[Presidential Directives and Executive Orders]

About the National Science and Technology Council

President Clinton established the National Science and Technology Council (NSTC) by Executive Order on November 23, 1993, and he serves as Chairman. This Cabinet-level council is the principal means for the President to coordinate science, space and technology policies across the Federal Government. The NSTC acts as a "virtual" agency for science and technology to coordinate the diverse parts of the Federal research and development enterprise. Membership consists of the Vice President, Assistant to the President for Science and Technology, Cabinet Secretaries and Agency Heads with significant science and technology responsibilities, and other White House officials.

An important objective of the NSTC is the establishment of clear national goals for Federal science and technology investments in areas ranging from information technologies and health research to improving transportation systems and strengthening fundamental research. The Council prepares research and development strategies that are coordinated across Federal agencies to form an investment package that is aimed at accomplishing multiple national goals.

To obtain additional information regarding the NSTC, contact the NSTC Executive Secretariat at 202-456-6100.
 

About the Office of Science and Technology Policy

The Office of Science and Technology Policy (OSTP) was established by the National Science and Technology Policy, Organization and Priorities Act of 1976. The OSTP's responsibilities include advising the President in policy formulation and budget development on all questions in which science and technology are important elements; articulating the President's science and technology policies and programs; and fostering strong partnerships among Federal, State and local governments, and the scientific communities in industry and academe.
 
 

We have a national obligation to protect to the extent possible the health of our military, veterans, and their families. Those we place in harm’s way to protect the national interest deserve the best. The 1991 Gulf War highlighted both our successes and failures. Even though the number of casualties, in the traditional sense, was low, Federal agencies responsible for the health of our troops were not prepared to deal with the health issues that followed the War’s completion.

Federal agencies discovered numeroushealth related deficiencies in monitoringthe health of deployed troops. For example, our record keeping capabilities were not designed to track troop and asset movements to the degree needed to determine who might have been exposed to any given environmental or wartime health hazard. Seven years later, we just now have a complete accounting of who was actually deployed to the Gulf.

In addition, we discovered major deficiencies in the way we approach health risk communication. While the desire is strong to disseminate all relevant health information to the affected groups as soon as possible, we must ensure that information is delivered in a way that is understandable and causes neither unwarranted concern nor undue complacency. We must ensure that even during wartime situations, the military leadership ensures accurate communication of risks associated with countermeasures, such as vaccines, and maintenance of accurate records.

Our Nation’s research programs also must be well coordinated and designed to fill gaps in our knowledge that can be applied to improving the health of our military, veterans, and their families. Here, coordination across Federal research agencies is required to ensure that scarce research dollars are spent in a way that addresses the special health needs associated with troop deployments.

The President is committed to heeding the lessons learned in the 1991 Gulf War and subsequent deployments in Bosnia, Haiti, Rwanda, and Somalia. The plan detailed in this report reflects that commitment. This plan provides a blueprint for coordination among Federal agencies and proposes strategies to correct deficiencies in our current state of military readiness and for improving health care for our military, veterans, and their families.
 
 

Improving the Health of Our Military, Veterans, and Their Families iii

Executive Summary vii

Chapter 1: Introduction

Appendix B: PRD/NSTC-5 Interagency Working Group and Task Forces

Appendix C: Establishment of NSTC/PRD-5

Appendix D: List of Abbreviations
 
 

We have a national obligation to protect to the extent possible the health of our military, veterans, and their families. Those we place in harm’s way to protect the national interest deserve the very best. The 1991 Gulf War highlighted both our successes and failures. Even though the number of casualties, in the traditional sense, was low, Federal agencies responsible for the health of our troops were not prepared to deal with the health issues that followed the War’s completion.

Federal agencies discovered numerous health related deficiencies associated with troop deployments. For example, our record keeping capabilities were not designed to track troop and asset movements to the degree needed to determine who might have been exposed to any given environmental or wartime health hazard. Seven years later, we just now have a complete accounting of who was actually deployed to the Gulf.

In addition, we discovered major deficiencies in the way we approach health risk communication. While the desire is strong to get all relevant health information out to the affected groups as soon as possible, we must ensure that information is delivered in a way that is understandable and causes neitherunwarranted concern nor undue complacency. We must ensure that even during wartime situations, health care professionals accurately communicate risks associated with countermeasures, such as vaccines, and maintain accurate records.

Our Nation’s research programs also be well coordinated and designed to fill gaps in our knowledge that can be applied to improving the health of our military, veterans, and their families. Here, coordination across Federal research agencies is required to ensure that scarce research dollars are spent in a way that addresses the special health needs associated with troop deployments.

The President is committed to heeding the lessons learned in the 1991 Gulf War and subsequent deployments in Bosnia, Haiti, Rwanda, and Somalia. The plan detailed in this report reflects that commitment. This plan provides a blueprint for coordination among Federal agencies and proposes strategies to correct deficiencies in our current state of military readiness and for improving health care for our military, veterans, and their families.
 
 

The Federal Government has an unwavering obligation to care for those placed in harm’s way to defend the vital interests of the Nation. Therefore, the Federal Government must be able to respond promptly and effectively to the health needs of our military, veterans, and their families. In particular, when health problems are identified following a military deployment, plans must be in place to improve and facilitate cooperation and coordination among the Departments of Defense (DoD), Veterans Affairs (VA), and Health and Human Services (DHHS), as well as among other appropriate agencies of the Executive Branch. This report provides the first comprehensive set of recommendations designed to help ensure that this obligation is met in a manner that takes into consideration the successes and failures of past deployments.

INTRODUCTION

Because of the subsequent health issues associated with veterans who served in the Gulf War, President Clinton established the Presidential Advisory Committee on Gulf War Veterans’ Illnesses (PAC) on May 26, 1995. This Committee was to ensure an independent, open and comprehensive examination of health concerns related to Gulf War service. The Committee issued its Final Report on December 31, 1996, which documented its review of the government’s outreach, medical care, research, efforts to protect against and to assess exposure to chemical and biologicalweapons warfare, and coordination activities pertinent to Gulf War veterans’ illnesses.

The Committee recommended that the National Science and Technology Council (NSTC) develop an interagency plan to address health preparedness for and readjustment of veterans and families after future conflicts and peacekeeping missions. Presidential Review Directive (PRD)/NSTC-5 responds to the Committee’s recommendation. In particular, PRD/NSTC-5 directs DoD, VA, and DHHS to review policies and programs and develop a plan that may be implemented by the Federal government to better safeguard those individuals who risk their lives to defend our Nation’s interests. The plan was to focus on existing policies and lessons learned from the Gulf War and other recent deployments such as those in Bosnia, Haiti, and Somalia.

How the Plan Was Developed

An NSTC Interagency Working Group (IWG) was established to conduct the review and planning process. Members of the IWG included representatives from DoD, VA, and DHHS. The IWG oversaw the work of four task forces that focused on (1) deployment health, (2) record keeping, (3) research, and (4) health risk communications. Each task force reviewed policies and programs that relate to health preparedness of, and readjustment for, veterans and their families after future deployments. In particular, each task force considered lessons learned from the Gulf War and other recent deployments such as in Bosnia and Somalia. Each task force paid special attention to issues associated with chemical and biological weapons as well as the impact of emerging technologies and international cooperation.
 
 

Major Factors Influencing the Plan

During the review and planning process, the following major factors (other factors are identified in chapter 1) were identified that influenced the plan’s development and its potential for success:

• Deployment can encompass a wide range of missions. Historically, most veterans’ health and benefit issues related to service in combat operations. Now, U.S. forces are more likely to deploy into non-combat environments such as peacekeeping, peacemaking, humanitarian assistance, or training.

• There is a division of responsibilities between DoD and VA for the health and health care of military service members and veterans of military service. The two Departments function under distinct titles of U.S. Code and distinct congressional oversight. In addition, DHHS has responsibility in cooperation with state and community governments for overall public health in the United States.

• Veterans’ response to present and future health and benefit issues and governmental actions may be tempered by a long history of military members’ experiences with government and military leadership, and by their frequent mistrust of and lack of confidence in government actions and motives.

• The evolution of science, medicine, and societal perceptions regarding health and illness limits our ability to predict the future reality and expectations regarding health, acceptable risks, disease prevention tools, and illness.

• The current expectation is for far fewer casualties than in the past forthe types of most missions we are likely to undertake.

Extensive review and analysis of Gulf War veterans’ illnesses and risk factors by government agencies, the Presidential Advisory Committee, and other groups have identified a number of opportunities for government action aimed at minimizing or preventing future post-conflict health concerns. Actions to ameliorate, avoid, or, ideally, prevent such health effects include: improving service members' understanding of health risk information; improving medical and non-medical countermeasures; enhancing government collection of health and exposure data, along with improving linkages among health information systems; coordinating agency research programs; and improving delivery of health care services to veterans and their families.

