Transforming Medicine Through Personalized Health Care at Ohio State University Medical Center

Clay Marsh, MDExecutive Director

Center for Personalized Health Care

Create the Future of

Medicine to Improve People’s

Lives Through Personalized Health Care

Harvard Business Review | October 2007 | hbr.org

Creating a Tipping Point

What underlies successful epidemics is a belief that change is possible. Tipping Points are a reaffirmation of the potential for change and the power of intelligent action. Look at the world around you. It may seem like an immovable, implacable place. It is not. With the slightest push; just in the right place; it can be tipped.

Malcolm Gladwell, The Tipping Point

How Do We Create Change?

Formula for Change

D x V x F > RD = Dissatisfaction with how things are now

V = Vision of what is possible F = Initial, concrete steps that can be taken towards the

vision.

If the product of these three factors is greater than R = Resistance, then change is possible.

Because of the multiplication of D, V and F, if any one is absent or low, then the product will be low and therefore not

capable of overcoming the resistance.

Do We Need to Change?

The Need for Transformation

• Total health care spending was $2.5 trillion in 2008, representing ~17% of the GDP, like to reach $4 trillion by 2016

• 75-90% were spent on managing and treating chronic illnesses that are preventable and effectively managed

• On a per-person basis, our health care costs are 50% higher than the second most costly nation.

• IOM reports that up to 98,000 preventable deaths occur per year and the research to practice gap is 17 years.

• The U.S. healthcare ranked by the WHO 37/191 countries in performance.

• Drugs prescribed for patients are effective in fewer than 60% of treated patients but costs of development is skyrocketed.

Standard Health Care Today• Doctor- and Hospital-focused• Population-based and poorly coordinated• Therapeutics and procedures reimbursed

best• Disease-oriented• Reactive, imprecise – 40% of medicine

does not work as prescribed

What is Our Vision at The Ohio State University?

Improve Quality AND Lower Cost

Transform Health Care from Reactive, Disease-Based Care of Today to Proactive,

Wellness-Based Care of the Future Through Systems Biology/Medicine Tools

Create Tools to Build a Health System Without Walls

P4 Medicine• Predictive:

– New precision diagnostic tools

• Personalized:– Through system

medicine and genomic tools

– Precise• Preventive:

– Focused on wellness

• Participatory– Patient empowered

and participates in all phases of care

– On demand and delivered at the patient’s place of choosing

Wellness and Risk Management

Alignment : One University

Medical Center

University Managed

Health Plan

The Structure of Our Plan

DISCOVERYSystems Biology/Systems Medicine

Genomics/Proteomics; Genetics; Informatics; Modeling (T1)

Personalized Health CarePersonalized Health Care

Translation

Experimental Therapeutics and

Devices; Preclinical to Clinical (T2)

Application/ Implementation

Health Care Delivery; Health

Care Effectiveness (T3)

DisseminationPractice to

Population Health Impact; Social

Networking Tools and Solutions (T4)

DISEASE TO WELLNESS

Disseminate

DiscoverApply

Translate

Discover

• Informatics Tools, Including Information Warehouse

• -Omics, including microRNA• Mathematical and Agent-

Based Modeling• Systems Biology

• Imaging• Biobank Tagged to

Deindentified Data Mart

PLATFORM CREATION

Complex Relationships Determine Health and Disease

• Complex interactions of genes and proteins explain differences between people

• 1:1 interactions between 25,000 genes is 336,000,000 possibilities

• What field has tools that we need to understand the organization of these complex interactions?

www.sysbio.de/figs/sysbio8.gif

• Emergent field that aims at systems understanding of biological systems.– Systems view focuses at

understanding:• The complexity of the

system• The networks activated in

the system• The control methods of

the system• Key nodes in the system

Systems Biology

The Institute for Systems Biology

How Can We Simplify This Complexity?

Network Hubs / Tipping Points

“Our analysis showed that microRNAs preferentially regulate hub nodes, i.e., top 5% of the highly connected nodes in the network..”

The Open Systems Biology Journal, 2008, 1, 1-8

Using Systems Biology Tools to Understand IPF

Identify Networks and Key Regulatory Nodes Controlling Networks

http://mcdb.colorado.edu/courses/3280/lectures/class16-2.html

MicroRNA

Carlo Croce, MD

Translate

• Diagnostics• Devices

• Targeted Therapeutics • Alignment Between

Clinicians and Scientists• Wellness

• Center for Clinical and Translational Science

(CTSA)

