House Committee on Veterans Affairs
Subcommittee on Health

Statement by Ms. Ellen Embrey

Deputy Assistant Secretary of Defense for Force Health Protection and Readiness Department of Defense

February 27, 2002

Mr. Chairman, I appreciate the opportunity to return to the House Veterans Affairs' Subcommittee on Health to discuss the Department of Defense's continuing efforts to improve its force health protection and to address the concerns of the General Accounting Office in its testimony provided for the record at your hearing on January 24, 2002. The Department appreciates the comments and suggestions of the GAO, and we recognize that even with the significant progress we have made in force health protection since the Gulf War, there is still much to do.

First, let me reiterate that the Department of Defense is committed to providing a world-class health care system for its servicemembers and their families. The Department's goal-and my primary focus-is to ensure that we deploy fit and healthy military personnel, that we monitor, their health and environmental exposures while they are deployed, and that we assess their health status and address their health concerns when they return. To that end, both the Office of the Secretary of Defense and the Joint Chiefs of Staff have issued policy to help define and standardize force deployment health protection, particularly health surveillance, for our servicemembers.

The August 1997 Department of Defense Directive 6490.2, "Joint Medical Surveillance," and Department of Defense Instruction 6490.7, "Implementation and Application of Joint Medical Surveillance for Deployments," set out health surveillance requirements. An Assistant Secretary of Defense for Health Affairs memorandum dated October 25, 2001, updated the policy for pre- and post-deployment health assessments and blood samples. Data from these assessments are maintained by the Defense Medical Surveillance System at the U.S. Army Center for Health Promotion and Preventive Medicine. A Chairman, Joint Chiefs of Staff memorandum, MCM-251-98 (December 4, 1995), "Deployment Health Surveillance and Readiness," spelled out the conceptual framework for force health protection with health surveillance as a critical component. A new CJCS memorandum MCM-0006-02 (February 1, 2002), "Updated Procedures for Deployment Health Surveillance and Readiness," takes effect on the first of March. It supersedes and updates MCM-251-98 and provides standardized procedures for assessing health readiness and conducting health surveillance in support of all military deployments. In addition, it requires the combatant command to determine the need for deployment specific medical countermeasures, including immunizations, chemoprophylactic medications, and other individual personal protective measures.

As a result, we collect and archive health data that.will allow retrospective analysis by DoD and the VA for those servicemembers who deploy and subsequently become ill. Building comprehensive systems that serve these purposes is neither easy nor quick. The necessary pieces of such systems are in various stages of design and implementation. For convenience, I will divide them into actions to be taken before, during, and after periods of deployment.

Health Care Before Deployments

Upon entry to the armed services, each military member must first pass a rigorous physical examination, which includes blood tests. Servicemembers must then pass periodic physical examinations, again with blood tests; annual dental examinations; and annual medical record reviews to update routine immunizations. DoD is piloting the Recruit Assessment Program (RAP) to develop a baseline of health on entry to the military, and perhaps allow us to make early interventions that will better protect our people from deployment-related illnesses. The Health Evaluation Assessment Review (HEAR) is another routine self-assessment of health for all military healthcare beneficiaries. These programs facilitate establishment of baseline health status for servicemembers and help ensure the medical readiness of military personnel to deploy worldwide in support of mission requirements. The pre-deployment health assessment is an addition to this system. Advances in health information management and technology are being aggressively pursued and applied in the Military Health System (MHS). Such initiatives include the next generation DoD Composite Health Care System (CHCS II) and automated immunization tracking and recording systems. In collaboration with the Department of Veterans Affairs, we are implementing the GAO's recommendations and initiating the Federal Health Information Exchange, previously known as the Government Computerized Patient Record or GCPR.

Health Care During Deployments

During deployments, health treatment is typically documented in an abbreviated, standardized individual medical record that is prepared and deployed with Army and Air Force servicemembers, while health care for Navy and Marine Corps servicemembers is documented in their outpatient medical records. Health surveillance information, including Disease and Non-Battle Injury (DNBI) data and inpatient and outpatient biostatistics, are routinely collected, reported, analyzed for adverse trends, and archived for future reference and research as part of the Defense Medical Surveillance System (DMSS). Significant health-related events, such as exposures to occupational and environmental hazards or chemical and biological warfare agents, are also documented to ensure that individual health records can be linked to exposure records.