The Deployment Health Task Force (chapter 2) developed objectives and strategies to support the following five goals: (1) maintain a healthy, fit, and physically- and mentally- ready military force; (2) identify and minimize or eliminate the short- and long-term adverse effects of military service, especially service during deployments (including war), on the physical and mental health of veterans; (3) preserve the health and well-being of those who have served and their families; (4) strengthen the national strategy to protect and defend military service members from warfare and terrorism with Cchemical and Bbiological Weaponswarfare (CBW) agents; and (5) implement an effective health risk communication strategy. The Task Force highlighted the importance of recent initiatives within DoD to improve force health protection and medical surveillance especially during deployments. In addition, the Task Force addressed the need for the government to respond promptly and in a coordinated manner to both the anticipated and unanticipated health needs and concerns of veterans returning from major deployments through appropriate programs for their evaluation, health care, and benefits/compensation determinations. To prepare for future health preparedness, DoD needs to critically evaluate current force health protection programs and exploit new and emerging technologies to improve force health protection continually.

The Record Keeping Task Force (chapter 3) focused on information management (IM) and information technology (IT) issues in two broad areas: military personnel information and health information management. Improvements are needed in both these areas to ensure the accuracy, timeliness, security, and retrievability of information that must be entered into records or automated systems that document personnel or health history for active duty, National Guard, and reserve service members and veterans. The Task Force highlighted current initiatives of DoD and VA that support the objectives and strategies necessary to meet these goals.

The Research Task Force (chapter 4) established six goals with supporting objectives and strategies. The first goal is for the Federal Government to have the coordinated capability to apply epidemiological research to determine whether deployment-related exposures are associated with post-deployment health outcomes. The second goal is for the Federal Government to maintain a balanced research program targeted at: (1) improved prevention, intervention, and treatment strategies for priority health risk factors and exposures and (2) improved biologically based dose-response models. The third goal is for the Federal Government to have the capability to collect systematically population-based demographic and health data to enable longitudinal evaluation of the health of all service personnel (active duty, reservist, National Guard) throughout their military careers and after leaving military service. The fourth goal is for the Federal Government to develop the capability to collect and assess data associated with anticipated exposures during deployments. The fifth goal is for the Federal Government to establish the capability to monitor deployments for the appearance of novel or unanticipated health risks and to deploy assets quickly to collect and assess data relevant to newly identified threats. The sixth goal is for the Federal Government to maintain a wide range of national and international collaborative relationships to enhance research efforts.

The Health Risk Communications Task Force structured its review and its goals, objectives, and strategies into a guide for developing health risk communications for deploying, deployed, and returning military members, veterans, and their families (appendix A). The Task Force’s planning guide outlines the questions and actions necessary to: develop a health communication plan and select a strategy; analyze and segment intended audiences; select appropriate messages and channels; develop written communication objectives; develop a written implementation and monitoring plan; and assess the effectiveness of the plan.
 
 

RECOMMENDATIONS

The IWG identified the essential recommendations emanating from the interagency plan (chapter 5). While each task force developed strategies, which in essence are recommendations for new or continuing actions in specific areas, key recommendations must be addressed in order to meet the goals and objectives contained in this plan.

There must be ongoing coordination of all agencies involved in maintaining the health of military members (active duty, National Guard, and reservist), veterans, and their families. Therefore, the IWG recommends creation of a Military and Veterans Health Coordinating Board (MVHCB). Once established, the MVHCB would ensure coordination among VA, DoD, and DHHS on a broad range of health care and research issues relating to past, present, and future military service in the U.S. Armed Forces. The MVHCB is modeled on the Persian Gulf Veterans Coordinating Board, which is enhancing interagency coordination especially on research and clinical care related to health issues of Gulf War veterans. The MVHCB should be chaired by the Secretaries of the DoD, VA, and DHHS. Representation on the MVHCB and its working groups should include policy and program level staff from these Departments. As necessary, the MVHCB should call upon representatives from veterans’ service organizations, other governmental agencies, and civilian institutions for expert advice and consultation. Note that the U.S. Coast Guard functions as part of the U.S. Department of Transportation (DOT), except in time of war, when it becomes a part of the U.S. Navy. DOT's advice will be important in carrying out the recommendation included herein.

To succeed with many of the goals and objectives laid out in this plan the government requires ongoing direction and coordination for the Departments’ health and personnel information management and record-keeping activities, especially activities associated with deployments. The IWG recommends that DoD and VA, in consultation with DHHS, establish an ongoing interagency task force to coordinate IM/IT efforts, including the development of standards and other requirements.

In addition to the creation of these two coordinating groups (MVHCB and IM/IT Task Force), the IWG recommends the following actions:

• DoD should complete implementation of recently issued directives on joint medical surveillance and force health protection. DoD should proceed with its contract with the National Academy of Sciences (NAS) and the National Research Council (NRC) for a 3-year program of scientific, technical, and policy analysis activities entitled "Strategies to Protect the Health of Deployed U.S. Forces."

• DoD and DHHS, Food and Drug Administration (FDA) should accelerate their efforts not only to identify regulatory issues associated with the use of investigational products during military exigencies, but also develop strategies to resolve them. Although relevant in some cases, use of investigational products by civilians, for example as countermeasures for domestic terrorism, is outside the scope of this activity.

• DoD and VA, in consultation with DHHS, should establish, with appropriate confidentiality safeguards, programs that:

• Develop and maintain comprehensive electronic health and health risk factor information on all recruits and officer accessions at the time of initial military training.

• Collect and maintain military personnel data, including demographic and occupational data, and longitudinal records of service member’s military experiences, including pertinent data on occupational and environmental exposures and events.

• Support transfer of pertinent data among DoD and VA health and compensation information systems.

• VA, DoD, and DHHS should develop and implement a coordinated interagency program to communicate health risk information related to current and future deployments, especially combat operations, to military members, veterans, family members, and the public.

• DoD and VA shall maintain a robust, biomedical research, development, testing, and evaluation program emphasizing research priority areas identified in this plan.

• DoD shall ensure that military medical manpower requirements include scientists trained in the medical specialties essential for force protection research and program execution.

The Nation has a commitment to protect and care for, to the maximum extent possible, the health of military personnel, veterans, and their families. The President has vowed "to improve the health of our veterans, their families, and all who serve our Nation, now and in the future." This responsibility includes minimizing adverse health effects of military service—both those experienced during the years of military service and those that first appear years after the period of military service. The Federal Government needs to demonstrate its commitment by making sure the practices and procedures to meet this goal are in place and effectively used. In addition, our civilian and military leaders at every level of government and military services need to keep in mind the importance of meeting this commitment.
 
 

LESSONS LEARNED

The Nation and the government’s response to the health problems and concerns of veterans after their return from the Gulf War did not match the battlefield health protection successes of that war. The Departments of Defense (DoD) and Veterans Affairs (VA) did implement health and readjustment programs to address the expected post-war health problems of veterans. However, DoD and VA were not fully prepared to recognize, respond promptly, and treat the type of health problems reported by a large number of Gulf War veterans. The number of veterans wounded or injured in the line of duty was small, but new challenges included:

• The possibility of injury due to chemical and biological warfare agents;
• Concerns over chronic diseases due to infectious and toxic exposures;
• Unexplained post-deployment symptoms;
• Concerns over illnesses with long latency periods following exposure;
• Concerns over illnesses that might affect family members, close contacts and children conceived post-deployment; and
• Higher rates of motor vehicle injury and death, and of other accidental injury, among war veterans.

The evolution of our Nation’s commitment to the health and health protection of military members parallels the evolution of our concepts of wartime strategy. With superior advanced technology, military planning and operations, our wartime strategy over the past 50 years has evolved and is continuing to evolve from reliance on strong logistical support and superior numbers of personnel and equipment to a strategy of light, mobile, highly capable forces. This strategy places fewer military members in harm’s way in the traditional sense, but those few will need to be more fit, healthier, more highly trained, and more mentally resilient.

The hazards during a deployment may be the physical threats of combat, environmental extremes, injury, or illness; the physical and psychological threats of weapons of mass destruction; toxic environmental threats; or the psychological threats associated with combat, peacekeeping, refugee care, disaster relief, arduous conditions, or physical and social isolation.

The Gulf War also exposed many deficiencies in the ability to collect, maintain, and transfer accurate data describing the movement of troops, potential exposures to health risks, and medical incidents in theater. These problems were of two basic types: the lack of procedures and mechanisms to support the automated collection, maintenance, and transfer of useful information; and lapses in the process of the collection of data by personnel and health care managers in theater. Without accurate record keeping, it has been extremely difficult to get a clear picture of what risk factors might be responsible for Gulf War illnesses. It also has been difficult to ensure that appropriate service-related benefits are allocated accurately to those who served.

Many of the major health concerns and uncertainties identified after the Gulf War are similar to those associated with other major foreign deployments. The response to these concerns could have been more effective if there were a better understanding of the potential biological and toxicological associations between exposure and response. Better knowledge of biologically based relationships between specific exposures and specific health outcomes enhances: (a) analysis of potential causes of illnesses; (b) research and development on effective prevention, intervention, and treatment strategies; and (c) development of an accurate and effective health risk communication plan to inform troops about potential exposure risks. Furthermore, if epidemiological researchers had comprehensive population-based troop health assessments and exposure monitoring data and data systems, they might have been better able to define potential associations between exposures and outcomes. A coordinated research program is required to ensure that, to the extent possible, this knowledge is available for future troop deployments.

