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2bPrecise Takes Precision Medicine Platform to Otolaryngology Practice as it Continues to Expand

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CHICAGO – 2bPrecise has been expanding the reach of its precision medicine platform this year through customer rollouts, new partnerships, and product updates.

Last month, the company said that San Francisco Otolaryngology, a medical group with five locations that specializes in ear, nose, and throat conditions, had chosen its technology to underpin a fledging precision medicine program, starting with pharmacogenomics. The practice is starting with a small cohort of patients to address aging-related health issues.

Also, in October, 2bPrecise established a strategic partnership with Vidence, a multiomics analytics company spun off from Cancer Treatment Centers of America this year. Under the deal, 2bPrecise is integrating its technology with Vidence's Scimon platform to deliver insights to oncologists at the point of care.

The deal with San Francisco Otolaryngology underscores observations by 2bPrecise Chief Medical Officer Joel Diamond a year and a half ago that there was increased interest in pharmacogenomics from small and midsize medical practices. But he also said that the firm, a wholly owned subsidiary of Chicago-based electronic health records vendor Allscripts Healthcare Solutions, was aspiring to serve both the pharmacogenomics and the inherited cancer risk markets, as well as population health across disease states.

Other developments illustrate the firm's recent expansion. Earlier this year, 2bPrecise moved its headquarters to Raleigh, North Carolina. Before that, it had been based in Be'er Sheva, Israel, and had its main US office in Pittsburgh. Some executives, including the firm's president and CEO, Assaf Halevy, still live in Israel, but the primary market now is the US.

Also, in July, 2bPrecise introduced version 3.0 of its core precision health platform, adding clinical decision support for germline testing in oncology. The new release also features one-click access to all genomic test results for a given patient, as well as the ability to import data from IT systems beyond the walls of a health system or medical practice.

Halevy said that the company has seen more interest in the last year in being able to check for drug-gene interactions among many populations and clinical conditions. "We see a lot of applicability in the cardiovascular space and behavioral health space," particularly with selective serotonin reuptake inhibitors, pain medications, and blood thinners, he said. 

While the ENT field does include head and neck cancers, San Francisco Otolaryngology is initially focusing its pharmacogenomics program on aging, and behavioral health and cardiovascular medicine are two important components of that. SF Otolaryngology President Jacob Johnson said that pharmacogenomics also is important for the practice's audiology and balance center, which mostly sees patients 60 and older, who tend to be on multiple medications.

One catalyst for the practice to adopt pharmacogenomics, according to Johnson, was the 2020 report of the Lancet Commission that looked at cognitive decline and dementia prevention. That report, published in July, found that about one-third of patients diagnosed with dementia could see cognitive improvements through more targeted prescribing and better management of medications.

The Lancet report also named 12 risk factors in developing dementia, several of which have highly effective medications available, including diabetes, hypertension, hearing loss, obesity, and depression.

"So the issue became that even though we're not primary care doctors, we couldn't in good conscience treat balance or treat hearing loss without at least making sure these major variables for wellness and cognition were addressed," Johnson said. "We needed something to spark a change, and that's why we incorporated the PGx testing for these high-risk patients."

If a patient is on more than four medicines and at high risk for falls based on an assessment form, the practice now will recommend PGx testing, in coordination with that person's primary care physician. If a PGx test then shows that certain drugs are not effective or well metabolized, "it creates this momentum both for the patient and the primary doctor then to change that medication, and often to eliminate medicines that are duplicative," Johnson said.

In addition to pharmacogenomics testing, the practice has added a neuropsychological assessment and brought on an exercise physiologist, all in the name of improving outcomes for its older patients. "ENT is kind of a sneaky field because we do a lot of different things in a lot of different spaces," Johnson said.

SF Otolaryngology currently has 12 physicians, including an allergist, plus about 10 more providers of other services, chiefly audiologists. The practice also offers speech therapy, physical therapy, and balance therapy.

So far, the practice has only tested PGx on a handful of patients on a pilot basis. Johnson said that the plan is to test about 30 more starting this month as the practice refines its workflows and usage of 2bPrecise analytics. "Hopefully by spring, it would become protocol in our office," Johnson said.

Once the practice is able to demonstrate the 2bPrecise functionality and optimize the workflow for clinical staff, Johnson expects pharmacogenomics to become just like any other test the clinical staff order, such as an MRI or ultrasound or blood work, though the workflow is key.

"In working with doctors, if it's hard for them to do, they generally don't do it," Johnson said. "It has to be easy on the workflow side." That attitude echoes a mantra that 2bPrecise parent company Allscripts had in the 2000s: "If doctors don't use it, nothing else matters."

