Megan Mahoney, MD, Clinical Professor of Medicine at Stanford University talks about the Humanwide Project and how it is beneficial to patients.
Interview conducted by Ivanhoe Broadcast News in October 2019.
Tell me, what is the Humanwide project?
MAHONEY: Humanwide project is an exciting pilot program where we integrated both high tech and high touch approaches to collect and analyze new streams of data, both physiological data and genetic data, to then craft a very customized plan for our patients. the data from the scales and the glucometer, blood pressure cuff and the pedometer were immediately uploaded into their electronic health records so we could track their progress over time. In addition we collected genetic and pharmacogenomic tests.
How does pharmacogenomics work?
MAHONEY: Pharmacogenomics – it’s a new field. We feel like at Stanford we have a lot of expertise with people who are nationally and internationally known for their leadership in pushing the field of pharmacogenomics further. Pharmacogenomics specifically tests for genes that look at the rate in which we metabolize drugs. Why that’s important is that it can determine the dosing of medications and then also predict any side effects that we can anticipate with the medications. In Humanwide about one in four of the patients that we had we treated actually had an adjustment in their dose of their medication based on the pharmacogenomics test.
That would explain why some people think they’re doing all the right things. And they’re still having symptoms.
MAHONEY: Yeah. I mean we talk about Debbie Spaizman who we’re going to meet a little bit later. So Debbie is my primary care patient. I’ve been following her for years. It’s really been a privilege to be her doctor. And she came in about to get a surgery done. But she was actually ambivalent about whether or not she should pursue this surgery because of previous adverse reactions to pain medications. So she knew she was going to require pain medication for her surgery. And so she actually was thinking about not going through with the surgery because of her concerns about the side effects of the opioid medications that would be required post operatively. And so because of that, while we were talking I was conducting the Humanwide pilot in a different clinic at that time. And I realized that a lot of her symptoms probably suggested that there was a pharmacogenomic change that would then help us understand how to go forward with her, with a regimen that she would need for her pain control. And so I presented the program to her. She was delighted. She had some other lifestyle related goals that also were going to be addressed during the pilot as well. And then she was tested. And lo and behold we were able to identify that she did have an alteration in the metabolism of certain opioids, but not all of them. And so we were able to identify the class of opioids that would work for her based on her pharmacogenomic makeup. And then she was able to go through with the surgery and was very well medicated with pain control throughout the whole process. So that was an incredible success. And I think that demonstrates why pharmacogenomics can be a powerful tool in primary care. It’s a relatively new field. The price point of the testing is coming down. So it can be accessible to a general population at this point. So we’re very excited about being the leaders and pursuing pharmogenomics testing in primary care.
You’re seeing how it’s kind of cutting edge. Outside of the Stanford community, are there other hospitals or doctors?
MAHONEY: We’re not aware of any other primary care system that has fully integrated pharmacogenomics testing. And we know that over 90 percent of people- you, me, everybody- will have a clinically relevant finding. So it can be incredibly useful. It just hasn’t become standard of care yet. And that’s why we feel like we’re at the cutting edge because we were able to demonstrate how to implement a pharmacogenomics program in primary care. There is one institution that is starting to integrate it. And they’re moving along pretty much at the same pace as we are.
Tell me more how it’s individualized here.
MAHONEY: Up until this point in traditional health care, we are requiring the patients to come in for their services. We are reactive and waiting for the abnormal result to come to us. And we check their physiologic metrics in clinic. So it’s a one time test that perhaps occurs once a year because that’s how often patients on average are coming in. And so the way that we’re moving more towards individualized care is that we are tracking patients physiological changes at home, when they’re at work, when they’re playing, and over time. And so then that way we can be a lot more proactive. So we can anticipate when there’s going to be a problem and then intervene and then hopefully prevent the progression of it. And so then also for an individual who was having leg cramps, he was taking anti cholesterol medication, we did the pharmacogenomic test. We were able to understand that he’s a slow metabolizer of the statin that he’s taking. And so we reduced the dose based on that. But by reducing the dose, his leg cramps went away. So these are sort of examples that if we were just to use our traditional methods of seeing patients we would miss out on those opportunities to craft a more customized care plan.
So you’re not trying to make patients fit in a specific mold.