Our actions before, during, and after the Gulf War also made it apparent that we must do a much better job of health risk communication. For example, service members must understand the risks associated with countermeasures, such as vaccines. DoD and VA must routinely develop well-reasoned health risk communication strategies when attempting to convey to large numbers of veterans the potential risk associated with hazardous exposures.

The President has committed the Nation to applying to future troop deployments the lessons learned from the Gulf War and other recent military actions. He has directed DoD and VA to create a new force health protection program. He has stated that "Every soldier, sailor, airman, and marine will have a comprehensive, life-long medical record of all illnesses and injuries they suffer, the care and inoculations they receive, and their exposure to different hazards."
 
 

ESTABLISHMENT OF PRD/NSTC-5

Because of the subsequent health issues associated with Gulf War veterans, President Clinton established the Presidential Advisory Committee, on Gulf War Veterans’ Illnesses (PAC) on May 26, 1995. This Committee was to ensure an independent, open, and comprehensive examination of health concerns related to Gulf War service. The Committee issued its Final Report on December 31, 1996, which documented its review of the government’s outreach, medical care, research, efforts to protect against and to assess exposure to chemical and biological weapons, and coordination activities pertinent to Gulf War veterans’ illnesses. During the course of the Committee’s deliberations, government efforts to address and to resolve veterans’ concerns continued, consistent with respective agencies’ missions.

Extensive public review and analysis of Gulf War veterans’ illnesses and risk factors have identified a number of opportunities for government action aimed at minimizing or preventing future post-conflict health concerns. Ameliorating, avoiding or, ideally, preventing such health effects can be approached through a variety of means. These include improving service members' understanding of health risk information; enhancing government collection of health and exposure data; coordinating agency research programs; and improving the delivery of health care services to veterans and their families.

The Committee recommended that the National Science and Technology Council (NSTC) develop an interagency plan to address "health preparedness for and readjustment of veterans and families after future conflicts and peacekeeping missions." Presidential Review Directive (PRD)/NSTC-5 responds to the Committee’s recommendation. In particular, PRD/NSTC-5 directs the DOD, VA, and DHHS to review policies and programs and develop a plan that may be implemented by the Federal Government to better safeguard those individuals who risk their lives to defend our Nation’s interests.
 
 

SCOPE OF THE PLAN

The plan will focus on existing policies and lessons learned from the Gulf War and other recent deployments such as those in Bosnia, Haiti, Rwanda, and Somalia. Using the Committee’s recommendations as a guide, the plan addresses the following areas:

• Health (e.g., stress prevention, treatment, research; medical surveillance adequacy, coordination; interventions for families).
• Outreach and health risk communication.
• Record keeping (e.g., accountability, timeliness, cross-agency coordination, application of new technologies).
• Research (e.g., adequacy, quality, coordination, dissemination of results).
• Biological and chemical weapons preparedness and research.
• Application of emerging technologies (e.g., telemedicine, technology transfer).
• International cooperation and coordination, especially on research and technology matters.

An NSTC Interagency Working Group (IWG) was established to oversee the review and planning process. Members of the IWG included representatives from DoD, VA, and DHHS. Specific components of the plan were delegated to the following four task forces:

• Deployment Health: addressing health issues associated with troop deployment (pre- to post-deployment), including surveillance, monitoring, prevention, and clinical services.

• Record Keeping: addressing issues associated with record keeping, including active duty/veteran health records and other types of records that are crucial to understanding the health risks associated with hazardous environmental and occupational exposures.

• Research: identifying research priorities and identifying gaps in the current portfolio of federally funded research. Special attention was given to research needs associated with protection from chemical and biological warfare (CBW) agents.

• Health Risk Communications: incorporating lessons learned and perspectives from agencies such as the Agency for Toxic Substances and Disease Registry (ATSDR), National Institute for Occupational Safety and Health (NIOSH), and Environmental Protection Agency (EPA), along with those of DoD and VA.

FACTORS INFLUENCING THE PLAN

A significant factor influencing this plan is the inherent diversity associated with modern troop "deployments." Numerous military deployments occur each year. An individual may deploy many times during a military career. The total career deployment history for an individual is referred to as his or her deployment lifecycle. The number of military members in a specific deployment may be less than ten, several thousand, or hundreds of thousands. A deployment may last for a few days or forsix 6 months or longer. Military members may deploy to a well-supported U.S. or foreign military base in a developed country, may be on a ship making foreign port visits, or may deploy to a field setting in an urban or rural part of a developing country. The deployment missions vary. They include: military liaison and training support, joint and coalition force exercises, construction projects, humanitarian assistance (including healthcare), refuge relief, peacekeeping, peacemaking, low intensity conflict, and war, or any combination of these and other missions. Within the United States, military members "deploy" to fight forest fires, provide disaster relief, assist against terrorist actions, maintain civil order, or support drug interdiction and border patrol operations.

Another major influence on this plan is the division of responsibilities for the health and health care of military service members and veterans of military service inherent in the DoD and VA. The two Departments function under distinct Titles of United States Code and with oversight by different congressional committees. The two Departments must respond to their own legislative, regulatory and administrative mandates and restrictions in areas of eligibility for care, benefits and compensation, different missions, and budget realities. In addition, DHHS is responsible (in coordination with the States) for overall public health in the United States, manages an extensive biomedical research portfolio including diseases of military significance, maintains surveillance and registries applicable to military medicine, and has broad regulatory responsibilities [e.g., Food and Drug Administration (FDA)]Food and Drug Administration () FDA that affect the military.

The long history of military members’ experiences with government and military leadership, and the not infrequent mistrust of government actions and motives, tempers any response to present and future health and benefit issues for veterans. A mandate for the government to be responsible and accountable for actions and exposures that affect the short- and long-term health of military members and veterans requires the government to know their health status at entry into service and over the continuum of their military service and remaining life span. Real and perceived uses of the extensive data that need to be collected will lead to valid questions regarding the confidentiality of health data and the bioethical safeguards on the use of such data. In addition, efforts to protect, preserve, or enhance the health of military members may be viewed with suspicion if such measures appear to restrict retention in the military, infringe on freedom of choice, limit personal or career opportunities, pose a potential adverse health effect, or exceed current civilian norms regarding risk and benefit.

The evolution of science, medicine, and societal perceptions regarding health and illness limits our ability to predict the future reality and expectations regarding health, acceptable risks, disease prevention tools, and illness. Thus, even guided by past and present experiences, our vision of the future is limited regarding the potential health effects of military service in the next century and the tools that we will require to mitigate those health effects. Therefore, this plan must be dynamic and flexible to address unforeseen challenges and capitalize on important developments.

Finally, the plan must acknowledge the current, national expectation that, compared to military deployments during the first half of this century, most modern deployments are expected to carry much less risk to the health and well-being of those who deploy and their families. The concern with placing or keeping U.S. forces in harm’s way is not limited to going into combat and sustaining combat casualties. The current expectation influences approaches and decisions regarding military training, use or non-use of protective countermeasures, environmental hazards during deployment, psychological stresses of deployment and service, terrorist threats, and other issues. The military and civilian leadership of the government is being held to the extremely high standard of avoiding adverse health effects subsequent to military service—service that by definition, tradition, and reality is inherently hazardous.

Other important factors include:

• Budget Constraints. Budgetary constraints are a concern for any major development effort. Several of the initiatives identified in this plan have been delayed because funding for them was not programmed. Rapidly evolving technological advances can also have an impact on budgetary considerations, as can congressional actions or new legislative requirements.
• Congressional Actions. Congressional actions, especially those that change entitlements, must be addressed. Sometimes, these actions can delay other changes as available resources are redirected. New legislative mandates can also have an impact on current or future program requirements in the area of revised or more stringent procedures that can delay program milestones and subsequent systems development.
• Security Issues. The development of the databases that are required to support the information requirements must be carefully monitored to ensure that sensitive data are protected. The sensitive data may relate to either national or personnel security.
• Increasing Personnel and Operations Tempo. The current tempo of operations and increased deployment of personnel increases the potential exposure to health risks. Personnel are more likely to be participating in many different operations in varying geographic locations during their career.
• Increased Development of Chemical and Biological Weapons (CBW) agents by Other Countries. As more and more countries continue to develop CBW agents, the need to document both preventive and intervention therapies is more important.
• Compliance with Procedures and Mechanisms. There is still the potential for lapses in the established processes in areas such as data collection and health risk communication by personnel and health care managers military leadership and their medical support in theater. Such potential lapses must be addressed through training and monitoring.
• Health Care Received Outside the Military Health System (MHS). Care is often rendered outside the MHS by civilian health care providers for some active duty members, their families, and retirees, and for Reserve and National Guard members. Unless beneficiaries receiving care from civilians make their personal health information available to DoD or VA, government record keeping will be incomplete.

