As global IH/OH professionals, we are positioned to effectively contribute as exposure scientists not only to the occupational health of individuals but to their overall well-being. This education session will demonstrate how the United States Air Force is ushering in a bold solution to capture workplace, environmental, and lifestyle exposures to the individual using advances in science, technology, and informatics called Total Exposure Health (TEH). TEH provides a framework and tools to strengthen prevention and reduce illness and injury through effective early intervention, improved health-related risk assessment decision-making, and risk mitigation. Individual Exposure Health Risk Profiles (IEHRP) attempt to quantitatively evaluate individual health risks based on genetics, occupational, lifestyle, and environmental exposures, medical disposition, protective factors,etc. Participants will have a new view of population-based standards and will explore the potential future of individual occupational exposure standards.

1. I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Headquarters U.S. Air Force
Total Exposure Health
A New Approach to the Exposure Sciences
Richard Hartman, PhD
United States Air Force Medical Service
24 September 2018
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2. I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Disclosure
n No conflicts of interest
n No discussion of off-label uses
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3. I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Shifts in Healthcare
Patient Care
to
Patient Experience
Face-to-Face
to
Virtual Health
Population
to
Personalized
Health
Disparate
to
Marketplace
Collaborations
Volume
to
Value-based
Care
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4. I n t e g r i t y - S e r v i c e - E x c e l l e n c e
21st Century Healthcare
Disruptors & Multipliers
AI
TELEGENETICS
BLOCKCHAIN
ELECTRONIC HEALTH RECORD
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5. I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Imagine If…
Doctors could understand the
effects of exposures on a
patients health throughout their
life
Identify diseases at the
molecular level before
the onset of disease
Enable rapid interventions
and supportive medical
care
Reduce disability by truly
preventing disease
Demonstrate significant cost
savings and efficiencies
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6. I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Total Exposure Health
TEH Overview
TEH aims to capture workplace, environmental & lifestyle exposures to the individual (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
Total Exposure Health (TEH) represents a paradigm shift in military medicine – from a primary focus on
disease and injury treatment to a more holistic approach that focuses on health and prevention.
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7. I n t e g r i t y - S e r v i c e - E x c e l l e n c e
TEH: A Bold New Initiative
An emerging system of
personalized healthcare that
considers individual’s
exposures, genetic variation,
and lifestyles to improve the
health and performance of our
Active Duty, veterans, civilians,
and their families.
Applying new research to
connect our genome with
exposure effect - each
individual will have a
better understanding of how
their daily lives impact their
health and well-being.
Provides innovative
technology to identify and
monitor an individual’s
combined and accumulative
exposures from workplace,
lifestyle, habits, and the
environment.
What is Total Exposure Health?
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8. I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Reimagining
Healthcare with TEH
TEH will bring together distinct systems and initiatives into one portfolio: integrating exposure science, information
technology, and existing healthcare programs to develop end-to-end systems.
TEH capabilities will maximize the value of these advances by translating data collection, analysis, management,
and visualization into clinically and personally actionable results.
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9. I n t e g r i t y - S e r v i c e - E x c e l l e n c e
TEH Beyond the DoD
Enhances Warfighter Performance Protects Worker Health
IndustryDepartment of
Defense
Increases Lethality
Reduces Healthcare Costs
Increases Productivity
Reduces Healthcare Costs
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10. I n t e g r i t y - S e r v i c e - E x c e l l e n c e
THOUGHT
EXERCISE
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11. I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Case Study: Well-Child Visit
STAGES
PROCESS
Well-Child
Visit
Well-Child
Visit
Genetic
Screening
Pesticide / Insecticide
Exposures
Pesticide / Insecticide
Exposures
Individual Longitudinal
Exposure Risk Profile
(ILER) & EHR
Symptomatic
Pediatric &
Specialist Visits
Pediatric &
Specialist Visits
Decreased costs,
resources, and time
Increased costs,
resources, and time
Future State: Total Exposure Health
Current State
VISIT EXPOSED TREAT & MAINTAIN OUTCOME DIAGNOSE
TEH: A Use Case Example at a
USAF Smart Base
Smart Base
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12. I n t e g r i t y - S e r v i c e - E x c e l l e n c e
REAL WORLD
EXAMPLE
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13. I n t e g r i t y - S e r v i c e - E x c e l l e n c e