While the majority of health care documentation during today's deployments is contained in paper-based medical records, we are continuing to focus on the development of automated systems such as the Theater Medical Information Program (TMIP). We are in the initial phase of field testing TMIP and will include the deployable version of the next generation Composite Health Care System (CHCS II), as well as the Transportation Command Regulating and Command and Control Evacuation System (TRAC2ES). TMIP will integrate health data on deployed personnel and function as the medical component of DoD's Global Combat Support System. We have also selected the Common Access Card Electronic Information Carrier as the automated device for documenting individual health data and treatment in theater

Health Care After Deployments

At the end of a deployment, servicemembers will complete a post-deployment health assessment to document any immediate concerns or symptoms. The DoD anticipates there will be servicemembers who, despite the best preventive efforts, may become ill following deployment. A newly implemented Post-deployment Clinical Practice Guideline will focus DoD and Veteran's Affairs' health care providers on appropriately caring for individuals who have deployment-related health concerns. The DoD will also continue to monitor post-deployment health through research studies like the Millennium Cohort Study and through registries like the DoD Birth Defects Registry. DoD also analyzes trends of diagnoses for all inpatient and outpatient healthcare. With proper collection and archiving of this health information, the DoD should enhance its ability to detect long-term changes in the health of servicemembers, as well as provide better information for transfer to the VA.

Tracking the Movement of Servicemembers

In addition to the Department's efforts to improve health care before, during, and after deployments, we recognize the need to improve our ability to relate the location of servicemembers during a deployment with possible toxic exposures or environmental hazards. The GAO is correct - we do not have a single system to track movement of servicemembers within the deployment theater. From our experience in analyzing possible Gulf War exposures, we recognized fully the importance of tracking individual servicemember and unit locations over time. I believe we have made steady, significant progress against this requirement.

As much as I would like to report that we know "who was where when," I must underscore that this is a complex problem. Today, we cannot field practical, mission-compatible technologies that would permit capturing, recording, and, archiving data on where each servicemember is to square-meter accuracy, minute by minute. At present, we assign people to units and identify unit locations. Personnel systems record individuals' unit assignments. Tracking unit locations is an operational responsibility with reporting in separate channels. In addition, fluid contingency deployment situations involve troops accompanying or being temporarily attached to units other than their own. Unit location data generally is classified when prepared and particularly sensitive for special operations forces like those used extensively in Afghanistan. Furthermore, unit-level locations may not always translate into servicemember locations. For instance, platoon-level or squad-level elements can operate miles from their assignment unit's main location.

We also have fielded, planned, or have under development future capabilities that should help overcome the remaining challenges. For example, the Global Status of Resources and Training System permits the combat commanders and the Joint Staff to regularly track units' status and locations. We are now archiving these data monthly. The Joint Personnel Asset Visibility system, under development as part of the larger Joint Total Asset Visibility system, will greatly assist in tracking servicemembers deploying to or from contingencies, including medical evacuations. The Personnel Tempo reporting system also will feed individual's location and unit of assignment data to .the DoD archive database. The Defense Integrated Military Human Resources System (DIMHRS) will eventually replace about 80 separate Service personnel systems. When fully implemented, DIMHRS will provide uniform information

availability on individual assignments and many other personnel aspects with unprecedented accuracy and detail. DIMHRS has provisions for regular data archiving. As we improve real time environmental surveillance and when technology becomes capable of validating environmental exposures from individual sampling, detailed location tracking data may become less critical.

Environmental Surveillance

Again, we agree with GAO that the establishment of the U.S. Army Center for Health Promotion and Preventive Medicine was a major improvement to the ability of the Department to monitor, track, and warn of environmental hazards. Its work has continued for the current deployment assisting commanders prepare servicemembers before deployment. For example, the Center has developed several "Staying Healthy Guides" for several countries/regions, including Afghanistan/Pakistan, Central Asia, Southwest Asia, and other countries. These documents and others are included on a web site for Operation Enduring Freedom. The site identifies numerous guidance documents on deployment related issues such as force health protection, environmental exposures, pest management issues, and retrograde issues. Links to other sites are also provided.

The Center is continuing occupational and environmental health surveillance measures in support of Department of Defense medical units deployed for Operation Enduring Freedom. It conducts pre-deployment and during-deployment environmental health intelligence preparation of the battlefield measures through the development of industrial hazard assessments for planned and identified base camps or forward operating bases. The Center collaborates with the Armed Forces Medical Intelligence Center in producing these assessments, which are classified. The Center is providing deployed medical units with occupational and environmental health surveillance equipment sets, which contain sampling equipment, media, and administrative supplies, so that air, water, and soil field samples can be collected. In addition, it is conducting operational risk management estimates for base camps and forward operating bases where occupational and environmental health surveillance field samples have been collected and analyzed. This involves the assimilation and comparison of the analyzed field sample results to military exposure guidelines, where any identified medical and/or health threats are assessed. Appropriate conclusions and recommendations are communicated to the Commander in operational risk management terminology. In summary, these activities support Force Health Protection measures outlined in Department of Defense Joint Medical Surveillance Directives and US Central Command Force Health Protection guidance.

In conclusion, I believe the Department of Defense has made great progress to meet the needs for medical surveillance, but we are not satisfied. We will continue to pursue initiatives that will enhance our ability to establish a comprehensive medical surveillance system for our deployed forces and a world-class health care system for our servicemembers, veterans, and their families.

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