The Nation and the military long have recognized the obligation to minimize the hazards of wartime military service and to provide both acute and chronic care for those injured or disabled during wartime service. Weapon systems and protective measures are continuously improved to allow U.S. military men and women to achieve their military objectives with the least risk to their survival and their survival as a military force. Threats from chemical and biological warfare agents present special problems and require the Nation to greatly improve its detection and protective measures. Immediate medical and surgical capability, rapid medical evacuation, and an extensive system of military medical centers provide for care on the battlefield and care, treatment, and rehabilitation upon return home. VA medical centers provide care for those requiring extensive rehabilitation and chronic care following separation from military service.

Force health protection before and during the Gulf War was implemented in varying degrees. Although U.S. forces experienced historically low rates of classic preventable diseases and combat casualties, force health protection efforts were incomplete, were neither standardized nor centralized among deployed forces, were not well documented, and, for the most part, did not anticipate the need for follow-up post-deployment. While field commanders made a concerted effort to ensure their forces were protected from medical hazards, there was not a sufficiently strong, centralized program requiring specific protection against known threats or to ensure specific force health protection actions. Implementation of countermeasures often was localized and, at times, not adequate, consistent, or systematic. Similarly, medical surveillance when conducted at the local level was incomplete and not always well documented; therefore, centralized analysis of exposures and health consequences was extremely difficult during and after the war.

Lessons learned from the Gulf War resulted in a complete review of doctrine, policy, oversight, and operational practices for medical surveillance and force health protection. Major lessons were applied in subsequent operations and improvements in force health protection were realized during subsequent deployments. For example:

• In Haiti, disease threats were identified pre-deployment and prevention guidance was provided to commanders at deployment. Force health protection initiatives were implemented locally, but there were limited efforts to ensure use of appropriate countermeasures, conduct medical surveillance, and analyze the effectiveness of the programs and initiatives.
• Commanders in Somalia employed personal protection and countermeasures based on pre-deployment threat assessments. Medical surveillance was better coordinated and more effective. Medical personnel used the deployed military public health laboratory to isolate the cause of diarrheal disease among Marines and to recommend effective countermeasures. Medics and commanders took preventive actions to control mosquitoes and rodents before exposures occurred. Analysis of health events during and after this operation led to definite improvements in force health protection for future operations.
• Preventive medicine officers deployed as part of the first teams into Rwanda in support of this United Nations operation involving 300-400 U.S. military members. The U.S. European Command had specific force health protection requirements in operational guidance and established surveillance for diseases and health risks. Military members received specific health risk information during pre- and post-deployment activities.
• The operation in Bosnia had a formal, theater-wide health surveillance and force health program including: (1) systematic risk assessments ; (2) useof of appropriate countermeasures; (3) comprehensive medical surveillance, including ongoing medical, environmental, laboratory, and operational hazard monitoring; and (4) analysis of procedures for further improvements.

Until recently, DoD leadership had not fully integrated post-deployment health issues (other than rehabilitation of injuries) into military operational planning. Indeed, the military has not been sufficiently sensitive to military members' health concerns and generally has responded slowly to post-deployment health problems. Now, the Office of the Secretary of Defense (OSD), the Joint Chiefs of Staff, and the military services, in consultation with the VA, are aggressively pursuing unified force health protection strategies to protect military members from health hazards associated with military service. The civilian and military leadership together is actively involved in this dynamic process. There is clear recognition of the importance of protecting military members in every operation. For the first time all government departments with a role in assuring military members’ health are actively collaborating to assure that preventable post-deployment health concerns are addressed throughout military service and after separation.

DEPLOYMENT HEALTH GOALS, OBJECTIVES AND STRATEGIES

Goal 1. Maintain a healthy, fit, and physically and mentally ready military force.

Objective 1.1. Direct military doctrine and policies for maintaining a healthy, fit, and ready force that reflect the lessons learned from preparations for recent major deployments.

The desired outcome is a healthy and fit force that is physically and mentally ready to succeed in fulfilling the military mission. This overarching strategy relies on the military services’ action to ensure the health and fitness of their service members, successful application of all capabilities of DoD’s Military Health System (MHS), and coordination of DoD activities with the VA and DHHS. During peacetime or in training, the MHS provides comprehensive health services throughout DoD that equal or exceed civilian standards of care. DoD, through the military services and the MHS, targets the health and fitness and the optimal physical and emotional well-being of military members and their family members.

The involvement of military leaders in all aspects and levels of force health protection is critical. Ultimately, the fitness, readiness, and well-being of the military force are an operational commander’s responsibility. Line leadership, direction, and support will be critical to assuring the highest degree of health and health readiness of the deploying force commensurate with achieving operational objectives.
 
 

Goal 2. Identify and minimize or eliminate short- and long-term adverse effects of military service, especially service during deployments (including war), on the physical and mental health of veterans.

Objective 2.1. Direct doctrine and policies that reflect lessons learned from the Gulf War and subsequent major deployments to protect the health of the military force during future deployments.

In November 1997, President Clinton directed "the Departments of Defense and Veterans Affairs to create a new Force Health Protection Program." The desired outcome is a military force fully protected from preventable and avoidable health threats throughout military operations and deployments. The four critical elements of the Force Health Protection Strategy, from an operational perspective, are: as follows:

• Threat analysis. Identifying operational, disease, environmental, biological/chemical or other medical hazards or stress risks to deployed forces before and during a deployment.
• Countermeasures. Using appropriate strategies (during training, as a part of long- range health readiness preparations, and immediately before and during deployments) to mitigate these risks: personal protection; drugs and vaccines; chemical and biological detection, protection, and decontamination; deployment stress reduction and critical incident debriefings; and other health service systems.
• Medical surveillance in the area of operations. During the operation, monitoring the health status of the force and the health threats to determine short- and long-term risks to health and to take appropriate countermeasures.
• Analysis. Conducting current, prospective, and retrospective analyses to determine outcomes and trends in health status and health threats, and to assess the need for or the effectiveness of changes in policy, doctrine, or operational practices.

The involvement of military leaders in all aspects and levels of force health protection is critical. Ultimately, the protection and well-being of the military force is a commander’s responsibility. In future deployments, line leadership, direction, and support will be critical to assuring the highest degree of health protection for the deployed force. The degree of involvement of senior civilian and military leadership within the Office of the Secretary of Defense OSD and the Joint Staff in the development of doctrine and policy has been unprecedented. The force health protection strategy ensures commanders and leaders at every level have a force that is protected through any operation, and supported with exceptional physical and mental health care capability. Service members deserve every measure of protection as they serve in the military. Leaders’ commitment and charge must be to ensure the protection of military members today, tomorrow, and into the next century.

DHHS (FDA) and DoD need to explore viable options to allow access to products that may protect military members during military exigencies. As part of DHHS (FDA) and DoD’s exploration of viable options, both Departments may also consider whether there is a limited need to modify certain existing vaccine and drug requirements for military personnel under differing exigencies. Information on those requirements must be included in the training of military personnel who may, for their protection, be required to use or be offered vaccines and drugs that have not been approved for marketing for the intended use.

The prevention and amelioration of the adverse effects of combat and deployment-related stress help to preserve military strength. The emotional health of the service member, although invisible, affects all aspects of his/her behavior. In theater, stress that adversely affects emotional health may affect the ability to maintain physical health and hygiene, may hinder the ability to physically complete a mission, or may affect the good judgement and creativity needed to find and apply solutions to accomplish the mission on the rapidly moving, high-tech battlefield. Long-term adverse effects of combat and deployment-related stress may include poor physical and mental health, dysfunctional family and work relationships, substance abuse, and poor military and civilian work performance.
 
 

Goal 3. Preserve the health and well-being of those who have served and their families.

Objective 3.1. Improve and coordinate interagency efforts to provide for the health care needs of military service members, including reserve component personnel , and their families following return from deployments.

• Post-war illnesses, including diagnosed and unexplained symptomatic illnesses
• Diseases with long latent periods following exposure
• Diseases affecting family members and close contacts
• Reproductive health outcomes

Support for the family of a military member before, during, and after a deployment requires additional attention, especially for prolonged deployments or deployments into a combat theater and for reserve component members. Deployment may create problems within a family unit or may exacerbate existing problems. Deployment may strain already fragile family relationships and coping mechanisms. The heightened personal and interpersonal stress upon all family members due to the sudden changes—first from separation and second, and far more significant, from the military member's return—can have adverse effects on the physical and mental health of each family member. The stresses also may have adverse effects on interpersonal relationships within the family unit. Spousal abuse and child abuse—physical, emotional, and sexual—frequently result from heightened family stress due to deployment and return home.

