MILITARY MEDICINE

ORIGINAL ARHCLES

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MILITARY MEDICINE, 172. 11:1133.2007

Human Performance Optimization: An Evolving Charge to theDepartment of Defense

Guarantor. COL Francis G. O'Connor. MC USAContributors: Patricia A. Deuster. PhD MPH*: COL Francis G. O'Connor. MC USA*; CDR Kurt A. Henry. MC USNf:Lt Col Valerie E. Martlndale. USAF BSC|: Col U u r a Talbot. USAFR§; LTC Wayne Jonas, MC USA (Ret.)SI:COL Karl Friedl, MS USA||

Uniformed Services University of the Health Sciences hosted aconference in June 2006 entitled "Human Performance Opti-mization in the Department of Defense: Charting a Course forthe Future" with the goal of developing a strategic plan forhuman performance optimization (HPO) within the Depart-ment of Defense (DoD). The conference identified key issues:(1) advocating for HPO at all DoD levels, (2) defining HPOspecific to DoD requirements. (3) developing valid and stan-dardized metrics for HPO, (4) translating HPO research intothe operational community, and (5) establishing effective com-munication and coordination across military services andwithin the medical, research and operational communities.The program objectives should enhance mental and physicalresilience of the war fighter; accelerate recovery; reduce injuryand illness; provide seamless knowledge transfer from labora-tory to line; improve the human system contribution to mis-sion success; and allow the U.S. to remain in the lead in thisarea.

Introduction

The 21st centuTy has brought unexpected challenges to theU.S. military and the Department of Defense (DoD), The

Military Health System (MHS) has siieeessfully responded tothe new demands of the post-September 11 environment withan emphasis on a higher operational tempo through longer andmore frequent deployments. The MHS has achieved unprece-

'Department of Military and Emergency Medicine, Uniformed Services University ofIhe Health Sciences, 4301 Jones Bridge Road. Beihesda, MD 20814,

+Naval Medical Research Center. 503 Robert Grant Avenue, Silver Spring, MD20910.

tU.S. Air Force Office of the Surgeon General. 110 Luke Avenue. Suite 400. BoilingAir Fon-e Base. DC 20332 7050,

§School of Nursinji. Uniformed Services University of ihe Health Sciences. 4301Jones Bridge Road, Bethesda, MD 20814.

ISamiiefi institute. 1700 Diagonal Road, Suiie 400. Alexandria, VA22314,lITelemedicine k Advanced Technology Research Center, 1054 Patchel Street, Fort

Detrick.MD 21702,This manuscript was received for review in February 2007. The revised manuscript

was accepted for publication in Ju!y 2007,Reprint & Copyright © by Association of Military Surgeons of U,S,, 2007.

dented and dramatic results in combat casualty care: case fa-tality rates for combat injury during the Global War on Terrorare roughly one-half that of Vietnam and one-third that of WorldWar 11.' Technological innovation has resulted in systemchanges such as the implementation of tactical combat casualtycare at the point of injury, forward surgical team success withrapid forward resuscitative surgical intervention, and criticalcare air transport teams ensuring rapid exit of the criticallywounded to higher levels of medical/surgical care.''^

A new emphasis has been placed on the human as the mostimportant weapon system in the Global War on Terrorism. TheGlobal War on Terrorism, identified as The Long War" in the2006 Quadrennial Defense Review.̂ will demand optimal per-formance from Soldiers. Sailors, Airmen, and Marines. The Spe-cial Operations Forces has recognized that "humans are moreimportant than hardware" in this new aspect of asymmetricwarfare.

In May 2005. the Director of the Office of Net Assessmentreleased a report entitled "Human Performance Optimizationand Military Missions,"** The report was based on interviewswith four operational units along with discussions among med-ical and research personnel within the DoD in the area related tohuman performance. This report defined human performanceoptimization "as the relatively precise, controlled and combinedapplication of certain substances and devices over the short andlong-term to achieve optimization in a person or unit's perfor-mance overall,"'' This report resulted in a request from the DoD/Health Affairs (HA) to the Uniformed Services University of theHealth Sciences (USUHS) to host a conference in June 2006.The goal of the conference was to initiate the development of astrategic plan for HPO within the military. This article summa-rizes the conclusions of the conference and the challenges facingthe MHS in their efforts to optimize war fighter performance.

