publication date: Sep. 30, 2016
Two Gigantic Health Systems Integrate Cancer Data to Bring Precision Medicine to Community Care
By Matthew Bin Han Ong
Two of the nation’s biggest nonprofit health systems—Dignity Health and Catholic Health Initiatives—launched a precision medicine program that has the potential to create the largest collection of clinical cancer data ever compiled by a single organization.
Together, Dignity and CHI, based in San Francisco and Englewood, Colo., respectively, operate nearly 150 hospitals and care centers across the U.S. Both rank in the top five largest nonprofit hospital systems.
The two systems serve about 12 million patients annually, and CHI alone sees about 36,000 new analytic cancer cases per year. The numbers for Dignity weren’t available.
With the combined total of 21,866 staffed acute care beds, the two systems are larger than the nation’s largest nonprofit health system, St. Louis-based Ascension Health, which has 16,825 beds, figures published by Becker’s Hospital Review show.
The just-announced Precision Medicine Alliance will enable cancer patients to receive targeted therapies based on genetic and molecular information, the two systems said.
The alliance will initially focus on advanced diagnostic tumor profiling in cancer treatment and will later expand into other areas, including cancer and cardiovascular risk, and pharmacogenomics.
This is significant, because genomic profiling of tumors at this scale is usually part of the standard of care at large academic medical centers, not in community practice settings, where physicians are more likely to prescribe standard therapies without taking into account the patient’s genomic information.
“When patients have used up all the standard therapies and we’re looking for something different, we do one of these genomic tests, and we refer them out to someplace else to get further therapies or clinical trials,” Shahzad Siddique, chairperson for the clinical council of oncology for Dignity Health, said to The Cancer Letter. “The Precision Medicine Alliance allows us to use the tests effectively and more often, and it brings our standard closer to the standard of an academic center.”
A cornerstone of the alliance is Syapse, the precision medicine IT platform that Vice President Joe Biden highlighted at the National Cancer Moonshot Summit in Washington, D.C. (The Cancer Letter, July 1).
Syapse, an informatics software program that integrates oncology data from electronic health records with genomic data, will enable physicians to compare notes with other practitioners throughout Dignity and CHI.
“If we develop this program, we would be running similar molecular tests on our patients,” said Siddique, who is also medical director for clinical research at Mercy Medical Group, based in Sacramento, Calif. “We would be storing the data, using the data to help develop a base of clinical trials that we can enroll patients in. The size is important, because it is probably the largest effort to do this in the community setting, where we’re not a large academic health center.”
The alliance forms at a time when Biden, through the National Cancer Moonshot Initiative, is pushing for federal agencies, hospitals, and data companies to collaborate and improve the state of oncology bioinformatics.
“The Precision Medicine Alliance between Dignity Health and Catholic Health Initiatives represents a massive commitment to precision medicine by two community health systems,” said Jonathan Hirsch, founder and president of Syapse. “I believe this is a real turning point for adoption of precision medicine in the community, and we are already seeing strong interest from large community health systems to roll out their own precision medicine programs.
“The alliance has several distinguishing facets: a large geographic reach, aligned academic research groups such as Baylor College of Medicine, and a robust community research program. When you pair this with the operational efficiency and commitment to health IT that both CHI and Dignity have demonstrated, you have the makings of a very successful, potentially transformational, precision medicine program.
“The commitment by CHI and Dignity to participating in Syapse cancer data sharing networks will help advance our collective goal of building the clinical utility evidence necessary to bring precision medicine to all cancer patients. This is a major leap forward for our work on the Cancer Moonshot efforts.”
Other data-sharing networks with similar goals include the Oncology Precision Network—comprising Stanford Cancer Institute, Intermountain Healthcare and Providence Health—and CancerLinQ, a clinical decision support database operated by the American Society of Clinical Oncology (The Cancer Letter, June 24, 2016; Feb. 20, 2015).