Local commanders need the support and tools for preventing or dealing with the destructive outcomes from these tenuous family situations. The family stress and the lack of the personal and family skills to respond productively to that stress often result in a less effective military member. Adverse outcomes may include marital discord, substance abuse, divorce, discipline problems, and arrest and conviction for abuse. Family problems readily become mission-related issues if they detract from a military member’s ability to perform his/her duties or take the command leaders’ attention away from performing their mission. Professional resources need to be available to respond to military families in crisis—before, during, and after deployment—and also to provide the family and marriage counseling needed to prevent the crises. Both DoD and VA need contingency plans to respond to the increased needs of military families before, during, and after deployments. The prevention of adverse effects on the family of military deployments can minimize associated long-term adverse effects on the military member's physical and mental health, performance, and career, and on the family members’ physical and mental health.
 
 

Goal 4. Strengthen the national strategy to protect and defend military service members from warfare and terrorism with chemical, biological, radiological, and chemical agents.

Objective 4.1. Assure strong national commitment to improving military defense and response capability against CBW agents.

The Gulf War emphasized the threat of biological and chemical warfare on the battlefield and the effect of its use, or threat of use, on the conduct of war and its aftermath. While there is continued concern about our ability to protect and defend our military forces from terrorism associated with CBR warfare CBW agents, DoD does have unique capabilities and requirements for the protection of military members from CBWwarfare agents, whether used on the battlefield or as terrorist weapons. Part of the NAS and NRC task is to assess current techniques for detecting and tracking exposures of military members to harmful agents, including chemical and biological warfare CBW agents, and make recommendations for improvements in technologies and policies. The NAS will evaluate current policies, doctrine, and training, and recommend adjustments to strategies to afford better protection against such agents. The effort includes a focus on technologies, tools and methods for improved detection and monitoring,; physical protection and decontaminations,; and vaccines and other prophylactic agents.

Goal 5. Establish an effective health risk communication program that educates and informs active military personnel, veterans, and their families throughout the deployment lifecycle and beyond on issues related to health risks and available services.

Objective 5.1. Coordinate health risk communications efforts of the DoD and VA.

Health risk communicators (public affairs officers, line commanders, researchers, medical professionals, community involvement specialists, and others) must often work closely with their intended audience concerning health risk issues and the consequences of hazardous exposures. Unfortunately, communicators frequently rush to provide information before they have definitive information about the health risk or hazard.

What are the planning problems faced by do these communicators face? Effective health risk communicators must initially determine what exposure data are available, consider what scientific uncertainty is evident from the data, and understand what is being done to provide appropriate medical care. Then, they must determine how to convey the problematic concepts to an intended audience that expects accurate and complete answers. Additionally, they must understand the meaning of thehealth risk associated with the hazardous exposure. Finally, communicators must understand their limits and get helpon with scientific issues that require more technical expertise. Once these communication aspects have been developed,Then, the communicator must translateall the scientific information into an easily understandable message. To meet these objectives, health risk communication professionalsfacing these situations must develop an overall health communication strategic plan.

Whether derived from research findings or not,tThe way risk estimates are conveyed to the intended audience significantly affects how individuals perceive those risks. Single-value estimates do notprovide an indication of indicate the degree of uncertainty of risks associated with the exposure estimate. On the other hand, communicating a range of risk estimatesdoes not often convey seldom conveys the conservative nature of some risk estimates. For example, most individuals maynot be aware be unaware that risk estimates are typically created by extrapolating from information based on high dose exposures to the very low dose that an individual might actually encounter.

"Risk" is a complex concept and "hHealth rRisk cCommunication" often appears complicated and unstructured. A large and growing body of literature confirms the common intuition that humans factor much more into perceptions of risk than the "objective" findings of well- designed research studies. For example, is the risk voluntary or involuntary? If Does an individual or group that imposes a risk on others,does it listen attentively to the concerns of the risk bearer, or turn a deaf ear?

An additional layer of such fFactors, those associated with risk controllability, may be particularly salient within the context of "risk perception." Often too many elements pertain to a risk’s relative significance for any single health communication process to yield a single correct approach. Nonetheless, a strategic planning process can yield more effective communication outcomes by fosterfostering sustained dialogue between different factions of the scientific community and between scientists and the intended audience.

The health risk communicator must realize that an audience’s reaction to a message about a hazard ismuch more complexthan just considering the hazard itself. Many personal variables contribute to risk perception and how an individual will respond to the risk,. including: Such variables include education, values, cultural background, religion, social experience, health, economic status, psychological outlook, and trust level. These factors will also influence the level of trust and mutual respect between the communicator and the audience. Therefore, when developing communication messages, the health risk communicator needs to know the intended audience in great depth, including its attitudes, concerns, channels, and the consequences of specific risk factors. To be successful, the health risk communicator must develop an approach in which determine how to achieve effective two-way communication, constructive discussion, and resolution of health risk issues can be achieved.
 
 

MILITARY PERSONNEL INFORMATION MANAGEMENT

ALlack of data on personnel deployments and movements in theater makes it difficult to accurately monitor deployment-related health risks or conduct research on populations at risk. Further, data currently collected are often difficult to access and are stored in multiple locations. As a result:

• Commanders in Chief in theaters of operations may not have accurate or timely data on personnel assets (numbers, characteristics, and locations) needed to assess operational capabilities;.
• Research analysts and joint managers may not be able to make necessary assessments and comparisons across military services and their respective components (active, reserve, and guard);.
• Linkages between the personnel and pay functions differ among the services resulting that result in multiple data entry, complex system maintenance, and pay problems that have an impact on service members and their families..
• Reservists who are mobilized are often "lost" in the system (both automated and administrative) and are not effectively tracked or accounted for as they transfer from active to reserve status; and.
• Personnel (active, reserve, and civilian) are not consistently tracked or accounted for in and around the theater.
• Personnel (active, reserve, and civilian) are not consistently tracked or accounted for in and around the theater.

Military personnel functions and information systems support and sustain active duty and reserve service members, and their families, throughout their military careers. This includes periods of peacetime, during mobilization and war, and beyond military service as members separate or retire and transition back into civilian life. Many interactions and transfers of data with other agencies must be supported, especially with the VA. The Military Personnel Information Management Strategic Plan supports the entire military personnel life cycle with primary emphasis on the deficiencies highlighted during and after the Gulf War. This discussion focuses on the parts of the plan that relate directly to those deficiencies and on our objective to develop a system to provide a seamless process of life-cycle support to the service member integrated with transparent delivery of benefits and entitlements to the veteran.
 
 

MILITARY PERSONNEL INFORMATION MANAGEMENT GOALS, OBJECTIVES, AND STRATEGIES

Goal 1. Ensure the accuracy, timeliness, security, and retrievability of information that must be entered into records or automated systems that document personnel history for active, guard, and reserve service members and veterans.

Objective 1.1. Resolve the record keeping deficiencies that continue tohave an impact on affect readiness, contingency and peacekeeping operations as well as those that have an impact on affect the quality of service we provide to service members and veterans to ensure that they receive correct pay, accurate credit for service, and appropriate benefits and entitlements.

Strategy 1.1.1

Current deficienciesare a direct resultof from the inability of the existing systems (over 1770 separate systems with multiple, complex interfaces) to support collection and maintenance of the required information, especially in the areas of personnel accountability and asset visibility. These deficiencies continue to affect our readiness, contingency, and peacekeeping operations. They continue toimpact affect our ability to assess potential health hazards and the quality of service we provide to service members to ensure that they receive correct pay, accurate credit for service, and appropriate benefits and compensation. The Defense Integrated Military Human Resources System (DIMHRS) will be designed to resolve the information collection and access deficiencies identified. DIMHRS will enable the Department DoD to collect and maintain the standard military personnel data and will address the problem of asset visibility. It will enhance our ability to account for reservists who are mobilized and change to active duty status. It will assure that they receive proper credit for service, timely pay, and benefits and entitlements for themselves and family members. It will also give DoD the capability to track military and civilian personnel in and around the theater of operations, support the collection of casualty and medical evacuation information that will be integrated with medical management systems, and provide data for use by outside agencies such as the VA and the Red Cross. DIMHRS will correct the personnel, pay, and operational records keeping issues that were made obvious during the Gulf War. It will be a single, fully integrated, all-service, all-component, military personnel and pay management system. DIMHRS will be a major link in a process that will provide seamless delivery of personnel services and veterans’ benefits and entitlements. Since much of the required data must be collected in the field and transmitted to central databases, DIMHRS must encompass both the field level data collection capability and the central databases for all services. It will use modern, web-based technology and be built on a COTS commercial off-the-shelf platform.

Funding for initiation of DIMHRS was obtained in FY1998 and an initial operating capability is planned for 2003. Detailed requirements are being defined with full coordination and support from all service components, the Joint Staff, and other communities who may need information from the personnel data (for instance, the medical community). The DIMHRS requirements definition team will also participate in the Health Affairs business process reengineering project to define requirements for tracking the use of investigational drugs and to ensure that the personnel system will incorporate their requirements.

After the initial investment establishing DIMHRS, significant savings are expected as maintenance and development costs for specified legacy systemswill be are eliminated and military personnel management processeswill be are streamlined and improved. The project isa complexone in that it requiresthe coordination and support from all of the services as well as from OSD. Senior management must ensure that action officers throughout the Department understand the importance of the program and the inadequacies of current practices.

