An Analysis of the U.S. Department of Defense's Military Health Readiness Assessments

A military force cannot be effective in combat or as an organization if its service members are not sufficiently healthy and ready to serve. The Department of Defense's (DoD) Health Readiness Support Division within the Defense Health Agency (DHA) Public Health monitors service members' health and readiness to deploy by tracking issues that could negatively affect their individual medical readiness (IMR). DoD and its service branches use a suite of health assessments to conduct this tracking: the annual Periodic Health Assessment (PHA) and several deployment-related assessments including the Pre-Deployment Health Assessment (Pre-DHA), the Post-Deployment Health Assessment (PDHA), and the Post-Deployment Reassessment (PDHRA); the Mental Health Assessment (MHA) is incorporated into each of the other assessments. These assessments are administered at regular intervals in the deployment cycle and are meant to help identify health problems early so that the service member may obtain care and avoid negative impacts to their IMR. Command leaders also use data from the assessments to measure the overall fitness to serve at the unit level.

The suite of health assessments demonstrates DoD's commitment to comprehensively monitor the health of its service members. However, over time the number of items in the assessments has grown, and the mandated time frames in which they must be conducted (relative to deployment timelines) may create unnecessary burden and cost. The Office of the Assistant Secretary of Defense for Health Affairs asked the RAND National Defense Research Institute (NDRI) to evaluate DoD's suite of health readiness assessments against their stated objectives and to identify potential opportunities for improvement, increased efficiencies, and cost savings. This study presents the key findings and recommendations from that evaluation.

Approach

To identify potential opportunities to improve the efficiency of DoD's suite of health assessments, we conducted a number of reviews, interviews, and analyses:

• a review of DoD and service branch policies behind the assessments to gain an understanding of how they were intended to be implemented and conducted and to identify areas where language in policy may lead to differences in implementation across the department
• an inventory and analysis of the content and timing of the assessments to delineate the content areas covered in them, the extent of overlap across assessments, and the potential burden for assessment respondents (service members and providers) and record reviewers
• a focused literature review of best practices in civilian health screening and prevention, per the U.S. Preventive Services Task Force (USPSTF), as well as the use of such screenings within other high-risk professions among civilians, in order to provide reference points for comparison with the DoD suite of assessments
• a series of interviews with military leaders and providers to gather data on their perceptions of the suite of assessments, including perceived overlaps and gaps in content, processes for referral and follow-up, and recommendations for improvement.

This study was also initially intended to gather information on the costs to administer and participate in these assessments, as well as identify areas for cost savings. However, the data available to the research team made this portion of the study infeasible. We discuss ways to explore associated costs within Recommendation 2.

Key Findings

Four key findings emerged from the integrated results of the analyses described above.

Substantial Service Member Burden and Item Redundancy Exists Across Health Assessments, Particularly for Behavioral Health

The five health readiness assessments included 925 unique items that we classified into seven domains, 23 subdomains, and 107 topics. The behavioral health domain had the highest level of redundancy, both within and between assessments. That domain covered mental health concerns such as depression and posttraumatic stress disorder (PTSD), as well as negative health behaviors such as substance use. Among the three respondent types (i.e., service members, providers, and record reviewers), service members had the highest burden due to the number of items to which they are required to respond and also because of the timing of the assessments. Service members could be required to answer as many as 1,100 to 1,500 items over a 24-month period; 359 to 500 of those items are in the behavioral health domain and are related to depression and PTSD. Many interview participants expressed that the assessments are too long and entail too much redundancy. Though many viewed some redundancy as potentially valuable (e.g., for increasing the odds of identifying mental health issues and presenting an opportunity to track service members' responses over time), others emphasized that it contributed to survey fatigue for service members and providers.

Content of Health Readiness Assessments Largely Aligns with Recommended Preventive Screenings, But May Not Always Be Clearly Clinically Relevant

Of the seven USPSTF screenings that fit our criteria (preventive screenings for nonpregnant adults that use a patient-report mode), five aligned with the DoD health readiness assessments. The two USPSTF screenings not covered by the DoD assessments concerned anxiety and intimate partner violence. Our attempt to identify screenings used in a professional civilian setting for high-risk jobs, such as line-of-duty (LOD) jobs in fire and police departments, was not fruitful at least in part because legal requirements of the Americans with Disabilities Act prohibit mandatory ongoing routine health screenings of the mental health of civilian workers. Some interview participants perceived the contents of the DoD health readiness assessments as effective for prevention and early intervention. In contrast, however, many others described aspects of the current assessment process as ineffective. Some participants suggested the assessments should be evaluated to determine their clinical relevance and alignment with existing evidence, and some expressed the view that the addition of certain items to the PHA was politically motivated.

Process Issues May Limit the Utility of Health Readiness Assessments for Their Intended Purpose of Assessing Individual Medical Readiness

Interview participants raised three main concerns related to the utility of DoD health assessments to assess IMR or serve as a prevention or early intervention tool. First, several factors related to data collection—redundancy and survey burden, the timing of some assessments, and service members' comfort level with providers completing the assessment—could influence the accuracy of service member responses and compromise data quality. Second, DoD policy guidance provides little detail about requirements for referral processes and does not proscribe specific mechanisms for tracking whether service members receive needed follow-up care. This may contribute to inconsistent tracking of referrals and follow-up, and, as suggested by some interview participants, it can leave service members responsible for following through on their own with recommended care. Third, many participants described assessments as being divorced from a service member's primary care, which can lead to missed opportunities for providers to identify critical symptoms or incorporate health assessment data into follow-up care.

