Seamless Journey from Population Health to Precision Medicine
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Precision medicine is happening now! Join us as we examine the opportunities to leverage your initial core data sets and prepare for new data types to deliver real-time population health and precise medicine. This webinar will demonstrate how modern healthcare organizations (HCO) are expanding clinical integration and upgrading to higher performing technology stacks on their journey to the omics-based and real-time delivery of precision medicine. We’ll chat with Dr. Chris Hobson, CMO and CPO at Orion Health, Doctor Dylan Mordaunt, Clinical Director Research at Orion Health, and with Orion Health’s Executive Vice President of Product and Strategy, Dave Bennett about the importance of real-time data mining and re-mining, and which new computational tools and techniques you need to meet your population health goals and future proof your organization for the delivery of precision medicine. In this webinar, we will explain: How new models of medicine (e.g., molecular medicine, value-based medicine, etc.) are driving the immediate need for patient-specific decision support assistance How existing and new data sets can be leveraged with integrated and real-time analytics (e.g., family history, pharmacogenics) for immediate reduction in adverse events and improved outcomes How innovative organizations are answering this demand with high-performing technology
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Seamless Journey from Population Health to Precision Medicine
- 2. Dr. Chris Hobson, Chief Medical Officer and Chief Privacy Officer Dr. Dylan Mordaunt, MB ChB FRACP, Clinical Director, Research Dave Bennett, Executive Vice President, Product & Strategy
- 3. Page 3 • 2016 © Orion Health™ group of companies Agenda § Context: Journey to precise health (Dave Bennett) § 6 As to population health and precision medicine (Dr. Hobson) § Current approach to population health § How to add precision medicine § The power of pharmacogenomics (Dr. Mordaunt) § Introduction to phamacogenomics § Use Case 1: Coronary artery disease § Use Case 2: Behavioral Health § Use Case 3: Breast cancer § The platform for precise health (Dave Bennett) § Q&As
- 4. 60% from exogenous sources 30% from genomic sequencing 10% from health systems A vast amount of untapped data could have a great impact on our health 80%-90% of health determinants are NOT related to health care Other Determinants of Health: ONC Shared nationwide interoperability roadmap Source: Health Aff (Millwood). 2002 Mar-Apr;21(2):78-93. The case for more active policy attention to health promotion. McGinnis JM, Williams-Russo P, Knickman JR. Environmental Economic Activities Nutrition Social Industry Trends | Most determinants of health exist outside medical systems
- 5. Page 5 • 2016 © Orion Health™ group of companies Considered rare when it affects fewer than 200,000 patients Genomic Data Underpins Precise Care Plans It’s not so rare to have a rare disease 1 in 10 Americans affected (~30 million in the US, 315 million globally) 80% of rare diseases attributed to genetics 7,000 rare diseases Industry Trends | Rare versus common diseases
- 6. Page 6 • 2016 © Orion Health™ group of companies ADOPTION Maturity Model | Pop Health & Precision Medicine ACQUISITION AGGREGATION Orion Health SERVICES Clinical and Data Governance Change Management Clinical Consulting AMADEUS Clinical Data Spaces Data Engine AMADEUS Rhapsody Communicate COMPREHENSIVE SOLUTION ACTION COORDINATE Care Plan Healthcare Pathways Orders and Medications ACCESS ENGAGE Clinical Portal/EMR Connect Patient Portal Mobile Apps ANALYTICS AMADEUS Analytics Engine Population Health Explorer