One of the most significant problems in managing military personnel in theater and through mobilization is that the different services, and their components (Aactive, Rreserve, and Gguard), collect data that are inconsistent and incomplete. During the period fFrom 1992 through 1995, the DoD personnel community focused on the definition of information requirements, development of the Defense Personnel Data Model (DPDM), and definition of standard personnel data elements to address the information requirements. These data will beimplemented acquired through the DIMHRS.

Strategy 1.1.2

A series of focused workshopswere was held to identify information requirements for effective military personnel management, including tracking personnel in theater and maintaining adequate personnel records for future access to ensure appropriate benefits, documentation of potential exposures, and accurate credit for service. The workshops included full participation from all military components (active, reserve and guard), OSD staff analysts and managers (from Reserve Affairs, Health Affairs, and other parts of OSD), Joint Staff representatives, and, for areas of special interest, representatives fromVeterans Affairs VA and other Federal Aagencies. Data defined by the workshops were incorporated into the DPDM.

As a parallel effort, all data collected by the services military personnel systems (active, reserve and guard) were analyzed and also incorporated into the DPDM. A set of standard data elements was defined and coordinated throughout the personnel community, with other DoD communities and with other agencies. Standard data elements will replace the approximately 30,000 component- and system-specific elements identified in our systematic review of personnel systems. The Defense Personnel Data Model (DPDM) is complete and maintained through the regular data administration program. Over 1,500 standard personnel data elements have been developed.

Strategy 1.1.3

Even after DIMHRS is fully implemented, there will be a need to access data and information collected, and archivedprior to before the systembecoming becamebecomes operational. DIMHRS is expected to be available in 2003. Full integration and connectivity with other Federal agencies in order to deliver support and services based on online or real-time access to DoD databases and systems will not be feasible until well after that date. As DoD and VA work toward providing transparent delivery of services, support, benefits and entitlements to service members and veterans, we will need to implement interim procedures and take incremental steps toward the above mentioned interagency systems integration and connectivity. Since data collected and maintained in older legacy systems, and in other technological formats (paper, micro-fiche and optical storage) must be kept for at least 75 years, an interim capability to facilitate access to these other sources of information is critical.

Several studies have identified business process improvements within DoD, VA, and the National Archives and Records Administration (NARA) that will facilitate access to current and historical personnel information. Business Process Reengineering initiatives that will facilitate access to existing data are briefly described below.

• Transfer of Medical Records to VA. One of the earliest issues tackled by a joint DoD/VA task force, in 1992, was the failure to transfer expeditiously medical records to the VA for Gulf War (and other) veterans filing compensation claims. After review of the processes then in place, the task force recommended that the Health Treatment Records be transferred to VA upon separation from active duty. This expedites the availability of needed medical information to the VA for Rreserve members returning from active duty deployment and for those regular active duty members separating or retiring. While access to the existing medical records does not improve the content of the records, it goes a long wayin toward accelerating the process that veterans must go through to obtain the benefits they have earned.
• Integrated Imaging Systems. In order tTo provide further interim actions to facilitate electronic exchange of information between DoD and other Federal agencies needing data extracts, or copies of personnel records and information, DoD is pursuing a Defense Personnel Records Imaging System (DPRIS) using optical imaging technology. DPRIS seeks to achieve interoperability among the existing service optical imaged personnel file management systems. Adjuncts to this initiative include extending electronic query capability to other government agencies authorized to access military personnel records, and retiring optically imaged personnel records to NARA.
• Retirement and Retrieval of Clinical Records. In 1995, DoD and NARA initiated the DoD/NARA Medical Records Retirement and Retrieval Project that recommended an automated system be put in place that would use an electronic record index for retiring clinical treatment records for military members and their families. Under the current system, medical treatment record retrieval is costly,not timely slow, and sometimes does not occur. The proposed system will correct these inefficiencies and increases the probability that service members and their families will be able to retrieve records of clinical treatment in military medical facilities during periods of mobilization, active duty, and deployment. This system will ease post-deployment transitions for family members of activated reservists as they move back into civilian lifeout of the military environment.
• Joint Disability Evaluation Tracking System (JDETS). In the years following the Gulf War, a significant effort has been expended throughout DoD has tried to discernthe effects of how service in the Gulfupon affected the health of service members. Analysis of the services' Ddata on Gulf War veterans discharged with disabilitieswas attempted to assist in determining potential were analyzed to determine possible causes of any ill effects and to ensure equitable compensation of members affected. There were many deficiencies in the services' ability to retrieve disability data without constructing new databases for each new query. The lack of common data across the services, combined with differences in the tracking capabilities of the services, impeded the analyses and reporting capabilities of the Department. A business process reengineering study resulted in the definition of requirements for a consolidated tracking system, the JDETS. JDETS introduced the capability to tag members by specified criteria and track or analyze subgroups of specific, defined data. Future planned interfaces with the Defense Integrated Military Human Resources System (DIMHRS) will result in additional benefits both in further improve data quality and in processing time for personnel in the disability evaluation system.
• Joint Personnel Asset Visibility (JPAV). Personnel asset visibility is the visibility of individual, unit, and location data that describe all personnel resources available to accomplish a Joint Task Force mission. JPAV will provide a database in theater that will contain information needed by the Commanders in Chief (CINC) to support operations and to identify locations of individuals. JPAis dependentV depends on the military personnel systems to obtain core data. During deployed operations, the United States transports massive amounts of materials, supplies, and personnel using all available means of conveyance. JPAV will collect data from a variety of systems and display that information to the user in a prescribed format. A JPAV prototype was deployed to Thailand for Exercise COBRA GOLD 96 in May 1996. Future interfaces with DIMHRS will allow full realization of the potential benefit from JPAV.
• Defense Casualty Information Processing System (DCIPS). During the Gulf War several problems in the casualty affairs and mortuary affairs arena surfaced. Congressional hearings on some of these problems were held early 1992, and a 1993 DoD Inspector General Report documents other deficiencies including the lack of common automated support for the management of casualty and mortuary affairs information and lack of casualty tracking information. Each service has its own casualty affairs and mortuary affairs offices and information systems to support its own requirements. The services all conduct business in basically the same way under current DoD guidance. The Department has undertaken development of the Defense Casualty Information Processing System (DCIPS) tobetter manage better the automated information processes that support the casualty/mortuary environment. Future interface with DIMHRS will ensure that DCIPS will have a full set of common information from all services.

In 1994, the Defense Medical Information Management and Information Technology Program was established. It specifically addresses both the management of health information and the supporting technology. The goal of the program is to provide the right health information to the right people at the right time across theentire continuum of health care operations. To this end, the MHS Information Management and Information Technology Strategic Plan, which is updated annually, addresses health information requirements including those necessary to resolve issues that arose during and after the Gulf War. The specific issues the plan addresses include:

• Accurate and Accessible Health Records. Current health records do not adequately capture all care rendered (including classified information). Health records kept in the MHS are a combination of manual and automated data, which is contained in multiple health records (inpatient, outpatient, mental health, and dental). Ideally, the provider manually enters the required medical information directly into the appropriate health record. However, when the record is not available at the time care is rendered, the information is collected on the appropriate form and sent to the records room to be filed later. Computer-generated information is available either electronically or in printed copy that is then filed in the health record. Paper-based medical records may be filed inappropriatelyand therefore (that renders them temporarily inaccessible), lost, or damaged. Paper-based records are difficult to maintain and do not allow for a seamless exchange of patient informationwhen needed.
• Tracking of Patients. During the Gulf War, information regarding the admission and diagnosis of patients at the deployed medical units in the theater of operations was not timely or complete. In addition, patients could not be adequately tracked within the medical evacuation process or at field facilities.
• Deployment of Medical Personnel with Necessary Deployment Skills. Identification of fully qualified medical personnel for deployment to the Gulf or to supporting activities in Europe and the United States was hampered by insufficient, inaccessible, or inadequate data. In addition, necessary interfaces between health and personnel systems either did not exist or were not robust enough for adequate transfer of data.
• Capture and Transfer of Information Needed by the Office of the Assistant Secretary of Defense for Health Affairs [OASD (HA)], other DoD, or Federal Aagencies. Existing health processes or systems do not capture adequately information needed by other organizations such as the Under Secretary of Defense (Personnel and Readiness) [USD (P&R)] VA, or FDA. Health information is needed by these other agencies to determine disability and VA health care entitlements and to meet FDA reporting requirements for investigational new drugs. In addition, information contained in systems managed by these agencies is not always available to support health care delivery.

Goal 2. Ensure the accuracy, timeliness, security, and retrievability of information that must be entered into records or automated systems that document health history for active, guard, and reserve service members and veterans.

Objective 2.1. Resolve deficiencies in health record keeping that have an impact on the health of our forces which in turn affects our readiness posture, contingency activities, and operations other than war as well as those that have an impact on the quality of both preventive care and treatment for injury and illness provided to service members.