Johnson said that it is important to minimize clicks for physicians. He related the story of being in a technology planning meeting where someone suggested adding seven clicks to the workflow. That kind of user experience just won't fly, he said. "Netflix doesn't go, 'Let's do seven more clicks.' Uber doesn't say, 'Let's add eight more clicks.' That just doesn't work," Johnson said. "We have to create a scenario where it's very easy for doctors to do their job."

He said that physicians of all specialties need help with medication management and care coordination, among other workflow issues, since patients tend to get prescriptions from multiple doctors.

"Let's say an older patient comes in. They have three specialists that are prescribing meds," Johnson said. "The amount of time it would take me to call, discuss, coordinate, improve, strategize, and then prescribe, it would take me half a day to then see one patient."

One thing that would improve the user experience for physicians is better integration with electronic health records systems, so patient medication lists are complete and PGx test results and recommendations are easily accessible.

All of the physicians at SF Otolaryngology have academic appointments at the University of California, San Francisco, and the practice actually has an installation of UCSF's Epic Systems EHR. An independent practice association that Johnson also is affiliated with has an Allscripts EHR. Neither is fully integrated with 2bPrecise, in that medication lists and PGx test results often come in as PDF forms, which are not machine readable and must be interpreted by humans.

"It's not 'live' data … but it is available," Johnson noted. "Then from there, we send a message to all the relevant providers" like cardiologists and primary care physicians to let them know that their patients will want to talk to them about their medications.

Tighter integration would allow the doctors to skip this step because it would be automated, he said. "This is important to us because there is no point giving [patients] balance exercises if they're on a medicine with the main side effect to make you kind of dopey and imbalanced and sedate," Johnson said. "It's wasted time if you don't get rid of the medication side effect or the lack of efficacy before we move on to [something] like balance therapy."

Within a year or two, Johnson would like to see the 2bPrecise system more closely integrated into Epic at the practice and Allscripts at the IPA so he could search populations for patients with a specific condition or on a certain medication. That would help doctors make more informed decisions on whether to order PGx testing, he said.

As an example, Johnson said he personally wants to focus on improving diabetes care. Ideally, he would be able pull up every patient at the practice with diabetes to see how their medications and hemoglobin A1c levels are managed.

As an ENT practice, SF Otolaryngology would be able to identify candidates for hearing aids, hearing surgery, balance testing, or fall prevention based in part on genetic profiles, Johnson said.

"If the diabetes, the medications, and the hemoglobin A1c are not well managed, then I feel a responsibility to let that primary [care] team and the patient know," he said. "I can give you a hearing aid or I can have you do six weeks of balance therapy, but it's useless, like you are spitting in the wind or washing your feet with your socks on, until you've changed this tsunami of disease that's in your body."

Halevy said that the SF Otolaryngology plan aligns with the 2bPrecise vision for growth in the next year or two. He said he wants tighter integration with major EHRs as well, and that process is underway.

This year, for example, 2bPrecise won certification for interoperability by Cerner under that EHR vendor's Cerner Open Developer Experience (CODE) program. That means that the precision medicine platform is now available in the "app store" of sorts for Cerner customers, so those users will be able to share data between the two technology platforms. Similar integration is also happening with analytics vendors like Vidence.

On the customer side, Halevy said that the company will be introducing "candidate certifications," following clinical rules and data standards, to help identify which patients might benefit the most from more precise care, including based on pharmacogenomics.

A third point of emphasis heading into 2021 is improving the company's ability to educate and train users to increase the value of the 2bPrecise technology to them, so that clients are able to apply germline-based, pharmacogenomic-based, or somatic-based precision medicine to all suitable patients, according to Halevy.

The efficiency gains from molecular risk stratification might even make financial sense to providers in the context of bundled and value-based payments, Halevy said, even if specific services are not yet covered by payors. As an example, he mentioned maturity-onset diabetes of the young, or MODY, a form of diabetes that does not fit neatly into type 1 or type 2 treatment protocols, as an area ripe for precision medicine. "The standards-based treatment, for lack of a better term, is not necessarily the applicable, efficient solution," he said. "Sometimes, finding those patients is also of meaningful value by itself."

Johnson said that the 2bPrecise platform has offered the practice a starting point even before the EHR integration is done. "That has been very helpful for us to kind of move forward and then maybe demonstrate back to the larger UCSF or to the IPAs that it is a good idea," he said.

"It doesn't take heavy and long cycles of implementation and work on either side to start to make those things really work for the patients," Halevy added.

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