MAHONEY: That’s exactly right. What we know is that health and health outcomes are mostly driven by things that are outside of a clinical setting. I mean this is no surprise to any of us. But if you think about the way that health care systems have been designed, it has required patients to adapt to the system, whereas what we’re really asserting with Humanwide is what we think will be the future of medicine – that it will become much more patient centered and much more data driven. I can talk about how the providers really have enjoyed Humanwide. They felt like they were much more connected to the patients. Patients felt empowered because they had the data just as much as the providers did. We had a number of patients who were working at startups. These are younger patients – or in other companies. And stress from work it was maybe their first job and moved away from home and they were given a glucometer. We gave glucometers to everybody not just patients who are at risk for diabetes. And they notice that their measurements were coming in at a pre diabetes or even a diabetes range. They were able to change their diet. And then that eliminated the risk. They were able to cure their problem on their own. So I think that that’s exciting. It is that concept of the democratization of health care – empowering patients, engaging with patients, and then that then really reserves the effort and the expertise that the health care system has for the patients who absolutely need us, and not the patients who actually could do just fine without heavy interaction with us.
So firstly they come in they have their complaint or their issue, you swab them. Get their results. Then they go home. They go to work. They have their life. But during that time they give them a set of different tools. So tell me about that.
MAHONEY: Sure, the whole process. The patients, when they enrolled, they met with us for about an hour. We reviewed all of their social determinants of health. So we got their social history. We get a sense of their environmental context. We also looked at their behaviors, their lifestyle, their sleep, stress level. We understood their preferences, what their goals were for their own health care as well. And then we collected their physiological data through the devices as I mentioned and their genetic data and their pharmacogenomic data through swaps. And so once we got all that information and we brought it together for them., we discussed, “what are your goals?” Based on their preferences we crafted a plan. And then we paired them with a certified health coach to carry out the plan. And if let’s say a person’s priority – and we have many patients who fell into this category – a person’s priority was their own genetic risk for cancer or cardiovascular disease. They had a mom or another family member or multiple family members who were affected by cancer or cardiovascular disease. That was their priority. So then we crafted the entire care plan around that priority in getting them access to genetic counselors and talking to them about their own cancer risk.
If they wanted to check in with us, either in person or by phone or even just through messaging on a weekly basis, biweekly basis, once a month, whatever cadence they preferred, we just met them where they were. And then over time we saw real progress. So people were attaining their goals. Or we found out about new risks that they were not aware of before. And then we create a plan that would help them prevent disease progression based on that.
One thing though when you’re saying that it sounds like it wasn’t just pharmacogenomics that you’re were focused on.
MAHONEY: No. We were also assessing every single patient for genetic risk for cardiovascular and cancer cardiovascular diseases and cancer. And we gave every patient the wearable devices, whether or not they were well or if they had chronic disease or if… we had several patients who were post heart transplant, patients who been through kidney transplants. We had three patients who were undergoing cancer treatment. And so what we wanted to do was we wanted to recruit a broad spectrum of patients along the lines of their medical risk, but also along the lines of gender, race, age, in order to demonstrate what aspects of this new model resonated with which groups. And we found that there was something for everybody.
How long were each of the patients in the program?
MAHONEY: We started enrolling in January of 2018. And we stopped enrollment in December of 2018
Okay. And it was kind of a team approach.
MAHONEY: We utilized the integrated team based care model that had already been developed three to four years ago. So Stanford Medicine has undergone a major transformation in response to this epidemic of physician burnout particularly within primary care by developing team based care in primary care. What that does is it distributes the effort, the work, and the responsibility of patient care across the entire team. We have a nutritionist, clinical pharmacist and a behavioral health clinician. And they’re all part of the team. And depending on what the patient’s needs are and their priorities, these different members of the team will become involved in their care. So it was great to have that model already in place when we then started bringing in new streams of data that they could then respond to and work with the patients on.
Great. How was Debbie?
MAHONEY: I’m really happy about Debbie’s involvement because I really feel like that exemplifies the promise of pharmacogenomics. Now she feels very comfortable. I think she’s even had an additional surgery since that initial one. And so now she can get her health care needs met. How important is that? Without any fear or concern about the anesthesia and the pain medications that she might need. So that was incredibly gratifying. And then it also turns out she had other goals, like weight loss, like you know increasing her activity level, like looking after diet. And so we had all that information for her and gave her the tools so that she could meet her health-related goals as far as weight loss and exercise. So I think she not only benefited from the pharmacogenomics aspect of it but she also benefited from the entire complement that was offered to her.
So the grand plan is to implement the tools and what you guys have learned.
So are you going to continue with the Humanwide?
MAHONEY: Yeah. This is the manifestation of Stanford Medicine’s vision for precision health. And it’s applied in a primary care setting. And so once the environment around us changes towards what we think is the future we’ll be very well situated to expand Humanwide.
END OF INTERVIEW
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