation visited did not have a formal 
quality assurance program; compliance depended largely on the 
initiative of the assigned medical officer. We believe that the lack of 
effective quality assurance processes at the Marine Corps installations 
contributed to lower rates of compliance with force health protection 
and surveillance requirements. In our September 2003 report, we 
recommended that DOD establish an effective quality assurance program 
and we continue to believe that implementation of such a program could 
help the Marine Corps improve its compliance with force health 
protection and surveillance requirements.

Agency Comments and Our Evaluation:

In commenting on a draft of this report, the Assistant Secretary of 
Defense for Health Affairs concurred with the findings of the report. 
He suggested that the word "Appears" be removed from the title of the 
report to more accurately reflect improvements in compliance with force 
health protection and surveillance requirements for OIF. We do not 
agree with this suggestion because the number of installations we 
visited for OIF was limited and different than those in our previous 
review for OEF/OJG with the exception of Fort Campbell. As pointed out 
in the report, the data for OIF were limited in some instances to only 
one sample at one installation. We believe that it is important for the 
reader to recognize the limitations of this comparison.

The Assistant Secretary also commented that the department is aware of 
variations in progress among the services and is committed to 
demonstrating full compliance through the continued application of 
aggressive quality assurance measures. He further commented that the 
department is focusing on and supporting recent policy efforts by the 
Marine Corps to improve its deployment health quality assurance 
program. He commented that plans have been initiated to conduct a joint 
quality assurance visit to Camp Pendleton, Calif., in early 2005, 
following the implementation of an improved quality assurance program 
and the return of significant numbers of Marines currently deployed in 
support of OIF.

The department's written comments are incorporated in their entirety in 
appendix II.

We are sending copies of this report to the Secretary of Defense; the 
Secretaries of the Army, the Air Force, and the Navy; and the 
Commandant of the Marine Corps. 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 (202) 512-5559 or Clifton Spruill on (202) 512-4531. Key 
contributors to this report are listed in appendix III.

Signed by: 

Derek B. Stewart, Director: 
Defense Capabilities and Management:

[End of section]

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 Deployment Health Support Directorate; 
the National Guard Bureau; and the Offices of the Surgeons General for 
the Army, Air Force, and Navy Headquarters in the Washington, D.C., 
area. We also performed additional work at AMSA and the U.S. Central 
Command.

To determine the extent to which the military services were meeting the 
Department of Defense's (DOD) force health protection and surveillance 
requirements for servicemembers deploying in support of Operation Iraqi 
Freedom (OIF), we identified DOD's 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 Southwest Asia in support of OIF required 
by the U.S. Central Command. We tested the implementation of these 
requirements at selected Army, Air Force, Marine Corps, and Navy 
installations. To identify military installations within each service 
where we would test implementation of the policies, we reviewed 
deployment data showing the location of units, by service and by 
military installation that deployed to Southwest Asia in support of OIF 
or redeployed from Southwest Asia in support of OIF from June 1, 2003, 
through November 30, 2003. [Footnote 31] After examining these data, we 
selected the following military installations for review of selected 
servicemembers' medical records, because the installations had amongst 
the largest numbers of servicemembers who deployed or re-deployed back 
to their home unit from June 1, 2003, through November 30, 2003:

Army:

* Fort Lewis, Wash.

* Fort Campbell, Ky.

* Fort Eustis, Va.[Footnote 32]

Marine Corps:

* Camp Lejeune, N.C.

* Camp Pendleton, Calif.

Air Force:

* Moody Air Force Base, Ga.

Navy:

* Naval Construction Battalion Center, Gulfport, Miss.

In comparing compliance rates for OIF with those for Operation Enduring 
Freedom (OEF) and Operation Joint Guardian (OJG), we reviewed active 
duty servicemembers' medical records for Army servicemembers and Air 
Force servicemembers at selected installations. For OIF, we reviewed 
active duty Army servicemembers' medical records at Fort Campbell and 
Fort Lewis and active duty Air Force servicemembers at Moody Air Force 
Base. For OEF and OJG, we reviewed active duty Army servicemembers' 
medical records at Fort Drum and Fort Campbell and active duty Air 
Force servicemembers at Travis Air Force Base and Hurlburt Field.

Due to the length of Army deployments in support of OIF, we sampled two 
groups at the military installations consisting of (1) servicemembers 
who deployed within the selected time frame and (2) servicemembers who 
re-deployed back to their home unit within the selected time frame.

