Community hospitals can do precision medicine too – here's how

It's a common misconception that precision medicine techniques are only able to be mastered by large and well-capitalized academic medical centers. But at the HIMSS Precision Medicine summit on May 17, two experts in genetics and molecular medicine explained how their community hospital has embraced personalized care with new technologies and workflows.

The Gibbs Cancer and Research Institute, part of the Spartanburg Regional Healthcare System in upstate South Carolina, decided to launch a precision medicine program with a Duke Endowment Grant it had received.

The years since have seen big changes in the organization's clinical strategies, impacting every department: oncology, pathology, lab, IT, billing, navigation, research and more. Their journey offers some lessons for smaller hospitals looking to try something similar.

"We don't have the resources an academic medical center would have," said Jennifer Buhay, administrator of the Duke Endowment Grant for Gibbs Cancer Center. "But we knew we had a lot to work with and had physician champions."

At the same time, Gabriel Bien-Willner, MD, molecular director of the precision medicine program at Gibbs emphasized that "physician champions are great, but you need executive buy-in" for any serious genomics program to not only get off the ground buy gain traction and have staying power.

Leadership that understands the value of precision medicine, that's willing to hire, assign and deploy the necessary resources for the program is essential.

Still, it is physicians on the front lines who will be putting the new techniques into practice, so it's important to educate, incentivize and support them as they find their way around these new skill sets and workflows, said Bien-Willner.

For example, one of the first items on the cancer centers to-do list, beyond the hiring of a new Molecular Program Manager and Molecular Medical Director, was to train pathologists in the handling specimens, and to similarly educate other clinicians, such as its interventional radiologist, he said.

"Physicians have to feel part of this process, especially when you're sending samples out to vendors," said Bien-Willner.

Pathologists at Gibbs have embraced the new way of doing things, and some have even helped co-develop an IT system to help with the process of microdissection, he explained.

"They created this biomarker report that not only tracks what they've done from a billing perspective but also tracks the adequacy of the specimen and actually improves the transparency in communication between the pathologist and oncologist and also the vendor laboratories," he said.

But for all the physicians' enthusiasm, ongoing education was still critical, said Bien-Willner.

"It's really important to understand that precision medicine relies on the application of really complicated genetics and genomics, as well as complex systems biology," he said. "While oncologists are very smart individuals and very well-trained in their field, you should understand that molecular genetics is not their field."

In other words, they are not and should not, he said, be expected to be experts in genomics.

As they educated their docs ("make it fun and relevant," they said) the cancer center also further built out its organizational framework for this new genomic paradigm, creating a molecular advisory board, performing molecular workflow assessments, brainstorming and creating new IT applications.

It's an all-hands on deck process. For example, even something as seemingly simple as getting a sample tested is actually very complex, said Buhay.

"Once you figure out the tests you want and don't want, then you have to figure out will it even work? Can we get the sample out the door?" she explained. "We get the billing people involved, we get the IT, how do we build the order? All of these people have to get together and you have to figure out what are the hangups to getting this out the door."

That IT process is important and requires open, creative and strategic thinking, said Buhay.

"It's really an entrepreneur mindset and an innovation mindset where you translate your workflow into a solution," she said. "What happens typically is you get an IT solution and then you have to figure out a workflow to go along with whatever was installed."

For year three of the project, Gibbs Cancer and Research Institute is focused on further designing, rolling out and augmenting the IT tools it's developed and integrating the findings from its tightly developed molecular workflow (it's complicated, but more detail can be found in their slide presentation here) into the cancer center's tissue tumor boards.

There have been challenges, said Bien-Willner, including the fact that electronic health records don't just come in many varieties, but many subspecies within them, making it complex to manage data and workflows. Interoperability specs such as FHIR, he said, will help improve issues like those.

But the successes so far have been such that, moving forward, the center plans to extend its precision medicine expertise beyond oncology and toward cardiology, pre-natal, pharmacogenomics and more.

For others looking to attempt a similar project, Bien-Willner has some advice.

"Really work on an audit process, if you're going to get into precision medicine, to understand what you're good at and what you're not good at," he said. "Advance technology will help a great deal to improve your processes."

Moreover, "education is very important to physicians and staff alike, but it's important to understand that you need real experts in this space," he added. If you want to have a precision medicine program run by people who are just kind of interested in it, it's not going to be very successful. You want people who really understand this field for it to work."

Lastly, Bien-Willner said, "one major lesson, and learn from our mistake, is that you need administrative buy-in. We were successful in many aspect of this project but we didn't get admin support at the beginning because we were relying on these grant funds."

That money was "supposed to be a bridge to a more sustainable program," he explained, and as it runs out, "we have not yet gotten a commitment from the executive administration." Discussions continue, but there's no guarantee the project – as promising as it has been – will be able to continue as it has.

Twitter: @MikeMiliardHITN
Email the writer: [email protected]

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