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Would you like to exchange best
practices and ideas to improve care,

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enhance operational efficiency,

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and address financial
challenges with your peers?

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Becker's Healthcare is facilitating these
conversations at their eighth annual

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health, IT digital health and RCM meeting.

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You can check your eligibility for
complimentary attendance at the Lincoln,

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the description. We are excited
to welcome you in October.

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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 <laugh>,

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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 <laugh>. It took the
pandemic for it to become <laugh>,

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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 <laugh>.

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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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It's so important for leaders at the
top of organizations to keep learning,

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00:18:17,010 --> 00:18:18,700
stay sharp, grow their networks,

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00:18:19,090 --> 00:18:22,180
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00:18:22,280 --> 00:18:26,020
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