Air Force Medical Service

AIR FORCE MEDICAL SERVICE
Total Exposure Health

Strategic Plan FY19-23
Prepared by:
Col Philip Goff and Richard Hartman, PhD
The information in this report is exempt from public disclosure in accordance with
Title 5 USC § 552(b) (5) (Freedom of Information Act (FOIA) Exemption (b)(5)).
Air Force Medical Service
Total Exposure Health Strategic Plan FY19-23
STRATEGIC PLAN
FOR
TOTAL EXPOSURE HEALTH (TEH)
Sponsoring Organization: HAF SG3/5

Date Submitted: 22 Jan 2018
Approval Authority: Surgeon General
Validation Authority: Surgeon General
Document Point of Contact

Col Philip Goff, Phone: 703-681-6912 NIPRNET:
AFMSA/SG3/5PB DSN: 761-6912 philip.e.goff.mil@mail.mil
_______________________________
MARK A. EDIGER
Lieutenant General, USAF, MC, CFS
Surgeon General
Headquarters Air Force
OPR: Air Force Medical Support Agency/Operations and Research Directorate (AFMSA/SG3/5PB)
DSN: 761-6912
Commercial: (703) 681-6912
Unclassified
Table of Contents
1. EXECUTIVE SUMMARY .....................................................................................................................................1
2. INTRODUCTION...................................................................................................................................................2
2.1 BACKGROUND ..........................................................................................................................................2
2.2 TEH VISION ..............................................................................................................................................3
2.3 CHALLENGES AND OPPORTUNITIES ................................................................................................4
3. STRATEGIC FOCUS AREAS ............................................................................................................................... 6
3.1 STUDIES AND ANALYSES ....................................................................................................................6
3.2 RESEARCH AND DEVELOPMENT .......................................................................................................6
3.3 PARTNERSHIPS AND COLLABORATIONS ........................................................................................7
3.4 REGULATORY .........................................................................................................................................7
3.5 INFRASTRUCTURE ................................................................................................................................8
3.6 HEALTH AND HEALTHCARE ...............................................................................................................8
3.7 TRAINING ................................................................................................................................................9
3.8 READINESS ..............................................................................................................................................9
4. EXECUTION STRATEGY: STRATEGIC GOALS AND OBJECTIVES ........................................................... 10
GOAL 1: SYNTHESIZE, IDENTIFY, AND UNDERSTAND CURRENT AND EMERGING
TRENDS THROUGH STUDIES AND ANALYSES TO ADVANCE PREVENTION STRATEGIES .......10
4.2 GOAL 2: ADVANCE HEALTH AND HEALTHCARE THROUGH RESEARCH AND
DEVELOPMENT ............................................................................................................................................11
4.3 GOAL 3: ENSURE COMPLIANCE WITH REGULATORY STANDARDS .........................................12
4.4 GOAL 4: BUILD INFRASTRUCTURE TO SUPPORT ADVANCES IN HEALTHCARE ...................13
4.5 GOAL 5: FOSTER A NETWORK OF INTERNAL AND EXTERNAL COLLABORATIVE
PARTNERS ....................................................................................................................................................13
4.6 GOAL 6: PROVIDE ENHANCED EXPOSURE HEALTH EDUCATION AND TRAINING ..............15
4.7 GOAL 7: IMPROVE QUALITY OF CARE AND ENCOURAGE GOOD LIFESTYLE CHOICES ....16
4.8 GOAL 8: OPTIMIZE FORCE READINESS AND HUMAN PERFORMANCE BY REDUCING
HAZARDOUS EXPOSURES .........................................................................................................................17
4.9 GOAL 9: SHORT, MID, AND LONG TERM EXECUTION PLAN .......................................................17
5. STRATEGIC BUSINESS PLAN AND IMPLEMENTATION............................................................................. 20
5.1 STRATEGIC BUSINESS PLAN DEVELOPMENT AND METHODOLOGY .....................................20
5.2 ORGANIZATION STRUCTURE AND STAFFING ..............................................................................20
6. STRATEGIC TECHNICAL PLAN AND IMPLEMENTATION ......................................................................... 21
6.1 TEH TECHNICAL SYSTEM DEVELOPMENT ....................................................................................21
7. ENABLERS FOR TEH SUCCESS ....................................................................................................................... 26
7.1 CULTURAL AND TECHNOLOGY ENABLERS ..................................................................................26
8. MEDICAL PRIVACY AND ETHICS .................................................................................................................. 29
8.1 DATA COLLECTION INTEGRATION .................................................................................................29
8.2 SENSOR DEVELOPMENT ....................................................................................................................30
8.3 DATA INTEGRATION WITH HEALTH RECORDS ............................................................................30
9. CONCLUSION ..................................................................................................................................................... 31
APPENDIX A: LIST OF ACRONYMS ........................................................................................................................ 33
APPENDIX B: STRATEGIC PLAN ENDNOTE REFERENCES................................................................................ 36
APPENDIX C: GLOSSARY ......................................................................................................................................... 38
APPENDIX D: ADDITIONAL SELECTED PUBLICATIONS AND REFERENCE MATERIAL ............................ 41
APPENDIX E: TOTAL EXPOSURE HEALTH INFOGRAPHIC ................................................................................ 46
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Table of Figures
Figure 1. Vision for TEH Portfolio ................................................................................................................................. 3
Figure 2. Current State and Future State with TEH ........................................................................................................ 4
Figure 3. TEH Variables ................................................................................................................................................. 4
Figure 4. Focus Areas of the Future TEH ....................................................................................................................... 6
Figure 5. TEH Strategic Goal ....................................................................................................................................... 10
Figure 6. Sample Regulatory Workflow for TEH Studies ............................................................................................ 12
Figure 7. Capabilities Development Lifecycle ............................................................................................................. 20
Figure 8. Initial Proposed Organizational Structure for TEHO .................................................................................... 21
Figure 9. TEH End-to-End System Development ........................................................................................................ 22
Figure 10. Framework for Health Informatics .............................................................................................................. 25
Figure 11. Future State of Exposure Data Supporting Theater and Clinical Operations .............................................. 26
Figure 12. The Decreasing Cost of Next Generation Sequencing ................................................................................ 27
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1. EXECUTIVE SUMMARY
Total Exposure Health (TEH) is the Air Force Medical Service (AFMS) solution to capture workplace,
environmental and lifestyle exposures to the individual using advances in science, technology &
informatics to prevent disease, preserve health and well-being and develop precision health solutions.
As a new way of delivering care, and responds to both congressional and several national military
readiness strategies such as, the 2013 National Defense Authorization Act (NDAA) and the 2017
National Security Strategy. To support the TEH capability, the AFMS commissioned the development of
this TEH Strategic Plan to define the responsibilities and processes necessary for the development and
implementation of TEH in a way that brings the most value to the AFMS. By supporting TEH, the
AFMS will lead an innovative approach to protecting its beneficiaries, promoting readiness, and
achieving truly personalized prevention health.
The TEH Strategic Plan will delineate how the focus areas, goals, and objectives for TEH align to the
overarching vision of AFMS: Healthiest Performing Population by 2025. The plan will outline current
and future operational drivers and challenges in healthcare delivery, how TEH addresses those
challenges, and identifies the required capabilities, potential supporting programs, and platforms
necessary for TEH execution. The eight (8) strategic focus areas (below) create a framework for the
Strategic Plan that is aligned with the AFMS strategic direction as determined by our environmental scan
and stakeholder analyses.
 Understand current and emerging trends through studies and analyses to advance primary
prevention
 Ensure compliance with regulatory standards
 Advance Medicine through Research & Development (R&D)
 Build Infrastructure to Support Advances in Healthcare
 Foster a network of collaborative partners
 Increase access to exposure science education and training
 Improve quality of care and encourage good lifestyle choices
 Increase Force Readiness and Human Performance
Through the Strategic Plan, TEH will leverage and advance exposure science, sensors and technologies,
health informatics, and clinical support systems as a cutting edge way to obtain a holistic understanding
of an individual’s health, root causes of disease and injury, and innovative but accessible methods for
primary prevention. The spectrum of resources will include:
 R&D to expand TEH capabilities into sensor, informatics, and database platforms
 Regulatory expertise for TEH deployment
 Infrastructure, resources, and activities management
 Military, public, academic, and private partnerships
 Care provider, workforce, and patient training
 Enhanced support, ancillary services and benefits
 Healthcare delivery towards primary prevention
 Organizational change and Military Readiness supported by validated data
 Individual Exposure Health Risk Profiles (IEHRP)
 Data integration into Individual Longitudinal Exposure Records (ILER)
The Strategic Plan’s near-term goal is to improve exposure characterization and to identify and
understand individual variability, susceptibility, and vulnerability to cumulative exposures. In the long-
term, TEH will translate these findings into clinically actionable recommendations to protect and
improve well-being of military members and their beneficiaries. The bottom line is that TEH is a future-
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focused and progressive approach that represents a disruptive but necessary paradigm shift to help the
Air Force and the Military Health System (MHS) enhance human performance, support force health
protection, and ultimately transition from healthcare to precision health.
2. INTRODUCTION
2.1 BACKGROUND
The AFMS Strategic Vision seeks to ensure that the AFMS’s “supported population is the healthiest and
highest performing segment of the U.S. by 2025.” Achieving this vision will require 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. TEH is an approach to primary prevention and precision health
that seeks to evaluate the totality of an individual’s exposure history and integrate that with an
individual’s genetic makeup and clinical disposition, in order to understand the root causes of wellness,
injury and disease.
TEH to promote a healthy and high performing workforce

The Air Force is dedicated to being the “healthiest and highest performing segment of the US by 2025”.
The AFMS can only achieve Healthiest Population by true prevention and Total Exposure Health positions the AFMS to be
healthiest & highest performing population by 2025 with emphasis on “Personalized Healthcare”, going beyond healing the ill
and preventing early disease.
Total Exposure Health was initiated as a “Strategic Directive” through the Air Force Medical Service
FY17-21 MPPG:
“AF/SG/3/5 will define requirements and develop courses of action to integrate health promotion,
occupational health, environmental health, and "hobby health" evaluations to enhance overall delivery of
care in the Air Force Medical Home. Integration of all possible exposure pathways captured in data
analytics to ensure full spectrum of patient lifestyles is considered to create the healthiest segment of the
population by 2025.”
After demonstrating the feasibility of the TEH concept, TEH became an AFMS “Strategic Priority” in
the AFMS FY19-23 MPPG.
“AF/SG/3/5 will create a solution to capture workplace, environment, and lifestyle exposures and
connect to the individual (i.e., genome) in response to mandates in the 2013 National Defense
Authorization Act (NDAA) Section 313, PRD 05, 2017 National Security Strategy, 2015 National Health
Security Strategy, and DoDI 6055.05, using advances in science, technology and informatics to improve
health and well-being of the Air Force beneficiaries – Healthy performing populations by 2025.”
Since its inception, SG3P has been positioning the Air Force to lead the TEH initiative by identifying
collaborative partnerships within AFMS, the military components, Office of the Secretary of Defense,
federal agencies, and academia to integrate exposomics, advances in sensor technology, informatics, and
precision healthcare into TEH. Ultimately the goal of TEH is to prevent illness and disease by informing
Servicemembers and their beneficiaries to make and/or embrace preventive health choices in their
lifestyles, workplaces and homes.
The purpose of this Strategic Plan is to define the focus and goals of the initiative from FY19-23 as it
transitions to an operational Total Exposure Health Office (TEHO) and the methodologies that will be
used to ensure TEHO’s ability to provide support to both AFMS and the larger MHS community in
achieving the Healthy Performing Populations 2025 goal.
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2.2 TEH VISION

TEH aims to integrate and provide exposure-related data to individuals, clinicians, and organizations to
improve health-related decision making that will strengthen prevention, human performance, resilience,
workforce, and readiness programs. As shown in Figure 1, TEH will partner across multiple program
areas and integrate occupational, lifestyle, and environmental exposure data from traditional and new
exposure assessment technologies (including sensors and –omics-based molecular biology) with clinical
and genomic data. Leveraging a Big Data infrastructure and advanced analytics, TEH will provide a new
and novel capability that will inform and encourage healthy lifestyle choices, enhance resilience and
human performance, and reduce illness and injury. These capabilities will inform preventive strategies by
reducing the health impacts of exposures, hence improving human performance and readiness of all
Airmen. Moreover, by educating individuals about their exposure profile, TEH will enable individuals
and families to make healthy lifestyle choices and become proactive about their own health.
THE VISION STATEMENT:
“Total Exposure Health (TEH) program will enrich the clinical/patient experience allowing beneficiaries
to take control of their own health.”
TEH MISSION STATEMENT:
“Total Exposure Health will achieve precision health through advances in medicine, sciences,
technology and informatics using interactive and transparent precision health information platforms to
improve health and well-being of all Air Force beneficiaries.”
Figure 1. Vision for TEH Portfolio
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2.3 CHALLENGES AND OPPORTUNITIES

Organizational Change and New Collaborations. TEH aims to transform the current state of disparate
exposure monitoring, research studies, data collection, and healthcare records to holistic and integrated
systems that quantitate total exposure and inform health outcomes (Figure 2) into actionable insights and
initiatives.
Current State - Prev Med Future State – Prev Med