Technological Challenges Reduce Efficiency, Particularly for Providers Who Complete Assessments

Interview participants, especially providers, described multiple technology-related barriers to viewing and using assessment data, tracking referrals and follow-up, and integrating the assessment data with clinical care. Some needed multiple screens or programs to view a service member's health record while completing assessments. Viewing service member assessment responses over time was cited as a challenge as well. Many participants did not know of any systems available to help manage post-assessment referrals or follow-up care. DoD and DHA require health readiness assessment data to be collected electronically, but differences in implementation across service branches can compound inefficiencies for providers. Some providers suggested that data systems should be standardized to better support completion of health readiness assessments.

Recommendations

Using the key findings from our analyses, we developed three recommendations to inform ongoing efforts by DoD to improve the efficiency and effectiveness of health readiness assessments.

Recommendation 1. Use Systematic Criteria to Evaluate the Content of Health Assessments, Especially When Adding or Removing Items

Given the differences in opinion regarding the advantages or disadvantages of redundancy across assessments, DHA should develop and apply criteria to systematically evaluate additions and deletions from health assessments. This process could begin by first identifying domains to be used in evaluating assessment content, such as clinical relevance, alignment with existing research, potential impact on IMR, validity and reliability of assessment measurement, frequency of assessment, and prevalence of the underlying condition being assessed. With criteria in place, DHA could then evaluate the pros and cons of adding or removing items, and it could consider evaluating the suite of assessments on a regular basis to ensure their relevance over time. A working group of leaders, providers, and combatant commanders could also help with the review process. Such structures currently exist within DoD (e.g., the Periodic Health Assessment Optimization Working Group), although without publicly accessible documentation of working group charters, it is unclear what process is used by them to evaluate assessment content and whether expertise outside of DoD is utilized during the assessment process.

Recommendation 2. Conduct an Evaluation of the Costs and Benefits Associated with the Suite of Health Readiness Assessments

Administration of the suite of health readiness assessments likely involves substantial costs, including the time and labor for service members, providers, and record reviewers to complete the assessments. We were not able to obtain data to evaluate these costs for this study, but the identified overlaps and redundancies in the assessments as well as the questions raised about the effectiveness of the assessments by interviewees suggest that a cost-benefit analysis of the current system is still worth pursuing. To get this analysis off the ground, DoD would need to gather several types of data that describe the cost of completion: how long it takes respondents to complete the assessments, which could be available in the electronic administration system; the cost of this time in terms of the person's pay or salary; and the number of assessments they would need to complete over a certain period of time. For the benefit part of the analysis, DoD would need to identify and then monetize the expected outcomes associated with the health readiness assessments, which could include the number of service members screening positive for a condition, the number of referrals for follow-up care (at a substance use disorder clinic or in physical therapy, for example), the number of follow-ups successfully completed from referrals, the number of service members eligible for deployable status after resolution of an issue identified in the assessments, and an aggregate measure of unit-level personnel readiness. The final step would be for DoD to compare the costs and benefits. Such an analysis could be used to identify how changes to implementation—including adding or removing content, changing the timing of assessments, and using different types of providers—could shift the cost-benefit ratio.

Recommendation 3. Explore Opportunities for Improved Technological Efficiency in the Health Readiness Assessment Process

We did not identify any specifications in DoD policy for electronic systems beyond the basic requirement that such a system exist and that it be integrated into the Defense Medical Surveillance System (Military Health System, 2024; U.S. Department of Defense Instruction 6490.03, 2019). Service branches track IMR and communicate duty limitations using different electronic systems (e.g., eProfile for Army, the Limited Duty Sailor Marine Readiness Tracker for Navy and Marine Corps, and the Aeromedical Services Information Management System for Air and Space Forces). Working across these multiple systems that are not integrated with GENESIS, the Military Health System's (MHS's) electronic health record, can add to the burden on providers for assessment completion. Military leaders and providers we interviewed recommended improving the technology that supports administering the health readiness assessments, as well as optimizing systems to help track and manage follow-up. DHA could explore opportunities for improved efficiency by evaluating the landscape of existing systems to pinpoint challenges and identify potential solutions. Such an evaluation might uncover ways to streamline assessment administration through skip patterns, strategies to help providers more easily flag service members for follow-up, or approaches to creating dashboards that would summarize assessment data for providers. It could also illuminate the extent of interface difficulties reported by our interview participants. With a more complete understanding of the technological challenges and opportunities, DHA could then create a plan to scale up promising strategies and other essential improvements. Implementation could also involve establishing a set of best practices to use across MHS as well as examining the potential to securely use artificial intelligence in an exploratory way within existing systems. Integration of GENESIS with the electronic assessment systems could be a laudable (if expensive) long-term goal, but there may be smaller incremental improvements that could be made that result in better care for service members.