Methods/Approach

War fighters, line commanders, safety officers, health profes-sionals, and researchers were among the 89 attendees from 56

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1134 HPO; An Evolving Charge to the DoD

DoD organizations and the Coast Guard who participated in aworkshop entitled "Human Performance Optimization in DoD:Charting a Course for the Future" held in June 7-9, 2006, Theconference started with keynote remarks from DoD senior lead-ership concerning the importance of this effort. This was fol-lowed by presentations from the Air Force. Army. Navy, and U.S.Special Operations Command regarding research initiatives inHPO. The attendees were broken into five working groups todiscuss current and brainstorm future approaches in HPO. Theworking group sessions consisted of the following: (1) dietarysupplements and other self-improvement products, (2) leader-ship and teamwork. (3) physical training. (4) devices, and (5)innovative approaches. After several hours of discussion, pre-sentations by each group were prepared to create a framework,The important HPO approaches identified on day 1 were appliedto a war game scenario on day 2. The artificial scenario involvedthe rapid deployment of a unit to a fictitious land where themedical planner confronted human performance challenges in-cluding sleep deprivation, heat stress, altitude extremes, andprolonged nocturnal operations. The day 2 working groups werecharged with applying HPO approaches to important aspects ofpredeployment. deployment/employment, and postdeployment.Day 1 working groups were reshuffled into new groups for theday 2 assignment to encourage more "outside the box" thinking.

In response to the success of the USUHS workshop. DoD/HAconvened a HPO Integrated Product Team (IPT) to review theUSUHS report, collect relevant data from the services, and ini-tiate recommendations for a novel comprehensive HPO pro-gram. This effort resulted in a working defmition of HPO and adirective to the Army Surgeon General to incorporate key HPOrequirements, such as an information clearinghouse, into theJoint Medical Research Command as a key focus arca.^

Findings

Based on the findings of the working group, issues were cat-egorized as (1) organizational. (2) communication, (3) scientific,and (4) operational, based on the type of action required toresolve the identified obstacles to HPO within the DoD. Opera-tional concerns were further subdivided into predeployment, •deployment/employment, and postdeployment phases.

Organizational Issues

A defmition of HPO within the DoD is viewed as a criticalorganizational issue, since this wili allow the concept and ap-plication of HPO to be clearly embraced. A DoD definition of HPOwill impart a vision and imply advocacy from above to guide warfighters, commanders, practitioners, and researchers. A HPOdefinition should he all-inclusive and not limited to the medical.MHS community, and culture. The definition must address tar-get populations, embrace relationships with other areas anddistinguish between disease treatment, "fitness" for health andwcUness versus "fitness" to perform specific militaiy tasks. TheHPO definition must delineate the diiferences associated withHPO technology.

In the current environment, commanders have limited guid-ance concerning HPO, as some existing policies may be coun-terproductive. Existing policies need to be reviewed withguidance to ensure consistency of various HPO approaches.

Importantly, a mechanism for its evolution in response to newdevelopments must be identified. First and foremost, command-ers want permission to enhance the performance of their warfighters. However, current guidance and policy may not endorsethe concept of performance enhancement. As an example, theU.S. Special Operations Command has banned the use of allpotential performance-enhancing products that are considereddietary supplements because of unknown, long-term side ef-fects. Some products may be helpful for specific types of perfor-mance (e.g.. creatine), and yet such products cannot be usedbecause of existing policy, HPO advantages supported by sci-ence should be translated through consistent policies.

Another important organizational issue relates to operationaltranslation of knowledge and research directly to commandersand war fighters. A Joint Center for Human Performance Opti-mization to focus on translating existing knowledge into theDoD standard of Doctrine. Organization, Training. Material,Leadership. Personnel, and Facilities would he a useful andcritical step forward. However, the flow must be bidirectionalsuch that the needs of the war fighter go directly back to theCenter so requirements can be updated and new technologiespertinent to the battlefield can be identified.

Communication Issues

The dominant theme of the conference was communication.Commanders and clinicians in the field are typically unaware ofcurrent HPO information and research efforts. Operators at thehighest levels arc often unaware of laboratory research endeav-ors and existing solutions. To a great extent, important infor-mation about HPO is also unknown to the average war fighter;most of their information is derived from commercial venuestrying to promote selected products. Likewise, it is not usual forresearchers to access commanders to offer possible solutions oraccess lessons learned, which could and should direct researchand development efforts. Operators and researchers need to beable to communicate directly with each other because effectivecommunication strategies are requisite for HPO. Without effec-tive mechanisms for facilitating communication among opera-tors, medical personnel, and the various research communities,the war fighter may not have access to some imporiant advan-tages. Cross-communication and synergy are requisites for ad-dressing operational needs and acquiring new technologies in atimely marmer.

