Total Exposure Health - A Bold Approach to Transform the Delivery of Healthcare through Primary Prevention
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As the medical consumer becomes more informed, as science and technology improve, and as it becomes clear that one size medicine does not fit all, the healthcare delivery system needs a significant paradigm shift from its primary focus on disease and injury treatment to a holistic approach to health and prevention. To meet this emerging demand, the Air Force Medical Service (AFMS) created Total Exposure Health (TEH), which associates human exposures to the lowest common denominator – the individual’s DNA (N=1) – to enrich clinical decisions with a forward vision using the advancements in science, technology, medicine, and informatics.
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Total Exposure Health - A Bold Approach to Transform the Delivery of Healthcare through Primary Prevention
- 1. Total Exposure Health – A Bold Approach to Transform the Delivery of Healthcare through Primary Prevention 06 Nov 2017 American Public Health Association Annual Meeting 2017 Col Kirk Phillips United State Air Force Medical Service 1Cleared for Public Release, SAF/PA Case Number:2016-0444
- 2. Disclosure Col Kirk Philips ∎ No Relationships to Disclose Cleared for Public Release, SAF/PA Case Number:2016-044411/4/2017 2
- 3. Healthcare is Changing… Healthcare in Changing – Focus on the Individual 11/4/2017 3Cleared for Public Release, SAF/PA Case Number:2016-0444 Policy, technology, marketplace & consumer expectations are disrupting healthcare & we can position ourselves to better support “Personalized Healthcare”
- 4. Vision: What if we could… Such a capability would Enhance individual human performance Help providers understand the effects of exposures on a patients health now and throughout their life “True Comprehensive Health Surveillance” Enable rapid intervention and supportive medical care, with more confidence Reduce disability by truly preventing disease Lead to significant savings in total health care costs . . . tell if a person has unacceptable exposure- related health risks in near real-time? Servicemember working in a burn pit in Balad, Iraq. (Public Domain) We are the sum of our experiences (and exposures).... Factory emission (Public Domain) Cleared for Public Release, SAF/PA Case Number:2016-0444 4
- 5. Total Exposure Health Description: Solution to capture workplace, env & lifestyle exposures to the ind (i.e., N=1, genome) using advances in science, technology & informatics to prevent disease; improve health and well-being: Healthiest Performing Population by 2025 E H Increase use of genomic research and knowledge Improve exposure monitoring through sensors and wearables Better understanding of monitored exposure to performance and individual health outcomes Advance operational decisions using advancements in science, medicine, technology, and informatics with digital biodata bank, Big Data analytics, and expert systems Cleared for Public Release, SAF/PA Case Number:2016-0444 5
- 6. Total Exposure Health- Visualized EFFECT DOSE 11/4/2017 When we account for genetic variance we find we are all unique! But we can also use this information to protect health and enhance performance “Sensitive” Individual “Resilient” Individual “Average” Individual Chemical Allergen Radiation Cleared for Public Release, SAF/PA Case Number:2016-0444
- 7. * SEG – Similar Exposure Group Current State - Prev Med Future State – Prev Med Work exposure only Work, environment, lifestyle (home, rec, etc) exposures Animal models of exposures are applied to population and (SEG)* with safety factors for Airmen protection and clinical intervention Individual exposure applied to each Airman’s genome with tailored interventions to include prevention, protection, career, placement and clinical Limited sensors (time, sensitivity, analytes) Individual and area sensors with full analyte complement, real time/all-the-time, sensitive to human based exposure levels Clinical intervention based on organ function disruption/damage Clinical intervention based on molecular biology changes brought by exposure Paper-based exposure summary somewhere in the clinical record Expert system (EHR) matching billions of bits of information (DNA, sensor, etc) relevant to exposure with clinical recommendation Prevention concerns applied post- occupational/lifestyle choice Prevention of key health outcomes part of the care decision for career/life from recruitment to separation/retirement TEH Total Exposure Health: Where it takes us Cleared for Public Release, SAF/PA Case Number:2016-0444 7
