DHH S Report Personalized Health
DHH S Report Personalized Health
DHH S Report Personalized Health
September 2007
September 2007
Roadmap for Medical Research: Clinical and Translational Science Award Program.....................42
Evidence-Based Practice.................................................................................................................48
Family History..................................................................................................................................57
Advisory Committee on Heritable Disorders and Genetic Diseases in Newborns and Children......61
Michael O. Leavitt
In the coming years, new gene-based knowledge, combined with the advent of health information
technology, can make possible a new kind of medical care for Americans: Personalized Health Care.
Of course, health care professionals have always aimed at making medical care as individualized as
possible. But in truth, our ability to deliver the right care for each person has been limited.
We have had only partial understanding of human biology at the molecular and genetic levels, where
each of us is biologically unique. Our understanding of each person’s particular susceptibility to diseases, as
well as his or her individual responses to therapies, has been limited. Physicians diagnose and treat on the
basis of symptoms that can be seen and felt. But they have not had access to the underlying biological
processes, unique to each of us, that start with the “instructions” in our genes.
At the same time, even our systems for using the health care information that we possess have
remained paper-based and siloed. Patient records, filed in different settings, can be difficult to access – a
poor foundation for personalization of care.
Finally, we have yet to use the power of networked information that has transformed many other
sectors. Despite growing complexity in health care, there is limited online support at the bedside to help
health care professionals deliver the best standard of care for each patient. In addition, while controlled
clinical trials remain the staple of progress in biomedical science, the additional wealth of information that
might be reaped from millions of encounters in day-to-day medical practice remains untapped.
This is not to say that the progress made by American medicine has been anything but remarkable. But
the opportunities that present themselves today hold the possibility of a transformation over the coming
years and decades that is even more far-reaching. It involves not only breakthroughs in scientific knowledge
but, equally important, the application of this knowledge on a patient-by-patient basis. We can see the
possibility of health care that is increasingly calibrated to each patient and personally effective for each
individual.
One part of the foundation for such a change is our rapidly growing understanding of the human
genome and the processes it directs. We envision health care that could:
• predict our individual susceptibility to disease, based on genetic and other factors;
• provide more useful and person-specific tools for preventing disease, based on that
• detect the onset of disease at the earliest moments, based on newly discovered chemical
markers that arise from changes at the molecular level;
• preempt the progression of disease, as a result of early detection; and
• target medicines and dosages more precisely and safely to each patient, on the basis of
genetic and other personal factors in individual response to drugs.
Another part of the foundation for personalized health care is the potential for health information
technology to help develop new knowledge and put it to effective use. When health information exists in
electronic form, capable of being shared securely, it can:
• make the patient’s complete health information available when and where needed;
• provide support to clinicians when they need it, to help them give patients the best standard of
care, including information based on individual genetic and molecular factors;
• through secure networks, bring together masses of data from day-to-day medical practice to
accelerate our understanding of which treatments work best, and to monitor for safety problems in
real time; and
• use the medical evidence developed from such networks to understand differences in patients’
response to drugs and other therapies, learning who benefits from specific treatments, so that
therapies can be targeted on a more individualized basis.
Personalized health care is information-based health care. It is health care that works better for each
patient, based partly on scientific information that is new and partly on technology to make complex
information useful. Whether it involves new biomedical knowledge, data networks for developing that
knowledge, or computer supports to manage that knowledge, personalized health care is about a
transformed role for information in health care.
This report is an early “reconnoitering,” a glimpse from the perspective of the Department of Health and
Human Services (HHS) of the work that lies ahead to achieve personalized health care. From this early
stage, we can outline the opportunity. We can roughly see the building plan and identify some of the key
elements and pathways that must be traversed. We can recognize the importance of collaboration. We can
identify broad prerequisites for personalized health care. And we can identify the HHS resources that are
already in play.
We can also identify the need for standards in many new areas. More broadly, we can see the
imperative for collaboration across the private and public sectors and across many disciplines and
stakeholders.
Finally, we must remember that the true foundation of this progress is public trust. It is not enough
merely to develop the knowledge and information that will make personalized health care possible. In
addition to developing the information, we must use it correctly.
One of my priorities as HHS Secretary is to help build a strong foundation for personalized health care.
That means coordinating work across HHS agencies as well as addressing crosscutting issues, to ensure
that new information and capabilities will be used appropriately.
We cannot entirely foresee how different health care may be in the coming decades. It seems inevitable
that there will be a significant period of disruption and learning as new capabilities are developed and
adopted. Nonetheless, it is incumbent on us to take steps now, even as basic knowledge and technologies
are being developed, to anticipate and enable that future. The goal of the health care professional remains
to deliver the right care to the right patient at the right time, and that is what personalized health care is
about.
Personalized health care means knowing what works, knowing why it works, knowing who it works for,
and applying that knowledge for patients. These goals may sound elementary, but a generation of effort lies
before us in achieving them – perhaps one of the most complex science-based endeavors in our history. We
approach it with high hopes and humility.
OPPORTUNITIES
prevention, including early diagnostic indicators as demand for such products increases in tune with patient
and physician demand.
This vision of a new kind of health care rests on the achievements of the past, the gathering speed of
advances in biomedicine and information technology, and decades of further work. But if the past is
prologue to the future, we can expect the investment of time, talent, and resources to grow steadily and the
speed of change to be rapid. Converging biomedical technology, medical practice, demographics, and
policy initiatives offer a new vehicle to drive personalized health care forward.
CHALLENGES
Public Trust
The introduction of powerful genomic technologies into the health marketplace has the ability to
positively impact us as individuals and as a society. Genomic information has unique potential to identify
and predict the health outcomes of individuals and their families. Establishing the public’s trust for use of
personal health and genetic information in electronic health care management systems will be key to
ensuring public acceptance of new medical genetic technologies.
An overarching principle of personalized health care is that an individual’s predictive genetic
information, when acquired for health care purposes, should be used only for health-related activities, and
should not be used inappropriately in making employment or health insurance coverage decisions.
increasingly important element of health care. The development of systems for developing evidence from
the health care delivery can add significantly to the evidence base and to growing knowledge of individual
variations in response to treatments.
PATHWAYS
• Genome-wide association studies: These studies are a kind of medical detective work, matching
the genetic profiles of large numbers of patients in clinical trials with their health conditions. These
associations can help uncover patterns that point toward the roles of different genetic elements in
health and disease. (NIH)
• Genes and environment: The complex relationship between genetics and environmental factors,
including factors like nutrition and physical activity, help determine each person’s health. The
Genes, Environment and Health Initiative (NIH) and the Human Genome Epidemiology Network
(CDC) are early efforts in understanding this relationship.
• Population genetics: To help make genetic information useful, it is important to know the
prevalence of genetic mutations and other factors in the population. This information can also be
useful in targeting public health activities. Existing health surveys are used to compile this
information. (CDC, HRSA, NIH)
• The “Omics”: Extensive work is needed to understand molecular biological elements beyond the
focus on DNA and RNA. In particular, research is needed regarding proteomics, metabolomics,
and epigenetics. (NIH)
• Computational biology: With 3 billion DNA base pairs and 20,000 active genes in each
individual’s genetic makeup, development of information is dependent on sophisticated computing
power. The computing tools needed for genetic and molecular biology research are in a constant
state of invention. (NIH)
• Biomarker identification: Chemical and other markers that indicate specific biological activities
can provide useful tools for clinical diagnosis and treatment as well as help to speed product
development. A public/private Biomarkers Consortium has been formed to help identify useful
biomarkers. (FDA, NIH)
• “Learning” health care: By aggregating large amounts of de-identified patient data from day-to
day medical practice, researchers can monitor safety and add rapidly to the evidence about what
treatments work best and for whom. Combined with controlled clinical trials, this “learning” from
practice through health IT can add significantly to effectiveness in health care. (AHRQ, CMS)
• Informatics and nomenclature: Deriving useful information from health care delivery will require
standardization in measures and nomenclature, as well as sophisticated computer programming.
