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One CIO’s View of the Path to Precision Medicine

May 10, 2018
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Beth Israel CIO John Halamka describes the powerful combination of patient-generated data, genomics and ‘exposome’

In a wide-ranging May 9 discussion with Health Catalyst Senior Vice President Eric Just, John Halamka, M.D., M.S., CIO at Beth Israel Deaconess Medical Center in Boston, delivered some strong opinions about the future of precision medicine and gave some concrete examples of transitions already under way at Beth Israel.

For instance, Halamka spoke about how his organization is taking advantage of the Internet of Things and mobile devices to help create and track patient care plans. He discussed a blockchain pilot project Harvard is doing with M.I.T., and he noted that the move to precision medicine is proceeding at different paces in different regions of the country just as the shift to value-based care is.

Halamka started by drawing a distinction between personalized medicine and precision medicine, two terms that often get conflated. (In fact, they often seem to be used interchangeably.) If you have a 50-year-old female patient with diabetes, personalized care would be following treatment guidelines and protocols that have shown to be effective for other 50-year-old females with diabetes. It is really more of a population health approach.

Precision medicine goes beyond that to take into account genomics, diet, immunizations and the environment — which Halamka referred to as the “exposome.” That term has been defined as the measure of all the exposures of an individual in a lifetime and how those exposures relate to health. Halamka said he foresees a continuum will develop between the population health personalization approach and precision medicine, which takes into account much more individual detail, including genomics. He used some examples from his own experience and that of his family to make the case that general guidelines about how patients respond to certain drugs, for instance, are much less valuable than a much more targeted approach aided by genomic insights.

In an example of how a patient’s own experience can be used to fine-tune care, Beth Israel has created a mobile app called BIDMC@Home to help patients manage their health from home, as directed by their physicians.

Halamka noted that it highlights several industry trends at once: patient-generated data, mobile apps and IoT devices, and new reimbursement methods. The app allows clinicians to create care plans that remind patients what they should be doing that day. “Patients help us close the loop by entering whether they took their medications and whether they are sticking to a low-sodium diet,” he said.  Beth Israel can pair that with IoT data the patient might agree to share, such as data from a digital scale or blood pressure or pulse oxometer readings. There are spirometers that plug into iPhones, he added. With the care plan and compliance combined, you can start to see the effect. “The idea is that we can gather and show you insights into your behavior and whether it is leading to better health or not,” he said. “We believe it is going to be very cost-effective to do as cost models change to value-based purchasing.” Using telehealth and putting digital scales in the homes of chronic heart failure patients is the wave of the future as new reimbursement methods take hold, he said.

Another tech trend Beth Israel is taking advantage of to help solve real-world problems is machine learning. The hospital found that 25 percent of patients were not showing up for specialist appointments. By using machine learning to predict which patients those are, it can intervene. Perhaps they lack transportation, and the hospital can arrange for an Uber pickup. In another example, it used machine learning to analyze operating room schedules and surgeon’s usage of time blocks.  “We found that just by changing the schedule of 15 surgeons, we could free up 30 percent of operating room capacity,” he said.

Halamka is interested in the potential of blockchain in healthcare, while clearly stating that it is early days. Speaking about a blockchain pilot project between Harvard and MIT, he said they are starting to work on the possibility of advanced consent management using a public ledger. You would state your consent preferences and applications could derive your consent preferences from the ledger.

Beth Israel recently announced that Halamka is leading the newly launched Health Technology Exploration Center (HTEC) to explore new and emerging technologies such as the Internet of Things, machine learning and blockchain. By fostering relationships with partners around the globe via telemedicine, BIDMC hopes the center will improve healthcare quality, advance new treatment options, and shape the delivery of patient care.

In the Q&A section of the webinar, Halamka was asked what a reasonable time frame might be for precision medicine to begin driving value: He responed by noting that different regions of the country are proceeding at different paces. “We are starting to get to elements of it on the East Coast. Why? Because our financial livelihood depends on it,” he said.  In other areas of the country, such as the Midwest, there is not the same level of data aggregation and curation. In a few areas, precision medicine may have an impact in the next year or two, he said, while in others it may be between five to 10 years from now. “Early pilots will tell us what works and what doesn’t,” he added.

Halamka noted that he was involved in a lot of the Meaningful Use regulatory work at ONC, and added that he thinks this is “not an era for more regulation.” Rather, he sees it as a time for experimentation and pilots of new tools and techniques. “I believe the next few years belong to the innovators and the private sector. I hope we don’t have more regulation in the near term.”

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