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Clear Genetics Developing Chatbot to Triage, Supplement Genetic Counseling

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NEW YORK (GenomeWeb) – Startup Clear Genetics is aiming to make genetic counseling more accessible and help genetic counselors determine which patients need to be seen quickly with the development of a chatbot tool.

The San Francisco-based firm recently received more than $2.5 million to develop its idea.

"There's a really big need today to bring genetic services to the primary care provider and to the point of care and make things much more accessible to patients," said Moran Snir, Clear Genetics CEO and co-founder. "The initial idea was more about triage and the ability to help the patient navigate, answer questions for the patient, and remove the stress levels that the patient has before they go for testing."

The idea has caught the eye of care providers like Geisinger Health System, which has partnered with Clear Genetics to develop chatbots to aid in returning exome sequencing results.

Genetic counselors said that such a tool could have a place in handling straightforward cases — provided it is put through its paces and tested — but more complicated ones might need the human element. Laura Hercher, a genetic counselor at Sarah Lawrence College, said she is cautiously optimistic about such a tool, calling it "innovative."

Snir has envisioned the chatbot as a way to scale up genetic counseling services, while also addressing the shortage of genetic counselors. In 2014, there were only some 2,400 genetic counseling jobs in the US, according to the Department of Labor, and some regions of the country are stretched thin for their services. Clear Genetics is envisioning their chatbot as being incorporated into hospitals or healthcare providers' systems, not as a direct-to-consumer service.

The chatbot idea is an offshoot of work that Snir and her colleagues did in Israel. There, they developed a software program to triage Jewish Ashkenazi women for carrier genetic disease testing and genetic counseling services by examining their family history. In this way, they could identify women who needed counseling and ones who could be offered the genetic testing panel without counseling.

Since Snir and her company are working with genetic counselors for this chatbot, She said they've observed counseling sessions and have tried to incorporate counselors' approaches into the bot. "They tell a story and they build pieces on pieces, and we try to do that in the same way," Snir added.

According to Snir, a chatbot could be used to weed out the trickier patients who might need to see a genetic counselor immediately. The chatbot could also address the basic questions that patients typically have and educate them so that when they do visit a live counselor, the sessions are more productive. "The patients come already understanding some key concepts, have better questions to ask, or have specific things they want to clarify with a genetic counselor," she said.

Sarah Lawrence's Hercher agreed that a chatbot could help handle routine inquiries. Some parts of the genetic counseling session are fairly standardized, added Andrea Forman, a genetic counselor at Fox Chase Cancer Center. She noted that some counselors have been developing videos and other tools and could be adapted to a chatbot interface as well.

"I think we're moving to where genetic counselors handle complicated situations like positive results," Hercher said. Genetic counselors, she added, could then operate more like a SWAT team responding to a tricky situation.

Snir also said a chatbot could also handle questions about billing or insurance that arise alongside genetic testing.

Such questions about what the patient's insurance covers, at which lab they need to seek testing, and what their copay or deductible is can take over genetic counseling sessions, Forman added. "Patients are anxious about it, so you spend a lot of time talking about it, which probably isn't the best use of our skill set, necessarily," she said.

But not all counseling areas might be amenable to using a chatbot. Some, Forman said, might require a live person. As a genetic counselor at a cancer center, she has to deal with complex cases. When a patient receives a new cancer diagnosis and finds out that family members may also be at risk, it can be an emotional session. "I think that in that setting, having somebody who can respond with compassion and empathy is important, " she added.

It's not only chatbots that have been developed to try to fill this gap. Genetic counselors have been exploring new ways to deliver their services, such as through telegenetics and remote counseling. Forman noted that a number of counselors offer their services over the phone and may, in that way, reach people in areas where there are fewer opportunities for in-person sessions.

At the same time, healthcare providers like nurses have also been trained to act as genetic counselor extenders. They, too, might see the simple cases while genetic counselors see the complicated ones.

Hercher added that she'd like any chatbot tool to include a way for patients to connect immediately to a genetic counselor. She noted that when people call customer service lines, they often repeat the word "agent" in hopes of getting a live person. Some patients might want to opt out of using a chatbot and get a live counselor in the same way.

Snir noted that her company is building in such a feature. It's also going to rely on people's answers to the chatbot to gauge whether or not to send them to a live counselor.

Another feature they are building asks patients if they remember concepts from previous chats. The company also plans to study when in the conversation patients become less engaged so they can tailor the length of the conversations to end earlier based on certain types of responses or to keep it going if more questions are being asked.

Currently, Clear Genetics is working with two health systems and in is pilot phases with three others with its chatbot. One of the systems it's working with is Geisinger, which is interested in using the chatbot as part of its MyCode Community Health Initiative. As part of that project, Geisinger aims to sequence the exomes of 250,000 people and, so far, it has analyzed the exomes of more than 90,000 people.

But the stumbling blocks to growing the MyCode project are the delivery of clinical genetic reports as well as educating and counseling patients, according to David Ledbetter, the executive vice president and chief scientific officer at Geisinger. He noted that that's despite having more than two dozen genetic counselors. Ledbetter is also now the chief scientific advisor for Clear Genetics.

Geisinger and Clear Genetics are currently working on developing chatbots to handle follow up with patients after they get pathogenic or likely pathogenic MyCode results. Ledbetter said that they commonly find and report back BRCA1 and BRCA2 mutations as well as Lynch syndrome and familial hypercholesterolemia mutations to participants.

Amy Sturm, a genetic counselor at Geisinger, said that when patients get their findings, they are told to not only set up an appointment with a clinical provider and a genetic counselor, but also to gather their family history and share their results with family members. "It's a lot to ask somebody to do right away," said Sturm, who is one of coordinator of the project with Clear Genetics and has become an advisor to the company.

As it takes a lot of human effort to do that, Geisinger is interested in testing whether a chatbot developed with Clear Genetics can help people to act on their results. Ledbetter added that they are also exploring using chatbots for the consent process.

The chatbots are still in alpha phase, according to Sturm, and Geisinger is still building and iterating on them to ensure the flow makes sense and to make sure the key messages are being relayed.

Ledbetter estimated that they would begin pilot testing the bots in a few months. Sturm said that they would first test them internally before evaluating their usability with MyCode participants. Geisinger also is interested in examining whether participants understand what the bots are telling them.

Eventually, if the testing is promising, Ledbetter said Geisinger plans to roll out chatbots more broadly to its patient population.

Snir added the feedback from Geisinger patients on each step of the way, from consent to return of results, is going to be crucial to the bot development process.

"I think if you can show data that the patients did get what they needed out of those interactions, that goes a long way to supporting the argument that this may be a useful tool," Fox Chase's Forman said.

"I don't think [a chatbot] is going to replace the genetic counselor completely," she added. "But could it assist in a lot of these things? That's probably the reality of a tool like this."

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