Emerging Developments and Your Future in PathologyEmerging Developments and Your Future in PathologyJared N. Schwartz, MD, PhD, FCAPPresident, College of American PathologistsPresbyterian HealthCharlotte, NC

John Winbern Turner, MD, FCAPJohnston-Willis HospitalRichmond, VA

Emerging Developments and Your Future in Pathology

• What is happening in healthcare?

• How will that affect your career as a pathologist?

• What are the emerging technologies?

• What can you do to better prepare yourself?

• What is the College doing to help you along the way?

Niels Bohr, 1885-1962

Prediction is difficult, especially about the future

Traditional trial-and-error method of care is no longer acceptable

Patient presents with

symptoms

Doctor makes a “most likely” diagnosis, may order tests to confirm,

and prescribes a treatment plan (usually drugs and/or surgery)

Weight & age may affect drug

selection & dosage or other

intervention

Plan works or doesn’t work, +/-

side effects?

Treatment plan success

Doctor revises treatment plan

The occasional result: sub-optimal treatment, prolonged periods of trial and error, medical noncompliance, and increased cost—factors that can increase patient morbidity and mortality

In spite of all the money and effort devoted to biomedical research, the outcomes are not very satisfying

• Over 60% of patients diagnosed with Type II diabetes have blood sugars that exceed the recommended target level

• Only 17% of patients with heart disease ever reach the national guidelines treatment goals for cholesterol management

• Among patients diagnosed with depression, only half report a 50% improvement in symptoms after using antidepressant medications– 32% of patients who received a placebo also experienced a 50%

improvement in symptoms!

Patient response rates to a major drug in selected categories of therapy

Category of Disease % who respond to therapy

Analgesics for pain (Cox-2 inhibitors) 80%

Asthma 60%

Cardiac Arrythmias 60%

Schizophrenia 60%

Migraine (acute) 52%

Migraine (prophylaxis) 50%

Rheumatoid Arthritis 50%

Osteoporosis 48%

HCV 47%

Alzheimer’s Disease 30%

Oncology 25%Source: Physicians’ Desk Reference

What does the consumer want?

• High quality• Reasonable cost• Delivery as fast as

possible• Minimal inconvenience• Access to care with the latest technology• Reduced risk• Confidence and trust

…and they are being ‘educated’ by the media

Help!• Fast and accurate results• Understandable and

useful information• Direction on therapy• Low costs--may not be as

important

What does the patient’s treating physician want?What does the patient’s treating physician want?

Market demand and emerging technologies are accelerating the shift to “Precision” medicine

• Provision of care for diseases which can be precisely diagnosed and subsequently treated with predictably effective rules-based therapies– Precision technologies driving the disruption of existing

healthcare business models– Precise diagnosis must precede predictably

effective therapy

• Requires technology progress on two fronts– Understanding the cause of disease– Ability to detect those casual factors Patient

presents with symptoms

Doctor makes a “most likely” diagnosis, may order tests to confirm,

and prescribes a treatment plan (usually drugs and/or surgery)

Weight & age may affect drug selection &

dosage or other intervention

Plan works or doesn’t work,

+/- side effects?

Treatment plan success

Doctor revises treatment plan

Patient presents with

symptoms

Doctor makes a “most likely” diagnosis, may order tests to confirm,

and prescribes a treatment plan (usually drugs and/or surgery)

Weight & age may affect drug selection &

dosage or other intervention

Plan works or doesn’t work,

+/- side effects?

Treatment plan success

Doctor revises treatment plan

Source: Christensen/Hwang

Precision medicine is not new; consider the history of infectious disease therapy

• Earliest categorization schemes: immorality, weakness of faith

• Unsanitary conditions in the city• Exposure to affected individuals; contact with certain

insects and animals • Microscopes and various staining techniques

– Identification of microbes that caused disease with overlapping symptoms offering clues to the aggressiveness and spread of disease and the prognosis

– Tailored antibiotic therapy based on the species of organism– Molecular subtype and resistance profile of the involved strain