(NIH, ONC)
• Quality improvement and health IT adoption: Demonstrations of health IT in a variety of health
care settings will measure the impact on quality of care and the dynamics of health IT adoption in
real-world situations. (AHRQ, HRSA)
• Provider and consumer education: New medical tools will be useful only if they are trusted and
used by health care professionals and patients. Communities and professional groups will need to
be engaged in learning new practices. CaBIG, the Cancer Biomedical Informatics Grid, is a leading
example, linking researchers, patients, and physicians throughout the cancer community to learn
new practices and feed back into research. (NIH, HRSA, AHRQ)
• Knowledge management and decision support tools: An important element of health IT will be
clinical decision support to help providers deliver “the right care to the right person at the right
time.” Knowledge management tools will also play a part in delivery of more complex care based
on genetic testing and therapy. (ONC, AHRQ, HRSA)
• Effective use of genetic tests: More than 1,000 genetic tests are now available, but clinicians and
consumers need support in determining the appropriate and effective use of such tests. The
Evaluation of Genomic Applications in Practice and Prevention (EGAPP) project is a potential
model for providing needed guidance. (CDC, CMS, FDA, AHRQ, HRSA)
• Family history: Collection of family history information can be a powerful early tool for improving
care and building the base for personalized health care. (CDC, NHGRI, ONC, Office of the
Surgeon General)
• Costs and reimbursement: The value delivered by new personalized health care products will
need to be demonstrated and evidence of effectiveness shown. New approaches in rewarding high
quality and value through reimbursement techniques are being tried. (CMS)
Standards
The concept of using gene-based factors and health information technology together to personalize
health care is at an early stage. As we build the foundation, it is especially important to agree on standards
in order to create common interfaces, measurements, and vocabularies. Standards are essential both for
collaboration in building a system, and for enabling future value-enhancing competition.
Data and technical standards are critical to the advancement of the national health IT agenda and
achieving the intended health goals and outcomes. By harmonizing standards, different information
systems, networks, and software applications will be able to “speak the same language” and work together
technically to manage and use consistent, accurate, and useful health information for providers and
consumers. For this reason, harmonizing interoperability standards is a priority for the Secretary of HHS,
and with the advice of the American Health Information Community, the Secretary will continue to recognize
interoperability standards.
Standards of performance are also important in nourishing a market for health IT. When providers
invest in health IT, they need to have measures to demonstrate the value of their purchase. With AHIC’s
guidance, the Secretary recognized a number of performance standards for health IT systems last year that
were then incorporated into the process by which health IT products and systems are certified by the
Certification Commission for Health Information Technology.
Standards are equally important in research. An important challenge in seeking out the associations
between genetic factors and health will be standard nomenclatures, especially for health and disease
conditions. An early start has been made with SNOMED, a broad collaborative effort carried out with HHS
support to establish a standardized vocabulary of clinical and pathology terms. NIH, FDA and other
agencies continue to bring together stakeholders for extensive further work in these areas.
Agreements on nomenclature and standards for outcome measurement will also be important as we
seek to use data from clinical practice to add to our base of evidence about the effectiveness of treatments
and to improve quality of care.
These are only a few examples of collaborative efforts that are under way to build the base of standards
that will help accumulate information, transform information into knowledge, improve care, and create new
value.
Genomic information and health information technology both convey new power. As we seek to use
that power to improve care and health, we need to exercise the wisdom and discretion to avoid misusing it.
In the end, the usefulness of these advances will depend on public trust. That trust must be fostered and
protected.
A starting point is to avoid misusing genetic information to deny employment or health insurance to
individuals. While genetic discrimination has not emerged as a significant problem at this time, surveys
show that Americans are concerned about the possibilities for abuse in the future, and they want protections
put in place. The Administration supports Federal law to prohibit such misuses.
A leading objective throughout HHS agencies is to build a strong foundation for personalized health
care. HHS Secretary Michael Leavitt has launched a PHC initiative, with several cross-cutting elements:
• The President’s budget for 2008 includes $15 million in startup funding to create a new electronic
network that would draw together data from major health data repositories. This distributed network
would be a prototype for a “learning health care system.” De-identified data from day-to-day health
care practice would enable researchers to add to our base of medical evidence on effectiveness
and safety of alternative treatments.
• The American Health Information Community (AHIC) is charged with developing recommendations
for consensus standards and other actions that would support President Bush’s goal of electronic
health records for most Americans by 2014. This year, the AHIC has also formed a new workgroup
to develop recommendations for the AHIC on standards for including genetic test information and
family history in electronic health records.
• Efforts are under way in HHS to consider issues relating to the use of genetic test information to
improve quality of health care within the framework of providing protections for the patient’s privacy.
• As a result of the advances in technology development and increased medical knowledge about
the roles of genes in health and disease, greater use of genetic tests in health care is anticipated.
To prepare for this, HHS is also examining opportunities to help facilitate medical product
development and encourage innovation, while taking into account potential processes to assess
safe and effective health care applications. The goal is to ensure a coherent framework across
HHS agencies and to support value and innovation in genetic testing applications in health care.
• Many new research projects are establishing databases of genomic information from clinical
studies. HHS is working to maximize the benefits that derive from federally sponsored research
resources by considering common approaches for the availability of their data to the research
community.
These steps represent a systems strategy. They are aimed at building a foundation that will use new
methods of genetic analysis to better manage a patient’s disease or predisposition to a disease, while at the
same time facilitating the discovery and testing of new products. They emphasize the development of
standards to derive the greatest possible benefit as health information technology brings about exchange of
health information, including better bridges between research and health care delivery.
The end goal is to transform the effectiveness of treatments provided for each patient, while building
understanding and trust among providers and patients in a new kind of health care.
RESOURCES
had to be tested in every individual. Later studies showed that only some 500,000 SNPs needed to
be tested across the genome to assess a person’s genetic variation. These technical advances led
researchers to organize the International HapMap Project, a coordinated effort to map genetic
variation in populations of people from Africa, Asia, and Europe. The HapMap produced a catalog
of common variations across the entire human genome that has been used to quickly and cheaply
assess all the common variants in an individual. This capability laid the foundation for genome-
wide association studies to identify the genetic underpinnings of common illnesses (described
later). See http://www.hapmap.org/.
• But even acquiring the sequence of the human genome and starting to understand genetic
variation were only the first steps in understanding how the human genome works; researchers
now need to understand what it does and how it works. Estimates suggested that only a few
percent of the human genome actually encoded proteins, the workhorses of the living cells that
make up the body. To begin to understand the genome’s dynamism, The NHGRI launched a public
research consortium named ENCODE (http://www.genome.gov/10005107), the Encyclopedia Of
DNA Elements, in September 2003, to carry out a project to identify all functional elements in the
human genome sequence. The project is being conducted in three phases: a pilot project phase, a
technology development phase, and a planned production phase. Major findings from the pilot
project were published in two scientific journals, Nature and Genome Research, in mid-June;
details can be found at http://genome.gov/25521622.
• Since 1990, NHGRI has been investing funds to develop and improve DNA sequencing
technologies. DNA sequencing costs have fallen dramatically, more than fiftyfold over the past
decade. The goal of this technology development program is to reduce the cost of sequencing a
human-sized genome to $1,000. Several new NHGRI-supported technologies aimed at an
intermediate goal of $100,000 per genome are now reaching the market place and others show
strong potential to become commercially available within the next 5 years. Beyond the intermediate
goal, another set of investigators are being supported to develop revolutionary technologies to
sequence a human genome extremely inexpensively (conveniently referred to as the “$1,000
genome”). Having the ability to sequence an individual genome so inexpensively would not only
dramatically stimulate biomedical research, but would also support personalized health care goals.
Researchers envision a day when anyone can have his or her genome sequenced, one time, as
part of routine medical care and have access to it in some digital form, such as on a CD-ROM or a
flash memory card. Physicians would then use a computer to screen that individual genome for
genetically increased risks to common disease, such as cancer or diabetes, as well as use that
information to predict which medical interventions will best work to prevent the disease from
occurring, treat it effectively if it does, and select therapies that cause the fewest unwanted adverse
reactions or side effects. In many ways, these technical genome-sequencing innovations will be
needed to make personalized health care economically feasible for all.
