Sigrun Hallmeyer, MD, Advocate Health Care, discusses the logistical challenges that health care workers encounter when treating patients with malignancies and employing precision medicine pathways, noting the impact that these challenges can have on a patient's trajectory through their illness.

Transcript:

My name is Dr Sigrun Hallmeyer. I'm a medical oncologist just outside of Chicago in Park Ridge, Illinois. I work for what used to be Advocate Rural Healthcare System. We've now just become Advocate Health Care, as we joined yet another health care system called Atrium Health. And I am a medical oncologist. I specialize in breast cancer and melanoma, and I also direct the cancer service line at my hospital.

I was contacted by ACCC a number of months ago in preparation for the summit here. And we had talked about the “hot topic” of precision medicine, which we felt we needed to level set first as to what precision medicine or our personalized medicine really is. And so ACCC was great in assembling a team between myself and other community oncologists and a genetic counselor to really come up with a great theme for a workshop, which we call “Deep Dive Into Precision Medicine.” And so we spent probably the first half hour or so just level setting, where we talked about a definition of precision medicine, what is molecular testing, and why it matters, really showing how significantly survivorship can be improved in cancer patients when targeted therapy can be employed effectively.

My role in the workshop was more to talk about barriers, so the logistical challenges that I see on a daily basis when treating patients with malignancies and employing precision medicine pathways and certain tests and whatnot. And then the genetic counselor who was part of this was talking a little bit more about the barriers and problems that are seen frequently once the test results come into the office, and how the information then is translated in a patient-physician relationship and how to translate that into an actionable change in the patient's treatment. And so, yeah, that's what this workshop was all about.

I introduced what it looks like from my very perspective in terms of understanding precision medicine and the very significant impact it can have on a patient's trajectory through their illness. We all come to the bedside saying, "I want to do the best I can for the patient in front of me." And then I go back to my desk and say, "All right. Well, what is the question that I'm actually asking here? So, which particular mutation do I want to interrogate to see if that could offer a particular treatment for my patient?”

Once I have that question, now I'm going to find out which laboratory I utilize to answer that question. And I actually showed a slide with probably 20 or even 30 different laboratories that provide precision medicine testing or next generation sequencing testing that is available to any of us. And then the question is, okay, now if I've identified which laboratory I want to use, how do I order it? Do I need to be part of the portal and register there? Or do I have a paper requisition that I fax somewhere? Even if I get to that point, now the question is, well, how do I make sure that this laboratory that I'm ordering the test on will actually contact my pathologist and request the correct specimen in which this test needs to be done? Now I need to be sure that this particular specimen gets shipped and packaged and gets to the testing laboratory. I need to be sure that the testing laboratory has the right quality control, QC, in order to make sure that the specimen is sufficient for the testing that needs to be done. If it isn't, I need to know because I need to redo it then.

So that's just the very, very beginning. And we went in our workshop through the entire excerpt, essentially from me as the doctor, “I have an idea” what I could do. And how that idea translates into action, how many different people are involved in order to make that process happen, so a week or two or three later, when that test result ultimately arrives back on my desk, I'm going to now go back in the room with the patient and say, "So, Mrs Doe, here is what we learned about your tumor. This is what this means. And here is what we can do to take advantage of what we have identified."

I joined a private practice oncology setting out of fellowship now almost 20 years ago. And this private practice now became part of Advocate Healthcare, which is the largest health care provider in the state of Illinois, and that system then joined with Aurora, which is the largest health care provider in Wisconsin, and now we joined Atrium. And so literally over the last decade of my professional life, I have really learned to think from the private practice setting one patient at a time, being very nimble, “idea today is a plan tomorrow is an action on the following day,” to now thinking about much larger health care systems, and how do we actually make sure that our quality care is provided equally across such a large footprint? And so this is where pathways come in.

And I can tell you that many physicians look at pathways and standardized care as more or less an enemy of good health care because they feel like we're rubber-stamping things. And I've been in this business long enough that I have a different perspective on it. And I really do feel that pathways can absolutely enable good quality care as long as these pathways are developed with good committees and obviously physician input, but many other things need to come together in order for this to work well. And so at my institution, we're using the VR pathways as part of our clinical integration. And I have actually just stepped up into the co-chair position to chair the Clinical Pathways Development Committee for the breast cancer charge within these clinical pathways. And so I have a true passion for how that can ultimately also lead to better outcomes and incorporating precision medicine as a big, big part of that.

So where clinical integration or pathways can actually really make an impact on our physician practices when physicians utilize these pathways to inform their decisions at the bedside. The biggest barrier that I see in that is very much born out of my own experience and practice where, let's just say it's 9:20 in the morning, I'm going in with a new patient, I'm reviewing all his or her information, and as I'm learning about everything, I'm looking at a pathology, I'm looking at all the detailed information that's important for me to arrive at a decision, what I want to do, I'm pretty much already walking in the room with an idea of what I want to do. That ultimately gets translated in that, say one hour visit, I walk out of it, the patient signed consent, the whole machinery gets going. At the very end of the day, I then sit down in front of my EMR and I dictate. Saw this 64-year-old African American female, etc., I develop a treatment plan, I click on my pathway that I developed, and I put in all the integral information, the stage and all that kind of stuff. And then the pathway tells me, "Oh, you had a clinical trial." But I didn't think of it as I was in there. The problem is that these pathways typically happen after the patient interaction. And that is too late. And so we can have the very best tools in place that really are meant to standardize care and get everybody to be cutting edge. But if they're not used in the right scenario and in this setting simply in the right timeframe, they're ultimately not very useful. And so in that, pathways play a huge role in making precision medicine happen and ultimately getting access for many patients in a standardized way. But we still need to tweak the details in terms of how physician interact with these pathways, when they interact, and how they become useful.