Imporiantly. any form of communication must be joint andcoordinated within and across services. The physiological andpsychological principles are the same regardless of service, al-though the appropriate use and applications of HPO solutionswill vary according to service and mission-specific require-ments. Interactive and integrated communication would be op-timal, such that consultative services, educational materials,and research efforis would all be linked. Finally, working scien-tists need opporiunities to communicate with operators aboutdeveloping projects. Organizations that conduct HPO researchneed to be teamed with representatives from acquisition, oper-ators, and medical personnel from the field to discuss currentresearch efForts. provide opportunities for cooperation, and di-rect future HPO needs.

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HPO: An Evolving Charge to the DoD 1135

Scientific Issues

The dominant scientific issues relate to the need for oper-ationally relevant and standardized metrics to meet joint mil-itary requirements. Metrics are the single most importantissue for research and application of HPO. Different metrtcsare in use by various laboratories and organizations and a fewhave been validated within narrow contexts. However, metricsthat reflect combat effectiveness are limited. Importantly, fewdei'ined baseline metrics against which to measure the suc-cess of HPO approaches have been established. One exampleof a successful baseline metric is demonstrated within theDoD refractive surgery program: medical experts in coordina-tion with line commanders and the aviation community de-fined baseline scientific visual metrics to monitor and improveperformance in the operational environment. Once other relevantmetrics are validated and standardized, baseline data can be col-lected for future comparisons, This effort will require significantcoordination and several meetings of various communities to re-view and agree upon metrics that can be used both operationallyand for military relevant HPO research.

In addition, unlike weapon systems where performance is mon-itored and life cycle is linear, the performance of humans is cyclicaland time-phased (Fig. 1). The human "system" requires an inte-grated program of preparation, training, and monitoring beforemission execution, followed by a sequenccd period of recovery and"reset." This programming is carefully monitored for injury withrapid diagnosis and interventions for transitloning back into apreparatory phase for the next mission. HPO programming pre-serves human capital by addressing individual weaknesses andminimizing susceptibility to injuiy. disease, and other factors thatinfluence performance.

Operational Issues

Collaboration between operators and medical researchers isessential for the development and operational fielding of effec-tive HPO approaches. There is no substitute for the insights andexperiences of war fighters in the field. With their help, criticalareas within each of the three phases of operations were iden-tified at the conference, with leadership, teamwork, and appro-priate metrics always being emphasized.

Predeployment

The questions posed to the groups were "How do we and howshould we prepare our war fighters for deployment? How can weminimize injuries during the preparation process?" The criticalissues identified for the predeployment phase included func-

R«-Evaluat«/Returnto Duty

PrepareH'rain/Prevent/Monitor

RehabilitateExecute

Sustain /Missions

tional fitness, performance nutrition, cognitive and psychologi-cal readiness, and preparation for prospective environmentalthreats. It was generally agreed that HPO approaches duringpredeployment strategies should have the greatest impact onminimizing problem areas for deployment and postdeploymentphases. The approaches believed to be most effective for HPOduring the training phases before deployment are presented inTable I in various categories.

Deployment/Employment

The question posed for HPO approaches during deploymentswas "How do we sustain predeployment preparation during de-ployments?" A number of the essential performance issues forthe deployment phase were similar to predeployment. but addi-tional ones, such as maintaining wakefulness. pain control,environmental exposures, cognitive overload, situational aware-ness, stress, communication/control, and language/cultural is-sues were identified. The issues proposed to be most responsiveto HPO approaches during the deployment/employment phaseare presented in Table II.

Postdeployment

Postdeployment. the last phase of operations, focused on de-ployment experiences and recovery. The crucial operational is-sues wherein HPO approaches would be helpful included returnto functional fitness and predeployment physical state, psycho-logical consequences associated with combat stress, exposuresto diseases and toxins, and processes for reintegration. Specificareas of interest to HPO are included in Table III.

TABLE I

HPO APPROACHES FOR PREDEPLOYMENT HEALTHAND PERFORMANCE

Therapy

Fig, 1. Model for optimizing health and human performance.