- 7. Page 7 • 2016 © Orion Health™ group of companies Maturity Model | Acquisition COMPREHENSIVE SOLUTION ▸ Individual Patient centric strategy – Comprehensive data from all sources ▸ Technical Interoperability – HL7 v2, v3, FHIR, CCD, web services, APIs, Non standard and proprietary interfaces – Direct data entry, forms, apps, devices, patient-entered data ▸ Benefits – No redundant data entry – Complete longitudinal patient record ▸ Key decision – Anonymized data or individually identifiable? ▸ Interoperability Challenges – Is all the data available, of high quality, clinical grade? – Blurring the distinction between research, clinical knowledge, and data ▸ Technical options – GA4GH API – Matchmaker Exchange DATA ACQUISITION AMADEUS Rhapsody Communicate POPULATION HEALTH: PRECISION MEDICINE:
- 8. Page 8 • 2016 © Orion Health™ group of companies Maturity Model | Acquisition COMPREHENSIVE SOLUTION ▸ Strategy – Data used for multiple purposes – Improved performance and analytics via central store – Normalized, standardized, and coded Technical Approach – Store all types of data from records ▸ Benefits – Complete view at population and individual patient level – Ability to build widest range of applications leveraging the data ▸ Concerns – Privacy & security of massive data stores ▸ Improved data models ▸ Data quality – Free text documents = need for NLP – Patient entered data, social indicators, claims, omics, microbiome ▸ Knowledge repository – Traditional Lab result “comments” become complex detailed interpretations and probabilities that change over time ACQUISITION AMADEUS Rhapsody Communicate AGGREGATION AMADEUS Data Engine POPULATION HEALTH: PRECISION MEDICINE:
- 9. Page 9 • 2016 © Orion Health™ group of companies Maturity Model | Acquisition COMPREHENSIVE SOLUTION ▸ Strategy – Secure, privacy controlled environment – Measures such as NCQA, expand capabilities to “any” measure – Actionable measures – NOT anonymized ▸ Technical Approach – Real-time analysis of data streams – Advanced layering of privacy ▸ Benefits – Drill down to one patient/provider level – Identify gaps and quality of care – Data driven & actionable care management dashboards ▸ Population Scale Genomics – Cloud computing – Genomic aggregation studies – Relevant population level reporting – Chronic disease – genome linkages – Actionable data ▸ Visualization challenges ▸ Practical Limits – 5,000 samples and 70 terabytes of data sequenced in seven days ACQUISITION AMADEUS Rhapsody Communicate AGGREGATION AMADEUS Data Engine POPULATION HEALTH: PRECISION MEDICINE: ANALYTICS AMADEUS Analytics Engine Population Health Explorer
- 10. Page 10 • 2016 © Orion Health™ group of companies Analytics | Integrated real-time stratification Drill down to the individual patient level
- 11. Page 11 • 2016 © Orion Health™ group of companies Maturity Model | Acquisition COMPREHENSIVE SOLUTION ▸ Strategy – Configured for local and individual user needs – Granular privacy & consent ▸ Technical Approach – Portals, mobile, apps, integration back into EMR systems are all required – Advanced privacy services on sensitive data – Filter the available data to most relevant ▸ Benefits – Complete patient information at the point of care – Capture frequent stories from clinicians ▸ Privacy & Safety – Must ensure accurate data is presented against the right patient – High value data, implies strong access controls ▸ Usability – Challenges: • Relevant info only at the point of care • Organized intuitively • Ontologies such as SNOMED/Human Phenotype Ontology to organize data ACQUISITION AMADEUS Rhapsody Communicate AGGREGATION AMADEUS Data Engine POPULATION HEALTH: PRECISION MEDICINE: AMADEUS Analytics Engine Population Health Explorer ACCESS COORDINATE & ENGAGE Clinical Portal/EMR Connect Patient Portal Mobile Apps
- 12. Page 12 • 2016 © Orion Health™ group of companies Access | Actionable Longitudinal Patient Record No more blind spots