It took centuries of significant events to get us to this point

Leeuwenhoek observes “little animals” under

microscope

Fleming discovers Penicillin

Reed proves mosquitoes are vector

for yellow feverEhrlich introduces the acid-

fast staining technique

Pasteur explores Germ Theory of Disease

Jenner administers smallpox vaccine

Koch proves Germ Theory with discovery

of B. anthracis Semmelweis proposes

handwashing to prevent spread of disease

Lister adopts antiseptic technique in surgery

1670 19201870182017701720

The cost of diagnosing and treating infectious diseases

has declined 5% per year since 1940

The cost of diagnosing and treating infectious diseases

has declined 5% per year since 1940

Source: Christensen/Hwang

Today, Cancer is experiencing a similar shift toward precision medicine

1920 1930 1940 1950 1960 1970 1980 1990 2000 2010

Disease of the blood

2 types: leukemia & lymphoma

Farber develops 1st chemotherapy

for leukemia

3 types of leukemia (acute, chronic, preleukemia) and 2 types of lymphoma (indolent,

aggressive)

Novartis launches Gleevec, the 1st molecular targeted drug, to

treat myeloid leukemia

38 types of leukemia; 51 types

of lymphoma

Source: Mara Aspinall, Genzyme

Precision medicine implies personalization and all its benefits• Diagnosis predicting risk of

disease• Determining whether a treatment

is working • Monitoring healthy people to

detect early signs of disease• Producing safer drugs by

predicting potential for adverse effects earlier

• Targeting groups of people most likely to benefit from a drug, while keeping its use from those who may be harmed by it

• Producing better medical products• Ready access to information• Decreasing health care costs

Diagnostic tests and data integration are the critical links to the success of personalized medicine

Industry recognizes the opportunity and are willing to work with anyone

Are diagnostics the Are diagnostics the newnew wonder drug wonder drug on Wall Street?on Wall Street?

What kinds of emerging technologies will impact my

future practice?

Practice of medicine is moving from the treatment of illness to the aggressive promotion of wellness

DATA & SYSTEMS INTEGRATION

EVOLUTIONARY PRACTICES

DIS

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Automated systems

Organized(error-reduction)

Nonspecific(treat symptoms)

1st generation diagnostics

Information Correlation

Personalized(disease prevention)

HEALTHCARE TODAY

HEALTHCARE TODAY

TRANSITIONAL MEDICINETRANSITIONAL MEDICINE

PERSONALIZED HEALTHCARE

Genetic Predisposition TestingGenetic Predisposition Testing

Clinical Clinical GenomicsGenomics

Molecular MedicineMolecular Medicine

CACA--diagnosisdiagnosis

Lifetime TreatmentLifetime Treatment

PrePre--symptomatic Treatmentsymptomatic Treatment

Digital ImagingDigital Imaging

Episodic TreatmentEpisodic Treatment Artificial Expert SystemArtificial Expert SystemElectronic HealthElectronic Health

RecordRecord

Moving from the treatment of illness to the aggressive

promotion of wellness

SOURCE: IBM LIFE SCIENCES SOLUTIONS

DATA & SYSTEMS INTEGRATION

EVOLUTIONARY PRACTICES

DIS

TR

IBU

TE

D H

IGH

-TH

RO

UG

HP

UT

AN

AL

YT

ICS

REV

OLU

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NA

RY

TEC

HN

OLO

GIE

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Automated systems

Organized(error-reduction)

Nonspecific(treat symptoms)

1st generation diagnostics

Information Correlation

Personalized(disease prevention)

HEALTHCARE TODAY

HEALTHCARE TODAY

TRANSITIONAL MEDICINETRANSITIONAL MEDICINE

PERSONALIZED HEALTHCARE

Genetic Predisposition TestingGenetic Predisposition Testing

Clinical Clinical GenomicsGenomics

Molecular MedicineMolecular Medicine

CACA--diagnosisdiagnosis

Lifetime TreatmentLifetime Treatment

PrePre--symptomatic Treatmentsymptomatic Treatment

Digital ImagingDigital Imaging

Episodic TreatmentEpisodic Treatment Artificial Expert SystemArtificial Expert SystemElectronic HealthElectronic Health

RecordRecord

Moving from the treatment of illness to the aggressive

promotion of wellness

SOURCE: IBM LIFE SCIENCES SOLUTIONS

IVDs will become increasingly vital components of the health care system

• High value Dx provide critical information to help physicians make clinically relevant decisions

• Molecular Dx and AP are fastest growing segments – AP market is growing at 15% CAGR and moving towards

automation and digitalization– Continued growth of Pap is likely to slow down when MDx

assays start gaining acceptance

• Other high growth segments– ICH, ISH and special stains– Digital pathology– Tissue microarrays

