Predict, prevent, cure — precisely

In an old family snapshot, three women and a man perch on a yellow couch, flanked by three men standing behind them. They look introspective, as if the photographer missed the moment when they smiled for the camera.

Eugene Celis pointed to a short-haired woman whose hands are neatly clasped. “My Auntie Lourdes,” he said. “She died at the age of 80 of a stroke.”

He touched the image of the man behind her in a patterned shirt. “My Uncle Edgardo. He died at the age of somewhere in the 60s range, of heart attack.

“My Uncle Alberto.” A serene man in white. “He died of complications of diabetes.”

The list stretched on and included several relatives who died before age 60 either of a heart attack or complications of diabetes. Celis’ grandfather died of a heart attack. His father passed away in his 50s. His brother, sister, cousins: “They all have high triglycerides,” Celis said. “Just like me.”

At 42, Celis was already worried. During annual checkups, his doctor would say his blood pressure was fine. But when Celis used his mother’s at-home blood pressure cuff, the readings were sometimes high.

All of it — the high triglycerides, family history, blood pressure — nagged at Celis like a persistent, unscratchable itch. He knew medication could help, but was reluctant to use it because triglyceride medication harmed his liver years ago. Was he on the road to early heart disease?

“Most of my family on my dad’s side, they don’t even reach the age of 60,” Celis said. “I don’t want to be in the same situation. I want to see my grandkids.”

A business supply chain analyst living in San Jose, California, Celis longed for objective answers to his health questions. Last year, after he mentioned concerns about his triglyceride level and medication, his primary care doctor invited him to participate in a Stanford Medicine project called Humanwide.

The yearlong pilot, which concluded in December, involved 50 patients and demonstrated a new approach to primary care, using information from genetic screenings, at-home digital monitoring devices and detailed wellness assessments to address current health concerns and lessen future risks.

In a paper published in May in the Annals of Family Medicine, Humanwide’s architects found that patients and clinicians embraced the new tools for preventive care, and care teams identified — and started treatment for — previously undiagnosed health conditions in several participants. Such insights provide a starting point for future care models based on analytics from individual patients, they wrote.

Lloyd Minor, MD, dean of the Stanford School of Medicine, said Humanwide offers a glimpse into a future when medicine can be more proactive and focus on averting disease through personalized care.

“Our vision of precision health is to predict, prevent and cure — precisely,” Minor said. “With Humanwide, we have begun to realize that vision in a clinical setting. The information gathered in this pilot suggests approaches to primary care that may ultimately benefit many thousands of people.”

Seeds for Humanwide were planted in 2015, when Stanford Medicine leaders set out to craft a new way of delivering primary care. They were responding to national trends showing that patients increasingly required complex care for multiple ailments and that physician burnout was accelerating.

Over 18 months, a group of clinicians and executives studied clinics around the country, commissioned interviews, synthesized information into a design for running a clinic, and refined the model based on feedback from patient and physician advisory groups.

The resulting Primary Care 2.0 model reconfigured the teams delivering care, assigning three to four medical assistants to the role of care coordinators who support a physician and an advanced practice provider, such as a nurse practitioner or physician assistant.

The model also brought other health professionals on-site, including a clinical pharmacist, behavioral health clinician and dietitian. Everything from the clinic’s physical layout to the schedule of daily and weekly meetings emphasized collaboration and communication on each patient’s care. In June 2016, Stanford Medicine’s Santa Clara clinic started providing care using the Primary Care 2.0 model.

The next step was to develop a way to collect key health data for individual patients, and to integrate that information into their care. Megan Mahoney, MD, took the lead on the design, which would eventually become Humanwide. She’d arrived at Stanford Medicine in 2014 with a track record of establishing and revamping health care practices: She’d co-founded one of the first U.S. clinics to serve both HIV-infected patients and their family members in San Francisco, and she’d helped with an overhaul of California’s prison health system.

“We saw this as an opportunity to bring in more data that was previously not available, giving us an unprecedented understanding of our patients’ risks. It gave us the ability to proactively take care of them in a way we’ve never had before.”

