Latest / Becker’s Healthcare - Clinical Leadership Podcast / David Flannery, MD, Director of Telegenetics and Digital Genetics at Cleveland Clinic

Transcript

David Flannery, MD, Director of Telegenetics and Digital Genetics at Cleveland Clinic · Becker’s Healthcare - Clinical Leadership Podcast

• 0:00
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  This is Laura Ddo with the Becker's Healthcare Podcast.
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  I'm thrilled today to be joined by Dr. David Flannery,
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  director of Telegen Genetics and Digital Genetics at Cleveland Clinic. Dr.
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  Flannery, it's a pleasure to have you on the podcast today.
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  It's good to be here.
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  And I'm really excited about this discussion because I know that there's so many
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  interesting things happening in this space, and really I,
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  I'm looking forward to your expertise. But before we dive in,
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  could you tell me a little bit more about yourself and your background?
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  Sure. I'm a, uh, physician. I'm an MD medical geneticist.
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  Uh, that means that I, you know, physician who sees patients, uh,
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  for genetic, uh, conditions or possible genetic conditions,
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  and we work in teams with genetic counselors and,
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  uh, see patients, uh,
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  for all ages from before birth to oldest patient
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  I've seen was like, I think 84 years old.
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  So we talk about it as being the real family medicine because everybody
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  has genes and we see patients and families.
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  Wow, that's a really great point,
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  and what a fascinating space to be in where you, you know,
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  can be working with somebody before they're even born and then, you know,
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  all the way up through the old age. So that, that's an awesome space to be in.
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  Um, you know, given the genetics and telegen genetics, uh,
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  what are some of the big opportunities that you're seeing in that space,
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  especially as the digital technologies come in and then headwinds you have your
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  eye on right now as well?
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  Well, just as background, um,
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  genetics becoming a more and more important part of medicine and more and more
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  genetic tests become available,
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  and there's the whole vision of precision medicine,
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  which is to use people's genes to guide their treatment and
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  preventive care, et cetera.
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  The problem is that we have only 1600 MD geneticists in the
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  country, and we have about 5,000 shed counselors.
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  So this is a very small workforce compared to the need.
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  And so my vision was to use digital tools to increase access
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  for patients to genetic services and to also
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  use them to let practitioners practice at the top of their license.
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  And so Cleveland Clinic gave me the opportunity to come here in 2018
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  in order to start implementing that vision.
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  And we've done that here very successfully.
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  We see about 10,000 to 11,000 patients per year in genetics,
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  and currently we're sustaining our use of, uh,
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  telemedicine for genetic services at about 45 to 50% of all of
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  our outpatient encounters, which is truly, uh, wonderful.
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  It saves patients having travel,
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  it saves patients from having to do things like five childcare.
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  It, uh, sometimes makes it easy,
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  especially for us seeing patients with behavioral issues like autism.
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  It's actually better to see the patient in their home. It's not just disruptive.
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  And we can do, you know, pretty good physical exams virtually now.
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  And of course, genetic counseling is very well suited to virtual care.
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  Other tools we implemented was, uh,
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  what we call eConsults eConsult electronic consult, uh,
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  from the providers to a provider. And so, just for example,
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  yesterday I had two eConsults come in from two different primary care doctors
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  who had concerns about possible genetic, uh,
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  problems in their patients or family history of condition,
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  whether it could be genetic.
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  And so they can send this structured email in the
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  electronic health record and ask their questions,
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  and then the consultant, like myself or the other members of our virtual team,
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  can then look at the patient's record, review the information,
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  give advice and recommend whether the patient needs to see genetics or whether a
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  certain test would be indicated before they come to see genetics. Um,
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  or in the case of one of the patients yesterday,
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  just tell them how to reassure the family not to worry about a genetic
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  condition.
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  But that's been very good because that sort of like a triage system
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  for genetics.
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  And then the other tool we've implemented has been chatbots,
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  and we've done several chatbot projects in the past that were research that were
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  doing genetic risk gratification and then offering genetic the counseling to
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  patients. But, uh,
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  we've recently implemented a c chatbot that we just created that does pretest
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  genetic education for patients who've been referred for what's called
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  pharmacogenomic testing.
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  And it's been really excellent.
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  More than 60% of the patients who get referred have been referred for
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  pharmacogenomic testing, uh,
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  when offered the choice of a virtual visit with us versus having the
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  chatbot have chosen the chatbot. And what this has done, uh,
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  for example, on Tuesday mornings from a the S clinic,
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  we have four slots. And typically in the past,
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  before we uploaded the chat bot about three quarters of the patients,
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  or sometimes all the patients would be patients who are seeing us
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  for pre-test education and making decisions about having testing.
