House of Representatives Committee on Veterans Affairs
Subcommittee on Health
Statement by Dr. William Winkenwerder, Jr.
Assistant Secretary of Defense for Health Affairs
March 27, 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
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
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
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)
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
Our Deployment Health Support Directorate is in the process of developing
DoD-wide systems for quality assurance of medical record keeping and medical
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
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.
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
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
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.