Strategy 2.1.1

The MHS requires a single, integrated system that collects health data and makes it available worldwide. A Ccomputer-based Ppatient Rrecord will capture comprehensive, relevant, and accurate health information during each beneficiary’s lifetime. It will provide the MHS with the ability to supply clinical data to predict and evaluate health outcomes and to view clinically relevant data where and when needed within a single, transportable computer-based patient record. An electronic patient record provides the capability makes it possible to combine several enterprise-wide electronic medical records concerning patient. A computer-based patient record generally meets five criteria:

• Developsing a system for identifying all health information, wherever it is provided.

• Makesing information from multiple providers in various locations a part of the electronic record.
• Developsing standardized terminology, data sets, and structure.

• Createsing a consensus on security systems that protect the privacy of health information.

• Usesing data and knowledge bases to enhance services between geographic areas.

• Composite Health Care System (CHCS). This is a system currently supportsing electronic capture of laboratory, radiology, pharmacy, patient scheduling, and patient administration (e.g., admissions, internal military treatment facility medical records tracking). The next upgrade of CHCS generation of this system, CHCS II will also include the Mmedical Rrecords Ddisposition and Aarchiving function. This is a tracking mechanism is essential for collection of information on the handling and storage of health records as they move from medical to personnel (responsible for records disposition and storage) and on to the VA (responsible for storage and archiving of records). The next generation of this system, CHCS II, The CHCS II will support the comprehensive computer-based patient record. CHCS II will add new areas of electronic data capture to include the operating room, anesthesia, mental health, ambulatory care documentation, vision, pharmacy, and consult tracking, and utilization management. The computer-based patient record will be built as a patient receives care (in theater or in a fixed military treatment facility). It will facilitate the electronic documentation of the delivery of care, and preventive services, increase interoperability with other computer systems, and facilitate the exchange of data among the many players whether in the theater of operations, at the sustaining base, at other locations, or with other fFederal agencies.
• The Personal Information Carrier (PIC). Considering the mobile nature of many personnel during deployments, how can health information necessary for treatment be made available to health providers? One promising technology currently being developed is the Personal Information Carrier (PIC). The PIC is a small, rugged, tag-like device intended to store an individual’s medical status and history, to include pertinent medical documents, radiographs, and vaccination records. The PIC can be carried by service members and updated by medical personnel using portable computers at the time care is rendered. The PIC would be one piece of a computer-based medical record system. The information on the PIC could be transmitted to central databases as aredundancy safeguard in case of loss or damage to the card.
• Preventive Health Care System (PHCS). This system will include immunization tracking (important for readiness), preventive health, and health enrollment risk appraisal information. This system will support the "Put Prevention Into Practice" initiative (implementing the national Healthy People 2000 program), and automate the Health Enrollment Appraisal Review (HEAR) questionnaire currently used for health risk assessment. It will also integrate medical history data contained in CHCS II. Medical personnel will use this system to document and track immunization status, assess beneficiary health status, develop an individualized plan for preventive care, and track the steps in the delivery of these preventive services as well as the outcomes.

A seamless process and mechanismthat that includes in-transit visibility and can track personnel from the time they enter the medical system until they are returned to duty, placed in a medical holding unit, medically retired, or die on active duty, including in-transit visibility, is essential to managing casualties. The following two initiatives address this need:

• Patient Administration Real-time Reporting and Tracking System (PARRTS). PARRTS will allow military leaders to obtain accurate computerized updates on hospitalized personnel involved in military operations. It provides timely patient information, a fuller accountability of patients under treatment in the theater, and an ability to pass that information to leaders and to casualty notification officers on a near real-time basis. The information includes the number of beds in use in the theater, the number of admissions, total number of patients, battle casualties, non-battle injuries, diseases, evacuations, and deaths. This information is essential for identifying capability, early recognition of health trends, and location of patients. The surveillance data can be used to monitor medical threats and plan for appropriate defenses. It also allows medical commanders to reshape the medical force (quantity, mix, and location) based on current, accurate information,. It also and provides a database for planning future operations. This legacy system is operational and has supported Operation Joint Endeavor in Bosnia.
• Patient In-Transit Visibility. The Transportation Command Regulating and Command and Control and Evacuation System (TRAC²ES) will be the automated decision support system, within a global network, that assists in the command and control of patient movement. The system will facilitate the assignment of lift (movement), beds, and en route patient care management. This will enable effective depiction of the impact of patients on transportation and other supporting activities and systems, allow for visibility of patients as they move throughout the system, and alert receiving activities of patient and follow on support requirements. TRAC²ES will be available for joint, combined, and component operations in peace, operations other than war, and war. In the interim u Until this program is operational, the Defense Medical Regulating Information System and the Automated Patient Evacuation System each provide part of this functionality.

Medical leaders need to be able to make informed decisions regarding which medical personnel are qualified for deployment in support of military operations and what positions they should fill. This information allows medical commanders to select the right individuals to achieve the necessary quantity and mix of medical personnel at each deployed location. This They need current and accurate information must be current and accurate and should includingde the status of general readiness training, medical skills, specialty skills, and the training required for assignment to a particular type of field facility. The following initiative is currently underway:

• Centralized Credentials Quality Assurance System (CCQAS). CCQAS will supports medical readiness by facilitatinge the identification of providers and selection of medical personnel with the requisite skills to support military operations. At the military treatment facility, this database collects, tracks, and reports demographics, the provider's credentials information, specialty details, professional and additional training, license information, board certification, affiliations, and malpractice insurance. CCQAS supports medical readiness by capturing the above information for review during selection of medical personnel for deployment. This information is enhanced with five data fields: date of initial medical readiness training, current unit identification code (UIC) for deployment, date of the UIC verification, date of commander verification of sustained medical readiness training, and mobilization practice specialty. This information is transmitted quarterly by the military treatment facility each quarter and aggregated by the services. The next upgrade, CCQAS 2.0, will add risk management data (malpractice claims and adverse actions). Planning is also underway to include privileging information in future upgrades of CCQAS.

Information must flow smoothly among DoD activities, the various departments, and agencies who have a need to access to health information. In addition, medical personnel need information related to treatment within the VA health system, exposure to potentially harmful materials, and personnel information (such as location, duty history, and demographics). Exchange of information is facilitated by standardized data definitions, standardized technology, and mechanisms designed to bridge systems with differing data or technology standards. The following initiatives address this need:

• Technology Standardization and Insertion. OASD (HA) works closely with the Iinformation Mmanagement community to develop and implement common technical standards to achieve interoperability between DoD automation systems. Efforts are also underway to export these emerging standards to the VAeterans Administration for their adoption. The proliferation of a multitude of unique vendor approaches in hardware and software has created a technical architecture where many existing systems cannot pass or share data. The Defense Information Systems Agency, with participation from the MHS, is guiding the overall DoD standardization effort through the development of a Joint Technical Architecture and Common Operating Environment. This Aarchitectural Fframework and associated policies haves been expanded to address unique healthcare requirements. These standards enhance the ability to share data and also allow for software reuse, simplify system administration, and provide a consistent user interface throughout the MHS.
• Data Standardization. OASD (HA) currently is staffing a proposal for developing data standards for Llaboratory, Ppharmacy and Rradiology files. Data shared within an enterprise must be standardized to eliminate the cost of delays, miscommunication, inconsistency, and incomplete information, as well as costs associated with redundancy of data storage and duplication of data capture. Standardization of data across an enterprise is essential if the enterprise is to achieve the goals of sharable, consistent, reliable data that is accessible through interoperable automated systems. The standardization of data is essential for enterprise-wide programs such as the Composite Health Care System CHCS II, the Personal Information Carrier, and clinical outcome performance metrics, to facilitate the transfer of data between departments and agencies and reduce the amount of retraining required to operate for new computer applications.
• Information Exchange within DoD. The Composite Health Care System CHCS II will support data exchange such as tracking patient movement and location of medical information and health records with other DoD departments. The Defense Enrollment Eligibility Reporting System (DEERS), an Under Secretary of Defense USD (Personnel and Readiness)(P&R) system, will provide basic demographic information to the Composite Health Care System II. DEERS will be the repository for the central Master Patient Index (MPI), which locates clinically relevant data automated data stored in CHCS II at military medical treatment facilities. DEERS will also receive information from the health system (e.g., blood type, immunization status) needed by DoD programs and commanders in support of military operations.
• DoD/VA Data Sharing. DoD and VA systems are not compatible for direct transfer of information. Modification of either system is not feasible. The DoD and VA are focused on sharing data through the use of open systems standards, rather than the adoption of a single automated system. On a monthly basis, information from the Comprehensive Clinical Evaluation Program (DoD’s registry and evaluation program for Gulf War veterans) is available to the VA via the World-Wide Web and File Transfer Protocolsthus providing convenient retrieval. The Ccomputer-based Ppatient Rrecord will also facilitate transfer of data to the VA and other Federal agencies when appropriate. Efforts are underway to identify data exchange requirements and create additional interface mechanisms that will act as bridges between existing systems.
• Information Exchange with the FDA. Investigational new drugs may be critically necessary during a deploymentin order to provide potential protection to deploying personnel or treatment for deployed personnel. Following a deployment, it may be necessary to determine if the uses of the drugs are a contributing factor in illnesses among this group. Further, FDA’s regulations for investigationalnew drugsregulations require the collection of data concerning safety and efficacy of the product. Therefore, the capture of data related to these drugs is essential. A business process reengineering effort will be evaluated as a solution to address issues related to the use of investigational new drugs in support of deployments. Such an effort would consist of input from DoD, VA, FDA, and other agencies as appropriate. The record-keeping portion of this endeavor must support data requirements identified by the Health Issues portion of this Task Force. Data requirementswill need to be identified, processes established to capture the necessary data, funding obtained, and possibly technology acquired to support the program. This proposal to implement a business process reengineering effort will be explored with the Health Issues Group of this Task Force and with the organizations mentioned above.

