House of Representatives Committee on Government Reform
Subcommittee on National Security, Emerging Threats,
and International Relations

Statement by Dr. William Winkenwerder, Jr.
Assistant Secretary of Defense for Health Affairs

March 25, 2003

Mr. Chairman and members of this distinguished committee, thank you for the opportunity to be here today and thank you for your continuing support of the men and women who have served in our Armed Forces.

As the Assistant Secretary of Defense for Health Affairs, safeguarding the health and safety of our military members is my highest priority. Our Force Health Protection program has made great strides, based on the lessons learned from Operation Desert Storm. I believe our efforts are in line with your own objectives, as expressed in Public Law 105-85. Force Health Protection is a strategy that applies to the continuum of medical care experienced by each Service member from entrance into the military to separation from the military and transition in many cases to the VA healthcare system. The vigorous requirements of the medical entrance physical examination, the periodic physical examinations, periodic HIV screening, annual dental examination, physical training and periodic testing, and the regular medical record reviews are parts of this continuum.

In order to clarify our program, I will address the requirements of Public Law 105-85 individually, and then explain our actions that go beyond what that law requires.

Public Law 105-85 - Section 765 (a) - Improved tracking system

Our actions are based on two primary medical tracking policy documents. DoD Instruction 6490.3, August 7, 1997, Implementation and Application of Joint Medical Surveillance for Deployments, implements policy and procedures, and assigns responsibilities for joint military medical surveillance in support of all applicable military objectives. It describes routine military medical surveillance activities during major deployment, or deployments in which there is a significant risk of health problems. Updated Procedures for Deployment Health Surveillance and Readiness provides standardized procedures for assessing health readiness and conducting health surveillance in support of all military deployments.

Based on those policies, the DoD has taken steps to improve deployment-related medical record keeping by developing the Composite Health Care System II (CHCS II) and the Theater Medical Information Program (TMIP), and by expanding the electronic tracking and centralized collection of immunization data. Electronic tracking of immunizations was initially implemented for the Anthrax Vaccine Immunization Program (AVIP) in 1998, using Service-specific automated systems. Efforts are underway by the Services to electronically track all immunizations and to centralize collection of immunization data for surveillance and research purposes.

The Defense Medical Surveillance System (DMSS) has been established under the Army Center for Health Promotion and Preventive Medicine (CHPPM) to provide improved DoD joint health surveillance capabilities. Operated by the Army Medical Surveillance Activity (AMSA), the DMSS database contains historical and up-to-date data on diseases and medical events such as hospitalizations, and ambulatory visits, as well as longitudinal data on personnel and deployments.

The Services have begun implementation of health surveillance and computerized medical record keeping during deployments, allowing for surveillance of health events as well as documentation of health care and countermeasures utilized during deployment. The TMIP, which is currently undergoing testing, will gather individual medical information throughout operational deployments. This information will help to document deployment-related health problems and can be shared with the VA to facilitate continuity of care for veterans.
In the past few months, DoD has developed and implemented the Joint Medical Work Station. This is the most recent addition to our capability to monitor the health status of our deployed forces. Using the Force Health Protection portal to our classified system, DoD now has the electronic capability to capture and disseminate near real-time information to commanders about in-theater medical data, patient status, environmental hazards, detected exposures and critical logistics data such as blood supply, beds and equipment availability.

For longitudinal study, one important health surveillance initiative prompted by post-Gulf War health issues is the monitoring of birth defects among DoD beneficiaries through establishment of a birth defects registry. This registry has been established and is a valuable resource. Another is the use of the DoD Serum Repository for routine and pre-deployment collection and storage of serum specimens, which are subsequently available for analysis regarding military- and deployment-related health concerns.

In addition, the Millennium Cohort Study is an ongoing comprehensive DoD health research initiative that responds to concerns about whether deployment-related exposures are associated with post-deployment health outcomes. A cross-sectional sample of 100,000 military personnel and veterans will be studied prospectively over a 21-year period.
Section 765 (b) - Predeployment medical examinations and postdeployment medical examinations

The DoD has instituted a deployment health surveillance program that includes pre-deployment and post-deployment health assessments which documents individuals' medical readiness to deploy and address health concerns upon their return, along with improved occupational and environmental health surveillance programs for protecting Service members' health during deployment.

Deploying personnel receive individual health assessments that are documented on DD Form 2795, Pre-Deployment Health Assessment. Individual pre-deployment health assessments include eight questions and further include reviews of required immunizations and other protective medications/measures, personnel protective and medical equipment, DNA and serum (HIV) samples (preserved in the DoD Serum repository), dental classification, and briefings on deployment-specific health threats and countermeasures.