Work exposure with limited Work, environment and lifestyle (home,
environmental and lifestyle exposures recreation, etc) exposures
Animal models of exposures are applied Individual exposure applied to each
to population and (SEG)* with safety Airman’s genome with tailored
factors for Airmen protection and clinical interventions to include prevention,
intervention protection, career, placement and clinical
Limited sensors (time, sensitivity, Individual and area sensors with full
analytes) analyte complement, real time/all-the-
time, sensitive to human based exposure
Clinical intervention based on organ

function disruption/damage
TEH levels
Clinical intervention based on molecular
biology changes brought by exposure
Paper-based exposure summary Expert system (EHR) matching billions of
somewhere in the clinical record bits of information (DNA, sensor, etc)
relevant to exposure with clinical
recommendation
Prevention concerns applied post- Prevention of key health outcomes part of
occupational/lifestyle choice the care decision for career/life from
recruitment to separation/retirement
* SEG – Similar Exposure Group
1
Figure 2. Current State and Future State with TEH
In its current state the MHS is experiencing multiple challenges which are affecting quality, access and
readiness while increasing costs. To boost military readiness, reduce cost, and improve quality and
access, the MHS enterprise is modernizing its institutional health system to combine prevention with
treatment which will reduce clinical errors, improve workflows and enhance clinical outcomes with
improved patient engagement. By integrating with various MHS change management and trusted care
paradigms, TEH can save lives, money and improve force readiness.
The challenges presented by developing TEH capabilities
vary from organizational coordination across a complex
set of stakeholders to funding and research prioritization.
With the advent of the Defense Health Agency (DHA),
TEH capability development must eventually work in a
joint environment resulting in the addition of multiple
stakeholders and less direct control. Synchronization and
optimization of R&D efforts, policy and programs begin
with the AFMS Panels which are extended to other
Services and the interagency space, as well as commercial
and academic partners. This process increases the
complexity and breadth of stakeholder management,
which will be addressed through the TEHO and a cross
functional team of subject matter experts (SMEs) to
negotiate programmatic boundaries and concerns. Figure 3. TEH Variables
TEH and its impact on human health will rely on collecting,
integrating, and analyzing a dataset of diverse variables like never before (Figure 3). Staying abreast of
developments within the rapidly evolving areas of exposomics, precision medicine, genomics, sensors,
health information technology (HIT) and Big Data analytics will require a broad spectrum of resources,
analytics, and technology, as well as a far reaching network of academic, industry, and federal agency
partnerships. Furthermore, competition for research funding warrants TEH capability development efforts
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be coordinated with a diverse set of stakeholders to ensure their needs are met and leveraged to provide
effective support to ongoing research activities.
Policies. After the military’s experiences with Agent Orange exposure during the Vietnam War and the
significant adverse health claims by Servicemembers deployed to the Persian Gulf War, the necessity to
monitor and document the health status of military forces was codified into Public Law 105-85 in 19971
whereupon the Department of Defense (DoD) was mandated to develop a deployment health surveillance
system to detect, prevent, or minimize health problems arising as a result of environmental exposures
during deployments and operations. This mandate has been followed by various policies2 to standardize
basic medical record keeping across the Services.
Expectations for deployment health surveillance and record keeping remain high as military personnel
continue to be deployed overseas in support of operational missions. More recently, the 2013 National
Defense Appropriations Act (NDAA) Section 313 mandated the Military to collect, document and act on
long-term environmental health risks in garrison.2
TEH will help to comply with current policy while informing future policy with more precise information
to better leverage our limited resources by leveraging recent advances in exposure science, sensor and data
technologies, health informatics, and clinical support systems to establish a more complete understanding
of an individual’s health and risks, root causes of disease and injury, and translating them into policy.
Opportunities. Opportunities exist based upon the disruptive growth and shift in exposure assessment
technologies for the Air Force (AF), DoD, and beyond. TEH will transition traditional clinical care into
personalized health as a better understanding of the relationships between exposures (i.e., internal vs.
external and harmful vs. beneficial) and health outcomes (positive and negative) is established. As a
result, the AFMS will be able to develop preventive and protective recommendations, based upon an
individual’s unique health profile and exposures, for improving health and well-being. For example,
through TEH, sensor technologies integrated with existing and emerging data platforms will be used to
detect environmental, occupational, and lifestyle exposures in real or near real-time to capture a
comprehensive longitudinal exposure record. Human genomic data from next generation sequencing and
exposure data will be integrated using bioinformatics to develop individual health risk profiles that will
support the development of a more advanced Clinical Decision Support System (CDSS) to complement
clinical and personal interventions.
A critical element of TEH involves the ability to centralize disparate and unstructured data from past
exposure data archives as well as current exposure data collection efforts to derive maximal value from
both historical and on-going work in this area. These existing resources will be used to assess the
relationships between an individual’s genetic predispositions, epigenetic factors, and exposure to
chemicals from lifestyle, occupation, and the environment. Thus, this initiative will support development
of diagnostic approaches, treatment methods, and intervention strategies that efficiently and appropriately
integrate all available data. In due course, there may also be substantial research value in this dataset (i.e.
the ability to discover new relationships that influence health and risk).
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3. STRATEGIC FOCUS AREAS

TEH has eight areas aligned with the AFMS strategic map. These areas of focus guide the strategic
goals and activities of the TEH Initiative (Figure 4).
Figure 4. Focus Areas of the Future TEH
3.1 STUDIES AND ANALYSES

TEH aims to streamline cross-cutting studies and analyses
Federal agencies, Services and academia are working on a myriad of Studies and Analysis (S&A) from prevention to cures,
using genomics, sensors, and Big Data. There is no overarching program of record to bring these disparate, resource-
intensive, activities together. TEH S&A environmental scans and market assessments will identify existing and current S&A
for proper resource allocation.
Imagine the Air Force, Navy, Army, National Institute for Occupational Safety and Health (NIOSH), and Environmental
Protection Agency (EPA) working on studies for a perfluoroalkyls (e.g., PFOA and PFOS) sensor, a wide-spread contaminant
in the environment. The TEH S&A would identify any duplication of effort and recommend actions that may support all the
studies, a mix, or one to reduce duplication and reprogram funding towards other high priority studies.
To achieve TEH’s vision of acting as an integrator of multiple research, policy, and health efforts, TEH
will continue to initiate studies and demonstrations that help understand and characterize the roles and
activities the TEH Initiative should support. Due to the rapid pace of technological advancement (such as
genomics, medicine, sensors and informatics) and the changing legislative environment (such as new
presidential initiatives, healthcare policies, etc.), the TEHO will conduct environmental scans, literature
reviews, and market research to develop materials to better inform policy and the allocation of resources
to support and transform military healthcare.
Noise study to identify hearing loss risk
Currently the USAF School of Aerospace Medicine (USAFSAM) is working on a “noise” exposure TEH research
demonstration to demonstrate the ability to collect, store, and utilize unstructured “noise” exposure data to identify the unique
health risk associated with noise and manage Noise Induced Hearing Loss (NIHL). The demonstration will pull all the aspects
of TEH (sensing, seeing and action) with data to include: sensor, survey, DOEHRS, and genetics.
3.2 RESEARCH AND DEVELOPMENT

The challenge for developing TEH capabilities is bringing together distinct systems and initiatives into
one portfolio: integrating exposure science, information technology, and existing healthcare programs to
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develop end-to-end systems. For the current and near-term, TEH has identified the key areas within
science and technology that research and development should be focused; including, but not limited to
science, engineering, medicine, and informatics. TEH aims to expand the standalone fields of study and
integrate them into a system that can transform exposure data into behavioral and clinical actions. Sensor
technologies integrated with existing and emerging data platforms will be leveraged to detect
environmental, occupational, and lifestyle exposures in near-/real-time to capture a comprehensive
exposure record that can identify risk factors and inform risk prevention.
Human genomic data generated from next generation sequencing and exposure data will be combined
through bioinformatics to develop individual exposure health risk profiles using informatics to support
the development of a more advanced CDSS to compliment clinical and personal interventions.
3.3 PARTNERSHIPS AND COLLABORATIONS
Accelerating AFMS Research by Leveraging Partners’ Existing Collaborations
SG3/5 is working with various federal, academic and private sector entities. One example is our work with the Pacific
Northwest National Laboratory (PNNL), a leader in exposure sciences and genetics. Given PNNL’s unique position as a
national laboratory, AFMS has positioned assets to develop and integrate AFMS research using PNNL as an access
point to consortium of institutions from academia, the private sector, and other federal agencies.
TEH is at the epicenter to focus synergistic initiatives within the Air Force, DoD, and at national levels to
advance health and healthcare with advances in science, technology, medicine, and informatics.
Establishing public-public and public-private partnerships will ensure appropriate coordination and
support, while minimizing duplicative efforts—a key priority for TEH. These partnerships will also help
to ensure data sharing, dissemination of results, and efficient use of resources, particularly in constrained
budgetary environments. It is paramount that partnerships and collaborations are created to form shared
resources and link together existing initiatives to move forward with the best value and minimize the
number of new efforts, which are increasingly difficult to fund in today’s constrained budgets.
R&D will be a major focus for TEH and the questions that TEH will tackle will be large, challenging
problems that are best addressed through collaborative efforts. For example, sharing of best practices and
lessons learned across the exposomics community will be critical to advancing the state of the science,
particularly as the tools and technologies central to TEH are still rapidly evolving. This approach will be
used to ensure that TEH is using cutting edge technologies, and focusing on unique research areas and
topics, without duplicating efforts, that will supplement existing initiatives and take TEH to the next
level of actionable healthcare decision support.
3.4 REGULATORY
Consequences of Exposure Data Collection
Imagine a Servicemember purchased an off-the-shelf wearable pollution monitor to monitor/control their Chronic Obstructive
Pulmonary Disease only to find out that their workplace was not safe. Will the Air Force allow personal devices into the
workplace? What are the ethical legal, policy implications? This is one of many complex issues associated with all aspects
of TEH that need to be addressed.
There are numerous policy, legal and ethical considerations regarding the execution of TEH that must be
addressed while active studies are being conducted and before full implementation of TEH. Planning
and development of study documentation for research protocols is a lengthy, technical process and a
deep understanding of the requirements is essential to initiating studies without delays. It is important to
ensure that a lack of regulation does not become an obstacle to the implementation of R&D. Compliance
to regulatory guidelines must be considered at several levels across multiple agencies. Communications
with relevant agencies (e.g., OSHA, DHA and FDA) must start early and remain on-going so to ensure
existing compliance as well as anticipate future regulatory issues. Examples of issues that need to be
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addressed include revisions and implementation of TEH in accordance with the Affordable Care Act
(ACA), compliance with military regulations for meaningful use of personalized data, the Genetic
Information Nondiscrimination Act (GINA), and exposure data to improve both individual and
population health, as well as policy support to allow deployment of new technologies and tools such as
wearables and sensors to workplace environment.
With the advent and introduction of new technologies (sensors), clinical diagnostics (genetics) and
information technology (Big Data) within and outside the military workplace various ethical and privacy
issues will surface that will need deeper investigation. The findings, challenges and opportunities will
drive both policy and operations for early and future adoption. Therefore, it will be critical to ensure these
issues are identified and planned for with execution based on current rules, standards, and guidance.
The TEHO will take all these issues into consideration as they program and plan with a focus on realistic
adoption within the current ethical, social and legal constraints while pushing for the adoption, use, and
integration of advances in science, medicine, and information technology to improve the health and
welfare of our forces.
3.5 INFRASTRUCTURE
The Collection, Storage, and Retrieval of Exposure Data Enables Personalized Healthcare Delivery
to Our Servicemembers and Veterans
A Servicemember is going to an appointment at her local clinic. He/she discusses their concerns related to
deployments and the impact it may have on her health and the health of her family. With her exposure record
available through the future TEH system, the provider can see all of her personal and group exposure histories with
interpretations to make the best possible education and health plan.
The optimal infrastructure to support the TEH program should include but not be limited to resources such
as sensor platforms, database servers, high-performance computing, and the cloud. TEH-related programs
such as the Personal Exposure Monitor (PEM), Coriell Hearing Study3, Digital Biobank, Bio-
environmental Threat Surveillance (BETS), Defense Occupational and Environmental Health Readiness
System (DOEHRS), and BLUE Longitudinal Exposure Record (BLER), are stood up through separate but
linked AFMS and DoD programs. Furthermore, besides Information Technology (IT) infrastructure, the
AFMS needs to define the needs to support all aspects of TEH, including laboratory and medical support.
The requirement here is to determine what distinct resources and infrastructure TEH will need to support
functional integration and fill gaps not provided by the related initiatives.
3.6 HEALTH AND HEALTHCARE
TEH Systems Will Reveal Unexpected Health Risks and Their Root Cause
A Servicemember authorizes genetic testing for a newborn family member and it reveals sensitivity to certain pesticides. The
end-point of TEH is to give providers a Clinical Decision Support System (CDSS) that will flag providers to such findings and
combine them with data from a variety of sources (sensors, medical records, lifestyle, occupational hazards, etc.) and
nonclinical data sources to include “smart base” data like Civil engineering pesticide application. When the clinician reviews
the CDSS information for this family it shows that in addition to the genetic sensitivity to pesticides, they are vegetarian and
live in a rural setting, thus potentially exposing them to higher pesticide levels. This information allows the provider to order
specific diagnostic tests and provide appropriate clinical interventions.
TEH will usher in a disruptive paradigm shift in healthcare. Whereas most providers care is oriented
toward “disease/illness care,” with TEH and other related initiatives, including the AFMS-led Digital
Biobank under their Precision Medicine Program, education for healthcare providers at all levels can
begin leaning more heavily toward prevention. The knowledge provided by TEH will foster an
understanding of how to interpret and integrate a wide variety of exposure-related data (including but not
limited to occupational, environmental, genomic, and health behavior data from new media) into clinical
practice and preventive medicine to optimize human performance and readiness. Ultimately, this will
allow individuals to take ownership of their health and to be more informed about their health-related
choices and behaviors.
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3.7 TRAINING
Training and Education: How Understanding Genes Can Modify Behaviors
As we learn more about genetics, both patients and providers will realize we are more unique than previously thought. This
has already been shown in exposure to noise, with recent understanding that a collection of genes significantly affect
predisposition for hearing-loss and likely elucidate different levels of risk (risk profiles). Training and education will play a
crucial role in TEH, particularly when individuals and healthcare professionals will need to understand what personalized risk
profiles mean and how guidance will be best implemented in changing behaviors to prevent hearing loss through advanced
technology and lifestyle/workplace modifications.
Additional training and education will also need to be developed for AFMS beneficiaries, including
Servicemembers, family members, as well as veterans and retirees who receive healthcare through the
AFMS and the MHS. The resulting health system will be a participant-engaged and data-driven endeavor
that synthesizes with advances in understanding human biology, behavior, genetics, occupation and
environment, along with data and computational science to produce new knowledge that reveals new
pathways for promoting health, enhancing human and operational performance, and preventing and
treating disease.
Once exposure records are accessible to healthcare providers and staffs, they will need training programs
to ensure they understand how to evaluate exposure data and utilize it to support their healthcare decisions.
Clinicians’ understanding of their patient’s symptoms will be less reliant on self-reporting and enhanced
by technology. Additionally, the limited and static snapshot of their patient’s health available during
examination will be less dependent on patients to conduct the burdensome task of self-logging often
undependable diaries of symptoms, exposures, and behaviors.
The TEH Initiative will not only affect clinicians, nurses, and other healthcare professionals. New training
and education will also need to be developed for the Air Force Bioenvironmental Engineering, Public
Health, and numerous other members of the exposure science, preventive medicine, and public health
functions of the AFMS so they can properly understand and leverage these advances in data collection,
computational biology, toxicology, toxicogenomics, and other rapidly evolving disciplines. By doing so,
the AFMS and by extension the DoD can assess, quantify, and understand exposures which in turn will
strengthen AFMS precision medicine, preventive medicine, population health, human performance, and
readiness initiatives.
3.8 READINESS
TEH Together with Other AFMS Domains, Ultimately Improves Force Health and Readiness
In response to the Global Health Engagement, the exposure health data from TEH will enhance the AFMS
integrative/integrated medicine initiatives. Additionally by incorporating the exposure data from various geographic areas, we
can ensure our deploying forces have the most accurate medical intelligence with emphasis on their unique deployment
history and protective equipment.
Before a Senate Appropriations Panel committee meeting on March 9, 2016, Air Force Surgeon General,
Lieutenant General Mark A. Ediger said, “The broad scope of care we provide is key to our readiness.” 4
If the broad scope of care the AFMS provides is the key to our readiness, then a TEH-informed health
system is an enabler of readiness on several levels. First, TEH will provide clinicians , nurses and other
healthcare professionals and staff with a much richer and knowledge-conveying set of data regarding
exposures as well as individual (e.g., genomics, metabolomics, pre-existing conditions, etc.)
susceptibilities to use in primary, secondary, and tertiary prevention efforts and the Air Force’s
Personalized Medicine Program (PMP), all of which increase readiness. Second, this expanded and
enriched data will drive an increased understanding of exposure-disease relationships and individual
susceptibilities that will optimize the deployment screening process to more accurately and tightly
identify those individuals with true deployment-limiting medical conditions—which increases readiness
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and reduces the likelihood of putting individual’s in harm’s way. For example, with the development of
the ILER, TEH capabilities can improve military operation decision making by identifying personnel
who may be susceptible to certain exposures. Third, by empowering individuals with information about
their health, their exposures, and their unique individual susceptibilities, we will be arming them with
information to drive health behavior change and improve readiness.
4. EXECUTION STRATEGY: STRATEGIC GOALS AND OBJECTIVES