TEH– Helping to Solve Military
Hearing Loss
NEDP Overview
The NEDP aims to identify and characterize integrated health exposure risk (noise) and derive actionable decisions and
support related to NIHL.
Background
n $1B in costs associated with noise induced hearing lose (NIHL).
n Research Problem: We are under protecting Airmen from NIHL based on limited measurements of noise exposure.
n Research Question: Will the measurement of a “total” noise exposure dose (workplace, lifestyle & environmental) and genetic
proclivity to NIHL identify Airmen who receive no or limited interventions to prevent NIHL?
n Research Hypothesis: Total cumulative noise exposure exceeds DoD measured worker exposure.
NIHL genetic data
Wearable sensor for
monitoring noise exposures
(both ambient and
earphone)
Combine and correlate integrated exposure
data with DOEHRS, previous exposures, and
genetics (TEH Situational Awareness/Data
Analytics)
Phase II: Leverage genetics, individual-specific data for direct intervention, protection, and care.
E
H
Better understanding of
monitored exposure to
performance and individual
health outcomes through the
Individual Exposure Health Risk
Profile (IEHRP)
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14. I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Noise Exposure Demonstration
Project (NEDP)
• Noise demonstration project:
• Demonstrated 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
• Conceptualized the Individual Exposure Health Risk Profile
(IEHRP)
• Result will inform 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
Turn Data into
Insight
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15. I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Technology - Highlights
n Noise monitoring sensor
measures
n External (ambient/
audio)
n “Digital”
n 24/7
n Bluetooth
n Agnostic app for
individual's device
n Low- Profile low cost
On duty Off duty
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16. I n t e g r i t y - S e r v i c e - E x c e l l e n c e
NIHL and Genetics
CDC 2011-12 National Health and Nutrition
Examination Survey
n 40 million American adults have lost some
hearing
n ¼ of Adults between 20-69 suffer
n 24% had a deterioration in the ability to hear
low frequencies
n 53% said they have no regular exposure to
hazardous noise
n 19% of people between 20-29 had some hearing
loss
n No US regulations outside the workplace
One in eight people in the United States aged 12 years or older has hearing loss in both ears, which directly
impacts accessions and beneficiary costs
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17. I n t e g r i t y - S e r v i c e - E x c e l l e n c e
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
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18. I n t e g r i t y - S e r v i c e - E x c e l l e n c e
NEDP Noise Data: Rethinking
Noise TLV’s for Total Noise
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19. I n t e g r i t y - S e r v i c e - E x c e l l e n c e
NEDP Summary and Future
Demo
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Successes:
§ Developed low cost noise dosimeter/sensor that monitors external/
media smart phone device noise sound levels 24/7/365
§ Advanced analytics; multiple sensors and geospatial layering
§ Genomics and DOEHRS(IH/HC) data integration
§ 24-hour monitoring identified high/med/low risks significantly below
OSHA standards; potential need for new standards
§ Participants sensor use compliance
§ Commercial interest in AFMS Technology; Industry interest in TEH
Lessons Learned:
§ Hearing protection compliance low w/high noise events
§ Low media device noise data capture
§ Use in operational environments (e.g. flight line)
§ Small sample size; participation; and command support
To demonstrate the feasibility of 24/7/365 exposure monitoring;
identify cumulative noise exposure (Env/Media); explore
individual exposure health risk index (IEHRI) concept.
NEDP II
Solve challenges from NEDP 1; incorporate real individual genomics/
medical data for IEHRI; investigate hearing protection use
Challenges:
§ IRB
§ Funding
Proposal:
§ Real individual data integration with genomics/medical record
and advanced sensor improvements
§ Wireless media/smart phone device noise monitoring
§ Advanced data analytics, visualizations and geospatial monitoring
§ Larger sample size; improved marketing and awareness
§ Improve use compliance w/accelerometer
§ Account for hearing protection use; improved risk
§ Passive store and forward for SMU and Conventional forces
NEDP I
Benefits:
§ US Gov Technology transfer; low cost; comprehensive; precision health
§ Reduce hearing loss; lower compensation; improved indiv performance

20. I n t e g r i t y - S e r v i c e - E x c e l l e n c e
INDIVIDUAL EXPOSURE
HEALTH RISK INDEX/PROFILE
(IEHRI/P)
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21. I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Our Clinical Disposition
Individual Exposure Health Risk Index/
Profile (IEHRI/P)
Our Unique Genetic Proclivity
IEHRI/P:
Individual
Exposure
Indices/Profile Our Exposures
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22. I n t e g r i t y - S e r v i c e - E x c e l l e n c e
IEHRI/P: Expressed
Mathmatically
IEHRI
IEHRP
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23. I n t e g r i t y - S e r v i c e - E x c e l l e n c e
IEHRI/P Exposure Index Data Sources






