homosassa cancer center “ using knowledge to reduce the burden of human cancer” slide 1...

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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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.


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.


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)

http://www.whitehouse.gov/the-press-office/2015/01/30/fact-sheet-president-obama-s-precision-medicine-initiative

http://www.whitehouse.gov/the-press-office/2015/01/30/fact-sheet-president-obama-s-precision-medicine-initiative


Positioning for Growth: Upcoming Market Trends


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.


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


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


DNA Mutations and Cancer


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


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


HER2 biomarker and Herceptin


EGFR in Lung and Colorectal Cancer

http://www.mycancergenome.org/content/disease/lung-cancer/egfr/21/

http://www.mycancergenome.org/content/disease/lung-cancer/egfr/21/


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?


Big Data

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Falling Costs, Increasing Size

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source: http://www.slideshare.net/GerryHiggins1/next-generation-sequencing-in-pharmacogenomics


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


source: GenomOncology (2014)


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


Proposed Architecture


Proposed Scope


High level Roadmap

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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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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


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


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


Why Pharmacogenomic Clinical Trials

Indirect Downstream service revenue

Increased market share

Direct NCI funding Increased Access to pharmaceutical

industry trials


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


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)


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


Potential Revenue Increase for Breast Cancer


* 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


Summary


APPENDIX

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REFERENCESCarlson, J. J., Garrison, L. P., RAY Ramsey, S. D., & Veenstra, D. L. (2009). The potential clinical and economic outcomes of

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


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.


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/


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


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.


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 1...

Documents

cancer homosassa cancer

burden of human cancer

cancer screening

human genome

precision medicine initiative

goal of precision chemotherapy

better patient outcomes

therapy efficient