Setting clear goals is critical for TEH to maximize how it can benefit AFMS, existing research and health
programs, and the health of the community. Each of the following goals reflect a targeted approach to
delivering tangible results and deliverables in alignment with the TEH Focus Areas (Figure 5).
Figure 5. TEH Strategic Goals
GOAL 1: SYNTHESIZE, IDENTIFY, AND UNDERSTAND CURRENT AND EMERGING

TRENDS THROUGH STUDIES AND ANALYSES TO ADVANCE PREVENTION
STRATEGIES
There is currently an explosion of studies, research and technical development in the fields of
medicine, genomics, science, technology, informatics, and Big Data in the exposure sciences5. To
systematically identify, and understand current and future TEH efforts, robust studies and analyses
are required to reduce duplication, partner with similarly minded groups, and focus on exposure
science initiatives that have military relevance. This process will require a comprehensive analysis
and cataloging of current and emerging technologies in the fields listed below.
 Genomics, Exposomics, “omics” Goal 1 Example Activities and Milestones

 Sensor and mobile applications
Conduct a systematic literature analysis
 Big Data (storage, transfer and use) Develop mechanisms to continuously learn about
 Informatics emerging technologies that are not yet
 Medicine published/publicized
 Healthcare Policies Drive policy change and implementation into
 Precision and personalized medicine healthcare delivery
 Public Health and Environmental Monitoring
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OBJECTIVE.1.1: SYSTEMATIC LITERATURE, WEB AND FUNDING ANALYSIS
The TEHO will become the centralized repository for everything exposure science related and will tie
specific research, technologies, initiatives, and programs to each AFMS panel to integrate into the
healthcare delivery system.
OBJECTIVE 1.2: CONTINUOUSLY LEARN
As the central repository for everything exposure science the TEHO will advance science and technology
while supporting the evolution and development of policies to support TEH implementation.
Through this process TEH will support the development of improved methodologies for sharing available
information, findings, and data in the exposure sciences and the expansion of studies and analyses, both
within DoD and through external stakeholders.
4.2 GOAL 2: ADVANCE HEALTH AND HEALTHCARE THROUGH RESEARCH AND
DEVELOPMENT
A defining characteristic of TEH is its use of Goal 2 Example Activities and Milestones
technology to ultimately drive personalized evidence-
based medicine that will enrich the patient/provider Develop evaluation criteria and selection processes
relationship transferring ownership to the individual with TEH Stakeholders to determine which
technologies to support and implement on a cyclical
to ultimately encourage health-promoting behaviors.
basis
TEH also promotes the promise of Big Data, which is Finalize and execute the Strategic Technical Plan
sensing (collecting exposures with sensors), seeing (Chapter 6)
(using informatics to make sense of the data) and Coordinate demonstrations of supported research
acting (using expert systems so clinicians can make Support new and innovative studies on the
better interventions). exposure sciences.
Partner with scientists to influence study design to
Therefore one of TEH’s strategic goals is to advance maximize efficiency during regulatory approval
the state of research and development that is relevant processes
to furthering exposure detection and our ability to
make use of large volumes of disparate datasets that will eventually contain information about the
individual’s exposure, clinical disposition and genetics. This integration of disparate and unstructured
data will require a comprehensive analysis and cataloging of current and emerging technologies in the
fields listed below.
 Data collection tools and mechanisms (e.g., sensors, smartphone apps, Internet-of-Things (IoT)
 Technologies that facilitate the feasibility of transferring exposure and health data
 Solutions and infrastructure that are able to manage large volumes of disparate data
 Solutions that enable rapid and more efficient analytics of this data
 Expert health IT systems that facilitate the incorporation and use of data by healthcare providers
 Solutions that enable use of exposure data for individual as well as population health through
surveillance, warning, and countermeasure methods
TEHO aims to expand and optimize AFMS capabilities in technology; sensor development, data
analytics, and health IT systems. The deployment and integration of the future R&D portfolio of TEH
will allow AFMS to improve the health and well-being of its beneficiaries while reducing healthcare
associated costs, manpower, and staff burden.
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4.3 GOAL 3: ENSURE COMPLIANCE WITH REGULATORY STANDARDS

The healthcare industry and military medicine are in Goal 3 Example Activities and Milestones
constant flux driven by complex current and emerging
policy initiatives. The excess of existing policy Catalog all existing policy, guidance and
associated with the complexities of the TEH initiative recommendations associated with the TEH initiative.
is daunting and requires a catalog to address not only Identify and stay abreast of policies associated with
the exposure science issues but also those concerning technologies that may not have designated
approval processes
preventive medicine, genomics, technology, and
Integrate TEH concepts into current and emerging
information technology to name a few. A holistic view policy and guidance.
is needed to i dent i f y existing policies and also to Be involved in the shaping of regulatory policies for
integrate TEH precepts as new and emerging policies emerging technology
are developed to reap the benefits of the TEH approach
to improve the delivery of healthcare.
Figure 6. Sample Regulatory Workflow for TEH Studies
For example, the TEH goal of integrating wearable sensors, personal exposome data gathering,
genomics, and next generation electronic health records presents a unique and complex challenge with
respect to the spectrum of quality and regulatory requirements that govern this space. The cutting-edge
nature of TEH is more advanced than the policy and guidance materials that are currently in place.
Therefore, due to the absence of strong regulatory information, some additional delays in navigating the
protocol review and approval process are expected. Figure 6 illustrates several stages of development,
review, and approval authority signatories that TEH SMEs will obtain before TEH research with human
subjects can begin. Fortunately, some elements can be done simultaneously and some approvals may not
be required in the near-term.
OBJECTIVE 1: SYSTEMATIC POLICY AND REGULATORY REVIEW
TEH will require a comprehensive scan of existing policies and regulations around personalized sensors,
wearables, and the use of genetic data and will identify areas where TEH can be integrated into existing
DoD healthcare and public health policies and guidance.
OBJECTIVE 2: REVIEW OF REGULATORY PROCEDURES AND COMPLIANCE MANUALS
Since TEH will be using sensors and personalized wearables and individual genetic sequencing, these
issues need to comply with documents, lists, policies, programs, and statements relating to compliance
references used by FDA.
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4.4 GOAL 4: BUILD INFRASTRUCTURE TO SUPPORT ADVANCES IN HEALTHCARE

Full implementation of TEH throughout the AFMS enterprise will require an infrastructure that supports
both the clinical and technology advancements to healthcare. This will need to be a carefully phased,
incremental approach for providing clinical support such as labs, pharmacy, etc.
Technology, applications, informatics networks, and participation by the vast population of Military and
their beneficiaries will need a significant initial investment and operating cost, though the expectation of
healthcare cost saving will justify the investment. Paramount to developing a TEH infrastructure will be
leveraging existing systems, working with currently
successful processes and innovative technology, and Goal 4 Example Activities and Milestones
collaborating closely with agencies under a similar Leverage understanding of emerging technology
mission so to reduce costs and drive infrastructure and health trends gained from Goals 1 and 2 to
building forward in an efficient way. identify capability and capacity gaps
The TEHO will also have established structures to Engage with leadership within AFMS and MHS such
meet the objectives outlined for each of its goals. as Medical Support to ensure infrastructure
expansions can be integrated with preexisting and
These structures serve as building blocks for future future systems
innovation and expansion. The organization of
TEHO (see Figure 8 in Section 5.2) depicts how these structures work together to support the current
AFMS healthcare infrastructure to be the healthiest and highest performing population by 2025.
The reach of Medical Support touches upon all future stakeholders of TEH including Benefits, Laboratory,
IM/IT, and Pharmacy. Furthermore, one of the main near-term objectives of TEH is to transform exposure
data into an individual health exposure risk profile that can be integrated into ILERs and ultimately be
interoperable with DoD electronic health record (EHR), MHS GENESIS. Together, TEHO aims to work
with Medical Support to develop guides and implementation policies relevant to information assurance and
Medical Records Management and execution of the Health Information Portability and Accountability Act
(HIPAA) as it relates to the operation of TEH technologies and services.
OBJECTIVE4.1: CONDUCT AN ENVIRONMENTAL SCAN OF EXISTING AFMS INFRASTRUCTURE
A comprehensive analysis of how to integrate existing IT systems and infrastructure to help TEH
identify current and future needs, and drive an AFMS wide modernization initiative that will support
TEH and other upcoming healthcare needs and challenges must be conducted.
OBJECTIVE4.2: PILOT TEST NEW PLATFORMS UNDER AFMS’S SECURE ENVIRONMENT
To ensure optimal integration of new tools and technologies for TEH initiative, pilot testing the most
critical technologies will be a necessary step to secure full integration of new systems into existing
infrastructure and also ensure interoperability and health information exchange among systems.
OBJECTIVE 4.3: IDENTIFY CURRENT AND FUTURE PHARMACY AND LABORATORY NEEDS
As TEH R&D matures there will be an expansion of various biomarkers and genetic testing required to
understand the individual’s health risks. Once the health risks are identified through environmental scans,
the Studies and Analysis and R&D focus areas, various pharmacological alternatives may exist or need
to be created that will eventually get on the AFMS formulary.
4.5 GOAL 5: FOSTER A NETWORK OF INTERNAL AND EXTERNAL COLLABORATIVE
PARTNERS
In order to efficiently maximize the capabilities and comprehensiveness of TEH supported risk
assessments and future CDSS in a resource constrained environment, a central goal of TEH is
maintaining relationships with multiple programs and initiatives that can provide rich sources of data.
TEH will accomplish this by fostering a network of partners within the AFMS, across the DoD, other
federal agencies (e.g., Department of Health and Human Services, National Institutes of Health (NIH),
NIOSH, and throughout industry and the private sector.
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 Within the Air Force: TEH will collaborate Goal 5 Example Activities and Milestones
with AF/SG5 derived R&D and studies and
analysis programs to support development of Identify the most impactful conferences and meetings
individual sensor, communications and to hold oral presentations and workshops
Establish roles within the office to handle
analytics systems for individual exposure
MOUs, MTAs, teaming agreements, etc.
monitoring, data integration and smart system
Once a group of partnerships are established, plan
analytics for integration into MHS GENESIS. and host annual TEH symposium
TEH will also support staff’s ability to better Publish review articles and book chapters on TEH
collect exposures, translate these data, and concepts and exposomics
implement protective and medical
interventions. As TEH evolves, TEH will remain engaged with AF entities outside of AFMS,
including Civil Engineering, Services, Human Resources and the Chief Information Officer (CIO),
to shape policy and implement TEH developed innovations to integrate with the “Smart Bases”
concept, for example.
 MHS & DoD: As TEH matures, TEH can apply its experience expanding capabilities within
AFMS to support development of a similar system across the larger Defense Health Agency while
collaborating with MHS and DoD efforts, such as the Center for Deployment Health Research &
Millennium Cohort Study and the Collaborative Health Initiative Research Program.
 Initiatives in the Public Sector: Due to resources needed to handle the size and complexity of data
involved in TEH analyses, TEH aims to bring together community resources wherever possible.
Federal organizations such as the NIH, NIOSH, CDC, and EPA, have all conducted research on
occupational and environmental exposures, biomonitoring, and exposure versus effect. Key
exposome initiatives in Europe and the United States could prove to be particularly valuable
partners for TEH.
 Academia and National Laboratories: Leveraging current relationships with various academic
institutions and National laboratories, such as, PNNL and expanding relationships will be key to
bringing the best in class solutions to the TEH initiative. With the rapid changes in science,
technology, medicine and informatics developing relationships outside the military complex will
be critical to advancing the product needs to support TEH.
 Private Sector & Industry: The issues related to delivering healthcare and ensuring employee
productivity and health are not restricted to the AF or the DOD, these issues burden our entire
healthcare system as well as employers. By fostering public/private relationships we can work
together to solve complex problems for the federal government. We will promote and foster
innovation by enabling the rapid development and transition of critical technologies and services
for use to resolve complex TEH issues and stimulate the transition of cutting-edge, innovative
lifesaving and outcome-improving technologies and services to the commercial/private sector.
OBJECTIVE 5.1: PARTNER WITH AFMS PANELS AND TO DEVELOP INTERNAL TEH SUPPORT
Establish a TEH advisory board that will be structured from AFMS Panel members and SME’s to help
drive TEH initiative, but also through their expertise and understanding of current operations and
developments to help identify needs and overcome challenges related to TEH efforts.
OBJECTIVE.5.2: EXPAND AND DEVELOP PUBLIC-PUBLIC COLLABORATIONS
Identify public stakeholders with focus on TEH and its concepts, including public sector agencies, non-
profit organizations, and promote and support communication, collaboration, and innovations in areas of
interest for AFMS and TEH through collaborative programs and funding initiatives.
OBJECTIVE.5.3: INSTITUTIONALIZE PUBLIC-PRIVATE COLLABORATIONS
Focus on the development and support of public-private partnerships (PPP) (over the more traditional
market-driven models), that will drive innovation and help promote the adoption and implementation of
TEH concepts and efforts from personal to institutional and public health levels. Through these
collaborations, private and public stakeholders can work together to identify and overcome risks and
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challenges and share the benefits of this collaboration.
4.6 GOAL 6: PROVIDE ENHANCED EXPOSURE HEALTH EDUCATION AND TRAINING