Common data standards, language, and protocols will be key to advancing the goals of the moonshot, said Bill Dalton, CEO of M2Gen, founding director of the Moffitt Cancer Center Personalized Medicine Institute, and one of the founders of the Oncology Research Information Exchange Network, also known as ORIEN.
“I think it is great that Dignity Health and Catholic Health have teamed up to form a precision medicine network and hopefully we will all be partners in what ultimately will be a ‘network of networks,’” Dalton said to The Cancer Letter. “Diversity of initiative and purpose, especially in the early days of this effort, could be rewarding especially if the networks share lessons learned from their respective efforts.
“I also believe we should be thinking of creating standards for data collection and operation procedures that ultimately will promote interoperability and data sharing as is being promoted by the Moonshot.”
To date, ORIEN, a research consortium that uses a standardized IRB-approved protocol, has accrued 150,000 patients from nine active sites. ORIEN has 14 members—mostly academic cancer centers—and sees about 60,000 cancer cases annually (The Cancer Letter, March 13, 2015).
Alliance: We Will Share Data
Ironically, Biden’s moonshot is allowing him to circle back and fix the systemic errors that were created by the American Reinvestment and Recovery Act of 2009, when the Obama administration invested $35 billion to enable doctors to transition from paper to electronic health records (The Cancer Letter, June 3).
Alas, the White House’s $680 million proposal to fund the moonshot has not been authorized by Congress. It remains to be seen whether the broad scientific and public health initiative will develop incentives for data sharing.
Biden’s goals for data sharing are threefold: to make information interoperable, publicly available, and accessible.
Dignity and CHI’s Precision Medicine Alliance is committed to those goals, said Dax Kurbegov, vice president of the CHI Institute for Research and Innovation.
“Our goal from the get-go is to contribute to the body of knowledge that allows us to advance this science, and that allows us to understand how to best incorporate these technologies,” Kurbegov said to The Cancer Letter. “Syapse is a key partner in the cancer moonshot program, and it is our desire to support that series of goals through our participation in the moonshot and with Syapse.
“What form that takes and whether it’s ultimately a single public database in which all of that data is stored, that’s probably not something I know exactly how it’s going to play out. But it is very much our organizational commitment to be active contributors to this knowledge base.”
Dignity and CHI don’t plan on developing their own genomic profiling capabilities. Through Syapse, Dignity and CHI physicians will be able to choose from a panel of genomic testing companies, which include Foundation Medicine, Caris Life Sciences, Intermountain Healthcare, Guardant Health, and Stanford.
“Our feeling is that our expertise is in providing care at the community level, not in these emerging technologies,” Kurbegov said. “We want to create an open environment where our clinicians are provided support, but have the freedom and latitude to choose a test provider or a test of specific interest to them. We think one of the compelling advantages for us is that we then don’t have onus or the burden of driving in-house the technology development, that we’re not constrained in any way and have a lot of freedom by doing that.”
Moving Beyond EMR
Prior to the alliance, Dignity and CHI oncologists who wanted a genomic profile of a patient’s tumor would order the test, receive the results on paper, and have no immediate and comprehensive way of analyzing and translating the information into clinical decisions.
“I may or may not act on the test and I may not know what’s the right thing to do with the results, whether to put the patient on trial or treat with standard of care. The difference is, being in a program, you develop relationships with the labs so that there’s an interface built into your EMRs so you can get the results electronically,” Dignity’s Siddique said. “You build relationships with the software company and you take the information from the tests, save that, and you know what your population is and you can work with pharmaceutical companies to get clinical trials that suit your population.
“A program like this would allow us to kind of provide the same standard of care [as academic cancer centers] in terms of using this type of technology.”
Electronic health and medical record behemoths have yet to catch up: to this day, some physicians and hospitals find it difficult to transfer patient information between systems, or, for that matter, between facilities within systems.
“Right now, our EMRs, they are much better than paper charts,” Siddique said. “But I have no way of pulling up the last 10 breast cancer patients that I treated. The EMRs aren’t really smart in the sense that they’re not searchable.
