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EVALUATION OF THE U.S. DEPARTMENT OF DEFENSE PERSIAN GULF COMPREHENSIVE CLINICAL EVALUATION PROGRAM GOALS AND PROCEDURES OF THE CCEP Overview s The CCEP was developed by the DoD to provide a "systematic in-depth medical evaluation for all military health care beneficiaries who are experiencing illnesses which they believe may be related to Persian Gulf deployment" (DoD, 1 995d). It was designed primarily as a clinical program to evaluate and treat the health problems of individuals. As a secondary goal, the DoD has released a series of reports that have summarized the results of the medical evaluations of the CCEP patients. The CCEP and a similar U.S. Department of Veterans Affairs (DVA) protocol were implemented beginning in June 1994. Members of the service who are still on active duty or who are still active in the Reserves or National Guard request their medical evaluations from the DoD. Veterans who have already left the service, Reserves, or National Guard request their medical evaluations from DVA. Phase I of the CCEP consists of a medical history, physical examination, and laboratory tests. These are comparable in scope and thoroughness to an evaluation conducted during an inpatient internal medicine hospital admission. Depending on the complexity of the patient's symptoms, this first phase is more comprehensive than the evaluation that a patient would usually receive in a primary care level outpatient work up (DoD, 1995a). All participants in the CCEP receive an evaluation by a primary care physician at their local medical treatment facility (MTF) and appropriate specialty consultations. Patients are referred to Phase II for further specialty consultations at a regional medical center (RMC, a tertiary care hospital) when it is clinically indicated in the judgment of the primary care physician (DoD, 1995a). Phase II evaluations consist of targeted symptom-specific examinations, lab tests, and consultations, as mandated in the protocol. Both Phase I and Phase II are designed to be thorough for each individual patient and, at the same time, to be consistent among patients (DoD, 1995a). Every MTF has a designated CCEP physician coordinator who is a board- certified family practitioner or internal medicine specialist. This physician coordinator is responsible for overseeing both the comprehensiveness and the quality of the Phase I exams. The CCEP activities at RMCs are coordinated by board-certified internal medicine specialists who oversee the program operations of the MTFs in their regions. In March 1995, the DoD established the Specialized Care Center (SCC) at Walter Reed. The purpose of the SCC is to provide additional evaluation, treatment, and rehabilitation for patients who are suffering from chronic debilitating symptoms. A small select group of patients have been referred from

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6 EVALUATION OF THE U.S. DEPARTMENT OF DEFENSE PERSIAN GULF COMPREHENSIVE CLINICAL EVALUATION PROGRAM RMCs to the SCC for an intensive 3-week evaluation and treatment program which is designed to restore participants to a maximum state of health and fitness (DoD, l995d). All medical records from the CCEP are sent to the Navy Medical Information Management Center (NMIMC) in Bethesda, Maryland, to be coded and computerized for entry into the national CCEP database. At NMIMC, the reports undergo quality review for completeness, thoroughness, and accuracy of diagnostic coding (DoD, 1995d). The CCEP was implemented in June 1994. By June 1, 1995, there were 16,729 requests for evaluations, and the DoD had been able to complete 13,150. The records for 10,020 of these evaluations had been reviewed for completeness, validated, and computerized (DoD, l995d). The DoD has been able to develop the infrastructure necessary to efficiently contact, schedule, refer, and track thousands of patients through the system. Committee Assessment of the Overall Goals and Procedures of the CCEP The CCEP clinical protocol is a thorough, systematic approach to the diagnosis of a wide spectrum of diseases. A specific medical diagnosis or diagnoses can be reached for most patients by using the CCEP protocol. The DoD has made conscientious efforts to build consistency and quality assurance into this program at the many MTFs and RMCs across the country. Overall, the committee is impressed with the quality of the design and the efficiency of the implementation of the clinical protocol, the considerable devotion of resources to this program, and the remarkable amount of work that has been accomplished in a year. The high professional standards, commitment, and diligence of the physicians involved in the CCEP at the RMCs were readily apparent at the three committee meetings. The committee commends the DoD for its efforts to provide high-quality medical care in the CCEP and the success that it has achieved to date in developing the infrastructure necessary to efficiently contact, schedule, refer, and track thousands of patients through the system. Overall, the systematic, comprehensive set of clinical practice guidelines set forth in the CCEP are appropriate, and they have assisted physicians in the determination of specific diagnoses for thousands of patients across the country.