Discovering Precision Health. Lloyd Minor
that influenced my thinking was The Decision Tree, by Thomas Goetz, who at the time was executive editor of Wired magazine [16]. The “decision tree” of his title was a system that would help guide people toward the best decisions about their health—drawing on new science and new technologies, in particular. I found it to be an excellent overview of the different ways in which health and health care could be reoriented to focus more on prevention.
With all of that as a backdrop, in November 2014 I had breakfast at Buck’s—a popular restaurant a few miles from Stanford—with two professors at the School of Medicine, Peter Kim and Steve Quake. I had asked them to meet with me because I wanted to brainstorm about some of the overarching themes for the work of the medical school, and I knew I could count on them for insightful and creative ideas.
My colleagues and I had recruited Peter to join the faculty—his previous positions included leading global R&D for Merck and serving as a professor at MIT’s Whitehead Institute for Biomedical Research. Steve had developed a way of measuring and detecting cell‐free DNA, which was one of the greatest diagnostic advances of the first decade of the 21st century. (I discuss it in more detail in chapter 5.)
We discussed several principles and topics—such as behavior, genomics, economics, measurement, prevention, and prediction. But the first two words I wrote in my notebook that morning were “precision” and “health.” With Steve’s background in diagnostics, we were able to talk about shifting the focus of health care so there would be more emphasis on the “health” part. The three of us agreed that Stanford was uniquely positioned to put forward a new vision, built around using prediction and prevention to advance health.
Our breakfast discussion led me to sketch out several ideas, which I presented in my closing remarks at a Stanford Medicine retreat in January 2015, at Fort Baker near San Francisco. I didn’t go into great detail—I just wanted people to hear some of my preliminary thoughts about Precision Health and I wanted their feedback. I was pleased that my thoughts seemed to strike a chord with many of those in attendance. In particular, the theme and the message resonated strongly with the then leaders of the two hospitals that are a part of Stanford Medicine: Amir Rubin, president and CEO of Stanford Health Care (SHC), and Christopher Dawes, president and CEO of Lucile Packard Children’s Hospital Stanford (LPCH). Since coming to Stanford, I had been searching for a theme that would bring the three entities of Stanford Medicine (School of Medicine, SHC, and LPCH) closer together: a theme that could help unite the different components of Stanford Medicine and advance its mission. We all agreed that Precision Health was exactly that theme.
Just a few weeks after our retreat, we were pleasantly surprised when President Obama held an event at the White House to announce a federal government initiative devoted to “precision medicine.” The objective, he said, would be “delivering the right treatments, at the right time, every time, to the right person” [17]. The initiative had five parts:
Using the federal government’s National Cancer Institute to help expand and improve research into cancer treatments
Working with the NIH to create a research group of one million people, known as “All of Us,” and using the data from that cohort to discover the causes—and eventually the cures—of deadly diseases
Modernizing regulation, with a focus on developing a new approach to evaluating next‐generation genetic tests
Expanding public‐private partnerships to enable development of the infrastructure needed for the cancer treatment research and the “All of Us” initiative
Protecting patient privacy
To help put precision medicine in perspective, the director of the NIH, Francis Collins, and the director of the National Cancer Institute, Harold Varmus, published an article on the website of the New England Journal of Medicine. They pointed out that it was now possible to bring more precision to medicine thanks to developments like biological databases (such as the human genome sequence), new forms of characterizing patients (such as proteomics and metabolomics), and new computational tools to analyze large data sets [18].
The Obama administration’s focus on “medicine” (treatment of diseases after they occur) contrasted with our focus on “health” (with more emphasis on prediction and prevention of diseases), but we interpreted the shared focus on “precision” as a signal that we were on the right track. We soon organized a faculty working group, led by the Department of Medicine chairman Bob Harrington, and including faculty and staff from the School of Medicine as well as from SHC and LPCH. That group spent more than a year developing the ideas that would define Precision Health. Their expert work led to the development of a comprehensive plan for Precision Health. The working group released its findings in October 2016, and since then we have been working to instill the Precision Health plan throughout the School of Medicine, SHC, and LPCH.
It’s been gratifying to see broad adoption of the theme and components of Precision Health throughout our enterprise. David Entwistle, who began as president and CEO of SHC in July 2016, and Paul King, who began as president and CEO of Lucile Packard Children’s Hospital and Stanford Children’s Health in February 2019, have firmly embraced the vision. After David’s arrival, we were able, for the first time, to develop a truly integrated strategic plan for Stanford Medicine, with Precision Health being the unifying principle. Marc Tessier‐Lavigne, who became Stanford’s 11th president on September 1, 2016, and who has previously worked as a neuroscientist, biotechnology executive, and president of a biomedical research university, has endorsed Population and Precision Health as an important strategic objective for Stanford University’s research community.
It has also been reaffirming to see that several other institutions have recently adopted Precision Health as a strategic theme. These include Cedars‐Sinai, Geisinger Health System, Indiana University, UCLA, the University of Chicago, the University of Michigan, and the University of Texas.
ABOUT THE BOOK
I was determined to write this book to provide an overview of the Precision Health vision. But I also wanted to help reorient how health and medicine are viewed in the United States, and even throughout the world. While you’ll see that Stanford professors feature prominently, as do several companies operating near Stanford, the vision I’m putting forward is universally applicable. My inclusion of the companies is intended to provide an overview of the wide‐ranging approaches and technologies that have the goal of improving health and health care. This overview of commercial activity is not intended to be comprehensive, nor does the inclusion of a company in any way reflect an endorsement of its approach or likelihood of success [19].
Virtually any institution, or any individual, can embrace the tenets of Precision Health and begin working toward achieving better health outcomes. And all communities—regardless of income levels and ethnic, racial, or religious composition—can benefit from Precision Health. Indeed, while Silicon Valley is seen as a cradle of wealth, it’s also home to several jurisdictions where incomes are well below the national average, and where public health indicators paint a picture of distress. We are working in these communities with as much or more determination as we are in other communities with wealthier and healthier profiles.
To showcase the importance of Precision Health, chapter 1 is devoted to the state of health in the United States, as well as the health care delivery system. While there are gains to report on both fronts, it’s also clear that there’s considerable room for improvement and reform. In chapter 2, I address a fact that gets overlooked in most discussions of health: medical care plays only a small role in determining our health outcomes. Much more important are environmental, social, and behavioral factors, and I explore some of the reasons why they have been so difficult to address and why I believe components of Precision Health, such as the revolution in digital health, offer promising new hope.
Progress