- 13. Page 13 • 2016 © Orion Health™ group of companies Maturity Model | Acquisition COMPREHENSIVE SOLUTION ▸ Strategy – Decision support at point of care ▸ Technical Approach – CPOE, e - Prescribing – Care pathways for chronic diseases – Secure messaging – E-Referrals – Care coordination/Transition of care ▸ Benefits – Improved outcomes and higher quality care – Reduced utilization/overall cost of care – Population wide improvements ▸ Improved clinical decision support – Pharmacogenomics – Cancer genomics • Cancer trials Meta–Analyses– Outcomes were better when treatment guided by precision medicine – Pediatric screening ▸ Major chronic diseases are more complex and less well proven ACQUISITION AMADEUS Rhapsody Communicate AGGREGATION AMADEUS Data Engine POPULATION HEALTH: PRECISION MEDICINE: AMADEUS Analytics Engine Population Health Explorer ACCESS COORDINATE & ENGAGE Clinical Portal/EMR Connect Patient Portal Mobile Apps ACTION COORDINATE & ENGAGE Clinical Portal Care Plan Healthcare Pathways Precision Medicine Yields Better Outcomes for Patients in Phase I Clinical Trials – ASCO, May 18, 2016 https://www.asco.org/about-asco/press-center/news- releases/precision-medicine-yields-better-outcomes- patients-phase-i
- 14. Page 14 • 2016 © Orion Health™ group of companies Action | Improved decision support with genomics Higher outcomes and quality
- 15. Page 15 • 2016 © Orion Health™ group of companies Maturity Model | Acquisition COMPREHENSIVE SOLUTION ▸ Effectiveness – Targeted treatments ▸ Safety – Modifying dosing based on uncertain genomic data is potentially risky ▸ Patient centered – Large volumes of data overwhelm patient and provider ▸ Equity – Anything that segments patients risks marginalizing some – Ethnic minorities not well represented in genomic databases ▸ Efficiency – Timeliness • Extensive turn around times reduce efficiency ACQUISITION AMADEUS Rhapsody Communicate AGGREGATION AMADEUS Data Engine CLINICIAN PERSPECTIVE AMADEUS Analytics Engine Population Health Explorer ACCESS COORDINATE & ENGAGE Clinical Portal/EMR Connect Patient Portal Mobile Apps ACTION COORDINATE & ENGAGE Clinical Portal Care Plan Healthcare Pathways DOI: 10.1200/JOP.2016.015321 Journal of Oncology Practice 12, no. 10 (October 2016) 839-843. ADOPTION
- 16. Page 16 • 2016 © Orion Health™ group of companies ADOPTION Maturity Model | Pop Health & Precision Medicine ACQUISITION AGGREGATION Orion Health SERVICES Clinical and Data Governance Change Management Clinical Consulting AMADEUS Clinical Data Spaces Data Engine AMADEUS Rhapsody Communicate COMPREHENSIVE SOLUTION ACTION COORDINATE Care Plan Healthcare Pathways Orders and Medications ACCESS ENGAGE Clinical Portal/EMR Connect Patient Portal Mobile Apps ANALYTICS AMADEUS Analytics Engine Population Health Explorer
- 17. Page 17 • 2016 © Orion Health™ group of companies Pharmacogenomics | Traditional treatments Disease Diagnosis NORMAL RESPONSE CAUTIONARY RESPONSE ALTERED RESPONSE TOXIC RESPONSE NO RESPONSE Same Prescription and Standard Dose Around 100,000 people in the United States die, annually, from adverse drug reactions Ng, Murray, Levy, & Venter, 2009 Patient Group
- 18. Page 18 • 2016 © Orion Health™ group of companies Pharmacogenomics | Personalized regimens Improved adherence Reduced overall costs Reduced adverse events Improved efficacy Improvement in patient outcomes
- 19. Page 19 • 2016 © Orion Health™ group of companies Genetics 101 CELL CHROMOSOMES GENE PROTEIN DNA
- 20. Page 20 • 2016 © Orion Health™ group of companies Mutations 101 RED RDD The car was RED The car was RDD CHROMOSOMES GENES MUTATIONS
- 21. Page 21 • 2016 © Orion Health™ group of companies Pharmaceuticals 101
- 22. Page 22 • 2016 © Orion Health™ group of companies Drugs Interact with Everything Drug-disease Drug-gene Drug- environment Drug-nutrition
- 23. Page 23 • 2016 © Orion Health™ group of companies Two Approaches What is the best drug for this person based on their absorption, distribution, metabolism and excretion? What is the best drug for this person based on their actual/predicted disease/tumor characteristics?
