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

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

Science and Medicine ©2009 RALPH SNYDERMAN 1900s Germ Theory Chemistry Physiology Pathology Physics Find It Fix It Understanding Disease

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

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

Disease-oriented

Find it, fix it

Reactive

Sporadic

Physician-directed

Very expensive

Science and Medicine ©2009 RALPH SNYDERMAN 1900s Germ Theory Chemistry Physiology Pathology Physics 2000s Genomics Proteomics Metabolomics Systems Biology Informatics Micro/Nano Processing Find It Fix It Predict It Personalize It Understanding Disease Understanding Health, Disease and Complexity

Concepts of Disease ©2009 RALPH SNYDERMAN 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 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 Prevention Early Intervention End of Life Care Disease Management Personal Health Plan

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

Health risk analysis

Pathogenesis tracking

Molecular diagnosis

Clinical event prediction

Therapeutic potential analysis

Predictive Model Development ©2009 RALPH SNYDERMAN CLINICAL DATA COHORT OTHER PROTEOMIC GENETIC CLINICAL 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

Paradigm Shift to Personalization ©2009 RALPH SNYDERMAN 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

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

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

©2009 RALPH SNYDERMAN Model for Personalized Health Approach PATIENT PHYSICIAN 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

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

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

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

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