For the selected military installations, we requested officials in the 
Deployment Health Support Directorate, in the services' Surgeon General 
offices, or at the installations to provide a listing of those active-
duty servicemembers who deployed to Southwest Asia in support of OIF 
for 30 or more continuous days to areas without permanent U.S. military 
treatment facilities or redeployed back to the military installation 
from June 1, 2003, through November 30, 2003. For Army reserve and 
National Guard servicemembers, we requested listings of those 
servicemembers who deployed during the period June 1, 2003, through 
January 31, 2004, and those servicemembers who redeployed from 
Southwest Asia in support of OIF from June 1, 2003, through December 
31, 2003.

For Marine Corps servicemembers at Camp Lejeune and Camp Pendleton, we 
modified our selection criteria to draw one sample because a number of 
servicemembers met the definition for both deployment and redeployment 
within our given time frames. Specifically, servicemembers at these 
installations had both deployed to Southwest Asia in support of OIF and 
redeployed back to their home unit from June 1, 2003, through November 
30, 2003, staying for 30 or more continuous days.

For our medical records review, we selected samples of servicemembers 
at the selected installations. Five of our servicemember samples were 
small enough to complete reviews of the entire universe of medical 
records for the respective location. For the other locations, we drew 
probability samples from the larger universe. In all cases, records 
that were not available for review were researched in more detail by 
medical officials to account for the reason for which the medical 
record was not available so that the record could be deemed either in-
scope or out-of-scope. For installations in which a sample was drawn, 
all out-of-scope cases were then replaced with another randomly 
selected record until the required sample size was met. For 
installations in which the universe was reviewed, the total number in 
the universe was adjusted accordingly. There were four reasons for 
which a medical record was unavailable and subsequently deemed out-of-
scope for purposes of this review:

3. Charged to patient. When a patient goes to be seen in 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 
following their clinic visit.

4. 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.

5. Permanent change of station. Servicemember is still in the military, 
but has transferred to another base. Medical record transfers with the 
servicemember.

6. Temporary duty off site. Servicemember has left military 
installation, but is expected to return. The temporary duty is long 
enough to warrant medical record to accompany servicemember.

There were a few instances in which medical records could not be 
accounted for by the medical records department. These records were 
deemed to be in-scope, counted as non-responses, and not replaced in 
the sample. The number of servicemembers in our samples and the 
applicable universe of servicemembers for the OIF deployments at the 
installations visited are shown in table 7.

Table 7: Servicemember Sample Sizes at Each Visited Installation:

Installation (type of sample): Fort Campbell: Tennessee Army National 
Guard (deploying sample); 
Sample: 125; 
Universe: 125.

Installation (type of sample): Fort Campbell: Reserve (re-deploying 
sample); 
Sample: 166; 
Universe: 197.

Installation (type of sample): Fort Campbell: Active duty (deploying 
sample); 
Sample: 300; 
Universe: 1,797.

Installation (type of sample): Fort Eustis: Reserve (deploying); 
Sample: 116; 
Universe: 116.

Installation (type of sample): Fort Eustis: Reserve (re-deploying); 
Sample: 127; 
Universe: 140.

Installation (type of sample): Fort Lewis: Active duty (deploying 
sample); 
Sample: 195; 
Universe: 370.

Installation (type of sample): Fort Lewis: Active duty (re-deploying 
sample); 
Sample: 255; 
Universe: 594.

Installation (type of sample): Camp Lejeune: Active duty sample; 
Sample: 90; 
Universe: 90.

Installation (type of sample): Camp Pendleton: Active duty sample; 
Sample: 180; 
Universe: 391.

Installation (type of sample): Moody Air Force Base: Active duty 
(re-deploying sample); 
Sample: 146; 
Universe: 204.

Installation (type of sample): Naval Construction Battalion Center,
Gulfport, MS: Active duty (re-deploying sample); 
Sample: 162; 
Universe: 292.

Installation (type of sample): Total; 
Sample: 1,862; 
Universe: 4,316. 

Source: GAO.

[End of table]

Because we followed a probability procedure based on random selections, 
our sample is only one of a large number of samples that we might have 
drawn from the sampled installations. Because each sample could have 
provided different estimates, we express our confidence in the 
precision of our particular sample's results as a 95 percent confidence 
interval (e.g., plus or minus 5 percentage points). This is the 
interval that would contain the actual population value for 95 percent 
of the samples we could have drawn. As a result, we are 95 percent 
confident that each of the confidence intervals in this report will 
include the true values in the study population. The 95 percent 
confidence intervals for percentage estimates are presented along with 
the estimates in figures and tables in this report.