In order to truly realize the beneficial impact of TEH, the individual, health providers and public health
professionals play a major role in changing the current paradigm of care into one that takes a holistic
approach to preventing disease and promoting health. Therefore, as technologies such as sensors,
exposomics, and individual exposure risk profiles
mature, TEH will work with Force Development to Goal 6 Example Activities and Milestones
identify training needs for clinical and non-clinical Make available review articles and book chapters
career fields to develop and implement training on TEH concepts and exposomics to the medical
programs dedicated to transforming health and staff (Communications Plan)
science roles to include exposure science. Exposure As TEH data matures, develop materials for user-
science will for example: specific training modules to enable patients, care
providers, etc., to understand and use exposure data
 Increase the public health professionals’ to benefit health
awareness and knowledge of the exposure Apply for Continuing Medical Education
sciences through the use of sensors and Big accreditation to provide industry recognized training
Data platforms to improve surveillance to healthcare professionals
 Train clinicians in interpreting new exposure and susceptibility data as it becomes more integrated
with clinical records, to increase exposure data’s role in clinical decision support.
 Expand scientific and engineering roles into the exposure science field.
The development of these training programs will involve an integrated approach from all the AFMS
panels as well as programmatic leads from the scientific, policy, and IT domains to develop the strategy,
prioritize the curriculum and resources needed to execute the training.
TEH will work with Force Development Panel SMEs and stakeholders and with public health
professionals to develop TEH within the Military Force through guidance, training, and providing a
knowledge base resource.
Education and training is not limited to clinical and non-clinical staff, it also requires training and
education for AFMS beneficiaries and the civilian workforce to help them better understand the
exposures not only in their workplace but through their individual choices and the environment they live
in. To identify these current and emerging needs, the TEHO will work with industry, academic, and
public sector SMEs to emphasize AFMS TEH.
OBJECTIVE 6.1: DEVELOP NEW EDUCATION RESOURCES FOR MEDICAL STAFF
Develop web portals populated with informational material about the scope and importance of TEH and
exposomics in promoting individual health and population/public health, and how these initiatives can
support personalized and precision medicine initiatives, reduce healthcare cost, and promote healthy
living.
OBJECTIVE 6.2: DEVELOP A COMMUNICATIONS PLAN
Communication plans will be developed to include medical staff, nonmedical staff and beneficiaries to
ensure understanding of TEH capabilities as they are available throughout the development. The
communications plan will include information on promoting individual and family health through
advancements in personalized medicine, healthy choices and enhanced understanding of personal and
family exposures.
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4.7 GOAL 7: IMPROVE QUALITY OF CARE AND ENCOURAGE GOOD LIFESTYLE CHOICES
According to the 2014 MHS Review, there are
approximately 10M beneficiaries while there are Goal 7 Example Activities and Milestones
0.25M primary care physicians6, 7. Given this ratio, Enhance Engagement with AF line leadership and
it is extremely challenging to achieve the patient- stakeholders
provider relationship necessary for personalized Integration of Individual Longitudinal Exposure
care. Records (ILERs) into EHRs allowing providers to
understand patients’ health even without clinical
TEH equips healthcare providers in 4 ways:
presentation which is difficult to capture
 Individual exposure records allow physicians Development of push-pull or bidirectional user-
to more easily understand a patient’s friendly mobile applications that not only push
exposure and risk history that may contribute to their exposure
concerns. data
 Integration of TEH data into expert systems (e.g. clinical decision support systems) helps care
providers make decisions more efficiently about screenings, diagnostics, and treatments to
prescribe.
 Identify and leverage health promotion activities, campaigns and practices that improve lifestyle
decisions and behaviors.
 Improve patient and family activation and engagement.
Realizing the pathway from monitoring exposures and translating them into a succinct patient/provider
clinical dashboard is in the distant future; we must recognize the potential of the future and work towards
it. By incrementally introducing the precepts into policy, technology and medical operations, the benefits
of TEH will gradually be realized by the entire medical enterprise.
Beyond creating an enriching clinical experience that will translate into positive behavioral changes,
TEH also aims to simultaneously enable Airman and beneficiaries to easily understand their exposures
and its effect on their health through an integrated approach with AFMS Health Promotions,
Occupational and Preventive Medicine. This could be accomplished through reports similar to those
provided in genomic services such as 23andMe or through mobile applications where individuals can
track their exposures in real time similar to the Fitbit’s or Apple Health’s mobile applications.
Collectively, TEH will bridge the divide between the care provider and the patient where the patient is
better equipped to take ownership of their healthcare with information and to participate in the
development of clinical plans that are individualized to encourage healthy lifestyle choices, safer
workplaces and a better understanding of the environment to enhance human performance and military
operations.
OBJECTIVE 7.1: DEVELOP NEW PATIENT FACING EDUCATION TOOLS AND RESOURCES
Provide beneficiaries and their families general information about exposures, how they affect their health,
how AFMS is prioritizing exposure science, and how patients can improve their overall health and
performance by adopting and promoting healthy lifestyle’s and health choices.
OBJECTIVE.7.2: DEVELOP INTERACTIVE TOOLS AND DASHBOARDS FOR PATIENTS TO FOLLOW THEIR
HEALTH
Patient facing tools and dashboard can be developed and integrated into the new MHS GENESIS for
beneficiaries to allow them to track their health, set up goals, and provide them with smart choices and
advise about protecting their health, adopting healthy choices, and recognizing and limiting harmful
exposures.
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4.8 GOAL 8: OPTIMIZE FORCE READINESS AND HUMAN PERFORMANCE BY REDUCING

HAZARDOUS EXPOSURES
A TEH informed health system enhances and enables readiness. TEH will provide healthcare providers
with a knowledge-conveying set of data regarding exposures as well as individual (e.g., genomics,
metabolomics, pre-existing conditions, etc.)
Goal 8 Example Activities and Milestones
susceptibilities to use in primary, secondary, and
tertiary prevention efforts and the Air Force’s Engage with Force Development leadership and
Personalized Medicine Program, all of which increase stakeholders
readiness. Integration of Individual Longitudinal Exposure
Records (ILERs) into EHRs allowing physicians to
 This expanded data will drive an increased understand patients’ health even without clinical
understanding of exposure-disease presentation which is difficult to capture
relationships and individual susceptibilities that will optimize the deployment screening process by
more accurately and specifically identifying those individuals with true deployment-limiting
medical conditions—which increases readiness and reduces the likelihood of putting individuals’
in harm’s way.
 Empowering individuals with information about their health, their exposures, and their unique
individual susceptibilities, will enable them with information to drive health promoting and health
improving behaviors which again increases readiness.
 TEH mitigates exposure to improve performance by providing the proper intervention geared to
the individual and their medial disposition, exposure and genetic propensity.
To reduce risks TEH will use exposure risk indices that will be part of the CDSS to develop protocols or
courses of action (COA) to enhance prevention and protect military members from chronic and adverse
exposures. Collectively TEH creates the ability to reduce the potential outcome of the exposure through
various means such as removing the hazard, changing the operational process, instituting engineering
controls, and implementing personal protective countermeasures such as gear or vaccinations/prophylaxis.
Longer term solutions will focus more on biological mechanisms. As those mechanisms are better
understood, a myriad of potential mitigation strategies could appear that may be more focused on giving
cells better defense mechanisms or making an organ more resilient. The end state is enhanced human
performance and a ready force.
TEH aims to ensure the medical readiness of individual Servicemembers through understanding of
exposures at the individual level, which will drive prevention behaviors and increase human performance
and mission effectiveness. In order to impact the care of AFMS beneficiaries, ILERs and exposure-based
health risk profiles can be integrated into clinical encounters and medical surveillance programs.
Therefore, TEH will work closely with the Medical Readiness Panel members to understand the issues and
impact TEH systems will have on training & medical operations at the individual level (e.g., sensors,
personal apps, questionnaires).
4.9 GOAL 9: SHORT, MID, AND LONG TERM EXECUTION PLAN
Establishing a TEH capability can be a complex process that will require incremental development and
establishment of new technologies and research tools, the engagement of multiple stakeholders, and
changes in policies and procedures and healthcare practices. To be able to establish performance metrics
a n d monitor the progress of the TEH capability, well defined goals need to be followed throughout the
development of this capability. These goals are divided into short-term, mid-term, and long-term goals.
Near-Term Tasks (6-12 months)
 Finalize the TEH Strategic Plan
 Develop the TEH Concept of Operations (CONOPS)
 Develop Capabilities Based Assessment (CBA) & informational briefs
 Strategic Business plan
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 Strategic Technical Plan from SG5 Research Development Document (RDD)
 Develop the appropriate doctrine, organization, training, materiel, leadership and education,
personnel and facilities (DOTMLPF) for each focus area.
 Conduct TEH demonstration project with an emphasis on noise
 Understand the landscape of existing initiatives within AFMS, the Surgeon General Office, and its
stakeholders
 Conduct an environmental scan to understand how TEH affects the AFMS and all stakeholders
 Bring together a consortium of stakeholders with shared goals to develop relationships and
combine resources, align deliverables, reduce redundancies, and identify gaps and solutions
 Expand relationships with intra and interagency partners to include the Department of Homeland
Security and agencies with the Department of Health and Human Services.
 Develop memorandums of agreements or memorandums of understanding with inter and intra
government agencies and potentially DoD allies, non-governmental organizations, etc.
 Identify existing DoD-approved computer infrastructures projects with Authority to Operate for
HIPPA-compliant personal identifiable information (PII)/protected health information (PHI)
aggregation and analysis
 Identify all potential infrastructures that can be used to support TEH Information Technology (IT)
and tech initiatives (sensors, Big Data, analytics, etc.) for data collection, storage, and analysis
 Create a plan to integrated TEH IT and technology initiatives (sensors, Big Data, analytics, etc.)
as a path toward an Initial Authority to Operate (IOA) and/or Authority to Operate (ATO)
 Identify and develop synergistic partnerships with other public sector, private sector, and academic
efforts.
Mid-term Tasks (1-3 years)
 Establish the TEH Program with sufficient structure to support the following:
o Develop the Initial Capabilities Document
o Leadership Function
• Establish performance metrics and monitor the progress of the TEH capability
• Develop Informational briefs, presentations and day-to-day documentation to support the
TEH
• Develop the TEH Business Plan from the TEH Strategic Plan
o Policy and Program Support
• Monitor changes in policies and procedures and healthcare practices.
• Develop the Initial Capabilities Document and the final CBA
• Develop the appropriate doctrine, organization, training, materiel, leadership and
education, personnel and facilities (DOTMLPF) for each focus area
o Research and Development
• Develop and engage with multiple public, industry and academic stakeholders
• Develop the TEH technical plan for the Research Development Document
• Leverage existing technologies and begin to shape exposure monitoring systems that
connect with data analytics and clinical research (e.g., genomics) to provide meaningful
health solutions (e.g. clinical decision support)
o Program for training and education
• Identity training requirements for specialty fields/clinical and non-clinical
• Strategically and tactically continue to identify programmatic needs to support training,
education, and manpower needs as TEH transforms medical services
• Work with various AFMS research and development partners to develop technology
needs assessment to support staff to better collect exposure information, translate and
take appropriate protective and medical interventions.
 Identify program gaps, resource needs, and institutionalize TEH within the AFMS and OSD
o Strategically and tactically continue to identify programmatic needs to support training,
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education, and manpower needs as TEH transforms medical services
o Work with various AFMS research and development partners to develop technology
needs assessment to support staff to better collect exposure information, translate and
take appropriate protective and medical interventions.
o Build on the AFMS experience to build out beyond AFMS to the other services and
DHA.
o Identify program gaps, resource needs, and institutionalize TEH within the AFMS and OSD
• Develop both Air Force and AFMS service TEH policies that expand beyond the AFMS
to include other Air Force partners like the Civil Engineer, Human Resources and CIO.
• Work with various intra Air Force agencies to create the policies outside of healthcare to
institute TEH in to the Air Force landscape
• Integrate with Individual Longitudinal Exposure Record (ILER) and MHS GENESIS
• Develop the plan to support, augment and integrate TEH into the ILER
• Develop the plan to support, augment and integrate TEH into Genesis
 Identify training requirements for specialty fields/clinical and non-clinical
o Work with each AFMS Associate Chief to identify training needs
o Develop a training plan with specific training needs and programmatic plan to institute into
the AFMS Force Development Panel plan
 Leverage existing technologies and begin to shape exposure monitoring systems that connect
with data analytics and clinical research (e.g., genomics) to provide meaningful health solutions
(e.g. clinical decision support)
 Develop both Air Force and AFMS service TEH policies that expand beyond the AFMS to
include other Air Force partners like the Civil Engineer, Human Resources and CIO.
 Expand relationships with inter and interagency partners to include the Department of Homeland
Security and agencies with the Department of Health and Human Services.
 Investigate feasibility of Federal, Interagency and other public sector partners and/or
Public/Private partnerships as an innovative approach to ensure the AFMS does not bear the
total cost or resources to find common ground to collectively bring TEH to the forefront and
support the advancement of healthcare
o Develop the plan to create partnerships and identify ways to leverage resources to find
common ground to advance healthcare
 Integrate TEH with ILER and MHS GENESIS
 Establish sensor portfolio to generate a comprehensive, real-time/near-time, continuous
exposure monitoring of the individual.
Long-term Tasks (3-7 years)
 Fully integrate TEH into future DOD policy/JCS doctrine, programs (e.g. ILER)
 Integrate exposure data into MHS GENESIS and ILER
 Promote protective health behaviors based on TEH research findings
Given that TEH is a bold and novel holistic integration of technology and health across many areas
(occupational, military threats, environmental, etc.) that are rapidly advancing, the expansion of TEH
capabilities will be an iterative process where once one phase is complete and lessons learned are
captured, future phases will be reviewed and reevaluated based on experience and emerging trends that
may impact TEH. This will ensure the TEH remains relevant and provides the most beneficial support to
the AFMS.
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5. STRATEGIC BUSINESS PLAN AND IMPLEMENTATION