Researchers have known since the first analysis of the draft human genome sequence in 2000 that
people are 99.9 percent identical at the genetic level. Within that 0.1 percent, where people differ one from
the other, however, lies the reason why one person has a higher risk of a common disease, such as
diabetes, than someone else. Studies show that common variations exist across the genome; GWAS will
systematically associate the common variations with specific common diseases. Whereas past genetic
research found strong effects from single gene defects that caused rare inherited diseases, such as cystic
fibrosis or muscular dystrophy, GWAS will identify many genetic variations that, when summed, produce an
increased relative risk for common diseases, such as cancer or Alzheimer’s disease. The genetic variations
identified by GWAS may also identify combinations of genetic variation that confer good health (i.e., lower
relative risks) and even show doctors which medications will best work to treat an individual with a given
genetic makeup.
In many ways, the results from GWAS will provide the information physicians need to interpret an
individual’s genome once it has been sequenced by the technologies described in the sequencing
technology section above.
Those results will be arriving rapidly over the next few years. The diseases for which results already are
available include age-related eye diseases, Parkinson’s disease, attention deficit hyperactivity disorder
(ADHD), schizophrenia, and psoriasis.
In addition, recent reports have appeared in the scientific literature on a wide range of GWAS findings,
including:
1. Type 2 diabetes: Three scientific reports in April, including one involving NHGRI, linked 10 genes
to Type 2 diabetes.
2. Coronary heart disease: Two studies linked genetic markers on chromosome 9 with coronary
heart disease and heart attacks. Moreover, one of the genetic variants in the heart studies
appeared in the same region as a genetic variant in the Type 2 diabetes studies reported earlier in
the month.
3. Adult obesity: One study linked one form of a single gene to body mass index and discovered it
predisposes to childhood and adult obesity.
4. Adult height: Another study linked a gene variation to height in different populations around the
world.
5. AIDS: The first GWA study of an infectious disease provided new insights into why some patients
suffer less harm during an acute infection with human immunodeficiency virus (HIV) than others
who are less able to suppress the virus that causes AIDS. The insights may well lead to more
effective treatments.
6. Age-related macular degeneration: One of the earliest modern GWAS discoveries found a
relationship of a gene involved in an inflammatory response with a type of blindness that occurs in
elderly individuals. The discovery immediately suggested a therapeutic intervention that should
slow the progression of the blindness.
7. Results from numerous other disease-related GWA studies have begun producing results on
various disorders, such as glaucoma, Type 1 diabetes, breast cancer, Crohn’s disease, prostate
cancer, rheumatoid arthritis, multiple sclerosis, and asthma. Results from illnesses being studied
with the GWAS strategy have risen dramatically, and equally dramatic results can be expected in
the next few years.
Other advances are expected from large-scale projects launched by several of the NIH’s Institutes and
Centers, including the Framingham Genetic Research Study, launched by the National Heart, Lung, and
Blood Institute in February 2007, in which 9,000 participants of the long-running Framingham Heart Study
will undergo genomic analysis. The National Cancer Institute (NCI) also launched a GWAS aimed at
identifying the genes involved in cancers of the breast and prostate. The 3-year, $14 million initiative was
launched in 2006.
Through a series of GWA studies, using samples from existing case-control studies of patients with
common diseases, these projects will contribute to the identification of genetic pathways that make us more
susceptible to these diseases and thus facilitate discovery of new molecular targets for prevention,
diagnosis, and treatment.
Status and Next Steps
• After a period of public consultation, the NIH in August released a new policy for Genome-Wide
Association Studies supported and conducted by NIH. The policy addresses (1) data-sharing
procedures, (2) data-access principles, (3) intellectual property, and (4) issues regarding the
protection of research participants through all phases of GWAS. Many of the principles
contained in the policy reflect and extend existing NIH polices and other recent NIH
discussions. The GWAS policy will be applicable to competing grant applications, proposals for
contracts, and intramural research projects beginning on January 25, 2008. The policy can be
accessed at http://www.genome.gov/19518660.
The National Library of Medicine (NLM) recently initiated a new database known as dbGaP to distribute
data from GWAS. dbGaP, the database of Genotype and Phenotype, will for the first time provide a central
location for interested parties to see all study documentation and to view summaries of the measured
variables in an organized and searchable Web format. Already, the NIH database of Genotype and
Phenotype (dbGaP) makes data from several GWA studies freely available to researchers around the world.
See http://www.ncbi.nlm.nih.gov/sites/entrez?db=gap.
• To monitor trends in the prevalence, awareness, treatment, and control of selected diseases.
• To monitor trends in risk behaviors and environmental exposures.
• To analyze risk factors for selected diseases.
• To study the relationship between diet, nutrition, and health.
• To explore emerging public health issues and new technologies.
• To establish a national probability sample of specimens for genetic analyses:
– CDC has defined a “top 100” list of genetic variants of public health significance, and is
currently leading a collaborative effort with the NCI to determine how common these variants
are in the U.S. population, using over 7,000 biologic specimens collected in NHANES III. This
work will be completed later this year and will provide a foundation for further studies to
understand how genetic variation contributes to human disease.
CDC and the CDC Foundation are launching a new initiative, Beyond Gene Discovery (BGD), to
measure hundreds of thousands of genetic variants in about 15,000 NHANES biologic specimens, and to
coordinate the comprehensive analysis of associations among variations in genotype, phenotype, and gene-
environment interaction.
Biomarkers Consortium
http://www.fnih.org/Biomarkers%20Consortium/Biomarkers_home.shtml
Description
The development of biomarkers is being carried out by work in several NIH Institutes, as well as
through the Biomarkers Consortium. The Consortium is a public-private biomedical research partnership of
the Foundation for the NIH that involves a variety of public and private stakeholders including the NIH; U.S.
Food and Drug Administration (FDA); Centers for Medicare & Medicaid Services (CMS); pharmaceutical,
biotechnology, diagnostics, and medical device industries; nonprofit organizations and associations; and
advocacy groups. The goals include accelerating disease-specific research and ensuring that safe,
innovative, and effective medicines and diagnostics are expeditiously developed to address health care
needs, improve medical care, and promote and improve public health. The Biomarkers Consortium
facilitates personalized health care by developing tools and information that facilitate understanding about
individual differences in disease conditions.
Status and Next Steps
The Consortium’s first project will be to qualify a method to use imaging methods to detect tumor
response to new chemotherapy agents. A method known as fluorodeoxyglucose positron emission
tomography (FDG-PET) is considered a potential biomarker for response of cancer to treatment. FDG-PET
measures glucose uptake by tumors using a radioactive form of fluorine incorporated in a sugar molecule.
Tissues that accumulate radioactive glucose are visible through positron emission tomography (PET), an
imaging method to detect gamma rays.
Researchers believe that FDG-PET could become a tool for gauging a cancer patient’s response to
chemotherapy or radiation by accurately measuring tumor metabolism. Physicians will thereby rapidly know
whether the tumor is responding to therapy or when to switch therapies to provide the best chance for curing
or managing the cancer. FDG-PET can also assist clinical research and drug development by helping to
assess a study subject’s response to investigational drugs.
Initially, the Consortium will focus its FDG-PET efforts on non-Hodgkin’s lymphoma and lung cancer.
Non-Hodgkin’s lymphoma strikes over 55,000 Americans each year and kills close to 20,000 according to
the NCI. Lung cancer makes up 13 percent of all cancer cases in the United States. More than 170,000
individuals are diagnosed with lung cancer each year, and close to that number die from the disease.
Although it was once thought to almost exclusively be caused by smoking, approximately 13 percent of lung
cancer patients have never smoked.
the OAI will provide an unparalleled, state-of-the-art longitudinal database of images and clinical outcome
information to researchers worldwide to facilitate the discovery of biomarkers for development and
progression of OA. In this effort, a biomarker would be a physical sign or biological substance that indicates
changes in bone or cartilage. Today, 35 million people, 13 percent of the U.S. population, are ages 65 and
older, and more than half of them have radiological evidence of OA in at least one joint. By 2030, an
estimated 20 percent of Americans, about 70 million people, will have passed their 65th birthday and will be
at increased risk for OA.