Clinical
Narratives
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24. I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Genetics
Diagnostics
Sensors and
Mobile Data
Lifestyle
Occupation
Medical History
Environment
Family History
IEHRI can have many variables
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25. I n t e g r i t y - S e r v i c e - E x c e l l e n c e
IEHRI & IEHRP: Expanded
IEHRP
n IEHRI – Which vi,j value is more important?
n WFi,j = weighting factor– importance of each variable (vi,j) when
compared with all the variables with in the IEHRI (e.g. are genes more
important than exposure measure?-
n CFi,j = correction factor – variability (confidence) in the (vi,j) based on
the process, procedures, methods, device, etc. for each (vi,j)
Individual Exposure Health Risk Index (IEHRI) (exposure) =
[(v1,1)(CF1,1)(WF1,1) + (v1,2)(CF1,2)(WF1,2) + … (vi,j)(CFi,j)(WFi,j)
Individual Exposure Health Risk Profile (IEHRP) =
[(v1,1)(CF1,1)(WF1,1) + (v1,2)(CF1,2)(WF1,2) + (v1,3)(CF1,3)(WF1,3)] , [(v2,1)(CF2,1)(WF2,1) + (v2,2)
(CF2,2)(WF2,2) + (v2,3)(CF2,3)(WF2,3)] , … ,
[(vi,1)(CFi,1)(WFi,1) + (vi,2)(CFi,2)(WFi,2) +…+ (vi,j)(CFi,j)(WFi,j)]
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26. I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Visualizing the IEHRP –
Individual
IEHRP will aid in
visualizing an
individual’s unique
exposure
susceptibilities
Lee
NOISE BENZENELEAD RADIATION GLUTEN
SUSCEPTABILITY
HIGH
LOW

27. I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Visualizing the IEHRP –
Population
Yr 1 Baseline IEHRP
Intervention/Changes
Y2 IEHRP
See Unique Patterns
An
n
Al
Lily
Le
e
Ric
h
YEAR 1
BENZENE
LEAD
RADIATION
GLUTEN
NOISE
YEAR 2

28. I n t e g r i t y - S e r v i c e - E x c e l l e n c e
IEHRP
APPLICATIONS
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29. I n t e g r i t y - S e r v i c e - E x c e l l e n c e
IEHRI Example: Noise
n Basic linear equation for noise:
Individual Exposure Health Risk Index (Noise) = Personal Monitored Exposure (Noise) +
Medical/Clinical Disposition (Noise) + Genetic Proclivity (Noise)
n Adding chemical exposure the equation changes to:
Individual Exposure Health Risk Index (Noise) = Personal Monitored Exposure (Noise) +
Medical/Clinical Disposition (Noise) + Genetic Proclivity (Noise) + Ototoxins (Noise)
n The Individual Exposure Risk Index becomes more refined as we identify
confounding factors that affect the risk of NIHL:
Individual Exposure Risk Index (Noise) = Personal Monitored Exposure (Noise) +
Medical/Clinical Disposition (Noise) + Genetic Proclivity (Noise) + Ototoxins (Noise)
– Protective factors (Noise) – Protective Interventions (Noise)
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30. I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Rethinking Exposure Limits
INCREASINGEFFECT
INCREASING DOSE
Exposure limits Pop
Based
Protects based on
Economic Feasibility
We all Respond
Differently
Super humans?
EXPOSURE
CURVE
OSHA PEL
“SUPER”
Rich
Lily
Lee
Al
“No-Effect”
Range
Maximum Effect
Range
Increasing Effect with
Increasing Dose
Ann

31. I n t e g r i t y - S e r v i c e - E x c e l l e n c e
How will
Similar Exposure
Groups (SEGs) be
determined?
By Exposure?
or
By Profile?
An
n
Al
Lily
Le
e
Ric
h
By Exposure?
BENZENE
LEAD
RADIATION
GLUTEN
NOISE
Rethinking the Similar Exposure
Group (SEG)By Profile?