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, as applicable;

* Tuberculosis screening test (within 1 year of deployment);

* Pre-deployment immunizations:

* hepatitis A;

* influenza (within 1 year of deployment);

* measles, mumps, and rubella;

* polio;

* tetanus-diphtheria (within 10 years of deployment); and:

* typhoid (within 5 years of deployment); and:

* Immunizations required prior to deployment or in theater:

* anthrax (at least one immunization); and:

* smallpox:

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 automated immunization sources, including the Army's 
Medical Protection System (MEDPROS), the Navy's Shipboard Non-tactical 
Automated Data Processing Automated Medical System (SAMS), and the 
Air Force's Comprehensive Immunization Tracking Application (CITA). In 
those instances where we did not find a deployment health assessment, 
we concluded that the assessments were not completed. Our analyses of 
the immunization records was based on our examination of 
servicemembers' permanent medical records and immunizations that were 
in the Army's MEDPROS, the Navy's SAMS, and the Air Force's CITA. In 
analyzing our review results at each location, we considered 
documentation from all identified sources (e.g., the servicemember's 
medical record, AMSA, and immunization tracking systems) in presenting 
data on compliance with deployment health surveillance policies.

To identify whether required blood samples were drawn for 
servicemembers prior to and after deployments, we requested that the 
AMSA staff query the DOD Serum Repository to identify whether the 
servicemembers in our samples had a blood sample in the repository not 
older than 1 year prior to their deployment, and to provide the dates 
that post-deployment blood samples were drawn.

To determine whether the services were documenting in-theater medical 
interventions in servicemembers' medical records, we requested, at six 
of the seven installations visited for medical records review, the 
patient sign-in logs for in-theater medical care providers--such as the 
Army's and Marine Corps' battalion aid stations--when they were 
deployed to Southwest Asia in support of OIF. At the Army and Marine 
Corps locations, we randomly selected sick call visits from non-
automated patient sign-in logs, but we randomly selected visits from 
the automated Global Expeditionary Medical Support (GEMS) at Moody Air 
Force Base and from the automated SAMs at the Naval Construction 
Battalion Center. 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 Standard Form 600--of the servicemember's 
visit to the in-theater medical care providers.

To determine whether the service's deployment health-related records 
were retained and maintained in a centralized location, we requested 
that officials at the AMSA query the AMSA database for the 
servicemembers included in our samples at the selected 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. To identify the completeness of servicemember 
medical records, we then compared the data identified from the AMSA 
queries with the data we found during our medical records review.

To determine whether DOD has established an effective quality assurance 
program for ensuring that the military services comply with force 
health protection and surveillance policies, we interviewed officials 
within the Deployment Health Support Directorate, the offices of the 
services' Surgeons General, and at the installations we visited for 
medical records review about their internal management control 
processes. We also reviewed quality assurance policies and other 
documentation for ensuring compliance with force health protection and 
surveillance requirements.

We took several steps to ensure the reliability of the data we used in 
our review. DOD electronic lists of servicemembers who either deployed 
or redeployed within certain time frames were used to generate random 
samples for which primary data was then collected. It was our premise 
that no systematic errors for inclusion or exclusion of cases in the 
database existed and the randomness of the sample generated controlled 
for those records selected for review. The final universe for which 
sample size was based was adjusted to account for out-of-scope cases. 
In addition, we took mitigating measures to (1) avoid relying 
exclusively on the automated databases and (2) identify and resolve 
inconsistencies, as described below:

Personnel Deployment Databases. Because of concerns about the 
reliability of deployment data maintained by the Defense Manpower Data 
Center, we requested, in consultation with officials at the Deployment 
Health Support Directorate, personnel deployment data from the military 
installations selected for medical records review. DOD officials 
believed that the military installations were the most reliable sources 
for accurate personnel deployment data because servicemembers are 
deployed from, or redeployed to, these sites. However, we decided to be 
alert for indications of errors as we reviewed servicemember medical 
records and to investigate situations that appeared to be questionable.

