 Terrific. Thank you. Well, I appreciate the opportunity to address this conference here While I get the opportunity this really represents the work of a lot of people at North Shore I have a lot of great team members. So I'm very excited to share our initial experiences As I was mentioning during the lunch session, I think with the implementation of this We're definitely charting a new direction But that path is still a dirt road and we have yet to pave it So we've learned a lot but consider this version 0.9 not even version point 1.0 of where we need to be and where we want to go So just some quick disclosures here Just for those of you who may not be familiar with North Shore University health system We are our medium to large-sized health care system on the north side of Chicago We are patient catchment areas from downtown Chicago up to basically the Wisconsin border We have a relatively large center for medical genetics with three MDs and five genetic counselors on staff currently But like most institutions, you know, we were asked, you know, the fundamental question Well, how do we really start to scale services over a relatively broad geographic area? recognizing even with a large by many standards genetics Division, how do we really capture the patients that we need to be seen or at least identifying patients who may benefit from? genetic risk assessment and testing potentially we all start faced with a lot of Similar realities that are like local patient population is just demanding these services We're in a competitive area. Our footprint is also One where they demand the the latest innovation and application to their care as well We did have our center for medical genetics, which for those in the crowd may not realize We were actually started initially by Henry Lynch of Lynch syndrome in 1997 so we do have some historical roots in trying to Bring genetics and genetic applications to our clinical care, but like many centers You know, we're limited in capacity with how many patients we can actually see and really this served our clinic as a foundation Well, how do we integrate and expand into other specialty clinics and overcome the same obstacles in a more systematic way? That's preventing us from identifying patients who may benefit from clinical genetic services And really our vision has been now with the Center for personalized medicine How do we really bring genomics to the front lines of care? You know, we used our specialty clinics as a launch pad for this for assistive-wide initiative and really Was the foundation for the creation of our Center for personalized medicine To help us with developing the workflows and the educational aspects both our provider and patient facing that are critical To have success in this arena So we're not immune to the challenges many of us face. There are a lot of time constraints We have to educate not only your physicians, but patients and all their healthcare providers from The administrative staff who helps check in the patient to our nurses to the clinicians and patients themselves Challenging bowels with appointment links in terms of how do you deploy sort of a risk assessment tool? There's many competing initiatives and guidelines that our primary care force have to manage for that are important for patient care and Still there's a lot of realities versus myths that are out there regarding cost of testing insurance reimbursement Awareness of Gina and other protections and where those limitations are in terms of the regulations and Sort of the elephant in the room is how are we really going to integrate this into electronic medical record? One of my goals is help create more seamless workflows We're on an epic-based system and we have a long history of integration across our health system So how do we start to leverage our EMR in a positive way with genetics? Whereas before finding a genetic result could be very difficult in the electronic medical record As I mentioned well There are relatively few of us who are fully dedicated to our Center for personalized medicine in terms of FTE support the FTE's Involvement has to cross many different lines and divisions and so breaking down the traditional Barriers of siloed approaches was key to our launch and in our broader mission within the Center for personalized medicine So having representatives of all these key steaks stakeholders and really how do we also facilitate the handoff from the research in a translational aspect? to the clinical and bedside care So this led to our genetic and wellness assessment Tool it was a pilot that began in 2017 and basically it's a checklist of genomics I check less that's sent to all patients before their annual history and physical care via a North Shore connect So North Shore connect is what we call at our epic my chart application and basically it was approximately 30 questions with Branson logic to help Identify patients, which we know is a challenge in any health system who may benefit from targeted testing So NCC and guideline-based testing etc. And it have either genetic testing presented as an option for Being proceeded with or for to one of our personalized medicine clinics as well The key to this is integrating with existing workflows We couldn't take our primary care physician out of their normal channels and of workflows Workflows once you tell them to go outside the EMR your project is pretty pretty much not going to be a success It also started to provide us with a platform to address some of the educational initiatives giving real-time Information to the clinician of why this is important for the patient and what could come of it? And what are the next steps of action as well? so It also was an opportunity of us to explore That transition and that opportunity from reactive and proactive testing. So what do I mean by that? Well, the reactive manner is you know traditional questions of NCC guidelines is there a history of breast cancer a personal history of breast cancer Oxygenase Jewish ancestry and probing at some of the cardiomyopathy questions with sudden cardiac arrest or or SIDS in the family as well as Or top of the these are things we know we should be asking about there are guidelines for incorporating genetic testing But we still have to do better as a health system of dead identifying these patients But then also moving to well an option for proactive because again There's a growing segment of our population for sure and we start we see this trend across The country a patients who want to know is there something in our DNA or change in our DNA that I should know about because I need to incorporate That into my screening and management Our health the