Achieving and sustaining functional fitnessMission-based physical Rest and recovery

fitness programFunctional screen Conibat-speclftc metricsIncentives for maintaining Biomarkers of physical fitness

readinessPerformance nutrition

Predepioynient diet plans Nutrition education intraining

Nutritional biomarkers for Dietary supplementsperformance

Cognitive readinessMenial preparation and Memory aids and sleep plans

cognitive techniquesBlornarkers of cognitive Dietary supplements

readinessPsychological readiness

Desensitivlty training Cultural awarenessStress inoculation Relaxation techniquesBiomarkers for resilience

Environmental threatsAcclimation strategies Nutrition and dietary

supplementsCognitive techniques Personal protective devicesBiomarkers for susceptibility

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1136 HPO; An Evolving Charge to the DoD

TABLEn

HPO APPROACHES FOR DEPLOYMENT/EMPLOYMENT HEALTHAND PERFORMANCE

Sleep, fatigue, and alertnessPharmacological agents Various devices (light therapy)Dietary supplements Cognitive techniques

Pain and casualty careDietary supplements Devices (blood clotting.

nanosecond pulsedelectromagnetic Heldtechnology)

Performance nutrftionDeployment diet plans Dietary supplements

Situational awarenessCognitive techniques Devices and human systems

IntegrationStress reduction

Cognitive techniques Mental self-managementLeadership and teamwork Relaxation techniques

Environmental/occupational exposuresDietary supplements Personal protective devicesLanguage/cultureHand-held language translators Advanced educational devices

TABLEm

HPO APPROACHES FOR POSTDEPLOYMENT HEALTHAND PERFORMANCE

Regainlng/retum to functional fitnessRehabilitation programsFunctional rescreenBiomarkers for "return to

normal"

Rest and recoveryAcceleration of Healing

Psychological consequences of combat stressCircadian resynchronizationDevices (light therapy)Subordinate evaluation of

leadershipReset programs

Biomarkers of psychological stateCognitive techniquesRelaxation/meditation

Family reintegration programsRecovery nutrition

Nutritional assessment Dietary supplementsEnvironmental/occupational exposures

Dietary supplementsBiomarkers of exposure

Personal protective devicesDevices tor neutralization

Postdeployment processesJoint long-term follow-up

strategiesPrograms for reset and

ramp dovmLong-term follow-up for

reserve componentsTargeted psychological

assessments

Life cycle management of warfighters

Maintaining unit integrity for warfighters

Technologies for facilitatingrelnlegration

Evaluation of postdeptoymentprocesses

Discussion

HPO depends on many factors, including biological, phys-ical, psychological, cultural, and social, all of which interact.Management heuristics and nonpersonalized solutions havelimited use and may actually compromise human perfor-mance. Thus, systematic approaches for optimizing humanperformance must be identified. From a systems perspective,

performance optimization integrates four basic components:(1) a measurable function for selective maximization. (2) a setof variables which affect the objective function, (3) a set ofconstraints which allow the variables to assume certain char-acteristics, and (4) attention to the "ground" (function-cyclecontext) that addresses system priming and preparation andenvironmental optimization in which the variables operate.For HPO. we must identify these four basic components anddetermine how to maximize function by manipulating andshaping the constraints on the critical variables. Combateffectiveness and leadership are two overarching goals of themilitary. However, to optimize combat effectiveness, we mustidentify the specific functions and primary variables that im-pact human performance. The variables affecting functioninclude biological attributes, cognitive abilities, training andmotivational techniques, individual and social expectancies,leadership styles, and the use of products and devices and/or various types of equipment. The term HPO in thiscontext reflects the application of various approaches and com-binations of approaches that can optimize the performance ofthe war fighter to successfully achieve the mission.

Following submission of the USUHS HPO Conference Sum-mary Report and a briefing to HA, an IPT was convened by HAto discuss and make further recommendations regardingHPO, The IPT reviewed, discussed, and validated the USUHSHPO conference findings, developed a working definition of HPOfor use by HA (Office of the Secretary of Defense (HA)), andpresented concrete recommendations to Office of the Secretaryof Defense (HA). Importantly, the IPT. as suggested by theUSUHS report, identified processes to facilitate HPO in conjunc-tion with organizational options to implement the needed pro-cesses and functions. Furthermore, strong advocacy for HPO inthe DoD was recommended. In part, this would be achieved byaligning HPO research to DoD priorities, facilitating interchangebetween researchers through chat rooms, a HPO library, andconferences, developing lines of communication between oper-̂ational commands and HPO research to ensure synergy towardcommon cndpoints, and by creating standards for HPO re-search. One primary avenue for integrating these multiple pro-cesses and functions would be through a DoD clearinghouse forHPO information. Although the previous clearinghouse (the Hu-man Systems Information Andysis Center) failed to be sus-tained and supported through the services, a new effort isneeded.

