1. ©2007 RALPH SNYDERMAN Third Annual Prospective Health Care Conference "Where are We Now?" Ralph Snyderman, MD Chancellor Emeritus, Duke University November 1, 2007

2. ©2007 RALPH SNYDERMAN Contemporary Practice of Medicine Disease oriented Find it, fix it Reactive Sporadic intervention Physician-directed Not Standardized Not Personalized

3. ©2007 RALPH SNYDERMAN The Inflection and Opportunities for Intervention Disease Burden Time Cost 1/reversibility Health Care Cost vs. Disease Progression Typical Current Intervention Earliest Clinical Detection Earliest Molecular Detection Initiating EventsBaseline Risk

4. ©2007 RALPH SNYDERMAN Factors Impacting Medicine Today Genomics Proteomics Metabolomics Medical technologies Informatics Risk Prediction

5. ©2007 RALPH SNYDERMAN Tools Needed for Prediction and Personalized Care Disease Burden Time Cost 1/reversibility Typical Current Intervention Earliest Clinical Detection Earliest Molecular Detection Initiating EventsBaseline Risk Decision Support Tools: Baseline Risk Preclinical Progression Disease Initiation and Progression Assess RiskRefine Assessment Predict/Diagnose Monitor Progression Predict Events Inform Therapeutics Sources of New Biomarkers: Stable Genomics: Single Nucleotide Polymorphisms (SNPs) Haplotype Mapping Gene Sequencing Dynamic Genomics: Gene Expression Proteomics Metabolomics Molecular Imaging Therapeutic Decision Support

6. ©2007 RALPH SNYDERMAN Prospective Health Care Risk Assessment and Decision Support Tools Disease Burden Time Low Risk High Risk Early Chronic Cost 1/reversibility Personal Lifestyle Plan Disease Management Risk Modification Personalized Health Plan Late Chronic Participating Population

7. ©2007 RALPH SNYDERMAN Needs for Prospective Health Care Health risk assessment tools Therapeutic evaluation tools Aligned health care providers Aligned reimbursement systems Motivated consumers

8. ©2007 RALPH SNYDERMAN So, Where Are We Now? Research Clinical Models Personalized Medical Records Payers Advocacy Groups Medical Education