Source: Scientia

Molecular diagnostics is at the core of the personalized medicine vision

Diseases will be diagnosed long before the patient begins to manifest any evidence using traditional tools

In vitro Laboratory

Tests

In vitro Laboratory

Tests

In vivo Imaging

Techniques

In vivo Imaging

Techniques

Signs & SymptomsSigns & Symptoms

Molecular DiagnosticsMolecular

Diagnostics…and biomarkers willbe a primary tool

Compression of the biomarker development timeline is accelerating progress

Preclinical exploratoryClinical assay

& validationRetrospective

longitudinalProspective

screeningCancercontrol

1977: FDA approves PSA for patients

already diagnosed

1996-7: 4 new chemical entity therapeutics

approved for prostate cancer

2002-04: Period and retrospective

analyses on survival

1994: PSA approved as predictive indicator

2007: “220 therapeutics emerging”; 100 in Phase II;

20 on market

Source: Bartsch, et al, IBM (Imaging) Biomarker Summit III, Jan 2007

PSA Biomarker development: 30 years

Circulating Tumor CellsWhat is the impact of CTC assays on pathology?

Technology Overview• Potentially powerful predictors of

progression-free survival• Assays count rare events – epithelial

tumor cells in the peripheral bloodstream and compare to established frequency profiles

• May predict treatment response more quickly than usual clinical practice with radiologic imaging (2-3 days vs 2-3 months), allowing rapid therapy modification

• FDA-approved for patients with metastatic breast cancer; tool for predicting progression-free and overall survival, monitoring disease progression

• Ongoing research evaluating efficacy for other tumor types

Pro

bab

ility

of

Ad

op

tio

n in

to C

linic

al U

se Technology Curve:CTC Assay

0Pre-

Clinical

3Consensus Adopters

2Early

Adopters

1Innovators

5Late

Adopters

4Cautious Adopters

Other

Metastatic Breast Cancer

• Expected rate of adoption: Slow• Barriers: Only clinical evidence is in therapy

monitoring for metastatic breast cancer• Accelerators: FDA approval of additional

applications/tumor types

Impact may be dramatic…or not

2006 2008 20122010 20162014

Impact Timing

Screening N/A

Diagnosis & Staging 2014

Treatment Planning 2010

Therapy Monitoring 2008

High Medium Low

35

30

25

20

15

10

5

0

Tests (Thousands)

CTC Assays for Therapy MonitoringOP Test Volumes, US Market *

• Current utilization almost exclusively limited to research

• As clinical benefits are established, utilization will grow significantly

* Source: Sg2 Analysis, 2007

Potential Impact by Indication

Screening Virtual Colonoscopy What is the impact of Screening VC on pathology?

Technology Overview• VC uses CT technology as an

alternative to optical screening colonoscopy

• VC digitally reconstructs the CT image into 2D and 3D pictures of colonic luminal surfaces (achievable, manipulatable, post procedure review)

• Early studies indicate VC offers sensitivity and specificity similar to OC; VC does not require sedation

• Patients with suspicious VC exams immediately referred for an optical colonscopy, often on same day, for possible biopsy and/or polyp excision

Pro

bab

ility

of

Ad

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to C

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se Technology Curve:Screening VC

0Pre-

Clinical

3Consensus Adopters

2Early

Adopters

1Innovators

5Late

Adopters

4Cautious Adopters

• Expected rate of adoption: Moderate• Barriers: Public preference; Payment—

must be driven by provider• Accelerators: Publicity for screening, public

preference

Destructive or positive impact?

2006 2008 20122010 20162014

9

8

7

6

5

4

3

2

1

0

# of Procedures (Millions)

Growth in Virtual and OpticalColonoscopy, US Market *

• VC will increase colorectal cancer screening and therapeutic volumes

• Pathology volumes for colon biopsy will mirror therapeutic colonoscopy volumes

* Source: Sg2 Analysis, 2007

Optical Colonoscopy (Screening)

Optical Colonoscopy (Therapeutic)

Virtual Colonoscopy (Screening)

-9%

+59% >200%

Q1 ‘04 Q3 ‘04Q2 ‘04 Q1 ‘05Q4 ’04

3000

2500

2000

1500

1000

500

0

# of Procedures

Virtual

Optical

Total Colonoscopies (Virtual & Optical)University of Wisconsin *

UW Clinical Experience Year 1

VC patients referred for OC (size ≥ 10 mm) 4%

VC patients who would be referred if all patients with lesions ≥ 6 mm were sent for an OC

11%

Patients in VC study 1,110

1680s: English Tripod Microscope

1595: 1st Compound Microscope

Mid-1700s: Cuff-style microscope; 1st to provide ease of use and accurate focusing mechanisms

It has taken us 500 years to get to this point…It can’t just be about making pretty pictures!