• Scientists have discovered how human T cell leukemia virus type 1 (HTLV-1), which infects about
20 million people worldwide, evades being held in check by one of the body’s natural defense
mechanisms. (An active infection with HTLV-1 leads to T cell leukemia in up to 5 percent of all
cases worldwide.)
These programs are part of an infrastructure that will develop resources to support discovery of new
genetic markers of cancer that can be used to identify individuals at risk for them. Completion of these pilot
projects will establish a research capability to support individualized approaches to health care.
http://biospecimens.cancer.gov/
Description
The Office of Biorepositories and Biospecimen Research (OBBR) was established at the NCI in 2005 to
facilitate and accelerate the development of personalized cancer medicine by ensuring the availability of
high-quality, clinically annotated human specimens for postgenomic cancer research. Toward this end, the
OBBR is committed to the development of evidence-based standards of biospecimen acquisition,
processing, and storage that optimally preserve the quality and integrity of biospecimens for molecular
analysis and ensure reproducibility of molecular tests performed on those specimens. Such standards will
become the standards of pathology/laboratory medicine practice in an era of personalized medicine.
Status and Next Steps
• In order to create a baseline to assess, improve, and ensure the quality of human biospecimen
resources, the OBBR has developed a comprehensive set of state-of-the-science guidelines for
biobanking, NCI Best Practices for Biospecimen Resources. The Best Practices, accepted in final
form by the National Cancer Advisory Board in June 2007, will serve as the national standard,
while OBBR engages in a stepwise process of increasing the scientific base for further data-driven
standards and operating procedures that are molecular analysis platform-appropriate.
• The Best Practices guidelines also have served as the basis for a comprehensive set of
Biospecimen Resource Evaluation Criteria (the BRET) developed by the OBBR that can be used to
objectively assess the quality of any existing or planned biospecimen resources based on the
current state of the science.
• The OBBR has developed an intramural Biospecimen Research Network (BRN) and an extramural
program known as Biospecimen Research for Molecular Medicine to systematically investigate the
effects of acquisition, processing, and storage variables on biomolecular profiles in specimens.
Such data will form the scientific basis of data-driven procedures for patient specimen handling in
molecular medicine.
• The OBBR has established collaborations on data-driven protocol development with authoritative
professional organizations like the College of American Pathologists that can both monitor
implementation through its Laboratory Accreditation Program and educate its constituents about
the importance and practicalities of compliance with these new standards.
• The Best Practices guidelines advocate cost recovery but not profit-generating business models for
biospecimen resources. In order to help biospecimen resources define actual costs in a modular
fashion that can be customized to any given resource model, OBBR has undertaken a Biobanking
Economics initiative and plans to publish guidance for cost recovery on the basis of the findings.
• The OBBR is collaborating in transformative, large-scale NCI strategic initiatives that will enable
personalized medicine in which the principles of high-quality shared biospecimen resources are
critical for achieving the research goals. Such projects include those that emphasize high-quality
biospecimens as shared resources for cancer researchers, such as the NCI Community Cancer
Centers Program; caBIG™ projects; The Cancer Genome Atlas; Clinical Proteomic Technologies
Assessment for Cancer; and the Nanotechnology Alliance.
• The OBBR also has established collaborations with other major initiatives outside the NCI,
nationally and internationally, to achieve global harmonization of approaches to biospecimen
issues throughout the translational research enterprise. Projects include the Interagency (NCI,
FDA, CMS) Oncology Task Force and the Biomarkers Collaborative (NCI, FDA, AACR).
• The OBBR is committed to the development of educational tools and resources for all potential
stakeholders (public, professional, private) that address the spectrum of issues related to human
biospecimens in order to align interested constituencies on the importance of high-quality shared
biospecimen resources. Projects include OBBR Web site enhancements for biospecimen research
and resource data sharing; development of educational programs for professionals; outreach to
patient advocacy groups; and development of hands-on training programs for biobankers.
http://www.cdc.gov/cancer/npcr/
Description
State-based cancer registries are data systems that collect, manage, and analyze data about cancer
cases and cancer deaths. In each State, medical facilities (including hospitals, physicians’ offices,
therapeutic radiation facilities, freestanding surgical centers, and pathology laboratories) report these data to
a central cancer registry. Established by Congress through the Cancer Registries Amendment Act in 1992,
and administered by the CDC, the National Program of Cancer Registries (NPCR) collects data on the
occurrence of cancer; type, extent, and location of the cancer; and type of initial treatment.
Status and Next Steps
• Before NPCR was established, 10 States had no registry, and most States with registries lacked
the resources and legislative support they needed to gather complete data. Today, NPCR supports
central cancer registries in 45 States, the District of Columbia, Puerto Rico, the Republic of Palau,
and the Virgin Islands. These data represent 96 percent of the U.S. population. Together, NPCR
and the NCI’s Surveillance, Epidemiology, and End Results (SEER) Program collect data for the
entire U.S. population.
• Since 2002, CDC and NCI have combined their data sources to publish annual Federal cancer
statistics in the United States Cancer Statistics (USCS): Incidence and Mortality report, produced in
collaboration with the North American Association of Central Cancer Registries. This year’s report
includes cancer incidence data from registries covering 96 percent of the U.S. population, and
mortality data from all States and the District of Columbia.
• CDC has collaborated with NPCR-funded programs to define, test, and release NPCR data in
WONDER, an online reporting system hosted at CDC. This new system, launched in early 2006,
allows more access to NPCR data than previously was available. Finding critical data that can help
guide and evaluate interventions focused on cancer prevention and control now is easier than ever.
• NPCR has developed software programs to make the process of submitting data easier for
hospitals. By standardizing the way data are checked for validity, EDITS software improves data
quality. Hospitals also can use any of the Registry Plus suite of programs for routine or special data
collection. CDC provides and distributes these software programs, which are compliant with
national standards, free of charge to the public health community.
http://www.hhs.gov/healthit/
Description
The American Health Information Community (AHIC) was chartered in 2005 to make recommendations
to the Secretary of HHS on how to accelerate the development and adoption of health information
technology. AHIC was formed to help advance efforts to reach President Bush’s goal for most Americans to
have electronic health records within 10 years. It provides input and recommendations to HHS on how to
make health records digital and interoperable and ensure that the privacy and security of those records are
protected, in a smooth, market-led way.
Status and Next Steps
In May 2006, the AHIC delivered its first set of recommendations to the Secretary of HHS. The
Secretary officially accepted these recommendations, which were in four areas of focus:
• Consumer Empowerment. To create a consumer-directed and secure electronic health-care
registration information and medication history for patients.
• Chronic Care. To use secure messaging, such as e-mail, for communication between patients and
their health-care providers.
• Electronic Health Records. To create standardized, secure records of past and current laboratory
test results that are accessible by health professionals.
• Biosurveillance. To enable the transfer of standardized and de-identified health data to authorized
public health agencies within 24 hours.
In addition, AHIC has made significant progress in standards harmonization:
• The AHIC recommended three sets of “Interoperability Specifications” approved by the Health
Information Technology Standards Panel (HITSP), a standards panel established by the American
National Standards Institute (ANSI) to help in harmonizing hundreds of competing standards.
Secretary Leavitt accepted these standards, which form the basis of interoperability.
In 2006, AHIC created three new workgroups to make recommendations to the AHIC, which in turn will
provide recommendations to the Secretary:
• Confidentiality, Privacy, and Security
• Health Care Quality
• Personalized Health Care
The grants support the use of EHRs as a tool to improve the safety, quality, efficiency, and
effectiveness of health care delivery. They also will test the ability of health centers and other safety-net
providers to adopt and effectively use EHRs, create sustainable business models for deploying HIT, and
leverage initiatives and resources to improve quality and health outcomes.