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  But on Tuesday, two of the patients had done the chat bot,
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  the, that had generated an order that I saw in the electronic health record.
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  They got a test kit shipped to their home,
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  they got a cheek swab sample for their DNA was shipped it in,
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  and they had results in two weeks.
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  And we were seeing them to go over their results and explain what they mean for
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  their medical treatment drug choices and things of that sort.
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  And actually the first two people who had had a chatbot.
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  So I'm expecting to see more and more patients who've had the chatbot and had
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  testing. And that's an example of us in the,
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  the pharmacist who works with us practicing higher on your license
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  rather than have us be doing like basic education and helping people make an
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  informed decision, we're actually imparting, you know, important, uh,
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  information and making medical recommendations and suggestions to them.
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  We have two other chatbot projects that we're working on developing, um,
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  that'll be similar about genetic test information for
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  patients. And eventually we'll have an intake chatbot for, um,
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  patient referrals that can go through their family history.
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  So all of this is to help improve the, uh,
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  access and to help make just, uh, more efficient practitioners.
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  I love that. I think, you know,
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  all the different areas where there's on the clinical side of the operational
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  and, and really making things more convenient for patients too, um, is so,
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  so meaningful and definitely adds a lot of value to, uh,
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  the patient interaction. Um, from your perspective, how do you see the,
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  um, digital genetics and telegen genetics really growing to become a larger
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  part of, um, you know, the organization,
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  whether it's from your side or even potentially connecting with other
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  departments and services in, in kind of sharing learnings.
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  What does that look like for you?
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  Well, that gets to another project that we have been trying to get into. The,
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  the, uh, pharm d uh,
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  Pharmac genomic specialist and myself have, uh,
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  been participating against AL Project Echo Project ECHO is
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  a tele mentoring program. It was started in, um,
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  New Mexico by a specialist who found
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  that he was getting lots of referrals to patients to treat, uh,
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  them for hepatitis C.
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  This is because her like expensive medications for treating that and
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  knowing the ins and outs of the disease as well as the use of the
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  medication was not something that most primary care physicians are not
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  familiar with. But this, uh,
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  clinician realized that he was being overwhelmed with patients for
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  Hepatitis C and they're sort of filling up his schedule and other patients were
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  not being able to be seen.
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  So he came up with a brilliant idea of a tele mentoring program,
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  and he called it Project fl.
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  And so what he did is he set up a structured telemedicine kind of
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  thing, actually more likely, um, video conferencing.
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  And they would schedule sessions for echo and providers would sign up
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  and it'd be scheduled at a certain time per month.
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  And providers would all log in and the expert would talk about hepatitis C
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  and talk about some different medications.
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  And then each primary care doctor who signed in would
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  present, uh,
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  information about a patient and ask about advice if they, you know,
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  how they should manage it, what they should do, et cetera.
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  And then the expert would give them advice. And similar, the other, uh,
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  primary care providers would present their cases and get advice.
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  And what's most interesting about this is if the success factor
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  was the number of providers who stopped coming to the ECHO
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  sessions because this was evidence that they had learned how to manage the
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  patients. And so, uh,
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  they just changed that model to other disorders. And for us,
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  we really want to have pharmacogenomics, uh,
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  be something that all of our
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  hospitals in our Leon Clinic system would be able to offer to
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  patients. But there's a big learning curve. Very few people know about this.
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  And so we envisioned setting up the project Echo for pharmacogenomics,
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  and we found that University of Minnesota has had one.
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  And so we've been learning from them participating in their, uh,
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  ECHO project for pharmacogenomics.
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  And once we get this all figured out,
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  we wanna go ahead and establish a project echo and offer that to
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  first, uh, pharmacist, uh, throughout the, you know,
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  our system so they can start learning about this and then start off,
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  get them to providers as well. So that's an example of, you know,
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  yet a new model of using, uh, digital tools to,
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  you know, help in healthcare.
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  That's amazing to hear. And,
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  and how inspiring a a way that you can really work with others and learn from
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  others too, um, within the healthcare space to, to make a big difference. Uh,
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  from your perspective, what's next?
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  What are some of the additional investments that you see making, I,
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  I know you just talked about the, um, on the pharma side, but you know, are,
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  are there other areas where you see investments and then big growth
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  opportunities for the future?
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  Well, I mean, for precision medicine to work,
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  what we have to do is we have to get patients tested and we have to get their
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  results into the electronic health record and then have them be actionable.