It has taken us 500 years to get to this point…It can’t just be about making pretty pictures!

What is virtual microscopy?

1998: State of the art contains accessories for DIC, fluorescence, polarized light, phase contrast, and photomicrography

1899: Ernst Leitz Compound Binocular Microscope

Digitalization offers both advantages and challenges

Digitalization offers both advantages and challenges

It’s just a matter of time

40-sec20x scan

20-second40x multi-angle

scan

20-sec20x scan

Multispectral imagingIm

ag

ing

Pathology PACS

Enterprise image management

100 PetabytesPetabytes100 Terabytes

Sto

rag

e

Subspecialistwork flow

triage

Rapidsecondary

consultations

Computer-aided detection

Computer-aided diagnosis

Ap

pli

ca

tio

ns

2007 2012 2017

* Source: Sg2 T3 Virtual Slide Imaging

ImagingImaging

Prognosis & TreatmentPrognosis & Treatment

Predisposition, Signs, SymptomsPredisposition,

Signs, Symptoms

The value of traditional pathology has not diminished.

It simply will no longer be sufficient.

Pathologist

Gene ExpressionPharmacogenomics

Gene ExpressionPharmacogenomics

BiomarkersBiomarkers

TraditionalPathologyTraditionalPathology

Each pathologist and organization has a place on the Technology Adoption Curve

Early Adopters—target for leadership and

resource committees

Innovators—target for foundation grants

Consensus Adopters—Primary target for education and accreditation products

Late Adopters—Members at the

sunset of their careers

1 2 3 4 5

Early Adopters—target for leadership and

resource committees

Innovators—target for foundation grants

Consensus Adopters—Primary target for education and accreditation products

Late Adopters—Members at the

sunset of their careers

1 2 3 4 5

Where is the specialty of pathology?

Cautious Adopters—Target for technology education

Cautious Adopters—Target for technology education

What does this mean for you?

What does this mean for you?

We’re interested in your thoughts…

1. In 5 years, what will be your primary role as a clinician? How about 10 years?

2. What technology would you like for your program to teach but it doesn’t? Why?

3. What current technologies in pathology could be absorbed by other specialties and what technologies could pathology absorb?

4. How does the concept of personalized medicine affect pathology?

We’re interested in your thoughts…

5. How can the testing and certification programs in pathology training be re-oriented to the changing field of medicine?

6. What is the real difference between clinical and anatomic pathology anyway?

7. If your first job out of training required you to read a PET scan, could you / would you be willing to do it and how would you go about learning how?

8. How do other specialists view pathologists, and does that perception need improvement?

But I am just a resident…

…words from the newly experienced

Do you feel powerless as a trainee, or are you using your status as a crutch to avoid challenging the status quo?

But I’m just a resident…

How to prepare yourself for the future now…

• In training• How you choose a job or fellowship• In early practice

But I am just a resident…

During training

• Take advantage of pioneers in your facility• Get exposure out of your training program• Insert yourself into the flow of patient care

(e.g. projects, sign out)

Leaving training

PATHOLOGISTS WANTED

• Choose a job that will allow you to pursue your learning and practice goals– Ask about opportunities to be

involved in new technologies and new activities

– Find out what innovations have recently been implemented

– Ask about decision-making processes

– Get involved

In early practice

• Re-learn skills of systems-based knowledge and challenge peers

• “Keep your head up” for additional challenges/ opportunities

Will you experience frustration as you launch into your new career?

Yes…but CAP is implementing strategies to ensure you have the tools, education and advocacy necessary for a successful, relevant career in pathology

Vision of PathologistsPathologists are physicians who take an active role in patient care, utilizing all available tools to integrate and interpret diagnostic information to provide an accurate diagnosis of disease. Pathologists work closely with other members of the medical team to assess the patient condition and prognosis in order to determine optimum therapy alternatives.