32. I n t e g r i t y - S e r v i c e - E x c e l l e n c e
IEHRP: Future
Future
n Leverage noise demo to expand into physical, chemical, biological exposures
n Implementation into Clinical Decision Support System (CDSS)
n Full integration into individual EHR: Individual Longitudinal Exposure Record (ILER)
Plan Ahead
q Phase I: IEHRI basic equation: 3 variables, 1 exposure each (v1,1) + (v1,2) + (v1,3)
q Phase II: Introduce correction (CFi,j) & weighted factors (WFi,j) for IEHRI
(v1,1)(CF1,1)(WF1,1) + (v1,2)(CF1,2)(WF1,2) + (v1,3)(CF1,3)(WF1,3) + … (v1,j)(CF1,j)(WF1,j)
q Phase III: Multiple variables and exposures
[(v1,1)(CF1,1)(WF1,1) + (v1,2)(CF1,2)(WF1,2) + (v1,3)(CF1,3)(WF1,3)] , [(v2,1)(CF2,1)(WF2,1) + (v2,2)(CF2,2)(WF2,2) + (v2,3)(CF2,3)(WF2,3)] , … ,
[(vi,1)(CFi,1)(WFi,1) + (vi,2)(CFi,2)(WFi,2) +…+ (vi,j)(CFi,j)(WFi,j)]
q Phase IV: Build IEHRP array w/ censored data* - - (v1,3) (v1,4)
(v2,1) (v2,2) - (v2,4)
*variables may be missing or not measured - (v3,2) - -
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33. I n t e g r i t y - S e r v i c e - E x c e l l e n c e
IEHRP Benefits: Tailorability
A
B
“Policymaker”“Healthcare Provider”
NOISE BENZENE GLUTEN RADON
NOISE BENZENE GLUTEN RADON
NOISE GLUTEN RADON BENZENE
RADON NOISE BENZENE GLUTEN
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34. I n t e g r i t y - S e r v i c e - E x c e l l e n c e
TEH Full Implementation
SADA
&
IEHRP
Sensor Data
PHA Surveys
Genomic /
Biodata bank
DOEHRS
Other databases
MHS Genesis
ILER
VBA
Vet
Benefits
DOD
Provider
analytics
ingest
sharing
T
E
H
Clinical
Decision
Support
System
T
E
H
VHA/EHR
Provider
DoD/VA
Researchers
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35. I n t e g r i t y - S e r v i c e - E x c e l l e n c e
TEH/IEHRP Brings these things
together:
n Area sensors, Personnel/Physiological Sensors, …
n Integrated with all genetics, previous exposures, DBs, …
n All information integrated about an individual
n Advanced analytics and decision support
n Situational awareness tools for real-time monitoring/use
n Predictive capability for optimized readiness and performance
n Open, integrated, advanced system for force health protection,
improved care, and operational use
n Technologies are real, available, and ready for application/use
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36. I n t e g r i t y - S e r v i c e - E x c e l l e n c e
n Retain health and increase human performance for people
n Comply with regulatory standards and Congressional mandates
regarding comprehensive health surveillance
n Better understand current and emerging exposure trends and
their impacts on health
n Advance true primary prevention to address health risk before
the onset of disease
n Develop rapid intervention and supportive medical care with
more confidence
n Create significant savings in total health care costs and
reduced disability by preventing disease
Collectively we can:
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37. I n t e g r i t y - S e r v i c e - E x c e l l e n c e
QUESTIONS?
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38. I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Total Exposure Health-
Visualized
EFFECT
DOSE
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

39. I n t e g r i t y - S e r v i c e - E x c e l l e n c e
2 2
3
1
IEHRP Visualization &
Normalization
X
RADONNOISE BENZENE
MEASURED
EXPOSURE
Genetics
Medical Record
GLUTEN
Graphing the raw data we get the
following IERP. However, to address
censored data requires - Normalization
= censored data
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40. I n t e g r i t y - S e r v i c e - E x c e l l e n c e
1 11 1
IEHRP Visualization &
Normalization
X
RADONNOISE BENZENE
MEASURED
EXPOSURE
Genetics
Medical Record
GLUTEN
Normalization = all indices will have
values between 0 and 1. Accounting for
the censored data we get the following
IEHRP
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41. I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Total Exposure Health will:
• Drive the development of medical expert systems, sensors
and R&D
• Through TEH we will advance the science and understand the
effects of currently undetectable exposures and what we clinically
know about exposure, gene expression, and disease
• Through TEH genomic data will be transparently incorporated into
the clinical decision process
• Patients/providers afforded TEH data real-time into healthcare
enhancing the Doctor/Patient experience
• Incrementally maximize human performance to not only
retain personal health attributes but enhance them
“The distant future is really not that distant”
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