ABSTRACT This paper will introduce the origins and demonstrate how the concept and implementation of Total Exposure Health (TEH) is ushering in a bold solution to capture workplace, environmental, and lifestyle exposures to the individual using advances in science, technology, and informatics. It will also introduce and describe the power behind Total Exposure Health, which is a mathematical process to quantitatively evaluate individual health risks based on genetics, occupational, lifestyle, and environmental exposures, medical disposition, protective factors, etc., forming the Individual Exposure Health Risk Profile (IEHRP). KEYWORDS Genomics; informatics; noise; precision health; risk assessment; sensors Hartman, R.T. and Oxley. M., Total Exposure Health, MultiConference on Computer Science and Information Systems (MCCSIS), Porto, Portugal, 18 July 2019.

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Total Exposure Health
11th International Conference on e-Health
Porto, Portugal
Richard Hartman, PhD
Graduate School of Engineering and
Management
Air Force Institute of Technology (AFIT)
Wright-Patterson AFB, OH
17 Jul 2019

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Disclosures
• Presenter has no interest to disclose.
• No discussion of off-label uses
• The views expressed are those of the author and do not necessarily
reflect the official policy or position of the Air Force, the Department of
Defense, or the U.S. Government.

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21st Century Healthcare Disruptors & Multipliers
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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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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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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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INDIVIDUAL EXPOSURE HEALTH RISK
INDEX/PROFILE (IEHRI/P)

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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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IEHRI/P: Expressed Mathematically
IEHRI
IEHRP
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Individual Exposure Health Risk Profile (IEHRP) = (IEHRI 1, IEHRI 2 ,…, IEHRI i ) = ([v1,1
+ v1,2 + v1,3 ], [v2,1 + v2,2 + v2,3] ,…, [vi,1 + vi,2 + vi,3])

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Visualizing the IEHRP – Individual
IEHRP will aid in visualizing an
individual’s unique exposure
susceptibilities
Lee
NOISE BENZENELEAD RADIATION GLUTEN
SUSCEPTABILITY
HIGH
LOW

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IEHRI with Multiple Variables
• Limitations to the IEHRI became evident,
which only accounted for three variables
to describe an individual exposure.
• This required the IEHRP to be modified
so it could account for multiple
confounding factors
IEHRP = (IEHRI1 , IEHRI2 , … , IEHRIj )
= ([v1,1 + v1,2 + v1,3 +…+ v1,j ] , [v2,1 + v2,2 +
v2,3 +…+ v2,j ] , … , [vi,1 + vi,2 + vi,3 +…+ vi,j ])
Genetics
Diagnostics
Sensors and
Mobile Data
Lifestyle
Occupation
Medical History
Environment
Family History

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IEHRI & IEHRP: Expanded
IEHRP
 IEHRI – Which vi,j value is more important?
 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?
 Relative Risk
 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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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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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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IEHRP Benefits: Example
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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REAL WORLD
EXAMPLE

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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
 $1B in costs associated with noise induced hearing lose (NIHL).
 Research Problem: We are under protecting Airmen from NIHL based on limited measurements of noise exposure.
 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?
 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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Technology - Highlights
• Noise monitoring sensor
measures
• External (ambient/audio)
• “Digital”
• 24/7
• Bluetooth
• Agnostic app for individual's
device
• Low- Profile low cost
On duty Off duty
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NIHL and Genetics
CDC 2011-12 National Health and Nutrition Examination
Survey
• 40 million American adults have lost some hearing
• ¼ of Adults between 20-69 suffer
• 24% had a deterioration in the ability to hear low frequencies
• 53% said they have no regular exposure to hazardous noise
• 19% of people between 20-29 had some hearing loss
• 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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Noise Exposure Demonstration Project (NEDP)

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Conclusion…
• Total Exposure Health can:
• Drive the development of medical expert systems, sensors and R&D
• Advance the science and understand the effects of currently undetectable exposures
and what we clinically know about exposure, gene expression, and disease
• Through the IEHRP:
• All information integrated about an individual
• Area sensors, Personnel/Physiological Sensors…integrated with all genetics, previous exposures
• Genomic data will be transparently incorporated into the clinical decision process
• Collectively
• Patients/providers will be afforded data real-time into healthcare enhancing the
Doctor/Patient experience
• Incrementally maximize human performance to not only retain personal health
attributes but enhance them
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QUESTIONS?
Richard Hartman, PhD
Healthcare Strategist
Air Force Institute of Technology (AFIT)
Office: 1- (703) 922-0275
richard@hartmanphd.com

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Backup Slides
Richard Hartman, PhD
Healthcare Strategist
Air Force Institute of Technology (AFIT)
Office: 1- (703) 922-0275
richard@hartmanphd.com

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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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IEHRP Visualization & Normalization
IEHRP
= (IEHRI1 , IEHRI2 , IEHRI3, IEHRI4 )
= ([v1,1 + v1,2 + v1,3 ] , [v2,1 + v2,2 + v2,3] , [v3,1 + v3,2 + v3,3] , [v4,1 + v4,2 + v4,3 ])
= ([1 + 1 + 1] , [1 + (-) + 1] , [1 + 1+ (-)] , [(-) + (-) + 1])
= (3, 2, 2, 1)
Normalization Factors w.r.t. censored values in each IEHRI
Normalized IEHRI1 = (1/3) IEHRI1 = (1/3) [1 + 1 + 1] = 1
Normalized IEHRI2 = (1/2) IEHRI2 = (1/2) [1 + 0 + 1] = 1
Normalized IEHRI3 = (1/2) IEHRI3 = (1/2) [1 + 1 + 0] = 1
Normalized IEHRI4 = (1/1) IEHRI4 = (1/1) [0 + 0 + 1] = 1

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Values and Factors Matrices
Modified values
Sum row entries
to produce indices =
IEHRI1
IEHRI2
IEHRI3
IEHRI4
Hadamard product is entry-wise multiplication

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Values and Factors Matrices
Modified values
Sum row entries
to produce indices =
IEHRI1
IEHRI2
IEHRI3
IEHRI4
Hadamard product is entry-wise multiplication

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More Values and Indices
=
IEHRI1
…….
……..
IEHRIm

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Matrix Notation
column vector of
indices
matrix multiplication

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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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NEDP Noise Data: Rethinking TLV’s
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https://apps.dtic.mil/dtic/tr/fulltext/u2/1071653.pdf

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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

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THOUGHT
EXERCISE

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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 OUTCOMEDIAGNOSE
TEH: A Use Case Example at a USAF Smart Base
Smart Base
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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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• 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
Through TEH we can:
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