homosassa cancer center “ using knowledge to reduce the burden of human cancer” slide 1...
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Homosassa Cancer Center “using knowledge to reduce the burden of human cancer” Slide 1
Presented By: Alice ChowRay Yip
Michelle BurkeAnne-Marie Lesko
Presented On: March 8, 2015MMI 404 Winter 2015
Homosassa Cancer CenterFlorida Health Alliance Hospital
“Personalized” Cancer Therapy
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Homosassa Cancer Center “using knowledge to reduce the burden of human cancer” Slide 2
Precision Medicine (PM)...
...is an emerging approach for disease treatment and prevention that takes into account individual variability in genes, environment, and lifestyle for each person.
Homosassa Cancer Center “using knowledge to reduce the burden of human cancer” Slide 3
PharmacoGenomics (PGX)...
...uses information about a person's genetic makeup, or genome, to choose the drugs and drug doses that are likely to work best for that particular person.
It combines the science of how drugs work, pharmacology, with the science of the human genome, genomics.
Homosassa Cancer Center “using knowledge to reduce the burden of human cancer” Slide 4
Precision Medicine Initiative: Objectives
• More and better treatments for cancer• Creation of a voluntary national research cohort• Commitment to protecting privacy• Regulatory modernization• Public-private partnerships
(from:http://www.whitehouse.gov/the-press-office/2015/01/30/fact-sheet-president-obama-s-precision-medicine-initiative)
Homosassa Cancer Center “using knowledge to reduce the burden of human cancer” Slide 5
Positioning for Growth: Upcoming Market Trends
Homosassa Cancer Center “using knowledge to reduce the burden of human cancer” Slide 6
How will PM and PGx align with IOM’s 6 Aims?
Safe:
a. Effective Clinical Decision Support System (CDSS)
b. Smartpumps
c. Certified staff--physicians, nurses, pharmacist
Effective:
d. Cancer screening=early identification
e. Chemotherapy effectiveness based on precision chemotherapy will
need to be statistically evaluated over time.
Homosassa Cancer Center “using knowledge to reduce the burden of human cancer” Slide 7
Alignment with IOM’s 6 Aims (cont.)Patient-Centered:
a. This is the goal of precision chemotherapy and PGx.
b. The facility is modeled for comfort and serenity
c. Staff will be trained to provide competent and compassionate care
d. Multi-disciplinary approach beyond physicians and nursing to provide
encompassing care per patient needs
i. Social Work
ii. spiritual support
iii. genetic counselor
iv. financial specialist to assist to navigate insurance
Homosassa Cancer Center “using knowledge to reduce the burden of human cancer” Slide 8
Alignment with IOM’s 6 Aims (cont.) Timely:
a. “quick” genomic testing for specific biomarker results EMR will lead to
increased accessibility of results
b. Coordinating testings (i.e. getting tissue biopsy assays results) prior to therapy
Efficient:
c. Genomic testing will lead to more accurate diagnosis and therefore less time
wasted “treating the wrong thing”
a. Targeted therapy leads to better patient outcomes and fewer side effects
Equitable:
b. As we participate in research, grant moneys will be available to support
treatment for underprivileged patients
Homosassa Cancer Center “using knowledge to reduce the burden of human cancer” Slide 9
Homosassa Cancer Center “using knowledge to reduce the burden of human cancer” Slide 10
DNA Mutations and Cancer
Homosassa Cancer Center “using knowledge to reduce the burden of human cancer” Slide 11
Molecular Tumor TestingDNA Sequencing -most direct and informative
• Allele-specific point mutations• Hot-spot custom panels- insertions, deletions, duplications• NGS-whole exome sequencing• NGS-whole genome sequencing
Homosassa Cancer Center “using knowledge to reduce the burden of human cancer” Slide 12
Use of Biomarkers in the Continuum of Cancer Care
Risk Stratification
DiagnosisTreatment Selection &
management
Treatment Response
Assessment
Risk Biomarker Diagnostic Biomarker
Prognostic Biomarker
Predictive Biomarker
Response Biomarker
Homosassa Cancer Center “using knowledge to reduce the burden of human cancer” Slide 13
Homosassa Cancer Center “using knowledge to reduce the burden of human cancer” Slide 14
HER2 biomarker and Herceptin
Homosassa Cancer Center “using knowledge to reduce the burden of human cancer” Slide 15
EGFR in Lung and Colorectal Cancer
http://www.mycancergenome.org/content/disease/lung-cancer/egfr/21/
Homosassa Cancer Center “using knowledge to reduce the burden of human cancer” Slide 16
Types of Decision Support for Clinicians
Which tests to order? When to order?
