A Google map for healthcare

Much of the effort to develop cures using precision medicine has been for cancer patients, but an area that's getting more attention and could have more of an impact in the long term is population health. In that arena, instead of designing care around a particular individual, patient groups with certain genetic dispositions may be targeted with a different kind of care or screening.

While there are concerns about equitable access to precision-based population healthcare, researchers are optimistic about precision medicine's potential to make population health management more fruitful.

"In the future, I think precision medicine will become an important ingredient for population health outcomes," said Dr. Muin Khoury, director of the Office of Public Health Genomics at the Centers for Disease Control and Prevention.

Most of the focus of precision medicine so far has been driven by the federal government's large investment in developing new therapies. In October, the National Institutes of Health launched a five-year, $215 million collaborative initiative with 11 drug companies to advance research in immunotherapies as part of the Cancer Moonshot project.

More than 62% of healthcare organizations made oncology the primary area of focus when conducting their precision medicine initiatives, with cardiology second at 50%, according to a 2017 study conducted by .

The University of Michigan Medical School is one of the research institutions looking at pushing the envelope by targeting populations with personalized health solutions.

The research institution recently launched an initiative with such a focus. "Where we're headed to really change the health of populations is to infuse perspectives that lie outside of the classic biomedical industrial complex to include policymakers, payers, community developers and social workers," said Dr. Sachin Kheterpal, associate dean for research information technology at the University of Michigan Medical School and a co-director of its Precision Health initiative.

Kheterpal said the goal was to provide patients with more informed choices that include such health determinants as environmental exposures and socio-economic status, based on real-world data. "How I think we go from precision medicine to population health is to extend beyond our historical data streams of clinical medicine and genetics," he said.

The University of Michigan is not alone. A handful of research institutions are working to find ways in which precision medicine can be used to advance their population health management efforts. Though there's no obvious link between the two concepts, a growing number of providers feel the technological and data-driven tools used in precision medicine offer the best chance to make significant strides toward improving public health.

The CDC's Khoury said the rapid decrease in the cost of sequencing a genome has played an important part in advancing the field. Since 2014, that cost has fallen to less than $1,000, while consumer-based services like 23andMe and Ancestry.com have offered genetic testing for less than $100.

Khoury said one of the many hopes is that precision medicine and the widespread availability of genetic testing will provide an opportunity to develop better, evidence-based health screening guidelines that target populations disproportionately affected by certain health conditions compared with the general population.

One area where better screening guidelines could significantly improve health outcomes is in chronic diseases such as diabetes; ethnic and racial minority groups tend to have higher incidence rates of Type 2 diabetes compared with whites and are more likely to develop severe health complications such as the need for amputation. Improved screening based on genetic testing could provide clinicians with better assessments of a certain population's risk and give the experts the evidence needed to develop screening guidelines that account for the risk.

"When you're better able to target your strategies to the highest-risk populations because you understand better, those types of things will help us to target our interventions on a population level," said Dr. Kirsten Bibbins-Domingo, vice dean for population health and health equity at the University of California at San Francisco's School of Medicine.

But for all of precision medicine's potential, one question remains unanswered about its role in population health management: How can such technologies help address health conditions that are predicated more on patients' risky health behaviors than their genetics?

Faculty members from most of the University of Michigan's 19 schools and colleges spent nearly a year planning the Precision Health initiative before it was launched in October, Kheterpal said. The goal of the discussions was to get advice on to how best to use patient data the medical school has already amassed within its biobank, as well as other bioresearch investments made over the past decade.

The result was the formation of two major elements in the initiative. One was the development of the "platform," which incorporates the constant collection and analysis of patient data to include socio-economic information along with medical and genetic history. The second element involves advancing the research team's knowledge on how precision medicine can be used to address specific health cases.

The first project the team decided to tackle was the opioid-abuse crisis, given the severity of its impact throughout the state, Kheterpal said. "So much of that problem involves the environment around you, your social situation, and your family support structure. So it forces our Precision Health initiative to grow and solve problems that demand that breadth of experience."

The project started under the initiative is what Kheterpal calls "precision opioid prescribing," where data are being collected from clinicians across the state on how they prescribe opioids after acute events. Researchers then follow up with patients to find out how many pills they actually took so they can compare the amount they used with the amount they were prescribed. Prescribers are given information on how many opioids they distribute to each patient compared with the actual amount their patients use in the hope that the information will prompt them to prescribe fewer pills, lowering the risk of abuse.

The next step in the initiative's precision opioid prescribing strategy is to incorporate patient socio-economic data along with their mental health history to give providers a more accurate picture of the number of opioids they need to prescribe. Kheterpal said the goal is to provide prescribing recommendations based on an individual patient's needs.

"Whenever I leave work I always turn on Google Maps, not because I don't know how to get home, but because it gives me a recommended pathway, tells me how long it will take, gives me an option B and an option C, and gives me information on why it's giving me those options," Kheterpal said. "We're going to offer both the provider and the patient a Google Maps for their healthcare, which is a series of choices to get from point A to point B."

Perhaps the greatest potential for the use of precision medicine toward advancing population health involves the ability to more accurately identify among entire populations the severity of specific health conditions, allowing healthcare providers to concentrate care resources more efficiently.

One of a number of projects conducted by researchers at the UPMC health system over the past year has been the development of a model to collect genomic data from 30,000 congestive heart failure patients. Through the use of a technique called precise genotyping, as many as 1,600 patients were identified as generating more than 40,000 hospitalizations in a year's time, which accounted for nearly half of hospital admissions for the entire patient group.

"We've added more precision to the understanding of who those heart failure patients are," said Dr. Oscar Marroquin, chief clinical analytics officer at Pittsburgh-based UPMC. "Now when a patient comes to our office we can identify who is a patient on the high-risk side of things or on the low-risk side of things, so that we can then more thoughtfully deploy tools we have available to better manage our patients."

Some believe precision medicine gets to the very heart of population health management by allowing clinicians to move away from simply treating a disease to prediction and prevention of disease. "We now have the ability to unlock a number of secrets that we didn't have in the electronic medical record," said Dr. Stephen Parodi, associate executive director for the Permanente Medical Group. As the physician practice arm of Kaiser Permanente, the group has more than 9,000 doctors overseeing the care of more than 4.1 million patients in Northern California.

Parodi said precision medicine lets clinicians see in real time how they are treating people, their health outcomes, and to identify the most effective treatments, something unavailable to most physicians just a few years ago.

The Kaiser Permanente health system recently began to incorporate social determinants of health such as poverty, unemployment, lack of green space, pollution, etc., within its more complex approaches toward disease management.

About a year ago, the system began developing a predictive model that looks at a patient's medication history and prior emergency department utilization, as well as where they live and prior use of social services and behavioral health professionals. All of those factors are calculated into a risk score that Parodi said allows clinicians to better understand which patients may need additional care coordination to help them manage chronic health conditions and determine what types of health professional patients might need on their care teams.

"We believe it's not just about healthcare but about total health," Parodi said.

The extent to which precision medicine reshapes how hospitals manage population health will ultimately depend on how well all patients, especially those with socio-economically disadvantaged backgrounds, can access the benefits of technological advances.

"If the advancements are demonstrated only in those who are tech-savvy, and have the right devices, and are already very comfortable with technology, then we are going to further exacerbate the gap in health and healthcare disparities," said Dr. Megan Mahoney, associate chief of primary care and population health at Stanford Health Care in Palo Alto, Calif. "While I do see the promise in democratizing healthcare and making healthcare more affordable and accessible to individuals who have been historically disadvantaged, there is a risk that we will actually make things worse."