- 24. Case 1: Coronary Artery Disease 39 yo ♂ with acute coronary syndrome Very high cholesterol Placed on clopidogrel (Plavix) Represents at 6 months CYP2C19 slow metabolizer
- 25. Page 25 • 2016 © Orion Health™ group of companies Clopidogrel Efficacy Hulot JS, et al. doi:10.1016/j.jacc.2009.12.071 MACEwith↓metabolism MACE with N metabolism 0.0 0.1 0.2 0.3 0.0 0.1 0.2 0.3 0.5 Slope: 1.59 95% CI (142-1.76) Intercept: -0.048 95% CI (-0.074-0.022) Collet et al Dunn et al Ho et al Aubert et al Banerjee et al Juurlink et al Gasper et al Simon et al Bhatt et al O’Donoghue et al Ramirez et al
- 26. Case 2: Behavioral Health 39 yo woman with depression Complex social course Multiple medications Multiple adverse effects Killed husband Survived an overdose of various drugs Selma JM, DOI: 10.1016/j.jflm.2016.04.003
- 27. Page 27 • 2016 © Orion Health™ group of companies ROI for ADME Pharmacogenomics Cost-effectiveness thresholds $800-1200 Testing costs as little as $50 for common alleles 80 routinely used medications with meta-analysis/guideline level evidence ePrescribing and integrated decision-support critical, both readily available Eliminates the need for therapeutic drug monitoring, in some cases
- 28. Case 3: Breast Cancer 36 yo ♁ with ER+ breast cancer Prescribed adjuvant tamoxifen Becomes depressed Prescribed fluoxetine (Prozac) CYP2D6 slow metabolizer
- 29. Page 29 • 2016 © Orion Health™ group of companies Tamoxifen efficacy Schroth W, DOI: 10.1200/JCO.2007.12.2705 RFProbability RFT (months) 0.4 0.6 0.8 1.0 0 30 60 90 120 (32%) 2D6-EM/2C19incr (39%) 2D6-EM/2C19 2D6-EM/2C19incr (29%) 2D6-EM/2C19incr 2D6-PM or IM
- 30. Page 30 • 2016 © Orion Health™ group of companies Patterns in Precision Medicine c d ea b A B Lumpers Splitters Increasing numbers of categories Decreasing patient numbers within each category Need to define and explore cohorts Need to aggregate data Need to normalize and standardize Need to extract information from unstructured fields
- 31. Page 31 • 2016 © Orion Health™ group of companies Perhaps 2Tb of Data Factors Influencing HealthSocial Data Environment Device Data Transcriptome Proteome Epigenetic Metabolome Microbiome Genome Imaging Clinical Data McGinnis et. al. Human Affairs, Vol 22 (2) The platform for precise health | Capturing the digital you
- 32. Page 32 • 2016 © Orion Health™ group of companies Missing or old Clinical Data Soon…a Tsunami of new data 17 new academic research papers published each day 15 minutes to make a decision Info from Dr. Google 1010101101010101010101101010101010100110111010100 0101101010101011111010101101010101010101101010101 01010101011010101011010 “Evidence Based Medicine” decision making…?? =? ? ?? The Impossible Job of a clinician
- 33. Page 33 • 2016 © Orion Health™ group of companies Custodian of the Patient’s Medical Record § TRADITIONAL Data Sources § Hospitals § PCPs § Labs § Radiology § Pharmacy § Patients and Circle of Care § Payer Data § User Generated Data (Engage, HealthKit) § NEW Data Sources § Genomics § Web and social networking- based data § Health Publication and clinical reference data § Business and organizational data § Environmental data § Doctors, Nurses and other Providers Precise Health The platform for precise health | Handling data complexity Healthcare is changing from a closed community into an ecosystem centered around the patient including many elements not traditionally captured. Machine Learning and Thinking Software Orion Health Amadeus EMRs & EHRsLabs/Rads Payer DataHIEs Public Health
- 34. Page 34 • 2016 © Orion Health™ group of companies The platform for precise health | | How Big Data is handled in other industries HIGH VOLUME AND VELOCITY FLEXIBILITY AND SCALABILITY OF DATA MODEL DATA LIQUIDITY PRIVACY AND SECURITY
- 35. The platform for precise health | Open APIs for a secure, scalable, & distributed solution Open APIs Management Layer Domain Logic Layer Web App Layer Data Access Layer Database Device Mobile Browser Browser Mobile Unlimited third party apps Unlimited third party plugins Care Coordination Applications Wellness & Patient Devices Applications Reporting Applications Patient Engagement Applications
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