How to interpret and report results?
How to apply results to patient care?
Homosassa Cancer Center “using knowledge to reduce the burden of human cancer” Slide 17
Big Data
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Homosassa Cancer Center “using knowledge to reduce the burden of human cancer” Slide 18
Falling Costs, Increasing Size
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source: http://www.slideshare.net/GerryHiggins1/next-generation-sequencing-in-pharmacogenomics
Homosassa Cancer Center “using knowledge to reduce the burden of human cancer” Slide 19
Integration of Genomic Data With Electronic Health Records. From Crossing the Omic Chasm A Time for Omic Ancillary Systems by Starren, J., Williams, M. S., & Bottinger, E. P. (2013, Mar 27). Retrieved from JAMA: http://jama.jamanetwork.com/article.aspx?articleid=1666972
Homosassa Cancer Center “using knowledge to reduce the burden of human cancer” Slide 20
source: GenomOncology (2014)
Homosassa Cancer Center “using knowledge to reduce the burden of human cancer” Slide 21
source: GenomOncology (2014)
Homosassa Cancer Center “using knowledge to reduce the burden of human cancer” Slide 22
Building Genomic CDS in EHR
Images from Usability evaluation of pharmacogenomics clinical decision support aids and clinical knowledge resources in a computerized provider order entry system: A mixed methods approach by Devinea, et al. (2014). Retrieved Feb 23, 2015 from http://www.sciencedirect.com/science/article/pii/S1386505614000689
Example: Evidence based knowledge about PGx results Example: PGx-CDS Alert
Homosassa Cancer Center “using knowledge to reduce the burden of human cancer” Slide 23
Proposed Architecture
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Proposed Scope
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High level Roadmap
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Homosassa Cancer Center “using knowledge to reduce the burden of human cancer” Slide 26
Success Metrics & Goals High Standards of Quality● measured by ASCO QOPI calculations● 80% score to achieve ASCO quality certification
Cost Savings Sharings● Reduced hospital LOS● Bundled payment initiatives
o CMSo Large payors
Brand enhancement● Retain community patients in geographic area● Attract high quality physicians to area
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Homosassa Cancer Center “using knowledge to reduce the burden of human cancer” Slide 27
Technical Costs
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Identified Technical Costs Functionality One Time Actual
Expenditure/YR
CDSS Setup Fee Setting up the one time fee for the decision support software, and licensing our users
15000 + 1000/user $54,000.00
Workbench Server $10,000.00 $10,000.00
SANS Storage Provide additional storage space
$6,500.00 $6,500.00
$70,500.00
Homosassa Cancer Center “using knowledge to reduce the burden of human cancer” Slide 28
Identified Staffing Needs: Functionality/Purpose Operational Cost One Time Actual Expenditure/YR
Form multi-disciplinary team
*Involve all stakeholders in the process to include current and new team members
15 hours month for team members to meet/perform duties
Pharmacy FTE
*Supervise chemotherapy administration
*Use Medrec to ensure clinical pathways are safe
*Participate in CDS development
Requires support from the Med Rec staff
$98,000.00
Clinical Informaticist
*Participate in CDS Development Disseminate information to the appropriate organizations
*Oversee efforts to gather and report on quality and outcome metrics
$65,000.00
Marketing Campaign *promote brand, consumer awarenessadditional marketing team staff hours, physician sales engagement
$25,000.00 $10,000.00
Clinical Trial Coordinator
*Works with clinical informaticist to provide clinical reporting
*Grant administration for clinical and pharma research trial participation
$65,000.00
Clinical Systems Analyst *Incorporate CDS material into existing EMR
$75,000.00
