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Center for Personalized Healthcare Summer 2013

An Interview With Megan Doerr, MS, CGC, About Her Experience In The Field Of Implementation Science Research

JD: What is implementation science?

MD: Within healthcare, we’re constantly trying to study what it is that we can do to provide the best health outcomes for patients. That’s what we do as caregiver-scientists. Implementation science is the framework that we use for evaluating if an evidence-based intervention leads to a better outcome in a particular setting; it allows for us to look within a system to see what are the barriers and what are the facilitators for bringing something new into clinical practice.

JD: Can you briefly explain the process of implementation science?

MD: You have to have some evidence-based intervention that you are trying to implement: a tool, technique, or process that you want to be using in a clinical setting. You then describe that intervention, you describe the clinical practice area, and then you set up a research framework to assess how that intervention works within that clinical setting. That might involve direct observation. It might involve monitoring some product of the intervention. It might involve surveying patients about their experience or the support staff within a clinical practice area. So you establish this research framework and then you do the research, just like if you were doing an experiment in the lab. You would write out your process and then you would follow your process just like a recipe in a cookbook, hoping to get to the outcome that you hope to get to.

JD: Why is implementation science important?

MD: If we don’t study what we’re doing, we have no way of knowing why it works or why it doesn’t work. It’s essential for us to be studying any new intervention because the last thing we want to do is cause harm or create care disparities. What we do want to do is improve clinicians’ ability to care for patients, which should improve both patients’ healthcare experience as well as their health.

JD: What types of projects should utilize implementation science?

MD: Any project that introduces an evidence-based tool or process to clinical practice. So any discipline: cardiology, primary care, oncology, surgery. All of these areas are areas that can use an implementation science framework.

JD: Are there any limitations or projects that implementation science would not be usable or feasible?

MD: When it comes to clinical care, I would say no. For any sort of project within the realm of clinical care, using an implementation science framework allows you to assess the barriers and facilitators to that change or tool or process.

JD: If people wanted to further explore implementation science, where would they go to get more information?

MD: There are a few really good places to go including the Fogerty International Center, National Institutes of Health website. Also, there is actually an implementation science journal (Implementation Science), and so that journal is a great starting place.

JD: Can you explain how you hope understanding implementation science will advance your own projects in CPH?

MD: Right now, we are using an implementation science framework for the pilot of the MyFamily program. MyFamily is a family history collection and risk assessment tool that we are using in a number of different clinical settings including primary care here at Cleveland Clinic. This implementation science framework that we’re using is allowing us to assess: is the MyFamily system acceptable and usable by providers; does it fit into current clinical protocols; does it create any health disparities; is there any chance of harm associated with using this program? So in this way we are doing our due diligence around this intervention. The intervention was developed based on the best evidence we have and with the best intentions, but we want to make sure that we have proof that we’re not having any negative effect and in fact, we hope to prove that we’re having a positive impact on the quality of care that patients receive.

Third Annual Personalized Healthcare Summit Brings Experts Together In Cleveland

After months of planning, The Center for Personalized Healthcare has just wrapped up their third annual Summit. This year’s theme was “from concept to practice.” To drive the point home, they featured relevant speakers in the field like Ahmed El-Sohemy, PhD, who spoke about the emerging technology of nutrigenomics and David Levin, MD, who moderated a panel discussion about driving clinical utility from big data. To round out the forum, we invited patient speakers as a testament to the importance of taking responsibility for your health choices. Joe and Retta Beery opened the conference with their touching story about their disabled and frequently misdiagnosed children whose fate was brightened tremendously only after whole genome sequencing was performed. On the second day of the Summit, Allyn Rose, Miss District of Columbia 2012 bravely described the path she took to come to the decision to proceed with bilateral prophylactic mastectomy to mitigate her risks for inherited breast cancer. The Center’s director, Dr. Kathryn Teng, is proud of the event and the people it draws. “Our summit is now in its third year and we feel we have plenty to offer in the personalized healthcare space. Our intent is to bring together thought leaders, clinicians and patients in a forum where there is an open exchange of ideas as well as face time with people in the field who matter. We are happy to provide this platform and build on our experience to plan for future events.”

We exceeded our expectations this year with over 120 participants from 14 states as well as international attendees. Attendees included healthcare providers, government, industry, ethicists and students from around the country. Dr Teng: “It is my hope that people were inspired by the ideas shared during the panel discussions and embraced new ideas regarding scientific discoveries, clinical integration, education, use of big data, and ethical-legal issues that they can share throughout their organizations.”

Other highlights of the Summit included:

  1. A panel discussion on reimbursement of personalized healthcare approaches
  2. A discussion about the integral part personalized healthcare plays in value-based operations (VBO)
  3. A unique demonstration combining genomics and music

Planning is already underway for the 2014 summit. The event will undoubtedly be larger and more inclusive than those of bygone years. “As attendance grows, so does the demand for a comprehensive agenda,” says Peter Balint, project manager at the Center for Personalized Healthcare. “An engaging and meaningful event requires year round planning and we have already started thinking of the best ways to deliver our message to future attendees.”

Important Dates and Events for The Center for Personalized Healthcare

We know it’s only June, but the Center for Personalized Healthcare is already looking forward to November because November is Personal Healthcare Month! We are planning a few events to celebrate this year.