HRSA also is working to expand the number of users of a HRSA Web portal called the HRSA Health
Information Technology Community. The site provides a “virtual” meeting place for users, most of whom are
staff from health centers, health center networks, and primary care associations. Users take part in online
discussions, share documents, and exchange tools and resources on using electronic technology to
promote patient safety and quality of care. HRSA will expand access to the site to organizations that receive
grants from HRSA’s HIV/AIDS Bureau, Maternal and Child Health Bureau, Office of Rural Health Policy, and
Office for the Advancement of Telehealth.
• Research questions that have been previously addressed through analysis of Part A (hospital
insurance) and Part B (medical insurance) claims have contributed to very significant
improvements in public health, have been critical in assessing the quality of care and costs of care
for patients in the Medicare program, and have in many cases spurred other types of research. The
final regulation allowing the use of Part D claims data is expected to be published later in 2007.
Best Practices and Quality Measurement. In addition, Medicare is examining ways to share
information with national and regional quality collaboratives to help in developing standards of care and
“best practices,” as well as measuring performance by providers.
Companion Guidance for the Pharmacogenomic Guidance. A Companion Guidance for the
Pharmacogenomics Guidance has been drafted to recommend protocols in the generation of genomic data
from microarrays where a consensus exists for their use and to encourage a discussion leading to a
consensus where it is currently lacking. This Companion Guidance has its roots in VXDSs and the
experience the FDA has gained from these VXDSs regarding the need for a consensus on how genomic
data are generated, reported, and reviewed.
Microarray Quality Control Consortium. This experience has also led to the development of
collaborative consortia such as the Microarray Quality Control Consortium (MAQC) to identify sources of
variability in the generation of genomic data from microarrays. In its initial phase, MAQC identified sources
of variability in the generation of differential gene expression data. MAQC is currently in a second phase,
focused on the identification of sources of variability in the determination of predictive genomic signatures.
Predictive Safety Testing Consortium. A collaborative consortium has also been developed to help
bridge the gap between exploratory and qualified biomarkers. The Predictive Safety Testing Consortium
(PSTC) is working through the C-Path Institute to share data, biomarkers, and nonclinical and clinical
samples for the qualifications of nonclinical and clinical biomarkers of safety. The PSTC is a key tool in
taking drug-independent exploratory biomarkers into qualification through the Pilot Process for Qualification
of Biomarkers.
FDA review of diagnostic devices has been advanced by recent statutory changes including the charge
by Congress to ensure “least burdensome” regulatory reviews and to provide additional scientific resources
and training by implementation of device user fee programs.
FDA has also been proactive in educating stakeholders in its regulatory and scientific work processes.
The agency routinely participates in more then two dozen outreach talks per year in the areas of biomarker
development, genomics, and personalized medicine; has cosponsored a joint workshop with AdvaMed in
2006 to address issues of importance in pharmacogenomics; and holds a yearly joint training program with
industry designed for novice regulatory affairs personnel on how to submit good premarket submissions.
Status and Next Steps
Over the past 5 years, FDA has published almost a dozen guidance documents relevant to
development of tests to support personalized medicine. These include:
Class II Special Controls Guidance Document: Factor V Leiden DNA Mutation Detection
Systems – Guidance for Industry and FDA Staff – March 2004. This document was the first FDA-
published guidance for clearance of a widely used genetic test system for predisposition to clotting
disorders. It represented a milestone in pragmatic approaches to establishing analytical performance,
classification flexibility, and use of existing clinical literature to support clinical use.
http://www.fda.gov/cdrh/oivd/guidance/1236.html
Instrumentation for Clinical Multiplex Test Systems – Class II Special Controls Guidance
Document – Guidance for Industry and FDA Staff – March 2005. This document provides general advice
on FDA premarket review criteria for multiplex signal measurement instrument systems. It was published
with FDA guidance on drug metabolizing enzyme genotyping
(http://www.fda.gov/cdrh/oivd/guidance/1551.pdf) to allow clearance of the first microarray system for
genetic determinations for metabolic enzyme activity. It provides information on basic hardware, software,
and analytical study requirements for this type of system. http://www.fda.gov/cdrh/oivd/guidance/1546.html
Drug-Diagnostic Co-Development Concept Paper – April 2005. This concept paper provides a
preliminary but comprehensive overview of administrative and scientific issues of importance in the co
development of a drug in parallel with use of a diagnostic product.
http://www.fda.gov/cder/genomics/pharmacoconceptfn.pdf
Class II Special Controls Guidance Document: RNA Preanalytical Systems (RNA Collection,
Stabilization and Purification Systems for RT-PCR used in Molecular Diagnostic Testing) –
September 2005. This document provides general advice on how to demonstrate quality and standardized
performance for preanalytical accessories to genetic test systems. Given the critical importance of proper
collection and processing of genetic samples to ensure quality results, this document provides valuable
information for manufacturers to ensure the ability of their test systems to generate reliable results.
http://www.fda.gov/cdrh/oivd/guidance/1563.html
CFTR Gene Mutation Detection Systems – Guidance for Industry and FDA Staff – Class II
Special Controls Guidance Documents – October 2005. This guidance provides information on approval
of the first multiplex system for cystic fibrosis. It utilizes existing literature and practice standards to allow for
premarket review without new or additional clinical studies. http://www.fda.gov/cdrh/oivd/guidance/1564.html
Guidance for Industry and FDA Staff – Pharmacogenetic Tests and Genetic Tests for Heritable
Markers – June 2007. This document was first issued as a draft in 2003 and then reissued in 2006. It
includes concise recommendations on how to establish analytical and clinical performance for new tests. It
also provides information on how sponsors can use published literature, when available, to reduce the
burden of bringing new tests onto the market by building on existing data and information.
http://www.fda.gov/cdrh/oivd/guidance/1549.html
Guidance on Informed Consent for In Vitro Diagnostic Device Studies Using Leftover Human
Specimens That Are Not Individually Identifiable – Guidance for Sponsors, Institutional Review
Boards, Clinical Investigators, and FDA Staff – April 2006. This document provides clarification on how
researchers and companies developing new tests can have access to leftover samples, while ensuring
patient privacy, for product development when samples would otherwise be discarded.
http://www.fda.gov/cdrh/oivd/guidance/1588.html
Draft Guidance for Industry, Clinical Laboratories, and FDA Staff – In Vitro Diagnostic
Multivariate Index Assays – September 2006 and July 2007. This draft guidance indicates FDA interest
in applying its regulatory processes to a small niche of unique diagnostics that integrate multiple signals into
a composite signal or score for use in cutting-edge diagnostics. A key criterion for this test category is
inability of the health care provider to independently verify or interpret the test result without the help of the
test developer. The draft guidance indicates that for tests of this type, whether developed for sale to multiple
laboratories or for use at a single laboratory, FDA intends to enforce regulatory requirements. The intent is
to ensure that nontransparent tests that are difficult to validate are subject to adequate oversight before
being offered in the medical marketplace. http://www.fda.gov/cdrh/oivd/guidance/1610.html
Guidance for Industry and FDA Staff – Class II Special Controls Guidance Document: Quality
Control Material for Cystic Fibrosis Nucleic Acid Assays – January 2007. This document was the first
FDA guidance on addressing issues unique to the quality control of genetic tests. Although written
specifically for a submission for quality control for cystic fibrosis, principles in this document apply broadly to
quality control for other genetic-based methodologies. http://www.fda.gov/cdrh/oivd/guidance/1614.html
Guidance for Industry and FDA Staff – Statistical Guidance on Reporting Results from Studies
Evaluating Diagnostic Tests – March 2007. This comprehensive document was developed to assist
manufacturers in statistical options for study of diagnostic devices and how to label the devices truthfully
and accurately based on the types of studies done to support product intended use(s).
http://www.fda.gov/cdrh/osb/guidance/1620.html
Guidance for Industry and FDA Staff – Class II Special Controls Guidance Document: Gene
Expression Profiling Test System for Breast Cancer Prognosis – May 2007. This document provides
information on FDA premarket review requirements for RNA expression arrays. For the first FDA-cleared
test of this type, FDA reviewed studies of the entire molecular signature as a surrogate for individual
analytical studies of each biomarker signal and was able to use the information in this control to clear and
classify this device in a 60-day total review time. http://www.fda.gov/cdrh/oivd/guidance/1627.html
FDA is also developing additional guidance to assist companies in meeting patient safety requirements
including guidance on medical device reporting and recalls, guidance on new molecular diagnostic devices,
and guidance on tumor biomarkers. FDA is collaborating actively with multiple NIH partners including the
Program on Assessment of Clinical Cancer Tests (PACCT), Early Response Detection Network (EDRN),
Specialized Program of Research Excellence (SPORE), and NIH Proteomics Program to develop
educational programs, white papers, and research collaborations to advance the development of biomarkers
for use in promoting personalized medicine. In some cases, formal MOUs have been developed; in others,
work is done on a more informal basis.