System Administrator (½ FTE)
*Provide network availability,
$45,000.00
$240,000.00
Homosassa Cancer Center “using knowledge to reduce the burden of human cancer” Slide 29
Reviewing RiskImpact Clinical Cultural Technical Ethical Financial
Positive
*We achieve better patient outcomes
*We improve care and outcome disparities in our community
*We use analytics to provide accurate, granular metrics for patient outcomes
*Analytics data helps support our position in the bundled care opportunities
*We provide the best possible patient experience
*We attract volume from payors
*Attract grant and research dollars
Risks to Monitor*Volume of data and its ability to be curated
*Physician resistance *Consumer wariness
*Lack of informatics experience *Reporting of Findings
(need to know)
Potential High Impact Risks
*Clinical Pathways cause harm
• Negative perceptions
• Reimbursement structure and payor mix widens disparities
* Poor EMR integration * Data use, especially in registries and clinical trials
*Quality metrics not achieved
*Potential Revenue lost
Homosassa Cancer Center “using knowledge to reduce the burden of human cancer” Slide 30
Why Pharmacogenomic Clinical Trials
Indirect Downstream service revenue
Increased market share
Direct NCI funding Increased Access to pharmaceutical
industry trials
Homosassa Cancer Center “using knowledge to reduce the burden of human cancer” Slide 31
Cancer Center Brand Drivers
Source: StraightLine NYC
N=628= (302 patients, 294 physicians, 32 pharma)= Total (n=628)
Primary drivers
Location ranked in the lower tier
Homosassa Cancer Center “using knowledge to reduce the burden of human cancer” Slide 32
Calculating Evidence Informed Care Rate (ECR)
Average Cost of typical care $ 29,850.00
Severity adjustment FACTOR<> $ 15,000.00 $ 44,850.00
Margin 10% $ 4,485.00 PAC Allowance $ 3,619.50
Flat Fee 480 Proportional Rate 7%
Total ECR = $ 52,954.50 (severity Rate+
PAC Allowance + Margin)
Homosassa Cancer Center “using knowledge to reduce the burden of human cancer” Slide 3333
Column1 2013 Patient Voume Projected 2018 Projected 2023
New Patients 3799.5 4369 5547
Hospital Admissions 2378 2735 3472
Outpatient regestrations 21680.5 24933 31654
Chemo Infusions/Related 22781.5 26199 33261
Radiation 11102 12767 16209
Assumptions Current Avg / CaseUsing ECR with 10% no volume increase
Breast Cancer $ 26,700.00 $ 29,370.00
Lung Cancer $ 29,500.00 $ 32,450.00
Colorectal Cancer $ 33,000.00 $ 36,300.00
Projected Volume 2018 Projected Volume 2023Breast Cancer (15% new
patient) $ 15,216,997.50 $ 16,738,697.25 $ 19,249,501.84 $ 24,438,497.99
Lung Cancer(11%) $ 12,329,377.50 $ 13,562,315.25 $ 21,268,176.19 $ 16,899,375.90
Colorectal (8%) $ 100,306,800.00 $ 110,337,480.00 $ 135,757,870.88 $ 172,353,470.85
$ 127,853,175.00 $ 140,638,492.50 $ 176,275,548.90 $ 213,691,344.74
Homosassa Cancer Center “using knowledge to reduce the burden of human cancer” Slide 34
Potential Revenue Increase for Breast Cancer
Homosassa Cancer Center “using knowledge to reduce the burden of human cancer” Slide 35
* Harvard Business Review article by Rita Gunther McGrathand Ian C. MacMillan in 1995
Return on Innovation Measures Growth
Expansion of CDSS functionality
Renewed commitment to patient centric approaches
Genetic testing incorporated into clinical pathways
Homosassa Cancer Center “using knowledge to reduce the burden of human cancer” Slide 36
Summary
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APPENDIX
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pharmacogenomic approaches to EGFR-tyrosine kinase inhibitor therapy in non-small-cell lung cancer. Value Health, 12(1), 20-27. doi: 10.1111/j.1524-4733.2008.00415.x
Cimino, G. D., Pan, C.-x., & Henderson, P. T. (2013). Personalized medicine for targeted and platinum-based chemotherapy of lung and bladder cancer. Bioanalysis, 5(3), 369-391. doi: 10.4155/bio.12.325
Crawford, J. M. M. P. (2014). The Business of Genomic Testing: A Survey of Early Adopters. Slide Share: Knome_Inc.