healthy gene panel is our prime example of this And so this is actually if a patient doesn't answer Firmatively to some of the more targeted questions they're presented with an option to do a healthy gene panel And this is in vitae's healthy gene panel. I'm looking at approximately 139 genes related to Health risk as well as pharmacogenomics taking that proactive approach of well I want to make sure I'm on the right medication and while pharmacogenomics is not a crystal ball It's not going to tell the precise dose and the exact drug someone should be on It's another piece of information that can be layered upon traditional clinical parameters and one could argue that pharmacogenomics could also be a reactive We know there's a diagnosis for example perhaps depression that this information will be important as Getting in terms of the next step for the our patients care So practically what what what does this look like? Well part of the experiences It needs to look like it's part of the patient experience as well Just like any other appointment process as well So this is an example of what a patient would see through our North Shore Connect again. This is What we call our epic my chart and basically about five to seven days before Patients encounter they get a message. There's some things you need to do in terms of your upcoming appointment So for example reviewing insurance information, etc The usual logistic things that we need to take care of but then you have a health assessment tool That's here. The reason why it's called a health assessment tool is it's not just genomics initiative But we also have other things for example The depression screen tool that were required to deploy the wooly depression score as part of this initial questionnaire So this is the web view So your physician has asked you to complete this questionnaire and it asks for the knowledge Would you like to do it? This is an optional patients aren't required to do it but provides a way for our patients who are engaged To get this information to have an opportunity to Have this examined It needs to be compatible on a mobile phone or mobile devices many of our patients particularly the Millennials all they want to do is interact with their mobile phone and we recognize this. This is actually me filling it out before my annual history and physical exam What's what's been important is we've also tried to integrate with information that's already in epic So for example when I did this and I completed it here It says what some of the initial questions are do you have or is there someone in your family has had cancer? Someone had heart disease It's pre-populated with yes because it's pulling with them for pulling from information That's already in the EMR because one thing as a genesis that bothers me is when I go for my update my annual history and physical exam Every year I get the same blank family history Questionnaire and it's a little embarrassing as a jenessa that I have to think boy How did I answer it last year because if I get this wrong? This is going to be really embarrassing in front of my colleagues So we're working on the bi-directional aspect of it and that's a longer term ask But again, this is part of the dirt path we're building and we need to pave that road as well So part of this is well, how do we get this information in the workflow of our clinicians? So again, this is during normal workflow for physician Triaging based on the patient's answers and questions and recommends it depending on what the logic dictated a best practice to learn so this is one where we've gone through a variety of iterations as we've tried to You know engage our primary care of physicians Well, what is it what you want out of a BPA and so in the blue for those who can't read from the back Back this is what was answered affirmatively so we know what the reason so that offers an opportunity for the clinician to clarify Is this really what was part of the medical history that was important a little bit about well Why is this important some basic information? So in this case you're talking about the chance of finding a BRCA mutation someone who may have had oxygen anodized ejuice Ancestry then putting information about well, what are the guidelines say in terms of what would I do with this information? And then sort of what would be the next steps? And so part of this is providing a clear path Well, what do I do with this information so the clinician can know and Understand why this is important and sort of what's next and talk to their patient about this So continuing on this there are always There are a variety of options that can occur depending on what the condition is But there's always an option to refer to one of our personalized medicine clinics We're not trying to turn everybody into geneticists or genomics experts, but trying to provide an outlet for those clinicians who Want to be proactive in this manner So Part of it too is if there is a targeted indication there is a smart set that's built for a genetic test order That a clinician can Can utilize if they're comfortable with talking about the issues around genetic testing and that's an ongoing educational effort But for a lot of our OBGYN colleagues, so this pilot or this Program is for all our primary care, which we consider internal mass and family medicine as well as OBGYN Certain clinicians are very comfortable with this conversation in certain domains So with that We've had some some initial great success So again this although the pilot started in spring of 2017 We weren't really live at all our sites until about end of october november of last year. So we have had about 90 000 encounters That were eligible for this This questionnaire to be triggered. We have about 75 percent 77 percent completion rate And then we have about 51 percent of patients Who there was a best practice alert fired We're still working on scrubbing the data to make sure it's accurate. Well, what are these alerts? But it looks like maybe about a third could be related to More of the proactive elements of the healthy gene panel versus The pharma genomics testing so certainly encouraging because patients are you know are Adapting and and or excuse me adopting this and one of this part of their care So as far as you know, where do we need to go in an improvement? We have to get under the hood of the data and so we've created this personalized medicine dashboard That really helps us drill down on the processes and this is certainly Why the morning session with the implementation science really caught my eyes Because this is what we're trying to do use this data and figure out. Well, what are the choke points? We know