CHICAGO – When electronic medical records vendor Allscripts Healthcare Solutions sold 2bPrecise to molecular laboratory and software company AccessDx for an undisclosed amount last August, 2bPrecise went from being a subsidiary of one firm to that of another.
But the Pittsburgh-based firm, which integrates genetic and genomic test results into electronic medical records as discrete data, was largely run independently from Allscripts, and AccessDx seems to be taking a similar approach to the asset. 2bPrecise Cofounder and Chief Medical Officer Joel Diamond said that operations have not changed much since the sale, which he described as good for the company.
"We need to be an independent space" for interoperability, not connected to an EMR vendor, he said.
Allscripts purposely kept 2bPrecise as a separately operated entity to avoid a pitfall EMR vendors have been keenly aware of since Cerner bought clinical decision support content provider Zynx Health from Cedars-Sinai Health System in 2002. Cerner sold Zynx off to media conglomerate Hearst two years later, in part because providers using non-Cerner EMRs were reluctant to work with Zynx.
Diamond said that 2bPrecise does not see itself as an interoperability engine for genomics, but he understands the perception. Instead, the firm, founded in Israel in 2015 and now headquartered in Pittsburgh, wants to be the bridge between laboratory-generated genomic information and frontline clinical decision support.
"There is a real opportunity to make healthcare better," said Maulik Purohit, associate chief medical informatics officer at Cleveland-based University Hospitals, a 2bPrecise customer.
Diamond, who holds an adjunct faculty appointment in biomedical informatics at the University of Pittsburgh and still practices family medicine part-time, said that 2bPrecise wants to be "as close to the sequencer as possible," then cross-reference sequencing results with phenotypic data to make the information clinically actionable.
Notably, the AccessDx subsidiary just requires its clients to build a single feed to its technology platform, then handles the interfaces to individual labs. In doing so, 2bPrecise presents the information within clinician workflows in multiple brands of EMR.
Small practices, especially in primary care, are still on kind of a treadmill, where they have to see dozens of patients a day as quickly as possible for financial reasons and don't really have time to stop and think about genomics. If there is a genetic test in a patient's record, many do not know what to do with it.
"This is our problem to solve, [putting] that in the workflow, making it easy," Diamond said. "Every time I go to prescribe a medicine, it's in my workflow, inside my EMR. I see those results and now I'm always thinking about it."
The Patient Protection and Affordable Care Act mandates that US health insurance companies pay for preventive care, including an annual physical, and doctors typically order chemistry profiles and lipid panels during such exams.
For someone who has had excellent cholesterol numbers several years in a row, "doing a lipid panel every year is absolutely worthless," Diamond said. "The cost of doing that lipid panel is the same cost as doing a PGx test, which you do once and extrapolate over" for the rest of the patient's life.
"As a primary care doctor, this is hard," Diamond said. Technology can help capture family history as discrete data, then feed algorithms to suggest appropriate genetic testing that physicians likely are not thinking about.
"This is the holy grail of clinical decision support, but it's far too little, too late that genetics is part of it," Diamond said.
There is some uptake of pharmacogenomics among specialists, such as oncologists looking for the right chemotherapy. But the same oncologists might not know about the pharmacogenomic component of prescribing anti-nausea drugs, pain medications, or antidepressants, Diamond said.
"Even people that have comfort within precision medicine within their subspecialty, it tends to be very narrow," Diamond added. "This data needs to be liberated to everybody in the organization because it is 'test once and query often.'"
University Hospitals uses an Epic Systems EMR. Despite the former Allscripts ownership, 2bPrecise can interface with Epic, Cerner, Meditech, Athenahealth, eClinicalWorks, Greenway Health, and other major EMR vendors, including Allscripts.
"I think [Epic] is very good at some of the technical back-end stuff with the genomics in the sense that they might be able to make a feed" to a lab, Purohit said. However, it requires the organization to build interfaces with each lab it works with. "It is an immense amount of work for a health system to do and maintain," he said.
"If our IT stuff is burning and churning hours to maintain all those data feeds to all those different labs, that's hours that we can't use to innovate and move ahead" in patient care, Purohit added. "Our staff now is freer to handle higher-level functionality."
Purohit also serves as the health system's innovation lead for transformation. In that role, he educates healthcare providers on how best to use technology, including the 2bPrecise platform.
Another issue is that clinicians generally do not want or need raw genomic data. 2bPrecise curates data and presents it in a way that Purohit said can be used for clinical decision support.
University Hospitals started with 2bPrecise in cancer and has since expanded to reproductive health on its own, without any push from the vendor, thanks to clinician demand, according to Diamond. "A concerted effort to do pharmacogenomics across the enterprise is the next piece," he added.
2bPrecise sends a flow of discrete genomics data back to University Hospitals' Epic installation, which the health system sets up as clinical decision support in the clinician workflow.
Diamond said that it is largely a workflow problem. Primary care physicians are unsure what to do with genomic information, particularly if results come back from the lab as a PDF file that is not machine-readable and thus cannot inform automated clinical decision support.
Purohit said that University Hospitals is seeing substantial growth in demand for genetic counseling. Since adopting 2bPrecise, the organization has been able to give more targeted advice, to the level consumers have gotten accustomed to.
"If you go to Netflix, they have data on every movie you watch," Purohit said. "If you go to Google, they complete my searches even before I do. They write half my emails. And so I think in today's world, that level of sophistication is the expectation."
Diamond noted that University Hospitals has looked at its use of 2bPrecise not as a genomics project or a data project, but rather a clinical exercise.
For example, he said the health system is applying pharmacogenomics to address what he called treatment-resistant depression, namely patients who have had little or no success on multiple antidepressants.
"Now they know that those patients probably have failed multiple treatments because they were on the wrong drug," Diamond explained. "So they're not approaching this as either a technical or a genomics problem. It's just part of an initiative they have in identifying those patients."
Diamond also said that 2bPrecise has a module for addressing severe drug-gene interactions in polypharmacy patients, many of whom are elderly.
The company wants to make the process of identifying patients with such interactions opaque to physicians. "The doctor should probably not think of this as a genetic problem. It should fit into existing problems they have," Diamond said.
Many physicians, he said, were not trained in genetics and see genomics as a series of yes/no questions when it really is a continuum.
The technology also helps an organization like University Hospitals scale its clinical genomics program by not having to refer every case to a geneticist, he said.