  1. Mark your calendars now for Healthcare Built Around You: Emerging Concepts in Genomics workshop which will be held on November 18, 2013 from 12pm-4:30pm at CCAC in Beachwood. This workshop, co-sponsored by Cleveland Clinic’s Center for Personalized Healthcare (CPH) and Center for Personalized Genetic Healthcare (CPGH), will utilize non-traditional genomic testing to educate the audience about basic genomics concepts. All attendees will have the ability to partake in a broad direct-to-consumer genomics test as well as a nutrigenomics test prior to the event. The event will consist of lectures followed by roundtable discussions. Topics include a genetics primer, process of genetic testing and Genome-Wide Association Studies (GWAS), pharmacogenetics, nutrigenomics, and Ethical, Legal, and Social Implications (ELSI). This workshop is open to all Cleveland Clinic physicians and nurses.
  2. The Center for Personalized Healthcare is teaming up with the Wellness Institute for an event focused on patients and consumers. The event will be held on November 14 at TRW in Lyndhurst. More details to come.
  3. We are also hosting a visiting professor for Medicine Institute Grand Rounds on November 7 at 7:30am. Dr. Howard McLeod from The University of North Carolina at Chapel Hill will be speaking about pharmacogenomics.

Look for registration to open for Healthcare Built Around You: Emerging Concepts in Genomics this summer. If you would like to receive more information, please contact us at cphinfo@ccf.org.

Celebrating our Heroes

Please help us congratulate Dr. Tara Mastracci, MD, the 2013 2nd quarter recipient of the Personalized Healthcare Hero award.

The Personalized Healthcare Hero award is given quarterly to a Cleveland Clinic employee who demonstrates commitment to the personalized healthcare initiative, embraces personalized healthcare approaches in their daily activities, and advocates for integration of personalized healthcare into the standard practice of medicine. In addition, this individual has contributed to advances in personalized healthcare and supported the specific initiatives and projects sponsored by the Center for Personalized Healthcare. Recipients of this award will be announced quarterly in our E-newsletter and recognized formally once yearly.

This quarter’s recipient, Dr. Tara Mastracci is a staff surgeon in the Department of Vascular Surgery. Dr. Mastracci has been instrumental in the MyFamily tool, a patient-entered family history collection tool which integrates into Epic, providing risk assessment/decision support for clinicians. The ultimate goal of MyFamily is to better facilitate the use of family history as a risk prediction tool, allowing for better prediction and prevention of disease and driving appropriate utilization of resources. Specifically, Dr. Mastracci assisted as a content expert in developing the algorithms related to risk for abdominal aortic aneurysm (AAA). Her insight was particularly valuable in establishing Cleveland Clinic standards for AAA screening, standards which hope to impact quality of care with earlier detection of AAA and result in cost savings for the system with earlier, non-emergent intervention. Our team has enjoyed working with Dr. Mastracci. Her tireless enthusiasm for better prediction of AAA and her dedication to personalized healthcare inspire us all.

We applaud Dr. Mastracci for her work. We thank her for her partnership, and we look forward to working with her on future personalized healthcare initiatives.

Nutrigenomics: A Physician’s Personal Story

by Kathryn Teng, MD

As a primary care physician, I often talk to my patients about decreasing their salt intake, but I never considered the advice for myself. It never occurred to me that I might be eating too much salt.

Even though my father has high blood pressure, mine has always been fine. Despite our family health history, I was oblivious to the fact that I might need to think about the amount of salt I am eating. Why am I suddenly re-thinking my salt intake? Because I think it is interfering with my sleep, which is causing both physical and mental exhaustion. For years, I have been drinking 10-12 glasses of water a day (no caffeine, no sodas), and I am up three times a night to empty my bladder. This brief awakening was not a problem until my sleep was further disrupted (the effect of having 2 children). The outcome - grumpy, sleep-deprived doctor – Not good!

I always suspected that Americans consume too much sodium. Eating high amounts of sodium raises blood pressure, which in turn increases the risk for heart disease and stroke, which are the leading causes of death in the United States. The Institute of Medicine recommends 1500 mg of sodium per day as the Adequate Intake level for most Americans, and most nutritionists recommend that adults consume no more than 2300 mg of sodium per day. In fact, studies have shown that we actually only need about 180-500 mg of sodium per day to keep our bodies working properly.

Even more interesting is that recently, studies have shown that some individuals who have certain genetic variants are even more sensitive to salt than the average person. These individuals are so sensitive to sodium that even when they eat normal or low amounts, they are at increased risk for high blood pressure. This type of effect is an example of a new field of medicine called nutrigenomics – the study of how nutrients impact gene expression, biochemistry, and metabolism. When I took a nutrigenomics test recently (just for fun), I found out that I am one of those individuals who is extra-sensitive to even normal amounts of salt in the diet. I don’t eat more than 1500 mg of salt a day as it is, but I suspect this sensitivity has been making me want to drink more water than most people. As a result, I changed my diet – I cut back on my salt intake, and I am drinking less water a day (because I am not as thirsty). I’m sleeping better, and I’m not grumpy anymore.

As a doctor, I always wonder what it will take to make my patients change their behavior and lifestyle for the better. In my case, it took this genomic test (something tangible) to make me stop and think about the connection between salt and my sleep. And knowing this information definitely made me change my behavior – for the better. No more grumpy doctor!