FDA is also working with NCI and the American Association for Cancer Research to draft guidelines
and recommendations to be used by FDA to create future guidance in areas relevant to advances in
regulation of devices and drugs used in personalized medicine. This program includes brainstorming and
interaction with multiple stakeholders from academia (both clinicians and laboratorians) and from industry
(both drug companies and diagnostic companies). It is hoped that this collaborative work will be the
beginning of a successful use of leveraging of multidisciplinary talent to advance FDA’s mission of
promoting and protecting public health in this important and growing new era of personalized medicine.
http://www.nigms.nih.gov/Initiatives/PGRN/
Description
An emerging area of science known as “pharmacogenomics” is yielding new approaches to evaluate
individual patients’ genomic makeup to determine the best therapy or to guide selection to improve clinical
outcome. The NIH Pharmacogenetics Research Network (PGRN) was formed in 2000 to enable a network
of multidisciplinary research groups to conduct studies addressing research questions in how genes play a
role in differences in individuals’ response to therapies, and to populate a knowledge base. Researchers
studying this evolving field have formed a network to accelerate progress in this area. These projects are
helping develop genetic tests that are now being used in identifying diseases earlier and selecting the right
medications for the right patients. These types of studies are helping us understand disparities in the
outcomes in certain populations of patients and will help overcome them. Medical research projects are
under way to support the connections between the genetic basis of disease and their clinical manifestation.
Status and Next Steps
Described here are examples of research accomplishments:
• Accurate Dosing of Chemotherapy for Children With Leukemia. Researchers have made
several discoveries that are likely to improve the treatment of childhood leukemia. They looked
across the entire genome to discover 124 genes that can explain why some leukemias are
resistant to chemotherapy drugs. They also found that differences in two genes can lead to a
higher risk for leukemia relapse. Children with these high-risk genes may benefit from more
aggressive therapy. On the flip side, the researchers discovered two other gene variations that
predispose to a serious side effect when the children are treated with steroids, one of the standard
therapies for leukemia.
• Cancer Drug Label Now Includes Pharmacogenetics Warning. One finding by researchers
spurred changes in the prescription label for irinotecan, a drug approved in 1996 that treats
colorectal, lung, and other cancers. Approximately 10 percent of the North American population
has two copies of a genetic variation that puts them at higher risk for serious, even life-threatening
reactions to irinotecan. In the summer of 2005, the label of the drug was changed to include
information about the gene and potential impact and to encourage doctors to use a lower starting
dose for patients known to have this variation.
• Gene Tests Could Indicate Best Asthma Treatment. Researchers have learned details about
how variations in certain sets of genes affect the way people respond to asthma medicines,
specifically inhaled steroids and beta agonists. Testing for these genes will help doctors
recommend the best treatment for individual patients. Scientists expect to develop prototype tests
for the gene variants within a year.
• Genes Shed Light on Sudden Death From Irregular Heartbeats. Scientists have tracked down
gene variants that put people at higher risk for fatal heart arrhythmias. This information will help
doctors target high-risk patients for more aggressive screening and preventive medications.
Because some arrhythmias are brought on by medications that treat conditions as diverse as
bacterial infection and psychiatric disease, the research will also help doctors tailor medications to
individual patients. In the future, it may even lead to new drugs based on gene targets.
• Pharmacogenetics and Pharmacogenomics Knowledge Base. A key component of the PGRN
is the Pharmacogenetics and Pharmacogenomics Knowledge Base (PharmGKB), a shared online
resource that contains pharmacogenetics data from the PGRN and others and is freely available to
the entire scientific community. PharmGKB integrates carefully curated and annotated information
about genes, drugs, and diseases, including data about more than 10,000 unique human gene
variations involved in drug responses. In addition to facilitating data-sharing, PharmGKB helps
researchers identify and fill in knowledge gaps. To protect the privacy of research study
participants, names and other identifying information are not stored in this library.
Many grants have been made to researchers to expand the PGRN. Examples of progress in research
for the next several years include the study of the genetic basis for variation in response to medications for
tobacco dependence or how genetic differences between individuals impact the response to statins, a
widely used class of cholesterol-lowering drugs. Results from these and the many other studies funded
through the PGRN will enrich the scientific base and inform clinical decision-making.
to the DailyMed RSS data feeds. Additional labels will be added as annual updates to labels are
received from pharmaceutical manufacturers and approved by the FDA.
• Alignment of Terminology and Messaging Standards (http://www.nlm.nih.gov/healthit.html).
HL7 (Health Level Seven) is an ANSI-accredited Standards Development Organization creating
messaging protocols to transfer clinical and administrative data between systems. HL7 is one of a
suite of designated standards for use in U.S. Federal Government systems for the electronic
exchange of clinical health information and is also a required standard in interoperability
specifications of the Healthcare Information Technology Standards Panel (HITSP). In 2004, NLM
contracted with HL7 to facilitate the alignment of HL7’s messaging standards with key terminology
standards. The focus of the contract is reviewing the terminology subsets identified for each
messaging protocol and, where appropriate, replacing or enhancing the terminology subsets with
standard terminologies (e.g., SNOMED CT; LOINC). The initial analysis will be completed in the fall
of 2007.
• Vocabulary Mapping Projects (http://www.nlm.nih.gov/healthit.html). Health care providers
must produce billing and statistical data using the HIPAA code sets. The use of standard clinical
vocabularies will be more attractive and cost-effective if required HIPAA code set data can be
generated from health care information recorded using standard clinical vocabularies. Toward this
end NLM has the responsibility for funding, coordinating, and/or performing official mappings
between standard clinical terminologies and HIPAA code sets. The first such map released for
public review and comment is the draft LOINC to CPT (Current Procedural Terminology) map. Also
under development are mappings between SNOMED CT and CPT as well as a mapping between
SNOMED CT and ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical
Modification). Robust testing and validation procedures are under development.
• Human Genetic Variation Information Resources (http://www.ncbi.nlm.nih.gov/). Multiple
databases available at NCBI contain information about genotypes and phenotypes, including
PubMed and PubMed Central (the primary literature); Online Mendelian Inheritance in Man, or
OMIM (allelic variant records); dbSNP (single nucleotide polymorphisms, small-scale
insertions/deletions, polymorphic repetitive elements, and microsatellite variations); dbMHC (major
histocompatibility complex data); and dbRBC (genetics of red blood cell antigens). NCBI’s dbGaP
(database of Genotype and Phenotype) has been designated the trans-NIH repository for Genome-
Wide Association Studies. This database will contain NIH-supported clinical and longitudinal
studies with high-density genotyping on the participants and associations between genetic markers
and clinical traits. For each study, the database generally will include all the study documents, such
as protocols and questionnaires, summary data for measured phenotype variables, summary data
for genotype results, and de-identified individual-level genotype and phenotype data for each
participant.
The Collaboration, Education, and Test Translation (CETT) program is sponsored by NIH’s Office
of Rare Diseases (ORD) and provides funding and other support to move genetic tests from the
research setting to clinical practice. In connection with the CETT program, clinical laboratories are
beginning to supply NCBI with information about results of their genetic tests, including the
reference sequences they use to test patients’ DNA and de-identified test readouts and diagnoses.
RefSeqGene is a reference sequence database specifically designed to provide a gene-specific
genomic sequence for each human gene that is a target for genetic testing. RefSeqGene will
provide a common language for communicating about variations in gene sequences, which is
especially important when a gene has multiple splice variants or frequent mutations in
nontranscribed regions.