5.1 STRATEGIC BUSINESS PLAN DEVELOPMENT AND METHODOLOGY
This TEH Strategic Plan identifies the technical requirements and activities necessary for the
development and implementation of TEH capabilities. It delineates the goals, objectives, focus areas, and
strategic technical investments for TEH aligned to the overarching vision of AFMS. In order to make
T E H capabilities a reality, a comprehensive Strategic Business Plan will be developed to document the
foundational business practices to facilitate success. The Strategic Business Plan identifies how current
and future TEH capabilities and projects will be planned, prioritized and executed. The plan will set forth
how success, through the achievement of goals and objectives, will be measured and communicated.
Additionally, the plan will identify how funding will be
budgeted, executed, and monitored. Development of the
Strategic Business Plan is an iterative process. Just as this
Strategic Plan will be reviewed and refined, the Strategic
Business Plan will be updated and modified to reflect
necessary changes based on the development and
implementation of TEH capabilities. The Strategic Business
Plan will outline a fundamental and cyclical methodology
to Plan, Prioritize, Budget, Execute, and Measure TEH
initiatives and capability development (Figure 7).
Figure 7. Capabilities Development Lifecycle
Plan: The Strategic Business Plan will delineate key processes
and practices, organizational structures, and resources to be implemented in order to initiate and sustain
the TEH capability, identify capability gaps and make the TEH capability a reality. This section includes
the identification and management of focus areas, technical initiatives, and R&D projects to achieve
TEH goals and objectives. The planning section will identify how risks (financial, operational, business,
regulatory, et.al.) will be identified, managed and strategically communicated with internal and external
stakeholders.
Prioritize: The Strategic Business Plan will identify how key technical initiatives and R&D projects will
be prioritized and selected. The Strategic Business Plan will delineate the methodology to be implemented
to identify, prioritize, and select future TEH efforts.
Budget: The process by which budgets will be determined, allocated, and monitored for individual
initiatives or R&D projects will be documented. Additionally funding for the TEH capability will be
planned, programmed and budgeted through the Program Objective Memorandum (POM) process and
other AFMS procedures.
Execute: The Strategic Business Plan will identify how the selected and budgeted initiatives and projects
will be executed and monitored. Each initiative and project should develop customized schedules, budgets,
and risk registers to manage the overall success.
Measure: This section of the plan will outline techniques to measure both incremental success of
individual initiatives and projects as well as total cumulative success of the TEH capability. Outcomes
from the measuring techniques outlined in this section of the Strategic Business Plan will inform future
planning efforts.
5.2 ORGANIZATION STRUCTURE AND STAFFING
Organization structure and staffing will be addressed and completed in FY18 after specific CONOPS and
other analysis such as the Business Plan and Capability Based Assessment. The initial structure for TEHO
that was proposed for the FY 19-23 POM can be found in the COA and Supporting Documents section of
this Plan. A TEHO initial proposed organization structure can be found in Figure 8. Final decisions will be
made as part of the final CONOPS and associated analyses.
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Figure 8. Initial Proposed Organizational Structure for TEHO
6. STRATEGIC TECHNICAL PLAN AND IMPLEMENTATION

6.1 TEH TECHNICAL SYSTEM DEVELOPMENT
The challenge for developing TEH capabilities is bringing together distinct systems and initiatives into
one portfolio: integrating exposure science, information technology, and existing healthcare programs to
develop end-to-end systems (Figure 9). 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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Figure 9. TEH End-to-End System Development
6.1.1 EXPOSURE MONITORING AND DATA COLLECTION

In order to create a comprehensive TEH analytics platform, the Air Force will need to integrate traditional
and non-traditional exposure assessment technologies to develop a robust exposure assessment capability.
The capability will consider the current state of the science and the future technologies being developed
(e.g., area monitoring, personal air sampling, survey instruments and questionnaires, etc.) with an
increased emphasis on internal measurements of exposure and effect that come from traditional
biomonitoring and new biotechnologies, including all of the -omics.
Given the current state of the science, a robust combination of these exposure assessment tools is
necessary to ensure data from the far field (smart home devices, GPS-related ambient environmental
inputs), near field (individual sensors/dosimeters; patient generated data; Internet of Things [IoT]),
medical records, and biological sources (urine, serum, sputum, saliva, stool, etc.). Micro-level or near-
field sensors need to be mobile, user-friendly, accurate, low power, and economical. The popularity of
this technological niche has created a vibrant market with an increasing number of useful devices
becoming available. Taking advantage of the impressive and ubiquitous blue-tooth and Wi-Fi enabled
technologies and sensors developed over the past few years, TEH intends to assess the value and utility
of these data to reveal overall trends and improve current successes in personalized medicine efforts.
Additionally, this shift from active self-reporting to passive surveillance of health and exposure data
enhances reporting adherence and accuracy of information, which can greatly optimize costs in the MHS.
6.1.2 GENOMICS AND ASSOCIATED -OMICS
Genomics is the foundation of our understanding of genetic predispositions to disease and disorder, but
genomic sequencing is only the tip of the iceberg in understanding complex functional interactions
between human health and the environment. It is estimated that genetics only account for 10-30% of
illness and disease8, leaving the vast majority of human health effects related to environment (workplace,
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lifestyle, and personal) exposures. The identification and phenotypic expression of genes are critical to
predicting risk/susceptibility from exposure(s). In order to achieve a level of understanding to inform
TEH initiatives, research and development in ‘-omic’ fields such as exposomics, metabolomics,
lipidomics, transcriptomics and proteomics will need to be integrated through technologies for mining
and analyzing large amounts of data (i.e., Big Data) to discover statistical associations between
exposure, genetic biomarkers, and susceptibility factors. Multidisciplinary fields of study such as
exposomics, the microbiome, and environmental epigenetics are focused on understanding these
complex relationships that align with TEH goals.
6.1.2.1 Exposomics
Exposures from our environment, microbiome, lifestyle, and workplace affect our physiology and health
through epigenetics and the application of internal and external exposure assessment methods are crucial to
understanding these interactions for health optimization and promotion. In addition to the above, research
in fields of study such as transcriptomics and proteomics will be utilized by TEH to understand internal
exposures, while external exposure assessment relies on measuring environmental exposures that stress
and degrade human health. Paramount to exposomics is the ability to accurately measure exposures and
exposure effect through "omics" research and technologies.
6.1.2.2 Microbiome
The human gastrointestinal tract harbors diverse and abundant microbiota that are essential for human
health. The human body is a highly complex ecosystem that has formed a permanent symbiotic
relationship with our enteric cells9. In recent years, there have been major gains in our understanding of the
role of microbiome in host physiology. Alteration of the gut microbiome composition and function has
been associated with the pathology of many diseases to include obesity and type 2 diabetes10, as well as
more complex diseases like inflammatory bowel disease, and autoimmune diseases such as rheumatoid
arthritis. With diet being a significant exposure to the human body as well as the microbiome, it is
imperative that we take advantage of recent advancements in the field of gut microbiome to help in further
understanding the etiology of various biological disorders as part of the TEH solution set .
6.1.2.3 Epigenetics
Exposures from our environment directly affect how gene expression is activated, repressed, and
regulated. This is part of the larger filed known as epigenetics and TEH must understand how epigenetic
changes in response to our exposures are involved in a wide range of what we currently believe as
genetic diseases. Links between environmental exposures and epigenetics is not straight-forward and
will involve integrating research and analyses from collaborating programs such as the National Institute
of Environmental Health Sciences (NIEHS) and NIOSH to fully understand how environmental factors
can cause epigenetic changes that lead to health problems or disease. One prime example is the National
Institute of Health Roadmap Epigenomics Mapping Consortium, which is tasked with creating and
cataloging reference epigenomes for use by the larger scientific community to use for comparative
research.
6.1.3 CLINICAL EXPOSURE RECORDS
The MHS has had a long standing directive to support the integration of exposure data into EHRs for
Servicemembers. This was initially to relieve the burden on veterans who had to prove their hazard
exposures encountered during deployment in order to claim compensation benefits.
However, the success of exposure data integration into the clinical record so far has been limited due to
the reliance on self-reporting as well as the uncertainty that medical conditions were caused by hazards
(or undetected hazards). Therefore, TEH aims to increase the accuracy of exposure records by enhancing
exposure data collection so that it is collected in quantifiable units that can later be used in mechanistic
studies.
Through TEH we can improve the exposure data collection process with more advanced and mobile
sensors that will allow passive data collection, minimizing data gaps resulting from patient
noncompliance with data entry and can detect exposures in terms of concentration in context with time
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and geographical location. Secondly, exposure data needs will be incorporated into military EHRs in a
user-friendly, and eventually automated way. While reinventing EHRs is not feasible or productive, TEH
will determine requirements and limitations for integrating individual exposure data into MHS
GENESIS in order to establish technical requirements such as data format for new analytical platforms.
The DoD has many systems and data warehouses and TEH will focus on integrating systems of record
that already are being consolidated/interoperable and integrating with additional EHR systems over time.
Systems to be considered include, but are not limited to:
 Health Services Data Warehouse (HSDW)
 Medical Data Repository (MDR)
 MHS Data Mart (M2)
 Defense Medical Surveillance System (DMSS)
 Defense Occupational and Environmental Health Readiness System – Industrial Hygiene
(DOEHRS-IH), including DOEHRS-Environmental Health and DOEHRS-Incident Reporting
Module
 Defense Occupational and Environmental Health Readiness System – Hearing Conservation
(DOERHS-HC)
 MHS GENESIS, the DoD’s new EHR system (when available; currently being tested in the
Pacific Northwest)
 Veterans Health Administration Corporate Data Warehouse (CDW)
 Veterans Health Administration Health Data Repository (HDR)
 Veterans Health Administration eHealth Management Platform, the Veterans Affairs (VA) new
EHR system (when available)
 Purchased care network
 Non-MHS healthcare providers
6.1.4 DATA MANAGEMENT: COLLECTION, STORAGE, AND TRANSFER
TEH will require a workflow that will include organizing, storing, integrating, and retrieving medical
and exposure data using effective and efficient informatics solutions. These solutions will be able to
standardize clinical and exposure data in a meaningful way, and enable healthcare professionals to
analyze disparate data to discover associations between exposures and diseases/conditions. The
development of electronic health records/electronic medical records (EHR/EMR) solutions, personal
trackers and sensors, and the advancement of –omics technologies have made health informatics a
necessary discipline among TEH initiatives.
This conceptual TEH Health Informatics network will assist the TEH initiative to manage Big Data from
multiple sources, organize, and analyze it in a meaningful way, and provide public health professionals the
capability to recommend better treatment to improve healthcare outcomes but more importantly identify
risk factors and health behaviors which if are mitigated may prevent the onset of a disease.
6.1.5 DATA ANALYTICS
Given the use of multiple and diverse sensor types and data sources, TEH will seek technical solutions to
uniformly standardize data and ensure interoperability between legacy and future systems.
To be able to improve the level of healthcare provided to patients and impact healthcare outcomes, all
different systems and solutions that generate data must be capable of differentiating between an
abundance of data, select only meaningful types of data, and integrate this data under a common
ecosystem for further processing and analysis (Figure 10).
Ideally TEH data can be ingested and processed using the same data analytical engines as those that are
currently used or will be used to analyze health and genomic data and integrated into MHS GENESIS.
These systems should be modular, with the ability to swap in more advanced components into the
technology stack when available and create limitless options in terms of sensors and data collection tools
and techniques.
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Figure 10. Framework for Health Informatics
6.1.6 INDIVIDUAL EXPOSURE HEALTH RISK PROFILES (IEHRPS)

Optimizing human performance is contingent on the ability to accurately identify, monitor/measure and
document risk factors at the individual level. A logical extension to exposure monitoring, data collection
and integration is deriving actionable information for either the individual and/or the clinician. This is
achieved through the Individual Exposure Health Risk Profile (IEHRP), which is derived from the
individual’s exposure, medical disposition, genetics and various variables.
IEHRP development is a research initiative in the AFMS to leverage existing and ongoing exposomic,
genomic, and epigenetic research studies to gather comprehensive data for understanding the risk at which
an individual will develop a particular disease based on their individual exposome and genetic and clinical
predispositions. IEHRP models will ultimately ingest data from AFMS/SG5 derived R&D programs and
stakeholder developments. The ultimate goal is to have TEH systems that ingest exposomic and genomic
data with monitored exposures and current medical disposition at the individual level and calculate
personal risk profiles that can be used to inform and guide the individual to understand their risk profile
and make healthy choices to reduce disease and illness and further use the aggregate information for
population health and for policy and resource decision making.
The problem facing the AFMS is how to quantify and statistically validate the combined impact of:
(1) occupational, lifestyle, and environmental exposures in deployed, local, and home environments
(2) clinical disposition and (3) genetic pre-dispositions and susceptibilities to exposure-related illness
and injury, which contributes to health risk and drive preventive or protective COA Steps to reach these
goals in the near term are:
 Develop statistically validated algorithms that determine health risk profiles and drive
preventive COA strategies for individuals
 Establish an implementation plan to apply individual clinical, genetic and exposure data to
IEHRP models that result in risk profiles to inform individuals for preventive behaviors and
improved health outcomes.
 Design and support execution of research studies that address DoD and AF healthcare disease
priorities.
When fully developed, the IEHRP will provide a new capability that will inform and encourage healthy
lifestyle choices, enhance resilience and human performance, and reduce illness and injury. These
capabilities will inform preventive strategies by reducing the health impacts of exposures, hence
improving human performance, readiness, and the resiliency of all military members and their
beneficiaries. Moreover, by educating individuals about their exposure profile, the IEHRP will enable
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individuals and families to make healthy lifestyle choices and become proactive about their own health
(Figure 11).
Figure 11. Future State of Exposure Data Supporting Theater and Clinical Operations
6.1.7 EXPERT SYSTEMS – CLINICAL DECISION SUPPORT SYSTEMS

