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