Other key activities for the next year include collaborating with a range of partners (e.g., medical
professional organizations, health plans, public health) to effectively disseminate evidence reports and
recommendation statements, and surveying stakeholders to assess the usefulness of the products and
potential impact of the information in practice.
Roadmap for Medical Research: Clinical and Translational Science Award Program
CTSA-supported researchers, located at academic health centers across the Nation, will rapidly and
efficiently transfer discoveries made in the laboratory into treatments for patients, including personalized
approaches. For example, high-throughput equipment to describe the genetic characteristics of individuals
is included in many CTSA sites. These technologies enable investigators to identify genes that predict how
a patient will respond to drugs they are testing. Ultimately, this support will enable doctors to reduce the risk
of adverse effects of medications as well as achieve the desired effects more rapidly.
The overall CTSA goal is to enable interdisciplinary teams to design new and improved clinical research
informatics tools, forge new partnerships with private and public health care organizations, expand outreach
to minority and medically underserved communities, develop better designs for clinical trials, and train the
next generations of clinical and translational researchers. The CTSA awardees operate as a consortium so
that expertise that is developed at one location can be shared with other sites, an important element of
replicating approaches to personalized health care across the Nation.
This new consortium is the preeminent initiative to address the NIH Roadmap for Medical Research
theme of Re-engineering the Clinical Research Enterprise. For more information, see www.ctsaweb.org.
from many and diverse data sources and support research into the understanding of individual
differences in cancer risk. The underlying service-oriented infrastructure for caBIGTM is caGRID.
Examples of Datasets:
• Cancer Genome Anatomy Project (CGAP). This program has supported gene expression
profiles of normal, precancer, and cancer cells, leading eventually to improved and customized
detection, diagnosis, and treatment for the patient.
• Cancer Molecular Analysis Project (CMAP). CMAP enabled researchers to identify and evaluate
molecular targets in cancer. The project provides molecular profiles, targets, targeted agents, and
therapeutic trials to patient-specific disease applications.
The infrastructure and tools of caBIG™ are already widely applicable beyond the cancer community,
and the initiative collaborates with health and biomedical information technology efforts in other domains. As
caBIG™ continues to grow and more and more organizations become involved, caBIG™ will increasingly
involve a cross-section of diverse users, contributors, and beneficiaries.
• Working with other Federal agencies (especially CDC, FDA, and NIH) and professional
availability of proficiency testing (PT) materials and programs and alternatives for PT.
• Enhancing the expertise of surveyors and CMS in the area of genetic testing to better serve the
community, and providing specific survey guidance to surveyors to assess compliance for these
tests.
• Considering innovative alternatives for specialized survey of these laboratories and the review of
their data.
Status and Next Steps
laboratories are subject to CLIA when tests are used to diagnose, prevent, assess or treat
human illnesses and conditions. CMS will also seek to raise awareness in the research
laboratory community of the need for laboratories to enroll in CLIA when genetic tests are
used in patient care.
– Training for Surveyors: CMS is exploring the development of a customized survey protocol to
assess compliance in genetic laboratories where unique technologies and methodologies are
utilized. This fall, CMS is providing surveyors with technical training on current technologies
and the quality aspects of genetic testing by subject matter experts from the field.
– CLIA Web Site Enhancement: CMS will coordinate with CDC to provide helpful educational
genetic testing guidance and updates on its Web site for surveyors and laboratories.
information exchange between users and providers of reference materials, and coordinate efforts for
contribution, development, characterization, and distribution of reference materials for genetic testing. GeT-
RM is coordinated by the CDC, but all of the actual work, including decisions about reference material
priorities, specimen collection, material development, and characterization occurs through voluntary
collaborations with laboratories in the genetics community.
GeT-RM has recently developed 57 characterized cell line-based reference materials for fragile X,
disorders on the Ashkenazi Jewish Panel (Bloom syndrome, Canavan disease, Fanconi anemia, familial
dysautonomia, Gaucher’s disease, mucolipidosis IV, Neimann-Pick disease, and Tay-Sachs disease), cystic
fibrosis, and Huntington’s disease. These materials are (or will be) publicly available from Coriell Cell
Repositories. A characterization study of 14 DNA materials with important mutations causing cystic fibrosis
is currently under way in 6 clinical laboratories. Studies to characterize DNA materials with mutations in
genes important for many of the disorders included in state newborn screening panels (including congenital
adrenal hyperplasia, medium-chain acyl-CoA dehydrogenase deficiency, maple syrup urine disease, cystic
fibrosis, and galactosemia), additional mutations included in the Ashkenazi Jewish Panel (Gaucher, Tay-
Sachs, Canavan) and several other disorders including inherited breast cancer (BRCA1 and 2), alpha-1
antitrypsin, and MEN2 will soon be initiated.
To date, the GeT-RM has focused its efforts on DNA-based testing for inherited genetic disorders.
However, there is a similar lack of reference materials for other areas of genetics, including molecular
oncology, molecular infectious disease testing, and biochemical genetic testing. To address these needs,
GeT-RM, together with the genetics community, relevant professional organizations, and government
agencies, is working to provide information about currently available reference materials for molecular
oncology, molecular infectious disease, and biochemical genetic testing. Mechanisms to address reference
material needs for these areas are also being considered.
Evidence-Based Practice
http://effectivehealthcare.ahrq.gov
Description
The Effective Health Care (EHC) Program conducts knowledge synthesis, new knowledge generation,
and knowledge translation and dissemination for health care effectiveness research. These activities are
coordinated by the AHRQ.
Status and Next Steps
• Evidence-Based Practice Center (EPC) Program. A network of 13 centers that focus on
evaluation and synthesis of published evidence of effectiveness and comparative effectiveness of
health interventions and in clarifying the gaps in knowledge. For example, a recent EPC report
evaluated the effectiveness and safety of different treatment alternatives for gastroesophageal
reflux disease (GERD).
• Developing Evidence to Inform Decisions about Effectiveness (DEcIDE) Program. A new
network of 13 centers that focuses on rapid-turnaround research to inform gaps in the current
research on health care interventions. These centers specialize in secondary data analysis but are
also geared to perform primary data collection and analysis. Currently work includes developing
best practices for use of registries to improve evidence on benefits and harms of medical
innovations in practice, and conducting pilot studies that examine use of linked administrative data
for surveillance for drug safety, in anticipation of CMS Part D data becoming available.
Agency for Healthcare Research and Quality and U.S. Food and Drug Administration
http://www.certs.hhs.gov/index.html
Description
The Centers for Education and Research on Therapeutics (CERTs) is a research program administered
by the AHRQ, in consultation with the FDA, and agencies within the HHS. The mission of the CERTs is to
conduct research and provide education that will advance the optimal use of drugs, medical devices, and
biological products.
Status and Next Steps
• Evaluation of the Incremental Cost-Effectiveness of Long-Term Clopidogrel Therapy
Following PCI. Explore the economic implications of widespread adoption of evidence-based
therapies for secondary prevention of coronary artery disease and heart failure from multiple
perspectives.
• Determination of Genetic Predictors of Drug-Induced QT Interval Prolongation. Part of a
collaboration with NIH/National Institute of General Medical Sciences Pharmacogenetics Network.
• Consultation with the Coalition for Affordable Quality Healthcare (CAQH) on Their
Cardiovascular Quality Initiative. Collaborate with CAQH in developing a national initiative to
evaluate long-term use of beta-blockers in patients with previous myocardial infarction.
• Evaluation of the Impact of Heart Failure on the Medicare Program. Predicting high-cost
beneficiaries by developing a prediction rule to identify high-cost/high-risk heart failure patients.
• Develop an Association of Working Conditions With Prescribing Errors in Primary Care. The
overall objective of this study is to evaluate the association of rates of risky prescribing events with
both structural and functional characteristics of the primary care practices of two managed care
organizations.