Analyzed exposure data needs to be visualized and made easily accessible to care givers by integrating
exposure records with clinical decision support systems. These systems are capable of taking data curated
from medical and scientific literature, federal guidance and policies, traditional health data from EHRs and
eventually, exposure record data, and generating recommendations for clinical courses of action such as
screenings, diagnostic tests, prescriptions, and prevention plans in some instances.
TEH will need to understand the current expert systems being used in MHS and ensure interoperability
with these systems. This will require evaluating the technology behind any current systems, understanding
its impact of exposure data integration on patient data security, and determining how TEH data will be
integrated. For example, InterQual has currently been adopted by MHS as a way to make medical
admissions and authorizations more efficient11. In this instance, TEH may collaborate with vendor specific
engineers to configure InterQual’s algorithms to take into account a patient’s exposure record.
7. ENABLERS FOR TEH SUCCESS
7.1 CULTURAL AND TECHNOLOGY ENABLERS
TEH will represent a major shift in approach with respect to healthcare and prevention. An examination
of the current landscape, both within AFMS and externally, reveals a favorable environment that will
support the successful development of a fully realized TEH capability. Rapidly evolving cultural factors
make the launch of a TEH capability favorable at this time. The ubiquity of mobile phones, increased
public adoption of “wearable” sensors and mobile health applications, as well as advancements in Big
Data analytics can be leveraged by TEH capabilities. Further, cultural and policy shifts in military,
federal, and private sectors to preventive and precision medicine establish both the foundation and the
need for development of TEH capabilities.
7.1.1 COMMERCIAL POPULARITY OF HEALTH WEARABLES
Individual “wearable” sensors permit both the generation of Big Data for analysis as well as personalized
data for tailored care. Sensor systems need to be mobile, low power, and economical in order to
maximize the continuity of data from an individual. Building from advancements in the global
popularity of mobile phone technology, commercial products of this nature are rapidly emerging, and
more now than ever, individuals are voluntarily interested in wearing health monitors to passively obtain
data for themselves. The global market for health wearables is estimated to be $30B by 2018 12. Tech
giants like Google have recently developed a wearable that captures light exposure and noise levels in
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addition to basic biometrics (heart rate, temperature, etc.)13. Another Google product being tested is a
contact lens that monitors blood glucose levels14.
Likewise, The AFMS is investing in the development of wearable sensors. One example is the PEM,
which is a wearable wireless monitoring device that measures long-term exposure to agents of interest
on and off duty. Data from the PEM would be automatically integrated with other exposure data (e.g.
DOEHRS) and genomics data if available. The sensor would be one that is small and out of the way for
the user while maintaining its functionality in a variety of field environments.
These wearable and “pocket” sensors permit both generation of “Real World Evidence” (RWE) for
analyses and individual data for tailored care. New sensor development will provide new and better
contextual information, rapidly identify unknown threats, and draw associations with low-level exposure
biomarkers from human genomics, proteomics, metabolomics, etc. With a more complete picture of the
impacts of exposures on health outcomes, the AFMS can tailor interventions to promote health and
reduce adverse outcomes.
7.1.2 ADVANCES IN GENOMICS, BIG DATA AND OTHER SUPPORTING TECHNOLOGIES
Also critical to the success of TEH are advances in technologies including high-throughput molecular
characterization, genomic sequencing, and Big Data analytics. The cost of sequencing has plummeted
over the past decade (Figure 1215), to less than $1000 per genome, giving access to more laboratories to
rapidly identify genetic variants or elements that are associated with disease, immunity, response to
treatment, etc., thereby making individual genomic analysis a reality. Advances in Big Data such as high-
performance computing and cloud-based infrastructure permit the aggregation of millions of individual
disparate exposure data points from “wearables”, etc., and the analysis of that data into information that
can be used for public health and medicine.
Figure 12. The Decreasing Cost of Next Generation Sequencing
7.1.3 AFMS MEDICAL MODERNIZATION

There has been renewed interest in recent years to modernize and transform the AFMS into an exemplary
healthcare system. This mindset has led to an increased willingness across the AFMS to move beyond
traditional medicine, to embrace innovation, and to invest in preventive interventions. TEH supports the
AFMS to move beyond just the treatment of illness and injury and to include preservation of health and
optimization of performance, namely a move from healthcare to health. Driven by these emerging values
and changes in attitude, the AFMS is well positioned to embrace novel and innovative approaches like
TEH, which have the potential to significantly advance prevention and better health.
The new Chief of Innovation for the Military Health System has indicated that change is needed in how
future healthcare is delivered. “From an innovation perspective, the MHS needs to accelerate progress in
health and readiness. Innovation is about identifying tools, practices and opportunities to partner to
better serve our beneficiaries and meet our operational mission.” said Steffensen. He has stated that he
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seeks to align innovation with the mission and strategy of the MHS and emphasizes that the scope of
innovation in the MHS includes the combat, community, and global health space16.
The AFMS and all other components of the MHS have made promoting a patient centered approach to
healthcare a priority. The MHS Medical Home key initiative is designed to improve patient satisfaction,
transitioning to patient and family centered care, and quality improvement in healthcare. Further, the
AFMS established a strategic objective to cultivate the Air Force Medical Home (AFMH) as a
Cornerstone of Trusted Care, transforming and growing the existing AFMH delivery system by
institutionalizing patient-centered care practices to maximize health, human performance, and mission to
support.
To help achieve these priority objectives, TEH capabilities will augment options for patient- centered
treatments, clinical care, and precision medicine by assessing the whole life experience (and exposures)
of patients. Furthermore, by having an expanded understanding of exposures and impacts, TEH will also
support the Air Force’s efforts to become a High-Reliability Organization (HRO) which is a new major
initiative for the MHS and the Defense Health Agency (DHA).
In 2015, a Task Force of senior military medical leaders began establishing a framework to guide the
MHS towards becoming a HRO. Currently there are a number of efforts to move the MHS to a top
performing HRO health system. One example is The Joint Commission (TJC) Center for Transforming
Healthcare Oro™ 2.0 High Reliability Organizational Maturity pilot program underway at four Military
Treatment Facility (MTF) sites, one in each Service and at the National Capital Region (NCR) Medical
Directorate. MHS continues to explore innovative ways to reach the vision of creating HRO health
delivery17.
TEH will promote patient-centric care, a domain of change toward HRO healthcare, by creating a
healthcare system focused on a greater understanding of, and participation from, patients. TEH will place
the patient squarely as the cornerstone of the healthcare system and will maximize a tailored, patient-
centric approach to treatments, interventions, and health promotion activities. TEH will improve patient
safety, increase the quality of care, and strengthen preventive medicine and health promotion programs.
Furthermore, the advent of TEH will likely affect developing HRO policy and guidance, promote
precision medicine, and drive business process improvements.
Additionally as the DoD’s EHR, MHS GENESIS, evolves and matures, TEH through the IEHRP will
quantitatively evaluate individual health risks based on exposure, clinical, and genomics data. This
approach will result in individual-level estimates of disease risk that will utilize and integrate within
MHS GENESIS as a CDSS to inform and promote health and well-being through effective early
intervention and risk mitigation protocols.
7.1.4 EMERGING ILER PROGRAM TO CREATE PERSON-CENTRIC HISTORY
The Individual Longitudinal Exposure Record (ILER) is an emerging DoD and Department of Veteran’s
Affairs (VA) program to create a person-centric history that connects person, time, place, event, and all-
hazard occupational and ambient environmental monitoring data with medical encounter information
(diagnosis, treatment, and laboratory data) to enable the extraction and presentation of knowledge to
support medical care, exposure assessment, disability evaluations, benefit determinations, and
epidemiologic studies, and other analyses.
As it is developed, the ILER will be highly related to the Exposome, Precision Medicine, and Precision
Health, with the ILER ultimately building upon and overlaying the Exposome (for Servicemembers,
Veterans, and DoD civilian employees to the extent this data/information is available) with details about
longitudinal “exposure history” (time, place, event details, and exposures) to: (1) understand the
implications (associations) between exposure(s) and health or morbidity and mortality, and (2) more
fully inform Precision Medicine and Precision Health initiatives18.
The building blocks of TEH capabilities already exist, making the development of TEH capabilities far
more feasible. TEH capabilities will capitalize on rapidly accelerating advances in science, technology,
and informatics as it matures and would establish a framework by which the total exposure data will be
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integrated with the DoD EHR data, MHS GENESIS, and the DoD’s ILER. This will support creating
new knowledge and understanding to protect and prevent disease, encourage patient/provider interaction,
and improve overall health and well-being of all Air Force beneficiaries. The integration of ILER into
TEH capabilities will promote early diagnosis using current diagnostic tests.
8. MEDICAL PRIVACY AND ETHICS
There are several ethical and privacy-related issues that must be navigated as TEH develops and
programs, processes, and studies are implemented. The most complex of these may be those involved
with identifiability, the increasingly sensitive nature of genetic information, and the limits of
confidentiality—particularly for military populations.
Genetic Information Nondiscrimination Act of 2008 (GINA) 19. Due to the sensitivity and impact that
TEH data can reveal about an individual’s health risks, special consideration needs to be taken within
AFMS and beyond regarding individual privacy and how to properly handle this data and to prevent any
discrimination against individuals that have participated in TEH studies. This will be handled in
compliance with the GINA, which was mandated by Congress in response to the impact genetic studies
were having on one’s ability to receive health benefits or be employed.
Although there are some legal protections, increasing advances in our understanding of genetic
information make these connections and repercussions an even larger threat. Therefore, even with the use
of protections such as a Certificate of Confidentiality, a thorough examination of privacy, identifiability,
and the limits of confidentiality will be crucial to protect and adequately inform TEH participants.
The integration of medical records and the development of a clinical decision support tool poses another
potential pitfall regarding the validation required for such a system to be used in a clinical care setting.
With FDA regulatory oversight and assistance, TEH investigators must be certain that the decision
support tool is fully compliant with all required regulations as well as studied and tested sufficiently to be
valid in a clinical care setting.
Health Insurance Portability and Accountability Act of 1996 and the Privacy Act of 1974. In addition
to GINA, TEH will include and depend on vast amounts of data to include PII as well as PHI. This
information is critical to the functionality and purpose of TEH to provide an individualized assessment of
the health and well-being for our military and beneficiaries. To ensure the integrity and the protection of
such information, all measures will be taken to comply with the rule and intent of the subject laws and
ancillary policy and or guidance regarding the protection and use of health related data.
8.1 DATA COLLECTION INTEGRATION
The increasing availability of Big Data and the wealth of information it contains will play a critical role
to the development of TEH science and understanding of the interactions of exposures and biological
processes and the impact they have on overall health outcomes.
For TEH to effectively utilize exposure data, maximize value and usage, it requires the development of a
strategy that will enable better characterization and understanding of the type, format, and nature of the
data collected, the value behind it, and how it can be integrated with the existing data-flow currently in
place within AFMS and existing EHRs/EMRs (MHS GENESIS). This strategy should include the
following phases:
 Identify and determine the sources of data
 Develop extraction methodologies
 Establish transmission routes
 Develop model for data integration with existing systems
 Develop data transformation rules
 Develop security rules
 Unify data under a common eco-system
 Apply advanced analytics.
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As part of the integration model, TEH would benefit from developing a mapping guide and ontologies
that will reference exposure profiles and exposure risks.
8.2 SENSOR DEVELOPMENT
Key for the successful delivery of TEH goals will be the monitoring, collection, identification and
understanding of different types of exposures, the development of biomarkers, technologies, and sensors
to measure exposures, as well as the integration of multiple data streams and sources into a unified
framework that can provide useful and actionable information to improve healthcare outcomes.
New tools and technologies have led to the wide development and adoption of different types of sensors
that can monitor internal and external signals with high sensitivity and accuracy, be connected and
communicate under a common ecosystem/network, and share and analyze data ad hoc. Multiple portable
devices and sensors have been developed that offered critical in field functionalities such as geotagging,
rapid data analysis, web-based access, as well as situational awareness dashboards. These solutions
include passive/active remote sensors for environmental exposures (capture radiation, chemicals,
biological agents), microsensor and micromodule systems.
These devices can be used to support rapid detection, data sharing among deployed groups, analytical
capabilities, and organizational and management support. For TEH to be successful and effective, it
requires the adoption and/or development of both personalized wearable sensors as well as
environmental stationary sensors capable of detecting and monitoring the presence of a wide variety of
agents (chemical, biological, mechanical, etc.), and provide data regarding the type, duration, and
intensity of the exposure. Once this Big Data is harnessed and captured, they can be further analyzed to
identify relationships, associations and causality, and provide feedback related to prevention and
intervention strategies.
Since TEH focuses on all possible exposures and the totality they have in human health, sensors need to
be capable of recognizing exposures to multiple agents such as gases, particulates, water quality, noise,
and other environmental agents. The current availability of low-cost and sensitive sensors creates a
unique opportunity to develop a viable and reliable TEH capability. Low-cost sensing offers the
possibility to improve and widen the scale of environmental measurements, and allows for monitoring of
areas with large temporospatial variations in pollutant concentrations and exposures. For this to occur, it
is necessary to conduct an environmental scan and identity existing sensors that can be used as part of
the near-term TEH capability development and help researchers collect and analyze data that will
contain spatial, temporal and contextual details for the development of accurate TEH models. As TEH
matures and evolves, necessary adjustments will be required specifically related to accuracy and
effectiveness of sensor technology. During that phase, TEH would need to focus on the development of
new sensors that will overcome some of the current environmental monitoring limitations and enhance
data collection in under-monitored and rural areas and will cover a wider-spectrum of exposure risk
factors. New sensor development will assist TEH and provide new or more detailed information for
known risk factors, and rapidly identify unknown threats and new risk factors that impact human health.
Some of the R&D focus areas for TEH include:
 Applied toxicology sensor and model development for rapid identification of unknown threats
 Low-level exposure sensors
 Exposure measurement sensors.
Through these initiatives, TEH will be able to improve exposure characterization and identify and
understand individual variability, susceptibility, and vulnerability to cumulative exposures and risks
factors.
8.3 DATA INTEGRATION WITH HEALTH RECORDS
One of the challenges TEH will have to address as this capability matures is the integration of exposure
data and genetic data with EHRs/EMRs. With continuous government support for EHR adoption and
integration and meaningful use of EHR data to improve quality and safety of healthcare delivery,
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developing interfacing tools with EHRs will be one of TEH priorities as this capability matures. To
overcome this limitation, TEH needs to further support and promote interoperability and data
standardization as a functional solution (open solution) that will support TEH’s role to improve
healthcare outcomes, eliminate risk factors, and promote healthy behaviors for individuals.
Although data standardization has gained traction, EHR systems are still highly fragmented and there are
limitations with EHR interoperability (communication between systems, data access, data sharing, data
integration, privacy and security issues, etc.). As a result, achieving interoperability across multiple EHR
systems through custom interfaces can be impractical and not effective. To overcome this limitation,
TEH needs to promote and support the development of an interoperable health information technology
infrastructure/ecosystem (TEH Ecosystem) based on existing vocabulary, data, and technical standards
used in healthcare industry.
This TEH Ecosystem will have specific core functionalities that will include:
 Operational Security (OPSEC)
 Data integration from EHRs/EMRs, Exposure sensor data, and genomic (and other –omic) data
 Information exchange and data management functionality
 Vocabulary/Ontology support
 Results management (clinical results, laboratory results)
 Decision support.
This solution can be implemented easily and provide the most effective (both functionally and financially)
approach for TEH to overcome the challenges associated with EHR system fragmentation, enable usages
of the silos of information that cannot be currently linked together, and move towards a fully interoperable
TEH solution that can provide benefits to AFMS healthcare benefits, and the population it covers and
supports.
9. CONCLUSION
The Air Force is dedicated to being the “healthiest and highest performing segment of the US by 2025” but
the AFMS can only achieve Healthiest Population by true prevention - available like never before due to
advances in science, technology, and medicine. Total Exposure Health positions the AFMS to meet this
vision with emphasis on “Personalized Healthcare” going beyond healing the ill and preventing early
disease.
A bold and novel concept, TEH associates exposures to the lowest common denominator – the individual’s
DNA (N=1) – enriching operational decisions with forward vision using advancements in science,
technology, and informatics to maximize Human Performance and advance the health and well-being of all
Air Force beneficiaries.
Through TEH the new knowledge of the relationships between individual’s genetic predispositions,
epigenetic factors, and exposure to chemicals from lifestyle, occupation, and the environment will support
development of diagnostic approaches, treatment methods, and intervention strategies that consider all
variables collectively.
Hence, TEH will provide a comprehensive understanding of multiple exposures with genomic information
and will support a necessary paradigm shift from healthcare to health by promoting more rapid
identification of risks to health and well-being and enabling earlier and more tailored interventions.
This will involve developing diagnostic systems that merge genomics to find relationships at the individual
level to inform risk of disease and promote health and well-being through intervention and mitigation of
these risks along with various Big Data from sensors, medical records, and various disparate unstructured
data sets in order to understand the root causes of injury and disease and truly implement primary
prevention.
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TEH will transform the current state of disparate exposure monitoring, research studies, data collection,
and healthcare records to holistic and integrated systems that quantitate total exposure and inform health
outcomes into actionable insights and initiatives.
For each current state of preventive and clinical medicine there is a bright and feasible future where TEH
seeks to leverage and advance exposure science, sensor and data technologies, health informatics, a cutting
edge way to obtain a holistic understanding of an individual’s health, root causes of disease and injury, and
innovative but accessible methods for primary prevention through a clinical decision support system - a
future-focused and progressive approach that represents a disruptive but necessary paradigm shift to
improve the theater military health system.
Overall, TEH aims to integrate and provide exposure-related data to individuals, clinicians, and
organizations to improve health-related decision making that will strengthen prevention, human
performance, resilience, workforce, and readiness programs.
As described in the strategic plan, these goals can only be accomplished by partnering across multiple
program areas from traditional and new exposure assessment technologies (including sensors and –omics-
based molecular biology) with clinical and genomic data as well as multiple partners and stakeholders
Ultimately, development of TEH and integration into MHS GENESIS will accomplish the following:
 Increase Force Readiness and Human Performance by reducing hazardous exposures.
 The Individual data will:
o Aggregate will help to better understand current and emerging trends through studies and
analyses to advance primary prevention
o Advance Medicine through Research & Development (R&D)
o Ensure compliance with regulatory standards
o Improve quality of care and encourage good lifestyle choices.
When fully implemented, TEH will provide a new and novel capability that will inform and encourage
healthy lifestyle choices, enhance resilience and human performance, and reduce illness and injury.
Unclassified 32
APPENDIX A: LIST OF ACRONYMS
Acronym Term
ACA Affordable Care Act
AF Air Force
AFMH Air Force Medical Home
AFMS Air Force Medical Service
AFRL Air Force Research Laboratory
BETS Bio-environmental Threat Surveillance
BLER Blue Longitudinal Exposure Record
CBA Capabilities Based Assessment
CDC Centers for Disease Control
CDSS Clinical Decision Support System
CIO Chief Information Officer
COA Course of Action
CONOPS Concept of operations
CPI Continuous Process Improvement
CPIC Clinical Pharmacogenetics Implementation Consortium
CPMC Coriell Personalized Medicine Collaborative
DHA Defense Health Agency
DOD Department of Defense
DODI Department of Defense Instruction
DOEHRS Defense Occupational and Environmental Health Readiness System
DOTMLPF Doctrine, organization, training, materiel, leadership and education, personnel and facilities
EGAPP Evaluation of Genomic Applications in Practice and Prevention
EHR/EMR Electronic Health Record/Electronic Medical Record
Unclassified 33
Acronym Term
EPA Environmental Protection Agency
FDA Food and Drug Administration
FY Fiscal Year
GINA Genetic Information Nondiscrimination Act of 2008
HIPAA Health Information Portability and Accountability Act
HIT Health Information Technology
HRO High-Reliability Organization
ILER Individual Longitudinal Electronic Records
IEHRP Individual Exposure Health Risk Profile
IoT Internet of Things
IM/IT Information Management/ Information Technology
JCS Joint Chiefs of Staff
MOA Memorandum of Agreement
MOU Memorandum of Understanding
MPPG Medical Planning and Programming Guidance
NDAA National Defense Authorization Act
NIEHS National Institute of Environmental Health Sciences
NIH National Institutes for Health
NIHL Noise Induced Hearing Loss
NIOSH National Institute for Occupational Safety and Health
OSD Office of the Secretary of Defense
OSHA Occupational Safety and Health Administration
PEM Personal Environmental Monitor
PHA Phytohemagglutinin
Unclassified 34
Acronym Term
PNNL Pacific Northwest National Laboratory
POM Program Objective Memorandum
PRD Presidential Review Directive
R&D Research and Development
RDD Research Development Document
S&A Studies and Analysis
SME Subject Matter Experts
TEH Total Exposure Health
TEHO Total Exposure Health Office
USAF United States Air Force
USAFSAM US Air Force School of Aerospace Medicine
VA Veterans Affairs
Unclassified 35
APPENDIX B: STRATEGIC PLAN ENDNOTE REFERENCES
1 Public Law 105-85 (HR 1119). National Defense Authorization Act for Fiscal Year 1998,
Subtitle F, Section 765, November 1997
2 United States Congress. National Defense Authorization Act (NDAA): Section 313, January 2013
3 Coriell Personalized Medicine Collaborative, tps://cpmc.coriell.org/about-the-cpmc-study/overview
4http://www.health.mil/News/Articles/2016/3/21/Surgeons-General-say-medical-readiness-aligns-with-
overall-readiness, March 2016
5 National Research Council. Exposure Science in the 21st Century: A Vision and a Strategy. Washington,
DC: The National Academies Press, 2012. doi:10.17226/13507
6Military Health System – Final Review, 2014
7 ARHQ – Primary Care Workforce Facts and Stats No. 1.
http://www.ahrq.gov/research/findings/factsheets/primary/p cwork1/index.html
8 Rappaport, S. M. & Smith, M. T. (2010). Environment and Disease Risks. Science, 330(6003), 460-461
9 Flint, H. J. (2012). The Impact of nutrition on the human microbiome. Nutrition Reviews, 70(S 1), 510-
513
10 Qin, J., Yingrui Li, Zhiming Cai, et al. (2012). A metagenome-wide association of gut microbiota in
Type 2 diabetes. Nature. 490(7418) 55-60
11http://www.mckesson.com/about-mckesson/newsroom/press-releases/2016/the-military-health-system-
selects-interqual-for-utilization-management
12 http://nuviun.com/digital-health/sensors-and- wearables
13http://www.cnet.com/news/google-unveils-smart- wristband-for-health-tracking-but-its-not-for-
consumers/
14http://www.techtimes.com/articles/63868/201506/28/google-smart-contact-lens-to-hit-the-market-
soon.htm
15 The Cost of Sequencing a Human Genome. https://www.genome.gov/27565109/the-cost-of-sequencing-
a-human-genome/. Last updated July 2016
16http://www.airforcemedicine.af.mil/News/Article/608557/new-mhs-innovation-chief-looks-to-accelerate-
progress-in-health-and-readiness, July 2015
17 https://health.mil/News/Articles/2016/06/01/HRO- Corner-The-Oro-HRO-Maturity-Pilot-Program-and-
the-MHS, June 2016
18 ILER Vision Document
19 Genetic Information Nondiscrimination Act of 2008, https://www.eeoc.gov/laws/statutes/gina.cfm

