©2009 RALPH SNYDERMAN 1 Personalized Health Care: The Foundation of Rational Health Reform Ralph Snyderman, MD Chancellor Emeritus, Duke University James B. Duke Professor of Medicine Personalized Health Care National Conference Ohio State University Medical Center October 1, 2009

©2009 RALPH SNYDERMAN s Germ Theory Chemistry Physiology Pathology Physics Science and Medicine Find It Fix It Understanding Disease

©2009 RALPH SNYDERMAN 3 Concepts of Disease Reductionism: Single factor Causative Factor Causative Factor Disease

©2009 RALPH SNYDERMAN 4 Contemporary Practice of Medicine Disease-oriented Find it, fix it Reactive Sporadic Physician-directed Very expensive

©2009 RALPH SNYDERMAN s Germ Theory Chemistry Physiology Pathology Physics 2000s Genomics Proteomics Metabolomics Systems Biology Informatics Micro/Nano Processing Science and Medicine Find It Fix It Predict It Personalize It Understanding Disease Understanding Health, Disease and Complexity

©2009 RALPH SNYDERMAN 6 Concepts of Disease Emergence: Multiple factors Reductionism: Single factor Baseline Risk Environmental Factors Preclinical Progression Disease Initiation Disease Progression Irreversible Damage Causative Factor Enhance Health and Well-Being Disease

©2009 RALPH SNYDERMAN 7 Time Cost 1/reversibility Disease Burden Typical Current Intervention Earliest Clinical Detection Earliest Molecular Detection Baseline Risk Initiating Events Stable Genomics Dynamic Tracking Therapeutic Decision Support Personalized, Predictive, Prevention PreventionEarly Intervention End of Life Care Disease Management Personal Health Plan

©2009 RALPH SNYDERMAN 8 New Clinical Tools Health risk analysis Pathogenesis tracking Molecular diagnosis Clinical event prediction Therapeutic potential analysis

©2009 RALPH SNYDERMAN 9 Predictive Model Development CLINICAL DATA COHORT OTHERPROTEOMICGENETICCLINICAL PREDICTIVE MODELER ADDITIONAL DATA; NEW BIOMARKERS STATISTICAL VALIDATION y = f (x 1, x 2,…x n ) OUT OF SAMPLE POPULATIONS DATA PREDICTION MODELS BASELINE RISK DISEASE PROGRESSION EVENT PREDICTION DECISION SUPPORT PATIENT PHYSICIAN PATIENT’S DATA PREDICTIVE MODEL CLINICAL EVENT

©2009 RALPH SNYDERMAN 10 Traditional Medical Evaluation and Record Chief Complaint History of Illness Past Medical History Family History Social History Physical Exam Diagnostic Tests Assessment and Plan Personalized Health Plan Health Risk Assessment Current Health Status Tracking Wellness and Pathogenesis Clinical Event Prediction Wellness Plans Therapeutic Plans Paradigm Shift to Personalization

©2009 RALPH SNYDERMAN 11 Personalized Health Plan PATIENT’S EVALUATION Medical “work up” -- including relevant predictive factors and biomarkers PATIENT’S EVALUATION Medical “work up” -- including relevant predictive factors and biomarkers PATIENT’S OUTCOME Tracking Data Clinical Event Data PATIENT’S OUTCOME Tracking Data Clinical Event Data Patient’s Digital Data Base Patient’s Digital Data Base Risk Models Library Risk Models Library PERSONALIZED HEALTH PLAN Current Health Status Health Risk Assessment Health Risk Tracking Disease Event Prediction Health and Wellness Plans Therapeutic Plans PERSONALIZED HEALTH PLAN Current Health Status Health Risk Assessment Health Risk Tracking Disease Event Prediction Health and Wellness Plans Therapeutic Plans

©2009 RALPH SNYDERMAN 12 Fragmented Health Care PRIMARY CARE SPECIALTY CARE HOSPITAL CARE ER CARE URGENT CARE SELF CARE

©2009 RALPH SNYDERMAN 13 Model for Personalized Health Approach PERSONAL HEALTH PLAN Health Risk Assessment Current Status Health Tracking Health and Wellness Plan Health Enhancement Resources Navigator Health Care Provider Team And Resources Integrated Delivery System PATIENT PHYSICIAN

©2009 RALPH SNYDERMAN 14 Personal Health Plan Coordinates Care PRIMARY CARE SPECIALTY CARE HOSPITAL CARE ER CARE URGENT CARE SELF CARE Health Navigator Personal Health Plan

©2009 RALPH SNYDERMAN 15 Clinical Decision Support at the Point of Care EHR Clinical Risk Predictors Clinical Decision Support Diagnostics Selectors Therapeutic Predictors Payer Adjudication PDx Server Clinical Research New Model Validation Biocausality Engine

©2009 RALPH SNYDERMAN 16 Example: A point-of-care predictive test for prevention of febrile neutropenia (FN)

©2009 RALPH SNYDERMAN 17 Key Factors in Health Care Reform Universal access Health education and personal empowerment Personalized prevention and strategic health planning Biomedical research and regulatory reform Delivery systems integration Reimbursement reform

©2009 RALPH SNYDERMAN 18 “There is nothing more difficult to plan, more doubtful of success, nor more dangerous to manage than the creation of a new system. The initiator has the enmity of all who profit from the old institution and merely lukewarm defenders in those who would gain the new ones.” Niccolo Machiavelli

©2009 RALPH SNYDERMAN 19 “Is is not the strongest of the species that survives, but rather the one most responsive to change.” Charles Darvin