Devinea, E. B., Leea, C.-J., Overby, C., Abernethy, N., McCune, J., Smith, J. W., & Tarczy-Hornoch, P. (2014, Apr 15). Usability evaluation of pharmacogenomics clinical decision support aids and clinical knowledge resources in a computerized provider order entry system: A mixed methods approach. Retrieved from International Journal of Medical Informatics: http://www.sciencedirect.com/science/article/pii/S1386505614000689
Fenstermacher, D. A., Wenham, R. M., Rollison, D. E., & Dalton, W. S. (2011). Implementing Personalized Medicine in a Cancer Center. Cancer journal (Sudbury, Mass.), 17(6), 528-536. doi: 10.1097/PPO.0b013e318238216e
Guttmacher, A. E., McGuire, A. L., Ponder, B., & Stefansson, K. (2010). Personalized genomic information: preparing for the future of genetic medicine. Nat Rev Genet, 11(2), 161-165.
Huttin, C. C., & Liebman, M. N. (2013). The economics of biobanking and pharmacogenetics databasing. Technology & Health Care, 21(2), 183-190.
Joseph L. Kannry, M. S. (2013). Integration of genomics into the electronic health record: mapping terra incognita. Retrieved from Genetics in Medicine: http://www.nature.com/gim/journal/v15/n10/full/gim2013102a.html
Kreys, E. D., & Koeller, J. M. (2013). Documenting the benefits and cost savings of a large multistate cancer pathway program from a payer's perspective. J Oncol Pract, 9(5), e241-247. doi: 10.1200/jop.2012.000871
Homosassa Cancer Center “using knowledge to reduce the burden of human cancer” Slide 39
Malin, B., Benitez, K., & Masys, D. (2011). Never too old for anonymity: a statistical standard for demographic data sharing via the HIPAA Privacy Rule. J Am Med Inform Assoc, 18(1), 3-10. doi: 10.1136/jamia.2010.004622
Masys, Daniel R. et al. (2012). Technical desiderata for the integration of genomic data into Electronic Health Records. Journal of Biomedical Informatics , Volume 45 , Issue 3 , 419 - 422. Retrieved from http://www.j-biomed-inform.com/article/S1532-0464%2811%2900219-X/fulltext
Mehr, S. R. (2014, Feb 11). Is Medicare Ready for Oncology Clinical Pathways? Retrieved from The American Journal of Managed Care: http://www.ajmc.com/publications/evidence-based-oncology/2014/february-2014/Is-Medicare-Ready-for-Oncology-Clinical-Pathways
My Cancer Genome. (n.d.) Types of Molecular Tumor Testing. Retrieved from http://www.mycancergenome.org/content/molecular-medicine/types-of-molecular-tumor-testing/
National Cancer Institute. (n.d.) BRCA1 and BRCA2: Cancer Risk and Genetic Testing. Retrieved from http://www.cancer.gov/cancertopics/genetics/brca-fact-sheet
National Cancer Institute. (n.d.) Enhancing Breast and Ovarian Cancer Care: The Discovery of BRCA1 and BRCA2. Retrieved from http://www.cancer.gov/aboutnci/servingpeople/cancer-research-progress/discovery/brca
Quackenbush, J. P. (2012). Building a Program in Personalid Medicine. Slide Share: Dana-Farber Cancer Institute.
Scott, G., Shah, P., Wyatt, J., Makubate, B., & Cross, F. (2011). Making electronic prescribing alerts more effective: scenario-based experimental study in junior doctors. J. Am. Med. Inform. Assoc., 789–798.
Homosassa Cancer Center “using knowledge to reduce the burden of human cancer” Slide 40
SG2 Healthcare Intelligence Market Research Firm. (2013). Cancer : Service Line Snapshot.