20 https://www.niehs.nih.gov/research/supported/health/envepi/
Unclassified 36
21 http://www.cdc.gov/niosh/topics/exposome/
22 http://www.cdc.gov/niosh/topics/exposome/
Unclassified 37
APPENDIX C: GLOSSARY
Big Data
A term describing large and complex data sets that cannot be processed or analyzed by traditional
applications. These data are often from disparate sources and are structured and/or unstructured, and of
high volume, making it difficult to curate, process, analyze, make sense of, and store. In a TEH system
consisting of multiple and diverse sensor platforms, medical data sources, and large volumes of genomic
data – TEH will inevitably be handling Big Data.
Clinical Decision Support System

A health information technology system that intelligently filters, visualizes, and presents data that can
assist in healthcare decision making.
Environmental
Relating to or associated with the environment; of or relating to the external conditions or surroundings.
Environmental Epigenetics
Epigenetics modify the way genetic information is expressed without directly changing the genetic code
stored in DNA. Environmental Epigenetics is understanding how environmental factors can cause
epigenetic changes that lead to health problems or disease.20
Exposome
The measure of all the exposures of an individual in a lifetime and how those exposures relate to health.21
Exposomics
The study of the exposome and relies on the application of internal and external exposure assessment
methods. Internal exposure relies on fields of study such as genomics, metabolomics, lipidomics,
transcriptomics, and proteomics. Commonalities of these fields include 1) use of biomarkers to
determine exposure, effect of exposure, disease progression, and susceptibility factors, 2) use of
technologies that result in large amounts of data and 3) use of data mining techniques to find statistical
associations between exposures, effect of exposures, and other factors such as genetics with disease.
External exposure assessment relies on measuring environmental stressors. Common approaches include
using direct reading instruments, laboratory-based analysis, and survey instruments.22
Exposure: The intensity, frequency, and length of time personnel are subjected to a hazard
[Source: DoDI 6055.05]
Federal sector: relating to the central government of a federation
Genomics: Science field that utilizes high throughput methods to sequence entire genetic compositions
of samples and computational methods to analyze this data.
ILERS: The individual longitudinal exposure record (ILER) is a Department of Defense (DoD) -
Veterans Affairs (VA) initiative to collate, present, and/or provide occupational and environmental
exposures for individuals over the course of their careers. DoD is leading the development of the ILER
in collaboration with the VA. ILER will use a person-centric business intelligence strategy that enables
the connection of person, time, place, event, and all-hazard occupational and environmental data with
medical encounter information (diagnosis, treatment, and laboratory data) and other authoritative /
authorized sources as appropriate
[Source: ILER CONOPS, Final 01132014]
Unclassified 38
Industrial sector: Goods-producing segment of an economy, including agriculture, construction,

fisheries, forestry, and manufacturing. It is the part of the economy devoted to producing goods, as
opposed to sectors devoted to providing services and raw material products.
Informatics: Science of manipulating data for storage, retrieval, and use.
Internet of Things
Environment where objects have internet connectivity and therefore can send and receive data as well as
create a monitored and controllable ecosystem.
Lifestyle
The way in which a person or group lives; the habits, attitudes, tastes, moral standards, economic level,
etc., that together constitute the mode of living of an individual or group.
Medical Surveillance
The ongoing, systematic collection, analysis, and interpretation of data derived from instances of
medical care or medical evaluation, and the reporting of population-based information for characterizing
and countering threats to a population’s health, well-being, and performance
[Source: DoDD 6490.02E]
MHS GENESIS
The electronic health record for the Military Health Service.
Microbiome
The collective genomes of the microbes (composed of bacteria, bacteriophage, fungi, protozoa and
viruses) that live inside and on the human body. Humans have about 10 times as many microbial cells as
human cells.
Occupational- of or relating to a job or profession, including military
Occupational and Environmental Health (OEH) Hazard

A health hazard found within worksites or environments of a chemical, biological, radiological, or nuclear
nature; this includes chemical warfare agents, toxic industrial materials, environmental contaminants,
biological warfare agents, causative agents of potentially epidemic infectious diseases, and radiological
substances and materials; these health hazards can adversely affect the health of exposed individuals;
effects can occur immediately and/or sometime after exposure; health effects may or may not resolve in a
short time period or last for long periods of time
[Source: JHRM Working Group]
-Omics
Informally refers to fields of study ending in -omics, such as genomics, proteomics, lipidomics,
transcriptomics, metabolomics or/and the constellation of an organism’s “-omic” information, which
includes the genome itself (genomic), transcription products (transcriptomic), protein products (proteomic)
and metabolic products (metabolomics).
Precision Medicine
An emerging approach for disease treatment and prevention that takes into account individual variability in
genes, environment and lifestyle for each person vs a one size fits all approach in which disease treatment
and prevention strategies are developed for the average person
Unclassified 39
Preventive Medicine
Anticipating, predicting, identifying, preventing, and controlling illnesses, injuries, communicable
diseases (including vector-, food- and water-borne diseases), and diseases due to exposure to
occupational and environmental health hazards
[Source: DoDD 6200.04. Oct 9, 2004]
Private sector
Encompasses all for-profit businesses that are not owned or operated by the government.
Public sector
Comprised of companies and corporations that are operated by the government.
Regulatory
Requirements promulgated by executive branch agencies, OSHA, EPA, NRC, FDA, etc., in policies,
standards and laws.
Unclassified 40
APPENDIX D: ADDITIONAL SELECTED PUBLICATIONS AND