Automated Immunization Databases. Service policies require that 
immunizations be documented in the servicemember's medical record. For 
the most part, immunizations are documented on Department of Defense 
Form 2766. The services also use automated immunization systems--the 
Army uses MEDPROS, the Air Force uses CITA, and the Navy/Marine Corps 
use SAMS. We did not rely exclusively on either of these sources 
(Department of Defense Form 2766 or automated immunization systems). 
For servicemembers in our samples, we reviewed both the servicemembers' 
medical records and queries of the services' automated immunization 
system for each servicemember. If we found documentation of the 
required immunizations in either source, we considered the immunization 
documented because it was evident that the immunization was given.

AMSA Centralized Database. DOD policy requires that pre-and 
post-deployment health assessments be documented in the servicemember's 
medical record and also that a copy be sent to AMSA for inclusion in 
the centralized database. We did not rely exclusively on the AMSA 
centralized database for determining compliance with force health 
protection and surveillance policies. For servicemembers in our 
samples, we reviewed both the servicemember's medical record and 
queries of the AMSA centralized database for health assessments and 
immunizations for the servicemember. If we found documentation of the 
required pre-or post-deployment health assessments or immunizations in 
either source, we considered the servicemember as having met the 
requirement for health assessments and immunizations.

Our review was performed from November 2003 through August 2004 in 
accordance with generally accepted government auditing standards.

[End of section]

Appendix II: Comments from the Department of Defense:

THE ASSISTANT SECRETARY OF DEFENSE:
HEALTH AFFAIRS:

WASHINGTON, D. C. 20301-1200:

Mr. Derek B. Stewart: 
Director:
Defense Capabilities and Management:
United States Government Accountability Office: 
Washington, DC 20548:

NOV 4 2004:

Dear Mr. Stewart:

This is the Department of Defense (DoD) response to the GAO draft 
report, GAO-05-120, "DEFENSE HEALTH CARE: Force Health Protection and 
Surveillance Policy Compliance Was Mixed, but Appears Better for Recent 
Deployments," dated October 20, 2004 (GAO Code 350469).

The Department concurs with the findings of this report. We are pleased 
your review confirmed notable improvements in compliance with force 
health protection and surveillance requirements for Operation Iraqi 
Freedom. To more accurately reflect those improvements, we would 
respectfully suggest the word "Appears" be removed from the title of 
the report.

We believe there is ample evidence that compliance clearly has improved 
with force health protection and surveillance requirements. We are 
aware of variations in progress among the Services, and are committed 
to demonstrating full compliance through the continued application of 
aggressive quality assurance measures. In particular, we are focusing 
on and supporting recent policy efforts by the Marine Corps to improve 
their deployment health quality assurance program. Accordingly, plans 
have already been initiated to conduct a joint quality assurance visit 
to Camp Pendleton, CA in early 2005, following the implementation of an 
improved Quality Assurance program and the return of significant 
numbers of Marines currently deployed in support of Operation Iraqi 
Freedom.

The Department appreciates the opportunity to comment on this GAO draft 
report. My points of contact are Dr. Michael Kilpatrick at 703-578-8510 
(functional) and Mr. Gunther Zimmerman (audit liaison) at 703-681-3492.

Sincerely,

Signed by: 

William Winkenwerder, Jr., MD: 

[End of section]

Appendix III: GAO Contact and Staff Acknowledgments:

GAO Contact:

Clifton E. Spruill (202) 512-4531:

Acknowledgments:

In addition to the individual named above, Steve Fox, Rebecca Beale, 
Margaret Holihan, Lynn Johnson, Susan Mason, William Mathers, Clara 
Mejstrik, Christopher Rice, Terry Richardson, Kristine Braaten, 
Grant Mallie, Jean McSween, Julia Matta, John Van Schaik, and R.K. Wild 
made key contributions to this report.

FOOTNOTES

[1] Section 765 of Pub. L. 105-85 amended title 10 of the United States 
Code by adding section 1074f.

[2] See GAO, Defense Health Care: Quality Assurance Process Needed to 
Improve Force Health Protection and Surveillance, GAO-03-1041 
(Washington, D.C.: Sept. 19, 2003); and Defense Health Care: DOD Needs 
to Improve Force Health Protection and Surveillance Processes, GAO-04-
158T (Washington, D.C.: Oct. 16, 2003).

[3] Problems cited in our May 1997 report included the following: 
required medical assessments not prepared for many servicemembers; 
incomplete medical record keeping; an incomplete centralized health 
assessment database; and an inaccurate personnel deployment database. 
See GAO, Defense Health Care: Medical Surveillance Improved Since Gulf 
War, but Mixed Results in Bosnia, GAO/NSIAD-97-136 (Washington, D.C.: 
May 13, 1997).

