Headquarters U.S.

Air Force
Integrity - Service - Excellence

Total Exposure Health

A New Approach to the Exposure Sciences

Richard Hartman, PhD

United States Air Force Medical Service
24 September 2018
1
 Disclosure

n  No conflicts of interest

n  No discussion of off-label uses

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 Shifts in Healthcare

Volume Face-to-Face
to to
Value-based Virtual Health Disparate
Care to
Marketplace
Collaborations
Population
Patient Care to
to Personalized
Patient Experience Health

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 21st Century Healthcare
Disruptors & Multipliers
N E TICS
GE
TELE
CH AIN
BL OCK AI

E C ORD
R
E A LTH
H
R ONIC
CT
ELE

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 Imagine If…

Doctors could understand the Identify diseases at the

effects of exposures on a Enable rapid interventions
molecular level before and supportive medical
patients health throughout their the onset of disease
life care

Demonstrate significant cost

Reduce disability by truly savings and efficiencies
preventing disease

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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

Advance operational
decisions using
Better understanding of
Improve exposure advancements in
Increase use of monitored exposure to
monitoring through science, medicine,
genomic research performance and
sensors and wearables technology, and
and knowledge individual health
informatics with digital
outcomes
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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 TEH: A Bold New Initiative

What is Total Exposure Health?

An emerging system of Provides innovative Applying new research to

personalized healthcare that technology to identify and connect our genome with
considers individual’s monitor an individual’s exposure effect - each
exposures, genetic variation, combined and accumulative individual will have a
and lifestyles to improve the exposures from workplace, better understanding of how
health and performance of our lifestyle, habits, and the their daily lives impact their
Active Duty, veterans, civilians, environment. health and well-being.
and their families.

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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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 TEH Beyond the DoD

Department of Industry
Defense

Enhances Warfighter Performance Protects Worker Health

Increases Lethality Increases Productivity

Reduces Healthcare Costs

Reduces Healthcare Costs

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 THOUGHT
EXERCISE

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 TEH: A Use Case Example at a
USAF Smart Base
Case Study: Well-Child Visit
STAGES VISIT EXPOSED DIAGNOSE TREAT & MAINTAIN OUTCOME

Current State



Well-Child Pediatric & Increased costs,
Pesticide / Insecticide Symptomatic Specialist Visits
Visit resources, and time
Exposures


PROCESS Future State: Total Exposure Health




Well-Child Genetic Individual Longitudinal Pediatric &
Pesticide / Insecticide Specialist Visits
Decreased costs,
Visit Screening Exposure Risk Profile
Exposures resources, and time
(ILER) & EHR
Smart Base

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 REAL WORLD
EXAMPLE

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 TEH– Helping to Solve Military
Hearing Loss
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.

NEDP Overview

The NEDP aims to identify and characterize integrated health exposure risk (noise) and derive actionable decisions and
support related to NIHL.
E

Combine and correlate integrated exposure Better understanding of

Wearable sensor for data with DOEHRS, previous exposures, and monitored exposure to
NIHL genetic data
monitoring noise exposures genetics (TEH Situational Awareness/Data performance and individual
(both ambient and Analytics) health outcomes through the
earphone) Individual Exposure Health Risk
Profile (IEHRP)

Phase II: Leverage genetics, individual-specific data for direct intervention, protection, and care.

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 Noise Exposure Demonstration
Project (NEDP)
Big Data Turn Data into
Exposure
Analytics Insight

•  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

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 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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 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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 Gene x Environment Interactions &
Prevention

Multiple genetic variants in multiple genes associated with NIHL or related phenotypes
Odds Ratios range from 5.2 to 22.36
*Data Derived from Air Force Coriell study

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NEDP Noise Data: Rethinking
Noise TLV’s for Total Noise

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 NEDP Summary and Future
Demo
NEDP I NEDP II