there are some how do we deploy in a systematic way to overcome some of the hurdles So to give you examples what we're tracking we can look at everything from the patient demographics Who's really up taking us drill down to what alerts are being fired? Where are missed opportunities meaning we're a bpa fired but wasn't perhaps acted on What's happening to the referrals being generated? Are they matriculating to the clinics? Why are we not which labs are being ordered and whether they've been What part of the process they are I think something that's also key to is we're looking at well What's the downstream effect of this from a downstream revenue aspect because there's been a considerable investment Has been discussed. It's not just the cost of the testing but cost of a lot of the other Architecture around it. So what is the downstream revenue associated with this effort to justify? And to make sure that we're not shifting the paradigm in in the wrong direction in terms of our Of cost and care. We can drill down to patients or practice details at Sykes we know there's implementation challenges at different sites depending on the the patient population But also the physician population And so we can drill down at the physician level as well to start to really understand Where where do we need to provide more support or education as a personalized medicine program? So we believe at North Shore that there's a benefit To both patients and North Shore it's a start to a scalable approach. Well, how do we start to achieve system-wide integration? We are identifying patients who are at risk and who are unaware possible carrier status We've already had several BRCA positive individuals who've already Underwent preventive mastectomy as a result of this program We had an adopted patient who did not know the biological family history who was identified with the pms2 mutation and has already seen Our our colonel our our gi experts as well to put in appropriate screening as well as our gyna Specialists as well So we already seen these anecdotal But what we want to do is try to bring this into a more complete picture For the for the genomic community and we're seeing integration of our proactive screening There are definitely some early adopters and power navigators that are interested in information And we see this continuing to grow and we're gaining valuable experience in this effort as well We believe it's a differentiator for primary care We did some marketing analysis or our marketing team did some marketing analysis and about a third of patients had a significant Improvement and impression of the care delivered by the parent primary care physician as well as North Shore when they were engaged in this process I'm not a marketing expert, but I hear it's rare to get a single factor that really shifts You know a primary care Allegiance in such a way and so that's part of the reason why We launched a campaign highlighting primary care In this aspect our primary care physicians, you know, it's an exciting opportunity for them as well because not too many marketing campaigns or Initiatives really highlight primary care as much as some of the specialists There are significant challenges and opportunities that we still have to tackle education education education today list education It's something that You know, we are continuing to work on I myself have been going out. I'm on my second round of going to every primary care site Which is about 30 sites talking to them what's working what's not working We've done more traditional methods with grand rounds, etc. And webinars But I think, you know, we continue to need to ask well, what how can we do this better? Improve patient and clinical team follow-through. We know there's a drop-off at each step So we know we can do this, but how can we do it better now is kind of the key question We're looking at well, how do we systematically do? Where is the best opportunity? And really we think this is um, you know, how do we start to integrate this into somewhere of our affiliate physician practices as well to help, you know, the whole community Which is really, you know, important in our footprint and important stakeholders in their community And create that infrastructure that is necessary for this data sharing across different places that a patient might have touchpoints for their care So goals, you know, we're looking to employ some of the implementation research approaches to really assess these viewpoints From key stakeholders again continuing to support our primary care sites as we continue to educate them on the goals and the mission and improve our pull through statistics as well and ultimately improve patient care So with that, I appreciate the opportunity to share our early experience with this program Okay, uh quick quick clarifying question Could I just ask on the the pcp sites that you're working with? Did you choose them in some way or are you doing everybody or We we chose them because they're North Shore primary care sites. So it's all our primary care sites So we had three initial ones as a pilot But that was about a month and then we started to basically roll out One to two sites every week where I or one of my colleagues was on on site with the when they quote went live And so we did about two to three practices over the summer Going into we finally ended up in october and november where every medical group primary care site is is live And so by primary care primary care again, I mean family practice internal mess and an obgyn Okay, use your right. Sorry. Thank you I just a question with a 36 of respondents who you identified needing follow-up. That seems high What was driving that we have similar experience by way in florida campus. It was also a high when we used a question Yeah, so that's part of what we're trying to figure out. What's driving that response. So it could be a number of reasons Could be some of the elective things it could be was there confusion about the questionnaire And we're taking steps to further validate the questionnaire as as well the short answer is We're we're that's part of our year two goal is to see what's truly driving it We know some early things like we had some melanoma questions that You know, this is where we had to pivot They were not getting the sensitivity and specificity. We wanted and so we had to suppress those so It's a complicated question But we're trying to look at what are the key drivers and I don't have that yet But that's part of what we're building right now with our dashboards Peter thank you. I think we'll move on to Lisa Basterosh from Vanderbilt I'm looking at phenotypic mining in the electronic health records