As part of his job as chief medical officer at Ascension Wisconsin, the Badger State outpost of the country's largest non-profit health system, Douglas Reding, MD, chairs a task force to explore best practices for precision medicine and help to encourage adoption of those best practices across the enterprise.
As a hematologist-oncologist, Reding sees big promise for personalized approaches to cancer care based on a patient's own genetic makeup. But more broadly, beyond oncology, he expects precision medicine to continue making huge leaps in the next few years. As clinical research and biotechnology continue to evolve, Reding sees precision techniques becoming almost the standard of care within the next decade.
Still, there are challenges along the way that will hinder physicians, patients and payers from making the most of the advances promised by genomics – from basic questions of education to complex hurdles involving data management and infrastructure.
Indeed, for precision medicine to truly come to fruition, Reding says artificial intelligence will need to mature further, as it will play a starring role in helping clinicians match patients own genetic anomalies with the treatments or clinical trials they're best-suited.
Some of those advances are already taking place in earnest, some still have a way to go. But for hospitals to properly put in place the processes needed to set the stage, they'll have to convince executive leadership of the value proposition and business case for personalized care.
Ascension, clearly, is already convinced. At the HIMSS Precision Medicine Summit in Washington, D.C., on May 17-18, Reding will lay out what he said are the biggest decisions health organizations need to think about in context of precision medicine as they help put programs in place and build that value case for their own hospitals.
"One of the things we, as an oncology service line for Ascension, started talking about, about 18 months ago, was developing a precision medicine task force," Reding explained. "And also perhaps setting up precision medicine as a service line offering."
Initial discussion focused around how precision techniques would impact oncology, since a lot of target therapies for various types of cancer have been discovered using genetic profiling, he said. Almost everyone in leadership from the oncology service line saw the promise and asked to be on the task force.
"We then did a survey around laboratory testing, and care management for our patients, and found out that there are basic elements of a precision medicine initiative that would be important," said Reding. "They centered around lab testing, patient care, patient education, provider education, linking decisions about care to best available treatments."
Also, it was key to be able to track those precision-care patients over time to see how they did clinically, especially when compared with other oncologists' patients.
Building a business case
"It took about 12 months to discern those key questions," said Reding. "We came up with a recommendation that we present as a business case and a value proposition. Will it enable our providers to provide highest-quality care? Yes. Will it satisfy our patients based on appropriate care in the right setting? Can it lead to growth of service opportunities in oncology?"
But it's not just oncology where precision medicine will ultimately have the most impact. Given the chance to evolve and be implemented the right right way, he said it has enormous potential to drive big savings through better outcomes as the system-wide standard of care.
"I do think it will impact all avenues of care," he said. "We know there are germline mutations that people are born with. And as we get better with research and discovery – and technology – we'll have therapies that will have a meaningful impact for individuals born with those disorders.
"That germline may impact how you're screened for breast cancer or colon cancer – but if it's a metabolic disorder that results in sickle cell anemia, we may have solutions for that also," he explained. "So not only will it impact oncology, but all medical care: The person born with hyperlipidemia, how do you identify and treat and track that patient over time? I do think precision medicine will be how we practice all medicine in the future."
In the meantime, however, physicians, patients and payers all have a lot of learning to do, and Reding said there are five key areas that need sorting out:
Laboratory testing. It's a brave new world out there, and "everybody is trying to figure out what the implications of this are, because the genetic testing is not inexpensive," said Reding. "Do you take a very targeted approach initially, and then do more tests later which is expensive? Or do you take a shotgun approach to testing knowing that, if what you decided to do doesn't work, you have other options for therapies that might already be available."
Patient education. "These are my genetic results: what do they mean to me and my family?" That's a new question many providers – whose medical school genomics curricula were minimal if they existed at all – are often unprepared to answer, he said. "These are the genetic abnormalities, how is BRCA2 linked to pancreatic cancer and how do we screen for that? I think it's going to transform how we think about care."
Provider education. "Just based on the rapidity of knowledge and technology changes, I think clinicians and providers are going to have to rely on artificial intelligence to direct them to what treatment options make sense," said Reding. "Every day I see the approval of a new drug for lung cancer or kidney cancer, or whatever. It's very difficult, even in the oncology arena to stay abreast of all those changes in terms of clinical options. I can't imagine how a primary care physician could do this without some assistance."
Data aggregation. "You'll be able to learn from what other people are doing and having all that data aggregated in one spot and spit back to you as a provider," he said. "You'll really be on top of the best therapies as opposed to relying on having read the right journals at the right time. Obviously the bigger the 'n' in that bucket, you can compare and contrast treatments much more quickly and come to best practices much faster."
Electronic health records. The challenge is that too many EHR systems, with their roots as glorified billing systems, still aren't quite ready to handle the data associated with precision medicine. "They don't really aggregate all of the information into one spot," said Reding. "So having a bunch of lab tests that you have when you're in a busy clinic does not help you.
"Having an EHR that might have a treatment regimen embedded – if your treatment is in a different system and your patient goes across town to a different healthcare provider, there's no way to transfer that information," he added. "So there's not good 'intraoperability' within the record, and at best minimal interoperability across systems of healthcare. All of those things are going to have to be attended to for this to be truly an efficient form of care."
Still, Reding said he's extremely optimistic about where the trend lines are headed.
Precision medicine has come a long way in a short time so far, but "we're probably at the initial 10 percent of the true impact of what it means in terms of how it will impact all the care that's delivered – probably as soon as five or 10 years from now," he said. "This is kind of a paradigm shift in how we think about treating disease."
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