Pathology will assume a critical role in health care delivery

Pathology will assume a critical role in health care delivery

• Have a unique knowledge of disease processes

• Are knowledge integrators• Can get access to all the

diagnostic data necessary• Are responsible for the

testing that is driving therapy

Pathologists

CAP is ready to pursue a transformational role for the specialty and pathologists

Mission

The CAP, the leading organization of board-certified pathologists, serves patients, pathologists, and the public by fostering and advocating excellence in the practice of pathology and laboratory medicine.

Vision

The CAP is the primary driver in the transformation of the specialty of pathology and pathologists. As the transformation agent, CAP will greatly strengthen and evolve its position into:– The leading organization guiding

pathologists– The leader in promoting quality patient

care– The primary resource for information and

education – The most influential advocate for

pathologists

While maintaining a solid foundation, the CAP is pursuing change

• Broad initiatives: The Four “Big Things”

• Laboratory Quality & Improvement for the 21st Century (LQI-21) Ad Hoc Committee

• Technology Assessment Committee

• Personalized Medicine Committee

• Diagnostic Database Initiative

Strategic Planning identified 4 initiatives that would contribute most significantly to the transformation of the specialty

• Institute• Laboratory Quality & Patient Safety Center• Personalized Healthcare• EBIDA

CAP Institute will deliver multifaceted leading-edge programs that provide you what they WANT today and what you will NEED in the future

• Programs to support MOC, MOL and hospital privileging

• Certificate programs in emerging technologies, organ systems, etc.

• Practice management tools• Research studies and

publications• Virtual and on-site practicums

with an “Institute-approved” curriculum

• Education programs targeting system-based practice

• Re-training programs for qualified individuals interested in re-establishing active practice status

• Guidelines for “best practice” residency programs

• Program Director tools to assess resident medical knowledge and ability to apply this knowledge

• Comprehensive branding

Education combined with the standards, best practice and policy to support pathology

CAP Laboratory Quality & Patient Safety Center Clearly define and develop programs that ensure quality in Dx medicine, its linkage with patient outcomes, and the role of the pathologist in improving quality and contributing to patient care

Personalized HealthcareDevelop and implement a comprehensive College-wide plan to maximize influence on the ongoing development of public policies designed to support current needs and the transformation of the specialty including a focus on personalized health care

And a solid foundation to ensure we can do everything we want to accomplish

EBIDA from ongoing operationsTo ensure that the CAP has the resources to support the other three Big Things in addition to our normal operations, the College intends to maintain a positive cumulative EBIDA from ongoing operations for every three-year rolling period.

‘Big Thing’ plan development and implementation has already begun

• Establish member/staff planning team(s)• Identify strategies that help define the Big

Things• Determine current operations that already fit;

determine things that don’t fit• Develop high-level Institute plan for Board

review in May• Launch Institute at CAP ’08• Initiate Center plans• Ensure integration of ‘Big Things’

What happens if, and when CLIA ’88 is finally cracked open?

Evaluate current and future patient safety initiatives, laboratory oversight legislation and regulations, and other related issues in the development of specific CAP position recommendations that give consideration to the scientific, medical and economic implications for patients, laboratories, pathologists, and the College. Recommendations will be presented to the Board of Governors in February 2009 or sooner if necessary.

Chair: E. Randy Eckert, MD, FCAP

What is pathology and the CAP’s role in the new world of personalized healthcare?

Initial charge: Develop a white paper to define the issues, opportunities and challenges for the College to position the specialty to maximize the effectiveness of its input into the government initiative to transform the health care system

Chair: Louis Wright, MD, FCAP

Integrating the information about patients, and their body tissue and fluids, that is necessary for diagnosis, assessing prognosis and defining treatment alternatives

Will the future EHR adequately address our needs and the value of the information we provide?

• Information derived from specimens and specimens themselves

• Patient data about history and outcome• Requisitions and orders• Lab, pathology and radiology results and reports• Collections of similar, related and derivative

information used for interpretation• Knowledge integration, interpretation and

communication

Will we be prepared to harness the influx of emerging technologies affecting today’s practice?