• Estimating Odds Ratios Under Misclassification of the Outcome in a Large Database Cohort
Study When Medical Records Are Sampled. Large sample sizes are needed to study rare
diseases and events; misclassification of the outcome is common and verification of all
presumptive cases not feasible. The goal is to extend previously developed methodology by this
group for adjustment for misclassification, which uses all or most exposed cases but only a
Family History
upon the foundation laid by the Surgeon General’s Family History Initiative, NHGRI named two new Family
History demonstration projects, focused on Alaska Native and urban Appalachian populations. The 1-year
projects, each of which received $100,000, will develop community-based models to increase awareness
among the public and health care professionals about the value of family history information in promoting
health and preventing disease.
The NIH is developing a state-of-the-science conference on family history to review the current body of
literature about how family history information is collected and what impact it has on the way patients are
treated. The conference will probably be held in fiscal year 2009.
In addition, other HHS-funded efforts are encouraging State health departments to increase awareness
about family history among health care providers and the general public. The CDC is funding the State
health departments in Utah, Oregon, Minnesota, and Michigan to incorporate genomics into their health
promotion and disease prevention activities. All four States are tying activities to the Surgeon General’s
initiative to increase awareness about family history among health providers and the general public.
plan or to the HHS Office for Civil Rights (OCR), which is charged with investigating complaints
and enforcing the privacy regulation. Information about filing complaints should be included in each
covered entity’s notice of privacy practices. Consumers can find out more information about filing a
complaint at http://www.hhs.gov/ocr/hipaa or by calling (866) 627-7748.
The Privacy Rule requires covered health plans, pharmacies, doctors, and other covered entities to
establish policies and procedures to protect the confidentiality of protected health information about their
patients. These requirements are flexible and scalable to allow different covered entities to implement them
as appropriate for their businesses or practices.
http://www4.od.nih.gov/oba/sacghs.htm
Description
The Secretary’s Advisory Committee on Genetics, Health, and Society (SACGHS) serves to (1) provide
a forum for expert discussion and deliberation, (2) assist HHS and other Federal agencies (at their request)
in exploring issues raised by the development and application of genetic technologies, and (3) make
recommendations to the Secretary on solutions. The SACGHS explores, analyzes, and presents options on
the broad range of policy needs associated with the scientific, clinical, public health, ethical, economic, legal,
and social issues raised by the development, use, and potential misuse of genetic and genomic
technologies.
Status and Next Steps
The SACGHS has made a number of recommendations to the Secretary regarding:
• Coverage and reimbursement of genetic tests
• Genetic discrimination
• Direct-to-consumer marketing of genetic tests
• Genetics education for health professionals
• Health information infrastructure
• Surgeon General’s Family History Initiative
• Large population studies
The SACGHS is currently addressing a wide variety of topics, including oversight of genetic testing,
pharmacogenomics, and gene patents and licensing practices.
http://ncvhs.hhs.gov
Description
The National Committee on Vital and Health Statistics (NCVHS) is the statutory public advisory
committee on health information policy to the Secretary of HHS. The Committee, first chartered in 1949, is
composed of 18 individuals from the private sector who have distinguished themselves in the fields of health
statistics, electronic interchange of health care information, privacy and security of electronic information,
population-based public health, purchasing or financing health care services, integrated computerized
health information systems, health services research, consumer interests in health information, health data
standards, epidemiology, and the provision of health services.
Status and Next Steps
The NCVHS has delivered dozens of letter reports to the Secretary, including recent recommendations
on:
• Data Linkages To Improve Health Outcomes
• Privacy issues in the Nationwide Health Information Network (NHIN)
• Functional requirements for the NHIN
• Improvements to data on race, ethnicity, and language
• Personal health records and systems
• Data standards for health information
• Quality measurement
• Lessons learned from the first 10 years of HIPAA
The NCVHS is currently addressing a wide variety of topics, including secondary uses of health data in
the NHIN, individual control of sensitive information in the NHIN, the National Provider Identifier, HIPAA
streamlining, and performance measurement and quality improvement.
Advisory Committee on Heritable Disorders and Genetic Diseases in Newborns and Children
http://mchb.hrsa.gov/programs/genetics/committee/
The Advisory Committee on Heritable Disorders and Genetic Diseases in Newborns and Children
(ACHDGDNC) was established to assist the Secretary of HHS by providing:
• Advice and recommendations concerning the grants and projects authorized under the Heritable
Disorders Program.
• Technical information to develop policies and priorities for this program that will enhance the ability
of the State and local health agencies to provide for newborn and child screening, counseling and
health care services for newborns and children having or at risk for heritable disorders.
The Committee advises and guides the Secretary regarding the most appropriate application of
universal newborn screening tests, technologies, policies, guidelines and programs for effectively reducing
morbidity and mortality in newborns and children having or at risk for heritable disorders.
OVERVIEW OF FEDERAL
Department of Defense
DoD and the VA and the data mediation, mapping, and terminology services required for the exchange of
computable information.
TRICARE Online (patient Web portal, https://www.tricareonline.com/preloginHome.do)
TRICARE Online (TOL) is the Military Health System (MHS) portal for secure access to applications
and services for beneficiaries, providers, staff, and external support contractors. TOL improves access to
health care services and benefits and provides high-quality health care information from trusted sources.
Using TOL, beneficiaries can schedule appointments online via a secure Internet site; access is
provided to 18 million pages of general health information, including symptoms and treatment options for
children, automated tools for checking medications for possible adverse reactions and creating a personal
health journal, and details on specific MHS services and benefits.
TOL services for providers include viewing and printing a patient’s pre-and-post deployment forms, and
MTFs can process, route, review, and authorize nonavailability statements. TOL also gives providers remote
secure access to the Composite Health Care System resources as well as a 24/7 interactive Web-based
training module based on their specific roles within TOL. Security and authentication benefits of TOL include
a single sign-on solution for all Web applications used by MHS staff.
GLOSSARY OF TERMS
(For a complete list, see the National Human Genome Research Institute’s
“Talking Glossary” at http://genome.gov/10002096.)
Biomarkers: Biological parameters associated with the presence and severity of specific disease states.
Biomarkers are detectable and measurable by a variety of methods including physical examination,
laboratory assays, and medical imaging.
Genome: All the genetic information possessed by an organism.
Genomics: The study of this genetic information.
Genotype: The genetic identity of an organism.
Genome-Wide Association Studies: An approach that involves rapidly scanning markers across an
individual’s genome, to find genetic variations associated with a particular disease. Once new genetic
targets are identified, researchers can use the information to develop better strategies to detect, treat, and
prevent the disease.
Health informatics, or medical informatics: The intersection of information science, medicine, and health
care. It deals with the resources, devices, and methods required to optimize the acquisition, storage,
indexing, retrieval, and use of information in health and biomedicine. Health informatics tools include not
only computers but also clinical guidelines, formal medical terminologies, and information and
communication systems.
Microarray technology: A new way of studying how large numbers of genes interact with each other and
how a cell’s regulatory networks control vast batteries of genes simultaneously.
Personalized health care: Describes medical practices that are targeted to individuals on the basis of their
specific genetic code in order to provide a tailored approach. These practices use preventive, diagnostic,
and therapeutic interventions that are based on genetic tests and family history information. The goal of
personalized health care is to improve health outcomes and the health care delivery system as well as the
quality of life of patients everywhere.
Pharmacogenomics: The study of how variations in the human genome affect an individual’s response to
medications.
Phenotype: The observable traits or characteristics of an organism, for example, hair color, weight, or the
presence or absence of a disease. Phenotypic traits are not necessarily genetic.
• Genome Resources
http://www.ncbi.nlm.nih.gov/genome/guide/human/resources.shtml
• Database of Single Nucleotide Polymorphisms (SNPs)
http://www.ncbi.nlm.nih.gov/SNP/index.html
• DNA and Clinical Data Related to Major Histocompatibility Complex (MHC)
http://www.ncbi.nlm.nih.gov/mhc/MHC.cgi?cmd=init
• dbGAP
http://www.ncbi.nlm.nih.gov/sites/entrez?db=gap
NHLBI Resequencing and Genotyping
http://rsng.nhlbi.nih.gov/scripts/index.cfm
http://www.hhs.gov/myhealthcare/