The recommendations of the IPT were reported and haveresulted in an action memorandum. On January 4, 2007. theAssistant Secretary of Defense for HA signed a memorandumasking that HPO be established as a core program within thenew Joint Medical Research Command.^ The formation of aJoint Medical Research Command was previously announcedin a memorandum signed by the Secretary of Defense onNovember 27. 2006.'' The memorandum stated that a UnifiedMedical Research Command would be formed under the ArmyMedical Research and Materiel Command. A forma! plan forthis Joint Medical Research Command should be available inthe spring of 2007. The majority of DoD medical research isalready consolidated under the U.S. Army Medical Researchand Materiel Command, and medical research on HPO isalready coordinated through the Armed Services Biomedica!

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HPO: An Evolving Charge to the DoD 1137

TABLE IV

KEY DoD LABORATORIES AND FUNDERS OF HPO RESEARCH

Laboratories (listed in decreasing order of annual core funding)U.S. Army Research Institute of Environmental Medicine,

Natick. MassachusettsDepartment of Neuropsychlatry and Neurosciences, Walter

Reed Army Institute of Research, Bethesda. MarylandNaval Health Research Center. San Diego. CalifomiaHuman Effectiveness Research Division. Air Force Research

Laboraiory, Wright-Patterson Air Force Base. OhioU,S. Army Aeromedical Research Laboratory. Fort Rucker,

AlabamaNaval Submarine Medical Research Laboratory, Groton.

ConnecticutFunding organizations

Defense Sciences Office. Defense Advanced Research ProjectsAgency. Arlington, VA

U.S. Anny Medical Research and Materiel Command, FortDetrick. MD

War Fighter Performance Department (code 34). Office of NavalResearch, Arlington, VA

Air Force Office ol Scientific Research, Arlington. VAArmy Research OlBce, Adeiphi, MDBlomedical Initiatives Steering Committee, Special Operations

Command. Tampa, FL

Research Evaluation and Management Armed Services Bio-medical Research Evaluation and Management, representingall service interests (Table IV). This can be readily enhancedand supported to expand the transition of HPO research touse across the DoD, As succinctly stated in a document putforth by the U. S. Special Operations Command; "Humans aremore important than hardware,"

ConclusionsWithin the DoD. a focus on HPO is in development. A culture

that emphasizes HPO is critical to the health and well-being andfuture effectiveness of our war fighters. The solutions exist foreffective development and implementation of HPO in the DoD,and the people and organizations to conduct and implementthose solutions are available. However, a structure to connectthem is essential. Immediate attention is required to create aneffective HPO program in the DoD. A robust HPO program will

(1) enhance the mental and physical resilience of the war fighter;(2) Result in reduced injury and illness or more rapid recovery:(3) provide seamless information and knowledge transfer fromlaboratory to line; (4) improve the human weapons system'sability to accomplish the mission: and (5) allow the UnitedStates to remain at the leading/cutting edge in this area.

References

1. HolcombJB. StansburyLG. Champion HR Wade C. Bellamy RF: Understandingcombat casualty care statistics. J Trauma 2006: 60: 397-401.

2. Mllitar>' Medical Technology Online Archives. Derember 18,2006. Vol 10. Issue 8,Interview with Colonel Rocky Farr. Command Surgeon U.S. Special OperationsCommand. Available ai http://w'ww.n]ilitary medical-technology.com/article.clm?DoclD=!846: accessed June 12, 2007.

3. 2006 Quadrennial Deiense Review. Available al www.defensellnk.mil/pubs/pdfs/gDR20060203,pdf: accessed June 12, 2007.

4. Russell A. Dulkley B, Grafton C. Human Perfonnance OptimtzaUon and MilitaryMissions: Final Report. ONA, GS-10F-O297K, May 2005.

5. Assistant Secretary of Defense, Health Affairs. Memorandum for Surgeon Generalof the UnJied States Army, January 4. 2007, "Human Perfonnance OptimizationFocus in the Joint Medical Research Command." Washin(^on. DC.

6. Assistant Secretary of Defense. Health Affairs. Memorandum for Secretary ofDefense. November 27. 2006. "Joint/UnU'ied Medical Command [J/UMCj WayAhead.' Washington. DC.

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