Mahoney’s drive to improve primary care came from a personal place. She was 11 years old when her older sister, Cindy, was diagnosed with multiple sclerosis. Over the next two decades, Mahoney watched her family struggle to navigate a fragmented health care system to get what Cindy needed, from securing Medicare coverage to obtaining a wheelchair. The experience motivated Mahoney to set aside aspirations to study economics and instead pursue medicine. Her sister died in 2007 at the age of 38.

“She did not have a medical ally — somebody who was going to walk that journey with her,” said Mahoney, who is now Stanford Medicine’s chief of general primary care. “When I see a patient, I like to say that ‘it’s an honor to walk this journey with you.’”

Those kinds of trusting, long-term relationships are at the heart of Primary Care 2.0, which frees physicians to spend more time with patients by distributing case management duties among the core members of the care team.

With Humanwide, Mahoney gave the teams another tool for personalizing patient care: data. Lots and lots of data. Beyond the usual questionnaire, this compilation included information captured from wearable devices and gleaned from genetic tests — results that patients often learn at home from consumer products but don’t necessarily share with their providers.

It also included evaluations of how each patient’s genetic makeup influences their medication responses, and answers to in-depth questions about sleep, stress, exercise, nutrition and weight. The care team assembled all of this information into individual portraits of each patient’s health, which they used to develop plans for accomplishing personal goals.

For the pilot, Mahoney sought a diverse group of participants. They were men and women from ages 24 to 86, who came from varying racial and ethnic backgrounds and had a range of medical circumstances. More than half of the participants were obese, and more than half had a major cardiovascular risk factor. Three patients were being treated for cancer, one was awaiting a kidney transplant and another had already undergone a kidney transplant. Three patients had severe heart disease, and one had received a heart transplant.

“We saw this as an opportunity to bring in more data that was previously not available, giving us an unprecedented understanding of our patients’ risks,” Mahoney said. “It gave us the ability to proactively take care of them in a way we’ve never had before.”

Setting personal goals

On March 6, 2018, Celis pulled into the tree-lined parking lot of the one-story Stanford Medicine Primary Care 2.0 clinic for his Humanwide intake appointment with nurse practitioner Debra Hummel. He underwent a one-hour wellness assessment that included a family history questionnaire to determine whether further genetic testing for disease risk was appropriate.

He swabbed the inside of his cheek to supply DNA for an evaluation of gene interactions with medications, and he received personal health tracking devices. Data from these devices — an at-home glucometer, scale, blood pressure cuff and pedometer — would automatically flow into his electronic health record for the care team to monitor remotely.

During the wellness assessment, Celis mentioned his stress at work and his concerns about high triglycerides and heart disease. Asked about overall personal goals, he thought of his two young daughters and imagined when they’d have children of their own.

“Being able to see my grandchildren,” Celis responded. “Being active. Always being able to travel.”

Armed with his newly issued digital devices, Celis tracked his health information at home with interest. Sure enough, before long he saw high blood pressure readings: 140 over 90, 160 over 100.

“We were able to think ahead, and map out which direction to take if he were to face potential health situations, given his risk factors.”

During an appointment at the clinic, he discussed the numbers with Hummel. They found nothing out of the normal range in a review of his in-office readings but, based on his readings from home, his care team decided he should undergo a more formal 24-hour test. Over the course of a day and night, he wore a blood pressure cuff attached to a monitoring device that took numerous readings.

The readings confirmed the diagnosis: hypertension.

Despite his predisposition for the condition, Celis struggled to accept it. He wanted to believe that the stress of his work, his mother’s illness and a visit from an aunt could all have made the day unusual. In the end, however, he decided the numbers told the truth.

“It’s not like I was stressed only for one week, and I only have one week of data,” he said. “I have more data accumulated over time.”

Meanwhile, other pieces of Celis’ health puzzle pointed to a high risk of cardiovascular disease. As he suspected, his family history was notable, his doctors said. Additionally, they said, while his inherited health didn’t signal any risks that could be tested by genetic screenings, his Filipino-American heritage was a factor to consider.

“Because of his family history, and because of his personal history of high triglycerides, and because I knew that Filipinos were more prone to early heart disease given my research, it was clear to me that he was on the higher end of the risk continuum, and we should act accordingly,” said Latha Palaniappan, MD, who led Humanwide’s genetic component and is Stanford Medicine’s scientific director of precision genomics and pharmacogenomics in primary care.