Snow, S. (May 5, 2003). Cancer facilities find Lakeland to be inviting. Tampa Bay Biz Journal. Retrieved from http://www.bizjournals.com/tampabay/stories/2003/05/05/story2.html
Snyder, C. F., Wu, A. W., Miller, R. S., Jensen, R. E., Bantug, E. T., & Wolff, A. C. (2011). THE ROLE OF INFORMATICS IN PROMOTING PATIENT-CENTERED CARE. Cancer journal (Sudbury, Mass.), 17(4), 211-218. doi: 10.1097/PPO.0b013e318225ff89
Snyder, S. R., Mitropoulou, C., Patrinos, G. P., & Williams, M. S. (2014). Economic Evaluation of Pharmacogenomics: A Value-Based Approach to Pragmatic Decision Making in the Face of Complexity. Public Health Genomics, 17(5-6), 256-264.
Song, P. H., Reiter, K. L., Weiner, B. J., Minasian, L., & McAlearney, A. S. (2013). The Business Case for Provider Participation in Clinical Trials Research: An Application to the National Cancer Institute's Community Clinical Oncology Program. Health Care Manage Rev, 38(4), 284-294. doi: 10.1097/HMR.0b013e31827292fc
Starren, J., Williams, M. S., & Bottinger, E. P. (2013, Mar 27). Crossing the Omic ChasmA Time for Omic Ancillary Systems. Retrieved from JAMA: http://jama.jamanetwork.com/article.aspx?articleid=1666972
Suther, S., & Kiros, G. E. (2009). Barriers to the use of genetic testing: a study of racial and ethnic disparities. Genet Med, 11(9), 655-662. doi: 10.1097/GIM.0b013e3181ab22aa
The eMERGE Network. (n.d.). The eMERGE Network. Retrieved from The eMERGE Network: http://emerge.mc.vanderbilt.edu/
Homosassa Cancer Center “using knowledge to reduce the burden of human cancer” Slide 41
Current Facility Profile
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Organization Name Homosassa Cancer Center; owned and operated by Central Florida Community Health
Clinical Services Provided:
Outpatient chemotherapy and related therapies, Cancer screening, Radiation Oncology therapy, Psychological support, Oncology surgical services
MIssion Statement Reduce the burden of human cancer through the pursuit of knowledge and apply this knowledge to the prevention of cancer and the treatment of cancer patients
Hours of Operation: Monday thru Friday, 7 am to 9 pm
Number of Providers: 1 Chief of Oncology, 6 Employed medical oncologists, 10 Affiliated medical oncologists, 2 surgical oncologists, 1 radiation oncologist
Number of Mid-level Providers:
9--one for each employed physician and three to support the infusion center
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Facility Profile (cont)
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Other FTEs: 1 director, 1 nurse manager, 2 administrative assistants, 4 front desk staff, 25 RNs, 4 CNAs (certified nursing assistants), 2 pharmacists, 5 radiation technologists, 1 CDS specialist, 3 HIT Integration Specialists, 1 informaticist. For additional psycho-social support, there are also 2 social workers to help coordinate follow-up care and adherence..
Volunteer Pool: Members of the community who desire to support patients receiving oncology treatment may volunteer time in the infusion center as coordinated by an administrative assistant.
Patient Population & Characteristics:
Our 2014 Community needs assessment identifies that cancer is the leading cause of death in our region, with females between the ages of 60 and 79 suffering the highest instances of new cancer detection.
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Facility Profile (cont)
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Facility Characteristics
● The first floor has a reception area, a 25-chair infusion center with a supply room and nurse’s desk areas, a staff room, a kitchen, and 6 offices (director, nurse manager, genetic counselor, social worker, etc).● The second floor has 10 physician offices, 10 exam rooms, 1 large conference room, 2 small conference rooms, 3 bathrooms, and a kitchenette. ● The third floor houses Radiation Services.● The fourth floor has 1 large conference room, 2 small conference rooms, 5 offices for IT staff, and 3 bathrooms. This floor is available for use for group classes, staff training as well as community educational opportunities.● Behind the structure is a Serenity Garden where patients and families may visit. A portion of the infusion chairs overlook the Serenity Garden.● The facility is equipped with internet and WiFi.
Homosassa Cancer Center “using knowledge to reduce the burden of human cancer” Slide 44