PLATFORM TRANSLATION

CTSA is an outcome of the Roadmap for Research from NIH

Apply

• Alignment with Managed Health System

• Pilot Programs• Coriell Personalized Medicine Collaborative

• Grid-enabled IT• Accountable Medical Care

Organization, including Medical Home Teams

• Tele-Health • Comparative Effectiveness

PLATFORM APPLICATION

What Are Being Done at the OSUMC?Molecular Diagnostic and Prognostic Markers

Molecular Tests Clinical IndicationBRAF •Differential marker for Lynch

Syndrome•Guide for further management

FLT3 •Prognostic marker and target for identifying acute myeloid leukemia with normal karyotype

IGH Somatic Hypermutation •Prognostic marker in chronic lymphocytic leukemia

•Guide for the clinical management

JAK2 •Diagnosis for myeloproliferative disorder

•Guide for treatment of hematopoieitic disease

What Are Being Done at the OSUMC?Targeted Therapy/Treatment Selection

Molecular Tests Clinical IndicationHER2 amplification by FISH •Herceptin treatment for breast

cancer

KRAS Mutation •Erbitux® and Vectibix® treatment for colorectal cancer 

EGFR mutation or amplifications (FISH)

•TKI treatment for non-small call lung carcinoma

CYP 2D6 •Tomaxifen therapy for ER-positive breast cancer

OncoType Dx •Predict a patient’s benefit from chemotherapy for breast cancer (node-native, ER positive)

•Predict risk of recurrence for breast cancer

Crops to Clinic“Nutrients and bioactive chemicals in foods represent important factors in the prevention and treatment of disease. They are Mother Nature’s drugs, and we are trying to understand how they interact once they are ingested,”

Mark Failla, PhD, professor and chair of the Department of Human Nutrition in the College of Human Ecology.

“According to scientific estimates, there are 20,000 chemicals and 50 to 60 essential nutrients in the human diet,” Steven Schwartz, PhD, professor of food science and technology in the College of Food, Agricultural and Environmental Sciences.

Coriell Personalized Health Care Collaborative

Michael Christman, Ph.D., CEO Coriell Institute

Overview of OSUMC/OSU Managed Health Care Personalized Health

Care Demonstration Projects

Baseline Assessment

InformedConsent

GeneticTests

Comprehensive health risk assessment

Physical Examination

Customers

• Receive form in the mail or email.

• Send in signed consent form or bring the form to meeting with physician.

Web-based risk assessment tool to include:

• Individual health history• Family health history• Life style / exercise• Behavioral / stress• Nutrition / environment

• Genetic test kit is sent directly to customer’s home

• Customer provides sample and send sample to lab via mail

• Lab runs genetic test and post test results to customer web portal

• Customer authorize release of test results to care team

• Care team (Prime care physician, exercise physiologist) perform physical exam of customer

Confidential and privileged. Do not copy or distribute. © OSU Medical Center, 2009

Information Warehouse

Transforming Medicine:Disruptive Innovation

Disruptive Innovation to Create Value and Reduce Costs

• Create precision medicine (personalized care)

• Push care from more to less specialized providers using rules-based approaches

• Decentralize medical care• Integrate medical information• Incentivize health from

integrated organizations that benefit from health of its members (like Ohio State)

Wellness

Your Strategic Plan for Health

GeneticTests

Comprehensive health risk assessment

Physical Examination

Data and Analysis:• Genetic risk profile• Major health risk

factors• Current state of

physical health• Current state of

emotional health• Current state of life

style and environments

Care Team to include:• Physician• Genetic counselor• Psychologist• Exercise physiologist• Bio-nutrition counselor• Nurse• Pharmacist

Care Team review, conference, and

recommendations

Your Strategic Plan For Health

Customer visit care team to review and finalize plan:• Current strengths and weaknesses• Opportunities for improvement• Health and wellness targets for next 2, 5, and 10 years• Action Plan: recommendations

Confidential and privileged. Do not copy or distribute. © OSU Medical Center, 2009

Specialized Personalized Health Clinics

Care Team review, conference, and

recommendations

Your Strategic Plan For Health

Customer visit care team to review and finalize plan:

• Current strengths and weaknesses

• Opportunities for improvement

• Health and wellness targets for next 2, 5, and 10 years

• Action Plan: recommendations

Optional special clinics that meet individual needs

Genomics/ Molecular

Diagnostics

Behavioral health

Bio-nutrition & dietary

Exercise & performance

• Genetic risk factor awareness and education

• Molecular wellness tools

• Behavioral risk factor awareness and mitigation strategies

• Focus on resilience

• Evidence-based recommendations

• Nutrition and diet with analysis of epigenetic / molecular signature effects

• Exercise and physical performance routines designed for individual needs

Confidential and privileged. Do not copy or distribute. © OSU Medical Center, 2009

Chronic Disease

Disseminate

• Process Creation• P4 Medicine Medical School

Curriculum • Social Networking and

Media• Information Support Tools

PLATFORM DISSEMINATION

iPOD Touch Program

The Power of Process

N Engl J Med 1999;340: 286-92

Improving people’s lives through personalized health care