1. Redefining Personalized Medicine Dr. Scott Joy October 16, 2013

2. Not Just for Specialists Challenged by a presentation on how genetic factors are associated with the risk and progress of diabetes, Dr. Joy thought that he could bring more value to his patients using ‘personalized’ medicine. Reference: Joy, Scott V., MD. Redefining Personalized Medicine in the Primary Care Setting. Medscape. Oct 10, 2013. http://www.medscape.com/viewarticle/812376?n lid=35763_1521 http://www.medscape.com/viewarticle/812376?n lid=35763_1521

3. Personalized Medicine 1.0 Assess health status Focus on collecting biometric data – Blood pressure – Cholesterol – Body mass index – Allergies (food, medication) – Family/social history Treat detected problems The ‘Platinum’ Edition – Calculate 10-year risk for a cardiac event (Framingham Risk Score) – Calculate risk of developing diabetes (Diabetes Risk Test) – Calculate risk for bone fracture due to osteoporosis (FRAX score)

4. Personalized Medicine 2.0 Leverage technology and patient participation to provide a more efficient and better experience for both patient and provider Pre-visit, Patient uses secure portal to: – Schedule appointment – Update medical, family, and social history – Update medications and allergies – Identify and Schedule needed lab tests

5. Personalized Medicine 2.0 The day before the appointment, the patient gets a reminder email and uses secure portal to: – Verify insurance info – Confirm labs have been completed – Lists goal(s) for appointment – Checks in online The provider can review all information prior to the appointment – Has biometric data in advance – Knows exactly what the patient wants to get out of the visit – Can focus on discussion of specific indicators and setting goals for improved wellness

6. Personalized Medicine 2.0 Summary Includes all of 1.0 ‘Platinum’ Patient portal Bidirectional electronic communication between patients, providers, and practices Integrated risk calculators into the EHR with prepopulation of relevant clinical data List of community resources

7. Personalized Medicine 3.0

8. Pre-appointment genetic testing completed at home using a buccal swab. Data are analyzed and the results are automatically uploaded into the EHR. Painless skin sensor monitors metabolic and activity levels Monthly summaries of these data are uploaded into the EHR and crosschecked with biometric data, family/social history, medication and allergy lists, and data from risk calculators. By the visit, the health information system has generated an enhanced health risk assessment that includes risk of developing chronic conditions based on genetic test results, biometric data, and medical/family/social history Recommendations to alter risks of developing these conditions are suggested to the provider, along with pharmacologic recommendations based on her pharmocogenomics profile. Community resources to help and support engagement in healthy behaviors that are available in the zip codes where the patient lives and works are identified and presented for consideration

9. The Challenge: Take our currently fragmented systems and integrate them into the clinical workflow of a primary care practice and the health information systems that support these practices. Build on the collection of data in a patient's EHR, introduce genetic testing results as a variable, and leverage HIT to synthesize these data to produce recommendations that will enhance the health and safety of the patients we serve