To identify, evaluate, and monitor emerging technologies and to develop and monitor processes for communication and program development to ensure that the College is aware of and prepared to respond to technologies that may impact upon patient care, the specialty of Pathology and Laboratory Medicine, and the College of American Pathologists.

Chair: Greg J. Davis, MD, FCAP

TAC serves as core technology investigators and explorers with a long term perspective, complementing CSA committee work

• Accelerate emerging technology investigation; sift through and prioritize

• Translate findings into knowledge and recommend action– Collaborative relationships with sentinel industry organizations

provide knowledge emerging technologies CAP can influence– Visit with key innovators that are “doing it” and have early

demonstrations of how new technologies can impact pathology

• Recommend technology strategy priorities– Define emerging technology strategies CAP should pursue – Recommend who should be doing what– Consider resources necessary to implement action plans– Facilitate cross council discussion on emerging technology

implications

EnvironmentScan

Watch

Analyze

Plan

Execute

Monitor for indication to re-assess a technology or

proceed to the next step

TAC will operationalize a technology assessment

framework to ensure that pathology continues to be

relevant and integral to patient care in a changing technological health care

environment

On the Rise

At the Peak Sliding into the Trough

Climbing the Slope

Entering the

Plateau

Technology Trigger

R&D

Startup companies, 1st round of VC

funding

Lab prototypes

No working products

Mass media hype begins

1st generation products, high price, lots of

customization needed

Negative press begins

Consolidation & failures

2nd/3rd rounds of VC funding

2nd-generation products

Less than 5% adoption

3rd generation products, out of the

box

High-growth adoption starts--~20% of target

audience has or is adopting the technology

TAC will focus on emerging technologies as they move through the Hype Cycle

Emerging Technology Prioritization

0

1

2

3

4

5

6

7

8

9

10

0 1 2 3 4 5 6 7 8 9 10 11 12

Probability of Adoption

Ma

gn

itu

de

of

Imp

ac

t

For emerging technologies with For emerging technologies with the most significant impact and the most significant impact and probability of adoption, what probability of adoption, what should the CAP do?should the CAP do?

…and if it’s the “real deal”

• Action Item recommending completion of a detailed action plan– Council/committee leadership/plan “ownership”– Planning team composition (not specific individuals but rather expertise

needed)– Specific elements that should be addressed by the plan (e.g., value to

be delivered, elements to be analyzed—operations impact, CPT codes, education)

– General timeline for action plan execution based on TAC characterization of impact timing

• SPC and Board approval will instigate plan development with the appropriate expertise

• Execution and monitoring involve TAC and the “owning” Council

Advocacy/Policy

Information, Education & Tools

Standards/Best Practices

Financial Stability & Growth

CAP’s strategy addresses the essential components to ensure the continued relevance and strength of our specialty in the dynamic world of medicine

Engage the change—integrate new concepts and technologies

Early Adopters—target for leadership and

resource committees

Innovators—target for foundation grants

Consensus Adopters—Primary target for education and accreditation products

Late Adopters—Members at the

sunset of their careers

1 2 3 4 5

Early Adopters—target for leadership and

resource committees

Innovators—target for foundation grants

Consensus Adopters—Primary target for education and accreditation products

Late Adopters—Members at the

sunset of their careers

1 2 3 4 5

Where do you intend to be?Where do you intend to be?

Cautious Adopters—Target for technology education

Cautious Adopters—Target for technology education

Re-assess your tool kit—all diagnostic tools are available to you• Acknowledge market forces

driving changes in practice of pathology

• Be life long learners

• Expand beyond the tissue on the slide

• Market your services for consults – Establish and advertise an

open door policy

– Meet with your clinician peers to review slides, case histories and interpretations

• Expand value by influencing prognosis and treatment– Pursue educational

opportunities that demonstrate integration of pathology with the rest of the treatment plan

– Collaborate with others providing diagnostic data

• Go see patients– Actively participate in patient

grand rounds

– Review charts and talk to the attending physicians

The three great essentials to achieve anything worth while are, first, hard work; second, stick-to-itiveness; third, common sense.

~ Thomas Edison

Futurescape 2008

Transforming Pathology: Emerging Technology Driving Practice Innovation

Futurescape 2008

Transforming Pathology: Emerging Technology Driving Practice Innovation

Learn how to harness technology to keep your skills and practice at the forefront of a rapidly advancing health care environment