- 8. Reimagining Healthcare w/TEH Cleared for Public Release, SAF/PA Case Number:2016-0444 8
- 9. TEH PROOF OF CONCEPT 9Cleared for Public Release, SAF/PA Case Number:2016-0444
- 10. TEH – Helping to Solve Military Hearing Loss ∎ Common exposure We all experience noise exposure in workplace, lifestyle and environment Untreatable hearing loss can negatively affect one’s quality of life ∎ Costly Exposure $1.5-3B DoD/VA annual bill (Benefits and Medical) Hearing loss and tinnitus are among the top medical complaints, and most widespread injuries, Linked to chronic disease, dementia, depression, and anxiety. ∎ Affects the mission Mission effectiveness directly proportional good communication Good hearing is prerequisite for peak performance Cleared for Public Release, SAF/PA Case Number:2016-044411/4/2017 10
- 11. Noise Demonstration Project • Noise demonstration project will: • Demonstrate the ability to collect, store, and utilize unstructured “noise” exposure data to identify the unique health risk associated noise and manage NIHL • Data to include: sensor, survey, clinical, and genetics • Create intervention strategies to protect beneficiaries (training, medical interventions such as functional hearing tests and customized protection) • Identify future research questions and research needs Exposure Big Data Analytics Cleared for Public Release, SAF/PA Case Number:2016-0444 11 Turn Data into Insight
- 12. Multiple Gene variants associated w/NIHL Cleared for Public Release, SAF/PA Case Number:2016-0444 12
- 13. Gene x Environment Interactions & Prevention *Data Derived from Air Force Coriell study Multiple genetic variants in multiple genes associated with NIHL or related phenotypes Odds Ratios range from 5.2 to 22.36 Cleared for Public Release, SAF/PA Case Number:2016-0444 13
- 14. Technology - Highlights ∎ Noise monitoring sensor measures External (ambient/audio) “Digital” 24/7 ∎ Bluetooth ∎ Agnostic app for individual's device ∎ Low- Profile low cost 14 On duty Off duty Cleared for Public Release, SAF/PA Case Number:2016-0444
- 15. Our Clinical Disposition Total Exposure Health – Exposure Indices 15 Our Unique Genetic Proclivity IEHRP: Individual Exposure Indices Our Exposures 11/4/2017 Cleared for Public Release, SAF/PA Case Number:2016-0444
- 16. Genetics Diagnostics Sensors and Mobile Data Lifestyle Occupation Medical History Environment Faimly History Cleared for Public Release, SAF/PA Case Number:2016-0444 Exposure Index can have many variables 11/4/2017 16
- 17. Visualizing the IEHRP – Individual 11/4/2017 IEHRP will aid in visualizing an individual’s unique exposure susceptibilities Kirk NOISE BENZENELEAD RADIATION GLUTEN SUSCEPTABILITY HIGH LOW Cleared for Public Release, SAF/PA Case Number:2016-0444
- 18. Visualizing the IEHRP – Population Cleared for Public Release, SAF/PA Case Number:2016-044411/4/2017 Yr 1 Baseline IEHRP Intervention/Changes Y2 IEHRP See Unique PatternsAnn Al Lily Kirk Rich YEAR 1 BENZENE LEAD RADIATION GLUTEN NOISE YEAR 2
- 19. TEH WRAP-UP 19Cleared for Public Release, SAF/PA Case Number:2016-0444
- 20. ∎ Retain health and increase human performance for people ∎ Comply with regulatory standards and Congressional mandates regarding comprehensive health surveillance ∎ Better understand current and emerging exposure trends and their impacts on health ∎ Advance true primary prevention to address health risk before the onset of disease ∎ Develop rapid intervention and supportive medical care with more confidence ∎ Create significant savings in total health care costs and reduced disability by preventing disease Collectively we can: 20Cleared for Public Release, SAF/PA Case Number:2016-0444
- 21. QUESTIONS? 21Cleared for Public Release, SAF/PA Case Number:2016-0444
Editor's Notes
- It is estimated that there are almost one million more veterans with service-connected hearing loss and/or tinnitus who do not meet the criteria for receiving compensation. The cost of compensation for hearing and tinnitus-related disabilities in fiscal year (FY) 2006 was over USD 1.2 billion. The VA has additional expenditures associated with dispensing of hearing aids and other audiological services. In FY 2007, the VA dispensed 348,920 hearing aids at an estimated cost of USD 141.3 million, and provided audiological services at a cost of approximately USD 147.1 million. It is thus clear that hearing loss resulting from military service is a huge financial and clinical burden for the VA.