REFERENCE MATERIAL
1. AFMS Fiscal Year (FY) 19-23 Medical Planning and Programming Guidance (MPPG).
2. Fries, J.F. (1980). Aging, natural death, and the compression of morbidity. New England Journal of
Medicine, 1980(303), 130–135.
3. Lenzetti, L. (2016, June 29). How IBM’s Watson Supercomputer Is Going to Help 10,000 Veterans.
Retrieved from http://fortune.com/2016/06/29/ibm-watson-cancer-moonshot/
4. Gamm, L. D., Hutchinson, L. L., Dabney, B. J., and Dorsey, A. M. (2003). Rural Healthy People
2010: A Companion Document for Rural Areas. The Texas A&M University System Health Science
Center, School of Rural Public Health, Southwest Rural Health Research Center.
5. Cha, A. E. (2015, April 4). Tech titans’ latest project: Defy death. Retrieved
from http://www.washingtonpost.com/sf/national/2015/04/04/tech-titans-latest-project-defy- death/
6. Cha, A. E. (2015, May 9). The Revolution Will Be Digitized: Wearable gadgets portend vast health,
research and privacy consequences. Retrieved
from http://www.washingtonpost.com/sf/national/2015/05/09/the-revolution-will-be-digitized/
6. Committee on Human and Environmental Exposure Science in the 21st Century; Board on
Environmental Studies and Toxicology; Division on Earth and Life Studies; National Research
Council (2012). Exposure Science in the 21st Century: A Vision and a Strategy. National Academies
Press, ISBN: 978-0-309-26468-6. Retrieved
from https://www.nap.edu/catalog/13507/exposure-science-in-the-21st-century-a-vision-and-a
7. Zielhuis, R.L. (1986). Total Exposure and Workers' Health.

http://www.ncbi.nlm.nih.gov/pubmed/4091368
8. Genetic Testing May Be Coming to Your Office, (December 2015). Associated Press, Online Fox
News http://www.foxnews.com/health/2015/12/16/genetic-testing-may-be-coming-to-your-
office.html
9. Bohmer, R. M. (2011). The four habits of high-value healthcare organizations. New England Journal
of Medicine, 365(22), 2045-2047. Retrieved
from http://www.nejm.org/doi/full/10.1056/NEJMp1111087#t=article
10. Health Situational Awareness to Support Decision-Making. NHSS Legal Authority Guidance
document. http://www.phe.gov/Preparedness/planning/authority/nhss/Pages/situational-
awareness.aspx
Unclassified 41
11. CDC Exposome and Exposomics – NIOSH Workplace Safety and Health Topic, (April 2014).
Retrieved from http://www.cdc.gov/niosh/topics/exposome/
12. Joint AMIA/AHIMA Summary of their Relationship and Links to the Informatics Field, (January
2012). Online article, no author. Retrieved
from http://bok.ahima.org/doc?oid=106812#.V9m2c7HD_4g
13. www.Clinicaltrials.gov Listing for D-methionine to reduce noise-induced hearing loss (NIHL),
(April 2011). https://clinicaltrials.gov/ct2/show/NCT01345474
14. Standard Guide for Environmental Health Site Assessment Process for Military Deployments,
Designation E 2318-03, (December 2003). Withdrawn 2012, no replacement. Retrieved from
https://www.astm.org/Standards/E2318.htm
15. Wild, D.C., Brewster, M.J., Banerjee, A.R. (2005). Noise-Induced Hearing Loss is Exacerbated by
Long-Term Smoking. ClinOtolaryngol, 30, 517-520. Retrieved
from http://www.ncbi.nlm.nih.gov/pubmed/16402976
16. Neitzel, R.L., Svensson, E.B., Sayler, S.K., Ann-Christin, J. (2014). A Comparison of Occupational
and Nonoccupational Noise Exposures in Sweden. Noise Health, 16:270-278. Retrieved from
17. Precision Medicine Initiative and Data Security, (2016). Matthews Burwell, S., Monaco, L.O.
HHS.gov Blog. Retrieved from https://www.whitehouse.gov/blog/2016/05/25/precision- medicine-
initiative-and-data-security
18. Glavinic, T. (2010). Human Genome and Patient Privacy: A Proposal to Expand Protections for
Patients and Family Members. Inquiries Journal, Vol 2, No.
1. http://www.inquiriesjournal.com/articles/132/the-human-genome-and-patient-privacy-a-
proposal-to-expand-protections-for-patients-and-family-members
19. Towards a 21st Century Approach: Advancing a Vision for Prevention and Public Health, (October
2013). Prevention Institute via the Robert Wood Johnson Foundation. Retrieved from
www.rwjf.org/content/dam/farm/.../rwjf408427
20. Loy, P.J., Smith, K.R. (2013). A Discussion of Exposure Science in the 21st Century: A Vision and a
Strategy. Environmental Health Perspectives, Vol. 121, No.
4. http://ehp.niehs.nih.gov/1206170/
21. Snyder, E.G., Watkins, T.H., et al (2013). The Changing Paradigm of Air Pollution Monitoring.
American Chemical Society, Environ. Sci. Technol. 47, 11369-
11377. http://pubs.acs.org/doi/abs/10.1021/es4022602
Unclassified 42
22. Porter, M.E., Pabo, E.A., Lee, T.H. (2013). Redesigning Primary Care: A Strategic Vision to
Improve Value by Organizing Around Patient Needs. Health Affairs, 32, No. 3: 516-
525. http://content.healthaffairs.org/content/32/3/516.abstract
23. Evans, K. (2015). Major Inflection Point Looms for US Healthcare Costs. CNBC.com, online article
and video. Retrieved from http://www.cnbc.com/2015/06/08/major-inflection-point-looms- for-us-
healthcare-costs.html
24. Leswing, K. (2016). Apple Just Hired a Guy That Could Completely Re-invent the Company.
Yahoo Finance, Business Insider, online article. Retrieved
from http://finance.yahoo.com/news/another-big-health-hire-apple-163012380.html
25. 8 Digital Health Startup and Investment Trends We’re Watching in 2016. CB Insights Blog.
Retrieved from https://www.cbinsights.com/blog/health-tech-trends-2016/
26. Morgan, K. (2015). Patient Uprising. American Way Magazine. Retrieved from
http://magazines.aa.com/content/patient-uprising#c4kmwL44fJ1Rc823.97
27. Arnette, R. (2016). NIH Scientists Determine How Environment Contributes to Several Human
Diseases. National Institute of Environmental Health Sciences (NIEHS), online article. Retrieved
from https://www.nih.gov/news-events/news-releases/nih-scientists-determine-how-environment-
contributes-several-human-diseases
28. Lazer, D., Kennedy, R., King, G., Vespignani, A., (2014). The Parable of Google Flu: Traps in Big
Data Analysis. Science, Vol 343. Retrieved
from http://science.sciencemag.org/content/343/6176/1203/F2
29. Hoover, M.D., Debord, D.G., (2015). Turning Numbers into Knowledge: Sensors for Safety, Health,
Well-Being, and Productivity. Synergist (Akron), 26(3): 22-
26. http://www.ncbi.nlm.nih.gov/pubmed/26770055
30. Casteleyn L., Aerts D., (2015). In Harmonized Human Biomonitoring on a European Scale:
Experiences in Seventeen Countries. Environmental Research, 141: 3-14.
31. Fox, M. (2015). Pineapple Pesticide Linked to Parkinson’s Disease. NBC News online. Retrieved
from http://www.nbcnews.com/health/health-news/pineapple-pesticide-linked-parkinsons- disease-
n477346
32. Steenhuysen, J. (2015). Beyond Fitbit: The Quest to Develop Medical-Grade Wearables. Reuters
online. Retrieved from http://www.reuters.com/article/us-usa-health-wearables-insight-
idUSKBN0U10G120151218
Unclassified 43
33. Wishart, D., et al (2015). T3DB: The Toxic Exposome Database. Nucleic Acids Research, 43(D1):
D928-D934. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4383875/
34. Barrett, J., (2016). Different People, Different Outcomes. Environmental Health Perspectives, Vol.
124, No. 7, A121. http://ehp.niehs.nih.gov/124-a131/
35. Crouch, D.J.M., Goddard, G.H.M., Lewis, C.M. (2013). REGENT: A Risk Assessment and
Classification Algorithm for Genetic and Environmental Factors. European Journal of Human
Genetics, 21, 109-111. http://www.ncbi.nlm.nih.gov/pubmed/22669417
36. Lalloue, B. (2014). Data Analysis Techniques: A Tool for Cumulative Exposure Assessment.
Journal of Exposure Science and Epidemiology, 2015 Mar-Apr, Vol. 25(2), 222-
37. Regulation of Genetic Tests. National Human Genome Research Institute (NHGRI). Retrieved
from https://www.genome.gov/10002335/regulation-of-genetic-tests/
38. Delaney, S.K., et al (2016). Toward Clinical Genomics in Everyday Medicine: Perspectives and
Recommendations. Expert Review of Molecular Diagnostics, Vol. 16(5), 521-
39. CDC Exposome and Exposomics topics. Retrieved from https://www.cdc.gov/niosh/topics/
40. Fact Sheet: Obama’s Precision Medicine Initiative. Office of the Press Secretary, January 30,
2015. https://www.whitehouse.gov/the-press-office/2015/01/30/fact-sheet-president-obama-s-
precision-medicine-initiative
41. Friend, S. (June 2013). Big Data and Personalized Medicine. Whitehouse.com blog. Retrieved
from https://www.whitehouse.gov/blog/2013/06/20/big-data-and-personalized-medicine
42. The United States Military’s Contribution to National Security, June 2015.
43. National Health Security Strategy and Implementation Plan, 2015-2018. Retrieved
from http://www.phe.gov/Preparedness/planning/authority/nhss/Pages/default.aspx
44. Interim Guidance for Implementing the National Strategy for Biosurveillance.
45. Assessment of Wearable Sensor Technologies for Biosurveillance. Hirschberg, D.L. November
2014. Edgewood Chemical Biological Center, U.S. Army Research, Development and Engineering
Command, ECBC-TR-1275. www.dtic.mil/cgi-bin/GetTRDoc?AD=ADA611718
Unclassified 44
46. Initial Capabilities Document for Health Risk Management (JHRM). USNORTHCOM SG, Sponsor,
May
2013. www.dtic.mil/doctrine/concepts/joint_concepts/joint_concept_health_services.pdf
47. Human Performance Concept of Operations (CONOPS). May 2014, Office of the Air Force Surgeon
General. Retrieved from http://www.e-
publishing.af.mil/shared/resource/EPubLibraryV3/EPubLibrary.aspx%3Ftype%3DPubs%26org%
3D6887%26show%3Dall
48. U.S. Army Human Dimension Concept. May 2014. Retrieved from http://www.tradoc.army.mil/tpubs/
Unclassified 45
APPENDIX E: TOTAL EXPOSURE HEALTH INFOGRAPHIC
Unclassified 46

Air Force Medical Service - Total Exposure Health Strategic Plan

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Total Exposure Health

Col Philip Goff and Richard Hartman, PhD

Sponsoring Organization: HAF SG3/5

Document Point of Contact

TEH to promote a healthy and high performing workforce

2.2 TEH VISION

THE VISION STATEMENT:

TEH MISSION STATEMENT:

Figure 1. Vision for TEH Portfolio

2.3 CHALLENGES AND OPPORTUNITIES

Current State - Prev Med Future State – Prev Med

Clinical intervention based on organ

3. STRATEGIC FOCUS AREAS

Figure 4. Focus Areas of the Future TEH

3.1 STUDIES AND ANALYSES

Noise study to identify hearing loss risk

3.2 RESEARCH AND DEVELOPMENT

4. EXECUTION STRATEGY: STRATEGIC GOALS AND OBJECTIVES

Figure 5. TEH Strategic Goals

GOAL 1: SYNTHESIZE, IDENTIFY, AND UNDERSTAND CURRENT AND EMERGING

 Genomics, Exposomics, “omics” Goal 1 Example Activities and Milestones

4.3 GOAL 3: ENSURE COMPLIANCE WITH REGULATORY STANDARDS

Figure 6. Sample Regulatory Workflow for TEH Studies

4.4 GOAL 4: BUILD INFRASTRUCTURE TO SUPPORT ADVANCES IN HEALTHCARE

4.6 GOAL 6: PROVIDE ENHANCED EXPOSURE HEALTH EDUCATION AND TRAINING

4.8 GOAL 8: OPTIMIZE FORCE READINESS AND HUMAN PERFORMANCE BY REDUCING

5. STRATEGIC BUSINESS PLAN AND IMPLEMENTATION

Figure 8. Initial Proposed Organizational Structure for TEHO

6. STRATEGIC TECHNICAL PLAN AND IMPLEMENTATION

Figure 9. TEH End-to-End System Development

6.1.1 EXPOSURE MONITORING AND DATA COLLECTION

Figure 10. Framework for Health Informatics

6.1.6 INDIVIDUAL EXPOSURE HEALTH RISK PROFILES (IEHRPS)

6.1.7 EXPERT SYSTEMS – CLINICAL DECISION SUPPORT SYSTEMS

Figure 12. The Decreasing Cost of Next Generation Sequencing

7.1.3 AFMS MEDICAL MODERNIZATION

APPENDIX A: LIST OF ACRONYMS

ACA Affordable Care Act

AFMH Air Force Medical Home

AFMS Air Force Medical Service

AFRL Air Force Research Laboratory

BETS Bio-environmental Threat Surveillance

BLER Blue Longitudinal Exposure Record

CBA Capabilities Based Assessment

CDC Centers for Disease Control

CDSS Clinical Decision Support System

CIO Chief Information Officer

COA Course of Action

CONOPS Concept of operations

CPI Continuous Process Improvement

CPIC Clinical Pharmacogenetics Implementation Consortium

CPMC Coriell Personalized Medicine Collaborative

DHA Defense Health Agency

DOD Department of Defense

DODI Department of Defense Instruction

DOEHRS Defense Occupational and Environmental Health Readiness System

EGAPP Evaluation of Genomic Applications in Practice and Prevention

EHR/EMR Electronic Health Record/Electronic Medical Record

EPA Environmental Protection Agency

FDA Food and Drug Administration

GINA Genetic Information Nondiscrimination Act of 2008

HIPAA Health Information Portability and Accountability Act

HIT Health Information Technology