[4] This request also asked us to examine how the Department of 
Veterans Affairs and DOD are collaborating to provide physical exams 
for servicemembers who leave the military and apply for service-
connected disability compensation. See GAO, VA and DOD Health Care: 
Efforts to Coordinate a Single Physical Exam Process for Servicemembers 
Leaving the Military, GAO-05-64 (Washington, D.C.: Nov. 12, 2004).

[5] Throughout this report, we refer to all of our sample or universe 
selections of medical records at the installations we visited as 
"samples."

[6] The Army Medical Surveillance Activity is DOD's executive agent for 
collecting and retaining the military services' deployment 
health-related documents--including the pre-deployment and 
post-deployment health assessments and immunizations.

[7] GAO-03-1041.

[8] All percentage estimates from our sample review of medical records 
have 95 percent confidence intervals that are displayed in tables and 
figures presented in this report.

[9] GAO, Military Personnel: DOD Needs to Address Long-term Reserve 
Force Availability and Related Mobilization and Demobilization Issues, 
GAO-04-1031 (Washington, D.C.: Sept. 15, 2004).

[10] GAO-03-1041.

[11] GAO/NSIAD-97-136.

[12] Section 765 of Pub. L. 105-85 amended title 10 of the United 
States Code by adding section 1074f.

[13] DOD Instruction 6490.3, "Implementation and Application of Joint 
Medical Surveillance for Deployments," August 7, 1997.

[14] Under Secretary of Defense for Personnel and Readiness Memorandum, 
"Enhanced Post-Deployment Health Assessments," April 22, 2003.

[15] GAO-03-1041.

[16] Office of the Chairman, the Joint Chiefs of Staff, Memorandum MCM-
0006-2, "Updated Procedures for Deployment Health Surveillance and 
Readiness," February 1, 2002.

[17] The Joint Staff, Joint Staff Memorandum MCM-0006-2.

[18] U.S. Central Command, MOD 3 TO DEPLOYMENT GUIDANCE (Mar. 30, 2003) 
and MOD 4 TO USCINCCENT: Individual Protection and Individual/Unit 
Deployment Policy (July 18, 2003).

[19] U.S. Central Command, "Personnel Policy Guidance for 
U.S. Individual Augmentation Personnel in Support of Operation Enduring 
Freedom," October 3, 2001.

[20] Under Secretary of Defense for Personnel and Readiness Memorandum, 
"Enhanced Post-Deployment Health Assessments," April 22, 2003.

[21] Office of the Chairman, The Joint Chiefs of Staff, Memorandum MCM-
0006-02, "Updated Procedures for Deployment Health Surveillance and 
Readiness," February 1, 2002.

[22] Air Force Joint Instruction 48-110, Army Regulation 40-562, Bureau 
of Medicine and Surgery Instruction 6230.15 and Coast Guard Commandant 
Instruction M6230.4E, "Immunizations and Chemoprophylaxis," May 12, 
2004.

[23] Army Regulation 40-66, "Medical Records Administration," October 
23, 2002, Air Force Instruction 41-210, "Health Services Patient 
Administration Functions," October 1, 2000, and Department of the Navy 
NAVMED P-117, "Manual of the Medical Department," December 23, 1994.

[24] Office of the Chairman, The Joint Chiefs of Staff, Memorandum MCM-
0006-02, "Updated Procedures for Deployment Health Surveillance and 
Readiness," February 1, 2002.

[25] DOD plans to deliver full capability to all health facilities at 
all installations by 2008.

[26] GAO-03-1041.

[27] In comparing compliance rates for OIF and OEF/OJG, the data for 
OIF were limited in some instances to only one sample at one 
installation. We caution that the reader should recognize the 
limitations of this comparison.

[28] H.R. Rep. No. 108-106 at 336 (2003).

[29] GAO-03-1041.

[30] GAO-04-158T.

[31] We selected this time frame after consultation with service and 
Deployment Health Support Directorate officials, because it was after 
the revised DOD policy requiring an enhanced post-deployment health 
assessment and a post-deployment blood serum sample effective in May 
2003. 

[32] We selected Fort Eustis, Va., because Army reserve units had 
mobilized at the installation for deployments to Iraq in support of 
OIF.

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