Redeploying personnel receive individual health assessments that are documented on DD Form 2796, Post-Deployment Health Assessments. These assessment forms include questions on health and exposure concerns. Medical personnel review the forms and positive responses result in a review of deployment health records and appropriate referral for follow-up care.

Follow-up health care is also available through military and VA providers using the jointly-developed Post-Deployment Health Clinical Practice Guideline, which has been designed specifically for addressing deployment-related health concerns. The guideline provides a structure for the evaluation and management of Service members and veterans with deployment-related concerns. It also provides access to expert clinical support to physicians and other health care professionals for patients with challenging symptoms and illnesses, and may provide a useful platform for research into post-deployment health concerns. The post-deployment health care process is managed by the DoD Deployment Health Clinical Center (DHCC) located at Walter Reed Army Medical Center.
Section 765 (c) - Improved medical record keeping
The original deployment health assessment forms are placed in the Service member's permanent medical record. Copies of the forms are sent to the Army Medical Surveillance Activity, where the forms are scanned and the data entered into the Defense Medical Surveillance System for archiving and analysis.

Immunizations are tracked by specific systems within the Services and the data is fed into the Defense Eligibility Enrollment Reporting System (DEERS). The Army's Medical Protection System (MEDPROS), and the Navy's Shipboard Automated Medical System (SAMS) are partially implemented. The Air Force Comprehensive Immunization Tracking System (AFCITA) is fully implemented. We have developed DD Form 2766 as the standard form in the medical record for recording essential readiness indicators. This form accompanies the deploying Service member.

We are currently transitioning from paper based medical records to automated medical records for patient encounters and disease non-battle injury (DNBI) reporting.
Section 765 (d) - Quality assurance
Currently, quality assurance is being executed by the individual Services. The Air Force has included deployment health quality assurance in their medical Inspector General inspection checklist. The Army Surgeon General has recently sent out a memo requiring audits of medical surveillance records.

Our Deployment Health Support Directorate is in the process of developing DoD-wide systems for quality assurance of medical record keeping and medical surveillance data.

Section 767 - Tracking Service member location

As previously reported, TMIP has been partially implemented and DoD has implemented an interim deployment medical surveillance system, the force health protection portal. In the future, TMIP developments will tie into the Defense Manpower Data Center that will capture data on unit and individual locations. TMIP will also tie into operational, personnel and medical data systems that will capture information on possible harmful exposures or health related events. The Defense Integrated Military Human Resource System (DIMHRS) will ultimately receive and archive both medical and personnel information. DIMHRS is several years away from implementation, but an interim solution is in progress. DoD is also in the process of developing individual medical readiness standards and looking at developing a comprehensive DoD health surveillance system.

Section 768 - Specialized units for monitoring chemical/biological hazards

The DoD now routinely deploys preventive medicine, environmental surveillance, and forward laboratory teams in support of worldwide operations. For example, the Army's Center for Health Promotion and Preventive Medicine (CHPPM ) conducts pre- and during-deployment environmental health intelligence studies for the battlefield, and performs extensive environmental assessments of operationally selected staging areas and base sites. CHPPM also supplies environmental sampling materials for deployed forces, conducts operational risk management estimates for field commanders, and develops pocket-sized "staying healthy" guide books for deployed Service members.

Additional efforts

Beyond the actions required by Congress, DoD has taken several steps that we believe to be vital for the protection of the health of deployed service members. For example, the DoD has established three deployment health centers. One is focused on deployment health surveillance, another on deployment health care, and the third on deployment health research. These centers are concentrating their efforts on the prevention, treatment, and understanding of deployment-related health concerns.
The DoD has improved health risk communication through the provision of regionally specific medical intelligence, environmental risk assessments, medical threat briefings, pocket-sized health guides, and deployment-focused web sites.
We are developing improved health protection measures to counter an increasingly broad range of threats. Such measures include the fielding of new biological and chemical warfare agent detection and alarm systems; the operational testing of integrated electronic medical surveillance and emergency response networks; current vaccines and anti-malarial drugs; and research on the next generation vaccines and pharmaceuticals.

In addition to pre- and post-deployment health assessments, the military medical departments incorporate routine health and medical readiness appraisals to ensure service members meet and maintain health standards. A complementary effort is underway to develop standardized DoD-wide individual medical readiness indicators.

Mr. Chairman, this concludes my statement. I thank you and the members of this committee for your outstanding and continuing support for the men and women of the Department of Defense.