- Policy, Competition, Innovation & Consumer Expectations are Disrupting Healthcare: As the medical consumer becomes more aware, science and tech improve and as we realize one size medicine does not fit all, the prospect of individualized healthcare will have positive impacts the individual and the military by engaging the Airman to become more active in their healthcare while reducing cost do to the focused interventions that prevent and heal with laser focus. Regarding change...it's happening look around with the more informed consumer actively participating in their healthcare interventions, our understanding of the human genome, wearable and sensor technology with real-time diagnostics. It's a very exciting time to be in healthcare and Total Exposure Health helps to revolutionize how we provide primary prevention to identify the cause with an emphasis on” Personalized Health” bridging true primary prevention for our military beneficiaries vs. just a treatment or cure. That is, our medicine is not the only pathway to health. The food we eat, the choices we make, etc. all contribute to our well-being. If we only focus on medicine then we take away the prospects of what “Precision Medicine” can be and that’s “Personalized Health”.
- Note: The E -> H in the diagram is Exposure -> Health
- Typical “Dose vs. Exposure” curve and verbiage CLICK 1: With regards to exposures, generally 3 categories of individuals… CLICK 2: “Average” individuals who fit the curve of a given exposure (based on understood/accepted tox data) CLICK 3: “Sensitive” individuals to the same exposure (“above the curve”) CLICK 4: “Resilient” individuals to the same exposure (“below the curve”) CLICK 5: When applied to a population, we determine which individuals are susceptible to “Chemical X” CLICK 6: With each person being unique, individuals will “move” demonstrating variable “dose-to-exposure” susceptibility. Now we determine who is susceptible to “Frequency Y” of EMF, noise, etc. CLICK 7: Finally, we determine individuals susceptible to “Allergen Z”, perhaps from diet or ambient air. In conclusion, everyone’s susceptibility to exposures plus each individual’s unique variability is demonstrated, forming the basis and need for TEH.
- BLUF: There are significant opportunities for the military healthcare system to shift from current state to future state with the advances in medicine, science, tech, and IT. Additional Info: 2013 NDA Section 313 TEH Provides a solution to the 2013 NDAA Section 313 to Collect, Document and Act on Long-Term Environmental Health Risks (Individual Longitudinal Exposure Record (ILER) and expands with a comprehensive vision to include Workplace and Lifestyle Exposures for Military Personnel and Beneficiaries
- BLUF: Total Exposure Health when fully developed will: Improve delivery of care & health outcomes providing beneficiary centric exposure monitoring. Increase use of genomic knowledge/research in primary prevention Advance clinical decision support using funded digital biodata bank, Big Data analytics & expert system integration into DHMSM. Additional Info: Precision Health Advances Epidemiology & “Big Data” - Aggregates millions of individual exposure data from wearables/sensors using advanced informatics to improve global operations Fosters research & technology - Sensor development, rapid ID of unknown threats and low-level exposure biomarkers in human genomics in real-time
- It is estimated that there are almost one million more veterans with service-connected hearing loss and/or tinnitus who do not meet the criteria for receiving compensation. The cost of compensation for hearing and tinnitus-related disabilities in fiscal year (FY) 2006 was over USD 1.2 billion. The VA has additional expenditures associated with dispensing of hearing aids and other audiological services. In FY 2007, the VA dispensed 348,920 hearing aids at an estimated cost of USD 141.3 million, and provided audiological services at a cost of approximately USD 147.1 million. It is thus clear that hearing loss resulting from military service is a huge financial and clinical burden for the VA.