To demonstrate the feasibility of 24/7/365 exposure monitoring; Solve challenges from NEDP 1; incorporate real individual genomics/
identify cumulative noise exposure (Env/Media); explore medical data for IEHRI; investigate hearing protection use
individual exposure health risk index (IEHRI) concept.
Proposal:
Successes:
§  Real individual data integration with genomics/medical record
§  Developed low cost noise dosimeter/sensor that monitors external/ and advanced sensor improvements
media smart phone device noise sound levels 24/7/365
§  Wireless media/smart phone device noise monitoring
§  Advanced analytics; multiple sensors and geospatial layering §  Advanced data analytics, visualizations and geospatial monitoring
§  Genomics and DOEHRS(IH/HC) data integration §  Larger sample size; improved marketing and awareness
§  24-hour monitoring identified high/med/low risks significantly below §  Improve use compliance w/accelerometer
OSHA standards; potential need for new standards
§  Account for hearing protection use; improved risk
§  Participants sensor use compliance
§  Passive store and forward for SMU and Conventional forces
§  Commercial interest in AFMS Technology; Industry interest in TEH
Challenges:
Lessons Learned:
§  IRB
§  Hearing protection compliance low w/high noise events
§  Funding
§  Low media device noise data capture
Benefits:
§  Use in operational environments (e.g. flight line)
§  Small sample size; participation; and command support §  US Gov Technology transfer; low cost; comprehensive; precision health
§  Reduce hearing loss; lower compensation; improved indiv performance

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 INDIVIDUAL EXPOSURE
HEALTH RISK INDEX/PROFILE
(IEHRI/P)

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 Individual Exposure Health Risk Index/
Profile (IEHRI/P)

IEHRI/P:
Individual
Exposure
Indices/Profile Our Exposures

Our Unique Genetic Proclivity

Our Clinical Disposition

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 IEHRI/P: Expressed
Mathmatically
IEHRI

IEHRP

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IEHRI/P Exposure Index Data Sources



 Clinical
Narratives 



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 IEHRI can have many variables

Medical History

Genetics Family History

Diagnostics Occupation

Environment Lifestyle

Sensors and
Mobile Data

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 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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 Visualizing the IEHRP –
Individual
HIGH

Lee
SUSCEPTABILITY

IEHRP will aid in

visualizing an
individual’s unique
exposure
LOW
susceptibilities
NOISE LEAD BENZENE RADIATION GLUTEN

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 Visualizing the IEHRP –
YEAR 1 YEAR 2 Population
Lily
Yr 1 Baseline IEHRP
Intervention/Changes
Y2 IEHRP
An
n See Unique Patterns

Ric
h

Al

NOISE
LEAD
Le BENZENE
e
RADIATION
GLUTEN

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 IEHRP
APPLICATIONS

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 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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 Rethinking Exposure Limits
OSHA PEL EXPOSURE
Increasing Effect with CURVE
“No-Effect”Increasing Dose Maximum Effect
Lee
Range Range
INCREASING EFFECT

Rich

Exposure limits Pop

Based
Protects based on
Economic Feasibility
Ann We all Respond
Differently
Lily Super humans?
Al

“SUPER”

INCREASING DOSE
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 Rethinking the Similar Exposure
By Exposure? By Profile?
Group (SEG)
Lily
How will
Similar Exposure
An
Groups (SEGs) be
n
determined?

By Exposure?
Ric
h
or
By Profile?

Al

NOISE
LEAD
Le BENZENE
e
RADIATION
GLUTEN

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 IEHRP: Future
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) - -

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)

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 IEHRP Benefits: Tailorability

NOISE GLUTEN RADON BENZENE NOISE BENZENE GLUTEN RADON

RADON NOISE BENZENE GLUTEN NOISE BENZENE GLUTEN RADON

“Healthcare Provider” “Policymaker”

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 TEH Full Implementation
ILER
VBA
Vet
Benefits
Sensor Data

PHA Surveys
SADA
T T &
E E IEHRP DoD/VA
Researchers
H Genomic / H
Biodata bank
MHS Genesis

sharing

DOEHRS analytics
VHA/EHR
ingest Clinical Provider
Decision
Support
Other databases
System

DOD
Provider

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 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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 Collectively we can:
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

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 QUESTIONS?

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 Total Exposure Health-
Visualized
Chemical

Radiation

Allergen

When we account for

genetic variance we
EFFECT

find we are all unique!

“Sensitive” “Average” “Resilient” But we can also use

Individual Individual Individual this information to
protect health and
enhance performance

DOSE
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 IEHRP Visualization &
Normalization
Graphing the raw data we get the
3 following IERP. However, to address
censored data requires - Normalization

X 2 2 = censored data

MEASURED
EXPOSURE

Genetics

Medical Record

NOISE RADON BENZENE GLUTEN

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 IEHRP Visualization &
Normalization
Normalization = all indices will have
values between 0 and 1. Accounting for
the censored data we get the following
IEHRP

X 1 1 1 1

MEASURED
EXPOSURE

Genetics

Medical Record

NOISE RADON BENZENE GLUTEN

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 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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