Personnel Information Management

The Under Secretary of Defense (USD) Personnel and Readiness (P&R) Information Management Program involves the entire Mmilitary Ppersonnel community. The Joint Requirements and Integration Office manages and implements the IM program and ensures that each initiative meets the Department’s goalsand is effectively coordinated and implemented. Every initiative receives four or five levels of review: first, the project-specific working group, with appropriate representation from the services, Joint Staff, USD (P&R), and, where appropriate, other Federal agencies; second, internal P&R staff; third, the Joint Integration Group (JIG); fourth, where available, existing functional-area-specific steering committees (for instance, the Joint Casualty Advisory Board and the Military Personnel and Pay Management System Steering Committee); and fifth, the Military Personnel Policy Review Committee (PRC).

The JIG provides high-level review and coordination on all products and recommendations. It is a group of senior military personnel and pay representatives from all components, the Joint Staff, OASD (Reserve Affairs), and USD (P&R). Members are briefed regularly and kept informed of project status and plans. Recommendations from the JIG are incorporated into both the selection and performance of projects.

The PRC, chaired by the Deputy Under Secretary (Program Integration), is a Deputy Assistant Secretary level group that includes the Service Personnel Chiefs, the Director of Personnel (J1) from the Joint Staff, and representatives from OSD and the Service Secretariats. The PRC provides final review and coordination. After comments are received from the PRC members, recommendations and decision packages are forwarded to the USD (P&R).

Additionally, the Joint Requirements and Integration Office maintains close work ties to works closely with other Federal agencies and carries out interagency business process reengineering programs through the DoD/VA Reinvention Partnership Agreement signnged by the Secretaries of Defense and Veterans Affairs in June 1994.
 
 

Health Information Management

A consolidated MHS Information Management and Information Technology Program, which addresses health care requirements across the operational spectrum, is thekey cornerstone to establishing a health information baseline, meeting future requirements, and addressing issues discussed in this plan. In addition, the service member life-cycle depicts the need for information at differentpoints in times during the career of the service member. An It is importantfactor to successfully capturing the necessary information is to identifying a single point of data entry for the collection of necessary information.

The OASD (HA) has an established a management and oversight structure that provides senior executive oversight of the MHS Information Management and Information Technology Program and ensures that MHS investment in information systems and technologyare is firmly based on the goals and objectives of the MHS. The TRICARE Readiness Committee and the TRICARE Executive Committee develop broad policy guidance. The MHS Information Management Proponent Committee and the Information Management Program Review Board oversee execution and ensure integration at the enterprise level. Functional Proponent Working Groups ensure the functional requirements are defined and prioritized to support customer needs and the policies set forth by the TRICARE Readiness Committee and the TRICARE Executive Committee.

The Theater Functional Steering Committee oversees the integration and approval of health requirements in support of joint and combined military operations. This committee aggregates and prioritizes medical requirements for all echelons of care and addresses functional areas including command and control, medical logistics, blood management, patient regulation and evacuation, medical threat/intelligence, health care delivery, manpower/training, and medical capabilities assessment and sustainability analysis. Requirements approved by the Theater Functional Steering Committee are managed through the Theater Medical Information Program which integrates the capabilities into medical deployment packages for use in land-based, non-fixed medical facilities, and aboard ship.

OASD (HA) has clustered information management and technology activities into six discrete business areas: Cclinical, Eexecutive Iinformation/Ddecision Ssupport, Rresources, Llogistics, Ttheater, and Iinfrastructure. Each of these business areas has prescribed responsibilities, expected outcomes, support requirements identified by the Theater Functional Steering Committee, and is managed by an Executive Agent.

Health information systems developed in the future will consist of standards-based commercial off-the-shelf, government -off-the-shelf, or MHS-developed functional applications, in that order of preference. Functional applications will be supported by a DoD standard computing and communications infrastructure to facilitate the seamless flow of patient information across the operational continuum.

The MHS is actively engaged in business process reengineering activities that cover the spectrum of from continuous improvement at the military treatment facility level to radical changes in the delivery and management of health care services for the entire enterprise. These activities focus on improving the processes associated with providing health care in peacetime, wartime and operations other than war.

In support of health information exchange for health care delivery to military members (active, retired, and separated) who are entitled to care in the VA health system, an DoD/VA Executive Council DoD/VA meets on a monthly basis to address health care issues.
 
 

Many of the major health concerns and uncertainties identified after the Gulf War are similar to those associated with other major foreign deployments. The response to these concerns could have been more effective had there been a better understanding of the potential biological and toxicological associations between exposure and response. Better knowledge of biologically -based relationships between specific exposures and specific health outcomes enhances: (a) analysis of potential causes of illnesses; (b) research and development on effective prevention, intervention, and treatment strategies; and (c) development of an accurate and effective health risk communication plan to inform troops about potential exposure risks. Furthermore, if epidemiological researchers had comprehensive population-based troop health assessments and exposure monitoring data and data systems, they might have been better able to define potential associations between exposures and outcomes.

Attention to the uncertainties of exposure-related health outcomes during deployment could have resulted in directed (or focused) research efforts, the results of which could have been applied before and during these deployments to mitigateagainst adverse health outcomes.

Furthermore, population-based health assessments of troops before and after deployments could have improved the ability to answer readily the deployment-related health concerns of veterans. Such knowledge could have also helped to plan for future deployments. Although design, development, and implementation of databases are not research per se, they play an important part in the research process because the quality of these activities can have a significant impact on the ability of epidemiological researchers to answer important questions about deployment health. Consequently, this strategic plan also describes database requirements necessary to enable the pursuit of research.

The concerns of many veterans from other wars regarding their deployment experiences and their potential connection to long-term health problems underscore the need for a government focus on deployment health. Employment of effective, evidence-based actions to mitigate deployment-related health problems in the past is enhanced by research aimed at identifying and understanding these problems. It is for this reason that research is an essential component of the overall deployment health strategy presented in this document.

The brief duration of the Gulf War and the relatively low incidence of traumatic injuries focused attention on combat-related illnesses. Such illnesses include the potential health consequences of exposures from the wartime environment. New health issues associated with chemical, biological, and radiological threats also emerged. These emergent health issues have brought to the government’s attention a requirement to enhance capabilities of addressing deployment-related health problems. The following have been identified as essential needs as the foundation for this research plan This research plan is designed to achieve following essential needs:

• Epidemiological research capability and capacity to investigate exposure-outcome relationships;
• Focused research on deployment-related risk factors;
• Epidemiological research-driven data and data system requirements for health outcomes and exposures (anticipated or novel).

RESEARCH GOALS, OBJECTIVES, AND STRATEGIES

Goal 1. The U.S. gGovernment will have the capability to apply epidemiological research to determine whether deployment-related exposures are associated with post-deployment health outcomes.

Objective 1.1. Maintenance of the capability and capacity to conduct epidemiological health studies (morbidity and mortality) as follow-up to military deployments.

For the government to successfully acquire appropriate health and exposure data using well designed data collection, archiving, and management systems, itneeds to have the capability to must be able to apply sound scientific principles to determine whether exposure-outcome relationships exist in connection with a deployment.

Different departments, DoD and VA in particular, have epidemiological capability and capacity that is spread across many sectors within those departments. Essential to the establishment of the capability t To carry out exposure-outcome assessment, is the identification of the departments must identify a locus for that activity.
 
 

Goal 2. The U.S. Government will have balanced research programs targeted at (1) improved prevention, intervention, and treatment strategies for priority health risk factors and exposures, and (2) improved biologically based dose-response models.

Because some deployment-related health risk factors are already the subjects of substantial targeted research efforts within the fFederal gGovernment, it would not be prudent to include them in this strategy. Consequently, this plan identifies a number of research priority areas that currently deserve special emphasis. These research areas are as follows:

1. Chemical, biological, and radiological warfare (CBR) agents.
2. Stressors.
3. Emerging health concerns.
4. Infectious diseases.
5. Occupational risk factors and non-combat injuries.

Objective 2.1. A broad knowledge base of the possible health effects of low-level exposures to CBR agents.