- Why Noise? Common exposure We all experience noise exposure in workplace, lifestyle and environment Untreatable hearing loss can negatively affect one’s quality of life Costly Exposure $1.5-3B DoD/VA annual bill (Benefits and Medical) Hearing loss and tinnitus are among the top medical complaints, and most widespread injuries, Linked to chronic disease, dementia, depression, and anxiety. Affects the mission Mission effectiveness directly proportional good communication Good hearing is prerequisite for peak performance Total Exposure Health “Noise” demonstration project that will be conducted at Moody AFB (projected second quarter of 2017) under the research oversight of researchers at the 711th at WPAFB. The project has been approved by the AF Institutional Review Board (IRB), the technologies are being refined and we expect to recruit participates at Moody AFB in early 2017. The “Noise” Exposure demonstration project will: Demonstrate the ability to collect, store, and utilize unstructured “noise” exposure data to identify the unique health risk associated noise and manage NIHL Data to include: sensor, survey, DOEHRS, and genetics Create intervention strategies to protect beneficiaries (training, medical interventions such as functional hearing tests and customized protection)
- 10 published studies Small to modest sample sizes Multiple genetic variants in multiple genes associated with NIHL or related phenotypes Grondin et al 2015. “Genetic Polymorphisms Associated with Hearing Threshold Shift in Subjects during First Encounter with Occupational Impulse Noise.” PLoS ONE 10 (6): e0130827. Effect sizes are surprisingly large Odds Ratios range from 5.2 to 22.36 Several associated genotypes are already typed in the available genechips
- Additional Info: Genes and NIHL Multiple genetic variants in multiple genes associated with NIHL or related phenotypes Effect sizes are surprisingly large Odds Ratios range from 5.2 to 22.36 Several associated genotypes are already typed in the available genechips Here we’ve drawn it in terms of hearing loss where bigger values are bad with respect to the degree of protection involved in the intervention. Here, the orange data point in the middle (the “Aa” individuals) look just like baseline with minimal protection but it takes “extra protection” for “AA” individuals (in blue) to get back to being fully protected.
- Show sensor tag and discuss how the overall system operates (wearable sensor->mobile phone w/ survey -> cloud)
- Rethinking Exposure we need a way to accesses, manage, mitigate and communicate. This is accomplished through the concept of the Individual Exposure Health Risk Profile.
- Expanding on the clinical, exposure monitoring, and genetics, we can add more variables to the index further refining the individual’s risk index.
- Typical “Dose vs. Effect” exposure curve and verbiage CLICK 1: We expect most individuals of a population to fall along this curve… CLICK 2: Specific Exposure #1: Noise (Lily is susceptible) CLICK 3: Specific Exposure #2: Benzene (Kirk is susceptible) CLICK 4: Specific Exposure #3: Lead (Al is susceptible) CLICK 5: Specific Exposure #4: Radiation (Rich is susceptible) CLICK 6: Specific Exposure #5: Gluten (Amy is susceptible) CLICK 7: Finally, we layer these exposures demonstrating that all individuals are unique…
- Typical “Dose vs. Effect” exposure curve and verbiage CLICK 1: We expect most individuals of a population to fall along this curve… CLICK 2: Specific Exposure #1: Noise (Lily is susceptible) CLICK 3: Specific Exposure #2: Benzene (Kirk is susceptible) CLICK 4: Specific Exposure #3: Lead (Al is susceptible) CLICK 5: Specific Exposure #4: Radiation (Rich is susceptible) CLICK 6: Specific Exposure #5: Gluten (Amy is susceptible) CLICK 7: Finally, we layer these exposures demonstrating that all individuals are unique…