She referred Celis to the preventive cardiology clinic, where he underwent a CT scan that generated detailed X-ray images of his heart. The scan revealed calcifications that suggested early atherosclerosis, a disease in which deposits of fat, cholesterol, calcium and other substances build up in the arteries.

The amount of deposits was high for a person Celis’ age. In fact, 42 was too young to even be on the chart; and among 45-year-old men, he was in the 85th percentile, meaning most of his peers would have a lower amount of calcifications than he did.

Left untreated, Celis’ condition could lead to heart attack or stroke. Luckily, both his hypertension and the calcium deposits could be managed with medication. But he had qualms about taking prescription drugs because of the side effects he had experienced years before.

“I hate taking medication if I don’t have to,” Celis said.

Identifying better medications

Pharmacogenomic testing — another genetic screening through Humanwide — helped Celis’ doctors identify two drugs that would work best for him, meaning that his body would process them in the intended way, at the intended rate. Rosuvastatin would help control his triglyceride level and cholesterol without side effects. Losartan would help regulate his blood pressure without causing dizziness or adversely affecting his kidneys.

The pharmacogenomics test also helped determine which drugs would best prevent blood clotting for Celis if he were to have a heart attack.

“We were able to think ahead,” Palaniappan said, “and map out which direction to take if he were to face potential health situations, given his risk factors.”

Serving as a health coach, Mahoney met with Celis over five 20-minute sessions, and they added goals to improve his habits: Increase exercise by walking 30 minutes up and down a hill more than once a week. Walk before or after dinner. Cut down on salt in his diet.

Celis told Mahoney he would try to make changes. He, his wife and daughters would make an effort to eat healthier food. However, he said, “I’m not yet addicted to workouts. It takes a long time for someone to get used to that daily routine.”

Although Humanwide has ended, Celis still checks his blood pressure at home on occasion, and he continues to benefit from insights gained through the project. He said he appreciated that the comprehensive approach helped him identify and address his most pressing health concerns in a systematic way — “not just guessing,” he said.

Mahoney said she was gratified that Humanwide made such a substantive difference for Celis: “We’re aggressively addressing his cardiovascular risk, and that was really important for him.”

Celis’ experience in Humanwide wasn’t unique, she said.

“With Humanwide, we’re able to focus on the whole human: who they are when they’re working, who they are when they’re playing, who they are when they’re at home. I feel like this is just the beginning of where medicine will be going.” 

The team flagged a number of undiagnosed conditions and overlooked or “rising” health risks. That included a very high risk of breast cancer for five patients — the clinicians recommended ongoing, enhanced monitoring for them. Pharmacogenomics screening resulted in more than a dozen changes in medication prescriptions or dosages, including, in one case, identifying an adverse reaction to a narcotic pain reliever.

Continual readings from home-based devices also helped providers detect and address early diabetes or hypertension in several patients, as well as refine medication dosages for others with chronic illness.

In an initial evaluation of Humanwide, patients and providers said they liked its holistic focus, the care-team model and the longer interactions it allowed, said Steven Asch, MD, vice chief of primary care and population health, who led the analysis.

Hummel, the nurse practitioner on Celis’ care team, said she and her patients enjoyed learning more about their health. “Having the opportunity to do an extensive intake and really getting to know the patient story is always very beneficial,” she said.

Five more studies related to Humanwide are in the works, examining implementation of the digital health, genetics and pharmacogenomics components, among other subjects. Because the pilot was a small project focusing on patient and provider engagement in the approach, there aren’t plans to analyze potential costs, Mahoney said.

However, she is exploring how to most effectively integrate elements of Humanwide into care for patients at varying levels of health. For example, patients who are chronically ill or have medically complex conditions like cancer would likely benefit from more-intensive remote monitoring than patients without those types of conditions.

“With Humanwide, we’re able to focus on the whole human: who they are when they’re working, who they are when they’re playing, who they are when they’re at home,” Mahoney said. “I feel like this is just the beginning of where medicine will be going.”