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  And this is a, a big challenge because, uh, most genetic test results,
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  uh, come to, to, uh,
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  whoever ordered the test as a PDF ,
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  so they're not in the E E H R. And that's become the big challenge,
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  is figuring out how to get laboratories to get their results
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  of the genetic test into a form.
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  They can then be loaded into patient's electronic health record.
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  And then once it's in there, it needs be able to be recognized,
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  enacted upon.
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  And that's where algorithms and artificial intelligence will need to come into
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  play, because then they can sit there and in the health record,
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  develop what we call clinical decision support tools.
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  And so then what would happen is,
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  say if patient sees their doctor and they've had testing done
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  and the doctor wants to prescribe a certain drug and
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  clinical physician support tool would recognize the patient's genotype
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  versus that drug and put up an alert that says,
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  you may not want to use that medication on this patient.
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  And that could be for very,
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  a very interesting number of different kinds of conditions, not just for, uh,
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  pharmacogenomics, which has to do with how the patient metabolizes a drug.
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  It could also be for things like, for say, uh, seizures.
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  It's, uh, at this point in time,
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  we now know that there epilepsy has
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  hundreds of different genes that can cause it.
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  And once we characterize which gene is malfunctioning in a patient with
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  epilepsy, you can then know that there's certain drugs,
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  it would be more effective for that patient rather than just the usual routine
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  drugs. And then conversely,
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  they could know that the usual routine drug you would start with is not gonna be
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  of benefit to this patient. It's a,
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  rather to start that trial and error process,
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  it would alert the physician to go and try a more appropriate drug to
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  start with.
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  And this could be applied to a wide variety of other types of disorders.
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  And so that's really where the,
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  the real benefit of, uh,
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  genetics in medicine is gonna happen if we get to that point.
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  But it's a matter of getting the information, getting patients tested,
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  getting their genetic results into the electronic health record in an actionable
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  way, and then actually have the, uh,
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  algorithms for artificial intelligence that can help put the patient's
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  information together with their genotype and then give advice to
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  the physician.
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  Yeah, absolutely. That, you know, just sounds like an amazing, uh,
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  amazing way to deliver care. And you know how,
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  when you think about that ideal that you just described,
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  obviously it takes a lot to get everything, um, transitioned and,
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  and really be in a space where, you know, the, you,
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  you're able to leverage the EHR and, and, um, AI appropriately.
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  How far away do you think that we are from a reality, you know, where,
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  where that's possible and where that's being done every day?
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  Well, um, interesting. Um,
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  Geisinger Health System in Pennsylvania started a project called
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  MyCode and they started off wanting to do, uh,
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  genetic sequencing of a hundred thousand patients in their health system.
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  And they've exceeded that now, and they did a whole,
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  we call it exome test on their patients.
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  And then they would identify what abnormalities were found in
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  different genes and what medical action may be attached to that.
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  By this point in time,
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  they still haven't achieved nirvana of this all being in the health
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  record and immediately actionable. Uh, but that's,
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  they're sort of demonstrating how this can be done. Uh,
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  another place is doing this is North Shore Health in Chicago,
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  land near where you are. Um, that started off I think,
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  10,000 patients who they did genetic testing on and then working with,
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  uh,
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  some software companies to then get that information into their
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  E H R and then having it become actionable.
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  And once again, that's still a work in progress as well.
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  But that's certainly going along of that. And so we,
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  we expect to learn from these, uh, other pioneers, uh, for us to do this,
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  uh, for us, for pharmacogenomics. We actually, um,
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  are talking with a software company that has done incorporation
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  of pharmacogenomic results into the EHR and
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  has clinical decision support tools built in.
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  So we're looking forward to,
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  to meeting with them and figuring out how that works and, you know,
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  perhaps even piloting it, you know, the future is coming. Of course,
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  I kept telling people I started doing telemedicine for genetics in 1995,
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  that telemedicine was the future, and I kept telling people,
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  it's the future . It took the pandemic for it to become ,
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  you know, very common place.
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  Yeah, absolutely. Well, hopefully this transition is much quicker and, and,
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  you know, definitely, um, seems like amazing things happening. So Dr. Ry,
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  thank you so much for being on the forefront of this and, and sharing, um,
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  you know, what you're doing there at Cleveland Clinic with us today.
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  I'm always happy, as my wife says,
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  like if we're at a party and someone asks me about it,
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  I start telling about telegen. She said like, oh boy,
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  you're in for it 45 minutes. Easily .
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  Absolutely, definitely. No, it's, it's great, um, to have,
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  you know how passionate you are and that definitely shines through. So, um,
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  we really appreciate it. I've had a lot of fun in, in, um,
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  talking with you today and just find all of this very fascinating.
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  Oh, my pleasure.
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