“You can’t calculate things like survival and outcomes very well. When you take all these patients and you store their data and outcomes and therapies, you can take a much closer look at how well did the last 10 patients do, who got the molecular tests and received a specific therapy. Was it a beneficial outcome? Is it helpful to do this? We don’t really know that in a lot of the cases.
“Patients are interested in individualized medicine. They want their cancer to be treated more specifically so I think it is attractive to patient to receive personalized care.”
Dignity Health uses Cerner in all hospitals and the outpatient clinics use a variety of EHR products. Siddique’s Mercy Medical Group, for instance, uses Allscripts. The system hopes to move most facilities to Cerner.
The primary hospitals at CHI operate with Epic, Cerner and Meditech, whereas the system’s oncology providers largely use Elekta Mosaiq; a few are on Varian and other EHRs.
“Part of this coordinated effort is to allow us to provide decision support, workflow support, in view of the molecular landscape of a patient in a way that is agnostic and independent from the individual EHR that’s being used,” Kurbegov said. “From our perspective, what we’re doing is we’re aggregating all of that patient information into a central, rationalized data warehouse, and then feeding that into Syapse, which then can pass information back and forth effectively. For us, it solves that challenge, that headache, because it’s a platform that essentially fits over and is able to dialogue back and forth with those systems.
“Syapse essentially facilitates or simplifies the process of test selection and test ordering. Because Syapse will aggregate clinical, financial, and molecular data in one place, and because the platform from the get-go is designed to create a learning environment, we now have a very robust picture of the entirety of the patients’ situation, and can leverage in any number of ways.
“The most obvious of these is you can power molecular tumor boards or dialogues so that clinicians have access to expert opinion or commentary in circumstances where the molecular report in and of itself still presents some clinical dilemma or uncertainty.
“It certainly allows us to do things like clinical trials matching—identifying clinical trials within our network that are available at the site to make it easy and hopefully improve the rate of accruals to precision medicine trials, but can identify trials outside the system as well that might be important for the patient.”
For Dignity and CHI, having a self-sufficient precision medicine program means having the ability to generate a database that would be directly tailored for the needs of their patients.
“So much of the landscape of molecular profiling, up until now, has been dominated by what industry is hoping to glean,” Kurbegov said. “So when we look at the panels and profiles that are out there, the majority of that information isn’t meaningful or actionable to an individual patient or to the provider who is taking care of that patient.
“It has more profound meaning for industry, looking at these broad datasets. That creates a tension that exists between our reimbursement and payer world and our provider world in that payers traditionally don’t want to pay for discovery, for research.
“So it is very much our hope both in terms of potentially addressing that gap that exists with payers, but also because we can work with our partners to develop panels and tests and find that sweet spot where really what we’re testing is potentially actionable either through FDA-approved drugs—but perhaps not for that indication—or through matching to clinical trials.”
The program goes further: physicians will be able to track and assess cost of care.
“We certainly realize that in a resource-constrained environment, particularly in an environment that is increasingly moving to a value-based paradigm around reimbursement, that it’s important to not just know that you’re improving outcomes for patients, but that you’re doing so in a responsible and sustainable way,” Kurbegov said. “All of that secondary research on the program is facilitated by this platform that we’re constructing.”
The alliance will be rolling out the program with two to three pilot sites within the next six to eight months, followed by a more rapid implementation across the system over 12 to 18 months.
For CHI, the program will be first deployed in the Tacoma, Wash. and South Puget Sound region through the Franciscan Health system, followed by Nebraska, Colorado and Ohio. Dignity will start with Sacramento and Phoenix, Ariz.
“This was really the outgrowth of the desire of two like-minded systems to pool resources, share expertise, and uncover opportunities to work together to share a common problem,” Kurbegov said. “The ideal here is that we are pairing the patient with the most informed therapy that we can give regardless of location.
“In light of the Cancer Moonshot, one of the mandates and driving factors is to accelerate and enable data sharing across systems, across industries. We’re very much committed to doing exactly that.”