seamless journey from population health to precision medicine

Seamless journey from

population healthto

precision medicine

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

• 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

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


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 10Americans affected

(~30 million in the US,315 million globally)

80%of rare diseases

attributed to genetics

7,000rare diseases

Industry Trends | Rare versus common diseases


ADOPTION

Maturity Model | Pop Health & Precision Medicine

ACQUISITION

AGGREGATION

Orion Health SERVICES

Clinical and Data

Governance

Change Management

Clinical Consulting

AMADEUSClinical Data Spaces

Data Engine

AMADEUSRhapsody

Communicate

COMPREHENSIVE SOLUTION

ACTIONCOORDINATE

Care PlanHealthcare Pathways

Orders and Medications

ACCESSENGAGE

Clinical Portal/EMR ConnectPatient PortalMobile Apps

ANALYTICSAMADEUS

Analytics EnginePopulation Health Explorer


Maturity Model | AcquisitionCOMPREHENSIVE 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 ACQUISITIONAMADEUSRhapsody

Communicate

POPULATION HEALTH: PRECISION MEDICINE:



▸ 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

ACQUISITIONAMADEUSRhapsody

CommunicateAGGREGATION AMADEUS

Data Engine




▸ 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



Data Engine


ANALYTICSAMADEUS



Analytics | Integrated real-time stratification

Drill down to the individual patient level



▸ 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



Data Engine


AMADEUSAnalytics Engine

Population Health ExplorerACCESS

COORDINATE & ENGAGEClinical Portal/EMR Connect

Patient PortalMobile Apps


Access | Actionable Longitudinal Patient Record

No more blind spots



▸ 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



Data Engine






ACTIONCOORDINATE & ENGAGE

Clinical PortalCare 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


Action | Improved decision support with genomics

Higher outcomes and quality



▸ 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



Data Engine

CLINICIAN PERSPECTIVE





ACTIONCOORDINATE & ENGAGE

Clinical PortalCare Plan

Healthcare Pathways

DOI: 10.1200/JOP.2016.015321 Journal of Oncology Practice 12, no. 10 (October 2016) 839-843.

ADOPTION


ADOPTION

Maturity Model | Pop Health & Precision Medicine

ACQUISITION

AGGREGATION

Orion Health SERVICES

Clinical and Data

Governance

Change Management

Clinical Consulting

AMADEUSClinical Data Spaces

Data Engine

AMADEUSRhapsody

Communicate

COMPREHENSIVE SOLUTION

ACTIONCOORDINATE

Care PlanHealthcare Pathways

Orders and Medications

ACCESSENGAGE

Clinical Portal/EMR ConnectPatient PortalMobile Apps

ANALYTICSAMADEUS



Pharmacogenomics | Traditional treatments

Disease Diagnosis

NORMALRESPONSE

CAUTIONARYRESPONSE

ALTEREDRESPONSE

TOXICRESPONSE

NORESPONSE

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


Pharmacogenomics | Personalized regimens

Improved adherence

Reduced overall costs

Reduced adverse events

Improved efficacy

Improvement in patient outcomes


Genetics 101

CELL CHROMOSOMES GENE PROTEIN

DNA


Mutations 101

RED

RDD

The car was RED

The car was RDD

CHROMOSOMES GENES MUTATIONS


Pharmaceuticals 101


Drugs Interact with Everything

Drug-disease Drug-gene

Drug-environment Drug-nutrition


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?

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


Clopidogrel Efficacy

Hulot JS, et al. doi:10.1016/j.jacc.2009.12.071

MAC

E w

ith ↓

met

abol

ism

MACE with N metabolism

0.0 0.1 0.2 0.30.0

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 alBhatt et al

O’Donoghue et al

Ramirez et al

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


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

Case 3: Breast Cancer

36 yo♁ with ER+ breast cancer

Prescribed adjuvant tamoxifen

Becomes depressed

Prescribed fluoxetine (Prozac)

CYP2D6 slow metabolizer


Tamoxifen efficacy

Schroth W, DOI: 10.1200/JCO.2007.12.2705

RF

Prob

abilit

y

RFT (months)

0.4

0.6

0.8

1.0

0 30 60 90 120

(32%)2D6-EM/2C19incr

(39%)2D6-EM/2C192D6-EM/2C19incr

(29%)2D6-EM/2C19incr2D6-PM or IM


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


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


Missing or old Clinical Data

Soon…a Tsunami of new data

17 new academic research papers

published each day

15minutes

to make a decision

Info from Dr. Google

10101011010101010101011010101010101001101110101000101101010101011111010101101010101010101101010101

01010101011010101011010

“Evidence Based Medicine” decision making…??

=?? ??

The Impossible Job of a clinician


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 thepatient including many elements not traditionally captured.

Machine Learning and Thinking Software

Orion Health Amadeus

EMRs & EHRsLabs/Rads

Payer DataHIEs

Public Health


The platform for precise health | | How Big Data is handled in other industries

HIGH VOLUME

AND VELOCITY

FLEXIBILITY AND

SCALABILITY OF DATA MODEL

DATALIQUIDITY

PRIVACY AND

SECURITY

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

DeviceMobile Browser

Browser Mobile

Unlimited third party apps

Unlimited third party plugins

Care Coordination Applications

Wellness & Patient Devices

Applications

ReportingApplications

Patient Engagement Applications

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seamless journey from population health to precision medicine

Health & Medicine